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For example buy dipyridamole 100 mg low cost, negative life events generic 25 mg dipyridamole free shipping, such as being arrested for an acquisitive crime motivated by a need to finance a drug habit discount 25 mg dipyridamole fast delivery, can introduce conflict in the detainee’s mind about substance misuse and may increase the likelihood of successful intervention generic 100 mg dipyridamole fast delivery. Arrest referral schemes are partnership initiatives set up to encourage drug misusers brought into contact with the police service to voluntarily participate in confidential help designed to address their drug-related prob- lems. Early evaluation of such projects in the United Kingdom provides good evidence that such schemes can be effective in reducing drug use and drug- related crime (10). In the United States, it has also been recognized that 288 Stark and Norfolk point of arrest is an appropriate stage of intervention for addressing sub- stance misuse (1). Most individuals are not detained in police custody for long, and, therefore, medical treatment may not be required. This is particularly so if there is any question that the detainee may have recently ingested substances, the full effects of which may not as yet be obvious. Reassessment after a specific period should be recom- mended, depending on the history given by the detainee and the examination findings. It is good practice for all new substitute opiate prescriptions to be taken initially under daily supervision (11). In the custodial situation, if the detainee is on a super- vised therapy program, one can be reasonably sure the detainee is dependent on that dose; the detainee may of course be using other illicit substances as well. Recent urine test results may be checked with the clinic to see whether methadone or other drugs are detected on screening. Particularly with opiate substitution treatment, in the absence of with- drawal signs, confirmation of such treatment should be sought before autho- rizing continuation. The prescribed dose of opiate substitution therapy may not necessarily indicate accurately the actual amount taken each day if not supervised, because part or all of the dose may be given to other individuals. It should be remembered that giving even a small amount of opiates to a nondependent individual may be fatal. Cocaine abuse accelerates the elimina- tion of methadone; therefore, higher doses of methadone must be prescribed to individuals on maintenance regimes who continue to abuse cocaine (12). Any decision to prescribe should be made on the assessment of objective signs as opposed to subjective symptoms, and a detailed record of the history and examination should be made contemporaneously. Good practice dictates that where treatment can be verified, it should be continued as long as it is clinically safe to do so. Medical Complications of Substance Misuse Medical complications of substance misuse may give an indication of a problem in the absence of acute symptoms or signs of intoxication. Intrave- nous injection may result in superficial thrombophlebitis, deep vein thrombo- sis, and pulmonary embolus and chronic complications of limb swelling and venous ulcers. If injection occurs accidentally into an artery, vascular spasm may occur and result in ischemia, which, if prolonged, can lead to gangrene and amputation. Cellulitis and abscesses may be seen around injection sites, and deep abscesses may extend into joints, producing septic arthritis. Skin manifestations of drug addiction may be seen more commonly in opiate rather than stimulant users, even though stimulant users inject more frequently (14). This is partly because stimulants do not cause histamine release and, therefore, are seldom associated with pruritus and excoriations and also because cutaneous complications are frequently caused by the adulter- ants injected along with the opiates, rather than the drugs themselves. Fresh puncture sites, tattoos used to cover needle tracks, keloid formation, track marks from chronic inflammation, ulcerated areas and skin popping resulting in atro- phic scars, hyperpigmentation at sites of healed abscess, puffy hands (lymphe- dema with obliteration of anatomic landmarks and pitting edema absent), and histamine-related urticaria (opiates act on mast cells resulting in histamine release) may be seen. Opiate Intoxication and Withdrawal The characteristics of the medical syndromes in opiate intoxication, over- dose, and withdrawal are given in Table 4. Opiates, such as heroin, may be taken orally, more usually injected, or smoked—chasing the dragon. Chronic administration of opiate drugs results in tolerance (Table 5) to effects such as euphoria mediated by the opiate receptors and to the effects on the autonomic nervous system mediated by the noradrenergic pathways. Tolerance to heroin can develop within 2 weeks of commencing daily heroin use, occurs more slowly with methadone, and may go as quickly as it devel- ops. With abrupt withdrawal of opiates, there is a “noradrenergic storm,” which is responsible for many of the opiate withdrawal symptoms (Table 6). Cyclizine may be taken intravenously in large doses with opiates, because it is reported to enhance or prolong opioid effects, also resulting in intense stimulation, hallucinations, and seizures; tolerance and dependence on cyclizine may also result (17). Many opiate users are also dependent on ben- zodiazepines, and concurrent benzodiazepine withdrawal may increase the severity of opiate withdrawal (18). Substance Misuse 291 Table 4 Medical Syndromes in Heroin Users Syndrome (onset and duration) Characteristics Opiate intoxication Conscious, sedated “nodding”; mood normal to euphoric; pinpoint pupils Acute overdose Unconscious; pinpoint pupils; slow shallow respirations Opiate withdrawal • Anticipatory 3–4 h after Fear of withdrawal, anxiety, drug-craving, drug-seeking the last fix (as acute behavior effects of heroin subside) • Early 8-10 h after Anxiety, restlessness, yawning, nausea, sweating, nasal last fix stuffiness, rhinorrhea, lacrimation, dilated pupils, stomach cramps, increased bowel sounds, drug-seeking behavior • Fully developed 1-3 d Severe anxiety, tremor, restlessness, pilo-erection (cold- after last fix turkey), vomiting, diarrhea, muscle spasms (kicking the habit), muscle pain, increased blood pressure, tachycar- dia, fever, chills, impulse-driven drug-seeking behavior • Protracted abstinence Hypotension, bradycardia, insomnia, loss of energy and appetite, stimulus-driven opiate cravings From ref. Treatment of Opiate Withdrawal Symptomatic treatment of the opiate withdrawal syndrome can often be achieved using a combination of drugs, such as benzodiazepines for anxiety and insomnia; loperamide or diphenoxylate and atropine for diarrhea; promet- hazine, which has antiemetic and sedative properties; and paracetamol or non- steroidal antiinflammatories for generalized aches. Substitution treatment may be required in more severe cases of opiate dependence using a choice of methadone, buprenorphine, or dihydrocodeine. Because street heroin varies in purity, the starting dose cannot be accurately estimated on the basis of the amount of street drug used. Therefore, substitu- tion therapy should be titrated against the symptoms and signs of withdrawal. For example, dihydrocodeine may be commenced in a dose of 120 mg three times a day, with the dose being increased if the patient has demonstrable clinical signs of opiate withdrawal (19). Clonidine and lofexidine act as presynaptic α2-adrenergic agonists, which inhibit the noradrenergic storm associated with opiate withdrawal. Either of the following: • Cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer) • Administration of an opioid antagonists after a period of opioid use B. Three (or more) of the following, developing within minutes to several days after Criterion A: • Dysphoric mood • Lacrimation or rhinorrhea • Nausea or vomiting • Diarrhea • Muscle aches • Fever • Pupillary dilation, piloerection, • Yawning or sweating • Insomnia C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. By contrast, lofexidine has been used in detoxification from opiates with fewer side effects (20). Maternal opiate withdrawal syndrome may be life threatening for the fetus, and special care should be taken to ensure that a pregnant, opiate- dependent woman’s medication is continued while she is in custody. There should be a low threshold for referral for hospital assessment, especially in the third trimester. Buprenorphine (Subutex ) Buprenorphine is an opioid with mixed agonist-antagonist properties that may be abused or used as an alternative to methadone in detoxification from opiates (21). It is taken sublingually, and self-administration of the drug in the custodial environment must be personally supervised by the doctor who should observe the patient for 5 min to ensure that the drug has fully dissolved (22). An unusual property of buprenorphine is that after chronic administration the onset of the abstinence syndrome is delayed. Heroin addicts who are depen- dent on a small dose of opiate can be transferred onto buprenorphine, which can be withdrawn fairly easily because of the delayed onset of the abstinence 294 Stark and Norfolk Table 7 Half-Lives and Observation Times Required After Acute Narcotic Overdose Duration of action Observation Opioid via iv route t 1/2 time Methadone May be days 15–72 24–36 (Dolophine, Amidone) Morphine Usually 2-4 h 3 6 Heroin Usually 2-4 h v. However, if it is given to an individual dependent on large doses of opiates, the antagonist properties precipitate withdrawal symptoms (23).

In the above detailed problem cases there was agreement among both the defense and the prosecution experts that these were indeed human bite- marks cheap dipyridamole 25 mg online. Te disagreements were related to features and orientation of the bitemarks and to who could have or who could not have inficted the bites generic dipyridamole 100mg on line. Te problems were compounded in some cases by the use of mathematical degrees of certainty or overreaching statements of the value and certainty of bitemark evidence purchase 100 mg dipyridamole otc. Te most recent and highly publicized of Bitemarks 327 these cases is that of Kennedy Brewer in Mississippi order dipyridamole 25mg amex. Brewer was convicted in 1995 of the murder and sexual assault of Christine Jackson. Te body of the three-year-old victim had been found in a nearby creek on a Tuesday morn- ing, the third day afer her Saturday night disappearance. Michael West, examined Christine Jackson on May 9, 1992, and wrote in his May 14, 1992, report that nineteen human bitemarks were found on the body, and that “the bitemarks found on the body of Christina [sic] Jackson are peri-mortem in nature. West later testifed that “indeed and without doubt” and that “to a reasonable degree of medical certainty” the teeth of Mr. Brewer made fve of those marks, and that it was “highly con- sistent and probable that the other fourteen bite mark patterns were also inficted by Brewer” (West in original trial transcript in Brewer v. Souviron, testifed that the patterned injuries on the body were not human bites at all but were patterns that were made by other means. Tere could be fsh activity or turtle activity or who—God knows what” (Souviron in original trial transcript in Brewer v. Neither profle included Brewer but did point to another man, Justin Albert Johnson, who, ironically, had also been an early suspect in Jackson’s murder. Johnson later confessed to killing Christine Jackson and another young girl who had been similarly sexually assaulted and murdered. In that earlier case, Levon Brooks had also been wrongly convicted based, in part, on Dr. He testifed that “it could be no one else but Levon Brooks that bit this girl’s arm. How can an “expert” ignore the circum- stances and disregard the crime scene information? How can patterns with no class or individual characteristics of human teeth in patterned injuries found on a body that had been in water for more than two days be judged to be human bitemarks? To then associate those patterns to a suspect with any level of certainty seems unthinkable. Perhaps, an understanding of alter- native explanations to human teeth causing the marks should have been considered more seriously, especially in a case in which human bitemarks seemed unlikely. Souviron provided viable and testable theories for possible alternatives—the marks may have come from activity by insects, fsh, turtles, or other sources not readily apparent. Wallace, suggested that crayfsh, which were very abundant in the stream where the victim was found, were likely suspects and could have lef such marks on the victim’s body through normal feeding activity. Incredibly, the odontologist in this case associated only the upper inci- sor teeth to all of the “bitemarks”; there were no lower teeth marks identi- fed. West performed a simple test to determine if the patterns on the skin were in fact bitemarks of the type Bitemarks 329 Figure 14. An incision through a mark will reveal if there is the subepidermal hemorrhage ofen associated with human bitemarks (Figures 14. Alternatively, either could have harvested tissue from one or more of the patterned injuries. West had a history of simi- larly outrageous fndings in other cases (Keko, Harrison, Maxwell). He had identifed shoe marks on human skin and knife handle rivets on the hand of a murder suspect. He had made dramatic, overreaching statements in court, including conclusions to absolute certainty, “indeed and without doubt,” and incredible estimates of his own error rates, “something less than my savior, Jesus Christ. Tat the liberty, and indeed the life, of a human being is ofen in question and may depend upon the quality of experts’ opinions is of paramount importance and cannot be overemphasized. We cannot be too cautious, too conservative, or too diligent when analyzing the potential asso- ciation of a suspect to a bitemark. We should also recognize that eyewitnesses may be wrong or may have reason to lie. Since that time more programs and more comprehensive programs 332 Forensic dentistry have become available. Tese include programs at the Armed Forces Institute of Pathology, the University of Texas Health Science Center at San Antonio, McGill University in Montreal, the Miami-Dade County Medical Examiner’s Ofce, the University of Detroit–Mercy School of Dentistry, and others. Annual programs at the American Academy of Forensic Sciences and the American Society of Forensic Odontology highlight ongoing research and casework in forensic dentistry. Te American Board of Forensic Odontology sponsors workshops in dental identifcation, bitemark analysis, and expert witness testimony. Research, education, and due diligence are required if forensic odontology is to progress and, in the process, minimize the prob- ability of the occurrence of future problem cases. Te manual then describes a bitemark as “a circular or oval patterned injury consisting of two opposing symmet- rical, U-shaped arches separated at their bases by open spaces. Following the periphery of the arches are a series of individual abrasions, contusions, and/or lacerations refecting the size, shape, arrangement, and distribution of the class characteristics of the contacting surfaces of the human dentition”35 (Figures 14. Tere has been much discussion about whether bitemark should be written as one word or two (bite mark) or hyphenated (bite-mark), for any of the forms the meaning is understandable and gram- matically correct. Te authors contend that this is a pointless argument and choose to use the single word form except in quoted material that uses other forms. Tis may occur when skin or other objects contact the teeth instead of a biter intentionally closing his jaws, and hence his teeth, into skin or an object. A fst striking the teeth in an afray is a common and dangerous example ofen referred to as a clenched fst injury or “fght bite. Teeth marks are passive, as they involve no active, intentional or refexive jaw movement, whereas in bitemarks the jaw muscles are active, causing the jaws and thence the teeth to move into the bitten substrate. Teeth mark examples include marks lef by teeth on steering wheels, dashboards, or other objects during motor vehicle accidents. If struck in the mouth, the teeth of the victim may leave imprints 334 Forensic dentistry on the fst or other object. Teeth marks may be found on the inner aspect of a victim’s upper and lower lips afer an attack. Pressure applied to the lips, which are consequently pressed against the teeth, leaves the teeth marks, patterned injuries that may indicate asphyxiation by force. Teeth mark inju- ries have not been widely discussed in the literature separate from bitemarks.

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Client sets goals that are realistic and works to achieve those goals without evidence of fear of failure generic dipyridamole 100 mg amex. Possible Etiologies (“related to”) [Physical illness accompanied by real or perceived disabling symptoms] [Unmet dependency needs] [Dysfunctional family system] Defining Characteristics (“evidenced by”) Change in self-perception of role Change in [physical] capacity to resume role [Assumption of dependent role] Change in usual patterns of responsibility [because of conflict within dysfunctional family system] Goals/Objectives Short-term Goal Client will verbalize understanding that physical symptoms in- terfere with role performance in order to fill an unmet need purchase 25mg dipyridamole with visa. Long-term Goal Client will be able to assume role-related responsibilities by time of discharge from treatment cheap dipyridamole 100 mg without prescription. An accurate database is required in order to formulate appropriate plan of care for the client purchase 100mg dipyridamole visa. Identify ways in which client and other family members have responded to these conflicts. It is necessary to identify specific stressors, as well as adaptive and maladap- tive responses within the system, before assistance can be provided in an effort to create change. Help client identify feelings associated with family conflict, the subsequent exacerbation of physical symptoms, and the accompanying disabilities. Help client identify changes he or she would like to occur within the family system. Encourage family participation in the development of plans to effect positive change, and work to resolve the conflict for which the client’s sick role provides relief. Input from the individuals who will be directly in- volved in the change will increase the likelihood of a positive outcome. Allow all family members input into the plan for change: knowledge of benefits and consequences for each alternative, selection of appropriate alternatives, methods for implemen- tation of alternatives, and an alternate plan in the event ini- tial change is unsuccessful. Ensure that client has accurate perception of role expecta- tions within the family system. Use role-playing to practice areas associated with his or her role that client perceives as painful. Repetition through practice may help to desensitize client to the anticipated distress. As client is able to see the relationship between exacerba- tion of physical symptoms and existing conflict, discuss more adaptive coping strategies that may be used to prevent inter- ference with role performance during times of stress. The nurse may make suggestions and help the client practice through role-play, but the client alone must decide what will be adaptive in his or her personal situation. The nurse must be careful not to impose on the client ideas that the nurse thinks are more appropriate but which may not be adaptive for the client. Psychological Factors Affecting Medical Condition ● 273 Possible Etiologies (“related to”) Lack of interest in learning [Severe level of anxiety] [Low self-esteem] [Regression to earlier level of development] Defining Characteristics (“evidenced by”) [Denial of emotional problems] [Statements such as, “I don’t know why the doctor put me on the psychiatric unit. Long-term Goal By time of discharge from treatment, client will be able to verbal- ize psychological factors affecting his or her medical condition. Assess client’s level of knowledge regarding effects of psy- chological problems on the body. An adequate database is necessary for the development of an effective teaching plan. The client has the right to know about and accept or refuse any medical treatment. These feelings may have been suppressed or repressed for so long that their disclosure may be very painful. Verbalization of feelings in a nonthreatening environment and with a trusting individual may help the client come to terms with unresolved issues. Have client keep a diary of appearance, duration, and intensi- ty of physical symptoms. A separate record of situations that the client finds especially stressful should also be kept. Com- parison of these records may provide objective data from which to observe the relationship between physical symptoms and stress. Provide instruction in assertiveness techniques, especial- ly the ability to recognize the differences among passive, assertive, and aggressive behaviors and the importance of respecting the human rights of others while protecting one’s own basic human rights. These skills will preserve client’s self-esteem while also improving his or her ability to form satisfactory interpersonal relationships. Discuss adaptive methods of stress management such as relaxation techniques, physical exercise, meditation, breath- ing exercises, and autogenics. Use of these adaptive tech- niques may decrease appearance of physical symptoms in response to stress. Client verbalizes an understanding of the relationship between psychological stress and exacerbation of physical illness. Client demonstrates the ability to use adaptive coping strate- gies in the management of stress. These clusters, and the disorders classified under each, are described as follows: 1. For purposes of this text, passive-aggressive personality disorder is described with the cluster C disorders. The essential feature is a pervasive and unwarranted suspiciousness and mistrust of people. There is a general expectation of being exploit- ed or harmed by others in some way. Symptoms include guardedness in relationships with others, pathological jealousy, hypersensitivity, inability to relax, unemotional- ity, and lack of a sense of humor. These individuals are very critical of others but have much difficulty accepting criticism themselves. This disorder is character- ized by an inability to form close, personal relationships. Symptoms include social isolation; absence of warm, ten- der feelings for others; indifference to praise, criticism, or the feelings of others; and flat, dull affect (appears cold and aloof). This disorder is char- acterized by peculiarities of ideation, appearance, and be- havior, and deficits in interpersonal relatedness that are not severe enough to meet the criteria for schizophrenia. Symptoms include magical thinking; ideas of reference; social isolation; illusions; odd speech patterns; aloof, cold, suspicious behavior; and undue social anxiety. This disorder is charac- terized by a pattern of socially irresponsible, exploitative, and guiltless behavior, as evidenced by the tendency to fail to conform to the law, to sustain consistent employ- ment, to exploit and manipulate others for personal gain, to deceive, and to fail to develop stable relationships. The individual must be at least 18 years of age and have a his- tory of conduct disorder before the age of 15. The features of this dis- order are described as marked instability in interpersonal relationships, mood, and self-image. The instability is sig- nificant to the extent that the individual seems to hover on the border between neurosis and psychosis. Symptoms include exagger- ated expression of emotions, incessant drawing of atten- tion to oneself, overreaction to minor events, constantly seeking approval from others, egocentricity, vain and de- manding behavior, extreme concern with physical appear- ance, and inappropriately sexually seductive appearance or behavior. This disorder is char- acterized by a grandiose sense of self-importance; pre- occupation with fantasies of success, power, brilliance, beauty, or ideal love; a constant need for admiration and attention; exploitation of others for fulfillment of own desires; lack of empathy; response to criticism or failure with indifference or humiliation and rage; and preoccupa- tion with feelings of envy.

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The vagus nerve releases acetylcholine when it is stimulated purchase dipyridamole 100mg overnight delivery, which causes the tracheobronchial tube to contract safe 25mg dipyridamole. The opposite effect is created when the sympathetic nervous system releases epi- nephrine that stimulates the beta2 receptor in the bronchial smooth muscle buy generic dipyridamole 25 mg. In a healthy patient the sympathetic and parasympathetic nervous systems counter- balance each other to maintain homeostasis purchase dipyridamole 25mg fast delivery. Upper Respiratory Tract Disorders Respiratory disorders are divided into two groups: upper respiratory tract disorders and lower respiratory tract disorders. These include the common cold, acute rhinitis (not the same as allergic rhinitis), sinusitis, acute tonsillitis, and acute laryngitis. The rhinovirus is frequently accompanied by acute inflammation of the mucous membranes of the nose and increased nasal secretions. The rhinovirus is seasonable: 50% of the infections occur in the winter and 25% dur- ing the summer. Although no one has directly died from the common cold, it does create both physical and mental discomfort for the person and leads to a loss of work and school. During this time, the rhinovirus can be transmitted by touching contaminated surfaces and from contact with droplets from an infected patient who sneezes and coughs. After the incubation period, the patient experiences a watery nasal discharge called rhinorrhea, nasal congestion, cough, and an increasing amount of mucosal secretions. Many patients try home remedies to battle the rhinovirus, however these don’t affect the virus. Home remedies include rest, vitamin C, mega doses of other vitamins, and, of course, chicken soup. Vitamin C and mega doses of other vitamins have not been proven effective against the common cold. When home remedies fail, patients turn to both prescription and over-the- counter medication. Charts throughout these pages provide information about specific drugs in each group. Antihistamines (H blocker) 1 Many cold symptoms are caused by the body’s overproduction of histamines. Histamines are potent vasodilators that react to a foreign substance in the body such as the rhinovirus. H2 receptors cause an increase in gastric secretions and are not involved in this response. This is referred to as nasal con- gestion and is caused when the nasal mucous membranes swell in response to the rhinovirus. A decongestant is a drug that stimulates the alpha-adrenergic receptors to tell the brain to constrict the capillaries within the nasal mucosa. The result is that the nasal mucous membranes shrink, reducing the amount of fluid that is secreted from the nose. Decongestants are available in nasal spray, drops, tablets, capsules, or in liq- uid form. These are nasal decongestants that provide quick relief to the patient; systemic decongestants that provide a longer lasting relief from congestion; and intranasal glucocorticoids that are used to treat seasonal and perennial rhinitis. Cough Preparations A cough is a common symptom of a cold brought about by the body’s effort to remove nasal mucous that might drain into the respiratory tract. Antitussives are the ingredients used in cough medicine to suppress the cough center in the medulla. Although the cough reflex is useful to clear the air passages, suppres- sion of the cough reflex can provide some rest for the patient. Expectorants When an individual has a cold or other respiratory infection, it is common to have rather thick mucous that is difficult to expectorate. Expectorants are med- ications that loosen the secretions making it easier for the patient to cough up and expel the mucous. They work by increasing the fluid output of the respira- tory tract and decrease the adhesiveness and surface tension to promote removal of viscous mucus. A list of drugs utilized in the treatment of upper respiratory tract disorders is provided in the Appendix. Patients may take systemic or nasal decongestants to reduce the congestion that frequently accompanies sinusitis. Patients are told to drink plenty of fluids, to rest, and to take acetaminophen (Tylenol) or ibupro- fen for discomfort. In some cases, antibiotics are prescribed if the condition is severe or long lasting and an infection is suspected. Pharyngitis is caused by a virus (viral pharyngitis) or by bacteria (bacteria pharyngitis) such as the beta-hemolytic streptococci. Sometimes patients experience acute pharyngitis along with other upper respiratory tract disease such as a cold, rhinitis, or acute sinusitis. Patients who have a viral pharyngitis are given medications that treat the symptoms rather than attacking the underlying virus. Acetaminophen or ibupro- fen is given to reduce the patient’s temperature and discomfort. Saline gargles, lozenges, and increased fluid are usually helpful to soothe the sore throat. Patients who have bacterial pharyngitis are given antibiotics to destroy the beta-hemolytic streptococci bacteria. However, antibiotics are only prescribed if the result of the throat culture is positive for bacteria. Patients are also given the same treatments for viral pharyngitis to address the symptoms of pharyngitis. Patients who come down with acute tonsillitis experi- ence a sore throat, chills, fever, aching muscles, and pain when they swallow. A throat culture is taken to determine the cause of the infection before an appropriate antibiotic is prescribed to the patient. The patient is also given acet- aminophen or ibuprofen to reduce the fever and the aches and pains associated with acute tonsillitis. The patient is also encouraged to use saline gargles, lozenges, and increased fluid to soothe the soreness brought on by infected ton- sils. Other times it is caused by stress or overuse of the vocal cords—a common occurrence for fans whose team wins the Super Bowl. Refraining from speaking and avoiding exposure to substances that can irritate the vocal cords, such as smoking, is the preferred treatment for acute laryngitis. The result is an impairment of oxygen reach- ing lung tissues that can in some cases irreversibly damage lung tissues.

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