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By I. Cronos. Monmouth University, West Long Branch New Jersey. 2019.

This fnding has been attributed to the hard- ness and bigger particle size of sodium bicarbonate 100mg lady era with mastercard women's health center buffalo ny, which has also been observed to induce surface changes purchase lady era 100 mg without prescription breast cancer yoga mat. It was speculated that a certain amount of surface ablation might improve the biocompatibility of moderate rough surfaces (Schwarz et al cheap 100mg lady era free shipping women's health worcester ma. In the study in 2 chapter 5, the aim was therefore to assess the possible effect of fve commercially available air-abrasive powders, on the viability and cell density of three types of cells: epithelial cells, gingival fbroblasts and periodontal ligament fbroblasts. This study showed that powders 3 might indeed have different effects on various cells. It has been speculated that tricalcium phosphate residues on 4 the implant surface could improve biocompatibility and support wound healing (Tastepe et al. Chemotherapeutica 6 Surface decontamination Chemotherapeutic agents, alone or in combination with mechanical instruments, have also 7 been used for cleaning implant surfaces. Chapter 6 reviewed the literature for evidence re- garding the ability of different chemotherapeutic agents to decontaminate titanium sur- faces. Yet, it seems 8 that citric acid has the highest potential to remove bacteria and bacterial products from titanium surfaces. It should however be kept in mind that chemical agents are less capable in 9 removing bioflm than mechanical instruments. In an earlier study different results with respect to the killing potential of citric acid were reported. In this study the antibacte- rial effcacy of several antimicrobials on the oral microfora attached to titanium specimens …& Conclusions 229 1 with a machined surface after overnight contamination in the oral cavity of volunteers was assessed. All agents used were shown to signifcantly reduce the total number of attached bacteria after immersion for 1 minute. However, citric acid showed less bactericidal effect 2 compared to the other agents. It was concluded that the antiseptics sodium hypochlorite, hydrogen peroxide, citric acid, chlorhexidine, and essential oils might have some benefcial 3 effect in reducing the bacteria load on titanium surfaces (Gosau et al. Surface biocompatibility 4 Chemotherapeutic agents may have an effect on the elemental composition of the titanium surface, which subsequently may affect the biocompatibility of the surface and the biologic 5 responses. Elemental contaminants or salts have been found on titanium surfaces after treat- ment with chemical agents (Mouhyi et al. An in vitro study as- 6 sessed the effect of different chemical agents (citric acid, hydrogen peroxide, chlorhexidine, tetracycline, doxycycline, sodium fuoride and peroxyacetic acid) on the oxide layer morphol- ogy of titanium. The treatments consisted of immersion of samples in a solution or rubbing 7 them on with cotton swabs. Rubbing with swabs led to signs of titanium oxide damage in a pH-related manner (Wheelis et al. Treatment 9 with citric acid and hydrogen peroxide resulted in respectively similar or enhanced prolif- eration of epithelial cells compared to an untreated control. Less favourable results were observed with chlorhexidine due to adsorption on the titanium surface (Ugvári et al. It is also reported that chlorhexidine signifcantly impaired the proliferation of osteoblasts on treated titanium surfaces. Based on these fndings the use of chlorhexidine is not recom- mended because it produces cytotoxic effects and may thus compromise the biocompatibil- ity of the surface (Kotsakis et al. A clinical study demonstrated that the application of a 35% phosphoric etching gel at pH 1 adjunctive to the use of carbon curette and rubber cup resulted at 5 months in a higher reduction in gingival index scores and a lower number of colony-forming units compared to control treatment (Strooker et al. In patients with peri-implant mucositis, profession- ally administered chlorhexidine (irrigation, gel application or combination of both) failed to show adjunctive benefcial effects compared with mechanical debridement alone (Porras et al. Similarly, in the surgical treatment of peri-implantitis 230 Summary, Discussion… chlorhexidine resulted to a greater suppression of anaerobic bacteria in short term but failed 1 to show superior clinical results compared to placebo-control (De Waal et al. In the study in chapter 7, the 3 available evidence with respect to the patient-administered measures for mechanical plaque removal around implant-supported restorations was scrutinized. Compared to the studies fo- 4 cussing on placing dental implants the scientifc literature on how to maintain them is very limited. Powered 5 toothbrushes seem to be effective in cleaning both fxed and removable implant-supported restorations. No hard evidence was found that powered toothbruhing is superior to manual toothbrushing, although powered toothbrushing may help to overcome limitations in manu- 6 al dexterity and accessibility. These fndings are in accordance with the recommendations of the Ninth European Workshop on Periodontology regarding patient-administered measures 7 in the management of peri-implant mucositis (Jepsen et al. The evidence on interproximal cleaning around implant- 8 supported restorations is scarce. Interdental brushes, when used by a trained dental care professional, seem to be effective in removing plaque from interproximal areas (Chongcha- 9 roen et al. Often implant-supported restorations present contours and shapes that render plaque removal diffcult, even by the most capable individuals. A clinical retrospective study showed that high proportions of implants diagnosed with peri-implantitis were associated with inadequate plaque control or lack of accessibility for oral hygiene measures whereas peri- implantitis was rarely diagnosed at implants supporting cleansable restorations or when proper plaque control was performed (Serino & Ström 2009). Like Salvi and Ramseier (2015) stated: “Individually tailored oral hygiene instructions should be given to patients rehabili- tated with dental implants. Whenever possible, margins of implant- supported restorations should be placed at or above the mucosal margin to facilitate access for plaque control and implant-supported restorations with poor access for plaque removal should be adjusted or replaced by cleansable restorations”. Anyhow at present, home care recommendations are based mainly on the knowledge that is available with respect to cleaning of natural teeth. It …& Conclusions 231 1 becomes evident that there is an urgent need for academic institutions and industry to initi- ate and support high quality randomized controlled clinical trials on this topic in the near future. Consensus was reached on recommenda- 4 tions for patients with dental implants and dental care professionals with regard to the effcacy of measures to prevent or manage peri-implant mucositis. It was particularly empha- 5 sized that implant placement and prosthetic reconstructions need to allow proper personal cleaning, proper monitoring of the peri-implant tissues and professional plaque removal (Je- 6 psen et al 2015). Chapter 8 is an epitome of a clinical guideline developed in the Netherlands on behalf of the Dutch Society of Periodontology and the Dutch Society of Oral Implantology regarding the diagnosis, prevention and treatment of peri-implant diseases. Practically, guidelines attempt to distil a large body of medical expertise into a convenient readily usable format (Cook et al. The strength of the recommendations is in part dependent on the quality of the available evidence but also on other factors like the balance between desirable and undesirable consequences of specifc treatments and cost-effectiveness. Continuous imple- mentation and evaluation of the guideline is mandatory to remain up to date. Depending on the surface characteristics, the localization of the surface and the goal of the treatment, the best suitable instrument for 2 each surface should be chosen. Based on the available in vitro data, air abrasive devices with sodium bicarbonate powder appear to be effective in removing bioflm from both smooth and rough titanium surfaces, without causing major changes on the surface structure, especially 3 in the case of rough surfaces.

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The U-type needles were embedded at each acupoint once every other day in the first week buy lady era 100mg on-line menstrual extraction at home, twice in the second week buy discount lady era 100mg on line menopause sweating, and once a week from the third to the sixth week cheap 100 mg lady era visa menopause lower back pain. About 389 cases 431 Acupuncture Therapy of Neurological Diseases: A Neurobiological View quitted smoking over 6 months, and 102 cases reduced the number of cigarettes smoked from 20 to 4 or 5 in 6 months. The needles were inserted into the auricular-points at the depth of 2 mm, and into the body acupoints at the depth of 10 mm. The needles were left in place for 45 min, for 5 days a week (from Monday to Friday), a total of 6 weeks (Avants et al. Furthermore, Li et al (2000) inserted the needles at the body acupoints quickly and rotated them until the De-Qi was achieved. The needles were left in the acupoints for 30 min, with the cupping for 15 min, once a day. In another study, Olms (1981) adopted the acupoint Tianmei along with the Nasal-Gallbladder and Ear- Attack acupoints for smoking cessation. He applied silver needles on Tianmei and Ear-Attack acupoints, and subsequently exposed them to helium–neon laser for 10 min. The apparent effect appeared immediately after one treatment, and the effect of 2822 cases was as high as 90% (Olms 1981). It is also difficult to carry out studies on this issue, owing to the lack of general standard for animal models and evaluation of the effect. Most mechanisms of acu- puncture therapy for smoking cessation are hypotheses based on clinical observations. The possible mechanisms are presumed to be related to gustatory sensation and mouth environment, neuroendocrinology, and cardiorespiratory function. The long-term smokers were examined for the threshold of bitterness, saltiness, sweetness, and sourness. It was found that the threshold of bitterness increased by 8%, as the long chain organics and alkaloid (including nicotine) is presumed to produce the bitter taste as well as because of the fact that the root of tongue is sensitive to bitterness. Owing to the use of nicotine and being non-sensitive to bitter taste for a long time, the threshold of bitterness was observed to increase. However, after acupuncture treatment, the 432 16 Acupuncture for Smoking Cessation smokers’ taste of cigarette changed into bitter, tasteless, abnormal, or sweet, and resulted in the loss of the desire to smoke (Fang 1999). Zhang (1990) tested the pH values of the saliva in the mouth of the smokers and showed that the pH value was higher than normal. Therefore, it is believed that smoking might change the internal environment of the mouth, gullet, as well as stomach. Moreover, acupuncture treatment is considered to lead the smokers to feel bitterness, experience paralysis, cough, and dizziness symptoms when they smoked again, by regulating the internal environment of the mouth and whole body (Zhang 1990). The results showed that the contents increased in long-term smokers, but decreased after auriculo-acupuncture treatment (Fang and Li 1985). Furthermore, the blood carbonylhemoglobin was observed to be higher in smokers; the inner and outer environment of the erythrocytes changed and affected the fluidity of the membrane lipid zone. This might be the direct action of nicotine or a series of responses to nicotinic derivants. However, acupuncture is believed to reverse the effect of nicotine on the fluidity of membrane lipid zone, suggesting the role of acupuncture treatment for smoking cessation (Li 1984). According to the theory 433 Acupuncture Therapy of Neurological Diseases: A Neurobiological View of Zang-fu organs, the lung and the large intestine, as well as the spleen and the stomach, are the exterior-interior organs for each other. Hence, the smokers usually exhibit the heat-evil symptoms of the lung and stomach, such as cough with yellow sticky sputum, pain in the chest, xeromycteria, constipation, anorexia, xerostomia, halitosis, etc. Furthermore, smokers generally have a red tongue with yellow coating, and rapid pulse. Therefore, the principle of acupuncture treatment for smoking cessation is to clear away the heat-evil of the lung and stomach (Fig. Smokers usually present the heat evil symptoms of the lung and stomach, such as cough with yellow sticky sputum, pain in the chest, xeromycteria, constipation, anorexia, xerostomia, halitosis, etc. Therefore, the principle of acupuncture treatment for smoking cessation is to clear away the heat evil of lung and stomach. Researchers also found that the psychological factor of acupuncture treatment was principally from the support of therapists, but not the smokers themselves. When combined with the psychological and behavioral therapies, the effect of acupuncture treatment is observed to be better (Cui and Jiang 1992). Sun (2000) randomly divided 60 patients into two groups: auriculo-acupoints group and auriculo-acupoints with psychological treatment group. The patients of the latter group were given a 434 16 Acupuncture for Smoking Cessation professional introduction, transference, teaching, and rising morale. The results showed that there was obvious differences between the two groups, and the withdrawal symptoms of the auriculo-acupoints group, when compared with the auriculo-acupoints with psychological treatment group, were less and statistically insignificant. In summary, as a nature therapy, acupuncture is considered to be effective for smoking cessation, as it is presumed to regulate the whole body. However, there are still many problems that need to be addressed in the future, such as high recurrence rate, unstable immediate effects, etc. When compared with the pharmacologic or psychological methods, acupuncture therapy is observed to be unique and effective. However, owing to limited mechanistic researches, its use and development in the clinic environment is still not widespread. As the study on the effects of acupuncture treatment for smoking cessation has been carried out since the past 30 years, more work on the clinical study or basic research is believed to provide greater insight and offer great help to patients who are attempting to quit smoking. American Journal of Medicine 75: 1033 1036 Cui M (1996) The research development of withdrawal symptoms by acupuncture (continuation one). British Journal of Addition 86: 57 59 Hajek P, West R, Foulds J (1999) Randomized comparative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler. Zhongguo Ming Jian Liao Fa (Chinese Civilian Therapy) 14: 58 60 (in Chinese) Karnath B (2002) Smoking cessation. Zhen Jiu Lin Chuang Za Zhi (Journal of Clinical Acupuncture & Moxibustion) 16: 32 (in Chinese) Zhang Q (1990) 108 cases smokers treated by auriculo acupuncture and body acupuncture. Zhongguo Zhen Jiu (Chinese Acupuncture & Moxibustion) 10: 23 24 (in Chinese with English abstract) 436 17 Beneficial Effect of Acupuncture on Depression Qiong Liu and Jin Yu Department of Integrative Medicine and Neurobiology Shanghai Medical College of Fudan University, Shanghai 200032, P. China Summary This chapter presents the clinical and laboratory evidence regarding the effect of acupuncture on depression and its potential mechanisms.

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Distinguishing features of the trophozoites are large karyosomes and lack of peripheral chromatin, giving the two nuclei a halo appearance. This protozoa lacks mitochondria, although the discovery of the presence of mitochondrial remnant organelles in one recent study "indicate that Giardia is not primitively amitochondrial and that it has retained a functional organelle derived from the original mitochondrial endosymbiont" 240 Bacteriological Diseases ©11/1/2017 (866) 557-1746 Entamoeba histolytica Entamoeba histolytica, another water-borne pathogen, can cause diarrhea or a more serious invasive liver abscess. There is a rapid influx of calcium into the contacted cell, it quickly stops all membrane movement save for some surface blebbing. The symptoms often are quite mild and can include loose stools, stomach pain, and stomach cramping. Amebic dysentery is a severe form of amebiasis associated with stomach pain, bloody stools, and fever. Even less commonly, it spreads to other parts of the body, such as the lungs or brain. Scientific Classification Domain: Eukaryota Phylum: Amoebozoa Class: Archamoebae Genus: Entamoeba Species: E. Each cell has a separate stalk anchored onto the substrate, which contains a contracile fibril called a myoneme. Reproduction is by budding, where the cell undergoes longitudinal fission and only one daughter keeps the stalk. Vorticella mainly lives in freshwater ponds and streams - generally anywhere protists are plentiful. Domain: Eukaryota Phylum: Ciliophora Class: Oligohymenophorea Subclass: Peritrichia Order: Sessilida Family: Vorticellidae Genus: Vorticella 242 Bacteriological Diseases ©11/1/2017 (866) 557-1746 Rotifer The rotifers make up a phylum of microscopic and near-microscopic pseudocoelomate animals. Leeuwenhoek is mistakenly given credit for being the first to describe rotifers but Harris had produced sketches in 1703. Rotifers may be free swimming and truly planktonic, others move by inch worming along the substrate, whilst some are sessile, living inside tubes or gelatinous holdfasts. Rotifers get their name (derived from Greek and meaning "wheel-bearer"; they have also been called wheel animalcules) from the corona, which is composed of several ciliated tufts around the mouth that in motion resemble a wheel. These create a current that sweeps food into the mouth, where it is chewed up by a characteristic pharynx (called the mastax) containing a tiny, calcified, jaw-like structure called the trophi. Most free-living forms have pairs of posterior toes to anchor themselves while feeding. There is a well- developed cuticle which may be thick and rigid, giving the animal a box-like shape, or flexible, giving the animal a worm-like shape; such rotifers are respectively called loricate and illoricate. Males in the class Monogononta may be either present or absent depending on the species and environmental conditions. In the absence of males, reproduction is by parthenogenesis and results in clonal offspring that are genetically identical to the parent. Resting eggs develop into zygotes that are able to survive extreme environmental conditions such as may occur during winter or when the pond dries up. These eggs resume development and produce a new female generation when conditions improve again. The life span of monogonont females varies from a couple of days to about three weeks. Bdelloid rotifers are unable to produce resting eggs, but many can survive prolonged periods of adverse conditions after desiccation. This facility is termed anhydrobiosis, and organisms with these capabilities are termed anhydrobionts. Under drought conditions, bdelloid rotifers contract into an inert form and lose almost all body water; when rehydrated, however, they resume activity within a few hours. Bdelloids can survive the dry state for prolonged periods, with the longest well- documented dormancy being nine years. While in other anhydrobionts, such as the brine shrimp, this desiccation tolerance is thought to be linked to the production of trehalose, a non-reducing disaccharide (sugar), bdelloids apparently lack the ability to synthesize trehalose. Each is different and found on a different chromosome, excluding the possibility of homozygous sexual reproduction. As they are prokaryotes, bacteria do not tend to have membrane-bound organelles in their cytoplasm and thus contain few large intracellular structures. They consequently lack a nucleus, mitochondria, chloroplasts and the other organelles present in eukaryotic cells, such as the Golgi apparatus and endoplasmic reticulum. Typically, bacteriophages consist of an outer protein hull enclosing genetic material. Bacteriophages are much smaller than the bacteria they destroy - usually between 20 and 200 nm in size. Phages are estimated to be the most widely distributed and diverse entities in the biosphere. Phages are ubiquitous and can be found in all reservoirs populated by bacterial hosts, such as soil or the intestine of animals. One of the densest natural sources for phages and other viruses is sea water, where up to 9×108 virions per milliliter have been found in microbial mats at the surface, and up to 70% of marine bacteria may be infected by phages. In the case of the T4 phage, in just over twenty minutes after injection upwards of three hundred phages will be released via lysis within a certain timescale. This is achieved by an enzyme called endolysin which attacks and breaks down the peptidoglycan. In contrast, "lysogenic" phages do not kill the host but rather become long-term parasites and make the host cell continually secrete more new virus particles. The new virions bud off the plasma membrane, taking a portion of it with them to become enveloped viruses possessing a viral envelope.

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If a patient has three mercury amalgam fillings placed in the mouth and a week later has a kidney problem trusted 100 mg lady era weird women's health issues, will she call the dentist—or the doctor? Will they ever tell the dentist about the kidney problem or tell the doctor about the three fillings? It is common for patients who have had their metal fillings removed to have various symptoms go away but buy cheap lady era 100 mg on-line women's health subscription, again buy cheap lady era 100mg breast cancer 2a, they do not tell the dentist. If your dentist will not follow the necessary procedures, then you must find one that will. A properly cleaned socket which is left after an ex- traction will heal and fill with bone. If you allow the work to be done by a dentist who does not understand the im- portance of the above list, you could end up with new problems. Normal treatment cost is about $1,000 for replacement of 6 to 8 metal fillings including the examination and X-rays. For people with a metal filling in every tooth, or for the extraction of all teeth (plus dentures), it may be up to $3,000 (or more in some places). Clark: Removing all metal means removing all root ca- nals, metal fillings and crowns. But you may feel quite attached to the gold, so ask the dentist to give you everything she or he removes. The top surfaces of tooth fillings are kept glossy by brushing (you swallow some of what is removed). Bad breath in the morning is due to such hidden tooth infections, not a deficiency of mouthwash! Jerome: If your dentist tells you that mercury and other metals will not cause any problems, you will not be able to change his or her mind. Ask for the panoramic X-ray rather than the usual series of 14 to 16 small X-rays (called full mouth series). This lets the dentist see impacted teeth, root frag- ments, bits of mercury buried in the bone and deep infections. Cavitations are visible in a panoramic X-ray that may not be seen in a full mouth series. Unfortunately, many people are in a tight financial position because of the cost of years of ineffective treatment, trying to get well. Jerome: It is quite all right to have temporary crowns placed on all teeth that need them in the first visit. It is common to find a crowned tooth to be very weak and not worth replacing the crown, particularly if you are already having a partial made and could include this tooth in it. The metal is ground up very finely and added to the plastic in order to make it harder, give it sheen, color, etc. Jerome: Dentists are not commonly given information on these metals used in plastics. Their effects on the body from dentalware 21 Call the American Dental Association at (800) 621-8099 (Illinois (800) 572-8309, Alaska or Hawaii (800) 621-3291). Members can ask for the Bureau of Library Services, non-members ask for Public Infor- mation. Jerome: These are the acceptable plastics; they can be procured at any dental lab. The new ones are very much superior to those used 10 years ago and they will continue to improve. They do, however, contain enough barium or zirconium to make them visible on X-rays. Hopefully, a barium-free va- riety will become available soon to remove this health risk. Jerome: Many people (and dentists too) believe that porcelain is a good substitute for plastic. Porcelain is aluminum oxide with other metals added to get different colors (shades). Jerome for his contributions to this section, and his pioneering work in metal- free dentistry. Horrors Of Metal Dentistry Why are highly toxic metals put in materials for our mouths? Just decades ago lead was commonly found in paint, and until recently in gasoline. The government sets standards of toxicity, but those “standards” change as more research is done (and more people speak out). You can do better than the government by dropping your standard for toxic metals to zero! Opponents cite scientific studies that implicate mercury amalgams as disease causing. Cad- mium is five times as toxic as lead, and is strongly linked to high blood pressure. Occasionally, thallium and germanium are found together in mercury amalgam tooth fillings. If you are in a wheelchair without a very reliable diagnosis, have all the metal removed from your mouth. Try to have them analyzed for thallium using the most sensitive methods available, possibly at a research institute or university. Effects are cumulative and with continuous exposure toxicity occurs at much lower levels. The periph- eral nervous system can be severely affected with dying-back of the longest sensory and motor fibers. Acute poisoning has followed the ingestion of toxic quantities of a thallium-bearing depilatory and accidental or suicidal ingestion of rat poison. Acute poisoning results in swelling of the feet and legs, arthralgia, vomiting, insomnia, hyperesthesia and paresthesia [numbness] of the hands and feet, mental confusion, polyneuritis with severe pains in the legs and loins, partial paralysis of the legs with reaction of degeneration, angina-like pains, nephritis, wasting and weakness, and lymphocytosis and eosinophilia. Thallium pollution frightens me more than lead, cadmium and mercury combined, because it is completely unsuspected. For instance chromium is an essential element of glucose tolerance 24 Dangerous Properties of Industrial Materials, 7th ed.

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Where available buy discount lady era 100 mg online womens health total body transformation, and only if a mother’s breastmilk is unavailable or insufficient buy lady era 100 mg mastercard womens health 2013, give newborns pasteurized donor breastmilk until they go home buy 100mg lady era mastercard menstrual like cramping in late pregnancy. In special care facilities, separate infected infants from those who are premature or ill in other ways. No common bathing or dressing tables should be used, and no bassinet stands should be used for holding or transporting more than one infant at a time. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics; no individual case report, Class 4 (see Reporting). In communities with adequate sewage disposal system, feces can be discharged directly into sewers without preliminary disinfection. For severe enteropatho- genic infant diarrhea, oral trimethoprim-sufamethoxazole (10–50 mg/kg/day) has been shown to ameliorate the sever- ity and duration of diarrheal illness; it should be administered in 3–4 divided doses for 5 days. Epidemic measures: For nursery epidemics (see section 9B1) the following: 1) All babies with diarrhea should be placed in one nursery under enteric precautions. Suspend maternity service unless a clean nursery is available with separate personnel and facili- ties; promptly discharge infected infants when medically possible. For babies exposed in the contaminated nursery, provide separate medical and nursing personnel skilled in the care of infants with communicable diseases. Observe con- tacts for at least 2 weeks after the last case leaves the nursery; promptly remove each new infected case to the single nursery ward used for these infants. Maternity service may be resumed after discharge of all contact babies and mothers, and thorough cleaning and terminal disinfection. Put into practice the recommendations of 9A, in so far as feasible, in the emergency. It was subsequently recognized in India as being associated with persistent diarrhea (continuing unabated for at least 14 days), an observation that has since been confirmed by reports from Bangladesh, Brazil and Mexico. Identification—An acute bacterial disease primarily involving ton- sils, pharynx, larynx, nose, occasionally other mucous membranes or skin and sometimes conjunctivae or vagina. The characteristic lesion, caused by liberation of a specific cytotoxin, is an asymmetrical adherent greyish white membrane with surrounding inflammation. The throat is moderately to severely sore in faucial or pharyngotonsillar diphtheria, with cervical lymph nodes somewhat enlarged and tender; in moderate to severe cases, there is marked swelling and oedema of the neck with extensive tracheal membranes that progress to airway obstruction. Nasal diphtheria can be mild and chronic with one-sided nasal discharge and excoriations. The toxin can cause myocarditis, with heart block and progressive congestive failure beginning about 1 week after onset. The lesions of cutaneous diphtheria are variable and may be indistinguishable from, or a component of, impetigo; peripheral effects of the toxin are usually not evident. Case-fatality rates of 5%–10% for noncutaneous diphtheria have changed little in 50 years. Diphtheria should be suspected in the differential diagnosis of bacterial (especially streptococcal) and viral pharyngitis, Vincent angina, infectious mononucleosis, oral syphilis and candidiasis. Presumptive diagnosis is based on observation of an asymmetrical, greyish white membrane, especially if it extends to the uvula and soft palate and is associated with tonsillitis, pharyngitis or cervical lymphade- nopathy, or a serosanguineous nasal discharge. If diphtheria is strongly suspected, specific treatment with antibiotics and antitoxin should be initiated while studies are pending and continued even in the face of a negative laboratory report. Infectious agent—Corynebacterium diphtheriae of gravis, mitis or intermedius biotype. Toxin production results when bacteria are infected by corynebacteriophage containing the diphtheria toxin gene tox. Nontoxigenic strains rarely produce local lesions; however, they have been increasingly associated with infective endocarditis. Occurrence—A disease of colder months in temperate zones, primarily involving nonimmunized children under 15; often found among adults in population groups whose immunization was neglected. In the tropics, seasonal trends are less distinct; inapparent, cutaneous and wound diphtheria cases are much more common. A massive outbreak of diphtheria began in the Russian Federation in 1990 and spread to all countries of the former Soviet Union and Mongolia. This epidemic declined after reaching a peak in 1995; it was responsible for more than 150 000 reported cases and 5000 deaths (1990–1997). In Ecuador, an outbreak of about 200 cases, half of whom were 15 or older, occurred in 1993–94. Mode of transmission—Contact with a patient or carrier; more rarely, contact with articles soiled with discharges from lesions of infected people. Period of communicability—Variable, until virulent bacilli have disappeared from discharges and lesions; usually 2 weeks or less, seldom more than 4 weeks. Susceptibility—Infants born to immune mothers have passive protection, which is usually lost before the 6th month. Disease or inapparent infection usually, but not always, induces lifelong immunity. Many of these older adults may have immunological memory and would be protected against disease after exposure. Antitoxic immunity protects against systemic disease but not against colonization in the nasopharynx. Preventive measures: 1) Educational measures are important: inform the public, particularly parents of young children, of the hazards of diphtheria and the need for active immunization. The first 3 doses are given at 4- to 8-week intervals beginning when the infant is 6 8 weeks; a fourth dose 6–12 months after the third dose. This schedule should not entail restarting immunizations because of delays in administering the scheduled doses. A fifth dose is given at 4–6 years prior to school entry; this dose is not necessary if the fourth dose was given after the fourth birthday. For a previously unimmu- nized individual, a primary series of 3 doses of adsorbed tetanus and diphtheria toxoids (Td) is advised, 2 doses at 4- to 8-week intervals and the third 6 months to 1 year after the second dose. Limited data from Sweden sug- gest that this regimen may not induce protective anti- body levels in most adults, and additional doses may be needed. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Case report obligatory in most countries, Class 2 (see Reporting).

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