In addition to the above is the spectre of bioterrorism in relation to the intentional global spread of infectious disease women's health clinic rochester ny female viagra 50mg with visa. The global spread of infectious disease if not controlled would result in pandemics menstrual cramps 6 weeks pregnant buy 100 mg female viagra visa. The impacts of historic pandemics were devastating to human suffering and death women's health clinic fayetteville ar cheap 100mg female viagra overnight delivery, and the destruction of national economies especially on developing countries pregnancy in fallopian tubes order female viagra 100mg without a prescription. The effort of reducing and combating the rapid global spread of infectious diseases is no simple task menstrual bleeding order 50mg female viagra free shipping. The causes are multifaceted and ought to be identified before seeking their control womens health for life lima ohio purchase female viagra 50 mg with amex. Most infectious diseases are preventable but their aetiology oftentimes lies outside the control of the health sector menopause length of time generic 50 mg female viagra overnight delivery. The main key factors that contribute to amplify the global spread of infectious diseases involve globalization in particular international trade and travel women's health clinic uihc discount female viagra 100 mg with mastercard. As a result of this phenomenon, infections which were once limited to specific parts of the globe are now able to spread more easily and rapidly to the human population. Three maritime issues have been identified as significant contributing factors or causes to accelerate the international transmission of infectious diseases. Because of this it is important to examine the relevance of maritime law in attempting to reduce and combat the global spread of infectious disease. This paper will analyse the significance of infectious disease as an international issue and the legal responses to the issue in a maritime context. It will focus particularly on how the issue might impact on Kiribati and will suggest a way forward for Kiribati and other maritime nations in the South Pacific. In Chapter 2, as a novice to the area of the public health, it is necessary to insert a general overview on infectious disease. Chapter 3 describes the nexus between infectious disease and the maritime sector and the relevance of maritime law to respond to the issue. The International Public Health and Maritime Responses are covered under Chapter 5. The Kiribati Public Health and Maritime Laws and Institutions are detailed in Chapter 6. The conclusion posits proposals and recommendations as a way forward to reduce and contain the rapid global spread of infectious diseases from a maritime perspective particularly for Kiribati. Respiratory diseases are commonly acquired by contact with aerosolized droplets, spread by sneezing, coughing, talking, kissing or even singing9. Gastrointestinal diseases are often acquired by ingesting contaminated food and water10. They are mostly feared in their nature to emerge, spread and re-emerge to the human population. M, Risky Trade Infectious Disease in the Era of Global Trade, (Ashgate Publishing Ltd) (2006), at xiii 9 Kenneth J. The main determinants that contribute to the local spread or epidemic incorporate, again the absence of clean basic sanitation facilities, insufficient health and regulatory resources, and the unavailability of good diagnostic surveillance and epidemiological capabilities. The two most significant factors that contribute to accelerate the global transmission are international trade and travel. Re-emergence the second half of the twentieth century witnessed certain diseases which have been put under control to emerge again. Historic Pandemics and the Impacts the emergence and global spread of infectious disease is not a new phenomenon to the world. The 14th century was the age of the "Black Death" the bubonic plague, which became pandemic in 1348, decimated a substantial number of the population in Europe. The outbreak of bird flu (Avian Flu) in 2007, and the recent pandemic influenza of swine flu at the beginning of 2009. Globalization Globalization is defined as a process of closer interaction of human activity within economic, political, cultural, social, and other spheres and along spatial, temporal, and cognitive dimensions. One of the earliest recorded incidents of the spread of disease by sea transport occurred during the winter of 1346/47 of the fourteenth century when a small band of Genoese traders took shelter at Caffa (now Theodosia) on the Black Sea. In the nineteenth century (1838) the arrival of diseases in the Pacific Islands implicated also on the arrival of vessels. Williams wrote in his book about a visit to Rarotonga; "The natives said that the pestilence was brought to their island by a vessel which visited them just before it commenced its ravages. It is certainly a fact which cannot be controverted, that most of the diseases which have raged in the islands during my residence there have been introduced by ships"28 3. Taking on ballast water and discharging must be carefully controlled to ensure the safety of the vessel and the seafarers on boards. In 1991, cholera pandemic reached Latin America after almost a century without it. Everything from fish products to cotton sundries was embargoed by trading partners under the guise of preventing extension of cholera into their territories. Transmission on board vessels could happen on every vessel irrespective of size, type, and capacity. As far as the evidence goes, cargo ships and passenger ships have been documented as most prevalent and notorious in the transmission of infectious diseases on their board. Passenger Ships the passenger shipping industry (cruise ships and ferries) has expanded considerably in recent years with the substantial increase in size and passenger capacity. In 2007, 12 million passengers worldwide travelled on cruise ships, a 7% increase from the previous year. Typically passenger ships carry a large number of people in close proximity in confined spaces for increasingly long periods of time. It could be considered a gathering place for the global community, where opportunities for interpersonal interactions and sharing common activities, food and beverages are plentiful. Cruise itineraries incorporate all continents and areas which are not easily accessible by other means of travel. The diversity of passengers and crew members coupled with the rapid movement of the cruise ships from one port to another, and the semi closed and crowded environment of such cruise ships may impact in disease spread to other passengers and crew members, as well as dissemination of those diseases to visited ports/countries and the home communities of disembarking passengers and crew members. Outbreaks of measles, rubella, varicella, 34 35 36 International Travel And Health 2009. Such outbreaks are of concern because of their potentially, serious health consequences and high costs to the industry. In recent years, influenza and norovirus outbreaks have been public health challenges for the cruise industry. It is a very infectious disease and in one outbreak on a cruise ship in 1998, over 80% of the 841 passengers were affected. In June, 2006 a reported outbreaks on cruise ships suddenly increased; 43 outbreaks occurred on 13 vessels. To prevent and reduce outbreaks of gastroenteritis caused by norovirus, it is important for ships to enhance food and water sanitation measures and disinfection of surfaces. Legionella species can be found in droplets of water (aerosols) or in droplet nuclei (the particles left after the water has evaporated). International Travel and Health 2009, Mode of Travel: Health Considerations, at 27. Consequently, and in order to prevent the transmission, Australia has prompted authorities to divert the vessel away from the major population centers. The Pacific Dawn in compliance had diverted to anchor off one remote island and remain there while tests are carried out on samples from at least three more crew members who have come down with flu-like symptoms. It is important to note that crew members who serve passengers may become reservoirs for influenza infection and may transmit to passengers on subsequent cruises. Cruise Ships: high-risk passengers and the global spread of new influenza viruses. A large outbreak of influenza A and B on a cruise ship causing widespread morbidity. The Australian passengers were disproportionately represented in an initial attack of acute respiratory illness that subsequently spread through the ship, suggesting that they may have been infected before boarding. Cargo Ships the survey in respect of sea-farers indicates a number of seamen are infected with legionnaire. The Seafarers Seafarers have been implicated as reservoirs for transmissions of sexual transmitted diseases, to their spouses or sexual partners at any visited port or to their home countries. A 2004 survey indicated that Chlamydia was found in 75% of Kiribati experienced seafarers. Apparently the current and prospective vibrant acceleration of the maritime industry, coupled with burgeoning in international trade, and the proliferation as well as the popularity of the cruise industry had amplified and worsen 58 Miller, J. There is a need for constructive, efficient and effective responses to reduce and contain this problem. The definition of maritime law would confirm the important linkage and its relevance to address this instant problem. Maritime Law is defined as "that system of law which particularly relates to commerce and navigation, to business transacted at sea or relating to navigation, to ships and shipping, to seamen, to the transportation of persons and property by sea, and to marine affairs generally. Ibid at 4 - 18 - Other assessments to categorise developing states aside from the above involve distinctions based on geographical factors and size. In 1972 at their third session it was concluded that a panel of experts should denote and study the problems of island developing countries. The most commonly raised problems were issues of smallness and remoteness, constraints in transport and communications, distance from market centers, low resource endowment/narrow resource base, dependence on few commodities as sources of foreign exchange earnings, limited internal markets, and vulnerability to natural and environment disasters. Agenda 21, which was adopted by this conference, contained a special section (chapter 17, section G) devoted to the sustainable development of small island developing 68 69 Ibid at 5. Another resolution on island developing countries was routinely adopted by the General Assembly in the same year. These include International Conference on Financing for Development in 2002; the "Monterrey Consensus", the Johannesburg Plan of Implementation of the same year, and the Mauritius Strategy of Implementation of 2005. Moreover, the classification of developing countries on distinctions based on size reflected on the works of the International Economic Association (Lisbon) in 1957 which marked the first manifestations of global attention on this issue, and the Joint Task Force on small states of the Commonwealth Secretariat and the World Bank to make recommendations on desirable responses to the problems of "small economies" starting from 1982 through 2002. Each Member are categorised to the respective region of their origin or geographical location. The survival of small island developing states is firmly rooted in their human resources. It is imperative on the government to strengthen and maintain the health of the community if it has to achieve sustainable developments. Scientific advances in the development of vaccines and chemotherapeutic agents and at the same time with the improvements in human life standards have brought communicable diseases under control. In all such instances, the maritime 77 78 79 80 Mauritius Strategy of Implementation, 2005, at page 25. The social economic impact of the pandemic is expected to be devastating for all countries, and increasingly for women and children. It has three main island groups, the main group known as the Gilbert Islands which are made up of 16 islands including the capital island of South Tarawa, the Phoenix Islands include 8 atolls, the Line Islands with 8 coral islands, and Banaba Island. Isolation, 82 83 84 Agenda 21, 1992, at page 5 Ibid Ibid - 24 - sparse resources, and a fragile environment constrain economic activity. Kiribati is part of the Micronesia in the Pacific Region (refer to Figure 1 below). The People the people of Kiribati are by nature hardy, egalitarian, and conservative. On the basis of the growth rates derived from the 2005 census, the population is projected to pass 130,000 around 2025. Between 2000 and 2005, the population of South Tarawa increased by 3,594 and that of Kiritimati by 1,684. The average population density in Kiribati was 127 people per square kilometre (km2). Kanton, the only inhabited Phoenix island, was last with 41 persons on its 9km2 of land. Overcrowding in South Tarawa persists, however, putting stress on the environment and infrastructure. In-migration is constant between islands as individuals or as families in search of work, to change residence, or for education and family visits. Discharge of Ballast Water and Sediments Kiribati licensed over 250 vessels inclusive, fishing vessels, tankers and bunkers. Often times these vessels came to port for a few days in the only two ports of South Tarawa and on Kiritimati island. Fishing licences are the major income for Kiribati, 40% - 45% of national monetary income is derived from licensing fees, therefore there is a tendency of expanding this industry to generate more income. The influx of cargo as well as international passengers is experienced in this operation. The Government is seeking ways to increase competition in international shipping to Kiribati, thus it appears that the increase in international shipping services is anticipated in the future. In addition a proposal on the concept of Tarawa operating as a transhipment port for Nauru, Tuvalu, and Wallis and Futuna is being studied. This would increase the risk of global spread of infectious diseases to Kiribati if this project comes through. Transmission aboard and to countries via Cruise lines - 27 - Cruise ship tourism is essential for development. Passenger ships regularly visited one of the Line Islands (Tabuaeran or Fanning Island) once every 2 weeks during the months from September to March to put ashore passengers for a few hours before departing. The development strategy for the island envisages continuation of the present pattern of visits, with progressively more of the goods and services consumed by visitors while ashore provided by island residents. The chances of global transmission on Kiritimati and Tabuaeran is a threat since there is no hospital in Tabuaeran except for a small clinic and is remotely located that urgent medical assistance may take a while to get through. The hospital on Kiritimati is inadequately equipped and if there is a chance of an outbreak on this island, it may be difficult to respond urgently. With regards to maritime quarantine if a case is suspected, no port infrastructure exist on Taebuaran while the port on Kiritimati lacks required facilities at the site for medical procedures except to report and transfer all cases to the hospital. International Seafarers Seafarers and cruise ship employment is and established and essential area of employment for I-Kiribati. More than a thousand I-Kiribati seamen and women are employed on overseas merchant ships, fishing vessels and recently on cruise ships. There are prospects of increasing the number of seafarers over the next few years particularly for their high demand from the South Pacific Maritime Services and agreements by the Government and the Norwegian Cruise Line Ships. Aggravating health risk factors in Kiribati A number of environmental factors are increasing the risk of communicable diseases in Kiribati. High-density housing and overcrowding in urban areas, such as South Tarawa, is facilitating the transmission of infectious disease. For instance, tuberculosis incidence in Kiribati has now surpassed that of other Pacific island countries, and most reported cases (70%) in 2005) are found in the urban settlement of Betio in South Tarawa. The pandemic will inhibit growth of the service and industrial sectors and significantly increase the costs of human capacity-building and retraining. It is small and remote, experience high cost of transport and communication, isolated from market centres, with a low or narrow resource base and depend on few commodities for foreign exchange earnings, limited internal markets, and vulnerable to natural and environmental disasters. In this situation it is difficult to scale up resources, and capacity to respond to any incidence of a pandemic. Vaccines are costly, health capacity, resources and infrastructure at hospitals and port of entry is weak, it is surmountable to respond to pandemics adequately. In an incidence of a pandemic in Kiribati especially on the capital South Tarawa will adversely affect the health of the Kiribati community, the national economy and most importantly sustainable development. There is only one international seaport in Kiribati on South Tarawa, but the population residing on Tarawa is 43. The impacts will be devastating, if not from the embargoes and travel advisories to Kiribati, it will have adverse effects on human death and suffering and on the already weak economy from loss of human resources and the restitution of a skilled community. There is a need to develop, maintain, and strengthen domestic responses against pandemic incidents from all relevant sectors, particularly in this scenario, the public health and maritime sectors. The threat had transformed from being a sovereign issue, and at this time is widely acknowledged at the forefront of the international community. This chapter will examine responses from relevant international bodies or organizations. International, Regional Organizations and Governments are obligated by this universal goal to respond to this concern. It was preceded by certain important health organizations and events which led up to its birth. The origins on the international initiatives to set up an international health body date back to the nineteenth century with a focus on expanding the economic and trade interests for the Great Powers. The idea emanates from the difficult lesson posed by the Influenza Pandemic 105 106 107. The aftermath of the First World War was ruins; lack of housing, poor health care, poor water and sanitation and so forth. This was as generally understood contributed to disease emergence and consequently a pandemic. The cost of war had also weakened the capacity of many governments to respond to health needs. This had urged the move by governments for a need to set up an independent collective international body to enable them to respond to any occurrence of a disease outbreak. This is coincident with the advancements in medical academic which had enabled a better understanding on the nature of infectious diseases and the needs to respond effectively against their global transmission. After constructive preparations from the appointed Technical Preparatory Committee (consists of 16 experts in the field of health) on draft constitution, resolutions and agenda, the International Health Conference opened as the first conference to be held under the auspices of the United Nations in June 1946.
Also recommended for obsessive-compulsive disorder menstruation questions and answers order female viagra 50mg with amex, but higher dosages are needed menstruation quotes 100 mg female viagra, sometimes up to 80 mg daily menstrual gas trusted female viagra 50 mg. Suggested dosage: start at 10 mg once daily and titrate as needed; maximum dosage: 60 mg daily menstrual bleeding for 3 weeks order female viagra 50 mg with mastercard. Note: There is a risk of hypertension at the higher dosages of venlafaxine; monitor blood pressure women's health big book of exercises review trusted female viagra 50mg. It will take several weeks for patients to notice a decrease in anxiety; low-dose benzodiazepines may be used during this interval breast cancer awareness images order female viagra 50mg on line. The major potential adverse effects of buspirone are dizziness and lightheadedness breast cancer treatments cheap female viagra 50mg without prescription. Longer-acting benzodiazepines such as clonazepam (Klonopin) also may be useful at dosages of 0 womens health jackson michigan buy cheap female viagra 50 mg on-line. Section 8: Neuropsychiatric Disorders Panic Disorder 563 Panic Disorder Background Panic disorder is an anxiety disorder whose essential feature is the presence of recurrent, unexpected panic attacks. Panic attacks are discrete, sudden-onset episodes of intense fear or apprehension accompanied by specific somatic or psychiatric symptoms. A patient is diagnosed as having panic disorder when he or she has experienced such attacks, and at least one of the attacks has been followed by 1 month of persistent concern about additional attacks, worry about the implications or consequences of the attack, or a significant change in behavior related to the attack. Agoraphobia refers to anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available in the event of a panic attack or panic-like symptoms. The symptoms of panic disorder usually begin in late adolescence to the mid-30s and may coincide with the presentation of major depressive disorder, social phobia, or generalized anxiety disorder. Panic disorder can interfere with the ability to conduct activities of daily living. Symptoms may mimic those of various physical illnesses or be caused by other medical conditions. Patients with panic symptoms should be evaluated for other causative conditions Major depressive disorder occurs in 50% to 65% of people with panic disorder. Patients with panic disorder therefore should be screened for depression initially and periodically thereafter (see chapter Depression). Anxiety also commonly is experienced by persons with panic disorder; see chapter Anxiety for further information about this condition. Perform a complete physical examination, including thyroid, cardiac, pulmonary, and neurologic evaluation. During actual panic attacks, patients may have increases in heart rate, respiratory rate, or systolic blood pressure. Start at low dosage, may increase every 3-4 days in increments of 1 mg/day if tolerated. Treatment Once other diagnoses have been ruled out, consider the following treatments: Psychotherapy Options include cognitive-behavioral therapy, interpersonal therapy, exposure therapy, a stress-management group, relaxation therapy, visualization, guided imagery, supportive psychotherapy, and psychodynamic psychotherapy. The type of psychotherapy selected often will depend on the skills and training of the practitioners available in a given health care system or region. Emergency referrals may be needed for the most anxious patients and those with comorbid depression. For patients receiving clonazepam or alprazolam, it is recommended that these medications be used at the lowest dosages for the shortest duration possible. A traumatic event may be a single instance, such as a car accident or experience of a natural disaster, or an ongoing pattern of events, such as continuous neglect, physical or sexual abuse, or chronic exposure to war or violent conflict. Psychotherapy Options include individual cognitivebehavioral therapy, dialectical-behavioral therapy, interpersonal therapy, exposure therapy, a stress-management group, relaxation therapy, visualization, guided imagery, supportive psychotherapy, and psychodynamic psychotherapy. Long-term psychotherapy may be indicated if experienced professionals are available and the patient is capable of forming an ongoing relationship. The specific psychotherapy often depends on the skills and training of the practitioners available in a given health care system or region. Section 8: Neuropsychiatric Disorders Pharmacotherapy Antidepressants Most antidepressants should be started at low dosages and gradually titrated upward to avoid unpleasant side effects. Therapeutic effects may not be noticed until 2-4 weeks after starting a medication. Adverse effects may include dyslipidemia, hyperglycemia, weight gain, and sudden cardiac death. Other medications A variety of other medications have been used as adjunctive treatment when insomnia and nightmares persist despite adequate use of psychotropic medications. Longer-acting benzodiazepines such as clonazepam (Klonopin) may be useful at dosages of 0. Benzodiazepines can reduce anxiety rapidly, often within hours, but may have counterbalancing side effects early in the course of their use that include sedation and incoordination. In addition, physical dependency may develop in patients who use them for more than a few weeks. Benzodiazepines are not recommended for people who have a history of alcohol abuse or dependence. Benzodiazepines ideally would be used only briefly and intermittently to quell acute and severe anxiety symptoms. It usually must be taken for at least 1-2 weeks before anxiety symptoms begin to lessen. Low-dose benzodiazepines may be used during the initial weeks of buspirone therapy, until the effects of buspirone are felt. Anticonvulsants Mood stabilizers such as valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), and topiramate (Topamax) may be added for patients with a partial response to an antidepressant. They may be particularly helpful for those who have considerable irritability, anger, or hostility, as well as those with reexperiencing symptoms. These interactions generally are not clinically significant, but most agents should be started at low dosages and titrated cautiously while monitoring efficacy and adverse effects. The prevalence of distress in persons with human immunodeficiency virus infection. Pharmacotherapeutic treatment of nightmares and insomnia in posttraumatic stress disorder: an overview of the literature. Once present, insomnia tends to be chronic, unlike the transient disturbances of sleep that are a normal part of life. O: Objective Perform a general symptom-directed physical examination, including evaluation of body habitus, neurologic status, and mental status. A sleep evaluation (including polysomnography) may be indicated when a physiologic cause. Treatment Treat underlying illnesses that may be causing or contributing to insomnia. Insomnia 575 Pharmacotherapy Choosing a pharmacologic agent for insomnia A number of medications may be effective in treating insomnia. Treatment considerations There are limited data to guide the frequency (nightly, intermittently, as needed) and duration (brief, intermediate, long-term) of hypnotic medications. Hypnotics generally should be prescribed at the lowest effective dosage for the shortest possible period. The greater the degree of physical illness, the more likely the patient will need a low dosage of a hypnotic agent. When long-term treatment is necessary, benzodiazepines pose the greatest risk of tolerance, abuse, and dependence. Possible adverse effects of all hypnotics include excess sedation, daytime grogginess, and disruption of the sleep architecture. Some combinations may be contraindicated and others may require dosage adjustment. Trazodone can be used for an indefinite period of time as it is not associated with tolerance or addiction. They may have decreased addiction potential compared with benzodiazepine hypnotics. Patients should be advised to use these hypnotics on an as-needed basis rather than nightly; it is easier for patients to discontinue a drug that they are not taking every day. However, it may have severe adverse reactions, including hypersensitivity reactions such as anaphylaxis and angioedema. Routine testing of tricyclic blood levels should be performed on patients receiving higher doses (eg, 100 mg per day; 50 mg for nortriptyline), those on concurrently on ritonavir, and those with risk factors for cardiac conduction abnormalities. A routine electrocardiogram should be performed before prescribing tricyclics, and this class of drugs should not be prescribed to patients with cardiac conduction problems. However, tricyclic antidepressants also have characteristics that may benefit some patients, including treatment of chronic pain, promotion of weight gain, and reduction of diarrhea. Amitriptyline (Elavil) and doxepin (Sinequan) are the most sedating of the tricyclic antidepressants and therefore are the drugs in this class most often used for sleep. These may be not only signs of worsening insomnia, but also symptoms of anxiety, depression, medications, or changes in medical conditions. Clinical guideline for the evaluation and management of chronic insomnia in adults. Other oral lesions may be a sign of a systemic disease, a side effect of medications, or a result of poor oral hygiene. See chapters Oral Hairy Leukoplakia, Oral Warts, Oral Ulceration, and Necrotizing Ulcerative Periodontitis and Gingivitis for more information about those conditions. O: Objective the oral mucosal tissues appear dry and sometimes "shiny" in appearance. Dental decay may be present on the cervical portion of the teeth (near the gingival margin or "gumline"). Promote good oral hygiene with flossing and brushing with a fluoride toothpaste, and encourage regular (every 3-4 months) dental recall visits. Severe cases of xerostomia may be treated by prescribing cholinergic stimulants such as pilocarpine (Salagen). Burning Mouth Syndrome; Atrophic Glossitis S: Subjective the patient may complain of a constant burning sensation in the mouth or a numbness or tingling feeling of the tongue. A: Assessment the differential diagnosis for the cause of xerostomia includes medication side effects. Section 9: Oral Health P: Plan Identify the cause of xerostomia and modify, if possible. Discourage sucking on O: Objective the tongue and oral mucosal tissues may be normal in appearance or there may be a slight redness on the tip and lateral margins of the tongue. A: Assessment the differential diagnosis includes traumatic ulcers and herpes simplex virus ulcers. A: Assessment Possible systemic etiologies include nutritional and vitamin deficiencies (atrophic glossitis), chronic alcoholism, medication adverse effects, diabetes mellitus, and gastric reflux. Local etiologies include denture irritation, oral habits such as tongue or cheek biting, and excessive use of certain toothpastes or mouthwashes. Recurrent Herpes Simplex S: Subjective the patient complains of a locally painful ulcer or ulcers on the lips or intraoral areas. P: Plan Identify the cause of the burning sensation, if possible, by review of the medical history and by performing diagnostic tests as indicated. Once the underlying cause is identified, treatment may be as simple as changing a dentifrice or eliminating the identified irritant, or the condition may require systemic treatment. O: Objective Herpes lesions are located on the lips, gingival tissues, or the hard palate. A: Assessment the differential diagnosis includes aphthous ulcer and traumatic ulcer. For further information, see chapters Oral Ulceration and Herpes Simplex, Mucocutaneous. In addition, it is important to determine whether the patient has an O: Objective the typical appearance of an aphthous ulcer is a "red raised border with a depressed, necrotic (white-to-yellow pseudomembrane) center. Section 9: Oral Health Oral Health inflammatory oral disease process that may further compromise his or her health. If significant periodontal disease is suspected, refer to an experienced dentist for diagnosis and treatment. Gingivitis, a milder form of periodontal disease, usually is reversible with proper professional and home oral health care. For further information on necrotizing ulcerative periodontitis or necrotizing ulcerative gingivitis, see chapter Necrotizing Ulcerative Periodontitis and Gingivitis. S: Subjective the patient may complain of red, swollen, or painful gums, which may bleed spontaneously or with brushing; chronic bad breath or bad taste in the mouth; loose teeth or teeth that are separating; or a "bite" that feels abnormal. Dental Caries Caused by Methamphetamine and Cocaine Use Dental decay seen in individuals who smoke methamphetamine or crack cocaine, or use cocaine orally, often is referred to as "meth mouth. Spontaneous gingival hemorrhage and purulent discharge may be evident around the teeth, especially if pressure is applied to the gingivae. O: Objective In meth mouth, the enamel on all teeth or multiple teeth is grayish-brown to black in color (owing to decay), and appears "soft" (this has been described as a "texture less like that of hard enamel and more like that of a piece of ripened fruit"). The gingiva appears red or inflamed, and there may be spontaneous bleeding of the gingiva around the teeth. Another pattern of dental decay can be seen in cocaine users who rub the drug along the gingiva in order to test its strength or purity. Consequently, plaque sticks to the cervical portion of the teeth in the area where the cocaine is rubbed, resulting in A: Assessment the differential diagnosis includes gingivitis, periodontitis, trench mouth, and oral abscesses. Patients with severe or recalcitrant disease should be referred to a dental care provider for definitive diagnosis and treatment. A: Assessment the differential diagnosis includes oral squamous cell carcinoma, lymphoma, Kaposi sarcoma, traumatic ulcer, hyperplasia, and hyperkeratosis. P: Plan Refer to a dentist for appropriate care, which may involve restorative, endodontic therapy, periodontal care, and oral surgery. In severe cases, extraction of the involved teeth and replacement with a partial or complete denture may be necessary. P: Plan An ulcerated lesion or symptom described above that is present for 2 weeks or longer should be evaluated promptly by a dentist or physician. If cancer is suspected, a biopsy should be obtained to make a definitive diagnosis. Data suggest two distinct pathways for the development of oropharyngeal cancer: one driven predominantly by the carcinogenic effects of tobacco or alcohol (or both), another by genomic instability induced by human papillomavirus. The patient may complain of a mouth sore that fails to heal or that bleeds easily, or a persistent white or red (or mixed) patch. The patient may note a lump, thickening, or soreness in the mouth, throat, or tongue; difficulty chewing or swallowing food; difficulty moving the jaw or tongue; chronic hoarseness; numbness of the tongue or other areas of the mouth; or a swelling of the jaw, causing dentures to fit poorly or become uncomfortable. Bruxism S: Subjective the patient may complain of chronic facial or jaw pain, sensitive teeth, earache, or waking up with a headache or facial pain. Often, the patient is not aware that he or she is clenching or grinding the teeth. Bruxism very often is a result of increased stress or anxiety, causing the patient consciously or unconsciously to clench or grind the teeth. However, some people may be "nighttime bruxers" and grind their teeth while sleeping, often loudly enough to wake others sleeping in the same room. O: Objective Perform a focused evaluation of the oropharynx, jaw, and facial muscles. The teeth may appear shortened, flattened, or worn down as a result of chronic grinding or clenching of the teeth. There may be hyperkeratotic lesions on the inside of cheeks as a result of chronic grinding or biting. Section 9: Oral Health O: Objective Perform a thorough evaluation of the oropharynx, as well as lymph nodes in the head and neck. Suspicious lesions may occur on the lips, tongue, floor of the mouth, palate, gingiva, or oral mucosa, and may appear as an ulcer or a soft-tissue mass or masses that can be pink, reddish, purple, white, or mixed red and white. The lesion typically is indurated and Oral Health 583 A: Assessment the differential diagnosis includes other causes of facial or jaw pain, including caries, dental abscesses, and trauma. Maxillary Tori; Mandibular Tori S: Subjective the patient may complain of a "lump" in the roof or floor of the mouth, or behind the lower front teeth. Treatment may include wearing a bite guard or psychological or behavioral management therapy. O: Objective Exostosis of normal bone (covered by oral mucosal tissue) can appear as a nodular or lobulated protuberance centrally located on the hard palate (maxillary tori) or unilaterally or bilaterally located behind the mandibular incisors (mandibular tori). This develops slowly and the patient may become aware of exophytic growth only if the area is inadvertently traumatized. Oral Piercing S/O/A: Subjective/Objective/ Assessment Jewelry worn in piercings in the tongue, lips, or cheeks can chip or fracture the teeth.
Circulatory shock is possible with normal arterial blood pressure pregnancy week calculator female viagra 100mg line, and not all patients with arterial hypotension have a circulatory shock womens health associates columbia mo cheap 100 mg female viagra otc. Resuscitation aims to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion breast cancer cookies 100mg female viagra overnight delivery. In absence of a definitive diagnosis at presentation womens health beaver dam wi female viagra 100mg low price, which is common (in the Golden hour) menstruation through the ages buy female viagra 100mg on-line, empiric broad-spectrum therapy should be initiated to cover all likely pathogens (including bacterial menstruation rectal pain female viagra 50mg with mastercard, potentially fungal or viral coverage) women's health clinic fremantle buy female viagra 50mg. Selection of an optimal empiric antimicrobial regimen in sepsis and septic shock is one of the central determinants of outcome breast cancer 9 lymph nodes order female viagra 100 mg fast delivery. Various factors which must be taken into consideration for deciding the choice of empiric antimicrobial therapy are shown in box 2. Box 2: Factors determining the selection of antimicrobials for sepsis and septic shock 1. Age and concomitant underlying diseases, chronic organ failures, medications, indwelling devices 5. Recent infections, intake of antimicrobials within the previous 3 months 31 Sepsis can originate from community locations as well as a healthcare facility. The common sites of infection leading to sepsis include lungs followed by abdomen, bloodstream, renal and genitourinary tracts. Refer to the appropriate sections in this guideline for the empirical antibiotic therapy for a different site of infection. Longer courses appropriate in slow clinical response, undrainable foci of infection, bacteremia with S. Measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy. Triazoles are acceptable in hemodynamically stable, less ill patients who have not had previous triazole exposure and are not known to be colonized with azoleresistant species. De-escalation includes discontinuation of combination therapy within the first few days in response to clinical improvement and/or evidence of infection resolution. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock. Effect of Piperacillin-Tazobactam vs Meropenem on 30-Day Mortality for Patients with E coli or Klebsiella pneumoniae Bloodstream Infection and Ceftriaxone Resistance A Randomized Clinical Trial. Manish Soneja Associate Professor Department of Medicine All India Institute of Medical Sciences. These infections are the commonest reasons for outpatient visits as well as antibiotic misuse in both adults and children. Pneumococcal resistance in non meningeal isolates is very low in our country and hence standard doses of amoxicillin generally suffice. Conversely, pneumococcal resistance to co-trimoxazole and macrolides is widespread. Resistance to amoxicillin by production of beta lactamase in Hemophilus influenzae is around 30% and that in Moraxella is 90%. The term influenza like illness is used when there are systemic signs such as fever and malaise along with the upper respiratory symptoms. The patients should be warned about symptoms which indicate complications like breathing difficulty, persistent fever beyond 4-5 days or ear pain. The use of oseltamivir in patients with influenza when started within 48 hours of onset reduces duration of symptoms by 1 day, viral shedding/ infectiousness and may reduce the risk of development of complications. Empiric therapy with oseltamivir may be considered in patients with influenza like illness during an ongoing outbreak if they are at high risk of complications such as pregnant women, those with co-morbidities and the immunocompromised. Examination findings include tonsillo-pharyngeal erythema and exudates, palatal petechiae, tender anterior cervical adenopathy and sometimes scarlatiniform rash. The positive predictive value of these signs for streptococcal sore throat is around 60%. The centor score (3 of 4 criteria) can be used to predict a bacterial etiology: exudative pharyngitis, tender cervical lymphadenopathy, fever, absence of cough. Confirmation of diagnosis by rapid antigen test or throat swab culture is desirable but not always possible. The first line drug for patients who have not received penicillin in the past one month and those with absence of purulent conjunctivitis is amoxicillin. Co- amoxiclav should be used in others and if the patient fails to respond to amoxicillin. The duration of therapy for severe disease and children less than 2 years is 10 days. Children between 2 and 5 years with mild disease can be treated for 7 days and those above 5 years with 5-7 days of therapy. New focal chest signs on examination (bronchial breath sounds and/or crackles); with no other explanation for the illness. The percentage contribution of viruses reduces as age advances and the relative contribution of mycoplasma increases. Mycobacterium tuberculosis should also be considered a possible etiology in some individuals with a slightly protracted illness. Since penicillin resistance is very low, standard doses of amoxicillin (30-40 mg/ kg/day or 500 mg thrice daily in adults)suffice. Resistance in Hib to ampicillin in a recent study evaluating lower respiratory tract isolates was 10%. In the outpatient setting the diagnosis should be confirmed before starting therapy. The choice of antibiotics depends on various factors including severity of disease, presence or absence of co-morbidities, likely pathogen, likely resistance pattern and previous antibiotic use. Similarly, drugs with anti-tubercular activity including linezolid and aminoglycosides should not be used. Patients can be considered for discharge if they are afebrile, accepting orally and hemodynamically stable for 48 hours. Longer duration of therapy should be considered in patients with bacteremic pneumococcal pneumonia, S. Duration of therapy for outpatients is 5 days and for uncomplicated pneumonia in inpatients is 7 days. The pleural fluid should be tapped and if it is purulent/ has organisms on the gram stain or culture, empyema is confirmed. Drainage of the infected fluid is paramount and can be done by chest tube with or without fibrinolytics. Infectious Diseases Society of America/ American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Serotype distribution and antimicrobial susceptibility pattern in children5years with invasive pneumococcal disease in India - A systematic review. Increasing incidence of penicillin- andcefotaxime-resistant Streptococcus pneumoniae causing meningitis in India: Time for revision of treatment guidelines? Microbiological Characterization of Haemophilus influenzae Isolated from Patients with Lower Respiratory Tract Infections in a Tertiary Care Hospital, South India. Invasive Haemophilus influenzae disease in India: a preliminary report of prospective multihospital surveillance. Tanu Singhal Consultant Pediatrics and Infectious Disease Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai 2. Generally, if the infection remains confined to the viscus, it is considered uncomplicated and if infection spreads from the organ into the peritoneum causing localized or diffuse peritonitis, it is termed as complicated intra-abdominal infection. For the purpose of management of complicated intra-abdominal infections, take into consideration the suspected point of origin of infection, i. High severity or high risk patients Hospital acquired infections /Health care associated infections 5. In these cases, the patient usually has an underlying comorbidity that can lead to bacterial migration into the peritoneum. Such comorbidities may include ascites and indwelling peritoneal dialysis catheters. Primary peritonitis is estimated to occur in 10% to 30% of patients with alcoholic cirrhosis. Considering the plethora of microflora existing within the abdominal organs, migration of the bacteria from any of the organs into the sterile peritoneum can lead to an inflammatory response, resulting in secondary peritonitis. Dispersion of bacteria from their host organs may result from puncture due to trauma, surgery, or perforation. Ulceration, ischemia, or obstruction may cause the perforation of abdominal organs. Classification of peritonitis is useful in clinical practice as it can facilitate appropriate diagnosis and treatment. Since numerical scores for severity assessment may be as good as clinical judgement. Broad principles of management of intra-abdominal infections include the following: Early initiation of antimicrobials. While culture and sensitivity from intra-op cultures may not be essential for management of an individual case, it would help in formulating empiric antimicrobial policy, particularly for community acquired intraabdominal infection. For hospital acquired infection, culture and sensitivity testing may be useful for guiding empirical therapy. For patients requiring hemodynamic support, fluid management should be initiated and done as needed. Adequate source control is the backbone of management of patients with intraabdominal infections. Laparotomy, laparoscopy or percutaneous drainage as appropriate is various options for source control. Candida species, usually Candida albicans are important healthcare associated pathogens in patients who have received antibiotics. If the prevalence is less than ten percent, then third generation cephalosporin may be used. For patients receiving third generation cephalosporins, additional administration of metronidazole would be needed. Empiric cover for Enterococcus, methicillin resistant Staphylococcus aureus or Candida is not necessary in patients with community acquired intra abdominal infection. For health care associated infections, the empiric regimen would largely be determined by the profile of organisms found in the hospital settings. A reasonable choice would be imipenem or meropenem (depending on the susceptibility pattern in hospital setting). Covering for enterococci may be needed for healthcare associated infections particularly for postoperative patients, immunosuppressed patients or those who have been on antibiotics which select out enterococci such as cephalosporins. In health care associated infections, carbapenem resistant gram negative organisms may be present and may need coverage. An intraoperative culture is usually of benefit in patients with healthcare associated infections. Empiric coverage for Candida may be needed in immunosuppressed patients, patients with perforated gastric ulcer on acid suppressants, presence of malignancy, recurrent intra-abdominal infection and if the intra-op cultures showing candida. Recently some data suggests that in those patients who are not severely ill and have achieved good source control a shorter duration of treatment may be as good (3-5 days). For healthcare associated infections, particularly with carbapenem resistant organisms, a longer duration (10-14 days) of treatment may be needed, assuming adequate source control and resolution of clinical symptoms and signs. For patients receiving antifungal treatment, generally 2 weeks of therapy may be needed, assuming adequate source control and resolution of clinical symptoms and signs. If multi-drug resistant organism is isolated, based on susceptibility patterns, colistin, tigecyline may be used. Infected pancreatic Imipenem-cilastatin Therapy to be adjusted as per necrosis, pancreatic and vancomycin the culture and sensitivity abscess results from pancreatic aspirate or necrosectomy. Antifungal cover with fluconazole, or echinocandins may be added if risk factors for disseminated candidiasis. For nosocomial infections, depending on the culture and sensitivity data, colistin/ tigecycline may be used. Cholangitis, cholecystitis As for community associated complicated intra-abdominal infections Liver Abscess CefoperazoneThe treatment should be sulbactam or changed as per culture report piperacillinand amoebic serology 48 tazobactam with metronidazole to cover for possible bacterial and amoebic etiology subsequently. For an initial diagnostic paracentesis, other tests should be performed as clinically warranted on the remaining ascitic fluid which includes albumin, total protein, glucose, lactate dehydrogenase, amylase, and bilirubin. Prior to administering antibiotics, ascitic fluid (at least 10 ml) should be obtained and then directly inoculated into a blood culture bottle at the bedside, instead of sending the fluid to the laboratory in a syringe or container. The practice of immediate inoculation in blood culture bottles improves the yield on bacterial culture from approximately 65 to 90%. For patients with a possibility of harboring multi-drug resistant organism imipenem or meropenem may be more reasonable. However these antibiotics are unlikely to be useful for prophylaxis in India as the prevalence of resistance is >20% even for community acquired isolates, and may drive further resistance. Diagnosis and management of complicated intraabdominal infection in adults and children: guidelines by the surgical Infection society and the Infectious diseases society of america. Montravers P, Dupont H, Leone M, Constantin J-M, Constantin J-M, Mertes P-M, et al. Anaesth Crit Care Pain Med 2015;34:117-30 Comments Antibiotics should be tailored as per the culture and sensitivity data. Treatment of complicated intra-abdominal infections in the era of multi-drug resistant bacteria. Review article: spontaneous bacterial peritonitis-bacteriology, diagnosis, treatment, risk factors and prevention. The diarrheal diseases represent one of the five leading causes of death worldwide and are the second leading cause of death in children under five years of age. Acute diarrhea is defined as diarrhea of 14 days in duration, in contrast to persistent (>14 days and 30 days) or chronic (>30 days) diarrhea. Epidemic disease; Vibrio cholera Other causes include Campylobacter jejuni, enteroinvasive and enterohemorrhagic E. The patient should be evaluated for signs of dehydration, including decreased urine output, thirst, dizziness, and change in mental status. Vomiting is more suggestive of viral illness or illness caused by ingestion of a preformed bacterial toxin. Symptoms more suggestive of invasive bacterial (inflammatory) diarrhea include fever, tenesmus, and grossly bloody stool. In contrast, shigellosis is typically characterized by the frequent passage of small liquid stools that contain visible blood, with or without mucous. Infection with Entameba histolytica presents with frequent passage of small liquid stools that contain visible blood and mucous associated with tenesmus. Symptoms ascribed to Candida-associated diarrhea in the literature include prolonged secretory diarrhea with abdominal pain and cramping but without blood, mucus, fever, nausea, or vomiting. A stool culture is indicated if the patient has grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, or is immunuosuppressed [6]. Routine microscopy of fresh stool is inexpensive and can identify the presence of numerous fecal leukocytes, suggesting an invasive bacterial infection. Microscopic evidence of Entamoeba trophozoites containing red blood cells provides sufficient basis for treating for amoebic dysentery instead of shigellosis. Notably, finding cysts or 52 trophozoites without red blood cells in a bloody stool does not indicate that Entamoeba is the cause of illness, since asymptomatic infection is frequent among healthy persons. Antimicrobial therapy is not typically indicated for the treatment of acute watery diarrhea in adults. An important exception is the treatment of severe cholera in outbreak settings, for which antibiotics can decrease the duration of illness and the volume of fluid losses. The use of probiotics or prebiotics for the treatment of acute diarrhea in adults is not recommended, except in cases of postantibiotic-associated illness. In contrast to the treatment of watery diarrhea, adults with bloody diarrhea should be treated promptly with an antimicrobial that is effective against Shigella. Antibiotics reduced the duration of diarrhea and fever in infections caused by Shigella, which is the most common cause of dysentery in resource-limited settings and can otherwise be associated with severe complications. Stool microscopy and cultures has to be sent routinely in dysentery syndromes and antibiotics should be selected based on the microscopy and sensitivity testing. Cholerae Doxycycline (Not recommended in children and pregnant women) 300mg once Azithromycin 1 g as a single dose Shigella Ciprofloxacin 500 mg b. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Epidemiologic and clinical features of patients infected with Shigella who attended a diarrheal disease hospital in Bangladesh. Vishnu Rao Consultant, Department of Infectious diseases, Yashoda hospital, Hyderabad 3. They can present with a wide spectrum of clinical presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis. The major challenge lies in the diagnosis of the exact extent of the disease to institute appropriate management. Trauma, underlying skin lesions and spread from adjacent infections such as osteomyelitis can lead to the development of cellulitis. Furuncles appear as red, swollen, and tender nodules on hair-bearing parts of the body. The distinctive features of erysipelas are well defined indurated margins, particularly along the naso-labial fold, rapid progression and intense pain. Early and aggressive surgical debridement and treatment with appropriate antibiotics are important to reduce mortality. Gentle probing is performed with a blunt instrument or index finger and if the tissue dissects with minimal resistance, then probe test is considered to be positive. Thus, clinicians must be aware of such infections and should not underestimate their potential extent or severity. Staphylococcus aureus, Enterobacter species, Streptococcus species, Pseudomonas species, gram negative bacilli.
All of these species are considered opportunistic pathogens in humans and none are considered communicable menopause years buy female viagra 50 mg line. Mycobacteria are frequently isolated from clinical samples but may not be associated with disease menstrual cycle symptoms cheap 100mg female viagra with visa. Agent Summary Statements: Bacterial Agents 147 Occupational Infections Laboratory-acquired infections with Mycobacterium spp women's health clinic nowra cheap female viagra 50 mg on-line. Natural Modes of Infection Person-to-person transmission has not been demonstrated womens health 8 week challenge discount female viagra 50 mg on-line. Presumably women's health center new lenox il 50mg female viagra otc, pulmonary infections are the result of inhalation of aerosolized bacilli menopause 2 periods a month generic 100 mg female viagra fast delivery, most likely from the surface of contaminated water pregnancy pops buy cheap female viagra 100mg line. They are also common in potable water supplies womens health advantage buy female viagra 100mg overnight delivery, perhaps as the result of the formation of biofilms. Laboratory Safety and Containment Recommendations Various species of mycobacteria may be present in sputa, exudates from lesions, tissues, and in environmental samples. Direct contact of skin or mucous membranes with infectious materials, ingestion, and accidental parenteral inoculation are the primary laboratory hazards associated with clinical materials and cultures. Aerosols created during the manipulation of broth cultures or tissue homogenates of these organisms also pose a potential infection hazard. Selection of an appropriate tuberculocidal disinfectant is an important consideration for laboratories working with mycobacteria. Neisseria gonorrhoeae Neisseria gonorrhoeae is a gram-negative, oxidase-positive diplococcus associated with gonorrhea, a sexually transmitted disease of humans. The organism may be isolated from clinical specimens and cultivated in the laboratory using specialized growth media. Natural Modes of Infection Gonorrhea is a sexually transmitted disease of worldwide importance. The 2004 rate of reported infections for this disease in the United States was 112 per 100,000 population. This usually occurs by sexual activity, although newborns may also become infected during birth. Accidental parenteral inoculation and direct or indirect contact of mucous membranes with infectious clinical materials are known primary laboratory hazards. Gloves should be worn when handling infected laboratory animals and when there is the likelihood of direct skin contact with infectious materials. Neisseria meningitidis Neisseria meningitidis is a gram-negative coccus responsible for serious acute meningitis and septicemia in humans. Thirteen different capsular serotypes have been identified, with types A, B, C, Y, and W135 associated with the highest incidence Agent Summary Statements: Bacterial Agents 149 of disease. Almost all the microbiologists had manipulated sterile site isolates on an open laboratory bench. Natural Modes of Infection the human upper respiratory tract is the natural reservoir for N. Invasion of organisms from the respiratory mucosa into the circulatory system causes infection that can range in severity from subclinical to fulminant fatal disease. Transmission is person-to-person and is usually mediated by direct contact with respiratory droplets from infected individuals. Parenteral inoculation, droplet exposure of mucous membranes, infectious aerosol and ingestion are the primary hazards to laboratory personnel. Based on the mechanism of natural infection and the risk associated with handling of isolates on an open laboratory bench, exposure to droplets or aerosols of N. Special Issues Vaccines the quadrivalent meningococcal polysaccharide vaccine, which includes serogroups A, C, Y, and W-135, will decrease but not eliminate the risk of infection, because it is less than 100% effective and does not provide protection against serogroup B, which caused one-half of the laboratory-acquired cases in the United States in 2000. Typhi Salmonellae are gram-negative enteric bacteria associated with diarrheal illness in humans. They are motile oxidase-negative organisms that are easily cultivated on standard bacteriologic media, although enrichment and selective media may be required for isolation from clinical materials. Occupational Infections Salmonellosis is a documented hazard to laboratory personnel. Case reports of laboratory-acquired infections indicate a presentation of symptoms (fever, severe diarrhea, abdominal cramping) similar to those of naturally-acquired infections, although one case also developed erythema nodosum and reactive arthritis. An estimated 5 million cases of salmonellosis occur annually in the United States. A wide range of domestic and feral animals (poultry, swine, rodents, cattle, iguanas, turtles, Agent Summary Statements: Bacterial Agents 151 chicks, dogs, cats) may serve as reservoirs for this disease, as well as humans. The disease usually presents as an acute enterocolitis, with an incubation period ranging from 6 to 72 hours. Laboratory Safety and Containment Recommendations the agent may be present in feces, blood, urine, and in food, feed, and environmental materials. Personal protective equipment should be used in accordance with a risk assessment, including splash shields, face protection, gowns, and gloves. Care in manipulating faucet handles to prevent contamination of cleaned hands or the use of sinks equipped with remote water control devices, such as foot pedals, is highly recommended. Salmonella Typhi Recent taxonomic studies have organized the genus Salmonella into two species, S. Typhi is a motile gram-negative enteric bacterium that is easily cultivated on standard bacteriologic media, although enrichment and selective media may be required for isolation of this organism from clinical materials. Secondary transmission to other individuals outside of the laboratory is also a concern. Typhi infections usually present with symptoms of septicemia, headache, abdominal pain, and high fever. The infectious dose is low (<103 organisms) and the incubation period may vary from one to six weeks, depending upon the dose of the organism. The natural mode of transmission is by ingestion of food or water contaminated by feces or urine of patients or asymptomatic carriers. Ingestion and parenteral inoculation of the organism represent the primary laboratory hazards. Typhi are available and should be considered for personnel regularly working with potentially infectious materials. Shiga toxin (Verocytotoxin)-producing Escherichia coli Escherichi coli is one of five species in the gram-negative genus Escherichia. This organism is a common inhabitant of the bowel flora of healthy humans and other mammals and is one of the most intensively studied prokaryotes. This summary statement provides recommendations for safe manipulation of Shiga toxin-producing E. Transmission usually occurs by ingestion of contaminated food, including raw milk, fruits, vegetables, and particularly ground beef. Human-to-human transmission has been observed in families, day care centers, and custodial institutions. Water-borne transmission has been reported from outbreaks 154 Biosafety in Microbiological and Biomedical Laboratories associated with swimming in a crowded lake and drinking unchlorinated municipal water. However, a variety of food specimens contaminated with the organisms including uncooked ground beef, unpasteurized dairy products and contaminated produce may present laboratory hazards. This agent may be found in blood or urine specimens from infected humans or animals. Personal protective equipment, such as splash shields, face protection, gowns, and gloves should be used in accordance with a risk assessment. The importance of proper gloving techniques and frequent and thorough hand washing is emphasized. Special attention to the timely and appropriate decontamination of work surfaces, including potentially contaminated equipment and laboratory fixtures, is strongly advised. Shigella the genus Shigella is composed of nonmotile gram-negative bacteria in the family Enterobacteriaceae. There are four subgroups that have been historically treated as separate species, even though more recent genetic analysis indicates that they are members of the same species. Members of the genus Shigella have been recognized since the late 19th century as causative agents of bacillary dysentery, or shigellosis. Most transmission is by fecal-oral route; infection also is caused by ingestion of contaminated food or water. Complications of shigellosis include hemolytic uremic syndrome, which is associated with S. Laboratory Safety and Containment Recommendations the agent may be present in feces and, rarely, in the blood of infected humans or animals. Accidental ingestion and parenteral inoculation of the agent are the primary laboratory hazards. The 50% infectious dose (oral) of Shigella for humans is only a few hundred organisms. Treponema pallidum Treponema pallidum is a species of extremely fastidious spirochetes that die readily upon desiccation or exposure to atmospheric levels of oxygen, and have not been cultured continuously in vitro. No cases of laboratory animal-associated infections are reported; however, rabbit-adapted T. Venereal syphilis is a sexually transmitted disease that occurs in many areas of the world, whereas Yaws occurs in tropical areas of Africa, South America, the Caribbean, and Indonesia. Accidental parenteral inoculation, contact with mucous membranes or broken skin with infectious clinical materials are the primary hazards to laboratory personnel. Gloves should be worn when there is a likelihood Agent Summary Statements: Bacterial Agents 157 of direct skin contact with infective materials. Periodic serological monitoring should be considered in personnel regularly working with these materials. Growth of Vibrio species is stimulated by sodium and the natural habitats of these organisms are primarily aquatic environments. Although 12 different Vibrio species have been isolated from clinical specimens, V. Natural Modes of Infection the most common natural mode of infection is the ingestion of contaminated food or water. Other clinical specimens from which vibrios may be isolated include blood, arm or leg wounds, 158 Biosafety in Microbiological and Biomedical Laboratories eye, ear, and gallbladder. Yersinia pestis Yersinia pestis, the causative agent of plague, is a gram-negative, microaerophilic coccobacillus frequently characterized by a "safety pin" appearance on stained preparations from specimens. The incubation period for bubonic plague ranges from two to six days while the incubation period for pneumonic plague is one to six days. Pneumonic plague is transmissible person-to-person;155 whereas bubonic plague is not. Prior to 1950, at least 10 laboratoryacquired cases were reported in the United States, four of which were fatal. Natural Modes of Infection Infective fleabites are the most common mode of transmission, but direct human contact with infected tissues or body fluids of animals and humans also may serve as sources of infection. Agent Summary Statements: Bacterial Agents 159 Primary pneumonic plague arises from the inhalation of infectious respiratory droplets or other airborne materials from infected animals or humans. This form of plague has a high case fatality rate if not treated and poses the risk of personto-person transmission. Primary hazards to laboratory personnel include direct contact with cultures and infectious materials from humans or animal hosts and inhalation of infectious aerosols or droplets generated during their manipulation. Laboratory and field personnel should be counseled on methods to avoid fleabites and accidental autoinoculation when handling potentially infected live or dead animals. Special care should be taken to avoid generating aerosols or airborne droplets while handling infectious materials or when performing necropsies on naturally or experimentally infected animals. Gloves should be worn when handling potentially infectious materials including field or laboratory infected animals. Information on which to base assessments of risk from environments contaminated with anthrax spores. Investigation of bioterrorismrelated anthrax, United States, 2001: epidemiologic findings. Containment of pertussis in the regional pediatric hospital during the greater Cincinnati epidemic of 1993. Use and safety of acellular pertussis vaccine among adult hospital staff during an outbreak of pertussis. Evidence for a high attack rate and efficacy of erythromycin prophylaxis in a pertussis outbreak in a facility for the developmentally disabled. Analysis of Bordetella pertussis isolates from an epidemic by pulsed-field gel electrophoresis. Serological response to filamentous hemagglutinin and lymphocytosis-promoting toxin of Bordetella pertussis. Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996. Fatal case of unsuspected pertussis diagnosed from a blood culture-Minnesota, 2003. A twenty-five year review of laboratoryacquired human infections at the National Animal Disease Center. An outbreak of Brucella melitensis infection by airborne transmission among laboratory workers. Outbreak of Brucella melitensis among microbiology laboratory workers in a community hospital. Resistance of normal or immunized guinea pigs against a subcutaneous challenge of Brucella abortus. Pathologic changes associated with brucellosis experimentally induced by aerosol exposure in rhesus macaques (Macaca mulatto). Ecology of Burkholderia pseudomallei and the interactions between environmental Burkholderia spp. Burkholderia pseudomallei infection in a Puerto Rican patient with chronic granulomatous disease: case report and review of occurrences in the Americas. Application of serotyping and chromosomal restriction endonuclease digest analysis in investigating a laboratory-acquired case of Campylobacter jejuni enteritis. Mediastinal and supraclavicular lymphadenitis and pneumonitis due to Chlamydia trachomatis serovars L1 and L2. Toxin production by clostridium botulinum type A under various fermentation conditions. Recommended childhood and adolescent immunization schedule-United States, January-June 2004. Immunization against tularemia: analysis of the effectiveness of live Francisella tularensis vaccine in prevention of laboratory-acquired tularemia. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey. Epidemiological and environmental investigations of Legionella pneumophila infection in cattle and case report of fatal pneumonia in a calf. Primary cutaneous listeriosis in adults: an occupational disease of veterinarians and farmers. Preparation of acid-fast microscopy smears for proficiency testing and quality control. Laboratory-acquired gonococcal conjunctivitis: successful treatment with single-dose ceftriaxone. Introduction of salmonellae into a centralized laboratory animal facility by infected day-old chicks. Laboratory-acquired Salmonella typhimurium enteritis: association with erythema nodosum and reactive arthritis. Verocytotoxin-producing Escherichia coli in wild birds and rodents in close proximity to farms. Cholerae and other types of vibriosis: a story of human pandemics and oysters on the half shell. Doxycycline or ciprofloxacin prophylaxis and therapy against Yersinia pestis infection in mice. Occupational Infections Three groups are at greatest risk of laboratory-acquired infection: microbiologists, veterinarians and pathologists. Natural Modes of Infection the fungus has been reported from multiple geographically separated countries, but is best known as a fungus endemic to North America and in association with plant material in the environment. Outbreaks associated with the exposure of people to decaying wood have been reported. Parenteral (subcutaneous) inoculation of these materials may cause local skin infection and granulomas. Occupational Infections Laboratory-associated coccidioidomycosis is a documented hazard of working with sporulating cultures of Coccidioides spp. Smith reported that 28 of 31 (90%) laboratory-associated infections in his institution resulted in clinical disease, whereas more than half of infections acquired in nature were asymptomatic. Accidental percutaneous inoculation has typically resulted in local granuloma formation. The majority of ambient infections is subclinical and results in life-long protection from subsequent exposures. The incubation period is one to three weeks and manifests as a community-acquired pneumonia with immunologically mediated fatigue, skin rashes, and joint pain. A small proportion of infections is complicated by hematogenous dissemination from the lungs to other organs, most frequently skin, the skeleton, and the meninges. Laboratory Safety and Containment Recommendations Because of their size, the arthroconidia are conducive to ready dispersal in air and retention in the deep pulmonary spaces. The much larger size of the spherule considerably reduces the effectiveness of this form of the fungus as an airborne pathogen. Spherules of the fungus may be present in clinical specimens and animal tissues, and infectious arthroconidia in mold cultures and soil or other samples from natural sites. Inhalation of arthroconidia from environmental samples or cultures of the mold form is a serious laboratory hazard. Personnel should be aware that infected animal or human clinical specimens or tissues stored or shipped in such a manner as to promote germination of arthroconidia pose a theoretical laboratory hazard.
Initiate discussion of the psychological implications of raising a hearing-impaired child and how the family will cope with anger womens health youngkin order 100mg female viagra with amex, stress menopause vitamin e purchase female viagra 50mg without prescription, denial women's health center of santa cruz purchase female viagra 100mg with amex, grief menstruation after miscarriage female viagra 100 mg online, guilt pregnancy timeline generic female viagra 100mg free shipping, and over-compensation women's health magazine uk back issues buy female viagra 50 mg with mastercard. Additionally menstrual cycle day 6 generic 50mg female viagra with amex, address the stress of communication strategies; hearing aids and cochlear implant accommodation; behavioral issues pregnancy jokes female viagra 50 mg on-line, including sleep; and mismatch of chronologic and communicative ages. No Harm Photo courtesy of Oc ticon A/S A Meticulous care of remaining hearing is to be stressed. This includes advising about good ear hygiene and avoidance of ear-risk situations. Restriction of sporting activities is to be discussed if the patient has a labyrinthine dysplasia. Precautions related to aquatic activities may be indicated for the individual patient. To remove water from ear canal, evaporate with hair dryer (lowest heat and fan speed) held several inches from the ear. Keeping up to date with immunizations is important: childhood hearing impairment (notwithstanding inner ear dysplasia) is associated with an approximately five-fold increased relative risk of meningitis (Parner et al. For example, hearing "impairment" and hearing "loss" are often used interchangeably, as if they are synonymous terms. Strictly speaking, that is not the case-how can something that was never there be lost? Hearing impairment means deviation from the outer limits of an established standard. Epidemiologically, "hearing loss" would be a longitudinal term, whereas "hearing impairment" would be cross-sectional (Hannley, 2012). It is important that the parents receive a realistic and consistent message regarding available communication options. Deaf-blind patients are a special group, necessitating extraordinary anticipation and care. If not the customary listening and speaking mode facilitated by hearing aids or cochlear implantation preferred by hearing parents, then "total communication" or sign (manual) communication. Testing should proceed at regular intervals as recommended by the audiologist and early intervention providers. At least once, test each of the first-degree relatives to determine if any has a hearing problem. It will also help them to understand the difficulties/rigors of having hearing tests. This will enable the audiologic exam to become more accurate due to the ability of an older child to be more capable of responding to more sophisticated testing techniques. Regular testing will allow changes to be identified and provide a more accurate understanding of the etiology of the hearing loss. It is often very helpful to have a parent-maintained scrapbook of all the various tests and assessments of the child. This not only enhances parent involvement and empowerment, but also enables the professionals to have immediate access to all the relevant information necessary for optimum care of the child. The earliest possible education for the child and family are vital to successful outcomes. Best communicative outcomes involve a multidisciplinary team of at least the primary care physician, audiologist, therapist(s), educator(s), otolaryngologist, ophthalmologist, and geneticist. American College of Medical Genetics and Genomics guideline for the clinical evaluation and etiologic diagnosis of hearing loss. Newborn screening expands: Recommendations for pediatricians and medical homes-Implications for the system. Diagnostic yield in the workup of congenital sensorineural hearing loss is dependent on patient ethnicity. Children with sensorineural hearing loss after passing the newborn hearing screen. Ophthalmologic disorders in children with syndromic and nonsyndromic hearing loss. Year 2007 position statement: Principles and guidelines for Early Hearing Detection and Intervention. Unilateral hearing loss is associated with worse speech-language scores in children. Natural history of hearing loss in children with enlarged vestibular aqueduct syndrome. Improved diagnostic effectivenee with a sequential disgnostic paradigm in idiopathic pediatric sensorineural hearing loss. Clinical findings for a group of infants and young children with auditory neuropathy. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Designed by minimum graphics Printed in France Contents Abbreviations and acronyms Introduction Conclusions and recommendations Macronutrients Energy Protein Fat Micronutrients Multiple micronutrient supplements Nutrition and antiretroviral therapy Knowledge gaps and research needs References Annex A. There is an urgent need for renewed focus on and use of resources for nutrition as a fundamental part of the comprehensive package of care at the country level. As an urgent priority, greater political, financial and technical support should be provided for improving dietary quality and increasing dietary intake to recommended levels. Energy intakes need to be increased by 50% to 100% over normal requirements in children experiencing weight loss. Increased energy intake of about 20% to 30% is recommended for adults during periods of symptomatic disease or opportunistic infection to maintain body weight. However, such intakes may not be achievable during periods of acute infection or illness, and it has not been proven that such high intake levels can be safely achieved during such periods. Intakes should therefore be increased to the extent possible during the recovery phase, aiming for the maximum achievable up to 30% above normal intake during the acute phase. However, special advice regarding fat intake might be required for individuals undergoing antiretroviral therapy or experiencing persistent diarrhoea. The role of micronutrients in immune function and infectious disease is well established. Some studies show that there is evidence that supplements of, for example, B-complex vitamins, and vitamins C and E, can improve immune status, prevent childhood diarrhoea and enhance pregnancy outcomes, including better maternal prenatal weight gain and a reduction of fetal death, preterm birth and low birth weight. Results from several studies raise concerns that some micronutrient supplements. Iron-folate supplementation is a standard component of antenatal care for preventing anaemia and improving fetal iron stores. Multiple micronutrient supplements Adequate micronutrient intake is best achieved through an adequate diet. Some studies show that different multiple micronutrient supplements may have produced a broad range of beneficial outcomes. However, in settings where these intakes and status cannot be achieved, multiple micronutrient supplements may be needed in pregnancy and lactation. More research is needed on appropriate strategies for such counselling and management in resource-limited settings. Knowledge gaps and research needs New knowledge is urgently needed to provide the scientific evidence base required for making nutrition recommendations for rapid implementation. The recommendations made here underscore the urgent need to fill knowledge gaps and to refine further related conclusions and recommendations. The term "nutrition intervention" includes both food-based approaches and micronutrient supplementation. Does nutritional status affect the efficacy of therapy and the risk or severity of adverse events associated with it? Should there be a different mix of such strategies in resource-limited settings where undernutrition is prevalent? Acute phase response and energy balance in stable human immunodeficiency virus- infected patients: a doubly labeled water study. Resting energy expenditure and nitrogen balance in critically ill pediatric patients on mechanical ventilation. Increased resting energy expenditure in human immunodeficiency virus-infected men. For the Department of Health and Human Services working group on the prevention and treatment of wasting and weight loss. Total energy expenditure and carbohydrate oxidation are increased in the human immunodeficiency virus lipodystrophy syndrome. Whole-body protein turnover from leucine kinetics and the response to nutrition in human immunodeficiency virus infection. Iron supplementation during human immunodeficiency virus infection: a double-edged sword? Antenatal vitamin A supplementation increases birth weight and decreases anemia among infants born to human immunodeficiency virusinfected women in Malawi. Formulation and food effect on the oral absorption of a poorly water- soluble, highly permeable antiretroviral agent. General nutrition management in patients infected with human immunodeficiency virus. Herb-drug, food-drug, nutrient-drug and drug-drug interactions: mechanisms involved and their medical implications. Fawzi Associate Professor of International Nutrition and Epidemiology Harvard School of Public Health Bldg. Mandela School of Medicine University of Natal 4th Floor, 719 Umbilo Road Congella 4013 South Africa Tel: (254) 2 2720890/2716125 Fax: (254) 2 2725012 Email: dlmwaniki@wananchi. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Syphilis has been coined "the great imitator" due to its extreme heterogeneity of presentation and mimicry of other conditions. Therefore, it is essential that physicians be familiar with the full spectrum of its manifestations. Syphilis may also lead to oral lesions that, occasionally, are unaccompanied by concomitant tegumentary findings. A painful split papule (fausse perl`che or false angular cheilitis) was also e e present in the left commissure. Complete clinical remission was rapidly achieved after initiation of penicillin therapy. A comprehensive review of the literature on oral manifestations of syphilis is offered. Introduction Acquired syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum, subspecies pallidum. The disease has been coined "the great imitator" due to its great variability of presentation and mimicry of other conditions. Physicians unaware of its protean manifestations may easily overlook atypical presentations. Moreover, syphilis also leads to oral manifestations and such lesions may be even less likely to suggest the diagnosis [1, 2]. Oral lesions may occur at any of the three main stages of syphilis and the spectrum of manifestations may be mistaken for many other more prevalent disorders. Despite its clinical heterogeneity, oral manifestations can usually be correctly attributed to secondary syphilis when a concomitant skin eruption is present [3, 4]. A fibrin-covered e commissural papule (split papule) in the left oral commissure is indicated by the arrow. A 7-day treatment with fluconazole, followed by a 7-day course of itraconazole, had been offered without clinical improvement. The condition worsened to the point of weight loss and feeding difficulties due to sore throat and odynophagia. The patient was on successful highly active antiretroviral therapy with lamivudine, tenofovir, and efavirenz for more than 4 years. He reported no prior rash and denied the use of drugs other than his current antiretroviral regimen. Examination of the oral cavity (Figure 1(a)) revealed shallow, painful, round to oval depapillary erosions on a background of a whitish, nonwipeable hyperkeratotic thickening of the posterior aspect of the tongue. This commissural lesion was not a simple fissure as seen in angular cheilitis (perl`che). This sign, previously described as fausse perl`che e (or false angular cheilitis), is also associated with secondary syphilis [19, 21, 22]. On further history taking, the patient indicated having had unprotected oral and anogenital sexual contact approximately 3 months before the onset of symptoms. A complete clinical remission and resolution of oral lesions (Figure 1(b)) was rapidly recorded after the first of a total of three consecutive weekly administrations of 2. Discussion the oral cavity may be involved in primary, secondary, and tertiary stages of syphilis [19, 23, 24]. A chancre will present at the site of inoculation, which can be the lips, tongue, buccal mucosa, tonsils, and oropharynx. Lesions of primary syphilis commonly present as ulcerations that are painless [24]. Primary syphilis of the oral cavity, however, may pass unnoticed by both patient and physician and the untreated lesion will heal regardless of treatment [25, 26]. Tertiary syphilis of the oral cavity may present itself as a gumma or as atrophic luetic glossitis [2]. Gumma is a destructive, granulomatous, usually painless lesion that occurs anywhere in the oral cavity and may enlarge to invade adjacent tissues. In atrophic luetic glossitis, the dorsal aspect of the tongue assumes a smooth and shiny aspect due to atrophy of filiform and fungiform papillae, often with areas of leukoplakia presenting as a homogenous white patch (syphilitic leukoplakia) [1, 27, 28]. They may be accompanied Case Reports in Medicine by a concomitant cutaneous eruption [4] and cervical lymphadenopathy [9, 19, 29], which can occasionally dominate the clinical picture [30, 31]. Published case reports and case series testify the outstanding variability of clinical presentation. In 16 (80%) cases, oral lesions were either the first or most florid clinical sign, whereas in the remaining four patients (20%) they were part of a clinical picture already diagnosed as secondary syphilis. A comprehensive review of the literature shows that oral lesions have been described as solitary or multiple ulcerations [7, 14, 18, 23, 32, 33], as erosions [10, 14], as a bullous-erosive lesion resembling pemphigus vulgaris [34], as macular, papular, and nodular lesions [3, 14, 18], as condylomata lata [6], as leukoplakia-like [35, 36], as oral hairy leukoplakialike [8, 18] lesions, and as painless nodules on the tongue [37]. They are frequently described as painful oval or crescentic, slightly raised or shallow erosions. Mucous patches may also present as whitish plaques that may coalesce and form serpiginous lesions, referred to as snailtrack ulcers [36]. They present most often on the soft palate, pillars, tongue, and vestibular mucosa [4, 13, 18, 23, 35]. When the dorsal aspect of the tongue is affected, they will efface lingual papillae [11, 21]. At the angles of the mouth, the mucous patch may present as split papules, as recorded in our patient [19, 21, 22]. Reasonable precautions, such as glove wearing, should be taken when handling such lesions since they are reported to be the most infectious of all [5]. In the present case, these lesions were present on a background of a whitish, nonwipeable hyperkeratotic thickening of the posterior aspect of the tongue. The diagnosis of secondary syphilis was made based on full-history taking, clinical examination, absence of response to azole agents, positive serologic tests for syphilis, and fast remission after initiation of penicillin therapy. Histopathology can provide additional evidence of the diagnosis of syphilis [3, 20, 33, 38] and a biopsy would be required had the lesions not subsided completely. Therefore, a decision was made not to perform a biopsy for histopathological examination. Our patient complained of a burning mouth and dysgeusia that progressed to glossodynia. A burning mouth is occasionally reported as the first presentation of syphilis [39, 40]. In two recently published cases series (15 and 7 cases), pain was reported by all patients [14, 20] and symptoms were present from 5 to 120 days [20]. However, 3 painless oral lesions may also occur in secondary syphilis [11, 15, 23]. We are unaware of previous reports of dysgeusia and glossodynia as manifestations of oral syphilitic lesions. It is caused by diverse conditions such as glossitis, geographic tongue, xerostomia, glossopharyngeal nerve damage, and the use of certain drugs [41]. It ranges from obvious causes such as a neoplastic disease, ulcerative conditions, and tongue injury by a dental device, to many other diverse conditions, such as atrophic glossitis of nutritional deficiency and infectious disorders like trichinosis [41]. In the present case, complete clinical remission was rapidly achieved after initiation of penicillin therapy. Due to their transitory nature and heterogeneity of presentation, oral lesions of secondary syphilis are probably underdiagnosed when unaccompanied by tegumentary abnormalities. Udd and Lund [12] recently described a patient who sought relief of sore throat by visiting diverse clinics for more than 6 months. His symptoms were repeatedly attributed to fungal infection or aphthous stomatitis or simply were regarded as stress-related.
