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Many forensic pathologists under- take work involved in the clinical aspects of medicine super levitra 80mg, and 80mg super levitra, increasingly 80 mg super levitra, forensic physicians become involved in death investigation (21) super levitra 80 mg. Forensic work is now truly multiprofessional , and an awareness of what other specialties can contribute is an essential part of basic forensic education , work , and continu- ing professional development . Those involved in the academic aspects of fo- rensic medicine and related specialties will be aware of the relative lack of funding for research . This lack of funding research is often made worse by lack of trained or qualified personnel to undertake day-to-day service work . However, clinical forensic medicine continues to develop to support and enhance judicial systems in the proper, safe, and impartial dispen- sation of justice. A worldwide upsurge in the need for and appropriate imple- mentation of human rights policies is one of the drivers for this development, and it is to be hoped that responsible governments and other world bodies will continue to raise the profile of, invest in, and recognize the absolute necessity for independent, impartial skilled practitioners of clinical forensic medicine. T a b l e 3 C l i n i c a l F o r e n s i c M e d i c i n e : I t s P r a c t i c e A r o u n d t h e W o r l d Q u e s t i o n s a n d R e s p o n s e s J a n u a r y 2 0 0 3 Question A Is there a formal system in your country (or state) by which the police and judicial system can get immediate access to medical and/or forensic assessment of individuals detained in police custody (prisoners)? Police surgeons (forensic medical examiners/forensic physicians) are contracted (but not generally employed) by both police and courts to undertake this. Police surgeons do not necessarily have specific forensic training or qualifications. The formal and generic mechanism is for the individual to be taken to an emergency department of a nearby hospital. Rarely he or she may be sent for a specific purpose to a specialist forensic doctor. Under a Section of the Criminal Procedure Code, a police officer can immediately bring an arrested person to a doctor for examination. If the arrested person is a female, only a female registered medical practitioner can examine her. The accused/detained person can contact the doctor and have himself or herself examined. In larger institutions, senior doctors and, at times, forensic pathologists may examine them. The Netherlands Yes Nigeria Yes (for medical reasons) dependent on the availability of the physician. Spain Yes, any individual detained in police custody has the right to be examined by a doctor. In certain cases, one has the right to have a forensic assessment (by the Forensic Surgeon Corps of the Ministry of Justice). Sweden Yes Switzerland Yes Question B Who examines or assesses individuals who are detained in police custody to determine whether they are medi- cally fit to stay in police custody? Response Australia Nurses or medical practitioners who are employed or retained by police. Recent changes to statutory Codes of Practice suggest that an appropriate health care professional may be called. Hong Kong Currently, the duty police officer looks and asks if medical attention is required. Most duty officers are quite liberal in referring the individuals to the emergency department. The Netherlands Generally speaking: Public health officers, who are qualified in clinical forensic medicine. Nigeria Any doctor attached to prison services, the police or doctors in the local hospitals, depending on who is available. Serbia If there is an obvious health problem or if they have certain diseases that need medical attention, police will take them to a public healthcare facility or, in the case of emergency, call an ambulance. Spain When a person is under arrest (without having being put under regulation), he asks to be examined by a doctor, he is usually transferred to the Spanish Health Public System doctors. Switzerland The “prison doctor”: either a doctor of internal medicine of university hospital or in rural regions the district physician (acute cases). A forensic doctor of the Institute of Legal Medicine of the University of Zurich (not urgent cases, “chronic cases”). Question C If a prisoner is suspected of being under the influence of drugs or alcohol in police custody, is it usual for him or her to be examined by a doctor (or other health care professional) to determine whether they are fit to remain in custody? England and Wales Yes, if there are associated health concerns, or if there is a specific need to determine fitness to interview when either intoxication or withdrawal may render an interview invalid. Specific guidelines are published on care of substance misuse detainees in police custody. Germany Yes Hong Kong Yes, they will most certainly be sent to the emergency department. Registered addicts will occasionally be taken to a methadone clinic if they are suffering from withdrawal. The Netherlands Yes Nigeria No Scotland Only when a need is established or the prisoner requests medical assistance. Profound intoxication or suspicion of head injury would be an indication for examination. Serbia Intoxicated detainees may be requested to provide a blood or other appropriate samples for analysis. Samples are arranged outside police premises, usually in the public health institutions. Spain Yes, he or she is often examined and even blood samples are extracted (with his or her previous consent) if the prisoner is involved in some aggression, homicide or car driving, for example. Question D Does your country/state have specific codes/laws/statutes or regulations that make provision for the welfare of individuals in police custody? Response Australia Yes England and Wales Yes Germany Yes Hong Kong There are generic guidelines for all in custody; none specific to the police. India The Protection of Human Rights Act 1993 stipulates detailed provisions regarding this. Scotland Local procedures for each police force based on central guidance, but there is no statute. Serbia No South Africa Yes Spain Yes, there are specific rules in Constitution and in the Penal Code. Switzerland Yes Question E Who undertakes the forensic medical examination and assessment of alleged victims of sexual assault? England and Wales Police surgeons or sexual offense examiners or doctors employed within specialist sexual offenses units. Some forensic physicians, primary care physicians, emergency medicine physicians, and gynecologists undertake such examinations. The Netherlands Generally public health officers, qualified in clinical forensic medicine. Scotland Usually police surgeon, some may be admitted to hospital and be examined by hospital staff. Serbia There is no standard procedure for the examination of alleged victims of sexual assault. There are no protocols for the examination of victims, or for collection of forensic samples. Spain A forensic surgeon (médico forense) and a gynecologist (if the victim is female) or a proctologist (if the victim is male). A specialist in pediatric medicine or surgery always examines children, often, but not always, with a specialist in forensic medicine. Switzerland Physicians of Institute of Legal Medicine of University of Zurich (District Physician); Physicians of University Department of Gynecology, University Hospital Zurich. Question F Who undertakes the forensic medical examination and assessment of alleged perpetrators of sexual assault? India Different centers have different protocols (in this institution, forensic medicine specialists). A bizarre situation, where the victim goes to the gynecology department, whereas the accused in the same case comes to us. The Netherlands Generally speaking, public health officers who are qualified in clinical forensic medicine. Scotland Police surgeon (although experienced police surgeons are not readily available in some sparsely populated areas, and the inexperienced are often reluctant to embark on such an examination). Serbia In practical terms, rarely done although the Criminal Procedure Act allows examination of alleged perpetrators of any crime (including sexual assault) for forensic purposes even without their consent if the examination itself is not considered harmful to them. Switzerland Physicians of Institute of Legal Medicine of University of Zurich (District Physician). Question G In cases of sexual assault is it always possible for victim, perpetrator, or both to be examined by a doctor of the same gender if that is requested? Germany Yes Hong Kong No, there is currently only one full-time female forensic doctor able to do this. This would generally apply only to the victim (female gynecologists examine the victim anyway). Nigeria No Scotland Not always, but every effort is made to comply with an examinee’s wishes. Serbia There is no statutory provision that regulates free choice of either the victim or the perpetrator to be examined by a doctor of preferred (same) gender. Sweden No Switzerland Yes Question H Who undertakes the forensic medical examination and assessment of alleged child victims of sexual assault? Hong Kong Forensic pathologists/physicians, pediatricians, obstetricians, and gynecologists, sometimes jointly. India Female children—gynecologist, preferably female (which is generally the case anyway). The Netherlands Generally speaking, public health officers qualified in clinical forensic medicine. Scotland In the larger centers, joint pediatric/police surgeon examinations are common. Serbia Physicians with forensic training are rarely involved in initial examination and assessment. Switzerland Younger than 16 yr: female gynecologist at University Children Hospital. Question I Who undertakes the forensic medical examination and assessment of alleged child victims of physical assault? The Netherlands Generally speaking, public health officers qualified in clinical forensic medicine. Scotland Mostly pediatricians but some evidence is based on findings of family physicians. Situation is somewhat improved, but still poor cooperation between clinicians and forensic doctors. Switzerland Younger than 16 yr: doctors at University Children Hospital (Trauma-X group). Older than 16 yr: doctors of Institute of Legal Medicine of University of Zurich (District Physician). Question J Is there a system in your country/state whereby individuals detained in police custody who appear to have (or do have) psychiatric disorder or mental health problems or learning disability may be assessed? They are likely to be referred to psychiatrists or, in the case of learning disability, to social workers and/or clinical psychologists. This may not be strictly observed until and unless there is a court order that may need to be obtained by relatives. Israel Yes Malaysia Yes The Netherlands Yes Nigeria Yes Scotland Variable picture. If suspect is detained on the order of the investigative judge, then may be examined by psychiatrist and/or psychologist when need. If mental health problems are apparent, case is remitted to a judge and detainee is examined by a forensic surgeon and a psychiatrist. Sweden It’s part of the “police doctors” duties, but many custodies do have access to psychiatric consultants. Switzerland Those who have known disorders are followed by a specialized forensic psychiatric/psychological service; others are reported by the guards. Question K In your country/state are there specialized units or locations where victims of sexual assault are examined or assessed? Response Australia Yes England and Wales Yes, but not full geographical coverage; tends to be in urban centers. Germany No Hong Kong There are purpose-built video interview and medical examination suites. India No Israel Yes Malaysia Some major hospitals have “one-stop centers” with protocols for managements, both short- and long-term. Serbia No South Africa Yes Spain Victims of sexual assault are examined in gynecology or pediatric units of large hospitals. Question L In cases of alleged assault by police, who examines the police personnel? Response Australia Forensic medical officers (report and documentation of injuries). The Netherlands Generally speaking, public health officers qualified in clinical forensic medicine. Spain A forensic surgeon as member of the Ministry of Justice (completely independent of the police). Switzerland Physicians of Institute of Legal Medicine, University of Zurich (District Physician). Response Australia Forensic medical officers (report and documentation of injuries).

Books and Other Individual Titles on the Internet 1445 Box 72 continued from previous page super levitra 80 mg. In this case 80mg super levitra, give whatever name is used for the part and follow it with a comma and the title super levitra 80mg. Parts of a book on the Internet with equal text in two or more languages Title for a Part of a Book on the Internet (required) General Rules for Title • Enter the title of the part as it appears in the book Books and Other Individual Titles on the Internet 1447 • Capitalize only the frst word of a title 80 mg super levitra, proper nouns , proper adjectives , acronyms , and initialisms • Use a colon followed by a space to separate a title from a subtitle unless some other form of punctuation (such as a question mark , period , or an exclamation point) is already present • Follow non-English titles with a translation whenever possible; place the translation in square brackets • End title information with a semicolon and a space Specific Rules for Title • Titles for parts not in English • Titles for parts in more than one language • Titles for parts containing a Greek letter , chemical formula, or other special character • No title appears Box 76. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Books and Other Individual Titles on the Internet 1449 Box 77 continued from previous page. Veterinary public health and control of zoonoses in developing countries = Sante publique veterinaire et controle des zoonoses dans les pays en developpement = Salud publica veterinaria y control de zoonosis en Paises en Desarrollo [Internet]. Titles for parts containing a Greek letter, chemical formula, or other special character. Figure 3, Infuence of seed extract of Syzygium Cumini (Jamun) on mice exposed to diferent doses of γ-radiation; may become Figure 3, Infuence of seed extract of Syzygium Cumini (Jamun) on mice exposed to diferent doses of gamma-radiation; • If a title contains superscripts or subscripts that cannot be reproduced with the type fonts available, place the superscript or subscript in parentheses Box 78 continues on next page... Occasionally a part does not have a formal title, only a legend (explanatory text) for the table, fgure, appendix, or other part. Parts of a book on the Internet with equal text in two or more languages Books and Other Individual Titles on the Internet 1451 Date of Update/Revision for a Part of a Book on the Internet (required) General Rules for Date of Update/Revision • Parts of books may be updated or revised between editions or versions • Begin update/revision information with a lef square bracket • Use whatever word for update or revision is provided, such as updated and modifed • Always give the year of update/revision • Convert roman numerals to arabic numbers. Look for the date accompanied by such words as updated, modifed, revised, reviewed: • At the top, bottom, or sidebar of the frst screen for the part or the bottom of the last screen of the part • In the source code for the part if it is displayed by the Web browser Box 81. Parts of a book on the Internet with date of update/revision Date of Citation for a Part of a Book on the Internet (required) General Rules for Date of Citation • Always include the date the part of a book was seen on the Internet • Include the year month and day in that order, such as 2006 May 5 • Use English names for months and abbreviate them using the frst three letters, such as Jan Books and Other Individual Titles on the Internet 1453 • If a date of update/revision is given, place the date of citation afer it and follow both dates with a right square bracket • If no date of update/revision is given, place citation date information in square brackets • End date information with a semicolon placed outside the closing bracket Specific Rules for Date of Citation • Both a date of update/revision and a date of citation Box 84. Various words are used to show that the content of a part of a book has been changed. Squeezed: why rising exposure to health care costs threatens the health and fnancial well-being of American families [Internet]. When this occurs, give the total number of pages of the part you are citing, placed in square brackets, such as [5 p. Appendix 3C, Description of model output tables and graphs; [cited 2006 Dec 15]; [7 p. If a video clip, videocast , or podcast is part of a book: • Place the word Video, Videocast, or Podcast in square brackets followed by a comma and a space • Enter the title of the part, followed by a semicolon and a space • Give the date of update/revision (if known) and the date of citation in square brackets, separated by a semicolon and a space • End date information with a semicolon and a space • Give extent as the number of minutes needed to view/listen, placed in square brackets • Abbreviate minutes to min. Standard citation to a part of a book on the Internet with traditional page numbers for location 2. Hypertextbook of regional anaesthesia for obstetrics: an international perspective [Internet]. Parts of a book on the Internet with equal text in two or more languages Books and Other Individual Titles on the Internet 1459 Language for a Part of a Book on the Internet (required) General Rules for Language • Give the language of publication if not English • Capitalize the language name • Follow the language name with a period Specific Rules for Language • Parts appearing in more than one language Box 92. Veterinary public health and control of zoonoses in developing countries = Sante publique veterinaire et controle des zoonoses dans les pays en developpement = Salud publica veterinaria y control de zoonosis en Paises en Desarrollo [Internet]. Parts of a book on the Internet with equal text in two or more languages Examples of Citations to Parts of Books on the Internet 1. Chapter 3, Guide to the contents of a protocol and review; [cited 2006 Nov 17]; p. Cochrane handbook for systematic reviews of interventions [monograph on the Internet]. Chapter 3, Guide to the contents of a protocol and review; [cited 2006 Nov 17]; p. Communicators guide for federal, state, regional, and local communicators [Internet]. Developing a national registry of pharmacologic and biologic clinical trials: workshop report [Internet]. Communicators guide for federal, state, regional, and local communicators [Internet]. Chapter 5, Te healing power of chemistry; [cited 2006 Nov 17]; [about 10 screens]. Nutrition and physical activity feld assessment of children in rural America [Internet]. Table 1, Prevalence of overweight among rural children in Save the Children regions; [cited 2006 Nov 7]; p. Developing a national registry of pharmacologic and biologic clinical trials: workshop report [Internet]. Squeezed: why rising exposure to health care costs threatens the health and fnancial well-being of American families [Internet]. Guidelines for the production of scientifc and technical reports: how to write and distribute grey literature [Internet]. Annex, List of institutions adopting the Guidelines; [cited 2006 Nov 15]; [about 1 screen]. Case study 3, Promoting high reliability surgery and perinatal care through improved teamwork and communication at Kaiser Permanente; [cited 2006 Nov 7]; p. Section 2, Chapter 5, Maintaining good nutrition; [cited 2006 Nov 7]; [about 8 screens]. Te use of opioids for the treatment of chronic pain: a consensus statement [Internet]. Part 4, Current information and experience suggest that many commonly held assumptions need modifcation; [cited 2006 Nov 7]; p. Other unnamed parts of books on the Internet Prescription drugs: abuse and addiction [Internet]. Protriptyline; [revised 2007 Aug 1; reviewed 2007 Aug 1; cited 2008 Oct 2]; [about 5 p. Die Bedeutung der deutschen Arztevereine fur das wissenschafliche Leben, die medizinische Versorgung und soziale Belange der Stadt St. Leipzig (Germany): Universitat Leipzig, Karl-Sudhof- Institut fur Geschichte der Medizin und der Naturwissenschafen; 2000. Tabelle 1, Verteilung der deutschsprachigen Bevolkerung auf die einzelnen Stadtteile von St. Parts of a book on the Internet with equal text in two or more languages Robinson A, compiler. Veterinary public health and control of zoonoses in developing countries = Sante publique veterinaire et controle des zoonoses dans les pays en developpement = Salud publica veterinaria y control de zoonosis en Paises en Desarrollo [Internet]. Sample Citation and Introduction to Citing Contributions to Books on the Internet Te general format for a contribution to a book on the Internet, including punctuation: Examples of Citations to Contributions to Books on the Internet Contributions are found when a book has an overall editor or editors and the individual chapters or other components of the book are written by various authors, usually called contributors. See also 1466 Citing Medicine Chapter 2D Contributions to Books for additional examples of contributors to books in print or in microform (microflm, microfche). Because a reference should start with the individual or organization responsible for the intellectual content of the publication, begin a reference to a contribution with the author and title of the contribution, followed by the word "In:" and information about the entire book. Te primary diference between citing a contribution to a print book and one on the Internet is in expressing the location (pagination) of the contribution. Screen size, font used, and printers vary greatly, but the purpose is to give an indication of the length of the part. Medical texts frequently contain charts, fgures, and other illustrative material reproduced with permission from other sources. Contributions to a part of a book on the Internet, such as a table or fgure, may be cited as individual items. Continue to Citation Rules with Examples for Contributions to Books on the Internet. Citation Rules with Examples for Contributions to Books on the Internet Components/elements are listed in the order they should appear in a reference. An R afer the component name means that it is required in the citation; an O afer the name means it is optional. Author (R) | Author Afliation (O) | Title (R) | Connective Phrase (R) | Book Information (R) | Date of Citation (R) | Location (Pagination) (R) | Availability (R) | Language (R) | Notes (O) Books and Other Individual Titles on the Internet 1467 Author of a Contribution to a Book on the Internet (required) General Rules for Author • List names in the order they appear in the text • Enter surname (family or last name) frst for each author • Capitalize names and enter spaces within surnames as they appear in the document cited on the assumption that the author approved the form used. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Books and Other Individual Titles on the Internet 1469 Box 94 continued from previous page. Names in non-roman alphabets (Cyrillic, Greek, Arabic, Hebrew, Korean) or character-based languages (Chinese, Japanese). Romanization, a form of transliteration, means using the roman (Latin) alphabet to represent the letters or characters of another alphabet. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Books and Other Individual Titles on the Internet 1471 Box 98 continued from previous page. An organization such as a university, society, association, corporation, or governmental body may serve as an author. International Union of Pure and Applied Chemistry, Organic and Biomolecular Chemistry Division. American College of Surgeons, Committee on Trauma, Ad Hoc Subcommittee on Outcomes, Working Group. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Books and Other Individual Titles on the Internet 1473 Box 99 continued from previous page. Separate the surname from the given name or initials by a comma; follow initials with a period; separate successive names by a semicolon. Standard reference to a contributed chapter of an Internet book 1474 Citing Medicine 2. Contribution to an Internet book with optional full frst names for authors and editors 3. Contribution to an Internet book with authors having a family designation of rank 5. Contribution to an Internet book with author names having a particle or prefx (give as found in the publication) 6. Books and Other Individual Titles on the Internet 1475 Box 101 continued from previous page. If you abbreviate a word in one reference in a list of references, abbreviate the same word in all references. Marubini E (Istituto di Statistica Medica e Biometria, Universita degli Studi di Milano, Milan, Italy), Rebora P, Reina G. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Books and Other Individual Titles on the Internet 1477 Box 103 continued from previous page. Moskva becomes Moscow Wien becomes Vienna Italia becomes Italy Espana becomes Spain Examples for Author Affiliation 7. Contribution to an Internet book with author afliation included Title of a Contribution to a Book on the Internet (required) General Rules for Title • Enter the title of the chapter or other contribution as it appears in the original document, in the original language • Capitalize only the frst word of a title, proper nouns, proper adjectives, acronyms, and initialisms • Use a colon followed by a space to separate a title from a subtitle unless some other form of punctuation (such as a question mark, period, or an exclamation point) is already present 1478 Citing Medicine • Follow non-English titles with a translation whenever possible; place the translation in square brackets • End a title with a period unless a question mark or exclamation point already ends it Specific Rules for Title • Titles not in English • Titles in more than one language • Titles containing a Greek letter, chemical formula, or other special character Box 105. Diagnostika i kompleksnoe lechenie osnovnykh gastroenterologicheskikh zabolevanii: klinicheskie ocherki. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Books and Other Individual Titles on the Internet 1479 Box 105 continued from previous page. Base molecular de la expresion del mensaje genetico [Molecular basis of gene expression]. Diagnostika i kompleksnoe lechenie osnovnykh gastroenterologicheskikh zabolevanii: klinicheskie ocherki [Diagnosis and complex treatment of basic gastrointestinal diseases: clinical studies]. If a chapter or another contribution is presented in two or more equal languages, as ofen occurs in Canadian publications: • Give all titles in the order in which they are found on the title page or opening screens • Place an equals sign with a space on either side between the titles Example: Box 106 continues on next page... Le genome: avancees scientifques et therapeutiques et consequences sociales = Te genome: scientifc and therapeutic developments and social consequences. Books and Other Individual Titles on the Internet 1481 Box 107 continued from previous page. Contribution to an Internet book with title beginning with a lower-case letter or containing a special symbol or character 10. Contribution to an Internet book with a non-English title Connective Phrase for a Contribution to a Book on the Internet (required) General Rules for Connective Phrase • Place a space and the word "In" afer the title of the contribution • Follow "In" with a colon and a space Examples for Connective Phrase 1. Contribution has a date of publication or date of update/revision that difers from the book as a whole. Contributions may be published with individual dates separate from the date of the book as a whole or may be updated or otherwise revised separately from book as a whole. When this occurs: • Give a separate date of publication and/or date of update/revision afer the title for the contribution Box 108 continues on next page... Contributed paper in a conference proceedings on the Internet Date of Citation for a Contribution to a Book on the Internet (required) General Rules for Date of Citation • Always include the date the contribution to a book was seen on the Internet • Include the year month and day in that order, such as 2006 May 5 • Use English names for months and abbreviate them using the frst three letters, such as Jan • If a date of update/revision is given, place the date of citation afer it and follow both dates with a right square bracket • If no date of update/revision is given, place citation date information in square brackets • End date information with a period placed outside the closing bracket Books and Other Individual Titles on the Internet 1483 Specific Rules for Date of Citation • Both a date of update/revision and a date of citation Box 109. Various words are used to show that the content of a contribution a book has been changed. When this occurs, give the total number of pages of the part you are to citing, placed in square brackets, such as [5 p. Books and Other Individual Titles on the Internet 1485 Box 112 continued from previous page. If the entire contribution is a video clip, videocast, or podcast: • Enter the word Video, Videocast, or Podcast followed by a colon and a space • Give extent as the number of minutes needed to view/listen • Abbreviate minutes to min. Contribution to an Internet book with location (pagination) expressed as standard page numbers 16. Hypertextbook of regional anaesthesia for obstetrics: an international perspective [Internet].

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One study failed to show any benefit,68 while another showed that in some patients it prevents airway constriction and reduced breathing capacity. Supplemental selenium appears warranted to address any deficiency of glutathione peroxidase. Vitamin B12 Noted physician Jonathan Wright believes that “B12 therapy is the mainstay treatment for childhood asthma. Trendelenburg demonstrated that magnesium relaxed bovine bronchial smooth muscle in test tube studies. Nebulized magnesium has also proved useful as an adjunct to standard bronchodilation therapies in severe asthmatics, with a greater response in those with life-threatening asthma. In addition to correcting a vitamin D insufficiency, vitamin D supplementation may improve asthma control by blocking the cascade of inflammation-causing proteins in the lung. The researchers were surprised to find that the vitamin D not only decreased flu by 42% but also decreased asthma attacks by a remarkable 83%. A cross-sectional analysis of 601 adults with asthma found that 14% of asthma sufferers use either herbal products, coffee, or black tea in order to treat their condition. Unfortunately, this study illustrated that those who used these methods had a higher incidence of hospitalization. The most popular historical herbal treatment of asthma involved the use of Ephedra sinensis (ma huang) in combination with herbal expectorants. This approach appeared to have considerable merit, as ephedra and its alkaloids have proved effective as bronchodilators in treating mild to moderate asthma and hay fever. Ivy (Hedera helix) In Europe, herbal preparations containing extracts from the leaves of ivy (Hedera helix) enjoy great popularity for the relief of coughing as well as asthma. In 2007, more than 80% of herbal expectorants prescribed in Germany included ivy extract, amounting to nearly 2 million prescriptions nationwide. Ivy leaf contains saponins (alpha-hederin and hederacoside C) that show expectorant, mucolytic, spasmolytic, bronchodilatory, and antibacterial effects. The reviewers concluded that ivy leaf extract preparations improve a variety of respiratory functions in children with chronic bronchial asthma, but noted the data were meager. In the only placebo-controlled, double-blind study reviewed, 24 children with asthma between the ages of 4 and 12 were given a dry ivy leaf extract (35 mg) in cough drops or a placebo for three days with a washout of three to five days before crossing over to the other treatment. Superiority of the ivy leaf extract over the placebo was noted by small improvements in airway resistance, residual volume, and breathing capacity when the baseline measurements were compared with the third day at three hours after the morning dose. Licorice Licorice (Glycyrrhiza glabra) root has a long history of use as an anti-inflammatory and antiallergic agent, and there is considerable documentation in the scientific literature. The primary active component of licorice root in this application is glycyrrhetinic acid, a compound that has shown cortisol-like activity. In particular, glycyrrhetinic acid has been shown to inhibit phospholipase A 2, the enzyme responsible for cleaving arachidonic acid from the phospholipid membrane pool and initiating the formation of inflammatory prostaglandins and leukotrienes. Capsaicin from Cayenne Pepper Experimental evidence has shown that capsaicin, the major active component of cayenne pepper (Capsicum frutescens), desensitizes airway mucosa to various mechanical and chemical irritants. Because of the location of substance P and its physiological action, it is believed to play an important role in atopic conditions such as asthma and atopic dermatitis. Jujube Plum The jujube plum (Zizyphi fructus) has been used extensively in Chinese medicine for the treatment of asthma and allergic rhinitis. Tylophora The leaves of tylophora (Tylophora asthmatica) have been used extensively in ayurvedic medicine for asthma and other respiratory tract disorders. Tylophora’s mode of action is unknown but is thought to be due to its alkaloids, especially tylophorine, which have been reported to possess antihistamine and antispasmodic activity, as well as inhibition of mast cell degranulation. Several double-blind clinical studies have shown tylophora to produce good results. In another double-blind study of 103 patients, those receiving 40 mg of the dry alcoholic extract of Tylophora indica per day for only six days demonstrated significant improvement in symptoms of asthma compared with a placebo group. The incidence of side effects such as nausea, partial diminution of taste for salt, and slight mouth soreness was 16. These results, as well as the results from an additional study, indicate that the benefits of tylophora are short-lived. The antiasthmatic effects of orally administered or inhaled ginkgolides have been shown to produce improvements in respiratory function and reduce bronchial reactivity in several double- blind studies. Aloe Vera Administration of aloe vera preparations may be effective for patients who are not dependent on corticosteroids. In one study, the oral administration of an aloe vera extract for six months was shown to produce good results in the treatment of asthma in some individuals of various ages. Subjecting the leaves to dark and cold results in an increase in the polysaccharide fraction—1 g of crude extract obtained from leaves stored in cold and dark produced 400 mg neutral polysaccharide compared with only 30 mg produced from leaves not subjected to cold or dark. The dosage was 5 ml of a 20% solution of the aloe vera extract in saline twice per day for 24 weeks; 11 of 27 patients (40%) without corticosteroid dependence felt much better at the study’s conclusion. The mechanism of action is thought to be restoration of protective mechanisms, plus augmentation of the immune system. Coleus Coleus forskohlii extract may be particularly useful in asthma, as its active component, forskolin, has been shown to have remarkable effects in relaxing constricted bronchial muscles in asthmatics. However, on the basis of the plant’s historical use and additional mechanisms of action, it appears likely. Boswellia The Indian ayurvedic botanical Boswellia serrata exerts anti-inflammatory and anti-allergy effects. In one double-blind, placebo-controlled study, bronchial asthma was reduced in 70% of 40 patients treated with boswellia gum resin at 300 mg three times per day for six weeks, whereas only 27% of the control group improved. Improvement was seen in physical symptoms and signs such as shortness of breath, the number of attacks, breathing capacity, and eosinophil counts. This model considers that acute symptoms may be caused by invasion from cold wind (environmental factors) or by an internal condition stemming from a lung heat condition (increased inflammation and eosinophilia). Chronic asthma is considered more of a weakness in the lung itself or a weakness of the spleen, which is responsible for nourishing the lung chi. In one study, 41 patients with chronic obstructive asthma were randomly assigned to receive acupuncture plus standard care, acupressure plus standard care, or standard care alone. For each subject, 20 acupuncture treatments were given, and self-administered acupressure was performed daily for eight weeks. According to a standard respiratory questionnaire, the acupuncture subjects showed an average 18. Additionally, for patients who received acupressure, the irritability domain score exhibited an 11. On the basis of breathing function and shortness of breath scores, 6-minute walking distance measurements, and state anxiety scale scores, the acupressure group had significant improvements in breathing and less anxiety compared with the sham group. We recommend consulting a naturopathic physician or another medical practitioner who can help coordinate all of these different factors. Environment Airborne allergens such as pollen, dander, and dust mites are often difficult to avoid entirely, but measures described above must be taken to reduce exposure. If the patient is willing, or if his or her asthma is unresponsive to recommended therapy, a vegan diet (with the possible inclusion of cold-water fish) should be tried for a minimum of four months to one year. Moderate fruit consumption, especially apples, should also be encouraged, along with the liberal use of green tea. Counseling is also important for children with moderate to severe asthma, who may develop behavioral problems. Acupuncture and Acupressure Regular acupuncture and home acupressure treatments should be used. Clinical observation and epidemiological surveys typically report a greater incidence in boys than girls (approximately 2:1). Onset is usually by the age of three, although the diagnosis is often not made until later, when the child is in school. These characteristics are frequently associated with difficulties in school, both in learning and in behavior. Research into what causes these changes has focused on genetic, environmental, and nutritional factors. These medications reportedly improve behavior and cognitive functioning in approximately 75% of children in formal placebo-controlled trials. However, the success of treatment when studied in actual clinical practice may be significantly lower. Furthermore, follow-up studies have failed to demonstrate long-term benefits with these stimulant medications. Additionally, these drugs are associated with a high prevalence of adverse effects such as decreased appetite, sleep problems, anxiety, and irritability. Some of the long-term effects of these drugs could be extremely detrimental to both brain function and behavior. Maternal-to-fetal transport of various neurotoxins can occur readily during pregnancy. A woman who has an ongoing exposure to or a significant body burden of neurotoxic substances (e. Children remain susceptible to neurotoxins following birth, and some of these agents have been shown to be common among children in North America. Consumers Union recently conducted the largest study to date looking at the level of human exposure to a wide range of pesticides in the U. Since Feingold’s presentation on this subject to the American Medical Association in 1973, the role of food additives as a contributing cause of hyperactivity has been hotly debated in the scientific literature. In actuality, however, researchers have focused on only 10 food dyes, though Feingold was concerned with 3,000 food additives. At first glance, it appears that the majority of the double-blind studies designed to test the hypothesis have shown essentially negative results. However, upon closer examination of these studies and further investigation into the literature, it becomes evident that food additives do, in fact, play a major role in hyperactivity. The results showed that the children given the artificial food coloring agents had a statistically significant adverse increase in hyperactivity. Feingold contended that there is a conflict of interest on the part of the Nutrition Foundation, an organization supported by major U. It seems significant that the Nutrition Foundation has financed most of the negative studies. The conflict of interest arises because these companies would suffer economically if food additives were found to be harmful. Other countries have significantly restricted the use of artificial food additives because of possible harmful effects. Critics of the hypothesis ignore the significance of these clear, reproducible individual results. The bottom line is that some children react strongly enough to food additives to warrant eliminating these compounds in the diet for at least 10 days to judge their significance in a particular child. One study demonstrated that destructive- aggressive and restless behavior significantly correlated with the amount of sugar consumed. In another study, researchers performed five-hour oral glucose tolerance tests on 261 hyperactive children; 74% displayed abnormal glucose tolerance or hypoglycemia. This should not be surprising: omega-3 fatty acids are critical in the structure and function of brain cells. Several clinical trials have now demonstrated positive effects of zinc supplementation in hyperactive children. Anemia from iron deficiency is estimated to affect approximately 20% of infants, and many more are thought to suffer milder iron deficiencies without anemia, leaving them at risk for impairment of brain development. These organisms function as part of the first line of defense in gut immunity and have been shown to counteract altered gut permeability due to food allergies. In two of the studies, children supplemented with Pycnogenol (1 mg/kg per day) showed improved antioxidant status. Biofeedback In biofeedback training treatment, individuals are provided with real-time feedback about their brainwave activity through electronic instrumentation. This feedback allows the subject to learn self- regulation of brainwave intensity and frequency. Diet An allergy elimination (oligoantigenic) diet for a period of four weeks, followed by reintroduction of (challenge with) suspected foods (full servings at least once a day, one food introduced every three to four days), is the most sensible and economical approach for identifying food allergies; for more information see the chapter “Food Allergy. Asperger syndrome differs from autism in that it does not involve delays in mental development and language. In many cases the child appears to be developing normally but then suddenly becomes silent, withdrawn, self-abusive, or indifferent to social overtures. Diagnosis is now possible in many cases at 18 months and in some cases as early as 12 months. Early behavioral or cognitive intervention can help autistic children gain self-care, social, and communication skills. The number of reported cases of autism increased dramatically in the 1990s and early 2000s. It does have a strong genetic component, but as with most health conditions, dietary and environmental factors play a huge role in whether and how the genetic predisposition is manifested. Perhaps more important than a specific genetic marker are the factors that determine how genes are expressed, such as environmental and nutritional factors. Although controversies surround the various proposed environmental causes, such as heavy metals, pesticides, or childhood vaccines, there is little doubt that genetic factors on their own are insufficient to lead to autism. In general, the earlier these interventions are initiated the better the prognosis.

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