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The space is important surgically as tumour cells may involve lymph vessels of this space and hence this space should be excised along with the growth area medicine urology buy paroxetine 30mg fast delivery. Paraepiglottic Space: Cricoid Cartilage It is a ring cartilage which has a narrow anterior arch and a broad posterior lamina symptoms 7 days after embryo transfer generic paroxetine 30 mg on-line. The anterior arch is connected with the inferior border of the thyroid cartilage by the cricothyroid membrane medications kidney damage buy online paroxetine. The posterior lamina gives attachment to medicine quotes cheap paroxetine 30mg mastercard the muscles and articu lates with the arytenoid cartilages at the cricoarytenoid joints. Abduction the pyramid articulates with the cricoid facet posterior cricoarytenoid, B. Corniculate Cartilage (Cartilage of Santorini) the muscles are subgrouped according to this is situated at the apex of the arytenoid their action and are named according to their cartilages on either side in the mucous attachments (Fig. The lateral Cuneiform Cartilage (Cartilage of Wrisberg) cricoarytenoid is the main adductor. It It is situated in each aryepiglottic fold just in arises from upper border of the lateral part front of the corniculate cartilage. Abductor muscle: the posterior cricoary Muscles of the Larynx tenoids are the sole abductors of the vocal cords. The muscles arise from the lower these are divided into two groups, extrinsic and medial surface of the posterior of muscles and intrinsic muscles. When these other structures and includes the sterno muscles contract, they move the vocal thyroid, thyrohyoid, sternohyoid, omohyoid, cords apart causing widening of the glottis. Tensors of vocal cords: these include Saccule of the Larynx cricothyroid and thyroarytenoid muscles. From the anterior part of the ventricle, a pouch the thyroarytenoids arise on each side called saccule of the larynx extends between from the inner aspect near the angle of the the vestibular fold and inner aspect of the thyroid cartilage and vocal ligament proceed thyroid cartilage. Its dilatation is thought to ing backwards to the arytenoid cartilage and be the cause of laryngocele. The transverse arytenoid muscle is a single Vocal Cords muscle which extends from the posterior these are fibroelastic bands which extend aspect of one arytenoid to the other and helps from the angle of the thyroid cartilage ante in closing the interarytenoid region. These are formed by reflection of the cricothyroid muscle is supplied by the the mucosa over the vocal ligaments which external laryngeal nerve which is a branch of are the free edges of the cricovocal membrane. Other intrinsic the cords have stratified squamous epithe muscles are supplied by the recurrent lium with no submucous layer. Interior of the Larynx the rima vestibuli and rima glottidis: the The laryngeal inlet is bounded above and in space between the two vestibular bands is front by the free margin of the epiglottis, late called rima vestibuli while the space between rally by the aryepiglottic folds, and posteriorly the vocal cords is called rima glottidis. It lies between the inlet of larynx and the level of vestibular folds or false cords. Blood Supply of the Larynx It is bounded above by margins of the Larynx is supplied by the superior and infe laryngeal inlet, in front by the posterior aspect rior thyroid arteries. The superior thyroid of the epiglottis, laterally by the inner aspect artery is a branch of the external carotid artery of the aryepiglottic fold, and posteriorly by while the inferior thyroid artery arises from the mucosa covering the anterior surface of the thyrocervical trunk of the subclavian the arytenoid cartilage. Sinus of the Larynx Lymphatic Drainage of the Larynx It is a small recess, the opening of which lies between the vocal cord and the ventricular the part of the larynx above the vocal cords fold. It secretes mucus and thus lubricates the is drained by lymphatics which proceed vocal cords. Glottis It consists of the vocal cords, anterior the part of the larynx below the vocal cords commissure, and posterior commissure. Posterior commissure is the area at the the vocal cords themselves are practically posterior end of the vocal cords, between the devoid of lymphatics. Subglottis It is the area of the larynx which Nerve Supply of the Larynx extends from 5 mm below the level of the vocal the superior laryngeal nerve is sensory to the cords up to the lower border of the cricoid laryngeal mucosa above the vocal cords. The undersurface of the cords is Besides it is motor to the cricothyroid muscle excluded. Mucosa Supraglottis It is the region of the larynx above of the larynx below the vocal cords and all the level of the vocal cords and includes the other intrinsic laryngeal muscles are supplied ventricles, vestibular bands and vestibule. Comparison of Infantile with the Average Measurements of Adult Larynx Adult Larynx 1. Size: the difference in size is not only real, Up to puberty the size of the larynx both in but also relative, for the lumen of infantile males and females is almost the same but larynx and trachea is smaller in proportion thereafter in males it increases nearly twice in to the body as a whole. The measure “choke” is present in the subglottic region ments are given in Table 52. Consistency of the tissues of the larynx: In Length 44 mm 36 mm young children all the laryngeal tissues Transverse diameter 43 mm 41 mm Anterior diameter 36 mm 26 mm including the cartilaginous framework, musculature, and mucous and submucous tissues are softer than in adults. Surgical Subdivisions of the Larynx the cartilage is softer and more pliable For clinicosurgical purposes, the larynx has and the mucosa loose and less fibrous. Right superior lobe bronchus: It arises from border of the fourth cervical vertebra. At the right principal bronchus and is seven months it lies about the middle of divided into three segmental bronchi— the sixth vertebra and it is still found in apical, posterior, and anterior. Middle lobe bronchus: It arises from the descent occurs until in adult life it lies anterior aspect of the main bronchus, opposite the lower border of the sixth is directed forwards and downwards to cervical vertebra, while the top of the be divided into two segmental bronchi, epiglottis lies opposite the lower border of the lateral and medial. Right inferior lobe bronchus: the inferior As a result of the higher position of the lobe bronchus gives the following seg larynx in infants, the entry of the air current mental bronchi—apical, medial basal, is straighter than in adults and the anterior basal, lateral basal, and poste epiglottis less overhanging. Shape: the upper end of the larynx and trachea is funnel-shaped in infants, the the left main bronchus is longer, narrower cricoid plate being tilted backwards while and more horizontal. It divides into the the tracheal lumen becomes smaller as it following subdivisions. The trachea divides at the level of the upper the lingular bronchus which is a branch border of the fifth thoracic vertebra into two of the left superior lobe bronchus divides into: main bronchi separated by a projection of the (i) superior lingular, and (ii) inferior lingular lowest ring of trachea called carina. The left inferior lobe bronchus divides into Right Main Bronchus the following segmental bronchi: (i) apical the right main bronchus is wider, shorter and bronchus, (ii) anterior basal, (iii) lateral basal, more vertical than the left main bronchus. Larynx and Tracheobronchial Tree 313 There is no medial basal bronchus on the During inspiration the bronchial diameters left side. Absence of these movements on the successive divisions of the bronchial bronchoscopy denotes fixation of the bron tree are termed principal bronchi, lobar chial wall by a neoplastic process. The bronchi, segmental bronchi, bronchioles and advantage of this widening on inspiration is terminal bronchioles. Respiratory passage: It is a part of the upper produced by vibration of vocal cords. Intratracheal high pressure column of air: this sphincter at the upper end of the respi is produced by contraction of the ratory tract and closure of this sphincteric expiratory muscles in the thorax and the mechanism helps in following ways: abdominal wall. Reflex protection against entry of and made tense by contraction of the foreign bodies. Closure of the sphincter helps in the vibrating cords cut the expired column thoracic fixation and building of high of air into a series of puffs, causing a series intrathoracic pressure as required in of compression and rarefaction waves of straining, micturation, explosive air. This sphincteric action is Various explanations have been given to exerted at three different levels by the explain the vibration of cords. Reflex action: the larynx plays an impor and enhanced by a resonating mechanism tant part in the cough reflex. It is a recep provided by the lung tissues, pharynx, oral tive field for reflexes. Phonation: the larynx plays the main role resonating mechanism gives an individual in phonation and speech. The larynx moves up towards the base of the sphincteric mechanism of the larynx tongue and thus brings the pharyngo comes into action and prevents the oesophageal junction nearer to the bolus. Any disease which Increased respiratory rate, indrawing of the interferes with vibration of the vocal cords, larynx and trachea into the mediastinum, and approximation of the vocal cords or their recession of the intercostal spaces and movements produces a change in voice. A supraclavicular fossae indicate a laryngeal or breathy voice occurs due to air leak as is tracheal obstructive pathology. Puberphonia: Crackling of voice or break in which prevents the approximation of the cords voice occurs at puberty in males as the results in a weak cry. The larynx and trachea, aspiration of fluids due to Common Symptoms of Laryngeal Diseases 317 sphincteric incompetence, crusting in atrophic Sometimes a vague feeling of a lump in the pharyngitis and laryngitis are the common throat or difficulty in swallowing may occur factors in cough production. Odynophagia (painful Difficulty in swallowing (dysphagia) is not a swallowing) may be a feature of laryngeal common symptom in laryngeal diseases.
In addition symptoms 7 order discount paroxetine online, the medication selected should be permissible under the rules of the governing body for their sport chi royal treatment paroxetine 30 mg without a prescription. The general principle of initiating treatment with monotherapy still holds symptoms underactive thyroid cheap paroxetine 20mg line, but the choice of medications requires caution treatment plant order paroxetine with a visa. In athletes, diuretics are relatively contraindicated, as they can impair athletic performance due to volume depletion, and they are prohibited by many of the governing bodies in sport because they may be used to prevent detection of performance enhancing drugs. In addition, beta blockers decrease heart rate and thus can reduce exercise tolerance; they too are prohibited in some sports. Starting doses for athletes are the same as for members of the general population, as is the approach to increasing the dose as needed based on patient response. Persistent hypertension — Athletes with hypertension that has persisted for a longer period (6 to 12 months) or that has not responded to lifestyle modi cations and pharmacotherapy should be assessed with an echocardiogram(2,3). Prognosis the potential long-term complications from hypertension in athletes are thought to be similar to those in the general population, and include myocardial infarction, stroke, renal failure, and death(4). Left ventricular hypertrophy deserves close attention in athletes, as the degree of hypertrophy can a ect exercise capacity. It is important for an experienced clinician to review any echocar diographic studies obtained to distinguish between athletic heart (eccentric or concentric hypertrophy with an increase in left ventricular volume) and left ventricular hypertrophy of hypertension (concentric hypertrophy with a diminished left ventricular volume). This adaptive physiology is needed to meet the greatly increased demand for oxygen by a large mass of muscles. Symptoms of heart failure in athletes Ambitious athletes are inclined to dissimulate symptoms or blame them on non-cardiac causes. From athlete’s heart to heart failure the most challenging group is elderly athletes who often attribute their exertional dyspnea or fatigue to ageing. In pathological hypertrophy, there is inadequate • Persistent fatigue and muscle pains of uncertain etiology, refractory to anti-in amount of nutrients and oxygen reaching the heart muscle due to excessive growth in response fammatory medications, physiotherapy, reduction in training intensity or to stressors such as hypertension. Initially there may be features of Left Ventricular Outfow Tract exercise cessation obstruction, giving a murmur similar to that of aortic stenosis, and might also lead to syncope. Concentric and Eccentric Hypertrophy • Lower extremities swelling As depicted in the diagram below, exercise with a predominantly static component is characterized • Anginal pains by sustained periods of increased mean arterial pressure and peripheral resistance, and only a • Recent history of respiratory tract infection and drop in performance moderate increase in oxygen consumption. Physiological response to elevated mean pressure is • Persistent heartbeat irregularities concentric left ventricular wall thickening with relative contraction of the chamber volume (red panel). The most challenging group is elderly athletes who often attribute their exertional dyspnea or fatigue to ageing. It should be noted that electrocardiography, tragic and potentially avoidable event. Hence, the persistence of symptoms in cases with in well-conditioned young athletes(5). The vast majority of these sudden deaths are caused by normal physical examination should always be supplemented by cardiac imaging, prolonged previously unidentifed and asymptomatic underlying cardiovascular conditions. Early diagnosis in the absence of symptoms is often di cult and the initial presentation in 30% of patients is syncope(10). Congenital coronary artery anomalies Normal coronary artery anatomy for the majority of individuals includes a left main coronary artery and a right coronary artery that originate at their respective sinuses of Valsalva. Coronary artery angiography has traditionally been considered the gold standard for diagnosis, but newer noninvasive techniques, such as magnetic resonance imagery and computed tomography, are replacing angiography. However, all individuals in whom arrhythmias are suspected (palpitations, irregular pulse/heart rate or abnormal heart sounds) require urgent cardiovascular evaluation a physician or cardiologist. Eligibility and Disqualifcation Recommenda tions for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hyper tension: A Scientifc Statement from the American Heart Association and the American College of Cardiology. Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care. The electrocardiogram as a diagnostic tool for hypertrophic cardiomyopathy: revisited. Prevalence of hyper trophic cardiomyopathy in highly trained athletes: relevance to pre-participation screen ing. Heidbuchel H, Corrado D, Bi A, Homann E, Panhuyzen-Goedkoop N, Hoogsteen J, et al. Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Arrhythmogenic right ventricular cardiomyopathy: diagno sis, prognosis, and treatment. Palliative care is required throughout the course of illness regardless of access to disease modifying treatment. Bene ts of palliative care • Causes patients to spend more time at home and reduces the number of hospital inpatients days • Improves symptom management • Provides patient, family and care takers satisfaction • Reduces overall cost of disease • Prolongs survival • Improves quality of life of patients and family Kenya National Guidelines for Cardiovascular Disease Management | 221 | 17:2 Provision of Palliative Care Services Table 17:1 Palliative care services AspectofPalliative/ Supportive C are Definitionand Scope Palliative care plan Palliative care should be provided by a multidisciplinary team A patient should have a detailed holistic assessment and care plan developed by the palliative care provider in collaboration with the patient and family in order of priority Paincontrol Effective pain control is central to palliative care using both pharmacological and non-pharmacological measures. Pediatric Pain Control • Pain assessment tools should be age appropriate (Refer to Annex 8, National Palliative Care Guidelines – 2013). Appropriate information according to age shall be communicated in clear and simple language at their pace • Children shall be allowed to lead a normal life that includes access to education within the limitation of their illness. School teachers, community members including other children shall be encouraged to support and deal sensitively with the a ected child • Recreation activities shall be encouraged like play activities, drawings, poems or songs. Stella Njagi Christian Health Association of Kenya Beatrice Gachambi Medicines Sans Frontieres Dr. Curtailing period of the labour by use in the key maternal and new-born health of oxytocic drugs adversely impacts natural indicators. It is estimated that approximately secretion of hormones and physiological 46% maternal deaths, over 40% stillbirths and mechanism that contribute to the cognitive 40% newborn deaths take place on the day of development. Prerequisite improved outcome for the maternal and of such approach would also hinge upon the newborn health. Clinical protocols for routine care & for management of Medical College Hospitals handle substantial procedure labour maternal and newborn caseloads, besides y ‘Out of Pocket y Use of Labour beds imparting teaching and training the doctors, Expenditures instead of tables specialists, nurses and para-medical staff. Ensuring that at least all government stabilization of the complications before medical college hospitals and high case referral to higher centres. These committees will also support implementation y National Mentoring Group would include of LaQshya interventions. Assessment and modifcation of the Medical Education would jointly create referral directories prepared by the institutional arrangement for seamless fow of districts. The coaching team in districts with medical college could include (d) Facility Level one or more retired faculty members as a coach for medical college labour rooms and operation y Quality Circle: Quality circles are informal groups of the staff in each department that theatre. All coaching teams Paediatrician, Matrons and Nursing Staff & must be trained in skills lab/Dakshata, so that Support Staff. The Quality Circles will work Responsibilities in coordination with facility level quality i. Mentoring of the Quality circles, Support team headed by the Medical Superintendent for the campaign and its monitoring. Periodic Internal review Monthly visits Responsibilities of coaching/support teams for hand i. Ensuring Adherence to Protocols & holding, problem solving, and verifying Clinical guidelines. Monitoring of availability of point for Standardisation of Labour Rooms at of care diagnostic services and blood Delivery Points’. Death audit and clinical discussion on near miss/maternal and neonatal After 18 months, this initiative would be complications. This would b) Human Resource augmentation and skill require substantial reorganization of labour upgradation. Summary of c) Ensuring availability of adequate functional interventions is given in Figure 2. Ensuring round the clock availability of Blood transfusion services, diagnostic Interventions services, drugs & consumables. Ensuring availability of triage area and skilled human resources as per case-load functional newborn care area. Rapid Improvement Events Six cycles ensuring that ‘C’ Sections are undertaken of two months each as defned below judiciously in those cases having robust will need to be rigorously supervised and clinical indications. For each capturing of benefciaries’ independent area, a targeted campaign would be feedback through mechanism ‘Mera launched for a two month duration, Aspataal’ or manual recording, or with the frst month for the roll-out, Grievance Redressal Help Desk and followed by sustaining such efforts take action to address concerns, during the subsequent month (Period for continual enhancement in their for one event – 2 months). Facilitating management of complications including branding of all high case load facilities strengthening of referral protocols.
Preventive measures: 1) Educate the public and health care personnel in basic personal hygiene medications given for bipolar disorder purchase genuine paroxetine on-line, especially transmission via unprotected coughs and sneezes symptoms 6 days before period due 40mg paroxetine with mastercard, and from hand to symptoms insulin resistance order paroxetine with a mastercard mucous membrane treatment uti generic 20 mg paroxetine. Inuenza immunization should prefer ably be coupled with immunization against pneumococcal pneumonia (see Pneumonia). A single dose sufces for those with recent exposure to inuenza A and B viruses; 2 doses more than 1 month apart are essential for children under 9. Routine immunization programs should be directed primarily towards those at greatest risk of serious complications or death (see Identi cation) and those who might spread infection (health care personnel and household contacts of high-risk persons). Immunization of children on long-term aspirin treatment is also recommended to prevent development of Reye syn drome after inuenza infection. The vaccine should be given each year before inuenza is expected in the community; timing of immunization should be based on the seasonal patterns of inuenza in different parts of the world (April to September in the southern hemisphere and rainy season in the tropics). Contraindications: Allergic hypersensitivity to egg pro tein or other vaccine components is a contraindication. Subsequent vaccines produced from other virus strains have not been clearly associated with an increased risk of Guillain-Barre. The use of these drugs should be consid ered in nonimmunized persons or groups at high risk of complications, such as residents of institutions or nursing homes for the elderly, when an appropriate vaccine is not available or as a supplement to vaccine when immediate maximal protection is desired against inuenza A infection. The drug will not interfere with the response to inuenza vaccine and should be continued throughout the epidemic. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Reporting outbreaks or laboratory-conrmed cases assists disease surveillance. Re port identity of the infectious agent as determined by laboratory examination if possible, Class 1 (see Reporting). In epidemics, because of increased patient load, it would be desirable to isolate patients (especially infants and young children) believed to have inuenza by placing them in the same room (cohorting) during the initial 5–7 days of illness. Dosages are 5 mg/kg/day in 2 divided doses for ages 1–9, 100 mg twice a day above 9 years (if weight less than 45 kg, 5 mg/kg/day in 2 doses) for 2–5 days. Doses should be reduced for those over 65 or with decreased hepatic or renal function. Neuraminidase inhibitors may also be considered for the treatment of inuenza A and B. During treatment with either drug, drug-resistant viruses may emerge late in the course of treatment and be trans mitted to others; cohorting people on antiviral therapy should be considered, especially in closed populations with many high-risk individuals. Patients should be watched for bacterial complications and only then should antibiotics be administered. Surveillance by health authorities of the extent and progress of outbreaks and reporting of ndings to the community are important. Disaster implications: Aggregations of people in emergency shelters will favor outbreaks of disease if the virus is introduced. Identication—An acute febrile, self-limited, systemic vasculitis of early childhood, presumably of infectious or toxic origin. Clinically characterized by a high, spiking fever, unresponsive to antibiotics, associ ated with pronounced irritability and mood change; usually solitary and frequently unilateral nonsuppurative cervical adenopathy; bilateral non exudative bulbar conjunctival injection; an enanthem consisting of a “strawberry tongue”, injected oropharynx or dry ssured or erythematous lips; limb changes consisting of oedema, erythema or periungual/general ized desquamation; and a generalized polymorphous erythematous exan them that can be truncal or perineal and ranges from morbilliform maculopapular rash to urticarial rash or vasculitic exanthem. Typically there are 3 phases: 1) acute febrile phase of about 10 days characterized by high, spiking fever, rash, adenopathy, peripheral ery thema or oedema, conjunctivitis and enanthem; 2) subacute phase lasting about 2 weeks with thrombocytosis, desquamation, and resolution of fever; 3) lengthy convalescent phase during which clinical signs fade. According to Diagnostic Guidelines of Kawasaki Disease (Japan Kawasaki Disease Research Committee, 2002), at least 5 of the following 6 principal symptoms should be satised, although patients with 4 principal symptoms can be diagnosed when coronary aneurysm or dilatation is recognized by two-dimensional echocardiography or coronary angiography: 1) Fever persisting 5 days or more (including cases in whom the fever has subsided before the 5th day in response to treatment); 2) bilateral conjunctival congestion; 3) changes of lips and oral cavity: reddening of lips, strawberry tongue, diffuse injection of oral and pharyn geal mucosa, 4) polymorphous exanthema, 5) changes of peripheral extremities: reddening of palms and soles, indurative oedema in the initial stage, and membranous desquamation from ngertips in the convalescent stage, 6) acute nonpurulent cervical lymphadenopathy 2. Postulated to be a superantigen bacterial toxin secreted by Staphylococcus aureus or group A strepto cocci, but this has neither been conrmed nor generally accepted. Occurrence—Worldwide; most cases (around 170 000) reported from Japan, with nationwide epidemics documented in 1979, 1982 and 1986. In Japan, where the disease has been tracked since 1970, peak incidence occurred in 1984–85. Since then, the incidence rate has been steady, about 140 per 100 000 children under 5. Mode of transmission—Unknown; no rm evidence of person-to person transmission, even within families. Seasonal variation, limitation to the pediatric age group and outbreak occurrence in communities are all consistent with an infectious etiology. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Clusters and epidemics should be reported immediately, Class 5 (see Reporting). Recourse to high doses of aspirin is recom mended during the acute phase, followed by low doses for at least 2 months. Epidemic measures: Investigate outbreaks and clusters to elucidate etiology and risk factors. Onset is gradual, with malaise, fever, headache, sore throat, cough, nausea, vom iting, diarrhea, myalgia and chest and abdominal pain; fever is persistent or spikes intermittently. About 80% of human infections are mild or asymptomatic; the remaining cases have severe multisystem disease. In severe cases, hypotension or shock, pleural effusion, hemor rhage, seizures, encephalopathy and oedema of the face and neck are frequent, often with albuminuria and hemoconcentration. Transient alope cia and ataxia may occur during convalescence, and eighth cranial nerve deafness occurs in 25% of patients, of whom only half recover some function after 1–3 months. The overall case-fatality rate is about 1%, up to 15% among hospitalized cases and even higher in some epidemics. The rate is particularly high among women in the third trimester of pregnancy and fetuses. Heating serum at 60°C (140°F) for 1 hour will largely inactivate the virus, and the serum can then be used to measure heat-stable substances such as electrolytes, blood urea nitrogen or creati nine. Infectious agent—Lassa virus, an arenavirus, serologically related to lymphocytic choriomeningitis, Machupo, Junn, Guanarito and Sabia viruses. Serologically related viruses of lesser virulence for laboratory hosts in Mozambique and Zimbabwe have not yet been associated with human infection or disease. Reservoir—Wild rodents; in western Africa, the multimammate mouse of the Mastomys species complex. Mode of transmission—Primarily through aerosol or direct con tact with excreta of infected rodents deposited on surfaces such as oors and beds or in food and water. Period of communicability—Person-to-person spread may theo retically occur during the acute febrile phase when virus is present in the throat. Susceptibility—All ages are susceptible; the duration of immunity following infection is unknown. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Individual cases should be reported, Class 2 (see Reporting). Nosocomial transmission has occurred, and strict procedures for isola tion of body uids and excreta must be maintained. Re course to a negative pressure room and respiratory protec tion is desirable, if possible. Male patients should refrain from unprotected sexual activity until the semen has been shown to be free of virus or for 3 months. To reduce infectious exposure, laboratory tests should be kept to the minimum necessary for proper diagnosis and patient care, and only performed where full infection control measures are correctly implemented. Technicians must be alerted to the nature of the specimens and supervised to ensure application of appropriate specimen inactivation/isolation procedures. Dead bodies should be sealed in leakproof material and cremated or buried promptly in a sealed casket. Establish close surveillance of contacts as follows: body temperature checks at least 2 times daily for at least 3 weeks after last exposure. Deter mine patient’s place of residence during 3 weeks prior to onset; search for unreported or undiagnosed cases. Epidemic measures: Rodent control; adequate infection con trol and barrier nursing measures in hospitals and health facilities; availability of ribavirin; contact tracing and follow-up. Disaster implications: Mastomys may become more numer ous in homes and food storage areas and increase the risk of human exposures. International measures: Notication of source country and to receiving countries of possible exposures by infected travel lers. In Legionnaire disease, a chest X-ray may show patchy or focal areas of consolidation that may progress to bilateral involvement and ultimately to respiratory failure; the case-fatality rate has been as high as 39% in hospitalized cases; it is generally higher in those with compromised immunity.
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