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Trichloroethylene is a colorless liquid which is used as a solvent for cleaning metal parts purchase cheap estradiol line menstrual discharge. Drinking or breathing high levels of trichloroethylene may cause nervous system effects order estradiol 1mg visa women's health clinic rockingham wa, liver and lung damage estradiol 1 mg low price pregnancy 1, abnormal heartbeat buy estradiol 2 mg overnight delivery women's health center tallahassee, coma, and possibly death. When determining the total dissolved solids, a sample should be filtered before being poured into an evaporating dish and dried. Demineralization may be necessary in a treatment process if the water has a very high value Total Dissolved Solids. Ion exchange is an effective treatment process used to remove iron and manganese in a water supply. When determining the total dissolved solids, a sample should be filtered before being poured into an evaporating dish and dried. Demineralization may be necessary in a treatment process if the water has a very high value Total Dissolved Solids. Can be used to accomplish accurate and reliable remote monitoring and control over a long distribution system. A method of testing by adding a reagent of known strength to a water sample until a specific color change indicates the completion of the reaction. Generally, the higher the total alkalinity, the greater the resistance to pH change. If total coliform is present, the sample will also be tested for either fecal coliform or E. The weight per unit volume of all volatile and non-volatile solids dissolved in a water or wastewater after a sample has been filtered to remove colloidal and suspended solids. These systems do not have to test or treat their water for contaminants which pose long-term health risks because fewer than 25 people drink the water over a long period. It must meet or surpass all drinking water standards to be considered safe to drink. The most common class of disinfection by-products created when chemical disinfectants react with organic matter in water during the disinfection process. The most common class of disinfection by-products created when chemical disinfectants react with organic matter in water during the disinfection process. These tubes are approximately 1 inch deep and 36 inches long, split-hexagonal shape and installed at an angle of 60 degrees or less. These tubes provide for a very large surface area upon which particles may settle as the water flows upward. The slope of the tubes facilitates gravity settling of the solids to the bottom of the basin, where they can be collected and removed. The large surface settling area also means that adequate clarification can be obtained with detention times of 15 minutes or less. As with conventional treatment, this sedimentation step is followed by filtration through mixed media. Tubercles are formed due to joining dissimilar metals, causing electro- chemical reactions. A qualitative measurement of water clarity which results from suspended matter that scatters or otherwise interferes with the passage of light through the water. This agency sets federal regulations which all state and local agencies must enforce. For a given quantity of flow, the velocity head will vary indirectly as the pipe diameter varies. For a given quantity of flow, the velocity head will vary indirectly as the pipe diameter varies. Solidification of a vitreous solid occurs at the glass transition temperature (which is lower than melting temperature, Tm, due to super cooling). When the starting material is solid, vitrification usually involves heating the substances to very high temperatures. Vitrification may also occur naturally when lightning strikes sand, where the extreme and immediate heat can create hollow, branching rootlike structures of glass, called fulgurite. When applied to whiteware ceramics, vitreous means the material has an extremely low permeability to liquids, often but not always water, when determined by a specified test regime. The microstructure of whiteware ceramics frequently contain both amorphous and crystalline phases. The term often is used in a legal or regulatory context and in such cases the precise definition is a matter of law. The term may refer both to well characterized organic compounds and to mixtures of variable composition. The term often is used in a legal or regulatory context and in such cases the precise definition is a matter of law. The term may refer both to well characterized organic compounds and to mixtures of variable composition. Depending on the difference of electrical potential it is called extra low voltage, low voltage, high voltage or extra high voltage. It measures the potential energy of an electric field to cause an electric current in an electrical conductor. Depending on the difference of electrical potential it is called extra low voltage, low voltage, high voltage or extra high voltage. Each cell has a separate stalk anchored onto the substrate, which contains a contracile fibril called a myoneme. Reproduction is by budding, where the cell undergoes longitudinal fission and only one daughter keeps the stalk. Vorticella mainly lives in freshwater ponds and streams - generally anywhere protists are plentiful. A positive bacteriological sample indicates the presence of bacteriological contamination. Source water monitoring for lead and copper be performed when a public water system exceeds an action level for lead of copper. Weathered: The existence of rock or formation in a chemically or physically broken down or decomposed state. But there are some positive and negative charges in it, due to the formal charge, owing to the partial charges of its constituent atoms. The following are terms that will be found in this course, especially in the waterborne disease area and laboratory/sampling chapters. Community water system is a public water system which serves at least 15 service connections used by year-round residents, or regularly serves at least 25 year-round residents. Compliance cycle is the nine-year calendar year cycle during which public water systems must monitor. Contaminant is any physical, chemical, biological, or radiological substance or matter in water. Maximum contaminant level is the maximum permissible level of a contaminant in water which is delivered to any user of a public water system. Such term includes: any collection, treatment, storage, and distribution facilities under control of the operator of such system and used primarily in connection with such system; and any collection or pretreatment storage facilities not under such control which are used primarily in connection with such system. During any period when a State or Tribal government does not have primary enforcement responsibility pursuant to section 1413 of the Act, the term "State" means the Regional Administrator of the U.
The buccal mucosa proven 2mg estradiol menstruation after miscarriage, palate cheap 1mg estradiol menopause 60 years, and alveolar mucosa are the most common sites of involvement buy estradiol once a day women's health ucsf primary care. Differential diagnosis Verrucous leukoplakia generic 1 mg estradiol otc women's health center knoxville tn, papilloma, verruciform xanthoma, white sponge nevus, squamous-cell carcinoma. Squamous-Cell Carcinoma Squamous-cell carcinoma has a wide spectrum of clinical features (see p. In about 5–8% of cases, it appears in the early stages as a white asymptomatic plaque identical to leukoplakia (Fig. Biopsy and his- topathological examination are important for the diagnosis in these cases. Usage subject to terms and conditions of license 38 White Lesions Skin and Mucosal Grafts Definition Skin and mucosal grafts are often utilized in the oral cavity to cover mucosal defects after extensive surgery for benign and malig- nant tumors, or as free gingival graft. Clinical features Clinically, both forms of grafts (skin and mucosal) usually present as a whitish, or gray-white plaque (Figs. Occasionally, the color of the skin graft is black, due to melanin overproduction. The tongue, buccal mucosa, palate, gingiva and alveolar mucosa are the most common sites where skin and mucosal grafts are placed. Usage subject to terms and conditions of license 40 White Lesions Epithelial Peeling Definition Epithelial peeling is a relatively common superficial des- quamation (epitheliolysis) of the oral mucosa. Etiology It is caused by the direct irritating effect of toothpastes that contain sodium lauryl sulfate or pyrophosphates. Clinical features Clinically, epithelial peeling presents as superficial painless white plaques or dots that can be easily lifted fromthe oral mucosa (Figs. The buccal mucosa, lip mucosa, and mucobuccal and mucolabial folds are more frequently affected. The lesions usually disappear when the individual stops using these toothpastes or mouth- washes. Usage subject to terms and conditions of license Laskaris, Pocket Atlas of Oral Diseases © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license White Lesions 43 2 Red Lesions Red lesions are a large, heterogeneous group of disorders of the oral mucosa. Traumatic lesions, infections, developmental anomalies, allergic reactions, immunologically mediated diseases, premalignant lesions, malignant neoplasms, and systemic diseases are included in this group. The red color of the lesions may be due to thin epithelium, inflammation, dilatation of blood vessels or increased numbers of blood vessels, and extravasation of blood into the oral soft tissues. Usage subject to terms and conditions of license 44 Red Lesions Traumatic Erythema Definition and etiology Traumatic erythema occurs when a traumatic effect results in hemorrhage within the oral tissues. Clinical features Traumatic erythema can present either as an ecchy- mosis or as a hematoma. Clinically, it appears as an irregular, usually flat, area with a bright or deep red color (Fig. Differential diagnosis Hematomas due to anticoagulants, thrombocy- topenia, thrombasthenia. Thermal Burn Definition and etiology Thermal burns to the oral mucosa are fairly common, usually due to contact with very hot foods, liquids, or hot metal objects. Clinical features Clinically, the condition appears as a red, painful erythema that may undergo desquamation, leaving erosions (Fig. Differential diagnosis Chemical burn, traumatic lesions, herpes sim- plex, aphthous ulcers, drug reactions. Usage subject to terms and conditions of license 46 Red Lesions Radiation Mucositis Definition and etiology Oral radiation mucositis is a side effect of radiation treatment of head and neck tumors. Early reactions may begin at the end of the first week of radiotherapy, and consist of erythema and edema of the oral mucosa (Fig. Xerostomia, loss of taste, and burning and pain during mastication, swallowing, and speech are common. Differential diagnosis Mycositis due to chemotherapy, graft-versus- host disease, erythema multiforme, herpetic stomatitis, lichen planus. Cessation of the radiation treatment, B-com- plex vitamins, and sometimes low doses of steroids are indicated. Etiology Orogenital sex and the negative pressure or repeated “irrita- tion” applied during fellatio. Clinical features The lesions present as petechiae, erythema, or ecchy- moses usually at the junction of the soft and hard palate (Fig. They disappear spontaneously within a week, and the diagnosis is made on the basis of the history and the clinical features. Differential diagnosis Thermal burn, trauma, erythematous candidia- sis, infectious mononucleosis, thrombocytopenic purpura, leukemia. Usage subject to terms and conditions of license 48 Red Lesions Geographic Tongue Geographic tongue or erythema migrans (see also p. Characteristically, the lesions persist for a short time in one area, disappear within a few days, and then develop in another area. The dorsal surface of the tongue is the site of predilection, but infrequently the lesions may appear at other mucosal sites. Differential diagnosis Psoriasis, Reiter syndrome, plasma-cell stoma- titis, mucous patches of secondary syphilis, candidiasis. Median Rhomboid Glossitis Definition Median rhomboid glossitis is a rare condition that occurs exclusively on the dorsumof the tongue. Clinical features It presents as a well-demarcated erythematous rhomboid area along the midline of the dorsum of the tongue, immedi- ately anterior to the circumvallate papillae (Fig. Differential diagnosis Candidiasis, lymphangioma, geographic tongue, syphilis, hemangioma, non-Hodgkin lymphoma. Usage subject to terms and conditions of license 50 Red Lesions Denture Stomatitis Definition Denture stomatitis, or denture sore mouth, is a frequent condition in patients who wear dentures continuously for extended times. Etiology Mechanical irritation fromdentures, Candida albicans,ora tissue response to microorganisms living beneath the dentures. Clinical features The condition is characterized by diffuse erythema, edema, and sometimes petechiae and white spots that represent accu- mulations of candidal hyphae, almost always located in the denture- bearing area of the maxilla (Fig. Clinically, it is characterized by erythematous patches or large areas, usually located on the dorsumof the tongue and palate (Fig. Usage subject to terms and conditions of license 52 Red Lesions Squamous-Cell Carcinoma The early stage of squamous-cell carcinoma (see also p. The clinical features are identical to erythroplakia, erythematous candidiasis, or contact reactions to dental materials. Usage subject to terms and conditions of license 54 Red Lesions Erythroplakia Definition Erythroplakia, or Queyrat erythroplasia, is a premalignant lesion frequently occurring on the glans penis, and rarely on the oral mucosa. It is defined as a red, nonspecific patch or plaque that cannot be classified clinically and pathologically under any other disease.
Male to female an average incubation period of three weeks purchase 2mg estradiol with mastercard pregnancy outside the uterus, the ratio is high in chancroid buy 1 mg estradiol amex womens health kaiser roseville, and this ratio leads one lesion begins as a red bump that ulcerates and then to infer that prostitutes are involved in transmis- heals within several weeks discount 1 mg estradiol with visa menstrual girls. Both men and women are symptomatic discount estradiol american express womens health magazine, but often female prostitutes with ulcers do not seek chancroid A sexually transmitted disease that is medical treatment. These lesions are believed to be characterized by a papule that turns into a pustule a major risk factor for the heterosexual spread of that ulcerates and becomes painful. Cause Diagnosis/Testing It is an ulcerative lesion, caused by Haemophilus ducreyi, which can affect the vulva, vagina, cervix, A Gram stain of an ulcer that reveals gram-nega- urethra, penis, or anus. Chancroid is an endemic tive rods in chains (“schools of ﬁsh”) suggests the disease in Korea and Vietnam and is highly diagnosis of chancroid. This disease has decreased in late agar with vancomycin may yield a positive the United States, the peak number of cases since result, and a biopsy specimen is diagnostic. Chancroid is a genital ulcerative out the diagnosis of syphilis, which is curable. The end of epi- lates reported to have intermediate resistance to demics in North American cities coincided with them. The ulcers and lymph nodes usually take the widespread use of the antibiotic ceftriaxone approximately 10 days to heal. If that is the reason for times the lymph nodes become fluctuant and the demise of the epidemic, it points to the many have to be drained. These usually are painful red become the leading cause of death in children and ulcers, with ragged borders and yellow–gray young adults in some parts of the United States. The natural out- chronic yeast infections, skin infections, pneumonia, come of this silent stage is that the disease may not and other infections that healthy children rarely get. Caregivers should use gloves when changing tion recommends chlamydia testing at least once a diapers and when cleaning up blood and body ﬂuids, year for all sexually active women up to age 19, and they should quickly wash with soap and water and annual testing for any woman 20 or older who when breast milk is spilled onto skin. Children is at risk (does not use condoms and has had a new should not be allowed to share toothbrushes. Only about a givers should disinfect surfaces that are splashed with third of doctors routinely screen their young blood or body ﬂuids, cover any open wounds, and female patients for chlamydia. The inexpensive, quick test for this infec- tion uses a dye to detect bacterial proteins. This can Chlamydia trachomatis Chlamydia is the most be done during a routine checkup. This will facilitate characterized by swelling and inﬂammation of the screening, making it simpler than in the past. In or more than one sex partner during the last Chlamydia trachomatis 25 three months, and women 24 and older who Concerned about the high rate of this disease, meet both criteria. Researchers report pelvic inﬂammatory disease, a common culprit in that about 4 million cases are diagnosed in the future ectopic pregnancy and infertility in women. Aggressive treatment of chlamydia is imperative Treatment and should be considered if there is any evidence Once an individual receives a diagnosis of chlamy- whatsoever of uterine spread. This could be a allowed to reach the fallopian tubes, the woman is one-day course of azithromycin or seven days of at risk for scarring, tubal obstruction, ectopic preg- doxycycline. It is estimated that in about 40 percent of scribes azithromycin, erythromycin, or amoxicillin. Furthermore, of pleting the medicine, the patient should return to those 40 percent, about 18 percent have chronic the doctor for follow-up evaluation. All sex partners should be evaluated and A woman who has chlamydia has a greatly treated to prevent reinfection. About 60 percent of days after treatment to be sure the problem is babies who are exposed to chlamydia infection at eradicated. Intercourse should be avoided until fol- birth have pneumonia or chlamydial eye infections. It is common for people to infect sexual partners, Chlamydia can also cause proctitis (inﬂamed rec- because chlamydial infection often is present in the tum), conjunctivitis (inflammation of the lining absence of symptoms. Those who have multiple of the eye), and trachoma—the most common pre- sex partners, especially women 25 or younger, ventable cause of blindness worldwide. People who Women should be made aware of the complica- are sexually active and use condoms or diaphragms tions associated with chlamydia, and it is important during intercourse may reduce the likelihood of to note that when a woman has chlamydia infec- transmission of chlamydia. Usually performed on newborn Psychosocial Issues infants, circumcision has an element of preven- A woman who is diagnosed with chlamydia often tive maintenance, and, in some cultures, this is very concerned about her ability to have chil- relates to religious customs. Some researchers dren—a situation the woman must live with conjecture that absence of circumcision makes a because treating the disease may not prevent its man more likely to contract sexually transmitted causing infertility. More uncircumcised than circumcised women about their future reproductive ability. Researchers con- transmitted disease, they feel anxiety about their cluded that there was ample reason to look at future fertility, and they often experience difﬁculty issues of safety, acceptability, feasibility, and cost- in disclosing the infection to partners. Women effectiveness of promoting male circumcision in report feelings ranging from self-disgust to distress. Causes of cirrhosis include hepatitis, alco- Research holism, autoimmune diseases, chronic heart fail- In the article “Chlamydia Toxin and Chronic Ill- ure, and chronic obstruction of the bile duct. About 30 percent of those with hepatitis C Chlamydia trachomatis that produces a toxin respon- ultimately have cirrhosis of the liver. This discov- ple in whom cirrhosis develops, about 20 percent ery also helps explain why only some strains of C. It was the sequenc- is a problem because this has carried over into var- ing of the organism’s entire genome that provided ious forms of discrimination that hamper the indi- answers. Examples are job harassment Infectious Diseases’ Rocky Mountain Laboratories and firing, housing discrimination, and public in Hamilton, Montana, Harlan Caldwell, Ph. The hope is that this ﬁnding will of transmission, pros and cons of prevention and lead the way to antitoxin vaccines (Proceedings of the educational efforts as means of promoting behav- National Academy of Sciences, early edition online, ior that is sexually “deviant” or promiscuous, uni- November 13, 2001). This compla- glean information on the epidemiological charac- cency manifests itself in relaxed attitudes toward teristics of diseases. Some pundits argue that many tis has symptoms of diarrhea, abdominal pain, and Americans are also convinced that a cure for bloody stools. This is done with alternate or simulta- infected, and 17 percent were “less safe” about sex neous administration of the drugs. Subjects were 693 gay and bisexual men the evolution of drug-therapy-resistant strains. The upshot was that Concorde cells, red blood cell count, hemoglobin level, and appeared to shoot down the gains that had been platelet count. Conducted in Great Britain, endorse and promote the use of condoms, but France, and Ireland as a project of the British high-risk practices remain common, as 13 percent Medical Research Council and the French of men and 5 percent of women in U. It is no secret that genital, anal, and oral rate or disease progression in the two groups.
The first cleanse may rid you of them for a few days 1 mg estradiol overnight delivery womens health redding ca, but as the stones from the rear travel for- ward generic 2mg estradiol otc women's health center in santa cruz, they give you the same symptoms again buy estradiol 1mg mastercard womens health kaiser roseville. Sometimes the bile ducts are full of cholesterol crystals that did not form into round stones purchase generic estradiol line pregnancy calculator due date. My opinion is based on over 500 cases, including many persons in their sev- enties and eighties. However it can make you feel quite ill for one or two days afterwards, although in every one of these cases the maintenance parasite program had been neglected. This is why the instructions direct you to complete the parasite and kidney rinse programs first. I like to think I have perfected this recipe, but I certainly can not take credit for its origin. It is easy to understand why this is thought: by the time you have acute pain attacks, some stones are in the gallbladder, are big enough and sufficiently calcified to see on X-ray, and have caused in- flammation there. When the gallbladder is removed the acute attacks are gone, but the bursitis and other pains and digestive problems remain. People who have had their gall- bladder surgically removed still get plenty of green, bile-coated stones, and anyone who cares to dissect their stones can see that the concentric circles and crystals of cholesterol match textbook pictures of “gallstones” exactly. Lugol’s Iodine Solution It is too dangerous to buy a commercially prepared solution. The recipe to make 1 liter (quart) is: 44 gm (1½ ounces) iodine, granular 88 gm (3 ounces) potassium iodide, granular Dissolve the potassium iodide in about a pint of the water. Most of the organisms listed below are dead on commer- cially available and prepared slides (see Sources for biological supply companies). Some testing was done with a more accurate frequency generator at a lower power level so some bandwidths are reported much more narrowly. If the same person retests the same specimens with the same equipment within a few days, the results will be absolutely identical (within 1 Hz) 90% of the time. Some specimens have more than one range listed; this may be characteristic of the organism or may be due to having an undocumented organism on the same microscope slide. Blank locations represent organisms for whom there are prepared slides available, but whose bandwidth has not been determined. Tapeworms can have very large bandwidths (range of fre- quencies), and it varies by the length of the specimen! If you accidentally kill middle segments instead of working your way up from the bottom, you may conceivably promote dispersion! Finding out the frequencies of these illnesses helps you identify them (use the Pathogen Frequency Chart) and also lets you know if you are chronically getting them back. This is because I never could find them present in the white blood cells, and I finally gave up searching for them. Most of them were obtained as Atomic Absorption Standard Solutions and are, therefore, very pure. They were stored in ½ ounce amber glass bottles with bakelite caps and permanently sealed with plastic film since testing did not require them to be opened (they get close enough to the frequency field). The exact concentration and the solubility characteristics are not important in this qualitative test. The main sources of these substances in our environment are given beside each item. These are chemicals, very pure, obtained from chemical supply companies, unless other- wise stated. Only the vitamin sources listed were found to be pollution-free, and only the herb sources listed were found to be potent, although there may be other good sources that have not been tested. The author has no financial interest in, influence on, or other connection with any company listed, except for having family members in the Self Health Resource Center. Note to readers outside the United States of America: Sources listed are typically companies within the United States because they are the ones I am most familiar with. You may be tempted to try a more convenient manufacturer in your own country and hope for the best. This chapter will be updated as I be- come aware of acceptable sources outside the United States. Bando American makes other belts, some of which might be the right size for your dryer. Call for a dealer near you, make sure it says "Made In America", right on the belt. Black cherry concentrate Health food store Black Walnut Hull Tincture Self Health Resource Center, New Action Products Borax, pure Grocery store Boric acid, pure Now Foods, health food store, pharmacy Cascara sagrada Natures Way, health food store Chemicals for testing. Citric acid Now Foods or health food store Cloves San Francisco Herb & Natural Food Co. Hydrogen peroxide 35% New Horizons Trust (food grade) Iodine, pure Spectrum Chemical Co. Lysine Bronson Pharmaceuticals Magnesium oxide Bronson Pharmaceuticals Marshmallow root (herb) San Francisco Herb & Natural Food Co. Niacin 100 mg or 250 mg time release, Bronson Pharmaceuticals Ornithine Now Foods, Jomar Labs Ortho-phospho-tyrosine Aldrich Chemical Co. Rascal Kroeger Herb Products, New Action Products (as Raz-Caps) Salt (sodium chloride), Spectrum Chemical Co. Vitamin E capsules Bronson Pharmaceuticals Vitamin E Oil Now Foods Washing soda (sodium Grocery store carbonate) Water filter pitchers Pure Water Products Wormwood capsules Self Health Resource Center, Kroeger Herb Products, New Action Products Zinc Bronson Pharmaceuticals Zinc oxide Spectrum Chemical Co. The living things are both large and small: from worms we can see, to microscopic bacteria, viruses and fungi. The non living things are pollutants in our air, food, dental metal and body products. The good news is that our body can reclaim its sovereignty by throwing the rascals out. With the new electronic insights and technology, our parasitic invaders can be vanquished with the closing of a switch. The tragedies of surgery, organ replacements, radiation, chemotherapies, doses of drugs, even death can be avoided. Killing your invaders is an easy matter: you simply purchase or build the device that can do that and take the proper herbs. Cleaning up dentalware is under your control, too—a financial expense not beyond your reach, hopefully. Trading your body products for unpolluted varieties is a job but not insurmountable. Use your new wisdom and sharp eye to choose a new dwelling as free of pollutants as you can. They allow invaders into the most jealously guarded recess of your being: your genes.
Surveillance by health authorities of the extent and progress of outbreaks and reporting of ﬁndings to the community are important buy discount estradiol 2mg line women's health clinic buffalo ny. Disaster implications: Aggregations of people in emergency shelters will favor outbreaks of disease if the virus is introduced cheap 1 mg estradiol fast delivery women's health clinic jacksonville fl. Identiﬁcation—An acute febrile purchase discount estradiol on line menopause quiz, self-limited cheap estradiol online ucsf mt zion women's health center radiology, systemic vasculitis of early childhood, presumably of infectious or toxic origin. Clinically characterized by a high, spiking fever, unresponsive to antibiotics, associ- ated with pronounced irritability and mood change; usually solitary and frequently unilateral nonsuppurative cervical adenopathy; bilateral non- exudative bulbar conjunctival injection; an enanthem consisting of a “strawberry tongue”, injected oropharynx or dry ﬁssured or erythematous lips; limb changes consisting of oedema, erythema or periungual/general- ized desquamation; and a generalized polymorphous erythematous exan- them that can be truncal or perineal and ranges from morbilliform maculopapular rash to urticarial rash or vasculitic exanthem. Typically there are 3 phases: 1) acute febrile phase of about 10 days characterized by high, spiking fever, rash, adenopathy, peripheral ery- thema or oedema, conjunctivitis and enanthem; 2) subacute phase lasting about 2 weeks with thrombocytosis, desquamation, and resolution of fever; 3) lengthy convalescent phase during which clinical signs fade. According to Diagnostic Guidelines of Kawasaki Disease (Japan Kawasaki Disease Research Committee, 2002), at least 5 of the following 6 principal symptoms should be satisﬁed, although patients with 4 principal symptoms can be diagnosed when coronary aneurysm or dilatation is recognized by two-dimensional echocardiography or coronary angiography: 1) Fever persisting 5 days or more (including cases in whom the fever has subsided before the 5th day in response to treatment); 2) bilateral conjunctival congestion; 3) changes of lips and oral cavity: reddening of lips, strawberry tongue, diffuse injection of oral and pharyn- geal mucosa, 4) polymorphous exanthema, 5) changes of peripheral extremities: reddening of palms and soles, indurative oedema in the initial stage, and membranous desquamation from ﬁngertips in the convalescent stage, 6) acute nonpurulent cervical lymphadenopathy 2. Postulated to be a superantigen bacterial toxin secreted by Staphylococcus aureus or group A strepto- cocci, but this has neither been conﬁrmed nor generally accepted. Occurrence—Worldwide; most cases (around 170 000) reported from Japan, with nationwide epidemics documented in 1979, 1982 and 1986. In Japan, where the disease has been tracked since 1970, peak incidence occurred in 1984–85. Since then, the incidence rate has been steady, about 140 per 100 000 children under 5. Mode of transmission—Unknown; no ﬁrm evidence of person-to- person transmission, even within families. Seasonal variation, limitation to the pediatric age group and outbreak occurrence in communities are all consistent with an infectious etiology. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Clusters and epidemics should be reported immediately, Class 5 (see Reporting). Recourse to high doses of aspirin is recom- mended during the acute phase, followed by low doses for at least 2 months. Epidemic measures: Investigate outbreaks and clusters to elucidate etiology and risk factors. Onset is gradual, with malaise, fever, headache, sore throat, cough, nausea, vom- iting, diarrhea, myalgia and chest and abdominal pain; fever is persistent or spikes intermittently. About 80% of human infections are mild or asymptomatic; the remaining cases have severe multisystem disease. In severe cases, hypotension or shock, pleural effusion, hemor- rhage, seizures, encephalopathy and oedema of the face and neck are frequent, often with albuminuria and hemoconcentration. Transient alope- cia and ataxia may occur during convalescence, and eighth cranial nerve deafness occurs in 25% of patients, of whom only half recover some function after 1–3 months. The overall case-fatality rate is about 1%, up to 15% among hospitalized cases and even higher in some epidemics. The rate is particularly high among women in the third trimester of pregnancy and fetuses. Heating serum at 60°C (140°F) for 1 hour will largely inactivate the virus, and the serum can then be used to measure heat-stable substances such as electrolytes, blood urea nitrogen or creati- nine. Infectious agent—Lassa virus, an arenavirus, serologically related to lymphocytic choriomeningitis, Machupo, Junı´n, Guanarito and Sabia´ viruses. Serologically related viruses of lesser virulence for laboratory hosts in Mozambique and Zimbabwe have not yet been associated with human infection or disease. Reservoir—Wild rodents; in western Africa, the multimammate mouse of the Mastomys species complex. Mode of transmission—Primarily through aerosol or direct con- tact with excreta of infected rodents deposited on surfaces such as ﬂoors and beds or in food and water. Period of communicability—Person-to-person spread may theo- retically occur during the acute febrile phase when virus is present in the throat. Susceptibility—All ages are susceptible; the duration of immunity following infection is unknown. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Individual cases should be reported, Class 2 (see Reporting). Nosocomial transmission has occurred, and strict procedures for isola- tion of body ﬂuids and excreta must be maintained. Re- course to a negative pressure room and respiratory protec- tion is desirable, if possible. Male patients should refrain from unprotected sexual activity until the semen has been shown to be free of virus or for 3 months. To reduce infectious exposure, laboratory tests should be kept to the minimum necessary for proper diagnosis and patient care, and only performed where full infection control measures are correctly implemented. Technicians must be alerted to the nature of the specimens and supervised to ensure application of appropriate specimen inactivation/isolation procedures. Dead bodies should be sealed in leakproof material and cremated or buried promptly in a sealed casket. Establish close surveillance of contacts as follows: body temperature checks at least 2 times daily for at least 3 weeks after last exposure. Deter- mine patient’s place of residence during 3 weeks prior to onset; search for unreported or undiagnosed cases. Epidemic measures: Rodent control; adequate infection con- trol and barrier nursing measures in hospitals and health facilities; availability of ribavirin; contact tracing and follow-up. Disaster implications: Mastomys may become more numer- ous in homes and food storage areas and increase the risk of human exposures. International measures: Notiﬁcation of source country and to receiving countries of possible exposures by infected travel- lers. In Legionnaire disease, a chest X-ray may show patchy or focal areas of consolidation that may progress to bilateral involvement and ultimately to respiratory failure; the case-fatality rate has been as high as 39% in hospitalized cases; it is generally higher in those with compromised immunity. Pontiac fever has the same initial symptoms as pulmonary legionellosis (including productive cough) but is not associated with pneumonia or death; patients recover spontaneously in 2–5 days without treatment; this clinical syndrome may represent reaction to inhaled antigen rather than bacterial invasion. Infectious agent—Legionellae are poorly staining, Gram-negative bacilli that require cysteine and other nutrients to grow in vitro. In all, 35 species of Legionella with at least 45 serogroups are currently recognized. Since then, the disease has been identiﬁed throughout North America, as well as in Africa, Australia, Europe and South America. Although cases occur throughout the year, both sporadic cases and outbreaks are recognized more com- monly in summer and autumn. The proportion of cases of community-acquired pneumonias due to Legionella ranges between 0. Epidemic Pontiac fever has shown a high attack rate (about 95%) in several outbreaks. Hot water systems (show- ers), air conditioning cooling towers, evaporative condensers, humidiﬁers, whirlpool spas, respiratory therapy devices and decorative fountains have been implicated epidemiologically; the organism has been isolated from water in these, as well as from hot and cold water taps and showers, hot tubs and from creeks and ponds and the soil from their banks.
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