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Epidemiologists can gain valuable information from looking at carefully planned descriptions of the patterns of cancer within populations, usually national or regional populations. Because cancers do not occur uniformly in all populations, such studies have provided many important clues about the causes of cancer. Later, we will describe the distributions of different cancers in the European Community to illustrate how much variation can exist even between rather similar countries. Much greater variations exist between countries in different continents and between groups with very different social and economic standing. Some cancers, notably breast cancer, are strongly associated with the pattern of fife found in developed societies in Europe and North America. Others, notably cancer of the liver, are found much more frequently in the developing world. Clues can therefore be sought by seeing what factors might be most closely linked to the individual cancers under study. Not only can national, social and economic differences yield information. The incidence of cancer at different ages and in different sexes and different races and at different times in history can yield valuable facts and dues. By studying the pattern of cancers in these groups the epidemiologists will seek to identify factors in the environment or factors in the host (the person with cancer) which put that person at a greater risk of cancer and, when possible, to provide an accurate measurement of the size of that risk.
In any population the pattern of cancer can be described in a number of ways:
• Incidence – the number of new cases in each year per head of the population or usually, to make comparisons easier, per 100,000 or per million heads.
• Mortality – the number of people who die of that cancer in each year per head of the population or per 100,000 people.
• Prevalence – the number of cancers that exist at any one time in a particular population, which will depend both on the incidence (new cases developing) and the mortality.
At first glance it might seem easy to produce this information. In fact it can be surprisingly difficult. Death certificates ought to provide accurate information about the mortality from cancer in a whole population when records are kept. In fact death-certificate information can be quite inaccurate and is not always collected well.
Many countries have developed a system of cancer registration in order to collect information about cancer incidence. The information is collected from hospital records, death certificates and hospital laboratories, and great attention is now given to cross-checking and comparing information to ensure its reliability. Most European countries collect information on mortality. However, even within Europe, we find differences in national commitment to collecting such data (Luxembourg, for example, does not have cancer registration). Perhaps the countries with the most outstanding record of accurate collection of valuable information are Denmark and Scotland. In England and Wales the regional cancer registries are broadly accurate, but some registries arc better than others. Cancer registration is improving rapidly in the new southern European members of the European Community, such as Portugal and Greece.
IB the United States national cancer registration began towards the end of the nineteenth century, but it was not until 1933 that information was collected in all states and only as late as 1979 was a national registry of all cancer deaths established.
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WHY FEMALES DON’T PROMOTE ORAL-GENITAL STIMULATION?
A few females reciprocate genital stimulation but if they reciprocate it is a good gesture and gives an intense feeling of self satisfaction and recognition to the male partner. He expects it. But most of the females prefer being oro-genitally stimulated because it leads to orgasm very easily. Even then they very rarely oblige the male in return.
Female’s reluctance may have resulted from shyness, igonarance of what to do or fear of indecency or perversion. The possibility and fear that man might ejaculate in the process is further deterrent. But certain women in Paris, and Denmark etc. each are noted to have no hesitation in deliberately bringing a man to orgasm in this fashion.
What are the standard procedures of oral genital contacts?
Usually a man initiates and gently caresses the clitoris, the minor lips and the area of introit us with his tongue, occasionally sucking and nibbling them. Saliva produced acts as an extra lubricant and females enjoy it till orgasm. Women who are lucky to be excited this way get satisfaction of their lives reaching orgasm on more than 60 percent occasions.
In the male the glans is the primary focus of excitement. Gentle stroking of the frenulum with the tongue and lips and sucking the glans while firmly holding the penis and grasping and pulling gently at the scrotal sac with the other hand, gives the pleasure.
If the genitals are clean and body is perfumed then objections are difficult to support on hygienic grounds.*107\301\2*

HIV: OPTIONS FOR MEDICAL CARE-PHYSICIANS: PRIMARY CARE PHYSICIANSMost people receive medical care for HIV infection from one or more kinds of physicians: primary care physicians, AIDS physicians, and specialists.     Primary Care Physicians-Primary care physicians are usually family practice physicians or internists who have broad medical knowledge, and who may or may not have a special interest in HIV infection. Many people have gone to their primary care physicians for medical care for years and have developed close relationships with them. For a person with HIV infection, however, whether this relationship continues depends on whether the primary care physician feels able or willing to care for HIV infection and how much confidence the person with HIV infection has in the adequacy of that care.     Some primary care physicians practice in groups of between three and ten. Physicians in such groups usually have different areas of expertise: some treat stomach problems, for example, and some treat lung problems. The person with HIV infection will usually see the same physician for general health care, but will see other physicians for specific problems. The advantage of group practice is that these physicians are all under the same roof, and communication between physicians with specializations is good. Group practice is especially useful when one member of the group becomes skilled in AIDS care and becomes the primary physician or a consultant for people with HIV infection.     Most primary care physicians, whether they practice alone or in groups, received their training before HIV infection was known. Furthermore, new diagnostic tests and drugs and other therapies emerge constantly, so that many physicians have found it difficult to maintain their knowledge of both this field and the rest of medicine as well. As a result, some primary care physicians simply do not accept patients with HIV infection and will refer their previous patients who have become infected with HIV to another physician. Other primary care physicians provide medical care during early stages of the infection when medical complications are few and the guidelines for treatment are relatively simple.     During later stages of infection, the primary care physician will often either refer the person with HIV infection to a specialist or consult with a physician more experienced in HIV infection. If the primary care physician is in group practice, the referral may be to another physician in the group; if the physician practices alone, the referral may be to a completely different physician, to a clinic specializing in the care of HIV infection, or to a teaching hospital. In any case, the person with HIV infection will often see physicians informally called AIDS physicians.*153\191\2*

NONCONCLUSIVE STATUS EPILEPTICUS AND ITS TREATMENT: JOANE’S CASE HISTORYJoanne was a bright, sparkly second grader when we first met her. She was referred because of a “weird” episode the previous week. One day in school, she quite suddenly did not seem herself. She was quiet, wandered about the class, and responded inappropriately to the teacher. Her mother took her home, and after another hour or two, when she still wasn’t herself, she had been taken to another hospital. No cause for the sudden change was found, but the next morning an EEG showed slowing, as if she might have previously had a seizure.When we saw her the following week, she was fine and back to her usual self. Since she had never had seizures, and was otherwise normal, we asked her mother to bring her back during another episode, should one occur.It was almost a year later when we received a call from Joanne’s mother in the middle of the day. “She is doing it again.” We didn’t remember Joanne, but told her mother to bring her in immediately. A very attractive, dull ten-year-old came into the office. She could answer questions and count, but seemed to be mildly retarded. If her mother had not insisted that this was not Joanne’s usual state, and if our records had not confirmed a previously sparkling young lady, we might have been fooled.An immediate EEG confirmed “spike-wave stupor,” a continuous electrical status on the EEG, and after a small dose of diazepam (Valium), she immediately returned to her usual state. When she was admitted from the EEG lab to the ward, the resident wanted to know why we were admitting this perfectly normal, charming young lady. With anticonvulsant medication, she has never had another episode.There is no evidence that spike-wave stupor causes permanent damage to the brain, even when it goes on for hours or days. However, it clearly disrupts the child’s level of function. Spike-wave stupor can easily be treated, but it is far better to prevent these seizures with continued use of an appropriate anticonvulsant medication.Although many myths and fears still persist about status epilepticus, with early recognition and appropriate treatment, children who have an episode of status should return to their previous function and have no residual effects.*134\208\8*

TYPE I DIABETES: COMPLICATIONS OF DIABETESBaseball fans all around the world know that Jackie Robinson, the first African-American player to break into the Major Leagues, was one of baseball’s greatest superstars. But few realize he had diabetes.At first Jackie and his doctors were able to keep his disease under good control, and it hardly bothered him at all. But problems developed. First he developed an infection in a knee that he had once injured sliding into second base. The infection spread through his body, and Jackie almost died before antibiotics finally brought it under control.In later years diabetes affected Jackie’s nerves and blood pressure, causing burning pains in his legs that eventually made him give up playing golf. Tiny blood vessels in his eyes began to bleed. Though doctors fought the damage with the newest techniques of laser surgery, Jackie lost the sight of one eye, then of the other. Then three heart attacks struck within four years; the last one killed him at the age of fifty-three.Today very few people die of diabetic coma, but the disease can cause a number of serious complications that can limit and shorten life. People with diabetes are more likely than the average person to develop ailments of the heart and blood vessels, kidney problems, nerve damage, and eye problems, for example. (Diabetes is currently the leading cause of blindness in the United States.)Fortunately, there are a number of ways of diagnosing diabetes early, as well as treatments that can help to prevent its disabling and life-threatening effects in many patients. In 1993 diabetes specialists and their patients were excited by the report on a large-scale, federally sponsored study. The results of this ten-year study showed that keeping the blood sugar level under careful, tight control could prevent most of the damaging complications of the disease.*16\268\2*

CORONARY BLOCKAGES AND  HEART ATTACK : CORONARY ARTERY DISEASESYMPTOMS CAUSED BY CORONARY ARTERY  DISEASE – CAUSES OF ANGINA PECTORIS & HOW SERIOUS IS ANGINA PECTORIS?Causes of Angina Pectoris. Angina is the symptom that results from myocardial ischemia—insufficient blood and oxygen reaching the heart muscle because of blockage in the coronary arteries. The degree of coronary narrowing can vary, ranging from partial blockage in one vessel to extensive clogging of many vessels.How Serious Is Angina Pectoris? If angina occurs only after unusual physical exertion, no dramatic change in life-style is required to prevent the pain. However, some people experience frequent bouts of angina during routine daily activities. They may change their daily routine so they do not have to do any strenuous exercise. Interestingly, the severity of symptoms does not relate directly to how many coronary arteries have blockages. A tight blockage in a small branch of a coronary artery can cause more discomfort in one person than severe narrowing of all three major coronary artery trunks in another-person.Some people with ischemia do not have typical anginal chest pain. Instead, they experience shortness of breath or, less commonly, fatigue or weakness as the only or main symptom of cardiac ischemia.  Nevertheless, whatever the resulting symptoms, coronary artery disease represents ischemia in the heart muscle and should be monitored by your doctor.*149\252\8*

PEDIATRIC ONCOLOGY: ASSESSMENT OF BIOCHEMICAL DATAA. laboratory tests that can be monitored before and duringrepletion include the followingObtain laboratory panel to screen for organ function to include: sodium, potassium, chloride, bicarbonate, glucose, creatinine, blood urea nitrogen (BUN), calcium, phosphorus, magnesium, total protein, albumin, triglycerides, cholesterol, alkaline phosphatase, alaline aminotransferase, y-glutamyltransferase, and total bilirubin.Serum albumin <3.2 mg/dL may indicate decreased protein stores.Serum prealbumin level can be increased with impaired renal function (normal value varies with age), and decreased with altered hepatic function.B. Providing nutrition to patients who are depleted can result inabnormalities such as:1. The refeeding syndromeThis is seen in patients chronically deprived of adequate nutrition and is characterized by metabolic complications, severe fluid shifts, hypokalemia, and hypophosphatemia that occur in patients who are repleted enterally and par-enterally. Monitor sodium, potassium, chloride, bicarbonate, BUN, creatinine, calcium, magnesium, and phosphorus.2. Tube feeding syndromeThis is characterized by hypertonic dehydration, hyper-natremia, and prerenal azotemia in patients receiving highly osmotic enteral feeds.*65\168\2*

THE LIST OF FALSE REMEDIES FOR ARTHRITISAcupunctureThe ancient Chinese—to fight arthritis—pricked the skin with needles made from different kinds of metals. When the surface puncture did not bring relief, they turned to acupuncture—piercing the deeper-lying organic structures.The purpose of this “medical stunt” is still debatable, although it was believed that piercing altered nerve currents and blood-vessel reflexes. Another drastic form of “cure” was burning with fire-soaked fibres. Small cones of fibres—taken from a flax-like plant called artemisia—were drenched with saltpetre, placed in the inflamed region of the body, and lighted! Think of the excruciating pain . . . and be glad you live in modern times.These terrible customs were not limited to the Chinese. The Japanese, Tibetans, and Malayans also employed the same tactics.TattooingThe highly decorated bodies of the African Negros are considered beautiful among their fellows. But did you know that a tattoo was also supposed to ease their arthritic pains? Certain types of tattooing have long been used to chase evil spirits. It hasn’t worked yet. In fact, I have actually met a tattooed man in a circus side-show who has arthritis!Hindu Habits HurtAbout 1ooo B.C. the Hindus of India became convinced that superficial arthritis was a skin and muscle disturbance, and they thought that nerve and joint conditions were deeper organic malfunctions. To cure it was a question of alteration or elimination.So, the Hindus turned to vegetable drugs to cleanse their bodies. Their methods of counter-irritation included liniments, applying bloodsucking leeches to the body, bleeding of veins and cauterisation by burning. They even tried cutting . . . making small superficial incisions which they termed scarification. The result: soon they had scars and arthritis!HippocratesHippocrates, the immortal Greek, contributed a great deal to medicine. But he was just as wrong as everyone else about arthritis. He believed, way back there around the year 450 B.C., that arthritics should be “drained.” He insisted that inflammatory fluids should be drained through the skin. Today, it is known that all too many cases of this illness do not show any sign of fluid.Hippocrates also thought of arthritis in terms of retained body poisons—especially in the female sex, when scanty menstruation or menopause was present. The Greek scholar criticised the men, and blamed their arthritis on excessive wine and sexual relations. (Hippocrates was wrong! Sex habits are not related in any way with arthritis.)WineOn the matter of excessive wine drinking, however, he was on the right track. The fact that the value of oils can be largely destroyed by wines is a correct observation. Consuming wine—in great quantity, like the Greeks of old—would take a drastic toll of ingested fats.The heavy wine-drinking in those days had an injurious effect on metabolism. Kept the liver in a constant state of repairing itself. No wonder thousands of people in those days became victims of gouty arthritis.Purging the BodyAccording to Hippocrates, pain above the diaphragm could be eliminated by forced vomiting. And, he said, all other pain below the waist could be removed by downward purging—by the use of strong laxatives or enemas.Can you possibly imagine an enema relieving the pain in a finger of the left hand? According to physicians of old, why not? The finger is below the diaphragm—and a warm saline solution can cleanse the blood. From the standpoint of logic, Hippocrates went too far with his ideas about purging. In all probability he urged sweating and bleeding, too.The Greeks blamed Uric Acid and Horseback RidingIn early Greece, too much Spartan horseback riding was considered a cause of arthritis. If they had painful hips, it was supposedly due to riding —or deposits of uric acid in the hip joints.The Greeks thought that the sciatic nerve was accumulating sticky deposits of black bile. Horseback riding might—through constant friction— injure a susceptible joint inclined to accumulate uric acid.Now, more than 2000 years later, the term uric acid has replaced the title of black bile. Acids and friction do complicate arthritis, so there was a germ of truth in those early Greek ideas.Turning the Heat on ArthritisThere must be millions of arthritics today who have arthritis of the spine. Fortunately for them, the practices of Hippocrates are outmoded. His theory of cure for this malady consisted of cauterisation … by burning!The back, on both sides of the spinal column, were given four burns. Then fifteen more burns were inflicted on each side of the spine. And, to top it off, two burns were added to each side of the neck. There are not many persons, arthritic or otherwise, who could endure this form of torture. (Personally, we would probably rather have arthritis!)*55\146\2*

SUICIDAL THINKING: COMMUNICATION OF SUICIDAL INTENTIf physicians find it awkward to ask about suicide, it is because they rarely do so. Patients are unlikely to be embarrassed or offended when questions are raised at an appropriate time and when the physician’s manner is both straightforward and sensitive. Discussing the topic will not increase the risk of suicide but reduce it. Most suicidal patients readily acknowledge their thoughts and many speak openly about them.     Psychological autopsy studies demonstrate that 55-83% of individuals who commit suicide have made their intentions known — usually to more than one person and on more than one occasion. These communications are often unambiguous (e.g., “I’m going to kill myself”), though sometimes they are less direct (e.g., “You’ll be better off when I’m gone”) or take the form of actions rather than words (e.g., putting one’s financial affairs in order). Given that the great majority of people who kill themselves have a psychiatric illness, remarks about suicide made by patients with depressive disorders, substance abuse, or schizophrenia should be a special cause for concern.     Although many suicidal patients spontaneously reveal their plans, it is more often to family members than to physicians. Even when a suicidal patient sees a physician in the days before his death, discussions of suicide are uncommon. Because spontaneous disclosure of suicidal thoughts cannot be expected, physicians must ask patients about them.*54\172\2*

HOW TO DIFFERENTIATE BDD FROM NORMAL APPEARANCE CONCERNS: QUALITATIVE DIFFERENCE BETWEEN BDD AND NORMAL CONCERNSAnother qualitative difference between BDD and normal concerns is that BDD symptoms often diminish with medication. We wouldn’t expect normal appearance concerns to improve with medication, because the medication normalizes a “chemical imbalance”; if a chemical imbalance doesn’t exist in the first place, medications wouldn’t be expected to have this effect.Perhaps the best evidence for qualitative differences between BDD and normal appearance concerns are the MRI study and the two neuropsychological studies that I discussed in chapter 10. Although the results need to be replicated by other researchers, as a group people with BDD differed from healthy control subjects. In addition, a study I’ll discuss below found that people with BDD differed from healthy control subjects in their ability to visually discriminate between similar-appearing objects.These differences between BDD and normal concern (or between people with BDD and healthy control subjects) suggest that BDD may be qualitatively different from normal concern, with different psychological and biological processes coming into play. This seems especially likely in those with delusional BDD or delusional referential thinking. Additional biological studies (e.g., brain imaging) and other studies are likely to help us solve this puzzle.The qualitative and quantitative hypotheses are not incompatible. It’s possible—even likely—that BDD is both qualitatively and quantitatively different from normal appearance concerns. BDD may be on a continuum with normal appearance concerns—differing quantitatively, as a more severe version of normal concern. But it’s likely that at some point on this continuum, qualitatively different psychological and/or biological mechanisms (e.g., involving the brain chemicals serotonin and/or dopamine) begin to come into play. This model is similar to that for high blood pressure: higher blood pressure is on a continuum with lower blood pressure, differing quantitatively, or by degree. But at the higher end of this continuum, qualitatively different physiologic mechanisms may come into play that pose dangers to one’s health.*208\204\8*