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By G. Campa. Excelsior College. 2018.

In recent years these provisions purchase ranitidine 150mg without prescription, which provide no specific regulation for herbal medicines cheap ranitidine 300 mg on-line, have been considered inadequate to ensure their safety and quality. There are a number of reasons including: adverse effects from some herbal ingredients (natural does not mean safe); misidentification of some Figure 6. Traditional Chinese medicine | 159 herbs and occasional substitution of toxic for safe species; illegal inclusion of prescription-only drugs or heavy metals in some ‘herbal’ medicines; microbial contamination; and discovery of problematic herb–drug interactions. This establishes a registration scheme for industrially produced over-the-counter herbal medicines, under which manufacturers have to demonstrate safety and quality, but not efficacy. Quality is guided by European good manufacturing practice, and safety is protected by requiring evidence of at least 30 years of safe use, of which at least 15 years must be within the European Community. There is a lead-in time to allow manufacturers and suppliers to make the necessary adjustments, but after 2011 any over-the-counter herbal product that is not registered under this scheme will be illegal. This lead time is, however, only for products that were on the market before April 2004. Such medicines will not have to be licensed and, because they are not industrially produced, will not have to be registered under the European Directive. There are, however, concerns about the quality and safety of herbal medicines supplied by this route. The issue is how to strengthen the public’s protection while preserving their access to herbal medicines. First, members of the statutory register can be tied, through a codes of practice, to suppliers that have been audited and demonstrated satisfactory standards of quality assurance. The Register of Chinese Herbal 160 | Traditional medicine Medicine has provided a good model for such an arrangement through its Approved Suppliers scheme. As it will be illegal to practise under the title of herbalist or Chinese medicine practitioner without membership of the register, the public will have stronger assurance about the quality of Section 6. Second, some more potent items in the materia medica can be restricted to use by registered practitioners. These are unlicensed medicines that would be considered industrially produced and thus, once the European directive is in force, would have to be registered under that scheme in order to remain legal. However, it seems likely that most of these patents would be considered unsuitable for registration under the European directive, because even if they met the tough quality assurance standards, most would not be suitable for over-the-counter use. On the other hand, they are industrially produced, so they could not be supplied under the normal Section 6. One way in which access might be preserved is through the so-called ‘Specials’ regimen, a provision in European medicines law that allows authorised health professionals to commission a third party (who would have to possess a manufacturer’s license) to make up medicines according to a particular specification. As registered herbalists would be authorised health professionals, it would in principle be possible for herbalists to commission a range of products for the exclusive use of practitioners on the statutory register. Under the new specials regimen, it is the practitioner who would be responsible for the formulation of any herbal patent medicine. Suppliers would not be able to advertise their products but would be able to advertise that they are able to provide a service. Although there have been no prosecutions to date arising specifically from the use of non-plant ingredients – hence the Traditional Chinese medicine | 161 law has never been tested in the courts – the wider concerns about the lack of regulation of herbal medicines have put this issue in the spotlight and it is clearly desirable to put this part of the materia medica onto a secure legal footing. The herbal community is therefore pressing for an extension of the licensing exemptions to non-plant medicines. It is suggested that, although the research is of variable quality, it should not be ignored. Adverse events, tolerability, and haemato- logical and biochemical parameters were monitored during the study. Treatment of side effects associated with chemotherapy treatment Short-term side effects of chemotherapy include fatigue, nausea, vomiting, mucositis, and myelosuppression or neutropenia. These occur during the course of treatment and generally resolve within months of completion of 162 | Traditional medicine chemotherapy. A variety of Chinese medicinal herbs has been used for managing these side effects. This has led to problems, because most of those who seek treatment are unable to distinguish between adequately and inadequately trained practitioners. Practitioners fall into three broad categories: • Those who have had a full training in the discipline This may be practitioners who have trained in China, normally for 5 years. Fully trained practitioners have training similar to that given to orthodox doctors in the west. They receive some training in western medicine and can distinguish those conditions that would be best treated by western medicine. These medicines carry with them a risk of adverse reactions; the risk needs to be quantified and as far as possible minimised. They should not take them if they are not labelled and [do not] include a list of ingredients in English. Even then, clear labelling is not in itself a guarantee of good quality standards. These companies import herbs from the People’s Republic of China either directly or through dealers in Hong Kong. The quality of imported herbs varies considerably, and great skill is needed to ensure that the correct herbs are provided to the practitioner.

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Therefore ranitidine 300 mg on line, implementation intentions describe the ‘what’ and the ‘when’ of a particular behaviour order ranitidine 300 mg on line. For example, the intention ‘I intend to stop smoking’ will be more likely to be translated into ‘I have stopped smoking’ if the individual makes the implementation intention ‘I intend to stop smoking tomorrow at 12. Further, ‘I intend to eat healthily’ is more likely to be translated into ‘I am eating healthily’ if the implementation intention ‘I will start to eat healthily by having an apple tomorrow lunchtime’ is made. Some experimental research has shown that encouraging individuals to make implementation intentions can actually increase the correlation between intentions and behaviour for behaviours such as taking a vitamin C pill (Sheeran and Orbell 1998), performing breast self-examination (Orbell et al. This approach is also supported by the goal-setting approach of cognitive behavioural therapy. Therefore, by tapping into variables such as implementation intentions it is argued that the models may become better predictors of actual behaviour. Developing theory based interventions The cognition and social cognition models have been developed to describe and predict health behaviours such as smoking, screening, eating and exercise. Over recent years there has been a call towards using these models to inform and develop health behaviour interventions. First, it was observed that many interventions designed to change behaviour were only minimally effective. For example, reviews of early interventions to change sexual behaviour concluded that these interventions had only small effects (e. Second, it was observed that many interventions were not based upon any theoretical frame- work nor were they drawing upon research which had identified which factors were correlated with the particular behaviour (e. One interesting illustration of this involved the content analysis of health promotion leaflets to assess their theoretical basis. The authors then identified the best cognitive and behavioural correlates of condom use based upon a meta analysis by Sheeran et al. The results showed very little association between theory and this form of behavioural intervention. Specifically, only 25 per cent of the leaflets referred to ten or more of the correlates and two-thirds of the leaflets failed to frequently target more than two of the correlates. Although, research is often aimed at informing practice, it would seem that this is not often the case. Putting theory into practice Given the call for more theory based interventions, some researchers have outlined how this can be done. Step 2: Identify the most salient beliefs about the target behaviour in the target popula- tion using open ended questions. Step 3: Conduct a study involving closed questions to determine which beliefs are the best predictors of behavioural intention. Step 4: Analyse the data to determine the beliefs which best discriminate between intenders and non intenders. However, as Sutton (2002b) points out this process provides clear details about the preliminary work before the intervention. These included persuasion, information, increasing skills, goal setting and rehearsal of skills. These are guided mastery experiences which involve getting people to focus on specific beliefs (e. Bandura 1997) and the ‘Elaboration Likelihood’ model (Petty and Cacioppo 1986) involving the presentation of ‘strong arguments’ and time for the recipient to think about and elaborate upon these arguments. Studies have also used a range of methods for their interventions including leaflets, videos, lectures and discussions. However, to date although there has been a call for interventions based upon social cognition models clear guidelines concerning how theory could translate into practice have yet to be developed. Those based upon social cognition models have attempted to change a range of behaviours. They then developed an intervention based upon persuasion to change these salient beliefs. The results showed that after the intervention the partici- pants showed more positive beliefs about safety helmet wearing than the control group and were more likely to wear a helmet at five months follow up. Other theory based interventions have targeted behaviours such as condom use (Conner et al. Further, although there is some evidence that theory based interventions are successful, whether the use of theory relates to the success of the intervention remains unclear. Some studies exploring health beliefs have emphasized lay theories, which present individuals as having complex views and theories about their health which influence their behaviour. This perspective regards individuals as less rational and examines lay theories in a relatively unstructured format using a qualitative approach.

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Secondary prevention is more limited and focuses on people who are most likely to need it— those who display risk factors for a given disorder generic ranitidine 300 mg on line. Risk factors are the social generic ranitidine 150 mg with amex, environmental, and economic vulnerabilities that make it more likely than average that a given individual will [7] develop a disorder (Werner & Smith, 1992). The following presents a list of potential risk factors for psychological disorders. Some Risk Factors for Psychological Disorders Community mental health workers practicing secondary prevention will focus on youths with these markers of future problems. Community prevention programs are designed to provide support during childhood or early adolescence with the hope that the interventions will prevent disorders from appearing or will keep existing disorders from expanding. Interventions include such things as help with housing, counseling, group therapy, emotional regulation, job and skills training, literacy training, social responsibility training, exercise, stress management, rehabilitation, family therapy, or removing a child from a stressful or dangerous home situation. The goal of community interventions is to make it easier for individuals to continue to live a normal life in the face of their problems. Community mental health services are designed to make it less likely that vulnerable populations will end up in institutions or on the streets. In summary, their goal is to allow at-risk individuals to continue to participate in community life by assisting them within their own communities. Suicide is a leading cause of death worldwide, and prevention efforts can help people consider other alternatives, particularly if it can be determined who is most at risk. Determining whether a person is at risk of suicide is difficult, however, because people are motivated to deny or conceal such thoughts to avoid intervention or hospitalization. One recent study found that 78% of patients who die by suicide explicitly deny suicidal thoughts in their last verbal communications [8] before killing themselves (Busch, Fawcett, & Jacobs, 2003). They measured implicit associations about death and suicide in 157 people seeking treatment at a psychiatric emergency department. Using a notebook computer, participants classified stimuli representing the constructs of ―death‖ (i. Response latencies for all trials were recorded and analyzed, and the strength of each participant‘s association between ―death‖ and ―me‖ was calculated. The researchers then followed participants over the next 6 months to test whether the measured implicit association of death with self could be used to predict future suicide attempts. These results suggest that measures of implicit cognition may be useful for determining risk factors for clinical behaviors such as suicide. Imagine the impact of a natural disaster like Hurricane Katrina on the population of the city of New Orleans. How would you expect such an event to affect the prevalence of psychological disorders in the community? What recommendations would you make in terms of setting up community support centers to help the people in the city? The efficacy of group psychotherapy for depression: A meta-analysis and review of the empirical research. Researching self-help/mutual aid groups and organizations: Many roads, one journey. Reducing risks for mental disorders: Frontiers for preventive intervention research. Measuring individual differences in implicit cognition: The Implicit Association Test. Summarize the ways that scientists evaluate the effectiveness of psychological, behavioral, and community service approaches to preventing and reducing disorders. We have seen that psychologists and other practitioners employ a variety of treatments in their attempts to reduce the negative outcomes of psychological disorders. But we have not yet considered the important question of whether these treatments are effective, and if they are, which approaches are most effective for which people and for which disorders. Accurate empirical answers to these questions are important as they help practitioners focus their efforts on the techniques that have been proven to be most promising, and will guide societies as they make decisions about how to spend public money to improve the quality of life of their citizens [1] (Hunsley & Di Giulio, 2002). Psychologists use outcome research, that is, studies that assess the effectiveness of medical treatments, to determine the effectiveness of different therapies. In some cases we might simply ask the client if she feels better, and in other cases we may directly measure behavior: Can the client now get in the airplane and take a flight? In every case the scientists evaluating the therapy must keep in mind the potential that other effects rather than the treatment itself might be important, that some treatments that seem effective might not be, and that some treatments might actually be harmful, at least in the sense that money and time are spent on programs or drugs that do not work. One threat to the validity of outcome research studies is natural improvement—the possibility that people might get better over time, even without treatment. People who begin therapy or join a self-help group do so because they are feeling bad or engaging in unhealthy behaviors. After being in a program over a period of time, people frequently feel that they are getting better. But it is possible that they would have improved even if they had not attended the program, and that the program is not actually making a difference. To demonstrate that the treatment is effective, the people who participate in it must be compared with another group of people who do not get treatment.

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Both sphincters have supportive roles in maintaining fecal continence (175) cheap 300mg ranitidine free shipping, and their disruption can result in inconti- nence (see Subheading 10 150 mg ranitidine mastercard. Forensic Evidence The presence of semen in the anus or rectum of a male complainant can be corroborative evidence of alleged anal intercourse in conjunction with the presented history and possible physical findings. The same is only true for a female complainant if no semen is detected in the vagina, because semen has been found on rectal and anal swabs taken from women who described vaginal intercourse only. It is postulated that the presence of semen in these cases results from vaginal drainage (49,179). Swabs should also be taken if a condom or lubricant was used during the sexual assault and if anilingus is alleged (see Subheading 7. Just as when sampling the skin elsewhere, if the perianal skin is moist, the stain should be retrieved on dry swabs. If there is no visible staining or the stain is dry, the double-swab technique should be used (28). The forensic practitioner should use as many swabs as are necessary to remove any visible stain (repeating moistened swab followed by dry swab). Although not specifically defined for forensic pur- Sexual Assualt Examination 105 poses, the perianal area should be considered as an area with a radius of 3 cm from the anus. Even though traditionally these swabs have been labeled “external anal swab,” they should be labeled as “perianal swab” to clearly indicate the site of sam- pling. The anal canal is then sampled by passing a wet swab and then a dry swab, sequentially, up to 3 cm through the anus. The proctoscope (anoscope) is then passed 2–3 cm into the anal canal, and the lower rectum is sampled using a dry swab. As the proctoscope is withdrawn, the anal canal can be sampled, again with a dry swab. As discussed previously, when examining female complainants of anal intercourse alone, swabs should also be obtained from the vagina. If doctors decide for clinical reasons to use a lubri- cant, they should apply the lubricant (from a single-use sachet or tube) sparingly, taking care not to contaminate the swabs, and must note its use on the forms returned to the forensic scientist. In the process of sampling the rectum/anal canal, the proctoscope may accumulate body fluids and trace evidence. Therefore, the used proctoscope should be retained, packaged separately, and stored in accordance with local policy. If the proctoscope is visibly wet on removal, swabbing may be con- ducted to retrieve visible material. If storage space is restricted, then the instrument should be swabbed and the swabs retained instead. Stool samples and toilet paper need not be collected routinely because the other samples described should be adequate for laboratory requirements. Persistence Data Under normal circumstances, the maximum recorded interval between the act of anal intercourse and the identification of spermatozoa on a rectal swab is 65 hours (181). However, in one exceptional case in which a female remained prone in the hospital for several days because of injuries sustained 106 Rogers and Newton during a sexual assault, semen was detected on anal swabs taken 113 hours after the act of anal intercourse (181). Medical Evidence When an allegation of anal penetration is made, the perianal skin, anal canal mucosa, and, when tolerated, the lower portion of the rectum should be examined with the aid of a proctoscope/anoscope. It is generally accepted that with gradual dilatation and lubrication, con- sensual penile anal intercourse can be performed without any resultant injury (80,182). Furthermore, it is important to emphasize that nonconsensual anal penetration can also occur in both children and adults without producing acute or chronic injury (3). Although anecdotal accounts have detailed the anal and rectal injuries that result from consensual penile/object anal penetration (121,175), few peer- reviewed articles have addressed this subject. Similarly, many studies have documented the presence of anal symptoms or signs among complainants of sexual assault (133,170), but few of these have described the acute injuries in any detail or related these injuries to the specific complaint and its subsequent outcome. Anal Fissures, Tears, and Lacerations The most frequent injuries that are documented after allegations of nonconsensual anal penetration are anal fissures, tears, and lacerations. Use of these different terminologies is confusing and makes comparing the differ- ent data impossible. A consensus should be reached among forensic practitio- ners worldwide regarding what terms should be used and what they mean. Clinically, an anal fissure refers to a longitudinal laceration in the perianal skin and/or mucosa of the anal canal. Anal fissures may be acute (usually heal- ing within 2–3 weeks) or chronic and single or multiple. However, after healing, the site of some Sexual Assualt Examination 107 fissures may be apparent as a fibrous skin tag (183).

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