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By Q. Jesper. Liberty University.

The wound margins and the tissues within the base of the wound are usually blackened by smoke and may show signs of burning owing to the effect of flame order 20mg cialis sublingual free shipping erectile dysfunction what age. Because the gases from the discharge are forced into the wound cialis sublingual 20mg impotence surgery, there may be subsid- iary lacerations at the wound margin, giving it a stellate-like shape. This is seen particularly where the muzzle contact against the skin is tight and the skin is closely applied to underlying bone, such as in the scalp. Carbon mon- oxide contained within the gases may cause the surrounding skin and soft Injury Assessment 145 revolver, which tends to have a low muzzle velocity of 150 m/s, is a short- barreled weapon with its ammunition held in a metal drum, which rotates each time the trigger is released. In the self-loading pistol, often called “semi-automatic” or erroneously “automatic,” the ammunition is held in a metal clip-type maga- zine under the breach. Each time the trigger is pulled, the bullet in the breach is fired, the spent cartridge case is ejected from the weapon, and a spring mecha- nism pushes up the next live bullet into the breach ready to be fired. The rifle is a long-barreled shoulder weapon capable of firing bullets with velocities up to 1500 m/s. Most military rifles are “automatic,” allowing the weapon to continue to fire while the trigger is depressed until the magazine is empty; thus, they are capable of discharging multiple rounds within seconds. Shotgun Wounds When a shotgun is discharged, the lead shot emerges from the muzzle as a solid mass and then progressively diverges in a cone shape as the distance from the weapon increases. The pellets are often accompanied by particles of unburned powder, flame, smoke, gases, wads, and cards, which may all affect the appearance of the entrance wound and are dependent on the range of fire. Both the estimated range and the site of the wound are crucial factors in deter- mining whether the wound could have been self-inflicted. If the wound has been sustained through clothing, then important resi- dues may be found on the clothing if it is submitted for forensic examination. It is absolutely essential that the advice of the forensic science team and crime scene investigator is sought when retrieving such evidence. When clothing is being cut off in the hospital, staff should avoid cutting through any apparent holes. The entrance wound is usually a fairly neat circular hole, the margins of which may be bruised or abraded resulting from impact with the muzzle. In the case of a double-barreled weapon, the circular abraded imprint of the nonfiring muzzle may be clearly seen adjacent to the contact wound. The wound margins and the tissues within the base of the wound are usually blackened by smoke and may show signs of burning owing to the effect of flame. Because the gases from the discharge are forced into the wound, there may be subsid- iary lacerations at the wound margin, giving it a stellate-like shape. This is seen particularly where the muzzle contact against the skin is tight and the skin is closely applied to underlying bone, such as in the scalp. Carbon mon- oxide contained within the gases may cause the surrounding skin and soft 146 Payne-James et al. Con- tact wounds to the head are particularly severe, usually with bursting ruptures of the scalp and face, multiple explosive fractures of the skull, and extrusion or partial extrusion of the underlying brain. Most contact wounds of the head are suicidal in nature, with the temple, mouth, and underchin being the sites of election. In these types of wounds, which are usually rapidly fatal, fragments of scalp, skull, and brain tissue may be dispersed over a wide area. At close, noncontact range with the muzzle up to about 15 cm (6 in) from the skin, the entrance wound is still usually a single circular or oval hole with possible burning and blackening of its margins from flame, smoke, and unburned powder. Blackening resulting from smoke is rarely seen beyond approx 20 cm; tattooing from powder usually only extends to approx 1 m. Up to approx 1 m they are still traveling as a compact mass, but between approx 1–3 m, the pellets start to scatter and cause variable numbers of individual satellite punc- ture wounds surrounding a larger central hole. At ranges greater than 8–10 m, there is no large central hole, only multiple small puncture wounds, giving the skin a peppered appearance. Exit wounds are unusual with shotgun injuries because the shot is usu- ally dispersed in the tissues. However, the pellets may penetrate the neck or a limb and, in close-range wounds to the head, the whole cranium may be dis- rupted. Rifled Weapon Wounds Intact bullets penetrating the skin orthogonally, that is, nose-on, usually cause neat round holes approx 3–10 mm in diameter. Close examination reveals that the wound margin is usually fairly smooth and regular and bordered by an even zone of creamy pink or pinkish red abrasion. A nonorthogonal nose-on strike is associated with an eccentric abrasion collar, widest at the side of the wound from which the bullet was directed (see Fig. Atypical entrance wounds are a feature of contact or near contact wounds to the head where the thick bone subjacent to the skin resists the entry of gases, which accumu- late beneath the skin and cause subsidiary lacerations to the wound margins, imparting a stellate lacerated appearance. Contact wounds elsewhere may be bordered by the imprint of the muzzle and the abraded margin possibly charred and parchmented by flame. Punctate discharge abrasion and sooty soiling are usually absent from the skin surface, but the subcutaneous tissues within the depth of the wound are usually soiled. The effects of flame are rarely seen beyond 10 cm (4 in), with sooty soiling extending to approx 20 cm (8 in). Punctate discharge abrasions, which may be particularly heavy with old revolver ammunition, are often present at ranges up to approx 50 cm (20 in). It is impor- tant to remember that sooty soiling of the skin surrounding a wound is easily removed by vigorous cleaning carried out by medical or nursing staff. The soiling of contact close-range entrance wounds may be absent if clothing or other material is interposed between the skin surface and the muzzle of the weapon. Bullet exit wounds tend to be larger than entrance wounds and usually consist of irregular lacerations or lacerated holes with everted, unabraded, and unbruised margins. When the skin at the site of an entrance wound has been supported by tight clothing, eversion of the margins of the wound may be absent and the margins may even be abraded, albeit somewhat irregularly, but nevertheless making differentiation from entrance wounds more difficult. Entrance wounds caused by damaged or fragmented bullets may be so atypical that it may not be possible to offer a useful opinion as to their nature. It is inappropriate to offer an opinion on the caliber of a bullet based on the size of an entrance wound, and it is not possible to state whether the bullet was fired from a revolver, pistol, or rifle by only the appearance of the wound. These inju- ries typically are seen when an individual has tried to defend himself or herself against an attack and are the result of instinctive reactions to assault. When attacked with blunt objects, most individuals will attempt to protect their eyes, head, and neck by raising their arms, flexing their elbows, and covering their head and neck. Thus, the extensor surface of the forearms (the ulnar side), the lateral/ posterior aspects of the upper arm, and the dorsum of the hands may receive blows. Similarly, the outer and posterior aspects of lower limbs and back may be injured when an individual curls into a ball, with flexion of spine, knees, and hips to protect the anterior part of the body. In sharp-blade attacks, the natural reaction is to try and disarm the attacker, often by grabbing the knife blade. Occasionally, the hands or arms may be raised to protect the body against the stabbing motion, resulting in stab wounds to the defense areas.

Your skin is made up of three layers—the epidermis (outer layer of the skin) generic 20 mg cialis sublingual free shipping impotence effects on marriage, the dermis (under the epidermis cialis sublingual 20mg without prescription 5 htp impotence, containing blood vessels, hair follicles, and connective B tissue), and the subcutis (the final layer of skin containing adipose tissue and storage of nutrients). The skin provides a first line of defence against all forms of external toxins and bacteria, but this protective barrier may be burned at temperatures higher than 120°F. Skin burns occur from exposure to extreme heat such as the sun, fire, boiling water, hot beverages, or cooking heat, and hot objects such as an iron or steam. Other causes of burns include chemicals, electricity, lightning, or radioactive material. Depending on the cause and length of exposure, burns can range from mild to severe and potentially fatal. Burns are classified according to their degree of severity and the amount of skin affected: • First-degree burns damage the epidermis. Depending on the extent of the burn and subsequent tissue damage, second-degree burns may be self-treated, but must be diligently watched and treated to avoid infection. They may affect muscles, bones, nerves, and blood vessels, requiring extensive treatment, skin grafts, and therapy. Because of the risk of shock and infection, third-degree burns are always considered a life-threatening medical emergency. There are a variety of lifestyle recommendations and also natural products that can help relieve the pain and promote skin healing for first-degree and minor second-de- gree burns. Third-degree burns need to be managed by your doctor to reduce the risk of infection and serious complications. Three percent of burns reported are caused by hot-water scalding, most often in the bathtub. Most hot-water heaters are set at 140°F, which can instantly burn the thin skin of a child. The goals of burn treatment are to speed wound healing, prevent infection and scars, relieve pain, and restore the patient to normal health. As such, doctors may employ a variety of antimicrobial and antibiotic agents, as well as pain relievers, to achieve these goals. For extensive burns, extensive treatment is needed, which may include lengthy hospital stays to ensure that infection does not occur, and outpatient appointments for therapy. Dietary Recommendations A healthy diet is critical for effective burn treatment to replace vital nutrients, promote wound healing, and reduce the risk of infection and scars. Also, for more serious burns, the healing process consumes many calories and a healthy diet can help keep your body strong during this process. Foods to include: • Drink plenty of water and electrolyte drinks to replace lost fluids. Note: Those with severe burns need to increase total caloric intake because as the body tries to repair, it burns calories at a faster rate. To manage a minor burn: • Gently cool and clean the area with cold water or cold wet compresses for at least 15 minutes. Do not cover with any type of petroleum-based cream or butter, as they retain heat, slow healing, and in- crease risk of infection. Honey products are also available in a spray, salve, or tincture (The British Journal of Surgery, 1991: 78; 497–498). Top Recommended Treatments Aloe vera gel: Cooling, helps relieve pain and inflammation, and also has anti-inflammatory properties. It is commonly used to manage burns and has a long history of use to promote wound healing, although the scientific research is lacking. Use aloe vera from a plant (split open a leaf) or get pure aloe gel at a health food store or pharmacy. Antioxidants: Studies have shown that oral supplements of vitamins A, C, E, zinc, and selenium can help to protect the skin from sunburn due to free radical-producing ultravio- let rays. Topical vitamin E cream or oil is commonly used to promote skin healing and may reduce scarring. Complementary Treatments Calendula cream: Soothing, has anti-inflammatory properties, and may help promote tissue repair. After a burn has cooled, cleanse with chamomile B tea and apply fresh aloe vera gel. Eat a healthy diet packed with lots of fresh fruits and vegetables, whole grains, and fish. Increase total calorie intake during the healing process and drink lots of liquids. It is the leading cause of premature death in Canada—about 1,006,000 potential years were lost in 2003 as a result of cancer. Cancer has become an age-related phenomenon: 44 percent of new cancer cases and 60 percent of cancer deaths will occur among those who are at least 70 years old. Rather, in many cases it is generally thought that our lifetime exposure to factors that increase our risk, such as smoking or eating a poor diet, leads to the development of cancer. Our bodies are made up of millions of cells grouped together to form tissues or organs, such as muscles, skin, bones, and organs. Cancer occurs when there is an abnormal growth of cells, which can form lumps or tumours, or can spread through the bloodstream and lymphatic system to other parts of the body. Benign tumour cells stay in one place in the body and are not usually life-threatening. Malignant tumour cells are able to spread to invade nearby tissues and other parts of the body, which is a process called metastasis. Finding cancer early and getting treat- ment before it spreads can greatly help improve your chances of survival. While we think of cancer as one disease, it is actually a group of more than 100 different diseases. It can involve any tissue of the body and have many different forms in each body area. The four most common types of cancer in Canada are breast, prostate, lung, and colon. A great deal of research has focused on the underlying causes of abnormal cell growth. We do know that certain factors, such as free radical damage, genetics, diet, and lifestyle, are involved. While many of us may blame our family history, only about 5–10 percent of cancers are attributed to faulty genes. Having a family history may increase your risk of certain cancers, but researchers feel that whether or not those genes are “switched on” may depend largely on lifestyle and environment. These critical yet often overlooked factors play a role not only in prevention but also in the treatment and recovery from cancer. Based on current incidence rates, 39 percent of Canadian women will develop cancer during their lifetimes. Cancer is a very broad subject and it is beyond the scope of this chapter to discuss each type and make individualized recommendations.

He has authored books buy cialis sublingual paypal erectile dysfunction with diabetes, written articles cheap cialis sublingual 20mg fast delivery impotence young males, given afdavits, and pub- lished his opinions on his website. Bowers appears to feel that bitemark analysis should only be used to exclude or to associate an individual as a “possible biter. Only “reasonable medical/dental certainty,” “probable,” “exclusion,” and “inconclusive” remain as recommended conclusions. Bowers coauthored a textbook, now in its second edition, teaching methods for extensive bitemark detail analysis, metric analysis,exemplar crea- tion, and feature comparison. In spite of past or recent claims to the contrary, it may not be possible to mathematically or statistically prove the uniqueness of the anterior human dentition related to the information found in bitemarks. Consequently, a path similar to that recommended by Saks and Koehler seems the most sensible: Continue research into uniqueness, but collect data and build databases on the frequency with which those features and patterns of the anterior dentition appear, especially those features that may also be discernable in bitemark pat- terns. Tomas Johnson and a Marquette University team reported development of a computerized method of collect- ing data on dental characteristics (oral presentations in Johnson et al. Te method may be the frst step toward the creation of a database of the frequency at which dental characteristics and combinations of characteristics occur in a population. Roger Metcalf reported on an alternate method at the same 2008 meeting (oral presentation in Metcalf et al. Tat method is currently being investigated at the University of Texas Health Science Center in San Antonio. Tere is almost universal agreement among forensic dentists that human skin is a very poor material for faithfully and accurately recording those features. Most early bitemark-related papers that discuss skin con- centrate on the distribution of bitemarks, the classifcation of bitemarks, and the analysis of distortion in bitemarks or in preserved skin with bite- marks. Tose features must then be scientifcally analyzable, the distortion accounted for, and a statistical or mathematical basis for comparisons established. Also known as Leibniz’s law and the probability rule for indepen- dent variables, the rule is most commonly applied to problems in diferential calculus. For forensic research applications the following defnition may be most useful: “Te probability rule for independent variables, or product rule, states that the probability of the simultaneous occurrences of two indepen- dent events equals the product of the probabilities of each event. In the most ofen cited work on the subject of the uniqueness of teeth, the use of the product rule is essen- tial to the conclusion. Until signifcant research shows that the dental features are indeed independent, mathematical or statistical certainty cannot be assigned to either the features of the biting surfaces of the anterior dentition or to the marks that those teeth make in skin. As an alternative to those mathematical or statistical methods, research currently under way on collecting and recording data on the frequency of dental variation features is encouraging. To date there is insufcient scientifcally con- frmed information to support the association of bitemark patterns on human skin and sets of teeth with statistical or mathematical degrees of certainty. Te same seven sets of dental models served as the potential biters in all four cases. In only one of the cases, a bitemark in cheese, was the identity of the true biter known. Tis knowledge was based, at least in part, on the victim’s identifcation of the biter and the biter’s subsequent confession. Results were tabulated and two nondiplomates were authorized to perform a statistical analysis of the results and produce a paper for submission to a refereed journal. Te frst journal to which the paper was submitted, the Journal of Forensic Sciences, rejected the paper, citing the inappropriate design of the workshop for statistical analysis. Perhaps unfortunately, considering the later misinterpretations, the article was submitted to other journals and was ultimately published in 2001 in the journal Forensic Science International. In the paper the authors stated that the primary objective of the study was “to determine the accuracy of examiners in distinguishing the correct dentition that make a bitemark,” and the secondary 356 Forensic dentistry objective was “to determine whether examiner experience, bitemark certainty, or forensic value had an efect on accuracy. Consequently, mathematical or statistical analysis of the opinions of workshop participants was not possible without assuming that a true cause-efect relationship existed in each of the cases. Bitemark Workshop #4 was neither designed as, nor can it be used as, a profciency test for forensic odontology. Tests of consistency and validity (necessary in a profciency examination) were neither accomplished nor attempted; and, as subsequent reviewers of the data correctly pointed out, the construction of the examination and the workshop was not designed to produce an examination that had statistical validity and statistical con- sistency. In 2002 the Supreme Court of Mississippi was consider- ing a petition for postconviction relief in a death penalty case involving alleged bitemarks. Included in the petition was this material described by the court: In support of this claim, Brewer presents the afdavit of Charles Michael Bowers, D. He urges that this Court should not tolerate a science that, as Brewer claims, is more likely than not to identify the wrong suspect. Tese results counter balance the years of assured self-confdence shown by the dentists testifying on bite mark Bitemarks 357 evidence. Tus, they were wrong nearly half the time they tried to identify the source of a bitemark. More specifcally, it is their false positive error rate—the tendency to conclude that an innocent person’s dentition matches the bitemark—that accounts for the bulk of that overall error rate. If this refects their perfor- mance in actual cases, then inculpatory opinions by forensic dentists are more likely to be wrong than right. Bowers claimed, a “study regarding the reliability of bite mark identi- fcation evidence,” nor did it “produce data on the accuracy of results in bite mark identifcation forensic casework. Te authors of the Forensic Science International paper correctly stated in closing, “Tis study, despite its limitations, has opened the debate into evidence-based forensic dentistry. Forensic odontologists must ensure that the techniques they employ are backed by sound scientifc evidence and that the decisions they present in Court serve to promote justice and to strengthen the discipline. Because the number of cases in the study was too few, the reasons can be neither properly analyzed nor clearly understood from these data. Sixteen, half of the participants, scored 92% or better overall, and twelve had no single score lower than 91%. It seems clear from these data, in spite of the shortcomings of the study’s design, that some participants were able to accurately analyze the material and were clearly more skilled in analysis of that material than others. Tis information supports the shared opinion of this chapter’s authors that bitemark analysis, when performed by some expe- rienced forensic odontologists, following appropriate guidelines, can be a very accurate discipline. It also illustrates, conversely, that some forensic dentists should not be independently or individually responsible for bitemark analysis cases until their skills are sufciently developed and demonstrated. Tese data further support the recommended requirements for seeking second opinions, the need for true profciency testing for forensic odontologists in bitemark analysis, and mandatory remedial education for those not performing well on those profciency tests. It may also indicate that the qualifcations required to apply for board certifcation should be modifed to include an increase in the level of bitemark analysis experience required and the mandated oversight of the bitemark-related activities of new diplomates. Greenwald discussed the relationships between the ego and cognitive biases in his 1980 article. He theorizes that those biases combine to negative efect, especially in individuals involved in “higher level organizations of knowledge, perhaps best exemplifed by theo- retical paradigms in science. Greenwald, Tavris, and others assert that an integral part of cognitive conservatism, resistance to certain kinds of change, is the tendency toward susceptibility to confrmation bias, a persistent problem in the identifcation Bitemarks 359 sciences.

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