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Besides purchase 5 mg propecia fast delivery, your skin absorbs it from clothing discount propecia 5 mg amex, it is quite toxic to you order propecia 5mg otc, and can cause mental effects order propecia 5 mg free shipping. They do not clean quite as well as modern detergents, but there is less static cling, eliminating the need to put more chemicals in your dryer. Better Kitchen Habits Once a day, sterilize the sponge or cloth you use to wipe up the table, counter tops and sink. This little piece of contami- nated cloth is the most infectious thing in the house, besides the toilet. Sometimes it has a slight odor at first, which may warn you, but most pathogens do not have an odor! As we wipe up droplets of milk, we give the milk bacteria, Salmonellas and Shigellas, a new home to multiply and thrive in. The cloth or sponge recolonizes the kitchen and dining room table several times a day. No doubt, the last thing you do before leaving the kitchen is squeeze it dry with your hands. In two hours they are already multiplying in the greatest culture system of all: your body! To sterilize the sponge: drop it into a 50% solution of grain alcohol at the end of each day. Another way to sterilize the sponge or cloth is to microwave it, after wetting it, for 3 minutes. Another strategy is to use a fresh cloth or sponge each day, putting the used one to dry until laundry day. The counter and table top have on them whatever is in the kitchen dust and on the wipe cloth. Vacuuming sends up a hurricane of dust and distributes bathroom dust to the kitchen and kitchen dust to the bedrooms. So if one person has brought in a new infection, the whole family is exposed to it in hours via the dust. The newly contaminated dust drops into your ready and waiting glasses on the table and the open foods. Teach children to cough and sneeze into a suitable col- lecting place like a tissue, not their hands. If you must cough or sneeze and a tissue is not within reach fast enough, use your clothing! Never, never your hands unless you are free to immediately dash into the washroom and clean the contamination off your hands. Teach children this old rearranged verse: If you cough or sneeze or sniff Grab a tissue, quick-quick-quick! Better Housekeeping Throw out as much of the wall to wall carpeting as you can bear to part with. Modern shoes, with their deep treads, bring in huge amounts of outdoor filth which settles deep down into the carpets. When you see how much filth is in the water and realize how much dirt you were living with, you might be willing to trade in the “beauty” of carpets for the cleaner living of smooth floors. Cobalt, which adds “lustre” to carpets, causes skin and heart disease after it has built up in your organs. Nothing controls fleas reliably, except getting rid of the carpets and cloth furniture (keep pets out of bedrooms). Fleas and other vermin in the carpet simply crawl below the wetness level when you wash the carpet. Spraying a grain alco- hol solution with lemon peel in it (it needs to extract for a half hour) on the damp carpet will reach and kill a lot of these, to- gether with the residual bacteria. Molds and bacteria that grow right on the air conditioning unit get blown about for all to inhale. Never, never use fiberglass as a filter or to insulate your air conditioner around the sides. All dirt brought into the house by shoes gets circulated throughout the house by forced air systems of heating or cooling. A return to linoleum floor covering for kitchen and bathroom and hardwood for other rooms would be a good step of progress for a health conscious society. Throw rugs at doors and bedside, easy to clean, would “catch the dirt” as was the original intention. Modern cloth furniture with its foam interior is a repository of filth and fumes and a constant source of infectious dust. You are picking up and removing highly infectious filth (Ascaris and pinworm eggs, pet parasites, “dander” and house mites). Use plain water or vinegar water (50%), not a chemical combination which further pollutes the air. In places like Chicago where you can smell the air as you approach the city, it is wiser to keep your windows shut. Central air conditioning and a plain carbon filter at the furnace location (see Sources) may be the best solution in spite of blowing dust around the house. Keep the vents to the bedrooms closed to re- duce the air turbulence there but leave the cold air return open. Clean the vents in other rooms each week along with floors and carpets by pulling up the grating and reaching down the passage as far as possible. If you believe the air is free of highway exhaust and indus- trial smoke open the windows every day. Asbestos, fiberglass, freon, radon and plain dust can be reduced to a minimum by keeping windows open. Buy such small quantities that you can afford to throw it all away when you are done with them. Move to the other end of the house and furthest away from an attached garage door. Getting Rid of Mites We do not tolerate external parasites like bedbugs, lice, ticks, leeches. Lice were originally “controlled” by frequent washing, louse combs, and ironing the seams of clothing. Never allow a pet into the bedroom or the dust will have tapeworm eggs as well as mites. Deep, soft, wall to wall carpets compromise an ancient concept: everything should be washable and cleanable, without throwing the dirt into the air for humans to inhale. Never shake bedding or rugs where the dust will blow back into the house behind you.

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Hypertrichosis on the face and on more remote sites has been reported buy generic propecia 1 mg, particularly when higher concentrations of minoxidil are used (62) purchase 5 mg propecia otc. In the authors’ experience minoxidil solution is more reliably effective and better toler- ated than anti-androgen treatment buy propecia 5mg visa. Nevertheless buy 1mg propecia with amex, the gains are modest and it is helpful to have an objective measure, such as serial standardized clinical photographs, to convince the patient (and the physician) of the response. Although the recommended dosing schedule is 1 mL twice daily, 2 mL once daily is more convenient and, from clinical experience, appears to be as effec- tive. Antiandrogens The antiandrogens cyproterone acetate, spironolactone and flutamide have all been used to treat female androgenetic alopecia, as has the 5α-reductase inhibitor finasteride, although none is licensed for this purpose and there is little clinical trial evidence of efficacy for any of them. It also has progestational activ- ity and suppresses the production of gonadotrophins. It is not available in the United States but is widely used in Europe, usually in a cyclical regimen in combination with the oral con- traceptive Dianette™. In a randomized controlled trial in 66 women with female androgenetic alopecia cyproterone acetate 52mg daily plus a combined oral contraceptive was compared with minoxidil solution 2% (63). After 12 months treatment non-vellus hair density increased significantly in the minoxidil-treated group but fell in the cyproterone acetate group. However, sub-group analysis showed a small improvement in hair density in women with menstrual irregularities receiving cyproterone actetate. This study suggests that antiandrogens may be beneficial in women with evidence of androgen excess but not in those without, a conclusion in keeping with personal experience of the author. It also blocks androgen receptors and increases metabolic clearance of testosterone. Rushton and colleagues reported that women treated for 12 months with spironolactone showed less hair Androgenetic Alopecia 115 loss than an untreated group (64). In an open uncontrolled case series of 80 women treated for one year with spironolactone (200 mg daily), or cyproterone acetate, 35 (44%) showed improve- ment in hair growth as assessed by standardized photography (65). A randomized trial from Italy compared flutamide 250 mg daily with cyproterone acetate and finasteride in the treatment of 48 hyper- androgenic women with androgenetic alopecia. Those treated with flutamide showed a modest improvement in hair growth whereas those treated with cyproterone acetate or finasteride did not (66). The study appears not to have been blinded and the method of assessment, using the Ludwig grading system, was relatively crude. In a large randomized controlled trial in post-menopausal women with androgenetic alo- pecia finasteride 1 mg daily proved ineffective in preventing hair loss (67). Improvement has been reported, however, in a small cases series of hyperandrogenic women (68) and in a larger series of 37 pre-menopausal women treated for one year with finasteride 2. In the latter study 62% showed some improvement as assessed by global photography. As with minoxidil treatment has to be continued to maintain a response and women taking antiandrogens should not become pregnant because of the risks of feminizing a male fetus. Dose-related side effects of cyproterone acetate, including weight gain, fatigue, loss of libido, mastodynia, nausea, headaches and depression, are common. There is a significant risk of hepatotoxicity with flutamide and cyproterone acetate is also potentially hepatotoxic in high doses. Spironolactone may cause breast soreness and men- strual irregularities but is probably the safest option and is the personal preference of the author. Finasteride is well tolerated and is worth considering in post-menopausal and infertile women. Surgery Hair transplantation is less widely used in women than in men but can give good results in selected cases (57). It is most appropriate in women with pronounced hair loss of limited extent who retain good hair density in the donor site. Those with a mild degree of hair loss are less suitable as are those with involvement of the occipital region. Iron The idea that body iron stores, usually measured as serum ferritin, are important in hair growth is controversial and as yet unsubstantiated in a randomized controlled clinical trial (70). In an open trial of cyclical treatment with cyproterone acetate in women with serum ferritin levels above and below 40µg/l (10 subjects in each group) hair densities increased by about 15% in the high ferritin group after one year of treatment but were unchanged in the low ferritin group (71). However, there are no peer-reviewed trials that have tested the effect of iron supplementation on hair growth. Unfortunately, such trials are expensive and unlikely to be supported by the pharmaceutical industry in view of the lack of commercial potential. In the absence of more conclusive data it seems reasonable to check the serum ferritin and advise dietary supplementation with iron in those with a level below 40µg/L. Patients should be advised that iron treatment alone will not halt or reverse hair loss but it may improve the response to specific treatments. Treatment of Non-Caucasians The principles of managing androgenetic alopecia in non-Caucasians are generally the same as in Caucasians although there is relatively little published trial data. A large controlled study from Japan found that finasteride 1mg stimulated hair growth in nearly 60% of men with androgenetic alopecia (i. Improvement in hair growth in these men was almost as good as in those taking the higher dose (72). In a controlled trial of 1% minoxdil solution in the treatment of 280 Japanese women with androgenetic alopecia 29. Issues around the management of androgenetic alopecia in African women, including detailed consideration of surgical treatment, are discussed in a recent review (74). Topical minoxidil remains the mainstay of treatment in this group but patients should be warned that 116 Messenger the use of a solution-based product can return straightened hair to its natural curly state. In the author’s experience minoxidil solution is more likely to cause hypertrichosis in women from the Indian subcontinent and the Middle East than in Europeans, particularly in the fronto-temporal and sideburn regions. For many patients this is an acceptable side effect but they should be advised about it before starting treatment. The emo- tional aspect of hair loss means that it is not necessarily a trivial issue for the sufferer and, conse- quently, managing the patient with androgenetic alopecia can be difficult and time-consuming for the physician (the same is true of other hair loss disorders). Nevertheless, it can be rewarding to manage patients with androgenetic alopecia and, despite their limitations, current treatments can be of significant benefit providing the patient is fully aware of what can be achieved. Our knowledge of hair biology is expanding rapidly and we are making progress in understanding the genetic and molecular basis of androgenetic alopecia. It is unlikely, however, that medical treatments to reverse follicular miniaturization will be forthcom- ing in the foreseeable future and perhaps the best prospect for a more effective treatment will come from the clinical application of hair-follicle cell culture methods (76). The other approach is for there to be a sea change in cultural and societal attitudes toward hair loss. This may seem a bizarre and unlikely prospect but one that is not beyond the bounds of possibility if a few more “celebri- ties” could be persuaded to flaunt their hair loss rather than advertise fictitious remedies. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex.

Vaccination suppresses clinical occurrence of disease but the virus persists in the poultry population of the affected region discount propecia 5mg on-line, impeding exports purchase 5mg propecia otc. Studies in industrialized nations have shown that strict biosecurity can limit dissemination of avian influenza virus among commercial farms 88 and within integrations order propecia 1mg without prescription. Preventing the spread of virus is extremely difficult in the context of industries in developing countries where feed is delivered in bags cheap 5 mg propecia with mastercard, and eggs, culled hens and live broilers produced by small-scale farmers are distributed through a network of dealers to regional markets. These birds in turn transmitted virus to domestic subsistence chickens maintained under extensive management. Wild waterfowl may have also directly infected free-roaming domestic ducks and geese. Extensive movement of live domestic poultry to markets disseminated infection which eventually was introduced into large commercial operations. The H5N1 virus underwent mutation in large susceptible populations, resulting in a highly pathogenic agent. Spread of infection from China to Vietnam, Cambodia, Laos and Thailand was associated with unrestricted cross-border movement of live poultry including fighting cocks. In Japan, Taiwan, Malaysia and Korea, limited outbreaks of H5N1 infection have been eradicated applying appropriate control measures for regions where the disease is exotic. China and Indonesia have adopted vaccination to suppress clinical outbreaks, recognizing this strategy to be the most cost-effective control measure. As of mid-2004 there have been no reports of direct human-to-human contact transmission. It is possible that a recombinant event between avian H5N1 and human influenza strains could occur in domestic swine or other animal species 89 yet to be identified in the chain of transmission. This could potentially result in a more pathogenic virus affecting humans, justifying vigorous suppression of infection in poultry populations and absolute separation of swine and poultry. The extent and severity of H5N1 infection in Asia presumes persistence of virus in reservoir populations, requiring a commitment to long-term vaccination and intensified biosecurity for commercial farms. Subcutaneous hemorrhage characteristic of H5N2 strain of highly pathogenic avian influenza. Cyanosis of the head observed in cases of H5N2 strain highly pathogenic avian influenza. Severe hemorrhagic enteritis characteristic of highly pathogenic avian influenza or velogenic Newcastle disease. Vesicle formation on the wattle of a bird infected with highly pathogenic influenza virus. Infection of immature chickens causes a mild respiratory disease which may affect liveability and growth if exacerbated by adverse managemental, climatic stress or intercurrent mycoplasmosis. The initial live vaccine should always be administered to susceptible breeder and layer flocks before 12 weeks of age to avoid possible damage to the developing reproductive tract of 93 the pullet. Immunity in commercial layers can be boosted by administration of live attenuated vaccine either in drinking water or as a coarse spray during the production period. Broilers in endemic areas are vaccinated by aerosol at day-old or subsequently by coarse spray or in drinking water at a suitable time (10- 20 days) depending on maternal antibody transfer or pattern of field challenge. These conditions are responsible for extensive losses in broiler operations especially where flocks are exposed to concurrent viral respiratory diseases and environmental stress. The economic impact of mycoplasmosis in broilers includes severely depressed growth rate and feed conversion efficiency, elevated mortality, and condemnation at processing. Lateral transmission occurs by direct contact between clinically affected or recovered carriers and susceptible flocks. Indirect infection occurs through contact with contaminated equipment, feed bags, and personnel. The hemagglutination inhibition test is applied to confirm the provisional serologic diagnosis. Mycoplasma spp can be isolated and identified by inoculating tracheal swabs or serous joint exudate from acute cases onto special selective media. This procedure may require up to 30 days and may be inconclusive due to technical problems including contamination. The polymerase chain reaction assay can be applied as a commercially available, sensitive and specific test procedure. Chicks derived from known infected parent flocks can be treated with a suitable antibiotic during the first 48 hours after placement and re-treated subsequently at 20 to 24 days of age for a 24 to 48 hour period. It is emphasized that treatment does not eliminate the carrier state in infected flocks but will suppress excretion of the organism in respiratory exudate and vertical transmission through eggs. Infection of grandparent and parent level breeders occurs in developing industries due to deficiencies in biosecurity on farms operated by multipliers. It is essential to purchase parent and commercial stock from known mycoplasma-free breeder flocks. Inactivated vaccines administered as oil emulsions are available commercially but 96 are of limited value. It is noted that vaccination will suppress clinical signs of infection but will not eliminate the carrier state. Positive Mycoplasma gallisepticum Serum Plate Agglutination Test on right contrasted with negative test on left. Coryza results in decreased egg production in commercial multi- age laying and breeder operations. The pathogen does not remain viable outside the host for periods exceeding 24 hours. Egg production in young commercial or breeder flocks is reduced following infection. Clinically affected birds show unilateral or bilateral ocular discharge progressing to facial cellulitis and chronic sinusitis. Since the organism is susceptible to desiccation it is recommended that acutely infected live birds should be submitted to a diagnostic laboratory whenever possible. Isolation involves semi- aerobic culture on a blood agar medium streaked with Staphylococcus sp. These 99 drugs should not be administered to mature flocks due to residues in eggs and the deleterious effect of sulfonamides on production and shell quality. Combinations of tetracyclines are frequently used to treat coryza by administration in water or injected directly by the intramuscular route. Compulsory or recommended withdrawal periods before marketing eggs should be followed after treatment of commercial flocks. Immature flocks can be partly protected by administration of inactivated multivalent or homologous bacterins in aqueous suspension or oil emulsion. Two doses of inactivated vaccine should be administered by the subcutaneous or intramuscular route at four week intervals during the rearing period, as recommended by the manufacturer. Accumulation of purulent material in the infraorbital sinus is characteristic of coryza. Severe outbreaks associated with hatchery contamination may result in up to 15% chick mortality during the first two weeks. This is followed by subsequent infection of the respiratory tract of pipping embryos and hatching chicks. Horizontal transmission can occur in the hatchery or during handling and delivery.

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