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Cardiac Glycosides Diuretics Vasodilators Beta Adrenergic Receptor and Dopaminergic Receptor Agonists 6 erectile dysfunction treatment orlando purchase 20mg apcalis sx with mastercard. The following discussion is restricted only to those drugs which have not been dealt with so far. Uses Treatment of mild to moderate heart failure Control of ventricular response rate in patients with chronic atrial fibrillation. Digoxin increases left ventricular ejection fraction resulting in improvement of heart failure symptoms. Digoxin is often used in conjunction with a diuretic and an angiotensinconverting enzyme inhibitor for the treatment of heart failure. Massive acute cardiac glycoside overdose differs significantly from chronic toxicity. In acute overdose, the sodium-potassium pump is poisoned, producing a fall in intracellular potassium and a rise in extracellular potassium, which may be marked. The normal membrane resting potential is reduced, and electrical conduction is slowed, with eventual complete loss of myocardial electrical function. Clinically this results in high grade heart block, and eventually in asystole, which may not respond to electrical pacing. The most serious arrhythmias are ventricular tachycardia and ventricular fibrillation. Eye: Transient amblyopia, blurred vision, scotomata, photophobia, and chromatopsia. Toxicity is increased by diuretics (except potassiumsparing) and corticosteroids, because of hypokalaemia. Common drugs that may reduce the elimination of cardiac glycosides and result in digitalis intoxication include: amiodarone, propafenone, quinidine, and verapamil. Blood levels increased by Calcium channel blockers, spironolactone, quinidine and Calcium salts. Effectiveness reduced by phenytoin, neomycin, sulfasalazine, kaolin, pectin, and some antacids. Digoxin is metabolised to a very minor extent (about 16%) via hydrolysis, oxidation, and conjugation. After a single dose, digoxin is the major serum and urine metabolite of digitoxin. Most of an administered dose of digoxin is distributed to skeletal muscle after absorption (about 65%). The force of contraction of the heart (positive inotropic effect) is increased due to increase in cytosolic Ca++ during systole. Both Na+ and Ca++ enter the myocardial cells during each cycle of depolarisation, contraction, and repolarisation. Manifestations of digitalis overdose are mentioned separately for adults and children in Table 23. In an acute ingestion, nausea and vomiting are prominent as well as evidence of cardiotoxicity. In chronic poisoning, non-specific symptoms, such as malaise and weakness predominate, as well as the classic, but rare, visual disturbances. Lethargy, drowsiness, weakness, paraesthesias, and headache may occur with digoxin toxicity. Signs of toxic psychosis, including hallucinations, paranoia, agitation, confusion, and delirium, may also occur. In many patients, though, the sole evidence for digitalis toxicity is the appearance of a cardiac arrhythmia. The hallmark of digitalis poisoning is increased automaticity coupled with concomitant conduction delay. Although no single arrhythmia is always present, commonly appearing aberrations include frequent premature ventricular beats, bradyarrhythmias, paroxysmal atrial tachycardia with block, junctional tachycardia, and bidirectional ventricular tachycardia. Nausea, vomiting and abdominal pain are early manifestations of acute and chronic toxicity. Peak cardiac effects generally occur 3 to 6 hours following digoxin overdosage and may persist for the ensuing 24 hours or longer.

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Because pupillary constriction in response to zopiclone impotence cheap apcalis sx 20mg visa light is a major determinant of pupil size, blindness Table 2. Pupillary constriction or miosis can result from increased cholinergic stimulation, or inhibition of sympathetic dilation. Other ophthalmological manifestations along with their respective causes are mentioned in Table 2. Olfactory clues: Some poisons have distinctive odours which may be perceived in the vicinity of a poisoned patient, especially in the breath. Oral clues: Careful examination of the mouth can afford valuable information about the aetiology of poisoning in some cases (Table 2. Management of toxicological emergencies at different health care levels - a comparative study. As far as treatment is concerned, the emphasis should be on basic supportive measures. Decontamination this is with reference to skin/eye decontamination, gut evacuation and administration of activated charcoal. Poison Elimination Depending on the situation, this can be accomplished by diuresis, peritoneal dialysis, haemodialysis, haemoperfusion, etc. Antidote Administration Unfortunately, antidotes are available for less than 5% of poisonings. Nursing And Psychiatric Care General nursing care is especially important in comatose patients and those who have been incapacitated by the poison. Since some cases of poisoning leave behind persisting sequelae, adequate follow-up for a period of time may be necessary. Normal oxygen delivery requires adequate haemoglobin oxygen saturation, adequate haemoglobin levels, normal oxygen unloading mechanisms, and an adequate cardiac output. Increasing metabolic acidosis in the presence of a normal PaO2 suggests a toxin or condition that either decreases oxygen carrying capacity. The immediate need for assisted ventilation has to be assessed clinically, but the efficiency of ventilation can only be gauged by measuring the blood gases. Some drugs stimulate the respiratory centre: amphetamines, atropine, cocaine, and salicylates. Some drugs are associated with non-cardiogenic pulmonary oedema, characterised by severe hypoxaemia, bilateral infiltrates on chest X-ray, and normal pulmonary capillary wedge pressure (Table 3. Circulation Several drugs produce changes in pulse rate and blood pressure (Table 3. Signs comprise stridor, intercostal and substernal retractions, cyanosis, sweating, and tachypnoea. A practical guide that can be easily applied and is quite reliable is mentioned in Table 3. There are numerous causes for coma of which one of the most important is acute poisoning. A number of substances can induce coma, and it will require a great deal of astuteness and expertise to pinpoint the poison. Before proceeding to an elaborate exercise in diagnosis however, it may be desirable to first ascertain for sure that the patient is really comatose and not just pretending (psychogenic or hysterical coma). This is often encountered in cases of "suicide gesture" in contrast to "attempted suicide". The telltale 2 2 3 3 4 Comatose, reflexes 4 absent, respiratory and/or circulatory failure fluttering eyelids, the patient who is half-walked, half-dragged in by relatives, an elaborate suicide note, a phone call to a friend or relative informing them of the act, pill bottles strewn about, all may point to such a suicide gesture. In addition, the signs and symptoms manifested by the patient usually are out of proportion to the ingestion itself. So the question is, how does the doctor humanely determine whether the coma is true or fake? Several methods have been recommended of which the following constitute barbaric acts and must never be employed: Pinching nipples or genitals, or repeatedly pinching any part of the body. Instead, the following steps are recommended: Perform a quick physical examination with particular attention to the breathing, vital signs, and the gag reflex. Another indication is a tightly clenched jaw when attempts are made to open the mouth.

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Birds consuming some formulated diets or large quantities of fruits and vegetables will produce a loose voluminous feces and more urine than birds on a principally seed diet erectile dysfunction pump generic 20mg apcalis sx with amex. Monkey biscuit and some other formulated diets cause the production of brown feces, while parrots consuming seeds generally have green feces. Neonates fed most standard formulas have soft, semiformed voluminous feces, as do hens the clinician can examine the enclosure and determine what types of foods are offered and which of these foods are actually consumed. Fruits, vegetables and other moist foods can spoil rapidly, promoting the growth of bacteria (particularly Pseudomonas spp. A cuttlebone should be examined for beak marks to determine if it is being consumed by the bird. Excrement that is allowed to accumulate in the bottom of the enclosure, and perches that are dirty or positioned over the food or water containers are hygienically undesirable (see Chapter 1). Vitamins added to the water oxidize quickly (become inactive) and provide an excellent growth media for bacteria and fungi (see Chapter 3). The frequency of defecation and the volume of excrement varies with the species of bird. In general, smaller birds with more rapid metabolic rates will defecate more frequently than larger birds with a slower metabolic rate. A normal budgerigar may produce from 25 to 50 stools per day, while a Blue and Gold Macaw may defecate 8 to 15 times a day (Color 8. A reduced quantity of excrement can be an indication of decreased food intake, a decreased gastrointestinal transit time or a blockage (Color 8. Voluminous droppings may also indicate malabsorption (eg, gastrointestinal disease, pancreatitis, peritonitis or parasites), diabetes or renal tumors (Color 8. For some birds, especially house-trained birds, a voluminous feces is a normal morning dropping. Normal feces are smooth, and some high-fiber formulated diets will cause them to cling together in a tight, gelled cylinder. The presence of undigested food in the feces is not normal and must be differentiated from food that has fallen into the feces. Excreting poorly digested food can be an indication of maldigestion, malabsorption or hypermotility caused by parasites, pancreatitis, proventriculitis, ventriculitis or intestinal disease (Color 8. Loose, watery feces are normal in lorikeets and birds that consume liquid or nectar diets. In psittacine birds, most cases of diarrhea reported by clients are actually polyuria in which the feces are dispersed in an increased volume of urine. Finding bubbles (gas) in the feces is common in birds with true diarrhea (Color 8. Diarrhea can occur with various parasitic, fungal, chlamydial, viral and bacterial infections, systemic diseases and following the administration of some medications. Urine and Urates the kidneys excrete a pasty white-to-yellow urate (produced in the liver) and a sparse, clear, colorless watery urine that can be separated from the urates for analysis. The stress of being transported to the clinic will cause most birds to be polyuric when they are examined by the attending clinician. Idiopathic, reddish-brown urates have been described in some hand-fed babies that seem to be otherwise healthy with normal growth patterns (Color 8. This phenomenon is more common in birds that are receiving an animal protein-based diet, and some cases will resolve when a neonate is switched to a plant protein-based formula. Urine for detailed analysis should be collected from an impervious surface as soon as possible after it is excreted (see Chapter 11). The avian urinalysis should include cytology and determination of the pH, glucose, sediment, color and specific gravity. Uric acid crystals can be dissolved by adding several drops of sodium hydroxide to a urine smear. Urine may be excreted without urates when birds are nervous, polydipsic or consuming fruits and vegetables with a high-water content.

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The neoplastic cells may show varying degrees of cellular features of malignant neoplasia erectile dysfunction vasectomy cheap apcalis sx 20mg otc. There is usually an increase in the number of mitotic figures in samples obtained from lymphoid neoplasia. Cytologic samples of the liver are usually highly cellular with a predominance of hepatocytes, erythrocytes and free nuclei. Depending upon the location of sampling, there may be numerous lymphocytes present. Hepatocytes are large epithelial cells that occur in sheets or clusters or as single cells. These cells have an abundant, basophilic, finely granular cytoplasm and a round-to-oval, slightly eccentric nucleus. Hepatocytes are easily ruptured during slide preparation; therefore, the background of hepatic tissue resembles that of the hepatocyte cytoplasm, and many free nuclei are commonly seen. Normal hematopoiesis is occasionally found because the liver is a common location for ectopic hematopoiesis. An increase in the inflammatory cells and change in the color, clarity, and viscosity of the fluid is indicative of inflammatory joint lesions (see Figure 12. There may be a decrease in the granular eosinophilic background material, suggesting a decrease in mucin content. Erosion of the articular cartilage may result in the presence of multinucleated osteoclasts in the synovial fluid. Spindle-shaped fibroblasts suggest erosion into the fibrous layer of the articular capsule. Septic joint lesions may demonstrate bacterial phagocytosis by leukocytes (primarily heterophils). An increase in the number of inflammatory cells, especially heterophils, is also seen with traumatic arthritis. The presence of erythrocytes and erythrophagocytosis is supportive of a cytodiagnosis of hemarthrosis. Articular gout produces a cream-to-yellow-colored deposit in affected joints (see Color 21). The cytology of this material reveals numerous, needle-shaped crystals (monosodium urate) (Color 10. Inflammatory cells are often present and the mucin content is often reduced, as reflected in the reduction in the amount of eosinophilic granular background. It is important not to confuse normal ectopic granulopoiesis with heterophilic inflammation. If developing stages of the heterophils can be found, the cytology is representative of granulocytopoiesis (see Chapter 9). If the heterophils are mature cells, however, then the cytology indicates inflammation. The hepatocytes may demonstrate degenerative changes in the presence of hepatic inflammation. Avian tuberculosis produces a macrophagic inflammatory response in the liver (see Color 20). When stained with Romanowsky stain, the background of the smear contains numerous large bacterial rods that do not stain. Likewise, macrophages may contain numerous bacterial rods that do not stain (Color 10. Because mycobacterium have a waxy cell wall, they do not stain with routine cytology stains. Therefore, an acidfast stain is required to demonstrate the tubercle bacilli, which stain red (Color 10. However, the presence of a macrophagic inflammation with multinucleated giant cells and "ghost-like" bacterial rods provides a presumptive diagnosis for tuberculosis. Avian chlamydiosis often results in a mixed-cell or macrophagic inflammation in the spleen or liver with a marked increase in the number of plasma cells (Color 10. Small, blue-to-purple, intracytoplasmic inclusions suggestive of chlamydial elementary and initial bodies may be seen in macrophages (Color 10.

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Inhalant nitrites (poppers) have been used widely in the gay community as an orgasm-enhancer and muscle relaxer during sex erectile dysfunction from stress discount apcalis sx 20 mg mastercard. California still allows them to be sold but has a law requiring warning signs to be posted at point of sale. The multimillion dollar popper industry has managed to stay alive by classifying and selling its products as room odorizers, although under such interesting names as Hard Ware, with, for example, this slightly off-key inducement - "Never before has an aroma attracted such attention! It affirmed a policy of no-action against popper companies and offered no suggestions for regulating the nitrite drug-group. I agree that this information should be disseminated and I acknowledge the active role you have played in this effort. We certainly wish to point out that no data exist to indicate that using nitrites is a safe, risk-free practice. No serious attempt, at the federal health level, has been made to warn or advise against nitrites. With reinstatement of the prescription requirement in 1969, non-medicinal street variety volatile nitrites were made commercially available in the form of mixtures of impure butyl and isobutyl nitrite; some of these preparations also included amyl nitrite. These products have been found to be profoundly immunosuppressive for human lymphocytes in vitro, and their byproducts when metabolized into N-nitroso compounds have been known to be highly carcinogenic in many animal species. Publication of this letter in the "Advocate" will serve to alert the community to the health risks of using amyl nitrite. I hope you will see fit to include this information in the news section of the Advocate. Hank Wilson, chairman of the San Francisco-based Committee to Monitor Poppers, then got hold of another letter written to the Advocate by Joseph Miller, president of Great Lakes Products, Inc. Great Lakes manufactures nitrites and markets them through gay publications as room odorizers. Wilson and Lauritsen point out, "In 1981, the Stanford Medical Laboratories tested some samples of different brands of poppers, and found them to contain kerosene, hydrochloric acid, and sulfur dioxide, among other impurities. It is well established that heavy nitrite use has centered in pockets of the gay community, and that its use outside those circles, in such high dose levels, has been relatively rare. One answer is that exposure of the skin to nitrites produces carcinogenic compounds (called nitrosamines). A truer answer is that Kaposi is not really a cancer of the blood vessels at all, that its lesions are the results of blood vessels becoming weak and incompetent. That this incompetency is not a malignancy, but the onset of many lesions in many places, owing to the action of nitrites, which dilate the vessels. This repeated action, under extremely large doses, could cause mechanical breakdown of the blood vessels, which would result in lesions and bleeding. When patients do die of Kaposi itself, which is not often, it is usually the result of internal bleeding from the lesions. For the last year and a half, he has worked as administrator of the Natural Therapies Medical Clinic in Santa Monica, California. Since published studies along this line leave out one or more important factors, the best information at present comes from people like True. You go in different directions: this person did pain pills, that person did heavy antibiotics, another person did recreational drugs in large amounts over a long period of time. It turned out that, in Phoenix, he had a gay lover, and this was known only by his brother, who tried to get him certified and locked up. Difficult to unravel all the facts relevant to illness in this situation, because he is so secretive. Recently admitted a five-year period, in another city, when he was regularly visiting bathhouses. As a bathhouse attendant, he was usually paid in drugs for arranging rooms for customers. Got into the S and M lifestyle on the M side, and because he took so many drugs, he had to engage in more brutal games to feel anything because the drugs were desensitizing his body. A doctor in New Jersey started him on this regimen, which also involved cortisone and hormone creams.

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The extent that the 2 receptor subtype mediate the dysphoric properties of agonists will not be known until 2-selective agonists are developed impotence drugs over counter buy cheap apcalis sx 20 mg line. However, if the 2 receptor does mediate dysphoria during cocaine withdrawal, then selective 2 receptor antagonists may be useful for the treatment of the dysphoria that underlies relapse and perpetuation of cocaine misuse. While an enhancement of serotonin neurotransmission is believed to be inhibitory to the expression of cocaine-mediated behaviors or to have a minimal effect,138,139 there is some evidence that serotonin may play a role in the mood elevating effects of acute cocaine. Furthermore, drugs that antagonize these alterations in serotonergic systems may be efficacious for the treatment of cocaine dependence. From these observations it has been hypothesized that alterations in mesocorticolimbic glutamate transmission may in part contribute to the development of cocaine sensitization. Although this strategy has been somewhat beneficial, the development of an effective treatment for cocaine dependence may require multi-site targeting of distinct neuroreceptor populations that are known to modulate the activity of the drug reward circuit. Cocaine interacts with at least three distinct neurochemical systems in the brain including the dopaminergic, serotonergic, and noradrenergic systems. Cocaine enhances the neurotransmission of each of these systems by blocking the presynaptic reuptake. Chronic perturbations of monoaminergic neurotransmission that results from protracted use of cocaine may, in turn, alter cholinergic and glutamatergic neurotransmission by indirect actions. The ability of cocaine to alter signaling of multiple neurochemical pathways in the brain suggests that a multi-target pharmacotherapy may be an optimal approach for the treatment of cocaine dependence. In drug self-administration studies, ibogaine and related iboga alkaloids reduced intravenous self-administration of cocaine 1 h after treatment. This suppression on cocaine intake was evident one day later, and in some rats a persistent decrease was noted for as long as several weeks. The anti-addictive properties of ibogaine may, in part, be mediated by a pharmacologically active metabolite. Preliminary pharmacokinetic studies have suggested that noribogaine is generated rapidly and exhibits a slow clearance rate. Similar to ibogaine, noribogaine binds to the µ and -1 opioid receptors with micromolar potency. Pharmacotherapies that target one or more of the neurochemical systems that have been altered by protracted cocaine use may alleviate the dysphoria, depression, and anxiety that underlie relapse and compulsive cocaine use. Opposite effects of mu and kappa opiate agonists on dopamine release in the nucleus accumbens and in the dorsal caudate of freely moving rats. Excitatory amino acids and drugs of abuse: a role for N-methyl-Daspartate receptors in drug tolerance, sensitization and physical dependence. Autoregulation and monoamine interactions in the ventral tegmental area in the absence and presence of cocaine: A microdialysis study in freely moving rats. Opposing tonically active endogenous opioid systems modulate the mesolimbic dopaminergic pathway. Alterations in the dopaminergic receptor system after chronic administration of cocaine. Effect of cocaine on dopamine transporter receptors depends on routes of chronic cocaine administration. High affinity cocaine recognition sites on the dopamine transporter are elevated in fatal cocaine overdose victims. Altered dopaminergic synaptic markers in cocaine psychosis and sudden death National Institute of Drug Abuse Research Monograph 153, 491, 1995. A review of the effects of dopaminergic agents on humans, animals, and drug-seeking behavior, and its implications for medication development. High affinity dopamine reuptake inhibitors as potential cocaine antagonists: a strategy for drug development. Delineation of discrete domains for substrate, cocaine, and tricyclic antidepressant interactions using chimeric dopamine-norepinephrine transporters. Chimeric dopamine-norepinephrine transporters delineate structural domains influencing selectivity for catecholamines and 1-methyl-4-phenylpyridinium. Evaluation of the radioimmunoassay for benzoylecgonine (a cocaine metabolite) in human urine. Generation of polyclonal catalytic antibodies against cocaine using transition state analogs of cocaine conjugated to diphtheria toxoid. Synthesis of an immunogenic template for the generation of catalytic antibodies for (-) cocaine hydrolysis. Role of the dopamine receptors in the nucleus accumbens in the rewarding properties of cocaine.


  • Dwarfism deafness retinitis pigmentosa
  • Ichthyosis, erythrokeratolysis hemalis
  • Yim Ebbin syndrome
  • Gonzales Del Angel syndrome
  • Sclerosing bone dysplasia mental retardation
  • Oligodactyly tetramelia postaxial
  • Membranoproliferative glomerulonephritis (type II)

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A special type of organic mercurial poisoning relates to impotence stress generic 20 mg apcalis sx otc food poisoning through methyl mercury which has caused terrible tragedies in the past, and may well cause more havoc in the years to come, unless measures are devised to curb its far reaching effects. Between 1953 and 1970, on the island of Kyushu around Minimata Bay in Japan, more than 2000 people were diagnosed to be suffering from a curious cluster of neurological symptoms comprising paraesthesiae, narrowing of vision, dysarthria, diminution of hearing, amnesia, ataxia, staggering gait, weakness, and emotional instability. Some developed paralysis and became stuporous, and out of all the people afflicted nearly a hundred died. The most severely affected victims were actually infants who had been exposed in utero. In 1964, a similar outbreak of poisoning was reported from another part of Japan: Niigata along the Agano river. Forty three cases were diagnosed as having the Minimata disease out of whom six died. Then came the shocking tragedy in Iraq in 1971­72, when 500 people died out of a total of 6530 victims due to consumption of imported wheat and barley meant for sowing, treated with methyl mercury. Nearly 95,000 tonnes of seed grain treated with methyl mercury was baked into bread. Unlike inorganic mercury compounds, methyl mercury is a subtle, difficult to detect, long lasting poison. When large quantities of industrial waste and agricultural fungicides containing mercury are released Chemical Poisons Fig 9. This biological methylation is accomplished by a deep sea bacterium called methanobacterium omelanskii. When human beings partake of such contaminated fish, the scene is set for a tragedy. In the human body, methyl mercury is bound by haemoglobin and circulates in this form in the bloodstream for several weeks or months. Excretion is very slow and the estimated half life in man is 70 days, while in fish it is 200 days. Blood mercury level: Flameless atomic absorption spectrometry is best for deducing this. Symptoms of toxicity may occur at blood mercury concentrations of 5 mcg/100 ml or greater. Urine mercury level: Urinary mercury is the best biological marker for chronic elemental or inorganic mercury exposure. Urinary mercury concentrations are also useful for assessing the response to chelation therapy. Signs and symptoms of toxicity may begin to occur at urinary mercury concentrations of 20 to 100 mcg/100 ml. Urinary mercury levels, however, often do not correlate with clinical signs and symptoms of toxicity. If the globules are very minute and widely distributed in the intercellular spaces, excise the affected tissue. In death due to acute mercury poisoning, the mucosa of the mouth, throat, oesophagus, and stomach appears greyish in colour with softening and superficial corrosion. If there had been survival for a few days, the large intestine may reveal ulceration. Chapter 9 Forensic Issues Mercury and its compounds constitute important industrial, agricultural, and occupational toxic hazards. In the past when mercury was used in its various forms for the therapy of a wide variety of ailments including syphilis, iatrogenic poisoning was common. Acrodynia resulting from teething powders containing calomel has fortunately become a rarity. The tragic consequences of chronic industrial exposure to mercury have been outlined in the foregoing sections. Such exposure may result from inadvertent mercury spills (broken thermometers), or from home goldore processing. An important area that must be considered in relation to chronic mercury exposure is dentistry.

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This is for the purpose of ascertaining the circumstances in which poisoning occurred erectile dysfunction at age 29 order apcalis sx 20mg without a prescription, and to establish the exact cause and manner of death. The general procedure of examination is the same as for any medicolegal autopsy, with particular attention being paid to those aspects which can afford a clue to the detection of and identification of the poison involved. Putrefactive changes: Some poisons are said to retard the rate of decomposition of a dead body. Injection marks: Especially likely in a victim who had been a drug addict in life. Odour: It is preferable to open the cranial cavity first, since poisons impart a faint odour to the brain which may be difficult to perceive in the presence of overpowering odours from the thorax or abdomen if they have been opened earlier. Examples of such poisons include alcohol, chloroform, cresol, cyanide, and phenol. Evidence of inflammation: Ingested poisons may cause softening, reddening, corrosion, or even perforation of the gastrointestinal tract. Sometimes the poisonous substance in the form of tablets, powder, plant parts, or fluid may still be present. In some cases, there is evidence (gross or microscopic) of degenerative changes or even necrosis. Brain may be congested or oedematous, particularly in the case of neurotoxic poisons. Petechiae in the white matter are often seen with asphyxiant poisons, which also produce pulmonary oedema with consequent froth in the airways. The heart may demonstrate petechiae or degenerative changes in the case of cardiotoxic poisons. Subendocardial haemorrhages are said to be characteristic (though not pathognomonic) of acute arsenic poisoning. There may be evidence of corrosion in the form of discolouration and sloughing especially around the mouth, in caustic ingestion (acid/alkali). Presence of jaundice suggests a hepatotoxic poison, or one which causes haemolytic anaemia. Odour: Several poisons have characteristic odour which may be perceptible in the vicinity of the mouth. Colour of postmortem lividity*: Certain poisons impart characteristic colouration, for example- a. For this purpose, the pathologist conducting the autopsy must collect certain of the viscera and body fluids, Table 4. While submitting the samples for analysis it must be ensured that the correct quantity has been preserved in appropriate preservative in suitable, sealed containers. Sample Collection and Preservation the stomach is cut between double ligatures at the cardiac and pyloric ends, and transferred to a clean tray. The stomach is then placed along with its contents in a clean, wide-mouthed glass bottle of 1 litre capacity. Similarly, the first part of the jejunum is identified and a length of about 30 cm is cut between double ligatures at either end, and transferred to a tray. It is then slit open and placed along with its contents into the same container as the stomach. The liver is removed from the body in the usual manner, and about 500 grams portion is cut and preserved in another container of 1 litre capacity. It is desirable to include the gall bladder, since some drugs are concentrated in the bile, such as paracetamol, barbiturates, and opiates. The liver should always be sliced into pieces before placing it in the container, so that the preservative can exert its action more thoroughly. The kidneys are dissected out of the body and one half of each is sliced and placed in the same container as the liver. Preserving one kidney alone may not be advisable, since it may happen to be dysfunctional.

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They are known as primary epidermal ridges separated by corresponding dermal ridges erectile dysfunction at age 24 order apcalis sx 20mg visa. Loop: Ulnar loop-loop opens on ulnar side Radial loop-loop opens on radial side 2. Whorl: Concentric Spiral­clockwise Spiral ­ anticlockwise Double spiral Almond shape 3. Plain Method: · · In this method, inked fingers are brought in contact with unglazed paper and impressions are taken. Disadvantage of this method is that larger surface area is not obtained for comparison. Disadvantage is that it is somewhat difficult procedure and may blur the prints at places. Rolled Method: · In this method, the fingerprints are taken by rolling the fingers on paper from outward to inward direction without lifting fingers in such a way that an impression of whole tip is obtained. Plastic prints: these are the prints left over soft surface or articles such as soap, wax, clay, cheese etc. Latent prints: · these prints are either invisible or barely visible that were left at scene of crime. For the purpose of matching, pattern of ridge, ridge ending, missing ridge, counting of ridge, ridge breakage, fork formation, delta, island etc. The finger and fingertips of person is usually smeared by sebaceous secretion and sweat. Whenever a person touches any article or material, due to presence of sebaceous secretion, he leaves the impression of fingers over that article or material. Fingerprints at Scene of Crime Fingerprints encountered at a scene of crime are classified as: 1) Visible print 2) Plastic print 3) Latent print Fingerprints in Dead Bodies · Fingerprints are present over dermis and epidermis. If the skin is degloved as in advance decomposition, the skin should be removed, preserved in formalin and impressions can be taken from that degloved skin. Therefore, on basis of this primary classification, 1024 boxes are made and these boxes are called as pigeon holes. Presence of whorl pattern in finger Right thumb or right index finger Right middle or right ring finger Right little or left thumb Left index or left middle finger Left ring or left little finger Fingers with no whorl Score allotted 16 scores 8 scores 4 scores 2 scores 1 score No scores Mutilation or Alteration of Fingerprints · Criminals may at times, tries to hide the identity by destroying the fingerprints by applying burns or corrosive agents. Ridge alteration occurs in eczema, acanthosis nigricans, scleroderma, dry and atrophic skin. Permanent impairment of fingerprint pattern occurs in leprosy, electric injury, and radiation injury. Distance between ridges may change but pattern not change in rickets and acromegaly. In mummified bodies, the fingers are dry and shriveled and therefore prints are not possible. In such condition, the fingertips or skin is immersed in weak alkali solution to make them swell-up and then prints are taken. In primary classification, scores are allocated for presence of whorl pattern in different fingers of hand. At, both numerator and denominator, score 1 is added for convenience of calculation Example: suppose in a person, in all fingers he have whorl pattern, then the score will be as mentioned in Table 3. Thus by presence or absence of whorl Fallacy of using fingerprint50 If there is no reference available, even though fingerprints are available, they will have no use. These pores are opening of the ducts of sweat glands located in sub-epidermal region. These pores are permanent and unchanged during life of a person these pores vary in size, shape, position, extent and number over a given length of ridge in each person. This method is reliable as fingerprints and useful for positive identification this method is particularly useful when only fragment of fingerprint or partial fingerprints are available. In case of shoe prints, there are two type of markings51 Primary markings: these refer to markings about the make of shoes or soles of shoe. Secondary markings: these are the markings that are imparted over sole of shoe by the user and these markings are individualistic. Footprints are the foot patterns left by person at the scene of They are of two types: Bare footprint: these are prints left by barefoot Shoe prints: these are prints left with shoe or chappal (footwear) worn by person.

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As per the judgment erectile dysfunction psychological generic apcalis sx 20 mg without prescription, no doctor can be arrested simply on filling the complaint against him by any patient or relative of the patient. His arrest can only be there if needed for furthering the investigation or for collecting evidence or investigating officer think that doctor may run away to evade arrest. The judgment has given direction for the investigating officer how to proceed in such cases. Before proceeding against doctor, the investigating officer should obtain an independent and competent opinion preferably from a doctor in government service qualified in that branch of medical practice. The doctrine, legally, is a rule of circumstantial evidence that gives rise to an inference of responsibility for an injury or damage. In a negligence case where patient is unable to prove the breach of duty of care by doctor, the doctrine of Res ipsa loquitar may provide help. The doctrine is not an arbitrary rule, but rather, a common-sense appraisal of the probative value of circumstantial evidence. In doctrine of Res ipsa loquitar, the facts of case are sufficient to justify the conclusion that doctor was negligent and negligence of doctor is responsible for the harm suffered by the plaintiff (patient). The doctrine is not applicable ­ if the factors involved are so technical that ordinary layman are not competent to reach a proper conclusion unaided by expert testimony. Similarly, if the injuries/damages are an inherent risk of treatment and where the result, although rare, could have ensued even with the exercise of reasonable medical skill and care. Giving medicine carelessly or prescribing overdose of medicines producing ill effect. To prove Doctrine of Res ipsa loquitar, the following conditions should be satisfied: 1. Doctor had exclusive control of the circumstances or injury producing instruments or treatment. Operation on wrong limb Removal of wrong organ Wrong blood transfusion Leaving instruments in abdomen Performing criminal abortion Differences between civil and criminal negligence are mentioned in Table 2. For example ­ a female brought at term for delivery has to undergo Caesarian Section Forensic Medicine A 26 Principles of Forensic Medicine and Toxicology Table 2. For example ­ suppose an operated patient is shifted to recovery room and suddenly, due to earthquake, ceiling falls over the patient and the patient dies in the accident. A doctor may not be held responsible if damage occurred to patient due to new action, which intervenes in the treatment. For example ­ if a patient with gastroenteritis with dehydration comes to doctor; it is a matter of common sense that the patient requires fluid replacement. Here the plaintiff (patient) need not to show that doctor did not show reasonable degree of care and skill but it is common knowledge that such patient requires fluid therapy. In some individuals, despite giving good medical care and skill, the patient may suffer or does not respond properly to treatment. A Section · Medical Jurisprudence · If the doctor had exercised reasonable degree of care and skill and in spite of this the patient do not respond or medical maloccurence develops; the doctor would not be held responsible. According to this doctrine, a surgeon may be held responsible for the negligence of nurse or any other junior doctor. Therapeutic Misadventure · · Therapeutic misadventure is a mis-chance or accident or disaster, in which an individual may be injured or die due to some unintentional act of doctor or hospital. Experimental ­ where the patient had agreed to serve as subject in an experimental study. A doctor would not be held responsible for harm caused to the patient by adverse reaction by drug provided that doctor had exercised due care. Radiological procedure may prove fatal due to adverse reaction to dye used for contrast, provided that doctor had exercised due care. It is founded on the principle that a duty rests on every man in managing his affairs, whether by himself or by his agents or servants to conduct them so as not to injure/damage others. If he or his subordinate does not conduct the assignment smoothly due to which another is suffering injury/damages, then he shall answer for the damage. The concept is best summarized by the ancient Latin phrase "qui facet peralium, facet per se" i.


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  • https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_SurveillanceVaccinePreventable_16_Pertussis_R1.pdf?ua=1
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