By I. Armon. Bismarck State College.
The of contrast enhancement on T1-weighted sequences discount pyridostigmine 60mg overnight delivery muscle relaxant 551, entry for the schistosoma cercaria is active percutane- which is a centrally linear enhancement surrounded by ous discount pyridostigmine 60 mg mastercard muscle relaxant non-prescription. The adult parasites are harmless generic pyridostigmine 60mg amex spasms constipation, but their fertilized Acknowledgement eggs are highly pathogenic generic pyridostigmine 60mg on-line muscle relaxant intravenous. The eggs are released into the venous system from where they drif to diferent or- I would like to thank Professor Rakesch K. The lef-sided brain-stem lesion appears partially cystic and inhomogeneously hyperintense on T2-weighted c images (c) Parasitic Infections 165 Further Reading Lucius R, Loos-Frank B (2008) Biology of parasites. Initial neuroimaging has Presentation, Therapy 177 to rule out infectious foci of the skull base such as 11. The space of systemic diseases, such as sarcoidosis or vasculitis, between the arachnoid mater and the pia mater is the may involve the meninges. While bacterial and viral meningitis are supposed to exhibit enhancement that is thin and lin- ear, fungal meningitis and neoplastic infltration of the 11. A list of the potential causes of leptomeningeal enhancement is given in Table 11. Anatomically, the meninges consist of three layers: the The pachymeninges (thick meninges) consist of the dura mater; the arachnoid mater; and the pia mater. Terefore, the pachymeninges can be seen Inflammatory Diseases of the Meninges 171 Table 11. Probable causes of predominant pachymeningeal contrast enhancement in neuroimaging etiology type of enhancement Remarks Intracranial hypotension, e. Tickening and increased contrast enhancement of the who had been surgically treated for an oligodendroglioma of the pachymeninges with efusion into the subdural space (arrows lef frontal lobe. Further symptoms indicating irritation of the leptomeninges are nausea, conjunctivitis, hyper- 11. Approximately one fourth of Epidemiology, Clinical Presentation, Therapy the patients develop petechial rash, with N. One third Bacterial meningitis is the purulent infection of the ce- of the patients have focal neurological defcits such as rebral and spinal leptomeninges. Mortality ranges between 20 and 30%, and disease; they are more frequent in pneumococcal than neurological sequelae occur in 1540% of surviving pa- in meningococcal meningitis (van de Beek et al. Another path of infection is brain injury bacteremia and comprise the Waterhouse-Friderichsen with open or covered disruption of the dura mater, es- syndrome (e. Antiedematous adults Streptococcus pneumoniae and Neisseria menin- treatment with dexamethasone before or with the frst gitidis are found most ofen. In a recent study on the dose of antimicrobial therapy has been proven to re- epidemiology of 696 episodes of community-acquired duce the risk of unfavorable outcome, including mor- meningitis in adults, S. Afer neurosurgery and in patients with open brain injury or with dural fstu- In uncomplicated cases and the initial phase of the dis- lae, S. Bifrontal subdural exudates (c,d) with relatively high Inflammatory Diseases of the Meninges 175 a b Fig. A 3-year-old boy with medical history of premature birth, subarachnoid hemorrhage, and hydrocephalus occlusus. The child developed a pneumococcal meningitis due to shunt infection that was complicated by ventriculitis. Tin linear enhancement of the ependyma of the ventricles (b,c) and in the channel of the ventricular drainage c (c, arrow) 176 S. Pneumococcal meningitis with complicating hemicraniotomy was made due to pronounced general brain epidural empyema. A 14-year-old girl that pre- iotomy defects and hyperintense changes of the frontal cortex sented initially with clouded consciousness and recurrent gen- (arrow in d). One month afer the surgical intervention, the eralized seizures due to meningococcal meningitis. Axial and coronal contrast- for bifrontal hemicraniotomy was made due to pronounced enhanced T1-weighted images (e,f) demonstrate bifrontal pa- general brain edema. The meninges ingeal enhancement as well, known as carcinomatous are afected secondarily through hematogenous spread meningitis. Hydrocephalus and secondary vasculitis are are confrmed for patients with cranial nerve palsy: Im- main complications. Mortality is still 1020%; it is even aging should always be performed in the axial and coro- higher in underdeveloped countries and afer delayed nal plane using contrast-enhanced T1-weighted images diagnosis. Steroids should be given to enhancement, bacterial meningitis afects more ofen prevent secondary vasculitis. Furthermore, the combination of meningitis and parenchymal lesions suggests tuberculosis; however, some primary or meta- 11. Interestingly, recent studies have demonstrated that tuberculous meningitis Isolated infammation of the meninges due to virus is not only seen on contrast-enhanced T1-weighted im- infection is rare. Additionally, parain- has to be considered highly suggestive of tuberculous fectious meningitis is a common fnding in many sys- meningitis. Yet, one has to keep in mind that formation temic viral infections and afer antiviral vaccination. A 24-year-old patient, revealed basal meningitis with hyperintense exudates in the with a history of intravenous drug abuse, presented with prepontine and basal cisterns and thick, linear leptomeningeal headache and abducent nerve palsy. Specifc treatment with antiviral chemothera- neuroimaging reveals no abnormalities or only unspe- peutics (e. A 36-year-old patient, who was admitted with fever, headache, and confused mental state. Slightly hyperintense signal in the subarachnoid space of the sulci (arrow in a,b), sugges- tive of protein-rich infammatory exudates due to viral infec- c tion. Pathological fndings indicating the presence of en- cephalitis comprise hyperintensities on T2-weighted 11. Cryptococcal meningoencephalitis typically mani- fests with difuse meningeal enhancement and ven- 11. Hydro- neoplastic diseases, especially bacterial meningitis, have cephalus is found more ofen in immunocompetent pa- to be excluded. Parenchymal aspergillosis may appear as edematous and hemorrhagic lesions or solid, ring-like 11. Fungal cal meningoencephalitis manifests weeks afer asymp- meningitis ofen causes a thicker and more lumpy men- tomatic lung infection with clinical symptoms of basal ingeal enhancement than bacterial or viral meningitis. Typical features include stenosis and Therapy interruption of large and medium-large arteries, and vasculitic aneurysms (see also Chap. Syphilis is a curable sexually transmitted disease caused by the spirochete Treponema pallidum. The incidence of syphilis in industrialized lomatous diseases, especially tuberculosis, have to be countries is approximately 24/100,000 persons. Neu- rosyphilis (neurolues) is classifed into four syndromes: syphilitic meningitis; meningovascular syphilis; as well 11. It is thought to be the consequence of direct men- ingeal infammation due to small-vessel arteriitis. Pa- Sarcoidosis is a multisystem infammatory disease char- tients present with headache, meningeal irritation, and acterized by non-caseating epitheloid-cell granulomas. Tese symp- patients present with cranial nerve palsy, most ofen toms are caused directly by the infammation of the the facial nerve or the abducence nerve is afected. Fur- meninges and the parenchyma or secondarily by infarc- ther symptoms comprise meningeal irritation, signs of tions and (aneurysm associated) bleedings due to vas- increased intracranial pressure, seizures, and hypotha- culitis. The frst-choice treatment for all manifestations lamic or pituary gland dysfunction (e. A specifc treatment is not known, but corticoster- oids are useful in most patients.
The survival of immune system is important both for inhibit the carcino gen cell growth phase and to prevent its proliferation order 60 mg pyridostigmine visa muscle relaxant list by strength. The supplementation with ascor bate increases the number and the effectiveness of the lymphocytes and upgrades the phagocythosis The characteristics of the neoplastic cell and its behavior (invasiveness order pyridostigmine 60 mg with visa back spasms 24 weeks pregnant, selective nutrition and possibly accelerated growth) are caused by microenvironmental depolymerization buy pyridostigmine 60mg with visa muscle relaxant topical. This destabilization of the matrix is favored by constant exposure to lysosomal glycosidases con tinually released by the neoplastic cell pyridostigmine 60 mg without a prescription spasms near kidney. The synthesis of collagen is a major factor for the encapsulation of tumors or metastases de creased via the development of a nearly impermeable barrier. A loss of ascorbate significantly reduces the hydroxylation of proline and hydroxyproline and hydroxylysine to lysine respectively, affecting the cross linking of collagen. This disrupts the structure of collagen triple helix, which increases its catabolism s. These values can be normalized with extra supplements of 20-40 mg/d or corresponding to its maximum synthetic rate. The decrease in plasma ascorbic acid in diabetes plays an important role in the abnormali ties of collagen and proteoglycans. These are the 2 major constituents of the extracellular matrix and its abnormalities are associated with the pathogenesis and complications of dia betes. Ascorbic acid enhances the collagen and proteoglycans in fibroblast culture media. Insulin removes the inhibitory effect of glucose on the production of collagen, but the mechanism is not yet known. Thus high con centrations of glucose in diabetes damage the action of ascorbic acid at the cellular level. And in many cases is "asymptomatic" or people who have it doing not give importance. However there have been great efforts to use its measurement in the detection of primary or secondary essential hypertension for decades. Virtually the observed declines in blood pressure and its control in recent years due to better control among individuals diagnosed as hypertensive. Obesity, dietary sodium and alcohol consumption are strongly associat ed with low or high blood pressure values. A high intake of polyunsaturated fatty acids and magnesium are associated with for in stance with low pressure. It has also shown an inverse association between plasma vita min C and blood pressure. These subjects have a similar difference in diastolic pressure ranging from 78 to 73 mm Hg, a difference of 6%. These results were consistent in several studies regardless of quintiles being compared. Such relationships have also been identified in Chinese-American population; both men and women aged 60-96 years without antihypertensive treatment. This study revealed a statisti cally significant difference between the values of systolic and diastolic pressure in upper and lower quintiles of 14% (21 mm Hg) and 9% (8mmHg) respectively. It appears that vita 474 Oxidative Stress and Chronic Degenerative Diseases - A Role for Antioxidants min C has a lowering effect on systolic rather than diastolic pressure. Supplementation with vitamin C (1g/day) does not influence the diastolic pressure. Subjects with low vitamin C levels in serum have a high risk of developing stroke compared with those with high values in plasma of the vitamin. Hypertensive subjects, usually overweight, and low levels of se rum vitamin C have the same risk. The increase in the consumption of vitamin C during periods of fat restriction occurs on the one hand a reduction in blood pressure. Thus dietary antioxidants en hance the production of prostacyclin for the purification of free radicals and peroxides that inhibit prostacyclin synthase. Vitamin C and blood pressure then are related, because it has a lowering effect on blood pressure especially when fat intake is low. Ascorbic acid and cardiovascular disease Vitamin C acts as a regulator of the catabolism of cholesterol into bile acids in the guinea pig and is an important factor in the regulation of lipid in several animal species (rabbit, horse, and rat). Correlation studies in humans have shown an inverse relationship between vitamin C in take and mortality from cardiovascular disease. Experimental and observational studies in humans have been inconsistent but indicate that individuals with high cholesterol consumption, greater than or equal to 5. This effect is explained by the promotion or in hibition of degradation of prostacyclin and its implications for thrombosis and atherogene sis, in addition to its protective effect on lipid peroxidation. In patients with high cardiovascular risk, supplementation with antioxidant vitamins shows no reduction in over all mortality or incidence of any vascular disease, cancer or other adverse events. Recent findings indicate a relationship between the nutritional status of vitamin C (as meas ured by the concentration of ascorbate in serum), biological markers of infection and haemo static factors and support the hypothesis that vitamin C may protect against cardiovascular events through effects on the haemostatic factors in response to infection. This relationship is surprising given the uncertainty and potential error in the estimation of consumption of vitamin and vitamin C status assessment (determined mostly by food intake records of 24 h blood samples isolated). Add to this the wide variation between subjects is greater than within the same subject. Lower socioeconomic status and smoking are associated with low concentrations of ascor bate and high concentrations of homeostatic factors that may be confounding factors in cross-sectional studies. The inverse association between homeostatic factors and serum concentrations of ascorbate is strong and consistent, however only some markers of infection (e. C-reactive protein and 1-antichymotrypsin) are related inversely and significantly with serum ascorbate. It is possible that this low concentration of ascorbate may be the result rather than the cause, of a biological response to infection. The strong relationship between serum ascorbate and diet ary intake suggest however that their serum concentrations reflect the nutritional status of the vitamin. The various studies reported in the literature indicate that vitamin does not prevent respira tory infection but may modulate the biological response, leading to less severe disease, so it has a protective function in lung function. Effect of antioxidants in cardiovascular disease It has been suggested a protective effect of antioxidants such as vitamin C, A (-carotene) and E plus selenium in cardiovascular disease. Prospective studies so far have documented an inverse relationship between vitamin C intake and cardiovascular disease, and a strong protective effect of vitamin E supplementation on coronary patients. Finnish and Swiss studies showed that blood levels of ascorbate and therefore a diminished nutritional status of vitamin predicts myocardial infarction. Mediterranean studies showed a 70% reduction in mortality and risk of myocardial infarction independent of the effect on blood pressure and lipids. The infection may contribute to the inflammatory process observed in atherosclerosis. C-reactive protein and alpha-1 antichymotrypsin are acute phase proteins are synthesized in hepatocytes in large numbers in inflammatory processes. Elevated fibrinogen favors these mechanisms and therefore an increased cardiovascular risk. In this way a reduction in diet ary intake in winter for instance, would lead to lower serum ascorbate levels, an increase in susceptibility to infection and the factors haemostatic factors and therefore to an increase in cardiovascular mortality. Increased intake of vitamin C to 90-100 mg/day can increase in these subjects more than 60 umol/L, which has a significant effect on all risk factors. Ascorbic acid and immunity In stress situations the adrenal glands react liberating a large number of active and ready hormones. It has been suggested that 200 mg of vitamin C per day can reduce stress levels caused by these hormones. Megadoses of vita min C increases the body levels of antibodies in animal models (rats stressed and un stressed) having the highest values stressed rats. Healing is characterized by synthesis of connective tissue, whose main component is colla gen.
The origin of cancer cachexia are obscure Clinically anorexia is a common problem in patients with cancer generic pyridostigmine 60 mg with amex muscle relaxant in india. Reduced food intake has been related to abnormalities in taste and central control of appetite buy pyridostigmine 60 mg on-line spasms shown in mri. In patents with cancer cheap 60mg pyridostigmine visa muscle relaxant chlorzoxazone side effects, calorie expenditure often remains high and basal metabolic rate is increased despite reduced food intake order pyridostigmine 60 mg on-line spasms symptoms. Paraneoplastic syndromes Paraneoplastic syndrome is an aggregate of symptom complexes in cancer - bearing patients that can not readily be explained either by the local or distant spread of the tumour or by the elaboration of hormones indigenous to the tissue from which the tumour arose Paraneoplastic syndrome occurs in about 10% of patients with malignant disease Despite its infrequency, the syndrome is important for three reasons: 1. In affected patients, they may represent significant clinical problems and may even be lethal. Laboratory Diagnosis of Cancer Every year approach to laboratory diagnosis of cancer becomes more complex more sophisticated and more specialized with time. Clinical data are invaluable for optimal pathologic diagnosis for example radiation changes in the skin or mucosa can be similar to cancer and similarly section taken from a healing fracure can mimic remarkably an osteosarcoma. Advanced techniques Immunocytochemistry Flow cytometry Tumour markers Excisional biopsy Selection of an appropriate site for biopsy of a large mass requires awareness that the margins may not be representative and the center largely necrotic. Fine needle aspiration The procedure involves aspirating cell and attendant fluid with a small needle followed by cytologic examination of the stained smear This method is used most commonly for the assessment of readily palpable lesions such as breasts, thyroid and lymph nodes etc. Immunocytochemistry The availability of specific monoclonal antibodies has greatly facilitates the identification of cell products and surface markers. Some examples of utility of immunocyto chemistry in the diagnosis of malignant neoplasms are 209 o Categorization of undifferentiated malignant tumours here intermediate filaments are important. Keratin for carcinomas, desmin for neoplasms of muscle origin o Categorization of leukemias / lymphomas o Determination of site of origin of metastatic tumours o Detection of molecules that have prognostic or therapeutic significance: Detection of hormone ( estrogen /progesterone) receptors in breast cancer cells is of prognostic and therapeutic value because these cancers are susceptible to anti- estrogen therapy. Learning objectives By the time the student is through with this lecture note he/she should be able to: 1. Introduction Human beings are subjected to a variety of metabolic diseases, as we are a complex set of structures that function through quite a varied and intertwined metabolic processes. Most metabolic diseases have genetic basis while some are acquired in life or need the complex interplay between nature and nurture for their existence. Genetic diseases either follow a single gene disorder or a polygenic basis with multifactorial disorders. Metabolic diseases with a single gene disorder These metabolic diseases follow a Mendelian type of inheritance i. Phenylketonuria, Galactosemia, Glycogen storage diseases); and x-linked recessive disorders (e. These are all rare Biochemical genetic diseases and they are beyond the scope of this lecture note. Metabolic disease with a polygenic disorder These metabolic diseases have multifactorial modes of inheritance. They are caused by the additive effects of two or more genes of small effect but conditioned by environmental, non-genetic influences. Example in these groups of metabolic diseases 213 includes Diabetes mellitus and Gout. As to the new classification there are four types of diabetes of which the first two are the major types. This can be sited as evidence that genetic factors are involved in the pathogenesis of the disease. In studies of identical (monozygotic) twins in which one or both were diabetic, both members of the pair were affected in approximately half of the cases [i. B these 50 % concordance rate shows that environmental factors contribute to the development of the disease on a heritable predisposition 3. Additional evidence came from studies of genes that code for antigens of the major Histocompatibilty complex. The above three genetic factors/ evidences show that there is a genetic factor that is/ are important for the susceptibly to the disease and environmental factors are required to the development of an autoimmune reaction on these susceptible individuals. Circulating auto- antibodies against components of the beta cells and against insulin were demonstrated in the large majority of all newly diagnosed children with diabetes. The destruction of beta cells by an immune response is also evidenced by the presence of mononuclear cell infiltrates in the pancreatic tissue of a patient with type 1 diabetes 216 Environmental factors As mentioned earlier, the fact that a significant proportion of monozygotic twins remain discordant for Diabetes suggests that non-genetic factors are required for development of diabetes. This is because milk proteins provide specific peptides that share antigenic sites (molecular mimicry) with human B cell surface proteins there by eliciting the production of auto reactive antibodies. The hyperinsulinemia inturn results in decreased insulin receptors peripherally in the muscle and adipose tissue. Increased hepatic glucose production 218 Impaired insulin secretion - The reason for the impairment of insulin secretion is not clear - Genetic defect, increased hyperglycemia (glucose toxicity), increased free fatty acid level (lipotoxicity)- all are suggested as a cause or factors which worsen beta cell failure to secrete insulin Increased hepatic glucose production - Insulin promotes storage of glucose as hepatic glycogen and suppresses gluconeogenesis. Type 2 No decrease is the number of beta cells and there is no morphologic lesion of these cells. Causes: May be caused by missing meals or doing unexpected exercise after taking insulin doses. In diabetic patients with autonomic neuropathy, there could be hypoglycemic unawareness. This is so because the patient doesnt have symptoms of hypoglycemia, and wont take appropriate measure. This oxidation produces ketone bodies (acetoacetic acid and Beta hydroxybutyric acid), which are released into the blood and lead to metabolic acidosis. Non-ketotic Hyperosmolar state Is usually a complication of Type 2 because there is enough insulin to prevent ketosis Patient present with profound dehydration resulting from a sustained hyperglycemic diuresis and finally goes to a comatose state B. Late complications of Diabetes Mechanisms of development of diabetic late complications: Long-term hyperglycemia is essential for the development of diabetic late complications. Many mechanisms linking hyperglycemia to the complications of long-standing diabetes have been explored. Hyperglycemia leads to increased intracellular glucose, which is then metabolized by aldose reductase to sorbitol, a polyol, and eventually to fructose. The accumulated sorbitol and fructose lead to increased intracellular osmolarity and influx of water, and eventually, to osmotic cell injury. In the lens, osmotically imbibed water causes swelling and opacity cataract formation. Sorbitol accumulation also impairs ion pumps and is believed to promote injury of schwann cells 222 and pericytes of retinal capillaries, with resultant peripheral neuropathy and retinal microaneurysms. Diabetic macrovascular disease: Atherosclerosis > The extent and severity of atherosclerotic lesions in large and medium sized arteries are increased in long standing diabetes, and their development tends to be accelerated. Atherosclerotic lesions in large blood vessels lead to vascular insufficiency and an ultimate production of ischemia in the organs supplied by the injured vessels. Myocardial infarction, Brain infarction (resulting in stroke), gangrene of the toes and feet. Non proliferative retinopathy Is characterized by retinal vascular micro aneurysms, blot hemorrhages, and cotton wool spots 2. Thickening of glomerular basement membrane which results in glumerulosclerosis, renal arteriosclerosis as part of the systemic Involvement of blood vessels, and pylonephritis. Polyneuropathy - The most common form of diabetic neuropathy is distal symmetric polyneuropathy. It most frequently presents with distal sensory loss, Hyperesthesia, paraesthesia and pain also occur. It is also characterized by long-term complication affecting the eyes, kidneys, Nerves and blood vessels. It also results from impaired insulin secretion, and increased glucose production. Gout Represents a heterogeneous group of diseases in which the common denominator is an increased serum uric acid level and the deposition of sodium urate crystals in joints, soft tissue around joints and kidneys.
Although this condition is not can- tle is to eat less and burn more calories by exercising order pyridostigmine 60mg with visa spasms near anus. The dietitians guide to vegetarian risks pyridostigmine 60mg without a prescription muscle relaxant withdrawal, they require high-risk obstetric care and early diets: Issues and applications purchase 60mg pyridostigmine with mastercard muscle relaxant vicodin. The risk for testicular or uterine curettage (D&C) is a procedure done for both prostate cancer is unclear purchase pyridostigmine 60mg without a prescription muscle relaxant agents. D&C is one of the regular testicular self-exams and inform his physician of most commonly performed operations in the United his exposure and be examined periodically. Dilation may be done alone for problems of risks for exposed daughters and sons are being studied to cervical stenosis (scarring and/or narrowing of the cer- determine if they differ from the unexposed population. Individuals born between 1940 and 1971 should After the cervix is dilated, curettage may be per- ask their mothers or other relatives who might know of formed using a curette, a sharp instrument for scraping. Even if they have not had health lowing miscarriage or birth, or for termination of preg- problems, they need to know so they can get the health nancy (abortion). The need for treatment in the occasional case of uterine bleeding that an annual pelvic exam is critical and is slightly different does not respond to medical therapy, generally hor- from a routine exam. In those instances mental impairments so interfere with lifes activities, when perforation occurs, the outcome is usually not life including working, that they are set apart from those threatening nor is surgical intervention required. Whether the beholder is the Social Security or infection requiring further treatment. Severe cases Insurance companies and health professionals of bleeding may lead to hysterectomy. Another compli- sometimes measure disability in terms of how many cation of D&C is called Ashermans syndrome. It can be the method used to Another touchstone is the Social Security evacuate the uterus for a woman with a miscarriage or Administrations definition of disability, focused more unintended pregnancy. Obstetrics and gynecologic diagnosis and ment or suffer from an impairment so severe that it treatment (7th ed. Womens health: A primary the last 15 years and (5) prevents entry into other jobs care clinical guide (p. Whether a persons impairments prevent her from performing the duties of her own occupation is one measure of disability. Philadelphia: Temple University ability for the loss of a limb or the loss of use of a body Press. Flying without wings: Personal reflections on loss, Under the Americans with Disabilities Act, disabil- disability, and healing. Toronto, Ontario, Canada: Womens Educational dence are such findings of disability based? While fewer standing of the critical issues women face when making women suffer from mental disorders (not mental retar- medical choices. Identifying and drawing attention to dation and learning disabilities) than men, women are the problem areas is the first step to overcoming gen- twice as likely to struggle with depression. Healthy people do not typically gather in support care, and in some instances endure downright neglect. Women are often investment club as a celebration of physical or mental excluded from participating in research into new drugs, health. Disabled people and their families often connect medical treatments, and new surgical techniques. There with other disabled people and their families, linked by is a widespread practice in the medical community of the disease or impairment that has changed their lives. Syndromes and symptoms, diseases and diagnoses give The raw data garnered from these studies are then inter- disabled people something in common that goes preted to include women. Undoubtedly, for better or for worse, a disability but may ironically lead to less accurate models even in shapes a persons day and life in ways the rest of us can the male. Physicians consider research 222 Discrimination into heart disease as primarily addressing men; it is cover oral contraceptives. Equal Employment Opportunity Research has also provided one of the most fright- Commission that issued a ruling in its December 2000 ening instances of the total disregard by the medical findings that the exclusion of the costs of prescription establishment of womens unique vulnerabilities while contraceptives from health care packages (while at the pregnant. Some women, who took the many times fail to thoroughly examine female patients drug experimentally, were not told the truth about what and often disregard important and useful information they were taking and were instead told that they were that female patients provide to them. Their daughters dismiss womens complaints as psychosomatic, but there suffer vaginal and cervical cancer at a rate far in excess is a deeper reason for this than is readily apparent. Frequently, women with symptoms similar to Research, however, has also given us a glimmer of those of men are taken less seriously; the womens hope with one of the most positive and visible exam- examinations are less extensive than a comparatively ples of the changes women are instituting in medical performed exam on a male. Women have been primarily responsible for be provided with information on how to best diagnose the increase in funding for research relating to breast and treat the symptoms. In this setting, 1990s women pushed for a national policy shift that cul- women undergo humiliating and often unnecessary minated in congressional mandates to increase funding exams and procedures. Womens efforts have impacted other areas charac- One major problem in properly diagnosing women is terized by blatant sexism. When the removal of mam- that women many times have very little direct knowl- mography screenings from Medicare coverage was edge of their own bodies and as a result completely threatened in 1989, women successfully lobbied Congress defer their judgment to their doctor. The importance of providing ade- rible repercussions on their personal health choices quate coverage for breast cancer screenings has led to because medicine has the potential to become an insti- 39 states requiring at least some form of third-party cov- tution of dogmatic social control. Insurance companies have bitterly contested and influence beyond the scope of their training and expe- fought the inclusion of prescription contraceptives and rience and now advise women on the female sex role, related medical visits and exams in their basic health psychology, and sexuality, notwithstanding a lack of care packages. As a result, women are sometimes expertise in these fields and their tendency to interpret denied vital and basic health access and coverage, their findings from a primarily male point of view. Half of all fee-for-service health plans do not endure the most harsh and terrible form of discrimina- cover any contraceptive methods at all, and only a third tion. One of the most commonly recommended breast 223 Dissociative Identity Disorder cancer treatments is the removal of the entire affected Suggested Reading breast (a mastectomy) despite the fact that over 90% of Corea, G. The hidden malpractice: How American medicine women may be eligible to receive lumpectomies mistreats women. Outrageous practices: The not understand the psychological and emotional impact alarming truth about how medicine mistreats women. Male practice: How doctors manipulate consequently, may provide no assistance in dealing women. Ironically, one of the reasons given for performing a hysterectomy at a gathering of the American College of Obstetricians and Gynecologists was that it reduced the frequency of Dissociative Identity Disorder Dissociative unpleasant, humiliating pelvic exams and tests. As stunning as all Dissociation is a process wherein a person men- of these revelations about sexism in medicine are, it tally separates oneself from reality. The dissociation appears to serve ages women to be passive and dependent on male doc- as a protective defense mechanism and as a means of tors. The presence of two or more distinct identities or community and the reluctance of insurance companies personality states (each with its own relatively to provide adequate affordable care to women. There is enduring pattern of perceiving, relating to, and hope that these issues will be addressed more thor- thinking about the environment and self) oughly because an increasing number of women are 2. We must ensure that dis- states recurrently take control of the persons crimination in womens health becomes the subject of behavior discussion among historians, and not debate among 3. The disturbance is not due to the direct physio- Sexual harassment, United States Civil Rights Act of 1964 logical effects of a substance or a general 224 Divorce medical condition (American Psychiatric identification of individual personalities, with eventual Association, 1994) communication between them. Although the healing process the ages of 3 and 9), during which time he or she men- can be longstanding, and at times quite painful, reinte- tally separates from the experience in an effort to avoid gration appears to be a vital element in facilitating emotional and/or physical pain. Diagnostic and statistical frequently diagnosed in women than men, but some manual of mental disorders (4th ed. Attachment, trauma and multiplicity: Working has been observed more frequently in first-degree bio- with dissociative identity disorder. Individual psychotherapy ple, and when the couple cannot agree, a judge makes seems to be the most widely accepted and effective the decisions. Early in the history of our 225 Divorce country the grounds for divorce were very limited, to how to divide their possessions, the court can make often requiring proof of adultery.
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