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Serum anti-C trachomatis antibody concentrations are diffcult to determine erectile dysfunction treatment in kuala lumpur malegra fxt plus 160mg visa, and only a few clinical laboratories perform this test erectile dysfunction tampa buy malegra fxt plus 160 mg amex. In children with pneumonia erectile dysfunction holistic treatment generic malegra fxt plus 160 mg overnight delivery, an acute microimmunofuorescent serum titer of C trachomatis-specifc immunoglobulin (Ig) M of 1:32 or greater is diagnostic erectile dysfunction at age 27 buy discount malegra fxt plus online. Diagnosis of ocular trachoma usually is made clinically in countries with endemic infection impotence organic origin definition purchase malegra fxt plus 160 mg online. Limited data on azithromycin therapy for treatment of C trachomatis infections in infants suggest that dosing of 20 mg/kg as a single daily dose for 3 days may be effective erectile dysfunction bp meds order 160 mg malegra fxt plus otc. Oral sulfonamides may be used to treat chlamydial conjunctivitis after the immediate neonatal period for infants who do not tolerate erythromycin. Because the effcacy of erythromycin therapy is approximately 80%, a second course may be required, and follow-up of infants is recommended. The need for treatment of infants can be avoided by screening pregnant women to detect and treat C trachomatis infection before delivery. For children who weigh >45 kg but who are <8 years of age, the recommended regimen is azithromycin, 1 g, orally, in a single dose. For children >8 years of age, the recommended regimen is azithromycin, 1 g, orally, in a single dose or doxycycline, 100 mg, orally, twice a day for 7 days. For pregnant women, the recommended treatment is azithromycin (1 g, orally, as a single dose) or amoxicillin (1. Nonpregnant adult or adolescent patients treated for uncomplicated Chlamydia infection with azithromycin or doxycycline do not need to be retested unless compliance is in question, symptoms persist, or reinfection is suspected. Previously infected adolescents are a high priority for repeat testing for C trachomatis, usually 3 to 6 months after initial infection. Erythromycin base (2 g/day in 4 divided daily doses) for 21 days is an alternative regimen; azithromycin (1 g, once weekly for 3 weeks) probably is effective. Identifcation and treatment of women with C trachomatis genital tract infection during pregnancy can prevent disease in the infant. Pregnant women at high risk of C trachomatis infection, in particular women younger than 25 years of age and women with new or multiple sexual partners, should be targeted for screening. Sexually active adolescent and young adult females (younger than 26 years of age) should be tested at least annually for Chlamydia infection during preventive health care visits, even if no symptoms are present and even if barrier contraception is reported. All sexual contacts of patients with C trachomatis infection (whether symptomatic or asymptomatic), nongonococcal urethritis, mucopurulent cervicitis, epididymitis, or pelvic infammatory disease should be evaluated and treated for C trachomatis infection if the last sexual contact occurred during the 60 days preceding onset of symptoms in the index case. Predictors of scarring and blindness for trachoma include increasing age and constant, severe trachoma. Four distinct, naturally occurring forms of human botulism exist: foodborne, wound, adult intestinal colonization, and infant. Onset of symptoms occurs abruptly within hours or evolves gradually over several days and includes diplopia, dysphagia, dysphonia, and dysarthria. Classic infant botulism, which occurs predominantly in infants younger than 6 months of age (range, 1 day to 12 months), is preceded by or begins with constipation and manifests as decreased movement, loss of facial expression, poor feeding, weak cry, diminished gag refex, ocular palsies, loss of head control, and progressive descending generalized weakness and hypotonia. A few cases of types E and F have been reported from Clostridium butyricum (type E), C botulinum (type E), and Clostridium baratii (type F) (especially in very young infants). Outbreaks have occurred after ingestion of restaurant-prepared foods, home-prepared foods, and commercially canned foods. To increase the likelihood of diagnosis, suspect foods should be collected and serum and stool or enema specimens should be obtained from all people with suspected foodborne botulism. In foodborne cases, serum specimens may be positive for toxin as long as 16 days after admission. In infant botulism cases, toxin assay and culture of a stool or enema specimen is the test of choice. If constipation makes obtaining a stool specimen diffcult, a small enema of sterile, nonbacteriostatic water should be used promptly. Therefore, an important aspect of therapy in all forms of botulism is meticulous supportive care, in particular respiratory and nutritional support. Equine-derived investigational 1 For information, consult your state health department. However, because botulinum neurotoxin binds irreversibly, administration of antitoxin does not reverse paralysis. Penicillin or metronidazole should be given to patients with wound botulism after antitoxin has been administered. The role of antimicrobial therapy in the adult intestinal colonization form of botulism is not established. Immediate reporting of suspect cases is particularly important because of possible use of botulinum toxin as a bioterrorism weapon. Physicians treating a patient who has been exposed to toxin or is suspected of having any type of botulism should contact their state health department immediately. People exposed to toxin who are asymptomatic should have close medical observation in nonsolitary settings. Systemic fndings initially include tachycardia disproportionate to the degree of fever, pallor, diaphoresis, hypotension, renal failure, and later, alterations in mental status. Other Clostridium species (eg, Clostridium sordellii, Clostridium septicum, Clostridium novyi) also can be associated with myonecrosis. The sources of Clostridium species are soil, contaminated objects, and human and animal feces. Dirty surgical or traumatic wounds with signifcant devitalized tissue and foreign bodies predispose to disease. A Gram-stained smear of wound discharge demonstrating characteristic grampositive bacilli and absent or sparse polymorphonuclear leukocytes suggests clostridial infection. Clindamycin, metronidazole, meropenem, ertapenem, and chloramphenicol can be considered as alternative drugs for patients with a serious penicillin allergy or for treatment of polymicrobial infections. The combination of penicillin G and clindamycin may be superior to penicillin alone because of the theoretical beneft of clindamycin inhibiting toxin synthesis. Mild to moderate illness is characterized by watery diarrhea, low-grade fever, and mild abdominal pain. Disease often begins while the child is hospitalized receiving antimicrobial therapy but can occur more than 2 weeks after cessation of therapy. The illness typically is associated with antimicrobial therapy or prior hospitalization. Complications, which usually occur in older adults, can include toxic megacolon, intestinal perforation, systemic infammatory response syndrome, and death. Severe or fatal disease is more likely to occur in neutropenic children with leukemia, in infants with Hirschsprung disease, and in patients with infammatory bowel disease. Colonization by toxin-producing strains without symptoms occurs in children younger than 5 years of age and is common in infants younger than 1 year of age. C diffcile is acquired from the environment or from stool of other colonized or infected people by the fecal-oral route. A more virulent strain of C diffcile with variations in toxin genes has emerged as a cause of outbreaks among adults and is associated with severe disease. Isolation of the organism from stool is not a useful diagnostic test nor is testing of stool from an asymptomatic patient. Endoscopic fndings of pseudomembranes and hyperemic, friable rectal mucosa suggest pseudomembranous colitis. The predictive value of a positive test result in a child younger than 5 years of age is unknown, because asymptomatic carriage of toxigenic strains often occurs in these children. C diffcile toxin degrades at room temperate and can be undetectable within 2 hours after collection of a stool specimen. Intravenously administered vancomycin is not effective for C diffcile infection. The most effective means of preventing hand contamination is the use of gloves when caring for infected patients or their environment, followed by hand hygiene after glove removal. The short incubation period, short duration, and absence of fever in most patients differentiate C perfringens foodborne disease from shigellosis and salmonellosis, and the infrequency of vomiting and longer incubation period contrast with the clinical features of foodborne disease associated with heavy metals, Staphylococcus aureus enterotoxins, Bacillus cereus emetic toxin, and fsh and shellfsh toxins. Diarrheal illness caused by B cereus diarrheal enterotoxins can be indistinguishable from that caused by C perfringens (see Appendix X, Clinical Syndromes Associated With Foodborne Diseases, p 921). Enteritis necroticans (known locally as pigbel) results from necrosis of the midgut and is a cause of severe illness and death attributable to C perfringens food poisoning among children in Papua, New Guinea. At an optimum temperature, C perfringens has one of the fastest rates of growth of any bacterium. Illness results from consumption of food containing high numbers of organisms (>10 colony forming units/g) 5 followed by enterotoxin production in the intestine. C perfringens can be confrmed as the cause of an outbreak when the concentration of organisms is at least 10 /g in the epidemiologically 5 implicated food. Roasts, stews, and similar dishes should be divided into small quantities for refrigeration. Constitutional symptoms, including extreme fatigue and weight loss, are common and can persist for weeks or months. Chronic pulmonary lesions are rare, but up to 5% of infected people develop asymptomatic pulmonary radiographic residua (eg, cysts, nodules, or coin lesions). In soil, Coccidioides organisms exist in the mycelial phase as a mold growing in branching, septate hyphae. In tissues, arthroconidia enlarge to form spherules; mature spherules release hundreds to thousands of endospores that develop into new spherules and continue the tissue cycle. Using molecular markers, the genus Coccidioides now is divided into 2 species: Coccidioides immitis, confned mainly to California, and Coccidioides posadasii, encompassing the remaining areas of distribution of the fungus within the southwestern United States, northern Mexico, and areas of Central and South America. In areas with endemic coccidioidomycosis, clusters of cases can follow dust-generating events, such as storms, seismic events, archaeologic digging, or recreational activities. Person-to-person transmission of coccidioidomycosis does not occur except in rare instances of cutaneous infection with actively draining lesions and congenital infection following in utero exposure. Preexisting impairment of T-lymphocyte mediated immunity is a major risk factor for severe primary coccidioidomycosis, disseminated disease, or relapse of past infection. Coccidioides species are listed by the Centers for Disease Control and Prevention as agents of bioterrorism. Serologic tests are useful to confrm the diagnosis and provide prognostic information. Persistent high titers (fi1:16) occur with severe disease and almost always in disseminated infection. Because clinical laboratories use different diagnostic test kits, positive results should be confrmed in an experienced reference laboratory. Culture of organisms is possible but potentially hazardous to laboratory personnel, because spherules can convert to arthroconidiabearing mycelia on culture plates. Clinicians should inform the laboratory if there is suspicion of coccidioidomycosis. Repeated patient encounters every 1 to 3 months for up to 2 years, either to document radiographic resolution or to identify pulmonary or extrapulmonary complications, are recommended. In patients experiencing failure of conventional amphotericin B deoxycholate therapy or experiencing drug-related toxicities, lipid formulation of amphotericin B can be substituted. A subcutaneous reservoir can facilitate administration into the cisternal space or lateral ventricle. The newer azoles should be used in consultation with experts experienced with their use in treatment of coccidioidomycosis. Treatment for disseminated coccidioidomycosis is at least 6 months but for some patients maybe extended to 1 year. Surgical debridement or excision of lesions in bone, pericardium, and lung has been advocated for localized, symptomatic, persistent, resistant, or progressive lesions. Twenty percent develop worsening respiratory distress requiring intubation and ventilation. The overall associated mortality rate is approximately 10%, with most deaths occurring in the third week of illness. Pneumothoraces and other signs of barotrauma are common in critically ill patients receiving mechanical ventilation. Associated lymphopenia is less severe, and radiographic changes are milder and generally resolve more quickly than in adolescents and adults. They also are more likely to develop dyspnea, hypoxemia, and worsening chest radiographic fndings. Which of these modes are most important remains to be determined, and the possible role of aerosol spread requires further study. Specimens obtained from the upper and lower respiratory tract are the most appropriate samples for viral detection. There are reports of patients who were treated with supportive care only who recovered uneventfully. For hospitalized patients, following additional infection control practices as described previously is recommended. Pulmonary disease, when symptomatic, is characterized by cough, chest pain, and constitutional symptoms. Chest radiographs may reveal a solitary nodule or mass or focal or diffuse infltrates.

This made the use of iron lungs necessary when severe polio cases were seen in the past impotence nhs buy malegra fxt plus with visa. Mode of Transmission Transmission of the virus can occur by contact with pharyngeal (throat) droplets as well as through fecal-oral spread erectile dysfunction symptoms treatment buy discount malegra fxt plus 160 mg on line. Infectious Period Not clearly defined erectile dysfunction causes infertility purchase malegra fxt plus 160mg with visa, but transmission can occur as long as the virus is shed in the stool can you get erectile dysfunction pills over the counter generic malegra fxt plus 160 mg on line. Report to your local health jurisdiction of suspected cases is immediate and mandatory erectile dysfunction condom proven malegra fxt plus 160 mg. Refer to district infection control program protocol and policy for infectious diseases impotence lifestyle changes order malegra fxt plus us. Administration of oral (live virus) polio vaccine was discontinued in the United States in 2000. Internationally, polio control is achieved by immunization of any individual in an epidemic area who is over the age of 6 weeks and who is unvaccinated, incompletely vaccinated, or uncertain of vaccination history. When found on the body it is called tinea corporis; when on the scalp, tinea capitis; when in the groin, tinea cruris; and when on the feet, tinea pedis. Ringworm begins as a small, red patch or bump that spreads outward, so that each affected area takes on the appearance of a red, scaly, outer ring with a clear central area. Mode of Transmission Transmission of ringworm is generally by person-to-person or contaminated article-toperson contact. Future Prevention and Education Ringworm of the body is not particularly dangerous, has no unusual long-term consequences, and can generally be treated quite effectively with locally applied preparations. The first signs of rubella in children may be swollen, tender glands, usually at the back of the neck and behind the ears; and a low-grade fever followed by a rash. Rubella in adolescents and adults may cause painful or swollen joints (especially in females). Mode of Transmission Transmission is from nasopharyngeal secretions of infected persons. Make referral to licensed health care provider for laboratory tests to establish diagnosis and for necessary follow-up of suspected rubella cases. Because of the theoretical risk to the fetus, females of childbearing age should receive vaccine only if they say they are not pregnant and are counseled not to become pregnant for 1 month after vaccination. Scabies affects persons from all socio-economic levels without regard to age, sex, or standards of personal hygiene. The mite burrows into the outer layer of the skin in tiny red lines about half an inch long and then lays eggs. The parasite tends to be first located in the webs between the fingers or toes, around the wrist, or navel. It can also be commonly found on the backs of elbows, the folds of the armpits, the beltline and abdomen, the creases of the groin, and on the genitalia. Scabies usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Contact generally must be prolonged; a quick handshake or hug usually will not spread scabies. Infectious Period Scabies can be transmitted as long as the person remains infested and untreated, including during the interval before symptoms develop. Notification to the parent or guardian for appropriate referral to licensed health care provider is made by the school nurse for diagnosis and treatment of suspected cases. Students can be readmitted the following day after overnight treatment with a prescribed topical anti-scabicide cream. Discreetly manage scabies cases so that the student is not ostracized, isolated, humiliated, or psychologically traumatized. Contact with the licensed health care provider for additional comfort measures may be warranted. Scabies is widespread and transmission usually occurs through prolonged, close personal contact. Scabies in students, like lice and pinworms, does not necessarily indicate poor hygiene. If repeated infections occur despite proper treatment, an investigation for unrecognized cases among companions or household members should be undertaken. The most common cause of treatment failure is inadequate treatment of close personal contacts. The number of diseases listed in the sexually transmitted category has climbed sharply in recent years. Consider child sexual abuse when gonorrhea, chlamydia, or syphilis is present in a student who is not sexually active. Symptoms for females include mucopurulent cervicitis (inflammation of the cervix), cervical ectopy (redness) and friability (easily induced bleeding) of the cervix. If clinical services to support Chlamydia diagnosis and treatment exist at the school. Gonorrhea genital infections differ somewhat in presentation in males and females. Infection can spread to the pelvic areas and even to the joints, heart, brain, and other organs in both males and females. Coexisting chlamydial infection and potential pelvic inflammatory disease should be a concern, along with pharyngeal (throat) and anorectal infections. Mode of Transmission Gonorrhea is transmitted by sexual activity involving the penis, vagina, mouth, and/or rectum. Antibiotic resistant strains of gonorrhea may increase the risk of spreading this infection. School nurses should work closely with local health jurisdiction staff to better ensure successful treatment and discuss any student who reports his/her symptoms have not resolved. Genital herpes infection, due to either Type 1 or Type 2 virus, can be sexually transmitted. Provide education and counseling regarding transmission of disease, recurrence potential, and recommended prevention practices to prevent spread. If clinical services to support initial herpes diagnosis and treatment exist at the school. Provide education and counseling regarding transmission of disease, and recommended prevention practices to prevent spread. While chlamydia is the most frequent isolated agent, other agents are involved in a significant number of cases. Diagnosis is based on symptoms, laboratory studies, and negative cultures for gonorrhea. Control of spread involves an interview with the patient and referral of sexual contacts for medical examination and treatment. At this secondary stage, blood tests for syphilis are always positive (unlike the primary stage that can have negative serologic tests). Patients may remain asymptomatic throughout life or may progress to the late destructive stages of the disease. Mode of Transmission With the exception of congenital infection, syphilis is transmitted through direct contact with an infectious lesion or rash occurring in primary and secondary stages, typically by sexual contact. Infectious Period Appropriate antibiotic treatment ends infectiousness within 24 hours. Adequate treatment will limit spread from the primary site to other organs and from one individual to another. The untreated disease may become a very significant health problem in the years ahead. While trichomoniasis infects both males and females, males seldom have any symptoms. Symptoms for females include abnormal vaginal discharge, itching, burning, and vaginal odor. There is evidence linking trichomoniasis infection to low birth weight babies and premature births. Control of Spread Although the male is seldom symptomatic with trichomoniasis, control of spread and reinfection usually involves concurrent referral of male sexual contacts for medical examination and treatment. Only in this way can the female partner avoid reinfection once therapy is completed. The most prevalent types of vaginitis are trichomoniasis (trich), candidiasis (yeast), and bacterial vaginosis (Gardnerella vaginitis, nonspecific vaginitis). Mode of Transmission Vaginal infections may be transmitted by intimate sexual contact but symptoms also may originate from excessive douching, use of birth control pills, certain antibiotics, and other sources such as allergic reactions to vaginal products. Infectious Period Vaginitis caused by microorganisms is infectious for the duration of infection. Unlike chickenpox, lesions are at the same stage of development at the same time no matter where they are on the body. Vaccine virus can be spread from the vaccine inoculation site or from fresh scabs to another person by hands or skin contact. Infectious Period Lesions are infectious until the dry scab crusts have separated. A person with smallpox is sometimes contagious with onset of fever, but the person becomes most contagious with the onset of rash. Immediately report to your local health jurisdiction by telephone a suspected case of smallpox or smallpox vaccine rash. Cover lesions from smallpox vaccine, which is a different virus that is also contagious. Use standard precautions including gloves for any contact with dressings or with articles soiled with fluid or scabs from skin lesions. Dispose of all dressings in biohazard bags or disinfect dressings with 1:10 bleach and water solution. Future Prevention and Education In the event of an intentional release of smallpox virus, vaccination would be recommended for those exposed to the initial release, contacts of people with smallpox, and others at risk of exposure. This site includes updates, links, and education options along with general information. The infection occurs between the skin (in the fascia) and eventually results in tissue damage to the skin and underlying muscle. The signs and symptoms are fever with severe pain, followed by swelling and redness at a wound site. As with all unidentified rashes, especially those accompanied by fever or illness, make referral to a licensed health care provider. Untreated milder streptococcal infections can lead to serious complications (rheumatic fever and kidney disease [glomerulonephritis]). A person can move the infection from one part of the body to another by scratching. Students with sore throat and fever should be cultured and, if culture-positive, treated appropriately by a licensed health care provider. Significant increases in the number of sore throats or increases above normal in school absenteeism (above 10 percent) should be referred to your local health jurisdiction for epidemiologic investigation. The culturing of asymptomatic contacts of a strep case is not generally done except in facility outbreaks. Antibiotic resistance occurs when bacteria change in some way that reduces or eliminates the effectiveness of drugs designed to cure infections. Tetanus has not been reported in the United States in individuals who received an adequate primary immunization series. Mode of Transmission Transmission is through contamination of a wound by soil, dust, water, or articles, especially those that have been contaminated with animal feces or manure. Make referral to licensed health care provider for evaluation of the wound for additional medical care if needed and a tetanus booster, if needed. Different species of hard ticks can carry several infectious diseases in the western United States. Diseases and symptoms include: Lyme disease typically starts with an expanding circular target-shape rash. Rocky Mountain spotted fever typically starts with fever, vomiting, muscle aches, and headache. Cases occur throughout the state although tularemia is usually not tick-associated. Tick paralysis involves progressive paralysis starting in the legs resulting in weakness, numbness, and difficulty walking. In Washington there are reports every year of locally-acquired cases of Lyme disease, tularemia, and relapsing fever. Safe tick removal is described in How to Respond: Illness and Injury at School (2010) page 26, and at: here. If the student reports a known tick bite and the tick is no longer attached, wash the bite site thoroughly with soap and water. Inform parent of all tick bites and the importance of monitoring the site and any early symptoms of tick-borne illness, particularly "flu-like" symptoms or rash over the next month or so. If symptoms develop, the student should be evaluated by his/her health care provider. Refer suspected cases of any tick-borne illness to a licensed health care provider.

Nevertheless erectile dysfunction juice cheap 160 mg malegra fxt plus free shipping, it occurs 5 times less on Google Scholar and almost 9 times less on Google erectile dysfunction lack of desire purchase 160 mg malegra fxt plus visa, because of which I decided to include it in the record as an extra synonym erectile dysfunction 21 years old purchase malegra fxt plus 160mg visa. For the translation I found several options which all have been thoroughly researched in order to choose the most frequently used option goal of erectile dysfunction treatment purchase malegra fxt plus 160 mg overnight delivery. Reuter 642 offered the translation hantavirus pulmonary syndrome and hantaviruspulmonairsyndroom erectile dysfunction treatment philippines purchase malegra fxt plus, Codex Medicus 392 as well as Winkler Prins 206 presented hantavirus pulmonaal syndroom and Internet sources provided yet another term erectile dysfunction doctor nj trusted malegra fxt plus 160 mg, namely hantavirus pulmonair syndroom (written in separate words). In the table below all options are shown with their frequency on Google and Google Scholar (language set to Dutch): Google Google Scholar 1 Hantavirus pulmonary syndrome 69 9 Hantavirus pulmona(a)l(e) syndroom 31 (11) 1 Hantavirus pulmonair(e) syndroom 15 (23) 0 Hantavirus cardiopulmonaal syndroom 4 0 Hantavirus cardiopulmonair syndroom 2 0 Hantaviruspulmonairsyndroom 0 0 Table 1: possible translations for hantavirus pulmonary syndrome From table 1 can be deduced that hantaviruspulmonairsyndroom is not used in scientific texts. As it only occurs in the bilingual dictionary Reuter, I did not include this term in the record. Next to that, hantavirus cardiopulmonair syndroom and hantavirus cardiopulmonaal syndroom are barely used either, which is in contrary to the English term hantavirus 1 Of which two texts were in English. The other results, which had more success, were hantavirus pulmonaal and pulmonair syndroom. Compounds with these words are considered a germanism (which also confirms that hantaviruspulmonairsyndroom should not be included in the record). Since hantavirus pulmonair(e) syndroom does not occur in any of the dictionaries consulted and only in Google sources, I did not include it in the record. I opted to keep hantavirus pulmonaal syndroom and hantavirus pulmonary syndrome as full Dutch equivalents for two main reasons. Firstly, because the first one occurred in two dictionaries and in several texts on Google. However, it only occurred in one dictionary, because of which I opted to place the Dutch term as the prefererred term. For the Dutch definition, I resorted again to the dictionaries in which I found the above possibilities. Winkler Prins starts its definition with the announcement that the disease was first described in 1993 and only occurs in America. This is very restrictive, because in the future the disease could spread, there could develop another strain of the virus, and the infected rodents could be transferred to other continents. As there were so many possible synonyms, there had to be made a distinction between the full synonyms, the extra synonyms and the related terms. This is a significant difference in comparison with the first seven possibilities in the table. The reason why there are numerous different names for this disease, is explained by Gajdusek D. As there were several sources explaining that nephropathia epidemica is a milder form, I opted to include it as a related term instead of a synonym. Apart from this, hemorrhagic nephrosonephritis (in one word and with a hyphen), nephrosonephritis, Korean hemorrhagic fever and epidemic hemorrhagic fever were still open options. The latter had a record on GenTerm, which included hemorrhagic fever with renal syndrome as a synonym. In addition, it yielded many hits, appeared in four dictionaries and was described in the previous record as full synonym. Nevertheless, the preference should go out to hemorrhagic fever with renal syndrome. I did not use this definition, however, because Codex Medicus and Winkler Prins 206 claim that nephropathia epidemica is a different disease. Because of the ambiguous term, I therefore opted to use the definition provided by Reuter 128 (see record). Reuter 128 also offered a series of synonyms, which are acute hemorragische nefrosonefritis, Koreaanse hemorragische koorts, krim-congokoorts and nephropathia epidemica. Moreover, I researched the literal translation for the full synonym epidemic hemorrhagic fever, i. Pinkhof referred to krim-congokoorts for the definition of epidemische hemorragische koorts, which was also added to the possible synonyms list. In addition, krim-congokoorts provided other synonyms as well: nefrosonefritis and epidemische nefritis. Pinkhof stated under medisch geoniem that the geographic locality is often used in the name, which is similar to what Gajdusek D. Of the other synonyms, only Koreaanse hemorragische koorts and hemorragische koorts met renaal syndroom yielded 4 and 6 hits, respectively, on Google Scholar. On Google, the three most occurring terms were krim-congokoorts (66 hits), hemorragische koorts met renaal syndroom (44 hits) and Koreaanse hemorragische koorts (27 hits), the other synonyms had no more than 10 hits. As Koreaanse hemorragische koorts is a literal translation of one of the English synonyms and as it yielded quite some hits in which the same concept was described, I could include it as an extra Dutch synonym. Krim-congokoorts does not have an English equivalent and implies a geographical locality, but according to the several sources I consulted, it implies the same concept as hemorragische koorts met renaal syndroom because of which I also included it as an extra synonym. Moreover, no definitions were found for the full term in English monolingual dictionaries. Includes hog cholera, bovine virus diarrhea-mucosal disease and ovine border disease viruses. In my research on Google and Google Scholar for some more information about the infection I found several related terms, which can be considered as hyponyms, such as ruminant pestivirus infection, bovine pestivirus infection and ovine pestivirus infection. As the full English term could not be found in dictionaries, I suspected that there would be no results either in Dutch monolingual or bilingual dictionaries. This definition stated that Yersinia pestis is the causative agent of rodent and human pest. Additionally, this term often occurred in other dictionaries in combination with pest. Because of this, I assumed that the general term pest was caused by contamination with this pestvirus. From these hits, I could conclude that pestvirus is probably not from Flaviviridae family. This is stated by the International Committee on Taxonomy of Viruses 2016-07-25 and used on the Dutch website of Centrum voor Onderzoek in Diergeneeskunde en Agrochemie 2016-07-25. The entry date is 2003, which implies that it is a fairly new term in the medical field. This was confirmed by the fact that I could not find henipavirus infection, nor henipavirus in any dictionary. As there was no reference in any of the dictionaries, I was not able to provide a pronunciation nor a dictionary definition. Therefore, the English and the Dutch definitions were based on two scientific texts (Hayman D. This made me wonder if there could also be a subdivision of henipavirus infection as well. The little information found on henipavirus infections made it more difficult to understand, and thus also to translate it. Therefore, the translation for henipavirus infections is a neologism by analogy with the high number of other virus infections found in GenTerm and in this dissertation (see 2. Nevertheless, it had to be verified whether these synonyms are actually used in the medical sector. Moreover, research on the Internet provided another range of synonyms which had to be verified as well. The table below (table 3) shows the results on Google Scholar (language set to English) and BioMedSearch. If these synonyms were used, they were often used between brackets after the term peste des petits ruminants. While searching for peste-des-petits-ruminants on the Internet, I noticed that most of the texts referred to the concept without hyphens. In the first 100 results in Google Scholar (language set to English) 91 contained the term without hyphens. A Dutch equivalent could not be found in Reuter or in Dutch monolingual dictionaries, which means that I had to resort to the Internet. A first established fact about the disease is that it is hosted by sheep and goats. Some terms that regularly occurred in these hits were pest van (de)/bij kleine herkauwers, kleine herkauwerspest and ziekte van kleine herkauwers. To verify whether these terms are used in scientific texts I used Google and Google Scholar (see table 4). Google Google Scholar Pest van (de) kleine herkauwers 42 (29) 0 (0) Pest bij kleine herkauwers 38 2 Kleine herkauwerspest 38 0 3 Peste des petits ruminants 27 8 (minus one French source) Ziekte van kleine herkauwers 10 0 Table 4: possible translations for peste des petits ruminants Table 4 shows that ziekte van kleine herkauwers is not a good option, as it barely occurs in Internet sources. The rest of the possibilities had some more hits, but choosing the best translation option remained difficult. On the one hand, pest van kleine herkauwers had the highest number of hits on Google, but peste des petits ruminants occurred more frequently on Google Scholar. On the other hand, peste des petits ruminants frequently occurred in Google in combination with virus or in combination with pest van/bij kleine herkauwers, but then between brackets as an extra synonym. This could imply that peste des petits ruminants is less known in Dutch than pest van/bij kleine herkauwers. Moreover, as mentioned before, the term does not occur in any of the Dutch dictionaries consulted. Thus, I opted to include peste des petits ruminants as an extra synonym and not as a full synonym. Between pest bij kleine herkauwers, pest van kleine herkauwers and kleine herkauwerspest there is little difference on Google. However, as these last two do not occur in Google Scholar and as the first one is used in legal texts as well, I chose pest bij kleine herkauwers as the Dutch translation. The webpage of the College of Veterinary Medicine, for example, discusses pneumonic pasteurellosis in cattle, sheep, swine and rabbits. It was hard to find a translation, as I found many options, none of which covering the entire concept. Reuter 534 and 507 offered the parts of the compound separately, which gave some indication in which direction I had to look. However, when I researched septicemie in Pinkhof I discarded this as it clearly had a different meaning than the term I was researching. On GenTerm I found a record on shipping fever (with the same term as Dutch translation) in which pneumonic pasteurellosis was entered as an extra synonym. However, according to McGraw-Hill Concise Encyclopedia of Bioscience 2016-07-03, shipping fever is the form that occurs in cattle, as enzootic pneumonia occurs in swine. As I could not find a Dutch equivalent for the full term, I resorted to the dictionaries again to find information about the main term pasteurellosis. Elseviers Medische Encyclopedie 331, Winkler Prins 336 and Coelho 668 provided the terms pasteurellosis and pasteurellose. As I did not have a specific term to research, I tried several terms which I thought could be a possible translation: longpasteurellose, pulmonale or pneumonische pasteurellose, etc. I also tried more general search queries, such as pasteurellose+longen and Mannheimia Haemolytica, which led me to luchtweginfectie met Pasteurella-bacterien.

Pakistani) and special population groups (such as drug and alcohol mis-users) are more difficult to reach and therefore to diagnose (1 erectile dysfunction see urologist generic 160 mg malegra fxt plus amex, 2 erectile dysfunction urethral inserts cheapest malegra fxt plus, 5) erectile dysfunction pink guy generic malegra fxt plus 160 mg overnight delivery, and there are some outreach services for such groups (4) erectile dysfunction causes mnemonic malegra fxt plus 160mg cheap. The process of detection and treatment has improved over time for both the general population and high risk groups erectile dysfunction age 27 buy malegra fxt plus 160 mg mastercard, and one interviewee noted that this was the case especially regarding adherence to guidelines (2) doctor who cures erectile dysfunction 160 mg malegra fxt plus with amex. In part, improvements in England were attributed to a big push and campaigns to change physician attitudes and peer to peer education for patients about diagnosis and treatment (2). Although better diagnosis would, at a system level, improve the likelihood of treatment being administered when needed, some interviewees said that improved diagnosis would not necessarily improve health outcomes for patients dramatically until new treatments were available (3), that side-effects would still be a barrier in this regard, and that there would be new demands on financial resources and the healthcare workforce. I think that would give them a huge headache if we were that successful that quickly and. One interviewee felt that policymakers tended to underestimate the impact of the pathology, which is considered a chronic disease among others (10). There is still a stigma towards people affected and advocacy is still limited (10). Evidence on how this might influence equitable access to therapy is inconclusive, however. According to one interviewee, less urgent therapies are sometimes postponed because of financial challenges and staffing constraints (8), while another said that the funding model had no impact on access to therapy (7). Treatment is offered at a public sector level and usually guarantees universal coverage (17). Similar to other countries, the arrival of new and more expensive treatment (triple therapy) is seen as problematic, especially because currently the criterion of cost is already prevailing in all decisions (17). According to one interviewee, intense awareness raising and advocacy campaigns influenced the development of an action plan in Scotland in 2006, supported by fi43 million investment (4). For example, one interviewee commented that although there is a lack of ring-fenced funding, the budget is overall appropriate for needs, although additional support for the funding of first generation protease inhibitor treatments would be beneficial (1). According to interviewees, adherence to formal hospital procedures is followed widely. Spain Most Spanish interviewees stated that adherence to national guidelines is good. However, one interviewee noted that these 22 They are very similar to French Consensus Conference 2002 guidelines, but more up to date. The same interviewee also regretted that guidelines tend to recommend delay in the treatment (to not treat people who are at the early stage of the disease). Another interviewee stated that good guidelines existed, but they are not always followed because of economic constraints (20). United Kingdom Evidence on adherence to guidelines is ambiguous, but there was general agreement that adherence to guidelines has improved over time. Moreover, some interviewees felt that adherence to guidelines for treatment initiation decisions were variable across the country. The main identified challenges to guideline adherence were: patient adherence (especially in the case of difficult side-effects) (1); lack of physician experience in prescribing, associated with how many patients and what types of patients they see (1, 2, 5); challenging administration (injection, cold storage) influencing, in particular, the drugusing population (1); clinician perceptions about likelihood of successful treatment in special population groups; and financial resource constraints (5). Overall, guidelines on adjusting dosage or terminating treatment tend to be more standardised across patient profiles (and better adhered to) than guidelines about decisions to initiate treatment, which is not surprising given the higher complexity of the initiation decision. Guidelines are clearer for new direct-acting antivirals (interferon and ribavirin) than previous treatment approaches, but there is scope for improvement in areas such as dealing with special population groups. National comparative standards are needed and there is a hope that there will be improvement in this regard within a year or two of using new agents (1). As for clinical factors, it was observed that platelet counts of patients on and off treatment were monitored in all countries, but the evidence for thresholds on when to start, stop or adjust treatment was relatively inconclusive in the real world. In France and Spain, it was noted that it was rare that haematological factors would induce treatment cessation, but rather adjustments in treatment. All interviewees noted that there were trade-offs when it came to consideration of side-effects. In France and Spain, it was noted that only severe sideeffects would lead to treatment cessation, but in all countries side-effects were a major part of the consideration of whether to initiate, adjust or terminate treatment. Demographic and behavioural factors played a big part in treatment decisionmaking, mainly in treatment initiation, across all four countries. Demographic factors such as age also featured in decisionmaking, although clarity on thresholds was not found, and the consideration of age tends to be in conjunction with other factors. Interviewees from France and Spain also mentioned socioeconomic status as a factor in decisionmaking, considering the available support structure and awareness and education of patients. In most countries, diagnosis is undertaken at primary care, or incidentally, and then the patient is referred to specialist care. All of the countries noted that with changing treatments, care requirements would also change. Under-diagnosis is still a major problem in all of the countries, although diagnosis levels are increasing in some of them. Most interviewees felt that with an increase in diagnosis would come a constraint on available resources, particularly exacerbated by the arrival of new, more expensive, treatments. There appeared again to be variation in government support and funding across and within countries. There was ambiguous information about adherence to national and European guidelines on treatment initiation, adjustment and termination, with particular concerns raised about adherence once the new therapies become available. The typical point of entry in each system tends to be primary care, frequently also the location for initial diagnosis. Full diagnosis and confirmation of diagnosis, as well as treatment, is typically provided in secondary care units in hospital or by specialists outside hospital. Confirmation of the diagnosis and subsequent treatment is by referral to hospital specialist departments. However the patient journey is likely to change, with the emergence of outpatient specialist services and the role that outpatient specialist physicians (hepatologists) are expected to play in prescribing and delivering the new drugs. There are concerns about the differences in standards of care Refer to hospital for full diagnosis and and treatment across regions. In other countries, prisoners seem to be treated in a parallel system (under the authority of the Ministry of Justice in Spain and France). Confirmation of diagnosis and decision to initiate (and maintain) treatment occur in specialist care. This is because of the slow progression and asymptomatic character of the infection, so that many people are unaware of having it. The proportion of those unaware of their infection varies among countries, impacted largely by whether countries pursue an active screening policy. As a consequence, the infection is often diagnosed at a late stage when the probability of a successful outcome is reduced. However, even once people carrying the infection have entered the formal healthcare system, barriers to effective treatment persist. Initial diagnosis, primary care level: There is a notion that lack of awareness among primary care practitioners may impede the effectiveness of early diagnosis and, as a consequence, timely referral to the next care level might be delayed or not take place altogether. It is common that only a small proportion of those found to be eligible for treatment adhere to the regime and return for regular visits. Estimates for England suggest that the proportion of those who are referred is appropriately 70% of cases with the majority of those attending the clinic (70% of those referred) being indicated for treatment; furthermore 70% of these accept treatment; cumulatively just over 30% of those diagnosed actually receive treatment (Ramsay et al. The reasons for withdrawal from treatment are complex, involving a combination of patient-related factors. We lack evidence to identify specific issues at this level, as those patients constitute only a minority of the cases and interviewees did not highlight barriers to treatment specific to this level. It is worth noting that the new drug developments and more systematic adoption of triple therapy are likely to increase the role of highly specialised care units. This is because a proportion of specialist care providers are unable to deliver new treatments in the first instance because of lack of expertise. However, as treatments become routinised it may be possible that they will be progressively delivered in less specialised centres. However, there was no clear consensus among interviewees about the quality of the relationships between care providers. Depending on the system context, some felt that currently competition between providers might hinder better coordination as well as the way that systems are organised and financed, while others felt that teamwork was working well. There was also a notion that shortages of selected staff such as specialised nurses might impact on coordination as well as timely clinics and follow-up. The indicative observations from key informant interviews resonate with the work by Irving et al. This loss to follow-up was explained, largely, by delays in communicating test results, referral issues, and poor coordination between healthcare providers, among other reasons (Figure 5. The patient journey seems to follow a standardised, while not official, care pathway: the patient enters the healthcare system through primary care or an addiction centre, and is then referred to specialist care for further diagnosis. Thereafter, they are either in outpatient specialist care or hospital specialised units, depending on the healthcare system, the stage of the disease and their 26 Note: 51% of the infected patients were not referred for reasons including: test results not received or lost; patient refused referral or did not show up to appointment; physician considered the patient not suited for treatment; and patient died. The requirements of the discrete choice experiment design and cognitive limits of the respondents placed a restriction on the number of attributes that could viably be included in the experiments, as we were seeking to achieve a balance between the statistical power of the experiment and variety of attributes that would take into account a maximum of parameters. Each attribute was then described by a number of levels, which were also varied in the experiment (from two to six levels per attribute). For instance, F0 (the initial stage of liver fibrosis) is a factor in physician decisionmaking, and virtually all physicians will not treat someone at this stage, but instead delay treatment. Therefore this was not included as an attribute level in the experiment as it would perfectly explain choices and add little value; instead the levels started with F2, when the decision to treat or to delay treatment is not so obvious and was believed to vary between physicians. Some restrictions were placed on this design to prevent infeasible combinations within the levels of fibrosis and anaemia, and levels of fibrosis and platelet count. This introduced a low, but realistic, level of correlation between these attributes within the experimental design. Each physician was asked to consider nine such vignettes and indicate for the patient in question whether they would decide to commence treatment or not. No, I would not recommend this patient to initiate treatment the second experiment considered the decision to continue or change treatment as time progresses. For this, we took forward up to three of the patient profiles which the physician had indicated he or she would decide to treat in the first experiment. This ensured that the patients then being considered in this decision were patients who the respondent would have been prepared to treat in the first place. In this second experiment the status of the patient was presented a number of weeks later along with updated clinical data and information on behaviour and adherence. The physician was then asked whether he or she would continue, modify or stop the treatment considering the evolution of the disease, comorbidities, haematological test results, and the general response and attitude to treatment. For each hypothetical patient taken forward from the first experiment the physician was asked to consider a sequence of three different ways that their condition may have developed before then moving on to another of the patients who the respondent had indicated he or she would treat. In total the physician was asked to consider up to nine different vignettes within this second experiment (three hypothetical patients with three different developments of their conditions). It is important to note that the treatment regimen under consideration was pegylated interferon alfa and ribavirin, not triple therapy with protease inhibitors. They include questions about collaboration between clinicians from different specialties, the quality and timeliness of referral, the role of nurses, and so on. This information was then considered in developing the models of decisionmaking behaviour to see whether they influenced the decisions being made. The exact wording used for the background questions can be found in Appendix E (Table E. These were translated so that the survey was available in English, French, Italian and Spanish. The surveys were piloted with 13 physicians drawn from across the four target countries to test the process of interviewing, wording of the questions, and viability of the choice experiments prior to rolling out the main survey.

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