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11.
Sharma AN Nelson LS Hoffman RS 《The American journal of forensic medicine and pathology》2004,25(2):156-158
The neurologic manifestations of thallium poisoning include a severely painful ascending peripheral neuropathy, autonomic dysfunction, cranial nerve abnormalities, and a toxic encephalopathy. Although thallium has a short half-life, these neurologic manifestations commonly progress, even as the blood concentration of thallium decreases. This suggests either that thallium persists in neuronal tissues or that it initiates an injury cascade that takes time to fully manifest. As the latter mechanism is consistent with many toxin exposures, the concept of a central nervous system reservoir for thallium is often discounted. A recent case provided a unique opportunity to evaluate this possibility. A 48-year-old man was acutely and chronically thallium poisoned by his common-law wife. During his initial exposures, only gastrointestinal symptoms manifested. Following an acute ingestion, hospitalization was required. Over 3 days, his symptoms rapidly progressed from a severely painful neuropathy to slurred speech, ptosis, confusion, coma, respiratory insufficiency, and death. Because of considerations of alternative diagnoses, 2 lumbar punctures were performed, one on admission and another on the day of his death. Serum thallium concentrations obtained from stored blood samples were paired with spinal fluid concentrations from the same days. On day 1, serum and spinal fluid concentrations were 8700 mu/L and 1200 mu/L, respectively. On day 3, although the serum concentration had fallen to 7200 mu/L, the spinal fluid concentration had increased to 2100 mu/L. This case provides evidence to support the hypothesis that thallium distributes into the central nervous system more slowly than the blood compartment, and this may in part account for the progression of neurologic findings in the setting of decreasing serum concentrations. 相似文献
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Investigating why people use the hospital emergency department (ED) for visits considered medically nonurgent can enhance our understanding of people's expectations of health care services, of their conceptions of prudent lay judgment, and of difficulties in negotiating the logistics of primary care services. This study identified reasons for such ED use from users' perspectives in both pediatric and adult visits. Respondents were asked to explain what brought them to the ED and to define an emergency. The study was conducted in two northeastern U.S. hospital EDs. The analysis drew on a convenience sample of 408 (331 pediatric, 77 adult users) face-to-face interviews that employed both open- and closed-ended questions. Findings indicate most patients had medical insurance and a regular place of care and most arrived by car or taxi. Twelve main themes emerged under three main categories: conceptions of needs, appropriateness, and preference for the ED. The findings indicate that various reasons for ED use may be construed as access issues. These include beliefs regarding limited availability of after-hour consultation services and of timely appointments at one's primary care site. Drawing on the findings, a typology that distinguishes between groups of users according to their preference for the ED, a level of congruence between their own reason and their definition of an emergency was developed. The typology suggests that people's concerns that influence their decision to come to the ED cannot be solved simply by expanding primary care services or by educational interventions. Its application yields recommendations for services and interventions. 相似文献
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In August 2002, the Court of Appeals of the state of Victoria, Australia, reduced the non-parole portion of a man's prison sentence from two years to 18 months because imprisonment would be a greater burden on someone with HIV than on a healthy person. 相似文献
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Baker AM Johnson DG Levisky JA Hearn WL Moore KA Levine B Nelson SJ 《Journal of forensic sciences》2003,48(2):425-428
Diphenhydramine is an antihistamine available in numerous over-the-counter preparations. Often used for its sedative effects in adults, it can cause paradoxical central nervous system stimulation in children, with effects ranging from excitation to seizures and death. Reports of fatal intoxications in young children are rare. We present five cases of fatal intoxication in infants 6, 8, 9, 12, and 12 weeks old. Postmortem blood diphenhydramine levels in the cases were 1.6, 1.5, 1.6, 1.1 and 1.1 mg/L, respectively. Anatomic findings in each case were normal. In one case the child's father admitted giving the infant diphenhydramine in an attempt to induce the infant to sleep; in another case, a daycare provider admitted putting diphenhydramine in a baby bottle. Two cases remain unsolved; one case remains under investigation. The postmortem drug levels in these cases are lower than seen in adult fatalities. We review the literature on diphenhydramine toxicity, particularly as it pertains to small children, and discuss the rationale for treating these cases as fatal intoxications. 相似文献
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Managing incidental findings in human subjects research: analysis and recommendations. 总被引:8,自引:8,他引:0
Susan M Wolf Frances P Lawrenz Charles A Nelson Jeffrey P Kahn Mildred K Cho Ellen Wright Clayton Joel G Fletcher Michael K Georgieff Dale Hammerschmidt Kathy Hudson Judy Illes Vivek Kapur Moira A Keane Barbara A Koenig Bonnie S Leroy Elizabeth G McFarland Jordan Paradise Lisa S Parker Sharon F Terry Brian Van Ness Benjamin S Wilfond 《The Journal of law, medicine & ethics》2008,36(2):219-48, 211
No consensus yet exists on how to handle incidental findings (IFs) in human subjects research. Yet empirical studies document IFs in a wide range of research studies, where IFs are findings beyond the aims of the study that are of potential health or reproductive importance to the individual research participant. This paper reports recommendations of a two-year project group funded by NIH to study how to manage IFs in genetic and genomic research, as well as imaging research. We conclude that researchers have an obligation to address the possibility of discovering IFs in their protocol and communications with the IRB, and in their consent forms and communications with research participants. Researchers should establish a pathway for handling IFs and communicate that to the IRB and research participants. We recommend a pathway and categorize IFs into those that must be disclosed to research participants, those that may be disclosed, and those that should not be disclosed. 相似文献
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Theorists posit two fundamental tensions in negotiation. One is strategic: the tug-and-pull between creating value and claiming one's share of it. The other is interpersonal: the tension between asserting one's own interests and, at the same time, empathizing with the feelings and needs of other parties. 1 This research report analyzes how negotiators experience these tensions in practice. Specifically, their self-perceptions about their relative competence in several key areas allow us to see how strength along one dimension (like getting the maximum) is correlated with other important skills. Some of the authors' findings confirm familiar models. For example, people implicitly feel that being successful at asserting their own interests imposes a cost with respect to understanding others. There were some surprises, however: most notably, people who rated themselves as strong value claimers also saw themselves as good value creators. The authors explore some of the implications of their findings for both practice and teaching, and foreshadow a follow-up report they plan. They also note how other researchers can access their data for their own studies. 相似文献