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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Generativity in Late Adulthood Research suggests that generativity is not just a concern for midlife adults purchase ibuprofen with mastercard bayhealth pain treatment center, but for many elders cheap ibuprofen 600 mg line pain studies and treatment journal, concerns about future generations continue into late adulthood order ibuprofen 400 mg overnight delivery pain treatment medicine clifton springs ny. Additionally, they are volunteering in their community, and raising their grandchildren in greater numbers. Hooyman and Kiyak (2011) found that religious organizations are the primary settings for encouraging and providing opportunities to volunteer. Hospitals and environmental groups also provide volunteer opportunities for older adults. While volunteering peaks in middle adulthood, it continues to remain high among adults in their 60s, with about 40% engaging in volunteerism (Hooyman & Kiyak, 2011). While the number of older adults volunteering their time does decline with age, the number of hours older adults volunteer does not show much decline until they are in their late 70s (Hendricks & Cutler, 2004). African-American older adults volunteer at higher levels than other ethnic groups (Taylor, Chatters, & Leving, 2004). Taylor and colleagues attribute this to the higher involvement in religious organizations by older African-Americans. Older adults who volunteer experience more social contact, which has been linked to higher rates of life satisfaction, and lower rates of depression and anxiety (Pilkington, Windsor, & Crisp, 2012). Longitudinal research also finds a strong link between health in later adulthood and volunteering (Kahana, Bhatta, Lovegreen, Kahana, & Midlarsky, 2013). Lee and colleagues found that even among the oldest-old, Source the death rate of those who volunteer is half that of non-volunteers (Lee, Steinman, & Tan, 2011). However, older adults who volunteer may already be healthier, which is why they can volunteer compared to their less heathy age mates. New opportunities exist for older adults to serve as virtual volunteers by dialoguing online with others from around the world and sharing their support, interests, and expertise. These volunteer opportunities range from helping teens with their writing to communicating with ?neighbors in villages of developing countries. Virtual volunteering is available to those who cannot engage in face-to-face interactions, and it opens-up a new world of possibilities and ways to connect, maintain identity, and be productive. Grandparents Raising Grandchildren: According to the 2014 American Community Survey (U. Older adults have far less 415 energy, and often the reason why they are now acting Figure 9. While most grandparents state they gain great joy from raising their grandchildren, they also face greater financial, health, education, and housing challenges that often derail their retirement plans than Source do grandparents who do not have primary responsibility for raising their grandchildren. As individuals age, changes occur in these social networks, and the Convoy Model of Social Relations and Socioemotional Selectivity Theory address these changes (Wrzus, Hanel, Wagner, & Neyer, 2013). Both theories indicate that less close relationships will decrease as one ages, while close relationships will persist. The Convoy Model of Social Relations suggests that the social connections that people accumulate differ in levels of closeness and are held together by exchanges in social support (Antonucci, 2001; Kahn & Antonucci, 1980). According to the Convoy Model, relationships with a spouse and family members, people in the innermost circle of the convoy, should remain stable throughout the lifespan. In contrast, coworkers, neighbors, and acquaintances, people in the periphery of the convoy, should be less stable. These peripheral relationships may end due to changes in jobs, social roles, location, or other life events. These relationships are more vulnerable to changing situations than family relationships. Therefore, the frequency, type, and reciprocity of the social exchanges with peripheral relationships decrease with age. The Socioemotional Selectivity Theory focuses on changes in motivation for actively seeking social contact with others (Carstensen, 1993; Carstensen, Isaacowitz & Charles, 1999). This theory proposes that with increasing age, our motivational goals change based on how much time one has left to live. Rather than focusing on acquiring information from many diverse social relationships, as noted with adolescents and young adults, older adults focus on the emotional aspects of relationships. To optimize the experience of positive affect, older adults actively restrict their social life to prioritize time spent with emotionally close significant others. In line with this theory, older marriages are found to be characterized by enhanced positive and reduced negative interactions and older partners show more affectionate behavior during conflict discussions than do middle-aged partners (Carstensen, Gottman, & Levenson, 1995). Research showing that older adults have smaller networks compared to young adults, and tend to avoid negative interactions, also supports this theory. There is more support going from the older parent to the younger adult children than in the other direction (Fingerman & Birditt, 2011). In addition to providing for their own children, many elders are raising their grandchildren. Consistent with socioemotional selectivity theory, older adults seek, and are helped by, their adult children providing emotional support (Lang & Schutze, 2002). They found that the older parents of adult children who provided emotional support, such as showing tenderness toward their parent, cheering the parent up when he or she was sad, tended to report greater life satisfaction. In contrast, older adults whose children provided informational support, such as providing advice to the parent, reported less life satisfaction. Lang and Schutze found that older adults wanted their relationship with their children to be more emotionally meaningful.

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The audience for this document buy ibuprofen without prescription neuropathic pain treatment guidelines australia, practicing physicians order ibuprofen with visa pain treatment after knee replacement, would be expected to order ibuprofen 400 mg line pain solutions treatment center georgia know the answers to those questions. For families trying to make sense of the literature themselves, or juries attempting to make sense of a malpractice case, this information alone provides little help in weighing the risks and benefits against one another. They state that ?only 4% of encephalopathy can be attributed solely to intrapartum events (196). In other words, what clinicians once expected the technology to be able to prevent is not really possible in the first place. If the technology offers little in terms of measurable benefits and increases the chance that a woman will have to undergo surgery, is there not a better way to obtain the information needed to assure physicians that the fetus is fine? Why are there no conferences dedicated to improving this method or establishing consistent terminology to help clinicians determine when there is a problem? Why is there not sufficient 124 data to come up with similar guidelines for practice? First, auscultation is resource-intensive: ?Logistically, it may not be feasible to adhere to guidelines for how frequently the heart rate should be auscultated. The most common reason for unsuccessful intermittent auscultation included the frequency of recording and the requirements for recording (196). A shortage of nursing staff on labor and delivery floors is not named, but the implication is that the technology is too labor-intensive to make much logistical sense. The second reason is that ?intermittent auscultation may not be appropriate for all pregnancies. If such studies comparing the two technologies excluded high-risk patients, though, how do they know which one is better for that population? The recommendation that follows, ?The labor of women with high-risk conditions. In the conclusion section of the article, this recommendation falls under the lowest level of evidence, Level C, which is nothing more than expert opinion. The newer, electronic technology is assumed to be better because it is more efficient, more widely used, and less difficult and resource-intensive to administer. How Evidence Is Produced Matters the problem with using scientific research as the sole basis for medical care is not that scientifically derived information is irrelevant. The problem has three components: first, the 125 insights of medical research alone are not enough to give a full, contextual evaluation of the experiences of human beings and medical technologies. More interdisciplinary perspectives could enrich our understanding of the use of different technologies in different contexts. Second, the knowledge constructed by medical research is sharply contoured by the perspectives and biases of medicine, including the assumption that scientific knowledge is complete and authoritative and the belief that technology, if studied and refined enough, can eventually achieve whatever medical successes are desired, including the elimination of death and tragedy from the process of carrying and bearing children. Considering the ways that a medical perspective might shape the way ?evidence gets made could have implications for how we talk about what scientific evidence means and what kind of weight it carries in defining standard maternity care. Third, the formation of evaluative knowledge only within the confines of the medical research community prevents widespread systemic critique that might come from outside. As long as evaluations of technologies in obstetrics are confined by the current biomedical model of streamlined childbirth, imagining other possibilities remains limited. The material consequences of the attitudes represented in the relentless pursuit of science are that women do not get to make decisions about their health care; that each birthing body is treated in terms of its potential for catastrophe, rather than as an individual; and that physicians are constrained by the system they are in, rather than free to imagine a better, more healthful process. I felt the treatment this time was better than my last two deliveries when we had insurance even. I went online to find out if we qualified and it was too confusing so I just applied and we were approved for coverage. The gap between research and policy guidelines, practice standards, and hospital regulations is produced by a number of forces, including medical education, tradition, and, perhaps most importantly, economics. It would be easy to look at the conclusions of the last chapter and blame doctors: Why are they not practicing according to what the most current research suggests is most beneficial to mothers and babies? Why would they continue to utilize technologies that have been proven not to be 127 beneficial or even to cause harm? As this chapter will show, doctors are players in a much bigger system: they do not practice obstetrics in a vacuum, but under a host of cultural, professional, and economic pressures. Much of the literature on the medicalization of childbirth focuses on a disparate power dynamic in the doctor-patient relationship as the primary cause of continually skyrocketing rates of technological intervention with little measurable benefit to the health of women and children (B. What I will argue in this chapter is that focusing on that power dynamic alone misses an important opportunity for institutional critique: the current health care system in the United States is much bigger than practicing physicians, who are part, but not the totality of, a matrix of powerful corporate, government, and not-for-profit entities, especially the private health insurance industry and government funded maternity care programs under Medicaid. Looking at the narratives that undergird those systems helps to flesh out a more complicated picture of the institutional forces working to create knowledge about childbirth and its medical management. Additionally, because insurance discourse may be one of the first textual encounters pregnant women have that addresses them as patients, it plays an important role in positioning women within the other biomedical discourses we have looked at. Before I get to the analysis of such discourse, I will first explain a bit about how and why I arrived at the case studies that follow. Next, I will show how the theoretical perspective in this chapter fits within the rhetorical-cultural strategy I have employed so far, especially by adding the lens of professional and technical communication to illuminate the texts analyzed here. Situating Insurance on the Map: Methods and Theoretical Lenses Few rhetorical scholars have looked at health insurance discourse, and none, that I am aware of, have studied the particulars of maternity coverage. Because I am interested in the way 128 economics and discourse are working together to shape the conditions of maternity care, the work of former health care consultant and independent feminist scholar Barbara Bridgman Perkins provides a useful theoretical base for studying the economic factors at work in structuring maternity care. In the Medical Delivery Business: Health Reform, Childbirth, and the Economic Order, Perkins argues that at the heart of the core problems with health care in the United States lies the definition and organization of American medicine as a corporate business, modeled after industry, rather than as a service-provider. Further, she argues that maternity care provides an exemplary look at how that definition shapes care and the funding of care in ways that are not health-promoting, including ?running the labor and delivery unit like an assembly line, turning childbirth into an intensive care situation, managing labor pharmaceutically, and admitting well babies into intensive care units (156-57).

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Bone marrow reticulin fiber deposition in pediatric patients with acute lymphoblastic leukemia buy ibuprofen 400mg on line pain studies and treatment journal. Granular acute lymphoblastic leukaemia of child hood: a morphological phenomenon buy discount ibuprofen 400mg online pain management in dogs. Acute lymphoblastic leukaemia with giant intra cytoplasmic inclusions?a case report buy generic ibuprofen line pain treatment in rheumatoid arthritis. Fatal eosinophilic heart disease in a child with neurofibromatosis-1 complicated by acute lymphoblastic leukemia. Biological and clinical features of acute lymphoblastic leukaemia with cytoplasmic granules or inclusions: descrip tion of eight cases. Is B-lineage acute lymphoblastic leukemia with a mature phenotype and l1 morphology a precursor B-lymphoblastic leukemia/lymphoma or Burkitt leukemia/lymphoma? Early T-cell precursor leukaemia: a subtype of very high-risk acute lymphoblastic leukaemia. Classification of pediatric acute lymphoblastic leukemia by gene expression profiling. Folate pathway gene expression differs in subtypes of acute lymphoblastic leukemia and influences methotrexate pharma codynamics. A new recurrent and specific cryptic translocation, t(5;14) (q35;q32), is associated with expression of the Hox11L2 gene in T acute lymphoblastic leukemia. Gene expression signatures define novel oncogenic pathways in T cell acute lymphoblastic leukemia. Cytogenetics and molecular genetics of T-cell acute lymphoblastic leukemia: from thymocyte to lymphoblast. Age-related phenotypic and oncogenic differences in T-cell acute lymphoblastic leukemias may reflect thymic atrophy. Multiple rearranged immunoglob ulin genes in childhood acute lymphoblastic leukemia of precursor B-cell origin. Terminal deoxynucleotidyl trans ferase-containing cells in peripheral blood: implications for the surveillance of patients with lymphoblastic leukemia or lymphoma in remission. Expression of the recombination-activating genes in extrafollicular lymphocytes but no apparent reinduction in germinal center reactions in human tonsils. Terminal deoxynucleotidyl transferase positive lymphoid cells in reactive lymph nodes from children with malignant tumors: incidence, distribution pattern, and immunophenotype in 26 patients. Immunophenotypic analysis of hematogones (B-lymphocyte precursors) in 662 consecutive bone marrow specimens by 4-color flow cytometry. Immunophenotypic differen tiation patterns of normal hematopoiesis in human bone marrow: reference patterns for age-related changes and disease-induced shifts. Multiparameter phenotype mapping of normal and post-chemotherapy B lymphopoiesis in pediatric bone marrow. Terminal deoxynucleotidyl transferase expres sion in acute myelogenous leukemia and myelodysplasia as determined by flow cytometry. Acute leukemia of dendritic cell lineage in childhood: incidence, biological characteristics and outcome. Pax-5 protein expression in bladder cancer: a preliminary study that shows no correlation to grade, stage or clinical outcome. Pax-5 immunoexpression in various types of benign and malignant tumours: a high-throughput tissue micro array analysis. Role of pharmacogenomics and pharmacody namics in the treatment of acute lymphoblastic leukaemia. Genome-wide interrogation of germline genetic variation associated with treatment response in childhood acute lymphoblastic leukemia. Karyotypic abnormalities create discor dance of germline genotype and cancer cell phenotypes. Clinical significance of minimal residual disease quantification in adult patients with standard-risk acute lymphoblastic leukemia. Immunophenotypic changes between diagnosis and relapse in childhood acute lymphoblastic leukemia. Use of peripheral blood instead of bone marrow to monitor residual disease in children with acute lymphoblastic leukemia. Rearranged T-cell receptor beta genes represent powerful targets for quantification of minimal residual disease in childhood and adult T-cell acute lymphoblastic leukemia. Monitoring minimal residual disease with flow cytometry, antigen-receptor gene rearrangements and fusion tran script quantification in Philadelphia-positive childhood acute lymphoblastic leukemia. Stability of leukemia-associated im munophenotypes in precursor B-lymphoblastic leukemia/lymphoma: a single institution experience. Tettamanti, Clinica Pediatrica Universita di Milano Bicocca, Ospedale San Gerardo, Via Donizetti, 106, 20052 Monza, Italy. The most frequent signs are lymphadenopathies, hepatosplenomegaly, fever, signs of hemorrhage, and bone pain. Biological findings include hyperleukocytosis due to circulating lymphoblasts, anemia and thrombocytopenia. Diagnosis is established by bone marrow biopsy, which evidences the leukemic cells infiltration. The survival rate for children younger than 15 years of age reaches about 75%, but, despite the significant improvement of outcome during the last decades, still roughly 25% of patients suffer from a relapse of the disease. Even if the management of relapse remains largely controversial, an increasing use of high dose chemotherapy blocks and stem cell transplantation is adopted in most cases.

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Topical acyclovir (5%) ointment for primary genital herpes infection is not recommended cheap ibuprofen 600mg without prescription pain treatment center in lexington ky. Systemic or topical treatment of primary herpetic lesions does not affect the subsequent frequency or severity of recurrences generic 400 mg ibuprofen with amex pain treatment herpes zoster. Antiviral therapy for recurrent genital herpes can be administered either episodically to purchase ibuprofen without prescription pain treatment meridian ms ameliorate or shorten the duration of lesions or continuously as suppressive therapy to decrease the frequency of recurrences. Many patients beneft from antiviral therapy; therefore, options for treatment should be discussed with all patients. Oral acy clovir therapy initiated within 1 day of lesion onset or during the prodrome that precedes some outbreaks shortens the mean clinical course by approximately 1 day. If episodic therapy is used, a prescription for the medication should be provided with instructions to initiate treatment immediately when symptoms begin. Valacyclovir and famciclovir also are licensed and effcacious for treatment of adults with recurrent genital herpes. After approximately 1 year of continuous daily therapy, acyclovir should be discontinued and the recurrence rate should be assessed. Data on long-term use of valacyclovir or famciclovir as suppressive therapy in chil dren are not available. The safety of systemic valacyclovir and famciclovir therapy in pregnant women has not been established. Available data do not indicate an increased risk of major birth defects in comparison with the general population in women treated with acyclovir during the frst trimester. Counseling and educa tion of infected adolescents/adults and their sexual partners, especially on the potential for recurrent episodes and how to reduce transmission to partners, is a critical part of management. Pregnant women or women of childbearing age with genital herpes should be encouraged to inform their health care professionals and those who will care for the newborn infant. Topical acyclovir also may accelerate healing of lesions in immunocompromised patients. Under these circumstances, progressive disease may be observed despite acyclovir therapy. Therapeutic beneft has been noted in a limited number of children with primary gingivostomatitis treated with oral acyclovir. Slight therapeutic beneft of oral acyclovir therapy has been demonstrated among adults with recurrent herpes labialis. A topical formulation of penciclovir (Denavir) and another drug, docosanol (Abreva), have only limited activity for therapy of herpes labialis and are not recommended. In a controlled study of a small number of adults with recurrent herpes labialis (6 or more episodes per year), prophylactic acyclovir at a dosage of 400 mg, twice a day, was effective for decreasing the frequency of recurrent episodes. Although no studies of prophylactic therapy have been performed in children, those with frequent recur rences may beneft from continuous oral acyclovir therapy, with reevaluation being performed after 6 months to 1 year of continuous therapy; a dose of 30 mg/kg per day, in 3 divided doses, with a maximum 1000 mg/day is reasonable to begin as suppressive therapy in children. Valacyclovir has been approved for suppression of genital herpes in immunocompetent adults. Patients who are comatose or semicomatose at initiation of therapy have a poorer outcome. For people with Bell palsy, the combination of acyclovir and predni sone may be considered. Treatment of eye lesions should be undertaken in consultation with an oph thalmologist. For children with recurrent ocular lesions, oral suppressive therapy with acyclovir (800 mg/day in 2 divided doses in patients? Some experts believe that contact precautions are unnecessary if exposed infants were born by cesar ean delivery, provided membranes were ruptured for less than 4 hours. These women should be instructed about the importance of care ful hand hygiene before and after caring for their infants. The mother may wear a clean covering gown to help avoid contact of the infant with lesions or infectious secretions. A mother with herpes labialis or stomatitis should wear a disposable surgical mask when touching her newborn infant until the lesions have crusted and dried. Breastfeeding is acceptable if no lesions are present on the breasts and if active lesions elsewhere on the mother are covered (see Human Milk, p 126). Patients with localized recurrent lesions should be managed with standard precautions. During prenatal evaluations, all pregnant women should be asked about past or current signs and symptoms consistent with genital herpes infection in themselves and their sexual partners. During labor, all women should be asked about recent and current signs and symptoms consistent with genital herpes infection, and they should be exam ined carefully for evidence of genital infection. Fetal scalp monitors should be avoided, when possible, in infants of women suspected of having active genital herpes infection during labor. For infants born vaginally to mothers with a frst-episode genital infection, some experts recommend empiric parenteral acyclovir treatment. The sensitivity of viral cultures for detecting neonatal infection in infants whose mothers were treated with antiviral medication near the end of pregnancy is not known. Often, primary infections are asymptomatic, in which case the frst symptomatic episode will represent a reactivated recurrent infection. Care of Newborn Infants Whose Mothers Have a History of Genital Herpes But No Active Genital Lesions at Delivery.

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Serologic testing for H pylori infection by detection of immunoglobulin G (IgG) antibodies specifc for H pylori does not help clarify the current status of infection and is not recommended for screening children generic ibuprofen 400mg free shipping blaustein pain treatment center hopkins. Screening for and treatment of infection buy ibuprofen on line treatment pain during intercourse, if found order ibuprofen visa a better life pain treatment center flagstaff az, also is recommended for children with one or more primary relatives with gastric cancer, children who are in a high-risk group for gastric cancer (eg, immigrants from resource-limited countries or countries with high rates of gastric cancer) or children who have unexplained iron-defciency anemia. Treatment is recommended if infection is found at the time of diagnostic endoscopy for gastrointestinal tract symptoms even if gastritis is the only histologic lesion found. Eradication therapy for H pylori consists of at least 7 to 14 days of treatment; eradication rates are higher for regimens of 14 days. A number of treatment regimens have been evaluated and are approved for use in adults; the safety and effcacy of these regimens in pediatric patients has not been established. Effective treatment regimens include 2 antimicrobial agents (eg, clarithromycin plus either amoxicillin or metronidazole) plus a proton-pump inhibitor (lansoprazole, omeprazole, esomeprazole, pantoprazole, rabeprazole). Alternate therapies in people 8 years of age and older include bismuth subsalicylate plus metronidazole plus tetracy cline plus either a proton-pump inhibitor or an H blocker (eg, cimetidine, famotidine, 2 nizatidine, and ranitidine) or bismuth subcitrate potassium plus metronidazole plus tetra cycline plus omeprazole. Tetracycline products are not recommended in patients 8 years of age and younger (see Tetracyclines, p 801). A breath or stool test may be performed as fol low-up to document organism eradication after completion of therapy, although the stool antigen test may remain positive for up to 90 days after treatment. Salvage therapies for treatment failure include increasing the duration of therapy (ie, 2 to 4 weeks) or bismuth based quadruple therapy for 1 to 2 weeks (eg, bismuth subsalicylate plus 2 antibiotics and a proton pump inhibitor). Disease associated with arena viruses ranges in severity from mild, acute, febrile infections to severe illnesses in which vascular leak, shock, and multiorgan dysfunction are prominent features. Fever, headache, myalgia, conjunctival suffusion, bleeding, and abdominal pain are common early symp toms in all infections. Mucosal bleeding occurs in severe cases as a consequence of vascular damage, thrombocytopenia, and platelet dysfunction. Increased serum concentrations of aspartate transaminase can indicate a severe or fatal outcome of Lassa fever. Shock develops 7 to 9 days after onset of illness in more severely ill patients with these infections. Upper and lower respira tory tract symptoms can develop in people with Lassa fever. The principal routes of infection are inhalation and contact of mucous membranes and skin (eg, through cuts, scratches, or abrasions) with urine and salivary secretions from these persistently infected rodents. Laboratory-acquired infections have been documented with Lassa, Machupo, Junin, and Sabia viruses. The geographic distribution and habitats of the specifc rodents that serve as reservoir hosts largely determine the areas with endemic infection and populations at risk. Lassa fever is endemic in most of West Africa, where rodent hosts live in proximity with humans, causing thousands of infections annually. Lassa fever has been reported in the United States in people who have traveled to West Africa. These viruses may be isolated from blood of acutely ill patients as well as from various tissues obtained postmortem, but isolation should be attempted only under Biosafety level-4 conditions. Virus-specifc immunoglobulin (Ig) M antibodies are present in the serum during acute stages but may be undetectable in rapidly fatal cases. A negative-pressure ventilation room is recommended for patients with prominent cough or severe disease, and people entering the room should wear per sonal protection respirators. Update: management of patients with suspected viral hemorrhagic fever?United States. No specifc measures are warranted for exposed people unless direct contamination with blood, excretions, or secretions from an infected patient has occurred. If such contamination has occurred, recording body temperature twice daily for 21 days is recommended, with prompt reporting of fever. The vaccine is associated with minimal adverse effects in adults; similar fndings have been obtained from limited safety studies in children 4 years of age and older. Intensive rodent control efforts have decreased the rate of peridomestic Lassa virus infection, but rodents eventually reinvade human dwellings, and infection still occurs in rural settings. Because of the risk of health care-associated transmission, the state health department and the Centers for Disease Control and Prevention should be contacted for specifc advice about management and diagnosis of suspected cases. In the United States, one of these infections causes an illness marked by acute respiratory and cardiovascular failure (see Hantavirus Pulmonary Syndrome, p 352). Fever, fushing, conjunctival injection, abdominal pain, and lumbar pain are followed by hypotension, oliguria, and subsequently, polyuria. Nephropathia epidemica (attributable to Puumala virus) occurs in Europe and presents as a milder disease with acute infuenza-like illness, abdominal pain, and proteinuria. Acute renal dysfunction also occurs, but hypotensive shock or requirement for dialysis are rare. Fever, headache, and myalgia are followed by signs of a diffuse capillary leak syndrome with facial suffusion, conjunctivitis, and proteinuria. A hypotensive crisis often occurs after the appearance of frank hemorrhage from the gastrointestinal tract, nose, mouth, or uterus. Occasionally, hemorrhagic fever with shock and icterus, encephalitis, or retinitis develops. All genera except hantaviruses are associated with arthropod vectors, and hantavirus infections are associated with exposure to infected rodents. The most severe form of the disease is caused by the prototype Hantaan virus and Dobrava viruses in rural Asia and Europe, respectively; Puumala virus is associated with milder disease (nephropathia epidemica) in Western Europe. Seoul virus is distributed worldwide in association with Rattus species and can cause a disease of variable severity. The virus is arthropodborne and is transmitted from domestic livestock to humans by mos quitoes. The virus also can be transmitted by aerosol and by direct contact with infected aborted tissues or freshly slaughtered infected animal carcasses.


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