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Any sign lifeand limb-threatening immunologic reaction caused or symptom experienced by the patient during the by platelet activation resulting in a hypercoagulable infusion of a pharmacologic or biologic agent that state with a strong association to acne medication cheap decadron online mastercard vascular and arterial results in an immediate hypersensitivity reaction and thrombosis as a result of heparin exposure acne that itches discount decadron 1 mg overnight delivery. Having a concentration greater than the norreporting the results of blood coagulation tests acne 4 dpo purchase decadron 1mg visa. A preparation of lipids administered intravenously to skin care olive oil generic 1mg decadron free shipping maintain or support I nutrition. A needle used to control, direct, and place a reduced capability to react to pathogens or tissue damage. A noninvasive transdermal method of include the elastomeric balloon device and the spring administering medication via an electrical charge. A needleless connector with an cause life-threatening organ damage; a side effect of internal mechanical device that provides a fiuid pathfrequent blood transfusions. A microscopic collection of particles, potential for error and clearly defines acceptable such as platelets, leukocytes, and fibrin that occurs in behavior in a consistent manner. A filter that removes L microaggregates and reduces the occurrence of nonLaminar Flow Hood. A dilator/introducer assembly used in tion and collection of hazardous chemical fumes in the the Modified Seldinger Technique for insertion of a work area. An extremely small living body not products containing natural rubber latex intended for perceptible to the naked eye. A vascular access device measuring under state and federal laws to consent on behalf of a 8 inches or less with the distal tip dwelling in the basillegally designated person. One thousandth of an osmole; supervision within the scope of the individual’s granted osmotic pressure equal to one thousandth of the molclinical privileges, license, and organizational policies. The instillation of a solution into a vascular ions that the substance forms in 1 L of solution. The guidewire and dilator are removed, and the M catheter is advanced through the introducer, followed by Manual Flow-Control Device. Someone who has not reached adulthood N (as defined by state law) but who may be treated as an adult for certain purposes, such as consenting to medNeedleless Connector. A mature minor is not necessarily an emancineedleless devices for the administration of solutions pated minor. An umbrella term used to encompass ing used to avoid exposure to pathogens, including all types of needleless devices or products. Blood refiux into the catheter lumen P upon disconnection with movement of valve mechanism, Paired Blood Samples. Blood samples are drawn from a or when a fiuid container empties and remains connected catheter and from a peripheral venipuncture site; both to the administration set. Admixtures containing macronutrients and preparation of a peripheral insertion site. Once the site micronutrients that are vital for the maintenance of has been prepared, it is not to be touched unless sterile metabolism and growth. Items that touch only intact skin, tional needs for a patient who is unable to take appropriate not mucous membranes, or that do not directly touch amounts of food enterally; typical components include carthe patient. Matter relating to or composed of fine including, but not limited to, circulatory overload, particles. Activation of the analgesic infusion pump skin and to the intended location without passing by anyone other than the patient. A central registered nurses and licensed practical or vocational vascular access device inserted into an extremity and nurses within each state. Concepts that link specific nursing safety hazards; examples include, but are not limited to, activities and actions to expected outcomes. Infiammation of a vein; may be accompanied by such care are met comprehensively and effectively; pain, erythema, edema, streak formation, and/or a palincludes the steps of assessment, problem identificapable cord. An undesirable, visible reaction within a solution such as a change in color, clarity, Occlusion. The state of being occluded; the inability to presence of precipitate, or gas formation. The use of an approved drug in the treatpatient to move arms, legs, body, or head freely. Greater than 65 years of age as defined by the associated with spontaneous rupture and drainage or American Society of Geriatrics. A measurement of pressure; tion, analysis, treatment, and evaluation of real and 1 psi equals 50 mm mercury (Hg) or 68 cm water potential hazards. An engineered physical attribute the current state of knowledge about a specific disease of a device that effectively reduces the risk of bloodstate or therapy. A tip location of any cenlocation of any central vascular access device found tral vascular access device found to be in a suboptimal to be in a different, suboptimal position following position as determined by the initial chest radiograph. An adminisadministration set used to deliver solutions and medtration set attached to the primary administration set ications to the patient. Tasks that are documented to vessel is accessed with a needle, and a guidewire is produce issues for the patient, staff, or organization. A written statement of a series of steps required catheter is placed into the vessel over the guidewire and to complete an action. Closest to the center or midline of the body or col used for isolating and identifying microorganisms in trunk, nearer to the point of attachment; the opposite which a catheter segment is rolled across the surface of of distal. An unexpected occurrence involving death, dexterity as they relate to the thought process. An ongoing, systematic process projections capable of cutting or piercing the skin. A laboratory protocol fiuid pathway that contains no internal mechanisms used for isolating and identifying microorganisms in or moving pieces. A device, such as a vial or syringe, followed by serial dilutions and surface plating on agar. A bottle that is hermetically sealed with R a rubber stopper and is intended for one-time use. A method or product used to protect the radiation; detectable by radiographic examination. A data-driven, fact-based philosophy of qualito manage a known or potential serious risk associatty improvement that values prevention over detection. An authoritative statement enunciated and external moisture from contacting the insertion site of promulgated by the profession by which the quality the vascular access device. Guidelines designed to protect ing to the wrong catheter, port, or lumen that may result workers with occupational exposure to bloodborne in serious injury or death; examples include enteral or pathogens; all blood and body fiuids are treated as oxygen tubing connected to an intravenous administrapotentially infectious. A rigid metal object within a catheter designed to taneous tract of a tunneled catheter with or without a facilitate insertion. A vascular access device whose proxior solutions into the tissues beneath the skin. A surface-active agent that lowers the sursite and brought out through the skin at an exit site. Active, systematic, ongoing observation of the occurrence and distribution of disease within a populaUltrafiltration. A method used to remove excessive tion and of the events or conditions that increase or amounts of sodium and water from patients with fiuid decrease the risk of such disease occurrence. An event determined to have an T impact on patient care, and/or any practice felt to be Tamper-Proof. Infiammation of the vein in conjunction with formation of a blood clot (thrombus). The formation, development, or existence devices inserted into the vascular system, including of a blood clot within the vascular system. The thrombus may grow to surprofessional should be honest, give full disclosure to round a vascular access device, eventually obstructing the patient, abstain from deceit or misrepresentation, the device as well as the vessel. Factors that promote the and report known lapses of the standards of care to formation of a thrombus are vascular endothelial damthe proper agencies. An electronic device that converts one form of ed vascular pathway into surrounding tissue. The triad sion in which there is an immune response against the consists of the following components: vessel wall damtransfused blood cells or other components of the transage or injury, alterations in blood fiow, and hypercofusion.

Interactions between dietary fat acne mechanica decadron 0.5 mg lowest price, fish acne quotes purchase cheap decadron online, and fish oils and their effects on platelet function in men at risk of cardiovascular disease acne aid soap cheap 0.5 mg decadron visa. Fish consumption and cardiovascular disease in the Physicians’ Health Study: A prospective study acne treatment during pregnancy generic 0.5mg decadron free shipping. Changes in children’s total fat intakes and their food group sources of fat, 1989–91 versus 1994–95: Implications for diet quality. The gastrointestinal handling and metabolism of [1-13C]palmitic acid in healthy women. Decreased serum total cholesterol concentration is associated with high intake of soy products in Japanese men and women. Low-fat diets do not lower plasma cholesterol levels in healthy men compared to high-fat diets with similar fatty acid composition at constant caloric intake. The effect of dietary docosahexaenoic acid on plasma lipoproteins and tissue fatty acid composition in humans. The effect of dietary docosahexaenoic acid on platelet function, platelet fatty acid composition, and blood coagulation in humans. Problems with the report of the Expert Panel on blood cholesterol levels in children and adolescents. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Nutritional quality of a high carbohydrate diet as consumed by children: the Bogalusa Heart Study. Niinikoski H, Viikari J, Ronnemaa T, Lapinleimu H, Jokinen E, Salo P, Seppanen R, Leino A, Tuominen J, Valimaki I, Simell O. Prospective randomized trial of low-saturated-fat, low-cholesterol diet during the first 3 years of life. Niinikoski H, Lapinleimu H, Viikari J, Ronnemaa T, Jokinen E, Seppanen R, Terho P, Tuominen J, Valimaki I, Simell O. Growth until 3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and cholesterol. Niinikoski H, Viikari J, Ronnemaa T, Helenius H, Jokinen E, Lapinleimu H, Routi T, Lagstrom H, Seppanen R, Valimaki I, Simell O. Men who consume vegetable oils rich in monounsaturated fat: Their patterns and risk of prostate cancer (New Zealand). Energy intake and physical activity in relation to indexes of body fat: the National Heart, Lung, and Blood Institute Growth and Health Study. Effects of inherent responsiveness to diet and day-to-day diet variation on plasma lipoprotein concentrations. Calcium and magnesium absorption from the colon and rectum are increased in rats fed fructooligosaccharides. Fish consumption and coronary heart disease mortality in Finland, Italy, and the Netherlands. Dietary conjugated linoleic acids increase lean tissue and decrease fat deposition in growing pigs. The antioxidant/anticancer potential of phenolic compounds isolated from olive oil. A high-monounsaturated-fat/low-carbohydrate diet improves peripheral insulin sensitivity in non-insulin-dependent diabetic patients. Evidence that the trans-10,cis-12 isomer of conjugated linoleic acid induces body composition changes in mice. Relationship of dietary saturated fatty acids and body habitus to serum insulin concentrations: the Normative Aging Study. Lipoprotein concentrations in normolipidemic males consuming oleic acid-rich diets from two different sources: Olive oil and oleic acid-rich sunflower oil. Circulating levels of endothelial function are modulated by dietary monounsaturated fat. A Mediterranean and a high-carbohydrate diet improves glucose metabolism in healthy young persons. Impact of adopting lower-fat food choices on nutrient intake of American children. Role of life-style and dietary habits in risk of cancer among Seventh-Day Adventists. Dietary manipulation and energy compensation: Does the intermittent use of low-fat items in the diet reduce total energy intake in free-feeding lean menfi Effect of dietary manipulation on substrate flux and energy balance in obese women taking the appetite suppressant dexfenfluramine. Dietary supplementation of omega-3 polyunsaturated fatty acids improves insulin sensitivity in non-insulin-dependent diabetes. Effects of physical and chemical characteristics of food on specific and general satiety. Effects of degree of obesity, food deprivation, and palatability on eating behavior of humans. Ad libitum intake of a high-carbohydrate or high-fat diet in young men: Effects on nutrient balances. Replacement of dietary fat by sucrose or starch: Effects on 14 d ad libitum energy intake, energy expenditure and body weight in formerly obese and never-obese subjects. Insulin resistance, compensatory hyperinsulinemia, and coronary heart disease: Syndrome X revisited. Feasibility of using an oleate-rich diet to reduce the susceptibility of low-density lipoprotein to oxidative modification in humans. Effects of oleate-rich and linoleate-rich diets on the susceptibility of low density lipoprotein to oxidative modification in mildly hypercholesterolemic subjects. Effect of diets high in t-3 and t-6 fatty acids on initiation and postinitiation stages of colon carcinogenesis. The pattern of urinary stone disease in Leeds and in the United Kingdom in relation to animal protein intake during the period 1960–1980. The effect of high animal protein intake on the risk of calcium stone-formation in the urinary tract. Relationships between serum lipids, platelet membrane fatty acid composition and platelet aggregation in type 2 diabetes mellitus. Influence of macronutrients on adiposity development: A follow up study of nutrition and growth from 10 months to 8 years of age. The specificity of satiety: the influence of foods of different macronutrient content on the development of satiety. Satiety after preloads with different amounts of fat and carbohydrate: Implications for obesity. A randomized controlled trial of prenatal nutrition supplementation in New York City. Dietary supplementation of very longchain n-3 fatty acids decreases whole body lipid utilization in the rat. Single and combined prothrombic factors in patients with idiopathic venous thromboembolism. The influence of a fish oil high in docosahexaenoic acid on plasma lipoprotein and vitamin E concentrations and haemostatic function in healthy male volunteers. Influence of n-6 versus n-3 polyunsaturated fatty acids in diets low in saturated fatty acids on plasma lipoproteins and hemostatic factors. An ecological study of the relationship between dietary fat intake and breast cancer mortality. Changes in blood lipids and fibrinogen with a note on safety in a long term study on the effects of n-3 fatty acids in subjects receiving fish oil supplements and followed for seven years. Energy density of self-reported food intake: Variation and relationship to other food components. A prospective study of demographics, diet, and prostate cancer among men of Japanese ancestry in Hawaii. Is there a relationship between dietary fat and stature or growth in children three to five years of agefi Information about the fat content of preloads influences energy intake in healthy women. A population-based case-control study of dietary factors and endometrial cancer in Shanghai, People’s Republic of China. Inhibitory effect of conjugated dienoic derivates of linoleic acid and `-carotene on the in vitro growth of human cancer cells. The frequency of urolithiasis in hospital discharge diagnoses in the United States.

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Nitrogen dioxide radical generated by the myeloperoxidase-hydrogen peroxide-nitrite system promotes lipid peroxidation of low density lipoprotein skin care advice 0.5 mg decadron fast delivery. Vitamin E decreases urine lipid peroxidation products in young healthy human volunteers under normal conditions acne knitwear purchase decadron online pills. Effects of vitamin antioxidant supplementation on cell kinetics of patients with adenomatous polyps skin care during pregnancy discount 1 mg decadron visa. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans skin care summer buy 1 mg decadron mastercard. Premature rupture of amniotic membranes as functional assessment of vitamin C status during pregnancy. Oxidative stress and abnormal cholesterol metabolism in patients with adult respiratory distress syndrome. Effect of vitamin C supplementation on chromosome damage, apoptosis and necrosis ex vivo. A prospective study of the intake of vitamins C and B6, and the risk of kidney stones in men. Cigarette smoking is associated with unhealthy patterns of nutrient intake: A meta-analysis. Studies on the absorption of Lxyloascorbic acid (vitamin C) in young and elderly subjects. Ascorbic acid may protect against human gastric cancer by scavenging mucosal oxygen radicals. Effect of vitamin C upon gastric mucosal O6-alkyltransferase activity and on gastric vitamin C levels. The effect of supplemental ascorbic acid on serum vitamin B12 levels in myelomenigocele patients. The relationship between vitamin C intake, general health practices, and mortality in Alameda County, California. The distribution of ascorbic acid between various cellular components of blood in normal individuals, and its relation to the plasma concentration. Urinary and plasma oxalate during ingestion of pure ascorbic acid: A re-evaluation. Gas phase oxidants of cigarette smoke induce lipid peroxidation and changes in lipoprotein properties in human blood plasma. Effect of ascorbate supplementation on low density lipoprotein oxidation in smokers. Vitamin C and risk of death from stroke and coronary heart disease in cohort of elderly people. Textbook of Gastroenterology and Nutrition in Infancy and Childhood, 2nd edition. Ten-year retrospective on the antioxidant hypothesis of arteriosclerosis: Threshold plasma levels of antioxidant micronutrients related to minimum cardiovascular risk. A critical and constructive review of epidemiology and supplementation data regarding cardiovascular disease and cancer. Poor plasma status of carotene and vitamin C is associated with higher mortality from ischemic heart disease and stroke: Basel Prospective Study. Reported family aggregation of pancratic cancer within a population-based case-control study in the francophone community in Montreal, Canada. Substances that interfere with guaiac card tests: Implications for gastric aspirate testing. Gene expression of iron-related proteins during iron deficiency caused by scurvy in guinea pigs. Diet in the epidemiology of postmenopausal breast cancer in the New York State Cohort. Plasma ascorbate levels and inhibition of the antioxidant activity of caeruloplasmin. Biologically significant scavenging of the myeloperoxidase-derived oxidant hypochlorous acid by ascorbic acid. Protection by vitamin C of oxidant-induced loss of vitamin E in rat hepatocytes. Effect of vitamin C and E supplementation on susceptibility of plasma lipoproteins to peroxidation induced by acute smoking. Citrus fruit supplementation reduces lipoprotein oxidation in young men ingesting a diet high in saturated fat: Presumptive evidence for an interaction between vitamins C and E in vivo. Pathways for oxidation of low density lipoprotein by myeloperoxidase: Tyrosyl radical, reactive aldehydes, hypochlorous acid and molecular chlorine. Vitamin C, the placebo effect, and the common cold: A case study of how preconceptions influence the analysis of results. Glutathione blood levels and other oxidant defense indices in men fed diets low in vitamin C. Vitamin C improves endothelial function of conduit arteries in patients with chronic heart failure. Dietary factors and risk of breast cancer: Combined analysis of 12 case-control studies. A collaborative case-control study of nutrient intake and pancreatic cancer within the search programme. Effect of ascorbic acid on apparent iron absorption by women with low iron stores. A prospective study of the intake of vitamins C, E, and A and the risk of breast cancer. Urinary carnitine excretion increases during experimental vitamin C depletion of healthy men. Effect of varying ascorbic acid intakes on copper absorption and ceruloplasmin levels of young men. Vitamin C nutriture has little short-term effect on vitamin E concentrations in healthy women. Long-term vitamin C supplement use and prevalence of early agerelated lens opacities. False-negative stool occult blood tests caused by ingestion of ascorbic acid (vitamin C). Dietary antioxidants and cognitive function in a populationbased sample of older persons. Preservation of the endogenous antioxidants in low density lipoprotein by ascorbate but not probucol during oxidative modification. Physiologic levels of ascorbate inhibit the oxidative modification of low density lipoprotein. Complement component C1q unaltered by ascorbate supplementation in healthy men and women. Comparison of the absorption and excretion of three commercially available sources of vitamin C. Vitamin C depletion is associated with alterations in blood histamine and plasma free carnitine in adults. On the requirements of ascorbic acid in man: Steady-state turnover and body pool in smokers. Antioxidant vitamin intake and coronary mortality in a longitudinal population study. Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. Enhancement of hydroperoxide-dependent lipid peroxidation in rat liver microsomes by ascorbic acid. The effect of controlled ascorbic acid depletion and supplementation on periodontal health. Effects of ascorbic acid depletion and supplementation on periodontal health and subgingival microflora in humans. Vitamin C blocks inflammatory platelet-activating factor mimetics created by cigarette smoking. Vegetable consumption and lung cancer risk: A population-based case-control study in Hawaii. Ascorbic acid reverses endothelial vasomotor dysfunction in patients with coronary artery disease. Vitamin C pharmacokinetics in healthy volunteers: Evidence for a recommended dietary allowance. Vitamin C for the treatment of recurrent furunculosis in patients with impaired neutrophil functions.

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Larvae have been detected in sputum and gastric washings in patients with the rare complication of pneumonitis acne before and after purchase 0.5mg decadron. Enzyme immunoassay or Western blot analysis using antigens of A caninum have been developed in research laboratories acne dark spot remover purchase decadron toronto, but these assays are not available for routine diagnostic use skin care secrets purchase generic decadron on line. Orally administered albendazole or mebendazole is the recommended therapy (see Drugs for Parasitic Infection skin care 29 year old order decadron, p 848). Anorexia, nausea, vomiting, substantial weight loss, fatulence, abdominal cramping, myalgia, and prolonged fatigue also can occur. Infection usually is self-limited, but untreated people may have remitting, relapsing symptoms for weeks to months. Asymptomatic infection has been documented most commonly in settings where cyclosporiasis is endemic. In the United States, 10% of cases occur in people younger than 20 years of age, and a history of travel has been reported in approximately one third of people in the United States with cyclosporiasis. Both foodborne and waterborne outbreaks have been reported, with most cases in the United States occurring in May through July. Most of the outbreaks in United States and Canada have been associated with consumption of imported fresh produce, including Guatemalan raspberries and Thai basil. Direct person-to-person transmission is unlikely, because excreted oocysts take days to weeks under favorable environmental conditions to sporulate and become infective. The oocysts are resistant to most disinfectants used in food and water processing and can remain viable for prolonged periods in cool, moist environments. Surveillance for laboratory-confrmed sporadic cases of cyclosporiasis—United States, 1997–2008. This constraint underscores the utility of repeated stool examinations, sensitive recovery methods (eg, concentration procedures), and detection methods that highlight the organism. Oocysts are autofuorescent and variably acid-fast after modifed acid-fast staining of stool specimens (ie, oocysts that either have retained or not retained the stain can be visualized). Investigational molecular diagnostic assays (eg, polymerase chain reaction) are available at the Centers for Disease Control and Prevention and some other reference laboratories. People infected with human immunodefciency virus may need long-term maintenance therapy (see Drugs for Parasitic Infections, p 848). An infectious mononucleosislike syndrome with prolonged fever and mild hepatitis, occurring in the absence of heterophile antibody production, may occur in adolescents and adults. Infection acquired intrapartum from maternal cervical secretions or postpartum from human milk usually is not associated with clinical illness in term babies. Transmission occurs horizontally (by direct person-to-person contact with viruscontaining secretions), vertically (from mother to infant before, during, or after birth), and via transfusions of blood, platelets, and white blood cells from infected donors (see Blood Safety, p 114). Horizontal transmission probably is the result of salivary exposure, but contact with infected urine also can have a role. Excretion rates from urine or saliva in children 1 to 3 years of age who attend child care centers usually range from 30% to 40% but can be as high as 70%. In adolescents and adults, sexual transmission also occurs, as evidenced by detection of virus in seminal and cervical fuids. Cervical excretion rates are highest among young mothers in lower socioeconomic groups. Infection usually manifests 3 to 12 weeks after blood transfusions and between 1 and 4 months after organ transplantation. Virus can be isolated in cell culture from urine, pharynx, peripheral blood leukocytes, human milk, semen, cervical secretions, and other tissues and body fuids. Amniocentesis has been used in several small series of patients to establish the diagnosis of intrauterine infection. Differentiation between intrauterine and perinatal infection is diffcult at later than 2 to 4 weeks of age unless clinical manifestations of the former, such as chorioretinitis or intracranial calcifcations, are present. Oral ganciclovir no longer is available in the United States, but oral valganciclovir is available both in tablet and in powder for oral solution formulations. Valganciclovir administered orally to young infants at 16 mg/kg/dose, twice daily, provides the same systemic ganciclovir exposure as does intravenous ganciclovir at 6 mg/kg/dose. Antiviral therapy is not recommended routinely in neonates and young infants because of possible toxicities, including neutropenia in a signifcant proportion of recipients. If such patients are treated with parenteral ganciclovir, a reasonable approach is to treat for 2 weeks and then reassess responsiveness to therapy. If clinical data suggest beneft of treatment, an additional 1 to 2 weeks of parenteral ganciclovir can be considered if symptoms and signs have not been resolved. If such circumstances cannot be avoided, administration of antiviral therapy or monitoring for viremia and administering preemptive antiviral therapy is benefcial for decreasing this risk. Approximately 5% of patients develop severe dengue, which is more common with second or other subsequent infections. Less common clinical syndromes include myocarditis, pancreatitis, hepatitis, and neuroinvasive disease. Dengue is a dynamic disease beginning with a nonspecifc, acute febrile illness lasting 2 to 7 days (febrile phase), progressing to severe disease during fever defervescence (critical phase), and ending in a convalescent phase. Fever may be biphasic and usually is accompanied by muscle, joint, and/or bone pain, headache, retro-orbital pain, facial erythema, injected oropharynx, macular or maculopapular rash, leukopenia, and petechiae or other minor bleeding manifestations. Warning signs of progression to severe dengue occur in the late febrile phase and include persistent vomiting, abdominal pain, mucosal bleeding, diffculty breathing, early signs of shock, and a rapid decline in platelet count with an increase in hematocrit (hemoconcentration). Patients with nonsevere disease begin to improve during the critical phase, and people with clinically signifcant plasma leakage attributable to increased vascular permeability develop severe disease with pleural effusions and/or ascites, hypovolemic shock, and hemorrhage. In the United States, dengue is endemic in Puerto Rico, the Virgin Islands, and American Samoa. However, although 16 states have A aegypti and 35 states have A albopictus mosquitoes, local dengue transmission is uncommon because of infrequent contact between people and infected mosquitoes. Dengue occurs in both children and adults and affects both sexes with no differences in infection rates or disease severity. In humans, the incubation period is 3 to 14 days before symptom onset (intrinsic incubation). Infected people, both symptomatic and asymptomatic, can transmit to mosquitoes 1 to 2 days before symptoms develop and throughout the approximately 7-day viremic period. During the febrile phase, patients should stay well hydrated and avoid use of aspirin (acetylsalicylic acid), aspirin-containing drugs, and other nonsteroidal anti-infammatory drugs (eg, ibuprofen) to minimize the potential for bleeding. Additional supportive care is required if the patient becomes dehydrated or develops warning signs for severe disease at the time of fever defervescence. Early recognition of shock and intensive supportive therapy can reduce risk of death from approximately 10% to less than 1% in severe dengue. During the critical phase, maintenance of fuid volume and hemodynamic status is central to management of severe cases. Patients should be monitored for early signs of shock, occult bleeding, and resolution of plasma leak to avoid prolonged shock, end organ damage, and fuid overload. Patients with refractory shock may require intravenous colloids and/or blood or blood products after an initial trial of intravenous crystalloids. Reabsorption of extravascular fuid occurs during the convalescent phase with stabilization of hemodynamic status and diuresis. It is important to watch for signs of fuid overload, which may manifest as a decrease in the patient’s hematocrit as a result of the dilutional effect of reabsorbed fuid. A number of candidates are in clinical trials to evaluate immunogenicity, safety, and effcacy. No chemoprophylaxis or antiviral medication is available to treat patients with dengue. Travelers should select accommodations that are air conditioned and/or have screened windows and doors. Aedes mosquitoes bite during the daytime, so bed nets are indicated for children sleeping during the day. Travelers should wear clothing that fully covers arms and legs, especially during early morning and late afternoon. Dengue, acquired locally in the United States and during travel, became a nationally notifable disease in 2010. Membranous pharyngitis associated with a bloody nasal discharge should suggest diphtheria. Local infections are associated with a low-grade fever and gradual onset of manifestations over 1 to 2 days. Less commonly, diphtheria presents as cutaneous, vaginal, conjunctival, or otic infection.

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