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Commercial bleaches may contain higher concentrations of sodium hypochlorite and are more likely to cause serious injury purchase indinavir 400 mg without a prescription. Metabolic acidosis is rare 400mg indinavir with mastercard, but has been reported following the ingestion of household bleach. Pulmonary complications resulting from aspiration may also be seen after ingestion. Sources/Uses Sodium and calcium hypochlorite are manufactured by the chlorination of sodium hydroxide or lime. Sodium and calcium hypochlorite are used primarily as oxidizing and bleaching agents or disinfectants. They are components of commercial bleaches, cleaning solutions, and disinfectants for drinking water and waste water purification systems and swimming pools. Sodium Hypochlorite as a Disinfectant has the Following Advantages: It can be easily stored and transported when it is produced on-site. Waterborne Diseases ©6/1/2018 489 (866) 557-1746 Disadvantages Sodium hypochlorite is a dangerous and corrosive substance. While working with sodium hypochlorite, safety measures have to be taken to protect workers and the environment. Sodium hypochlorite should not come in contact with air, because that will cause it to disintegrate. Both sodium hypochlorite and chlorine do not deactivate Giardia Lambia and Cryptosporidium. The regulation for sodium hypochlorite is the same as the regulation considering chlorine. If the solution is made more acidic, sodium hypochlorite will dissociate, producing chlorine gas and oxygen. Sodium Hypochlorite is subject to degradation within the piping and pump systems as it releases oxygen gas and results in crystallization of the residual. If the oxygen gas or vapor is allowed to build up within the piping and reagent head in sufficient volume, a typical reciprocating piston metering pump, used for accurately feeding chlorine to the process, will not function properly as gas in the pump head is compressed, minimizing the discharge check valve to open upon discharge stroke of the pump. Consequently, this effect could require that the pump be re- primed for operation. Reciprocating piston metering pumps or diaphragm metering pumps have been historically preferred in the dispensing of Sodium Hypochlorite because of their superior ability to accurately dose chemicals into a process stream with great precision and repeatability at a constant pressure. Additionally, the diaphragm metering pump is sealless and leak proof by design with negligible maintenance and simple commissioning. Traditionally, the diaphragm metering pump industry has promoted the use of degas valves on the discharge port of the pump which diverts gas back to the suction supply source of the bleach. However, the small diameter ports in the valve system tend to plug and require continuous flushing or cleaning through human intervention since the system is open to atmosphere on the discharge side of the orifice. Additionally, an external bypass piping system and degas valve assembly require additional costs and maintenance while presenting more opportunities for undesired chlorine leak paths. Waterborne Diseases ©6/1/2018 490 (866) 557-1746 Troubleshooting Hypochlorination Problems Problem 1. Improper procedure for running chlorine residual test or expired chemical reagents. If that is the case, the feed rate must be increased to obtain the desired residual. Waterborne Diseases ©6/1/2018 492 (866) 557-1746 Shock Chlorination — Well Maintenance Shock chlorination is a relatively inexpensive and straightforward procedure used to control bacteria in water wells. Many types of bacteria can contaminate wells, but the most common are iron and sulfate-reducing bacteria. Although not a cause of health problems in humans, bacteria growth will coat the inside of the well casing, water piping and pumping equipment, creating problems such as:  Reduced well yield  Restricted water flow in distribution lines  Staining of plumbing fixtures and laundry  Plugging of water treatment equipment  “Rotten egg” odor. Bacteria may be introduced during drilling of a well or when pumps are removed for repair and laid on the ground. However, iron and sulfate-reducing bacteria (as well as other bacteria) can exist naturally in groundwater. A well creates a direct path for oxygen to travel into the ground where it would not normally exist. When a well is pumped, the water flowing in will also bring in nutrients that enhance bacterial growth. Ideal Conditions for Iron Bacteria Water wells provide ideal conditions for iron bacteria. Signs of Iron and Sulfate-Reducing Bacteria There are a number of signs that indicate the presence of iron and sulfate-reducing bacteria. Slime Growth The easiest way to check a well and water system for iron bacteria is to examine the inside surface of the toilet flush tank. Iron bacteria leave this slimy by-product on almost every surface the water is in contact with. Iron bacteria aggravate the problem by creating an environment that encourages the growth of sulfate-reducing bacteria in the well.

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Pulses are equal in the upper and lower extremities purchase 400 mg indinavir, and the lungs are clear to auscultation indinavir 400mg cheap. There is a concavity along the left heart border due to diminished pulmonary artery segment and the apex is slightly upturned. The patient is seen every few weeks in cardiology clinic with no significant change noted. Because there is adequate pul- monary blood flow, the patient remains “pink” and has normal development both before and after surgery. She has been doing well since discharge from the hospital after birth with excellent growth and development. Her parents report that she has not been eating well for the past 2 days and that her diapers are not as wet as usual for her. She has had some diarrhea as well and they are concerned because she is not at all “herself. Her blood pressure is normal and her pulses are strong, yet on auscultation the usually very loud murmur is no longer appreciated. Discussion: This patient is having a hypercyanotic spell (tet spell) likely brought on by dehy- dration from gastrointestinal illness. Because there is little pulmonary blood flow, the loud murmur which is due to pulmonary stenosis is no longer audible. The child must be referred immediately to a tertiary care center for management of a hypercyanotic spell using the emergency medical transport system. In the meantime, turn out the lights in the exam room (calming effect) and ask the mother 176 D. Torchen to hold the baby while bringing her knees to her chest to increase the systemic resistance by kinking the femoral blood vessels. Once a hypercyanotic spell has occurred, it is generally accepted that the best course of action is to undergo complete surgical repair to avoid occurrence of future similar spells. Because the word “predominantly” is somewhat vague, it is generally accepted that if >50% of a great artery is supplied by the right ventricle, it is to be considered to have arisen from that ventricle. Clinical Manifestations How a patient does prior to any repair or palliation varies based in large part on the underlying anatomy and generally falls into one of three categories: 1. Numbers represent volume of blood flow in liters per minute per square meter (l/min/m2). The former will cause congestive heart failure and the latter will cause poor cardiac output. A patient with this type of pathophysiology will not have congestive heart failure and the cardiac output will be adequate. However, the limited volume of pulmonary blood flow will result in significant cyanosis. There is a tolerable increase in pulmonary blood flow and adequate cardiac output 180 D. If left untreated, they exhibit extreme failure to thrive and eventually succumb due to complications such as respiratory infections. On examination, these patients are quite cyanotic and sickly appearing with the degree of cyanosis worsening in proportion to the amount of pulmonary stenosis. The lung beds are no longer reactive to changes in circulation or oxygen level thus rendering them ineffective. Once having reached this point, heart-lung transplantation may be considered; or palliative measures can be implemented to improve the quality of life. Mild or no pulmonary stenosis will cause increased pulmonary blood flow resulting in prominent pulmo- nary vasculature and cardiomegaly. The great arteries are well visualized in these views and one can make the determination of whether or not there is >50% “commitment” of the aorta to the right ventricle. In addition, pulsed and continuous wave Doppler allow interrogation of the pulmonary valve and right ventricular outflow tract so as to assess any pulmonary stenosis that may be present. Cardiac Catheterization Cardiac catheterization is generally not indicated for diagnosis, although in com- plicated cases it can certainly aid in delineating the anatomy. Treatment As with most congenital heart defects, the goal is to undergo a complete repair resulting in a physiologically normal heart. Depending on what was done to the pulmonary outflow tract, further operations may be necessary. Case Scenarios Case 1 A newborn male is noted to have a loud murmur while in the nursery. His heart rate is 155 beats/min and his blood pressure measures 86/54 in all four extremities.

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Gram-negative organisms are responsible for <10% of cases buy indinavir 400 mg otc, but are more com- mon in certain groups of patients such as neonates and immunocompromised patients buy discount indinavir 400 mg line. Infection of a prosthetic valve early after surgery is most likely to result from Staphylococcal species (Staphylococcus aureus and coagulase-negative Staphylococci). Other uncommon microorganisms are fungi which occur in immu- nocompromised patients, patients on prolonged antibiotic therapy, and neonates. Intravenous drug users are at special risk for fungal endocarditis and right-sided S. States of transient bactere- mia may then lead to the adhesion of bacteria to the thrombotic endocarditis via special adhesion molecules present on the bacterial surfaces. Subsequently, bacteria proliferate within the nidus of infection and are covered by fibrin which protects the bacteria in this milieu. Most of the bacteria inside the vegetations are in an inactive state which confers additional protection from antibiotics and explains the need for prolonged treatment. These structural alterations result in mani- festations like acute valvular regurgitation, obstruction, congestive heart fail- ure, and heart block. Those manifestations related to the infective process include the clinical manifestations of bacteremia and those due to the separa- tion of vegetations and systemic embolization. Cardiac manifestations depend on the site of infection: – Congestive heart failure might be related to acute valvular regurgitation. Extracardiac manifestations include the following: – Neurologic manifestations: these are reported in 20% of cases and are related to an abscess formation, infarct, aseptic meningitis, encephalopathy, or hemorrhage. Torchen – Neonates are more likely to present with extracardiac infections due to septic embolization that result in osteomyelitis, meningitis, or septic arthritis. Splenomegaly may be present in subacute disease of several weeks or months duration. Transthoracic echocardiography is more helpful in children than adults, especially with normal cardiac structure or isolated valvular disease. Transesophageal echocardiography should be used if transthoracic echocardiography is limited and in patients with prosthetic valves. Findings by echocardiography include valvular vegetations, valvular regurgi- tations, abscess formation, and rarely rupture of cardiac structures. In addition, vegetations may be noted; these may be attached to cardiac structures or foreign material such as prosthetic valves or central venous catheters. Rejected cases include those in which an alternative diagnosis is confirmed or if the fever resolves with a short course of antibiotics of less than 4 days. About half of the patients have positive rheumatoid factor or evidence of immune complexes. Anemia may be present and is caused by hemolysis or the presence of chronic infection. Prolonged therapy is usually required and the specific duration and combination of agents used is determined by the infecting microor- ganism, the location of the infection, whether it involves a native or a prosthetic valve, and the presence of complications. It is essential to obtain information about the microbiologic sensitivity to antibi- otics and the minimal inhibitory concentrations as this will determine the duration and combination of antibiotics used. Surgical treatment may be required in 25–30% of patients in the acute phase of the disease. Circumstances in which surgical treatment is necessary include patients with recurrent embolization despite antibiotic therapy, those who fail medical therapy, and those with progressive heart failure due to damage of cardiac struc- tures such as with severe valve regurgitation. Prognosis Infective endocarditis continues to have significant morbidity and mortality despite advances in medical and surgical treatment. Mortality rate for viridans streptococcal endocarditis with no significant complications is less than 10%. On the other hand, Aspergillus endocarditis after prosthetic valve surgery carries an almost 100% risk of death. Antibiotic prophylaxis is no longer recommended at the time of gastrointestinal or genitourinary procedures. Case Scenarios Case 1 History: A 6-year-old girl presents with 2-week history of intermittent fevers. She was initially seen in the first week of illness by her physician and was diagnosed with otitis media. In addition she complains of headaches, abdominal pains, and daily fevers with sweating. Cardiac examination is significant for regular rate and rhythm with no thrill; normal S1 and narrow splitting of S2. There is a 2/6 systolic ejection murmur at right upper sternal border and 2/4 early diastolic murmur at left midsternal border. Differential diagnosis: This patient is presenting with the complaint of a 2-week history of fever and lethargy.

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In rare instances buy indinavir 400mg otc, it is caused with the Norwegian type buy discount indinavir 400mg on-line, the former experiences by herpes simplex virus or other viruses or bacte- only a typical case of ordinary scabies—not the ria. Often this disease arises in infected items: linens, furniture, clothing, and so men who perform anal sex and become infected on. In most cases, in the room of a patient with Norwegian scabies the use of condoms prevents development of is likely to get the infection unless he or she nonspecific urethritis. Testing includes a urethral swab that is exam- Time from infection to symptoms is brief for ined for white blood cells. Usually nonspecific ure- Norwegian scabies—only about 10 to 14 days— thritis is treated with antibiotics. Partners must be whereas regular scabies usually causes symptoms evaluated and treated even if they are symptom- in about four to six weeks. Until treat- bies, the treatment is topical ectoparasiticide cream nutrition 159 (Permethrin) followed by application of 6 per- nukes The nickname for nucleoside analogs cent sulfur in petrolatum. A notifiable disease A disease that must be week later, his physician told a French newspaper reported to health authorities. Chlamydia trachomatis genital infections, cholera, coccidioidomycosis, cryptosporidiosis, cyclosporia- nutrition The process of nourishing one’s body or sis, diphtheria, ehrlichiosis, arboviral encephalitis the processes by which a human being takes in (California serogroup viral, Eastern equine, food and utilizes it. Someone who is malnourished is malaria, measles, meningococcal disease, mumps, not well equipped to fight off infections. Good pertussis, plague, paralytic poliomyelitis, psittaco- nutrition is extremely important to maintaining sis, Q fever, rabies (animal and human), Rocky the health of individuals with sexually transmitted Mountain spotted fever, rubella (congenital syn- diseases. However, some dietitians criticize this plan hepatitis B (acute), hepatitis B virus perinatal as deficient in needed nutrients and claim that it infection, hepatitis C (non-A, non-B, acute), cannot enhance one’s overall health. In most tetanus, toxic-shock syndrome, trichinosis, tuber- cases, physicians encourage those people who are culosis, tularemia, typhoid fever, varicella (deaths dealing with a sexually transmitted disease to fol- only), and yellow fever. This is favored over any plan that is based and understand the role that correct diet can play on dietary extremes. O occupational exposure Exposure to sexually oral mucosal lesions Lesions or sores in the transmitted disease that occurs during the normal mouth caused by several sexually transmitted dis- course of one’s occupation. These can be infectious and can be trans- a sex worker’s heightened chance of contracting mitted to a sex partner by means of oral sex. One can contract herpes type 2 in the mouth by performing oral ocular herpes A herpes infection of the eye that sex on someone who has genital type 2 herpes. A person who per- a herpes infection of the eye should consult an forms oral sex on a partner with syphilis may ophthalmologist (eye doctor) immediately. It is also important to note that many other physical conditions besides sexually transmitted diseases can cause mouth sores and ulcers. These oral–anal sex A form of sexual activity viewed by include Crohn’s disease, ulcerative colitis, and health care experts as extremely high-risk because some autoimmune conditions. The most com- a partner can come in contact with feces, which mon oral ulcers that are not sexually transmitted may transmit a sexually transmitted disease. The are called aphthous ulcers—the painful small act of performing oral–anal sex puts one individ- ulcers that sometimes occur on the sides of the ual’s mouth in contact with the anus of the other mouth or the inside of the lips, last about a week, partner, thus enhancing the likelihood of transmis- and then disappear spontaneously. A sore in oral–genital sex Cunnilingus, oral sex performed the mouth that does not heal is characteristic of on a woman’s clitoris and other sexual organs; fel- oral cancer; these lesions often occur under the latio is oral sex performed on a man’s penis. Warts in the mouth forms of sexual activity, repeated exposures can are common in patients who are treated in pose a more formidable risk. In secondary syphilis, ened if a person has cuts or sores in the mouth or mucous patches can occur in the mouth. To prevent infection in the act of having oral sex with a male partner, it is impor- orgasm The peak of sexual excitement that cul- tant to use a latex condom on the penis or a plas- minates in ejaculation in men and vaginal contrac- tic condom if one partner has an allergy to latex. The individual who is having oral sex with a female partner should use orifice An opening. Body orifices include the a latex barrier such as a dental dam or cut-open mouth, anus, and vagina. The virus can be transmitted diseases, it is not unusual for an indi- transmitted via blood, semen, preseminal fluid, vidual with a disease to be held at arm’s length by and vaginal fluid. This is noteworthy when one outercourse Referred to as sex play without considers that many people tend to view this intercourse, certain methods listed by Planned Par- mode of transmission as almost nonexistent. These and Opportunistic Infections (2000), the Centers include masturbation (alone or with a partner), for Disease Control and Prevention reported that erotic massage, and body rubbing. This study looked at risk other sexually transmitted diseases unless partners over-the-counter drug 163 exchange body fluids via oral or anal intercourse or menopause (the end of menstruation). P painful intercourse Pain during intercourse does The Pap test is named after the physician George not automatically signal that a person has a sexually Papanicolaou, who introduced this technique in transmitted disease.

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