Stephen Patrick Bergin, MD
- Assistant Professor of Medicine
https://medicine.duke.edu/faculty/stephen-patrick-bergin-md
A similar rate of arthritis resolution was seen in a prospective cohort study [364] of 20 patients with postantibiotic Lyme arthritis who were treated with synovectomy quit smoking florida free patches 35mg nicotinell fast delivery. In an earlier 10- to 20-year follow-up study [366] quit smoking 5 months ago and hot flashes purchase 17.5 mg nicotinell otc, 10 of 42 adult patients with previous Lyme arthritis had findings sug- gestive of degenerative arthritis in previously affected knees compared with none of 42 patients with previous Lyme disease without Lyme arthritis (P = quit smoking journals cheap nicotinell 17.5mg line. As quadriceps atrophy can occur with Lyme arthritis quit smoking quote of the day nicotinell 52.5mg mastercard, physical therapy is an important ad- junct to antibiotic treatment. Systemic autoimmune diseases that affect joints, such as rheumatoid arthritis, psoriatic arthritis, and spondyloarthritis, for which antibiotics are of no benefit, have been reported after an episode of Lyme disease, particularly early Lyme disease [365]. These patients typically have polyarthritis, including small joint disease, are male, have high body mass index, have a family history of autoimmunity, and have less IgG reactivity on immunoblot testing compared to patients with Lyme arthritis. Children Persistent infection has not been documented in this subgroup of patients, who are considered to have postantibiotic Lyme arthritis. Consultation with a rheumatologist or other trained specialists is suggested to ensure that there is no other potential explanation for joint swelling or syn- ovial proliferation (eg, underlying osteoarthritis) and that other nonpharmacologic modalities are used such as phys- ical therapy to improve outcomes, especially if atrophy of the quadriceps has developed. Prolonged Symptoms Following Treatment of Lyme Disease Twenty-three of 99 children (23. However, 3 children were treated with methotrexate and hydroxychloroquine or sulfasalazine. Children may be more likely than adults to regain normal function within 4 weeks after the initiation of antibiotic therapy. In a retrospective analysis, 29% of children with Lyme ar- thritis had persistent synovitis requiring second-line therapy [368]. Of these 112 children, 18 received intraarticular steroids with or without a second round of antibiotics; 17% of the chil- dren receiving intraarticular steroids developed postantibiotic Lyme arthritis, compared to 44% receiving a second course of antibiotics alone (P =. The prevalence of persistent symptoms following standard treatment of Lyme disease is unclear; estimates vary depending on the patient population and methods of longterm assessment. For patients who have persistent or recurring nonspecific symptoms such as fatigue, pain, or cognitive impairment fol- lowing recommended treatment for Lyme disease, but who lack objective evidence of reinfection or treatment failure, we recommend against additional antibiotic therapy (strong recommendation, moderate-quality evidence). Several clinical trials have investi- gated antibiotic re-treatment of patients with disabling symp- toms that had persisted for months after standard treatment for documented Lyme disease. At 30, 60, and 180 days there was no difference between the treatment and placebo arms as assessed by symptom severity and neurocognitive measures. At 6-month follow up there was an improved fatigue score compared with baseline in the treatment arm, though no improvement in the other domains tested; the fatigue scores and their interpretability are limited by methodological and statistical considerations [380]. A cognitive index score at week 24 did not differ between treatment and placebo groups. A secondary out- come measure improved at week 12 and was sustained to week 24 for pain and physical functioning, but not fatigue, the opposite of the findings in the second study. In the second and third of these studies, fatigue improved over baseline among placebo-treated patients (9. At the final observation point, 52 weeks following initiation of therapy, health-related quality of life scores did not differ signif- icantly among the 3 groups. In all studies, subjects improved-but the improvement was also experienced by placebo-treated subjects. Thus, the evidence does not support the hypothesis that per- sistent symptoms should be interpreted as clinical infection, or that antibiotic retreatment is safe and effective. Studies con- ducted in animal models have raised hypotheses of microbio- logic persistence. However, these studies are methodologically highly heterogeneous and have limited generalizability to nat- ural human infection [380]. Moreover, animal models cannot reproduce the human experiences of fatigue and pain, and it is unlikely that any animal study can give reliable insight into the biology of humans experiencing such symptoms following treatment of Lyme disease. Chronic Lyme Disease Early work in the field sometimes referred to patients with in- fection of more than 6 months duration-particularly North American patients with Lyme arthritis or European patients with acrodermatitis chronica atrophicans-as having chronic infection. This term has been largely supplanted by "late mani- festations" as these syndromes often appear after a long period of apparent clinical latency.
These large basins were filled with a basalt-sandstone rock sequence locally known as the Newark Supergroup quit smoking idaho buy nicotinell 17.5mg with amex. The bedrock in the Connecticut Valley consists of this sandstone quit smoking jacksonville florida order 17.5mg nicotinell overnight delivery, shale quit smoking free patches best nicotinell 17.5 mg, and conglomerate sequence quit smoking chantix 17.5 mg nicotinell amex. Basalt flows along the rift zones periodically spread across these shallow freshwater sediments. Today, these igneous rocks form many of the landmarks throughout the upper valley, such as Mt. It includes the cities of Springfield, Massachusetts, and Hartford, Connecticut, and the towns of Lebanon and Claremont, New Hampshire; White River Junction and Brattleboro, Vermont; Amherst and Northampton, Massachusetts; and Middletown, Meriden, and New Haven, Connecticut. Interstate 95 crosses the southern tip of the area, in New Haven, and Interstates 84, 90, and 89 cross the area. Dinosaur State Park in Connecticut and the Holyoke Dam in Massachusetts provide excellent sites for observing fossil dinosaur tracks. Nearly level to sloping lowlands are at the outer edges Climate the average annual precipitation in this area is 33 to 52 inches (840 to 1,320 millimeters). The precipitation is evenly of the United States 479 distributed throughout the year. During the winter, most of the precipitation occurs as moderateintensity storms (northeasters) that produce large amounts of rain or snow. Temperatures and the length of the freeze-free period increase from north to south. Some public supply and light industry water is obtained from wells drilled in the igneous and metamorphic rocks under the till in the lowlands. This water has slightly more total dissolved solids and generally is harder than the water in the valley fill and till aquifers. Also, there are more instances of iron concentrations exceeding 300 parts per billion (micrograms per liter) in the crystalline bedrock aquifer. High levels of radon-222 occur in wells drilled into granite that has high amounts of muscovite and biotite. About 23 percent is from ground water sources, and 77 percent is from surface water sources. Precipitation, perennial streams, and lakes provide an abundance of good-quality surface water in this area. Water for municipal and industrial needs is stored in reservoirs in this area and in adjoining areas. The surface water is of good quality, but it commonly requires some treatment prior to use as drinking water. Progress has been made in cleaning up municipal and industrial waste discharges into the Connecticut River and its tributaries. Public supply, municipal, and industrial water is obtained from the glacial outwash and the alluvial valley fill along the major rivers. It is acidic, is soft to very hard, and is very low in total dissolved solids, typically 75 to 125 parts per million (milligrams per liter). This aquifer is typically less than 100 feet (30 meters) thick, and the water table is often at a depth of 30 feet (10 meters). As a result, the water in the aquifer is highly susceptible to contamination by surface activities. Some public supply, municipal, and industrial water is obtained from the marine sediments in the parts of this area in Massachusetts and Connecticut. The water in this aquifer is moderately hard and has about 250 parts per million (milligrams per liter) total dissolved solids in the upper 200 feet (60 meters) of the aquifer. In the lower part of the aquifer, the level of total dissolved solids doubles and the water is very hard. Some deposits of copper, lead, zinc sulfides, and uranium minerals occur in this aquifer. Water pumped from areas with ore deposits must be treated before it can be used for drinking or for industrial purposes. Many shallow domestic wells obtain ground water from the till deposits that cover the bedrock in the lowlands on each side of the flood plain along the Connecticut River. The soil temperature regime generally is mesic but is frigid in the northern part of the area.
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They include Ustorthents (Guam series) quit smoking 0001 quality nicotinell 52.5 mg, Argiustolls (Banaderu series) quit smoking vermont buy 17.5 mg nicotinell, Haplustolls (Chinen series) quit smoking 0001 buy nicotinell 52.5 mg with visa, and Haplustalfs (Pulantat series) quit smoking vapor cigarette generic 52.5mg nicotinell amex. Shallow Haplustolls (Takpochao series) and Ustorthents (Ritidian series) are on limestone escarpments and steep slopes. The deep soils on limestone plateaus are Eutrustox (Saipan series), Acrustox (Yigo series), and Haplustepts (Dandan series). Deep alluvial soils are Endoaquepts (Inarajan series) on valley bottoms and Paleustalfs (Chacha series) on limestone plateaus. It makes up about 78 square miles (202 square kilometers), or about 37 percent of Guam. The Territory of Guam is in the western Pacific Ocean, about 1,600 miles (2,580 kilometers) east of the Philippine Islands and about 3,800 miles (6,130 kilometers) west-southwest of Hawaii. Guam is the largest island of the Mariana Islands and the economic hub of Micronesia. Biological Resources the native vegetation in this area consists of mixed tropical hardwoods, but the introduced tangantangan is the dominant forest species in areas underlain by limestone. Other prominent trees are gulos, Formosan koa, putting (or fishkill), and gaogao (or tiger claw). Other mammals, such as Sambar deer, pigs, goats, and water buffalo, have been introduced and can be seen in the wild. Several endemic bird species, rufous fantail, the fairy tern, and the Vanikoro swiftlet, an endangered species, inhabit the islands. The native bird populations on Guam have been decimated through the accidental introduction of the brown tree snake. A wide range of coral, anemones, and shellfish and Physiography this area is in the Pacific Islands Province of the Pacific Rim Area. The interior of south Guam has steep or very steep mountains deeply dissected by numerous streams and some rivers. The windward east side of the area consists of nearly level to moderately sloping plateaus that are highly dissected by streams. The primary seasons in the area are the dry season, from January through April, and the rainy season, from July through November. Many rivers and streams on the volcanic bedrock provide abundant, good-quality surface water. Municipal water is stored in the Fena Reservoir, which supplied approximately 7 to 9 million gallons per day (25 to 35 million liters per day) to the U. Some domestic water is pumped from sedimentary material in the northwest corner of the area, along the coast. Cliffs, gentle to steep slopes, beaches, and reef flats characterize the shoreline. More than 40 rivers and streams form the drainage pattern in the area, and the Fena Reservoir is near the center of the area. Geology South Guam consists primarily of deeply weathered volcanic rock from an uplifted submarine volcano. This volcanic origin is linked to the tectonic subduction of the Pacific Plate under the Philippine Plate. The volcanic material is primarily andesite and basalt reworked as tuff, tuff breccia, tuffaceous sandstone, shale, and volcanic conglomerate formed during the Oligocene and Miocene epochs. Areas of limestone are along the southeast coast and on the tops of ridges in some of the highest mountains. The soils are shallow to deep, well drained to somewhat poorly drained, and fine textured. These soils, along with Haplustalfs (Atate series) and Haplustepts (Sasalaguan and Togcha series), are on moderately sloping to steep uplands. Endoaquepts (Inarajan series) and Haplustepts (Ylig series) are on broad valley bottoms and 452 Major Land Resource Areas coastal lowlands.
When do you think you will have the opportunity to first try this behavior or discussion Suggested statements supporting and reinforcing the client: You have really done something good for yourself in putting this plan into place quit smoking brochures purchase 52.5mg nicotinell visa. For people who inject drugs quit smoking 80524 zip code cheap nicotinell 17.5mg amex, this includes those who have injected illicit drugs in the past 6 months and who have shared injection equipment or have been in drug treatment for injection drug use in the past 6 months quit smoking using e-cigarettes buy 17.5 mg nicotinell with amex. Pages 34-35 of that section contain algorithms for offering testing in low and high prevalence settings quit smoking devices discount nicotinell 17.5 mg online. Clients should be encouraged to commit to a single, explicit step to reduce their risk. Clients are more likely to comply with a concise, selfdeveloped risk reduction plan based on risk information that they have been made aware of through the counseling session. Pre-test counseling should be provided in a manner that encourages clients to return for their results. Any barriers related to clients receiving their results should be eliminated or reduced. Informed consent shall include an explanation that the information identifying the test subject and the results of the test are confidential and protected against further disclosure to the extent provided by law. Information shall also be included on the fact that persons who test positive will be reported to the local county health department, that anonymous testing is available and the locations of anonymous testing sites. The client need only be informed that the test will take place and that they have the option to opt out. Counselors should be aware of local shelters and make referrals and linkages as appropriate. The Florida Domestic Violence Hotline (1-800-5001119) provides information and referrals in English, Spanish, and Haitian Creole. The pre- and post-test counseling sessions, and the informed consent process, are slightly different when rapid testing is done. Please refer to the rapid testing counseling guidelines at the end of this chapter. Discuss indications for testing (medical indication and/or information obtained from the risk assessment). In very rare exceptions, it may take up to six (6) months for these antibodies to develop. Discuss the potential social, medical, and economic impact of a positive test result. Provide information on support services that are available during the waiting period for test results. Inform the client that the counselor who conducts the pre-test counseling session may not be the same for post-test counseling. The client should also be aware that Florida law provides penalties for breaches of confidentiality. Confidential testing can more readily facilitate access into medical care for positive clients and can assist medical providers in offering more integrated care for other medical conditions that positive clients may have. If anonymous testing is not available at a test site and clients want to be tested anonymously, a list of local anonymous test sites should be given to these clients. Establish rapport by introducing him/herself to the client (particularly if he/she did not do the risk assessment). Describe what a negative, positive & indeterminate test means and describe the role of the "window period" for detection of antibodies. Ask the client what impact a negative or positive test result would have on his/her behavior and what behavior changes he/she would make in each instance. Make an appointment for the client to return for his/her test results and stress the importance of keeping the appointment. Discuss appropriate risk reduction and elimination measures (personalize his/her risk). This information should be used to guide the counselor in determining whether the client was inside the "window period" at the time of this test, and the appropriate time for retesting.
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