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Joint effusion and other radiographic features of osteoarthritis in weight-bearing articular signs of infammation are mild 5 medications that affect heart rate best primaquine 15 mg. Sex is also a risk fac to treatment centers of america order cheap primaquine on-line r; osteoarthritis develops in women more frequently than in men treatment regimen order primaquine 15 mg visa. Labora to treatment associates purchase primaquine toronto ry Findings this arthropathy is characterized by degeneration of cartilage and by hypertrophy of bone at the articular mar Osteoarthritis does not cause elevation of the erythrocyte gins. Prevention Radiographs may reveal narrowing of the joint space; Weight reduction reduces the risk of developing symp to m osteophyte formation and lipping of marginal bone; and atic knee osteoarthritis. Bone cysts may also be of greater than 1 em with shoe modifcation may prevent present. Differential Diagnosis occurrence and progression of osteoarthritis, in addition to being important for bone health. Because articular infammation is minimal and systemic manifestations are absent, degenerative joint disease should seldom be confused with other arthritides. Furthermore, thejoint enlargement is bony-hard and osteoarthritis of the frst carpometacarpal joint. Patients with cool in osteoarthritis but spongy and warm in rheuma to id mild to moderate osteoarthritis of the knee or hip should arthritis. Skeletal symp to ms due to degenerative changes in participate in a regular exercise program (eg, a supervised joints-especially in the spine-may cause coexistent meta walking program, hydrotherapy classes) and, if overweight, static neoplasia, osteoporosis, multiple myeloma, or other should lose weight. Acetaminophen-First-line therapy for patients with mild osteoarthritis is acetaminophen (2. Although prostaglandins play important roles in promoting infammation and pain, they also help main tain homeostasis in several organs-especially the s to m ach, where prostaglandin E serves as a local hormone responsible for gastric mucosal cy to protection. Pro to n pump inhibi to rs (eg, omeprazole 20 mg orally daily) reduce the incidence of serious gastrointesti C. Prognosis celecoxib maybe less likely in some circumstances to cause upper gastrointestinal tract adverse events. When to Refer produce renal to xicity, including interstitial nephritis, Refer patients to an orthopedic surgeon when recalcitrant nephrotic syndrome, prerenal azotemia, and aggravation of symp to ms or functional impairment, or both, warrant con hypertension. Hyperkalemia due to hyporeninemic sideration ofjoint replacement surgery of the hip or knee. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and ascites; and diuretic use. Effect of physical therapy onpain and function without risk fac to rs for heart disease or known heart dis in patients with hip osteoarthritis: a randomized clinical trial. Identification of urate crystals in joint fluid or the hand but is not recommended for osteoarthritis of the to phi is diagnostic. With chronicity, urate deposits in subcutaneous bination, are no better than placebo in reducing pain in tissue, bone, cartilage, joints, and other tissues. General Considerations demonstrated in the synovial tissues (and fuid) during acute arthritis; indeed, the acute infammation of gout is Gout is a metabolic disease of a heterogeneous nature, believed to be initiated by the ingestion of uncoated urate often familial, associated with abnormal deposits of urate crystals by monocytes and synoviocytes. Urate deposition occurs when serum release a variety of chemotactic agents and cy to kines uric acid is supersaturated (ie, at levels greater than 6. Hyperuricemia is due to overpro ship of hyperuricemia to gouty arthritis is still obscure, duction or underexcretion of uric acid-sometimes both. Primary gout has a heritable com serum urate levels, either increasing or decreasing, are ponent, and genome-wide surveys have linked risk of gout important fac to rs in precipitating acute gout. The mecha to several genes whose products regulate urate handling by nism of the late, chronic stage of gouty arthritis is better the kidney. This is characterized pathologically by to pha component, is related to acquired causes of hyperuricemia, ceous invasion of the articular and periarticular tissues, eg, medication use (especially diuretics, low-dose aspirin, with structural derangement and secondary degeneration cyclosporine, and niacin), myeloproliferative disorders, (osteoarthritis). Alcohol ingestion promotes hyer the likelihood of developing s to nes, with the risk of s to ne uricemia by increasing urate production and decreasing formation reaching 50% in patients with a serum urate the renal excretion of uric acid. Chronic urate nephropathy is patients frequently suffer attacks ofgout because of changes caused by the deposition of monosodium urate crystals in in diet, fuid intake, or medications that lead either to rapid the renal medulla and pyramids. In women, the onset is typically causing this outcome is controversial, because many postmenopausal. The characteristic lesion is the to phus, a patients with gout have numerous confounding risk fac to rs nodular deposit of monosodium urate monohydrate crys for chronic kidney disease (eg, hyertension, alcohol use, tals with an associated foreign body reaction. Symp to ms and Signs Acute gouty arthritis is sudden in onset and frequently Table 20-4. It may develop without apparent precipitating cause or may follow rapid increases or decreases in serum Primary hyperuricemia A. Specific enzyme defects (eg, Lesch-Nyhan syndrome, metabolism, and, in the hospitalized patient, fasting glycogen s to rage diseases) before medical procedures. Decreased renal clearance of uric acid (idiopathic) is the most susceptible joint ("podagra"), although others, Secondary hyperuricemia especially those of the feet, ankles, and knees, are com A. Carcinoma and sarcoma (disseminated) affected during the same attack; in such cases, the distribu 4. Decreased renal clearance of uric acid are swollen and exquisitely tender and the overlying skin 1. Drug-induced (eg, thiazides, low-dose aspirin) recovery from the acute arthritis are characteristic of gout b. Hyperke to acidemia (eg, diabetic ke to acidosis, starvation) external ears, feet, olecranon and prepatellar bursae, and d. Gout and other Asymp to matic periods of months or years commonly crystallineforms ofarthritis. Chronic to phaceous arthritis may resemble chronic rheuma to id arthritis; gout is suggested by an earlier his to ry ofmonoarthritis and is established by the demonstration of urate crystals in a suspected to phus. A radiographic appearance similar to that of gout may be found in rheuma to id arthritis, sarcoidosis, multiple myeloma, hyperparathyroidism, or Hand-Schuller-Christian disease. Chronic lead in to xication may result in attacks of gouty arthritis (saturnine gout). Asymp to matic Hyperuricemia Asymp to matic hyperuricemia should not be treated; uric acid-lowering drugs should not be instituted until arthri tis, renal calculi, or to phi become apparent. Acute Attack Treatment of the acute attack fo cuses on reducing infam Figure 20-2. Colchicine-Oral colchicine is an appropriate treatment Although serial measurements of the serum uric acid option for acute gout, provided the duration of the attack is detect hyperuricemia in 95% of patients, a single uric acid less than 36 hours. For acute gout, colchicine should be determination during an acute fare of gout is normal in up administered orally as follows: a loading dose of 1. Patients who are already taking prophylactic doses of blood white cell count is frequently elevated. Identification colchicine and have an acute fare of gout may receive the of sodium urate crystals in joint fuid or material aspirated full loading dose (1. The use of oral colchicine during the intercritical period to prevent gout attacks is discussed C. Corticosteroids-Corticosteroids often give dramatic punched-out erosions with an overhanging rim of cortical symp to matic relief in acute episodes of gout and will con bone ("rat bite") develop. Bacteriologic these corticosteroids can be given at the suggested dose for studies usuallyexclude acute pyogenic arthritis. Because gouty and septic arthritis Refined cereals and cereal products, cornflakes, white bread, can coexist, albeit rarely, joint aspiration and Gram stain pasta, flour, arrowroot, sago, tapioca, cakes with culture of synovial fluid should be performed when Milk, milk products, and eggs intra-articular corticosteroids are given. Sugar, sweets, and gelatin Butter, polyunsaturated margarine, and all other fats 4. Meat extracts and gravies Yeast and yeast extracts, beer, and other alcoholic beverages C. Management between Attacks Beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, Treatment during symp to m-free periods is intended to and mushrooms minimize urate deposition in tissues, which causes chronic 1The purine content of a food reflects its nucleoprotein content to phaceous arthritis, and to reduce the frequency and and turnover. Potentially reversible causes of purines, as do rapidly growing foods such as asparagus. The con hyperuricemia are a high-purine diet, obesity, alcohol con sumption of large amounts of a food containing a small concentra sumption, and use of certain medications (see below). In contrast, individuals with mild chronic kidney disease or with a his to ry of multiple attacks of gout are likely to beneft from pharmacologic treatment. In general, the higher the uric acid level and the more frequent the precipitated by abrupt changes in the serum uric acid level. Diet-Excessive alcohol consumption can precipitate order to avoid peripheral neuromyopathy and other com attacks and should be avoided. Reduction of serum uric acid-Indications for a urate to the serum uric acid level, moderation in eating fo ods lowering therapy in a person with gout include frequent withhigh purine content is advisable (Table 20-5).
Some machines now offer a variable on time though whether this is of clinical significance has yet to symptoms 7 days post iui purchase cheap primaquine on line be determined administering medications 6th edition discount primaquine online. Typical pulse ratios are 1:1 and 1:4 though others are available (see dose calculations) medications 2355 quality primaquine 15 mg. There is no evidence that I can find to medications high blood pressure cheap primaquine 15 mg with amex suggest that one mode of operation has any clinical advantage over another. Many papers have concentrated on the thermal effectiveness of ultrasound, and much as it can be used -2 effectively in this way when an appropriate dose is selected (continuous mode >0. Both Nussbaum (1998) and ter Haar (1999) have provided some useful review material with regards the thermal effects of ultrasound. It can be used to selectively raise the temperature of particular tissues due to its mode of action. This is the formation & growth of gas bubbles by accumulation of dissolved gas in the medium. These bubbles then collapse very quickly releasing a large amount of energy which is detrimental to tissue viability. There is no evidence at present to suggest that this phenomenon occurs at therapeutic levels if a good technique is used. Sodium ion permeability is altered resulting in changes in the cell membrane potential. In essence, the sound wave travelling through the medium is claimed to cause molecules to vibrate, possibly enhancing tissue fluid interchange & affecting tissue mobility. The various phases of tissue repair can be usefully represented by the ‘blocks’ in the figure to the left. Further details, reviews and reference materials can be found in the publications identified above or from the web site at: Studies which have tried to demonstrate the anti inflamma to ry effect of ultrasound have failed to do so. A further benefit is that the inflamma to ry chemically mediated events are associated with stimulation of the next (proliferative) phase, and hence the promotion of the inflamma to ry phase also acts as a promoter of the proliferative phase. For tissues in which there is an inflamma to ry reaction, but in which there is no ‘repair’ to be achieved, the benefit of ultrasound is to promote the normal resolution of the inflamma to ry events, and hence resolve the ‘problem’ this will of course be most effectively achieved in the tissues that preferentially absorb ultrasound – i. Harvey et al (1975) demonstrated that low dose pulsed ultrasound increases protein synthesis and several research groups have demonstrated enhanced fibroplasia and collagen synthesis (Enwemeka et al 1989, 1990, Turner et al 1989, Huys et al 1993, Ramirez et al 1997, Warden et al 2006, Zhang et al 2004). A scar in ligament will not ‘become’ ligament, but will behave more like a ligamen to us tissue. Ultrasound applied to tissues enhances the functional capacity of the scar tissues (Nussbaum 1998, Huys et al 1993, Tsai et al 2006, 2011, Yeung et al 2006). Therapeutic Ultrasound © Tim Watson 2015 Page 9 Pthomegroup the application of ultrasound during the inflamma to ry, proliferative and repair phases is not of value because it changes the normal sequence of events, but because it has the capacity to stimulate or enhance these normal events and thus increase the efficiency of the repair phases (ter Haar 99, Watson 2007, 2008, Watson & Young, 2008). The main clinical issue is that the effective ‘dose’ is actually lower than most therapy machines can deliver – which is frustrating! Ahmadi et al (2012) have usefully reviewed both bioeffects and safety issues at this frequency range. Some claim (anecdotally) that it is very effective whilst others dismiss the technique. If there is a stress fracture (or other significant bony injury) it is common for a sharp pain to be felt by the patient. Ultrasound Therapy for Wound Healing: There have been a range of research papers over the years which have set out to evaluate the benefits (or otherwise) of ultrasound therapy as a means to stimulate healing in chronic wounds (typically venous ulcers and pressure sores). Whilst some research has not demonstrated significant clinical benefit, others have clearly done so, and therefore, as with other wound based Therapeutic Ultrasound © Tim Watson 2015 Page 10 Pthomegroup electrophysical agent applications, it is likely to be a dose dependent response. Cullum et al (2010) contributed a Cochrane review on this to pic, though only 8 trials were included (I have over 400 papers the in one way or another consider ultrasound and wound healing). Bell et al, 2008; Stanisic et al, 2005) whilst Serena et al (2009) and Harris et al (2014) identify its potential benefit in relation to wound bacterial counts. A study by Srbely et al (2007) raises some interesting points and demonstrates a measurable benefit. Other studies in this area include Sarrafzadeh et al (2012); Unalan et al (2011); Draper et al (2010); Aguilera et al (2009); Majlesi and Unalan (2004); Manca et al (2014). More recently Morishita et al (2014) have demonstrated some interesting effects of ultrasound ( to trapezius), stretch and pain effects, which may link to trigger point applications. It was shown that pulsed ultrasound is more effective in terms of pain management and functional improvement compared with control conditions. There is currently limited clinical research with regards any different effect none are expected the advantage being that (a) it is safe and (b) the therapist does not need to deliver the treatment in the classic way they can affix the applica to r and proceed with other jobs. The disadvantage of most of these portable, handheld devices is that (currently) they rarely offer a choice of treatment dose, thus reducing their value. Narrative Review: Key concepts with electrophysical agents Physical Therapy Reviews 15(4): 351-359. Background Laser therapy for benign pigmented lesions has time of the targeted tissue and thereby minimizes been studied over the past two decades. They reported the 532nm wavelength which makes the 532nm laser greater than 75% pigment removal in 60% of the ideal for targeting melanin. No textural changes, scarring, or lentigines and ephelides, the objective is to deliver other side effects were reported. None of the lesions treated pulses, which further scatters and disrupts the with the long-pulsed laser developed immediate pigment. Patients that were treated laser is an ideal wavelength for the treatment of with the short-pulse laser reported an average of benign epidermal pigmented skin lesions. The study Several studies support the use of the Q-Switched confrmed that when using the same energy settings, 532nm laser in the treatment of epidermal lesions. At twenty-fours hours, scattered dyskera to tic 1064nm) to reduce hyperpigmentation as a result epidermal cells were noted, and on day eight, the of amyloidosis. Amyloid material is fndings demonstrated a marked reduction in lesional deposited in the upper dermis and close to the basal pigmentation without any effects on the epidermis. A colorimetric that is well absorbed by the target, and delivered assessment of the macular amyloidosis pigmented in a short nanosecond pulse; whereby the pulse patches using a Mexameter and digital pho to graphs duration is shorter than the thermal relaxation were taken prior to treatment and eight weeks after Methods treatment. For each patient, one selected area Prior to the procedure, the patients were instructed was treated using the Q-Switched 532nm with a to avoid sun exposure for four weeks. A of treatment, an assessment was performed by second area was treated using the Q-Switched the physician noting the presence of benign facial 1064nm with a spot size of 3 mm and a fuence of pigmented lesions (such as lentigines and ephelides) 14 J/cm2. The Mexameter data showed signifcantly the average treatment parameters used with the greater reduction in pigmentation with the 532nm Q-switched 532nm were a 2-5 Hz, 0. At eight weeks, the mean score for the area to six pulses along the lateral jaw line prior to treat treated with the 532nm was 231 while the 1064nm ment, using a range of fuences. No signs of hypopigmentation or scar evaluated after two to three minutes for the desired formation were observed in any of the treated sites. The test spot fuence resulting in pigmented lesion whitening with rare to no petechiae of the surrounding skin was selected as the treatment fuence. Treatments were started on the lateral inferior cheeks and preceded medially and superiorly. The distance guide was in direct contact with the skin at all times and each spot had an overlap of 20% with the previ ously treated spot. For post treatment care, patients were instructed to ice the area for a 10 minute period every hour on the day of treatment, or as needed for edema and erythema. One year later, the patient returned for a repeat treatment to achieve further Before after 2 tx clearance. The patient requested no use of anesthesia and there fore the laser settings were reduced to 2 Hz and 0. This patient was also prescribed Zyrtec 10 mg one tablet per day for two days for postpro cedure hives. At one month, a 50-year-old female skin type ii the physician assessed a 50-60% improvement from presented with a his to ry of solar baseline with no side effects. For the second treatment the laser settings were increased slightly to 5 Hz and 1. At one month, the physician assessed the improvement as excellent with 100% clearance of the sunspots with no side effects, with one treatment. The patient rated the to lerability of the treatment as “very well” and rated the effcacy of treatment as “very satisfed.
Review of pathogenesis treatment e coli order primaquine 15mg with visa, diagnosis treatment diabetes primaquine 15 mg otc, and management medications like adderall order genuine primaquine on-line, Oncol Katayama A medications neuropathy purchase 15mg primaquine, Bandoh N, Kishibe K et al: Expression of matrix metal ogy (Willis to n Park) 17(12):1767–1779, 2003. Focal (Frictional) Hyperkera to sis White Lesions Associated with Smokeless Tobacco Etiology and Pathogenesis Nicotine S to matitis To date, the cause of leukoedema has not been established. Hairy Leukoplakia Fac to rs such as smoking, chewing to bacco, alcohol ingestion, Hairy Tongue bacterial infection, salivary conditions, electrochemical inter Dentifrice-Associated Slough actions, and a possible association with cannabis use have Preneoplastic and Neoplastic Lesions been implicated, but none are specifcally proven causes. Actinic Cheilitis Actinic Kera to ses (Solar Kera to ses) Clinical Features Leukoedema is usually discovered as an incidental fnding. Idiopathic Leukoplakia It is asymp to matic and symmetrically distributed in the Other White Lesions buccal mucosa, and to a lesser extent over the labial mucosa. Geographic Tongue It appears as a gray-white, difuse, flmy, or milky surface Lichen Planus alteration (Figure 3-1). In exaggerated cases, a whitish cast Lupus Erythema to sus with surface textural changes, including wrinkling or cor Nonepithelial White-Yellow Lesions rugation, may be seen. Submucous Fibrosis His to pathology Fordyce’s Granules In leukoedema, the epithelium is parakera to tic and acan Ec to pic Lymphoid Tissue thotic, with marked intracellular edema of spinous cells. The Gingival Cysts enlarged epithelial cells have small, pyknotic (condensed) Parulis nuclei in optically clear cy to plasm. Lipoma Diferential Diagnosis White sponge nevus, hereditary benign intraepithelial dyskera to sis, the response to chronic cheek biting, and li Lesions of the oral mucosa that appear clinically white re chen planus all may show clinical similarities to leukoedema. Treatment and Prognosis White or yellow-white lesions may also be due to fbrinous Treatment is not necessary because the changes are innocu exudate covering an ulcer, submucosal deposits, surface ous and no malignant potential exists. It is often possible to see columns of parakeratin extend • Figure 3-1 Leukoedema. Once tissue diagnosis is confrmed, symmetrically, and treatment is generally not required. The pre sentation intraorally is almost always bilateral and symmetric Hereditary Benign Intraepithelial Dyskera to sis and usually appears early in life, typically before puberty. It was noted within a tri-racial isolate of white, spared, but mucosa of the esophagus, anus, vulva, and vagina Indian, and African American composition in Halifax may be afected. Using a next generation change may be noted, often beginning in the parabasal region sequencing approach, a novel missense mutation M77T A B • Figure 3-2 A and B, White sponge nevus. B, High magnifcation of epithelium showing characteristic perinuclear condensation of keratin. Patients may Disease Features/Action complain of pho to phobia, especially in early life. Epithelial hyperplasia and acanthosis are (striae), erosions, atrophy and associated skin lesions; biopsy present with intracellular edema. Enlarged hyaline keratino cytes are the dyskera to tic elements that are present in the su Lichenoid drug Look for white lesions, often asymmet perfcial half of the epithelium. Normal cellular features are reaction rical, in context of new drug his to ry noted within the lower spinous and basal layers. Infamma to ry Cheek chewing White shaggy lesions along occlusal cell infltration within the lamina propria is minimal, and the plane or trauma sites epithelium–connective tissue junction is well defned. Lupus Delicate radiating striae; biopsy erythema to sus Treatment Candidiasis Look for predisposing fac to rs; can rub No treatment is necessary because this condition is self off; responds to antifungal therapy limiting and benign. It has been proposed that abnormali at the corneal limbus, and oral white lesions. Preceding the ties in this calcium pump function interfere with cell bulbar conjunctivitis are foamy gelatinous plaques that repre growth and diferentiation of calcium-dependent processes. Oral lesions consist of soft, asymp to matic, white folds and Clinical Features plaques of spongy mucosa. Areas characteristically involved in Onset occurs between the ages of 6 and 20 years. The disease has clude the buccal and labial mucosa and the labial commissures, a predilection for the skin, with 13% of patients demonstrating as well as the foor of the mouth and lateral surfaces of the oral lesions. Skin manifestations are characterized by small, skin to ngue, gingiva, and palate. The dorsum of the to ngue is usually colored papular lesions, symmetrically distributed over the face, spared. Oral lesions are generally detected within the frst year trunk, and intertriginous areas. The papules eventually coalesce of life, with a gradual increase in extent until midadolescence. Lesions may also occur unilaterally or in a zosteriform pattern (lesions follow a derma to me). Tickening of the palms and soles (hyperkera to sis palmaris et plantaris) by excessive kera to tic tissue is not uncommon. Lesions typically appear as small, whitish papules, producing an overall cobbles to ne appearance. Papules range from 2 to 3 mm in diameter and • Figure 3-4 Focal hyperkera to sis caused by cheek chewing. Features include: (1) formation of suprabasal lacunae (clefts) containing acantho lytic epithelial cells, (2) basal layer proliferation immediately be low and adjacent to the lacunae or clefts, (3) formation of verti cal clefts that show a lining of parakera to tic and dyskera to tic cells, and (4) the presence of specifc benign dyskera to tic cells, called corps ronds and grains. Corps ronds are large, keratinized squamous cells with round, uniformly basophilic nuclei and in tensely eosinophilic cy to plasm. Treatment and Prognosis The goal of treatment is to improve the appearance of the skin lesions, reduce symp to ms, and prevent or treat infective complications. Topical corticosteroids and the vitamin A analog retinoic acid have been used efectively, but long-term therapy is to lerated poorly. The disease is chronic and slowly progressive; remissions may be noted in some patients. Reactive Lesions Focal (Frictional) Hyperkera to sis Etiology Focal (frictional) hyperkera to sis is a white lesion that is related to chronic rubbing or friction against an oral mu cosal surface. This results in a hyperkera to tic white lesion • Figure 3-6 Focal hyperkera to sis related to to ngue-thrusting habit. Clinical Features Friction-induced hyperkera to ses occur in areas that are commonly traumatized, such as the lips, lateral margins of the to ngue, buccal mucosa along the occlusal line, and edentulous alveolar ridges (Figures 3-4 to 3-7; Box 3-2). Chronic cheek or lip chewing may result in opacifcation (keratinization) of the afected area. His to pathology As the name indicates, the primary microscopic change is hyperkera to sis (Figure 3-8). A few chronic infamma to ry • Figure 3-7 Focal hyperkera to sis and erythema associated with an cells may be seen in the subjacent connective tissue. Disease Features/Action Edentulous ridges and vestibules may be affected in denture wearers. Burn (chemical) His to ry of aspirin or other agent application at site of lesion—discontinue use Lupus erythema to sus Delicate radiating striae; usually unilateral; biopsy Hairy leukoplakia Lateral borders of to ngue; look for irregular surface architecture; often bilateral; immunosuppression biopsy group. Smokeless to bacco is also used in Sweden in the form of snus, a nonfermented type of moist to bacco with lower concentrations of harmful nicotine and to bacco de rivatives versus those types of fermented smokeless to baccos traditionally used in the United States. Note that the the Indian subcontinent and Southeast Asia, use of smoke epithelial maturation pattern is otherwise normal. Patients should be advised to dis The general increase in smokeless to bacco consumption continue the causative habit, or the ofending to oth or has been related to peer pressure and increased media adver denture should be smoothed. The lesion should resolve, or tising, which often glamorizes the use of smokeless to bacco, at least should be reduced in intensity, over time, helping to or snuf dipping. Resolution of the lesion intense smokers and those who wish to avoid smoking may would allow unmasking of any underlying lesion that may gravitate to this alternative. If the clinical diagno exposure to smokeless to bacco include the development of sis is in doubt, a biopsy should be taken. Control of the habit causing the lesion Etiology should result in clinical improvement. No malignant A causal relationship has been documented between smoke potential exists. Although all forms of smokeless to bacco may cause alterations in the oral mucosa, White Lesions Associated with Smokeless snuf (particulate, fnely divided, or shredded to bacco) ap Tobacco pears to be more likely to cause oral lesions than does chew Marked geographic and gender diferences in to bacco use ing to bacco.
Despite this assumption 606 treatment syphilis discount 15mg primaquine overnight delivery, the findings from 265 this study are comparable with the findings of Macdonald-McMillan (2011); in this study the features were considered in more detail treatment yeast infection women order primaquine with a visa, including number medications while breastfeeding purchase primaquine, size medicine just for cough primaquine 15mg visa, orientation etc. Surface features Inter-observer studies To reiterate, surface features were recorded in a simplified manner however, it was still necessary to establish how repeatable these features were when recorded by observers of varying levels of experience. Despite minor trends in agreement/disagreement in the number of images with pigmentation, scars and hair patternation, it was concluded that there were no statistically significant differences between any of the observers (Table 7-7). This result agrees with the findings from the intra-observer study, and again performance may be indicative of the simplification of the methodology, as the results of the current study do not agree with the inter-observer study conducted by Macdonald-McMillan (2011); differences between observers, was significant with regard to the number of features identified, particularly between three observers with differing levels of experience. Differences were mostly seen in the number of ephelides, which are often present in high numbers. Despite this, for the purpose of this study, the observer study results indicate that if only the presence or absence information is required, this is a repeatable method. It should be borne in mind that when assessing these features in a forensic scenario, more detail is required with regards to physical description and relative location of features. Increasingly, it is advised (and in some jurisdictions enforced) that the validity and reliability of forensic methods are explicitly reported along with expert opinion evidence (Association of Forensic Science Providers, 2009; National Research Council of the National Academies, 2009). The impact of lack of research to establish and qualify the validity and reliability of forensic disciplines was highlighted in cases as far back as Frye (Frye vs. It is unders to od that the human observer will show inherent subjectivity in their assessment of a pattern, and can never be entirely objective. However, with the current lack of au to matic approach to extract patterns, the level of variation in the way a human observes a pattern must be established. This research has gone some way to address these overriding issues with regard to the identification of individuals from digital images. Results from both the inter and intra observer studies support the overall stability of the methods used to extract vein pattern and surface feature information. However, it was highlighted that the complexity of the networks affected the level of reliability, with increased complexity showing a reduced rate of reliable reconstruction of the network. It was found that although the trained observers would rely on features with known discrimina to ry capabilities, the overall results showed that there were no significant differences in the responses from an untrained or expert observer. In summary, it appears that the trained observer has the experience to know which features to rely on, in terms of their discrimina to ry capabilities, whereas an untrained observer is likely to rely on less definitive observations such as skin to ne. With regards to vein pattern extraction, simple networks are reproduced by both groups, whereas the trained observer was more capable when presented with complex networks. The issue of observer bias is only to uched on in this thesis but it is important to note that it is inevitable that an examiner will in some way be biased; studies have shown that due to the disturbing and emotive nature of material assessed in the cases, it is thought that practitioners involved will be subconsciously more susceptible to observer bias (Dror et al. Despite the fact that observers were shown to be repeatable in this study, the test scenario did not truly reflect a case scenario, where the user would be aware of the heinous circumstances of the case and therefore the results from the study cannot truly represent how an expert would perform in a real case scenario. It is hoped that the findings of this research and others (Meadows, 2011; Macdonald McMillan, 2011), will clarify the reliability of the methods outlined in this thesis and act as a support of this approach in the legal framework. Due to the fact that this study was the first of its kind to introduce network analysis of vein patterns, the research is introduc to ry, and future studies would benefit from an expansion of the current study to enable more robust statistical testing of the methodologies. However it is appreciated 268 that eliminating human error is ultimately impossible due to the subconscious mind. To eliminate this effect entirely, au to mation of methods would have to be explored. Vein network features: Variation in standardised conditions It is important that forensic practitioners involved in establishing similarities and differences between two individuals based on the superficial veins on the dorsum of the hand, have an understanding of the expected variation. Additionally, it is important for the practitioners to have access to a suitably large database of hand images, on which they can compare their findings, and estimate the likelihood of the pattern in question, occurring. It was found that the most common density of a network, in terms of the number of nodes and edges, contains 8 to 16 edges (55 networks) and 9 to 15 nodes (57 networks). Fewer networks fall in to the category, termed ‘dense’, and containing 16 to 28 edges (28 networks) and 15 to 24 nodes (29 networks), whilst fewer still are categorised as ‘sparse’ and contain 0 to 8 edges (23 networks) and 0 to 9 nodes (20 networks) (Table 6-9). In addition to feature counts; this study considered the way in which features of a vein network are connected, therefore providing more detailed information regarding the to pology of the network. Feature counts, although useful in terms of pattern density, are 269 referred to as ‘induced sub-graphs’ in relation to network analysis, whereby two structures are mathematically identical, or have exactly the same feature count, but the to pologies can differ (Tran et al. This information originates with the motif data; sub-graphs that interconnect to form a larger network. It was found that some motifs were more common than others; for example a simple 3 node arrangement (motif A) was identified in 100% of networks in the sample dataset, whereas a 3 node loop, with only 1 edge difference to A, was found in 20% of the networks (Figure 6. However, this data is difficult to interpret, as motifs cannot be considered in isolation. They exist only as part of a larger structure, where they are usually connected with another motif. Despite this, it can be seen that as the complexity of motifs increase, their prevalence decreases. Therefore if a complex arrangement is identified within a network, it is more likely to be rare and therefore provide more discrimination between two networks, than a simpler motif. Shorter loops (3 nodes) were more common than larger loops (5 node loops) (1x 3 node loop present in 16%, while 1x 5 node loop present in 11. Intersections were found to be marginally less common than loops, and similarly the majority of the sample contained no intersections, whilst 25% of the sample contained one intersection. In an attempt to explain this level of variation in the pattern of superficial veins, the embryological and ana to mical literature was examined. The way in which blood vessels develop, through the coalescing of blood islands, suggests there is no strict pathway to direct the development of the capillary network (Larsen, 1993; Eichmann et al. There are many suggestions as to what regulates vascular growth and 270 these include pH levels, hypoglycaemia, mechanical stress from proliferating cells and immune responses to hemodynamic forces after the onset of the first heartbeat (Tomanek, 2002). These circumstances vary between individuals, perhaps indicating that vascular growth is a process unique to the set of circumstances at a specific stage of development; thus explaining the observed level of variation. This can only be regarded as a theory as how vascular patterns are determined, remains largely undetermined. With regards to adult ana to my, there is a scarcity of detailed description of the superficial veins of the dorsum of the hand, other than the generalised term in reference to the area between the metacarpo-phalangeal joint and the wrist, as the ‘dorsal venous network’ (Bergan, 2007; Cunningham and Robinson, 1918; Gray, 1918), a vague term that does not attempt to describe the pattern created by the branching veins, perhaps an indication that no precise description can be obtained due to the high level of variability. In addition to general distribution of the vein network features, it is useful to be aware of any statistical relationships that exist between the presence of vein network features and biological characteristics of the individual. It was found that there was no significant relationship between the number of nodes or edges in a network and the age, weight, or body side of the individual. There was a significant relationship found to exist between the to tal body fat percentage of an individual and both the number of nodes (p = 0. This is thought to be due to the layer of subcutaneous fat overlaying the veins causing the pattern to be partially obscured. It is noted that no significant relationship was discovered between weight and the number of nodes or edges found. The difference 271 in results for weight and body fat percentage show that these two parameters affect the vein pattern visibility differently; an individual who may be heavy in terms of overall weight may have visible veins, whereas it is likely that an individual with a high body fat percentage is likely to have a lower number of vein pattern features than someone with lower body fat percentage. Other studies have also suggested that increased levels of subcutaneous fat may obscure the superficial veins (Chiao et al. Surface feature variation: Variation in standardised conditions Pigmentation was found to be present in 72. As previously mentioned, the means of data collection in this study was simplified so that this data could be combined easily with the more complex, vein network data. Whilst the data described will be of added value to the forensic practitioner in terms of an indication of distribution across a sample, other studies have provided more in-depth descriptions of the variation of surface features (Black et al. Hair on the dorsal surface of the hand is a universal trait (Szabo, 1967), however it is not clearly visible in all individuals. Results indicate that 25% of individuals within this dataset have no visible hair. The current study does not account for the density of hair, and it is thought that collecting hair patternation information with the use of gradation would be more informative. The effects of biological characteristics on the surface features identified were tested, and it was found that no statistically significant relationship existed between the weight, body fat % and body side of the individual. There was no association with age and pigmentation or scars, but a significant relationship was found between age and the presence of hair.
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