By H. Hamlar. University of Minnesota-Duluth.

Te most recent and highly publicized of Bitemarks 327 these cases is that of Kennedy Brewer in Mississippi generic 30 gm himcolin. Brewer was convicted in 1995 of the murder and sexual assault of Christine Jackson cheap himcolin 30 gm fast delivery. Te body of the three-year-old victim had been found in a nearby creek on a Tuesday morn- ing generic 30gm himcolin with mastercard, the third day afer her Saturday night disappearance cheap 30gm himcolin visa. Michael West cheap 30 gm himcolin with amex, examined Christine Jackson on May 9, 1992, and wrote in his May 14, 1992, report that nineteen human bitemarks were found on the body, and that “the bitemarks found on the body of Christina [sic] Jackson are peri-mortem in nature. West later testifed that “indeed and without doubt” and that “to a reasonable degree of medical certainty” the teeth of Mr. Brewer made fve of those marks, and that it was “highly con- sistent and probable that the other fourteen bite mark patterns were also inficted by Brewer” (West in original trial transcript in Brewer v. Souviron, testifed that the patterned injuries on the body were not human bites at all but were patterns that were made by other means. Tere could be fsh activity or turtle activity or who—God knows what” (Souviron in original trial transcript in Brewer v. Neither profle included Brewer but did point to another man, Justin Albert Johnson, who, ironically, had also been an early suspect in Jackson’s murder. Johnson later confessed to killing Christine Jackson and another young girl who had been similarly sexually assaulted and murdered. In that earlier case, Levon Brooks had also been wrongly convicted based, in part, on Dr. He testifed that “it could be no one else but Levon Brooks that bit this girl’s arm. How can an “expert” ignore the circum- stances and disregard the crime scene information? How can patterns with no class or individual characteristics of human teeth in patterned injuries found on a body that had been in water for more than two days be judged to be human bitemarks? To then associate those patterns to a suspect with any level of certainty seems unthinkable. Perhaps, an understanding of alter- native explanations to human teeth causing the marks should have been considered more seriously, especially in a case in which human bitemarks seemed unlikely. Souviron provided viable and testable theories for possible alternatives—the marks may have come from activity by insects, fsh, turtles, or other sources not readily apparent. Wallace, suggested that crayfsh, which were very abundant in the stream where the victim was found, were likely suspects and could have lef such marks on the victim’s body through normal feeding activity. Incredibly, the odontologist in this case associated only the upper inci- sor teeth to all of the “bitemarks”; there were no lower teeth marks identi- fed. West performed a simple test to determine if the patterns on the skin were in fact bitemarks of the type Bitemarks 329 Figure 14. An incision through a mark will reveal if there is the subepidermal hemorrhage ofen associated with human bitemarks (Figures 14. Alternatively, either could have harvested tissue from one or more of the patterned injuries. West had a history of simi- larly outrageous fndings in other cases (Keko, Harrison, Maxwell). He had identifed shoe marks on human skin and knife handle rivets on the hand of a murder suspect. He had made dramatic, overreaching statements in court, including conclusions to absolute certainty, “indeed and without doubt,” and incredible estimates of his own error rates, “something less than my savior, Jesus Christ. Tat the liberty, and indeed the life, of a human being is ofen in question and may depend upon the quality of experts’ opinions is of paramount importance and cannot be overemphasized. We cannot be too cautious, too conservative, or too diligent when analyzing the potential asso- ciation of a suspect to a bitemark. We should also recognize that eyewitnesses may be wrong or may have reason to lie. Since that time more programs and more comprehensive programs 332 Forensic dentistry have become available. Tese include programs at the Armed Forces Institute of Pathology, the University of Texas Health Science Center at San Antonio, McGill University in Montreal, the Miami-Dade County Medical Examiner’s Ofce, the University of Detroit–Mercy School of Dentistry, and others.

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Beta1 Intensive care nursing 336 stimulation increases cell membrane permeability proven himcolin 30gm, thus increasing spontaneous muscle depolarisation generic himcolin 30 gm overnight delivery. The effects of β 1 stimulation include (Moss & Craigo 1994): ■ increased contractility ■ improved atrioventricular conduction ■ quicker relaxation of myocardium ■ increased stroke volume ■ increased heart rate (with potential dysrhythmias) ■ therefore net increased cardiac output ■ increased release of insulin purchase himcolin 30 gm visa, renin and antidiuretic hormone (Moss & Craigo 1994) ■ transient hyperkalaemia: as potassium moves out from hepatic cells ■ followed by prolonged hypokalaemia as potassium moves into blood and muscle cells Beta2 receptors are found mainly in bronchial smooth muscle generic himcolin 30 gm with mastercard, but a significant minority are also found in myocardium (15 per cent of ventricle and 30–40 per cent of atrial beta receptors (Moss & Craigo 1994)) cheap 30 gm himcolin with mastercard. Beta2 stimulation is especially chronotropic, increasing myocardial workload and predisposing to dysrhythmias (hence tachycardic/dysrhymthmic effects of bronchodilators such as salbutamol). Beta2 receptors are also found in other smooth muscle, such as blood vessels and skeletal muscle, vasodilating arterioles and reducing systemic vascular resistance (afterload). Insufficient brain stem production causes neurotransmission failure in Parkinson’s disease, but dopamine cannot permeate mature blood-brain barriers (van den Berghe & de Zehger 1996), and so intravenous dopamine does not affect cerebral receptors. Renal juxtaglomerular apparatus contains dopamine receptors; stimulation dilates afferent arterioles, increasing blood flow to the Bowman’s capsule, so increasing urine output. Provided sufficient drug is given to stimulate dopamine receptors, stimulation continues regardless of dose. Gut receptors similarly increase splanchnic perfusion, but attempts to reduce the translocation of gut bacteria with low-dose dopamine have proved disappointing (Azar et al. Prolonged beta stimulation causes ‘down regulation’—progressive destruction of beta receptors, requiring progressively larger doses of inotropes to achieve the same effect. Destruction starts within minutes of exposure to stimulants, reaching clinically detectable levels by 72 hours (Sherry & Barham 1997). Monitoring Ideally all drugs would be titrated to a patient’s weight; in practice, most drugs have a wide enough therapeutic range to enable ‘standard doses’, making both production and prescription safer and simpler. Most inotropes have very short half-lives (a few minutes); overdoses can cause massive, life-threatening hypertension, necessitating close monitoring and careful titration. While short half-lives make accumulation unlikely, flushing or failure of delivery (pump failure; change of syringe) can make blood pressure labile. Inotropes 337 Monitoring inotropes necessitates both careful monitoring of cardiovascular effects and careful recording of amounts delivered. Short half-lives of inotropes and gross hypertensive effects necessitate continuous (or very frequent—every minute) blood pressure measurement. Other cardiovascular monitoring, such as cardiac output studies, will probably be required. Peripheral vasoconstriction, especially from alpha stimulants, necessitates frequent monitoring of peripheral oxygen saturation (SpO2). Traditionally inotropes are measured in micrograms per kilogram per minute (see below), or variants (e. As normotension is the desired end of inotrope therapy, the value of investing nursing time in complex calculations is questionable, especially with calculations based on estimated weights, necessitating recalculation when one guess is replaced by another. Adrenaline (adrenalin, epinephrine) The adrenal medulla produces two hormones, both called ‘catecholamines’. Adrenaline, the main adrenal medullary hormone, stimulates alpha, β 1 and β 2 receptors, triggering the ‘fight or flight’ stress response via the sympathetic nervous system: ■ vasoconstriction (alpha receptors) ■ increased cardiac output (β 1 , β 2) Acting on both alpha and beta receptors, adrenaline effectively increases all factors contributing to blood pressure; it has therefore become the major inotrope used during cardiac arrests, where immediate short-term restoration of systemic blood pressure and circulation is essential. Since prolonged critical illness is more complex, it necessitates careful balancing of factors. Its bronchodilatory qualities (β 2) make nebulised adrenaline useful during asthma crises, especially with children. Intensive care nursing 338 Adrenaline causes gross tachycardia; with critical illness, increased myocardial oxygen consumption in already hypoxic patients may provoke angina or infarction. Alpha effects include peripheral shutdown, including reductions in glomerular filtration rates; the short half-life of bolus adrenaline does not make this problematic during resuscitation, but continued infusion during critical illness may aggravate impending renal failure. Adrenaline depresses insulin secretion, while blocking peripheral insulin receptors; with depressed insulin secretion and increased glycogenolysis, this causes stress-induced diabetes (whether adrenaline is endogenous or exogenous). Normoglycaemia may be restored once intravenous adrenaline is removed, although depleted intracellular glucose supply may prolong cellular recovery. Almost uniquely among drugs, adrenaline is marketed in the virtually obsolete form of ratios. The ratio represents grams per ml, so that 1:1,000=1 gram per 1,000 ml=1,000 mg per 1,000 ml=1 mg per ml; similarly, 1:10,000=1 mg per 10 ml; 1:1,000 is usually marketed in 1 ml ampoules and 1:10,000 in 10 ml ampoules (so that both contain 1 mg per ampoule).

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These included Egypt buy discount himcolin 30 gm online, where the Israelites lived for some centuries discount himcolin 30gm without a prescription, to Mesopotamia buy himcolin 30gm with mastercard, home of the Jewish patriarchs effective himcolin 30 gm. In differing periods Egyptian and Mesopotamian medicine were highly esteemed even though many of the medications came with their own associated religious and cultural practices buy cheap himcolin 30 gm on line, often inimical to that of Israel. Further, Israel enjoys a special climate located between sea and desert, with such remarkable land features as the Dead Sea and the River Jordan, and is located at the conjunc- tion of three continents with their varied plant and animal populations. Medicine in the Bible The Hebrew Bible records that the kohenim (priests) supervised cases of contagious diseases but, unlike in other contemporary cultures, did not perform the functions of a physician. Ben Sira wrote in the Apocrypha: Honour a physician with the honour due unto him for the uses which ye may have of him, for the Lord hath created him. The Lord has created medicines out of the earth; and he that is wise will not abhor them. However, it is difficult to find any reference to any medication taken for internal use, although many of the products that are mentioned throughout its text do have a medicinal component. There are indications of the under- standing of quarantine and health protection, and sanitary regulations concerned the eating of meat, the quick carrying out of burials and social hygiene. Treatments included bathing, anointing with oils, wine, balm and medicinal compresses, and splinting for fractures. The minstrel’s music enabled the prophet to be more Traditional Jewish medicine | 295 receptive to the Divine Message while David played on his harp to drive away the melancholy from King Saul. Ezekiel 47:9 talks of waters flowing from Jerusalem as ‘wherever the waters come they shall be healed and everything lives wherever the river comes’. The Book of Genesis relates that when Joseph was sold into slavery in Egypt the Ishmaelite traders were carrying gum, balm and laudanum. These plant resins, including balsam, were used for a range of medical disorders, such as fevers, stomach disorders and excessive sweating. When Jacob sent his sons for the second time to Egypt to buy food they were to take some of the produce of Canaan, including balm, honey, gum, laudanum, nuts and almonds as a gift to Joseph. The Book of Exodus records details of the special ointment used to consecrate the vessels of the Temple and anoint the kohenim. Calamus remains an essential ingredient in the manufacture of perfumes while it is also a psychoactive product, being hallucinogenic at high doses. Cassia is closely related to cinnamon and was prised for its aroma whereas myrrh has analgesic properties and can stimulate the appetite. Hyssop, which has mild purgative properties, is mentioned in the Book of Psalms (51:9) as a cleanser from sin (Figure 11. However, one of Hezekiah’s acts, for which he was praised by the rabbis, was to conceal the legendary Book of Remedies which was said to have contained the cures for all diseases and the authorship of which was attributed to King Solomon by the great mediaeval rabbi–physician Nachmanides, Ramban, (1194–c. The Biblical commentator Rashi (1040–1105) believed that people were being healed so quickly by these remedies that they did not develop the humility that their illness should have produced, and so they failed to see God as the true Healer. Further, it contained details of the formulae for poisons and antidotes, and this might have led unscrupulous people to use the poisons to kill their enemies. Medicine in the Talmud The nature of the Talmud, with its encyclopaedic view of the Jewish world spanning many centuries of Jewish life in both the land of Israel and the Babylonian diaspora, lent itself to coverage of a wide variety of traditional medical themes, including folk remedies and health beliefs. The Talmud builds on the range of medicinal products and hygienic procedures in the Bible supplemented by oral traditions, some said to have been preserved from the time of Moses. In addition, the Talmud contains a large number of medical references dealing with the rights and duties of the physician. From Talmudic times it was recommended that no wise person should live in a town that did not have a doctor. It was required for a patient to seek help for healing even on the Sabbath when religious restrictions might be set aside if there is any possible danger to health. Some of the popular medicine traditions recorded in the Talmud will naturally seem strange, even outlandish, to the modern mind but we should remember that in mediaeval Europe as late as the sixteenth century the apothecary was legally required to keep woodlice, ants, vipers, scorpions, crabs, sparrow brains and fox lungs in stock. Although the theoretical lists of available Jewish traditional remedies and materia medica contain many products from such animals as the eagle, lion, frog, hyena and Traditional Jewish medicine | 297 crocodile, they feature much less in lists of Jewish practical pharmacy. This is thought to be less due to commercial availability than to halachic consid- erations. Often the trees are used in their entirety, while sometimes just the leaves and rarely the bark are used.

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