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By S. Temmy. Central Missouri State University.

Person-to-person Poxviridae family) precautions must be transmission well documented order benicar 10 mg with amex. Patients on the other arm of the algorithm (patients without mediastinal widening purchase benicar 20mg overnight delivery, but with altered mental status) are diagnosed with inhalational anthrax. The limitations to this diagnostic scheme are that it was not derived prospectively, and its application is limited to previously healthy individuals (43). No single characteristic was sufficiently sensitive or specific, but the algorithm produced a result that was 70. Decontaminate as Appropriate Under most circumstances, victims of a bioterrorist attack will present hours or days later. Patients will be triaged and screened in the emergency department where all clothing will be removed and preserved for testing and as evidence. Decontamination of the patient is critical in the case of a chemical, biologic, or radiologic attack and should take place in a designated decontamination area, usually outside or adjacent to the emergency department. For most agents, removal and securing of all clothing and a five- to six-minute shower with soap and water is sufficient (56). Use of caustic solutions will harm the patient by damaging the skin and mucous membranes, complicate care, without realizing any advantage in decontaminating the patient (1). Standard solutions of hypochlorite are adequate to clean any surfaces contaminated with any potential pathogen, but should never be applied to the patient (1,57). Establish a Diagnosis The most definitive diagnostic test for each pathogen is listed in Table 9 (1,6,11,58–71). It is important to consider the possibility that the victim of bioterrorism may be infected or poisoned by more than one agent. Combinations of bacterial and viral agents, and/or agents with widely different incubation periods may be purposely employed to add confusion and increase the lethality of the attack. In the case of the use of two or more agents, their individual physical properties may allow for different distribution properties, and even organisms with similar incubation periods may present at widely different times. Relapses may be part of the disease course or the presentation of a second disease or intoxication. Render Prompt Treatment Table 10 outlines the recommended treatments for each of the pathogens (1,6,11,23,29,58–60, 75–98). As was our experience during the Trenton-anthrax threat of 2001, definitive recommendations will come from public health authorities once the pathogens are identified with sufficient certainty. Practice Good Infection Control Standard precautions are usually adequate to manage most patients with anthrax, tularemia, brucellosis, Q fever, Venezuelan equine encephalitis, and toxin-mediated diseases. After 10 seconds of washing, there was no difference in reducing the spore count between the antimicrobial soap and plain soap. There was also no difference between either soap by increasing washing from 10 to 60 seconds. Chlorine-containing microfiber towels were inferior to hand washing at 10 seconds duration, but superior at 60 seconds duration (56). Alert the Proper Authorities The hospital administration should notify local, municipal, state, and federal health and law enforcement authorities. Bypassing the institutional chain-of-command and protocol will lead to confusion, misinformation, and delay in responding appropriately. The first line of notification in most if not all institutions is infection control or the designated institutional individual for any suspected cases of a contagious disease, whether or not bioterrorism is suspected. All personnel on all shifts should be familiar with the institution’s individual protocol. Confirmatory testing (bioassay and stool cultures) for toxin may be time consuming. Other assays: a vertical-flow strip immunochromatography and a small disposable immunoaffinity column for type A toxin. Serology (enzyme- linked immunosorbent assay) or histologic examination of involved tissue may be needed. Viral hemorrhagic fevers [filoviruses Antigen testing by enzyme-linked immunoabsorbent assay (e. Table 9 Definitive Diagnostics (Continued) Pathogen Diagnostic test Typhus fever (R. Yellow fever: virus may virus and hantavirus; yellow fever virus, be isolated from blood during the first 3 days of illness. Other viruses within the enzyme immunoassay, probe hybridization, and same group are louping ill virus, Langat immunofluorescence assay. West Nile virus (a Flaviviridae) Pandemic and avian influenza (H5N1 Viral detection from oropharyngeal aspirate, swab, or lower- influenza) respiratory sample. Rapid immunofluorescence or enzyme immunoassay can differentiate between influenza A and B strains. Bioterrorism Infections in Critical Care 473 Assist in the Epidemiologic Investigation and Manage the Psychological Consequences The intensive care team will likely be the first caregivers with an opportunity to obtain detailed information from the patient and/or family. Accurate history-taking (food and water sources, occupation, place of employment, travel, modes of travel and commuting, human and animal contacts, etc.

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At the present time discount benicar 10mg online, genetic testing should be provided to the public only through the services of an appropriately quali- fied health care professional discount 10mg benicar with visa. The health care professional should be responsible for both ordering and interpreting the genetic tests, as well as for pretest and posttest counseling of individuals and families regarding the medical significance of test results and the need, if any, for follow-up. Due to the complexities of genetic testing and counseling, the self-ordering of genetic tests by patients over the telephone or the Internet, and their use of genetic “home testing” kits, is potentially harmful. Potential harms include inappropriate test utilization, misinterpretation of test results, lack of necessary follow-up, and other adverse consequences. This limits the sources of information available to con- sumers about these tests and their accuracy from those marketing the tests. This critical lack of information raises concerns that patients/individuals may not have the resources to make unbiased decisions regarding whether to proceed with genetic testing. Privacy Issues in Personalized Medicine Genetic tests challenge privacy depending on how comprehensive the test is and how the access to samples or digital information is controlled. Large-scale clinical trials, on the other hand, Universal Free E-Book Store Ethical Aspects of Genetic Information 659 result in large databases of genomic information. The magnitude of the genomic scans, implications of the inclusion of genetic information about relatives, security of storage and ease of dissemination of data present greater challenges to privacy compared to traditional, self-limited and often transient medical information. However, the health insurance measure would not go into effect until a year after, and the employment measure would take effect only after 18 months. The bill may be hard to enforce and it does not address discrimination by long-term care insurers or life insurers. The use of genetic information that the bill is likely to encourage may raise still more questions about how it should be used. Provisions of the Affordable Care Act set to go into effect in 2014 go a step further and will preclude consideration of all preexisting condi- tions, whether genomic or not, in establishing insurance premiums. Current federal laws, however, do not restrict the use of genomic information in life insurance, long-term care insurance, or disability insurance. Genotype-Specific Clinical Trials Genotype-specific clinical trials would likely include subjects likely to respond to a drug. The inclusion of subjects known to be unlikely to respond would pose ethical problems: • Genetic variations of pharmacological significance among ethnic groups might be a barrier to participation in clinical trials for fear of stigmatization • Genetic testing of populations as a part of development of personalized medicine raises ethical issues Universal Free E-Book Store 660 21 Ethical Aspects of Personalized Medicine • Genetic information about the patient, confided only to the physician in tradi- tional medicine, will be accessible to other healthcare personnel in clinical trials of personalized medicine, e. Social Issues in Personalized Medicine Introduction of personalized medicine in healthcare systems of Western cultures would need to fulfill requirements of basic social values. Pharmacogenomics with genotype-based optimization of therapeutic interventions would need to demon- strate the following: • Individual’s freedom of choice is not restricted by information generated by pharmacogenomics. It is now well documented that substantial disparities exist in the quality and quantity of medical care received by minority Americans, especially those of African, Asian and Hispanic heritage. In addition, the special needs and responses to pharmaceutical treatment of these groups have been undervalued or ignored. Genetic factors underlie varying responses to medicines observed among different ethnic and racial groups. Pharmacogenetic research in the past few decades has uncovered significant differences among racial and ethnic groups in the metabo- lism, clinical effectiveness, and side-effect profiles of many clinically important drugs. These differences must be taken into account in the design of cost manage- ment policies such as formulary implementation, therapeutic substitution and step- care protocols. These programs should be broad and flexible enough to enable rational choices and individualized treatment for all patients, regardless of race or ethnic origin. Race and Personalized Medicine Pharmacogenetics is growing fast and has reopened the debate on the biological basis of race and ethnicity. It is hoped that and it will lead to a more refined understanding of ethnic and racial differences in drug response. In spite of the contentious nature of discussions about human races, it is often assumed that racial categorization has clin- ical relevance when it comes to the choice of drug therapy. Chinese patients require lower dosages of heparin and warfarin than those usually recommended for Caucasian patients. The samples were used to find genes involved in diseases with particularly high rates among blacks, e. Over a 5-year period, blood samples or cheek swabs were gathered from 25,000 persons, mainly patients at hospitals associated with the Howard College of Medicine. The genetic information would help to find the cause of a disease, predict susceptibility to an illness and help to choose a drug that would work best for a particular patient. Race is frequently used by clinicians to make inferences about an individual’s ancestry and to predict whether an individual carries specific genetic risk factors that influence health. The extent to which race is useful for making such predictions depends on how well race corresponds with genetic inferences of ancestry. Recent studies of human genetic variation show that while genetic ancestry is highly cor- related with geographic ancestry, its correlation with race is modest. Because of substantial variation within human populations, it is certain that labels such as race will often be an inaccurate proxy when making decisions about disease predisposi- tion and drug response. Because data on the correspondence of race, ancestry, and health-related traits are limited, particularly in minority populations, geographic ancestry and explicit genetic information are alternatives to race that appear to be more accurate predictors of genetic risk factors that influence health and should be considered in providing more personalized health care.

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