Mark Corson

By W. Candela. University of Wisconsin-Madison.

However order 10mg escitalopram overnight delivery, these reports were largely anecdotal or from uncontrolled clinical trials escitalopram 20 mg sale. This encouraging preliminary study led to further trials on a larger number of subjects buy 20mg escitalopram free shipping, with longer periods of follow- up. The results showed no significant improvement, apart from a subjective improvement in bowel and bladder function in one of the studies. Detailed reviews and analysis of the 14 controlled trials of hyperbaric oxygen treatment showed that only one of the trials produced a significant positive effect. Simple steatosis is associated with obesity, occurring in 70% of patients who are 10% above ideal body weight and nearly 100% of those who are obese. In addition, special foods rich in factors that help protect the liver from damage and improve liver function include high-sulfur foods such as garlic, legumes, onions, and eggs; good sources of soluble fiber such as pears, oat bran, apples, and legumes; vegetables in the brassica family, especially broccoli, brussels sprouts, and cabbage; artichokes, beets, carrots, and dandelion; many herbs and spices such as turmeric, cinnamon, and cilantro; and green leafy vegetables that enhance detoxification processes in the liver. Nutritional Supplements Betaine and Other Lipotropic Factors Betaine, choline, methionine, vitamin B6, folic acid, and vitamin B12 are important lipotropic agents, compounds that promote the flow of fat and bile to and from the liver. Lipotropic agents have a long history of use in naturopathic medicine; in essence, they produce a “decongesting” effect on the liver and promote improved liver function and fat metabolism. The important thing in taking a lipotropic formula is to take enough to provide a daily dose of 1,000 mg betaine, 1,000 mg choline, and 1,000 mg methionine and/or cysteine. Carnitine plays an extremely important role in the utilization and metabolism of fatty acids in the liver as well as in the function of mitochondria, the energy-producing part of cells. Carnitine supplementation has been shown to significantly inhibit and even reverse alcohol-induced fatty liver disease. Since carnitine normally facilitates fatty acid transport and oxidation in the mitochondria, a high carnitine level may be needed to handle the increased fatty acid load produced by alcohol consumption or other liver injury. Results demonstrated significant improvements in the carnitine group, including improvement in liver function and evidence of improved mitochondrial function. Bile Acids Bile acids are naturally occurring compounds such as ursodeoxycholic acid and tauroursodeoxycholic acid that, like the liptropic agents described above, are effective in promoting the flow of bile and fat to and from the liver. Bile acid preparations are available by prescription, but mixtures of bile acids from ox bile are available in health food stores and may prove to be suitable alternatives. Botanical Medicines There is a long list of plants that have beneficial effects on liver function. However, the most impressive research is with the extract of milk thistle (Silybum marianum) known as silymarin. For more information on silymarin, see the chapter “Detoxification and Internal Cleansing. Certain foods are particularly helpful because they contain the nutrients the liver needs to produce and activate the dozens of enzymes involved in the various phases of detoxification or aid in the effective elimination of toxins. Such foods include: • Garlic, legumes, onions, eggs, and other foods with a high sulfur content. Osteoarthritis • Mild early-morning stiffness, stiffness following periods of rest, pain that worsens on joint use, loss of joint function • Local tenderness, soft tissue swelling, joint crepitus (crackling sound), bony swelling, and restricted mobility • X-ray findings (narrowed joint spaces, cartilage erosion, bone spurs, etc. The most common form of arthritis is osteoarthritis, which is also known as degenerative joint disease because it is characterized by joint degeneration and loss of cartilage, the shock-absorbing gel-like material between joints. Surveys have indicated that more than 40 million Americans have osteoarthritis, including 80% of those over the age of 50. Under age 45, osteoarthritis is much more common in men; after 45, it is a little more common in women. In primary osteoarthritis, the degenerative wear-and-tear process occurs after the fifth or sixth decade of life, with no apparent predisposing abnormalities. The cumulative effects of decades of use leads to the degenerative changes by stressing the collagen matrix, the support structure of the cartilage. Damage to the cartilage results in the release of enzymes that destroy cartilage components. With aging, the ability to restore and synthesize normal cartilage structures decreases. The incidence of osteoarthritis increases dramatically with age and body mass index for weight-bearing joints. Contributors to Osteoarthritis Age-related changes in collagen-matrix repair mechanisms Altered biochemistry Fractures and mechanical damage Genetic predisposition Hormonal and sex factors Hypermobility/joint instability Inflammation Inflammatory joint disease Other factors One of the most interesting clinical features of osteoarthritis is the lack of correlation between its severity as determined by X-rays and the degree of pain. In some cases the joint appears essentially normal, with little if any joint space narrowing, yet the pain can be excruciating. On the other hand, there are cases where there is tremendous deformity, yet little if any pain. In fact, about 40% of individuals with the worst X-ray classification for osteoarthritis are pain free. Therapeutic Considerations Normally the body deals with damage to cartilage by attempting to repair itself. The major therapeutic goal should be to decrease the rate of damage and enhance the repair and regeneration of the collagen matrix. All subjects had X-ray changes suggestive of advanced osteoarthritis, yet the researchers reported marked clinical improvement and X-ray evidence of repair in 14 of 31 hips over time. Although these drugs provide short-term symptomatic relief, they do not address the cause of the problem and may actually increase the rate of degeneration of the joint cartilage. Diet and Exercise The key dietary focus in the prevention and treatment of osteoarthritis is the achievement of normal body weight and improvement in insulin sensitivity. Excess weight means increased stress on weight- bearing joints, and there is also considerable evidence linking osteoarthritis to insulin resistance (see the chapter “Obesity and Weight Management”). Insulin resistance not only increases inflammation but also impairs cartilage regeneration. Weight reduction, possibly due to a combination of mechanical and physiological factors, reduces the risk for osteoarthritis and has also been shown to reduce pain and improve cartilage function in existing osteoarthritis, especially when combined with exercise.

When providing expert evidence regarding whether vaginal penetration has occurred buy 20mg escitalopram with amex, 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 buy 20mg escitalopram free shipping, which were only deposited on the outside of the vulva escitalopram 20 mg without a prescription, 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). At this point, the speculum may be manipulated within the vagina to locate the cervix. If doctors decide for clinical reasons to use a lubricant, then they should take care to apply the lubricant (from a single use sachet or tube) sparingly and must note its use on the forms returned to the forensic scientist. In the process of sampling the vagina, the speculum may accumulate body fluids and trace evidence. Therefore, the used speculum should be retained, pack- aged separately, and stored in accordance with local policy. If the speculum is visibly wet on removal, swabbing may be undertaken to retrieve visible material. In some centers, additional methods of semen collection are employed (5,63,103) in the form of aspiration of any pools of fluid in the high vagina and/or placing 2–10 mL of saline or sterile water in the vagina and then aspi- rating the vaginal washings. However, vaginal aspirates should not be neces- sary if dry swabs are used to sample the vagina in the manner described. Furthermore, there are no data to confirm that vaginal washings retrieve sper- matozoa more effectively than vaginal swabs. On these occasions, two dry swabs should be inserted sequentially into the vagina under direct vision, avoiding contact with the ves- tibule and hymen. An attempt should then be made to comprehensively sample the vagina by gently rotating and moving each swab backward and forward. Unfortunately, in such cir- cumstances, it is impossible to be certain that the high vaginal swab was not contaminated from semen in the low vagina, which could be there because of drainage from external ejaculation. Spermatozoa Some guidelines recommend that the forensic practitioner perform an immediate microscopic examination of a wet mount of the material obtained Sexual Assualt Examination 89 from the vaginal fornices to identify motile spermatozoa on the basis that the presence and motility of spermatozoa may help determine whether recent vagi- nal ejaculation had occurred. Forensic science laboratories have specialist extraction procedures, staining techniques, and microscopic equipment to maximize spermatozoa recovery and facilitate identification. A survey of 300 cases in which spermatozoa were eventually identified found that they were only detected in four of the cases in the native preparation (before the applica- tion of specialist stains) (105). Seminal Fluid If no spermatozoa are detected, an attempt is made to corroborate the allegation by the microscopic identification of seminal choline crystals. Semi- nal choline is present in high concentrations in seminal fluid, and the choline crystals can be precipitated by the addition of reagents (106). There are also electrophoretic techniques by which seminal fluid can be identified (107). This will be useful where the offender is suspected to be oligospermic or aspermic or when only minimal amounts of male epithelial cells have been deposited; Y chromosome-positive cells have been isolated from vaginal swabs taken immediately after intercourse where no ejaculation had occurred. Whenever bleeding is noted during the medical examination, the forensic practitioner should communi- cate to the scientist any possible source for the bleeding. In these cases, the presence of blood must be interpreted with caution, particularly if in small quantity, 90 Rogers and Newton because traces of uterine blood may be present at any time of the cycle (7) and, currently, there is no accepted method of differentiating between traumatic or uterine blood (111). Furthermore, even traumatic bleeding may result from con- sensual sexual acts (see Subheading 8. On rare occasions assailants injure their penises during a sexual act, and this may be the source of blood found in the vagina. The quantity of semen in the vagina will diminish progressively with time, usually as a result of drainage. The posture and activity of the complain- ant subsequent to the act are likely to affect this. Drainage of semen from the vagina may also result in soiling of intimate clothing items worn at the time, and these can prove valuable sources of body fluids. It has been observed that spermatozoa can be isolated for longer periods in the endocervix. Studies that compared paired swabs from the vagina and cervix have found that 2 days or more after vaginal ejaculation there is a larger quantity of spermatozoa on endocervical swabs compared with the vaginal swabs (115). Therefore, it is recommended that if a complainant presents 48 hours or more after alleged vaginal intercourse, an endocervical swab be taken in addition to the swabs from the vagina. There is interest in the possibility of determining the timing of inter- course by changes in spermatozoa. Spermatozoa may remain motile in the vagina for up to 24 hours and longer in the cervical mucosa (50,118,119), but the periods for persistence are extremely variable. For example, Rupp (120) observed that motile spermatozoa persisted longer in menstruating women but added that identification is hindered by the presence of red blood cells, and Paul (121) reported that the period of spermatozoa motility ranged Sexual Assualt Examination 91 from 1–2 hours at the end of the menstrual cycle to as long as 72 hours at the time of ovulation.

Do Not Overconsume Animal Foods Considerable evidence indicates that a high intake of red or processed meat increases the risk of an early death order escitalopram 10mg online. For example buy generic escitalopram 10mg line, in a cohort study of half a million people age 50 to 71 at the start of the study buy escitalopram 5mg on line, men and women who ate the most red and processed meat had an elevated risk for overall mortality compared with those who ate the least. At the same time, it contains lots of saturated fat and other potentially carcinogenic compounds, including pesticide residues, heterocyclic amines, and polycyclic aromatic hydrocarbons, the last two of which form when meat is cooked at high temperatures (grilled, fried, or broiled). As already discussed, the meat of wild animals that early humans consumed had a fat content of less than 4%. The demand for tender meat has led to the breeding of cattle whose meat contains 25 to 30% or more fat. Corn-fed domestic beef contains primarily saturated fats and virtually no beneficial omega-3 fatty acids (discussed later), whereas the fat of wild animals contains more than five times the polyunsaturated fat per gram and has substantial amounts (about 4–8%) of omega-3 fatty acids. Particularly harmful to human health are cured or smoked meats, such as ham, hot dogs, bacon, and jerky, that contain sodium nitrate and/or sodium nitrite—compounds that keep the food from spoiling but dramatically raise the risk of cancer. These chemicals react with amino acids in foods in the stomach to form highly carcinogenic compounds known as nitrosamines. Even more compelling is the evidence linking consumption of nitrates to a significantly increased risk of the major childhood cancers (leukemias, lymphomas, and brain cancers): • Children who eat 12 hot dogs per month have nearly 10 times the risk of leukemia compared with children who do not eat hot dogs. Fruits Fried foods, fatty snacks Vegetables, fresh salads Salt and salty foods Low-sodium foods, salt substitute Coffee, soft drinks Herbal teas, green tea, fresh fruit and vegetable juices Margarine, shortening, and other source of trans- Olive, macadamia nut, or coconut oil; vegetable spreads that contain no fatty acids or partially hydrogenated oils trans-fatty acids (available at most health food stores) Fortunately, vegetarian alternatives to these standard components of the American diet are now widely available, and many of them actually taste quite good. Consumers can find soy hot dogs, soy sausage, soy bacon, and even soy pastrami at their local health food stores as well as in many mainstream grocery stores. Those who must have red meat are encouraged to eat only lean cuts of meat, preferably from animals raised on grass rather than corn or soy. Eat the Right Types of Fats There is no longer any debate: the evidence is overwhelming that a diet high in fat, particularly saturated fat, trans fatty acids, and cholesterol, is linked to heart disease and numerous cancers. Both the American Cancer Society and the National Cancer Institute recommend a diet that supplies less than 30% of calories as fat. The goal is to decrease total fat intake (especially intake of saturated fats, trans-fatty acids, and omega-6 fats) while increasing intake of omega-3 fatty acids and monounsaturated fatty acids. What makes a fat “bad” or “good” has a lot to do with the function of fats in the body. The type of fat consumed determines the type of fatty acid present in the cell membrane. A diet high in saturated fat (primarily from animal fats), trans-fatty acids (from margarine, shortening, and other products that contain hydrogenated vegetable oils), and cholesterol results in unhealthy cell membranes. Without a healthy membrane, cells lose their ability to hold water, vital nutrients, and electrolytes. They also lose their ability to communicate with other cells and to be controlled by regulating hormones, including insulin. Without the right type of fats in cell membranes, cells simply do not function properly. Considerable evidence indicates that cell membrane dysfunction is a critical factor in the development of many diseases. The traditional Mediterranean diet has shown tremendous benefit in preventing and even reversing heart disease and cancer as well as diabetes. Olive oil contains not only the monounsaturated fatty acid oleic acid but also several antioxidant agents that may account for some of its health benefits. Keep Salt Intake Low, Potassium Intake High Electrolytes—potassium, sodium, chloride, calcium, and magnesium—are mineral salts that can conduct electricity when dissolved in water. For optimal health, it is important to consume these nutrients in the proper balance. Many people know that a high-sodium, low-potassium diet can cause high blood pressure and that the opposite can lower blood pressure,31,32 but not as many are aware that the former diet also raises the risk of cancer. Prepared foods contribute 45% of our sodium intake; 45% is added in cooking, and another 5% is added at the table. You can reduce your salt intake by following these tips: • Take the salt shaker off the table. These products are made with potassium chloride and taste very similar to regular salt (sodium chloride). Salt, soy sauce, salt brine, baking soda (sodium bicarbonate), and any ingredient with sodium in its name (such as monosodium glutamate) contain sodium. But experts believe that the optimal dietary K:Na ratio is greater than 5:1, which means we should be getting about ten times more potassium than we currently do. A natural diet rich in fruits and vegetables can easily produce much higher K:Na ratios, because most fruits and vegetables have a K:Na ratio of at least 50:1. The average K:Na ratios for several common fresh fruits and vegetables are as follows: Carrots 75:1 Potatoes 110:1 Apples 90:1 Bananas 440:1 Oranges 260:1 7. Avoid Food Additives Food additives are used to prevent spoiling, add color, or enhance flavor; they include such substances as preservatives, artificial flavorings, and acidifiers. Although the government has banned many synthetic food additives, it should not be assumed that all the additives currently used in the U. A great number of food additives remain in use that are being linked to such diseases as depression, asthma or other allergy, hyperactivity or learning disabilities in children, and migraine headaches. It is estimated that the per capita daily consumption of these food additives is approximately 13 to 15 g, with the result that each of us takes in an astounding 10 to 12 lb of these chemicals every year. However, many food additives fulfill important functions in the modern food supply. And while some are synthetic compounds with known cancer-causing effects, many substances approved as additives are natural in origin and possess health-promoting properties. Obviously, the most sensible approach is to focus on whole, natural foods and avoid foods that are highly processed.