Persantine

Pedro A. Sanchez-Lara, M.D.

• Children? Hospital Los Angeles
• Keck School of Medicine and Ostrow School of Dentistry
• University of South California
• Los Angeles, California

Donation may be considered where factors that have previously put the patient at risk of stone formation medicine 853 order 100 mg persantine overnight delivery. It is recommended that advice is obtained from a clinician with a specific interest in this field symptoms 5dp5dt fet buy persantine 100mg overnight delivery. A history of a previous infection-related (struvite) or cystine renal stone is generally considered a contra- indication to donation treatment alternatives for safe communities purchase persantine 100mg fast delivery. In potential donors who have a history of previous stones but no metabolic abnormality treatment of hemorrhoids order persantine 100 mg without a prescription, proceeding with donation should be considered providing the number medicine pouch cheap 100 mg persantine free shipping, size and frequency of previous stones has been low 4 medications walgreens purchase persantine with amex. Potential donors found to have small stone(s) on imaging, or cases where there is uncertainty as to whether there is a true calculus or parenchymal calcification, may be suitable to donate. Both need to be aware of the limited data regarding long-term outcomes in these circumstances (10). The smaller the stone bulk and the older the potential donor, the lower is risk associated with proceeding to donation. If donation proceeds, it is preferable to remove the kidney containing the suspected calculus. However, it is relatively straight forward, with urological input and modern flexible ureterorenoscopes, to inspect the collecting system and remove any confirmed stones ex vivo, before implanting the donor kidney (15,16). Leaving the donor with a single kidney containing a possible small stone is undesirable, but may be considered in exceptional circumstances. Full counselling of the donor is required in this situation and appropriate close long-term follow-up of the donor is necessary. People with bilateral kidney stones should in general not be considered as kidney donors. This situation both suggests an inherent metabolic or anatomical abnormality and would leave the individual with a single kidney containing a stone placing them at significant risk of a future stone event in a solitary kidney. Donors who have a past history of stones and those who have donated a stone- bearing kidney should be counselled about symptoms of renal/ureteric colic and anuria and information should be provided regarding the availability of local urological expertise. Donors should also be advised to maintain a high fluid intake for life (at least 2. Progression of nephrolithiasis: long-term outcomes with observation of asymptomatic calculi. The natural history of nonobstructing asymptomatic renal stones managed with active surveillance. Prevalence and early outcome of donor graft lithiasis in living renal transplants at the Mayo Clinic. The evaluation of living renal transplant donors: clinical practice guidelines: Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians. Living renal donor allograft lithiasis: a review of stone related morbidity in donors and recipients. Clinical characteristics of potential kidney donors with asymptomatic kidney stones. A report of the Amsterdam Forum on the care of the live kidney donor: data and medical guidelines: Council of the Transplantation Society. Ex vivo ureteroscopic treatment of calculi in donor kidneys at renal transplantation. Incidental renal stones in potential live kidney donors: prevalence, assessment and donation, including role of ex vivo ureteroscopy. All donors should have a full blood count and clotting screen as part of their assessment. In addition, the risks of general anaesthetic are much greater in this population. In addition, visible and non-visible haematuria are well described, often as a result of papillary necrosis. Careful screening for the presence of existing renal involvement is required, with particular attention to a history of macroscopic haematuria. There have been a few reports of minor tubular dysfunction in some patients with thalassaemia trait but there is no other reported association with renal disease (6). Other haemoglobin variants Other haemoglobinopathies may be encountered when screening donors of non- northern European heritage and in general should not pose a problem with kidney donation except where they form part of a compound heterozygote with Hb S (e. Such patients behave like patients with sickle cell disease and therefore should not be accepted as living kidney donors. Red cell membrane disorders these include hereditary spherocytosis and hereditary eliptocytosis, inherited haemolytic anaemias of variable severity. Renal function is not significantly impaired in these conditions and organ donation is acceptable in mild forms where treatment has not been required. However, such a decision has to be taken with great care and following discussion with the donor and their haematologist. Although the risk of disease transmission is considered negligible, the potential recipient should also be counselled re a potential increased risk associated with donation. As such there is a theoretical possibility of carry-over in a donor kidney to the recipient. However, those receiving bridging anticoagulation are more likely to have bleeding complications. These data should inform discussion with potential donors in this category and may represent a relative contraindication to donation but, in general, the risks should be discussed with a haematologist. Association of sickle cell trait with chronic kidney disease and albuminuria in African Americans. A long-term study of prognosis in monoclonal gammopathy of undetermined significance. Incidence and clinical complications of myelodysplastic syndromes among United States Medicare beneficiaries. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Bleeding, recurrent venous thromboembolism, and mortality risks during warfarin interruption for invasive procedures. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. The diagnosis of many familial renal diseases still relies on a high index of suspicion coupled with biochemical, radiological and histological investigations. It may also be revealed only through a detailed pedigree, which must be obtained for all individuals with renal disease who are being considered for transplantation. In such cases, confirmation of all diagnoses within the family is essential to identify whether there is a clinically significant genetic predisposition to renal disease that may be relevant to potential donation (3). However, in most cases the family history is due to polygenic influences such as diabetes, certain types of glomerulonephritis and hypertension for which no additional genetic testing or screening is required above that recommended for routine donor evaluation (3). Where the diagnosis is a known genetic disease or the family history is suggestive of a monogenic (Mendelian) disease, the pedigree will aid in the identification of the mode of inheritance (typically autosomal dominant, autosomal recessive or X-linked) and the identification of at risk relatives. This information is important to clarify the lifetime risk to a genetically related potential donor of developing significant renal disease. The genetic basis of many familial renal diseases has been elucidated, providing the opportunity to use molecular investigations for diagnostic testing in the recipient and predictive testing in the potential living related donor (4). Genetic testing may also aid the prediction of the likelihood of disease recurrence in the transplanted kidney. As genetic testing may be offered to individuals and families, involvement of clinical genetics services or specialist renal genetics services should be considered at an early stage to support the donor assessment team. This will be of value in identifying risks to family members and for the type and use of genetic testing for diagnostic and exclusion purposes. It should also be noted that molecular testing can take in excess of 3 months and, with the increasing use of gene panels containing many genes, the likelihood of identifying a genetic variant that requires further interpretation is increased. Projects such as the 100,000 Genomes project may facilitate the latter and further necessitates interaction with genetic services at an early stage of donor/recipient evaluation At risk relatives must be carefully evaluated for specific disease manifestations and consideration given to genetic testing to definitively clarify risk and therefore suitability as a potential donor. Parents will be obligate gene carriers and second degree relatives will be at 50% risk of also being gene carriers. It remains unclear what the risk of progression to proteinuria and renal impairment is for carriers, but this has been described (6,7). Molecular testing can be used to confirm the diagnosis in the affected individual and carrier status in parents and other relatives. It is currently unclear whether mutation carriers who do not have non-visible haematuria on repeat testing can be donors. Despite this uncertainty, carriers with no renal abnormality by age 45 might be considered as donors in a similar manner to X-linked Alport syndrome. The majority, >95%, will develop non-visible haematuria by adulthood but have a life-time risk of progressive renal disease of 5-20%. Gene testing for both conditions is available and is important for diagnostic confirmation and the carrier testing of other female family members. Therefore careful evaluation of renal function, possibly including renal biopsy, may be indicated in X-linked diseases to provide accurate risks for potential female donors who have been shown to be carriers. In all familial renal diseases, a genetically related potential donor can be offered predictive genetic testing if the familial mutation has been identified. This should only be offered by experienced individuals, usually via a regional clinical genetics service, because of the potential impact of identifying clinical or genetic status to an otherwise clinically asymptomatic individual. Any person found to carry the familial mutation would normally be excluded as a potential donor if this predicted development of disease, and should also be referred for appropriate follow-up. Genetic testing is currently available for diseases where a mutation has a high probability of predicting development of disease. These tend to be associated with a much smaller predictive value of developing disease and are relevant to populations and not families. Disease status in an at-risk potential donor may also be determined by clinical assessment without genetic testing. Genetic testing may therefore be helpful where equivocal imaging studies do not allow formal exclusion of the diagnosis. Reflux Nephropathy Vesico-ureteric reflux on the other hand is a condition where the genetic basis is unclear but where family studies show a high sibling recurrence risk and significant risk of inheritance (14). It affects around 1-2% of infants and is one of the most common reasons for transplantation in young adults. A careful search for evidence of reflux or its consequences should be undertaken in relatives being considered as donors. A history of childhood enuresis or urinary tract infection is common in affected individuals. Nuclear medicine scanning can detect renal scars and this can be used to look for indirect evidence of reflux in potential donors. Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians. Population-based screening for family history of end-stage renal disease among incident dialysis patients. Whole-genome linkage and association scan in primary, nonsyndromic vesicoureteric reflux. Two types of donor-derived malignancies are possible: inadvertent transfer of tumour tissue (donor transmitted), and de-novo malignancy arising after transplantation in donor-derived tissue (donor derived). More recent reports from both sides of the Atlantic suggest that transmission is much less common but still occurs (8-11). To minimise this risk, care must be taken during evaluation of the potential living donor to ensure that a past medical history of malignant disease is recorded and that symptoms consistent with undiagnosed malignancy are identified. It is worth stating that outcomes after transplantation should be compared to outcomes when remaining on dialysis, a condition with a high morbidity and mortality. Unfortunately, we do not know the biology of such tumours under the influence of immunosuppressive drugs. As an example it has been possible to transplant kidneys from unrelated donors with small renal cell carcinomas (<3 cm) with a very low risk of recurrence (12-14). During clinical examination, the possibility of occult malignancy should be borne in mind and care taken to exclude the presence of potentially malignant skin lesions, abdominal masses, breast lumps, testicular swelling and lymphadenopathy. A chest X-ray and imaging of the renal tract should be carried out, and urine analysis to look for haematuria. Evidence suggests that these are extremely unlikely to be malignant and if causing clinical concern can be removed at the same time as nephrectomy with minimal morbidity (17). It should be remembered that the risk of malignancy increases with age and that this effect is particularly marked over the age of 50; at least 75% of cancer cases are diagnosed in those over 65 years old (18). The situation is further complicated by wide variations in the natural history of different primary tumours. Registry data relating to tumour transmission from cadaveric donors indicate that certain tumours seem to be particularly high risk. There should be a low threshold to exclude any potential donor with a history of these cancers, although some potential donors with treated disease, no evidence of recurrence, long follow-up and favourable histology may be considered following careful oncology review. In contrast, other registry data have documented no evidence of tumour transmission, especially when most tumours were non-melanoma skin cancers or low-grade malignancies (19,20). Advice adapted from the Amsterdam Forum for Living Donation in 2005 (21) is shown in Table 5. The biology of the tumour should be considered and discussed with the relevant expert oncology team. There is universal agreement that tumours with a propensity to late recurrence. For other types of malignancy, it has been suggested that consideration for donation may be appropriate if there is no evidence of tumour recurrence after ten years (5).

Typically symptoms 1 week before period buy persantine 25 mg with mastercard, a patient with a suspicious neck mass is investigated by 99m Tc pertechnetate thyroid scintigraphy treatment yeast diaper rash cheap 25mg persantine. This cost is covered by the National Insurance system but most patients have no insurance and must pay full costs treatment gastritis order discount persantine line. About 25% of the population is covered by the National Health Insurance system medications quizlet buy persantine 100 mg line, 5% is 131 covered by private health insurance and 70% has no medical insurance treatment 02 bournemouth order 100 mg persantine with amex. I therapy is typically undertaken 4 weeks after surgery medicine prescription drugs persantine 25 mg online, but if longer, patients have thyroxine hormone replacement withdrawn for 4 weeks before treatment. In 131 Bolivia there is no legal limit for the amount of I that can be administered as an outpatient, and there is no legislation regarding radiation protection. The guidelines however include a maximum limit of annual radiation dose for the general public of 1 mSv, a maximum annual radiation dose for individual carers of patients of 20 mSv, and for a five year period less than 131 50 mSv. Serum thyroglobulin levels are also checked 4 weeks 131 after thyroid surgery, before I therapy. In preparation for the scan, the patient ceases thyroxine replacement therapy for 4 weeks. Of the past 47 patients treated for well-differentiated thyroid cancer, five have been lost to follow-up. This has been attributed to social and economic reasons, as well as a lack of understanding of the condition by the patient and the patient?s family. In Bolivia, there is a marked lack of uniformity in the management of thyroid cancer. Consequently, education of physicians and patients about the appropriate management of 131 thyroid cancer is limited. Attempts are being made to achieve consensus in the use of I and uniformity in a protocol to manage patients with well-differentiated thyroid cancer. Inherent problems remain due to the high cost of treatment, widespread poverty and lack of legislation and supervision from government health authorities. Guatemala Guatemala has a land area of 108 889 square kilometres and has borders with Mexico, Honduras, El Salvador and Belize. Indigenous Guatemalians make up 43% of the population and the remainder consists predominantly of those of mixed indigenous and European ethnicity (?Ladinos?). Up to 65% of the population resides in rural areas, and 75% live below the poverty line, 58% in extreme poverty. Of the indigenous population 32% speak only Mayan languages and 46% of the population are illiterate. These factors all influence the perception of illness and tend to increase non- compliance of medical advice and treatment. The estimated prevalence of iodine deficiency is 12% in the more remote mountainous regions and 8% in urban areas. Although no reliable data exist for thyroid cancer incidence and mortality in Guatemala, the female to male ratio is four and relapse following treatment of thyroid cancer is 10%. There are a total of four centres in Guatemala, all located in Guatemala City that administer 131 I therapy. Only two of these centres have full facilities including modern gamma cameras and isolation wards. Nuclear medicine physicians as well as some endocrinologists and 131 radiation oncologists administer I therapy. Either the endocrinologist or the surgeon takes the key management role, supervises therapy and long term follow-up. In order to treat 131 patients using I, in addition to the six years of basic medical training, another three years of specialty training in nuclear medicine or radiation oncology is required. Radiation licensing is also required following completion of a course in radiation protection that is run by the Ministry of Energy and Mining of Guatemala. Sub-total thyroidectomy (for example, lobectomy and isthmectomy) is generally performed in patients less than 40 years of age with non-invasive (thyroid capsule intact), non-metastatic tumours less than 2 cm. Near-total thyroidectomy/total thyroidectomy is performed at major referral centres and for patients greater than 40 years of age. This cost 229 is covered by the State in patients in public charity hospitals and social security hospitals. The former is a free service for the impoverished, and with the latter, the patient as a private or state employee, contributes a fixed amount together with his/her employer, on a monthly basis. Up to 30% of the population has health care covered by the Social Service, 10% have private medical insurance. The maximum annual radiation doses are 5 mSv for the general public, 20 mSv for individual carers and 20 mSv for family infants. The rate of loss to follow-up is greater than 40% of those patients treated in State hospitals, and less than 4% of private hospital patients. The high rate of follow-up loss is due to a number of factors including geographic isolation, poverty preventing good patient compliance and poor 131 education and understanding of the disease and the need for long term follow-up. Serum thyroglobulin assay has been available in Guatemala since late 2001 but only at one State hospital and two private laboratories. Serum thyroglobulin assay is not 131 routinely performed before I therapy, and measurements are generally taken on an annual basis. Furthermore, the high cost and need for imported I reduces availability for treatment. The limited imaging equipment and paucity of properly equipped isolation wards reflect the unfavourable economy of Guatemala and priority directing health resources toward primary care. Paraguay this country of 406 752 square kilometres of land area is bordered by Argentina, Bolivia and Brazil. There are two official languages, Spanish and the Indian language Guarani that is spoken by more than 90% of the population. A Government sponsored program to reduce endemic iodine deficiency was introduced in 1991. Only three physicians specialize in the field of nuclear medicine in Paraguay, and are the only physicians 131 to treat patients with I. Nuclear medicine specialty training of at least 2 years has to be obtained overseas. The surgeon takes the main responsibility in management of 131 thyroid cancer patients in all aspects other than I therapy. Under ultrasound guidance, percutaneous aspiration of the suspicious nodule is performed. Where thyroid cancer is confirmed, a near total thyroidectomy is performed but the surgical protocol may depend upon the size of the nodule, and estimated extent of disease. This cost is covered by the Government health care system that is funded by 9% of each employed person?s monthly salary. Private health care insurance is also available but may not cover chronic 131 illness. In Paraguay the 131 legal limit of a single I dose for an outpatient is less than 1. The maximum annual radiation dose allowed for the general public is 1 mSv and the maximum annual radiation dose for individual carers is 20 mSv or 100 mSv over 5 years. Five or six different laboratories in Paraguay assay anti-thyroglobulin antibody levels and also use appropriate 131 131 dilutions. There is usually good patient compliance with the first follow-up visit at six months, but the loss to follow-up is high after this time. The importation of I means that 15-20 days notice is required before a 131 131 therapy dose of I can be delivered. Furthermore, all imported I and other radiopharmaceuticals have to go through the standard administrative process at 231 customs, also adding to the delay in obtaining these products at the airport. In Paraguay there is no government support or private organizations offering support for nuclear medicine. Consequently, dissemination of knowledge to medical students and medical practitioners throughout Paraguay is very difficult, and nuclear medicine is greatly under-utilized. With only three practicing nuclear medicine physicians, limited equipment and no government support, the speciality of nuclear medicine in Paraguay is unlikely to keep pace with other countries. Conclusions the management of thyroid cancer is undertaken in a relatively standardized fashion throughout the world. This has been based largely upon standards and regulations set as benchmarks from North America and Europe, where resources are most available for research and data collection. Even countries with very few resources have a basic infrastructure in place that allows physicians to follow the recommended management protocols. The profound lack of resources in some countries however, prevents optimal basic diagnosis and limited follow-up (Tables 17. Furthermore, lack of resources limits the number of sites where thyroid cancer therapy can be undertaken. This may prohibit therapy in some cases, and result in increased costs of transport and overnight accommodation for patients who cannot afford such expense. Thyroid carcinoma is a disease that requires diligent long term, and often lifelong follow-up surveillance. Poverty, poor transport infrastructure and geographic isolation all contribute to inadequate long term management of patients with thyroid cancer in many developing countries. Continuing education of physicians is required in order to instigate appropriate management algorithms. In turn, the physicians need to promote education of the general public and dispel misinformation, so that patients will seek appropriate medical help as early as possible. In many countries cultural factors may also inhibit appropriate management of thyroid cancer. Patients may seek traditional family therapies as alternatives to modern medicine, and due to lack of information, may fear modern medical equipment and techniques. In addition to patient and physician education, there exists a need for the establishment of data registries in many countries. Even with the introduction of new equipment and staff, unless data is collected that accurately reflects the impact, or otherwise, of any change, the true benefit of change cannot be assessed. Such data is also a powerful tool for use at administrative and government levels in order to argue the benefit for ongoing financial support, or the need for additional support. This review of the experience related from various countries around the world offers insight as to the effectiveness of information networks related to the availability of information technology, and groups and societies whose goals are for the optimal management of as many patients as possible. However, this review indicates that there is much potential for improvement, and also that an inertia of knowledge growth has developed that should provide us with optimism for the future. The long term follow-up studies of external radiation-exposed victims of Hiroshima and Nagasaki have indicated the elevated risk of thyroid cancer during the lifespan of exposed individuals. Furthermore, the dramatic increase of childhood thyroid cancer around Chernobyl has changed conventional concept and understandings of the mechanism of radiation-induced thyroid carcinogenesis. The genes subject to mutations in thyroid carcinogenesis can be classified as oncogenes or anti-oncogenes (tumour suppressor genes) based on their mode of action. Some genetic changes leading to thyroid cancer are inherited through the germline, but most are acquired or somatic in nature. Here the molecular genetics of human thyroid cancer is summarized from the standpoint of genetic factors and environmental status. Especially discussed is the molecular mechanism of radiation-induced thyroid carcinogenesis. Oncogenes According to the accomplishment of ?Human Genome Project?, numerous ?oncogenes? have been recognized [18. These genes, normally silent, can become activated by chromosomal translocations, deletions, or mutations, and then can ?transform? normal cells into a condition of uncontrolled growth. Most oncogenes appear to be closely related to normal growth factors, genes that control cell division or to hormone receptors [18. In general, these genes, when turned on, promote cell growth, division and depress differentiation. Typically, activation of one such gene may not be enough to produce malignancy, but if accompanied by the expression of another oncogene, or if gene mutation or reduplication occurs, the cell may progress towards the transformation. The escape mechanism from cell apoptosis is also critical for abnormal cell proliferation. The genetic and chromosomal instability subsequently also occurs during the development of thyroid cancer. Recently mutations of thyroid hormone receptors have been reported in human thyroid cancer tissues, suggesting the up-regulation mechanism of c-myc at the transcriptional level [18. Activating mutations of H-ras at codons 12, 13, and 61 and overexpression of H-ras, are found in adenomas and carcinomas, but H-ras mutations are also found in nodular goitre tissue, suggesting that H-ras mutations could be an early event in oncogenesis [18. Enhanced sensitivity to apoptosis in ras-transformed thyroid cells may suggest the complexity of intracellular signal transduction during the early stage of thyroid oncogenesis [18. Another important oncogene is frequently and specifically expressed in papillary thyroid cancers. These mutations affect extracellular loops of the transmembrane domain and the transmembrane segments, and are proven to induce hyperfunction by transfection studies. Anti-oncogenes Compared to oncogene activation, second mechanism of thyroid carcinogenesis arises from inactivating mutations in genes that normally serve to limit cell proliferation. In general, single functional copy of antioncogene is sufficient to provide normal physiologic effects. The occurrence of tumour-specific suppressor genes is often detected by the lack of heterozygosity of chromosomal markers associated with deletions of segments of genetic material. Thus, evidence for characteristic chromosomal abnormalities within tumour cells may lead to recognition of a tumour suppressor gene. Mutation or deletion of the p53 tumour suppressor gene is found in only few differentiated thyroid cancers, but in many undifferentiated cancers, suggesting that this genetic deletion may be one of the final steps leading to anaplastic thyroid cancer growth [18. The involvement of cell cycle regulators remains to be further clarified at the standpoint of tumour suppressor gene during thyroid oncogenesis. Genetic background of radiation-induced tumourigenesis the genetic background of an individual can influence the susceptibility to carcinogenesis.

Interference of Hib vaccination with the immunoresponse to in recently vaccinated children treatment pneumonia purchase persantine 25 mg visa, and in sera pertussis vaccine has been described (3) symptoms 8 dpo purchase persantine 25 mg without prescription. It can be imagined sis in 5- to 9-year-old vaccinated children medicine rock cheap 25 mg persantine otc, who that such cases are reported medicine grinder cheap 100 mg persantine with amex, albeit not strictly in never received Hib vaccine medicine gustav klimt generic persantine 25 mg visa, was similar to the accordance with the case definition treatment diffusion quality persantine 25mg. To exclude the possibility that the rise in noti- Decreased vaccine efficacy due to interference of fication was the result of reporting cases diagnosed Hib vaccination is, therefore, very unlikely. It might be possible that circulating strains of increased from 20% in 1993 to 33% in 1994. The abrupt increase in the Thus, the 1996 increase in notification cannot be proportion of vaccinated patients reported in all attributed to this change in serodiagnostic practice. Our surveillance data suggest a decrease in Data from other countries in Europe indicate vaccine efficacy, but estimation of vaccine efficacy that the pertussis epidemic is restricted to the from surveillance data should be interpreted Netherlands. However, there are no indications has been noted in the United States since the late Vol. Nederlands Tijdschrift Netherlands at the end of 1996 may indicate a Geneeskunde 1995;139:1280-6. Impact of Haemophilus tricians of cases among hospitalized children was influenzae type b polysaccharide-tetanus-pertussis added to the routine surveillance based on vaccine. Dynamics of the population structure of Bordetella phism types and antigenic variants of B. Pertussis observed, which seems to reflect a true increase in - United States, January 1992-June 1995. Pertussis in Quebec: ongoing epidemic since the late mismatch between the vaccine and the circulating 1980s. Schellekens* *National Institute of Public Health and the Environment, Bilthoven, the Netherlands; and ?Inspectorate of Health, Rijswijk, the Netherlands Emerging Infectious Diseases 178 Vol. Two elderly women had lived in the same room, and the onset of their illness was 5 days apart. Hib isolates from blood cultures showed identical profiles by pulsed field gel electrophoresis. These findings suggest that Hib infection was transmitted within this nursing home. After the introduction of routine childhood Case 2 immunization against Haemophilus influenzae Two days after the first patient was type b (Hib), the incidence of invasive Hib disease hospitalized, an 80-year-old female resident of fell dramatically in several countries, including the same nursing home became ill with fever and Australia (1-3). However, clusters of Hib infection hypotensive (90/60 mm Hg) and had pretracheal have rarely been reported in adults. No clinical evidence of pneumonia was their relatedness, we investigated two fatal cases observed, and a chest X-ray was normal. Ceftriaxone 2 g, genta- Case Reports micin 80 mg, flucloxacillin 1 g, and metronidazole 500 mg were administered intravenously. Inotropes Case 1 were given for hypotension and acute renal In June 1996, a 71-year-old female nursing failure, but the patient?s condition deteriorated home resident was hospitalized after 3 days of rapidly, and she died 9 hours after admission to unproductive cough, fevers, confusion, and the hospital. She had a history of cere- subsequently isolated from blood cultures col- brovascular disease, muscular dystrophy, and lected before the patient died. She had clinical signs of left lower Investigation lobe pneumonia and was afebrile. A blood film For several months, these two women had was normal, but a chest X-ray showed exten- occupied beds in the same six-bed room (the sive bilateral pulmonary infiltrates. The blood gases showed severe hypoxia in room air home employed 37 nursing and ancillary staff. Ceftriaxone 1 g During 3 weeks before the investigation, 20 and metronidazole 500 mg were given intra- residents and several staff had been ill with venously for suspected aspiration pneumonia, bronchitis, for which many had received oral but the patient became severely hypotensive antibiotics. No sputum samples had been col- and died 8 hours after admission to the lected for culture from residents or staff. The following day, beta-lactamase- other elderly residents had died during the negative Hib was isolated from blood cultures preceding 10 days, but their case notes did not collected before the patient died. On the first day of our investigation, the isolates provide good evidence that trans- two elderly residents were febrile. One woman mission of Hib infection occurred in this nursing had bilateral bronchopneumonia that was not home. We were unable to demonstrate that Hib responding to oral cefaclor and was hospitalized; caused any of the associated reports of bronchitis blood and sputum cultures yielded no pathogens, and febrile illness among residents and staff, and and urine samples did not contain Hib capsular our prevalence study did not show any asymp- antigen. However, the survey was week, with a cellulitic leg ulcer and pleuritic performed 10 days after the onset of the second chest pain of uncertain etiology. Because of her case of septicemia following widespread use of other chronic illnesses she was treated palliatively antibiotics, and it may not have accurately reflected and died 1 week later. A swab of her leg ulcer the prevalence of Hib carriage at the time these yielded group G streptococcus, blood cultures cases occurred. Three other to all roommates of the index case patients and 28 clusters of Hib infection in adults have been des- staff who had been in regular close contact with cribed: one occurred in a nursing home attached the two case patients during the week before their to a hospital, and two were nosocomial? Our report weeks of follow-up, and Hib was not isolated from provides further evidence that Hib can cause any throat swab cultures. Given that diagnostic pro- pulsed field gel electrophoresis and had identical cedures are performed infrequently in many profiles that were distinguishable from several community nursing homes, Hib infection may be epidemiologically unrelated isolates (Figure). The relationship of these two fatal cases of We were especially interested in these two Hib disease in time and place and the clonality of cases in adults as they were the only instances of Figure. Pulsed field gel electrophoresis of Haemophilus influenzae type b (Hib) isolates from blood culture of two elderly nursing home residents (lanes 1 and 2) compared with epidemiologically unrelated H. These surveillance methods will In 1992, 27 of 30 notifications of invasive Hib identify groups at increasing or underrecognized disease in this area were of children aged less than risk that may benefit from immunization. Although invasive Hib infection remains uncommon Acknowledgments in adults in communities where childhood Hib vac- the authors thank Graham O?Donnell (Department of Microbiology, Westmead Hospital) and Marianne Kerr and cination is routine, the relative frequency of inva- Oanh Nguyen (Western Sector Public Health Unit). Hewitt,? introduction of Hib immunization, while the inci- Bin Jalaludin,* Christine Roberts,? dence of epiglottitis in adults remains steady or is Anthony G. Acute epiglottitis in children *Western Sector Public Health Unit, North is usually caused by Hib, and the falling inci- Parramatta, New South Wales; ?Australian dence of epiglottitis in this age group is explainable National University, Australian Capital Territory, by immunization. In adults, most culture-positive Australia; ?Department of Public Health and cases of acute epiglottitis are also caused by Hib Community Medicine, Westmead, New South Wales; (10,12). However, the incidence of Hib-related epi- and ?Institute of Clinical Pathology and Medical glottitis in adults does not appear to be changing Research, Westmead, New South Wales appreciably?at least in Rhode Island?and Hib does not account for the increasing incidence of epiglottitis observed in this age group (10). Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib incidence and ascertaining the etiologic agents in vaccine era. Rapid disappearance of Invasive Hib disease should continue to be Haemophilus influenzae type b meningitis after rou- monitored in all age groups after the introduction tine childhood immunisation with conjugate vaccines. Herceg A, Oliver G, Andrews G, Curran M, Crerar S, suggests that Hib immunization reduces the Andrews R, Evans D. Annual report of the National acquisition of Hib carriage in children, and Notifiable Diseases Surveillance System, 1995. Com- reduced carriage among children may indirectly municable Diseases Intelligence 1996;20:451. Acute epi- veillance data in western Sydney and metropolitan glottitis and infant conjugate Haemophilus influenzae type b vaccination in northern Finland. Arch Oto- Atlanta have not supported this hypothesis; laryngol Head Neck Surg 1995;121:898-902. Invasive Haemophilus influenzae in childhood disease (5; New South Wales Health disease in adults. A nosocomial Incidence, aetiology, and prognosis of acute epiglottitis outbreak of ampicillin-resistant Haemophilus influen- in children and adults in Sweden. Antibody prevalence increased with rising elevation (>1,200 meters) and correlated with a spatial cluster of hantavirus pulmonary syndrome cases in the Sierra Nevada. In spring 1993, a cluster of unexplained severe cases (14 cases, 8 deaths), after New Mexico (29 acute respiratory illnesses associated with a high cases) and Arizona (22 cases). Although specific risk factors are poorly North America, especially the western United defined, persons engaging in activities that bring States (6,7). Data from samples collected in 1975, 1976, and 1988 and stored at collected on the Channel Islands were analyzed the University of California, Berkeley, Museum of separately from mainland data where indicated. Vertebrate Zoology, and specimens collected from 1989 through early 1993 by local vector control dis- Sin Nombre Virus Antibody Prevalence tricts. Prospective surveys and human case inves- tigations were conducted from late 1993 through California Mammals the end of 1995. Wild rodent trapping and pro- A total of 4,626 (4,549 rodent and 77 non- cessing methods were as previously described (20). Wild rodents (most 3,109, from county, physical location of trapline, date of the family Muridae) made up 98% of the sample, survey, elevation, and habitat. Habitat was cate- followed by Sciuridae (1,369), and Heteromyidae gorized by a single dominant vegetation type: cha- (71). Among the Muridae, 78% were deer mice or parral, conifer trees, grassland, hardwood trees, related species, 11% were wood rats, 6% were sage/scrub brush, or urban environment (21). For archived specimens, liver Deer Mouse Populations tissue from frozen carcasses was used for poly- Of 1,921 P. A random effects model collected by the University of California, Ber- was chosen because of the presence of important keley in 1975 and 1976 were from Alameda, Kern, clustering effects from the sampling design. Prevalence of antibodies to Sin Nombre virus from the Channel Islands, which differed by among wild rodents in California, 1975?1995 seven amino acid substitutions. Antibody prevalence among deer mice collected in nearby Mono County in 1994 by only on the other islands was 7 (17. Likewise, antibody prevalence was higher among deer mice trapped in vegetation associated with these Table 2. Prevalence of antibodies to Sin Nombre virus among Peromyscus maniculatus by county, California, environments: 15. Geographic distribution of hantavirus pulmonary Angeles (Catalina, San Clemente), Santa Barbara (San syndrome cases and occurrence of Sin Nombre virus Miguel, Santa Barbara, Santa Cruz, Santa Rosa), and antibodies among deer mice (Peromyscus maniculatus), Ventura (Anacapa, San Nicolas) counties. Because 0 these related wild mice species frequently inhabit the same environment as P. Prevalence of Sin Nombre virus antibodies among deer mice each other, as would occur in (Peromyscus maniculatus) by elevation, California, 1975?1995 (n=1,539, a permanent virus-species excluding Channel Islands). The high preva- lence of antibodies identified in meadow voles Reservoirs of Hantavirus in California (22. Characteristics of selected hantavirus pulmonary syndrome cases and prevalence of antibodies to Sin Nombre virus in Peromyscus maniculatus collected at candidate sites of exposure, California, 1994-1995* Onset Suspect County Predominant Elevation No. For example, pational and recreational activities of the inhabi- deer mice in foothill/mountainous (14. Odds ratios for Sin Nombre virus antibody preva- isolated population of deer mice. Deer mouse lence among Peromyscus maniculatus by association with human cases and elevation, California, 1975?1995a populations have been on the Channel Islands long enough that each island has its own sub- Cases Controls Adj. Although travel (meters) from the mainland to the islands and from island 0-300 32 580 1. Serologic and genetic lected near buildings during investigation of human identification of Peromyscus maniculatus as the primary cases. Since other survey sites were probably less rodent reservoir for a new hantavirus in the South- likely to be located near human dwellings, this western United States. Hjelle B, Jenison S, Torrez-Martinez N, Yamada T, factor may represent a source of bias in our study. A novel hantavirus asso- Other biases may have been introduced because ciated with an outbreak of fatal respiratory disease in of nonrandom sampling and small sample size at the southwestern United States: evolutionary relation- some survey sites. Isolation of the causative identified in this analysis are needed to further agent of hantavirus pulmonary syndrome. Genetic identification of a hantavirus associated with an outbreak of acute respiratory illness. Hantavirus pulmonary syn- education of residents, visitors, and workers at drome: the first 100 cases. Hantavirus Human dwellings in the mountains may be more pulmonary syndrome - United States, 1995 and 1996. In addition, persons working in or virus associated with a fatal case of hantavirus pulmonary cleaning these structures may be at an even syndrome in Louisiana. Molecular linkage of hanta- Acknowledgments virus pulmonary syndrome to the white-footed mouse, the authors thank the many workers who conducted field Peromyscus leucopus: genetic characterization of the M surveys and participated in the compilation of a state-wide genome of New York virus. Genetic identification of a Chomel,? Minoo Madon,? David Sesline,? novel hantavirus of the harvest mouse Reithrodontomys Barryett A. Coexistence of several novel ?California Department of Health Services, hantaviruses in rodents indigenous to North America. Hantavirus in Montana deer mouse populations: Epidemiological studies of hemorrhagic fever with preliminary results. Epidemiologic linkage of rodent tured a decade before the recognition of hantavirus and human hantavirus genomic sequences in case pulmonary syndrome. Evolutionary genetics of California Islands infections in the deer mouse (Peromyscus maniculatus): Peromyscus. Dominant glycoprotein study of environmental factors associated with epitope of four corners hantavirus is conserved across a hantavirus pulmonary syndrome in the southwestern wide geographical area. In rare cases, pregnant women exposed to Chlamydia psittaci can contract gestational psittacosis: atypical pneumonia, sepsis, and placental insufficiency resulting in premature birth or miscarriage. In the United States, only two cases of gestational psittacosis have been reported, both from exposure to psittacine birds. Eleven other cases have been reported worldwide, mostly in the United Kingdom, all from exposure to infected birth fluids and membranes of farm mammals, notably sheep and goats.

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Free Redistribution: There must be no restrictions by the license on use medicine tramadol generic 100mg persantine with amex, distribution symptoms joint pain buy persantine now, or selling of a program that uses the code as a component treatment hepatitis b order persantine online. Derived Works: Any derived or modified works must be allowed distribution under the same licensing as the original software medications 4 less canada cheap persantine master card. Individuals must be allowed to use these ?patch files? upon building their program and allow distribution of this built program medicine 6 year in us safe persantine 25mg. No Discrimination Against Persons or Groups: No persons or groups can be discriminated against by the license treatment wetlands buy discount persantine 100mg. No Discrimination Against Fields of Endeavor: No fields can be restricted for use by the license. Distribution of License: Redistribution under the same rights must be possible without the need for an additional license 8. License Must Not Be Specific to a Product: the license and rights of the program cannot be limited to a specific product. License Must Not Restrict Other Software: the license must not restrict other software being used with the original program in any way. License Must Be Technology-Neutral: No individual technology or 4 style of interface can be specifically stated for use by the license. The open source tools also had to permit law enforcement agencies to use them, which can be found only in the fine print of license agreements. Some of the phones will be powered on, while the Page | 8 remainder will be powered off. Artifacts from 13 different areas of phone use will be created in equal amounts on the phone when available. Three open source tools will be used to analyze the created data: Paladin Forensic Suite?; Autopsy?; and Andriller?. The version of Andriller? used was a trial, but overall Andriller? is less expensive than a prorpietary tool. Once each of these tools has extracted and examined the data from each phone, the amount of data extracted will be noted and compared to each tool used. The last two steps of factory resetting the phones and another physical extraction are to see if there are any personal artifacts that can be left on the phones and if so, what types of artifacts are left. There has been research done about the amount of ?user-generated content? that can still be recovered after a factory reset. This research in particular found that some phones left user data like ?photographs, audio files, text files, login information and geolocation 5 data? on the phones proving the ?unreliable nature of a factory reset. With this experiment, digital forensic tools could be used more cost effectively, and the possibility of recovering lost data could catch a criminal. There was a computer used to not only analyze data, but to download open source tools. The open source tools used were Paladin Forensic Suite? with Autopsy?, Andriller?, and BitPim?. That left nine android phones to be examined for the possibility of being included in the experiment. It explains what write-blocking cord has to be used on a specific phone and where to put it, along with where to connect a receiving location device. There are three types of extractions that can be performed: physical, file system, and logical. Each phone is different and therefore has different extractions and artifacts that can be imaged from it. If a physical extraction was unavailable for a phone, then a file system and/or logical extraction was performed. Physical extractions were preferred because they get the most data from a phone compared to a file system or logical extraction. Page | 11 the extractions were saved to an external hard drive, to be analyzed later. Two phones only had a logical extraction because the physical and file system ones were not available. These two phones were then excluded because they were unable to provide hidden or deleted files. Three of them had the reset performed while the phone was turned on; the rest had the phones turned off (see Table 6 in Results). Each phone was given an identity and a Google Mail? (Gmail) account to set up the rest of the phone and install applications (see Table 1). Phone Account Info Phone Birthd Gmail? Passw Phone Microsoft Outlook Name Type ay Accounts ords Number Account 4- Kyocera C5170 Elizabeth 612-474- Mar- Lizzy. Dash Sensib 612-474- Same as Gmail?, 635 Dashwood 98 wood2468 ility 2468 just Outlook 22- Emma Emma. Page | 12 After the identities on each phone was created, artifacts were produced on each phone, when available. Artifacts Created for the Experiment Fake Text * Taken Videos Fake Call Log* Deleted Videos Emails Contacts Taken Pictures Web History Deleted Pictures Web Favorites/Bookmarks Downloaded Pictures Favorite Locations Calendar Events *Fake Text and Fake Call Log applications were not available for every phone. Each phone had roughly the same amount of artifacts created in each section; this was done to normalize the results as much as possible. Most of the time the number of artifacts per section was five total, though some had more due to accidental addition like fake calls, or deleted pictures. The calendar reminders also had the seven birthdays along with Halloween, Christmas, and New Year?s. The fake call log and fake text messages were from downloaded applications from the Google Play Store?, specifically, Fake Call Logs from Mobitop? and Fake Text Messages from NeruoDigital?. The emails were sent through the Gmail? accounts of the five phones that were included in the experiment. Page | 13 Notes 1 6 5 12 6 5 6 5 5 5 11 20 5 10 *Includes Email addresses from 4 2 6 5 16 6 5 7 5 5 7 10 9 5 10 contacts Could not send emails, but could receive them. Had no preformed contacts 7 - - - 7 5 5 5 5 5 7 11 5 10 (emergencies/phone company) Web History was grayed out, because although there was history made, the number of Web sites visited was not noted. Phones 3 and 7, stayed in the experiment even though the fake text and fake call logs were not installed. As a fall back to either one of the other extractions not working, a file system extraction was taken. Some of the phones could not do just one extraction at a time, but instead became multi-step extraction. This meant a physical extraction and file system extraction, or a logical extraction and file system extraction occurred at the same time. For Paladin? to work there is no need for a write-blocker because it mounts devices only as ?Read- Only? when initially plugged into the computer. After that, you can change a device to ?Read/Write,? which was only done for the external hard drive in order to save screenshots of the activities being performed. However, only phones 1 and 7 were recognized as external drives to be imaged through Paladin?. However, all of the phones were able to list what percentage of them was being used and for what purpose. Since only phones 1 and 7 were imaged, they were the only ones examined using Paladin?. When they were being imaged, a box for verification of hash values was checked in order to make sure nothing was added or removed from the phone. Though Autopsy? phones 1 and 7 were analyzed with their images taken from Paladin?. With this image, Autopsy? was able to create timelines for all the activities performed on each phone. It is specifically designed for android phones; phone 3 with the Windows? operating system, was not recognized, and could not be examined with this tool. Even when the program was directed to a similar phone to the one plugged in, it would not recognize the actual phone. With the inability to recognize any phone, BitPim? was unable to examine the phones. There were several open source tools looked at for this experiment, yet most of them had some defect, or inability to be used in this experiment. For a list of the tools and the reasons for their exclusion from this experiment, please refer to Appendix B. Once again, those phones that were left on for the first factory reset, were left powered on again. The physical extractions were preferred, but again file system and logical extractions were taken when the physical extraction was not offered. Phones from the Initial Extraction Notes Dump Performed Logical and file system extraction also performed. If the physical extraction was not performed a logical extraction was, and only one file system extraction was executed. The exclusion of those two phone, resulted in seven phones moving forward to factory reset. The reset was split into phones that were powered on or powered off when the factory reset was performed. Types of extractions performed on the phones after the experiment artifacts were added. The Disk Usage Analyzer is featured above, showing how much space is being used and for what. The Autopsy? tool was used to make a timeline of activities and artifacts on the Kyocera Hydro. Page | 23 Databases were not installed on the program or computer which limited Autopsy? as an analyzer tool. The Paladin? suite toolbox was unable to be used, so there was no further examination than what is shown. No other information was pulled from the phones, besides that shown above in Figure 2. Andriller? Reports Phones Wi-Fi Passwords Android Web Browser History Android Download History Contacts 1 1 1 38 8 2 2 27 12 - 3 4 1 30 13 - 7 2 44 5 11 Phone 3 was not recognized by Andriller?. The four other phones consistently got Wi-Fi passwords, web browser history, and download history. A description of the extractions performed on the phones for the last time after the second factory reset. Phone 3 was unable to have a file system extraction, leaving a logical extraction the only option. The three extractions happened before the phones were factory reset, after they were reset and the experimental data was created, and after another factory reset. The data dump had conflicting numbers between the physical 4 231 7, 12* - (7) and the logical (12) extractions. Know there were text messages that came in when the phone was 3 * N/A N/A turned on. The data dump had conflicting numbers between the physical (13) 4 179 13, 24* 0 and the logical (24) extractions. There are two different screenshots and one says there are 23 4 23* 26 2 photos while another says there are only 22. The data dump had conflicting numbers between the physical 7 24 23, 0* 18 (23) and the logical (0) extractions. The data dump had conflicting numbers between the physical 4 1 21, 31* 0 (21) and the logical (31) extractions. The data dump had conflicting numbers between the physical 7 193 11, 22* 0 (11) and the logical (22) extractions. The data dump had conflicting numbers between the physical 4 1 10, 20* 0 (10) and the logical (20) extractions. The data dump had conflicting numbers between the physical 7 42 10, 20* 0 (10) and the logical (20) extractions. A few phones had differing numbers when it came to physical extractions versus logical extractions. These occurrences happened in all but three of the data sections: photos carved, web history, and web favorites/bookmarks (see Tables 13, 16, and 17). The other eight sections had at least one conflicting incident noted (see Tables 9, 10, 11, 12, 14, 15, 18, and 19). Some phones did not extract data when they should have, namely phone 3 and sometimes phone 2 (see Tables 9, 10, 11, 15, 16, 17, 18, and 19). These phones were quickly rejected from the experiment, as there was no time to crack the codes, or potentially harm the data within them. The unlocked iPod Touch? did have a file system and a logical extraction took place. However, since there were no other Apple products being used, it was excluded in order to normalize the results. Since logical extractions are just showing what a person would see on a phone, instead of the hidden or deleted files that an investigation would want to look at, these phones were excluded from the rest of the experiment. The file system extraction extracts not only everything that can be seen on the phone, but also the files and hidden files within it. These hidden files could be essential in an investigation, especially one dealing with the criminal use of digital devices. This reset was done with some phones powered on and extracted via the settings menu. The phones chosen for this method would not factory reset without the phones being on. Two of these phones required not only a factory reset, but also a wipe of the cache partition. With those specific sections, the limits of the physical extraction were widened to see if email, web history, and web favorites were included.