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Nena Okello allergy forecast hutto tx cheap deltasone 40mg fast delivery, gave a brief overview of the program in Gambella Region allergy lips treatment generic deltasone 10 mg without a prescription, which was followed by a lively question and answer session allergy symptoms yogurt discount 5 mg deltasone fast delivery, including major challenges and set backs the program has encountered over the years allergy symptoms glands swollen buy deltasone 5mg with visa. The minister of health, the vice president of the region and all regional cabinet members also visited Gog Woreda (district), the only known remaining area with endemic dracunculiasis in Gambella Region, and held a community meeting in Fugnido Town (administrative center of Gog Woreda) to discuss the status of the program, followed by a brief visit to the Case Containment Center, where the group saw the first 2010 case of Guinea worm disease. Transmission of the disease from this case was successfully contained, and its source partially explained. Recommendations were: To intensify social mobilization throughout Gambella Region with particular focus in Gog Woreda. The visit and in particular the discussion with the stakeholders were extremely important in raising awareness among the authorities and the public in general and received intense attention by press media and other representatives. Moreover, the visit was very motivating for the community and local government in the area. Ethiopia has reported less than 100 cases per year for each of the past 10 years (Figure 2). During a visit to Accra to attend an African Regional Conference on the Right of Access to Information, President Jimmy Carter paid courtesy visits on Ghana’s President John Atta Mills, as well as Minister of Health Benjamin Kumbour on February 6. He was also briefed on the status of Ghana’s Guinea Worm Eradication Program by the national coordinator, Dr. All five of the cases reported by Ghana in January-February 2010 have reportedly been contained, and the sources of transmission of all five cases have been explained satisfactorily. The group interacted with several officials at the regional and national level of the Ghanaian Health Services including Dr Andrew Seidu-Korkor, the National Programme Manager and Mr Jim Niquette of the Carter Center in Ghana. The first two days were devoted to the review of the implementation of the 2009 plan of action. The meeting was followed by field visits to villages, health centres, the district and regional health offices to assess the implementation on the ground in Savelugu Nanton district (Northern Region) including Pong Tamale (a guinea-worm free sub district), Gulumpe/Kintampo North district (Brong-Ahafo), Kintampo South district (Brong-Ahafo), Ejura Sekyedumasi district (Ashanti). The cases in 2009 were reported from 52 localities, of which 24 had indigenous transmission. However, Gao District reported an increase in cases of 134% (from 35 to 82), while all other districts combined reported a reduction of 73% (from 382 to 104) (figure 4). Abolhassan Nadim, a member of the International Commission for Certification of Dracucunculiasis Eradication, included external experts Dr. Sadi Moussa, Ministry of Health/Niger and was complemented by independent national experts Dr. The field reviews were carried out using standardized questionnaires, and review of records and reports. Based on the assessment, it was concluded that while interruption of transmission appears to have occurred in Nigeria, the possibility of hidden cases needs to be ruled out from foci where the team came across rumours of cases in the past 1-2 years that were not investigated or recorded in the rumour registers. The awareness of reward for reporting dracunculiasis cases needs to be more widely disseminated nation-wide through appropriate communication strategies. The sensitivity of surveillance to detect any case of dracunculiasis outside of the formerly endemic areas within 24 hours needs to be further strengthened. Figure 4 M aliG uinea W orm EradicationProgram R eported cases ofdracunculiasis:2001 2009* 500 500 G ao District Ansongo District 405 400 400 360 326 341 301 300 300 278 188 193 178 200 200 158 135 91 103 100 82 100 78 62 35 40 0 0 2001 2002 2003 2004 2005 2006 2007 2008 2009* 2001 2002 2003 2004 2005 2006 2007 2008 2009* 500 Gourma Rharous District 400 300 200 187 *Provisional 95 100 76 44 31 31 19 15 24 0 2001 2002 2003 2004 2005 2006 2007 2008 2009* 500 500 Tessalit District Kidal District 400 400 300 300 201 200 200 100 86 100 65 26 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 2001 2002 2003 2004 2005 2006 2007 2008 2009* 2001 2002 2003 2004 2005 2006 2007 2008 2009* the evaluation revealed that 36 (72%) of the 50 villages under active surveillance have inadequate safe water sources, out of which 8 (16%) have no single source of safe water. The extent and quality of documentation of pre-certification activities was observed to be satisfactory. The National Certification Committee, which meets twice a year, also carried out situational assessments in the states in 2009. Without a clear understanding of when, where, and why transmission occurred, interventions aimed at interrupting transmission may not be targeted effectively. Failure to detect and contain transmission from cases on time (allowing contamination of sources of water). Stated more simply, stopping transmission means preventing everyone with emerging Guinea worms from contaminating sources of drinking water and stopping people from drinking contaminated water. If these objectives are understood by all of us, why is it that it has been so difficult to make more rapid progress in preventing infected persons from contaminating sources of drinking water and from drinking contaminated water Clearly, the quality of surveillance and interventions against the disease, the quality of supervision, and cultural factors are all parts of the answer to the question. With only 457 cases reported outside of Sudan from 115 villages during 2009, leaders must be constantly aware of which strategies and interventions are being applied, where and why. Below is a short list of critically important issues that require immediate attention as well as recommendations for resolving them, during this critical phase of the eradication campaign. The preferable goal now is to detect probable cases preferably during the pre-emergence stage, but if not possible, detect all cases within 24 hours of worm emergence and prevent patients from contaminating sources of drinking water, i. Flaw: There may be a disconnection between the above standard and the actual frequency of surveillance at the village level. To adhere to the standard, searches for cases need to be conducted daily in endemic areas. If cases are not detected the day the Guinea worm emerges or too much time elapses, the patient has a greater likelihood of contaminating water. Recommendation: Surveillance must be pro-active, there must be sufficient manpower at the village level to search for cases daily in an effective manner, and supervision of the case containment process needs to be done weekly at the village level to also match the tempo of surveillance for cases. Part of the standard for case containment includes having supervisors confirm the containment process within 7 days of the occurrence of the case. A case of Guinea worm disease is the first occurrence in a person during a calendar year of a skin lesion with a Guinea worm protruding from the lesion. The records for persons having nd rd 2, 3, or more Guinea worms are usually not reported since these are not new cases. Hence, any failures to fully contain transmission from persons having more than one Guinea worm may help explain why high rates of case containment may not be followed by a commensurate reduction in overall cases the following year. Such failures may also help explain the occurrence of unexpected outbreaks of the disease a year later. Recommendation: Require that all supervisors leave a copy of their logs (which they routinely must keep to determine who is a new case or not) containing information on the containment of transmission from all persons having additional Guinea worms emerge during the calendar year, and that they maintain an accurate record of these events and outcomes at the District level. Higher-level supervisors are expected to inspect these records to evaluate the consistency of quality of efforts to contain transmission at the village or case containment center level. An endemic village is one where chains of locally acquired infections with Guinea worm disease can be established, i. Flaw: the vast majority of villages in endemic countries outside of Sudan that reported cases in 2009 reported less than 5 cases. The majority of cases from villages reporting 1-4 cases only were likely imported from elsewhere within the country or from a neighboring endemic country. Currently, these investigations are still not being done systematically or consistently in all places. Recommendation: Investigate all alleged cases from villages that during the preceding year did not report cases or that reported only imported cases to determine if the infection may have been acquired elsewhere and to cross report such cases to the probable place where the infection originated. Report these as “villages under surveillance because of imported cases” and do not include these in the listing of endemic villages unless endemic transmission is established. Activate village volunteers to carry out surveillance, and provide training, materials, and supervision. On behalf of His Majesty Sultan Qaboos bin Said Al Said, the Ambassador delivered a check for $1 million to support the Guinea Worm Eradication Program. Their first contribution to the program was a two-year grant of $1 million provided in 2004. In gratitude, President Carter presented Ambassador Al Mughairy with a leather-bound copy of his book, Beyond the White House. Ambassador Al Mughairy is the Sultanate of Oman’s first female ambassador, and the only female ambassador to represent an Arab country in the United States. Oman’s generous donation and continued partnership are greatly appreciated in the fight to rid the world of this debilitating disease. Babatunde Osotimehin, held a press briefing in Abuja January 27, 2010 in which he informed the public of the “significant achievement” in which Nigeria had reported zero cases of Guinea worm disease for over twelve months, since November 2008. He thanked all Nigerians and their partners for the achievement, and pledged that the country would maintain adequate surveillance to ensure no cases remain or return. Have any of the other children you herd with had Guinea worm in the past two years For example: If they know the person If they live near the person If they are related If they farm together If they farm near each other If they gather water from the same source If they attend the same school If they swim together If they share other activities or relations Additional comments and observations: Table 5 Dracunculiasis Eradication Campaign Reported Importations and Exportations of Cases of Dracunculiasis: 2009* From To Month and number of cases imported Number of caes Jan. Inclusion of information in the Guinea Worm Wrap-Up does not constitute “publication” of that information. Guinea worm disease, also known as of drinking water, which stimulates the dracunculiasis, is a parasitic infection emerging worm to release larvae into caused by the nematode (roundworm) How is the disease treated and the water. The cycle begins again when a person consumes the Guinea worm There is no known curative medicine or How do you get Guinea infected water fleas.

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The recurrent rectocele rates for vaginal and transanal subgroups were 7 % and 40 % allergy upset stomach generic 5mg deltasone overnight delivery, respectively (p=0 allergy testing gp generic deltasone 10mg on line. In both groups the mean values of point Ap were significantly reduced closer to allergy institute purchase deltasone 20 mg online the normal value of –3 allergy forecast the woodlands tx generic 10 mg deltasone otc. However, the values of point Ap 12 months after surgery were statistically significantly better after vaginal than transanal surgery, being –2. In defecography, the mean depth of rectocele was statistically significantly reduced after vaginal surgery (6. However, the difference between the groups at follow-up was not statistically significant. The effect of operation on sexual activity and causes of inactivity in 103 patients. The mean total vaginal length for the whole study group but also for sexually active or inactive patients was 9. Nine patients were found to have a narrowed vagina; one of them reported being sexually active. The mean age of the sexually inactive patients versus active patients was 74±7 versus 61±9 years, respectively (p=0. None of the women attending the study reported de novo dyspareunia, while one patient in the transanal group suffered recurrent dyspareunia due to recurring rectocele. Six women in the vaginal and two in the transanal group reported improvement of sexual function. None of the patients had narrowed vagina upon examination nor reported any adverse effects of the operation in respect of sexual function. Seven patients reported de novo stress incontinence symptoms and six urgency or urge incontinence. Three (15 %) of the 20 patients attending follow-up reported symptoms of stress urinary incontinence and one of urgency. Four (20 %) patients were dissatisfied with the results of the operation; however, none of them suffered recurrent prolapse. The frequency of gas incontinence for the vaginal or transanal groups was zero versus four, respectively (p=0. The goals of reconstructive surgery are permanent relief of symptoms, restoration of anatomy and maintenance of vaginal capacity for sexual function in sexually active patients without adverse effects of surgery. An ageing female population with increased life expectancy in many countries means that in the future we will face this problem increasingly frequently and also with patients in their 80s or even 90s. As a vaginal procedure it can be performed under regional anesthesia, laparotomy is avoided and it facilitates concurrent pelvic floor repair, which is mandatory in relieving the patient’s symptoms. Vaginal posterior colporrhaphy has been used for a century, whereas the transanal technique was evolved by coloproctologists in the 1980s. Comparison of results of these techniques is difficult because different outcomes are reported and prospective randomized studies are lacking. The main concern after the vaginal technique has been dyspareunia (Kahn and Stanton 1998), whereas transanal technique may compromise anal sphincter function (Ho et al. In the present study, the retrospective design was chosen as being the only method to collect data on a sufficient body of patients; these 138 patients were operated during a fourteen-year period. There were no differences between the groups regarding important patient characteristics, which justifies our conclusions. The difference between the follow-up periods may have affected our results, but this was controlled for by the use of survival analysis. The sample size, 15 patients in both groups, was relatively small, but statistical differences in outcomes were 62 reached between the groups. Power calculation was not undertaken, because we estimated that patients with solitary rectocele and intact anal sphincter function are rare. After 30 patients recruitment was discontinued, as the process took over three years. Patient assessment in this study was adequate including interview, clinical examination, radiological studies and anorectal manometry. Short-term outcomes of surgery Sacrospinous ligament fixation Intraoperative blood loss (median 300 ml) in the present study was comparable with that previously reported, with mean or median values ranging from 225 to 585 ml (Hardiman and Drutz 1996, Colombo and Milani 1998, Meschia et al. In contrast, 16 % received blood transfusions, which is more frequently than reported by others and reflects the liberal use of blood transfusions in Finland. In a review article, Sze and Karram (1997) reported that 2 % of patients had received blood transfusion and others have reported frequencies from 0. The rate of cardiovascular complications here was 5 % while in the literature it has varied from 0 to 4 %; the majority of studies have not in fact addressed this point (Table 2). Four out of a total of seven cardiovascular complications took place in a subgroup of women aged 80 years or more. All four had coronary heart disease or arterial hypertension, which are known risk factors for cardiovascular morbidity (Shackelford et al. Operative morbidity and mortality increase with age, but are affected more by comorbid conditions and functional status than by age itself (Miller 1997), which is in accordance with our finding that patients without a history of vascular diseases did well after surgery. Control of hemostasis is imperative in that excess bleeding may stress a weakened myocardium in patients suffering from coronary heart disease or arterial hypertension (Shackelford et al. Early mobilisation and hospital discharge may be factors influencing the rate of thromboembolic complications. However, the shorter hospital stay had no influence on the frequency of such complications. In the early years of the study prophylaxis was seldom used, whereas nowadays it is routine being recommended as such especially for older patients (Miller 1997). Routine use of thrombosis prophylaxis might have reduced the incidence of cardiovascular events, although our patient who died of pulmonary embolism 63 had prophylaxis. On the other hand, antithrombotic prophylaxis may have a role in increasing intraoperative blood loss. Obliterative procedures such as colpocleisis or the Neugebauer-LeFort operation have been recommended for poor operative candidates. However, a 5 to 16 % incidence of cardiovascular complications and mortality up to 5 %, have been reported (Hanson and Keettel 1969, Ahranjani et al. Additionally, no reconstructive procedures can be performed, coital function will be lost, diagnosis of uterine malignancy is rendered difficult and these measures carry a risk of de novo urinary incontinence (Cundiff and Addison 1998, Toozs-Hobson 1998). Cysto and enterotomies occurred infrequently, as has been the case in previous surveys. Lengthier operation, on average by 21 minutes, cannot be regarded as a complication. The rate of postoperative vaginal cuff infection in published papers has varied from 0. These figures are difficult to compare because neither definition nor severity of postoperative infection is given. Febrile morbidity has also been used as a marker of postoperative infection despite its limited value (Shackelford et al. Hoffman and colleagues (1996) with an 18 % and Lovatsis and Drutz (2002) with a 0. Here, none of the patients with prophylaxis suffered vaginal cuff infection, which would witness the importance of prophylaxis. The high incidence of vaginal cuff infection reported by Hoffman and associates (1996) might be due to difference in definitions, not indicating poor efficacy of prophylaxis. No intravenous antibiotic prophylaxis, vaginal ulcerations and younger age were risk factors for postoperative infectious complications in univariate analysis and logistic regression. Intravenous antibiotic prophylaxis and treatment of ulcerations preoperatively is imperative in avoiding postoperative infections, although topical estrogen treatment is challenging in patients with advanced genital prolapse. The role of younger age as a risk factor for infectious complications is somewhat confusing, but may be attributable to a more virulent bacterial flora (Hager 1997). Buttock pain as a marker of nerve damage was seen in only three per cent of the patients and was relieved within four weeks without specific treatment. Some authors have reported higher frequencies (Table 2) and even permanent foot drop (Monk et al.

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Pharmacologic/Therapeutic Category this index will display an alphabetical listing of all pharmacologic categories allergy symptoms lethargy cheap 40mg deltasone otc. From this list allergy hair dye purchase deltasone 5mg otc, the user can click on any drug displayed and access the full monograph for that drug allergy medicine and weight gain purchase deltasone 5 mg on line. From the list dis played allergy symptoms light headed discount deltasone 40mg on-line, the user can click on any drug and access the full monograph. Monographs with Special Alerts this index displays a list of all drugs that have a Special Alert. The “Special Alert” feld displays important information, such as new warnings, adverse reactions, recalls, etc. From this list, the user can click on any drug and view the entire drug monograph. Clicking on the “Diseases” button from the home page will take the user to a listing of the available disease databases. This screen provides brief overviews of each disease database that is available within Lexicomp Online. Click on the database name to display a more detailed overview of the content available in that database as well as a list of the editorial panel. The “Available Disease Indexes” links on the left side of the screen can be used to browse each database via a number of useful indexes which were reviewed above. Clicking on the “Toxicology” button from the home page will take the user to a listing of the available toxicology databases. This screen provides brief overviews of each toxicology database that is available within Lexicomp Online. The “Available Toxicology Indexes” links on the left side of the screen can be used to browse each database via a number of useful indexes which were reviewed above. Clicking on the “Patient Education” button from the home page will take the user to a listing of the available patient education databases. This screen provides brief overviews of each patient education database that is available within Lexicomp Online. The left side of the screen provides links to the available indexes for each database. The “Available Patient Education Indexes” links on the left side of the screen may be used to browse each database via a number of useful indexes which were reviewed above. Clicking on the “Laboratory” button from the home page will take the user to a listing of the available laboratory databases. This screen provides a brief overview of the laboratory and diagnostic procedures database that is available within Lexicomp Online. The left side of the screen provides links to the available indexes for this database. Click on the database name to display a more detailed overview of the content available in that database, as well as a list of the editorial panel. Clicking on the “International Drugs” button from the home page will take the user to a listing of the available international drug databases. This screen provides a brief overview of the international drug databases that are available within Lexicomp Online. The left side of the screen provides links to the available indexes for these databases. Only databases that are available to the user and have a result will be displayed in the search results. To view the monograph within any database, click on the hyperlinked drug name displayed under the desired database. Filter Results the “Filter Results” drop-down menu can be used to sort your search results to display only specifc databases. The flter results can be used to flter by the following topic areas: • Drug Content • Toxicology Content • Disease/Lab Content • Patient Education Content • International Drug Content Field Selection To activate the “Jump to feld” menu, hover the cursor over the hyperlinked drug name in the results list and a list of the available felds within that monograph will display. From this list, the user can select a feld of interest and immediately open the drug monograph to that section. In the top left corner of the screen, the monograph title and database name will be displayed as a point of reference. Navigating a Monograph Once in the monograph, the user has three ways to navigate the informa tion presented. The frst method is to use the “Navigation Tree” displayed on the left side of the screen. This box provides a table of contents view of the available sections of the drug monograph. Sections that have a “ ” sign next to them have sub-sections that allow the user to jump to more specifc areas of content. To expose all of the sub-sections at once, click the “Expand All” link at the top right of the Navigation Tree box. To hide the Navigation Tree box and expand the screen space for monograph viewing, click the “Hide” link in the top right corner of the box. To open the Navigation Tree once it has been hidden, click the “Show Tree” link in the top left corner of the monograph window. To jump to a particular section, click on the desired feld from the drop down list. Lastly, the drug monograph can be viewed by scrolling through the entire document using the standard browser scroll bars located on the left side of the monograph window. Linking to Other Content from a Drug Monograph Throughout the drug monograph, hyperlinks are presented that allow the user to link to additional content. Clicking on these tabs will give users access to (1) images of various dosage forms; (2) adult patient education material and (3) pediatric patient education material. Images From a monograph, clicking on the images tab displays a list of the available products with images (oral solid dosage forms). To view a larger image and additional detail about a particular product, click on the image. Note: To access the drug identifcation tool for identifying unknown medications, click on the “Drug I. To return to the monograph information, simply click on the “Monograph” tab at the top of the content panel. This document can be navigated using the same three methods used to navigate a drug monograph: (1) the left panel Navigation Tree; (2) the “Jump to Section” drop-down menu in the upper right corner of the content panel; or (3) scrolling the document using the right side scroll bars. The patient education handouts are written at a consumer level and can be viewed in multiple languages. To view the document in a different language, click on the “Switch Language” drop-down menu in the upper right corner of the content panel. To print the document, click on the “Print” link in the upper right corner of the content window and a list of the available printers to which your computer is connected will be displayed. Lexi-Interact is a complete drug and herbal interaction analysis program capable of assessing potential drug-drug interactions, drug-allergy interactions, and duplicate therapy interactions. Begin by entering the list of medications and known drug allergies to be analyzed. The interactions tool allows users to enter medications (both prescription and over the-counter), natural products, foods and/or alcohol. To enter an item, begin typing a keyword into the “Search Drugs” and/or “Search Allergies” box. After you enter at least four (4) characters, suggested terms will populate, and you can select the desired term from the list. To remove an item from the list, uncheck the selected box next to the product you wish to remove. The Duplicate Drug Therapy feature is automatically checked to provide an analysis of the selected medications which are considered duplications because they belong to the same pharmacologic class. If you do not want the duplicate therapy screening to be performed, the box can be unchecked prior to selecting the “Analyze” button. The “Interaction Analysis” screen provides a summary of interactions organized by drug-drug, drug-allergy, and duplicate therapy sections. An assigned risk rating (A, B, C, D or X) appears next to each drug-drug and drug-allergy interaction. Each letter represents a different level of urgency in responding to the identifed interactions.

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In June 2001 allergy treatment for adults discount deltasone 10 mg without a prescription, two mechanics working on a cargo ship under repair in Barcelona allergy medicine for pregnant cheap deltasone 10 mg line, Spain were reported to allergy medicine otc comparison generic 10 mg deltasone visa have died after contracting Legionnaires’ disease allergy forecast georgia discount 5mg deltasone free shipping. Hot tubs and recreational pools — risk factors Hot tubs are installed on many cruise ships and on some ferries. The risks are similar to those on land (see Chapter 8), and there have been several outbreaks on ships due to hot tubs. In 1994, a cruise ship had 50 cases of Legionnaires’ disease, spread over nine cruises. The disease was believed to have been caused by inadequate bromination of the ship’s three hot tubs, and the risk of acquiring Legionnaires’ disease increased by 64% for every hour spent in the hot tub (Jernigan et al. Passengers spending time around the hot tub, but not in the water, were also signifcantly more likely to have acquired infection. One man had fallen into the cruiser’s hot tub and subsequently developed Legionnaires’ disease. In 2003, there were eight cases and one death among passengers who had been on a cruise around Iceland. This latter outbreak demonstrates the importance of international collaboration to investigate shipborne outbreaks, since the cases were detected and investigated in Germany after the vessel had docked there to disembark passengers, and it was investigated in its next port of call, in the United Kingdom. Air-conditioning — risk factors There are no confrmed reports of outbreaks of Legionnaires’ disease associated with air conditioning systems on ships, but these systems have been suspected in some outbreaks. In 1984, a large outbreak on a cruise ship occurred after the air-conditioning was turned on at Bordeaux, France. No common source was discovered, but the epidemic curve indicated that the air-conditioning system contributed in some way to the outbreak (Rowbotham, 1998). In another outbreak on a cruise ship in 1984, no source was identifed, but the outbreak investigation revealed problems with the air handling units (Christenson et al. Air-conditioning systems on ships are dry and do not have evaporative coolers; however, humidifers (including food display units) are often installed on ships and could generate aerosols. The steps involved in monitoring, some of which are discussed below, are to: • identify control measures (Section 7. Source water quality — control measures International health regulations require ports to supply potable water to ships; however, there is no requirement for potable water to be Legionella-free, and such a requirement would be unrealistic. Since the reliability of the water supply cannot always be guaranteed, precautions should be taken to ensure that the water is adequately disinfected on board. Hot and cold-water systems — control measures Primary and secondary methods of prevention and control, as applied to hotels, are based on experience acquired in managing outbreaks and are largely empirical. These measures do not, in general, differ from those that are applied to other types of buildings, in that they aim to eradicate Legionella in the installations by means of a risk assessment that focuses on: • factors leading to Legionella proliferation. The effcacy of these measures in the control and secondary prevention of outbreaks is well established, although they may be insuffcient in hotels repeatedly associated with cases. An example of a checklist specifcally designed for water systems in hotels is provided in Appendix 1. In ships, onboard exposure through piped water can be prevented by such water quality management measures as: • treating source water (where the water is non-potable) • maintaining water temperatures outside the range in which Legionella proliferates (25–50 C) • maintaining disinfection residuals greater than 0. Water fow in the distribution system should also be maintained during periods of reduced activity. Disinfection — control measures A study of 62 hotels in the Balearic Islands, Spain (Crespi et al. Another study evaluated the systematic purging of the hot and cold-water pipes in two hotels with water chlorinated at 1–1. Negative cultures were not obtained in the two hotels until fve and seven months respectively after the treatment, highlighting the recalcitrant nature of legionellae and the need for repeated and diligent disinfection. Temperature — control measures Some buildings may not be able to raise their hot-water temperature suffciently to control Legionella growth; therefore, an on-line treatment such as chlorine or copper/silver ionization should be considered. Chapter 4 has more information on control measures relating to temperature in distribution systems. Design, operation and maintenance — control measures the control of Legionella in water distribution systems in hotels is diffcult, and requires the continuous and effective maintenance of preventive measures. Hotel personnel responsible for the maintenance of hotel water systems must be educated and qualifed to perform these duties. The importance of training and education has been recognized in a large number of published preventive guides. Data from the application of training programmes are very encouraging, and suggest that education may be important in preventing legionellosis in the tourist sector (Crespi & Ferra, 2002). Preventing the risk of colonization during repair of the plumbing systems on ships deserves special attention. Air-conditioning — control measures Humidifers or devices likely to amplify or disseminate the bacteria should be periodically cleaned and replaced (Edelstein & Cetron, 1999). Special attention should be paid to the proliferation of Legionella in humidifers. Liquid should not be allowed to accumulate within such units; they must drain freely and be easily accessible for cleaning. If a source of Legionella transmission is identifed, especially after an outbreak, a disinfecting procedure (superheating or hyperchlorination) is recommended. As the incubation period of the disease could be longer than the length of a cruise, outbreaks could go undetected, even if the ship has a surveillance system in place. Thus, it is important for community physicians to enquire about recent cruise ship travel if patients present with symptoms of pneumonic illness. Routine surveillance by external authorities, such as through public health inspections of ships by environmental health offcers, should also be conducted, to pre-empt disease outbreaks. Today, there continue to be reports of outbreaks of infectious disease linked to swimming pools, but these can be avoided by: • good pool management, including adequate filtration and disinfection • bathers observing advice to shower before entering pools • bathers refraining from bathing if unwell with diarrhoeal disease. Immersion in water can be both pleasant and therapeutic, and various techniques have been used over centuries for a diverse range of physiological effects, such as healing injuries, reducing swelling and cooling burns, and for psychological effects, such as calming psychiatric patients (de Jong, 1997). The risk of Legionnaires’ disease from swimming pools, spas and hot tubs is low if they are well managed. Types of pools Sw mm ng pools Swimming pools may be supplied with fresh (surface or ground), marine or thermal water. In terms of structure, the conventional pool is often referred to as the main, public or municipal pool. It is by tradition rectangular, with no extra water features (other than possible provision for diving), and it is used by people of all ages and abilities. In addition, there are many specialist pools for a particular user type — for example, paddling pools, learner or teaching pools, diving pools and pools with special features such as “flumes” or water slides. Although termed “swimming” pools, they are often used for a variety of recreational activities, such as aqua aerobics, scuba diving and so on. Plunge pools Plunge pools are generally used in association with saunas, steam rooms or hot tubs, and are designed to cool users by immersion in unheated water. For the purposes of this document, they are considered to be the same as swimming pools. Hot tubs For the purposes of this document, the term “hot tubs” is used to denote various facilities that are designed for sitting in (rather than swimming), contain water usually above 32 C, are generally aerated, contain treated water, and are not drained, cleaned or refilled for each user. They may be domestic, semi-public or public, and may be located indoors or outdoors. They are known by a wide range of names, including spa pools, whirlpools, whirlpool spas, heated spas, bubble baths or Jacuzzi (a trade name that is also used generically). Both domestic hot tubs and those in commercial premises have dramatically increased in popularity in recent years; they are now found in sports centres, hotels, leisure and health spa complexes, on cruise ships and, increasingly, in the home environment. In some countries, especially when in health spa resorts, hot tubs may also be known as hydrotherapy spas or pools, though these terms are more usually applied to pools used within health-care premises. Wh rlpool baths Whirlpool baths are a type of hot tub often found in bathrooms of hotel suites or private residences. They are fitted with high-velocity water jets and/or air injection but, unlike the hot tubs described above, the water is emptied after each use. They are mainly intended for a single individual, but double versions are available. Because of their particular water characteristics, natural spas may receive minimal water-quality treatment. Hydrotherapy pools In addition, there are physical therapy pools, in which professionals perform treatments for a variety of physical symptoms on people with neurological, orthopaedic, cardiac or other diseases. These are termed “hydrotherapy pools”, and are defined as pools used for special medical or medicinal purposes. Hydrotherapy pools are not specifically covered by this document, although many of the principles that apply to swimming pools and hot tubs will also apply to them.

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Symptoms of dumping syndrome include facial flushing allergy to sunscreen discount deltasone 40mg amex, lightheadedness allergy medicine mixed with alcohol purchase deltasone 5 mg with visa, fatigue allergy symptoms latex discount deltasone 10 mg, and postprandial diarrhea following consumption of sugars and processed starches (Lee allergy medicine mold spores discount deltasone 10 mg free shipping, Kelly, & Wassef, 2007). Dietary modifications and supplementation of fat-soluble vitamins are often necessary. Treatment-related causes of constipation include adhesions due to surgical procedures, narrowed intestinal lumen due to surgery or radiation, and autonomic neuropathy due to chemotherapy. Taxanes, vinca alkaloids, platinum analogs, epothilones, proteasome inhibitors, and thalidomide are all associated with the development of peripheral neuropathy. Patients who have preexisting neuropathy due to diabetes or chronic alcohol use are at higher risk for chemotherapy induced peripheral neuropathy. Musculoskeletal Effects Many cancer survivors are at risk for osteoporosis related to hormonal manipulation of their cancers. It is well known that postmenopausal women are at risk for developing osteoporosis due to the loss of estrogen and its protective effects on bone density; women who have had oophorectomies are at risk for the development of osteoporosis at earlier ages than had they gone through natural menopause. This effect is most pronounced in the first two years of use, so bone density measurements should be done prior to starting these drugs and after six months to one year of use. Tamoxifen and other selective estrogen receptor modulators preserve bone density; tamoxifen may be the endocrine therapy of choice for postmenopausal women with preexisting osteopenia or osteoporosis. Men treated for prostate cancer with androgen deprivation therapy or orchiectomy and men treated for testicular cancers are also at risk for the development of osteoporosis and should be screened. Steroids, such as prednisone and dexamethasone, are used in some chemotherapy regimens and may lead to the development of osteoporosis, avascular necrosis, and other long-term effects. All patients at risk for osteoporosis should be encouraged to get adequate amounts of calcium and Vitamin D, either through diet or supplementation. Those with osteopenia or osteoporosis usually require treatment with bisphosphonates or other bone-strengthening medications. Patients on bisphosphonates should have thorough periodic dental examinations and inform providers immediately if experiencing jaw or tooth pain. Endocrine and Neuroendocrine Effects Patients and healthcare providers are aware that chemotherapy, surgery, radiation therapy, and hormonal therapies may result in infertility, but may not be familiar with the range of effects on the endocrine system as a whole. It is well known that postmenopausal women are at increased risk for hyperlipidemia, and coronary artery disease due to the loss of the protective effects of estrogen. Women who experience premature menopause as a result of cancer treatment may Copyright 2014 by the Oncology Nursing Society. Testosterone deficiency in men resulting from orchiectomy and androgen deprivation therapy also predisposes them to the development or worsening of hyperlipidemia and should be screened and treated. Testicular cancer is often diagnosed in men in their 20s or early 30s; screening for cardiovascular disease and hyperlipidemia should start approximately five years after treatment is completed (Efstathiou and Logothetis, 2006) Cranial irradiation and surgical resection of tumors often damages the pituitary gland, leading to hypopituitarism. Some chemotherapeutic agents, glucocorticoids, megestrol acetate, and interferon may also cause pituitary dysfunction. Growth hormone deficiency is often the earliest manifestation of pituitary dysfunction and causes reduced bone mineral density, decreased lean mass, increased adiposity, abnormal lipid profiles, and insulin resistance. Hyperprolactinemia is also implicated in the development of osteoporosis, as well as menstrual irregularities, erectile dysfunction, and insulin resistance. Damage to the hypothalamus-pituitary-thyroid axis from cranial irradiation also results in central hypothyroidism and gonadotropin deficiency. Adrenocorticotropic hormone deficiency is one of the least common, but most serious of the pituitary hormone disorders resulting from cranial irradiation or prolonged glucocorticoid therapy. Patients at risk for treatment-associated hypopituitarism should be screened periodically after completion of treatment and treated for any deficiencies. Primary hypothyroidism may result from cranial and neck irradiation, or from various drugs used in cancer treatment. Peripheral Neuropathy and Other Chronic Pain Syndromes Chronic pain syndromes may be the result of surgery and radiation therapy; often a neuropathic component exists. Breast cancer survivors treated with breast-conserving surgery and radiation therapy may experience breast pain lasting long after treatment ends. Healthcare Maintenance and Screening for Second Cancers Health and wellness promotion is important for all survivors. Healthy diet, weight management, and exercise enhance well-being and reduce the risks of developing diabetes, cardiovascular disease, other chronic diseases, and second cancers. Smoking and alcohol use are implicated in the development of some cancers; smoking cessation and counseling regarding alcohol use can help reduce the risk. Many survivors have ongoing pulmonary effects of treatment and should have yearly influenza immunizations, as well as periodic immunization against pneumococcus. Those who have had stem cell transplants require immunization, usually beginning three to six months after transplantation. Screening for Second Cancers Second and higher order primary cancers often occur several years, even decades, after treatment for the primary cancer. There is little question that younger cancer survivors should undergo screening for second cancers, but there is not necessarily a consensus regarding screening for second primaries when the cancer survivor is an older adult. The concern is that older patients may not tolerate treatment as well as younger individuals. Age should not be the only criteria on which to make screening decisions; performance status can be more important than age in determining if a particular individual is a candidate for treatment if a second primary is found. It is important for patient and provider to thoroughly discuss all concerns and to periodically revisit the issues. Patients who have recently completed difficult treatment regimens may initially decide that they will never undergo such treatment again, but may feel differently when faced with a new cancer. It is often difficult to tease out which of these are caused by cancer treatments versus genetic, environmental, and other factors that may have led to the development of the initial malignancy. Family history may suggest the presence hereditary predisposition to certain cancers, as can age at diagnosis. Patients whose cancers occur at younger ages than usual or whose families contain cancer clusters should be referred for genetic counseling and testing. The presence of a mutation is often important in guiding screening and risk reduction for siblings or children of cancer survivors. The risk of cancer recurrence is higher in the first few years after treatment, whereas second primaries may not manifest themselves for many years. Screening for recurrence is considered part of surveillance, whereas screening for new primaries is considered secondary screening. Based on information from National Comprehensive Cancer Network, 2013a; National Comprehensive Cancer Network, 2013d; National Comprehensive Cancer Network, 2013e; National Comprehensive Cancer Network, 2013j. Certain treatment modalities increase the risk of secondary primary cancers in cancer survivors. Anthracyclines/Herceptin the anthracyclines can cause cardiac toxicity because of oxidative stress of the myocardial cells, which will induce apoptosis (Arozal et al. This can lead to congestive heart failure, arrhythmias, and left ventricular dysfunction. Because of the cardiotoxic effects of these agents, they have a maximum cumulative dose. If the cumulative dose exceeds above the maximum dose established for each agent the probability of developing cardiac dysfunction increases greatly. Preexisting cardiac disease can also increase a person’s risk for progression of the already underlying disease. Therefore if at all possible, these agents should be avoided or careful monitoring of cardiac function must occur during administration. Other agents not in the anthracycline family can increase the risk of cardiac dysfunction so other agents with cardiotoxicities should be avoided. If cardiac toxicities do occur with anthracycline therapy, Copyright 2014 by the Oncology Nursing Society. Finally, side effects may not present immediately during exposure to the agents but may occur years after therapy has completed. Trastuzumab-related cardiac dysfunction is different from chemotherapy-induced cardiac dysfunction in that it does not generally cause death and is reversible once the drug is stopped. If cardiac dysfunction does occur with the administration of trastuzumab, once the agent is discontinued cardiac function will usually recover to normal, and the agent can often be restarted (Carver et al.

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