Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Quadruple therapy containing amoxicillin and tetracycline is an effective regimen to rescue failed triple therapy by overcoming the antimicrobial resistance of Helicobacter pylori buy prilosec online from canada atrophic gastritis symptoms nhs. Randomized comparison of two non bismuth-containing second-line rescue therapies for Helicobacter pylori order discount prilosec on-line gastritis symptoms causes. Second-line levofloxacin based triple schemes for Helicobacter pylori eradication buy cheap prilosec 10mg on-line treating gastritis with diet. Effectiveness of two quadruple, tetracycline or clarithromycin-containing, second-line, Helicobacter pylori eradication therapies. Randomized comparison of two nonbismuth-containing rescue therapies for Helicobacter pylori. Ranitidine bismuth citrate-based triple therapies as a second-line therapy for Helicobacter pylori in Turkish patients. Efficacy of levofloxacin-based rescue therapy for Helicobacter pylori infection after standard triple therapy: a randomized controlled trial. Prospective, randomized study of seven versus fourteen days omeprazole quadruple therapy for eradication of Helicobacter pylori infection in patients with duodenal ulcer after failure of omeprazole triple therapy. Efficacy of metronidazole as second line drug for the treatment of Helicobacter pylori Infection in the Japanese population: a multicenter study in the Tokyo Metropolitan Area. Levofloxacin versus metronidazole-based rescue therapy for H pylori infection in Japan. Randomized study comparing omeprazole with ranitidine as anti-secretory agents combined in quadruple second-line Helicobacter pylori eradication regimens. Impact of quadruple regimen of clarithromycin added to metronidazole-containing triple therapy against Helicobacter pylori infection following clarithromycin-containing triple-therapy failure. Comparison of three different second line quadruple therapies including bismuth subcitrate in Turkish patients with non-ulcer dyspepsia who failed to eradicate Helicobacter pylori with a 14-day standard first-line therapy. Helicobacter pylori infection: a randomized, controlled study comparing 2 rescue therapies after failure of standard triple therapies. Using health state utility values from the general population to approximate baselines in decision analytic models when condition specific data are not available. Eradication therapy in H pylori positive peptic ulcer disease: systematic review and economic analysis. A meta-analysis comparing eradication, healing and relapse rates in patients with H pylori-associated gastric or duodenal ulcer. The cost-effectiveness of screening for H pylori to reduce mortality and morbidity from gastric cancer and peptic ulcer disease: a discrete-event simulation model. Impact of endoscopic surveillance on mortality from Barrett?s esophagus-associated esophageal adenocarcinomas. Normalization of intestinal metaplasia in the esophagus and esophagogastric junction: incidence and clinical data. Screening for oesophageal adenocarcinoma: an evaluation of a surveillance program for columnar metaplasia of the oesophagus. Endoscopic surveillance of columnar-lined esophagus: frequency of intestinal metaplasia detection and impact of antireflux surgery. Health-related quality of life among patients with adenocarcinoma of the gastro-oesophageal junction treated by gastrectomy or oesophagectomy. An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett?s esophagus. Does cancer risk affect health-related quality of life in patients with Barrett?s esophagus? Barrett?s esophagus: Macroscopic markers and the prediction of dysplasia and adenocarcinoma. Quality of life in patients with various Barrett?s esophagus associated health states. Increased detection rates of Barrett?s oesophagus without rise in incidence of oesophageal adenocarcinoma. Clinical guideline 106 Barrett?s oesophagus ablative therapy for the treatment of Barrett?s oesophagus. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett?s oesophagus. Hiatus hernia A hiatus hernia is occurs when part of the stomach moves up in the chest through a defect in the diaphragm. Peptic ulcer disease A peptic ulcer is a break in the lining of the stomach or small intestine due to the acid-peptic activity of the digestion. Gastric and duodenal ulcers refer respectively to ulcers sited in the stomach and small intestine. Gastric and duodenal ulcers may not have distinct symptoms and symptoms alone are inadequate to identify patients with ulcers. Functional dyspepsia Also referred as non-ulcer dyspepsia?, describes people with dyspepsia symptoms but a normal endoscopy. Mauna Kea Technologies is not under any obligation to update the information contained herein and any opinion expressed in this document is subject to change without prior notice. No representation, warranty or undertaking, express or implied, is made as to the accuracy, completeness or appropriateness of the information and opinions contained in this document. The Company, its subsidiary, its advisors and representatives accept no responsibility for and shall not be held liable for any loss or damage that may arise from the use of this document or the information or opinions contained herein. This information has been drawn from various sources or from the Company?s own estimates. Forward-looking statements are subject to a variety of risks and uncertainties as they relate to future events and are dependent on circumstances that may or may not materialize in the future.
The triangular test to assess the outcomes after robot-assisted laparoscopic and conventional la the ef? Surg Endosc 2010;24: required to avoid long-term nutritional and metabolic complications 2647?69 order prilosec 40 mg with mastercard gastritis differential diagnosis. Transpyloric tube feeding in nissenfundoplicationcomparedwithlaparoscopicthalfundoplicationin very low birthweight infants with suspected gastroesophageal re? J Am Coll Surg 2012;215:61? stomy versus image-guided gastrojejunal tube for enteral feeding in 8discussion 68?9 buy 40 mg prilosec otc gastritis chronic cure. Endoluminal gastro at the time of gastrostomy in infants with neurological impairment buy prilosec online pills gastritis diet 3121. Follow-up of a cohort of neurologically impaired: an alternative to fundoplication? Gut reported? outcomes of total esophagogastric dissociation versus la 2014;63:871?80. Canadian Pharmacists Association Choosing Wisely Canada recommendation #4 Don?t continue a proton pump inhibitor at discharge unless there is a compelling reason to continue therapy. Deprescribing in a Family Health Team: A Study of Chronic Proton Pump Inhibitor Use. It can be used by physicians in community practice or by long-term care organizations to help achieve improvements in patient safety related to over-prescribing. Engaging allied health providers in deprescribing initiative In team settings, nurses, pharmacists or physician assistants often have contact with patients around chronic disease management and/or health promotion. They can provide telephone or in-person follow-up after a specifed duration of time, to see how the deprescribing effort is going, and to help patients troubleshoot rebound symptoms. When doing clinician education, make sure to include these team members, and outline the important role they can play in improving patient safety. Consider making two or four-week telephone follow-up a standard part of the intervention, provided by a non-physician team member. Where possible, include data managers and quality leads in your quality improvement initiatives. These experts hold a wealth of knowledge that will be important as you consider implementing interventions and accessing data. Flag charts of patients booked for upcoming periodic health exams: this strategy was used by Toronto Western Family Health Team in 2015 3. Yes No Seek pathology / note from institution / specialist and then complete this form Found pathology / consult note? They can advise on how to reduce the dose, whether to stop it altogether, or how to make lifestyle changes that can prevent heartburn symptoms from returning. Clinical algorithms, such as the one below, can be used in a health care setting as a reassessment tool. Indication still If unsur t if history of endoscopy, if ever hospitalized for bleeding ulcer or if taking because of chronic unknown? This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid J, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi P. How will this be followed, in order to see if it is a factor in success of deprescribing? A) Electronic medical record: a) Develop a search for active patients (those with a visit in the past 3 years) You may want to put an age restriction, eg > 18. This information should be provided to all new clinicians and trainees joining the clinic. Posters listing these indications can be posted in lunchrooms or clinician offce space. Potential harms of proton pump inhibitor therapy: rare adverse effects of commonly used drugs. Evidence-based clinical practice guideline for deprescribing proton pump inhibitors. It is, therefore, important to recognize that heartburn may be the presenting feature of other conditions ranging from functional heartburn to eosinophilic esophagitis and motility disorders such as achalasia, as well as extra-esophageal conditions, includ ing ischemic heart disease. Furthermore, although the term heartburn? is widely recognized, it may be understood diferently by diferent patients and healthcare providers in diferent linguistic, social and cultural settings. They will guide the course of the campaign, leading in the development of tools and activities throughout 2015 and beyond. Trough direct collaboration with our member societies in over 100 countries around the world and with the support of other professional societies with similar interests, non governmental agencies, governments and industry, we have helped to promote understanding and raise awareness on these issues. In this handbook, Professor David Armstrong and his team of international experts set out to rectify this omission. This is an opportune time to address this symptom and its related disorders given that we now have so much information on the varying prevalence, clinical presentation and impact of heartburn in diferent areas of the world. Tese variations have considerable implications for the assessment and management of heartburn; for example, the approach to a middle aged male from Western Europe or North America with a long history of heartburn will be very diferent to how a young female from China will be investigated and managed. We all have much to learn from these geographical and inter-individual variations in disease phenotype associated with a single, though highly prevalent, symptom: heartburn. Evidence demonstrates that it is indicated only Komfo Anokye Teaching Hospital in certain situations; inappropriate use generates unnecessary costs Kumasi, Ghana and exposes patients to harm without improving outcomes. Recurrent endoscopy after this follow-up examination is not However, this is not always the case and, on occasion, the clinician indicated in the absence of Barrett?s esophagus. In the absence of dysplasia, surveillance algorithms, preferably facilitated by a patient-completed question examinations should occur at intervals no more frequently naire. Variable Frequency score (points) for symptom Question 0 day 1 day 2?3days 4?7 days 1. How often did you have stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation)?
Salmonella are the second most frequent pathogens of bacterial diarrheal diseases in Germany behind Campylobacter (20 cheap prilosec 40 mg collagenous gastritis definition,000 60 buy 10 mg prilosec overnight delivery gastritis diet bananas,000 reported cases annually) order generic prilosec from india gastritis enteritis. Enteritic Salmonella are primarily transmitted through eggs, poultry and the meat products of other domesticated animals. Usually these cases are imported from abroad (< 200 cases reported annually in Germany). Typhus and paratyphus are septicemic diseases with an incubation period of 3 60 days. After an infection with enteritic Salmonella, immunologically related secondary diseases can occur, particularly reactive arthritis. Guillain Barre Syndrome is rarely observed after a Salmonella infection in contrast to intestinal infections caused by Campylobacter. This usually manifests 2 4 weeks after an intestinal infection as asymmetric oligoarthritis, particularly in the major joints of the lower extremities. However, serology can serve to determine a past infection in patients with reactive arthritis. Antibody detection alone is not sufficiently sensitive for diagnosing typhus and paratyphus ; however, it can help in establishing a diagnosis for typhus or paratyphus. During an immune reaction to Salmonella, antibodies form against the O-antigens of the outer membrane and the H-antigens (flagellum antigen). Anti-Vi antibodies also form when there is an infection with Salmonella serovars that carry the capsular antigen Vi. Antibodies against O and H-antigens (usually O:2, O:4, O:5, O:12, O:9,12 and H:b, H:d, H:a) are examined in separate assays. Constant amounts of H and O antigens are added to a dilution series of the patient?s serum and incubated for 2 hours in a 50 C water bath. They are incubated a further 3 hours at room temperature to detect antibodies against H-antigens, and for 2 hours at 37 C. Finally they are incubated overnight at room temperature to detect antibodies against O-antigens . The Widal test is often conducted in a microtiter plate format instead of using the classic tube agglutination procedure. The serum and antigen dilutions correspond to the tube agglutination test, however only 50 L of serum or antigen suspension are required per cavity. Titers over 200 or a quadrupling or more of titers in regions with a low incidence rate of typhus/paratyphus are considered positive. The sensitivity of the Widal tests (50 85%) is insufficient to serologically determine an infection. Moreover, false-positive results can occur in the Widal test in cases of infection with other Enterobacteriaceae, like Yersinia pseudotuberculosis, and in the case of malaria. There is a clear drop in IgM antibodies and IgA antibodies between the first and fourth month after infection. They can only be detected in 17 50% of patients after 3 months, and in 2 21% of patients after 12 months. They can be detected in 44 71% of patients after 3 months and in 11 35% of patients after 12 months. IgM, IgA and IgG antibodies persist for 2 3 months at a higher level in patients with Salmonella related reactive arthritis than in patients without reactive arthritis. Due to the longer persistence of the IgG antibodies, determination of IgA or IgM antibodies against Salmonella is particularly useful when Salmonella-related reactive arthritis is suspected. In order to rule out an unspecific IgA antibody test, it makes sense to also determine IgG antibodies against Salmonella. False-positive results for IgM antibodies against Salmonella also occur when the arthritis is caused by parvovirus B19 . In this case, IgA or IgM antibodies should be determined in parallel with IgG antibodies against enteritic Salmonella. Pathogen detection in culture is the diagnostic method of choice for diagnosing typhus and paratyphus. A Widal test can be used as a supplemental test for detecting antibodies in patients with a history of being abroad. Antibody detection is not suitable for determining an acute diarrheal disease caused by Salmonella. The pass rate for the Widal test was between 37 and 100% (average 95%) depending on the manufacturer. Shigella have a number of pathogenicity factors that are localized on virulence plasmids. In contrast to other Enterobacteriaceae, Shigella have no H (flagellum) or capsular antigens. This is characterized by stomach cramps and bloody diarrhea due to an acute colitis. Complications include intestinal perforation, toxic megacolon, symptoms of encephalitis and the development of hemolytic-uremic syndrome. After a Shigella infection, reactive arthritis can occur as an immunologically induced secondary disease. Reactive arthritis usually manifests 2 4 weeks after an intestinal infection as asymmetrical oligoarthritis, particularly in the major joints of the lower extremities.
This evaluator described collateral interviews with people in the neighborhood who reported hearing the husband scream the most disgusting things order prilosec discount gastritis que debo comer, and if the wife?s narrative is compelling and it?s detailed and it doesn?t sound rehearsed you begin to develop the sense that this is quite probably true purchase prilosec nhs direct gastritis diet. Therefore buy prilosec 20mg on-line gastritis diet in pregnancy, although he reviewed the records provided to him, in the end he relied on his interviews with the parents; most of the evaluators concurred. Time spent on evaluations Clearly related to the question of what sort of evidence the evaluators felt they needed to assess the veracity of domestic violence allegations is how much time is required to make that assessment. Given the range of views expressed as to whether the evaluator?s role is to serve as detective? or only to offer their clinical skills in interviewing, it is to be expected that the amount of time spent on custody evaluations also ranges widely. The most time evaluators reported ever spending on any evaluation ranged from 35 hours to 100 hours. Importantly, however, most did not feel it takes longer to conduct a custody evaluation if there are allegations of domestic violence than if there are not. They said that there are other factors that determine the length of time spent on the evaluation, such as the number of children, the complexity of the case, and whether they had to testify in court. Three disagreed, with one saying it took more time to tease out false allegations, another that there are more documents to review, and the third that it took more time to explore the history of the relationship. Psychological testing In the context of how the evaluators determine the accuracy of domestic violence allegations, they were asked whether and for what purpose they use psychological tests of the parents. Two of the interview participants were social workers (not a different proportion from those who conducted the evaluations in the case review study) and said they could not administer tests. Most were clear that there is no test that can identify whether someone is a perpetrator of domestic violence: The role of testing in these evaluations [is] somewhat controversial because they don?t have direct measurements of parenting?and we don?t have specific inventories for domestic violence either, or for violence. There are a lot of validity scales and a lot of validity subscales which are very useful?a high score on being phony on the test doesn?t guarantee they were phony in the interview? it?s another piece of data. But because she indicated a couple of issues, I 65 this document is a research report submitted to the U. This perspective was not unique: You know, sometimes the victim?s profile will come back that the person?s kind of detached, low self-esteem, passivity, and then that will lend credence to the domestic violence allegations. There?s no testing out there despite the fact that a lot of my colleagues really do a lot of testing that has any significant correlation with trying to predict what?s best for children. She also uses the Parent-Child Relationship Inventory, although it is a worthless test. Word count of domestic violence assessment process interviews For illustration purposes, a word count was conducted on the combined evaluator responses to questions about their processes for assessing domestic violence allegations. The most frequently cited words were children,? parents,? people,? know,? think,? get,? and look. Once an evaluator determines there was domestic violence, how does that factor into their conclusions? One of our primary research questions was whether the evaluators? theoretical orientation would affect their understanding of domestic violence and influence their recommendations regarding protection of the child and the mother in the custody and visitation arrangements. In particular, as justified in the literature review, we hypothesized that those who adopted a family systems perspective would be more victim-blaming in their assessment of domestic violence and more likely to believe that separation of the parents and therapeutic interventions would remedy the problem. This hypothesis was supported by a significant relationship between the evaluation explicitly adopting a family systems perspective and referring to the problem between the parents as conflict. The interviews provided an opportunity to examine those relationships more closely. Five of the evaluators identified their training and basic beliefs about human behavior and dynamics as psychoanalytic, and a sixth first said psychoanalytic but realized she relies on attachment theory in her custody evaluations. Four identified themselves as subscribing to family systems, but this identification seemed to mean different things to different respondents. Following the question about theoretical orientation, we asked whether the evaluators modified their application of a theory when evaluating a case involving domestic violence. This question led most interviewees to explain how they viewed the roots of and motivation for abusing an intimate partner. As will be seen below, an evaluator?s understanding of the causes of domestic violence is related to their assessment of the parenting ability of an abuser and ongoing danger to the other parent and/or child. For example, if the evaluator believes that a stable personality disorder causes a person to abuse his partner, that tendency is not likely to change and will affect his parenting. If the evaluator believes that intimate partner abuse is caused by a dynamic between two individuals, they will infer that the perpetrator is not likely to abuse a new partner and the child is not in danger. The explanations for why people abuse their intimate partners tended to be multi-faceted, with each evaluator providing several reasons in different domains. It was in answer to this question that the evaluators were most likely to mention the motive of controlling the partner. Two noted paranoid thinking in that the abuser sees himself as the victim of his partner. Along the same lines, several noted a form of narcissism, variously describing it as, self-indulgence,? under control of emotions? and, as a third explained, when there is a threat to the self-image, they smack someone around? and do not feel anxiety. One evaluator who identified his theoretical orientation as psychoanalytic started with a sociological model that ended with an explanation that was most consistent with a family systems model. We have a nuclear family in an atomized society and there?s a huge amount of loading on the needs placed on the nuclear family. There?s less extended family support, there?s less community support, there?s less religious affiliation. So I think there?s an awful lot of stress placed on the marital unit?We?re seeing the [divorces]?where there?s much more high conflict and tension. So in a certain way it?s a breeding ground for potential violent interactions?it?s perhaps why in certain ways I might tend to minimize and maybe sometimes overlook domestic violence because that phrase implies a kind of aggressor and victim, which I think is probably in these custody cases somewhat less the case.
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Immunosuppressed individuals are at risk of prolonged diarrhea cheap generic prilosec canada gastritis symptoms and duration, perhaps B lasting for months order genuine prilosec line gastritis symptoms itching, requiring fluid replacement and in severe cases enteral and/or parenteral feeding to combat malnutrition and weight loss buy 40mg prilosec otc gastritis radiology. Sporadic cases are rarely investigated and what follows concerns the differ ential diagnosis of outbreaks of gastroenteritis. Such diagnosis is based on the characteristic clinical features of the illness, that is vomiting in over 50% of cases and mild diarrhea without blood or mucus with a duration of about 48 hours, together with detection of norovirus in feces. Immune-electron microscopy molecular testing, electron microscopy was widely used but this technique to show antibody seroconversion. Notably immune-electron with gastroenteritis visualized by electron microscopy (A) after incubation with serum microscopy (Figure 5A and B) can be used to prove antibody seroconver taken from the patient in the acute phase sion in patients with norovirus gastroenteritis and is still used today in the of illness and (B) after incubation with research setting to concentrate virus. Viruses causing gastroenteritis and their epidemiological features Family Virus Epidemiological features Endemic infection Outbreaks of infection Food or water-borne in children in all ages Reovirus Group A rotavirus Major cause of Occasional in adults No childhood diarrhea most often among the elderly in hospitals or in residential homes Group B rotavirus Large outbreaks in China No Group C rotavirus Occur but uncommon No Caliciviruses Noroviruses Major cause of Yes outbreaks Sapoviruses Less common cause No of childhood diarrhea Adenovirus Adenovirus types Second most common No 40 and 41 cause of childhood diarrhea Astrovirus Human astrovirus 5?10% of childhood Family outbreaks occur No diarrhea cases Differential diagnosis the other possible viral causes are given in Table 1 notably outbreaks of diarrhea are commonly caused by rotavirus in young children and the eld erly. Bacterial causes and fecal samples should be tested for Salmonella, Shigella, and Campylobacter spp. In addition, Clostridium difficile can cause serious outbreaks with high morbidity and even mortality in hospitals. Management the illness is usually short and requires attention only to fluid and elec trolyte replacement, except in the case of persistent diarrhea in the immunosuppressed, which may also require enteral or parenteral nutri tion. Prevention this relies not only on clean drinking water and efficient sewage disposal but also on good standards of personal and food hygiene plus adequate cleaning arrangements in hospitals and residential homes. Raw shellfish should be cooked before consumption and fruit washed if to be eaten raw. Control measures rely firstly on limiting contact between ill and susceptible persons, for example by isolation of those affected in single rooms in hospital or nursing homes, and using contact (enteric) precau tions gloves, aprons, and scrupulous hand-washing or if more than one case by closing the hospital ward or relevant section of a nursing home to new admissions. Secondly, they rely on measures to prevent water-borne, food-borne, fomite-borne, and person to person spread transmission is often by more than one route in an outbreak. Thirdly, exclusion of those affected from food-handling is required for 48 hours after recovery. Note although the latest evidence suggests that virus is shed in feces for longer than this after recovery, it should be remembered that the virus load will be decreasing and it is impractical to exclude staff from work for 2 weeks. Vaccine: Given the lack of understanding of the nature of immunity to norovirus, it is not surprising that there is no vaccine available. What is the causative agent, how does it enter the intestine instead of enterocytes; it is unclear the body and how does it spread a) within the how this leads to diarrhea. What is the host response to the infection and spp, and in the hospital setting Clostridium difficile. Preventing person-to-person spread following gastrointestinal Communicable Diseases Report No. Case 27 Parvovirus A 25-year-old teacher, who was 12 weeks pregnant, went to see her doctor as she had developed an extensive erythematous rash on her face, trunk, and limbs (Figure 1). The unequivocal interpretation of these results was that the patient was suffering from an acute infection with parvovirus B19. Causative agent Parvovirus B19 belongs to the family of viruses known as the Parvoviridae. Parvovirus B19 belongs to the Erythrovirus genus within the subfamily Parvovirinae (and is therefore sometimes referred to as erythrovirus?). The suffix B19? is somewhat spurious, arising from the coding of the par ticular serum in which this virus was first identified, that is there are no parvovirus A or B1?18 viruses. About 6 days after infection, virus is found within the bloodstream, that is there is a viremic phase, which lasts about 6 days. Spread from person to person About 1 week after infection, at the time of the viremia, virus is detectable within the throat, and is shed from the respiratory tract, which represents the common route of spread. However, there is also a possibility of trans mission via blood and blood products if blood donation is made at this stage of infection. Virus in the maternal bloodstream will also gain access to, and may cross, the placenta, giving rise to fetal infection in utero. In temperate climates, while infection may occur throughout the year, it is more common in late win ter/spring and early summer. These are often based in primary schools, where over 50% of children may become infected, which also results in infection of susceptible adults such as parents and teachers. IgM antibodies to the virus can be detected in the bloodstream about 9 days after infection, but the IgG antibody response is not detectable for 2?3 weeks. The appearance of IgM anti-parvovirus antibodies coincides with a decline in viral titers in blood. The IgM levels peak after a few days, persist for 3 or 4 weeks, and then decline to undetectable levels 2?3 months post infection. The pathogenesis of disease has been revealed by experiments in which volunteers were inoculated with virus in the nose. An initial fairly nonspe cific illness with fever and mild upper respiratory tract symptoms occurred at around 6 days, and is due to the production of inflammatory cytokines and the presence of replicating virus in the respiratory tract, respectively. In some individuals there is then a second phase of illness, with a rash and joint pains (arthralgia) and even swelling (arthritis). These latter manifes tations arise at the time the IgG antibody response becomes detectable. Therefore parvovirus B19 has a particular predilection for rapidly dividing cells within the bone marrow, especially the erythroid precursors. The basis for this is that the cellular receptor for the virus is the blood group P antigen (also known as globoside), found in large amounts on such cells. Examination of a bone marrow aspirate in acute parvovirus B19 infection reveals abnormal nor moblasts, (late erythroid precursors) with characteristic intranuclear inclu sion bodies, which are the site of production of new virus particles, and hence the cause of the profuse viremia.