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Such support may be mixed, however, with what is experienced by the distressed parent as criticism, interference, obligations and demands which create stress above and beyond the divorce itself. Women were also more likely to involve these "support people" in the parental disputes (6). A stepwise progression of active and reactive coalition building was then likely to ensue. New Partners the advent of a new partner in divorce may escalate parental disputes over the child or precipitate new ones (6). Sometimes, new partners are the instigators and mobilizers of custody disputes, where previously there was little overt conflict between the parents. In many jurisdictions, the courts are increasingly relying on the assistance and input of mental health professionals. On the other hand, mental health services may be protracted and ineffective in high conflict cases. Potentially Harmful Influence of Mental Health Professionals Written and verbal statements by custody evaluators can have a negative impact on disputing parents, especially when the situation is explained in terms of what is wrong with the parents (6). Influence of Therapist Attitudes the fundamental beliefs of many therapists about the etiology of psychological problems and what constitutes appropriate treatment can make the therapist an unwitting reinforcer of alienation. They may also feel a sense of betrayal when a parent moves out and the parents are focusing more on their conflicts with each other than on their parental responsibilities (32). A detailed example of such a process is presented in the Real World of Child Interrogations which contains an analysis of multiple child therapy sessions in a contested custody case (36). Validators When abuse is alleged, anyone in a position of authority can act as a "validator," including therapists, police, child protection workers, and medical personnel (37). They see their role as validating the alleged abuse rather than conducting an objective investigation. An analysis of 150 tape-recorded abuse interviews with children identified specific adult interviewer behaviors which influence children to alter accounts and to say things that will satisfy or please the interviewer (36). Such effects occur even among professionals trained not to use suggestive methods. The implications for law enforcement and the courts are staggering since eyewitness testimony is heavily relied upon in these settings. When Cults Have a Role in Parental Alienation In extreme cases, a divorced parent determined to deprive the other parent of a relationship with the child will join a cult for the powerful help the group can provide in alienating the child from the other parent. In an effort to recruit and control members, cults have perfected the art of parental alienation. Y was eager to mediate the dissolution and offered to stipulate to joint legal custody with reasonable visitation to the father.
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Hunt for their sterling contributions in checking source materials and assisting with the fnal production of the report. Edwards and Constantine Gatsonis Committee Co-chairs this document is a research report submitted to the U. As recommended in the Senate Report, the persons selected to serve included members of the forensic science community, members of the legal community, and a diverse group of scientists. During these meetings, the committee heard expert testimony and deliberated over the information it heard and received. Between meetings, committee members reviewed numerous published materials, studies, and reports related to the forensic science disciplines, engaged in independent research on the subject, and worked on drafts of the fnal report. The testimonial and documentary evidence considered by the committee was detailed, complex, and sometimes controversial. Given this reality, the committee could not possibly answer every question that it confronted, nor could it devise specifc solutions for every problem that it identifed. Rather, it reached a consensus on the most important issues now facing the forensic science community and medical examiner system and agreed on 13 specifc recommendations to address these issues. Challenges Facing the Forensic Science Community For decades, the forensic science disciplines have produced valuable evidence that has contributed to the successful prosecution and conviction of criminals as well as to the exoneration of innocent people. Many crimes that may have gone unsolved are now being solved because forensic science is helping to identify the perpetrators. Those advances, however, also have revealed that, in some cases, substantive information and testimony based on faulty forensic science analyses may have contributed to wrongful convictions of innocent people. This fact has demonstrated the potential danger of giving undue weight to evidence and testimony derived from imperfect testing and analysis. Moreover, imprecise or exaggerated expert testimony has sometimes contributed to the admission of erroneous or misleading evidence. Further advances in the forensic science disciplines will serve three important purposes. First, further improvements will assist law enforcement offcials in the course of their investigations to identify perpetrators with higher reliability. Second, further improvements in forensic science practices this document is a research report submitted to the U. Numerous professionals in the forensic science community and the medical examiner system have worked for years to achieve excellence in their felds, aiming to follow high ethical norms, develop sound professional standards, ensure accurate results in their practices, and improve the processes by which accuracy is determined. Although the work of these dedicated professionals has resulted in signifcant progress in the forensic science disciplines in recent decades, major challenges still face the forensic science community. The best professionals in the forensic science disciplines invariably are hindered in their work because these and other problems persist. In so doing, the committee was able to better comprehend some of the major problems facing the forensic science community and the medical examiner system.
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Each of these segments consists of ordered sequences of the base pairs, called A, G, C, and T. Studies have been conducted to determine the range of variation in the sequence of base pairs at each of the 13 loci and also to determine how much variation exists in different populations. By contrast, before examining two fngerprints, one cannot say a priori which features should be compared. Moreover, a small stretching of distance between two fngerprint features, or a twisting of angles, can result from either a difference between the fngers that left the prints or from distortions from the impression process. For these reasons, population statistics for fngerprints have not been developed, and friction ridge analysis relies on subjective judgments by the examiner. For 10-print fngerprint cards, which tend to have good clarity, even automated pattern-recognition software (which is not as capable as human examiners) is successful enough in retrieving matching sets from databases to enjoy widespread use. When dealing with a single latent print, however, the interpretation task becomes more challenging and relies more on the judgment of the examiner. The committee heard presentations from friction ridge experts who assured it that friction ridge identifcation works well when a careful examiner works with good-quality latent prints. Those criteria become increasingly important when working with latent prints that are smudged and incomplete, or when comparing impressions from two individuals whose prints are unusually similar. The fngerprint community continues to assert that the ability to see latent print detail is an acquired skill attained only through repeated exposure to friction ridge impressions. Biological variability of the minutiae in the fngerprints of a sample of the Spanish population. The latent print community in the United States has eschewed numerical scores and corresponding thresholds, because those developed to date26 have been based only on minutia, not on the unique features of the friction ridge skin. Latent print examiners report an individualization when they are confdent that two different sources could not have produced impressions with the same degree of agreement among details. There has been discussion regarding the use of statistics to assign match probabilities based on population distributions of certain friction ridge features. Current published statistical models, however, have not matured past counts of corresponding minutia and have not taken clarity into consideration. Behavioral and electrophysiological evidence for confgural processing in fngerprint experts. As noted in Chapter 3, Jennifer Mnookin of the University of California, Los Angeles School of Law summarized the reporting of fngerprint analyses as follows: At present, fngerprint examiners typically testify in the language of absolute certainty. Both the conceptual foundations and the professional norms of latent fngerprinting prohibit experts from testifying to identifcation unless they believe themselves certain that they have made a correct match. Therefore, in order to pass scrutiny under Daubert, fngerprint identifcation experts should exhibit a greater degree of epistemological humility.
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Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus. The effect of flexor tenotomy on healing and prevention of neuropathic diabetic foot ulcers on the distal end of the toe. Tendon Achilles lengthening for the treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait. Examine the feet of all patients with diabetes annually for the presence of peripheral artery disease, even in the absence of foot ulceration. At a minimum, this should include taking a relevant history and palpating foot pulses. Clinically examine (by relevant history and palpation of foot pulses) all patients with diabetes and foot ulceration for the presence of peripheral artery disease. Always consider vascular imaging in patients with a diabetic foot ulcer, irrespective of the results of bedside tests, when the ulcer is not healing within 4-6 weeks despite good standard of care. Always consider revascularisation in a patient with a diabetic foot ulcer and peripheral artery disease, irrespective of the results of bedside tests, when the ulcer is not healing within 4-6 weeks despite optimal management. Do not assume diabetic microangiopathy, when present, is the cause of poor healing in patients with a diabetic foot ulcer, therefore always consider other possibilities for poor healing. Evaluate the entire lower extremity arterial circulation with detailed visualisation of below-theknee and pedal arteries, in an anteroposterior and lateral plane. When performing revascularisation in a patient with a diabetic foot ulcer, aim to restore direct blood flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the ulcer. As evidence is inadequate to establish whether an endovascular, open or hybrid revascularisation technique is superior, make decisions based on individual factors, such as morphological distribution of peripheral artery disease, availability of autogenous vein, patient co-morbidities and local expertise. Ensure that after a revascularisation procedure in a patient with a diabetic foot ulcer, the patient is treated by a multidisciplinary team as part of a comprehensive care plan. Urgently assess and treat patients with signs or symptoms of peripheral artery disease and a diabetic foot infection, as they are at particularly high risk for major limb amputation. Provide intensive cardiovascular risk management for any patient with diabetes and an ischaemic foot ulcer, including support for cessation of smoking, treatment of hypertension, control of glycaemia and treatment with a statin drug as well as low-dose clopidogrel or aspirin. Health professionals and patients are becoming increasingly aware of the seriousness of diabetes-related complications. Diagnostic tests may be less reliable due to the presence of peripheral neuropathy, medial arterial calcification 9 and peripheral oedema. They tend to have a different clinical presentation, natural history and outcomes. The aim was to ensure the relevance of the questions for clinicians and other health care professionals in providing useful information on the diagnosis, prognosis and management of peripheral artery disease in persons with diabetes and a foot ulcer. We also formulated what we considered critically important outcomes relevant for daily care, using the set of outcomes defined by Jeffcoate et al.
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Impact of an International Nosocomial Infection Control Consortium multidimensional approach on central line-associated bloodstream infection rates in adult intensive care units in eight cities in India. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Central line-associated bloodstream infections in limited resource countries: a review of the literature. Infection and Prevention Control: Module 10, Chapter 3 73 Preventing Hospital-Acquired Pneumonia Chapter 4. Preventing Hospital-Acquired Pneumonia Key Topics l Epidemiology and mechanisms of hospital-acquired pneumonia l Risk factors for hospital-acquired pneumonia l Strategies for preventing ventilator-associated pneumonia and other hospital-acquired pneumonias in adults, children, and infants l Monitoring and surveillance of ventilator-associated pneumonia l Quality improvement for prevention of ventilator-associated pneumonia Key Terms l Aspiration, in this chapter, refers to the breathing in of material (such as food, liquids, or stomach contents) from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract, including the lungs. In the context of aspiration pneumonia, the breathing in of fluid and microorganisms from the oral cavity inside the respiratory tract is more common in unconscious patients on mechanical ventilators. Intubation is commonly used to maintain the airway, prevent aspiration, and administer mechanical ventilation to patients in situations such as patients undergoing general anesthesia during surgical procedures, deeply sedated patients or those with decreased consciousness, and those who (for a variety of reasons) are experiencing respiratory distress not relieved by less invasive means. A wide variety of bacteria pathogens are implicated and a patient maybe infected with more than one pathogen. Mechanism Pneumonia usually occurs by breathing in (micro-aspiration) bacteria growing in the back of the throat (oropharynx) or stomach. In addition, hospitalized patients are at risk for aspiration pneumonia, which happens when they accidentally inhale food, drink, mouth secretions, or regurgitated stomach contents (vomit). Healthy people have the ability to cough, so microorganisms and food do not enter the lungs during breathing (aspiration). The following procedures should be followed to prevent transmission of pathogens: l Perform hand hygiene including after contact with body secretions or anything contaminated with body secretions (see Module 2, Hand Hygiene). Change gloves before and after patient contact and between contacts with contaminated body sites, the respiratory tract, or devices used on the same patient (see Module 3, Chapter 1, Personal Protective Equipment). Infection and Prevention Control: Module 10, Chapter 4 77 Preventing Hospital-Acquired Pneumonia l Clean hard surfaces that are frequently touched. The greatest opportunities for prevention of pneumonia are with those surgical patients not expected to need postoperative ventilation. Postoperative management As mentioned above, surgical patients should be taught preoperatively how to prevent postoperative pneumonia. Surgical units in health care facilities should have effective plans for: l Optimizing the use of pain medication to keep the patient comfortable enough to cough effectively l Moving and exercising patients on a regular schedule l Encouraging deep breathing in the immediate postoperative period and over the following few days after surgery Procedures that may increase the risk of infection include oxygen therapy, bi-level positive airway pressure. In addition, the use of large containers of saline or other fluids for instillation or rinsing of the suction catheter should be avoided.
