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Visiting the maternity wards in the early days of the epidemic was "frightening arteriovenous shunt buy isoptin 120 mg with mastercard," she said hypertension natural remedies buy cheap isoptin 40 mg on-line. By contrast blood pressure 9070 40mg isoptin, in Brazil heart attack brain damage cheap 120mg isoptin with mastercard, where abortion is illegal, it is very difficult to get a termination unless you are wealthy and can afford to travel abroad for the procedure. At this point, Turchi began to worry that the cases in maternity wards in Recife might be the tip of an iceberg. In all, Brazil recorded 4,783 suspected cases of microcephaly and 476 deaths in 2015, as opposed to 147 cases in 2014. By contrast, in the southeast, where Zika appeared later and was generally less severe, the rates were far lower-5. The question is, how much of this increase was due to Zika, as opposed to another cofactor, and why was the peak observed in the northeast so much higher than in other areas of Brazil? The laboratory-confirmed cases were then followed to term, together with those of two controls who had tested negative for the virus. The babies were examined for microcephaly and other manifestations of congenital Zika syndrome with clearly defined denominators. At the time of the epidemic, rumours abounded that the higher prevalence of microcephaly in the northeast might be due to exposure to insecticides used to control mosquitoes. Another widespread conspiracy theory was that the fault lay with vaccines administered during pregnancy. That would require better Zika seroprevalence data in order to ascertain whether women included in the study are representative of the wider population. More importantly, because Zika was not a reportable condition at the time of the epidemic, researchers have no way of gauging the total number of babies born to pregnant women infected with Zika in 2015­16 and thus whether the high rates of microcephaly observed in the northeast were really as high as they seem. Laura Rodrigues, a professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine who works closely with Turchi, suspects that northeastern Brazil may have had a fast-moving outbreak of a particularly severe strain of Zika. However, Rodrigues also acknowledges that this is "a gut feeling" and without better data she cannot be sure. Climate scientists point out that 2015 was an El Niсo year in South America, with higher than normal amounts of rainfall in northeast Brazil, increasing the risk of flooding. Turchi points out that prior to the 2015 Zika outbreak, Pernambuco had not suffered a major dengue epidemic for several years, whereas in central Brazil and the southeast, dengue had been a more recent visitor. On the other hand, in vitro studies by Marques and his colleagues using serum from pregnant women suggest that the presence of dengue antibodies can make Zika infections more severe. When the epidemic broke, such was the demand for testing that his laboratory became a public reference laboratory. Later, Marques and his colleagues developed a rapid diagnostic test for dengue, making it easier to diagnose and differentiate it from Zika. However, he does not discount the possibility that the high rates might be due to an unknown environmental cofactor. Although we had previously spoken by Skype, his English was halting and as my Portuguese was non-existent I feared much may have been lost in translation. Fortunately, when we did eventually meet at a restaurant near my hotel, he brought his daughter, Celina, a second-year medical student, to translate. The restaurant specialized in tapioca, the traditional accompaniment to any meal in Pernambuco, and after ordering some tapioca flour pancakes we got down to business. Why, during previous Zika outbreaks, had the association with microcephaly and neurological disorders been missed? French Polynesia has a population of just under 300,000, whereas the population of Pernambuco is nine million, of which four million live in Recife and the greater urban area. Pernambuco also has a very high birth rate, with some 170,000 babies being delivered at maternity wards across the state every year. In addition, in French Polynesia the microcephaly cases were scattered across the archipelago, whereas in Pernambuco they were concentrated in a handful of hospitals in and around Recife. However, it did not address the deeper questions of causation, of why the risk of microcephaly seemed to be so much higher for women from poor neighbourhoods, what the role of social conditions was, and how the provision of adequate water services and sanitation systems affected the transmission dynamics of Zika in Recife and other cities in Brazil.

Poor distribution may be evident from deposition or damage to arrhythmia event monitor generic isoptin 240mg with amex the top of the pack Visually inspect (ensure safe access) Where possible remove for thorough inspection Cooling tower water distribution system Deposition in trough or nozzles Poor water distribution Physical damage and leakage Deposits Damage Correct orientation and fitting Correct fitting and orientation Sagging Embrittlement Deposition and fouling Evidence of poor water distribution Drift eliminators Cooling tower pack Visual assessment techniques of the cooling tower pack include: removal of the entire pack removal of the representative sections of the pack use of a boroscope to blood pressure chart conversion isoptin 120mg amex inspect representative sections of the pack either removed or in situ wet weight assessment of pack sections compared to blood pressure graph buy discount isoptin 240mg on line new sections knock out dry sections of pack to blood pressure guidelines 2014 order isoptin 120mg overnight delivery dislodge deposits split pack blocks to inspect them internally visual assessment with a comprehensive written and photographic record Fill pack supports and Inspect these once the pack is removed or assess in internal structures another way if the pack cannot be removed, eg using a boroscope or a digital camera Fill baskets and tie rods (sheet pack) Cooling tower base tank (or pond) and other system sumps Where practical remove, otherwise inspect in situ Visual assessment after draining, but a more limited assessment can be made by probing a sump without draining Corrosion Sagging or collapse Build-up of deposits Corrosion or embrittlement Collapse of modules Build-up of deposits Evidence of process contamination Biofouling How do I interpret the findings of the inspection? Scale formation results in loss of heat transfer, reduced flow rates, loss of cooling efficiency Recommended action Where necessary, clean with appropriate process Review water treatment scale control measures For fill packs, see Table 1. Sediment can provide a microbial habitat and will encourage under-deposit corrosion For fill packs, refer to Table 1. If the material appears to be non-biological, anything no thicker than an eggshell can be considered to be an insignificant stain and not a deposit. If the contaminating material appears to be microbial, ie biofilm, irrespective of thickness, the pack should be cleaned. Deposits may be unevenly distributed within the pack, but the dirtiest areas should be used for classification of the deposit thickness. Compare the extent of the deposits with previous inspections to determine whether fouling is increasing. Once this is achieved, the fan(s) should be switched on for the remainder of the process to ensure that disinfectant reaches all internal surfaces that become wet during normal operation of the tower and which potentially could be contaminated. The normal disinfectant level required depends on the minimum circulation period adopted. A continuous minimum residual of 5 mg/l as free chlorine, for a minimum period of 5 hours, should be maintained, but if time available to conduct the operation is limited, using a higher disinfectant concentration for a shorter time may be acceptable. Systems with multiple sumps may require dosing at each sump to ensure good distribution of disinfectant. To achieve the same disinfection effect, its residual needs to be increased 3­4 times, ie in place of 5 mg/l for 5 hours 15­20 mg/l is required for the same period. Generally, this is not recommended, so if the system water is above pH 8 adopt one of the following procedures to compensate, without increasing the chlorine residual: introduce a heavy bleed-off for several hours to both reduce the pH of the system water and its chlorine demand before carrying out disinfection; reduce system pH by adding an acid; augment chlorine dosage with sufficient sodium bromide to change the disinfectant from chlorine to bromine. Pre-cleaning disinfection may not be needed if: the system is normally continuously automatically dosed with an oxidising biocide and bio-dispersant; and the control of the microbial activity and biocide residual has been consistently achieved since the previous cleaning operation (ie continuous minimum free chlorine residuals of 0. Accessible areas of the system should be washed adequately but cleaning methods that create excessive spray, eg high pressure water jetting, should be avoided. The area should be isolated and you should consider other occupied premises nearby, as well as people who may be nearby during cleaning. Staff using this equipment should be adequately trained and the equipment properly maintained. Once cleaned, the system should be sluiced out until the water going to drain is clear. Shut system down and drain all sumps, check cleanliness of strainers, heat exchangers and pack. If cleaning proves to be ineffective, consideration should be given to replacing heavily scaled pack. Review water treatment programme for scale control Acid clean using appropriate acid and inhibitor or suitable chelant/ dispersant. Review water treatment programme for corrosion control Identify the contaminant and select an appropriate solvent/ dispersant. Consideration should be given to modifying the cooling system to reduce or prevent contamination of the cooling system water with process material Hardness scale Corrosion products Organic process contaminants Cleaning of the cooling tower pack 1. The approach to cleaning the cooling tower pack will depend on a number of factors, including: the nature of the contamination; the design of the cooling tower and practicalities of accessing and/or removing the pack; the type of pack in use, ie block or sheet. However, a pack may appear clean from the visible surfaces but be fouled internally. However, whether the pack is removed or not, evidence of its cleanliness should be demonstrated, an assessment made using appropriate techniques as detailed in Table 1. Photographic records of pack condition can help in this process and should be maintained. Block-type pack cannot be cleaned effectively by jetting but may respond to flushing with high volumes of water or cleaning fluid. Application of a suitable cleaning solution formulated as a foam may remove light deposits in situ. Alternatively, the pack can be removed and immersed in a suitable cleaning solution ex situ. In some circumstances it may be possible to remove certain deposits by removing the pack, allowing it to dry out and then gently knocking or dropping it from a low height to shock the dried deposits off, taking care not to damage the pack itself. It is important that replacement pack and drift eliminator match or have the same dimensions and performance as the original, as this may impact on the amount of aerosol released from the system.

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Barry blood pressure chart for infants cheap isoptin 240mg without prescription, the Great Influenza:The Epic Story of the Deadliest Plague in History (New York: Viking Penguin arteria magna buy 240mg isoptin fast delivery, 2004) heart attack youtube discount isoptin 40mg visa, 187­88 blood pressure cuff cvs buy discount isoptin 240 mg. Silverman, "William Henry Welch (1850­1934): the Road to Johns Hopkins," Proceedings Baylor University Medical Center 24, no. Jim Duffy, "The Blue Death-Flu Epidemic of 1918," Johns Hopkins School of Public Health, Fall 2004, accessed 6 July 2017: magazine. Hib meningitis is a particular danger to unvaccinated children, and even with treatment approximately one in twenty will die. Eyler, "The State of Science, Microbiology, and Vaccines Circa 1918," Public Health Reports 3, no. Royal College of Physicians, London, "Prevention and Treatment of Influenza," British Medical Journal 2, no. Newson, Infections and Their Control: A Historical Perspective (Los Angeles and London: Sage, 2009), 36. Erling Norrby, "Yellow Fever and Max Theiler: the Only Nobel Prize for a Virus Vaccine," the Journal of Experimental Medicine 204, no. Davis, Taubenberger, and Bray, "The use of nonhuman primates in research on seasonal, pandemic and avian influenza, 1893­2014. Burnet, Changing Patterns: An Atypical Biography (Melbourne: Heinemann, 1968), 41, 90­91. Bristow, American Pandemic: the Lost Worlds of the 1918 Influenza Epidemic (New York and Oxford: Oxford University Press, 2012), 101. Baumgardt to Richard Collier, 28 May 1972, Richard Collier Collection, Imperial War Museum. The British virologist John Oxford has argued that such a reassortment could have occurred at Йtaples in the winter of 1916­17 when hundreds of soldiers at the camp were sickened by "purulent bronchitis. Similarly, John Barry argues that the ecological conditions for a reassortment with a bird flu virus were in place in Haskell County, Kansas, a sparsely populated farming area three hundred miles to the west of Camp Funston, where people raised poultry and hogs. However, his suggestion that the epidemic at Camp Funston in March 1918 was a precursor of the Spanish flu is undermined by the fact that, unlike during the later autumn wave or the outbreak at Йtaples in 1917, there were no reports of heliotrope cyanosis. Moreover, New York saw a similar wave of pre-pandemic flu activity in February­April 1918. According to the authors of the New York study, these findings are "inconsistent with the prevailing hypothesis of a spring 1918 Kansas origin, and. Oxford, "The So-Called Great Spanish Influenza Pandemic of 1918 May Have Originated in France in 1916," Philosophical Transactions of the Royal Society of London, Series B 356, 1416 (2001): 1857­59; John M. Barry, "The Site of Origin of the 1918 Influenza Pandemic and its Public Health Implications," Journal of Translational Medicine 2 (20 January 2004): 3; Viggo Andreasen et al. Goodpasture, "The Significance of Certain Pulmonary Lesions in Relation to the Etiology of Influenza," American Journal of Medical Science 158 (1919): 863­70. Burnet, Natural History of Infectious Disease (Cambridge: Cambridge University Press, 1953). Monographs from the Walter and Eliza Hall Institute of Research in Pathology and Medicine, no. Viseltear, "The Pneumonic Plague Epidemic of 1924 in Los Angeles," Yale Journal of Biology and Experimental Medicine 1 (1974): 40­54. William Deverell, Whitewashed Adobe: the Rise of Los Angeles and the Remaking of Its Mexican Past (Berkeley: University of California Press, 2004), 3. Emil Bogen, "The Pneumonic Plague in Los Angeles," California andWestern Medicine (February 1925): 175­76. Frank Feldinger, A Slight Epidemic:The Government Cover-Up of Black Plague in Los Angeles (Silver Lake Publishing Kindle edition, 2008), location 473. Ole Jшrgen Benedictow, the Black Death, 1346­1353:The Complete History (Suffolk: Boydell Press, 2004), 382. In 1898, Paul-Louis Simond, a French researcher based in Karachi, succeeded in transmitting plague from an infected to an uninfected rat by allowing fleas harvested from a cat to feed on the diseased rat, but other experts questioned his methods, casting doubt on his findings. Crawford, "Paul-Louis Simond and His Work on Plague," Perspectives in Biology and Medicine 39, no. The first person to posit the link with marmots was the Russian medical researcher Mikhail Edouardovich Beliavsky.

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Others report Spencer procured the precious serum from a physician at Johns Hopkins Hospital in Baltimore pulse pressure 12 order isoptin 240 mg fast delivery. What is not in dispute is that within hours of the serum entering his veins blood pressure medication itchy scalp cheap isoptin 120 mg amex, Armstrong rallied and his condition improved arrhythmia medicine 120 mg isoptin fast delivery. Over the next two weeks hypertension jnc 8 ppt buy 40mg isoptin free shipping, as Armstrong grew stronger, McCoy continued his investigation, mashing up the livers and spleens of dead parakeets before passing them through filters and inoculating the filtrate into healthy birds. Fearing further infections, McCoy forbade his staff from entering the makeshift laboratory in the basement of the north building of the Hygienic Laboratory, and from 7 February insisted on conducting the autopsies of parrots and disposing of their carcasses in person. At this point, it was still not known whether psittacosis could be communicated from person to person or whether the microbe was also conveyed as an aerosol in dust particles. To minimize the risk of accidental contamination, the only person McCoy allowed to approach the basement laboratory was the general foreman whose job it was to bring sandwiches for McCoy and feed for the birds. To reduce the chances of the sick birds accidentally spreading the infection to healthy parrots, McCoy also strung a muslin curtain across the archway between the laboratory rooms and wetted the floor each morning with creosol. Nevertheless, on occasion, McCoy would find diseased parrots, who had somehow freed themselves from the cages, wandering in a room reserved for healthy birds. However, Lanham had fallen sick eighteen days later, which was well outside the presumed incubation period. The next person to contract psittacosis was a laboratory assistant, whose symptoms became apparent on 28 February. Unlike Lanham, she had never breathed the same air as someone incubating psittacosis. However, her office was next door to the basement room where McCoy kept the healthy birds, and she had also handled material for culturing the organism, though since her principal role was to look for salmonella and streptococci McCoy thought it unlikely that she could have been exposed to psittacosis this way. However, the next group of casualties left McCoy in no doubt that his precautions had failed and that the north building was thoroughly contaminated. The first to fall ill was a medical officer whose office was on the side of the corridor opposite the autopsy room. The next day, 11 March, the general foreman was also taken ill, followed in quick succession by two cleaners and two bacteriologists engaged in research on other diseases. Even Ludvig Hektoen, a distinguished pathologist and chairman of the National Research Council, who was doing private research at the Hygienic and had merely spent his afternoons in one of the rooms, was admitted to the hospital. All told, between 25 January and 15 March, eleven people at the Hygienic were hospitalized with psittacosis. Despite drawing a floor plan of the infections, McCoy could discern no pattern in the cases, leading him to speculate that psittacosis may have been transferred to the upper floors by mice or cockroaches. Experimental animals not involved in psittacosis research were removed to temporary lodgings. Then McCoy entered the basement for the last time and exterminated all those that remained-a menagerie of parrots, guinea pigs, mice, rats, pigeons, and monkeys. Next, he burned their bodies in the incinerator and scrubbed their cages with creosol, and methodically worked his way through the building to seal the windows on each floor. Finally, when he was sure there was no living thing left inside the Hygienic, he ordered a fumigation squad to blitz the building with cyanide. The legend goes that so much gas was used that sparrows flying fifty feet above the Hygienic stopped in mid-flight and plummeted to Earth. The next day, the headline in the Sunday edition of the Washington Post read, "Parrot Fever Panic Seizes Laboratory. The infection often proved fatal, with thirty-three deaths recorded in the United States between November 1929 and May 1930. Of the 167 cases where the sex of the victim was known, 105, or two-thirds, had been women. Indeed, at one point Berlin Zoo had been forced to bar its gates to frightened parrot owners desperately looking for a temporary refuge for their birds. By the time the pandemic ended in May 1930, eight hundred cases had been recorded worldwide, with an average mortality rate of 15 per cent. Soon, researchers in other countries were also convinced the pathogen must be a filter passer and that Nocard had mistaken it for salmonella, the bacterium that causes typhoid. The first to succeed was a team led by Samuel Bedson, a senior researcher at the London Hospital. This greatly facilitated laboratory study of psittacosis as white mice were far less infectious than birds.

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References:

  • https://www.asge.org/docs/default-source/education/practice_guidelines/adverse_events_ercp.pdf?sfvrsn=9ad4e851_4
  • http://www.med.umich.edu/1libr/Hepatology/CirrhosisToolkit.pdf
  • https://www.aft.org/sites/default/files/ae-winter2019-2020.pdf