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By G. Marlo. Saint Norbert College.

Avian influenza viruses reveal an astonishing capability to retain infectivity in the environment and particularly in surface water in spite of their seemingly delicate morphology (Stallknecht 1990a+b proven 50 mg clozaril, Lu 2003) generic clozaril 50 mg with amex. Upon return for breeding purposes during the subsequent season, returning birds or their (susceptible) off- spring are re-infected with viruses released by chance from melting environmental water. Along these lines, it has been hypothesised that influenza viruses can be pre- served in environmental ice for prolonged time periods (Smith 2004), and that an- cient viruses and genotypes might be recycled from this reservoir (Rogers 2004). The risk that infection will be transmitted from wild birds to domestic poultry is greatest where domestic birds roam freely, share a water supply with wild birds, or use a water or food supply that might become con- taminated by droppings from infected wild bird carriers (Capua 2003, Henzler 2003). Birds are infected by direct contact with virus-excreting animals and their excretions or through contact with (abiotic) vectors which are contaminated with virus-containing material. So-called ‘wet’ markets, where live birds are sold under crowded conditions, are multiplicators of spread (Shortridge 1998, Bulaga 2003). Biosecurity measures, aiming at the isolation of large poultry holdings, effectively prevent transmission from farm to farm by mechanical means, such as by contami- nated equipment, vehicles, feed, cages, or clothing – especially shoes. However, during outbreaks in the Netherlands (2003) and Canada (2004), airborne spread has been considered (Landman and Schrier 2004, Lees 2004). The role of live vectors such as rodents or flies, which may act as ‘mechanical vectors’ and are not themselves infected, is largely indetermined but certainly does not constitute a major factor. In April 2005, however, Asian lineage H5N1-associated disease surfaced at Lake Qinghai in North Western China affecting thousands of bar-headed geese and other migratory species of ducks, cormorants and gulls (Chen 2005, Liu 2005). Therefore, transmission of Asian lineage H5N1 viruses by wild birds must be taken into account in future preventive concepts (discussed below). Since late 2003, some H5N1 viruses have been encountered in Asia which were highly pathogenic for chickens but not for ducks (Sturm-Ramirez 2005). Experi- mental infections using these isolates revealed a heterogeneous mixture with respect to genetic analysis and plaque formation capacities in cell culture (Hulse Post 2005). Ducks that survived infection with these isolates were shown to shed a virus population on day 17 that had lost its pathogenic potential for ducks. Transmission to Humans Transmission of avian influenza viruses to humans, leading to the development of clinically overt disease is a rare event (Table 3). These cases were epidemiologically linked to an outbreak of highly pathogenic H5N1 in live-bird markets (Yuen 1998, Claas 1998, Katz 1999). The risk of direct transmission of the H5N1 virus from birds to humans seems to be greatest in persons who have close contact with live infected poultry, or surfaces and objects heavily contaminated with their droppings. Exposure risk is considered substantial during slaughter, defeathering, butchering and preparation of poultry for cooking (http://www. In several such instances, it was reported that the person who slaughtered or prepared a sick bird for consumption developed fatal illness, while family members who participated in the meal did not (http://www. The H9N2 strain circulating in poultry at these times provoked significant symptoms and lethality rates in highly vulnerable species such as turkeys and chickens. To date, there is no evidence that properly cooked poultry meat or poultry products are a source of human infection by the Asian lineage H5N1. Transmission 65 Transmission to other Mammals Avian influenza viruses have been transmitted to different mammal species on sev- eral occasions. In European pig populations, avian-like H1N1 viruses are highly prevalent (Heinen 2002) and an H1N2 virus, a human-avian reassortant vi- rus, Þrst isolated in the U. A H9N2 virus of avian provenance is moderately prevalent in swine populations in the East of China (Xu 2004). In addition to swine, marine mammals and horses have been shown to acquire influenza A viruses from avian sources (Guo 1992, Ito 1999). Natural infection with H5N1 was described in tigers and other large cats in a zoo in Thailand after the animals were fed with virus-positive chicken carcasses (Keawcharoen 2004, Quirk 2004, Amosin 2005). In 2004, 3,000 serum samples obtained from free roaming pigs in Vietnam were tested serologically for evidence of exposure to the H5N1 influenza virus (Choi 2005). In experimental infections, it was shown that pigs can be infected with H5N1 viruses isolated in Asia in 2004 from human and avian sources. A mild cough and elevated body temperature were the only symptoms observed for four days post infection. Peak viral titres from nasal swabs were found on day 2 post infection, but none of the experimentally infected animals transmitted the infection to contact pigs. None of the avian and human H5N1 viruses tested were readily transmitted between pigs under experimental conditions (Choi 2005). Based on these observations, pigs probably do not currently play an important role in the epidemiology of the Asian lineage H5N1. An outbreak of the highly pathogenic H7N7 avian influenza in poultry, in the Neth- erlands, Belgium and Germany in Spring 2003, caused infection and mild illness, predominantly conjunctivitis, in 89 poultry workers exposed to infected animals and carcasses (Koopmans 2004). The infection of one veterinarian caused an acute respiratory distress syndrome and took a fatal course (Fouchier 2004). In addition, during the Dutch outbreak, H7N7 infection was virologically and serologically con- firmed in several household contacts, four of which showed conjunctivitis (Du Ry van Beest Holle 2005). Avian influenza viruses have never been detected in rats, rabbits and various other mammals present at live bird markets in Hong Kong where 20 % of the chickens were found positive for the Asian lineage H5N1 (Shortridge 1998). Most outbreaks were geographically limited, with only five resulting in significant spread to numerous farms, and only one which spread internationally.

The question which we occasionally asked was: why order clozaril 25 mg with visa, in addition to pre-publication (free online version) and publication (a book available for a fee) 100mg clozaril otc, pre-pre-publication in a blog? Conclusion Whereas for some people a book is completed after the last sentence, for others the adventure begins at this point. The advertising and marketing of books alone is an experience from which doctors can learn a lot. Summary Editor/Publisher Produce a pocket edition – it will be consulted more often than a book weighing a kilogram. Something you have written in English will be read 10 to 100 times more often than a text which does not exist in English. Playground, creativity Author Ask yourself if you can contribute to the expansion of the website. Do you have any ideas as to how the website of the project can be supplemented by an intelligent blog? Students If English is not your mother tongue: get used to the idea that information is only circulated on a global level if it is written in English. Bystander The removal of copyright was one of the creative contributions of the internet towards spreading medical knowledge more quickly. The author is available to committed colleagues at all times (contact via the known e-mail addresses). Epilogue You have seen how quickly you have produced a book and a website with your team of authors. The seventh day 80 Materials Letter to your authors – Working with Word – Copyright removal A. Letter to your authors My dear friends, May we take this opportunity to remind you of the deadline for our book project: 30th September 2006 As in the past few years, we can guarantee an author’s fee of X € + Y€ (X Euro now, another Y Euro once printing costs have been covered). On condition that: your chapters are updated and the literature published up to August 2006 is integrated into the text; the text arrives here by 30th September; the citations are newly compiled and correctly formatted (see below for further details). Original documents The text must only be written in the Word document which we have enclosed here. Citations In the text, the citation is placed between round brackets, only giving the surname of the first author and the year (Hoffmann 2004). There are more details in these three lines than you may think: There is no full stop after the initials of first names; several initials are written together. If there are more than 6 authors, the first 3 are named, then comes a comma, followed by “et al” and finished with a full stop. Only the end digits of the last page number, which are necessary for clear identification, are given. Thus, 2423-2429 becomes 2423-9, 134-141 becomes 134-41, 1891-1901 becomes 1891-901. Working with Word Working with styles Font size and typeface should only be changed via the so-called templates. Compiling the reference lists Citations must be given according to a uniform pattern. Tables Tables serve to break up the text and summarise important information in a concise manner. Working with Word Planning a medical textbook Only write if you want your book to be No. Those who cannot perform this task themselves should delegate the job to a professional reader. Keyboard shortcuts You write the text with your fingers, so you should use the many keyboard shortcuts. Your hand then stays on the keyboard, and you save yourself the trouble of reaching for the mouse. However, the main page of the publication – be it the home page of a website or a book cover – must mention the source of the information in this way: Adapted from www. In addition, the authors of the individual chapters have to be mentioned at the beginning of every single chapter. The translation into any other language must reproduce the original documents faithfully. Pay the greatest attention when translating crucial information such as dosage, dosage schedules, therapeutic regimens, drug descriptions, etc. Translating the text into any language does not confer on you any exclusive rights for that given language. A doctor who publishes his own textbooks can earn many times what he would be paid in royalties by a publishing house. More important than this, however, is the fact that a doctor who writes and publishes wants his texts to be read by as many colleagues, students and patients as possible. Te best way to achieve this is through free parallel publication of these texts on the internet. Free Medical Information describes how to produce a successful medical textbook: from defining the project, selecting the co- authors and fixing the deadlines to building the website, printing, marketing, distributing, and negotiating with the sponsors. A book for future publishers and authors, for doctors and students Free – for all those who would like to know how medical textbooks are produced today.

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Certain criteria have been established to help you decide whether a child has severe complicated or severe uncomplicated malnutrition: clozaril 100 mg line. The presence of any medical complications cheap 25 mg clozaril free shipping, including any of the general danger signs, pneumonia/severe pneumonia, blood in the stool, fever or hypothermia mean that the severely malnourished child is classified as severe complicated malnutrition and must be treated in an in-patient facility. Complication Referral to in-patient care when: General danger sign If one of the following is present: vomiting everything, convulsion, lethargy, unconscious, or unable to feed Pneumonia Fast breathing For child six-12 months 50 breaths per minute and above For a child 12 months-five years 40 breaths per minute and above For a child older than five years 30 breaths per minute and above Severe pneumonia A child with fast breathing as indicated above and chest in-drawing Dysentery If blood in the stool Fever or T° > 37. T° < 35°C or cold to touch Children with poor appetite are also classified as having severe complicated malnutrition and need to be referred to in-patient care. A poor appetite means that the child has a serious problem and will need to be referred for inpatient care. Remember that a child who has complications does not need to be given the appetite test and should be referred for in-patient care. A severely malnourished child who has complications should be The appetite test: steps to follow referred for in-patient care. If the child refuses then the caregiver should continue to quietly encourage the child and take time over the test. You should explain to the caregiver that the choice of treatment for the child is in-patient care; and explain the reasons for recommending this. This is a unit in a health centre or hospital where severely malnourished children with complications or poor appetite are referred and managed. Once the complications improve, these children will be referred back to you for continued out-patient follow-up in your health post. If not, when at the health centre try to use the opportunity to see the video if it is available. You will be able to see a child who passes the appetite test and another child who fails the appetite test. You should always make sure that the caregiver is fully aware of the condition of the child, and the need for weekly follow-up visits until the child reaches the discharge criteria. If the condition of the child progresses smoothly, the child normally recovers within five to seven weeks. This will enable you to verify if the message has been correctly understood by them. That means it does not need cooking, or any other process before feeding the child. It is high energy food contained in a concentrated form, enriched with minerals and vitamins to replenish a severely malnourished child. The caregiver should use soap and water to wash their hands before feeding the child. Sick children get cold quickly, so it is important to keep the child covered and warm at all times. Note that severely malnourished children should be given antibiotics (Amoxicillin) even if they do not have signs of infection such as fever. As a A severely malnourished child severely malnourished child has a very weak immune system, it often fails to should be given antibiotics even if develop a fever response. Therefore a severely malnourished child should be there are no signs of infection. Always make sure that the caregiver gives the child the first dose of the drugs in your presence. This will give you an opportunity to make sure that they are able to administer it appropriately. The caregiver can then confidently replicate what they have done in your presence, when caring for the child at home. You would then check for the presence of complications and finally you would do the appetite test. Diarrhoea, vomiting, fever or any other new complaint or problem the child may have. Step 3: Decide on what action to take based on the above follow-up assessment Refer if there is any one of the following:. For example, if the oedema was only on the feet during admission, and the child has developed increased swelling on higher parts of the body such as the legs or the face. A child who did not have oedema on the preceding visit is now presenting with oedema on the current visit. As a result, when the condition starts to resolve with the treatment you are administering, and the oedema fluid starts to be lost from the body, you might expect to see a decrease in body weight. A child with oedema, or one who has recovered from oedema, fails to gain weight for three consecutive visits. Major illness or the death of the main caregiver so that the child can’tbe managed at home. Providing any routine drug that needs to be given on the current visit according to the guidance in Table 10.

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Intralaboratory reproducibility of results in the two identical pairs of 10 isolates tested was 98% for isoniazid and rifampicin 50 mg clozaril with mastercard, 96% for ethambutol buy generic clozaril 100 mg on-line, and 91% for streptomycin. The number of countries participating in the project has increased nearly threefold since the first report. Performance criteria for the Supranational Laboratory Network have been developed, four new laboratories are candidates to join, and nine rounds of proficiency testing have been completed. Guidelines for the surveillance of drug resistance in tuberculosis have been revised, and a fourth version of software to analyse drug resistance has been developed. Most importantly, global results of the project are fuelling discussions about policy implications. The areas represented in this project are those with at least the minimum requirements to conduct surveillance, and it is likely that the worst situations have not yet been uncovered. The data reported in this third phase of the Project have reinforced many of the conclusions drawn in its first and second reports, and contribute to a more in-depth analysis of dynamics and trends. Despite the inclusion of different countries in each phase of the project, the medians for most resistance parameters were similar in all reports, but the outliers varied. Though the Global Project has been operating since 1994 very few countries have reported data for all nine years. Data from repeated surveys employing comparable methodologies over several years are essential to determine with any certainty in which direction prevalence of drug resistance is moving. A better programme can result in the reduction of the overall number of re-treated cases; however, difficult (resistant) cases may persist. Improvement in laboratory proficiency, particularly the sensitivity and specificity of drug susceptibility testing, may also affect the observed prevalence of resistance. The scenarios outlined above highlight the importance of evaluating trends in prevalence of drug resistance within the context of relevant programme developments. Only Botswana, Sierra Leone, and Mpumalanga Province, South Africa, have carried out repeat surveys. In general, drug resistance in the region is low, but the trends in Botswana and Mpumalanga Province in South Africa indicate that it is increasing. Botswana in particular showed a significant increase in prevalence of any resistance. Sierra Leone, with two data points in the first and second reports, showed very little change in prevalence of resistance. Reported prevalence of resistance from recent surveys in Algeria and the Gambia was very low, and only slightly higher in Zambia, confirming the low levels of resistance in the region reported in previous phases in the project. A survey in the city of Kinshasa, Democratic Republic of Congo, reported results for combined cases only. It will be important to conduct a nationwide survey, as urban centres in general report higher prevalence of resistance than the national average. Regular reports of drug shortages and high default rates from treatment over this period have given further evidence of conditions for increasing drug resistance. In contrast, data from a previous province-wide survey in Western Cape, not included in the Global Project but following the accepted methodology, indicated relatively stable levels of drug resistance. Prevalence of resistance found in the 2001–2002 survey was nearly the same as those reported in the 1993 survey. In the recent survey, it was the only province where there was not significant under detection of retreatment cases, i. The 1999 survey reflected a change in sampling methodology adopted to minimize bias, and the lower prevalences reported in this survey are probably a more accurate representation of actual levels in the country. Uruguay showed a slight increase in all resistance parameters; however, the magnitude of overall resistance in the country is, to date, the lowest reported in the region. The sample from Honduras indicated that prevalence of drug resistance is similar to that in the majority of countries surveyed in the region. Chile, which saw only slight and non-significant increases in resistance between 1997 and 2001, has employed one of the most innovative surveillance policies in the region, which may prove to be a useful model for other countries. Chile performs continuous surveillance of all previously treated patients, and conducts a survey on a representative sample of new cases every three years, thus obtaining accurate information on both populations, strengthening routine patient history interviews, and identifying resistance patterns of previously treated patients early in treatment. Brazil, Colombia, Costa Rica, Dominican Republic, Mexico, Panama, and Peru will commence surveys shortly. A second survey in Mexico will be nationwide and not partial as in the 1997 survey. Trends are available only for the Gulf States of Oman and Qatar, both with small numbers of total cases and low to moderate levels of resistance, much of which is imported. Surveys are under way in Jordan, Lebanon, and the Syrian Arab Republic, and the Islamic Republic of Iran and Morocco are preparing for repeat surveys, with nationwide coverage in Morocco. The European region displays the greatest heterogeneity of resistance parameters in the world, including both the highest and the lowest prevalences. Before 2001, drug resistance data in Germany were based on a nationally representative sample covering 55% of local health departments that had elected to report drug susceptibility test results, contributing 50. Since 2001, results of drug susceptibility testing are notifiable by law and are analysed centrally; the higher proportions observed in 2001 and 2002, therefore, do not necessarily reflect an increase over time, but may be due to the methodological change. In France, most resistance parameters among new cases are stable, and resistance in the country is relatively low.

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