Matthew Kendall McNabney, M.D.
- Program Director, Fellowship Training Program in Geriatric Medicine and Gerontology
- Associate Professor of Medicine
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0013576/matthew-mcnabney
An evaluation of 62 cases of pneumonia in 2003 found eight had seroconverted with Q fever antibody erectile dysfunction 25 discount viagra 50 mg with amex,111 and an additional four diagnosed cases in 2003 and 2004 were reported erectile dysfunction doctors in baltimore buy 25mg viagra otc. One serosurvey revealed 10% of 909 military personnel hospitalized during deployment in 20032004 with symptoms compatible with Q fever seroconverted erectile dysfunction treatment brisbane buy viagra 100 mg online,115 and another serosurvey studying the same company affected in the outbreak in 2005 found seroconversion in 7 erectile dysfunction age factor order viagra 25mg overnight delivery. Case Review of 2005 Q fever cases Biological Agent: C burnetii, gram-negative, facultative, intracellular coccobacillus Potential Epidemiological Clues: 1, 4 Review: An attack rate of 58% occurred in one platoon. Although the research team was unable to determine exact movements of the platoon, it is likely they had an exposure different from the other platoons. A relatively short epidemic curve, especially with a long and variable incubation period for the pathogen, suggests a point source. This outbreak probably resulted from an isolated exposure over a short time period. It is a disease of relatively high severity, had an unknown cause at time of outbreak, and can raise concern about potential intentional cause. Lessons Learned: All medical personnel should know what diseases are endemic in the area and previous history in deployed forces. Cases should be reported immediately to allow dissemination of recommended diagnostics and treatment. In this case, the Armed Forces Infectious Disease Society published a set of practice guidelines for diagnosis and management of Q fever to assist deployed medical personnel. Knowledge obtained will assist in preventing, recognizing, and rapidly treating future cases. Grunow and Finke developed an epidemiological assessment tool to rule out biological agent use during infectious disease outbreaks. The most significant nonconclusive criteria include a biological threat or risk, special aspects of a biological agent, a high concentration of biological agent in the environment, and epidemic characteristics. Or can an outbreak be explained by natural biological hazards, or the changes incurred by military conflict? With the advent of a nonendemic pathogen, a thorough evaluation should include epidemiological, epizootic, ecological, microbiological, and forensic analysis. Is the course of illness relative to disease intensity and spread in the population expected in naturally occurring illness? The Grunow-Finke epidemiological assessment procedure (Table 2-1) was used to evaluate the case studies presented in this chapter. To use the assessment tool uniformly for all the events described in this chapter, some artificial constraints were placed on the analysis. For this exercise, only nonconclusive criteria were used because the use of conclusive criteria may have excluded many of the case studies with a retrospective assessment. During an outbreak investigation, however, epidemiological investigators would also initially use the nonconclusive evaluation criteria. Grunow and Finke provide the following cut-off scores for nonconclusive criteria with respect to the likelihood of biological weapon use: · unlikely (0%33% confidence): 0 to 17 points; · doubtful (18%35% confidence): 18 to 35 points; · likely (67%94% confidence): 36 to 50 points; and · highly likely (95%100% confidence): 51 to 54 points. The basic epidemiological principles described earlier in this chapter (including those needed for disease recognition) to determine the occurrence of an unnatural event, and for basic outbreak investigation, are the foundation of infectious disease response and control. Public health authorities must remain vigilant to quickly and appropriately respond to any infectious disease event. However, even before confirmed diagnoses, disease reporting can be initiated upon patient presentation to healthcare providers with initial diagnoses, laboratory testing, and the reason provided by the patient for the hospital visit. Clinicians, laboratories, hospitals, ancillary healthcare professionals, veterinarians, medical examiners, morticians, and others may be partners in reporting diseases to public health authorities. If a medical surveillance system first detects a biological attack, there may already be a significant number of cases, and the available time to prevent further illness is short or perhaps already over. Some disease exposures could be prevented through publicized avoidance of the area at risk, prophylactic medication use, or vaccination of those exposed, coupled with immediate disease recognition and patient treatment. Such detectors could be of great utility when pre-positioned at large well-publicized gatherings or in cities that may be the greatest targets for terrorist activity. In most instances, the earliest opportunity to detect an attack will be by recognizing ill patients. Depending on the agent, the mode of dissemination, and the number exposed, initial cases will present in different ways.
It would be interesting to engage students in a case study where they discuss how they would respond to a patient who shows up to their office with results from their Google search guaranteed erectile dysfunction treatment discount 25 mg viagra overnight delivery, or other similar scenario erectile dysfunction treatment in mumbai viagra 25 mg low price. Web Design My foray into rhetoric and trust in online environments points to some practical implications for web designers erectile dysfunction treatment in pune cheap viagra 25 mg online, web writers erectile dysfunction low blood pressure effective 50 mg viagra, and other professional technical communicators tasked with fostering community and a trustworthy web presence. My findings most immediately apply, of course, to e-health, but I begin by addressing what my study might mean for online writing instruction. Design of online instruction I have already shared ways instructors can help their students think about trust to inform their writing projects, but another consideration is the importance of trust to a successful classroom environment. While instructors can take steps to promote trust among students, in an online course, the role of technology must also be considered. Online courses are becoming more popular, and, especially in writing courses where much of the learning takes place through small group interaction and peer feedback among students who have never met each other, instructors have been interested in how to foster a sense of community in the absence of a face-to-face classroom environment. As my study confirmed, dynamics like validation of others, politeness, ability to develop a reputation over time, and even humor all contribute to a functioning online community where trust can thrive, and such findings might even help teachers see interaction that they deem as off-topic as actually setting a foundation of trust that enhances interaction about class-related topics. Assuming that mutual trust among students and instructor is part of what makes a class community successful, instructors and administrators should attend to these dynamics. However, bringing the lens of trust and associated literature from internet studies and other fields could provide additional insights and translate into a direction for classroom research. At a different level, part of the answer to promoting trust in a class community lies in the design of course management systems and other digital spaces where students interact. Companies that develop such systems might take cues from social media sites that successfully deploy reputation systems and track metrics like helpfulness ratings from peers. Some software developed by writing scholars, for instance, collects data on the peer review process and enables students to rate helpfulness of feedback. Tools like this suggest the possibilities for capturing some of the social contributors to trust in computerized ways. Design of e-health websites My study has the most direct implications for e-health designers and communicators (though the implications could extend to any type of website where trust is crucial). One of the major findings of my study was how e-health sites of all types seem to be growing towards the social, if only in constrained ways. As I mentioned in the introduction, e-health is a sensitive situation in terms of trust because people use online information to make medical decisions. Legitimate health organizations need to know how to make their 186 websites, and their information, stand out amidst the false, misguided, or incomplete medical information out there. If a governmental website needs to get the word out about, say, vaccines, knowledge of the features that promote trust is essential. Of course, many patients deliberately seek out official, expert, information-based sites already, because these patients trust that kind of information. Therefore, I do not mean to suggest that informational sites will or should go away. However, the finding that patient experience and similarity can be particularly persuasive to users might be leveraged in lieu of or in addition to more traditional credibility strategies that reflect hierarchical views of medical information (wherein experts educate lay people in unidirectional manner). According to Miller (2003), conflating ethos and expertise edges out goodwill and virtue,44 the more relational aspects of ethos, and limits trust: "The impersonality of an ethos of expertise runs the risk of being persuasive to no one" (p. The issue of vaccination illustrates this need for a broadened view of how trust operates in e-health. The researchers found that provaccine sites demonstrated a unidirectional, non-interactive model that played up the expertise of their sources, while vaccine-skeptical sites employed a wider variety of features and sources with a particular focus on creating communities. Studies that assess e-health websites on the basis of only their quality and accuracy do not tell us 44 Miller also says of the technical, expert ethos: "the third component of ethos, phronesis, or "good sense" [at times translated "practical intelligence"], is transformed into a narrower and more technical form of knowledge, diminishing the practical, or relational, dimensions of knowledge itself" (p. Physicians and officials concerned with misinformation online have been interested in driving users away from potentially harmful websites. Instead, to promote good quality information, web designers for e-health might take cues from what actually seems to work in terms of trust. E-health designers might promote trust by thinking of ways to represent the patient voice. The case of Medpedia reflects, perhaps, the importance of creating a space for patient interaction even in information-based sites.
Differential inhibition of type I interferon induction by arenavirus nucleoproteins erectile dysfunction medscape buy viagra 100mg free shipping. Inhibition of the type I interferon response by the nucleoprotein of the prototypic arenavirus lymphocytic choriomeningitis virus erectile dysfunction age group order viagra 50mg free shipping. Physiological and immunologic disturbances associated with shock in a primate model of Lassa fever erectile dysfunction doctors in south jersey purchase 100 mg viagra with visa. Experimental infection of guinea pigs with Venezuelan hemorrhagic fever virus (Guanarito): a model of human disease erectile dysfunction treatment doctors in hyderabad buy viagra 100 mg on line. Ultrastructural and immunohistochemical study of the human kidney in Argentine haemorrhagic fever. Experimental Argentine hemorrhagic fever in rhesus macaques: viral strain-dependent clinical response. Virus-specific factors in experimental Argentine hemorrhagic fever in rhesus macaques. Experimental Argentine hemorrhagic fever in rhesus macaques: virus-specific variations in pathology. Replication of dengue and Junin viruses in cultured rabbit and human endothelial cells. Alteration of blood coagulation and complement system in neotropical primates infected with Junin virus. Studies of the coagulation system and blood pressure during experimental Bolivian hemorrhagic fever in rhesus monkeys. Studies of blood coagulation and pathology in experimental infection of guinea pigs with Junin virus. Junin virus infection of guinea pigs: immunohistochemical and ultrastructural studies of hemopoietic tissue. Early markers of blood coagulation and fibrinolysis activation in Argentine hemorrhagic fever. Normal platelet aggregation and release are inhibited by plasma from patients with Argentine hemorrhagic fever. Further studies on the plasma inhibitor of platelet activation in Argentine hemorrhagic fever. Early and strong immune responses are associated with control of viral replication and recovery in Lassa virus-infected cynomolgus monkeys. Low levels of interleukin-8 and interferon-inducible protein-10 in serum are associated with fatal infections in acute Lassa fever. Cutting edge: impairment of dendritic cells and adaptive immunity by Ebola and Lassa viruses. Lassa virus infection of human dendritic cells and macrophages is productive but fails to activate cells. Junнn virus infection of guinea pigs: electron microscopic studies of peripheral blood and bone marrow. Cell-mediated immunity and lymphocyte populations in experimental Argentine hemorrhagic fever (Junнn virus). Ultrastructural and immunohistochemical studies in five cases of Argentine hemorrhagic fever. Junin virus replication in peripheral blood mononuclear cells of patients with Argentine haemorrhagic fever. In vivo replication of pathogenic and attenuated strains of Junin virus in different cell populations of lymphatic tissue. Proinflammatory cytokines and elastase-1-antitrypsin in Argentine hemorrhagic fever. Tumor necrosis factor/cachectin-induced intravascular fibrin formation in meth A fibrosarcomas. Effects of hyperthermia and tumour necrosis factor on inflammatory cytokine secretion and procoagulant activity in endothelial cells. Tumor necrosis factor/cachectin increases permeability of endothelial cell monolayers by a mechanism involving regulatory G proteins.
During this period people will have gained awareness of the morbidity and mortality associated with the infectious agent or toxin and will have continued-possibly escalating-fear about exposure to this invisible threat erectile dysfunction see urologist cheap viagra 100 mg with mastercard. Ineffective messaging may have contributed to public fear and panic during the 2001 Amerithrax incident erectile dysfunction on coke order viagra 25 mg. Many people thought anthrax was a contagious disease erectile dysfunction caused by hernia 100 mg viagra for sale, and because the infectious agent was delivered in a powdered form there was widespread fear of powders in general erectile dysfunction in the age of viagra buy discount viagra 50mg on-line. People were more aware of powders and powder-appearing residues after the incident. Powders associated with many normal activities that went unnoticed or created no concern before the incident suddenly created concern, fear, and panic. Effective accurate communications may have mitigated some of these concerns and will remain important throughout any recovery. Exposed populations and contaminated buildings, equipment, and environments will likely be identified during the response effort, but continued surveillance will remain important to identify additional cases of human or animal disease and potential contamination spread that will need to be included in decontamination efforts. Its effectiveness will depend on accurate identification of the contaminating infectious agent or toxin; assessment of primary and secondary areas of contamination; and selection of suitable decontamination reagents, equipment, and methods that factor in effectiveness for the contaminating agent and the environment. Appropriate subject matter experts should be included in planning and executing decontamination. Personnel involved in recovery operations will not have the benefit of established clearance strategies for reoccupation of contaminated facilities or resumed use of contaminated equipment for all potential biological agents. Members of the Environmental Protection Agency and the Centers for Disease Control and Prevention published an interim clearance strategy for a building or an outdoor environment after an incident involving Bacillus anthracis in July 2012. It was determined that no detection of viable spores is the best practicable clearance goal,19 which is a sound goal for B anthracis as well as many other potential biological agents. It infers that the agent identification technology used will identify viability as well as continued presence of the pathogen on or in the sampled item. Some of the more sensitive agent identification technologies (nucleic acid amplification and antigen detection) will not demonstrate agent viability. Agents killed or neutralized during decontamination may still be detected by these technologies and not properly inform clearance decisions. Cleanup procedures could be unnecessarily prolonged with no added benefit if decisions are being made based on technologies that do not aid the risk assessment procedure by demonstrating agent viability. Local or state public health officials or property owners will likely make the final decision on clearance. Establishing transportation routes becomes critical during both response and recovery to facilitate response and recovery mitigation activities as well as continue providing critical services and support inside the contaminated area. Once a biological incident has occurred, containment becomes important 103 Medical Aspects of Biological Warfare to all aspects of the management strategy. Factoring containment considerations into all subsequent planning will prevent the incident from growing in scale and magnitude, minimizing impact on human health, infrastructure, and economy. Strategies will vary depending on the situation and conditions, but some basic principles can be applied to all. Whenever one is dealing with biological contamination, it is beneficial to establish at least three zones: 1. Operational procedures should be established for each zone that facilitate the movement of necessary supplies, personnel, and equipment to sustain operations and facilitate recovery without spreading contamination. If a clean corridor cannot be established through the warm zone to the hot zone, handoff procedures will need to be established for cross-zone movement. Decontamination procedures at each handoff point will need to be established for any movement from hot zone to warm zone and from the warm zone to the cold zone. One strategy may be to have dedicated equipment in each zone that will facilitate the movement of personnel and supplies from the cold zone to the hot zone and sustain operations in the warm zone and hot zone. Personal protective equipment requirements must also be established for each zone to prevent secondary contamination to workers. It affirms that local leaders and local governments maintain a primary role even when their response 104 capabilities have been overwhelmed and state or federal assistance is required. It recognizes that partnerships and collaborations with unity of effort are essential to successful recovery and emphasizes that compliance with the principles of equal opportunity and civil rights must be upheld. It further emphasizes the importance of clear, consistent, culturally appropriate, and frequent communications to the affected public.
Articular gout lesions also may be surgically opened and expressed to speed removal of uric acid crystal accumulation erectile dysfunction latest medicine cheap viagra 75mg amex. Use aggressive fluid therapy if articular or visceral gout is accumulating rapidly impotence treatment purchase 75mg viagra mastercard. Anadуn A erectile dysfunction evaluation cheap 100mg viagra overnight delivery, et al: Pharmacokinetics and residues of ciprofloxacin and its metabolites in broiler chickens erectile dysfunction treatment adelaide buy 75mg viagra free shipping. Angel R, Ballam G: Dietary protein effect on parakeet plasma uric acid, reproduction, and growth. Benador D, et al: Are younger children at highest risk of renal sequelae after pyelonephritis? Biancifiori F, Rondini C, Grelloni V: Avian toxoplasmosis: experimental infection of chicken and pigeon. Boulianne M, et al: Effect of exercise on the cardiovascular and respiratory systems of heavy turkeys and relevance to sudden death syndrome. Brayton C: Amyloidosis, hemochromatosis, and atherosclerosis in a roseate flamingo (Phoenicopterus ruber). Cacini W: Comparative accumulation of uric acid and hypoxanthine by slices of avian renal cortex. Chandra M: Hematologic changes in nephritis in poultry induced by diets high in protein, high in calcium, containing urea, or deficient in vitamin A. Chandra M, et al: Clinicopathological, hematological, and biochemical studies in some outbreaks of nephritis in poultry. Cheng A-C, et al: Pathologic and pathological characteristics of new type gosling viral enteritis first observed in China. Dнaz-Ruiz C, Asbert M, PйrezTomбs R: Immunochemical study of a transforming growth factor-related protein in the chicken kidney. Escarmis C, Bozal J, Calvet F: Influencia de la colchicina y del alopurinol sobre la uricogenesis. Gerlach H, et al: Membranous glomerulopathy as an indicator of avian polyomavirus infection in Psittaciformes. Gevaert D, Nelis J, Verhaeghe B: Plasma chemistry and urine analysis in Salmonella-induced polyuria in racing pigeons (Columbia livia). Giladi I, et al: Renal function and plasma levels of arginine vasotocin during free flight in pigeons. Guerin J-L, et al: A novel polyomavirus (goose hemorrhagic polyomavirus) is the agent of hemorrhagic nephritis enteritis of geese. Hofbauer H, KrautwaldJunghanns M-E: Transcutaneous ultrasonography of the avian urogenital tract. Larochelle D, Morin M, Bernier G: Sudden death in turkeys with perirenal hemorrhage: pathological observations and possible pathogenesis of the disease. Metastatic renal carcinoma in an African grey parrot (Psittacus erithacus erithacus). Machado C, et al: Disintegration of kidney stones by extracorporeal shockwave lithotripsy in a penguin. Macwhirter P Pyke D, Wayne J:, Use of carboplatin in the treatment of renal adenocarcinoma in a budgerigar. Quantitative renal scintigraphy in domestic pigeons (Columba livia domestica) exposed to toxic doses of gentamicin. Mateo R, et al: An epizootic of lead poisoning in greater flamingos (Phoenicopterus ruber roseus) in Spain. Miyamoto K: Evaluation of plasma clearance of inulin in clinically normal and partially nephrectomized cats. Murai A, Furuse M, Okumura J: Involvement of (n-6) essential fatty acids and prostaglandins in liver lipid accumulation in Japanese quail. Mutalib A, Keirs R, Austin F: Erysipelas in quail and suspected erysipeloid in processing plant employees. Nakamura K, Abe F: Respiratory (especially pulmonary) and urinary infections of Cryptosporidium in layer chickens. Neuman U, Kummerfeld N: Neoplasms in budgerigars (Melopsittacus undulatus): clinical, pathomorphological and serological findings with special consideration of kidney tumours.
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