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However blood pressure medication beginning with a cheap 80 mg exforge otc, the low prevalence of family history of Down’s syndrome amongst study participants makes this result unstable hypertension questionnaire order exforge 80mg on line. The putative association between Alzheimer’s disease and Down’s syndrome has been reported in a number of studies heart attack craig yopp discount 80 mg exforge otc. As such blood pressure video buy exforge 80mg with amex, this result should be considered tentative, requiring further confirmation. Given the complexity of the disorder, it is perhaps unsurprising that its aetiology also appears to be complex and multifactorial in nature. Possible reasons for the heterogeneity in results between previous studies include geographical variation in exposures and methodological differences between studies. The quality of the previous case-control studies has been highly variable and many have been limited by inappropriate participant selection and recruitment methods. The current study also considered many more exposures than the previous Australian studies, thereby providing data on exposures. The relative consistency in results between different studies for these factors may be due to them being easy to measure and qualitatively consistent across different geographic areas. However, when men and women were considered separately, an inverse relationship was seen in men, but not in women. The sex-specific relationships observed in the current study were also observed by Hernan et al. Among the environmental exposures previously examined, the most inconsistent results have been reported for rural residency. The nature of this exposure is likely to be highly heterogeneous both between countries and within countries, which may explain the inconsistency between studies. The different definitions of rural residency that have been used between studies are also likely to be substantial contributors to the lack of consensus. Furthermore, studies that rely on the participants to classify their previous residences as ‘rural’ themselves may be subject to substantial exposure misclassification. In the current research, when participants were asked to classify 31 each previous residence according to whether it was ‘rural’ or ‘remote’, only poor to moderate test-retest repeatability was achieved (kappa 0. Therefore to explore this association further, it may be more appropriate to examine particular aspects of rural living separately. These positive relationships may have been chance findings or may reflect a difference in the composition of groundwater in these countries compared to Australia. This result is similar to other case-control studies that assessed exposure to metals solely via self-report (Semchuk et al. Similar to the current study, most of those that examined these exposures have reported positive associations for some, but not all types of solvent exposures (Seidler et al. The first of these was conducted by McCann et al (1998) and the second, which has not been published previously, was described and analysed in Chapter 3 of this thesis. Both these existing studies had a number of potential limitations, discussed previously, which may affect the validity of their results. A number of differences in study design and methodology were employed in the current study compared to these previous studies, to overcome these potential limitations. The current study recruited cases from a defined population (one neurology clinic) rather than from multiple sources of unknown size and attributes. A community-based control group was obtained by random sampling of persons from the Commonwealth Electoral Roll, and individually matched to the cases on age, sex and residential suburb. Thus, the problems inherent to clinic-based controls and family/friend controls were minimised. There are a number of reasons why these potential sources of controls can be unsuitable for case-control studies. The assumption that controls drawn from the same clinic as the cases are also originally from the same source population as the cases is not always valid as it does not take into account the referral patterns that exist for different diseases. The lower participation rates that can be expected 217 amongst control participants that are also suffering from a medical condition can reduce the representativeness of the control sample. Furthermore, if there is any connection between the medical conditions of controls and the exposures of interest, the results will be biased towards the null or possibly inverted if the relationship between the control ‘disease’ and the exposure is stronger than the relationship between the condition of interest and the exposure (Rothman and Greenland 1998a). Family members can also be inappropriate controls as they are often overmatched on environmental exposures due to shared residential history, and can be mismatched on sex, in the case of spouse controls. Similarly, friends can often be overmatched on environmental exposures as they share common interests, work histories or lifestyle habits (Kaplan 1998). Cases are also more likely to suggest friends that are ‘outgoing’ or extroverted than reclusive friends. Friendship groups are also not simple collectives in which all friends have an equal chance of being selected. Individuals with many friends have a greater likelihood of being chosen and therefore their exposures may become over-represented in the control series. For these reasons, family and friend controls are generally not recommended for case-control studies (Flanders and Austin 1986; Austin et al. The previous Australian case-control studies did not employ formal selection and recruitment procedures. This may have led to inconsistency in how the potential participants were approached and the possibility that certain types of participants were over-represented. In the current study, a standardised protocol was employed and the number of approaches to potential cases and controls were recorded. This allowed response and participation rates to be examined with quantification of potential selection bias, unlike the previous Australian studies that did not collect such data. The recruitment of cases from a private neurology clinic for the current study is a potential limitation. The closer a study population represents the population to whom the results will be extrapolated (the ‘target’ population), the more valid the results (Tanner and Ross 2004). Secondly, less affluent cases are likely to be under-represented at a private clinic. However, the results obtained from a clinic-based case series would only be nongeneralisable to the general population if there were aetiologically-relevant differences between cases who attend the clinic and cases who do not. Representativeness of Sample Unfortunately, no information was available on the prevalence of exposures in the case non-participants and most of the control non-participants. Limited information from a phone interview was available for approximately 30% of potential controls who did not participate in the case-control study. The percentage of these potential controls who reported exposure to several variables (smoking, working with metal fumes and working with solvents) was similar to the participating controls. However, there were some dissimilarities concerning pesticide use and living or working on a farm. Use of home pesticides was lower amongst these non-participants than the participants (50% versus 75%), however the use of herbicides and insecticides at work was higher (16% versus 9% and 35% versus 14%, respectively). Ever having lived or worked on a farm was also more common amongst these non-participants, than participants (54% versus 33%; 58% versus 39%). The differences in prevalence of use of home gardening pesticides and ever having lived or worked on a farm may have changed the direction of the associations. Exposure Measurement An important feature of the current study was the inclusion of a test-retest repeatability study of the exposure measurement instrument prior to its use for data collection. High test-retest repeatability was observed for the majority of general exposures examined, particularly lifestyle behaviours such as smoking and coffee and tea consumption. Both of these studies had small samples sizes (seven and twenty participants, respectively) and short follow up times (two and four weeks, respectively). While the exposure measurement instrument used in the current study generally exhibited good test-retest repeatability in the sample, the reliance on self-report data for exposure measurement remains a major limitation of the current study. Many participants in the current study who indicated they had been exposed to metals or chemical agents (including pesticides) could not recall the names of specific metals or chemical agents to which they were exposed. Sample Size the majority of this study’s results lacked statistical significance as the study was under-powered to examine most of the exposures considered. However, a larger sample size was not possible due to the substantial time and budget constraints. No external funding was available for employment of additional interviewers to collect data from more participants and the time restrictions of the PhD program restricted the number of participants that could be interviewed by the candidate. This added to the time required for data collection as in addition to collecting the specimens, they also needed to be transported to the laboratory for storage. A clear relationship may have been difficult to observe for these exposures as subsets of highly exposed individuals may have been hidden within the broad definitions of exposure utilised in this study.

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Anakinra was other features observed include respiratory distress blood pressure medication extreme tiredness effective 80mg exforge, aphthous ulreported to fetal arrhythmia 38 weeks quality 80 mg exforge be effective in 1 patient arrhythmia breathing purchase exforge 80 mg on line, although this was not 664 prehypertension warsaw 2014 generic exforge 80 mg with amex,665 cers, hepatomegaly, and failure to thrive. Synovial aspirates from joint effuin patients with this disorder, from several weeks of life to young sions are sterile, with a predominance of neutrophils (>100,000/ 3 adulthood. Muscle pain in the lower extremities after exercise is a by high-grade fevers and erythematous skin eruption, which common finding. Infectious and environmental susceptibility factors, such as the specific 666,667 triggers are associated with disease fiares. It was not reported whether these values normalize mation of the underlying fascia, arthralgia, and/or periorbital 646,648,668,669 between episodes. Febrile fiares are longer lasting than in pa666,667 patients exhibited laboratory evidence of autoimmunity. Retinoids should be the mainstay of exercise, trauma, and hormonal changes are reported triggers. Colchicine can considered a recessive disorder, a substantial percentage of paalso cause lactose intolerance. Mediterranean and For infrequent attacks, short courses of prednisone at the time Middle Eastern populations have a higher carrier frequency of of a fiare might be effective. For more severe disease, etanercept different mutations, suggesting a heterozygous advantage for reduces symptoms of infiammation in a dose-dependent manner, 670 pathogens endemic to this region. Beneficial ef651-653,679 and episodic, lasting 1 to 3 days and manifesting with infiammafects of anakinra have been noted. The mechanism that invokes an attack is not be suspected in patients presenting with fevers with lymphadewell understood, although reported triggers include stress and nopathy, abdominal pain, diarrhea, vomiting, arthralgia, rash, menstruation. Abdominal symptoms include distention, rigidity, aphthous ulcers, and splenomegaly. At an early age, patients present the arthritis can respond to corticosteroid therapy; however, with recurrent fever spikes lasting 4 to 6 days accompanied by the associated adverse effects often limit their use. Consistent lymphadenopathy, abdominal pain, diarrhea, vomiting, arthralgia, with the evidence for increased infiammatory mediators, there are 684 rash, aphthous ulcers, and splenomegaly. The periorbital edema; hepatomegaly; lymphadenopathy; and failure clinical relevance and predictivevalue of IgD has been questioned to thrive. Increased levels of mevalonic acid can be deNishimura syndrome, Japanese autoinfiammatory syndrome 681-683 695 tected in urine during attacks. Clinical criteria to warrant genetic tests include earlydominant gain-of-function mutations in heterozygous pa700,701 onset disease, lymphadenopathy, skin rash, transient joint pain, tients. Most reports indicate a significant beneficial efhave shown variable responses based on small sample sizes. Pyogenic arthritis, pyoderma gangrekinase inhibitors might be a promising therapeutic modality. Cherubism can be mistaken for affecting metaphyses of the long bones can be seen on plain Noonan syndrome when the clinical findings are limited to sym709,710 radiographs. Many patients will have 714 hypertrichosis, hepatosplenomegaly, heart anomalies, early impaired neutrophil chemotaxis in vitro. Familial cases have 711-713 sensorineural hearing loss, hypogonadism, short stature, hallux also been affected with bullous skin lesions. It can present chronic fevers with vasculopathy (some consistent with polywith recurrent febrile episodes with systemic autoinfiammaarteritis nodosa) have been found to have recessive mutations in 707 715-717 tion. Additional features of these patients include tance, and prenatal molecular diagnosis can be performed on myalgia/arthralgia, livedo rash, cerebral, cardiac, and visceral anchorionic villi and amniotic cells. Biopsy specimens show portive, but early diagnosis of sensorineural hearing loss and diamediumand small-vessel leukocytoclastic vasculitis. Management of cine response, and diffuse lymphadenopathy and 716 moderate-to-severe psoriasis includes systemic immunosuppreshepatosplenomegaly. Fibro-osseous masses displace the ocular globe and result in the Summary statement 226. A relatively benign, self-limiting, and sporadic deficiencies or defects of phagocyte function. Febrile fiares last an absence of factor I, the alternative pathway is continually actiaverage of 5 days and occur with precise periodicity approxivated. Plasma C3 levels are depleted, leading to a similar propen737,742 mately every 28 days. Clinical manifestations are characterized sity toward bacterial (mainly respiratory tract) infection. Some of these might be at increased risk of infection, of symptoms is highly effective in aborting febrile episodes, particularly as infants. Additional doses of prednisone tory of recurrent bacterial respiratory tract infections. Cimetidine (20-40 mg/kg/ sociation was strongest in a subgroup with a variety of d) in divided doses has been reported to prevent recurrence. Prognosis is good, with a strong trend toward resolution of Ficolin 3 is another member of the collectin family having 720-722 symptoms on the average of 5 years after onset. Defects of ficolin 3 have Complement deficiencies been associated with bacterial respiratory tract infections and Many of the specific complement protein deficiencies have necrotizing enterocolitis in infants. Susceptibility to autoimmunity in pathe genes for all complement proteins (except properdin) are tients with these deficiencies does not appear to be as great as 729,731 autosomal. Carnevale-Mingarelli-Malpuech-Michels syndrome (facial dysHereditary angioedema is due to defects in the plasma protein morphism, growth deficiency, cognitive impairment, hearing C1 esterase inhibitor. This protein regulates the complement, loss, craniosynostosis, radioulnar synostosis, and eye and ear abkinin-generating, clotting, and fibrinolytic mediator pathways. Patients with recurrent bacterial sithat are mutated in patients with Carnevale-Mingarelli744 nopulmonary infections with or without autoimmune disease Malpuech-Michels syndrome. Partial deficiencies these cases C3 convertase might not be formed, and the down745 of C2 and C4 are the most common in this category and are found stream complement cascade is inhibited. Patients with susceptibility to neissewith C2 deficiency present with recurrent bacterial respiratory rial infections should be suspected of having a terminal pathway tract infections resembling those of patients with antibody deficomplement deficiency. This has also been described in association with defiby using the classical pathway complement hemolysis 50% 731 ciency of the alternative pathway component properdin. Defects in the complement lysis of antibody-sensitized sheep erythrocytes by fresh serum. This test is relatively insensitive compared factor H, a C3 regulatory protein, is inherited as an autosomal with functional tests of single complement proteins. If the be associated with macular degeneration in the elderly, a disease titer is less than normal but not 0, often this implies that the level 753 in which complement is known to be deposited in the retina. Patients with Shiga toxin–negative plies that a complement pathway has been activated. Factor H acts as a complement regulator, and circulating Liposomes are lysed by complement-fixing anti-dinitrophenyl autoantibodies to factor H can results in autoimmune atypical antibody and serum. Diagnosis of these autoantibodies is important because phosphate and nicotinamide adenine dinucleotide in solution, and 754 patients will respond to plasma exchange treatment. In a solidcomponents are unstable and tend to degrade with time, especially if blood or plasma phase method plates are coated with mannan and incubated with is warmed. If complement consumption is possible or suspected, while C1q binding is inhibited. A convenient way available in most to soluble C4a and C4b, which adheres to the plate. The amount of hospital laboratories to test for consumption is to measure levels of factor B and C4, refiecting activation of the alternative or classical pathway, respectively. Note that deficiency of factor H, factor I, or should be the major modes of treatment for complement defiproperdin could lead to a diminished level of C3 and other components. In the presence of an appropriate clinical history, low C4 levels in the presence of normal C3 levels might Patients with complement deficiencies require immunization suggest hereditary angioedema, and the levels and function of C1 inhibitor should be with relevant vaccines (S pneumoniae, H infiuenzae, and N menexplored. Chronic antibiotic therapy might be required in 729,752 patients with frequent infections but is usually not needed. Autoimmune diseases associated must be distinguished from complement consumption, as can occur with complement deficiency are treated as they would be in other during infection or autoimmune disease (see below). There is no available gene therapy at the present time, usually results from complement component use caused by and in most situations, supplying the missing complement protein 734,752,762 activation, as can occur in autoimmune disease or during infection. Antibody formation ative should be studied for associated anti-cytokine during acute infection can create immune complexes, which can autoantibodies.

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Additionally arteriosclerosis obliterans generic 80 mg exforge overnight delivery, gender blood pressure chart poster buy exforge 80 mg with visa, inently in their article blood pressure levels.xls exforge 80mg discount, Leventhal and colleagues (2015) race/ethnicity (Hispanic White prehypertension table buy 80mg exforge with amex, non-Hispanic White, showed a bidirectional relationship between e-cigarette other), grade (11th or 12th), and ever use of hookahs were use and other combustible tobacco product use in their tested as potential effect modifers of these associations, study: Use of other combustible tobacco products at but no evidence was found for the same. This hypothesis was not 1,332 Hispanic young adults in California who provided tested by Barrington-Trimis and colleagues (2016), Wills survey data in 2014 and 2015. Covariates in these regression models of e-cigarette use and other risk behaviors in adolesincluded age, gender, past month use of alcohol, and past cents and young adults. This is consistent with including their longitudinal nature, they had weaknesses the common liability model for substance use and other as well. Because nearly all by Leventhal and colleagues (2015) could not distincurrently available studies on this topic focus on regional, guish between those who merely began experimenting international, and at-risk samples, the conclusions from with a combustible product and those who became regmost studies cannot be generalized to the U. Youth and Young Adults 57 A Report of the Surgeon General that period (Cohn et al. Elsewhere, in a nonprobE-Cigarettes and Marijuana ability sample of college students 17–25 years of age, Because of their design, e-cigarettes may facilitate 66% of current e-cigarette users and 67% of current dual drug use among youth and young adults, as these produsers were heavy drinkers, defned as consuming at least ucts can be used as a delivery system for cannabinoids once, fve or more drinks (men) or four or more drinks and other illicit drugs (Giroud et al. While the frst generation of cannabis aerosolizers e-cigarette use was associated with greater use of mariwas developed to aerosolize dry cannabis, the widespread juana during the previous 30 days (Lessard et al. Elsewhere, the actual prevalence of users of marijuana aeroin a sample of young adults (18–23 years of age) at colsolizers and their experiences remain unclear and underleges and universities that was taken in 2013 in upstate studied (Van Dam and Earleywine 2010; Malouff et al. For example, when considering the associations derived from these observational studies, the order of iniUse of Flavored E-Cigarettes tiation of the products of interest cannot be inferred. Some studies acterizing “favors” are prohibited in cigarettes (with the adjusted for risk taking, sensation seeking, and impulexception of menthol and tobacco) by the Family Smoking sivity, while others did not. Therefore, further Data on the use of favored e-cigarettes among research on nicotine content using objective measures youth and young adults is presented in Table 2. In another study, which examined nonsmoking of favored e-cigarettes did not differ by gender and was middle and high school students and college-aged adults lowest among Blacks (Table 2. Those who did not select e-cigarettes were categorized as “no” for favored e-cigarettes. Excludes 82 current e-cigarette users whose answers were missing for all favored tobacco response options. Excludes fve every-day or some-day users who reported not using any noncigarette tobacco product in the past 30 days. Youth and Young Adults 63 A Report of the Surgeon General (Continued from last paragraph on page 59. In addition, sushigher levels of experimentation and current tobacco ceptibility to cigarette smoking among never smokers was use (Primack et al. Monitoring both absolute perassociated with perceptions of low harm for e-cigarettes ceived harm and perceived harm relative to conventional (Ambrose et al. Future tory of e-cigarette use, important differences become studies will beneft from examining the effect of harm perclear. A large survey were more likely to believe that e-cigarettes were more (n = 4,444) of college students in North Carolina conducted harmful than regular cigarettes (Amrock et al. The in 2009 found that, as with adolescents, perceived harm perceived harm of e-cigarettes decreased with increasing of e-cigarettes, compared with conventional cigarettes, levels of cigarette smoking, such that in 2012, 25% of adowas lower among college students who had ever used lescent never smokers, 41. There were 132 middle students excluded due to missing responses for e-cigarette use. This is further reinforced edge about the perceived harm of e-cigarettes relative to by a study of young adults from Switzerland, which found conventional cigarettes was associated with lower odds of that after 15 months of follow-up, e-cigarette use was not using e-cigarettes (Sutfn et al. However, in an article published reasons youth and young adults reported trying or using by this group (Bold et al. Electronic cigarettes may not be as bad as • Probability sampling methods (randomcigarettes for your health digit dialing) 2. Easier to cut down on the number of • Years sample drawn: 2010–2011 (Wave cigarettes you smoke 8), 2008–2009 (Wave 7; where available) 3. Can smoke in places where smoking • Youth: n/a conventional cigarettes is prohibited • Young adults: current smokers, 4. E-cigarettes can help people quit smoking associated with the following characteristics: (2013) • Interview 2. E-cigarettes are safer to use than tobacco age for perceived safety of e-cigarettes compared with • Random-digit-dial sampling cigarettes (n = 317) participants fi45 years of age • Years sample drawn: 2011–2012 2. I think e-cigarettes are safer in terms of (2013) students in a 100-level course “secondhand” smoke compared to tobacco • Year sample drawn: 2011 cigarettes • Youth: n/a 2. I think e-cigarettes are not as harmful to • Young adults: freshmen and sophomores users as tobacco cigarettes in a 100-level mass media in society • Indicate your level of agreement with course; n = 244 compatibility: 1. I believe using e-cigarettes would ft in well with the lifestyle of most smokers • Indicate your level of agreement with complexity: 1. Overall, e-cigarettes are no more complicated to use than ordinary tobacco cigarettes • Indicate your level of agreement with “trialability”: 1. Smokers could easily give e-cigarettes a try to see if they like them better than tobacco Zhu et al. For times when you don’t want to smoke – For the times when they don’t want to smoke around • Youth: Canadian youth recruited around others others (78. To help you cut back on the amount you – To help them while they are trying to quit smoking n = 1,188 smoke (80. To help you while you are trying to quit – As a cheaper alternative to cigarettes (80. Electronic cigarettes are for people who age for agreeing that “electronic cigarettes are for people • Recruitment by telephone-based want to stop smoking completely who want to stop smoking completely,” compared with omnibus survey and quitline client 2. To reduce cigarette consumption • Among those 18–34 years of age, approximately • Youth: n/a 3. To try something new (curiosity) 70% reported trying e-cigarettes to try something • Young adults: noninstitutionalized 4. To not disturb other people with smoke new (curiosity) adults in Montana; n = 5,000 5. Other Tucker et • Cross-sectional • 18-item measure of reasons for using • Most common reasons for use included: al. Youth and Young Adults 85 A Report of the Surgeon General (Continued from last paragraph on page 75. The increases among adults onset of other tobacco product and marijuana use among 25 years of age and older, by comparison, have been less youth and young adults (Leventhal et al. No differthat e-cigarettes convey “no harm” compared to never ences between boys and girls were observed among middle e-cigarette users, for both age groups (Tables 2. Additional research is needed to examine how reasons e-cigarette-related knowledge, attitudes, and beliefs is for use, including the appeal of favored e-cigarettes, are still developing and remains relatively sparse. Although relaalent among youth and young adults who currently use tive harm compared with cigarettes is important to assess, e-cigarettes. Among middle and high school students, both ever combustible tobacco products were also current and past-30-day e-cigarette use have more than triusers of e-cigarettes. Among youth—older students, Hispanics, and 2013 to 2014 following a period of relative stability Whites are more likely to use e-cigarettes than from 2011 to 2013. The most recent data available show that the prevalower levels of education are more likely to use lence of past-30-day use of e-cigarettes is similar e-cigarettes than females, Blacks, and those with among high school students (16% in 2015, 13. Flavored e-cigarette use among young adult current in 2013–2014 among young adults 18–24 years of users (18–24 years of age) exceeds that of older adult age—exclusive, past-30-day use of conventional cigcurrent users (25 years of age and older). For both age groups, dual use of majority used a favored product the frst time they these products is common. Adolescents’ the Journal of the American Medical Association and young adults’ perceptions of electronic cigarettes 2015;314(17):1871–3. International Journal of Public product use among adults—United States, Health 2016;61(2):225–36. Characteristics associated with awarenicotine delivery systems, smoking and cessation. Nicotine & Tobacco alcohol, marijuana use, and new and emerging tobacco Research 2015;17(10):1279–83. Addictive Giroud C, de Cesare M, Berthet A, Varlet V, Concha-Lozano Behaviors 2015;48:79–88.

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Like the arguments that swirl around this subject and its rising death rate hypertension 37 weeks pregnant generic 80 mg exforge otc, this chapter returns once more to blood pressure medication and zoloft cheap exforge 80 mg fast delivery the underlying medical science digital blood pressure monitor cheap exforge 80mg mastercard. Work pioneered by Stanley Prusiner (10 blood pressure index chart buy 80 mg exforge overnight delivery,11,52) supports the assertion that a modified host protein—the prion—not a virus causes the mad cow-like diseases. Experiments by Prusiner, Bruce Chesebro, Charles Weissmann (reviewed 11) and others have shown that, in the healthy brain, the prion protein exists in a form that is easily fragmented by certain proteolytic enzymes. In contrast, during the spongiform encephalitic disease state, the prion protein resists degradation by enzymes. This prion protein, which assumes an abnormally folded architecture, is associated with lesions in the brain and disease. Consequently, many if not most researchers working on this problem believe that conversion from the susceptible form (digested by enzyme) to the resistant form (resists digestion) of the protein is responsible for the disease. The Prusiner camp believes transmissible spongiform encephalopathies stem from a misfolded protein, an agent that lacks information programmed by nucleic acids (as required for all viruses and other microbes) but is presumably programmed by a protein structure. However, some medical scientists do not wholly accept the prion-only hypothesis as a possible cause of spongiform encephalopathies. For example, Chesebro is not totally convinced that a small virus or informational nucleic acid is excluded as the transmissible agent. The defining experiment requires synthesis in vitro (test tube) of the abnormally folded disease-producing protein, PrP scrapie, and proof that it can, by itself, transmit infection in a healthy animal. Until they do, the controversy will rage among scientists engaged in one of the most interesting subjects in contemporary biology and biomedical research. Russia’s withdrawal from the war enabled Germany to move more than one million experienced men and 3,000 guns to the Western Front, giving Germany vast numerical superiority there. This move gave the Germans thirty-seven infantry divisions in France and almost thirty more in reserve, their greatest assault force to date. In several sectors, it outnumbered those of the British and French by a ratio of four to one. The French were desperate, and the allied British army had sustained serious losses at the battle of Passchendaele in Belgium. With her enemies so depleted, Germany’s main hope of success depended on an early attack, before additional American forces could arrive. At first, the Germans made substantial progress, gaining over 1,250 square miles of French soil within four months. By May, the German army reached the Marne River, and its heavy artillery was within range of Paris. Everything seemed to be in Germany’s favor, yet the very speed of her advance coupled with an outbreak of infiuenza virus infection 305 306 Viruses, Plagues, and History brought her armies to near exhaustion. In late June, Eric von Ludendorff, the German commander, noted that over 2,000 men in each division were suffering from infiuenza, that the supply system was breaking down, and that the troops were underfed (2). Infection spread rapidly, and by late July Ludendorff blamed infiuenza for halting the German drive (1,2). Americans continued entering France in numbers that replaced the great losses of the British and French. Foch and General Henri Philippe Petain then led a grand offensive that aggressively blocked the German advance and regained French ground. Even though the casualties, both military and civilian, were massive during World War I, deaths from the epidemic of infiuenza virus in 1918–19 surpassed the war’s toll: Some 40 to 50 million people died of infiuenza in less than a year (3–7). An estimated one-fifth of the world’s human population was infected, and 2 to 3 percent of those infected died. In comparison, the other two major infiuenza pandemics occurring in 1957 and 1968 were relatively mild with estimates of one to one and a half million deaths worldwide, an overall mortality rate of those infected about 100-fold less at 0. But the 1918 pandemic differed in an important way from all previous ones of its kind and those to come because for the first time young, healthy adults succumbed. To the contrary, in past and subsequent infiuenza pandemics and epidemics, mostly the very young and the elderly died. Pandemic is derived from the Greek “pandemos” meaning “of all people” and indicates an outbreak of disease over a large geographic area. In contrast, epidemic refers to the involvement of a large segment that is regional but not global. Infiuenza is stems from the Italian word for “infiuence” and refers to “infiuence of the stars. Auden: Little birds with scarlet legs Sitting on their speckled eggs Eye each fiu-infected city. Although respiratory infection was a common companion of infiuenza during the 1918–19 pandemic, pneumonia in young adults has Infiuenza Virus, the Plague That May Return 307 been rare before and since. Over 80 percent of current and past deaths related to infiuenza have occurred in people over the age of seventy who most often die from secondary bacterial infections. The infiuenza pandemic of 1918–19 was lethal for healthy adults in the prime of life (3,6–8). Army war casualties were caused not by bullets, shells, or shrapnel but by infiuenza. From July 1917 to April 1919, this virus killed over 43,000 soldiers in the American Expeditionary Forces (7,8). Bureau of Census recorded 548,452 deaths for the last four months of 1918 and the first six months of 1919 (4,8,9). In 1919, the American Medical Association reported that one-third of all deaths of physicians was caused by infiuenza-related pneumonia. In South and Central America, the devastation wrought by infiuenza virus was enormous. In the several Mexican states in which records were kept, over one-tenth of the population died; in Guatemala 43,000 deaths occurred in a total population of 2 million, and in Rio de Janeiro, with a population of 910,000, there were 15,000 deaths during the last three months of 1918. Europe suffered as well; in England and Wales from June 1918 to May 1919, infiuenza killed 200,000, of whom 184,000 were civilians. Over the same time frame in Denmark, with a population of slightly over 3 million, there was a mortality of 11,357, and Sweden, with a population of 5. For the whole German population of over 60 million, there were over 230,000 deaths, while France with a population of 36 million recorded nearly 200,000 civilian deaths. In the French army, the mortality was three times higher than that reported for civilians. In France, the American military forces taking part in the Meuse Argonne offensive of 1918 reported 69,000 sick with infiuenza. The infection was indiscriminate, affiicting soldiers, sailors, civilians, and leaders of many governments. Among the best known were the prime minister of Germany, Prince Max of Baden; the prime minister of 308 Viruses, Plagues, and History England, David Lloyd George; the prime minister of France, Georges Clemenceau; and Woodrow Wilson, president of the United States. Also included were Sir Mark Sykes and Georges Picot, the British and French representatives who agreed to separate Arab-speaking areas from Turkish-speaking parts of the Ottoman Empire in the infamous Sykes-Picot agreement of 1916. A British administrator traveling through villages in northern Persia noted that “in village after village there are no survivors. In western Samoa, the ship Talune, which sailed from Auckland, New Zealand, on November 7, 1918, introduced the disease into the islands of Upola and Savii. Within three months, over 21 percent of those populations died as did the Fiji islanders and Tahitians. Day and night trucks rumbled throughout the streets, filled with bodies for the constantly burning pyres. Four islands, American Samoa, Australia, Tasmania, and New Caledonia successfully delayed or excluded the arrival of foreign ships, which limited the pandemic’s effect to less than 0. Conversely, islands that failed to enforce a vigorous maritime quarantine were devastated. West Samoa lost slightly less than 23 percent of its population with a mortality rate of 225/1000, and 150/1000 or 15 percent of Tahiti’s population died. The total global mortality for the 1918–19 infiuenza epidemic is not fully known but likely exceeded 50 million people (4,6–10). At that time a large part of the world’s population, especially in Africa and Asia, was not tracked by adequate death records. Where records were kept in those areas, the lists for a period of less than one year indicated that over 20 million died.

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  • http://meak.org/science/Kelly-C-Rogers/order-keppra-online-in-usa/
  • https://ctpharmacists.org/wp-content/uploads/2019/05/Presentation_Jennifer-Osowiecki.pdf
  • http://meak.org/science/Kelly-C-Rogers/purchase-online-prasugrel-cheap/
  • https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Pharmacy%20Services%20Report%201.pdf
  • https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf