The conjugated lone pair of the amide nitrogen atom is not available to form hydrogen bonds generic 100mg lady era with mastercard womens health group. Anti- parallel b-sheets (shown) have the peptide chains running in opposite directions buy lady era 100 mg cheap breast cancer test. Parallel b-sheet (not shown) have the peptide chains running in the same direction discount 100 mg lady era mastercard menopause type 9. For example buy lady era 100 mg low cost women's health clinic yonge and eglinton, the basis of the structure of the fibrous protein collagen which occurs in skin, teeth and bones, consists of three chains of the polypeptide tropocollagen in the form of a triple helix. Reproduced from G Thomas, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science, 1996, by permission of Prentice Hall, a Pearson Education Company and biological activity. For example, the water solubility of a protein is usually at a minimum at its isoelectric point whilst the charge on a protein may affect the ease of transport of a protein through a plasma membrane (see Appendix 5). It is also important in electrophoretic and chromatographic methods of protein analysis. Reproduced from G Thomas, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science, 1996, by permission of Prentice Hall, a Pearson Education Company Table 1. Monosaccharides are either polyhydroxyaldehydes (aldoses) or polyhydroxyketones (ketoses), which are not converted to any simpler polyhydroxyaldehydes and polyhydroxyketones res- pectively under aqueous hydrolysis conditions. How- ever, not all polyhydroxyaldehydes and ketones are classified as carbohydrates. For example, an aldohexose is a monosaccharide that con- tains a total of six carbon atoms including that of the aldehyde in its structure. Similarly, a ketopentose has five carbons in its structure including the one in the keto group. Oligosaccharides are carbohydrates that yield from two to about nine monosaccharide molecules when one molecule of the oligosaccharide is hydrolysed. Small oligosaccharides are often classified according to the number of monosaccharide residues contained in their structures. For example, disac- charides and trisaccharides contain two and three monosaccharide residues respectively whilst polysaccharides yield larger numbers of monosaccharide molecules per polysaccharide molecule on hydrolysis. They exhibit a wide variety of biological functions but in particular act as major energy sources for the body. Those with five or more carbon atoms usually assume either a five (furanose) or six (pyranose) membered ring structure. These cyclic structures are formed by an internal nucleophilic addition between a suitably positioned hydroxy group in the molecule and the carbonyl group (Figure 1. This internal nucleophilic addition introduces a new chiral centre into the molecule. The carbon of the new centre is known as the anomeric carbon and the two new stereoisomers formed are referred to as anomers. In this convention solid lines represent bonds above the plane of the ring whilst dotted lines are used to indicate bonds below the plane of the ring. Reproduced from G Thomas, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science, 1996, by permis- sion of Prentice Hall, a Pearson Education Company In many cases pure a- and b-anomers may be obtained by using appropriate isolation techniques. For example, crystallization of D-glucose from ethanol yields a-D-glucose [a] þ112. However, in aqueous solution these cyclic structures can form equilibrium mixtures with the corresponding straight chain form (Figure 1. The change in optical rotation due to the conversion of either the pure a- or pure b-anomer of a monosaccharide into an equilibrium mixture of both forms in aqueous solution is known as mutarotation (Figure 1. The specific rotation of the aqueous equilib- rium mixture is þ52 All monosaccharides have a number of stereogenic centres. The configurations of these centres may be indicated by the use of the R/S nomenclature system. However, the historic system where the configurations of all the chiral centres are indicated by the stem name of the monosaccharide (Figure 1. In the D form this hydroxy group projects on the right of the carbon chain towards the observer whilst in the L form it projects on the left of the carbon chain towards the observer when the molecule is viewed with the unsaturated group at the top. These configurations are usually represented, on paper, by modified Fischer projections (Figure 1. The D and L forms of a monosaccharide have mirror image structures, that is, are enantiomers (Figure 1. The system is based on the relative positions of adjacent hydroxy groups with the carbonyl group being used as a reference point for the hydroxy groups. Epimers are compounds that have identical configurations except for one carbon atom. For example, both a-D-glucose and a-D-fructose react with phenylhydrazine to form the same osazone. This means that after a short time a basic aqueous solution of a monosaccharide will also contain a mixture of monosaccharides that will exhibit their character- istic chemical properties. For example, a solution of fructose will produce a silver mirror when treated with an ammoniacal solution of silver nitrate (Tol- len’s reagent). This is because under basic conditions fructose undergoes tauto- merism to glucose, whose structure contains an aldehyde group, which reduces Tollen’s reagent to metallic silver. The approximate concen- trations of the isomers present at equilibrium are given in the brackets 1. Commonly used trivial names are given in the brackets monosaccharides are based on a stem name indicating the number of carbon atoms, a prefix indicating the configuration of the hydroxy group and either the suffix -ose (aldoses) or -ulose (ketoses). Five membered ring monosacchar- ides have the stem name furanose whilst six membered ring compounds have the stem name pyranose together with the appropriate configurational prefixes indicating the stereochemistry of the anomers (Figure 1. Monosacchar- ides in which one of the hydroxy groups has been replaced by a hydrogen atom have the prefix deoxy- with the appropriate locant, except if it is at position 2, when no locant is given. These are compounds which consist of a carbohydrate residue, known generally as a glycone, bonded to a non-sugar residue, known generally as an aglycone, by a so called glycosidic link to the anomeric carbon of the glycone. Since the glycosidic link is formed to the anomeric carbon both a- and b-isomers of a glycoside are known. Each type of glycosidic link will exhibit the characteristics of the structure forming the link. For example, oxygen glycosidic links are effectively acetals and so undergo hydrolysis in aqueous solution. In systematic nomenclature the radical name of the aglycone preceeds the name of the glycone, which has the suffix -oside. The shaded parts of the structures are the aglycone sections Glycoproteins are glycosides that have a protein aglycone. The links between between monosaccharide residues of a polysaccharide molecule are usually referred to in terms of the type of the numbers of the carbon atoms forming the link and the stereochemistry of the anomeric pos- ition. For example, the glycosidic link formed in maltose is refered to as an a-1,4-link (Figure 1. The anomeric carbon atom of the second glucose residue can undergo mutarotation and so maltose will exist as two isomers in aqueous solution. The structures are normally drawn so that the oxygen atom forming the glycosidic link is above or below the plane of the ring system. This sometimes requires the structure of a residue to be turned around and/or over in order to obtain the correct alignment of the oxygen atom. Enzymes that catalyse the aque- ous hydrolysis of the glycosidic links of polysaccharides will only usually cata- lyse the cleavage of a link formed by a particular anomer or anomers. For example, an a-glucosidase catalyses the hydrolysis of glycosidic links formed by an a-glucose residue acting as a glycone in the polysaccharide chain. These names are based on the systematic names of the monosaccharides corresponding to the residues. How- ever, the suffix -osyl is used for a substituent residue joined through its anomeric carbon to the next residue in the chain and the suffix -oside is used for the last residue in the chain (Figure 1. In all cases the poly- saccharide section may have linear or branched chain structures, which often contain the derivatives of both monosaccharides and aminosugars (Figure 1.
Active Diffusion Active diffusion is how drug particles swim upstream against the natural flow when there is a higher concentration of plasma than there is of drug particles cheap lady era 100 mg fast delivery women's health center lansing mi. Drug particles don’t have enough energy to go against the natural flow without help order 100 mg lady era mastercard women's health issues and physical therapy. Help comes from an enzyme or protein carrier that transports drug parti- cles upstream across the membrane and into the plasma discount 100mg lady era visa menopause jewelry. Pinocytosis Pinocytosis is the process of engulfing the drug particle and pulling it across the membrane 100 mg lady era with amex women's health big book of 15 minute workouts review. This is similar to how you eat an ice pop by engulfing a piece of it in with your mouth and swallowing it. How long the drug will be effective and how much drug is needed depends on the route of administration, the dose of the drug, and the dosage form (tablet, capsule, or liquid). The absorption rate of a drug is influenced by a number of factors that might increase or decrease the rate, This is similar to how more gasoline is used to drive at faster speeds. Absorption is affected by many factors that include pain, stress, hunger, fasting, food, and pH. Hot, solid, fatty foods can slow absorption such as eating a Big Mac before taking medication. During exercise, circulation to the stomach is diverted to other areas of the body and drug absorption is decreased. Circulation Blood flow to the site of administration of the drug will help increase the rate of absorption. An area that has a lot of blood vessels and good circulation will help absorb the drug quickly and circulate it to the intended site. When a patient is in shock and has a low blood pressure due to decreased circulation (blood flow) drugs may not be absorbed very quickly. Route of Administration The rate at which drug particles are absorbed is determined by the amount of blood vessels there are in the area where the drug is administered. For example, a drug is absorbed faster in the deltoid (arm) muscle than in the gluteal (butt) muscle because there are more blood vessels in the del- toid muscle. This additional step causes water- soluble drugs to be absorbed more slowly than fat-soluble drugs. If a high concentration of the drug is given, it will tend to be absorbed more rapidly. Sometimes larger (loading or priming) doses of a drug may be given that will be more than the body can excrete. After the first large dose, small maintenance doses will help keep the therapeutic effect. Drugs can be processed when they are manufactured to add other ingredients that will help or hinder absorption. For example, hydrochloric acid in the stomach destroys some drug particles before it can pass through the membrane and into the bloodstream. The percentage of a dose that reaches the blood stream is called the bio- availability of a drug. Typically, between 20% and 40% of drugs that are admin- istered orally reach the blood stream. This is called the first pass effect and is the beginning of the metabolism of a drug that is given orally. Sometimes very lit- tle of the drug remains available for a therapeutic effect after the first pass. Only drugs administered intravenously have a 100% bioavailability because they are directly injected into the vein. Pharmaceutical manufacturers must consider bioavailability when determin- ing the dose for a drug. The percent of active ingredient in a dose is referred to as the drug concentration. These are primary loading— a large concentration that is used to achieve a fast therapeutic effect such as the first dose of an antibiotic, and maintenance dose—a typical concentration of the drug that is used to provide an ongoing therapeutic effect such as subsequent doses of an antibiotic. These are referred to as “free” drugs because they are not bound to any receptor sites. These drug–protein complexes decrease the concentration of free drug in the circulation. The drug molecule is released from the protein and it becomes free drug and can be absorbed for use. Drugs affect areas of the body with good blood supply first, such as the heart, liver, kidney, and brain and then flow to areas with less blood supply, such as muscles and fat. Drugs accumulate in an area of the body and form a reservoir by binding to tissues. These are protein binding—when a drug binds to plasma proteins, and tissue binding—fat soluble drugs are stored in adipose (fat) tissue. Inderal (propranolol) is a heart medication that is highly bound to and only about 7% of free drug is available for use at a time. In addition, some drugs, such as the antibiotic Tetracycline like to be stored in bones which can interfere with growth of fetal skeletal tissues and can discolor teeth if given to children under eight years of age. Level of Plasma Protein A low level of plasma protein and albumin might not provide enough binding sites for drug particles. This happens when there is liver or kidney disease or if the patient is mal- nourished resulting in low albumin levels (hypoalbuminemia). Healthcare professionals should monitor a patient’s plasma protein and albumin levels and the protein-binding percentage of all drugs before administering drugs to the patient. Bloodflow There must be adequate bloodflow to target areas of the body; otherwise, insuf- ficient drug particles will reach affected parts of the body. Drugs that accumulate in fat are called lipid soluble and remain for about three hours because there is low blood flow in fat tissue. Competing Drugs Two drugs administered simultaneously might compete for the same binding sites making some drug particles unable to find a binding site. Two drugs that are highly protein bound—such as Coumadin (warfarin) and Inderal (propra- nolol)—will compete for the protein sites. This can cause serious problems and can result in toxic levels of one or both of the drugs when increased amounts of free drug become available. Abscesses, exudates, body glands, and tumors hinder the distribution of drugs in the body. The placenta metabolizes some drugs making then inactive and thereby protecting the fetus from drugs given to the mother. However, steroids, nar- cotics, anesthetics, and some antibiotics can penetrate the placental barrier and cause adverse effects to the fetus. This metabolism—called biotransformation—occurs in the liver where enzymes inactivate a drug by changing it into more water-soluble compounds that can be excreted from the body. Elimination occurs mainly through the kidneys, although some drugs are also eliminated in bile, feces, lungs, sweat, and breast milk. Patients suffering from liver diseases are prone to drug toxicity because the diseased liver no longer metabolizes the drug sufficiently to allow elimination through the kidneys. The result is a buildup of the drug, which can eventually lead to a toxic effect on the body. The amount of time for half of the drug concentration to be eliminated from the body is called the drug’s half-life and is a crucial measurement used to deter- mine how often to administer a drug.
Zollinger–Ellison therapy and Zollinger–Ellison syndrome cheap lady era 100mg visa women's health clinic kilkenny, the incidence of syndrome is an uncommon disorder caused by a gastrin- H cheap lady era 100mg pregnancy halloween shirts. It has been shown that the speed of ulcer healing obtained with acid-suppressing agents is acceler- The therapeutic objectives are as follows: ated if H cheap 100mg lady era overnight delivery menstruation at age 5. Documented duodenal or gastric ulcerations should be treated with an H2-blocker or proton-pump Lansoprazole 30mg bd inhibitor purchase 100mg lady era mastercard women's health ketone diet. Antacids have a number of actions which include neutralizing • Avoid ulcerogenic drugs (e. A number of preparations are available and the choice will The choice of regimen used to eradicate H. Most regimens include a combination In general terms, antacids should be taken approximately of acid suppression and effective doses of two antibiotics. Eradication should be confirmed, preferably by urea breath test at a minimum of four weeks post-treatment. There are a number of competitive H2-receptor Ulcer-healing drugs antagonists in clinical use, which include cimetidine and Reduction of acidity: ranitidine. The uses of these are similar and will be con- • antacids; sidered together in this section. Because each drug is so • H2-blockers; widely prescribed, separate sections on their individual • proton-pump inhibitors; • muscarinic blockers (pirenzapine). Poor solubility, weak antacids; Diarrhoea dihydroxide, carbonate, the trisilicates inactivate pepsin; trisilicate) increase lower oesophageal sphincter tone, and may be of use in reflux Aluminium hydroxide Forms an insoluble colloid in Constipation; absorption of dietary the presence of acid, and lines phosphate may lead to calcium the gastric mucosa to provide a depletion and negative calcium balance physical and chemical barrier; weak antacid, slow onset of action, inactivates pepsin adequate. Cimetidine transiently Most regimens include an H2-receptor antagonist or a increases serum prolactin levels, but the significance of this proton-pump inhibitor. Decreased libido and impotence have occa- endoscopically, as H2-blockers can improve symptoms sionally been reported during cimetidine treatment. Without gastric acid, the cimetidine administration can cause gynaecomastia, which is functions of which include providing a barrier to reversible and appears with a frequency of 0. Rapid infection, patients on H2-antagonists and proton-pump intravenous injection of cimetidine has rarely been associated inhibitors are predisposed to infection by enteric with bradycardia, tachycardia, asystole or hypotension. In cases of acute upper gastrointestinal haemorrhage and Drug interactions stress ulceration, the use of H2-blockers is rational, 1. Absorption of ketoconazole (which requires a low pH) although their efficacy has not been proven. Metabolism of several drugs is reduced by cimetidine due pancreatic insufficiency is often unsatisfactory due to to inhibition of cytochrome P450, resulting in raised destruction of the enzymes by acid and pepsin in the plasma drug concentrations. H2-blockers improve the effectiveness of these clinical importance include those with warfarin, enzymes in such cases. In anaesthesia, H2-receptor blockers can be given before other opioid analgesics, tricyclic antidepressants, emergency surgery to prevent aspiration of acid gastric lidocaine (cimetidine-induced reduction of hepatic blood contents, particularly in obstetric practice (Mendelson’s flow is also a factor in this interaction), terfenadine, syndrome). Cimetidine inhibits the renal excretion of metformin and nocte, while for ranitidine it is 150mg bd or 300mg nocte procainamide, resulting in increased plasma to treat benign peptic ulceration. Intramuscular and intra- bioavailability is only 50%, suggesting that there is appre- venous injections produce equivalent blood levels. Cardiovascular effects have been even more mucosa and stimulates the production of protective mucus. Ranitidine has a lower affinity for cytochrome P450 than cimetidine and does not inhibit the metabolism of warfarin, Adverse effects phenytoin and theophylline to a clinically significant degree. Diarrhoea, abdominal pain, nausea and vomiting, dyspepsia, Choice of H -antagonist flatulence, abnormal vaginal bleeding, rashes and dizziness 2 may occur. Cimetidine and ranitidine are most commonly prescribed and Contraindications have been available for the longest time. Cimetidine is the least expensive, but in young men who require prolonged treatment Pregnancy (or desired pregnancy) is an absolute contraindica- ranitidine may be preferable, due to a lower reported incidence tion to the use of misoprostol, as the latter causes abortion. It also include famotidine and nizatidine, but they offer no signifi- stimulates mucus production and may chelate with pepsin, cant advantage over ranitidine. Several studies have shown it to be as active as cimetidine in the healing of duodenal and gas- tric ulcers after four to eight weeks of treatment. H /K -adenosine triphosphatase enzyme system (the proton Bismuth chelate elixir is given diluted with water 30 min- pump) of the gastric parietal cell. Examples are omeprazole, utes before meals and two hours after the last meal of the day. This liquid has an ammoniacal, metallic taste and odour The main differences, if any, appear to be in relation to drug which is unacceptable to some patients, and chewable tablets interactions. Antacids or milk should not be taken con- nificant drug interactions with pantoprazole, whereas omepra- currently. Its action is entirely local, sphincter pressure, and coffee; with minimal if any systemic absorption. In addition it binds to pepsin and bile salts and prevents their contact with the ulcer base. The dose is 1g (one tablet) four times daily for Drugs that may be useful include the following: four to six weeks. It may also improve gastro- Sucralfate is well tolerated but, because it contains aluminium, oesophageal sphincter function and accelerate gastric constipation can occur and in severe renal failure accumulation emptying; is a potential hazard. A 25-year-old male estate agent complains of intermittent heartburn, belching and sub-xiphisternal pain which has been present on most nights for two weeks. It was particu- larly severe the previous Saturday night after he had con- sumed a large curry and several pints of beer. Non-drug measures which may be useful include the following: Prescribe alginate/antacids. If the oesophagus occurs at night when swallowing is much symptoms have still not completely resolved, refer the reduced and acid can remain in contact with the mucosa patient for endoscopy. Nausea and sickness during the first trimester of pregnancy will respond to most anti-emetics, but are rarely treated with drugs because of the possible dangers (currently Act of vomiting unquantifiable) of teratogenesis. Vomiting is preceded by intestinal obstruction, intracerebral space-occupying lesion) usually cures the vomiting. This vomiting centre These act partly by their antimuscarinic action on the gut, as (Figure 34. The major efferent in preventing motion sickness and is useful in single doses for pathways from the vomiting centre are the phrenic nerve, the short journeys, as the anticholinergic side effects make it visceral efferent of the vagus to the stomach and oesophagus, unsuitable for chronic use. Hyoscine is an alternative to anti- and the spinal nerves to the abdominal musculature. Drowsiness, blurred vision, dry mouth and urinary the area postrema of the fourth ventricle which is sensitive to retention are more common at therapeutic doses than is the emetic stimuli such as radiation, bacterial toxins and uraemia. They have additional anticholinergic actions, and these con- Anti-emetic drugs can be classified pharmacologically as tribute to their anti-emetic effect. They should only be used when the cause promethazine, betahistine and cinnarizine. The main limita- of nausea or vomiting is known, otherwise the symptomatic tions of these drugs are their modest efficacy and common dose- relief produced could delay diagnosis of a remediable and related adverse effects, in addition to antimuscarinic effects. It is more Metoclopramide potentiates the extrapyramidal effects of sedative than cyclizine. Its effects on intestinal • Betahistine is used in vertigo, tinnitus and hearing loss motility result in numerous alterations in drug absorption, associated with Ménière’s disease. Phenothiazines barium to reach the caecum and decreases the number of used as anti-emetics include prochlorperazine, trifluoper- films required; azine, perphenazine and chlorpromazine.
At the outset of the interview cheap lady era 100mg overnight delivery menstrual non stop bleeding, the suspects have a clear recollection that they were not involved in the alleged offense 100 mg lady era for sale menopause question and answers. However discount 100 mg lady era amex menopause vitamin d, as a result of subtle manipu- lative techniques employed by the interrogator buy lady era 100mg cheap women's health clinic in toronto, they begin to distrust their own memory and beliefs. Interrogators attempt to undermine the suspects’ confidence in their own recollection of events, which would create sufficient self-doubt and confusion to cause them to adjust their perceptions of reality. In contrast to the makers of coerced-compliant false confessions, those who make coerced-internalized false confessions only retract their confessions when they realize, or suspect, that they are in fact innocent. These retractions can take considerable time and, occasionally, may never occur if the original memory of events becomes permanently distorted. Suggestibility and Compliance Vitally important to an understanding of why false confessions can often prove so incriminating is an awareness of the theory of interrogative suggest- ibility (54,55). At the heart of the theory is the way leading questions can produce distorted responses from suspects because they are phrased to sug- gest the expected response. Through this process people can come to accept a piece of postevent information and incorporate it into their memory, thus 220 Norfolk and Stark appearing to have “special knowledge” about the alleged offense. This spe- cial knowledge may seriously mislead the police and the courts to assume the suspect’s guilt erroneously. Suggestibility correlates with anxiety, lack of assertiveness, poor self-esteem, and low intelligence (56). Compliance refers to the tendency of people to obey the instructions of others when they don’t really want to, because they are either overeager to please or simply unable to resist the pressure (57). The traits of both suggest- ibility and compliance are relevant to the issue of false confessions (58). Preventing False Confessions It is a fundamental tenet of both American and English law that reliance should only be placed on confession evidence that is given freely and voluntar- ily. In considering the voluntary nature of a confession, several factors need to be considered. These include the vulnerability of the accused (through factors such as age, mental illness and handicap, physical illness or injury, and intoxi- cation), the conditions of detention (lack of access to legal advice, failure to be given legal rights, and adequate rest periods during detention), and the charac- teristics of the interrogation (threats, physical abuse, and inducements). In America, the most important legal development designed to protect the rights of suspects and deter police misconduct relates to the case of Miranda v. The effect of this judgment was to ensure that all criminal suspects in police custody must be warned against self- incrimination and made aware of their right to remain silent and to receive legal advice. These rights have to be actively waived by the accused before interroga- tion can commence, and any violations of the requirements render any subse- quent confession inadmissible. In the United Kingdom, statutory safeguards are provided by the Police and Criminal Evidence Act 1984 and the Codes of Practice set up under sec- tion 66 of this Act (1), which regulate practice in respect to several matters, including the detention, treatment, and questioning of persons by police offic- ers. Confessions will generally be inadmissible if the provisions of the Codes of Practice are breached by the police (60,61). The role of the forensic physician when assessing a suspect’s fitness for interview is seen as fitting into this overall legal framework, the doctor’s primary concern being to recognize any characteristics that might render the individual vulnerable to providing a false confession so that adequate safe- guards can be put in place. To address this deficiency, Norfolk (63) proposed a definition that was used as the starting point for discussion by a subgroup set up by the Home Office Working Party on Police Surgeons in the United Kingdom. That working party made an in- terim recommendation (64) that has now been modified and included in the 2003 revision of the Police and Criminal Evidence Act Codes of Practice (1), thus providing the first Parliamentary approved definition of the term fitness for interview. The Codes of Practice state that: A detainee may be at risk in an interview if it is considered that: (a) Conducting the interview could significantly harm the detainee’s physi- cal or mental state (b) Anything the detainee says in the interview about their involvement or suspected involvement in the offense about which they are being inter- viewed might be considered unreliable in subsequent court proceed- ings because of their physical or mental state. Thus, a suspect with known ischemic heart disease who is experiencing chest pain satisfies the criteria of (a) above and clearly needs assessment and appropriate treatment before it is safe to conduct an interrogation. The concept of unreliability may be harder to evaluate and will require consideration of the various vulnerability factors associated with false confes- sions. In making an assessment, the Codes of Practice require the doctor to consider the following: 1. How the detainee’s physical or mental state might affect their ability to under- stand the nature and purpose of the interview, to comprehend what is being asked, and to appreciate the significance of any answers given and make rational deci- sions about whether they want to say anything. The extent to which the detainee’s replies may be affected by their physical or mental condition rather than representing a rational and accurate explanation of their involvement in the offense. How the nature of the interview, which could include particularly probing ques- tions, might affect the detainee. Scheme of Examination When assessing a detainee’s fitness for interview, the traditional medi- cal model of taking a history and then conducting an examination should be 222 Norfolk and Stark employed. As always, informed consent should be obtained and detailed and contemporaneous notes should be taken. The History As much background information as is practicable should be obtained and, when possible, an indication of how long any interview is likely to take. The demand characteristics of a long interview about a suspected murder will be much greater than a short interview about a shoplifting offense. A general medical history should be taken, with inquiry made about sig- nificant illness and any prescribed medication. The detainee should be asked whether he or she has suffered from psychiatric illness, past or present, and specific inquiry should be made about alcohol and drug misuse. There should be questions about the person’s educational background, because individuals with learning difficulties can be tough to recognize and inquiring about school- ing may aid identification. Ensure that the detainee has not been deprived of food or sleep, and inquire about significant social distractions (e. Detainees should be asked whether they have been detained before and, if so, whether they have had unpleasant experiences while in custody in the past. The Examination The examination should include observations on the general appearance, physical examination as appropriate, and mental state examination. A func- tional assessment should be performed regarding whether the detainee is aware of the reason for arrest, his or her legal rights, and is capable of making a rational decision (able to choose between relevant courses of action) and of carrying out the chosen course of action. Each examination needs to be tailored to the individual, but doctors should be able to assess the vulnerabilities of the detainees they have been asked to examine and thus ensure that any necessary safeguards are established before interrogation begins. Alcohol and Fitness for Interview It is generally accepted that severe alcohol intoxication renders a suspect unfit to be interviewed. However, there is much less agreement when it comes to deciding when somebody with mild or moderate intoxication should be considered fit to interview (62,65). The customary view that intellectual pro- cesses are impaired at lower blood alcohol levels than sensory or motor pro- Care of Detainees 223 cesses has been challenged. Indeed, the opposite has been shown, with intel- lectual processes being more resistant to alcohol than sensory and motor skills (66). Nonetheless, the effect alcohol can have on short-term memory should be remembered when advising the police on fitness. Research suggests that moderate quantities of alcohol impair the process of forming new memories (67). Deterioration in performance of a task assessing short-term memory occurred at blood alcohol levels of 70 mg/100 mL in one study (68), and a significant impairment of eyewitness memory has been demonstrated at aver- age blood alcohol levels of 100 mg/100 mL (69). When suspects mistrust their own memory of events, they are at increased risk of providing coerced–inter- nalized false confessions (52). The ultimate decision regarding whether a suspect who has been drink- ing is fit for interview is best decided on the medical and functional assess- ment performed by the doctor rather than on arbitrarily defined “safe” blood alcohol levels (70). Alcohol withdrawal states and the complications of alcohol withdrawal can impair cognitive functioning and affect a suspect’s ability to both cope with interrogative pressure and provide reliable testimony. Even the after effects of alcohol, or “hangover,” impair critical task performance, such as aircraft operation, and can impair judgment (71). Research evidence has also suggested that alcohol withdrawal can increase a suspect’s suggestibility, although it is not totally clear whether this is a direct result of the alcohol withdrawal or is secondary effect of its treatment (72). Substance Misuse and Fitness for Interview A substance misuser may be rendered unfit for interview by virtue of either intoxication or withdrawal.