There is an increased incidence of patients with nonseminoma erectile dysfunction rates age order cialis soft amex, serum Ovarian germ cell tumours of young the disease in individuals with a history of tumour markers alpha-fetoprotein and/or women share clinical features and treatan undescended testicle erectile dysfunction age at onset purchase cialis soft 40 mg mastercard, testicular femihuman chorionic gonadotrophin are elevatment approaches with male germ cell nization and those with a family history of ed in 80% of patients with disseminated tumours erectile dysfunction doctors albany ny cheap cialis soft 40mg visa. In utero exposure to disease and in 50% of patients with early monly associated with the presence of exogenous estrogens may increase the stage disease erectile dysfunction labs purchase cialis soft 20 mg with amex. Patients with testicular isochromosome 12p (an abnormal chrorisk of testicular cancer as a result of seminoma may have modestly elevated mosome 12 with two identical short increased incidence of cryptorchidism and levels of human chorionic gonadotrophin arms) causes of erectile dysfunction in 60s cialis soft 20 mg with visa, a region which contains the gene dysgenesis erectile dysfunction pills review order discount cialis soft line. The initiation of a to diethylstilbestrol has been associated There are no reliable screening tests for germ cell tumour is associated with varwith an increased relative risk of up to 5 impotence and alcohol order cialis soft 20mg otc. Testicular cancer is more common in a high cure rate erectile dysfunction prevents ejaculation in most cases order cialis soft 20mg with amex, advocacy of testicular mental pathway of the germ cell (Fig. About 90% of testicular malignancies tumours should yield average cure rates in arise from germ cells and these tumours excess of 95%, and even 80% of patients Detection are classified as seminoma (40%) (Fig. The division of a precursor cell, the spermatocyte (4n), produces 4 sperm cells each with one set of chromosomes (1n). The fusion of egg and sperm to form the zygote doubles the number of chromosomes to the normal complement (2n). Aberrant development may produce a cell which has twice the normal chromosomal complement (4n). Approximately 30% Stage I disease, confined to the testis, is Nonseminoma of patients under surveillance will relapse managed by post-operative radiotherapy Patients with local nonseminoma confined and are reliably cured with chemotherapy. Good toneal lymph node dissection and are Cancers of the male reproductive tract 213 found to have positive nodes can consider Patients with nonseminoma who have nortwo cycles of adjuvant chemotherapy malized serum tumour markers and resid(100% cure rate). Note the high incidence rates in Central and South America, Southern Africa and India. These changes are most rates are observed in China, and in evident for adenocarcinomas, which share Definition Western Asia. In developed countries, the to some extent the etiological agents of the majority of epithelial tumours of the incidence rates are generally low, with agesquamous cell carcinomas, but for which cervix are squamous cell carcinomas standardized rates of less than 15 per cytological screening is ineffective in coun(85%). Adenocarcinomas are less com100,000, with the exception of Eastern tering the increase in risk. Most cervical carcinomas arise at Europe, where incidence rates range from countries the situation is more mixed, with the junction between the columnar epithe18-35 per 100,000. The incidence of canhigh rates persisting in some areas (Latin lium of the endocervix and the squamous cer of the cervix begins to rise at ages 20America, India, Africa), and declines elseepithelium of the ectocervix, a site of con29, and then increases rapidly to reach a where, most notably in China. Only this requirement has revealed that high when invasive disease is established do parity, smoking and long-term use of oral symptoms such as vaginal bleeding, discontraceptives are co-factors that increase charge and pain become manifest. The assessment of the biopsy or hysterectomy specimen patholounder the normal squamous epithelium of the exorole of these co-factors requires that the gy. One of the precursors tology may ablate an undetected adenoof invasive adenocarcinoma is recognized carcinoma in situ or microinvasive carcinoas adenocarcinoma in situ. Recurrences or persistent residtimes difficult to diagnose, often not being ual disease may occur. For early stage invasive carcinoma, where Squamous cell carcinomas may be either the cancer is confined to the cervix or large cell non-keratinizing or large cell kerspread to the upper vagina, surgery and atinizing, or a less common variant, such radiotherapy are the primary treatment as the well-differentiated verrucous carcioptions. The worldwide prevalence of adenofor patients with advanced disease and carcinomas of the cervix has increased external beam therapy is used initially for from 5% in 1950-60 to 20-25% of all cervipatients with bulky tumours. The most common type is intracavity radium source is being replaced mucinous adenocarcinoma, which may be with caesium-137, which is considered intestinal, endocervical or signet-ring, folsafer. The observation that cancer may still recur, or residual disease the pelvic wall veins and lymphatics [6]. Cancers of the female reproductive tract 217 estrogen therapy for menopause or prior oophorectomy, increase the risk of cancer whereas oral contraceptives containing an estrogen-progesterone combination decrease it. Syndromes of increased endogenous estrogen exposure, such as granulosa-theca cell tumours of ovary and polycystic ovary, are also associated with an increased risk. Detection the most common sign is metrorragia (uterine bleeding), especially after menopause. Low rates occur in echography and hysteroscopy are useful common cancer of women with 189,000 Africa and Asia (Fig. Canada, are experiencing a clear decline in incidence and mortality from cancer of the Pathology and genetics uterus, particularly among young women. Uterine canthis tumour type is characterized by the cer occurs primarily in elderly women, the disappearance of stroma between abnormedian age of onset being around 60 years old; only 5% of cases develop before age 40. Etiology Cancer of the endometrium is linked to reproductive life with increased risk among nulliparous women and women undergoing late menopause (Reproductive factors and hormones, p76). The endometrium is normally a hormonally responsive tissue, responding to estrogens with growth and glandular proliferation and Fig. Postings into the lumens, disordered nuclear endometrial tumorigenesis is becoming operative radiation therapy is currently chromatin distribution, nuclear enlargecharacterized (Fig. Patients with given to patients at a high risk of relapse ment, a variable degree of mitosis and is lesions which are positive for cytoplasmic following surgery. In inoperable cases, associated with necrosis and haemorrhage estrogen and progesterone receptors have pelvic radiation therapy, usually external [16]. Adenosquamous carcinoma, which a better rate of disease-free survival than beam and intracavity irradiation, may be comprises 7% or less of cases, has a poor those with no identifiable receptors [16]. An enhanced susherin are associated with metastasis and cisplatin, doxorubicin and cyclophosceptibility to endometrial cancer has also depth of myometrial invasion. Estrogenand perimenopausal women and are estroabdominal hysterectomy and bilateral salpreplacement therapy is recommended gen-related, with hyperplasia antecedent ingo-oophorectomy (removal of the fallopiinitially only in patients with in situ dis(adenomatous and atypical adenomatous an tubes and ovaries) are the definitive ease or with low risk stage I tumours. More 75-85% and for localized disease up to appear in postmenopausal women tend to than 50% of recurrences occur in the first 90% (Fig. Thus regular and evidence to suggest that black women Cancers of the female reproductive tract 219 Fig. Pelvic ultraslightly increased with nulliparity and a personography, tumour markers and clinical Definition sonal history of breast cancer. Decreased examination have proved ineffective in mass the majority of ovarian cancers are carcirisk follows the use of oral contraceptives. In screening [7] and are employed only for nomas, which arise from the surface contrast, hormonal treatment for infertility patients having a high familial risk of ovarian epithelium of the ovary. The comparison of molecular profiles at the menopause is only associated with a generated by laser capture microdissection Epidemiology small risk. Early menarche or late is hoped to identify patterns of proteins About 190,000 new cases and 114,000 menopause may also entail a slightly which are uniquely expressed in early disdeaths from ovarian cancer are estimated increased risk [18]. Diet plays a role, with ease in order to generate valuable markers to occur annually. The highest rates are increased risk linked to obesity and height, as for early detection [20]. Low rates A history of pelvic inflammatory disease, Pathology and genetics are found in Africa and Asia (Fig. Detection lial tumours, including germ cell tumours, the great majority of patients with epithelial gonadal-stromal tumours and tumours which Etiology ovarian cancer present with disease that has have metastasized to the ovary, are less comAlthough most ovarian cancers are sporadic, spread outside of the ovary and even the mon. Three categories of lesions are recoga family history is the single most important pelvis [19]. Symptoms may include abdominized: benign, low malignancy potential or 220 Human cancers by organ site invasive malignant. The reasons for such differences undergo screening for breast, cervical and recorded with reference to national or othare likely to be complex and multifactorial. Such differences involvden is rarely distributed uniformly across Environmental/behavioural factors may difing increased incidence provide an opporsuch groupings. A number of variables may contribute quantities of red meat, large quantities of affected by ethnic and social differences. One such variable, fruit and vegetables) may be protective in For example, the way that pain is pergenetic make-up, is not amenable to interrelation to risk of colorectal cancer, but risk ceived and dealt with is influenced by the vention but nonetheless may have an increases with the adoption of a Western ethnocultural background of the patient impact. Ethical dilemmas can develop in cer risk, with high rates of incidence in multicultural settings due to differing culAfrican-Americans, which may be partly Timely visits to a medical practitioner and tural beliefs and practices. More research related to genetic differences in hormone participation in screening programmes are into the relationship between ethnicity metabolism (Farkas A et al. Language may be a barrier to support, survival, and quality of life is confer susceptibility to cancer may be carunderstanding health issues. Recognition of multicultural issues is this may be partly attributable to the novelbecoming more widespread. Women of lower Networks for Cancer Awareness Research than that of the general population. In Cancers of the female reproductive tract 221 early disease includes bilateral salpingoed with vincristine, actinomycin and oophorectomy and total abdominal hyscyclophosphamide; cisplatin, vinblastine terectomy, total omentectomy, appendecand bleomycin; or cisplatin, etoposide and tomy, collecting samples of peritoneal bleomycin. Recurrent ovarian cancer may washings for cytological analysis and posbe treated with cytoreductive surgery plus sibly removal of pelvic retroperitoneal and chemotherapy and palliative radiotherapy. Reproductive function Hormonal therapy may include progestaand fertility may be conserved in patients tional agents and anti-estrogens. Aneuploidy has therapy may play a limited role in selected been linked to poor survival. A standard chemotherapy for advanced five-year survival rates for all stages comstage ovarian cancer using cisplatin and bined (Fig. Most Management paclitaxel achieves response rates of up to women, however, present with late stage Surgery is most often the first recourse in 60-80%. Germ cell tumours are very sendisease which is associated with a fivediagnosis and treatment. Treatment of sitive to chemotherapy and may be treatyear survival rate of about 20%. Esteller M, Xercavins J, Reventos J (1999) Advances in Kearsley J, Williams C eds, Cancer: a comprehensive clinical the molecular genetics of endometrial cancer. High incidence rates occur in Northern Iran, the survival rates are less than 15%. Central Asian republics, North-Central China, parts of South America and in Southern and Eastern Africa. However, in particular areas, oesophageal cancer in distinct geographsuch as Normandy and Brittany in France ical areas are more extreme than and in the north-east of Italy, the inciDefinition observed for any other cancer. Regions dence rates are much higher in males (up the great majority of oesophageal canof high incidence of squamous cell carcito 30 per 100,000), while remaining relacers (over 95%) are either squamous cell noma in Asia [1] stretch from the tively low in females. Other incidence of all oesophageal cancers Cancers of the oesophagus are the sixth high-incidence areas are found in parts vary greatly (Fig. In of South America and in Southern and 2000, the number of deaths due to Eastern Africa. Even within these highEtiology oesophageal cancer amounted to some risk areas, there are striking local variaConsumption of tobacco and alcohol, 337,500 out of a total of 6. Studies of migrant populaassociated with low intake of fresh fruit, cer deaths worldwide. About 412,000 tions suggest that when they move to vegetables and meat, is causally associatcases of cancer of the oesophagus occur areas of low-risk, they lose their high ed with squamous cell carcinoma of the each year, of which over 80% are in develrates, confirming the importance of local oesophagus worldwide. In more developed countries, it is estiOesophageal cancer 223 being the outcome of chronic mucosal the vast majority of patients initially injury. Other risk factors include concomplain of progressive dysphagia, sumption of pickled vegetables, betel which may not become apparent until chewing in South East Asia, and oral consome two-thirds of the lumen has been sumption of opium by-products in the obstructed, especially in the case of Caspian Sea area. Regurhave proposed a role for human papillogitation and pain on swallowing are fremaviruses in squamous cell carcinoma quent, as is weight loss. Other environmental risk factors involvement may be indicated by hoarseinclude nitrosamines, food contamination ness. Patients with adenocarcinomas of with fungi such as Geotrichum candidum the cardia may also suffer from gastroand Fusarium sp. A barium swallow p43) and deficiency of vitamins A and C, (ingestion of liquid containing barium molybdenum, copper and zinc. Endoscopic ultrasonography Balloon tumour type is directly associated with is currently the most accurate staging Barrett oesophagus, a premalignant method, but is not widely available. In East Asia, mutations at A:T base pairs are less common, but transversions at G:C base pairs occur at a higher rate than in Western Europe [10]. It is often associated often subject to hypermethylation of the with chronic gastro-oesophageal acid Fig. In the Japanese population, a polymore commonly affected than women atypical squamous cells which infiltrate morphism in the gene encoding aldehyde [14]. There are three to squamous cell carcinoma is only parAdenocarcinoma of the oesophagus subtypes: fundic (base of oesophagus), tially understood (Fig. Mutation of mostly occurs within the distal third of cardiac (the region between the oesophthe p53 gene is an early event, detected the oesophagus and is preceded by a agus and the stomach), and intestinal. Oesophageal cancer 225 adenocarcinoma, reduced expression of the cadherin/catenin complex and increFactor Alteration ased expression of various proteases is detectable [15]. The primary treatment E-cadherin Loss of expression in intraepithelial and invasive carcinoma Catenins Similar loss of expression to E-cadherin for local disease is oesophagectomy. Placement of a prosthetic tube or neoplasia stent across the tumour stenosis (narrowMembrane trafficking ing) may be indicated to restore swallowrab11 High expression in low-grade intraepithelial neoplasia ing in patients not suitable for surgery. The presnative to surgery, particularly if combined ence of a p53 mutation in Barrett mucosa and in dysplasia may precede the development of adenocarcinoma. Almost half of these are C to T Netherlands 12 transitions at dipyrimidine sites (CpG Osaka, Japan 11. In contrast, a number of 8 Slovakia other loci are altered at a relatively late Madras, India 6. Prevalent changes (>50%) include loss of heterozygosity on chromosomes Qidong, China 4. Molecules involved in membrane % survival, both sexes traffic, such as rab11, have been reported to be specific for the loss of polarity Fig. Taniere P, Martel-Planche G, Puttawibul P, Casson A, eds (1997) Cancer Incidence in Five Continents, Vol. Gignoux M (1997) Alcohol, tobacco and oesophageal cancer: effects of the duration of consumption, mean intake 11. Br J Cancer, 75: steps in the development of squamous cell carcinoma of 1389-1396. Montesano R, Hollstein M, Hainaut P (1996) Genetic Teuchmann S (1990) Mate drinking, alcohol, tobacco, diet, alterations in esophageal cancer and their relevance to etiand esophageal cancer in Uruguay. Int J Maruyama K, Shirakura K, Ishii H (1998) Alcohol-related Cancer, 81: 225-228. Other less important causes include analgesic abuse (phenacetin), some types of cancer chemotherapy and, historically, occupational exposure to chemicals such as 2naphthylamine. In Egypt and some Asian regions, chronic cystitis caused by Schistosoma haematodium infection is a major risk factor. Although the majority of cases occur in develcountries, where 65% of patients live for oped countries, bladder cancer also occurs at high rates in some developing countries, including parts at least five years after diagnosis. Bladder cancommon are adenocarcinoma (6%), squaAbout 132,000 people each year die from cer risk increases approximately linearly mous cell carcinoma (2%) and small cell bladder cancer, men throughout the world with duration of smoking, reaching a fivecarcinoma (less than 1%). Approximately 336,000 new cases cases and 30% of female cases in populaWork in the rubber and dyestuff industries occurred in 2000, two-thirds of which were tions of developed countries [2]. Incidence and ly that smokers of black (air-cured) tobacaromatic amines, particularly including 2mortality rise sharply with age and about co are at a greater risk than smokers of naphthylamine and benzidine, are correlattwo-thirds of cases occur in people over the blond (flue-cured) tobacco and this may ed with a high risk of bladder cancer [3]. The male:female ratio is approxexplain some of the disparity observed in Exposure to polycyclic aromatic hydrocarimately 3:1. High incidence rates (>12 per European incidence rates and also the bons, polychlorinated biphenyls, formalde100,000 men and >3 per 100,000 women) high incidence observed in Uruguay. Such canals may provide a habitat for the snails which are host to Schistosoma parasites. Chronic infection with Schistosoma haematobium causes cystitis and often bladder cancer. In common with cancer of the renal pelvis, a has been proposed as a screening consistent relationship has been observed approach for bladder cancer, in particular between use of phenacetin-containing analamong industrial workers potentially B gesics and bladder cancer, with relative risks exposed to aromatic amines, but there is varying from 2. T T anticancer drug cyclophosphamide, an alkyOther methods are also under investigalating agent, has been strongly and consistion [5]. Non-Hodgkin Haematuria, usually painless, is the prelymphoma patients treated with cyclophossenting symptom for the majority of phamide therapy have a dose-dependent patients with bladder cancer. Diagnosis is made by urine analyder, moderately differentiated, with a papillary with an up to five-fold increased risk. Tissue for and in several West Asian countries, infechistopathological analysis may be tion as a result of ingestion of contaminated obtained through transurethral resection. Spread can squamous cell type, increases as from the Approximately 90% of bladder cancers are occur by growth into the submucosa and third decade of life. The infection is responclassified as transitional cell carcinoma muscularis of the bladder wall (25% of sible for about 10% of bladder cancer cases and are believed to originate in intracases). About 70% of transitional cell carin the developing world and about 3% of epithelial neoplastic transformation of the cinomas are of the papillary type (Fig. Altered expresEgypt, this type constitutes 90% of bladder sion of the phosphorylated form of the tumours [7]. Nuclear overexpression of p53 bladder carcinogens have been identified protein, essentially attributable to mutaand it has been hypothesized that subtion of the gene, is common and is associjects carrying specific genotypes could be ated with disease progression (Fig. There for superficial transitional cell carcinois no evidence for high-penetrance gene mas, to prevent recurrence, and possibly of the bladder, prostate and seminal vesimutations that carry an elevated risk of decrease progression and improve surcles in males or the bladder, ovaries, bladder cancer. Overexpression of the bovis bacterium which causes tuberculorestoration of bladder function, may be epidermal growth factor receptor is assosis. Cytotoxic drugs such as thiotepa, doxachieved through a range of reconstrucciated with invasive disease.
Disability is more common among women erectile dysfunction surgery buy 20mg cialis soft, older people erectile dysfunction organic causes purchase cialis soft now, children and adults who are poor johns hopkins erectile dysfunction treatment discount cialis soft master card. One of the most important characteristics of the Convention is its paradigm shift laptop causes erectile dysfunction buy discount cialis soft, making disabilities a societal problem outcome erectile dysfunction without treatment cialis soft 40mg otc, and not an individual one erectile dysfunction from nerve damage order cialis soft toronto. State parties impotence pills for men discount cialis soft 40mg on line, not the individual person with disabilities erectile dysfunction caused by low testosterone cialis soft 40mg low cost, are responsible for the promotion of rights, including reproductive rights. Article 25 is especially relevant, requiring states to ensure equal access to health services for persons with disabilities, with specifc mention of sexual and reproductive health and population based public health programmes. While the promotion of rights for persons living with disabilities has generally progressed, there is still a long way to go. It is best and usually easy to mainstream health services that accommodate persons with disabilities. They are often reference points for their communities, are respected having high credibility in addition to providing the communities with spiritual and moral support and (in many cases) educational and health services. In this respect it is important to consider religion and cultural values not only as obstacles (which they can be) but also as potential benefcial factors. Certain religious and traditional values can actually be seen as benefting reproductive rights just as religious and traditional leaders can become important allies in the struggle for the same rights. The big question, then, seems not to be whether religious and traditional leaders and structures should be involved when working with respect to reproductive rights but how best to do this. There are some examples, such as discussions with Buddhist monks in Sri Lanka, of efforts to correlate religious views with human rights. Examples from Eritrea have shown that it is possible to work with various religious groupings, such as both Christian and Muslim leaders, at the same time. This can be aided by using language that appreciates the nuances of religion and religious sensitivities. The Convention prohibits torture in Article 2 and other cruel, inhuman or degrading treatment and punishment in Article 16. The right to physical integrity implies that all Domestic and other forms of violence persons have the right to control their own against women, including rape, forced bodies, including their sexual and reproducabortion and sterilization, and female gentive life, and be free from any intervention, ital mutilation may constitute violations of medical or otherwise, save with their full, International Covenant on Civil and Political free and informed consent. Furthermore, in order not to violate the prohibition against torture, the prohibition against cruel, inhuman and detained pregnant women must receive degrading treatment is non-derogable like humane treatment, in particular during birth the prohibition against torture, and a state and while caring for newborn children; this violates Convention against Torture if it includes medical treatment and healthcare fails to prevent acts prohibited by the Confor such mothers and their babies. In Brazil the same fgures for 2000/2001 were 29% in the cities and 37% in the provinces. Surveys31 show that many women fnd their husband justifed in hitting or beating them, for example for refusing to have sex (for instance 37% in Burkina Faso (2003), 51% in Ethiopia (2000), 21% in Turkmenistan, 7% in Indonesia, and 14% in Haiti); for other reasons. Research has shown that violence against women has serious health consequences, not least with respect to reproductive health. Signifcant percentages of abuse happens during pregnancy, leading to pregnancy complications, stillbirths etc. Legislation needs to be in place criminalizing all acts of violence against women, including marital rape. Such rights are often ignored, that can be found in, among others, Article for example by the sterilization of, or per16 of the Convention on the Elimination of formance of abortions on, women with All Forms of Discrimination against Women. A minimum age for marriage is necessary to make full and free According to the Convention on the Elimconsent possible. Furthermore, the possibilination of All Forms of Discrimination ity to procreate being inherent in the right against Women, women have a right to to found a family should entail family planfreely choose their spouses and enter freely ning policies which are compatible with the into marriage; this right must be protected, International Covenant on Civil and Political for example against forced and coerced Rights and other human rights conventions marriages, and enforced by law. In addition, women are to be It is a duty of states to treat men and considered equal to men in marriage. The women equally in relation to the right to often subordinate role of women makes it marry; a minimum age for marriage (the more diffcult for them to refuse sex and to same for both sexes) that enables an demand safe sexual practices. The Convention on the Rights of Persons with Disabilities also guarantees accessible information for persons with disabilities in its Article 4(h). The rights to seek, receive, and impart inforthe information relating to sexual and repromation are protected by many human rights ductive health should be gender-sensitive instruments. These rights are essential to and age-appropriate, free from stereotypes, the realization of reproductive rights. This obligation mine whether to , when to and how often to is emphasized by the Convention on the have children, their opportunities to advance Rights of the Child and the Convention on towards secondary and superior education the Rights of Persons with Disabilities. Special care should be taken to due to the service provider being a private reach vulnerable children, such as children enterprise. This was a case of triple diswith disabilities, indigenous children, chilcrimination where the Committee found the dren belonging to minorities, and children victim to have been discriminated against living in rural areas or in extreme poverty. In addition to case of children, either the parent/guardian the recommendations directly concerning or the child must consent. Ill health is a human rights violation when caused by the failure of the state to respect, protect or fulfl a human rights obligation. Such a holistic approach One core obligation in relation to the procan be useful in preventing maternal gressive realization of the right to health deaths. In order to fulfl the right to health, states should at least adopt a national health policy with a detailed plan for the realization of the 56 Committee on Economic, Social and Cultural Rights, General Comment No. It is also due to medical and right to beneft from scientifc progress is scientifc development that assisted reproimportant because it is through scientifc duction is possible. Does this include the right to assistance for persons who cannot become parents unassisted, whether for medical reasons or because they are single or live in same sex relationshipsfi Undoubtedly, other issues will arise as technology develops and globalization makes the various countries of the world more and more interconnected. When a nouncements, in whatever way they are made, country ratifes one of the treaties, it assumes have considerable legal standing even though a legal obligation to submit regular reports to they are not strictly speaking legally binding. Reports from other institutions for example related to state reporting, most of than the government of the state in question them provide interpretation and other assistance are commonly referred to as shadow reports. Here the government presents mittee, Committee on the Elimination of All its report and then submits to questioning by Forms of Discrimination against Women, the Committee members. Based on this dialogue can consider individual complaints if the counwith government and the other information try in question has either ratifed an optional available, the Committee at a private session protocol or made a specifc declaration. It also needs to know whether the State party gives access to safe abortion to women who have become pregnant as a result of rape. In States parties where the practice of genital mutilation exists, information on its extent and on measures to eliminate it should be provided. The information provided by States parties on all these issues should include measures of protection, including legal remedies, for women whose rights under article 7 have been violated. That age should be set by the State on the basis of equal criteria for men and women. States parties should indicate whether marrying the victim extinguishes or mitigates criminal responsibility and, in the case in which the victim is a minor, whether the rape reduces the marriageable age of the victim, particularly in societies where rape victims have to endure marginalization from society. It is therefore essential that economic, full attention be given to economic, social and cultural rights in all of the social and relevant activities of these institutions. The scrutinizing of existing laws and administrative acts, as well as draft bills and other proposals, to ensure that they are consistent with the requirements of the International Covenant on Economic, Social and Cultural Rights; 3. Providing technical advice, or undertaking surveys in relation to economic, social and cultural rights, including at the request of the public authorities or other appropriate agencies; 4. The identif cation of national-level benchmarks against which the realization of Covenant obligations can be measured; 5. Conducting research and inquiries designed to ascertain the extent to which particular economic, social and cultural rights are being realized, either within the State as a whole or in areas or in relation to communities of particular vulnerability; 6. Accessibility further includes adequate access to buildings for persons with disabilities. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households. However, accessibility of information should not impair the right to have personal health data treated with conf dentiality. All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i. As well as being culturally acceptable, health facilities, goods and services must also be scientif cally and medically appropriate and of good quality. The realization of the right to health of adolescents is dependent on the development of youth-friendly health care, which respects conf dentiality and privacy and includes appropriate sexual and reproductive health services. Read in conjunction with more contemporary instruments, such as the Programme of Action of the International Conference on Population and Development, the Alma-Ata Declaration6 provides compelling guidance on the core obligations arising from article 12. To adopt and implement a national public health strategy and plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population; the strategy and plan of action shall be devised, and periodically reviewed, on the basis of a participatory and transparent process; they shall include methods, such as right to health indicators and benchmarks, by which progress can be closely monitored; the process by which the strategy and plan of action are devised, as well as their content, shall give particular attention to all vulnerable or marginalized groups. To ensure reproductive, maternal (pre-natal as well as post-natal) and child health care; 2. To provide education and access to information concerning the main health problems in the community, including methods of preventing and controlling them; 5. To provide appropriate training for health personnel, including education on health and human rights. Substantive equality is concerned, in addition, with the effects of laws, policies and practices and with ensuring that they do not maintain, but rather alleviate, the inherent disadvantage that particular groups experience. Substantive equality for men and women will not be achieved simply through the enactment of laws or the adoption of policies that are, prima facie, gender-neutral. Temporary special measures aim at realizing not only de jure or formal equality, but also de facto or substantive equality for men and women. States parties must take appropriate measures to eliminate violence against men and women and act with due diligence to prevent, investigate, mediate, punish and redress acts of violence against them by private actors. States parties in Economic, must therefore immediately adopt the necessary measures to prevent, Social and diminish and eliminate the conditions and attitudes which cause or C u l t u r a l perpetuate substantive or de facto discrimination. States parties must therefore adopt measures, which should include legislation, to ensure that individuals and entities in the private sphere do not discriminate on prohibited grounds. General Recommendation Provisions related to Reproductive Rights General States should: Recommendation No. Include in their national health policies appropriate strategies aimed at eradicating female circumcision in public health care. Include in their reports to the Committee under articles 10 and 12 of the Convention on the Elimination of All Forms of Discrimination against Women information about measures taken to eliminate female circumcision. Moreover, such services improve the general quality of life and health of the population, and the voluntary regulation of population growth helps preserve the environment and achieve sustainable economic and social development. It is discriminatory for a State party to refuse to legally provide for the performance of certain reproductive health services for women. Since gender-based violence is a critical health issue for women, States parties should ensure: 1. Gender-sensitive training to enable health care workers to detect and manage the health consequences of gender-based violence; 3. Adolescent girls and women in many countries lack adequate access to information and services necessary to ensure sexual health. As a consequence of unequal power relations based on gender, women and adolescent girls are often unable to refuse sex or insist on safe and responsible sex practices. In particular, States parties should ensure the rights of female and male adolescents to sexual and reproductive health education by properly trained personnel in specially designed programmes that respect their rights to privacy and conf dentiality. States parties should take appropriate measures to ensure that health services are sensitive to the needs of women with disabilities and are respectful of their human rights and dignity. Information on the rates at which these measures have reduced maternal mortality and morbidity in their countries, in general, and in vulnerable groups, regions and communities, in particular, should also be included. Many women are at risk of death or disability from pregnancy-related causes because they lack the funds to obtain or access the necessary services, which include antenatal, maternity and post-natal services. Article 16 (2) also proscribes the betrothal and marriage of children, an important factor in preventing the physical and emotional harm which arise from early childbirth. Prioritize the prevention of unwanted pregnancy through family planning and sex education and reduce maternal mortality rates through safe motherhood services and prenatal assistance. When possible, legislation criminalizing abortion could be amended to remove punitive provisions imposed on women who undergo abortion; 4. Monitor the provision of health services to women by public, non-governmental and private organizations, to ensure equal access and quality of care; 5. Temporary special In addition, the Convention requires that women be given an equal measures, 2004 start and that they be empowered by an enabling environment to achieve equality of results. Pursuit of the goal of substantive equality also calls for an effective strategy aimed at overcoming underrepresentation of women and a redistribution of resources and power between men and women.
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What is a (A) Kupffer cell erectile dysfunction treatment prostate cancer order discount cialis soft line, dendritic cell possible mechanism accounting for his symp(B) Kupffer cell erectile dysfunction at age 20 buy cialis soft 20mg otc, macrophage tomsfi She is diagnosed with a would be correct to conclude which of the folcondition associated with the release of proinlowingfi Examination of the phar(B) the patient has had previous pregnancies ynx reveals a cherry-red mass at the base of and all of her children are Rh-negative the tongue impotence tumblr cheap cialis soft 40 mg otc. To determine fetal (C) IgA protease Rh status, direct typing of fetal blood must (D) Polyribitol-ribose phosphate capsule be done. A type B blood group, Rh-positive recipient for three days after an exacerbation of emphymistakenly receives a kidney from a type A sema. Which of til the fourth hospital day, when she develops the following best describes the mechanism of shortness of breath, fatigue, and cough productransplant rejection that is most likely to ensue tive of yellow sputum. Thirty (A) Pre-formed recipient antibodies minutes after the initiation of antibiotics, the (B) Macrophages patient develops erythema of the face and (C) Pre-formed donor antibodies neck, itchiness, and hypotension. The patient (D) Donor T lymphocytes has no known drug allergies and has not been (E) Recipient T lymphocytes treated with vancomycin prior to this hospitalization. A 60-year-old postmenopausal woman presents the following symptoms is this patient most with fatigue, mild jaundice, and tingling in the likely experiencingfi Laboratory studies show ele(A) Episodic palpitations, sweating, and headvated serum levels of homocysteine and methaches with no apparent trigger ylmalonic acid, and mild thrombocytopenia. A (B) Intermittent ischemia of fngers and toes peripheral blood smear supports the diagnosis. A 10-month-old boy is brought to the pedia(C) Iron defciency anemia trician by his parents because of fever, cough, (D) Pernicious anemia and diffculty breathing. Which of the following is the most way is most important for which activity of the likely etiology of the increased level of IgM in immune systemfi An immune complex disease is suspected, and assays for autoantibodies in(A) Antigen presentation and destruction of inside neutrophils are conducted. What diseases tracellular pathogens are associated with the identifcation of anti(B) Defense against parasites by eosinophils myeloperoxidase and anti-proteinase-3 antibod(C) Immediate allergic hypersensitivity reacies, respectivelyfi A 35-year-old woman presents to the clinician lomatosis with symptoms suggestive of an autoimmune (C) Polyarteritis nodosa, Buerger disease etiology. A biopsy is sent for immunofuores(D) Takayasu arteritis, Wegener granulomatocent staining, and the results indicate the pressis ence of anticentromere antibodies. A 24-year-old woman presents with a four(D) Patients with juvenile rheumatoid arthritis month history of fever, night sweats, and are more likely to have systemic symptoms weight loss. X-ray of the chest reveals enlarged and high levels of serum rheumatoid factor mediastinal lymph nodes. The biopsy of one (E) Patients with juvenile rheumatoid arthritis such lymph node is shown in the image. From are more likely to have systemic symptoms which of the following cell types is the cell and large-joint involvement with the bilobed nucleus derivedfi A 6-month old boy is noted at his well-child visit to have very poor growth and weight gain since his last visit. His mother states that he was hospitalized for pneumococcal pneumonia, and has had several bad colds with purulent nasal discharge since he was born. His physician suspects an immunodefciency, and laboratory results indeed reveal defciency of a complement protein. Which of the following antibodies functions in the same manner as the missing complement protein in this childfi A 29-year-old intravenous drug user has suf(A) B lymphocyte fered from recurrent pneumonias, fungal (B) Fibroblast infections in the axillae, and a recent ear in(C) Macrophage fection. His mother denies absorptive and foul-smelling diarrhea, weaka previous tonsillectomy. The only recent change (D) IgG and IgM levels markedly decreased, in her diet is that she eats a bowl of cereal evno IgA ery morning with her parents before they go to (E) IgG and IgM levels normal, IgA markedly work. She tried a dairy-free diet a month ago, decreased but it did not improve her symptoms. A 26-year-old woman presents to the clinic with joint pain in her hands and wrists, diffculty breathing, and redness over her cheeks and nose. She also notes that her fngertips change color from white to blue to red when she is cold. A clinician is concerned that an Rh-negative (D) Viral enteritis mother may be pregnant with an Rh-positive (E) Whipple disease fetus. The potential pathology that the clinician is concerned about is classifed as which 20. Which of the following laboratory (A) Lyme disease abnormalities is most likely to also be presentfi A 58-year-old man presents to his physician be(E) Thrombocytopenia cause of fatigue, edema, and worsening kidney function. A 30-year-old woman presents to the emerhis physician decides to perform a kidney bigency department with a right-sided facial opsy. The pathologist notes numerous greendroop and bilateral swelling on the face near colored, proteinaceous deposits when he uses the angles of the mandible. A 7-year-old boy is brought to the physician by tender bulging of both cheeks; a right-sided his parents because of recurrent sinus infecdrooping of the mouth; cervical nodes; and tions. Results of a purifed protein had multiple lung infections and intermittent derivative test are negative. Which of the following types of hypersensitivity reaction is being tested, and which cells would be expected to mediate a positive test resultfi A 24-year-old, previously healthy woman pre(A) A noninfamed skin abscess sents to the outpatient clinic with a two-week (B) A repaired cleft palate history of drooping eyelids and diffculty rising (C) Frequent falls from a chair. Stimulation with a reversible ace(D) Skin granulomas tylcholinesterase inhibitor leads to the resolu(E) Visual hallucinations tion of her symptoms. A 3-year-old boy is brought to his pediatrician antibodies as present in this patientfi Physical ex(C) Sjogren syndrome amination of the skin reveals the lesion seen (D) Systemic lupus erythematosus in the image. Treatment infrom rejection of his recently transplanted cludes bone marrow transplantation. A hyperacute and fourth pharyngeal pouches to descend is rejection is mediated by pre-formed antibodknown as DiGeorge syndrome, and results in ies to the transplanted organ. Chromoit can be observed while still in the operating some 22q11 deletions are associated with Ditheater. Tetany from hypocalcemia but is most likely in the frst three months after and viral and fungal infections are common transplantation. It is due to human leukocyte due to the lack of T lymphocytes, while norantigen discrepancies between host and graft, mal B lymphocytes are present. Plasma cells are responsible for Escherichia coli, and Aspergillus are common antibody production and therefore would be pathogens. They are the cell type that leads to activity, and thus cannot have chronic granulochronic rejection of the graft. They do not attack pathogens kinase defect causes Bruton agammaglobulinor tissues and are not implicated in the patholemia, resulting in decreased levels of all imogy of acute rejection and negative selection. This defect in early stem cell differallel and sequential events occur within the entiation results in a lack of T and B lymphosynovium to cause joint destruction, includcytes. Kupffer cells are tissuetor-b plays a role in dampening the immune resident macrophages; the image depicts a response, and in the case of rheumatoid arLangerhans cell. Langerhans cells are ing T lymphocyte activation and proliferation, specialized, tissue-resident dendritic cells, not inhibiting biosynthesis of metalloproteinases, macrophages. When an Rhby helper T lymphocytes and helps stimulate negative mother gives birth to an Rh-positive macrophages. Thus, the indirect Coombs test is an important laboratory tool to monitor Answer D is incorrect. Tumor necrosis for Rh incompatibilities that may complicate factor-a is one of the main cytokines involved fetal health. The test result given in this quesin mounting an acute-phase response; it is setion indicates that the patient possesses anti-Rh creted by macrophages. Tumor necrosis facbe logical for the clinician to suspect previous tor-b has functions similar to tumor necrosis pregnancy with an Rh-positive fetus. The results of the test granules is unknown, but they are present only cannot be used to determine the Rh status of a with Langerhans cells. Upon antigen encouncurrent fetus; only direct typing of fetal blood ter, Langerhans cells upregulate costimulatory can determine its Rh status. Agglutination occurs when the tegral part in the activation of T lymphocytes anti-IgG antibody binds to the anti-Rh antibodand the subsequent induction of an adaptive ies that are already bound to the Rh-positive immune response. The incitoms also may be consistent with anaphylaxis, dence of this illness has decreased drastically the patient has never been exposed to vancoin recent years because of immunization efmycin; therefore, she would not have preforts. By the bacterial capsule antigen and diphtheria contrast, a vancomycin-induced anaphylactic toxoid protein. Because the bacterial capsule reaction involves histamine release from mast is a polysaccharide, it alone will not generate a cells and basophils without binding of presuffcient immune response. Another method of prevention is prepili are an important virulence factor of H intreatment with antihistamine. It does not, howreactions are mediated by pre-formed IgE antiever, play a role in vaccination. H infuenzae does not of the antigen-IgE complexes to Fc receptors generate protein A. This is a virulence factor on mast cells results in degranulation and refound in Staphylococcus aureus that binds the lease of vasoactive substances such as histaFc portion of IgG and thus helps prevent opsomine. This clinical scenario would result in hyperacute rejection (within Answer C is incorrect. Macrophages provide a secondary immune response in this situation Answer E is incorrect. The medullary cords but are not initially involved in acute or hypercontain lymphocytes and plasma cells, and are acute reactions. The smear would is typically mediated by pre-formed anti-donor have a hypersegmented neutrophil, classically antibodies that are possessed by the recipient. Serum levels of homocysteine and pouches, and thus the thymus and parathyroid methylmalonic acid can be elevated, and a glands. The recurrent viral and fungal infeccomplete blood cell count can show thrombotions are caused by a T-lymphocyte defciency. Vitamin B12 defciency also causes In lymph nodes, T lymphocytes are found in a megaloblastic anemia with hypersegmented the paracortical region, thus this region is ofneutrophils on peripheral blood smear. Folate ten underdeveloped in patients with DiGeorge defciency also results in a similar megaloblassyndrome. The medullary sinuses However, this patient shows signs of vitamin contain macrophages and communicate with B defciency, which would result in a macro12 lymphatics. Pyridoxine defciency (vitamin B), often caused by isoniazid therAnswer A is incorrect. The cell on the left Note that urethritis, conjunctivitis/anterior is a macrophage and the cell on the right is uveitis, and arthritis make up the classic triad a helper T cell. This patient most important mechanism for increasing killing of likely has hyper-IgM syndrome, which is intracellular pathogens such as mycobacteria. Since IgM is initially of eosinophils increase in hypersensitivity discreated and subsequently switched to the other eases such as asthma and in parasitic infection. Basophils and mast Two prominent clinical problems are Pneumocells are the primary mediators of the immedicystis jiroveci and neutropenia. The typical presentation of the disease body titer is usually a good indicator of disease is given away by the name, as symptoms inseverity, particularly in Wegener granulomatoclude cerebellar problems (ataxia) and spider sis, for which specifcity and sensitivity of antiangiomas (telangiectasia). Since neutrophils are unable to adhere to the endothelium and transmigrate into tisAnswer D is incorrect. The image reveals Job syndrome presents with recurrent staphyReed-Sternberg cells, which are found in lococcal abscesses, eczema, and high levels of Hodgkin lymphoma and can be identifed by IgE. In thymic aplasia (DiMost studies support a B-lymphocyte origin for George syndrome), the third and fourth phaReed-Sternberg cells. Evidence supporting this ryngeal pouches, and thus the thymus and includes rearrangements at immunoglobulin parathyroid glands, fail to develop. Neutrophil levels are which stains in a cytoplasmic distribution and elevated in acute infection and infammation. Opsonins adhere to microorevated in T-lymphocyte leukemias such as ganisms and promote leukocyte chemoattracT-cell acute lymphocytic leukemia and T-cell tion, antigen binding and phagocytosis, and chronic lymphocytic leukemia. IgA patrols mucosal years and must include arthritis in at least one barriers and prevents attachment of bacteria joint for at least six weeks. It does not fx complement, nor is morphologic joint pathology is similar to that it an opsonin. However, there are several signs and symptoms that occur more comAnswer B is incorrect. IgE mediates immediadenopathy, and hepatomegaly), large-joint inate (type I) hypersensitivity and immunity to volvement, and anti-nuclear antibody seroposihelminths by facilitating the activation of eotivity. IgM fxes (activates) complement but does not function by opsoAnswer A is incorrect. This patient has becreased likelihood of anti-nuclear antibody secome susceptible to opportunistic disease ropositivity. This patient should be started on highly active antiretroviral therapy, which commonly 17. This patient has alincludes the nucleoside reverse transcriptase ready had several bacterial infections, most inhibitor zidovudine. Specifcally, the protein C3b is responsible for the opsonization of bacteria, and is Answer C is incorrect. It is due to a are particularly susceptible to extracellular sensitivity to gluten, which is found in wheat, pyogenic bacterial infections with organisms grains, and many cereals. Biopsy shows marked such as Haemophilus infuenzae, Streptococatrophy, total loss, or fattening of the villi of cus pyogenes, Staphylococcus aureus, and the small bowel. Abetalipoproteinemia fnding for Bruton patients is the absence, or is an autosomal recessive disease that causes a near absence, of tonsils and adenoids, which defect in the synthesis and export of lipids by are B-cell-rich tissues. Patients diagnosed with mucosal cells because of the inability to synBruton will need to be treated with replacethesize apolipoprotein B. However, the clinical cytes would result in a defect in cell-mediated time course, suggested gluten sensitivity, and immunity, and the patient would be more fndings on biopsy make viral enteritis unlikely.
It is diagsyndrome and Hurler syndrome are similar erectile dysfunction ginseng purchase cialis soft in india, nosed with methenamine silver stain of lung Hunter syndrome is notable for the absence of biopsy tissue erectile dysfunction jet lag order on line cialis soft. P jiroveci pneumonia is treated corneal clouding impotence erectile dysfunction order cialis soft with mastercard, which is present in Hurler primarily with sulfamethoxazole-trimethoprim impotence at 55 buy cialis soft 40mg with mastercard, syndrome osbon erectile dysfunction pump cialis soft 40mg visa. Both sulfamethoxazole and trimethsevere disorder with a broad spectrum of clinioprim inhibit the folate-synthesis pathway erectile dysfunction surgery cost generic cialis soft 20 mg on-line. Morquio syndrome inhibit ergosterol synthesis erectile dysfunction medicine reviews buy cialis soft in india, including fuconis typically diagnosed around the age of one azole and terbinafne smoking and erectile dysfunction causes discount cialis soft 40mg otc. Although Pneumocystis year and is characterized primarily by short jiroveci is a fungus, antifungals that block erstature and joint laxity. Other musculoskeletal gosterol synthesis are not effective in the treatabnormalities are also associated with this aument of this infection. Cell wall synthedemonstrate hepatosplenomegaly, mild corsis is blocked by many antibiotics, including neal clouding, and valvular heart disease. There are multiple enTrimethoprim-sulfamethoxazole is the drug zyme defciencies associated with Sanflippo of choice for treating P jiroveci infection, and syndrome, but this class of disorders is primardoes not act on the cell wall synthesis pathway. Some of the physical abnormalribosomal subunit (30S) is the mechanism of ities seen in the other mucopolysaccharidoses action for many antibiotics, including aminoare also observed in Sanflippo patients, but glycosides and tetracyclines. None of these anthe hallmarks of this disease are developmental tibiotics is used for Pneumocystis jiroveci pneudelay and behavioral problems such as aggresmonia. Inhibition of the larger common in these patients, and the physical ribosomal subunit (50S) is the mechanism of fndings typically develop after the behavioral action of chloramphenicol, erythromycin, and sleep pattern abnormalities. The site of the lesion is include cardiovascular dysfunction and liver the substantia nigra, which sends direct profailure. N-acetylcysteine is the posed of the caudate and putamen, which treatment for acetaminophen toxicity, which is are involved in both direct and indirect mooften asymptomatic initially. The direct sionally present with nausea, vomiting, sweatpathway, promoted by dopamine release from ing, and lethargy. With continued exposure, the substantia nigra, facilitates movement, signs of nephrotoxicity (oliguria and electrolyte and the indirect pathway, inhibited by dopaabnormalities) develop. Naloxone is the treatdopamine is no longer released in adequate ment for opioid overdose. The globus pallidus inily from neurologic (headache, confusion, and ternus is a downstream nucleus in both direct seizure) and cardiovascular (tachycardia and and indirect pathways of the basal ganglia. Inmotor pathway and is not innervated by the creased ketone production causes an anion gap Sn. This patient presents and hyperosmolarity cause an increase in sewith signs and symptoms of lead poisoning. Hywrist and foot drop, in addition to the sympperglycemia and the resulting fuid shift out of toms described above. Major fndings of intestinal biopsy include and sodium levels and initially high potassium crypt abscesses and chronic changes including levels. Biopsy of the fects, spontaneous abortion, and neonatal ensmall intestine in celiac sprue shows fattened cephalitis. Congenital rubella intype of infammatory bowel disease that has fection can result in deafness, patent ductus intestinal complications such as chronic diarteriosus, pulmonary artery stenosis, cataracts, arrhea, malabsorption, and abdominal pain, and microcephaly. Congenital toxoplasphoma (mucosa-associated lymphoid tissue mosis infection can result in mental retardatumor) is frequently associated with chronic tion and chorioretinitis. Collagen is a macancers of the colorectum and endometrium, jor component of the basement membrane. A defect in nucleotide expression of collagenase and hydrolase can excision repair results in xeroderma pigmentoconfer that ability, leading to an invasive neosum, a disease characterized by extreme sensiplasm. Metastasis occurs when these cells estivity to sunlight, skin damage, and a predispocape the confnes of the basement membrane, sition to malignancies such as melanoma. The bcr-abl hybrid molecule used by T lymphocytes to migrate to gene is the result of a translocation between selective sites in lymphoid tissue. Chronic myportant in metastasis, it is not a factor in baseeloid leukemia is associated with t(9,22), or the ment membrane invasion. In several epiintracranial neoplasm and is typically seen thelial tumors, including adenocarcinoma of in older patients. The characteristic features the colon and breast, E-cadherin expression is shown in the image include a central area of decreased, not increased. Without this proofmonly block the fourth ventricle, resulting in reading function, errors can accumulate in obstructive (noncommunicating) hydrocephacrucial areas, such as inactivating mutations lus. Eosinophils are imporgiomas arise from arachnoidal cells of the metant effector cells in host defense against paraninges and classically exhibit calcifed whorls sites. Mast cells control the early infammatory response by release of poAnswer D is incorrect. Oligodendrogliomas body-producing B lymphocytes and an imporare slow-growing tumors that arise from oligotant component of the adaptive immune sysdendrocytes. Regulatory T lymphofried eggs with interspersed capillaries that apcytes are components of the adaptive immune pear like chicken wire. The child is presentencoded activating and inhibitory receptors ing with DiGeorge syndrome, which is due to that can detect and distinguish virally infected abnormal development of the third and fourth cells from uninfected cells. This leads rally infected cells often express less major to hypoplasia of the thymus and parathyroid histocompatibility complex class I on their surglands. This pattern of parampharyngeal arches do not play a role in Dieters is not seen in the setting of any form of George syndrome. For three days she experiences dysuria, polyuria, and fever, which she attributes to a recent urinary tract infection. Instead of consulting with her doctor, the woman decides to use the remaining pills from her old prescription to treat her symptoms. Three weeks later she gives birth to a mildly jaundiced boy who is otherwise healthy. Five days later, however, she brings the infant to the emergency department stating that the baby has become fussy, refuses feeding, and wails at a high pitch. A 9-year-old boy with no vaccine history pre(E) Trimethoprim-sulfamethoxazole sents with an erythematous maculopapular rash that erupted about fve days after the on2. A 42-year-old woman presents with red papular set of cough, conjunctivitis, coryza, high fever, lesions along her arm, some of which have uland white spots on the buccal mucosa. Initially there were only a couple of letypes of cells are the most capable of providing sions on her right forearm. Since then, more the two signals necessary for T lymphocyte aclesions have appeared along her arm approachtivationfi Next time you see him, tell him and natural killer cells he has made his patients extremely angry and should learn how to become a better doctor. A 54-year-old white man presents for a routine What would be the most suitable response to preoperative assessment. He does he recently traveled to upstate New York for a a great job with all of my patients. A young woman comes to the her primary (B) Discoloration of teeth care physician complaining of eight weeks of (C) Nephrotoxicity fevers, chills, night sweats, fatigue, and weight (D) Ototoxicity loss. About three weeks ago she noticed a large (E) Photosensitivity bump around her clavicle. On initial survey, the physician notes that the baby has good color and is crying loudly, but seems unable to move either of his legs very well and is not startled by loud noises. Radiography reveals healing fractures bilaterally in the femoral shaft and new fractures in the right tibia. The woman denies any signifcant abdominal trauma over the course of the pregnancy. A medical oncologist is seeing a patient who (E) Non-Hodgkin lymphoma has been diagnosed with breast cancer. A 60-year-old man who is being treated for department after returning home from a trip multiple myeloma develops osteonecrosis of to Mexico with a one-week history of intrachis maxilla. Laboratory tests show a serum a molar tooth extraction site that has healed bicarbonate level of 50. Localized serum sodium of 125 mEq/L, potassium of swelling, exposed bone, erythema, and a pu1. She is rulent discharge are noted on intraoral examitreated aggressively with fuid, electrolytes, and nation. A 54-year-old woman with breast cancer in cian because of recent onset of bruising. Her her right breast recently underwent surgical mother states that she has been healthy other lumpectomy with axillary lymph node dissecthan a recent infection that she developed on tion. Several weeks into her subsequent raa trip to Guatemala, for which she received andiation treatment, she presents with a swollen tibiotics while there. Physical examination is right arm and fngers, right facial edema that is remarkable for non-blanching purple and yelmost pronounced around the orbit, and shortlow bruises on her legs. Bone marrow biaccumulation of fuid in the right pleural cavopsy shows hypercellularity with fatty infltraity. A 36-year-old man with a history of depression cross-links in the cell wall is laid off from work. Which defense mechanism is physician with pain that she has had for sevthis man employingfi She describes the pain as constant, located in her neck, lower back, and hips, and (A) Displacement as interfering with her day-to-day activities. The physician prepares the patient for thera(A) A 14-day course of oral doxycycline peutic thoracentesis, and she inserts the needle (B) Behavioral therapy in the midaxillary line on the right side, in the (C) Group therapy lower margin of the ninth intercostal space. The image shows the gross pathology of a con(B) Parietal pleura genital abnormality that results from incom(C) Phrenic nerve plete obliteration of the omphalomesenteric (D) Right pericardiophrenic artery and vein (vitelline) duct. From which of the following is (E) Tenth intercostal nerve, artery, and vein the pictured tissue derivedfi A 3-month-old girl is brought to her pediatrician because she has a high fever and cough. Over the next 24 hours, her condition deteriorates and she is taken to the emergency department. Which of the following best explains the etiology of the immunodefciency syndrome from which the patient most likely suffersfi The mean is equal to the mecomplaints of having to use rewetting eye dian and the mode in the frst curve (labeled drops throughout the day. Which of the following correctly describes tion and review of systems are unremarkable the mean, median, and mode in the second except for a low-grade fever and morning joint curve (labeled B)fi Which of the following additional conditions is this patient most at risk for developingfi A (A) Dactylitis (B) Dental caries (C) Hyperglycemia (D) Jaundice (E) Septic joints B 20. A biopsy of a lymph node from a 3-year-old who developed paralytic poliomyelitis following administration of a live attenuated polio vaccine is performed, revealing nodal architecture that lacks germinal centers (shown below). A 12-year-old boy with moderate mental retardation comes to the physician because of painful swollen joints. During the examination, the physician notices that the boy makes several uncontrolled spastic muscle movements. Past medical history includes a diagnosis of muscular hypotonia at fve months of age. A 71-year-old man presents to his physician tal drug to a standard medication used in the because of a six-week history of progressive treatment of psoriasis. The pertension and a 60-pack-year history of smokstudy runs for 12 months, during which 30 paring. The patient has diffculty speaking and is ticipants drop out of the treatment group and breathing using his accessory respiratory mus10 participants drop out of the control group. Neck vein distention and tongue swelling At the conclusion of the study, researchers deare evident. Which of the following is most cide to only analyze data from those who relikely diagnosisfi The results show that the (A) Gastric adenocarcinoma experimental drug is better than the standard (B) Hodgkin lymphoma medication at treating psoriasis. The results of (C) Hypertrophic cardiomyopathy this study may be invalid because of what ma(D) Idiopathic pulmonary fbrosis jor issuefi A screening test for disease (D) Selection bias X was just developed, with a sensitivity of 80% (E) Small number of patients in the study and a specifcity of 70%. In his early 20s, however, he begins to (A) 20 smoke cigarettes, initially smoking one pack a (B) 80 day, escalating eventually to two-three packs (C) 100 per day. As he ages, his lung function gradu(D) 270 ally declines, and at age 60, he notices that he (E) 630 becomes tired easily and cannot climb a fight of stairs without having to catch his breath. A 54-year-old woman has had longstanding goes to see his primary care physician, who rheumatoid arthritis. What is the most man has a lesion that includes which of the likely etiology of the dilated ventriclesfi A 50-year-old Chinese immigrant presents to his primary care physician complaining of fever, night sweats, and blood-tinged sputum for the past three weeks. A 76-year-old woman presents to the emergency department complaining of blurry vision 27. Parents bring their 8-year-old boy to the emerand a headache that started fve hours ago. She gency department because his face appears has a long history of hypertension and poorlyswollen. On furrate of 75/min and blood pressure of 210/140 ther testing, he has a creatinine level of 1. A 35-year-old man presents to his primary because he feels short of breath and has to stop care physician complaining of episodes of and walk after brief runs. Approximately one diac surgery when he was an infant for a conmonth ago he began running two miles on a genital heart defect. For the past two shows an intact right hemidiaphragm that is weeks he has experienced a severe, throbbing much higher than the left one. He (A) Damaged left phrenic nerve is concerned because his younger brother, who (B) Damaged right phrenic nerve is 32 years old, recently had a mild heart at(C) Eisenmenger syndrome tack. In addition, both his father and his uncle (D) Left diaphragmatic hernia died from complications after having heart at(E) Right diaphragmatic hernia tacks when they were 45 years old. Some fats and proteins are both produced by examination reveals the lesions shown in the the body and consumed in the diet. Many image; lesions are also present on his arms and other nutritional components, however, canknees. His blood pressure is 130/80 mm Hg, not be synthesized by the body and must be pulse is 85/min, and respiratory rate is 12/min. Which of the following subLaboratory tests show a serum cholesterol level stances can a healthy adult synthesizefi Which of the following is the most likely explanation of the increased total protein observed in this manfi Ini(B) Follicular carcinoma of the thyroid tially the patient complained of generalized (C) Medullary carcinoma of the thyroid weakness and vision diffculties. Later, the pa(D) Thyroid lymphoma tient lost his peripheral vision and became un(E) Papillary carcinoma able to talk or walk. Oogenesis results in the production of one brain reveals multiple, non-contrast-enhancing haploid ovum and three polar bodies in a prolesions in the white matter, primarily in the cess of meiotic cell division. What stage of the cell cycle do oocytes (A) Cryptococcal meningitis remain in from birth to ovulationfi
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