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However heart attack the song discount triamterene 75mg with visa, the ability of new meningococcal vaccines to arrhythmia journal buy discount triamterene 75 mg on line induce herd immunity that use alternative antigens will need to blood pressure chart old cheap triamterene 75mg mastercard be demonstrated pulse pressure limits generic triamterene 75mg with amex. Due to the dynamic and unpredictable nature of the meningococcal epidemiology, combination conjugate vaccines against multiple meningococcal serogroups have been developed to broaden protection against the disease. The reference lists of relevant articles were used to identify further citations of interest. Additional searches were conducted of the websites of national and international public health agencies. Information from these studies was extracted relevant to each component of the study objective and described in a qualitative manner. The searches conducted indicate that there is a lack of more historical data available in the published literature for some countries. This lack of data is likely to reflect the lack of a formal surveillance system to chart epidemics in these countries and also the presence of endemic disease. Data for Mexico and Brazil associated with epidemics were identified for the late 1940s, with about 753 registered cases in Mexico seen for the period 1945­1949 [23] and a serogroup A epidemic from 1945 to 1951 in Sao Paulo, Brazil with incidence rates of 4. Due to scarcity of more historical data, the following sections focus on the epidemiology from 1970 onwards. Notably, Mexico has remained relatively unaffected since the 449 1940s and reports very low incidence of disease [23, 26]. The reported epidemics and outbreak clusters identified in the literature are displayed in Figure 1. Of Latin America as a whole, Brazil has reported the most outbreaks and epidemics, although this may be partly attributed to the existence of a well-established surveillance system. Serogroup A Although serogroup A is now extremely rare on the continent [28], serogroup A epidemics with high incidence rates were reported in the 1970s [24, 25]. In 1974, the spread of a serogroup A epidemic strain during an existing serogroup C epidemic period in Sao Paulo, Brazil resulted in incidence estimates as high as 180 cases/100 000 population per year [24, 25]. This epidemic provided the first major experience with polysaccharide A and C vaccines on a large scale, resulting in the successful control of the epidemic [25]. Serogroup B Serogroup B epidemics were reported in several Latin American countries in the 1980s, associated with the international spread of epidemic clones of the Downloaded from. Incidence and case-fatality rates of meningococcal disease, with serogroup specific information, if available, in several countries in Latin America (arranged by country and year) Ref. Region Year of observation 1993­2003 1990­2004 1990­2002 2003­2008 Incidence Low incidence 0­78 cases/year 0­73 cases/year 52­82 cases/year 0. This clone was associated with epidemic disease in Cuba, with a peak incidence of 14 cases/100 000 reported in 1983 [31]. This strain was also important in epidemics in Brazil in the late 1980s [33, 34], and was identified as dominant in Brazil in the 1990s [35]. The Cuban B (outer membrane vesicles)/C (polysaccharide) vaccine was developed in response to the serogroup B epidemic in 1983 (based on the prevalent serotype at that time in Cuba) and was used in a mass vaccination programme during 1987­1989 [36]. This vaccine was also used in other Latin American countries in subsequent years in response to serogroup B epidemics, such as in Brazil [18, 37], Uruguay [19], and Colombia [38]. However, various studies estimating the effectiveness of the Cuban B/C vaccine suggest that it does not provide protection against heterologous strains, and only Downloaded from. Caribbean Cube 1983 ­ B Trinidad 1993 ­ B South America Brazil 1945 ­ A Brazil 1971 ­ C Brazil 1974 ­ A Brazil 1988 ­ B Uruguay 1993 ­ C Brazil 1987 ­ B Brazil 1989 ­ B Brazil 1989/90 ­ B/C Brazil 1995 ­ B Brazil 1995 ­ B/C Uruguay 2001 ­ B Brazil 2009 ­ C Brazil 2005 ­ W135 Argentina 2008 ­ W135 Chile 2005 ­ W135 Chile 1978 ­ A Brazil 1989 ­ C Chile 1982 ­ B 1940 1950 1960 1970 1975 1980 1985 1990 1995 2000 2005 2010. Serogroups associated with each epidemic or outbreak are listed alongside the year of the event and the country. The occurrence of serogroup A is shown in light grey, serogroup C in dark grey, serogroup B is highlighted in white, and serogroup W135 in black. Those studies that are available indicate that serogroup B was the most prevalent endemic disease serogroup pre-2000 in several countries in Latin America, including Colombia (78 % of isolates identified between 1994 and 2006) [39], Chile (over 90% of isolates identified between 1992 and 1993) [40], Brazil [21] and Uruguay [19, 41]. Since then, serogroup B has been common in Cuba, Chile, Argentina and Uruguay [28, 42­44]. However the majority of serogroup C outbreaks and epidemics have been reported in Brazil [15, 46, 47].

Two months later prehypertension in your 20s buy cheap triamterene 75 mg on-line, they followed up with a study that found the overall percentage of protection offered by the remedy was 76 arteria 60 buy 75mg triamterene. The percentage of protection was higher in those who had taken the genus epidemicus properly and the protection rate higher among those who had not taken other medications at the same time arteria latin purchase triamterene 75mg fast delivery. The genus epidemicus heart attack chest pain triamterene 75mg with amex, although administered in the prophylactic dose, also had a curative action in those who were already affected by the epidemic; many symptoms were significantly reduced and of shorter duration. There were also fewer post epidemic symptoms, less expense, and a smaller number of work or study days lost. When treating individuals with hepatitis, he would also give their family members and school-mates the prophylactic. The purpose of this survey was to determine the effectiveness of the nosode (a remedy prepared from a disease component) as a homeopathic preventative (prophylactic). Almost 20% of the patients treated by conventional medical physicians contracted the flu. Those who did become ill recovered more rapidly than their allopathically treated patients. The number of working days lost by the allopathically treated patients was nearly eight and a half times greater than those lost by homeopathic patients. Gripp-Heel, a proprietary combination remedy demonstrated significant in vitro reductions of infectivity by 20% to 40% when tested against these viruses. Over the next 12 months the incidence of diagnosed acute respiratory infection or flu was 3 times higher in the placebo group than those given the prophylactics. The researchers commented that the low cost of treatment and the absence of adverse effects made these nosodes a useful therapeutic option for the Brazilian Public Health Service. A small decline in incidence occurred when homeopathic Belladonna was given as a prophylactic to some. When the Government Department of Indian Medicine and Homoeopathy began to systematically distribute prophylactics in 1999 via Public Health Centres, Government Homeopathic Dispensaries, homoeopathic pharmacies and homoeopathic doctors, notifications and mortality dropped to nil by 2003. The prophylactics were dispensed to approximately 20 million children under 15 years of age. Within weeks, the treated provinces had an 84% decrease in disease incidence while the numbers of those infected in untreated provinces continued at expected historical levels. The intervention was "strongly associated with a drastic reduction of disease incidence resulting in complete control of the epidemic. It assessed the influence of potential confounders on initial results and concluded that the results supported previous conclusions that homoeoprophylaxis can be used to effectively immunize people against targeted infectious diseases such as leptospirosis. Twenty-one of the volunteers had experienced 1 ­ 3 malaria episodes in the 18 months prior to the trial. During the trial, one person thought he may have developed malaria but this was not verified by blood test. In the 6 months prior to the study, all participants had experienced attacks of malaria or malaria-like symptoms at least once with 71% experiencing malaria or malaria-like symptoms at least once a month or every two weeks. Over the course of the study and use of the prophylactic only 12% (4 out of the 34 respondents) experienced an attack of malaria or malaria-like symptoms. Determined to prevent a repeat or worsening in 2011 the Health Minister instructed that a known homeopathic treatment and prophylactic remedy be distributed to 9 areas within the affected state. Significant protection was achieved with data showing that higher the number of doses of the prophylactic, the lower the number of malaria cases. On the strength of these results the program was expanded to 20 areas in 2012 and 40 areas in 2013. The combination of remedies showed significant preventive activity with chemosuppression that was higher than the standard drug, pyrimethamine. It also showed a moderate curative activity with complete clearance of parasites in 50% of surviving mice. The researchers stated, "These findings point to the significant antiplasmodial efficacy of the combination of these homeopathic drugs against Plasmodium berghei. The authors concluded: "The study establishes the effectiveness of the combination against P.

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Consistent with Federal Advisory Committee Act blood pressure negative feedback loop discount triamterene 75 mg, summaries of all Advisory Committee meetings and copies of all 68 Federal Register 238 (11 December 2003) Full charter available at heart attack damage 75 mg triamterene for sale. The Commission asks the Committee to hypertension test triamterene 75 mg fast delivery develop as much consensus on these recommendations as is achievable heart attack test discount triamterene 75 mg on line. On issues where the Committee does not or cannot reach consensus, this will be noted and the Commission may develop, if it so chooses, its own recommendations to Congress on those issues. Acknowledging this, Committee members agreed unanimously to discontinue efforts to reach agreement on a single consensus report to the Commission. The plan included: 1) Development of this summary of the Advisory Committee process; 2) Development of non-consensus statements by individual Advisory Committee members or groups of members that express views on the issues discussed by the Advisory Committee in response to its charter. Tackett Statement E: Commercial Shipping Industry Representative-Submitted by Kathy J. Metcalf Statement F: Scientific Research Caucus-Submitted by Submitted by Paul E. Worcester Statement G: California Coastal Commission-Submitted by Sara Wan Advisory Committee Members and Alternates Laurie K. Allen, National Marine Fisheries Service Office of Protected Resources; replaced by Donna Wieting, National Marine Fisheries Service Office of Protected Resources (Alternate: Stephen Leathery, National Marine Fisheries Service Office of Protected Resources) Kenneth C. Green, the Ocean Mammal Institute (Alternate: Linda Weilgart, Dalhousie University) Erin M. Heskett, International Fund for Animal Welfare (Alternate: Carole Carlson, International Fund for Animal Welfare) John A. Hildebrand, Marine Mammal Commission and Scripps Institution of Oceanography Martin Kodis, U. Fish and Wildlife Service) Robert LaBelle, Minerals Management Service (Alternate: Richard Wildermann, Minerals Management Service; replaced by James Kendall, Minerals Management Service; replaced by Judy Wilson, Minerals Management Service) Kathy Metcalf, Chamber of Shipping of America (Alternate: Joe Cox, Chamber of Shipping of America) Paul E. Pittenger, Woods Hole Oceanographic Institution (Alternate: Darlene Ketten, Woods Hole Oceanographic Institution and Harvard University) G. Michael Purdy, Lamont-Doherty Earth Observatory (Alternate: John Orcutt, Scripps Institution of Oceanography) James P. Rose, the Humane Society of the United States (Alternate: Sharon Young, the Humane Society of the United States) Charles J. Navy Office of the Chief of Naval Operations­Oceanographer of the Navy; replaced by Mark S. Navy Office of the Chief of Naval Operations (Alternate: Roger Nolan, Naval Reserve Readiness; replaced by Tim McGee, Naval Meteorology and Oceanography Command) Peter L. Tyack, Woods Hole Oceanographic Institution (Alternate through April 2005: Dan Costa, Long Marine Laboratory, University of California at Santa Cruz) Sara Wan, California Coastal Commission (Alternate: Mark Delaplaine, California Coastal Commission) Richard D. Yoder, National Science Foundation Division of Ocean Sciences; replaced by Michael Reeve, National Science Foundation Division of Ocean Sciences (Alternate: Alexander Shor, National Science Foundation Division of Ocean Sciences) Nina M. Young, the Ocean Conservancy; replaced by Morgan Gopnik, the Ocean Conservancy Independent Facilitators (Contracted through the U. Fish and Wildlife Service Daryl Boness, Smithsonian Institution (retired) and Marine Mammal Commission Colleen Corrigan, U. These draft procedures will be reviewed, discussed, revised and adopted by the Advisory Committee at its first meeting. Subcommittees: the Committee may establish subcommittees to assist it in developing draft proposals or products for consideration at specific Committee meetings. The membership of subcommittees is subject to the approval of the Committee and may be drawn from individuals who are not Committee members. The Committee will develop a scope of work for each subcommittee, outlining the desired membership and expertise, schedule, and product. Technical Resources: the Committee may identify the need for assistance from technical resource experts for the Committee or for Subcommittees. For expertise for the Committee, the Committee will identify experts through discussion and consensus to ensure that all members obtain information that they find useful. For Subcommittees, the Subcommittee will seek to develop the consensus on the experts it requests.

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The most clinically notorious member of this genus is Yersinia pestis arteria frontal cheap 75 mg triamterene, which causes plague blood pressure medication sweating buy triamterene 75 mg online, rather than enteric disease and hypertension table in icd 9 triamterene 75 mg free shipping, therefore blood pressure young female cheap triamterene 75mg without a prescription, is being discussed separately from the rest of the family. It produces V and W antigens, which are virulence factors, as are its endotoxin and antiphagocytic capsule. For example, rats are common reservoirs in urban areas of some countries (urban plague). However, in the United States, plague is predominantly found in the wild, where prairie dogs and ground squirrels are the most important reservoirs (sylvatic plague). Household pets, particularly cats allowed to roam in plague-enzootic areas, may also become infected. Plague is characteristically transmitted by fleas, which serve to maintain the infection within the animal reservoir. Plague can also be transmitted by ingestion of contaminated animal tissue or via the respiratory route (pneumonic plague). Pathogenesis Organisms are carried by the lymphatic system from the site of inoculation to regional lymph nodes, where they are ingested by phagocytes. However, the organisms are resistant to intracellular killing by phagocytes and instead may multiply within these cells. Furthermore, the bacteria released from lysed phagocytes have synthesized a new envelope antigen that confers increased resistance to phagocytosis. The affected lymph nodes display hemorrhagic necrosis accompanied by high concentrations of both polymor phonuclear leukocytes and extracellular bacteria. Hematogenous spread of bacteria to other organs or tissues may occur, resulting in additional hemorrhagic lesions at these sites. Less common presentations include plague meningitis (typically a secondary focus resulting from hematogenous spread of the organisms), cutaneous plague, and pharyngitis (the latter two generally acquired by handling or ingesting contaminated animal tissue). Bacteria spread by blood Bacterial growth in the lungs Inhaled by other humans Plague meningitis Pneumonic plague (rapid person-to-person spread) Figure 13. Bubonic (septicemic) plague: the infectious cycle begins when a 145 flea ingests a blood meal from an animal that is infected and bacteremic. The incubation period (from flea bite to development of symptoms) is generally two to eight days. Buboes (pronounced swellings comprised of one or more infected nodes and surrounding edema that led to the term "bubonic plague") are typically located in the groin, but may also occur in axillae or on the neck. As the disease proceeds, blood pressure generally drops, potentially leading to septic shock and death. Mortality of untreated bubonic plague generally exceeds fifty percent, with untreated and highly contagious pneumonic plague being invariably fatal unless rapidly treated. Other manifestations associated with bubonic plague include pustules or vesicles containing leukocytes and Y. It is also highly contagious, and the organisms cause pneumonic plague directly when inhaled. Plague meningitis: this results from hematogenous dissemina- tion of organisms to the meninges. It may occur following inadequately treated bubonic plague or, like septicemic plague, may occur without, or prior to, development of a bubo. The organism grows on both MacConkey and blood agars, although colonies grow somewhat more slowly than those of other Enterobacteriaceae. Treatment and prevention Streptomycin is the drug of choice; gentamicin and doxycycline are acceptable alternatives (Figure 13. A formalin-killed vaccine is available for those at high risk of acquiring plague. For individuals in enzootic areas, efforts to minimize exposure to rodents and fleas is important. Bartonella quintana Bartonella quintana causes trench fever, an often mild, relapsing fever with maculopapular rash.

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Rapidly growing awareness of the problem of sound and marine mammals on the part of those involved in sound-generating activities creates opportunities for action blood pressure chart guidelines discount 75 mg triamterene with visa. It may be possible in the near future to prehypertension parameters 75mg triamterene visa build on the following: the military has sophisticated technological capabilities and financial resources blood pressure 150 90 order triamterene 75 mg amex. For education and outreach arterial blood gas interpretation generic 75mg triamterene visa, materials and campaigns need to be carefully crafted and culturally sensitive, and public input is therefore essential. The primary aim should be to ensure that the issue is widely debated and placed on relevant agendas. Educational efforts 67 Report of an International Workshop: Policy on Sound and Marine Mammals need to be grounded in accurate reporting, with uncertainties explicitly acknowledged. Tasker believes that the military has made good progress but needs to be more transparent. The seismic industry has guidelines, but those may need to be open for comments and modification. Industry should be encouraged to continue development and testing of mitigation approaches (noting the considerable investment that has already been made). The shipping industry and ship designers should be challenged to develop quieter technology. In terms of legal frameworks, it is necessary to consider scale and transboundary aspects. In general, it will be necessary to choose between prescriptive and performance-based models, but the latter is preferable. It was agreed that sound should be incorporated as an element to be considered in environmental impact assessments. Internationally, the creation of a new treaty on sound and marine mammals would be hard to deliver. Acceptable risk is a cultural choice, and thus universality may be difficult to achieve. In considering what should happen next, participants made the following suggestions: With regard to the shipping industry, a compelling case needs to be made that ship noise has adverse effects on marine mammals. Scientists involved in acoustics research in the marine environment indicated that they wish to (a) establish scientific priorities for sound-generating research, (b) diversify the funding base for their research, and (c) develop outreach efforts that are accurate and that improve public understanding of their work. A suggestion was made that sound-generating research should be avoided if possible and that solid justification should be required before permits are issued for such research. A code of conduct for sound-generating ocean research is being developed in Germany. Scientists studying the effects of sound on marine mammals need to (a) identify priorities and key information gaps, (b) establish international and interdisciplinary collaborations, (c) publish their results in the peer-reviewed literature, and (d) improve their communication with non-scientists. An internationally funded and administered mechanism for investigating mass strandings of cetaceans is desirable. The workshop goals of (a) describing the range of existing management and mitigation approaches and (b) exploring and describing cross-boundary issues were largely met. The goal of identifying strategies and solutions to policy questions that might be transferable across national boundaries was met only partially. It might be useful to hold further meetings as offshoots of this workshop, focusing on some of the technical issues identified in London. Such meetings might include more case studies in which the entire management process is tracked from problem identification, to directed research, to management decision-making, to implementation. Selected Examples of Domestic Laws and Regulations Mentioned the examples provided are a subset of those discussed during the workshop. Summary of Multilateral Agreements Mentioned the agreements summarized below are those mentioned in the workshop proceedings, a subset of those discussed during the workshop. Ocean ambient sound: comparing the 1960s with the 1990s for a receiver off the California coast. Mitigating, monitoring and assessing the effects of anthropogenic sound on beaked whales. Acoustically enhanced bubble growth at low frequencies and its implications for human diver and marine mammal safety. Manuscript circulated at workshop by Wolfgang Dinter on behalf of the Federal Agency for Nature Conservation/BfN (Germany).

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