Rumalaya

Mitra Taghizadeh, MS, MT(ASCP)

• Former Assistant Professor
• Department of Medical and Research Technology
• University of Maryland School of Medicine
• Baltimore, Maryland

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Magnetic resonance imaging condition by reducing lactate levels and improving microcirculation. Melioidosis is a bacterial infection caused by Burkholderia pseudomallei, a gram-negative saprophytic bacillus. Cases occur sporadically in the Americas with an increasing number of cases observed among people with no travel history to endemic countries. To better understand the incidence of the disease in the Americas, we reviewed the literature, including unpublished cases reported to the Centers for Disease Control and Prevention. Of 120 identified human cases, occurring between 1947 and June 2015, 95 cases (79%) were likely acquired in the Americas; the mortality rate was 39%. Burkholderia pseudomallei appears to be widespread in South, Central, and North America. We conducted a literature review of human 3 cases diagnosed with melioidosis with residence, travel his endemic areas through inhalation, inoculation, or ingestion, with increasing evidence of ingestion playing a greater role in tory, or country of birth associated with the Americas, includ infection than historically thought. Keywords used included combina logic laboratories, and research facilities on a voluntary basis. Our search strategies resulted in a total of was recovered from environmental specimens (soap, floor, 1,937 articles. An additional 15 articles were identified through and shower hose) in a burn unit of a hospital in Belo hand searching, citations from other articles, and correspon 27 dence with subject matter experts. A prior review of melioidosis cases in the Americas remaining 884 articles were evaluated for relevancy. Final described 105 cases with an association (residence when diag selection of articles was based on the following criteria: 28 description or review of a case or cases diagnosed in the nosed, travel history, or country of birth) to the Americas. Two of the cases (one case reported from Oklahoma in 1976 Americas, or with travel history in the Americas, or resi and the other reported from Georgia in 1979) have since been dence in the Americas. A total of 61 articles (from 1945 to reclassified as infections with the closely related bacteria 2015) met our inclusion criteria (Figure 1). Abstracts and case summaries pub lished in Portuguese were already translated into English by the journal. This is consistent with other reports able cases were defined as having a positive result for from endemic regions. A library of all relevant references (including articles acquired the infection through occupational exposure. One identified through other sources) was built using EndNote X6 individual worked with B. The following data were abstracted from may have acquired the infection through contact with rep each article when available: year of diagnosis, gender, age, tiles (case no. The infants father was a Vietnam veteran with the year of diagnosis was documented as the year of publi unknown disease status. El Salvador, Puerto Rico, and tral Intelligence Agency 2004 World Factbook was used as a Martinique have the highest number of cases in Central reference guide in classifying countries into North, Central, America and the Caribbean (Table 1). Most Of 120 cases reviewed (Supplemental Appendix 1), 95 cases cases (13 of 15 cases) from El Salvador were Salvadoran (79%) were believed to have had acquired the infection in residents and reported never traveling outside the country. The remaining 25 cases the authors also did not report the year of diagnosis for those (Table 2) were either born in or had travel history to cases. Two patients that likely acquired disease in El Salvador melioidosis-endemic countries. One patient was from a 47-year-old Among those cases with reported source of exposure to U. A third individual, a 66-year-old Martinique Americas,28 more than 2 dozen cases have been identified in resident had traveled to non-endemic areas of Africa and patients with no travel history outside their native country in South America more than 40 years before diagnosis. The the Americas or in patients with travel history only within authors reported that the patient never lived in rural areas the Americas. The increasing occurrence of melioidosis in and that the source of infection remained unknown. Thirty-seven cases from 1962 to 2015 with ditions present in many of these countries, as well as envi suspected origin in South America were reported from Brazil, ronmental isolates of B. Specifically, does Brazil 28 the epidemiology of melioidosis in the Americas differ from Colombia 10 that elsewhere, or are the increasing numbers a reflection of Venezuela 3 increased awareness of this disease Since melioidosis is not considered endemic to the United this review has the major limitation of relying solely on 45 peer-reviewed and published case reports, which sometimes States (mainland), it raises the question of whether con taminated medical supplies (intravenous supplies, medications, lacked detailed information on source of exposure. Furthermore, many of the Vietnam published case reports reviewed did not contain travel his Philippines Cambodia tory. Finally, many of the published reports lacked informa India tion on underlying medical illness/risk factors and exposure Malaysia history, limiting our ability to investigate clinico-epidemiologic Africa patterns in more detail. With these limitations noted, this China Southeast Asia report is a more comprehensive review of melioidosis cases Hong Kong, Vietnam, Japan, Mexico, with presumed acquisition of infection in the Americas, pro or the Philippines viding an update to the seminal publication by Inglis and Indonesia others and contributing to better understanding of the global Laos or Cambodia and regional distribution of melioidosis. Laos or Thailand Saudi Arabia or Bangladesh Continued improvement in the accurate and timely diag Singapore, Malaysia, Burma, or Thailand nosis of melioidosis cases is crucial to understanding the inci Vietnam, southeast and central Asia, dence and epidemiology of the disease in the Americas. A case of melioidosis in a have addressed current diagnostics and future directions46;in macaque monkey. Melioidosis in imported be sensitized to the presence of melioidosis in the Americas. Naturally occur the State of Ceara, may consider additional studies, such as ring melioidosis in a colonized rhesus monkey (Macaca mulatta). An outbreak of melioidosis in imported primates in needed to address this emerging disease. Limmathurotsakul D, Thammasart S, Warrasuth N, Thapanagulsak Note: Supplemental appendix appears at Environmental isolates of Burkholderia pseudomallei in Ceara State, northeastern Brazil. Contact investigation of melioidosis cases by Burkholderia pseudomallei in drinking water, Thailand, 2012. Bacteriological evaluation of wounds in seriously living associated with acquisition of melioidosis in northeast burned hospitalized patients. National Burkholderia pseudomallei isolates in 2 pet iguanas, California, Surveillance Definition for Melioidosis. Chronic melioidosis: bacteriologic Clinical-epidemiological features of 13 cases of melioidosis in and clinical correlation in diagnosis. Olive C, Loetitia G, Desbois N, Roche B, Jouannelle J, Dodin selected reports of occupational exposures to Burkholderia A, 1995. This document is intended to provide guidance about reporting to physicians and other health care providers, hospitals and other health care institutions, and certain other groups specified below. For simplicity, the use of health care providers in this document refers to all those groups that are required to report, except laboratories, which have a separate guidance document for their use. In addition to the list of reportable conditions, Table 1 also indicates the timeframe for reporting. Several footnotes to the table elaborate on specific details, as do the following sections of this document: Legal Authority, Who Should Report, What to Report, How to Report, When to Report, and Where to Report. Any grouping or clustering of patients having similar disease, symptoms, or syndromes that may indicate the presence of a disease outbreak. Vibriosis, non-cholera, identified in any specimen taken from teeth, gingival tissues, or oral mucosa is not reportable. Outbreak Reporting Outbreak means: A foodborne disease outbreak, defined as two or more epidemiologically related cases of illness following consumption of a common food item or items, or one case of the following: Botulism Fish poisoning such as Ciguatera poisoning Cholera Scombroid poisoning Mushroom poisoning Paralytic shellfish poisoning Trichinosis Any other neurotoxic shellfish poisoning Three or more cases of a disease or illness that is not a foodborne outbreak and that occurs in individuals who are not living in the same household, but who are epidemiologically linked; An increase in the number of infections in a facility, such as a hospital, long-term care facility, assisted living facility, school, or child care center, over the baseline rate usually found in that facility; A situation designated by the Secretary as an outbreak; or One case of: Anthrax Rabies (human) Plague Smallpox Any of the single cases defined as a foodborne disease outbreak above An outbreak of a disease of known or unknown etiology that may be a danger to the public health should be reported to your local health department immediately. Public, private, or parochial school and child care facility personnel (teacher, principal, school nurse, superintendent, assistant superintendent or designee). Masters or person in charge of vessels or aircraft within the territory of Maryland. Laboratory directors may consult Maryland law or regulation, or visit our Internet site for additional reporting information specific to laboratories. Health care providers must report those diseases and conditions as indicated in Table 1. Reporting by laboratories does not nullify the health care providers or institutions obligation to report these diseases and conditions, nor does reporting by health care providers nullify the laboratorys obligation to report. It is acceptable to include other information that would aid in the public health follow-up of a report. Maryland local health departments will often follow up on the initial report by contacting the health care provider for additional disease specific information. When to Report: Health care providers should report according to the Timeframe for Reporting shown in Table1. Health care providers must submit a report in writing of diagnosed or suspected cases of the specified diseases and conditions to the Commissioner of Health in Baltimore City or the health officer in the county where the provider cares for that person. See Table 3 for addresses and telephone numbers for local health departments, including numbers for after hours or weekend reporting. Additional Information Should the health department need to contact the patient, the advice and assistance of the reporting health care provider will ordinarily be sought first. Health departments offer medical and epidemiological consultation and laboratory assistance to physicians and other health care providers. This includes conducting public health surveillance, investigations, or interventions. Reporting is by physicians and clinical and infection control practitioners at certain institutions (see Who Should Report, page 6). Maryland law and regulation require reporting of syphilis, gonorrhea, and chlamydia infection by both laboratories and health care providers. The dual reporting system is intentional the clinical and demographic information you provide (which is normally unavailable from laboratories) enables the health department to better monitor disease trends. Services include counseling, education, partner notification, and routine screening and medical evaluation of partners, while always adhering to the strictest measures of confidentiality. If you have a patient who recently tested positive for syphilis, gonorrhea, or Chlamydia infection, the state or local health department may contact your office for additional information, such as confirmatory test results or treatment type and date, as part of assuring comprehensive prevention and case management for your patients and their respective partners, and as part of monitoring for antibiotic resistant infections. Contact information for local and state health department offices can be found in Tables 3 and 4. All persons with newly diagnosed tuberculosis disease regardless of the number of drugs prescribed. All persons with tuberculosis disease who have been previously treated for tuberculosis disease, regardless of the time that has elapsed since treatment was completed or discontinued. Amendments to a "suspect" report should be submitted when bacteriological results become available. Voluntary reporting of positive tuberculin skin tests or positive blood tests for tuberculosis in children less than one year of age enables local health department investigators to identify a source case. Reporting is not required for other individuals determined to have latent tuberculosis infection. Treatment of Tuberculosis Consultation with the local health department is strongly recommended for treatment of all suspect and confirmed cases of active tuberculosis disease. If the initial specimens submitted for mycobacterial culture are sent to a private laboratory, please request that drug susceptibility testing is also done. Further information and medical consultation are available from the state Division of Tuberculosis Control at 410-767-6698 (see Table 4). Getting Up-to-Date Information Requirements for reporting diseases and other important information will change with time. Please call your local health department or the Maryland Department of Health and Mental Hygiene Division of Infectious Disease Surveillance (410-767-6709), or visit one of the following Internet sites to obtain the most current information. In effect, s l owed our progress towa rd unders t a n d i n g medicine, connecting scientific disciplines t h e re are diffe rent mitoch o n d ria with the biology underlying mitoch o n d rial disease. In the remaining genes are encoded in the cell diseases, but have also been implicated in cone cell photore c ep t o rs of the eye, nu cleus and the resultant proteins are ma ny common diseases of agi n g, i n cl u d i n g m i t o ch o n d ria make up 80% of the intra c e l t ra n s p o rted to the mitoch o n d ria. In ex t raocular mu s cles like about 3% of the genes necessary to make and dementia.

Bovine leukosis Bovine leukosis is a persistentand m alignantviraldisease ofthe lym phoreticularsystem treatment xanthelasma eyelid generic rumalaya 60pills with amex. The enzootic form is m ost com m only found in adultcattle medicine quizlet purchase rumalaya online from canada,particularly in cullcows symptoms upper respiratory infection buy generic rumalaya 60pills on line. Insecttransm ission is also a possibility;higherrates of infection were reported in the sum m er medicine numbers buy generic rumalaya 60pills line. Persistentdiarrhoea following infiltration ofthe abom asum wallby neoplastic cells 3 medicine 377 purchase 60pills rumalaya with mastercard. Enlarged haem olym ph nodes Judgem ent:Carcass ofan anim alaffected with leukosis (lym phosarcom a)is condem ned treatment glaucoma discount rumalaya master card. When a diagnosis cannotbe m ade by postm ortem findings,a laboratory diagnosis should be perform ed. Iflym ph node hyperplasia is the histologicaldiagnosis,the carcass is approved for hum an consum ption. Depending on disease prevalence,leukosis reactors m ay be totally approved orconditionally approved pending heattreatm ent. Differentialdiagnosis:Lym phadenitis,lym phoid hyperplasia,hyperplastic haem olym ph nodes, pericarditis,enlarged spleen in septicem ic conditions,otherneoplasm s and parasitism. Som e scientists suspectthatan unusualand atypicalvirus-like transm issible agentcalled a prion is file:///C:/versam m elt/index m eister. Transm ission:The ingestion ofprotein feed supplem ents prepared from sheep m eatorsheep by products contam inated with scrapie virus. Behaviourchanges (nervousness and aggressiveness),kicking in the m ilking parlour the progressive degeneration ofthe centralnervous system causes neurologic signs: 5. Diagnosis can be confirm ed only on the postm ortem histologicalexam ination ofbrain tissue. Differentialdiagnosis:Rabies,listeriosis,bovine pseudorabies (m ad itch),otherbrain infections in cattle,the nervous type ofacetonem ia,hypocalcem ia,hypophosphatem ia and file:///C:/versam m elt/index m eister. The breed,genderoryear and seasons are notassociated with the developm entofthis disease,noris contactwith sheep. The consum ption ofm ilk from affected anim als by hum ans oranim als is also prohibited. Edem a and haem orrhage ofthe brain Judgem ent:Carcass ofan anim alaffected with heartwateris condem ned in the acute stage of the disease. In a chronic case,the carcass m ay be approved ifadequately bled and m uscles are wholesom e in colourand texture. Differentialdiagnosis:Peracute form ofheartwatershould be differentiated from anthrax. The acute nervous form ofthe disease is differentiated from tetanus,rabies,cerebral trypanosom iasis,strychnine poisoning,piroplasm osis,theileriosis,lead and organophosphate poisoning,parasitism,arsenicalpoisoning and poisoning with certain plants. Q fever(Queensland fever,Nine m ile fever,Am erican Q fever,Australian Q fever) Q feveris a disease ofcattle,sheep,goats,donkeys,cam els,fowl,dogs,cats,pigeons and hum ans. The faeces deposited on anim alhide by ticks m ay be the source ofinfection forhum ans. Healthy anim als m ay serve as a carrierand shed the organism in m ilk,urine,faeces,placenta and fetal fluids. In the disease produced by the inoculation ofcows via the udderthe clinicalsigns m ay include: 1. Discussions:Coxiella burnetiiis highly resistantand was isolated from farm soil6 m onths afterthe rem ovalofanim als. The recovered anim al called lungersactas carriers and shedders,especially understress. Arthritis and tenosynovitis Judgem ent:Carcass ofan anim alaffected with contagious bovine pleuropneum onia is condem ned ifthe disease is associated with fever,inadequate bleeding ofcarcass,serous infiltration ofthe brisketand em aciation. Recovered anim als showing no generalized signs of the disease are approved and the affected organs are condem ned. Diseases caused by bacteria Black quarter(Black leg) Black quarteris an acute infectious disease ofcattle and sheep m anifested by severe inflam m ation ofthe m uscle with high m ortality. In sheep the agentis transm itted through wounds at shearing,docking and castration and during lam bing in ewes. Bloating ofcarcass and blood stained frothy exudates from the nostrils and anus 3. Dark-red skeletalm uscle ofa heifershowing haem orrhage,necrosis,edem a and em physem a. Itis prohibited to slaughterand dress an anim aldiagnosed with this disease atantem ortem exam ination. Differentialdiagnosis:Otheracute Clostridialinfections,lightning strike,anthrax,bacillary haem oglobinuria,lactation tetany,extensive haem orrhage and acute lead poisoning. Specific antitoxin and antibiotics are rarely effective in the treatm entofthis disease. An adequate preventive vaccination program m ay be the m osteffective m ethod in protecting the anim als from black leg. Itis seen in hum ans, anim als,birds and fish and is caused by various strains ofClostridium botulinum. Transm ission:Decom posed flesh and bones are the source ofinfection foranim als. Progressive m uscularparalysis from hindquarters to frontquarters,head and neck. M uscularparalysis Postm ortem findings:Foreign m aterialin fore-stom achs orstom achs m ay be suggestive of botulism. Differentialdiagnosis:Parturientparesis,paralytic rabies,equine encephalom yelitis,ragwort poisoning in horses,m iscellaneous plantpoisoning. Outbreaks ofbotulism in cattle and sheep in Australia, Southern Africa and the Gulfcoastarea ofthe United States are associated with phosphorus deficientdiets and ingestion ofcarrion. Cattle,sheep and rarely swine are susceptible to this file:///C:/versam m elt/index m eister. Seven strains ofthis organism (A through G)are distinguished according to im m unologicaldifferences. The diseases caused by various strains ofthis agentare frequently regarded as a separate entity owing to som e oftheirprom inentsigns. Nam es such as Bulbarparalysisin cattle, Lam siekte in sheepin South Africa (m eaning lam e sickness),and Lim berneck in poultry are often used. The m ajorsources ofthis organism are fish,hom e cured m eats, hom e canned vegetables and fruit. M ostfrequently,raw,insufficiently cooked foods orfoods notfully salted,cured, dried orsm oked are im plicated. Botulism toxins are heatlabile and food suspected ofhaving the organism should be boiled before serving. In m an the signs ofthe disease are weakness,dizziness,blurred ordouble vision,dilatation of pupils,dry m outh,difficulties in breathing and speech,progressive m uscularweakness, respiratory failure and death. M alignantedem a M alignantedem a is a bacterialdisease ofcattle,sheep,goats,swine,horses and poultry. Deep wounds associated with traum a provide idealcondition forthe growth ofthis agent. Softdoughy swelling and erythem a around the infection site Postm ortem findings: 1. M uscle tissue is dark-red buthas little orno gas Judgem ent:Carcasses ofanim als affected with m alignantedem a are condem ned. Tuberculosis Tuberculosis is a chronic disease ofm any anim alspecies and poultry caused by bacteria of the genus M ycobacterium. The organism s are excreted in the exhaled airand in allsecretions and excretions. When infection has occurred tuberculosis m ay spread:a)by prim ary com plex (lesion atpointofentry and the local lym ph node)and b)by dissem ination from prim ary com plex. These have usually a welldefined capsule enclosing a caseous m ass with a calcified centre. They are usually yellow in colourin cattle,white in buffaloes and greyish white in otheranim als. Active lesions m ay have a reddened periphery and caseous m ass in the centre ofa lym ph node. Lesions in the m eninges,bone m arrow and joints file:///C:/versam m elt/index m eister. Tuberculosis lesions can be classified as acute m iliary,nodularlesionsand chronicorgan tuberculosis. The incidence ofhum an tuberculosis caused by M ycobacterium bovis has m arkedly dropped with the pasteurization ofm ilk. Italso has dropped in areas where program s oftuberculosis eradication are in place. In cattle,lesions oftuberculosis caused by the avian type are com m only found in file:///C:/versam m elt/index m eister. Judgem ent:Carcass ofan anim alaffected with tuberculosis requires additionalpostm ortem exam ination ofthe lym ph nodes,joints,bones and m eninges. Itis suggested thatthe Codex Alim entarius judgem entrecom m endations forcattle and buffalo carcasses be followed. Heattreatm entofm eatis suggested during early and finalstages ofan eradication program m e:in low and high prevalence areas where one orm ore organs are affected,and where m iliary lesions,signs of generalization orrecenthaem atogenous spread are notobserved. In som e countries,the carcass is approved ifinactive lesions (calcified and/orencapsulated) are observed in organs and withoutgeneralization in lym ph nodes ofcarcass. Itis characterized by the thickening and corrugation ofthe wallofthe intestine,gradualweightloss and chronic diarrhoea and is caused by M ycobacterium paratuberculosis. The agentis persistentin soil,pasture,m anure and stagnantwaterforprolonged period. Carrieranim als,so called faecalshedders,are the m ostim portantsource ofinfection. Transm ission with sem en and in-utero are m inorsource ofinfection Antem ortem findings: 1. A poor,thin and slightly m oistcarcass should be held in the chillerand assessed after24 or48 hours. Ifthe dryness and setting ofthe carcass im proves during this tim e itcan be released. Differentialdiagnosis:Othercauses ofdiarrhoea and weightloss,m alnutrition,chronic salm onellosis,parasitism. Leptospirosis Leptospirosis is an im portantand relatively com m on disease ofdom estic and wild anim als and hum ans. In cattle,itis m anifested by interstitialnephritis,anaem ia and m astitis and abortion in m ostspecies. Transm ission:Anim als contractthe disease by eating and drinking leptospira-contam inated urine,water,orby directcontactofbroken skin orm ucous m em branes with m ud,vegetation file:///C:/versam m elt/index m eister. Recovered anim als and anim als with unapparent(subclinical)leptospirosis frequently excrete billions ofleptospiras in theirurine for severalm onths oryears. M ilk m ay be yellow,clotted and frequently blood stained Severely affected anim als 6. Abortion with frequentretention ofthe placenta (afterbirth) Severe illness in young calves m ay be associated with yellowish discoloration ofm ucous m em branes and reddish-brown urine before death. Ifm eningitis occurs,the anim alm ay show incoordination, salivation and m uscularrigidity. Differentialdiagnosis:Acute and subacute form s to be differentiated from babesiosis, anaplasm osis,rape and kale poisoning,bacillary haem oglobinuria,postparturient haem oglobinuria and acute haem olytic anaem ia in calves. The presence ofblood in the m ilk is a characteristic clinicalsign which willdifferentiate leptospirosis from otherinfectious diseases. Discussion:Leptospirosis is a zoonosis and is also an occupationalhazard forfarm ers, veterinarians and butchers. Hum an infection m ay occurby contam ination with infected urine and urine contents. The bacteria m ay be also found in m ilk in acute cases,however,itdoes notsurvive forlong period oftim e in m ilk. They can survive form onths in m oist and hum id environm ents,particularly in swam ps,ponds and stream s orpoorly drained pastures. Transm ission:An uninfected anim alm ay becom e infected with Brucella organism s by contam inated feed,pasture,water,m ilk,by an aborted fetus,fetalm em branes and uterine fluid and discharges. The disease m ay also be spread by dogs,rats,flies,boots,vehicles,the m ilking m achine and otherequipm entused in the barn. In chronic stage enlarged and hard epididym is,thickened scrotaltunics and frequently atrophic testicles 10. Infertility in ram s and abortion in ewes Judgem ent:Cattle and horse carcasses affected with brucellosis are approved (afterrem oval ofaffected parts),as Brucella bacteria rem ain viable foronly a shortperiod in the m uscles afterslaughter. Affected partofthe carcass,udder,genitalorgans and corresponding lym ph nodes m ustbe condem ned. Reactoranim als should be carefully handled during slaughterand dressing procedures. Discussion:Brucella organism s have only a shortlife in the m uscles ofslaughtered anim als. W hile slaughtering and dressing the reactors,a hook should be used in handling the uterus and udder. Em ployees in close contactwith infected anim als should weargloves and avoid accidentalcuts.

Intercurrentdiseases abro oil treatment rumalaya 60 pills on line,particularly hog cholera and the nutritionalstress caused by a sudden change in dietm ay predispose to infection with Salm onella organism s such as Salm onella typhim urium medicine cat herbs rumalaya 60pills low cost. Nervous signs m anifested by incoordination ofgait medicine hat mall buy discount rumalaya 60pills line,trem or treatment water on the knee buy rumalaya 60 pills overnight delivery,paralysis treatment alternatives for safe communities order on line rumalaya,convulsions medications 1-z buy rumalaya 60pills lowest price, recum bency and death. Abdom inaldilatation and frothy to pasty faeces in cases ofrectalstricture Postm ortem findings: Septicem ic syndrom e 1. Haem orrhages,petechiae and ecchym osis ofthe epiglottis,stom ach,intestine and bladder 4. Abdom inaldilatation and low grade peritonitis in cases ofrectalstricture Judgem ent:Viscera and carcass affected with salm onellosis are condem ned. In som e areas the heattreatm entofthe carcass is recom m ended because ofeconom icalreasons. Transm ission:Healthy carrierpigs shed the bacteria in m anure,where they m ay survive for5 m onths. The m anure is a reservoirofinfection from which bacteria are transferred to non infected piggeries via boots,cloths,birds,flies orotheranim als. Inflam ed and haem orrhagic m ucosa ofthe stom ach (paintbrush effect)and intestine 6. Edem atous and haem orrhagic lym ph nodes Judgem ent:An anim alaffected with an acute disease oferysipelas with erythem a ordiffuse cutaneous erysipelas with erythem a is condem ned on antem ortem inspection because of occupationalhazards. Carcass showing skin lesions orarthritis com plicated by necrosis or signs ofsystem ic effects is also condem ned. A localized skin lesion requires only the rem oval ofskin and the restofthe carcass is approved. Localized endocardiallesions oferysipelas withoutsystem ic changes orlocalized chronic inflam m ation ofjoints callforconditional approvalofthe carcass with heattreatm ent. The carcass m ay be totally approved,ifresults of a bacteriologicalexam ination show thatgeneralized disease is notpresent,antim icrobial substances are notfound and there is no health hazards to consum ers and food handlers. Differentialdiagnosis:Derm atitis,allergies,externalparasites,septicem ia,hog cholera,African swine fever,vesicularexanthem a,salm onellosis,arthritis and superficialbruises file:///C:/versam m elt/index m eister. M elioidosis M elioidosis is an infectious disease ofpigs,goats and occasionally ofotheranim als caused by Pseudom onaspseudom allei,presentin severaltropicaland subtropicalcountries in the Asia Pacific,M iddle Eastand Caribbean regions. Itcauses fatalinfections in a significantproportion ofinfected hum ans,especially those who are im m uno-com prom ised orhave intercurrent disease. Transm ission:Infection occurs by ingestion ofthe infective m aterialcontaining Pseudom onas pseudom allei,contam ination ofwounds orabrasions ofthe skin orperhaps bites ofinsects. M ultiple abscesses in m ostorgans especially in the regionallym ph nodes,spleen. Suppurative polyarthritis,the jointcapsules contain fluid and large m asses ofgreenish yellow pus. M eningoencephalitis In sheep the gross finding includes abscesses and suppuration in the nasalm ucosae. Judgem ent:Carcasses suspected to be infected with m elioidosis should be isolated and retained,and the affected tissues,preferably an excised unopened lym ph node and the spleen with abscesses should be sentto the appropriate laboratory forexam ination. Diagnosis is m ade on the basis ofisolation,culturalexam ination and pathogenicity test. Ifthere are no facilities forretention in isolation,the carcass suspected ortentatively diagnosed to have m elioidosis should be condem ned and properly disposed of. Persons handling the suspect carcass orm aterialshould disinfecttheirhands,forearm s,knives and othercontam inated equipm ent. Ifthe laboratory reportis negative the carcass has to be treated on the basisofthe lesionspresentand the subsequentdiagnosis. Anthrax (see page 80) Parasitic diseases Diseases caused by helm inths Trichinosis file:///C:/versam m elt/index m eister. However,the parasite has notbeen reported in dom estic pigs in a num berofcountries in developing regions. Larvae penetrate the epitheliallining ofthe sm allintestine,undergo fourm oults and becom e sexually m ature adults. The newborn larvae pass to the striated m uscles by the lym phatics and the blood stream. The predilection sites forthese larvae are the tongue, diaphragm,eye,m asticatory and intercostalm uscles. In the m uscles,larvae m ay persistfora long period oftim e orthey m ay die and becom e m ineralized. Swine,carnivores and hum ans becom e infected from eating infected pork,horse,sealorotherm eat. Larvae m ay survive fora long tim e in decaying and putrefying m uscle and carrion. The m ostcharacteristic sym ptom s ofhum an trichinosis are high fever,weakness,arthralgia, m yalgia,abdom inalpain with diarrhoea,edem a ofthe face and eyelids,and hives. Rem arks:Ifthe laboratory exam ination fortrichina is notperform ed in endem ic areas heating orcooking and freezing orcuring ofpork productm ustbe enforced. Trichinella exam ination can be carried outas follows: file:///C:/versam m elt/index m eister. Trichinoscopic exam ination Sam ples are taken from the diaphragm pillaratthe transition ofthe sinewy part. These pieces are then com pressed between glass plates and exam ined by using a m icroscope ortrichinoscope. The fluid in Petridishes is exam ined underthe m icroscope at40 tim es m agnification. Differentialdiagnosis:Sarcosporidiosis and Cysticercus cellulosae infection and tyrosine crystals in m uscles. Cysticercosis (Cysticercus cellulosae infestation) Cysticercuscellulosae found in pigs is the interm ediate stage ofthe tapeworm Taenia solium, which occurs in the sm allintestine ofhum ans. W ith ingestion ofinfected pork by hum ans,the larvae evaginate and attach to the proxim alpartofthe live form any years in the environm ent. The ingestion ofproglottides by scavenging pigs is the m ostfrequentway of transm ission ofcysticercito swine. Larvae hatch from eggs in the pig intestine and they furtherm igrate to m uscle tissue,brain,liverand otherorgans. The use ofinadequately treated hum an excrem ents as fertilizeris the othercause ofporcine cysticercosis. The auto-infection ofthe centralnervous system with the larvalform ofcysticercus in hum ans is m anifested with headache,dizziness,hydrocephalus,loss ofvision and nausea. In lightorm oderate infestation,the carcass m ay be conditionally approved pending heator freezing treatm ent. Due to scavenging nature ofpigs,infection is usually found only in free range anim als and notsty raised ones. Carcasses are usually severely affected (pearly pork) and are condem ned despite provision forfreezing treatm ent. Ascariasis accounts forsignificant losses to the swine industry due to reduction in growth rate,stunting ofyoung pigs and liver condem nations. The liverlesions are seen as m ilk spotsand degeneration ofthe liver parenchym a m ay occurwith subsequentcirrhosis. In the lungs,the larvae m ay cause haem orrhage and frequently verm inous pneum onia. Life cycle:Adultworm s live in the sm allintestine ofpigs where itlays a greatnum berofeggs. The eggs becom e infective within a few weeks and, ifthey are ingested by a host,larvae are released in the sm allintestine. The larvae m igrate through the intestinalwalland portalvein to the liverwithin 24 hours ofbeing swallowed. The larvae,during this m igration, dam age the liverand lungs and som etim es the kidneys. Larvae reach the pharynx through the bronchiand trachea,Afterthey are swallowed by the host,they m ature in the intestine and lay eggs. M ild inflam m ation ofthe intestine and rarely obstruction ofthe bile ducts caused by adult worm s 2. M ild isolated lesions willdisappearifthe liveris held overnightin the offalcoolerand itcan be released forhum an consum ption. Differentialdiagnosis:Enzootic pneum onia,chronic enteritis caused by Salm onella and Treponem a spp. Sparganosis Sparganosis in pigs is seen in the Asia-Pacific region and som e otherparts ofthe world and is caused by spargana,the larval(plerocercoid)stages ofthe tape worm Spirom etra erinacei. Life cycle:The adulttape worm Spirom etra erinaceilives in the sm allintestine ofthe cat,fox and dog. The egg passed in the faeces develops into a ciliated coracidium in water,which when ingested by cyclops (the waterflea),the firstinterm ediate host,develops into a file:///C:/versam m elt/index m eister. Ifthe cyclops with the procercoid is eaten by a frog,the second interm ediate host, the procercoid develops into a plerocercoid which resem bles the adulttape worm in m iniature butwithoutthe genitalia. When these frogs are eaten by a cat,fox and dog the plerocercoid develops into m ature tape worm s-Spirom etra erinacei. However,ifa frog is eaten by a pig or otheranim als such as snakes the plerocercoid m igrates to certain tissues,particularly the skeletalm uscles where they appearas cysts up to 6 m m long oras ribbon like structures. Caseated cysts orcysts up to 6 m m long with spargana in the skeletalm uscle orelsewhere 2. Differentialdiagnosis:Sarcocystosis,trichinellosis,cysticercosis,m yositis,nerve fibres file:///C:/versam m elt/index m eister. Diseases caused by protozoa Porcine babesiosis (Piroplasm osis,Texas fever,Red water,Tick fever) Babesiosis ofswine,cattle,horses,sheep and swine is a protozoan disease caused by various species ofprotozoa in the genus Babesia. Transm ission:Differentspecies ofticks in the fam ily Ixodidae serve as vectors in different locations. Edem atous and haem orrhagic lym ph nodes Judgem ent:Carcass ofan anim alshowing generalized signs ofinfection,jaundice and inadequate bleeding is condem ned. Differentialdiagnosis:Theileriosis,haem obartenellosis,leptospirosis,bacillary file:///C:/versam m elt/index m eister. The firsttwo species are m acroscopic and when fully developed are fusiform and m easure up to 1. The overallprevalence ofsarcocysts in pigs appears to be relatively low and the incidence appears to be decreasing largely due to m ethods ofhusbandry where pigs are being reared indoors. These hosts acquire the infection when they eatthe tissues ofpigs containing viable cysts ofSarcocystis. In som e countries up to 20 % ofcarcasses from free range pigs harbourthis parasite. In m oderate to lightinfestations the lesions are rem oved and the carcass passed. Hum ans can getinfected with Toxoplasm a cysts by ingestion ofuncooked anim altissue. In hum ans clinicalsym ptom s m ay vary from fever,m alaise,skin rash,pneum onia,m yocarditis, lym phadenopathy and encephalitis. Cats getinfected by eating m ice orbirds oranim altissue containing infective oocysts. The oocysts are furtheringested by the interm ediate host(pig,sheep,cattle and hum ans). From the intestine,oocysts m ove to various tissues including m yocardium,lungs,placenta and m ostfrequently to m uscle,brain and liver where they encyst. M ultiple granulom atous lesion in the brain Judgem ent:Carcasses ofanim als showing clinicalsigns ofacute disease are condem ned. This condition is m ore prevalentin the Pietrain,Poland China,Landrace and Landrace cross breeds ofhogs. Extrem ely firm,dry the finalassessm entofpork m uscle can be carried outafterchilling ofthe carcass for24 hours. Extensive involvem entofthe carcass m ay require down grading form anufacturing purposes, orcondem nation. Porcine viralencephalom yelitis should also be considered in differentialdiagnosis. Dark,firm and dry pork (right);pale,softand exudative pork (left);the norm alpork is in the m iddle. Itis m anifested with hepatitis and high m ortality in young lam bs and calves,and abortion in adultanim als. Hum an infection occurby handling diseased tissues,and strictprecautions should be instituted to preventinfection with this virus,such as wearing goggles and gloves. Congenitalm alform ation ofthe brain and m uscles file:///C:/versam m elt/index m eister. Edem atous unpigm ented skin showing cracking and sloughing due to photosensitization 2. Diarrhoea associated with haem orrhagic inflam m ation ofstom achs and intestine 5. Necrosis ofthe liverin lam bs (liverm ay be m ottled grey,orreddish-brown to brightyellow in colour) 3. Haem orrhage ofthe gastrointestinaltract,serosae,internalorgans and lym ph nodes 5.

Single dose pharmacokinetics of perindopril and its metabolites in hypertensive patients with various degrees of renal insufficiency medications used to treat adhd cheap 60pills rumalaya overnight delivery. Combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes medicine man pharmacy order rumalaya with a visa. Additive nephrotoxicity from roentgenographic contrast media: its occurrence in phenazopyridine induced acute renal failure treatment wrist tendonitis purchase rumalaya 60pills otc. Skin pigmentation and acute renal failure in a patient receiving phenazopyridine therapy medicine abbreviations buy rumalaya paypal. Methemoglobinemia and hemolytic anemia after phenazopyridine hydrochloride (Pyridium) administration in end-stage renal disease treatment 1st metatarsal fracture buy rumalaya 60pills free shipping. Acute renal failure due to phenazopyridine (Pyridium) overdose: case report and review of the literature symptoms kidney cancer buy rumalaya visa. Pharmacokinetics of phenobarbital during enhanced elimination modalities to evaluate their clinical efficacy in management of drug overdose. Low blood levels of phenobarbital due to poor gastrointestinal solubility of phenobarbital tablets [letter]. Effect of peritoneal dialysis on serum concentrations of three drugs commonly used in pediatric patients. Muscle necrosis and calcication in acute renal failure due to barbiturate intoxication. Treatment of convulsive status epilepticus: recommendations of the Epilepsy Foundation of Americas Working Group on Status Epilepticus. Changes in renal function following chronic phenobarbitone administration [abstract]. Glomerular ltration rate and effective renal plasma ow following treatment with phenobarbital. Effectiveness of hemodialysis in the extracorporeal therapy of phenobarbital overdose. Barbiturate and anticonvulsant treatment in relation to osteomalacia with haemodialy sis and renal transplantation. Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Estimating phenytoin concentrations by the Sheiner-Tozer method in adults with pro nounced hypoalbuminemia. Effect of age, height, weight and sex on serum phenytoin concentration in epileptic patients. Clinical response in epilepsy in relation to total and free serum levels of phenytoin. The inuence of seizure type on the efficacy of plasma concentrations of phenytoin, pheno barbital, and carbamazepine. Intravenous phenytoin loading in patients after neurosurgery and in status epilepticus: a population pharmacokinetic study. A rational basis for the measurement of free phenytoin concentration in critically ill trauma patients. Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. Efficacy and safety of intravenous phosphate replacement in critically ill patients. Severe hypophosphatemia: pathophysiologic implications, clinical presentations, and treat ment. University of Colorado Hospital Med-Surg Electrolyte Replacement Draft Guideline, 2011. Inuence of renal function on the pharmacokinetics and pharmacodynamics of piperacillin/tazobactam in intensive care unit patients during continuous venovenous hemoltration. Pharmacokinetics of piperacillin-tazobactam: intermittent dosing versus continuous infusion. Removal of piperacillin in critically ill patients undergoing continuous venovenous hemoltration. Inuence of renal function on trough serum concentrations of piperacillin in intensive care unit patients. Therapeutic drug monitoring of piperacillin-tazobactam using spent dialysate effiuent in patients receiving continuous venovenous hemodialysis. Pharmacokinetics of piperacillin in patients on peritoneal dialysis with and without peritonitis. Pharmacokinetics of piperacillin in patients with moderate renal failure and in patients undergoing hemodialysis. Pharmacodynamic modeling of intravenous antibiotics against gram negative bacteria collected in the United States. Randomized, open-label, comparative study of piperacillin-tazobactam administered by continuous infusion versus intermittent infusion for treatment of hospitalized patients with complicated intra-abdominal infection. Piperacillin-tazobactam-induced seizure rapidly reversed by high ux hemodialy sis in a patient on peritoneal dialysis. Clinical cure of ventilator-associated pneumonia treated with piperacillin-tazobactam administered by continuous or intermittent infusion. Intermittent intravenous piperacillin pharmacokinetics in automated peri toneal dialysis patients. Continuous-infusion b-lactam antibiotics during continu ous venovenous hemoltration for the treatment of resistant gram-negative bacteria. Pharmacokinetics of piperacillin-tazobactam in anuric intensive care patients during continuous venovenous hemodialysis. Identication of optimal renal dosage adjustments for traditional and extended infusion piperacillin-tazobactam dosing regimens in hospitalized patients. Recommended b-lactam regimens are inadequate in septic patients treated with con tinuous renal replacement therapy. Pharmacokinetics of piperacillin in subjects with various degrees of renal function. Single-dose and steady-state pharmacokinetics of piroxicam n elderly vs young adults. Piroxicam pharmacokinetics: recent clinical results relating kinetics and plasma levels to age, sex, and adverse effects. Pharmacokinetics of piroxicam, a new nonsteroidal anti-inammatory agent, under fasting and postprandial states in man. Relative bioavailability of two oral formulations of piroxicam 20 mg: a single-dose, randomized-sequence, open-label, two-period crossover comparison in healthy Mexican adult volunteers. The pharmacokinetics of piroxicam in elderly persons with and without renal impairment. Renal effects of ibuprofen, piroxicam, and sulindac in patients with asymp tomatic renal failure: a prospective, randomized, crossover comparison. Inhibition of mineralocorticoid receptor is a renoprotective effect of 3-hydroxy 3-methylglutaryl coenzyme A reductase inhibitor pitavastatin. Drug-drug interactions with statins: will pitavastatin overcome the statins Achilles heel Comparative efficacy of pitavastatin and simvastatin in high-risk patients: a random ized controlled trial. Pharmacology of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (sta tins), including rosuvastatin and pitavastatin. Place of pitavastatin in the statin armamentarium: promising evidence for a role in diabetes mellitus. Co-administration of ezetimibe enhances proteinuria-lowering effects of pitavastatin in chronic kidney disease patients partly via a cholesterol-independent manner. Effect of pitavastatin on urinary liver-type fatty acid-binding protein levels in patients with nondiabetic mild chronic kidney disease. Effect of pitavastatin on urinary liver-type fatty acid-binding protein levels in patients with early diabetic nephropathy. Poolsup N, Suksomboon N, Wongyaowarat K, Rungkanchananon B, Niyomrat P, Kongsuwan S. Meta-analysis of the com parative efficacy and safety of pitavastatin in patients with dyslipidemia. Clinical efficacy of pitavastatin, a new 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, in patients with hyperlipidemia: dose-nding study using the double-blind, three-group parallel com parison. Effect of low-dose (1 mg/day) pitavastatin on left ventricular diastolic function and albuminuria in patients with hyperlipidemia. Identication of prognostic factors for plerixafor-based hematopoietic stem cell mobi lization. Plerixafor dosing and administration in a patient with dialysis-dependent renal failure. Efficacy of pre-emptively use plerixafor in patients mobiliz ing poorly after chemomobilization: a single centre experience. Plerixafor: a review of its use in stem cell mobilization in patients with lymphoma or multiple myeloma. A pharmacokinetic study of plerixafor in subjects with vary ing degrees of renal function. Plerixafor (Mozobil) for stem cell mobilization in patients with multiple myeloma previously treated with lenalidomide. Plerixafor: a chemokine receptor-4 antagonist for mobilization of hematopoietic stem cells for trans plantation after high-dose chemotherapy for non-Hodgkins lymphoma or multiple myeloma. Pharmacokinetics and pharmacodynamics of plerixafor in patients with non Hodgkin lymphoma and multiple myeloma. Efficacy and cost-benet analysis of risk-adaptive use of plerixafor for autologous hematopoietic progenitor cell mobilization. Absorption of antibiotics during peritoneal dialysis in patients with renal failure. Antimicrobial treatment and clinical outcomes of carbapenem-resistant Acinetobacter bau mannii ventilator-associated pneumonia. The impact of polymyxin B dosage on in-hospital mortality of patients treated with this antibiotic. The use of intravenous and aerosolized polymyxin B for the treatment of infections in critically ill patients: a review of the recent literature. Polymyxins: pharmacology, pharmacokinetics, pharmacodynamics, and clinical applications. Polymyxin B in chronic pyelonephritis: observations on the safety of the drug and on its inuence on the renal function. Polymyxin B versus other antimicrobials for the treatment of Pseudomonas aeruginosa bacteraemia. Pharmacokinetics of polymyxin B1 in patients with multidrug-resistant gram-negative bacterial infections. Pharmacokinetics of polymyxin B in a patient with renal insufficiency: a case report [letter]. Prevalence and risk factors for acute kidney injury associated with parenteral polymyxin B use. Ampicillin/sulbactam compared with polymyxins for the treatment of infections caused by carbapenem-resistant Acinetobacter spp. Polymyxin B nephrotoxicity and efficacy against nosocomial infections caused by multiresistant gram-negative bacteria. Extended spectrum b-lactamase-producing Klebsiella pneumoniae chronic ambulatory peritoneal dialysis peritonitis treated successfully with polymyxin B. Parenteral polymyxin B use in patients with multidrug-resistant gram-negative bacteremia and urinary tract infections: a retrospective case series. Combination therapy with polymyxin B for the treatment of multidrug-resistant gram-negative respiratory tract infections. Polymyxin B for the treatment of multidrug-resistant pathogens: a critical review. Alternative adjustment: Dose adjustments for polymyxin B presently are controversial; recent clinical pharmacokinetic data suggest that dose adjustment for renal impairment, no matter how severe, is neither necessary nor appropriate and that larger doses are associated with better outcomes. Clinical pharmacological investigation of polythiazide, a potent oral diuretic agent. Diuretic effect of polythiazide and sodium meralluride: comparison in bedfast patients with edema. Clinical evaluation of polythiazide in hypertension and congestive heart failure: a comparative double-blind study. Antihypertensive properties of polythiazide and chlorothiazide: comparative double-blind study. Stein I, Katari G, the use of a new diuretic (polythiazide) in congestive failure and hypertension. If progressive renal impairment becomes evident, as indicated by a rising nonprotein nitrogen or blood urea nitrogen, a careful reappraisal of therapy is necessary with consideration given to withholding or discontinuing diuretic therapy. Bioavailability and pharmacokinetics of a new sustained-release potassium chloride tablet. New guidelines for potassium replacement in clinical practice: a contempo rary review by the National Council on Potassium in Clinical Practice. Efficacy and safety of potassium infusion therapy in hypokalemic critically ill patients. Bioavailability of potassium from three dosage forms: suspension, capsule, and solution. Therapeutic assessment of Slow-K and K-Tab potassium chloride formulations in hypertensive patients treated with thiazide diuretics.

The extent of the economic (f) Reserved funds that are not used for preconstruction hardship existing in a small community to be served by the grants shall be available for assignment to construction project shall be reflected in the priority score medicine 2015 lyrics discount 60 pills rumalaya with amex. Eligible projects shall be for inclusion is required and a separate priority determination given priority according to the extent each project is intended shall be made for each phase (preconstruction and to remove symptoms tonsillitis order rumalaya overnight, mitigate treatment modalities buy cheapest rumalaya, or prevent adverse effects on surface or construction) of a sponsors project medicine you can order online cheap 60pills rumalaya amex. For a preconstruction project symptoms 0f food poisoning cheap rumalaya 60pills, if a request for inclusion for which the list will be in effect medicine grace potter lyrics order rumalaya 60 pills with visa, a proposed list shall be remains incomplete after the above date, that project shall established. For a construction project, documentation required hearing to be held under this rule section, to all project under Rules 62-505. Bureau of Water Facilities Funding, 2600 Blair Stone Road, (4) Removal from priority list. Law Implemented weighted average base score (benefit) for that project shall be 403. Projects shall be subject to the charge system shall be designed to make the wastewater environmental, social, and economic requirements identified in management system financially self-sufficient. The revenue generation system shall be updated at least documentation shall include the following: annually, and may be updated as necessary to reflect changing (a) Sufficient illustrative detail of the local area to identify conditions, but it shall remain in effect in conformance with where the project or activity would be located, including this chapter. Consideration must be given to capital costs and an environmental review under Rule 62-505. A wastewater facilities plan shall facilities based on a discount rate projected to be in effect include documentation of the following: during a planning period of not less than five years. Grant funds shall be available for no more than the service area and future project service areas. The public meeting shall provide for public facilities plans for projects involving wastewater treatment, participation in the evaluation of project alternatives. The project sponsor shall hold a public hearing before preliminary design parameters, estimated capital costs, and adoption of its wastewater facilities plan. Final type of debt instrument, that will be implemented over a period permitted plans and specifications shall be submitted for each of five (5) years beginning with the year after the project has component of a design/build project when complete. The collections that will generate the revenues that will be environmental review shall establish the environmental dedicated to making the wastewater management system significance of a proposed project and whether the planning of financially self-sufficient. Written comments from the public shall be postmarked or delivered, (l) Responses generated by a multi-disciplined within the 30-day comment period, to the Department of intergovernmental review, if applicable. Rehabilitation of existing facilities or replacement of document the results of its environmental reviews as described structures, materials or equipment; in paragraphs (c) through (f) below. Facilities that will not result in more than an additional review document is amended in lieu of issuing a new document 100,000 gallons per day flow or, alternatively, not more than a to reflect proposed project changes that potentially have ten percent increase in daily flow at an existing treatment plant environmental impacts, the same basic procedures as were and, under either alternative, neither the discharge point nor the used to produce the original document shall be used. Facilities for unsewered communities that involve advance of completing the review for the entire system of self-contained individual or cluster systems providing both facilities, the environmental review process is partitioned. A treatment and disposal of wastewater near the buildings from partitioned environmental review, if requested by the project which the wastewater is to be discharged; sponsor, shall be performed only if all the following conditions d. Reclaimed water reuse facilities in areas where streets all environmentally sound, implementable alternatives for the have been established, underground utilities installed, or overall wastewater management system of which the building sites excavated if the treatment level enables component is a part have been identified, and the component unrestricted public access. The purpose of, and the need for, the project; project at the public hearing held, under paragraph (2)(i) c. Environmental enhancement measures to be result in the inability of existing facilities to meet permit implemented; criteria, result in unpermitted discharges, or provide capacity to . The public participation process; service previously undisturbed areas such that more than 30% f. Identify and evaluate project alternatives; maintenance of the project, or to otherwise carry out project 4. Plans and specifications minimized or eliminated; shall be in conformance with the facilities plan. Conclude the environmental review only after a 30-day (b) the Department has issued other authorization for public comment period has expired without receipt of project construction (includes design/build); or comments about adverse environmental impacts or if, after (c) the Department has determined that its authorization is receipt of such comments, the Secretary takes one of the not required prior to construction; or. When enhancement as a condition of confirmation of the original procuring property and services under a Small Community decision; or Wastewater Facilities Grant, a project sponsor shall follow the c. The Department shall perform an eligibility competitive or non-competitive proposals. Proposals shall be solicited from a minimum of three be obtained from a minimum of two qualified sources. Requirements for the formal waiver to this requirement for procurement when three sources advertised competitive bidding method of procurement shall be are not available. All solicitations shall incorporate a clear and accurate technical evaluations of the proposals received and for description of the technical requirements for the materials, selecting awardees. Procurement by noncompetitive proposals is minimum essential characteristics and standards to which they procurement through solicitation of a proposal from only one must conform to satisfy their intended use. A cost analysis is required verifying the proposed cost ensure maximum open and free competition. The invitation for bids, which shall include any maintenance over the useful life of the facilities shall be made. All bids shall be publicly opened at the time and place (b) the request for proposals shall describe the work prescribed in the invitation for bids, and a firm-fixed-price eligible for a grant, the requirements with which the successful contract (lump sum or unit price) awarded to the responsible respondent shall comply, and the evaluation process to be used bidder whose bid conforms to all the material terms and in selecting the successful respondent. Consideration shall be given to such matters as contractor (g) Requests for proposals shall be submitted to the integrity, compliance with public policy, record of past Department prior to advertising for a determination of performance, and financial and technical resources. These records assurance shall be given that project construction will be shall include the following: rationale for the method of completed. Such assurance may be in the form of a procurement, selection of contract type, contractor selection or commitment to maintain adequate reserve funds dedicated rejection, and the basis for the contract price. Other forms of such reasonable assurance include accordance with good administrative practice and sound requirements for contractors to provide performance and business judgment, for the settlement of all contractual and payment bonds under section 255. If such a determination has not been employees engaged in the award and administration of made, the minimum requirements shall be as follows: contracts. A payment bond on the part of the contractor for 100 Grant recipients may set minimum rules where the financial percent of the contract price. The Department shall recipient including the manner by which it shall be effected perform a determination of eligibility under Rule 62-505. Equal Employment Opportunity compliance; review shall establish the environmental significance of a b. Contracting with small and minority firms, womens applicable requirements of this chapter. Departments environmental review for each project shall be (j) Procurement of professional service shall be in issued as an environmental information document that shall be accordance with the Consultants Competitive Negotiations valid for five years from the date of issue. The project sponsor shall submit information documents are described in subsections (2) procurement documentation for approval by the Department through (5) below. The notice of availability the competitive or noncompetitive negotiation procurement shall include instructions about the procedures for accessing methods or the formal advertised competitive bidding method. Procurement requirements shall be as set comments from the public shall be considered by the forth in the following sections of 40 C. Briefly describe the project, the justification for the (10) Project changes after advertising for bids and before categorical exclusion, and the proposed grant funding; bid opening shall be made by addendum to plans and 2. No information is received about previously impacts; unconsidered adverse environmental impacts; b. A re-evaluation of the project is made as a result of the (b) Projects potentially eligible for categorical exclusion comments, and the Department confirms the original decision are: or requires environmental enhancement measures before 1. A re-evaluation of the project is made as a result of the (2) Projects in subsection (1) above, shall meet the per comments and the Department confirms the original decision capita income and population requirements of this chapter. The standard for determining indigence shall be that recognized by the Federal Poverty income guidelines produced by the United States Department of Health and Human Services. This period of assessment and evaluation shall be skills required for licensure as a Consultant Pharmacist. Minimum Skill Required Percent of Time Hours Minimum of 40 Hours in Maximum of Three Months 50-60% 20-24 1. Hurricane Orders issued by the Office of Insurance Regulation above are to be consistent with the Uniform Property & in the 2004 and 2005 hurricane seasons. The reporting shall Any person who wishes to provide information regarding a be submitted with such frequency and for such areas as set statement of estimated regulatory costs, or provide a proposal forth in the Order activating this subsection and may be revised for a lower cost regulatory alternative must do so in writing to reflect the phases of reporting necessary as set forth in form within 21 days of this notice. Commercial Multiple Peril Pursuant to the provisions of the Americans with Disabilities. The following standardized provisions may be Arrangements and Commercial Self-Insurance Trusts; and activated as provided herein: 4. References herein to policy or contract of insurance (a) All entities having direct premiums written in Florida includes all agreements regulated under the Insurance Code. No interest, penalties, or other charges, shall accrue or after the date specified in the Order. Victims of Hurricane [name of hurricane or natural (g) A cancellation or nonrenewal may occur prior to the disaster] will receive an automatic extension of time to and date specified in the Order, at the written request or written including [date specified in the Order], to bring their accounts concurrence of the policyholder. Therefore, if you this rule, would have taken effect during the dates specified in are a victim of Hurricane [name of hurricane or natural the Order, such notice is not made invalid by this rule; disaster], please contact us at once at the number provided at however, the bottom of this notice so that we may advise you of the 1. Issuing a 10 day notice of intent to cancel to the insured effective on the date the policy would have otherwise been by the means provided under Section 627. No late charges shall be assessed for any insured who Withdrawals qualifies for protection under this rule. Well construction documentation shall consist of provisions of paragraph (1)(f) or (1)(g). Effective not limited to the following: Aldicarb shall not be used on July 1, 2007, the well completion report or statement certified Florida citrus within 1000 feet of any well when any soil series by a Florida-licensed well contractor must contain the within the intended site of application is identified by the following information: well location; casing depth; static water U. Well location must be identified by county, range, surface or a minimum of 30 feet below the water table. Soil Conservation accurate to a minimum of five places after the decimal and Service as highly permeable well-drained sand include, but are must be in the format of this example: Latitude: 28. Tavares (j)(h) Any drinking water well found to contain aldicarb Well construction documentation shall consist of either a copy residues in excess of the standards established by the Florida of the well completion report issued by the appropriate water Department of Environmental Protection in Chapter 62-550, management district or a statement certified as to accuracy by a F. The well is not used for human consumption; or approved by the department indicate residue levels in 2. Permits may be obtained by filing an furnished the department well construction documentation application for permit with the department and meeting all confirming that the well is continuously cased to a depth of at permit requirements. Applications shall be filed either least 100 feet below ground surface or at least to a minimum electronically on the web site. Application sites (e) the department shall deny permit applications that list situated in more than one township, range, and/or section must application sites in areas determined by the department to be be submitted as multiple sites, with each site identified as one unsuitable for aldicarb application. Petitions for the reversal of determinations of provisions of paragraph (1)(f), well location must be provided unsuitability for aldicarb application shall be submitted to the for each well that determines an application setback at the department for review and consideration. Well location does not need to be provided for any documentation submitted by the petitioner to demonstrate that well that meets the provisions of paragraph (1)(f), but the proposed reintroduction of aldicarb use would not result in number of such wells within the application site must be water quality violations in potable wells in the area. The use, sale, distribution or application 5/04 new 2/02, hereby adopted and incorporated by reference, of aldicarb by any person in a manner inconsistent with the may be obtained from the web sites or or from the Pesticide provisions of this rule is a violation of Chapter 487, F. S, and Certification Section, Florida Department of Agriculture and subject to the penalties described therein. Administration of Florida that the wording of paragraphs Incorporated Forms: Insurance Capital Build-Up Incentive (3)(k), (4), (6), (8) and (9) of Rule 19-15. Under the the June 30, 2006 edition of the Florida Administrative Terms and Conditions section, the following changes have Weekly, Vol. New Capital does not include Citizens was the addition of a notarization clause following the first Property Insurance Corporation take-out bonuses pursuant to attestation signature line so that both attestations would be Section 627. Paragraph (6) has been amended to replace the may in the third sentence with shall. The Notice is hereby given that the following changes have been following shall govern operations, activities and such made to the proposed rule in accordance with subparagraph recreation on the lands under the management of the Office. No person shall introduce into this change was made to address a concern expressed by the any lands under the management of the Office any plant or Joint Administrative Procedure Committee. When utilizing recreational trails, users shall stay on necessary for riparian upland owners on Lake Rousseau and the trails designated for that purpose. User fees shall be established as follows: or when they are engaged in navigation, including anchoring or (a) User fees for primitive camping at campground trolling. User fees for recreational vehicle camping at within the Greenway, other than in an emergency, possession campground facilities on lands under the management of the of alcoholic beverages shall be prohibited. Florida law and local ordinances may require vendors to obtain (13) through (16) No change. Boating and operation of vessels Authorization from the Office for sale of food or other in waters within the boundary of on lands under the merchandise on lands managed by the Office does not replace management of the Office shall be conducted as follows: or supersede any such requirements. Facilities may be closed on the Office without first having applied for and received written Holidays listed in subsection 62S-3. Authorization shall be issued No person shall remain at any facility after closing unless when it is determined by the Office that the request to provide properly registered as an overnight visitor or in possession of this service would not adversely affect Office-managed valid authorization from the Office. Authorization may be resources, would be consistent with Office management obtained by submitting a written request to the Office of practices and would provide a needed visitor service. Authorization shall may be granted ensure that minors are not served and are not able to acquire by the Office, when it is necessary for safety, protection, alcohol, such as an over-21 area with no liquor to be taken construction, or restoration purposes. Alternative training is the site manager determines that any of the following exists: intended to correct a youths behavior by imposing minor staff, including law enforcement, is not immediately available sanctions. Disorder; Major Depression, Bipolar Disorder or other Mood (1) through (5) No change. Disorder; Generalized Anxiety Disorder or other Anxiety Disorder; Personality Disorder; or Specific Authority 260. It shall be clear to the youth shall be placed in the youths file and a copy given to the youth that the corrective action taken is a logical consequence of his to be kept in his or her possession. Withholding of telephone and visitation (a) Participation in physical training exercises, which are privileges shall not include depriving a youth access to his or designed to develop optimum physical conditioning of the her attorney, law enforcement, a representative of the clergy, youth. Prior to any youth having a privilege suspended, the (c) Community service or work assignments of a youth shall have the reason(s) for the suspension explained to productive nature; him or her.

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