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By Z. Josh. California National University for Advanced Studies.
The served with some frequency in psittacine birds with most common associations with nodular hyperplasia liver disease generic kamagra gold 100 mg otc. Bile duct hyperplasia is often seen are mycotoxin exposure and iron-accumulating hepa- concurrently with hepatic fibrosis and hepatocellular topathy discount kamagra gold 100mg fast delivery. The eti- Miscellaneous Hepatic Neoplasms: Miscellaneous ology of bile duct hyperplasia is often undetermined; neoplasms described in the liver include malignant however buy generic kamagra gold 100mg online, ingestion of mycotoxin-contaminated feed lymphoma, fibrosarcoma, hemangioma, he- should be considered in the differential diagnosis (see mangiosarcoma and lipoma. Furthermore, the liver may be involved in hema- Biliary Cyst: Biliary cysts are reported infrequently tologic neoplasia, which can be difficult to distinguish in birds. Pancreatic Neoplasms Most pancreatic neoplasms reported in birds arise Hepatocellular Carcinoma: In captive and free- from the exocrine pancreas, especially ductular ranging birds, the incidence of hepatocellular carci- structures. These neoplasms may be single or multi- noma is superseded only by cholangiocarci- 12,43,51,108 ple. Abdominal enlargement may Pancreatic Adenoma: Pancreatic adenomas occur in be apparent on physical examination. Neoplasms may vary in size and color, ranging from On gross inspection, multifocal pancreatic adenomas light tan to a more normal red-brown. Evidence suggests that multiple endo- crine neoplasia occurs in birds as well as in mammals. Intraductal neoplasms may cause local disten- neoplasms follow the path of least resistance, com- tion of affected ducts with concurrent compression pressing the hypothalamus and optic chiasm. Pigment changes such as alterations in feather col- oration pattern and cere color have been reported in a cockatiel and budgerigar; however, hormonal changes were not investigated. Microscopically, these neoplasms are composed of round-to-cuboidal cells arranged in sheets or The endocrine system is composed of widely distrib- sinusoidal patterns containing a delicate fibrovascu- uted tissues, glands and organs. Cells have round nuclei, stippled chroma- tem, in conjunction with the nervous system, main- tin and variable quantities of cytoplasm. In chromo- tains homeostasis by the ability to synthesize, store phobe adenomas, the cytoplasm stains poorly. These hormones are Mitoses are infrequent and a remnant of the pars distributed via the blood to effector cells, tissues or distalis may be apparent. Theo- neoplasms in birds, but have been reported and char- retically, thyroid neoplasia can be managed surgi- acterized in two budgerigars. Histologically, these neoplasms Thyroid Hyperplasia: Thyroid hyperplasia (goiter) are highly cellular and may contain foci of necrosis may be associated with iodine-deficient diets, inges- and hemorrhage. Confirmation of metastasis sup- tion of goitrogenic plants such as Brassica species, ports the presumptive diagnosis. These expan- distended follicles may result in glandular enlargements reaching 20 mm in diameter. Be- of improved diets for companion birds, thyroid hyper- cause of their anatomic location, surgical excision of plasia is reported less frequently than three decades ago. Pineoblastoma: A pineoblastoma has been described On gross necropsy examination, the thyroid glands in a cockatiel. His- depression, right-sided head tilt and inability to tologic sections of thyroid gland contain large, irregu- grasp objects with the right foot. Papillary pro- Necropsy examination disclosed a grey suprathal- jections of epithelium may protrude into the lumen amic mass extending into the right ventricle and of some follicles (see Chapter 23). Microscopically, the mass consisted of sheets, cords Thyroid Adenoma: Thyroid adenomas are usually and fewer palisades of round cells with round-to-oval unilateral but may occasionally cause bilateral glan- nuclei, stippled chromatin and lightly basophilic cy- dular enlargement. Occasional mitotic figures were observed Histologically, thyroid adenomas are poorly charac- throughout the mass. Most thyroid adenomas appear as Pinealoma: Pinealoma has been reported in two nodules of encapsulated glandular tissue. These neoplasms are lated, cellular and displaced cerebellar folia and ex- highly vascular. The mass had a lobular Adrenal Gland architecture, with some lobules containing single layers of ciliated columnar-to-pseudostratified-co- In contrast to mammals, avian adrenal glands have lumnar epithelium. When enlargement of the Enlargement of the thyroid glands may be observed adrenal glands is observed at necropsy, a primary with hyperplasia or neoplasia. Their anatomic location terrenal (cortical) cells and have rarely been re- near the thoracic inlet precludes palpation of masses unless glandular enlargements are extreme. A carotid body tumor has been reported cells appear pale with foamy cytoplasm and centrally in a parakeet, but no details of the neoplasm were located nuclei. Marked anisocytosis and anisokaryosis was appar- ent, including the presence of tumor giant cells. Mi- Nervous system and ocular neoplasms apparently toses were observed infrequently. Neoplastic cells are infrequent in birds with the exception of pituitary infiltrated adjacent nerves. These struction of cerebrospinal flow, or secondary edema, scattered islets are composed of a diverse aggregation hemorrhage or necrosis. These neoplasms have a of alpha, beta and delta cells that secrete glucagon, poor prognosis, and effective treatment regimens insulin and gastrin, respectively. Secretory islet cell sion below is confined to those neoplasms recently neoplasms may have diverse clinical presentations. An islet cell carcinoma has been reported in a budg- Astrocytoma: An astrocytoma is a differentiated neo- erigar with hyperglycemia. These neoplasms usually arise in the cere- glucagon hypersecretion and diabetes mellitus, but bral hemispheres, thalamus, brainstem, cerebellum this assumption was not proven. Therefore, persistent and dramatic neoplasm was lobulated and unencapsulated with hyperglycemia must be present to confirm a diagno- large globular cells in a fibrillar network. Histologically, this islet cell carcinoma consisted of Glioblastoma: A glioblastoma is an undifferentiated nests and lobules of pleomorphic, pale-staining cells neoplasm of astrocyte origin. Both com- in a budgerigar with weakness, incoordination, in- pression and invasion of the adjacent exocrine pan- ability to perch properly, tremors of the wings and creas were observed. Microscopically, a circum- scribed mass occupied a large area of the diencepha- lon and mesencephalon. Numer- severely dilated and had a fluid consis- ous masses were palpable throughout the tency. Abdominocentesis was used to col- body, and their occurrence was confirmed lect 10 mls of fluid that was used for cy- by radiographs (see Figure 25. The fluid had the topathology indicated an invasive fibrosar- characteristics of a modified transudate coma involving the soft tissues and bones of and contained cells suggestive of neoplasm. A large mass A six-year-old budgerigar was presented was filling the space between the descend- with a large, featherless mass involving the ing and ascending duodenum that is nor- ventral abdomen. Cytology tologic diagnosis was multicentric, indicated a lipoma with xanthomatosis of anaplastic pancreatic carcinoma with car- the skin overlying the mass (note the yel- cinomatosis of the serosal surfaces of the lowish, thickened skin). The tumor and as- abdomen and the tunica muscularis of the sociated xanthoma were surgically excised intestines (courtesy of Cheryl Greenacre). The bird did not non-healing wound that progressively en- respond to supportive care. Bi- and splenomegaly with raised white nod- opsy of the lesion revealed a squamous cell ules in the liver were noted at necropsy. Histopathology revealed an accumulation of lymphoid cells in the nodules, consistent Color 25. Histopathology of the mass con- A five-year-old male budgerigar was pre- firmed a squamous cell carcinoma (see Fig- sented for abdominal distention and left ure 25. The renal The mass was debulked and the histologic mass was histologically identified as a re- diagnosis was squamous cell carcinoma. The tumor margin was irradiated with a strontium-90 ophthalmic probe (courtesy of Color 25. A five-year-old budgerigar was presented with a rapidly growing firm mass on the Color 25. Cytology indi- A three-year-old cockatoo was presented cated a pleomorphic population of spindle with bilateral foot lesions characterized by cells suggestive of fibrosarcoma. If not associated with any The case was managed by amputating the specific dysfunction, lesions such as these affected wing (courtesy of Jane Turrel). A diffuse, firm, yellow A mature, male cockatiel was presented mass was noted in the carpal region on with a several-month history of poor gener- physical examination. The appearance of alized feather condition and feather loss the lesion was suggestive of xanthoma, and around the uropygial gland. A raised, firm, the demonstration of vacuolated macro- uropygial gland mass was evident. Cytol- phages, lipids and cholesterol crystals in a ogy of the mass revealed multiple mitotic fine-needle aspirate from the mass was figures. Radiographs indicated a history of a progressively enlarging ab- fracture of the mid-diaphyseal tibiotarsal dominal mass. This bird responded to a change in coma, and the client chose to have the bird diet and increased exercise over a three- euthanatized. Inset shows the dissected month period, followed by surgical excision bone, which had healed from the pathologic of the mass that was half its original size at fracture, with the pin in place. The bird was rhamphotheca, indicating inflammation of presented one year later with lethargy, the germinative layers of the beak. His- diographs indicated a large, soft tissue topathology was suggestive of a papilloma. Histologic lesions were consistent nal tubular adenocarcinoma with metasta- sis to the lung, liver and myocardium. A four-year-old budgerigar was presented with a rapidly growing, necrotic mass of the Color 25.
In the lower limbs study of the peroneal and tibial nerves can help differentiate between conus or cauda equina and epiconal lesions (37) discount 100mg kamagra gold fast delivery. They may help differentiate between complete and incomplete lesions in the acute stage following injury as they are not affected by the state of con- sciousness of the patient nor by spinal shock generic kamagra gold 100mg with amex. Magnetic cortical stimulation can be applied to conscious patients as it is less painful and more powerful than electrical stimulation generic 100 mg kamagra gold with amex. Unfortunately it is not advis- able to use magnetic stimulation in the presence of metal implants. The burden of care is the amount of time and energy which the carer who as- sists the disabled individual expends in achieving a defined task with and/or without an assistive device. The lack of an assistive device can therefore increase the burden of care as the carer will probably spend more time and energy without the assistive device to achieve that partic- ular task. Transfer between bed, chair and wheel- chair are documented together under one activity. For “Social Cognition” social interaction, prob- lem solving and memory are assessed as three separate activities Each activity is scored 1 through 7 based on the individual’s contri- bution to carrying out the task with a score of 1 denoting a requirement of total assistance with a task and a score of 7 describing complete inde- pendence in achieving a task timely and safely. A subject with a score of 1 can only contribute less than 25% to the activity thus requiring total as- sistance. A score of 2 means that the subject is capable of contributing 25% or more in carrying out the activity but requires maximum assis- tance. Complete dependence describes patients with scores of 1 and 2 as the former requires “Total Assistance” and the later or maximal assis- tance. Patients with modified dependence are scored 3,4 or 5 depending on their requirements of moderate assistance, minimal assistance or su- pervision only to achieve a task as well as their contribution of 50 % or more, 76% or more and 100% respectively. Patients with scores of 1 to 5 usually require personal assistance from a carer or a helper. It was published in 1997 by Catz and Itzkovich (62) and has been evaluated in a few countries. Independence or activity achieved with costlier, heavier or more challenging assistive devices or with medical shortcomings and /or discomfort is considered to be of lower value and is scored lower (66). Functional achieve- ments are rated according to their importance for the patients. The measure consists of 28 items divided into 3 subscales (areas of function) Self Care (score 0 to 20), Respiration and Sphincter Manage- ment (0 to 40), and Mobility (0 to 40). It was found to be suitable for use by both a multidisciplinary team and by a single nurse, through observation or interview. Scoring by a team and observation was however found to be slightly more accurate than by a single nurse through interview (69). Unfortunately no agreement between specialists from 15 countries could be reached (71). In the same year Frankel published the Frankel’s Classification in which the density of the neurological lesion could be described as com- plete or incomplete depending on the absence or presence of sensation and motor power below the level of the lesion. Patients with incomplete injuries could be further subdivided into three groups depending on the degree of sensory and motor sparing. Based on this Classification, Frankel published the outcome of postural reduction and conservative manage- ment of a large series of patients with spinal injuries at all levels. Using the Frankel’s grid (72) he demonstrated for the first time that neurologi- cal progress of groups of patients could be easily described by the asses- sor and easily understood by the reader (Fig. Since 1980 a number of classifications have been proposed but very few were found useful. In 1982, the American Spinal Injuries Association developed the Standards for Neurological Classification of spinal injured patients (73). In each square of the grid are two letters of the alphabet, the first related to the neurological lesion on ad- mission and the second to the neurological lesion on discharge. Using the Frankel’s grid (72) neurological progress of groups of patients can be easily de- scribed by the assessor and easi- ly understood by the reader. The Frankel Classification (72) is still the most commonly used classification by clinicians from all disciplines. Patients are grouped into five categories, based on their clinical neu- rological presentation. These categories range from patients with com- plete sensory and motor loss below the level of the injury (Frankel A), to patients with no somato-sensory loss and no sphincter disturbance; how- ever, abnormal reflexes may be present (Frankel E). The three categories inbetween describe various degrees of sparing below the level of the le- sion. Frankel B describes sensory sparing only including sacral sparing however with complete absence of motor power. Frankel C describes sen- sory and motor sparing below the level of the lesion, however the motor power is poor and of no practical use to the patient. Frankel D describes sparing of sensation and motor power below the level of the lesion which many patients could use to walk, with or without aids. The advantage of the Frankel Classification is that with one letter of the alphabet (from A to E) one is able to describe and/or understand in general terms both the density of neurological damage at a particular lev- el, the presence or absence of sparing, the modality(ies) functions spared and the usefulness of the motor functions spared, if any, below the level of the injury. Furthermore, any significant influence of treatment and/or time resulting in significant change of density and function can easily be docu- mented by repeating the assessment for the individual patient or the group of patients and documenting the findings in the Frankel grid (Fig. Similarly the qual- ity of ambulation and the need of lower limb orthosis and/or arm support are not specified in Frankel D. Although the Frankel Classification is good at measuring significant changes in neurology and function, it is not how- ever sensitive enough to elicit small changes in neurology when the pa- tient has not improved or deteriorated sufficiently to move from one Frankel grade to another. As a tool of measurement it is good at measur- ing most of what matters to the patient and the clinician but not neces- sarily what is required for the rigours of research and accurate compari- son between methods of treatment. The Frankel Classification however remains the most practical method of describing the progress of a patient or a group of patients in the clinical situation. Ambulation and sphincter functions will also require additional spe- cific documentation. The need for some consensus be- came however paramount as claims about effectiveness of various phar- macological agents and treatment modalities were being increasingly made. Donovan and colleagues showed that even among expe- rienced clinicians discrepancies occurred in classifying patients (74). Despite a number of changes that had been made, Priebe and Waring found that although there had been some improvement in the new ver- sion the inter-observer reliability of patient classification was less than optimal (76). They made a number of recommendations to improve reli- ability including the institution of formal training. Dittuno et al published the ‘International standards booklet for neurological and functional classification of spinal cord in- jury (78). A training package of 4 videos and a reference manual have been developed since 1994 by a committee to ensure standardisation of examination and documentation. Donovan et al found that further clarification was required to determine the sensory level and to score muscles inhibited in strength by pain (80). C=Incomplete: Motor function • The sensory level is documented is preserved below the neurological level, and more for each side separately. A score of is preserved below the zero denotes anaesthesia or inability neurological level, and at least to distinguish between sharp and half of key muscles below dull. A score of 1 implies ability to the neurological level have differentiate between sharp and dull a muscle grade of 3 or more. In case of doubt 8 out of function are normal 10 questions have to be correct in or- der that the area is given a score of 1. Central Cord • Light touch is assessed using a Brown-Sequard cotton-tip swab stroking the skin Anterior Cord over a distance not to exceed Conus Medullaris 1cm. A score of 2 describes nor- Cauda Equina mal light touch sensation, 1 sen- sation is impaired compared to face and 0 means absent sensation. For documentation purposes it is this latter segment only that is to be documented. These muscles were chosen because of their consistency being innervated by the same in segments and because of the ease of testing in the supine position. The criterion for a ‘complete injury’ is “the absence of sensory and motor functions in the lowest sacral segments (S4 and S5). In Group A there is almost no difference between the two classifications except for the wording. This means that a pa- tient who may have an incomplete spinal cord damage could be classed as ‘complete’ because the sensory tracts from the sacral dermatomes have been damaged while sensory tracts from other dermatomes distal to the level of injury have not. An unpublished modifica- tion of numerical sensory documentation by El Masri is currently being used to in order to evaluate the prognostic value of the different sensory appreciations of the spino-thalamic tract. Furthermore, in a field where there is ongoing controversy about the best method of treatment to the injured spine, assessment and documentation are paramount to quantify the actual benefit (or harm) of the various methods of treat- ment. Other factors include the adequacy of the containment of the physiological instability of the injured spinal cord (85) as well as the biomechanical instability of the injured spinal column. Further mechanical damage of the neural tissue at the time of the accident is obviously likely to cause neurological deterioration or lack of neurological recovery. The injured spinal cord which has sus- tained damage to the blood brain barrier, cell membrane disturbances and auto regulatory disturbances is also vulnerable to non-mechanical damage from complications outside the spinal canal namely hypoxia, hy- potension, sepsis and anaemia (85). These complications can easily oc- cur when there is a multi-system physiological impairment and mal- function as is the case with all patients with cord injury. Fortunately, with expert care the majority of these complications can be prevented. With good management of the multi-system dysfunction and of the spinal injury the great majority of patients with incomplete spinal cord injuries recover significantly. In general the majority of patients who pre- sent with motor power sparing or start regaining motor power within the first 48 to 72 hours following injury should walk again (86). Patients with spino-thalamic sensory sparing between the level of the injury and the 5th sacral dermatome but with no motor sparing also have a good chance of significant recovery (87-89). Over sixty percent of these patients will re- cover significantly to ambulate (88).
In the United States purchase kamagra gold 100 mg online, it has decreased in use since mace oleoresin capsicum sprays became widely issued because the latter appeared more effective buy cheap kamagra gold 100 mg on-line. Tasers are available in parts of Australia to specialist officers and also subject to review of their effectiveness order kamagra gold 100mg otc. More research on the medical effects of Taser usage will no doubt be forthcoming over time. Bean Bag Rounds Available widely in the United States and some Australian states but not the United Kingdom, bean bag rounds consist of rectangular, square, or circu- lar synthetic cloth bags filled with lead pellets and fired from a shotgun. For example, the “Flexible Baton” fires a bag containing 40 g of number 9 lead shot with a projectile velocity of approx 90 m/s. At impact, projectiles are designed to have separated from the shotgun shell and wadding, opened out to strike the target with its largest surface area before collapsing as they lose energy. The effect is to provide sufficient blunt force from an ideal range of 10–30 m to stop an adult’s progress. In one study (11), the most common injuries were bruising and abra- sions, followed by lacerations without having retention of the actual bean bag. However, significant other serious injuries have been documented, including closed fractures, penetrating wounds with retention of the bean bag projectile (and at times parts of the shell and/or wadding), and internal organ damage. Blunt injuries included splenic rupture, pneumothorax, compartment syndrome, tes- ticular rupture, subcapsular liver hematoma, and cardiac contusions. It was noted that retention of the bag was not always suspected on an initial clinical examination, being detected on subsequent scans. Clearly, this device has potential for significant trauma to anywhere on the body. Just as with other nonlethal alternatives for restraint, the forensic physician should always consider why such techniques needed to be deployed; use of drugs or alcohol and psychiatric illness are all common concurrent prob- lems in these situations. Cooper, Biomedical Sciences, Defence Sci- ence and Technology Laboratory, Porton, England, for information regarding baton rounds, and Sgt. John Gall and colleagues from Australia for providing information rel- evant to their jurisdiction. Discussion of “Effects of the Taser in fatalities involving police con- frontation. Detainees may have to be interviewed regarding their involvement in an offense and possibly further detained overnight for court; guidance may therefore have to be given to the custodians regarding their care. Although various laws govern the powers of the police in different juris- dictions (1), the basic principles remain the same (2,3). If an individual who is detained in police custody appears to be suffering from a mental or physical illness and needs medical attention or has sustained any injuries whether at arrest or before arrest, such attention should be sought as soon as possible. Increasingly, the police have to deal with individuals who misuse alcohol and drugs or are mentally disordered; if the detainee’s behavior raises concern, medical advice should be sought. Custody staff should also seek medical advice if an individual requests a doctor or requires medication or if the custody staff members suspect that the detainee is suffering from an infectious disease and need advice. In some areas, when a person under arrest is discharged from the hospital and taken to a police station, a doctor is called to review the detainee and assess whether he or she is fit to be detained and fit for interview (4). Medical assessments of detainees may be performed by either a doctor or a nurse retained to attend the police station (5,6) or by staff in the local hospital accident and emergency department (7). The basic principles on which doctors should base their conduct have already been outlined in Chapter 2. The health and welfare of detainees should be paramount, with any forensic considerations of secondary importance. The role of any physician in this field should be independent, professional, courteous, and nonjudgmental. If the police bring a detainee to the accident and emergency department or if the health professional is contacted by the police to attend the police station, it is important to find out why a medical assessment is required. It is essential that the doctor or nurse be properly briefed by the custody staff or investigating officer (Table 1). Fully informed consent from the detainee should be obtained after explaining the reason for the examination. Detainees should understand that they are under no obligation to give consent and that there is no right to abso- lute confidentiality. Notwithstanding the latter, custody staff should be given only that information necessary for them to care for detainees while they are in police detention. Such information will include details of any medical con- cerns, required observations, medication, and dietary requirements. Although those detained in police custody are usually young, there remains the potential for considerable morbidity and mortality among this group. There- fore, it is essential that a full medical assessment be performed and detailed con- temporaneous notes made. A sufficient quantity of medication should be prescribed to cover the time in detention. The medication should be given to the police in appropri- ately labeled individual containers or sachets; alternatively, medication may be prescribed and collected from the local pharmacist. It is most important that there is a safe regimen for medication administra- tion to detainees. Records should be kept showing that the prescribed medica- tion is given at the correct time and that any unused medicines are accounted for. Ideally, police personnel should ensure that when administering medication they are accompanied by another person as a witness, and the detainee should be observed taking the medication to prevent hoarding. If detainees are arrested with medications on their persons, medical advice should be sought regarding whether they should be allowed to self-administer them. It may be prudent for a physical assessment to be performed either in the custody suite or in the local hospital before self-administration of medications. Medication brought with the prisoner or collected from the home address should be checked to ensure that it has the correct name and dosage and that the quantity left is consistent with the date of issue. If there is doubt, police person- nel should verify with the pharmacist, family doctor, or hospital. If the medicine is unlabeled, it is preferable to issue a new prescription, especially with liquid preparations, such as methadone. The detainee should have access to food and fluids as appropriate and should also have a period of rest of 8 hours during each 24 hours. Epilepsy Many detainees state that they have “fits” and there is a need to differen- tiate, if possible, between epilepsy and seizures related to withdrawal from alcohol or benzodiazepines; it is also important to consider hypoglycemia. The type of seizure should be ascertained, together with the frequency and date of the most recent one. Treatment may be given if the detainee is in posses- sion of legitimate medication; however, if he or she is intoxicated with alcohol or other central nervous system-depressant drugs, treatment should generally be deferred until the detainee is no longer intoxicated. The custody staff should have basic first aid skills to enable them to deal with medical emergencies, such as what to do when someone has a fit. If a detainee with known epilepsy has a seizure while in custody, a medical assess- ment is advisable, although there is probably no need for hospitalization. How- ever, if a detainee with known epilepsy has more than one fit or a detainee has a “first-ever” fit while in custody, then transfer to a hospital is recommended. Diazepam intravenously or rectally is the treatment of choice for status epilepticus (11). Any detainee requiring parenteral medication to control fits should be observed for a period in the hospital. Asthma Asthma is a common condition; a careful history and objective recording of simple severity markers, such as pulse and respiratory rate, blood pressure, speech, chest auscultation, mental state, and peak expiratory flow rate, should identify patients who require hospitalization or urgent treatment (Table 4) (12). Detainees with asthma should be allowed to retain bronchodilators for the acute relief of bronchospasm (e. Diabetes It is often desirable to obtain a baseline blood glucose measurement when detainees with diabetes are initially assessed and for this to be repeated if necessary throughout the detention period. All doctors should have the means to test blood glucose, using either a strip for visual estimation or a quantitative meter. Oral hypoglycemics and insulin should be continued and consideration given to supervision of insulin injections. Regular meals and snacks should be provided, and all patients with diabetes should have access to rapidly absorbed, carbohydrate-rich food. If the blood glucose is less than 4 mmol/L in a conscious person, oral carbohydrates should be given. In a detainee who is 210 Norfolk and Stark unconscious or restless, an intravenous bolus of 50 mL of 50% dextrose solu- tion may be difficult to administer and may result in skin necrosis if extravasa- tion occurs; therefore, 1 mg of glucagon can be given intramuscularly, followed by 40% glucose gel orally or applied to the inside of the mouth. Glucagon can give an initial glycemic response even in a patient with alcoholic liver disease (13); however, it should be remembered that in severe alcoholics with depleted glycogen stores, the response to glucagon may be reduced or ineffective. Heart Disease The main problems encountered include a history of hypertension, angina, cardiac failure, and stable dysrhythmias. Basic cardiovascular assessment may be required, including examination of the pulse and blood pressure, together with auscultation of the heart and lungs for evidence of murmurs or cardiac failure. Prescribed medication should be continued, and detainees should be allowed to keep their glyceryl trinitrate spray or tablet with them in the cell. Chest pain that does not settle with glyceryl trinitrate will obviously require further assessment in the hospital. Sickle Cell Disease Most detainees with sickle cell disease are aware of their illness and the symptoms to expect during an acute sickle cell crisis. Medical management in custody should not pose a problem unless there is an acute crisis, when hospital transfer may be required. Conditions of detention should be suitable, with adequate heating and access to fluids and analgesics as appropriate.