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Moving beyond the gender binary in order to medications to treat bipolar purchase diltiazem with paypal "leave no one behind": Gender identities do not start or stop with "women" and "men medicine 0027 v buy generic diltiazem. Understanding environmental impacts and agency medicine administration buy diltiazem 60 mg amex, and the relationships of cultures to the environment, will be incomplete if only gender binaries are recognized. Moving beyond the gender binary is not only or primarily manifested at the level of the individual. Gender equality, similarly, exists on multiple planes simultaneously and progress across those planes is uneven. The highest ranked countries (Iceland, Norway, Finland, Sweden and Ireland) have closed over 80% of their gender gaps; the lowest ranked country (Yemen) has closed a little less than half of its gender gaps. Gender inequalities are intersectional and magnified by other social positions (Symington 2004; Crenshaw 1989). Multiple and multiplying layers of inequality are experienced by women who are indigenous; or members of sexual, racial or other minorities; or the elderly and the poor. Sometimes, as in the case of outbreaks of large-scale gender-based violence, individuals and institutions acting in what they see to be their vested interests, often in collusion with powerful institutional actors such as governments, actively hide the scale, scope and nature of the problem. Such denials are typically nested within and supported by the political and economic contexts that are the overarching contexts of everyday life. Large-scale structural forces, many of which have existed for decades (and some for centuries), hinder transformative change. They include: Conventional framing of "the environment": Most environmental assessments conceptualize "the environment" within a physical, biosystem framework. Political ecology frameworks that treat it as socially constructed and perceived are still marginalized in much mainstream environmental work (Beuchler and Hanson 2015; Forsyth 2004; Rocheleau 1996). The physical-sciences-first approach sidelines social and gender analysis (Castree et al. Pervasive gender inequality: One of the most powerful contexts of the current state of social and environmental relations is gender inequality. It is pervasive and universal, and is sustained by visible and invisible practices in public and private domains. As of 1 May 2016, women held 50% or more of elected legislative seats in only two countries in the world, Bolivia and Rwanda, while the world average was around 23% (Inter-Parliamentary Union 2016) (Table 3. Public corruption is one of the forces that works against opening up political systems to diverse and new participants (Freedom House 2012; Johnston 2005). Complex and often conflicting relationships between the state and the individual are at the heart of the gender-and-environment nexus in regard to development. Perverse economic systems: Scholarship by feminist ecologists and economists reveals the extent to which ecological and social systems are trapped in a vicious spiral of unsustainable economic priorities, enabled by unrealistic economic assumptions, and supported by inadequate analytical tools that are bringing about environmental devastation while simultaneously undermining gender equality (Klein 2014; Sassen 2014; Barry 2012; Gibson-Graham 2006; Elson 1998). A core insight of scholarship in this field is that classic economic models are framed by priorities that are stereotyped as male and reflect masculinist assumptions about how to measure economic activity (Box 3. Moreover, ecological economics, like orthodox economic approaches, ignores the gender bias in such approaches (Nelson 2009; Ferber and Nelson 2003). Many feminist ecological economists suggest that more holistic, humanistic and care-based approaches to human relationships to the environment need to replace econometrics in order to bring both gender and environmental equity to the foreground in thinking about how to define a healthy economy (Nelson 2009). Time poverty and unpaid labour, care and domestic work: In the past two decades feminist theorists and ecological economists have engaged with the conundrum of how to make a democratic and equityenhancing transition to an economy based on less material throughput (Perkins 2007; Eichler 1999; Elson 1998). A great deal of unpaid labour and "caring" work is at the heart of both productive and reproductive systems (Ghosh 2015; Boris and Parrenas 2010; Folbre 2006; Folbre 2003). Community activism, caring work that is not goodsbased, and ecological restoration activities are the real forces that sustain economic and environmental well-being, yet none of these has a secure place in mainstream economic processes and measurements. Without the unpaid (and currently uncounted) time that women and men put into sustaining themselves, their communities and local ecosystems, there would be even greater unsustainability. The care economy goes beyond "unpaid work" to encompass social reproduction work, looking after children, the elderly, and the disabled, and the home-based services that keep families and individuals alive and in good shape (Ghosh 2015; Boris and Parrenas 2010; Folbre, 2006).

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Neutrophils and lymphocytes generally accompany small histiocytes in early lesions treatment vs cure cheap diltiazem 180 mg on line. The histiocytes may include a variety of forms medications before surgery order diltiazem 60mg visa, often with a component of xanthomatized (foamy) and Touton multinucleate cells 9 medications that can cause heartburn diltiazem 180 mg generic. Langerhans cell histiocytosis (Incorrect) Tumor cells in Langerhans cell histiocytosis are smaller than those present in this case and have reniform (coffee bean) vesicular nucleus with inconspicuous nucleolus and moderately abundant, light eosinophilic cytoplasm. There is a variable admixture of inflammatory cells, often with numerous eosinophils. Rosai-Dorfman disease (Correct) Characteristic histologic features include sheets of very large histiocytes with abundant feathery cytoplasm, few multinucleate cells, numerous plasma cells, and nodular aggregates of lymphocytes. Birbeck granules (Incorrect) these granules are cytoplasmic organelles that characterize Langerhans cells. Epidermotropism (Incorrect) Spread of cells into the epidermis from a dermal or subcutaneous pathology. Extracellular lipid (Incorrect) Extracellular lipid is a finding in some types of xanthoma, including eruptive xanthoma. Small numbers of xanthomatous histiocytes may be present in Rosai-Dorfman disease but there is no extracellular lipid deposition. Monoclonal population of plasma cells (Incorrect) the majority of cutaneous plasmacytomas are monoclonal. Although there is a prominent plasma cell component in Rosai-Dorfman disease, the plasma cells are polyclonal. Also referred to as sinus histiocytosis with massive lymphadenopathy, it commonly involves the lymph nodes with secondary skin involvement. These cases present with prominent bilateral cervical lymphadenopathy accompanied by fever, malaise, night sweats, and weight loss. Skin lesions may be solitary or multiple and may present as papules or nodules that are dermal or subcutaneous. Purely cutaneous disease is not associated with systemic symptoms and does not evolve to systemic disease even with longterm follow-up. The clinical course is variable, with most lesions resolving spontaneously over weeks to months. Cutaneous Rosai-Dorfman disease: a clinical and histopathological study of 25 cases in China. Histologic features of cutaneous sinus histiocytosis (Rosai-Dorfman disease): study of cases both with and without systemic involvement. Effect of host, tumor, diagnostic, and treatment variables on outcomes in a large cohort with Merkel cell carcinoma. Tumor infiltrating immune cells and outcome of Merkel cell carcinoma: a population-based study. Antibodies to Merkel cell polyomavirus T antigen oncoproteins reflect tumor burden in merkel cell carcinoma patients. T antigen mutations are a human tumor-specific signature for Merkel cell polyomavirus. Lymphoblastic B-cell lymphoma (Incorrect) Characterized by a monotonous, diffuse or nodular dermal infiltrate separated from the epidermis by a grenz zone. The cells have little cytoplasm and round to oval nuclei with finely disperse chromatin and inconspicuous nucleoli. Tumor cells dissect collagen bundles, as in this case, but perineural invasion is not a usual feature. Malignant melanoma, small cell variant (Correct) the neoplasm is composed of relatively monotonous small cells with scant cytoplasm and hyperchromatic nuclei. There is a vague nested pattern superficially with a subtle intraepidermal component. Merkel cell carcinoma (Incorrect) Merkel cell carcinoma can have a variety of histologic patterns. It most commonly presents as nodules or diffuse sheets of basophilic cells with granular ("salt and pepper") chromatin pattern. The tumor cells dissect the collagen bundles, as in this case, and lymphovascular invasion is often present. Metastatic small cell carcinoma (Incorrect) Characterized by sheets, ribbons, or rosettes of small to medium-sized round-oval cells with minimal cytoplasm, salt and pepper chromatin, indistinct nucleoli, nuclear molding, smudging, and frequent mitotic figures. Peripheral primitive neuroectodermal tumor (Incorrect) Like this case, peripheral primitive neuroectodermal tumor is composed of relatively uniform small cells with round nuclei, finely distributed chromatin, and minimal cytoplasm.

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It occurs in 25% to medications to treat bipolar disorder cheap diltiazem 180mg otc 70% of lepromatous leprosy cases and occasionally in borderline-lepromatous cases during therapy symptoms ketoacidosis purchase 60 mg diltiazem visa. The clinical features include widespread eruptions of painful medications similar to cymbalta purchase 180mg diltiazem visa, erythematous, and violaceous nodules, often involving the extremities, and associated with systemic symptoms. Indeterminate leprosy is characterized by a superficial and deep perivascular and periadnexal lymphohistiocytic infiltrate, which involves less than 5% of the dermis. A mild proliferation of Schwann cells may be observed, but marked neural thickening is usually absent. Skin biopsies of tuberculoid leprosy resemble those of cutaneous tuberculosis, especially lupus vulgaris. Well-formed granulomas without caseation can be seen throughout the dermis without a Grenz zone; they are composed of epithelioid cells, giant cells, and lymphocytes and they frequently surround neurovascular bundles and erector pili muscle and may destroy the eccrine glands. They can erode the overlying epidermis or extend into peripheral nerves or pilar muscles. In borderline-tuberculoid leprosy, the noncaseating granulomas are less evident, and nerve destruction is less prominent. Borderline leprosy shows collections of epithelioid histiocytes with no giant cells and very few lymphocytes. Borderline-lepromatous granulomas consist of aggregates of lymphocytes and macrophages containing abundant granular to foamy cytoplasm. Lymphocytes and histiocytes infiltrate the nerve, producing laminated perineurium. Sheets of macrophages with a granular to foamy cytoplasm arranged in a perineural, perivascular, and periappendiceal fashion characterize lepromatous leprosy. The foamy histiocytes of leprosy resemble those seen in xanthoma; they are called lepra or Virchow cells. Effacement of the epidermal rete ridges with a distinct Grenz zone is often present along with scattered lymphocytes and plasma cells. The histology of histoid leprosy is characterized by relatively circumscribed nodules that are composed of predominantly spindle cells intermixed with small collections of foamy macrophages and arranged in a storiform pattern. At the sites of preexisting lepromatous leprosy, erythema nodosum leprosum shows a mixed dermal infiltrate of lymphocytes and a variable number of neutrophils. Less commonly, vascular occlusion occurs when the superficial vessels thrombose or endothelial cells swell. Solar lentigo Acral lentiginous melanoma Tinea nigra Acral nevus Ochronosis Tinea nigra is caused by Phaeoannellomyces werneckii, and the lesions consist of brown-black macules, usually located on the palms, that enlarge slowly and can be confused clinically with a melanocytic proliferation. Leishmaniasis Chromomycosis Foreign body reaction Ruptured cyst Mycobacterium marinum infection Important questions to ask include: A. How many miles does he jog each day Does he have a fish tank Does he eat raw oysters Is he in the military Has he lost weight Nontuberculous ("atypical") mycobacterial infections are caused by a heterogeneous group that excludes M. There has been an increase in the incidence of infections caused by these organisms over the past decades. Although they often lead to systemic disease in immunocompromised patients, they may affect the skin in many ways. Cutaneous infections are often referred to as swimming pool granuloma or fish tank granuloma the histologic findings in M. They range from suppurative dermatitis with ulceration and necrosis in early lesions to tuberculoid granulomas at the late stage. The epidermis often shows hyperkeratosis and papillomatosis and is occasionally ulcerated. Most often skin lesions develop in the midst of other systemic symptoms and signs of active disease although rarely the skin may be the first sign of disease. The pathologic correlate to these ulcerations can include granulomatous vasculitis but more often the changes are inflammatory, with a mixture of acute and granulomatous inflammation without obvious vasculitis. In this situation, clinical input is essential as this microscopic pattern is not diagnostic in a specific way but requires correlation with the clinical findings as well as serologic testing. Stains for micro-organisms should be done as there is the possibility of secondary infection.