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By: Vinay Kumar, MBBS, MD, FRCPath

  • Donald N. Pritzker Professor and Chairman, Department of Pathology, Biologic Sciences Division and Pritzker School of Medicine, The University of Chicago, Chicago, Illinois

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The wildlife trade is driven by a complex mix of economic arterial blood gases cheap amlodipine 10 mg, social and cultural factors hypertension young adults buy 2.5 mg amlodipine overnight delivery. The demand for and consumption of wildlife in southern China have increased in recent years blood pressure chart game order generic amlodipine from india, purportedly owing to blood pressure pulse 90 purchase amlodipine line improved economic conditions. Increases in legal and illegal wildlife trade have paralleled this growth in demand, with animals reportedly channelled from many and various locations in Southeast Asia. Different species and dishes are favoured for a range of social, business and health reasons. People believed that eating the animal (known colloquially as the "fruit fox" or "flower fox" because of its dietary preferences) provided the same health benefits as eating fruit. In the markets, wild-caught civets still attract a price premium, because people believe they are more health-giving (and taste better) than their grain-fed farmed counterparts. At the time of writing, 109 species of bats, representing 11 families and 44 genera, have been surveyed for CoVs (Table 5. CoVs were detected in 36 species, and anti-CoV antibodies in a further seven species (Tables 5. Miniopteridae Miniopterus africanus inflatus magnater minor natalensis pusillus schreibersii Molossidae Chaerephon pumilus sp. Molossus Mops major condylurus midas Otomops Tadarida Mormoopidae Mormoops Pteronotus Noctilionidae Nycteridae Noctilio Nycteris martinsseni brasiliensis sp. Coronavirus nomenclature: host species/country of origin/laboratory identification/year collected. Significant zoonotic diseases identified in bats 111 Group 1 bat coronaviruses Multiple authors (Poon et al. Group 1 bat CoVs have nucleotide sequence similarity (of 54 to 75 percent) to non-bat group 1 CoVs. They are highly divergent and related to CoVs previously identified from domestic animals (Figure 5. Group 1 bat CoVs have lower nucleotide sequence similarity to other CoVs from groups 2 and 3 (22 to 74 percent) and are distinguished from these groups by the addition of 14 amino acids in the spike (S) protein (Poon et al. As these formed distinct phylogenetic groups, but were closely related to other group 2 CoVs, it was postulated that they should constitute a new subgroup, group 2c (called group 5 by some authors) (Woo et al. The numbers at the nodes indicate the percentage of bootstrap trees containing this node. Coronavirus nomenclature: host species/country of origin/laboratory identification/year collected (GenBank accession). These findings suggest that genetically divergent bat CoVs are commonly present in and specific to different bat species (Tang et al. Their ability to fly provides great mobility and allows the possible exchange of viruses with other bat populations or other mammals (Tang et al. The roosting of large numbers of bats together also facilitates the exchange of viruses among individual bats (Tang et al. This diversity of CoVs in bats suggests that bats play an important role in the ecology and evolution of CoVs and implies that there are probably a great number of CoVs yet to be identified in bats and other animals (Lau et al. CoVs in bats have a stable genetic population, suggesting that they are endemic, although the epidemic-like growth in all other animals indicates repeated inter-species transmissions and occasional establishment (Vijaykrishna et al. The authors suggested that this was the result of interspecies transmission 208 to 322 years ago, but postulated that direct transmission from bats to humans would have been difficult Significant zoonotic diseases identified in bats 115 owing to the small viral load normally detected in bat faeces. Recombination may allow adaptation to new hosts and ecological niches, and transmission of CoVs among bats, other wildlife, livestock, companion animals or humans (Lau et al. CoVs identified in bats have great genetic diversity and are older than any CoVs previously identified in other animals, suggesting that bats are likely to be the natural reservoir host for all known CoVs, including human cold CoVs (Figure 5. Bat species groups 1, 4 and 5 group 4 Wild animals and humans All animal and human CoVs (groups 1, 2, 4 and 5, also known as groups 1, 2a, 2b and 2c) evolved from the interspecies transmission of CoVs from bats (solid lines). Interspecies transmission and evolution of group 3 CoVs in poultry possibly resulted via an intermediary host such as a raptor (dashed lines) preying on bats and poultry. The first symptom in 85 to 100 percent of patients was a fever (> 38 °C) for a mean duration of nine days (Booth et al. Other symptoms included fatigue (in 7 to 94 percent of patients), a non-productive cough (63 to 86 percent), sputum production (67 percent), chills and rigors (8 to 56 percent), headache (11 to 37 percent), general malaise (a general feeling of illness, 36 percent), myalgia (muscle pain or tenderness, 18 to 49 percent), dyspnoea (difficulty in breathing, 42 to 80 percent), sore throat (10 percent), vomiting and neck pain (Booth et al. Significant zoonotic diseases identified in bats 117 Laboratory findings included leucopenia (low white blood cell count, in 33 to 68 percent of patients), lymphopenia (low lymphocyte count, 53 to 95 percent), thrombocytopenia (low platelet count, 28 to 40 percent), hypocalcaemia (60 percent), hypoxaemia (low concentration of oxygen in arterial blood), elevated levels of lactate dehydrogenase (indicating anaerobic respiration, 58 to 88 percent) and aspartate aminotransferase or alanine aminotransferase (indicating hepatic cellular damage, 27 to 62 percent) (Booth et al. Levels of creatine kinase (indicating muscle damage) were reported as high by Liu et al. Abnormalities included small or large, single or multifocal patchy shadows or opacities (23 to 60 percent), which appeared after two to five days, and ground-glass-like opacification or consolidation (31 to 45 percent), which appeared after six to 19 days (Lu et al. Diagnostics the majority of CoVs identified in bats were identified from faecal material, indicating a predominantly enteric tropism (Lau et al. Amplicons consistent with the expected length of 440 nucleotides can be sequenced and phylogenetically compared with other known CoVs. Conclusion the significance of cultural and economic drivers for disease emergence is being increasingly recognised. The need for a combination of "hard" and "soft" sciences and a "big-picture" view is increasingly evident. Continued surveillance will advance understanding of the diversity of CoVs in bats. Detection and phylogenetic analysis of group 1 coronaviruses in South American bats. Treatment of severe acute respiratory syndrome with lopinavir/ritonavir: a multicentre retrospective matched cohort study. Treatment of severe acute respiratory syndrome with glucosteroids: the Guangzhou experience. Consideration of highly active antiretroviral therapy in the prevention and treatment of severe acute respiratory syndrome. Adverse effects of ribavirin and outcome in severe acute respiratory syndrome: experience in two medical centers. Detection and prevalence patterns of group I coronaviruses in bats, Northern Germany. Severe acute respiratory syndrome coronavirus-like virus in Chinese horseshoe bats. Investigational use of ribavirin in the treatment of severe acute respiratory syndrome, Singapore, 2003. Clinical and laboratory features of severe acute respiratory syndrome vis-a-vis onset of fever. Nursing care of patients with severe acute respiratory syndrome in the intensive care unit: case reports in Hong Kong. Prognostic significance of the radiographic pattern of disease in patients with severe acute respiratory syndrome. Distant relatives of severe acute respiratory syndrome coronavirus and close relatives of human coronavirus 229E in bats, Ghana. Circulation of group 2 coronaviruses in a bat species common to urban areas in Western Europe. Australian bat coronaviruses: identification, inter-species transmission and maintenance. Severe acute respiratory syndrome: report of treatment and outcome after a major outbreak. Early clinical predictors of severe acute respiratory syndrome in the emergency department. Comparative analysis of twelve genomes of three novel group 2c and group 2d coronaviruses reveals unique group and subgroup features. History has shown that in rural African settings, filovirus outbreaks can be large (> 150 cases), necessitating rapid responses by the international community to help implement detection, case management and epidemiologic surveillance, usually for a duration of several months. These facts emphasize the paramount importance of investigations to identify the natural reservoirs of filoviruses, the results of which are implicating bats as natural hosts. History: aetiology and linkage to natural host Although the natural reservoirs for filoviruses have not been identified definitively, the cumulative evidence now shows that bats can be a source of infectious virus. The monkeys were caught or temporarily maintained on the shores and islands of Lake Victoria, and were all from areas where fruit bats were prevalent (Smith, 1982). In the previous two weeks, the travellers had slept in rooms containing insectivorous bats at two locations in Zimbabwe and had visited the Chinhoyi Caves (formerly the Sinoia Caves) where bats may also have been present (Conrad et al. In the Sudan, the first six patients worked in a room of a cotton factory where bats were roosting (Arata and Johnson, 1978). Reston ebolavirus, which has not been shown to be pathogenic in humans, was repeatedly imported via virus-infected monkeys consigned to the United States of America and Europe from the Philippines.

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I (4­1­12 Edition) (1) All articles of labeling bearing ingredient declarations and used in conjunction with any one display unit or chart shall be identical and shall declare the ingredients of all products sold in conjunction with the display unit or chart for which the ingredient declaration is made pursuant to blood pressure healthy discount 5 mg amlodipine otc paragraph (i) of this section pulse pressure sepsis amlodipine 2.5 mg on-line. Whenever any formulation change is made blood pressure chart game discount amlodipine master card, and the labeling containing the declaration of ingredients is thereby required to blood pressure medication starting with x purchase 5 mg amlodipine fast delivery be used in conjunction with products of both the old and new formulations, the labeling shall declare the ingredients of both the old and new formulations separately in a way that is not misleading and in a way that permits the purchaser to identify the ingredient declaration applicable to each package, or which clearly advises the purchaser that the formulation has been changed and that either declaration may be applicable. Display units and replacement labeling for display units shall be accompanied by instructions to the retailer, which when followed will result in compliance with the requirements of this section. For the purpose of this paragraph, incidental ingredients are: (1) Substances that have no technical or functional effect in the cosmetic but are present by reason of having been incorporated into the cosmetic as an ingredient of another cosmetic ingredient. An alternative ingredient shall be declared either (1) immediately following the normally used in- § 701. This paragraph is inapplicable to any ingredient mentioned in advertising, or in labeling other than in the declaration of ingredients required by this section. For the purpose of this paragraph, surface area is not available for labeling if physical characteristics of the package surface. The color additive ingredients shall be declared in accordance with the provisions of paragraph (g) of this section. The term principal display panel as it applies to cosmetics in package form and as used in this part, means the part of a label that is most likely to be displayed, presented, shown, or examined under customary conditions of display for retail sale. Where packages bear alternate principal display panels, information required to be placed on the principal display panel shall be duplicated on each principal display panel. For the purpose of obtaining uniform type size in declaring the quantity of contents of all packages of substantially the same size, the term ``area of the principal display panel' means the area of the side or surface that bears the principal display panel, which area shall be: (a) In the case of a rectangular package where one entire side properly can be considered to be the principal display panel side, the product of the height times the width of that side; (b) In the case of a cylindrical or nearly cylindrical container, 40 percent of the product of the height of the container times the circumference; and (c) In the case of any other shape of container, 40 percent of the total surface of the container: Provided, however, That where such container presents an obvious ``principal display panel' such as the top of a triangular or circular package, the area shall consist of the entire top surface. In determining the area of the principal display panel, exclude tops, bottoms, flanges at the tops and bottoms of cans, and shoulders and necks of bottles or jars. In the case of cylindrical or nearly cylindrical containers, information required by this part to appear on the principal display panel shall appear within that 40 percent of the circumference which is most likely to be displayed, presented, shown, or examined under customary conditions of display for retail sale. I (4­1­12 Edition) (3) An appropriate illustration or vignette representing the intended cosmetic use. In the case of an individual, partnership, or association, the name under which the business is conducted shall be used. This shall be expressed in terms of weight, measure, numerical count, or a combination of numerical count and weight or measure. The statement shall be in terms of fluid measure if the cosmetic is liquid or in terms of weight if the cosmetic is solid, semisolid, or viscous, or a mixture of solid and liquid. If there is a firmly established, general consumer usage and trade custom of declaring the net quantity of a cosmetic by numerical count, linear measure, or measure of area, such respective term may be used. If there is a firmly established, general consumer usage and trade custom of declaring the contents of a liquid cosmetic by weight, or a solid, semisolid, or viscous cosmetic by fluid measure, it may be used. Whenever the Commissioner determines for a specific packaged cosmetic that an existing practice of declaring net quantity of contents by weight, measure, numerical count, or a combination of these does not facilitate value comparisons by consumers, he shall by regulation designate the appropriate term or terms to be used for such cosmetic. A common fraction shall be reduced to its lowest terms; a decimal fraction shall not be carried out to more than two places. A statement that includes small fractions of an ounce shall be deemed to permit smaller variations than one which does not include such fractions. It shall be placed on the principal display panel within the bottom 30 percent of the area of the label panel in line generally parallel to the base on which the package rests as it is designed to be displayed: Provided, That: (1) On packages having a principal display panel of 5 square inches or less, the requirement for placement within the bottom 30 percent of the area of the label panel shall not apply when the declaration of net quantity of contents meets the other requirements of this part; and (2) In the case of a cosmetic that is marketed with both outer and inner retail containers bearing the mandatory label information required by this part, and the inner container is not intended to be sold separately, the net quantity of contents placement requirement of this section applicable to such inner containers is waived. The propellant is included in the net quantity declaration; and (2) In the case of a package which contains the integral components making up a complete kit, and which is designed to deliver the components in the manner of an application (for example, a home permanent wave kit), the declaration may state the net quantity of the contents in nondeceptive terms of the number of applications available in the kit when the instructions for use as shown on the container are followed. Requirements of conspicuousness and legibility shall include the specifications that: (1) the ratio of height to width (of the letter) shall not exceed a differential of 3 units to 1 unit (no more than 3 times as high as it is wide). When upper and lower case or all lower case letters are used, it is the lower case letter ``o' or its equivalent that shall meet the minimum standards. Where the declaration is blown, embossed, or molded on a glass or plastic surface rather than by printing, typing, or coloring, the lettering sizes specified in paragraphs (i)(1) through (4) of this section shall be increased by one-sixteenth of an inch. Net weight or fluid measure of less than 1 ounce shall be expressed in common or decimal fractions of the respective ounce and not in drams. The term ``net weight' shall be used when stating the net quantity of contents in terms of weight. Use of the terms ``net' or ``net contents' in terms of fluid measure or numerical count is optional. It is sufficient to distinguish avoirdupois ounce from fluid ounce through association of terms; for example, ``Net wt. The declaration in terms of the largest whole units shall be in parentheses following the declaration in terms of inches and any remainder shall be in terms of inches or common or decimal fractions of the foot or yard. The declaration in terms of the largest whole units shall be in parentheses following the declaration in terms of square inches and any remainder shall be in terms of square inches or common or decimal fractions of the square foot or square yard; for example, ``158 sq. Reasonable variations caused by loss or gain of moisture during the course of good distribution practice or by unavoidable deviations in good manufacturing practice will be recognized. In administering the act, the Food and Drug Administration interprets the term ``soap' to apply only to articles that meet the following conditions: (1) the bulk of the nonvolatile matter in the product consists of an alkali salt of fatty acids and the detergent properties of the article are due to the alkali-fatty acid compounds; and (2) the product is labeled, sold, and represented only as soap. For example, such a product in bar form is subject to the requirement, among others, that it shall bear a label containing an accurate statement of the weight of the bar in avoirdupois pounds and ounces, this statement to be prominently and conspicuously displayed so as to be likely to be read under the customary conditions of purchase and use. The Commissioner establishes the following names for the purpose of cosmetic ingredient labeling pursuant to paragraph (e) of § 701. Ethyl ester of hydrolyzed animal protein is the ester of ethyl alcohol and the hydrolysate of collagen or other animal protein, derived by acid, enzyme, or other form of hydrolysis. The information requested should be given separately for each establishment as defined in § 700. The owner or operator of a cosmetic product establishment which is not exempt under § 710. This request extends to any foreign cosmetic product establishment whose products are exported for sale in any State as defined in section 201(a)(1) of the act. This amendment is also necessary when a registration is to be canceled because an establishment has changed its name and no longer conducts business under the original name. This validated copy will be sent only to the location shown for the registering establishment. A permanent registration number will be assigned to each cosmetic product establishment registered in accordance with the regulations in this part. The owner or operator of an establishment entering into the manufacture or packaging of a cosmetic product should register his establishment within 30 days after the operation begins. Registration of a cosmetic product establishment or assignment of a registration number does not in any way denote approval of the firm or its products by the Food and Drug Administration. Any representation in labeling or advertising that creates an impression of official approval because of registration or possession of a registration number will be considered misleading. The following classes of persons are not requested to register in accordance with this part 710 because the Commissioner has found that such registration is not justified: (a) Beauty shops, cosmetologists, retailers, pharmacies, and other persons and organizations that compound cosmetic products at a single location and administer, dispense, or distribute them at retail from that location and who do not otherwise manufacture or package cosmetic products at that location. This request extends to any foreign manufacturer, packer, or distributor of a cosmetic product exported for sale in any State as defined in section 201(a)(1) of the Federal Food, Drug, and Cosmetic Act. The completed form should be mailed or delivered to: Cosmetic Product Statement, Food and Drug Administration, 5100 Paint Branch Pkwy. The nonconfidential listing of the product name and/or trade name or name of the manufacturer or supplier of each proprietary fragrance and/or flavor mixture is optional. Any request for confidentiality of a cosmetic ingredient submitted with such forms or separately will be handled in accordance with the procedure set forth in this section. Any such petition shall include an adequate factual basis to support the petition, shall be in the form set forth in part 10 of this chapter, and will be published for comment if it contains reasonable grounds for the proposed regulation. Any representation in labeling or advertising that creates an impression of official approval because of such filing or such number will be considered misleading. A petition requesting such a regulation, as an amendment to this section, shall be submitted to the Division of Dockets Management in the form established in part 10 of this chapter. Any such ingredient or product whose safety is not adequately substantiated prior to marketing is misbranded unless it contains the following conspicuous statement on the principal display panel: Warning-The safety of this product has not been determined. The warning required by paragraph (a) of this section is not required for such an ingredient or product if: (1) the safety of the ingredient or product had been adequately substantiated prior to development of the new information; (2) the new information does not demonstrate a hazard to human health; and (3) Adequate studies are being conducted to determine expeditiously the safety of the ingredient or product. I (4­1­12 Edition) (c) In the case of products intended for use by children, the phrase ``except under adult supervision' may be added at the end of the last sentence in the caution required by paragraph (b) of this section. The sentence ``Spray at least 8 inches from skin' need not be included in the cautionary statement for products whose expelled contents do not contain a liquified gas propellant such as a halocarbon or hydrocarbon propellant. The use of any word or words which represent or suggest that such products have a medical usefulness renders such products misbranded under section 502(a) of the Act and illegal new drugs marketed in violation of section 505 of the Act. Excessive use or prolonged exposure may cause irritation to skin and urinary tract.

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Megachiroptera are commonly known as "fruit bats" hypertension guidelines aha amlodipine 2.5 mg amex, because they eat fruit and nectar; fruit bats occur in the subtropical and tropical regions of the Old World pulse pressure 25 buy 5 mg amlodipine fast delivery, from the eastern Mediterranean and the Arabian Peninsula prehypertension workout buy amlodipine 2.5 mg otc, a b University of Montana the State of Queensland heart attack the alias club remix generic amlodipine 5 mg online, Department of Employment, Economic Development and Innovation (2011) 16 Investigating the role of bats in emerging zoonoses across Africa to Asia, Australia and the islands in the Pacific (Rainey and Pierson, 1992). This designation is currently being re-evaluated, and new categories have been proposed, consistent with phylogenetic relationships. This section provides a basic overview of the natural history of bats in general, emphasizing the areas most pertinent to understanding the diseases bats carry. Some colonially roosting megachiropteran species form conspicuous aggregations (also called "camps"), often using exposed tree branches (Figure 2. In addition to their day-time roost locations, many bats also aggregate in night-time roosts, which are temporary and often close to feeding locations. Depending on the species, season, and location of the roost, colony sizes range from a few to millions of individuals. In particular, a few species of molossids and vespertilionids form the largest aggregations of Microchiroptera (McCracken and Gustin, 1991). More than one-third of megachiropteran species form colonies, with species from nine genera known to be strongly colonial: Acerodon, Aproteles, Boneia, Dobsonia, Eidolon, Eonycteris, Notopteris, Pteropus and Rousettus (Marshall, 1983; Pierson and Rainey, 1992). Mating system and life history traits Bat species exhibit a wide range of mating systems, from monogamy (uncommon in mammals), to lekking, to the promiscuous mating systems assumed in highly colonial species (Bradbury, 1977). The most prevalent mating system in bats is thought to be resourcedefence polygyny, in which a male defends a harem of females for exclusive reproductive access (Kunz and Pierson, 1994). Most bat species are mono-oestrus, reproducing once per year, while some tropical species produce two or even three offspring each year (see examples in Kunz and Pierson, 1994). Although there are solitary species of bats, in which a mother raises her young on her own, it is more typical for females to aggregate during the maternity season to give birth and raise their young. Bat pregnancies may last three to six months and are often variable (both among and within species) in response to environmental conditions (Racey, 1982; Racey and Entwistle, 2000). Bats typically have only one young per year, although some species (typically vespertilionids) may have twins (Racey and Entwistle, 2000). Female bats suckle their young longer relative to other mammalian species, waiting until the young are nearly as large as mature adults before weaning (Kunz and Stern, 1995). Life spans vary by species and the environment in which they live, but 15 years is not uncommon (Kunz and Pierson, 1994). These species represent every family in the Microchiroptera and are found throughout the global distribution of bats. About a quarter of all bats are frugivorous and/or nectivorous, meaning that they specialize on fruits and/or nectar and pollen from flowers. These bat species are found only in the subtropics and tropics and include all the Old World megachiropteran species and some subfamilies of the New World Phyllostomidae. Unlike most fruit bat species in the Old World, many of the frugivorous and nectivorous bat species in the New World have broad diets, which may include insects (von Helversen, 1993). The small number of bat species that remain are either carnivorous, specializing on small vertebrates. Activity patterns Bats are predominantly nocturnal, resting during the day and feeding at night, although some bat species are partially or completely diurnal. Most species of Microchiroptera and Megachiroptera depart from roost sites at early dusk to forage, and return to their day roosts by dawn (Kunz, 1982). The distance that bats travel during their foraging activities varies by species, habitat type, location, season, colony size and food availability. Microchiroptera have been tracked travelling 10 to 15 km from their day roost during foraging activities and may venture as far as 80 km (examples in Kunz and Pierson, 1994). Female bats are likely to travel shorter foraging distances during lactation periods, as they are limited by the increased weight of carrying their young (especially some species of Megachiroptera) and/ or the need to return to the roost to nurse young left behind. In addition to their daily movements, some bat species are also known for long-term, long-distance migration (Bisson, Safi and Holland, 2009). In northern temperate regions, Microchiroptera forced to deal with cold seasons/winter, when food supplies are lacking, migrate south to less extreme winter climates (Strelkov, 1969). Nectivorous and frugivorous species in both the New and Old Worlds also move over very long distances to follow flowering and fruiting seasons, travelling as far as 2 000 km (Richter and Cumming, 2008). For example, seven radio-collared Pteropus vampyrus individuals in Southeast Asia were tracked moving hundreds of kilometres to roost sites in several different countries in the course of a year (Epstein et al. Because these bats are highly mobile, they are also very effective in supporting their vegetative habitats, scattering nutrients across the landscape as they fly (Rainey et al. Fruit bats in the Old and New Worlds are ecologically important as seed dispersers and pollinators (see section on Positive roles of bats in human society). As they travel long distances during foraging, they distribute seeds and pollen across large areas, which is especially crucial to the regeneration of cleared areas (Fleming, 1988). In cases such as islands with few wildlife species, fruit bats are thought to play a "keystone" role in forest maintenance and community structure as the sole pollinators and seed dispersers of local plants (Rainey et al. Many of the negative perceptions people associate with bats are based on myths, fears and misinformation. There are some valid cases where bats pose problems to humans, but humans also value bats in a number of ways. People benefit from bats both directly, for food and for support of their agricultural crops, and indirectly, for the ecological roles bats play in maintaining ecosystems and thus securing the beneficial services rendered by those ecosystems. Negative roles of bats in human society Fear and lack of knowledge about bats Bats are disliked and feared in many regions of the world. Some cultures maintain positive feelings about bats, such as in China, where they are symbols of happiness and longevity, and Poland, where they are believed to bring good luck. Elsewhere, bats are associated with death and darkness, and traditional stories have evolved in which batlike characters play sinister roles causing harm to people. In Malaysia, for example, bats are considered dirty and are associated with evil spirits and vampires. Of the Malaysians interviewed, most (76 percent) had negative feelings towards bats, and half (49 percent) did not like bats at all. Fewer than 5 percent of Malaysians interviewed knew that bats pollinated flowers, dispersed seeds, ate insect pests or produced guano that could be used as fertilizer (Kingston et al. Bats as orchard pests, intruders and disease vectors Aside from folklore-inspired fears and misunderstanding due to lack of education, some concerns about bats are tied to reality. The most notable examples are among fruit farmers in the Old World, who continually face problems with fruit bats feeding on their fruit crops and aggregating in human-built structures, and the even more widespread fear of bats as disease vectors (see Chapter 5 for more information). Although these concerns are based in truth, fear and lack of education often lead to an exaggerated public response. In addition, people often fail to recognize the role that they themselves play in inviting conflict with bats. For example, in the Philippines, some fruit bat species forage on agricultural crops, but this may be because agricultural development has displaced their natural habitat. Studies have shown that bats prefer to forage in undisturbed natural forest, even when agricultural areas are available nearby (Mildenstein et al. With an ever-increasing human population, people have fractured natural landscapes and moved into and around bat habitats, creating more opportunities for negative interactions. It follows that human-bat conflicts have become far more pronounced in recent times (Daszak, Cunningham and Hyatt, 2000). Positive roles of bats in human society Bats as food An obvious direct benefit of bats to humans is as a food source. Although bat hunting is illegal throughout most of the Old World, people hunt bats for meat in much of 22 Investigating the role of bats in emerging zoonoses Asia, on islands in the Pacific and Indian Oceans, and in some parts of West Africa (Mickleburgh, Waylen and Racey, 2009; Figure 2. The hunted species are predominantly megachiropterans, but a few species of insectivorous bats are also hunted in Asia and Africa (Mickleburgh, Waylen and Racey, 2009). For some cultural groups, the hunting and eating of bats is linked to traditional customs and beliefs, such as indigenous tribes in the Philippines that believe bat meat has special medicinal properties (Mildenstein, 2002); other examples are in Swensson (2005) and Jenkins and Racey (2008). To other people, such as the Chamorros and Carolinians in the Mariana and Carolina Islands of the Federated States of Micronesia, fruit bats are a highly valued delicacy, traditionally eaten at celebrations. In many parts of Asia, however, bats are not a special food, and it is common for them to be hunted opportunistically as a novel supplemental food source. Guano the faecal matter of insect-eating bats, called guano, is well-known around the world as a fertilizer for agricultural crops. However, because guano is such an effective and valued resource, it is often harvested commercially at larger caves for international trade. It should be noted that while guano is a highly valued by-product of bat populations, guano mining is a major threat to bat populations around the world. Bat populations are very sensitive to disturbance, and cave ecosystems depend on guano as a source of nutrients. Pest control Unlike the previous two examples, some of the benefits that humans receive from bats do not affect the bats themselves.

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Post-psychotic depression (McGlashan and Carpenter 1976) hypertension benign essential 4011 buy amlodipine amex, as seen in some cases of schizophrenia hypertension headache order amlodipine 10mg free shipping, is distinguished by the fact that there is no exacerbation of psychotic symptoms during the depression pulse pressure below 20 discount amlodipine 10 mg overnight delivery. In major depressive disorder or bipolar disorder blood pressure chart who cheap amlodipine online master card, episodes of mood disturbance may, when severe, be accompanied by delusions and hallucinations; however, the differential may be easily made if one simply attends to the overall course of the illness. In mood episodes of major depressive disorder or bipolar disorder, psychotic symptoms occur only within the context of the mood episode, generally at their height, and are not present in the intervals between mood episodes. In contrast to the delusions seen in schizophrenia, the delusions of delusional disorder have a certain plausibility, and the eventual delusional system is within itself quite logical. The traditional name for this disorder, as originally bestowed by Kraepelin, was paranoia, and although this term is still seen in the literature, delusional disorder is probably a better name, for two reasons. First, it emphasizes the cardinal aspect of this disorder, namely the presence and prominence of delusions. Second, it avoids the unfortunate association of paranoia with persecution, and reminds us that delusions of persecution are but one of many types of delusions seen in this disorder. Eventually, persistent and clear-cut delusions occur, and the illness begins to assume its definitive form. Although the most common type of delusion seen in delusional disorder is that of persecution, other themes may be prominent: jealousy, grandiosity, erotic longing, litigiousness, and bodily concerns may all occur. Regardless of which delusion is most prominent, however, one typically also sees delusions of reference. Furthermore, as noted earlier, the delusions experienced by these patients often fit together quite logically, and the entire corpus of beliefs is well systematized. Traditionally, delusional disorder has been divided into several subtypes, depending on the type of delusion present (Winokur 1977); thus, there are persecutory, grandiose, erotomanic, jealous, and somatic subtypes, and these are described further below. In the persecutory subtype the dominant delusion is one of being persecuted or conspired against. Delusions of reference typically appear, and patients may believe that people on the street talk about them. Patients may move to another city to avoid their persecutors, and may feel safe for a while, but eventually their persecutors catch up with them. These patients may at times be dangerous and may attack others in what, to them, appears to be justified selfdefense (Kennedy et al. The litigious subtype may be the most difficult to diagnose as the initial delusion may appear very plausible and the ensuing delusions may have an almost unassailable logic to them. During the onset of the illness, patients are typically involved in legal proceedings that go badly for them. Patients become convinced that someone is at fault: their attornies are incompetent; the judges were biased; the juries were prejudiced. Patients may pore over trial manuscripts until, finally, some irregularity, no matter how minor, is found. New attornies are then hired and appeals are filed, and a series of legal proceedings is embarked upon. With each failed legal manuever, patients may become more convinced that the legal system as a whole is conspiring in the denial of justice. In the grandiose subtype, the dominant theme of grandiosity may come to light in a variety of ways. One man believed that his mother was an heiress who, out of shame for her out-of-wedlock pregnancy, gave him up for adoption to a poor family; the patient, believing that an inheritance would soon be his, quit his job as he felt no need for his income anymore. Others may believe themselves to be great, although unrecognized, inventors, and toil on in their homes, littering their walls with fantastic diagrams and sketches of their magnificent creations. For example, one woman believed that the mayor was in love with her and was unable to tell her this openly as he was married. She saw him at a political rally and he turned his gaze from her, a move she interpreted as evidence that he could not bear the unrequited longing he surely must have felt had he looked at her. In the jealous subtype, the patient becomes convinced that his or her spouse or lover is being unfaithful. The spouse is a few minutes late getting home from work and the patient believes that only passionate lovemaking could have caused the delay. Sheets and underclothing are inspected for telltale stains; telephone conversations are listened in on; a private detective may be hired. The patient may insist that the spouse stay at home, and at times spouses may become virtual prisoners in their own homes. In the somatic subtype patients believe, despite reassurances to the contrary from their physicians, that they have a serious disease. Two atypical variations on this subtype deserve mention, namely the olfactory reference syndrome (Videbech 1966) and parasittosis (Andrews et al. In the olfactory reference syndrome patients are convinced that they are emanating a foul odor from the mouth or some other orifice, and may anxiously ask others if they smell it also. In addition to delusions, some patients with delusional disorder may also have hallucinations, but these generally play only a minor role in the clinical picture and are consistent with the delusions. For example, a persecuted patient may hear a voice warning him that his life is in danger or an erotomanic patient may hear voices whispering caressing words. Mood and affect may be unremarkable or may show changes, again consistent with the delusions: the persecuted patient may become quite irritable and the grandiose patient may experience a shallow, contented euphoria. Overall, regardless of subtype, the behavior of these patients may be quite normal in areas of their lives that are not touched by their delusions. In paranoid schizophrenia, suspicions are mercurial and focus on others in seconds; thus the physician may be suspected moments after the interview begins. In delusional disorder, by contrast, patients take time to size others up, and indeed are often quite willing to confide in the physician. Hypochondriasis may enter the differential for the somatic subtype of delusional disorder. Course Although partial remissions may occur, for the most part delusional disorder appears to pursue a chronic waxing and waning course (Opjordsmoen and Rettersol 1991). An antipsychotic may be chosen using the scheme discussed in the section on schizophrenia; importantly, one should choose a medication with a low propensity for side-effects and start at a low dose, as patients with delusional disorder are typically prone to seize on the occurrence of a side-effect, no matter how trivial, as a reason to never take medication of any sort again. The somatic subtype may constitute an exception to the foregoing as there are case reports of this subtype responding to antidepressants such as clomipramine (Wada et al. Occasionally, hospitalization may be required to protect others, for example in the persecutory or erotomanic subtypes. Etiology Although the etiology is not known, delusional disorder appears to be familial; importantly, there is no evidence of any genetic relationship with schizophrenia (Kendler et al. Differential diagnosis Schizophrenia is distinguished on two counts, namely the lack of systematization and the presence of other symptoms. As noted, in delusional disorder the various delusions are logically connected into a well-systematized corpus of beliefs. By contrast, in schizophrenia there is always some lack of connectedness among the various delusions, which at times may be flatly contradictory. Furthermore, in schizophrenia one sees other symptoms, such as bizarre delusions, prominent hallucinations, speech disorganization, etc. In some cases, however, it may be difficult to differentiate paranoid schizophrenia from the persecutory subtype of delusional disorder. Thus the patient may not reveal certain bizarre beliefs, for example that a listening device has been placed in his abdomen or that he constantly 20. Delusions may appear and often center on the baby, who may variously be considered evil or the Messiah; auditory hallucinations may also occur and may be command in type, instructing the patient to do things to the baby. Course In the natural course of events, symptoms undergo a gradual, spontaneous, and full remission after a matter of weeks or months. Close to one-third of patients will have another episode should they have another child (Davidson and Robertson 1985; Kendell et al. In other cases one may use an antipsychotic, and the choice among these may be made utilizing the guidelines offered in Section 20. Consideration may also be given to sublingual estradiol: in one non-blind study, 1 mg four to five times daily yielded impressive results (Ahokas et al. Regardless of which pharmacologic strategy is employed, it should always be possible, given the natural course of this disorder, to eventually taper and discontinue treatment.

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