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The incidence of new cases has steadily declined since then impotence treatment after prostate surgery buy cheap viagra with dapoxetine 50/30mg on line, and the disease is now very rare (Hueston and Bryant 2005) low testosterone causes erectile dysfunction order viagra with dapoxetine 100/60 mg. All the species affected belonged to either the Bovidae or Felidae family erectile dysfunction without pills viagra with dapoxetine 50/30mg free shipping, with the exceptions of a small number of non-human primates (Imran and Mahmood 2011b) statistics of erectile dysfunction in india buy viagra with dapoxetine 100/60 mg with visa. Dogs and C horses express PrP with a very stable structure that is resistant to mis-folding erectile dysfunction solutions order discount viagra with dapoxetine line, and these Sc species are resistant to infection with PrP (Harman and Silva 2009; Zhang 2011) erectile dysfunction and alcohol discount 50/30mg viagra with dapoxetine free shipping. Mechanically recovered beef is more likely to be contaminated with infective material 5 in the spinal cord, and recovery of beef by this method is no longer permitted for human foodstuffs across Europe. In addition, mechanical recovery of meat from bones is prohibited in order to prevent inclusion of dorsal root ganglia, which may contain infectivity. Beef and beef products from countries with these and animal feed control systems are therefore considered to be safe for human consumption. Approximately 40% of Caucasians are homozygous for methionine (Met) at this position, 10% are homozygous for valine (Val) and 50% are Met/Val heterozygotes. Two of three PrP positive samples in an anonymous postsurgical study of appendices were from Val/Val homozygotes. This indicates that lymphoid tissue, at least, of 6 all three genotypes may become infected (Harman and Silva 2009; Will 2010; Mackay et al. The mean incubation period of kuru is 12 years, but the incubation period has exceeded 50 years in some individuals (Imran and Mahmood 2011a). Retrospective analysis of blood samples from kuru patients shows an age stratification of codon 129 genotype. The young kuru patients were mainly Met/Met or Val/Val homozygotes, whereas the elderly patients were mostly Met/Val heterozygotes. Eight of eleven of the more recent cases of kuru were Met/Val heterozygotes, which supports the hypothesis that the Met/Val genotype delays but does not prevent the onset of kuru in all individuals, because exposure of these individuals almost certainly ended more than 40 years ago when funerary cannibalism was outlawed (Mackay et al. Possible explanations include a higher rate of dietary exposure, increased susceptibility to infection or a reduced incubation period in this age group. Infective dose It appears that ingestion of less than 1 mg of infected brain material may be sufficient to transmit infection between cattle (Harman and Silva 2009). Virology Journal 8:559 Imran M, Mahmood S (2011b) An overview of animal prion diseases. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 2 Welcome Welcome to the Cirrhosis Management Program at the University of Michigan. As your healthcare team, we take pride in doing everything possible to maximize your health. You, the patient, can make an enormous difference in your health by eating right, taking your medications properly, and taking control of your disease management. To schedule an appointment, call: 888-229-7408 To speak with a nurse, call: 800-395-6431 What is the liver The liver has many important functions including Preventing infections Removing bacteria and toxins from the blood Digesting food and processing medications and hormones Making proteins that help the blood clot Storing vitamins, minerals, fats, and sugars for use by the body Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 3 What is liver cirrhosis When something attacks and damages the liver, liver cells are killed and scar tissue is formed. Any illness that affects the liver over a long period of time may lead to fibrosis and, eventually, cirrhosis. Heavy drinking and viruses (like hepatitis C or B) are common causes of cirrhosis. Cirrhosis may be caused by a buildup of fat in the liver of people who are overweight or have diabetes. This prevents blood from flowing through the liver easily and causes the build-up of pressure in the portal vein, the vein that brings blood to the liver. To relieve this pressure, the blood goes around the portal vein, through other veins. Some of these veins, called varices, can be found in the pipe that carries food from your mouth to your stomach (the esophagus) or in your stomach itself. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 4 Portal hypertension also causes blood to back up into another organ called the spleen. With cirrhosis, blood is blocked from entering the liver and toxic substances that the liver normally filters escapes into general blood circulation. This cancer can occur if some of the sick liver cells start to multiply out of control. There may be no signs of liver cancer until the cancer has grown very large and causes pain. In fact, a person may live many years with cirrhosis without being aware that her liver is scarred. But if nothing is done about the cause of cirrhosis (for example, if the person continues to drink alcohol, or if hepatitis or other causes of cirrhosis are not treated), the pressure in the portal vein gets higher and the few remaining healthy liver cells are not able to do all the work for the entire liver. At that point, you may notice symptoms like low energy, poor appetite, weight loss, or loss of muscle mass. As the disease progresses symptoms become more severe and may be life threatening. Backup of blood from the scarred liver may cause the veins in the wall of the esophagus to enlarge. The pressure inside the enlarged veins, called esophageal varices, is higher than normal. The increased pressure can cause the Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 6 veins to burst, leading to sudden and severe bleeding. Signs of bleeding varices include vomiting of large amounts of fresh blood or clots. People who have signs of bleeding varices should go to an emergency room immediately. If you vomit blood or your stool turns black and tarry, you must Unless the varices break and go to the emergency room bleed, patients have no symptoms immediately. Larger varices have a higher risk of breaking and bleeding, and if you have them your doctor will start treatment with medications called Beta Blockers. They include Propranolol (Inderal ), taken twice a day Nadolol (Corgard ), taken once a day Carvedilol (Coreg ), taken twice a day Your doctor will generally start you on a very low dose of one of these drugs and check your heart rate (pulse). The goal of treatment is to give you enough of one of these drugs to reduce your heart rate by 25%. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 7 Most people with low blood pressure tolerate beta blockers well. With this procedure the doctor creates an internal tunnel in the liver that reduces blood flow and pressure in varices. Managing ascites Another problem caused by high pressure in the veins of the liver is ascites. The most dangerous problem associated with ascites is infection, which can be life threatening. If you have ascites and you suddenly get a fever or new belly pain, you must go to the emergency room immediately. Abdominal Anatomy the abdominal cavity (the belly) contains the digestive organs such as the stomach, intestines and liver. Ascites is a medical condition in which excess fluid begins to puddle within the abdominal cavity. This fluid is outside of the intestines and collects between the abdominal wall and the organs within. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 8 Causes of Ascites Liver disease is the most common cause of ascites. This scar tissue changes the normally smooth liver surface to a lumpy surface that blocks the blood from exiting the liver. This condition causes the surface of the liver to "weep" fluid into the abdominal cavity. There may be a loss of appetite, frequent heartburn, fullness after eating, or abdominal pain. Eventually, there is swelling of the abdomen that looks similar to the later stages of pregnancy. During the day, gravity may carry some of the fluid down into the scrotum (the sac that hold the testicles) or legs causing swelling, (edema). As the condition worsens, however, the swelling may spread up the leg and be present day and night. As more fluid builds up, it may spread up to the chest and cause difficulty breathing. If infection, cancer, or heart failure is the cause, the treatment is directed appropriately to the underlying problem. However, in the majority of patients, ascites is a sign of advanced liver failure, or cirrhosis of the liver. The basis of treatment includes: Avoiding further liver damage Patients who drink alcohol must stop all alcohol consumption. Dietary sodium intake is usually restricted to less than 2000 mg per day (about 1 teaspoon). If there is no weight loss in the first two weeks, the dose is gradually increased up to a maximum of 400 mg of spironolactone and 160 mg of furosemide daily. Response to treatment varies and finding out which treatment plan works best for you takes time, as the doctor adjusts the dose of medications over a period of weeks or months. Tap provides a very quick relief of ascites symptoms, but it does not correct the underlying cause so the fluid eventually returns. You must follow strict sodium restriction and diuretic therapy in order to slow down the re-accumulation of fluid. Tap also has some serious side effects: o Removing 5 liters or more at one time can cause a drop in blood pressure, and kidney damage. This is especially true in patients taking diuretics (which may cause reduced kidney function and changes in the blood levels of sodium and potassium). The best way, you, the patient, can help the doctors manage your fluid problem is by recording your weight and dose of water pills (diuretics) you take every day. Use the log on page 27 of the toolkit to record your weight and diuretic dose daily. Symptoms include fever and abdominal pain but these symptoms may be absent during the early stages. After the first episode of peritonitis you will have to take an antibiotic pill to prevent recurrence of peritonitis. Even patients who have never had peritonitis, but need frequent paracentesis (Tap), may need to take antibiotics to prevent this infection from developing. Rapid kidney failure in people with cirrhosis who have ascites has a 90% chance of death if liver transplant is not performed. Liver transplant is the best treatment in appropriate candidates, but unfortunately, not all patients qualify for this procedure. Managing Hepatic Encephalopathy A poorly working liver may not be able to get rid of toxic substances like ammonia (which comes from the intestines), and it may allow these substances to go into the brain and cause confusion. Besides confusion, toxins in the brain cause changes in sleep, mood, concentration, and memory. If you have encephalopathy, you may have problems driving, writing, calculating, and performing other activities of daily living. Encephalopathy may occur when you have an infection or when you have internal bleeding. It may also occur if you are constipated or take too many water pills or take tranquilizers or sleeping pills. Having elevated ammonia in the blood does not necessarily mean you have this diagnosis.

Narcosis General and nonspecific reversible depression of neuronal excitability impotence mental block discount viagra with dapoxetine 50/30mg with mastercard, produced by a number of physical and chemical agents erectile dysfunction shake recipe purchase viagra with dapoxetine pills in toronto, usually resulting in stupor rather than in anesthesia erectile dysfunction opiates order viagra with dapoxetine 100/60mg fast delivery. Necrosis Pathologic death of one or more cells erectile dysfunction forum cheap viagra with dapoxetine online master card, or of a portion of tissue or organ erectile dysfunction pills in malaysia purchase 50/30mg viagra with dapoxetine with visa, resulting from irreversible damage how do erectile dysfunction pills work discount viagra with dapoxetine on line. Nephropathia epidemica A generally benign form of epidemic hemorrhagic fever reported in Scandinavia. A-6 Neutrophilia An increase of neutrophilic leukocytes in blood or tissues; also frequently used synonymously with leukocytosis, inasmuch as the latter is generally the result of an increased number of neutrophilic granulocytes in the circulating blood (or in the tissues, or both). Oropharynx the portion of the pharynx that lies posterior to the mouth; it is continuous above with the nasopharynx via the pharyngeal isthmus and below with the laryngopharynx. Pancytopenia Pronounced reduction in the number of erythrocytes, all types of white blood cells, and the blood platelets in the circulating blood. Pandemic Denoting a disease affecting or attacking the population of an extensive region, country, continent; extensively epidemic. Parasitemia The presence of parasites in the circulating blood; used especially with reference to malarial and other protozoan forms, and microfilariae. Passive immunity Providing temporary protection from disease through the administration of exogenously produced antibody. Percutaneous Denoting the passage of substances through unbroken skin, for example, by needle puncture, including introduction of wires and catheters. Pharyngitis Inflammation of the mucous membrane and underlying parts of the pharynx. Polymorphonuclear Having nuclei of varied forms; denoting a variety of leukocyte. Shock associated with sepsis, usually associated with abdominal and pelvic infection complicating trauma or operations; 2. Shigellosis Bacillary dysentery caused by bacteria of the genus Shigella, often occurring in epidemic patterns. Stridor A high-pitched, noisy respiration, like the blowing of the wind; a sign of respiratory obstruction, especially in the trachea or larynx. Superantigen An antigen that interacts with the T cell receptor in a domain outside of the antigen recognition site. This type of interaction induces the activation of larger numbers of T cells compared to antigens that are presented in the antigen recognition site. Tachycardia Rapid beating of the heart, conventionally applied to rates over 100 per minute. Thrombocytopenia A condition in which there is an abnormally small number of platelets in the circulating blood. A-8 Toxoid A modified bacterial toxin that has been rendered nontoxic (commonly with formaldehyde) but retains the ability to stimulate the formation of antitoxins (antibodies) and thus producing an active immunity. Urticaria An eruption of itching wheals, usually of systemic origin; it may be due to a state of hypersensitivity to foods or drugs, foci of infection, physical agents (heat, cold, light, friction), or psychic stimuli. Vaccine A suspension of attenuated live or killed microorganisms (bacteria, viruses, or rickettsiae), or fractions thereof, administered to induce immunity and thereby prevent infectious disease. Vaccinia An infection, primarily local and limited to the site of inoculation, induced in man by inoculation with the vaccinia (coxpox) virus in order to confer resistance to smallpox (variola). On about the third day after vaccination, papules form at the site of inoculation which become transformed into umbilicated vesicles and later pustules; they then dry up, and the scab falls off on about the 21st day, leaving a pitted scar; in some cases there are more or less marked constitutional disturbances. Varicella An acute contagious disease, usually occurring in children, caused by the varicella zoster virus, a member of the family Herpesviridae, and marked by a sparse eruption of papules, which become vesicles and then pustules, like that of smallpox although less severe and varying in stages, usually with mild constitutional symptoms; incubation period is about 14 to 17 days. The first inoculation for smallpox is said to have been done in China about 1022 B. Zoonosis An infection or infestation shared in nature by humans and other animals that are the normal or usual host; a disease of humans acquired from an animal source. Use care when handling sharps and use a mouthpiece or other ventilation device as an alternative to mouth-to-mouth resuscitation when practical. Conventional Diseases requiring Airborne Precautions: Measles, Varicella, Pulmonary Tuberculosis. Fully immunized (completed 6 shot primary series and up-to-date on annual boosters, or 3 doses within past 6 mo): continue antibiotics for at least 30 days. Potential additional antibiotics include one or more of the following: clindamycin, rifampin, gentamicin, macrolides, vancomycin, imipenem, and chloramphenicol. Cutaneous anthrax acquired from natural exposure could be treated with 7-10 days of antibiotics. Ciprofloxacin is a possible alternative, but has been associated with increased relapse rates in animal treatment models. For this reason, most experts feel initial therapy of glanders should be based on proven therapy for the similar disease, melioidosis. Severe Disease: If ceftazidime or a carbapenem are not available, ampicillin/sulbactam or other intravenous beta lactam/beta-lactamase inhibitor combinations may represent viable, albeit less-proven alternatives. A minimum of 10 days of therapy is recommended (treat for at least 3-4 days after clinical recovery). Although not licensed for use in treating plague, gentamicin is the consensus choice for parenteral therapy by many authorities. Alternate therapy or prophylaxis for susceptible strains: trimethoprim-sulfamethoxazole Other fluoroquinolones or tetracyclines may represent viable alternatives to ciprofloxacin or doxycycline, respectively. Significant side effects if administered inappropriately; sterile abscesses if prior exposure/skin testing required prior to vaccination. Initiation of postexposure prophylaxis within 7 days of exposure merely delays incubation period of disease. Tetracyclines are preferred antibiotic for treatment of acute Q fever except in: 1. If evidence of continued disease at parturition, use tetracycline or quinolone for 2-3 weeks. Gentamicin, although not approved for treatment of tularemia likely represents a suitable alternative. Adjust gentamicin dose for renal failure Treatment with streptomycin, gentamicin, or ciprofloxacin should be continued for 10 days; doxycycline and chloramphenicol are associated with high relapse rates with course shorter than 14-21 days. Under special circumstances, if the evidence of exposure is clear in a group of individuals, some of whom have well defined neurological findings consistent with botulism, treatment can be contemplated in those without neurological signs. Antibody response is poor, requires 3-dose primary (one month) and 1-2 boosters (one month apart). Primary series yields antibody response in 77%; 5%-10% of non-responders after boosts. Antibody response is poor, requires 3-dose primary (one month) and 3-4 boosters (one month apart). Immune Globulins For Select Vaccine Adverse reactions (Eczema vaccinatum, vaccinia necrosum, ocular vaccinia w/o keratitis, severe generalized vaccinia): 1. Recommendations for use of smallpox vaccine in response to bioterrorism are periodically undated by the Centers for Disease Control & Prevention. Proper collection of specimens from patients is dependent on the time-frame following exposure. These time-frames are not rigid and will vary according to the concentration of the agent used, the agent strain, and predisposing health factors of the patient. Blood samples: Several choices are offered based on availability of the blood collection tubes. Tiger-top tubes that have been centrifuged are preferred over red-top clot tubes with serum removed from the clot, but the latter will suffice. Blood culture bottles are also preferred over citrated blood for bacterial cultures. Pathology samples: routinely include liver, lung, spleen, and regional or mesenteric lymph nodes. Additional samples requested are as follows: brain tissue for encephalomyelitis cases (mortality is rare) and the adrenal gland for Ebola (nice to have but not absolutely required). The first two, along with early post exposure clinical samples, can help identify the agent in time to initiate prophylactic treatment. While the information will most likely be too late for useful prophylactic treatment, this information along with other information may be used in the prosecution of war crimes or other criminal proceedings. However, the sample collection concerns are the same as for during or shortly after a bioaerosol attack and medical personnel may be the only personnel with the requisite training. As in any hazmat situation, a clean line and exit and entry strategy should be designed. If it is possible to have a clean line, then a three person team is recommended, with one clean and two dirty. Aerosol collection during an attack would be ideal, assuming you have the appropriate collection device. Otherwise anything that appears to be contaminated can be either sampled with swabs if available, or with absorbent paper or cloth. Well after the attack, samples from dead animals or human remains can be taken (refer to Appendix F for appropriate specimens). All samples should ideally be double bagged in Ziploc bags (the outside of the inner bag decontaminated with dilute bleach before placing in the second bag) labeled with time and place of collection along with any other pertinent data. National Defense University, Center for Counterproliferation Research, Fredonia Books, 2002 3. Investigation of a ricin-containing envelope at a postal facility- South Carolina, 2003. Greek Fire, Poison Arrows & Scorpion Bombs: Biological and Chemical Warfare in the Ancient World. Missed sentinel case of naturally occurring pneumonic tularemia outbreak: lessons for detection of bioterrorism. Clinical recognition and management of patients exposed to biological warfare agents. A procedure for differentiating between the intentional release of biological warfare agents and natural outbreaks of disease: its use in analyzing the tularemia outbreak in Kosovo in 1999 and 2000. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Increased detection of rickettsialpox in a New York City hospital following the anthrax outbreak of 2001: use of immunohistochemistry for the rapid confirmation of cases in an era of bioterrorism. Biological warfare training: infectious disease outbreak differentiation criteria. Tularemia outbreak investigation in Kosovo: case control and environmental studies. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. A field-expedient algorithmic approach to the clinical management of chemical and biological casualties. Medical management of the suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient. Postal Service workers potentially exposed to Bacillus anthracis District of Columbia, 2001-2002. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science 2003; 1:97-110. Department of Defense preliminary evaluation of the association of anthrax vaccination and congenital anomalies. Use of anthrax vaccine in response to terrorism: supplemental recommendations of the advisory committee on immunization practices. Complications associated with Brucella melitensis infection: a study of 530 cases. Suspected brucellosis case prompts investigation of possible bioterrorism related activity New Hampshire and Massachusetts, 1999. Po-Ren Hsueh, Lee-Jene Teng, Li-Na Lee, Cheong-Ren Yu, Pan-Chyr Yang, Shen-Wu Ho, and Kwen-Tay Luh, Melioidosis: An emerging infection in Taiwan Cutaneous melioidosis and necrotizing fasciitis caused by Burkholderia pseudomallei. Out of hospital treatment of patients with melioidosis using ceftazidime in 24 h elastomeric infusors, via peripherally inserted central catheters. Further evaluation of a rapid diagnostic test for melioidosis in an area of endemicity. Gentamicin and tetracyclines for the treatment of human plague: review of 75 cases in new Mexico, 1985-1999. Surveillance for pneumonic plague in the United States during an international emergency: a model for control of imported emerging diseases. Comparison of different antibiotic regimens for therapy of 32 cases of Q fever endocarditis. Missed sentinel case of naturally occcuring pneumonic tularemia outbreak: lessons for detection of bioterrorism. Kosoy, Gjyle Mulliqi-Osmani, Roland Grunow, Ariana Kalaveshi, Luljeta Gashi, and Isme Humolli. Immunologic responses to vaccinia vaccines administered by different parenteral routes.

Antitoxin may be particularly effective in foodborne cases erectile dysfunction causes alcohol buy viagra with dapoxetine 50/30mg otc, where presumably toxin continues to be absorbed through the gut wall erectile dysfunction doctor london buy viagra with dapoxetine paypal. Animal experiments show that after aerosol exposure erectile dysfunction caused by radiation therapy buy viagra with dapoxetine no prescription, botulinum antitoxin is very effective if given before the onset of clinical signs acupuncture protocol erectile dysfunction buy 50/30mg viagra with dapoxetine otc. If the antitoxin is delayed until after the onset of symptoms erectile dysfunction medication uk discount 100/60 mg viagra with dapoxetine free shipping, it does not protect against respiratory failure erectile dysfunction natural remedies diabetes discount 50/30 mg viagra with dapoxetine with amex. This product has all the disadvantages of a horse serum product, including the risks of anaphylaxis and serum sickness. Two "despeciated" equine heptavalent antitoxin preparations against all seven serotypes have been prepared by cleaving the Fc fragments from horse IgG molecules, leaving F(ab)2 fragments. However, 4% of horse antigens remain, so there is still a risk of hypersensitivity reactions. The injection site is monitored and the patient is observed allergic reaction for 20 minutes. The skin test is positive if any of these allergic reactions occur: hyperemic areola at the site of the injection > 0. If no allergic symptoms are observed, the antitoxin is administered as a single dose intravenously in a normal saline solution, 10 ml over 20 minutes. Medical personnel administering the antitoxin should be prepared to treat anaphylaxis with epinephrine, intubation equipment, and intravenous access. This product has been administered to several thousand volunteers and occupationally at-risk workers, and historically induced serum antitoxin levels that correspond to protective levels in experimental animals. The currently recommended primary series of 0, 2, and 12 weeks, followed by a 1 year booster induces protective antibody levels in > 90 percent of vaccinees after 1 year. Adequate antibody levels are transiently induced after three injections, but decline before the 1-year booster. In the future, changes may be made to the protocol, to add a dose at 6 months and to add annual booster doses. Laboratory workers should be aware that the vaccine cannot be used as the sole protection against a possible laboratory exposure to A-E serotypes. Contraindications to the vaccine include sensitivities to alum, formaldehyde, and thimerosal, or hypersensitivity to a previous dose. Reactogenicity is mild, with 2 to 4 percent of vaccinees in a passive surveillance system reporting erythema, edema, or induration at the local site of injection which peaks at 24 to 48 hours. The frequency of such local reactions increases with subsequent inoculations; after the second and third doses, 7 to 10 percent will have local reactions, with higher incidence (up to 20 percent or so) after boosters. Severe local reactions are rare, consisting of more extensive edema or induration. Systemic reactions are reported in up to 3 percent, consisting of fever, malaise, headache, and myalgia. More recent data based on active surveillance revealed 23 percent reported local reactions and 7. There is no indication at present for using botulinum antitoxin as a prophylactic modality except under extremely specialized circumstances. Posteposure prophylaxis, using the heptavalent antitoxin, has been demonstrated effective in animal studies; however, human data are not available, so it is not recommended for this indication. The antitoxin should be considered for this purpose only in extraordinary circumstances. Airway necrosis and pulmonary capillary leak resulting in pulmonary edema may occur within 18-24 hours, followed by severe respiratory distress and death from hypoxemia in 36 72 hours. Diagnosis: Acute lung injury in large numbers of geographically clustered patients suggests exposure to aerosolized ricin. The rapid time course to severe symptoms and death would be unusual for infectious agents. Nonspecific laboratory and radiographic findings include leukocytosis and bilateral interstitial infiltrates. Treatment: Management is supportive and should include treatment for pulmonary edema. Gastric lavage and cathartics are indicated for ingestion, but charcoal is of little value for large molecules such as ricin. Prophylaxis: There is currently no vaccine or prophylactic antitoxin available for human use, although vaccination appears promising in animal models. Ricin is non-volatile, and secondary aerosols are not expected to be a danger to healthcare providers. Castor beans are ubiquitous worldwide, and the toxin is fairly easy to extract; therefore, ricin is widely available. When inhaled as a small particle aerosol, this toxin may produce pathologic changes within 8 hours and severe respiratory symptoms followed by acute hypoxic respiratory failure in 36-72 hours. When ingested, ricin causes severe gastrointestinal symptoms followed by vascular collapse and death. This toxin may also cause disseminated intravascular coagulation, microcirculatory failure, and multiple organ failure if given intravenously in laboratory animals. Worldwide, one million tons of castor beans are processed annually in the production of castor oil; the waste mash from this process is 3-5 percent ricin by weight. The toxin is also quite stable and extremely toxic by several routes of exposure, including the respiratory route. Ricin was apparently used in the assassination of Bulgarian exile Georgi Markov in London in 1978. Markov was attacked with a specially engineered weapon disguised as an umbrella, which implanted a ricin-containing pellet into his body. This technique was used in at least six other assassination attempts in the late 1970s and early 1980s. In 1995, a Kansas City oncologist, Deborah Green, attempted to murder her husband by contaminating his food with ricin. In 1997, a Wisconsin resident, Thomas Leahy, was arrested and charged with possession with intent to use ricin as a weapon. In October 2003, ricin powder was discovered in a South Carolina postal facility and in February 2004 in the mail room of a United States senator. There were no injuries and these events remain under investigation as of July 2004. Ricin has a high terrorist potential due to its ready availability, relative ease of extraction, and notoriety in the press. The toxins are made up of two polypeptide chains, an A chain and a B chain, which are joined by a disulfide bond. Large quantities of ricin can be produced relatively easily and inexpensively by low-level technology. Ricin can be prepared in liquid or crystalline form, or it can be lyophilized to make a dry powder. It can be disseminated as an aerosol, injected into a target, or used to contaminate food or water. Ricin is stable under ambient conditions, but is O O detoxified by heat (80 C for 10 minutes or 50 C for about an hour at pH 7. An enemy would need to produce it in large quantities to cover a significant area on the battlefield, limiting its large-scale use. In rodents, the histopathology of aerosol exposure is characterized by necrosis of upper and lower respiratory epithelium, causing tracheitis, bronchitis, bronchiolitis, and interstitial pneumonia with perivascular and alveolar edema. There is a latent period of 8 hours after inhalation exposure before histologic lesions are observed in animal models. Accidental sublethal aerosol exposures, which occurred in humans in the 1940s, were characterized by onset of fever, chest tightness, cough, dyspnea, nausea, and arthralgias within 4 to 8 hours. The onset of profuse sweating some hours later was commonly the sign of termination of most of the symptoms. Time to death in experimental animals is dose dependent, occurring 36-72 hours after inhalation exposure. Exposed humans can be expected to develop severe lung inflammation with progressive cough, dyspnea, cyanosis, and pulmonary edema. By other routes of exposure, ricin is not a direct lung irritant; however, intravascular injection can cause minimal pulmonary perivascular edema due to vascular endothelial injury. Ingestion causes necrosis of the gastrointestinal epithelium, local hemorrhage, and hepatic, splenic, and renal necrosis. Intramuscular injection causes severe local necrosis of muscle and regional lymph nodes with moderate visceral organ involvement. Acute lung injury affecting a large number of geographically clustered cases should raise suspicion of an attack with a pulmonary irritant such as ricin, although other pulmonary pathogens could present with similar signs and symptoms. Ricin intoxication is expected to progress despite treatment with antibiotics, as opposed to an infectious process. Ricin intoxication does not cause mediastinitis as seen with inhalational anthrax. Additional supportive clinical or diagnostic features after aerosol exposure to ricin include the following: bilateral infiltrates on chest radiographs, arterial hypoxemia, neutrophilic leukocytosis, and a bronchial aspirate rich in protein compared to plasma which is characteristic of high-permeability pulmonary edema. Ricin is an extremely immunogenic toxin, and paired acute and convalescent sera should be obtained from survivors to measure antibody response. Gastrointestinal intoxication is best managed by vigorous gastric lavage, followed by use of cathartics such as magnesium citrate. Although a vaccine is not currently available, candidate vaccines are under development which are immunogenic and confer protection against lethal aerosol exposures in animals. Gastrointestinal symptoms are thought to be more profound if toxin is swallowed or ingested. Artificial ventilation may be needed for very severe cases, and attention to fluid management is important. It can be decontaminated with soap and water and any contaminated food should be destroyed. Such toxins are referred to as exotoxins as they are excreted from the organism, and as they normally exert their effects on the intestines, they are called enterotoxins. This toxin causes a markedly different clinical syndrome when inhaled than it characteristically produces when ingested. Often these outbreaks occur in a setting such as a church picnic or other community event, due to common-source exposure in which contaminated food is consumed. They are produced in culture medium and also in foods when there is overgrowth of the organisms. This leads to the direct stimulation of large 98 populations of T-helper cells while bypassing the usual antigen processing and presentation. This induces a brisk cascade of pro-inflammatory cytokines (such as tumor necrosis factor, interferon, interleukin-1 and interleukin-2), with recruitment of other immune effector cells, and relatively deficient activation of counter-regulatory negative feedback loops. Initial symptoms after either route may include nonspecific flu-like symptoms such as fever, chills, headache, and myalgias. Oral exposure results in predominantly gastrointestinal symptoms: nausea, vomiting, and diarrhea. Inhalation exposures produce predominantly respiratory symptoms: nonproductive cough, retrosternal chest pain, and dyspnea. Gastrointestinal symptoms may accompany respiratory exposure due to inadvertent swallowing of the toxin after normal mucocilliary clearance, or simply as a systemic manifestation of intoxication. Gastrointestinal symptoms have been seen in ocular exposures in which ingestion was not thought to have occurred. Respiratory pathology is due to the activation of pro-inflammatory cytokine cascades in the lungs, leading to pulmonary capillary leak and pulmonary edema. The cough may persist up to 4 weeks, and patients may not be able to return to duty for 2 weeks. Conjunctival injection may be present, and postural hypotension may develop due to fluid losses. Chest examination is unremarkable except in the unusual case where pulmonary edema develops. All of these might present with fever, nonproductive cough, myalgia, and headache. Influenza or community-acquired pneumonia should involve 99 patients presenting over a more prolonged time interval. Naturally occurring staphylococcal food poisoning does not present with pulmonary symptoms. Tularemia and plague, as well as Q fever, are often associated with infiltrates on chest radiographs. Other diseases, including hantavirus pulmonary syndrome, Chlamydia pneumonia, and various chemical warfare agents (mustard, phosgene via inhalation) are in the initial differential diagnosis. Respiratory secretions and nasal swabs may demonstrate the toxin early (within 24 hours of exposure). Because most patients develop a significant antibody response to the toxin, acute and convalescent sera should be drawn for retrospective diagnosis. Nonspecific findings include a neutrophilic leukocytosis, an elevated erythrocyte sedimentation rate, and chest x-ray abnormalities consistent with pulmonary edema. Close attention to oxygenation and hydration is important, and in severe cases with pulmonary edema, ventilation with positive end-expiratory pressure, vasopressors and diuretics may be necessary.

You should never handle food if: You have diarrhoea and/or vomiting You have sores and cuts (unless they are covered with a waterproof dressing) 5 erectile dysfunction cycling purchase 100/60 mg viagra with dapoxetine fast delivery. This will kill any harmful bacteria that may be present erectile dysfunction no xplode discount viagra with dapoxetine 50/30 mg without a prescription, such as listeria and salmonella erectile dysfunction treatment old age order 100/60mg viagra with dapoxetine mastercard. If food has to be refrigerated the fridge temperature should be between 2 and 8 degrees centigrade 5 impotence mayo generic viagra with dapoxetine 50/30mg otc. It usually affects more than one lobe of the lung and is caused by a Gram negative bacillus Legionella pneumophila erectile dysfunction 18-25 purchase viagra with dapoxetine with mastercard. The air conditioning in buildings is a common source of Legionella pneumophila erectile dysfunction doctor in bhopal order cheap viagra with dapoxetine on line, the disease was first recognised during an outbreak involving delegates to the 1976 Pennsylvania American Legion convention at a Philadelphia Hotel. Clusters of cases are associated with air conditioning and there are sporadic cases, which presumably arise from domestic or hotel showers or baths. In hospital the organism may be transmitted from faulty air conditioning or in drinking water. Transmission Most transmission is by the inhalation of aerosols or by micro-aspiration of contaminated water. Aerosol-generating systems linked to outbreaks include cooling towers, wet evaporative air cooling systems, respiratory-therapy equipment and whirlpool baths. Several studies have shown nosocomial legionellosis associated with aspiration particularly via nasogastric tubes and a higher incidence among patients who had undergone head and neck surgery. Pontiac Fever is also caused by Legionella pneumophila and paradoxically is probably caused by a large inoculum. This is an influenza-like illness with a short incubation period and high attack rate. Antibody rises tend to be delayed so are not helpful in making the initial diagnosis. Isolation is not necessary If the case is suspected to be hospital acquired an outbreak meeting will be convened 4. Prevention: Trusts have a duty of care and responsibility to control legionellosis in the water supply by applying the guidance in: A. It is essential that any rooms with water outlets that are used for storage must either have: Access for staff to reach the sink, toilet, shower, bath to flush the system Or Notify the Estates Department to take the piping back to stop the water to that room. Temporary or Permanent Closure of Wards or Buildings the Estates Department must be informed of any temporary or permanent closures so that the water can either be turned off or flushing system be out in pace. Page | 149 Appendix 1:Register of underused outlets and flushing schedule Definition: Underused outlets are those outlets which are not used on a regular basis i. Shower in male toilet Wash hand basin in male toilet Tick Initials Tick Initials To help prevent Legionella Twice a week flush underused water outlets which are not used on a regular basis for a minimum of 2 minutes. However there are approximately 3% of the population who are naturally colonised with the spores as part of their normal bowel flora. Illness ranges from mild diarrhoea of short duration to severe and potentially life threatening inflammation of the bowel called Pseudomembranous colitis. Management A range of factors may cause diarrhoea and it is therefore essential to identify any underlying causes which are abnormal for the patient and may be indicative of infection. In order to prevent spread to other service users an assessment must be undertaken using the diarrhoea assessment tool (appendix 1) and contact precautions must be employed promptly the essential components in the prevention and control of C. Treatment a) Stop the antibiotic if it is still being prescribed b) Ensure hydration with fluid and electrolyte replacement c) Follow treatment algorithms from the Public Health England. Prevention the transmission of Clostridium difficile can be service user to service user, via contaminated hands of healthcare workers or via contaminated healthcare equipment. The disease presents at 55-75 years old and in 15% of cases is caused by an inherited gene mutation. A small proportion (1%) of cases has been transmitted in injections of human pituitary derived growth hormone, corneal transplants and brain surgery following contamination of instruments. Current data indicates that the epidemic reached a peak in the year 2000 when there were 27 diagnoses and 28 deaths and this has since declined to a current incidence of about 1 diagnoses/death per year the eventual number likely to develop the disease is uncertain. Prion proteins are found normally in the tissues of healthy people and animals but the disease is caused when a prion protein folds in an abnormal way, changing its shape. Nervous tissue in the brain and elsewhere is damaged resulting in a spongy microscopic appearance. The prion protein may be fixed rather than inactivated by normal sterilization methods. There is a possibility of transmission to another patient of the abnormal prion protein from lymphoid tissue of a patient in whom symptoms have not yet appeared. Surgical instruments may not be free of the abnormal protein despite standard methods of sterilization. The highest concentrations of the protein are in the brain, spinal cord and eye and it is almost never found in blood or urine. In most service users, mental deterioration with behavioural disturbance is rapidly progressive ending in death in 7-9 months Myoclonus, nystagmus, tremor and ataxia are common. Instruments which are difficult to clean should be gradually replaced with ones more easily cleaned. If instruments have been used on a suspected case, they must be quarantined until diagnosis is made. Instruments and equipment used in procedures on the brain, spinal cord or eyes of a patient at risk must be destroyed by incineration. Introduction Rubella is dangerous to the foetus if caught during pregnancy All staff must be immunised Rubella (German measles) is highly infectious and the foetus of a pregnant woman may be severely affected if she acquires the disease early in pregnancy. It is only by ensuring that all staff (including males) are immune, that cross infection in the hospital environment can be prevented. The aim of ensuring that all staff are immune is to prevent the acquisition and spread of rubella by all health care workers and subsequent transmission to patients. Objectives Protection of female service users who may be, or who are known to be pregnant Protection of female members of staff for their own future safety 3. Staff All staff will attend the appropriate Occupational Health Department, before commencement, clerical and administrative staff must undergo rubella screening in order to determine their immunity. Staff already in post, who have not been checked, should attend the Occupational Health Department at the earliest opportunity. Medical School Staff and Students Rubella screening and immunisation should be done and documented before students start on the wards. Guidelines for the Management of Pregnant Women Who Come Into Contact with Rubella 3. Accessed online 2/12/2013 Department of Health (2011) Health Technical Memorandum 07-01: Safe management of healthcare waste. Department of Health (2007) Pandemic Influenza: Guidance for infection control in hospitals and primary care settings. The Control of Substances Hazardous to Health Regulations with Approved Code of Practice 199-. Page | 160 Department of Health (2007): Saving Lives: reducing infection, delivering clean and safe care: Isolating patients with healthcare-associated infection A summary of best th practice. The Health Care Act 2006 code of practice for the prevention and control of health care associated infections. Winning Ways: Working Together to Reduce Healthcare Associated Infection in England. Review of Hospital Isolation and Infection Control related Precautions, Report of the Joint Working Group (Association of Medical Microbiologists, Infection Control Nurses Association, Hospital Infection Society, British Infection Society), July 2001. Department of Health (2006) Saving Lives: A delivery programme to reduce Healthcare associated infection. Department of Health July 2006 Department of Health (2006) the Health Act: Code of Practice for the Prevention and Control of Healthcare Associated Infections. Infection control guidance for new builds, refurbishments and renovations Department of Health (2013): Health Building Note 00-09: Infection control in the built environment London. Sarangi, J and Roswell, R (1995), Cleaning of carpets and soft furnishings, Journal of Hospital Infection, Vol 30 No 2. DiSalvo H, Haiduven D, Johnson N, Reyes V, Hench C, Shaw R, Stevens D (2000)Who let the dogs out Infection control did: Utility of dogs in health care settings and infection control aspects. Care of the deceased Communicable disease and public health volume 4, No 4 December 2001 Code of Practice for funeral workers: managing infection risk and body bagging. Department of Health infection control guidance for care homes (June 2006) Department of Health, London. Health Services Circular 1999/179: Controls Assurance in Infection Control: decontamination of medical devices, Department of Health. Winning Ways (2003) working together to reduce Healthcare associated infection in England. Department of Health (2004) Standards for Better Health Department of Health (2006) the health act code of practice for the prevention and control of healthcare associated infections. Health and Safety Executive (2002) Control of Substances Hazardous to Health th Regulations. Guidance of Clinical Health Care Workers: Protection against infection with Blood-Borne Viruses. The interdepartmental working group on Tuberculosis: the prevention and control of Tuberculosis in the United Kingdom. Chickenpox/shingles Department of Health (2006) Immunisation against infectious disease (Green Book) edited by Salisbury D, Ramsay M & Noakes K. Does the policy/guidance affect one group No less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender No Culture No Religion or belief No Sexual orientation including lesbian, gay and No bisexual people Age No Disability learning disabilities, physical disability, No sensory impairment and mental health problems 2. If you have identified potential discrimination, N/A are any exceptions valid, legal and/or justifiable What alternatives are there to achieving the N/A policy/guidance without the impact D Moderate evidence for lack of efficacy or for adverse outcome supports a recommendation against use. E Good evidence for lack of efficacy or for adverse outcome supports a recommendation against use. First, antigens, for which reliable typing is not routinely improvements in the supportive care of patients with available. However, ful consideration of the individual case in light of ev with other regimens, depletion of recipient lympho idence-based data. Future work is needed to augment the de studies are needed, rst to conclusively determine gree of immune reconstitution toward pathogens and what immune monitoring test has prognostic value malignancy and to identify accurate surrogate markers and ultimately to determine whether outcomes would of immunocompetence to guide the long-term improve if such a test were used to tailor infection pro management of this high-risk population. Assessment of the donor should include to both the usual consequences of the disorder and elements related to safety for the donor (eg, uncon the ease of managing those consequences. Similarly, those with acute toxoplasmosis 2006, 3269 (39%) adult products and 829 (40%) should not donate until the acute illness has resolved. The to determine their general state of health and whether sole exception is testing for syphilis, where a syphilis they pose a risk for transmitting infectious diseases to specic test is used for determination of eligibility [80]. Evaluation of donors is achieved through Use of Potentially Unsafe Products screening and laboratory testing [76-78, 80]. Abbreviated screening is an inquiry about topoietic cell product from an infected or infectious do any changes in history, risk factors, or physical nd nor unless no other stem cell product can be obtained ings. If storage is possible, the sample may be list all disease agents or diseases for which the donor obtained up to 30 days prior to donation; however, has shown reactive test results. Current, comprehensive dis antibacterial therapy for fever during neutropenia cussions of these issues are detailed in the Food and [148-152]. Local epidemiologi regulations [142], in the European Commission regu cal data should be carefully considered before applying lations [81], and in international standards established uoroquinolone prophylaxis, and once it is applied, the by the professional organizations [76, 77, 143]. Raad vate third-generation cephalosporins [158-160]; and In addition to general recommendations regarding quinolone-related development of a hypervirulent bacterial infections, this section provides specic rec strain of C. Other al in catheter removal and, much less commonly, in death ternatives, including lock solutions containing [175, 176]. To date, no serious disease has been reported exercise caution and decrease the dose as needed. A vaccine-associated rash occurs in ap (whether after exposure to a person with wild-type var proximately 1% to 5% and 0. Because the risk Treatment may be completed with oral valacyclovir of vaccine virus transmission is low, particularly in if the patient can tolerate oral medication. Of note, the response to vaccination is likely to be poor in patients undergoing chemotherapy.

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