By T. Rathgar. Lenox Institute of Water Technology.

The hymen may be annular (encircling the vaginal opening) cheap cefdinir 300 mg with amex, cres- centic (present at the lateral and posterior margins) cefdinir 300mg without prescription, fimbriated (frilly edged) order cefdinir 300 mg mastercard, or, usually after childbirth, present only as interrupted tags or remnants. It is important that the reader refer to atlases that illustrate these variations (2,92). Uncommon congenital vari- ants include two or more hymenal openings, referred to as septate or cribri- form, respectively, and, rarely, complete absence of an opening (imperforate hymen). Indentations or splits in the hymenal rim have been variously described as deficits, concavities, transections, clefts, notches, and, when clearly of recent origin, tears or lacerations (fresh and healed). In this text, the term notch will be used to describe divisions or splits in the hymenal rim. Super- ficial notches have been defined as notches that are less than or equal to half the width of the hymenal rim at the location of the notch, and deep notches have been defined as notches that are more than half the width of the hyme- nal rim at the location of the notch (93). Superficial notches of all aspects of the hymen have been described in both prepubertal (0–8 years) and postpu- bertal females (9. Deep notches of the anterior and lateral aspects of the hymen have been found in 14 of 200 postpubertal females (9. Deep notches of the posterior hymenal margin have not been described in prepubertal females screened for abuse. Deep notches of the hymenal mar- gin have been described among postpubertal females who deny having sexual activity, although because these females were not screened for abuse, it is not possible to state whether these were the result of unreported sexual abuse. The other pertinent anatomic landmarks in this area are the posterior fourchette (where the labia minora unite posteriorly), the fossa navicularis (a relatively concave area of the vestibule bounded anteriorly by the vaginal open- ing, posteriorly by the posterior fourchette, and laterally by the labia minora), and the anterior fourchette (where the labia minora meet anteriorly and form the clitoral hood). The skin of the labia majora and the outer aspects of the labia minora is keratinized squamous epithelium, but only the outer aspects of the labia majora are hair bearing. The skin of the inner aspects of the labia minora and the vesti- bule (including the hymen) is nonkeratinized. This area is usually pink, but in 86 Rogers and Newton the nonestrogenized child, it may appear red because the skin is thinner and consequently the blood vessels beneath its surface are more apparent (97). The forensically relevant areas of the internal female genitalia are the vagina and the cervix. The pertinent landmarks are the vaginal fornices (ante- rior, posterior, right, and left) and the cervical os (opening of the cervical canal). The vagina and cervix are covered by nonkeratinized squamous epithe- lium that normally appears pink in the estrogenized female. Occasionally, the columnar endocervical epithelium, which appears red, may be visible around the cervical os because of physiological or iatrogenic (e. Development The female hypothalamic–pituitary–gonadal axis is developed at the time of birth. The estrogen causes prominence of the labia and clitoris and thickening and redundancy of the hymen. During this period, the external genitalia gradually become less prominent; eventually, the hymen becomes thin and translucent and the tissues appear atrophic; occasionally, the hymen remains thick and fimbriated throughout childhood. The hypothalamic–pituitary–gonadal axis is reactivated in late childhood, and the breasts and external genitalia alter accordingly. This endogenous lubrication is enhanced with ovulation and with sexual stimu- lation (102). When the endogenous estrogen levels fall resulting from meno- pause, the vulva and vagina atrophy. Forensic Evidence Although legally it is not necessary to have evidence of ejaculation to prove that vaginal intercourse has occurred, forensic science laboratories are frequently requested to determine whether semen is present on the swabs taken Sexual Assualt Examination 87 from the female genitalia because semen evidence can play a central role in identification of the assailant. The female genitalia should also be sampled if a condom was used during the sexual act (see Heading 11) and if cunnilingus is alleged to have occurred (see Heading 7). It is also important to sample the vagina, vulva, and perineum separately when only anal intercourse is alleged to exclude the possibility of leakage from the vagina to account for semen in the anal canal (see Heading 10). Method of Sampling The scientist is able to provide objective evidence in terms of the quan- tity (determined crudely) and quality of the spermatozoa present and may be asked to interpret the results in the context of the case. When providing expert evidence regarding whether vaginal penetration has occurred, the scientist must be able to rely on the forensic practitioner to obtain the samples in a manner that will refute any later suggestions by the defense that significant quantities of spermatozoa, which were only deposited on the outside of the vulva, could have been accidentally transferred to the high vaginal area during the medical examination (7). It is worth noting that there has been no research to support or refute this hypothesis. Currently, there is no internationally agreed method for obtaining the samples from the female genital area. The following method has (October 2003) been formulated by experienced forensic practitioners and forensic scientists in England to maximize the recovery of spermatozoa while considering these po- tential problems: 1. Any external (sanitary napkins or pads) or internal (tampons) sanitary wear is collected and submitted for analysis with a note about whether the item was in place during the sexual act and whether other sanitary wear has been in place but discarded since the incident. Even though traditionally these swabs have been labeled “external vaginal swab,” they should be labeled as “vulval swab” to clearly indicate the site of sampling. However, if the vulval area or any visible staining appears dry, the double-swab technique should be used (28) (see Subheading 4. The labia are then separated, and two sequential dry swabs are used to compre- hensively sample the lower vagina. An appropriately sized transparent speculum is then gently passed approximately two-thirds of the way into the vagina; the speculum is opened, and any foreign bodies (e. Then, 88 Rogers and Newton two dry swabs are used to comprehensively sample the vagina beyond the end of the speculum (particularly the posterior fornix where any fluid may collect).

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List of titles are in accordance with the current textbook buy cheap cefdinir 300 mg on-line, and are shown on the noticeboard in front of the lecture hall cheap 300 mg cefdinir visa. Information on the practical part of the exam will be spread out during the semester purchase 300 mg cefdinir. Proof of completion of block practical is a requirement to take part in the second semester test. If the student decides not to accept the offered grade, the above described oral exam can be taken as exam “A”. Methods of conservative and operative treatment of physical examinations of different joints (hip, knee, ankle, congenital/developmental dysplasia, dislocation of the hip foot). Examination of Lecture: Bone tumours and tumour - like lesions patients by students and discussion. Basic physiotherapy Requirements Participation at practicals and compensation for absences from practicals and the requirements of signatures in lecture- books in orthopaedic surgery are not different from the general rules. Besides the textbook and the recommended book the material of lectures is included in the questions of the final examination. The students pick two titles, from the title list available at the beginning of the Semester. Students who attended at least 70 % of the lectures have to answer one title only. Year, Semester: 4th year/2nd semester Number of teaching hours: Lecture: 50 Seminar: 20 1st week: Antiepileptics and sedatohypnotics. Lecture: Centrally and peripherally acting skeletal muscle Seminar: Repetition of the pharmacology of the relaxants. Agents that affect bone Lecture: Chloramphenicol, tetracyclines, mineral homeostasis. Parathyroid Requirements Prerequisites: Pharmacology I Attendance at lectures is highly recommended, since the topics in examination cover the lectured topics. Please, ensure that your lecture book has been submitted to the Department for signing within 1 week after finishing the semester. At the end of the 2nd semester the students are required to take the Final Examination (written and oral), based on the material taught in the two semesters. To know the groups of drugs with examples in all of the chapters in pharmacology is compulsory. If one question is remained properly unanswered from the three titles the student is not allowed to pass. If lethal dose, not proper or ineffective treatment is discussed the student have to be failed. Year, Semester: 4th year/2nd semester Number of teaching hours: Lecture: 30 Seminar: 20 Practical: 15 1st week: 2nd week: Lecture: 1. Epidemiology of hepatitis Epidemiology of sexually transmitted diseases Seminar: 3. Control of nosocomial infections (visit) Prioritizing using public health database 4th week: 8th week: Lecture: 10. Environment and health: the effects of socio- diseases: facts and theories in preventive medicine 12. Introduction to the epidemiology of non-communicable Methods of financing health services26. Organization of public health gastrointestinal and liver diseases services Seminar: 9. Interpretation of public health databases (exam) all seminar teachers are preparig the exam sheets 6th week: Lecture: 16. Major challenges education techniques of preventive medicine and public health 7th week: Lecture: 19. Health status in developing and developed Requirements Requirements for signing the Lecture book: Attendance of Lectures is highly recommended. The slides of lectures can be downloaded from our website () Attendance of group seminars, visits and laboratory practices is obligatory. The head of the department may refuse to sign the Lecture Book if a student is absent more than two times from practices or seminars in a semester even if he/she has an acceptable excuse. The absences at seminars should be made up for with another group, at another time. Requirements for the final exam: The final exam (at the end of the second semester) consists of a written part and an oral exam (practical exam). The oral exam will cover the topics of all laboratory practices and seminars of the full academic year. The final mark of the practical exam is the average of the mark given for the interpretation of public health databases (week 9) and the mark obtained for the oral exam. The written exam will be accomplished by computer based test that covers the topics of all Lectures and group seminars of the full academic year. It is composed of three parts: environmental health, epidemiology and health policy (the three parts will be evaluated separately). The mark of the final exam will be calculated on the basis of the average of the mark given for the practical exam and for the written exam. The final exam will be failed if either the practical or any part of the written exam is graded unsatisfactory. The mark of the final exam will be calculated on the basis of the average of the repeated part and the previous parts of the exam. Requirements The rules written in the statue of the Organization and Operation of Medical University of Debrecen will be applied. In case of absence the student must compensate on the same week with another student’s group or should ask the tutor. The Head of the Department may refuse to sign the Lecture Book if a student is absent more than twice from practices in a semester.

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Harm Minimization Information and advice should be given to the detainee by the physician on reducing the harm from continued drug misuse purchase cefdinir 300 mg free shipping. Substance misusers who inject may have experienced a broken needle at some time in their injecting career (7) buy generic cefdinir 300 mg on-line. Central embolization may occur within a few hours up to several days purchase 300 mg cefdinir otc, and this can lead to potentially fatal conse- quences, including pericarditis, endocarditis, and pulmonary abscesses. Needle fragments must be removed as soon as possible to avoid future complications. This may be done by the users themselves or necessitate attendance at the accident and emergency department. Brief interventions, whereby it is possible to provide advice about the risks inherent in a range of patterns of substance use and to advise reducing or stopping use as part of screening and assessment, are useful with alcohol con- sumption (8). A person’s motivation to change is important in determining the likelihood of success of any intervention (9), and such motivation may alter depending on a variety of factors. For example, negative life events, such as being arrested for an acquisitive crime motivated by a need to finance a drug habit, can introduce conflict in the detainee’s mind about substance misuse and may increase the likelihood of successful intervention. Arrest referral schemes are partnership initiatives set up to encourage drug misusers brought into contact with the police service to voluntarily participate in confidential help designed to address their drug-related prob- lems. Early evaluation of such projects in the United Kingdom provides good evidence that such schemes can be effective in reducing drug use and drug- related crime (10). In the United States, it has also been recognized that 288 Stark and Norfolk point of arrest is an appropriate stage of intervention for addressing sub- stance misuse (1). Most individuals are not detained in police custody for long, and, therefore, medical treatment may not be required. This is particularly so if there is any question that the detainee may have recently ingested substances, the full effects of which may not as yet be obvious. Reassessment after a specific period should be recom- mended, depending on the history given by the detainee and the examination findings. It is good practice for all new substitute opiate prescriptions to be taken initially under daily supervision (11). In the custodial situation, if the detainee is on a super- vised therapy program, one can be reasonably sure the detainee is dependent on that dose; the detainee may of course be using other illicit substances as well. Recent urine test results may be checked with the clinic to see whether methadone or other drugs are detected on screening. Particularly with opiate substitution treatment, in the absence of with- drawal signs, confirmation of such treatment should be sought before autho- rizing continuation. The prescribed dose of opiate substitution therapy may not necessarily indicate accurately the actual amount taken each day if not supervised, because part or all of the dose may be given to other individuals. It should be remembered that giving even a small amount of opiates to a nondependent individual may be fatal. Cocaine abuse accelerates the elimina- tion of methadone; therefore, higher doses of methadone must be prescribed to individuals on maintenance regimes who continue to abuse cocaine (12). Any decision to prescribe should be made on the assessment of objective signs as opposed to subjective symptoms, and a detailed record of the history and examination should be made contemporaneously. Good practice dictates that where treatment can be verified, it should be continued as long as it is clinically safe to do so. Medical Complications of Substance Misuse Medical complications of substance misuse may give an indication of a problem in the absence of acute symptoms or signs of intoxication. Intrave- nous injection may result in superficial thrombophlebitis, deep vein thrombo- sis, and pulmonary embolus and chronic complications of limb swelling and venous ulcers. If injection occurs accidentally into an artery, vascular spasm may occur and result in ischemia, which, if prolonged, can lead to gangrene and amputation. Cellulitis and abscesses may be seen around injection sites, and deep abscesses may extend into joints, producing septic arthritis. Skin manifestations of drug addiction may be seen more commonly in opiate rather than stimulant users, even though stimulant users inject more frequently (14). This is partly because stimulants do not cause histamine release and, therefore, are seldom associated with pruritus and excoriations and also because cutaneous complications are frequently caused by the adulter- ants injected along with the opiates, rather than the drugs themselves. Fresh puncture sites, tattoos used to cover needle tracks, keloid formation, track marks from chronic inflammation, ulcerated areas and skin popping resulting in atro- phic scars, hyperpigmentation at sites of healed abscess, puffy hands (lymphe- dema with obliteration of anatomic landmarks and pitting edema absent), and histamine-related urticaria (opiates act on mast cells resulting in histamine release) may be seen. Opiate Intoxication and Withdrawal The characteristics of the medical syndromes in opiate intoxication, over- dose, and withdrawal are given in Table 4. Opiates, such as heroin, may be taken orally, more usually injected, or smoked—chasing the dragon. Chronic administration of opiate drugs results in tolerance (Table 5) to effects such as euphoria mediated by the opiate receptors and to the effects on the autonomic nervous system mediated by the noradrenergic pathways. Tolerance to heroin can develop within 2 weeks of commencing daily heroin use, occurs more slowly with methadone, and may go as quickly as it devel- ops. With abrupt withdrawal of opiates, there is a “noradrenergic storm,” which is responsible for many of the opiate withdrawal symptoms (Table 6). Cyclizine may be taken intravenously in large doses with opiates, because it is reported to enhance or prolong opioid effects, also resulting in intense stimulation, hallucinations, and seizures; tolerance and dependence on cyclizine may also result (17). Many opiate users are also dependent on ben- zodiazepines, and concurrent benzodiazepine withdrawal may increase the severity of opiate withdrawal (18). Substance Misuse 291 Table 4 Medical Syndromes in Heroin Users Syndrome (onset and duration) Characteristics Opiate intoxication Conscious, sedated “nodding”; mood normal to euphoric; pinpoint pupils Acute overdose Unconscious; pinpoint pupils; slow shallow respirations Opiate withdrawal • Anticipatory 3–4 h after Fear of withdrawal, anxiety, drug-craving, drug-seeking the last fix (as acute behavior effects of heroin subside) • Early 8-10 h after Anxiety, restlessness, yawning, nausea, sweating, nasal last fix stuffiness, rhinorrhea, lacrimation, dilated pupils, stomach cramps, increased bowel sounds, drug-seeking behavior • Fully developed 1-3 d Severe anxiety, tremor, restlessness, pilo-erection (cold- after last fix turkey), vomiting, diarrhea, muscle spasms (kicking the habit), muscle pain, increased blood pressure, tachycar- dia, fever, chills, impulse-driven drug-seeking behavior • Protracted abstinence Hypotension, bradycardia, insomnia, loss of energy and appetite, stimulus-driven opiate cravings From ref. Treatment of Opiate Withdrawal Symptomatic treatment of the opiate withdrawal syndrome can often be achieved using a combination of drugs, such as benzodiazepines for anxiety and insomnia; loperamide or diphenoxylate and atropine for diarrhea; promet- hazine, which has antiemetic and sedative properties; and paracetamol or non- steroidal antiinflammatories for generalized aches. Substitution treatment may be required in more severe cases of opiate dependence using a choice of methadone, buprenorphine, or dihydrocodeine. Because street heroin varies in purity, the starting dose cannot be accurately estimated on the basis of the amount of street drug used.