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Rawson generic atorlip-5 5mg free shipping cholesterol levels for age, the state’s expert buy atorlip-5 5mg low cost cholesterol guidelines 2014, prior to the second trial and asked him to reconsider his opinion cheap atorlip-5 5mg with mastercard cholesterol levels uk nhs, Dr buy generic atorlip-5 5 mg line cholesterol test exercise. When confronted, he obliquely confessed to the crime, reportedly stating that he only remembered strug- gling with the victim then awakening the next morning with blood on his 324 Forensic dentistry Figure 14. Piakis subsequently had the opportunity of compare Phillips’s dentition to the bitemark and stated that Phillips’s teeth were more consistent with the bitemark than Krone’s. Bitemarks 325 Te case of Ray Krone is a tragic indictment of law enforcement and legal prosecution practices and of the faulty application of bitemark analysis. Tis activity included overstating and overdramatizing the results of tests and experiments and failure to follow accepted guidelines by not seeking second opinions and disregarding or discounting the unsolicited opinions received. Te homicide detectives failed to thoroughly investigate and follow all leads, and the prosecutors exhibited tunnel vision and willingness to shop for expert opinions that supported their theory of the crime. During an inter- view by a prosecutor before the retrial, one defense odontologist remarked, “I hope you have other important evidence … the bitemark evidence is bad” and was bluntly told, “Doctor, this is a bitemark case and has always been a bitemark case. Tis triumvirate committed errors that compounded to produce a gross miscarriage of justice. Tis case is described in detail in a book authored by Jim Rix, Ray Krone’s cousin and the sponsor of his defense. One or more second opinions from other competent forensic odontologists should be sought and considered. Te Supreme Court of Michigan ruled that that type of testimony was inadmissible afer several cases in that state in which bitemarks were associated to a suspect with statements of mathematical degrees of certainty. Te 1991 case of the kidnapping, assault, and rape of Maureen Fournier featured the victim’s eyewitness identifcation of the fve men who participated in the attack and the two who allegedly bit her. Both Michael Cristini and Jefrey Moldowan were convicted based on the victim’s identifcations and two forensic odontologists’ testimony that the bitemark associations were posi- tive. Allan Warnick, testifed that one of the marks was made by Moldowan and the odds that someone else made the mark were 3 million to one. In another case he testifed that “the chances of someone else having made the mark would be 4. Homer Campbell and Richard Souviron independently reviewed the evidence and reported that, in their opinion, Moldowan and Cristini could be excluded. Te court ruled that no testimony regarding mathematical degrees of certainty for bitemarks would be heard. Berman, testifed that Cristini made the bitemark with a high degree of certainty, and the defense expert, Dr. In an unusual twist in this trial, one of the original odontologists for the prosecution in the frst trial in 1991, Dr. Hammel, took the stand for the defense and testifed that she had erred in the original trial. She stated further that she originally had doubts about the orientation of the bitemark, and afer gaining more experience and reviewing the evidence, she realized her error. It took a great deal of courage for her to admit the error, but it was absolutely the right thing to do. Cristini had been arrested and charged with eight counts of frst-degree criminal sexual conduct allegedly involving a fve-year-old child. First, that eyewitness testimony may or may not be accurate—here the victim may have been wrong about the identity of the biters. She accused others that were later proven to be else- where at the time of the crime. Second, there is no scientifc basis for math- ematical degree of certainty with bitemark evidence on skin. Tird, unlike in other cases, one of the experts had the courage to take the stand and admit an earlier error. In the above detailed problem cases there was agreement among both the defense and the prosecution experts that these were indeed human bite- marks. Te disagreements were related to features and orientation of the bitemarks and to who could have or who could not have inficted the bites. Te problems were compounded in some cases by the use of mathematical degrees of certainty or overreaching statements of the value and certainty of bitemark evidence. Te most recent and highly publicized of Bitemarks 327 these cases is that of Kennedy Brewer in Mississippi. Brewer was convicted in 1995 of the murder and sexual assault of Christine Jackson. Te body of the three-year-old victim had been found in a nearby creek on a Tuesday morn- ing, the third day afer her Saturday night disappearance. Michael West, 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.
One case involved a student athlete accused of cheating on an exam atorlip-5 5mg mastercard cholesterol test fasting coffee, one case involved a Hispanic student who allegedly physically attacked his roommate purchase atorlip-5 5 mg with visa cholesterol in eggs and cheese, and a third case involved an African American student who had been accused of selling illegal drugs purchase 5mg atorlip-5 otc cholesterol levels as you age. Each of these offenses had been judged via pretesting in the same student population to be stereotypically (although buy atorlip-5 5 mg overnight delivery cholesterol in eyes, of course, unfairly) associated with each social group. The research participants were also provided with some specific evidence about the case that made it ambiguous whether the person had actually committed the crime, and then asked to indicate the likelihood of the student‘s guilt on an 11-point scale (0 = extremely unlikely to 10 = extremely likely). Participants also completed a measure designed to assess their circadian rhythms—whether they were more active and alert in the morning (Morning types) or in the evening (Evening types). The participants were then tested at experimental sessions held either in the morning (9 a. Morning people used their stereotypes more when they were tested in the evening, and evening people used their stereotypes more when they were tested in the morning. Sleep researchers have found that sleeping people undergo a fairly consistent pattern of sleep stages, each lasting about 90 minutes. During this sleep stage our muscles shut down, and this is probably a good thing as it protects us from hurting ourselves or trying to act out the scenes that are playing in our dreams. Each of the sleep stages has its own distinct pattern of brain [4] activity (Dement & Kleitman, 1957). When we are awake, our brain activity is characterized by the presence of very fast beta waves. When we first begin to fall asleep, the waves get longer (alpha waves), and as we move into stage N1 sleep, which is characterized by the experience of drowsiness, the brain begins to produce even slower theta waves. During stage N1 sleep, some muscle tone is lost, as well as most awareness of the environment. Some people may experience sudden jerks or twitches and even vivid hallucinations during this initial stage of sleep. Normally, if we are allowed to keep sleeping, we will move from stage N1 to stage N2 sleep. During stage N2, muscular activity is further decreased and conscious awareness of the environment is lost. This stage typically represents about half of the total sleep time in normal adults. Stage N2 sleep is characterized by theta waves interspersed with bursts of rapid brain activity known as sleep spindles. Stage N3, also known as slow wave sleep, is the deepest level of sleep, characterized by an increased proportion of very slow delta waves. This is the stage in which most sleep abnormalities, such as sleepwalking, sleeptalking, nightmares, and bed-wetting occur. Some skeletal muscle tone remains, making it possible for affected individuals to rise from their beds and engage in sometimes very complex behaviors, but consciousness is distant. If smoke enters the room or if we hear the cry of a baby we are likely to react, even though we are sound asleep. These occurrences again demonstrate the extent to which we process information outside consciousness. Eventually, as the sleep cycle finishes, the brain resumes its faster alpha and beta waves and we awake, normally refreshed. Sleep Disorders: Problems in Sleeping [5] According to a recent poll (National Sleep Foundation, 2009), about one-fourth of American adults say they get a good night‘s sleep only a few nights a month or less. These people are suffering from a sleep disorder known asinsomnia, defined as persistent difficulty falling or staying asleep. Most cases of insomnia are temporary, lasting from a few days to several weeks, but in some cases insomnia can last for years. Insomnia can result from physical disorders such as pain due to injury or illness, or from psychological problems such as stress, financial worries, or relationship difficulties. Changes in sleep patterns, such as jet lag, changes in work shift, or even the movement to or from daylight savings time can produce insomnia. Sometimes the sleep that the insomniac does get is disturbed and nonrestorative, and the lack of quality sleep produces impairment of functioning during the day. Ironically, the problem may be compounded by people’s anxiety over insomnia itself: Their fear of being unable to sleep may wind up keeping them awake. Barbiturates, benzodiazepines, and other sedatives are frequently marketed and prescribed as sleep aids, but they may interrupt the natural stages of the sleep cycle, and in the end are likely to do more harm than good. Most practitioners of sleep medicine today recommend making environmental and scheduling changes first, followed by therapy for underlying problems, with pharmacological remedies used only as a last resort. Another common sleep problem is sleep apnea, a sleep disorder characterized by pauses in breathing that last at least 10 seconds during sleep(Morgenthaler, Kagramanov, Hanak, & [6] Decker, 2006). In addition to preventing restorative sleep, sleep apnea can also cause high [7] blood pressure and may raise the risk of stroke and heart attack (Yaggi et al. Most sleep apnea is caused by an obstruction of the walls of the throat that occurs when we fall asleep. It is most common in obese or older individuals who have lost muscle tone and is particularly common in men. Sleep apnea caused by obstructions is usually treated with an air machine that uses a mask to create a continuous pressure that prevents the airway from Attributed to Charles Stangor Saylor. If all other treatments have failed, sleep apnea may be treated with surgery to open the airway. Narcolepsy is a disorder characterized by extreme daytime sleepiness with frequent episodes of “nodding off. It is estimated that at least 200,000 Americans suffer from narcolepsy, although only about a quarter of these people [8] have been diagnosed (National Heart, Lung, and Blood Institute, 2008). Narcolepsy is in part the result of genetics—people who suffer from the disease lack [9] neurotransmitters that are important in keeping us alert (Taheri, Zeitzer, & Mignot, 2002) — and is also the result of a lack of deep sleep. Narcolepsy can be treated with stimulants, such as amphetamines, to counteract the daytime sleepiness, or with antidepressants to treat a presumed underlying depression. However, since these drugs further disrupt already-abnormal sleep cycles, these approaches may, in the long run, make the problem worse. Many sufferers find relief by taking a number of planned short naps during the day, and some individuals may find it easier to work in jobs that allow them to sleep during the day and work at night. Other sleep disorders occur when cognitive or motor processes that should be turned off or reduced in magnitude during sleep operate at higher than normal levels (Mahowald & Schenck, [10] 2000). One example is somnamulism(sleepwalking), in which the person leaves the bed and moves around while still asleep. Sleepwalking is more common in childhood, with the most frequent occurrences around the age of 12 years. In extreme cases, sleep terrors may result in bodily harm or property damage as the sufferer moves about abruptly.
Syndromes
- Can you eat, dress, and perform other everyday activities?
- Removal of the entire colon and the rectum is called a proctocolectomy.
- Allergies
- Hormone problems, such as too much testosterone, or too much or too little thyroid hormone
- Has your child recently been sick?
- Eye exam every year during infancy
The injuries may be of varied types discount atorlip-5 5 mg without prescription cholesterol medication options, including incised discount 5 mg atorlip-5 free shipping cholesterol and triglycerides, where the cutting edge runs tangentially to the skin surface cutting through skin and deeper anatomical structures 5mg atorlip-5 amex how do cholesterol lowering foods work, or stab cheap atorlip-5 5 mg amex cholesterol reduced eggs, where the sharp edge penetrates the skin into deeper structures. An incised wound is generally longer than it is deep, whereas a stab wound is generally deeper than it is wide. Forces required to cause sharp injuries and the effect of such injuries are variable because a sharp pointed object may penetrate vital structures with minimal force. Special types of cutting injuries included slash- or chop-type injuries from weapons such as machetes. Many impacts may cause initial pain and discomfort, which resolves within a few minutes, and tenderness, which may still be elicited hours or days later, with no visible sign of injury. The lay person must be aware that the absence of visible injury does not imply that no assault or injury has occurred. Wheals and erythema are also nonpermanent evidence of trauma caused by initial vasodilatation and local release of vasoactive peptides after an injury, such as a slap, scratch, or punch, which will leave no mark after a few hours. The classic features of the triple reaction are present, but no spe- cific damage is done to any tissues. Thus, an initial reddening associated with pain with possible subsequent development of local swelling may be present initially, but after a few hours has completely resolved, unlike bruis- ing, which will still be present after 24 hours or more. Size and Shape of the Injury Even though the size of an injury is perhaps the easiest measurement to ascertain, it is probably the most common omission from medical records. It should be ascertained using a ruler or a pair of calipers and recorded in centi- meters or millimeters. Because measurements given in imperial units may be easier for some individuals to understand, it is also acceptable to include the equivalent size of an injury in inches. The shape of the wound should also be noted; simple terms, such as circular, triangular, V-shaped, or crescent-shaped, best express this characteristic, but if the wound shape is irregular or complex, then it is possibly easier to record this feature on a body chart. Wounds may also have depth, but it is often not possible to determine this accurately in the living. Position of the Injury The best method of pinpointing the location of an injury is to use fixed anatomical landmarks. On the head, one can use the eyes, ears, nose, and mouth; on the neck, the prominence of the thyroid cartilage and the sternocleidomas- toid muscles can be used; and on the trunk, the nipples, umbilicus, and bony prominences can be used as points of reference. The advantages of using simple anatomical diagrams and body charts for locating the injury are self-evident. It is a simple process to record the position of an injury accurately, yet when medical records are reviewed, it is both surprising and disappointing to find only a vague indication of location. Aging Injuries Allotting a specific time or time frame to the infliction of an injury is one of the most frequently requested and most contentious of issues in foren- sic medicine. Injuries inflicted shortly before examination (both of the living and the dead) show no sign of healing. The healing process depends on sev- eral variables, including the site of injury, the force applied, the severity of tissue damage, infection, treatment, etc. Bruises often become more prominent a few hours or even days after infliction because of diffusion of blood closer to the skin surface; on occasion, a recent deep bruise may be mistaken for an older, more superficial lesion. Bruises resolve over a variable period ranging from days to weeks; the larger the bruise, the longer it will take to disappear. The colors of a bruise can include (dependent on the exam- iner) blue, mauve, purple, brown, green, and yellow, and all tints and hues associated with these. Thus, coloration of bruises and the progress and change of color patterns cannot, with the exception of a yellow bruise, which may be considered to be more than 18 hours old, be used to time the injury. It should be emphasized that estimation of bruise age from color photographs is also imprecise and should not be relied on because the color values are not accu- rate (6). This has recently been confirmed in another study (7) that identified great interobserver variability in color matching both in vivo and in photo- graphic reproductions. Abrasions sustained during life are usually red-brown and exude serum and blood, which hardens to form a scab. This scab organizes over a period of days before detaching to leave a pink, usually intact, surface. In the absence of medical intervention, lacerations tend to heal with scar- ring, usually over a period of days or weeks, whereas incisions, the edges of which may be apposed, can heal within a few days, although some may scar significantly. Transient Lesions Swelling, redness, and tenderness, although frequently caused by trauma, are not specific signs of injury. Although it is important to record whether these features are present, it must be remembered that there also may be nontraumatic causes for these lesions (e. Red marks outlining an apparent injury, for example, the imprint of a hand on the slapped face or buttock of a child, should be photographed immediately because such images may fade within an hour or so and leave no residual marks. Bruises The terms contusion and ecchymosis have been used to differentiate between different types of injury that can more simplistically be called bruis- ing. These terms have been used variously to describe different injury sizes but do not enhance understanding of either causation or mechanism of injury and should no longer be used. A hematoma is best used to refer to a collection of blood forming a fluctuant mass under the skin and may be associated with substantial trauma. The difference between that and a standard bruise is that a hematoma may be capable of being aspirated in the same way a collection of Injury Assessment 135 Fig. Bruising is caused when an impact damages blood vessels so that blood leaks into the perivascular tissues and is evident on the skin surface as discoloration. Such discoloration changes in color, shape, and location as the blood pigment is broken down and resorbed. In some cases, although blood vessels may be damaged, there may be no visible evidence on the skin. In certain cases, it may take hours or days for any bruise to become apparent because the blood diffuses through damaged tissue. The blunt force ruptures small blood vessels beneath the intact skin, and blood then escapes to infil- trate the surrounding subcutaneous tissues under the pumping action of the heart (see Fig. In fact, severe blows inflicted after death may cause some degree of bruising, although this is usually only slight. Bruises may be associated with other visible evidence of injury, such as abrasions and lacerations, and these lesions may obscure the underlying bruise. Bruising may need to be differentiated from purpura, which develop spon- taneously in those with a hemorrhagic tendency and in the elderly and tend to be rather blotchy, are less regular in outline, and are usually confined to the forearms and lower legs. Bruises vary in severity according to the site and nature of the tissue struck, even when the force of the impact is the same. Where there is an underlying bony surface and the tissues are lax, as in the facial area, a relatively light blow may produce considerable puffy bruising. Bruises can enlarge over a variable period of time, which can be mis- leading regarding the actual site of injury. Because a bruise is a simple mechan- ical permeation of the tissues by blood, its extension may be affected by movement and gravity.
