Department of Anesthesiology and Critical Care Medicine
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
C and D prehypertension youtube buy micardis us, Paraffin sections of the tarsus and metatarsus of a young human fetus hypertension teaching purchase 80mg micardis, stained with hematoxylin and eosin heart attack piano buy genuine micardis line. The separation of the interosseous muscles (im) and short flexor muscles of the big toe (sfh) is clearly seen hypertension in the elderly order micardis 80mg without a prescription. The plantar crossing (cr) of the tendons of the long flexors of the digits and hallux is shown in D blood pressure medication raise blood sugar purchase generic micardis. If the dorsal root supplying the area is cut hypertension and kidney disease purchase micardis 40 mg online, the dermatomal patterns indicate that there may be a slight deficit in the area indicated blood pressure 160 over 100 purchase 20mg micardis with mastercard. Because there is overlapping of dermatomes arrhythmia khan academy purchase micardis line, a particular area of skin is not exclusively innervated by a single segmental nerve. The limb dermatomes may be traced progressively down the lateral aspect of the upper limb and back up its medial aspect. A comparable distribution of dermatomes occurs in the lower limbs, which may be traced down the ventral aspect and then up the dorsal aspect of the lower limbs. When the limbs descend, they carry their nerves with them; this explains the oblique course of the nerves arising from the brachial and lumbosacral plexuses. All regions of the limbs are apparent and the digits of the hands and feet are separated. The primordial vascular pattern consists of a primary axial artery and its branches (see. The vascular patterns change as the limbs develop, chiefly by angiogenesis (sprouting from existing vessels). The primary axial artery becomes the brachial artery in the arm and the common interosseous artery in the forearm, which has anterior and posterior interosseous branches. As the digits (fingers) form, the marginal sinus breaks up and the final venous pattern, represented by the basilic and cephalic veins and their tributaries, develops. In the thigh, the primary axial artery is represented by the deep artery of the thigh (Latin, profunda femoris artery). In the leg, the primary axial artery is represented by the anterior and posterior tibial arteries. Although these anomalies are usually of no serious medical consequence, they may serve as indicators of more serious anomalies and may be part of a recognizable pattern of birth defects. A, Approximately 48 days, showing the limbs extending ventrally and the hand and footplates facing each other. B, Approximately 51 days, showing the upper limbs bent at the elbows and the hands curved over the thorax. ure 1610 Illustrations of the development of the dermatomal patterns of the limbs. B and E, Similar views later in the fifth week showing the modified arrangement of dermatomes. The primordial dermatomal pattern has disappeared but an orderly sequence of dermatomes can still be recognized. F, Note that most of the original ventral surface of the lower limb lies on the back of the adult limb. This results from the medial rotation of the lower limb that occurs toward the end of the embryonic period. In the upper limb, the ventral axial line extends along the anterior surface of the arm and forearm. In the lower limb, the ventral axial line extends along the medial side of the thigh and knee to the posteromedial aspect of the leg to the heel. This statement is based on clinical studies of infants exposed to thalidomide, a potent human teratogen, during the embryonic period. Exposure to this teratogen before day 33 may cause severe limb defects, such as amelia, the absence of limbs. Consequently, a teratogen that could cause amelia of the limbs or parts of them must act before 36 days, the end of the critical period of limb development. Many severe limb anomalies occurred from 1957 to 1962 as a result of maternal ingestion of thalidomide. This drug, widely used as a sedative and antinauseant, was withdrawn from the market in December 1961. Because thalidomide is now used for the treatment of leprosy and several other disorders, it must be emphasized that thalidomide is absolutely contraindicated in women of childbearing age. Several unrelated congenital anomalies of the lower limb were found to be associated with a similar aberrant arterial pattern, which might be of some importance in the pathogenesis of these defects. A, Sketch of the primordial cardiovascular system in a 4 week embryo, approximately 26 days. Causes of Limb Anomalies Anomalies or defects of the limbs originate at different stages of development. Suppression of limb bud development during the early part of the fourth week results in absence of the limbs, amelia (see. Arrest or disturbance of differentiation or growth of the limbs during the fifth week results in various types of meromelia (see. A reduced quantity of amniotic fluid (oligohydramnios) is commonly associated with limb deformations; however, the significance of in utero mechanical influences on congenital postural deformation is still open to question. Note also that the right leg is shortened and the femur and tibia are bowed and hypoplastic. C, Radiograph showing partial absence and fusion of the lower ends of the tibia and fibula in a 5yearold child. The hand or foot is divided into two parts that oppose each other like lobster claws. The hand deviates laterally (radially), and the ulna bows with the concavity on the lateral side of the forearm. This anomaly results from failure of the mesenchymal primordium of the radius to form during the fifth week of development. Brachydactyly Shortness of the digits (fingers or toes) is the result of reduction in the length of the phalanges. This anomaly is usually inherited as a dominant trait and is often associated with shortness of stature. Polydactyly the term supernumerary digits refers to the presence of more than the usual number of fingers or toes. Often the extra digit is incompletely formed and lacks normal muscular development. If the hand is affected, the extra digit is most commonly medial or lateral rather than central. Cutaneous syndactyly (simple webbing between digits) is the most common limb anomaly. Cutaneous syndactyly results from failure of the webs to degenerate between two or more digits. Osseous syndactyly (fusion of the bonessynostosis) occurs when the notches between the digital rays fail to develop; as a result, separation of the digits does not occur. Syndactyly is most frequently observed between the third and fourth fingers and between the second and third toes. Congenital Clubfoot Any deformity of the foot involving the talus (ankle bone) is called talipes or clubfoot. Clubfoot is a relatively common anomaly, occurring approximately once in 1000 births. It is characterized by an abnormal position of the foot that prevents normal weight bearing. Clubfoot is bilateral in approximately 50% of cases, and it occurs approximately twice as frequently in males. Clubfoot appears to follow a multifactorial pattern of inheritance; hence, any intrauterine position that results in abnormal positioning of the feet may cause clubfeet if the fetus is genetically predispositioned to this deformity. Congenital Dislocation of the Hip this deformity occurs approximately once in 1500 newborn infants and is more common in females than in males. The joint capsule is very relaxed at birth, and there is underdevelopment of the acetabulum of the hip bone and the head of femur. Generalized joint laxity is often a dominantly inherited condition that appears to be associated with congenital dislocation of the hip, which follows a multifactorial pattern of inheritance. The tissues of the limb buds are derived from two main sources: mesoderm and ectoderm. Apoptosis (programmed cell death) is an important mechanism in limb development, for example, in the formation of the notches between the digital rays. Limb muscles are derived from mesenchyme (myogenic precursor cells) originating in the somites. Most blood vessels of the limb buds arise as buds from the intersegmental arteries and drain into the cardinal veins. Initially, the developing limbs are directed caudally; later they project ventrally, and finally, they rotate on their longitudinal axes. The majority of limb anomalies are caused by genetic factors; however, many limb defects probably result from an interaction of genetic and environmental factors (multifactorial inheritance). This condition results from formation of one or more extra digital rays during the embryonic period. Cutaneous syndactyly (C) is the most common form of this condition and is probably due to incomplete programmed cell death (apoptosis) in the tissues between the digital rays during embryonic life. Zuniga A: Globalisation reaches gene regulation: the case for vertebrate limb development. It is the notochord and paraxial mesenchyme that induce the overlying ectoderm to differentiate into the neural plate. Formation of the neural folds, neural tube, and neural crest from the neural plate is illustrated in ures 171B to F and 172. Neurulationformation of the neural plate and neural tubebegins during stage 10 of development (22 23 days) in the region of the fourth to sixth pairs of somites. At this stage, the cranial two thirds of the neural plate and tube, as far caudal as the fourth pair of somites, represent the future brain, and the caudal one third of the neural plate and tube represents the future spinal cord. Fusion of the neural folds and formation of the neural tube proceeds in cranial and caudal directions until only small areas of the tube remain open at both ends. Here the lumen of the neural tubeneural canalcommunicates freely with the amniotic cavity (see. The cranial opening, the rostral neuropore, closes on approximately the 25th day and the caudal neuropore 2 days later (see. Closure of the neuropores coincides with the establishment of a blood vascular circulation for the neural tube. The neural canal forms the ventricular system of the brain and the central canal of the spinal cord. Nonclosure of the Neural Tube the current hypothesis is that there are multiple, possibly five, closure sites involved in the formation of the neural tube. Failure of closure of site 1 results in spina bifida cystica; meroencephaly (anencephaly) results from failure of closure of site 2; craniorachischisis results from failure of sites 2, 4, and 1 to close; and site 3 nonfusion is rare. It has been suggested that the most caudal region may have a fifth closure site from the second lumbar vertebra to the second sacral vertebra and that closure inferior to the second sacral vertebra is by secondary neurulation. The lateral walls of the neural tube thicken, gradually reducing the size of the neural canal until only a minute central canal of the spinal cord is present at 9 to 10 weeks (see. Initially, the wall of the neural tube is composed of a thick, pseudostratified, columnar neuroepithelium (see. These neuroepithelial cells constitute the ventricular zone (ependymal layer), which gives rise to all neurons and macroglial cells (macroglia) in the spinal cord. Macroglial cells are the larger members of the neuroglial family of cells, which includes astrocytes and oligodendrocytes. Soon a marginal zone composed of the outer parts of the neuroepithelial cells becomes recognizable (see. This zone gradually becomes the white matter (substance) of the spinal cord as axons grow into it from nerve cell bodies in the spinal cord, spinal ganglia, and brain. Some dividing neuroepithelial cells in the ventricular zone differentiate into primordial neuronsneuroblasts. These embryonic cells form an intermediate zone (mantle layer) between the ventricular and marginal zones. The primordial supporting cells of the central nervous systemglioblasts (spongioblasts)differentiate from neuroepithelial cells, mainly after neuroblast formation has ceased. The glioblasts migrate from the ventricular zone into the intermediate and marginal zones. Some glioblasts become astroblasts and later astrocytes, whereas others become oligodendroblasts and eventually oligodendrocytes (see. When the neuroepithelial cells cease producing neuroblasts and glioblasts, they differentiate into ependymal cells, which form the ependyma (ependymal epithelium) lining the central canal of the spinal cord. Sonic hedgehog signaling controls the proliferation, survival, and patterning of neuroepithelial progenitor cells by regulating Gli transcription factors (see. Microglial cells (microglia), which are scattered throughout the gray and white matter, are small cells that are derived from mesenchymal cells (see. Microglia originate in the bone marrow and are part of the mononuclear phagocytic cell population. A, Dorsal view of an embryo of approximately 17 days, exposed by removing the amnion. B, Transverse section of the embryo showing the neural plate and early development of the neural groove and neural folds. The neural folds have fused opposite the fourth to sixth somites, but are spread apart at both ends. D to F, Transverse sections of this embryo at the levels shown in C illustrating formation of the neural tube and its detachment from the surface ectoderm (primordium of epidermis). Note that some neuroectodermal cells are not included in the neural tube, but remain between it and the surface ectoderm as the neural crest. Reciprocal negative interactions assist to establish boundaries of gene expression in the embryonic ventral spinal cord. Wigle, Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, Manitoba, Canada. Differential thickening of the lateral walls of the spinal cord soon produces a shallow longitudinal groove on each sidethe sulcus limitans. This groove separates the dorsal part, the alar plate (lamina), from the ventral part, the basal plate (lamina). The alar and basal plates produce longitudinal bulges extending through most of the length of the developing spinal cord. This regional separation is of fundamental importance because the alar and basal plates are later associated with afferent and efferent functions, respectively. Cell bodies in the alar plates form the dorsal gray columns that extend the length of the spinal cord. Neurons in these columns constitute afferent nuclei, and groups of these nuclei form the dorsal gray columns. In transverse sections of the spinal cord, these columns are the ventral gray horns and lateral gray horns, respectively (see. Axons of ventral horn cells grow out of the spinal cord and form the ventral roots of the spinal nerves. As the basal plates enlarge, they bulge ventrally on each side of the median plane. Development of the Spinal Ganglia the unipolar neurons in the spinal ganglia (dorsal root ganglia) are derived from neural crest cells. The axons of cells in the spinal ganglia are at first bipolar, but the two processes soon unite in a Tshaped fashion. Both processes of spinal ganglion cells have the structural characteristics of axons, but the peripheral process is a dendrite in that there is conduction toward the cell body. The peripheral processes of spinal ganglion cells pass in the spinal nerves to sensory endings in somatic or visceral structures (see. The central processes enter the spinal cord and constitute the dorsal roots of spinal nerves. B, Lateral view of an embryo of approximately 24 days showing the forebrain prominence and closing of the rostral neuropore. C, Diagrammatic sagittal section of the embryo showing the transitory communication of the neural canal with the amniotic cavity (arrows). Development of the Spinal Meninges the mesenchyme surrounding the neural tube (see. The internal layer the piaarachnoid, composed of pia mater and arachnoid mater (leptomeninges), is derived from neural crest cells. Fluidfilled spaces appear within the leptomeninges that soon coalesce to form the subarachnoid space. Positional Changes of the Spinal Cord page 384 page 385 ure 174 A, Schematic lateral view of an embryo of approximately 28 days showing the three primary brain vesicles: forebrain, midbrain, and hindbrain. B, Transverse section of this embryo showing the neural tube that will develop into the spinal cord in this region. C, Schematic lateral view of the central nervous system of a 6week embryo showing the secondary brain vesicles and pontine flexure. In A to C, note that the neural canal of the neural tube is converted into the central canal of the spinal cord. The spinal cord in the embryo extends the entire length of the vertebral canal (see. The spinal nerves pass through the intervertebral foramina opposite their levels of origin. Because the vertebral column and dura mater grow more rapidly than the spinal cord, this positional relationship to the spinal nerves does not persist. The caudal end of the spinal cord gradually comes to lie at relatively higher levels. In a 6monthold fetus, it lies at the level of the first sacral vertebra (see.
These statistics exceed those of the general population for prisons blood pressure medication joint pain discount micardis 40 mg on line, in some cases by many times blood pressure of 100/70 buy cheap micardis 80mg on line. A 2003 report of the Department Incarceration by Gender Identity/Expression of Justice shows that 2 prehypertension high blood pressure buy micardis 40 mg online. However blood pressure 100 over 60 proven 20 mg micardis, the Department of 45 Justice report does not include jails whats prehypertension mean buy micardis 20 mg mastercard, so the general population 40 rate for being held in jail or prison should be higher than the 35 simple prison rate heart attack 10 hours order micardis canada. Black respondents reported the highest incidence of sexual assault in prison (34%) by other inmates or by staf blood pressure how to read generic 40mg micardis visa. Transgender inmates experienced physical and sexual assault at higher frequencies (19% and 16%) than their gender nonconforming peers (4% and 8%) blood pressure medication most common order 20mg micardis with visa. However, we 25 21% include the following table below to highlight the experiences of 20 18% 19% 16% transgender women by race. The data also demonstrate genderbased biases, with maletofemale respondents experiencing high rates of physical and sexual assault. Household income and education level were also relevant to treatment by police and the prison system, with lower educational attainment and household income associated with higher risk for incarceration, harassment and violence; in this regard, our sample refected the experiences of Americans in general. In jail and prison, abuse and violence continues in situations where transgender and gender nonconforming inmates often have no protection or escape. As noted in the health care section, access to health care is a fundamental right often denied to study participants. Data from the prison context confrms this, showing regular denial of both routine and transgenderrelated health care services. From every angle, the justice system is broken for transgender and gender nonconforming people. We recommend the following affrmative steps for police departments, corrections systems, and the justice system overall. Existing lesbian and gay units should expand to include transgender and gender nonconforming offcers and issues as well. A prison is administered by the state and used to house convicted criminals for generally longer periods. On the other hand, half of these They were spread amongst the racial categories, with a bit more respondents intend to remain in this category, which indicates concentration in white and Latino/a groups, making up 13% that it is a permanent identity. This contradicts assumptions of white respondents, 7% of Latino/as, 5% of Asian and multi that those who identify as crossdressers are moving toward a racial respondents, 4% of American Indians, and 3% of African transsexual identity. Since social heterosexual or bisexual and much less often samesex oriented isolation can have major impacts on mental and physical health, or queer than the full sample. He crossdressers who expressed a transgender identity or gender the settings we studied, equal told me that he would nonconformity in school experienced some type of problem, service was denied most often not give me a room including harassment, physical or sexual assault, or expulsion. These household income (22%) said they had been harassed in a retail store, 11% when levels were much higher than the full sample, of which 41% using buses, trains or taxis, 11% by hotel/restaurant personnel, percent earns $50, 000 or more annually. However, crossdressers do experience a range of biasrelated Housing negative experiences in the workplace: 13% reported losing a job Fiftyeight percent (58%) reported living in a home that they because of bias, 34% reported harassment at work, 12% reported own; this is nearly twice the rate of home ownership as the full being denied a promotion, 18% were denied a job they applied sample, and 9 percentage points under the national average. Twentyseven percent (27%) reported living in a space that they the rates of these negative workplace experiences are all lower rented. Five percent (5%) reported living in a home that is owned than the overall sample, except for sexual assault, which was by a partner/spouse, 3% reported living with family or friends approximately the same. Eighty percent dressers reported having moved into a less expensive home/ (80%) reported that they have hidden their gender or gender apartment because of being transgender or gender non transition and 56% have delayed transition. Seven percent (7%) have bias, 4% reported eviction, 6% were denied an apartment/home, participated in the underground economy for household income 14% had to fnd diferent places to sleep for short periods of time, (compared to 16% for the overall sample), including 4% doing and 8% had sex in exchange for housing or a place to stay. Eight percent (8%) reported being physically spouse limited or stopped their relationship with their children attacked by a police ofcer and 3% reported sexual assault. Twentynine percent (29%) indicated they were comfortable seeking police assistance and 46% indicated they were not Twelve percent (12%) reported they were victims of violence by a comfortable seeking police assistance as a transgender or gender family member due to their gender identity/expression. Crossdressers also reported drinking or using drugs to cope with the mistreatment they face as transgender/gender nonconforming persons: 6% reported current use and 7% reported former use. By contrast, (8%) of the full sample currently drinks or uses drugs to cope with mistreatment due to bias and (18%) reported former use. Because they can with wearing clothes of a diferent sex for men and women, we felt it was often make choices about when and if to come out to others, they important to focus here on the experiences of those crossdressers who seemed to be shielded from some of the hostile environments were born male. Nonetheless, a sizable number 2 Those respondents who did not strongly identify with any of the terms reported dealing with bias and violence in their lives. All of these factors deserve further study; statistically we know relatively little about the lives of crossdressers and additional 4 Kelly Ann Holder, U. Census Bureau, Housing and Household Economics research would greatly enhance our knowledge. The results show remarkable concurrence on priorities, and they also reveal the breadth of concerns that individuals prioritize as being the most essential to the improvement of their lives. The following are the 13 policy areas ranked in order of the frequency that respondents marked each. Over and over again, respondents were fred, evicted, denied medical care, faced dire poverty or were bullied in school at rates far above the national average. People of color very clearly experienced the compounding and devastating efects of racism, with far higher levels of discrimination and poorer health outcomes than the sample as a whole. Despite the stereotypes of broken families, and in light of all the stresses discrimination places on relationships, respondents maintained relationships with their partners, children and families. We recognize, too, that there are many, many people we have lost along the way, who have been unable to survive the unremitting discrimination, harassment and violence that they have encountered. For the purposes of this nor female, identify as a combination of both, or who present in a study, the term crossdresser refers to those who identifed with nongendered way. The administration of hormones to facilitate the development Drag Queen A term generally used to refer to men who of secondary sex characteristics as part of a medical transition occasionally dress as women for personal satisfaction or for the process. It is take testosterone while those transitioning from male to female also used incorrectly, sometimes in a derogatory manner, to refer may take estrogen and androgen blockers. Some Sex Development, such as being born with external genitalia, transgender people perform drag. In this defned as lesbian, gay, bisexual, or heterosexual and can also report, we use transgender woman, maletofemale transgender include queer, pansexual and asexual, among others. American Indian/Alaska Native people who are lesbian, gay, bisexual, transgender, intersex or gender nonconforming identify Metoidioplasty A surgical procedure to create a neopenis as TwoSpirit. Underground Economy A term that refers to marginal or Oophorectomy the surgical removal of the ovaries. Work in the Orchiectomy the surgical removal of the underground economy may be the only incomegenerating option testes (the scrotum and testicles). Visual NonConformer A term we developed to describe a Vaginoplasty the surgical creation of a vagina. As such, the questionnaire was quite lengthy, yet limited in the depth into each topic we delved. We encourage other researchers to use this as a starting point to dig deeper into areas of particular interest. As we analyzed our data, we were able to get a better sense of the strengths and weaknesses of our survey instrument. We consider these possibilities here in the spirit of expanding1 our collective learning. We informally tested the questionnaire to attempt to identify and correct problems with specifc questions before we felded the survey. If you want to change an answer, erase your first answer completely and darken the oval of your new answer. Anyone who left this question blank was includedfi Male Please read and answer each question carefully. If you want to change anfi Female or excluded based on their answers to other questions. We intentionally included respondents in the sample who did not identify asanswer, erase your first answer completely and darken the oval of your new answer. TranssexualDrag performer (King/Queen) fifi fifi fifi Going through the writein answers to Question 3 was timeconsuming, but very helpful. Third genderAndrogynous fi fi fi Feminine maleCross dresser fifi fifi fifi Masculine female or butchDrag performer (King/Queen) fifi fifi fifi A. Drag performer (King/Queen) fi fi fi Twospiritfi Always fi fi fi Other, please specify fi Most of the time fi fi fi Transgender fi fi fi fi Sometimes 5. Androgynous fi fi fi Asking more simplifed identity questions would create more simplifed categories. As a project with limited staf resources andFeminine male fi fi fi Masculine female or butch fi fi fi seemingly indefatigable volunteers, we found our dedication to nuance and complexity extremely challenging and, in most cases, veryA. Do you or do you want to live fulltime in a gender that is different from you gender at birthfi How many people know or believe you are transgender/gender nonconforming in each of the following settingsfi In private social settings fi fi fi fi fi fifi In public social settingsAge you began to live full time as a transgender/gender nonconforming person. To the best of your ability, please estimate the following ages, if they apply to you. For example, futureAge you began to live full time as a transgender/gender nonconforming person. We did not use the rural/urban classifcation to analyze our data but future researchers may do so. It is usually simpler for comparative purposes to draw on existing questions in federal surveys, but we continue to believe we made the right decision. What is your current gross annualfi Some high school to 12th gradehousehold income (before taxes)fi What is your current gross annualfi $100, 000 to $149, 999 household income (before taxes)fi If you are currently enrolled, please mark thefifi Single$150, 000 to $ 199, 999 previous grade or highest degree received. Therefore, we do not know to what extent our respondentsfifiNumber DivorcedSome college credit, but less than 1 year had access to the income they reported. For example, ifpeople are treating you differently because you are transgender or gender nonconforming. We used the phrase throughout the survey so that we could report with confdence on the connection between thefi Widowed fi Much worse discrimination reported and a respondent being targeted based on gender identity or expression. Because I am transgender/gender nonconforming, life in general is: fi Much improved fi Somewhat improved fi the same fi Somewhat worse fi Much worse fi In some ways better, in some ways worse 18. Living in a shelter fi Living in a group home facility or other foster care situation situationfi Please markfifi Living in a nursing/adult care facilityLiving with a partner, spouse or other person who pays for the housing "Not applicable" if you were never in a position to experience such a housing situation. Because you are transgender/gender nonconforming, have you experienced any of the following housing situationsfi Additionally, we could have diferentiated between those who were denied a rental home/apartment and those who encountered bias when they attempted to buy a house. I was forced to live as the wrong gender in order to be allowed to stay in a shelter. I decided to leave a shelter even though I had no place to go because of poor treatment/unsafe fi fi fi fi I was physically assaulted/attacked by residents or staff. Because of being transgender or gender nonconforming, have any of the following people close to you faced any kind of job Generally, this question yielded extremely important results. I am or have been underemployed, that is working in the field I should not be in or a. We wanted to know how many of our respondents were forced into the underground economy that leaves them at risk for arrest and other negative outcomes. Because of being transgender/gender nonconforming, which of the following experiences have you had in your interaction with section, with Question 33, we do ask about denial of treatment by doctors and other medical providers, so we do have data for thatthe policefi Had we done so, we would have been able to havefi Yes [Go to Question 36] Mental health clinic fi fi fi fi fi fi a better overall sense of harassment and hate crimes. Therefore, the survey data do not give a full picture of hate crimes committedPolice officerfi Under six months fi fi fi fi fi fi Judge or court officialfi Six months to a year fi fi fi fi fi fi against transgender and gender nonconforming people, which is unfortunate given the paucity of data on this severe problem. Because of being transgender/gender nonconforming, which of the following experiences have you had in your interaction with Depending on the purpose of additional research, researchers may want to diferentiate between interactions where the respondent wasthe policefi Because of being transgender/gender nonconforming, which of the following experiences have you had in your interaction withGovt. Judge or court officialfi Officers generally have treated me with respect fi fi fi fi fi fi 33. As a transgender/gender nonconforming person, how comfortable do you feel seeking help from the policefi Because you are transgender/gender nonconforming, have you been a target of harassment, discrimination or violence at We used this question to determine whether or not a respondent was out as transgender or was openly expressing gender nonschoolfi Graduate or professionalfi Yes [Go to Question 39]fi fi fi fi fi fi fi fi fi fi schoolfi No [Go to Question 41] Technical school fi fi fi fi fi fi fi fi fi fi 39. Because you are transgender/gender nonconforming, have you been a target of harassment, discrimination or violence at 40. Also, to determine whether respondents were openly transgender versus gender nonconforming at each school level, a more complex set of responses would need to be developed. However, it did not distinguish between K12 and college/technical/graduate school, though some questions like housing and scholarships are more applicable to higher education. For simplicity, it might have been better to separate these questions by school level. I do not use any health care providers fifi Student insurance through college or universityHealth clinic or health center that I or my insurance pays for 43. I have postponed or not tried to get needed medical care when I was sick or injuredfi Alternative medicine provider (acupuncture, herbalist) fi Not applicable. I have postponed or not tried to get checkups or other preventive medical care because I 43.
Other treatments which are sometimes helpful include anticholiner gics blood pressure checker micardis 80mg for sale, dopamine antagonists arrhythmia general anesthesia cheap micardis 20 mg amex, dopamine agonists heart attack the song micardis 40mg cheap, and baclofen xopenex arrhythmia buy cheap micardis 20 mg on-line. Druginduced dystonia following antipsychotic blood pressure medication gluten free generic 40 mg micardis overnight delivery, antiemetic blood pressure medication dry mouth purchase micardis online now, or antidepressant drugs is often relieved within 20 min by intramuscular biperiden (5 mg) or procyclidine (5 mg) hypertension medscape buy cheap micardis 40mg on line. Surgery for dystonia using deep brain stimulation is still at the experimental stage blood pressure of 100/70 cheap micardis express. Patients are asked to clap: those with neglect per form onehanded motions which stop at the midline. Hemiplegic patients without neglect reach across the midline and clap against their plegic hand. This may be observed as a feature of apraxic syndromes such as cor ticobasal degeneration, as a complex motor tic in Tourette syndrome, and in frontal lobe disorders (imitation behaviour). Synaesthesia may be linked to eidetic memory; synaesthesia being used as a mnemonic aid. Patients 126 Emotionalism, Emotional Lability E may develop oculopalatal myoclonus months to years after the onset of the ocular motility problem. Sometimes other psychiatric features may be present, particularly if the delusions are part of a psychotic illness such as schizophre nia or depressive psychosis. Clinical examination may sometimes show evidence of skin picking, scratching, or dermatitis caused by repeated use of antiseptics. Treatment should be aimed at the underlying condition if appropriate; if the delusion is isolated, antipsychotics such as pimozide may be tried. A distinction may be drawn between the occurrence of these phenomena sponta neously or without motivation, or in situations which although funny or sad are not particularly so. Also, a distinction may be made between such phenomena when there is congruence of mood and affect, sometimes labelled with terms such as moria or witzelsucht. The neurobehavioural state of emotional lability refiects frontal lobe (espe cially orbitofrontal) lesions, often vascular in origin, and may coexist with disin hibited behaviour. Cross References Delirium; Disinhibition; Frontal lobe syndromes; Moria; Pathological crying, Pathological laughter; Pseudobulbar palsy; Witzelsucht Emposthotonos Emposthotonos is an abnormal posture consisting of fiexion of the head on the trunk and the trunk on the knees, sometimes with fiexion of the limbs (cf. Cross References Opisthotonos; Seizures; Spasm Encephalopathy Encephalopathy is a general term referring to any acute or chronic diffuse dis turbance of brain function. Characteristically it is used to describe an altered level of consciousness, which may range from drowsiness to a failure of selective attention, to hypervigilance; with or without: disordered perception, memory. Although the term encephalopathy is sometimes reserved for metabolic causes of diffuse brain dysfunction, this usage is not universal. Conditions which may be described as an encephalopathy include Metabolic disorders: hypoxia/ischaemia, hypoglycaemia; organ failure, elec trolyte disturbances, hypertension; Drug/toxin ingestion; Brain infiammation/infection. Enophthalmos may also occur in dehydration (probably the most common cause), orbital trauma. The temptation to dismiss such bizarre symptoms as functional should be resisted, since environmental tilt is presumed to refiect damage to connections between cerebellar and central vestibularotolith pathways. It has been reported in the following situations: Lateral medullary syndrome of Wallenberg Transient ischaemic attacks in basilar artery territory Demyelinating disease Head injury Encephalitis Following third ventriculostomy for hydrocephalus Cross References Lateral medullary syndrome; Vertigo; Vestibuloocular refiexes Epiphora Epiphora is overfiow of tears down the cheek. This may be not only due to a blocked nasolacrimal duct, or irritation to the cornea causing increased lacrima tion, but it may also be neurological in origin. Lacrimation is also a feature of trigeminal autonomic cephalalgias such as cluster headache. Cross References Cover tests; Exophoria; Heterophoria Esotropia Esotropia is a variety of heterotropia in which there is manifest inward turning of the visual axis of one eye; the term is synonymous with convergent strabismus. It may be demonstrated using the cover test as an outward movement of the eye which is forced to assume fixation by occlusion of the other eye. With lateral rectus muscle paralysis, the eyes are esotropic or crossed on attempted lateral gaze towards the paralyzed side, but the images are uncrossed. Cross References Amblyopia; Cover tests; Diplopia; Exotropia; Heterotropia; Nystagmus Eutonia Kinnier Wilson used this term to describe an emotional lack of concern associ ated with the dementia of multiple sclerosis. Ewart Phenomenon this is the elevation of ptotic eyelid on swallowing, a synkinetic movement. Cross References Ptosis; Synkinesia, Synkinesis 130 Extinction E Exophoria Exophoria is a variety of heterophoria in which there is a tendency for the visual axes to deviate outward (latent divergent strabismus). Exophoria may occur in individuals with myopia and may be physiological in many subjects because of the alignment of the orbits. Cross References Cover tests; Esophoria; Heterophoria Exophthalmos Exophthalmos is forward displacement of the eyeball. Cross References Lid retraction; Proptosis Exosomaesthesia the sensory disturbance associated with parietal lobe lesions may occasionally lead the patient to refer the source of a stimulus to some point outside the body, exosomaesthesia. Exotropia Exotropia is a variety of heterotropia in which there is manifest outward turning of the visual axis of an eye; the term is synonymous with divergent strabismus. It may be demonstrated using the cover test as an inward movement of the eye which is forced to assume fixation by occlusion of the other eye. When the medial rectus muscle is paralyzed, the eyes are exotropic (wall eyed) on attempted lateral gaze towards the paralyzed side, and the images are crossed. It is important to show that the patient responds appropriately to each hand being touched individually, but then neglects one side when both are touched simultaneously. More subtle defects may be tested using simultaneous bilateral heterologous (asymmetrical) stimuli, although it has been shown that some normal individuals may show extinction in this situation. A motor form of extinction has been postulated, manifesting as increased limb akinesia when the contralateral limb is used simultaneously. The presence of extinction is one of the behavioural manifestations of neglect and most usually follows nondominant (right) hemisphere (parietal lobe) lesions. There is evidence for physiological interhemispheric rivalry or compe tition in detecting stimuli from both hemifields, which may account for the emergence of extinction following brain injury. Neural consequences of competing stimuli in both visual hemifields: a physiological basis for visual extinction. Clinically there is no visible contraction of orbicularis oculi, which distinguishes eyelid apraxia from blepharospasm (however, perhaps para doxically, the majority of cases of eyelid apraxia occur in association with blepharospasm). The underlying mechanisms may be heterogeneous, including involuntary inhibition of levator palpebrae superioris. Botulinum toxin A injections improve apraxia of eyelid opening without overt blepharospasm associated with neurodegenerative diseases. Volitional paresis without emotional paresis may occur when corticobulbar fibres are interrupted (precentral gyrus, internal capsule, cerebral peduncle, upper pons). Depending on the precise location of the facial nerve injury, there may also be paralysis of the stapedius muscle in the middle ear, causing sounds to seem abnormally loud (especially low tones: hyperacusis), and impairment of taste sen sation on the anterior twothirds of the tongue if the chorda tympani is affected (ageusia, hypogeusia). Lesions within the facial canal distal to the meatal seg ment cause both hyperacusis and ageusia; lesions in the facial canal between the nerve to stapedius and the chorda tympani cause ageusia but no hyperacusis; lesions distal to the chorda tympani cause neither ageusia nor hyperacusis. Lesions of the cerebellopontine angle cause ipsilat eral hearing impairment and corneal refiex depression (afferent limb of refiex arc affected) in addition to facial weakness. There is also a sensory branch to the posterior wall of the external auditory canal which may be affected resulting in local hypoaesthesia (Hitselberg sign). In primary disorders of muscle the pattern of weakness and family history may suggest the diagnosis. Emotional and non emotional facial behaviour in patients with unilateral brain damage. Emotional facial paresis in temporal lobe epilepsy: its prevalence and lateralizing value. Clinically, facilitation may be demonstrated by the appearance of tendon refiexes which are absent at rest after prolonged (ca. The classic example, and probably the most frequently observed, is abducens nerve palsy (unilateral or bilateral) in the context of raised intracranial pressure, presumed to result from stretching of the nerve over the ridge of the petrous temporal bone. Fasciculations may also be induced by lightly tapping over a partially denervated muscle belly. The term was formerly used synonymously with fibrillation, but the latter term is now reserved for contraction of a single muscle fibre or a group of fibres smaller than a motor unit. Persistent fasciculations most usually refiect a pathological process involving the lower motor neurones in the anterior (ventral) horn of the spinal cord and/or in brain stem motor nuclei, typically motor neurone disease (in which cramps are an early associated symptom). However, fascicula tions are not pathognomonic of lower motor neurone pathology since they can on rare occasions be seen with upper motor neurone pathology. The pathophysiological mechanism of fasciculations is thought to be spon taneous discharge from motor nerves, but the site of origin of this discharge is uncertain. Although ectopic neural discharge from anywhere along the lower motor neurone from cell body to nerve terminal could produce fasciculation, the commonly encountered assumption that this originates from the anterior horn cell body is not entirely supported by the available evidence, which points to an additional, more distal, origin in the motor axons. Denervation of muscle fibres may lead to nerve fibre sprouting (axonal and collateral) and enlargement of motor units which makes fasciculations more obvious clinically. Fasciculations may be seen in: Motor neurone disease with lower motor neurone involvement. Cross Reference Micrographia Fatigue the term fatigue may be used in different contexts to refer to both a sign and a symptom. The sign of fatigue, also known as peripheral fatigue, consists of a reduc tion in muscle strength or endurance with repeated muscular contraction. This most characteristically occurs in disorders of neuromuscular junction transmis sion. In myasthenia gravis, fatigue may be elicited in the extraocular muscles by prolonged upgaze causing eyelid drooping; in bulbar muscles by prolonged counting or speech causing hypophonia; and in limb muscles by repeated con traction, especially of proximal muscles. Fatigue as a symptom, or central fatigue, is an enhanced perception of effort and limited endurance in sustained physical and mental activities. Current treatment is symptomatic (amantadine, modafanil, 3, 4diaminopyridine) and rehabilitative (graded exercise). Fatigue may be evaluated with various instruments, such as the Krupp Fatigue Severity Score. A similar phenomenon may be observed if the patient is pulled backwards (retropulsion). Festination may be related to the fiexed posture and impaired postural refiexes commonly seen in these patients. It is less common in symptomatic causes of parkinsonism, but has been reported, for example, in aqueduct stenosis. Cross References Freezing; Parkinsonism; Postural refiexes Fibrillation Fibrillation was previously synonymous with fasciculation, but the term is now reserved for the spontaneous contraction of a single muscle fibre, or a group of fibres smaller than a motor unit, hence this is more appropriately regarded as an electrophysiological sign without clinical correlate. This is a disorder of body schema and may be regarded as a partial form of autotopagnosia. Finger agnosia is most commonly observed with lesions of the dominant parietal lobe. Isolated cases of finger agnosia in associa tion with left corticosubcortical posterior parietal infarction have been reported. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. It follows nondominant (right) hemisphere lesions and may accompany emotional dysprosody of speech. Cross References Abulia; Aprosodia, Aprosody; Facial paresis, Facial weakness FistEdgePalm Test In the fistedgepalm test, sometimes known as the Luria test or threestep motor sequence, the patient is requested to place the hand successively in three posi tions, imitating movements made by the examiner and then doing them alone: fist, vertical palm, palm resting fiat on table. Defects in this programming, such as lack of kinetic melody, loss of sequence, or repetition of previous pose or position, are espe cially conspicuous with anterior cortical lesions. Cross Reference Frontal lobe syndromes Flaccidity Flaccidity is a fioppiness which implies a loss of normal muscular tone (hypo tonia). This may occur transiently after acute lesions of the corticospinal tracts (fiaccid paraparesis), before the development of spasticity, or as a result of lower motor neurone syndromes. Alternative designations for this syndrome include amyotrophic brachial diplegia, dangling arm syndrome, and neurogenic maninabarrel syn drome. This may be the most sensitive and specific of the various signs described in carpal tunnel syndrome. This has been documented in various conditions including congenital achromatopsia, following optic neuritis, and in autosomal dominant optic atrophy. Paradoxical pupillary phenomena: a review of patients with pupillary constriction to darkness. Cross Reference Pupillary refiexes Foot Drop Foot drop, often manifest as the foot dragging during the swing phase of the gait, causing tripping and/or falls, may be due to upper or lower motor neurone lesions, which may be distinguished clinically. At worst, there is a fiail foot in which both the dorsifiexors and the plantar fiexors of the foot are weak. Other lower motor neurone signs may be present (hypotonia, arefiexia, or hyporefiexia). Causes of fioppy foot drop include Common peroneal nerve palsy Sciatic neuropathy Lumbosacral plexopathy L4/L5 radiculopathy Motor or sensorimotor polyneuropathy. This type of behaviour may be displayed by an alien hand, most usually in the context of corticobasal degeneration. Forced upgaze may also be psychogenic, in which case it is overcome by cold caloric stimulation of the ear drums. Cross Reference Oculogyric crisis Forearm and Finger Rolling the forearm and finger rolling tests detect subtle upper motor neurone lesions with high specificity and modest sensitivity. Either the forearms or the index fin gers are rapidly rotated around each other in front of the torso for about 5 s, then the direction reversed. Normally the appearance is symmetrical but with a unilat eral upper motor neurone lesion one arm or finger remains relatively stationary, with the normal rotating around the abnormal limb. Thumb rolling might also be a sensitive test for subtle upper motor neurone pathology. This syndrome probably overlaps with other disorders of speech production, labelled as phonetic disintegration, pure anarthria, aphemia, apraxic dysarthria, verbal or speech apraxia, and cortical dysarthria. A case of foreign accent syndrome, with followup clinical, neuropsycho logical and phonetic descriptions. Cross References Aphasia; Aphemia Formication Formication is a tactile hallucination, as of ants crawling over the skin.
A large majority of departments (88 percent) require officers to complete incident reports for all domestic violence calls to which they are dispatched blood pressure chart medication buy micardis 20 mg fast delivery, regardless of outcome blood pressure medication karvezide buy micardis 80 mg overnight delivery. Almost twothirds of departments (63 percent) require officers to fill out a supplemental form for domestic violence arteria3d cartoon medieval pack cheap micardis line, and most require written justification when no arrest is made (68 percent) or when there is a dual arrest (86 percent) arteria lingual order generic micardis canada. The research on the effectiveness of prosecution of domestic violence has found mixed results in terms of stopping abusers from reabusing their victims blood pressure levels in adults discount micardis 20 mg online. The same researchers recently completed a review of 31 prosecution studies and found no consistent evidence that prosecution had a deterrent effect over arrest without prosecution; prosecution without conviction blood pressure yeast infection order micardis 40 mg without prescription, or conviction regardless of sentence severity heart attack what everyone else calls fun micardis 40 mg with visa. Especially if the victim specifically wants the case prosecuted prehypertension need medication buy 80mg micardis with visa, prosecutors should be encouraged to do so. There was no evidence that emotional support from family and friends or institutional support from police or advocates facilitated victim cooperation with prosecution. Despite some victim vacillation between prosecution and dropping the case, the large majority (65 percent) ultimately supported prosecution. Victims whose abusers used alcohol or drugs were more likely to have a documented wish for prosecution, but victims who themselves used alcohol or drugs were much less inclined to press for prosecution. After the case was prosecuted, 73 percent reported they were satisfied or somewhat satisfied. Fear of abuser retaliation is among the most stated reasons expressed by victims, followed by fear of testifying in court. A study of five jurisdictions in three states found that victims across all sites reported that fear of defendant retaliation was the most common barrier to participation with prosecutors. Specifically, victims expressed fear that the prosecutors would not prepare them adequately to testify. For at least some of the reasons, action by prosecutors may eliminate reluctance and persuade victims to cooperate with prosecution. Advocates should assist prosecutors in devising remedies that may address victim concerns Measures to counter victim fear, for example, may require appropriate pretrial restrictions on defendants, and meeting with victims to inform and prepare them for trial. Multiple prosecution and arrest studies broadly concur that a high proportion of abusers who come to the attention of the criminal justice system reabuse and are likely to do so sooner rather than later. In a Massachusetts court study, about 40 percent of the arrested abusers reabused their victims within one year. Among those charged with order violations, a felony in New York, the rearrest rate was 47 percent, including 37 percent for violating the protective order again. Despite the fact that most prosecutors see the lack of victim cooperation as the reason why domestic violence prosecutions cannot proceed, both individual jurisdiction and comparative studies clearly suggest that either lack of victim cooperation is exaggerated or victims are not the key variable in successful prosecution programs. A study of almost 100 domestic violence trials in San Diego found that uniformly high conviction rates were obtained independent of victim or defendant statements, witness testimony and corroborating evidence. In fact, outcomes were also independent of whether the victim testified for the prosecution or for the defense! For example, in the three statewide examinations of tens of thousands of 160 this document is a research report submitted to the U. Studies confirm that jurisdictions with specialized domestic violence prosecution programs generally support the highest rates of successful prosecution. For example, they either help create or are associated with courts with expedited domestic violence dockets. For example, as a result of the specialized prosecution in San Diego, processing time for domestic violence cases decreased to 32 days, with almost half of the defendants (46 percent) pleading guilty at arraignment. In Everett, Washington, prosecutors reduced time to trial to 80 days, and in Omaha, Neb. Shortened trial times proved to reduce both victim vulnerability to threats and rates of reconciling with the abuser pending trial. In both San Diego and Everett, bail was regularly set at $10, 000 per domestic violence charge (with no cash alternative in the latter location). As a result, for defendants unable to raise bail, there was an incentive to plead guilty to get out of jail. The availability of evidence (911 tapes, photographs, medical records and police testimony) was not associated with the likelihood of a conviction. Controlling for other factors that predicted prosecution success, including victim injuries, jailing the defendant pretrial, crimes against children, reseachers concluded the video program accounted for a 3. The rates would have been higher but 20% of the defendants refused to 161 this document is a research report submitted to the U. The rates were highest (46%) when defendants admitted on camera that they knew of the protective orders they were accused of violating. Lack of evidence may be more likely to deter prosecutors from going forward than deterring defendants from pleading guilty. The seeds for victim engagement in prosecution may be planted before the case even reaches prosecutors. A Portland, Oregon police study found that the following police activities significantly correlated with increased prosecution: (1) Police contacted victims. These measures contrast with those used in some jurisdictions, in which studies indicate some prosecutors treat victims like civil claimants. In a large 45county study of upstate New York domestic violence prosecutions, researchers found that half of the prosecutors required victims to sign complaints in order to file charges. Further, they provided affidavits to victims to confirm their interest in having charges withdrawn. Specific studies suggest that the more prosecutionrelated burdens are placed on victims, the less likely victims are to participate in the prosecution. In Milwaukee, a study found the majority of cases were dismissed when victims were required to attend a charging conference within days of the arrest of their abusers. However, when victims were absolved of this responsibility, Milwaukee prosecution rates increased from 20 percent to 60 percent. In the Ohio court study, the strongest predictor of a guilty verdict in domestic violence misdemeanor cases was how many times the prosecutors met with the victim before trial. However, the study found that the majority of victims never received rudimentary information from prosecutors before trial, including court dates. In almost 90 percent of the court cases, prosecutors never spoke with the victim on the phone and, in more than half of the cases (52 percent), never met with them before the trial date. The studies found that victims appreciated contact with victim advocates/liaisons and reported a high degree of satisfaction with their services. In a Massachusetts study, for example, 81 percent of the victims reported satisfaction with the time they spent with victim advocates, and three quarters (77 percent) said they would talk to the advocate again if a similar incident recurred. However, the same study reported that advocate contact with victims was not associated with victim participation in the court phase of criminal cases. If this is indicated in more than a minority of cases, Victim Advocates and Service Providers should work with police and prosecutors to reduce barriers to victim participation. The same research that documents that most victims want their abusers prosecuted, also found that even a greater number are satisfied after their abusers are prosecuted. The majority of victims were satisfied even if they initially had wanted the charges dropped, remained unchanged, or increased. Surprisingly, even among those who felt the prosecution decreased their safety, the majority reported being satisfied with the prosecution. The satisfaction rates for 163 this document is a research report submitted to the U. However, 85 percent of the victims concluded that it was good that the case had been prosecuted. Advocates, however, can promote safety and satisfaction with criminal case outcomes by working with prosecutors andvictims safety throughout criminal cases to implement safety plans and related activities E. A study of a large number of arrests in three states (Connecticut, Idaho and Virginia) found that those who were prosecuted and convicted for domestic violence were more likely to be rearrested than offenders who were not convicted. However, in this study, those prosecuted and convicted were significantly more likely to be higher risk offenders as measured by prior criminal history. This led researchers to recommend jail sentences for domestic violence defendants with any prior criminal history. Although jail sentences were significantly related to lower odds of subsequent misdemeanor or felony intimatepartner assaults after two years, prison sentences were not significantly related. The likelihood of new charges was nine percent less for those jailed (compared to those sentenced to probation), but the likelihood was only two percent lower for those imprisoned, compared to those placed on probation. Finally, diversion of abusers has been found to endanger a significant proportion of victims. The few studies that have examined reabuse among diverted or discharged abusers have consistently found that a steady minority continued to reabuse, notwithstanding no prior or minimal prior records. In the Quincy arrest study, for example, a quarter of the arrested defendants were continued, without a finding and charges to be dismissed, if they remained arrest free for six months to a year, a disposition reserved for first or lesser defendants. A quarter was arrested or had new protective orders taken out against them within two years of their study arrest. Although this reabuse rate was still half that of defendants with more substantial prior criminal histories, it was substantially higher than prosecutors and judges had anticipated. Victim assessments of the dangerousness of suspects have been found to be good predictors of subsequent violence [48, 50, 127, 128, 129], although victim preferences on case disposition may not speak to risk of recidivism. The victims in the Quincy, Massachusetts study who wanted the charges dropped were no more likely to be reassaulted (51 percent vs. In other words, when judges imposed sentences to which victims objected, these victims were no more or less likely to be re victimized than victims who wanted their abusers to be prosecuted and sentenced. No research to date measures offender recidivism or victim satisfaction when judges tailor criminal sanctions to the specific requests of victims regarding incarceration, restitution, protective conditions, monitoring or treatment programs, or blanket terms of probation. However, the research suggests that if victims express fear of their abusers or even if they say they are unsure, judges should pay attention. Although advocates may be asked to 166 this document is a research report submitted to the U. When advocates disagree with the requests made by victims, they should not speak against victim preferences without victim permission. Just as research suggests that abusers who are gone when police arrive on the scene are more likely to reabuse their victims [100], research suggests the same for abusers who fail to show for scheduled court appearances. A Cook County study found that noshow defendants had a significantly greater number of new arrests than those who appeared in court as ordered, 78% compared to 46%. Measures taken to increase defendant appearance rates were associated with reduced reabuse. Victim preference was not found to be a significant factor in sentencing in Quincy, Massachusetts, Everett, Washington, Klamath Falls, Oregon, Omaha, Nebraska, San Diego, California, or Ohio. Safeguards and sentencing preferences requested by victims also should be addressed in sentencing. Although national surveys reveal that almost all domestic violence program service providers report providing victim advocacy, definitions of what that means vary widely. The programs provided legal assistance for victims dealing with law enforcement and prosecutors (91 percent), information on the legal process (82 percent), escorts to court to obtain protective orders (73 percent), and assistance to victims for obtaining victim compensation from a state fund (55 percent). The survey did not include any information on systembased advocacy by the domestic violence programs. Victims receiving intensive, comprehensive advocacy services during and after shelter residence are more likely to achieve the goals they develop for safety, wellbeing and legal process than those not. Advocacy for victims in criminal and civil legal systems provides victims with the information, supportive relationships, safety planning, intervention with legal system professionals, evidence gathering, accompaniment to court, etc. Another study of legal advocacy for battered women revealed that those receiving advocacy were more likely to call the police, and their assailants were more likely to be arrested, prosecuted and convicted. Torrington, against a police department and City for failure to enforce a court protective order and safeguard an individual victim, might constitute both individual and systembased advocacy. In this example, as a result of the lawsuit, the state of Connecticut enacted mandatory domestic violence arrest legislation and training of law enforcement. Implications: Victim Advocates and Service Providers should map the individual and system advocacy undertaken by their respective organizations in the last decade and examine the outstanding needs of victims for individual and system advocacy. Through collaboration within communities, plans should be developed to fill the gaps for essential advocacy for victims. Nurses and advocates work together as a team to attend to survivors emotional needs, link them to advocacy and counseling, and provide information about criminal justice system process. In other words, the focus on patient care and service, rather than a specific criminal justice focus, actually increased positive criminal justice outcomes. When victim trauma is addressed and victims are wellinformed, they are in a better position to participate in the criminal justice system. The combination of stronger forensic cases, coupled with increased victim participation, appears to result in increased case progression through the criminal justice system. A Detroit study that compared outcomes from police precincts with institutional advocates and those without found no differences in police performance in regard to arrests or issuance of warrants against alleged abusers. The role of institutional advocates was to provide information about the legal system, make referrals and conduct safety 171 this document is a research report submitted to the U. While 20 percent had only cursory communication, 15 minutes or less, the rest spent from 15 to 45 minutes or more with advocates. Satisfaction with the victim advocates was high at 81 percent reporting being very or somewhat satisfied. Victims generally find institutionallyembedded advocates to be helpful, and such advocacy should be encouraged as it can facilitate legal and social service outcomes preferred by victims. The administration of criminal justice is not uniform across states, much less the entire country. What Performance Measures Should Advocates Require of Law Enforcement in Terms of Arresting Suspect Abusersfi A better measure of police arrest performance is to look at arrests per capita in any jurisdiction. Researchers examined 577, 862 incidents of aggravated assault, simple assault, and intimidation, with 235, 690 arrests resulting. They found that 49 percent of the offenses involving intimate partners (spouses, exspouses and boy or girlfriends but not exboy/girlfriends) resulted in an arrest. This compared to 44 percent for nonintimates including family members, 28 percent for acquaintances and 31 percent for strangers. In addition to an intimate partner arrest rate of 49 percent, in an additional 15. In other words, based on this 19 state study, on average, 172 this document is a research report submitted to the U. However, the same research finds that police are much more likely to arrest both parties when the incident involves same sex couples. The 19 state study also found mutual arrests rates of a little more than a quarter for same sex couples, male or female compared to less than one percent for cases with male offenders and female victims or three for cases of female offenders and male victims. What Percent of Arrests Should be for Female Perpetrators of Intimate Partner Violencefi While second guessing each arrest may be problematic, aggregate arrest statistics that reveal less than 80% of the arrests involve female victims indicate a need for further police training. As a result, the rate of felony compared to misdemeanor arrests vary based on state statute. In California, approximately 41 percent of intimate partner arrests are for felonies. In two stalking studies where researchers specifically analyzed police arresting and charging behavior and the specific conduct for which the abusers were arrested and charged, they found great variance. If the state has a felony enhancement law for repeat offenses, advocates should determine if police and/or prosecutors are checking prior records in order to charge abusers appropriately. Further, the research finds that these laws do not result in more female victims being arrested. States without mandatory or preferred arrest laws or policies had more than four times higher dual arrest rates than those with mandatory or preferred arrest laws or law enforcement policies. The arrest rate in the 19 state police study, for example, found for those abusers gone when police arrive, the arrest rate was eventually 42. If not, advocates should review state laws and/or individual law enforcement policies to promote mandatory or preferred arrest policies, as well 174 this document is a research report submitted to the U.
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