Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Chronic 360 million of these are chronically infected carriage is thought to cheap brahmi 60caps with mastercard medicine result from vertical trans (Lee purchase brahmi in united states online medicine natural, 1997; Chen et al generic 60caps brahmi visa medications used to treat bipolar disorder. Genotype A is People’s Republic of China, the Republic of prevalent in Europe, Africa, and North America. Korea, Taiwan (China), and several other coun Genotype B is prevalent in Taiwan (China), tries in South-east Asia (Chen et al. C is prevalent in China, Japan, the Republic The worldwide variation in the endemicity of Korea, and South-east Asia. Genotypes F and G are mostly In areas of high endemicity, the lifetime risk found in Central and South America. Perinatal transmis practices, including the re-use of contaminated sion usually happens at the time of birth; in-utero equipment for medical, cosmetic or dental proce transmission is relatively rare, accounting for less dures, failure to use appropriate disinfection than 2% of perinatal infections in most studies. The virus may spread from because most persons have been infected since inanimate objects such as shared towels or tooth childhood. But controlling bedbugs by insecti In persons with acute hepatitis B, the incuba cide spraying of the child’s dwelling did not have tion period afer becoming infected is usually 102 Hepatitis B virus 3–4 months, with a range of 6 weeks to 6 months. Following the immune tolerance phase, Symptoms and signs of disease usually last for infected patients progress through a phase of several weeks. About 1–2% of persons with acute immune detection/clearance where the host hepatitis B die from fulminant hepatitis. The immune clearance phase chronic infection that usually lasts throughout is highly variable in duration and frequency life. Persons afected with chronic infection but a prolonged phase or recurrent episodes of ofen do not become sick from their infection for acute liver infammation may result in repeated decades afer becoming infected. Early life/perinatal infection is or what is sometimes referred to as the ‘inac characterized by a period of ‘immune tolerance’ tive carrier state’. This immune tolerance may last for events that occurred during the immune clear years generally without evidence of liver injury. Although occult tion progress directly to the chronic infection hepatitis B has long been documented (Hoofnagle phase, and do not experience an immune toler et al. Cancer in Humans ment response of chronic hepatitis C (Hu, 2002; Torbenson & Tomas, 2002). The majority of the case–control studies 1998), and Senegal and The Gambia (Vildosola, examined also showed a strong association. Of these, the majority A second group of cohort studies included the of studies (n = 7) were conducted in Asia (Chang individuals who had pre-existing liver disease. Signifcant dren were vaccine failure, and a failure to receive heterogeneity was found between studies that hepatitis B immune globulin at birth (Chang could not be explained by the generation of the et al. However, the results remained consistent in progress since the mid-80s in Qidong, China in showing that the risk of concurrent infection (Sun et al. The majority of other associated with urinary afatoxin biomarkers remaining subjects were infected with genotype was 3. The assess was correlated with urinary afatoxin–albumin ment was made difcult by the fact that signs and adduct levels. Tree were conducted undergoing chemotherapy for non-Hodgkin in Europe (Crook et al. The estimates of relative risks among and the risk of extra-hepatic cancer other than 112 Hepatitis B virus non-Hodgkin lymphoma. With sustained proliferation, at some point and for reasons as yet poorly understood, the regu lation of proliferation may become unrestrained, 4. This nisms, distortion of the lobular architecture of response is tightly controlled and lasts only until the liver by fbrosis, and nodular regeneration of the initial number of hepatocytes is restored; it hepatocytes in cirrhosis modify normal cell-to does not normally lead to cancer (Fausto, 1997, cell and cell-to-extracellular matrix interactions, 114 Hepatitis B virus which may contribute to the loss of cell-growth 4. Putative ized by the evolution of clones of hepatocytes mechanisms of free-radical-induced hepatocyte with increased telomerase expression and an damage and malignant transformation are the immortalized phenotype (Farazi et al. Integration is an early event and selective clonal amplifcation of hepatocytes with unique integration patterns is thought to occur during progression to malig nancy (Minami et al. This efect is mediated through signal acid receptor, cyclin A2, mevalonate kinase, transduction pathways. The p53 protein main growth suppression (Chan & Ng, 2006; Cheng tains chromosomal integrity by arresting the cell et al. Tere is evidence that contributed to a progressive disease culminating genome-wide methylation patterns may vary in liver cancer (Chisari et al. This evidence was confrmed in ecological studies wherein the majority of which, At the time of writing, no mechanisms are the increased risk was multiplicative (reviewed in known that might explain the noted limited Kew, 2003; Gouas et al. A recent study shows that this epoxide forms preferential 122 Hepatitis B virus 4. The e antigen and vertical transmission of hepatitis B surface have been observed between chronic infection antigen. Hepatitis B virus X protein molecular functions and its role in virus life cycle and pathogenesis. Seroepidemiology of hepatitis B virus infection in Concurrent hepatitis B and C virus infection and Saudi children 8 years afer a mass hepatitis B vacci risk of hepatocellular carcinoma in cirrhosis. Cancer inci Evidence for an association between the aetiology of dence in people with hepatitis B or C infection: a large cirrhosis and pattern of hepatocellular carcinoma community-based linkage study. Hematopoietic malignancies associated with viral and Pancreatic cancer and factors associated with the alcoholic hepatitis. Cancer Epidemiol Biomarkers Prev, insulin resistance syndrome in the Korean cancer 17: 3069–3075. Survival of hepatitis B virus genotype B in hepatitis B e antigen hepatitis B virus afer drying and storage for one week.
Nonpharmacologic treatment of chronic insomnia: an American Academy of Sleep Medicine review brahmi 60 caps without prescription treatment urinary retention. Objectives • Describe the symptoms buy brahmi 60caps low cost treatment synonym, contributing factors discount 60caps brahmi overnight delivery medications you cant take with grapefruit, and effects of sleep deprivation & poor sleep quality • Develop an action plan for improving sleep quality • Create an individualized strategy for managing duty hours in a healthy way Symptoms • People with sleep deprivation will commonly have a decline in work performance and also present as: – anxious – forgetful – easily distracted – sad – more prone to have accidents the challenge of shift work • 75 % of people who work at night report feeling drowsy at work • Rotating shifts between day, night and evening often result in disturbed sleep and reduced alertness • Disruptions in sleep can lead to change in mood including increased irritability Basic facts • Insomnia is the most frequent health complaint following pain and headaches. Rx: Improving sleep quality • Avoid caffeine, nicotine, alcohol, and chocolate several hours before bedtime • A fixed sleeping and waking schedule for all 7 days a week (not always possible) • Daily exercise (but not before bedtime) • Relaxation techniques • Development of a series of behaviors associated with bedtime (“a sleep ritual”) • Avoid exposure to electronic light 60 minutes before bedtime Rx: Improving sleep quality • Restrict time spent in bed to actual amount of time spent asleep • Go to bed only when sleepy • Leave the bedroom if you’re not sleeping within 15-20 minutes. Checking the time will increase anxiety and further delay sleep • Avoid daytime naps Sleep hygiene • Enhance the bedroom environment – “Dark and cool” sleep is better in a cool room (65-68F) and with the least light present – White noise machine or air conditioner produces soothing sounds – Comfort is key! Comfortable mattresses and pillows are essential for a good night’s rest Assessment • Recall your sleep habits for the last 3 days • Sleep diary – What time did you get into bed American Academy of Sleep Medicine Healthy Sleep Habits: Prior to Sleep Loss Get adequate (7 to 9 hours) sleep before anticipated sleep loss. Types: Preventive (pre-call) Operational (on the job) Naps as short as 15 minutes can ameliorate performance decrements if provided at 2-3 hour intervals Timing: - if possible, take advantage of circadian “windows of opportunity” (2-5 am and 2-5 pm) Caffeine • the strategic use of caffeine involves ingestion at times that will promote alertness and performance during periods of vulnerability. Caffeine content Red Bull 80 mg Jolt 72 mg Mountain Dew 55 mg Diet Coke 46 mg Iced Tea (black) 40-60 mg Green Tea 35 mg Coffee Starbucks Ve n t i 550 mg Starbucks Grande 375 mg Starbucks Ta l l 250 mg Espresso (2 oz) 100 mg Instant coffee 65-100 mg Managing shift work • Guidelines to minimize disruption: – Maintain the same sleep-wake schedule on days off to synchronize your sleep rhythms – Allow sufficient time to wind down after work. If you finish work at 8 am, don’t force yourself to be asleep by 9 am – Ensure that your sleep won’t be interrupted by telephones, people, street noises or doorbells. Use earplugs or fan to reduce noise Managing shift work • Guidelines continued: – When preparing for a shift change, adjust your bedtime and wake-up times a few days prior to new shift – Avoid exposure to bright light during the few hours before bedtime. Wearing dark glasses when leaving work in the morning may prevent sunlight from increasing alertness level. In fact, one in four people experience sleep difficulties, which include trouble falling asleep, trouble staying asleep, early morning waking, sleeping too much, or restless or unsatisfying sleep. Getting a good night’s sleep can improve your mental well-being and help you to better manage your anxiety. To improve your sleep, try some of the following strategies: Create a Comfortable Sleep Environment. If you want to have a good sleep, it helps to create a comfortable sleep environment. Also, try to ensure that your room is not too hot or cold, minimize noise, and block out light. Or, try a relaxation exercise (see Calm Breathing and Progressive Muscle Relaxation), meditation, or listening to calming music. Although a heavy meal late in the evening can disrupt sleep, a healthy light snack in the evening can improve sleep. Try eating light cheese and crackers, turkey, or bananas, or drink a warm glass of milk. For example, have a hot bath, put on your pajamas, brush your teeth, and then listen to soft music and read on the couch until you start to feel sleepy and then go to bed. Try waking up at the same time every day (even on weekends) no matter how well or how poorly you have slept. Don’t force yourself into bed at a particularly time if you’re not feeling sleepy. Try to avoid reading, watching television, working, or studying in bed, because these activities keep your mind active, which gets in the way of sleep. If you can’t fall asleep after 20 to 30 minutes, get out of bed and do something boring. This strategy can feel like you are making things worse, but if you stick with it, it can really help. If you wake up in the middle of the night worrying, try writing down your worries and tell yourself that you will address them in the morning. Let go of your belief that you have to get eight hours of sleep or you can’t function. Although you may think that alcohol will help you fall asleep, it interferes with sleep later in the evening. Try to avoid smoking at least four hours before bedtime as it can interfere with a good night’s sleep. Getting some sunlight early in the day can be helpful for setting your body’s natural wake and sleep cycle. The goal is to slowly start increasing behaviours that can help you sleep, while reducing the things that are interfering with your sleep. Use the Sleep Diary form to keep track of the strategies you’re using and your weekly progress. Continued from cover signifcant improvements in sleep, effect sizes are small and not Evidence also exists that shows patients frequently discontinue clinically signifcant. Like insomnia, nightmares frequently do not prazosin use prematurely (Alexander, Lund, Bernardy, Christopher, & improve with trauma-focused treatment although the degree of Friedman, 2015). The antihistaminergic drug hydroxyzine was found to decrease nightmares and improve sleep in one placebo-controlled It is important to be aware that insomnia and recurrent nightmares trial (Ahmadpanah et al. What is clear is that screening for sleep disorders beyond sustained improvement in insomnia symptoms on follow-up insomnia and recurrent nightmares needs to be routinely incorporated assessments ranging from 1 to 3 years. The preferred treatment approach for insomnia, when available, is cognitive behavioral therapy. However, there are very few clinical trials examining the positive outcomes in civilian populations.
According to buy brahmi toronto treatment yeast infection male the National Cancer Institute order discount brahmi on line medications guide, 90 percent of Americans say cancer drugs are 99 too expensive purchase brahmi pills in toronto medicine clipart. Information on brand-name cancer medication provided by National Cancer Institute. Comparison of United States and Germany Rebate Rates and Price Differentials One of the major arguments from the pharmaceutical industry on these international price differentials is that while list prices are much higher in the U. Table 4 in Appendix B shows drugs in our dataset that were available in both Germany and the U. Comparison of United States and International Rebate Rates and Price Differentials Table 2 shows the average drug prices across the study sample and the rebate rate that would be required to lower U. Estimation of Medicare Part D Savings under External Reference Pricing System In 2016, the U. We replicated this billion in annual Medicare Part D comparison using both German and U. Purchasing these same drugs using the “basket list price” would reduce estimated Part D spending by $48. Likewise, using German prices would reduce estimated Part D spending by $42 billion. Due to data constraints, these estimates are based on list rather than retail drug prices, meaning that the potential savings presented in Figure 11 are likely overestimated. Due to data constraints, these estimates are based on list rather than retail drug prices, meaning that the potential savings presented here are likely overestimated. The extent of these pricing differentials varies by drug, manufacturer, and disease group, but the results we present make a compelling case for the existence of large differences between the U. But the results clearly show that Americans are paying more for the same drugs, leading many policymakers to look abroad for models that work better in reigning in costs. A Call for Help: Medicare Part D Negotiation In response to the rising cost of drugs – particularly in Medicare Part D, where the bulk of Medicare drug dollars are spent – many experts and Proponents believe that Medicare stakeholders have called for Medicare to negotiate the could leverage its massive 104 price of prescription drugs on behalf of beneficiaries. Allowing the Secretary to negotiate drug prices on behalf of Medicare beneficiaries has overwhelming public support – 86 percent across political parties, 90 percent of Democrats, 80 106 percent of Republicans, and 87 percent of Independents. Proponents believe that Medicare could leverage its massive purchasing power better than individual Part D plans to drive down 107 drug costs. Despite the argument about the potential for a negotiation policy to limit access to treatments and therapies, patient groups continue to strongly support negotiation – and many 104Cubanski, J. Furthermore, from 2006 to 2015, the 25 largest pharmaceutical companies witnessed their average sales revenues increase by $241 billion, while only increasing R&D 111 funding by $7 billion. During the Committee on Ways and Means February 8, 2019, hearing entitled “The Cost of Rising Prescription Drug Prices,” witness Rachel Sachs echoed these sentiments: “These claims assume a whole host of other conditions, including that there are no other opportunities to obtain savings within pharmaceutical companies’ current business models. Through those legislative negotiations, Congress ultimately landed on a private-market-driven drug coverage program, through which private plans would compete on the basis of cost and coverage, negotiating drug prices directly 112 with drug manufacturers. The noninterference clause also makes Part D distinct from the rest of Medicare, which sets the amount it pays doctors and hospitals, for example. Negotiation is likely to be effective only if it is accompanied by some source of pressure on drug manufacturers to secure price concessions. The authority to establish a formulary, set prices administratively, or take other regulatory actions against firms failing to offer price reductions could give the 114 Id. Independent researchers have estimated that the federal government could save between $15. Conclusions the results from this study clearly show that a new approach is needed in the U. A policy of Medicare prescription drug negotiation using international prices would help rebalance a distortion created by Medicare’s overpaying for drugs that could yield significant savings for American families. Given that one in four Americans report taking four or more medications, action in Medicare alone is not enough, as 180 million Americans with employer coverage also 122 123 124 struggle with prescription drug bills. Efforts at lowering consumers’ costs need to be broad in scope so that all Americans are getting a fair deal in what they pay for drugs. Experiences abroad can provide policymakers with a better understanding of their own system, but the solution to the drug pricing crisis lies within the U. One element is certain, though: the system in place now does not work for the Americans who depend on it, and change, however challenging, is paramount. Tracking the rise in premium contributions and cost-sharing for families with large employer coverage. The sample of 79 single-source brand-name drugs used for this report comes from an analysis So-Yeon Kang et al. They created the 79-drug sample by first examining 163 brand-name drugs that accounted for 70 percent of total spending in Medicare Part D. Then, they eliminated all multisource drugs that had generic substitutes in the countries examined to produce the 79-drug sample. Data Sources and Database For the 12 countries included in this analysis, we used publicly available 2018 pharmaceutical ex-factory pricing data to compare drug prices. Table 3 provides an overview of the data source for each country’s drug prices, along with the number of the 79 drugs available in the database. We aggregated drug pricing data from these sources into a single Excel database by cross-walking the files by the active ingredient variable and/or brand-name variables to create an analytic file with the brand-name, dosage, manufacturer, 2017 U. Medicare Part D spending, and 2017 beneficiary utilization data, among other variables. Using External Reference Pricing in Medicare Part D to Reduce Drug price Differentials with Other Countries. Prescription Drug Price Data Sources for Select Countries, 2018 Pharmaceutical Price Sources Country Pharmaceutical Price Source Drugs Listed U. Descriptive Statistics First, we calculated summary statistics on prescription drug prices for all 12 countries, across all 79 drugs for which data were available. We determined ex-factory unit price per standard dose (the prices at which manufacturers sell their products to wholesalers) for any available brand-name drug on the drug list.
In 2006 order brahmi 60caps fast delivery medicine joji, pneumonia and infuenza combined ranked as the nation’s eighth leading cause of death with 56 purchase brahmi without a prescription symptoms 0f heart attack,326 generic 60 caps brahmi with amex 6mp medications. Pneumonia consistently accounts for the overwhelming majority of deaths between the two, as 55,477 people died of pneumonia in 2006. The proportion of deaths associated with infuenza and pneumonia were above the epidemic threshold for 13 consecutive weeks beginning in January 2008. In 2006, the age-adjusted death rate due to infuenza and pneumonia American Indians and Alaska Natives 16. They also felt that it could be prevented by taking traditional anti-cold and “stay healthy” precautions, such as hand washing, taking vitamins, eating right, and getting enough sleep. Others expressed a strong distrust of the government, physicians and drug companies, and demonstrated a frm belief that they could control their own health status and outcomes. Researchers found that providers were aware of older African Americans’ fear of the vaccine giving them the fu and distrust of the vaccine and healthcare system. However, the providers were not aware of concerns about allergic reactions and interactions with other medications. Addressing these beliefs and lack of trust and offering further information to African American patients may help to decrease the gap in vaccination rates between African Americans and the rest of the U. Here as well, the best information comes from mortality rates, where Hispanics fared much better compared to other groups. Hispanics had one of the lowest age-adjusted mortality rates due to infuenza and pneumonia among all racial/ethnic groups in 2006 at 15. Hispanics were almost 16 percent less likely to die from infuenza or pneumonia than Caucasians. However, the little information available shows that Asian Americans and Native Hawaiians/Pacifc Islanders bear a smaller burden from these diseases compared to other racial and ethnic groups. In 2006, there were 1,327 deaths due to infuenza and pneumonia among Asians and Pacifc Islanders, the lowest age-adjusted death rate of any racial or ethnic group at 12. Despite that, infuenza and pneumonia ranked as the sixth leading cause of death overall and the fourth leading cause of death in those over the age of 65 among Asian Americans and Native Hawaiian/Pacifc Islanders (Figure 1, above). Major national health surveys have begun to collect data on this group, but because of small sample sizes, estimates are not considered statistically accurate and are not published or released. The rate for Asians 65 years of age and older was above the national average and signifcantly higher than during the 2005-06 season. Flu Shot Vietnamese Americans had a higher rate 61 of infuenza vaccination (61%) than other 45 Asian Americans (45%) and Caucasians 52 (52%). Vietnamese Americans however, had a lower rate of pneumococcal vaccination Pneumonia Shot (41%) than other Asian Americans (56%) 41 and Caucasians (67%). This study indicates 56 that health behaviors and outcomes can 67 differ widely among Asian subgroups. Analyses of preventive care measures 0 10 20 30 40 50 60 70 80 in Asian Americans should focus on Percent Vietnamse Americans subgroups to ensure accuracy and quality Other Asian Americans of assessments. Inuenza and Pneumococcal Vaccination Rates among Vietnamese, Asian, and Non-Hispanic White Americans. In 2006, there were 261 deaths among American Indians and Alaska Natives due to, infuenza and pneumonia. Pneumonia and infuenza ranked as the tenth leading cause of death overall and the seventh leading cause of death in those over the age of 65 in 2006 among American Indians and Alaska Natives. Among those who died from novel H1N1, American Indians and Alaska Natives were much more likely to have had asthma or diabetes compared to other groups. Regional variation indicated a need to monitor coverage and target interventions to reduce disparities within geographically and culturally diverse subpopulations of American Indians/Alaska Natives. September 26, 2008; 57(38):1033-9 9 Fiscella K, Dressler R, meldrum S, Holt K Impact of Infuenza Vaccination Disparities on Elderly mortality in the United States Preventive Medicine. December 11, 2009; 58(48):1341-4 33 Centers for Disease Control and Prevention State-Specifc Infuenza Vaccination Coverage Among Adults — United States, 2006–07 Infuenza Season Morbidity and Mortality Weekly Report. Other recognized causes1 include radon,2 secondhand smoke,3 and some occupational chemicals and air pollutants like benzene,4 formaldehyde,5 and diesel air pollution. Asbestos, a product used in insulation and manufacturing for years, is also an important cause of lung cancer. Because of the interactions between exposures, the combined attributable risk for lung cancer exceeds 100 percent. Unfortunately, efforts to detect lung cancer early have not led to a reduction in lung cancer deaths. Non-small cell lung cancer is much more common and accounts for 85 percent of all lung cancer cases. Lung cancer incidence rates among men have decreased by 29 percent since 1980, while among women they have increased by sixty percent (Figure 1). It 1973-2006 has been the leading cause of 120 cancer death among men since the early 1950s, and in 1987 100 it surpassed breast cancer to become the leading cause of cancer deaths among women 80 Male as well. Men and women who smoke are 23 and 13 times, respectively, more likely to develop lung cancer. The smoking epidemic among men was refected in steady increase in the male lung cancer death rate through 1990, after which it began to decline. The lung cancer death rate among women, who took up regular cigarette smoking later than men, has begun to plateau after increasing for many decades. However, lung cancer survival rates tend to increase when the disease is caught in an 20 15. Racial/ Ethnic Diferences African Americans African Americans have higher lung cancer incidence rates than any other ethnic or racial group, including Caucasians (64. This suggests that factors besides exposure contribute to the difference in lung cancer rates, such as healthcare coverage or access or community beliefs concerning the disease.
Cheap brahmi 60 caps line. Symptoms of Legionella Pneumonia.
Although tick larvae are smaller than nymphs they rarely carry borreliae at the time Figure 5 buy cheapest brahmi medicine ball. Appearance and relative sizes of feeding and are probably not important in the transmission of Lyme dis of adult male and female order brahmi 60caps online medicine education, nymph discount brahmi generic medications kidney failure, and ease to humans. While adult ticks can transmit borreliae they are less likely larval ticks including deer ticks (Ixodes to do so than nymphs. This is because their larger size means that they are scapularis), lone star ticks (Amblyomma more likely to be noticed and removed from a person’s body within a few americanum), and dog ticks hours and they are most active during the cooler months of the year, when (Dermacentor variabilis). Both OspA and OspB mediate adherence of the spirochetes to the cells of the tick mid-gut, which allows them to avoid endocytosis by tick enterocytes during digestion of the blood meal and subsequently allows their detachment when the tick takes a second blood meal so that the bacteria can enter the vertebrate host. In the mid-gut, during tick feeding, the bacteria up-regulate expression of OspC, which presages their move toward the salivary glands. The environmental cues for up and down-regulation of Osps include temperature and pH. Several salivary gland proteins are induced during tick feeding and one of these, Salp15, has immunosuppressive activity where the tick saliva is deposited in the skin. It has been shown that there is a specific interaction between tick Salp15 and OspC, both in vitro and in vivo. The organism demonstrates a tropism for the central nervous system, heart, joints, and eyes, all of which may become chronically infected, giving rise to neurological disease, carditis, arthritis, and conjunctivitis (see Section 3). It is possible in a woman who contracts Lyme disease during pregnancy for the borreliae to cross the placenta leading to infection of the fetus, but this occurs rarely. Epidemiology Lyme disease is the most common tick-borne disease in North America and Europe. However, in the 10 states where Lyme disease is most common (see above), the incidence was 31. Reported cases or estimated cases and incidence by European country Year 2001 2002 2003 2004 2005 Incidence [cases] Incidence [cases] Incidence [cases] Incidence [cases] Incidence [cases] Country Slovenia 163  169  177  193  206  Austria (estimate***) – [–] – [–] – [–] – [–] 135 [–] Netherlands (estimate)* 74  – [–] – [–] – [–] 103  Czech Republic 35  36  36  32  36  Lithuania 33  26  106  50  34  Lander of Former East Germany – [–] 18  24  26  – [–] Finland 13  17  14  22  24  Latvia 16  14  31  31  21  Estonia 25  23  42  36  21  Slovakia 13  11  14  13  16  Belgium 9. Incidence is the number of new cases per 100000 population per year *estimated number of erythema migrans case-patients **voluntary reporting ***estimate based on physician survey Taken from. Because the spirochete is delivered to the host via the bite of a tick it bypasses the physical barrier of the intact skin and the antimicrobial factors in sweat. Resident macrophages in the area of the inoculum are able to bind, phagocytose, and kill borreliae without the need for opsonization by complement or antibody. Binding may be mediated by the mannose binding receptor and/or the Mac-1 receptor. Adaptive immunity There is little doubt that IgM and IgG antibodies play the principal role in the clearance of B. Murine IgG and IgM monoclonal anti bodies have been developed that are bactericidal for borreliae in the absence of complement. The finding that mice deficient in a/b T cells or deficient in a/b and g/d T cells can clear spirochetemia indicates that T cells are not required for spirochete clearance. First of all as mentioned earlier, Salp15 salivary gland protein induced during tick feed ing has immunosuppressive activity where the tick saliva containing the borreliae is deposited in the skin. This mechanism may be particularly important in Lyme-endemic areas where infected ticks frequently feed on their primary hosts that may possess pre existing antibodies against B. Another candidate may be OspE, since the gene for this Osp has two hypervariable domains and repeat regions that allow recombination with other genes, which may result in the formation of new antigens. Pathogenesis the tissue injury in Lyme disease is mediated by inflammation induced by B. The manner in which the bacterium induces inflammation in the host is not fully understood. Spirochetemia results in the invasion of tissues such as the heart and joints and the host reponds with a vigorous inflammatory response. It has been suggested that chemokines produced at the site of infection may be more important in the influx of inflammatory cells to the site of infection 3. The spirochete may be cleared without any manifestations of disease, the only indicator of infection being that the individual is seropositive. Alternatively, the spirochete establishes in the skin and after a variable incubation period ranging from a few days to a month produces a charac teristic spreading rash termed erythema migrans. The rash begins as a small macule (a visible change in the color of the skin that cannot be felt) or papule (a small, solid and usually conical elevation of the skin), which then expands, ranging in diameter to between 5 and 50 cm (Figure 6). The rash has a flat border and central clearing so that it resembles a ‘bull’s-eye. From the initial focus of infection in the skin the spirochete spreads throughout the body. Systemic spread of the spirochete results in malaise, headaches, chills, joint pain, myalgia, lymphadenopa thy, and severe fatigue. This 2007 photograph depicts treated, over two-thirds of infected individuals manifest neurological and the pathognomonic erythematous rash cardiac symptoms. These manifestations may occur as early as a month or in the pattern of a ‘bull’s-eye,’which as late as 2 years or more post-infection. Neurological sequelae include manifested at the site of a tick bite on meningitis, encephalitis, and peripheral nerve neuropathy, particularly this Maryland woman’s posterior right seventh cranial nerve palsy (Bell’s palsy). Lyme disease patients who cardiac sequelae may be followed by arthralgia and arthritis. About two are diagnosed early and receive proper thirds of patients with untreated infection will experience intermittent antibiotic treatment usually recover rapidly bouts of arthritis, with severe joint pain and swelling. These manifestations may last for diagnosis is recognition of the months to years with little evidence of bacterial invasion. The manifesta characteristic Lyme disease rash called tions of Lyme disease are related to the particular genospecies of Borrelia erythema migrans. The term chronic Lyme dis ease is used in North America and in Europe as a diagnosis for patients with persistent pain, neurocognitive symptoms, fatigue, either separately or together, with or without clinical or serologic evidence of previous early or late Lyme disease.