Communicable diseases Essay Example for Free

Communicable diseases Essay 95 Infectious agents and examples of diseases The organisms that cause disease vary in size from viruses,  which are too small to be seen by a light microscope to  intestinal worms which may be over a metre long. The groups  of infectious agents are listed with examples of diseases they cause. Bacteria Pneumonia, tuberculosis, enteric fever, gonorrhoea Viruses Measles, varicella, influenza, colds, rabies Fungi Ringworm, tinea pedis (athlete’s foot) Protozoa Malaria, giardia Metazoa Tapeworm, filariasis, onchcerciasis (river blindness), hookworm Prions Kuru, Creutzfeld-Jacob disease, Bovine spongiform encephalopathy (BSE) Modes of transmission Direct transmission s Direct contact with the infected person as in touching, kissing or sexual intercourse s Droplet spread through coughing sneezing, talking or  explosive diarrhoea s Faecal-oral spread when infected faeces is transferred to  the mouth of a non infected person, usually by hand. Indirect transmission  s Indirect transmission of infectious organisms involves  vehicles and vectors which carry disease agents from the  source to the host. Infectious agents Modes of transmission Definitions and terms  used Symptoms and signs General management and treatment Anthrax Cellulitis Chickenpox (Varicella) Cholera Dengue fever Diphtheria Enteric fever (typhoid and para-typhoid fevers) German measles (Rubella) Glandular fever Hepatitis (viral) Influenza Malaria Measles Meningitis Mumps Plague Poliomyelitis Rabies Scarlet fever Tetanus Tuberculosis Typhus fever Whooping cough (Pertussis) Yellow fever Sexually transmitted diseases including HIV (AIDS) NOTE. Other communicable diseases such as Lassa Fever do not fall within the competence of this book. When in doubt notify the Port Health Officer. Communicable diseases CHAPTER 6 Communicable diseases are those that are transmissible from one person, or animal, to another. The disease may be spread directly, via another species (vector) or via the environment. Illness will arise when the infectious agent invades the host, or sometimes as a result of toxins produced by bacteria in food. The spread of disease through a population is determined  by environmental and social conditions which favour the  infectious agent, and the relative immunity of the  population. An outbreak of infection could endanger the  operation and safety of the ship. An understanding of the  disease and the measures necessary for its containment and  management is therefore important. 96 THE SHIP CAPTAIN’S MEDICAL GUIDE Vehicles are inanimate or non-living means of transmission of infectious organisms. They include: s Water. If polluted, specifically by contaminated sewage. Water is the vehicle for such  enteric (intestinal) diseases as typhoid, cholera, and amoebic and bacillary dysentery. s Milk is the vehicle for diseases of cattle transmissible to man, including bovine tuberculosis,  brucellosis. Milk also serves as a growth medium for some agents of bacterial diseases such as campylobacter, a common cause of diarrhoea.  s Food is the vehicle for salmonella infections (which include enteric fever), amoebic  dysentery, and other diarrhoeal diseases, and poisoning. Any food can act as a vehicle for infection especially if it is raw or inadequately cooked, or improperly refrigerated after cooking, as well as having been in contact with an infected source. The source may be another infected food, hands, water or air. s Air is the vehicle for the common cold, pneumonia, tuberculosis. influenza, whooping  cough. measles. and chickenpox. Discharges from the mouth. nose, throat, or lungs take the form of droplets which remain suspended in the air, from which they may be inhaled. s Soil can be the vehicle for tetanus, anthrax, hookworm. and some wound infections. s Fomites. This term includes all inanimate objects, other than water, milk, food, air, and soil,  that might play a role in the transmission of disease. Fomites include bedding, clothing and the surfaces of objects. Vectors are animate or living vehicles which transmit infections in the following ways: s Mechanical transfer. The contaminated mouth-parts or feet of some insect vectors  mechanically transfer the infectious organisms to a bite-wound or to food. For example, flies may transmit bacillary dysentery, typhoid, or other intestinal infections by walking over the infected faeces and later leaving the disease-producing germs on food. s Intestinal harbourage. Certain insects harbour pathogenic (disease causing) organisms in their intestinal tracts. The organisms are passed in the faeces or are regurgitated by the vector, and the bite-wounds or food are contaminated. (e.g. plague, typhus.) s Biological transmission. This term refers to multiplication of the infectious agent during its  stay in the body of the vector. The vector takes in the organism along with a blood meal but is not able to transmit infection until after a definite period, during which the pathogen changes. The parasite that causes malaria is an example of an organism that completes the sexual stages of its life cycle within its vector, the mosquito. The virus of yellow fever also multiplies in the bodies of mosquitoes. Terms used in connection with communicable diseases A carrier is a person who has the infection, either without becoming ill himself or following recovery from it. A contact is a person who may have been in contact with an infected person. The incubation period is the interval of time that elapses between a person being infected with any communicable disease and the appearance of the features of that disease. This period is very variable and depends upon the infectious agent and the inoculum (the amount of the infectious agent). The isolation period signifies the time during which a patient suffering from an infectious disease should be isolated from others. The period of communicability is the time during which a patient who may be incubating an infectious disease following contact can communicate the disease to others. The quarantine period means the time during which port authorities may require a ship to be isolated from contact with the shore. Quarantine of this kind is seldom carried out except when serious epidemic  diseases, such as, for instance. plague. cholera, or yellow fever are present or have recently occurred on board. Chapter 6 COMMUNICABLE DISEASES Symptoms and signs In reality it is often very difficult to make an accurate diagnosis of an infectious disease without laboratory investigations. It may be possible if there are very specific features such as a rash (varicella) or cluster of suggestive features (regular fever, enlarged spleen and history of mosquito bites in an endemic area). Because of the difficulty in making an accurate diagnosis on board ship you may have to give a variety of treatments each directed at different infectious agents. Onset Almost all communicable diseases begin with the patient feeling unwell and perhaps a rise in temperature. This period may be very short, lasting only a few hours (meningococcal sepsis), or more prolonged (hepatitis). In some diseases the onset is mild and there is not much general disturbance of health, whereas in others it is severe and prostrating. During the onset it is rarely possible to make a diagnosis. The rash The diagnosis of some communicable diseases is made easier by the presence of a characteristic rash. In certain diseases (e.g. scarlet fever) the rash is spread evenly over the body, in others it is limited to definite areas. When examining an individual suspected to be suffering from a communicable disease, it is of great importance to strip him completely in order to get a full picture of any rash and its distribution. General rules for the management of communicable diseases Isolation The principles of isolation are described in Chapter 3 and Chapter 5. If you have a suspicion that the disease with which you are dealing is infectious it is advisable to invoke isolation precautions as soon as possible. Treatment An essential element in treatment is maintaining the patient’s well being. This is achieved through good general nursing and it is important to ensure that the patient does not become dehydrated. Advice on specific medical treatment for infectious diseases which are likely to respond to specific drugs is given under the sections on treatment for the individual diseases. You may also be advised to administer drugs to prevent secondary infection occurring. See Chapter on General Nursing and on how to reduce a high fever. Diet Diet will very much depend on the type of disease and severity of fever. Serious fever is invariably accompanied by loss of appetite and this will automatically tend to restrict diet to beverages such as water flavoured with lemon juice and a little sugar or weak tea with a little milk and perhaps sugar. Essential basic rules s Isolate. If anyone suffers from a temperature without obvious cause it is best to isolate him until a diagnosis has been made. s Strip the patient and make a thorough examination looking for any signs of a rash in order to try to establish the diagnosis. s Put him to bed, and appoint someone to look after and nurse the patient. s Give non-alcoholic fluids in the first instance. s If his temperature exceeds 39.4C make arrangements for tepid sponging. 97 98 THE SHIP CAPTAIN’S MEDICAL GUIDE s Arrange for the use of a bed pan and urine bottle if the patient shows any sign of prostration or if his temperature is high. s If the patient is seriously ill and if in any doubt as to the diagnosis seek RADIO MEDICAL ADVICE, failing which you should consider the need for making for port. s Treat symptoms as they arise. Do not attempt to get the patient up during convalescence if he is feeble, but keep him in bed until the next port is reached. When approaching port, send a radio message giving details of the case to enable the Port Health Authority to make arrangements for the isolation of the case and any contacts on arrival and Disinfection. Immunisation and travel advice It is important that up to date advice on immunisation and the prevalent diseases should be obtained before arrival in a foreign port. This is most easily available from the following publications: Health Information for Overseas Travel, produced by the UK Department of Health, and International Travel and Health, WHO, Geneva Anthrax French: Charbon German: Milzbrand Italian: Carbonchio Spanish: Carbon Incubation Period: 2 to 7 days, usually 2 Period of communicability: No evidence of transmission from person to person Isolation Period: No evidence of transmission from person to person Quarantine Period: None. Anthrax is an uncommon but serious communicable disease which may occur in man and animals. It occurs in man either as an infection of the skin (malignant pustule), or as an attack on the lungs or intestines, or as a widely spread infection throughout the body by means of the blood circulation. Anthrax is, in man, usually contracted by handling infected animals, skins, hides, or furs. It can also be conveyed by the consumption of infected or insufficiently cooked meat, or by the inhalation of dust containing the organism. Symptoms and signs In most cases anthrax is accompanied by severe symptoms such as fever and prostration. When it appears as a skin infection, it begins as a red itching pimple which soon changes into a blister and within the next 36 hours progresses into a large boil with a sloughing centre surrounded by a ring of pimples. Alternatively it may take the form of a painless widespread swelling of the skin which shortly breaks down to form pus in the area. The gastro-intestinal form of anthrax resembles food poisoning with diarrhoea and bloody faeces. The lung form develops into a rapidly fatal pneumonia. Treatment Should a case of anthrax occur at sea, which is unlikely unless as a result of handling animals, hides, skins, etc., all dressings or other material that come into contact with the discharge must be burnt or disposed of by disinfection. Instruments must be used to handle dressings as far as possible, and the instruments must subsequently be sterilised by vigorous boiling for not less than 30 minutes, since the spores of the anthrax germ are difficult to kill. Treatment is not easy on board and the patient should be put ashore as soon as possible. In the meantime treatment is with Penicillin No attempt at surgical treatment (incision or lancing of the sore) should be made as it does no good. Cover the sore with a dressing. Seek advice from a Port Health Authority about the treatment of cargo. Chapter 6 COMMUNICABLE DISEASES Cellulitis (Erysipelas) French: Erysipà ¨le German: Erysipel Incubation Period:1 to 7 days Period of communicability: None Isolation Period: None Quarantine Period: None Italian: Erisipela Spanish: Erisipela This disease is an acute inflammatory condition of the skin caused by a germ entering the body through a scratch or abrasion. Cellulitis occurs anywhere, but most commonly on the legs, arms and face. The onset is sudden with shivering, and a general feeling of malaise. The temperature rises rapidly and may reach about 40oC. The affected area becomes acutely inflamed and red on the first or second day of the infection and the inflammation spreads rapidly outwards with a well-marked, raised, and advancing edge. As the disease advances the portions of the skin first attacked become less inflamed and exhibit a yellowish appearance. Blisters may appear on the inflamed area which can be very painful. General treatment The patient must be kept in bed during the acute stage. Specific treatment Give the patient benzyl penicillin 600 mg followed by oral antibiotic treatment. Paracetamol can be given to ease the pain. Chickenpox (Varicella) French: Varicelle German: Windpocken Italian: Varicella Spanish: Varicela Incubation Period: 14 to 21 days, usually 14 Period of communicability: Up to 5 days before the onset of the rash and 5 days after the first crop of vesicles Isolation Period: Until the vesicles become dry Quarantine Period: None This highly infectious disease starts with fever and feeling unwell. Within a day or two the rash appears on the trunk but soon spreads to the face and elsewhere, even sometimes to the throat and palate. The rash starts as red pimples which quickly change into small blisters (vesicles) filled with clear fluid which may become slightly coloured and sticky during the second day. Within a day or two the blisters burst or shrivel up and become covered with a brownish scab. Successive crops of spots appear for up to five days. Although usually a mild disease, sometimes the rash is more severe and very rarely pneumonia may occur. Treatment A member of the crew who has had chickenpox, and therefore has immunity, could make a suitable nurse. If all of the crew have had chickenpox in the past then there is no need to isolate the patient. The patient need not be confined to bed unless he is unwell. He should be told not to scratch, especially not to scratch his face otherwise pock marks may remain for life. Calamine lotion, if available, dabbed onto the spots may ease the itching. 99 100 THE SHIP CAPTAIN’S MEDICAL GUIDE Cholera French: Cholà ©ra German: Cholera Italian: Colà ©ra Incubation Period: 1 to 5 days, usually 2–3 days Period of communicability: Usually for a few days after recovery Isolation Period: Until diarrhoea has settled Quarantine Period: 5 days Spanish: Cà ³lera Cholera is a severe bacterial infection of the bowel producing profuse watery diarrhoea, muscular cramps, vomiting and rapid collapse. Infection occurs principally through drinking infected water and sometimes through eating contaminated uncooked vegetables, fruit, shell fish or ice cream. It generally occurs in areas where sanitation is poor and where untreated sewage has contaminated drinking water. Other bacterial and viral causes of diarrhoea can sometimes produce a similar clinical picture and may be just as severe. Symptoms and signs Most cases are mild and will not be differentiated from any other form of diarrhoea. In a severe case the onset is abrupt, the vomiting and diarrhoea extreme with the faeces at first yellowish and later pale and watery, containing little white shreds of mucus resembling rice grains. The temperature is below normal, and the pulse rapid and feeble. The frequent copious watery faeces rapidly produce dehydration. Vomiting is profuse, first of food but soon changing to a thin fluid similar to the water passed by the bowel. Cramps of an agonising character attack the limbs and abdomen, and the patient rapidly passes into a state of collapse. As the result of the loss of fluid, the cheeks fall in, the eyes become shrunken and the skin loses its normal springiness and will not quickly return to its normal shape when pinched. The body becomes cold and covered with a clammy sweat, the urine is scanty, the breathing rapid and shallow,  and the voice is sunk to a whisper. The patient is now restless, with muscle cramps induced by loss of salt, and feebly complaining of intense thirst. This stage may rapidly terminate in death or equally rapidly turn to convalescence. In the latter case the cessation of vomiting and purging and the return of some warmth to the skin will herald convalescence. Treatment If there is a suspected case of cholera on board RADIO MEDICAL ADVICE ON MANAGEMENT SHOULD BE OBTAINED PROMPTLY. The patient should be isolated and put to bed at once. Every effort should be made to replace fluid and salt loss. Therefore, keep a fluid balance chart. The patient should be told that his life depends on drinking enough and he should be encouraged and if necessary almost forced to drink as much as possible until all signs of dehydration disappear (until his urine output is back to normal). Thereafter he should drink about 300 ml after each stool until the diarrhoea stops. It is best to drink oral rehydration solution (ORS), if this is not available, make up a solution from 20 gm of sugar with a pinch of salt and a pinch of sodium bicarbonate and juice from an orange in 500 ml sterile water. Give Doxycycline 200 mg first dose then 100 mg once daily. If vomiting, give an antiemetic tablet or injection before each dose. The patient must be kept in bed until seen by a doctor. Caution Cholera is a disease which is transmitted from person to person. If cholera is suspected, the ship’s water supply must be thoroughly treated to make sure that it is safe. The disposal of infected faeces and vomit must be controlled carefully since they are highly infectious. The hygiene precautions of all attendants must be of an order to prevent them also becoming infected and all food preparation on board must be reviewed. Chapter 6 COMMUNICABLE DISEASES Dengue fever French: Dengue German: Denguefieber; Siebentagefieber Italian: Dengue; Febbra dei sette giorni Spanish: Fiebre dengue Incubation Period: 3 to 14 days, usually 7 to 10 days. Period of communicability: No person to person transmission. Infective for mosquitoes for about 5 days from just before the end of the febrile period. Isolation Period: None Quarantine Period: None This is an acute fever of about 7 days’ duration conveyed by a mosquito. It is sometimes called break-bone fever. It is an unpleasant, painful disease which is rarely fatal. A severe form of the disease, dengue haemorrhagic fever, can occur in children. Features of the disease are its sudden onset with a high fever, severe headache and aching behind the eyeballs, and intense pain in the joints and muscles, especially in the small of the back. The face may swell up and the eyes suffuse but no rash appears at this stage. Occasionally an itchy rash resembling that of measles but bright red in colour appears on the fourth or fifth day of the illness. It starts on the hands and feet from which it spreads to other parts of the body, but remains most dense on the limbs. After the rash fades, the skin dries and the surface flakes. After about the fourth day the fever subsides, but it may recur some three days later before subsiding again by the tenth day. General treatment There is no specific treatment, but paracetamol will relieve some of the pain, and calamine lotion, if available, may ease the itching of the rash. Control is by removal of Aedes mosquitoes. Diphtheria French: Diphtà ©rie German: Diphterie Italian: Difterite Spanish: Difteria Incubation Period: 2 to 5 days Period of communicability: Usually less than 2 weeks, shorter if the patient receives antibiotics Isolation Period: 2 weeks Quarantine Period: None Diphtheria is an acute infectious disease characterised by the formation of a membrane in the throat and nose. The onset is gradual and starts with a sore throat and fever accompanied by shivering. The throat symptoms increase, swallowing being painful and difficult, and whitish-grey patches of membrane become visible on the back of the throat, the tonsils and the palate. The patches look like wash leather and bleed on being touched. The neck glands swell, and the breath is foul. The fever may last for two weeks with severe prostration. Bacterial toxins may cause fatal heart failure and muscle paralysis. General treatment Immediate isolation is essential as diphtheria is very infectious, the infection being spread by aerosols. Specific treatment Specific treatment is diphtheria anti-toxin which should be given at the earliest possible opportunity if the patient can get to medical attention. Antibiotic treatment should be given to all cases to limit the spread of infection but it will not neutralise toxin which has already been produced. 101 102 THE SHIP CAPTAIN’S MEDICAL GUIDE Enteric fever – typhoid French: Fià ¨vre typhoide German: Typhus abdominalis Italian: Febbre tifoidea Spanish: Fiebre tifoidea Incubation Period: 1 to 3 weeks, depending on size of infecting dose Period of communicability: Usually less than 2 weeks. Prolonged carriage of salmonella typhi may occur in some of those not treated. Isolation Period: Variable. Quarantine Period: None The term enteric fever covers typhoid and para-typhoid fevers. Enteric fever is contracted by drinking water or eating food that has been contaminated with typhoid germs. Seafarers are advised to be very careful where they eat and drink when ashore. Immunisation gives reasonable protection against typhoid but not para-typhoid. In general the para-typhoids are milder and tend to have a shorter course. The disease may have a wide variety of symptoms depending on the severity of the attack. Nevertheless, typhoid fever, however mild, is a disease which must be treated seriously, not only because of its possible effect upon the patient, but also to prevent it spreading to others who may not have been immunised. Strict attention must be given to hygiene and cleanliness and all clothing and soiled linen must be disinfected. During the first week the patient feels off-colour and apathetic, he may have a persistent headache, poor appetite, and sometimes nose bleeding. There is some abdominal discomfort and usually constipation. These symptoms increase until he is forced to go to bed. At this stage his temperature begins to rise in steps reaching about 39–40 ºC in the evenings. For about two weeks it never drops back to normal even in the mornings. Any person who is found with a persistent temperature of this kind should always be suspected of having typhoid, especially if his pulse rate remains basically normal. In 10 to 20% of cases, from about the seventh day, characteristic rose-pink spots may appear on the lower chest, abdomen and back, which if pressed with the finger will disappear and return when pressure is released. Each spot lasts about 3–4 days and they continue to appear in crops until the end of the second week or longer. Search for them in a good light, especially in dark-skinned races. During the second week,  mental apathy, confusion and delirium may occur. In the more favourable cases the patient will commence recovery but in the worst cases his condition will continue to deteriorate and may terminate in deep coma and death. Even where the patient appears to be recovering, he may suffer a relapse. There are a variety of complications but the most dangerous are haemorrhage from, or perforation of, the bowel. Where the faeces are found to contain blood at any stage of the disease the patient must be kept as immobile as possible and put on a milk and water diet. If the bowel is perforated, peritonitis will set in. General treatment Anyone suspected of having typhoid or para-typhoid fever should be kept in bed in strict isolation until seen by a doctor. The patient’s urine and faeces are highly infectious, as may be his vomit. These should all be disposed of. The attendants and others coming into the room should wash their hands thoroughly after handling the bedpan or washing the patient, and before leaving the room. The patient should be encouraged to drink as much as possible and a fluid input/output chart should be maintained. He can eat as much as he wants, but it is best if the food is light. Specific treatment If you suspect somebody has enteric fever get RADIO MEDICAL ADVICE. Give ciprofloxacin 500 mg every 12 hours for one week. On this treatment the fever and all symptoms should respond within 4–5 days. All cases should be seen by a doctor at the first opportunity. The case notes including details of the amount of medicine given should be sent with the patient. Chapter 6 COMMUNICABLE DISEASES German measles – rubella French: Rubà ©ole German: Rà ¶teln Italian: Rosolia Spanish: Rubà ©ola Incubation Period: 14 to 23 days, usually 17 Period of communicability: For about 1 week before to at least 4 days after the onset of the rash Isolation Period: Until 7 days from the appearance of the rash Quarantine Period: None German measles is a highly infectious, though mild disease. It has features similar to those of mild attacks of ordinary measles or of scarlet fever. For the differences in symptoms and signs see the table. Usually the first sign of the disease is a rash of spots, though sometimes there will be headache, stiffness and soreness of the muscles, and some slight fever preceding or accompanying the rash. The rash is absent in half the cases and lasts from 5 to 6 days. The glands towards the back of the neck are swollen and can easily be felt. This is an important distinguishing sign. This swelling will precede the rash by up to 10 days. General treatment Give the patient paracetamol, and calamine lotion, if available, for the rash. Specific treatment NOTE: Particular care should be taken to isolate patients with German measles from pregnant women: Any pregnant woman on board should see a doctor ashore as soon as possible so that her immunity to rubella can be confirmed. If a patient has seen his wife in the last week he should be asked whether his wife might be pregnant. If so, his wife should be advised to see her doctor. Glandular fever – infectious mononucleosis French: Fià ¨vre glandulaire; Mononucleose infectieuse German: Drusenfieber; Infektiose Mononukleose Italian: Febbre ghiandolare (Mononucleosi infettiva) Spanish: Fiebre glandular (Mononucleosis infecciosa) Incubation Period: 4 to 6 weeks Period of communicability: Prolonged, excretion of virus may persist for a year or more Isolation Period: None Quarantine Period: None This malady is an acute infection which is most likely to affect the young members of the crew. Convalescence may take up to two or three months. The disease starts with a gradual increase in temperature and a sore throat; a white covering often develops later over the tonsils. At this stage it is likely to be diagnosed as tonsillitis and treated as such. However it tends not to respond to such treatment and, during this time, a generalised enlargement of glands occurs. The glands of the neck, armpit and groins start to swell, and become tender; those in the neck to a considerable extent. The patient may have difficulty in eating or swallowing. His temperature may go very high and he may sweat profusely. Occasionally there is jaundice between the fifth and fourteenth day. Commonly there is a blotchy skin rash on the upper trunk and arms at the end of the first week. Vague abdominal pain is sometimes a feature. A diagnosis of diphtheria may be considered due to the appearance of the tonsils, but the generalised glandular enlargement is typical of glandular fever. General treatment Paracetamol should be given to relieve pain and to moderate the temperature. Any antibiotics which have been prescribed to treat the tonsillitis should be discontinued. There is no specific treatment. If complications arise get RADIO MEDICAL ADVICE. 103 104 THE SHIP CAPTAIN’S MEDICAL GUIDE Hepatitis (viral) French: Hà ©patite : Hepatitis German: Hepatitis Italian: Epatite Spanish: Hepatitis Incubation Period: 15 to 50 days for hepatitis A, 60 to 90 days for hepatitis B (may be much longer) Period of communicability: None after jaundice has appeared in hepatitis A, can be indefinite for hepatitis B Isolation Period: During first week of illness Quarantine Period: None This is an acute infection of the liver caused by viruses. There are two main causes of acute hepatitis: hepatitis A and hepatitis B. Two other viruses may cause hepatitis (C and E), but these are uncommon. The most likely cause will be hepatitis A and this is spread by the faecal-oral route (as is hepatitis E). Hepatitis B is spread sexually or by contaminated blood or needles. There is no way of differentiating one type of viral hepatitis from another. The urine and faeces will show the typical changes associated with jaundice. Treatment There is no specific treatment. The patient should be put to bed and nursed in isolation. Plenty of sweetened fluids should be given until the appetite returns. When the appetite returns a fat-free diet should be given. No alcohol should be allowed. All cases must be seen by a doctor at the next port. Influenza French: Grippe; Influenza German: Epidemische Influenza; Grippe Italian: Influenza Spanish: Influenza; Grippe Incubation Period: 1 to 5 days Period of communicability: 3 to 5 days (7 in children) from the onset of illness Isolation Period: Often impractical because of the delay in diagnosis. In an outbreak it would be advisable to keep all affected individuals together and away from those who are well Quarantine Period: none This is an acute infectious disease caused by a germ inhaled through the nose or mouth. It often occurs in epidemics. The onset is sudden and the symptoms  are, at first, the same as those of the common cold. Later the patient feels much worse with fits of shivering, and severe aching of the limbs and back. Depression, shortness of breath, palpitations, and headaches, are common. Influenza may vary in severity. Commonly a sharp unpleasant feverish attack is followed by a prompt fall in temperature and a short convalescence. Pneumonia is a possible complication. General treatment The patient should be subject to standard isolation. He should be watched for signs of pneumonia such as pains in the chest, rapid breathing and a bluish tinge to the lips. He should be given plenty to drink and a light and nutritious diet if he can manage it. Specific treatment There is no specific treatment for the uncomplicated case, but the patient should be given paracetamol as needed. Chapter 6 COMMUNICABLE DISEASES Malaria French: Paludisme German: Malaria Italian: Malaria Spanish: Paludismo Incubation Period: 12 days or more, depending on the type of malaria Period of communicability: The patient will remain infectious for mosquitoes until they have been completely treated Isolation Period: None if in mosquito-proof accommodation Quarantine Period: None Malaria is a recurrent fever caused by protozoa introduced into the blood stream by the bite of the Anopheles mosquito. The malaria-carrying mosquito is most prevalent in districts where there is surface water on which it lays its eggs. It is a dangerous tropical disease which causes fever, debility and, sometimes, coma and death. Malarial areas Ports between latitudes 25 ºN and 25 ºS on the coasts of Africa (including Malagassy), Asia, and Central and South America should be regarded as infected or potentially infected with malaria. Enquiries should be made prior to departure to allow appropriate prophylaxis to be arranged and treatment drugs obtained. Before arrival in port further enquiries should be made as to the current malaria situation and prophylaxis issued to the crew if necessary. Prevention of malaria The risks of attacks of malaria can be very greatly reduced if proper precautions are taken and the disease can be cured if proper treatment is given. Despite this, cases have occurred in ships where several members of the crew have been attacked by malaria during a single voyage with severe and even fatal results. The precautions are: s avoidance of mosquito bites; s prevention of infection. Avoidance of mosquito bites The best way to prevent malarial infection is to take measures to avoid being bitten. The advent of air conditioned ships has made many traditional preventive measures obsolete. However, when within two miles of a malarial shore it remains important that: s doors are kept closed at all times after dusk; s any mosquitoes which enter compartments are killed using insecticide spray; s persons going on deck or ashore after dusk wear long sleeved shirts and trousers to avoid exposing their arms and legs; s no pools of stagnant water are allowed to develop on deck or in life boats, where mosquitoes might breed. In ships which are not air conditioned other traditional measures to protect against mosquitoes should be implemented. These include: s placing fine wire mesh over portholes, sky lights, ventilators and other openings; s screening lights to avoid attracting mosquitoes; s fixing mosquito nets over beds where accommodation spaces cannot be made mosquito proof. Prevention of infection The fewer the bites, the smaller is the risk of infection but even when the greatest care is exercised it will seldom be possible entirely to prevent mosquito bites either on shore or in the 105 106 THE SHIP CAPTAIN’S MEDICAL GUIDE ship. For this reason in all cases when a ship is bound for a malarial port, Masters (in addition to taking all possible measures to prevent mosquito bites) should control infection by giving treatment systematically to all the ship’s crew. Preventive treatment (prophylaxis) does not always prevent a person from contracting malarial infection, but it will reduce the chance of disease. All persons, therefore, should be warned that they have been exposed to the chance of malaria infection and that, if they fall ill at a later date, they should inform their doctor without delay that the fever from which they are then suffering may be due to malaria contracted abroad. The most appropriate prophylaxis will vary with the location as there are different types of malaria in various parts of the world. There is also increasing resistance to anti-malarials which will affect their effectiveness. Up to date information should be obtained before departure if possible or from the local health authorities. General guidelines Start taking the prophylaxis before arrival at a malarial area in accordance with specific instructions and depending on the region. (Usually 1-3 weeks before departure).This will allow the tolerance and side-effects (if any) of the prophylactic drug to be assessed. Prophylaxis should be continued for 4 weeks after leaving the malarial area so as to ensure all stages of the parasite have been killed. No drugs for the treatment of malaria are specified in the MSN 1726 as the advice varies with destination and the pattern of disease in any given malarial area at the time. For information, the UK’s present guidelines recommend 3 different regimes depending on destination: s Proguanil 200 mg once daily and chloroquine 300 mg weekly s Mefloquine 250 mg once weekly s Maloprim (a combined tablet of dapsone and pyrimethamine) 1 tablet weekly and chloroquine 300 mg weekly Other regimes may be used in areas of high level resistance Treatment of malaria Features of the illness Malaria cannot be diagnosed with certainty without laboratory assistance. If the person has been in a potentially malarial area within the last few months and has a fever they should be assumed to have malaria. The characteristic patterns of fever associated with malaria (fever every 2 to 3 days) may not be obvious. The illness may progress rapidly without many features other than fever and sweating. There will often be a severe headache. If there is any doubt about whether to treat or not get RADIO MEDICAL ADVICE. General treatment for mild or severe malaria The patient should be put to bed in a cool place and his temperature, pulse and respiration taken four hourly. If body temperature rises to 40oC or over, cooling should be carried out. The temperature should be taken and recorded at 15 minute intervals until it has been normal for some time. Thereafter the four-hourly recording should be resumed until the attack has definitely passed. Specific treatment for mild or severe malaria Anti-malarial drugs are not specified in MSN 1726 as treatment depends on the area and patterns of resistance. If anti-malarials are to be carried seek appropriate advice on which to obtain/use. The following examples of current regimes are given for information: s Quinine 600 mg every 8 hours for 7 days followed by Fansidar (see below) 3 tablets as a single dose or s Mefloquine 500 mg (2 tablets) for 2 doses 8 hours apart Chapter 6 COMMUNICABLE DISEASES Chloroquine is not used for treatment except for proven single infections with vivax and other benign malarias because of drug resistance. If quinine, Fansidar or mefloquine are not available then chloroquine 300 mg 8 hourly for three doses then 300 mg daily for 2 days should be used. If the patient is unable to take medicine by mouth or is vomiting then quinine 600 mg should be given by intramuscular injection every 8 hours. As soon as the patient is able to swallow it should be given by mouth. Quinine may produce ringing in the ears or dizziness, but this should not normally be a reason to stop treatment. NOTE: All patients who have been treated for malaria or suspected malaria must see a doctor at the next port because further medical treatment may be necessary. Measles French: Rougeole German: Masern Italian: Morbillo Spanish: Sarampion Incubation Period: 7 to 18 days usually 10 until onset of fever, 14 days until rash Period of communicability: about 10 days, minimally infectious after the second day of the rash Isolation Period: 4 days after onset of rash Quarantine Period: None Measles does not often occur in adults. See also the sections on German measles and scarlet fever and the table of differences of symptoms. The disease starts like a cold in the head, with sneezing, a running nose and eyes, headache, cough and a slight fever 37.5 ºC–39 ºC. During the next two days the catarrh extends to the throat causing hoarseness and a cough. A careful examination of the mouth during this period may reveal minute white or bluish white spots the size of a pin’s head on the inner side of the cheeks, or the tongue and inner side of the lips. These are known a ‘Koplik spots’ and are not found in German measles and scarlet fever. The rash appears on the fourth day when the temperature increases to 39–40 ºC. Pale rose-coloured spots first appear on the face and spread down to cover the rest of the body. The spots run together to form a mottled blotched appearance. The rash deepens in colour as it gets older. In four or five days the rash begins to fade, starting where it first appeared. The skin may peel. The main danger of measles is that the patient may get bronchitis, pneumonia or middle ear infection. General treatment This highly infectious disease is conveyed to others when the patient coughs or sneezes. There is no specific treatment, but the patient may have paracetamol. Calamine lotion, if available, may be applied to soothe the rash. Meningococcal disease (meningitis and septicaemia) French: Mà ©ningite cà ©rà ©bro-spinal à ©pidà ©mique German: Epidemische Meningitis Cerebro-spinal Italian: Meningite cerebro-spinal epidemica Spanish: Meningitis cerebro-spinal epidemica Incubation Period: 2 to 10 days, usually 3 to 4 Period of communicability: Generally not communicable whilst the patient is on antibiotics Isolation Period: For 24 hours after the start of antibiotics Quarantine Period: None Infection caused by the meningococcus (a bacterium) can cause either meningitis, with inflammation of the membranes surrounding the brain and spinal cord, or a septicaemia characterised by a generalised rash that does not fade on pressure. Unless treated promptly and effectively, the outcome is nearly always fatal. It occurs in epidemics which may affect closed communities such as a ship. The infection enters by the nose and mouth. Meningitis starts suddenly with fever, considerable headache and vomiting. Within the first day the temperature increases rapidly to 39 ºC or more and the headache becomes agonising. 107 108 THE SHIP CAPTAIN’S MEDICAL GUIDE Vomiting increases and there is general backache with pain and stiffness in the neck. Intolerance of light (photophobia) is usually present. The patient may be intensely irritable and resent all interference, or may even be delirious. As the meningitis develops the patient adopts a characteristic posture in bed, lying on the side with his back to the light, knees drawn up and neck bent backwards. Unconsciousness with incontinence may develop. The septicaemia caused by the meningococcus also starts suddenly with a flu like illness. A rash develops quickly, starting with pin prick like spots which will not blanche when pressed. This rash may progress to form large dark red areas. Individual cases may vary in the speed of onset, the severity of the illness and the clinical features which are present. If meningitis is suspected get RADIO MEDICAL ADVICE and it will help the doctor if the results of the two following tests are available: The neck bending test Ask the patient to attempt to put his chin on his chest. In meningitis the patient will be unable to do so because forward neck movement will be greatly restricted by muscle contraction. Try to increase the range of forward movement by pushing gently on the back of his head. The neck muscles will contract even more to prevent the movement and the headache and backache will be increased. The knee straightening test – Figure 6.1 A. Bend one leg until the heel is close to the buttock. (A) Bend one leg until the heel is close to the buttock. B. Move the bent leg to lie over the abdomen. C. Keeping the thigh as in (B) try to straighten the lower leg. In meningitis it will be impossible to straighten the knee beyond a right angle and attempts to force movement will increase the backache. (B) Move the bended leg to lie over the abdomen. General treatment The patient should be nursed in a quiet, well-ventilated room with shaded lights in strict isolation. He should be accompanied at all times by an attendant who should wear a face mask to cover his nose and mouth. Tepid sponging may be necessary and pressure points should be treated. Usually there is no appetite but he should be encouraged to drink plenty of fluid. Ice packs may help to relieve the headache. (C) Keeping the thigh as in (B) try to straighten the lower leg. Figure 6.1 The knee straightening test. Specific treatment Give benzyl penicillin 3 g intramuscularly at once, and get RADIO MEDICAL ADVICE as to the amount and frequency of subsequent injections of benzyl penicillin. Until such advice is received, give benzyl penicillin 2.4 g at six hourly intervals. The headache should be treated with codeine. The patient should come under the care of a doctor as soon as possible. Chapter 6 COMMUNICABLE DISEASES Mumps French: Oreillons Italian: Malaria Orecchioni German: Mumps – Ziegenpeter Spanish: Orejones Incubation Period: 12 to 26 days, usually 18 Period of communicability: 7 days before glandular swelling and up to 9 days after Isolation Period: 9 days after swelling started Quarantine Period: None Mumps is a viral disease which causes the swelling of the salivary glands in front of the ears and around the angle of the jaw. The swelling usually affects both sides of the face though it may only affect one side and it may make the mouth difficult to open. The onset is usually sudden and may be accompanied by a slight fever. The swelling gradually diminishes and should disappear entirely in about 3 weeks. About 20% of men with mumps get orchitis which is the swelling of one or both testicles; when this occurs it usually happens around the tenth day. Whilst very painful, orchitis does not usually result in infertility and never in impotence. General treatment The patient should be put in standard isolation for 9 days and stay in bed for 4 to 5 days or until the fever is no longer present. He can be given paracetamol to relieve the symptoms, but there is no specific treatment. If he develops swollen painful testicles (orchitis) he should stay in bed. He should support the scrotum on a pad or small pillow. The testicles should also be supported if the patient gets up for any reason. Plague French: Peste German: Pest Italian: Peste Spanish: Peste Incubation Period: 2 to 6 days Period of communicability: As long as infected fleas are present. Person to person spread is uncommon except with plague pneumonia. Isolation Period: For 3 days after the start of antibiotic treatment Quarantine Period: 6 days Plague is a serious bacterial disease transmitted to man by infected rat fleas. It may present in three ways Bubonic in which buboes (swollen lymph nodes) are the most obvious feature. The nodes are painful and may ooze pus. Pneumonic in which pneumonia is the main feature. The type of plague is very infectious as the sputum contains the plague bacterium. Septicaemic which is rapidly fatal. The attack begins suddenly with severe malaise, shivering, pains in the back and sometimes vomiting. The patient becomes prostrated and is confused. His temperature reaches about oC C and the pulse is rapid. After about 2 days the buboes may develop, most commonly in 38 the groins. The buboes may soften into abscesses. General treatment The patient should be cared for by an attendant who should wear a face mask to cover his nose and mouth The patient should be isolated and taken as soon as possible to a port where he can be treated. He should rest in bed, be encouraged to drink as much fluid as possible and have a very light diet. If the abscesses burst they should be dressed with a simple dressing, but they must not be lanced. Soiled linen and bed clothes should be boiled for 10 minutes or destroyed. 109 110 THE SHIP CAPTAIN’S MEDICAL GUIDE Specific treatment Give Doxycycline 100 mg once daily for at least 5 days. The patient should remain on complete bed rest during convalescence. Prevention Plague should be notified to the local health authorities at the next port of call. The quarters of the patient and the crew should be treated with insecticide powder and dust to ensure the destruction of fleas. Warning Dead rats should be picked up with tongs, placed in a plastic bag, which should be sealed with string, weighted and thrown overboard; if the ship is in port, the dead rats should be disposed of in the manner required by the port medical health authority. Poliomyelitis – infantile paralysis French: Poliomyà ©lite Italian: Poliomielite German: Poliomyelitis Spanish: Poliomielitis Incubation Period: 3–21 days, commonly 7–14 days Period of communicability: Cases are most infectious during the first few days before and after the onset of symptoms Isolation Period: Not more than 7 days Quarantine Period None Poliomyelitis is an acute viral disease that occurs mostly in children. It is a disease almost entirely preventable by immunisation. The severity ranges from non-apparent infection to non-specific febrile illness, meningitis, paralytic disease and death. Symptoms of the mild disease include fever, malaise, headache, nausea and vomiting. If the disease progresses, severe muscle pain and stiffness of the neck and back, with or without paralysis will occur. The most commonly affected parts are the legs and arms, shoulders, diaphragm and chest muscles. The development of paralysis is generally complete within two days and then recovery begins. The recovery may be complete or leave some degree of paralysis Affected muscles are usually painful and tender if touched. They are always limp and movements of the affected parts are either weakened or lost by the wasting which appears very soon after paralysis. Paralysis of the respiratory muscles may cause breathlessness and blueness of the lips. General treatment There is no specific treatment but much can be achieved by good nursing. The patient should have complete rest in bed. Pain should be treated with paracetamol and/or codeine. If a limb has been affected it should be supported by pillows in such a way that the paralysed muscles cannot be stretched. The joints above and below the paralysis should be put through a full range of movement morning and evening to prevent stiffness. In all cases, as soon as paralysis appears, RADIO MEDICAL ADVICE must be sought. If the respiratory muscles are affected, breathing difficulty may ensue. Urgent steps must be taken to get the patient to skilled hospital treatment as soon as possible. Chapter 6 COMMUNICABLE DISEASES Rabies – hydrophobia French: La rage German: Tollwut Italian: Rabbia Spanish: Rabia Incubation Period: in humans the incubation period is usually 2 to 12 weeks, shortest for patients bitten about the head and those with extensive bites Communicability: Rabies is rarely, if ever, spread from human to human. Nevertheless for the duration of the illness contamination with saliva should be avoided by wearing gloves when nursing the patient Isolation Period: Duration of the illness Quarantine Period: Rabies is an acute infectious viral disease that is almost always fatal. When a rabid mammal bites humans or other animals, its saliva transmits the infection into the wound, from where it spreads to the central nervous system. Rabies is primarily an infection of wild animals such as skunks, coyotes, foxes, wolves, racoons, bats, squirrels, rabbits, and chipmunks. The most common domestic animals reported to have rabies are dogs, cats, cattle, horses. mules, sheep, goats, and swine. It is possible for rabies to be transmitted if infective saliva enters a scratch or fresh break in the skin. The development of the disease in a bitten person can be prevented by immediate and proper treatment, Once symptoms of rabies develop, death is virtually certain to result. Thus prevention of this disease is of the utmost importance. Local port authorities should be informed of possible rabid animals, so that appropriate public health measures can be instituted. Treatment As soon as an individual aboard ship Is known to have been bitten by a dog or other possibly rabid animal, RADIO MEDICAL ADVICE should he obtained at once. Usually suspected cases are sent ashore to obtain the expert treatment and nursing care needed to prevent the disease. Immediate local care should be given. Vigorous treatment to remove rabies virus from the bites or other exposures to the animal’s saliva may be as important as specific anti-rabies treatment. Free bleeding from the wound should be encouraged. Other local care should consist of: s thorough irrigation of the wounds with soap or detergent water solution; s cleansing with antiseptic solution; s if recommended by radio, giving an antibiotic to prevent infection: s administering adsorbed tetanus toxoid, if indicated. s Suturing of bite wounds should be avoided. Prevention When abroad, seamen should keep away from warm-blooded animals especially cats, dogs. and other carnivores. It is strongly advised that pets should not be carried on board ship as these may become infected unnoticed, through contact with rabid animals in ports. 111 112 THE SHIP CAPTAIN’S MEDICAL GUIDE Scarlet fever French: Scarlatine German: Scharlach Italian: Scarlattina Spanish: Escarlatina Incubation Period: 1 to 3 days Period of communicability: 3 days Isolation Period: 14 days in untreated cases, 1 to 2 days if given antibiotics. Quarantine Period: None Scarlet fever is not often contracted by adults. It has features similar to those of measles and German measles; see the table of differences of symptoms. The onset is generally sudden and the temperature may rapidly rise to 39.5 to 40 ºC on the first day. With the fever the other main early symptom is a sore throat, which in most cases is very severe. The skin is hot and burning to the touch. The rash appears on the second day and consists of tiny bright red spots so close together that the skin assumes a scarlet or boiled lobster-like colour. It usually appears first on the neck, very rapidly spreads to the upper part of the chest and then to the rest of the body. There may be an area around the mouth which is clear of the rash. The tongue at first is covered with white fur and, when this goes, it becomes a very bright red (strawberry). The high fever usually lasts about a week. As the rash fades the skin peels in circular patches. The danger of scarlet fever arises from the complications associated with it, e.g. inflammation of the kidneys (test the urine for protein once a day), inflammation of the ear due to the spread of infection from the throat, rheumatism and heart disease. These complications can be avoided by careful treatment. General treatment The patient must stay in bed and be kept as quiet as possible. The patient can be given paracetamol to relieve the pain in the throat which may also be helped if he takes plenty of cold drinks. He can take such food as he wishes. Specific treatment As scarlet fever usually follows from a sore throat or tonsillitis you may already be giving him the relevant treatment. Otherwise give the specific treatment for tonsillitis. Tetanus – lockjaw French: Tetanos German: Wundstarrkrampf Italian: Tetano Spanish: Tetanos Incubation Period: 4 to 21 days Period of communicability: No person to person transmission Isolation Period: None Quarantine Period: None Tetanus is caused by the infection of a wound by the tetanus bacterium which secretes a powerful poison (toxin). This bacterium is very widespread in nature and the source of the wound infection may not always be easy to trace. Puncture wounds are particularly liable to be dangerous and overlooked as a point of entry. In the UK immunisation against the disease usually begins in childhood but it is necessary to have further periodic inoculations to maintain effective immunity. Fortunately the disease is a very rare condition on board ship. The first signs of the disease may be spasms or stiffening of the jaw muscles and, sometimes, other muscles of the face leading to difficulty in opening the mouth and swallowing. The spasms tend to become more frequent and spread to the neck and back causing the patient’s body to become arched. The patient remains fully conscious during the spasms which are extremely painful and brought on by external stimulus such as touch, noise or bright light. The patient is progressively exhausted until heart and lung failure prove fatal. Alternatively, the contractions may become less frequent and the patient recovers, but there is a high mortality. Treatment The patient should be isolated in a darkened room as far as possible from all disturbances. Get RADIO MEDICAL ADVICE. Give antibiotic treatment and give diazepam or chlorpromazine as sedation and to control spasms. The patient must be got to hospital as soon as possible. Chapter 6 COMMUNICABLE DISEASES Tuberculosis – TB, consumptIon French: Tuberculose German: Tuberkulose Italian: Tuberculosis Spanish: Tuberculosis Incubation Period: 4 to 12 weeks Period of communicability: indefinite, 2 weeks after antibiotics Isolation Period: depends on the degree of infection, rarely necessary Quarantine Period: None This infectious disease is caused by the tubercle bacillus. Although the lung (pulmonary) disease is the most common, TB bacteria may attack other tissues in the body: bones. joints. glands, or kidneys. Unlike most contagious diseases, tuberculosis usually takes a considerable time to develop, often appearing only after repeated, close, and prolonged exposures to a patient with the active disease. A healthy body is usually able to control the tubercle bacilli unless the invasion is overwhelming or resistance is low because of chronic alcoholism, poor nutrition, or some other weakening condition. The pulmonary form of the disease is spread most often by coughing and sneezing. A person may have tuberculosis for a long time before it is detected. Symptoms may consist of nothing more than a persistent cough, slight loss of weight, night sweats, and a continual ‘all-in‘ or ‘tired-out‘ feeling that persists when there is no good reason for it. More definitive signs pointing to tuberculosis are a cough that persists for more than a month, raising sputum with each cough. persistent or recurring pains in the chest, and afternoon rises in temperature. When he reaches a convenient port, a seaman with one or more of these warning signs should see a physician. Treatment Every effort should be made to prevent anyone who has active tuberculosis from going to sea. since this would present a risk to the crew’s health as well as the individual’s. The treatment of tuberculosis by medication will not usually be started at sea, since the disease does not constitute an emergency. To prevent the spread of tuberculosis, every patient with a cough, irrespective of its cause, should hold disposable tissues over his mouth and nose when coughing or sneezing and place the used tissues in a paper bag, which should be disposed of by burning. The medical attendant should follow good nursing isolation techniques (see Isolation Chapter 3). No special precautions are necessary for handling the patient’s bedclothes, eating utensils, and personal clothing. Tuberculosis control A tuberculosis control programme has three objectives: (I) to keep individuals with the disease from signing on as crew-members; (2) to locate those who may have developed the disease while aboard ship and initiate treatment: and (3) to give preventive treatment to persons at high risk of developing the active disease. The first objective can be achieved by periodic, thorough physical examinations including chest X-rays and bacteriological examination of sputum. To identify those who might have developed active tuberculosis, a chest X-ray should be taken and a medical evaluation including bacteriological examination of sputum requested when in port, if a crew-member develops symptoms of a chest cold that persist for more than two weeks. Also, when any active disease is discovered, survey should be made of close associates of the patient and others in prolonged contact with him. Such persons are regarded as contacts and are considered at risk from the disease; they should be given a tuberculin test and chest X-ray when next in port. If they develop symptoms, full medical examination, including bacteriological examination of sputum, should be requested. 113 114 THE SHIP CAPTAIN’S MEDICAL GUIDE Typhus fever French: Typhus exanth\Aematique Italian: Tifo petecchiale German: Flecktyphus Spanish: Tifus petequial Incubation Period: 6 to 15 days, usually 12 Period of communicability: Not directly transmissible from person to person Isolation Period: not required after de-lousing Quarantine Period: 14 days This disease should not be confused with typhoid fever. Typhus is caused by a small bacterium. The disease is conveyed by lice, fleas, ticks and mites. Treatment for the various types of typhus is the same and the symptoms are very similar. The main typhi are epidemic (from lice) and murine, or ship typhus, (from rat fleas). Symptoms and signs Onset is sudden with headache, vomiting, shivering and nausea. The temperature rapidly rises and may reach 40.0 ºC to 40.6 ºC. The patient suffers great prostration, and may be delirious or confused. About the fifth day a rash appears on the front of the body, spreading to the back and limbs in the form of dusky red spots which give the skin a blotchy appearance. The disease if untreated lasts about two weeks. With tick or mite borne typhus there is usually a punched out black ulcer (eschar) which corresponds to the site of attachment. Treatment In the case of louse-borne typhus isolate the patient at once. Bedding and clothing of the patient and close contacts should be treated with a residual insecticide. The patient should receive Doxycycline until his temperature settles plus one day. The response is normally prompt. Whooping cough – pertussis French: Coqueluche German: Keuchhusten Italian: Pertosse Spanish: Tos Ferina Incubation Period: 7 to 10 days, rarely exceeding 14 days Period of communicability: 21 days, normally no more than 5 days after antibiotics Isolation Period: 5 days after antibiotics Quarantine Period: None This disease occurs among unvaccinated children; unvaccinated adults may contract it. The disease in adults has no typical features. Symptoms and signs The onset occurs as a severe cough which after about 7 to 10 days is marked by a typical ‘whoop’, with or without vomiting. The whoop is caused by a convulsive series of coughs reaching a point where the patient must take a breath. It is this noisy indrawing of breath which produces the ‘whoop’. The coughing bouts may be very distressing. Treatment Give erythromycin for 5 days. This is unlikely to affect the course of the disease unless given very early, but it will reduce the infectiousness of the patient. In children, during the bouts of coughing, feeding may induce vomiting. It is best, therefore, to give light food in between the coughing bout and to keep the child quiet in bed. Chapter 6 COMMUNICABLE DISEASES Yellow fever French: Fià ¨vre jaune German: Gelbfieber Italian Febbra gialla Spanish: Fiebra amarilla Incubation Period: 3 to 6 days Period of communicability: 6 days Isolation Period: 12 days only if stegomyia mosquitoes are present in the port or on board Quarantine Period: 6 days This is a serious and often fatal disease which is caused by a virus transmitted to humans by a mosquito. The disease is endemic in Africa from coast to coast between the south of the Sahara and Kenya, and in parts of the Central and Southern Americas. Prevention Travellers to these areas should be inoculated against the disease. Many countries require a valid International Certificate of yellow fever inoculation for those who are going to, or have been in or passed through, such areas. See also the note on prevention of mosquito bites in the section dealing with malaria. Features of the disease The severity of the disease differs between patients. In general, from 3 to 6 days after being bitten the patient fluctuates between being shivery and being over hot. He may have a fever as high as 41 ºC, headache, backache and severe nausea and tenderness in the pit of the stomach. He may seem to get slightly better but then, usually about the fourth day, he becomes very weak and produces vomit tinged with bile and blood (the so-called ‘black vomit’). The stomach pains increase and the bowels are constipated. The faeces, if any, are coloured black by digested blood. The eyes become yellow (jaundice) and the mind may wander. After the fifth or sixth day the symptoms may subside and the temperature may fall. The pulse can drop from about 120 per minute to 40 or 50. This period is critical leading to recovery or death. Increasing jaundice and very scanty, or lack of, urine are unfavourable signs. Protein in the urine occurs soon after the start of the illness and the urine should be tested for it. General treatment The patient must go to bed and stay in a room free from mosquitoes. The patient must be encouraged to drink as much as possible, fruit juices are recommended. 115

Marketing Of German Brand Bionade

Marketing Of German Brand Bionade The German brand BIONADE which produces and distributes organically lemonade brewed like beer but without alcohol {BIONADE #1}, tries to enter markets all over the world. {Dagmar Mussey 08/10/2007 #2}. With the threat of going bankrupt with its beer brewery {Dagmar Mussey 08/10/2007 #2}, the head of the company Leipold, tried to spread its product range and invented a brewed soft drink for children. With its superficial marketing strategy with just few money BIONADE managed to get known all over Germany in shortest time by sponsoring events and viral marketing. {Ralph Atkins #3} In 2009 the large German group Dr. Oetker bought with 70% the majority of BIONADE. {Weiguny 2009 #18} After distributing in most European countries since 2008 the companys aim is now, that their organic drink will become a Weltdrink.{Ralph Atkins 12.12.2007 #3} How BIONADE can reach the target and what they should considered, it is indicated in this paper on the example entering the US beverage market. Environmental Analysis BIONADE needs to analyse the market of US. The retailing market in the United States is very competitive and dynamic. Consumers can choose out of a large number of retailers. With the information of the internet consumers can easily compare all products and retailers. So retailing has been led to a hard job and you have to observe the consumers needs, because consumers have the power. {Weitz 2010 #4} Market trends BIONADE aims to go on the American beverage market. The carbonated drink sector is the most established in the soft drink industry with about 40% of the volume. {Jonathan Thomas 2010 #6} But the growth almost stagnates with just 1.2% growth rate and the share will fall more, because more consumer prefer healthier beverages like fruit juices, fruit based drinks or bottled water. In this case, there is a chance for BIONADE to put its organically healthy and nearly sugarless beverage on the US market. In addition it should be mentioned, that the market shares for sport and energy drinks within the carbonated soft drink segment has raised about 7% last year, and it is assumed that this trend will last. {Jonathan Thomas 2010 #6} The study, which was ordered by just-drinks, says that the fruit-based drinks are expected to remain strong. Customers BIONADEs target group are healthy, young consumers and aware of the health. Examining the consumers in US nowadays it can be noticed, that there is a change in lifestyle. For decreasing the problems of fat children, which has become a major issue in the US, the government planned to ban sugared drinks like Coca Cola from school. {Atkins 12.12.2007 #3} Consumers strive away from convenience and fast food to fresh cooked meals and healthy, organic products, which are traded fair. {Lifestyle Food and Drinks Future 2008 #10}Business Insides report Lifestyle Food and Drinks (2008) says in addition, that many habitants of the US do have work-related stress, which they try to compensate with healthy drinks and food to get more energy and fun. Additionally America has an ageing generation. These people do all their best to stay young and healthy. Therefore they consume e.g. many anti-ageing products, which aim this target group. Altogether there is a broad diversity of different reasons, why people want to live healthier, which is shown in the illustration 1. Figure : The complexity and diversity of modern lifestyles {Lifestyle Food and Drinks Future 2008 #10} Competitiors The beverage market is a strong market in the United States. Global players like Pepsi and Coca Cola are settled in America as well as the US brand Dr. Pepper. These three brands are in 2010 the best-selling companies, and most customers bought drinks of these companies. {Sector Soft Drinks Non-Alcoholic 2010 #11} They also try to establish healthier drinks, to follow the trend. Coca Cola put The Spirit of Georiga on the market, which is competitive lemonade to BIONADE. They also try to do a partnership with Honest Teas, which also is settled in the health and wellness segment.{Beverage World 2011 #13} Nestlà ©, who is also a big player one the beverage market, also put some health drinks, like ready-to-drink teas on the market. Viewing the global health drink and food segment it can there were more than 4000 new products came on the market in 2009, which are more than double as much as in five years ago.{Heather Landi #12} There is a keen competition in this field. Analysis and Theories With entering a new market there are many topics which should be considered. The SWOT analysis is a management tool which shows clearly arranged which strength and weaknesses a company has, and which opportunities and threats are given from the environment of a company. The points are aimed on the target, a company has. In this case it targets the entry of BIONADE on the American market. {Simon 2002 #9} Strengths Weaknesses Large Network Only breed lemonade Experience on other markets Large target group Good references in Europe Plans for adopting the product for the US market (new flavours) Unique product (the only brewed lemonade) Just one product site Workers with no knowledge Large Supply-Chain High costs New unknown market Opportunities Threats Changing Consumer Behaviour Growing sustainable and health market Growing Beverage Market Banning sugared drinks in schools Market niche Large Beverage Market Many Competitors like Coca Cola (Georgia) Other organic certificates in the US than in Europe Many other healthy drinks Figure : SWOT-analysis for BIONADE on the US-market {Simon 2002 #9} To get an overview of the market, Porter invented the tool Porters 5 Forces. {Porter 1998 #14} Porter has identified five competitive forces at work in every industry and every market. The expression of these forces determines the intensity of competition in an industry and thus its profitability and attractiveness. The objective of corporate strategy should therefore in looking for ways to weaken competitive forces in relation to the company itself. {Porter 1998 #14} Figure : Porters five forces {Porter 1998 #14} Analysing the American health beverage market, which BIONADE wants to enter, there is a variety of forces, which should be considered. Buyers: It can be a threat, because buyers have the force to choose other drinks. Substitutes: There are some substitutes. They are and mainly they will become a threat. There are not only other healthy lemonades but also bottled waters, ready-to-drink teas and fruit juices. Suppliers: Meanwhile there is no big threat by suppliers, because BIONADE exports its own bottles form Germany and uses the concentrate which is produced in its producing site in Germany. Potential Entrants: This would be the biggest threat. Because of the large market and the huge chance because of the trend of changing lifestyle, many competitors will get on the market. There will be keen competition which should be considered by entering the market and solutions must be found for each problem. Some solutions can be in the marketing mix, like pricing politic or with clever product placement. Strategies With its aim generating a larger turn-over, BIONADE entered the US market because there is a niche market. There is no other brewed lemonade in America, but there are customers who would buy healthy drinks. With this unique position, they have a chance to challenge other companies and take market share. {Doole 2004 #20} Because of the large competitors like Coca Cola and Pepsi, BIONADE should distinguish in marketing, product, product placement and aim with a unique marketing-mix at the target group to prevent other companies taking their business idea.{Kotabe 2008 #21} The best strategy for BIONADE was Differentiation. {Doole 2004 #20} Because of the flexibility of a SME, the company can meet customer needs very fast and can distinguish from other beverages. To have not a high level of risk BIONADE made a joint venture with a German noodle company, which piggybacks the product. This indirect exporting method can work, because both products are organic, but they are no competitive products. BIONADE can profit of the reputation of the noodles. As the noodle company does not have the knowledge in the beverage segment it would be a better strategy to get help of an agent, who knows the market. With direct export the companies risk shrinks but the cost raise. {Kotabe 2008 #21} BIONADE established a production site in the US. With this strategy they can save costs for transport, which are mainly the highest costs of the supply chain. {Kotabe 2008 #21} But with this strategy the quality of the beverage can decrease. The employees dont have the knowledge like the staff in Germany. In addition there is also the risk, that BIONADE does not sell as much as calculated and the assembly lines are not working to their full capacity. Recommendation To keep successful BIONADE can go different ways. There is the possibility of entering more markets, or to penetrate new markets or put new BIONADE products on the market. In this chapter is shown, how BIONADE can manage these two different paths of expanding the brands value. Staying competitive with entering new markets or products New Products ExistingAnsoff(1957) invented a method, which makes it for companies possible to generate more profit and growth. His theory is divided in four ways, which are entering new markets or inventing new products. This method can help BIONADE to succeed on the market during the next years. Existing Markets or segments New Figure : Ansoff matrix {H. Ansoff #15} Potential strategies are: Market development: BIONADE can generate growth with entering new markets with existing products, like BIONADE already has done in countries around the domestic market. There are the possibilities which are shown in chapter 4.1. It is recommended that BIONADE searches for a partner in US who supports the company by selling the beverage. A good partner could be McDonalds, because it changed the strategy to healthier food. There already exists a partnership between both in Germany, which can be expanded to North America. {Weiguny 2009 #18} Market penetration: In this field, Ansoff describes in his theory, there are is not much growth expected. {H. Ansoff #15} But BIONADE can use its experience to gain new customers on the existing market or sells more to regular customer. It can be aimed with setting up a marketing campaign like making cocktails with BIONADE. New product development: This strategy has more risks than just market penetration. {Thommen 2009 #16} It is useful to stay successful. BIONADE can remain successful on the existing market with introducing new flavours like Cranberry for the US market, new design of bottles or maybe thermo jugs of BIONADE to keep the beverage cool in summer. Diversification: The strategy of entering new markets with new products has the highest risk rate. {Thommen 2009 #16} BIONADES has a variety of possibilities from putting a sports drink on the US market or inventing sweets or ice cream for kids. But another strategy to stay competitive is to keep an eye on the global market trends and spread the beverage in more foreign markets. Entering new markets BIONADE is on shelves in almost in the whole northern part of the hemisphere, like in almost whole Western Europe, North America, and Russia, as it is shown on the map below. Figure : BIONADES current and potential market entries {Daniel Dalert #17} As the SWOT analysis shows in chapter 2.1 BIONADE has many opportunities and chances, not only in the US market. The trend to a healthier life exists in almost all Western countries. To expand the market, it is recommended to enter step-by-step all Western European countries, like the missing countries Portugal and the East European countries, with new special flavours adopted for the countries. Because of the short trade routes it could be made by exporting the bottles. If North America runs well, there is the opportunity to go to Australia, which is also a Western country with loads of sportive, healthy living people on the beaches. It could be the strategy to sell the beverage first on the coast in cafes and bars. With the same strategy like in Germany and with just low marketing campaign they could sponsor surfing contests. Also Brasilia is a good target market with healthy living, open-minded people. With their favourite trend fruit Acai berry there is even a flavour for this ma rket. Because of its hot climate there is the possibility to sell it as a healthy refreshing drink for day and night, even for cocktails. It is recommended not to concentrate to just a view countries, because the beverage market has keen competition. Entering more markets and to have in all countries a little market share is the key to BIONADEs success. Conclusion For BIONADE, there is still high potential to raise the growth like in the last few years, especially with entering new markets. {Weiguny 2009 #18} But BIONADE gets harsh critics, especially in Germany, because they had a change of their strategy. {Matthias Benirschke 05.02.2011 #19} It is said BIONADE is not that bio like they say and it is not any more a drink for a better world, and they stopped sponsoring some events. In Germany there is at the moment the threat of losing regular customers because of just trying to gain the highest profit. The target group is very sensible and should be taken very into account. {Matthias Benirschke 05.02.2011 #19} Appendices

The Crucible, by Arthur Miller Analysis

The Crucible, by Arthur Miller Analysis Arthur Miller, the author of The Crucible was involved in communist activities during the Cold War in the United States which, considering the historical context brought him to court. This demonization of people who expressed different political views materialized by a witch hunt impregnates the play in the sense that the author compares his situation to the one of the hundreds of thousands innocent women that were sometimes killed for the sake of personal satisfaction. This will to label people and call for abomination when someones thoughts and opinions differ from social conventions is symbolized in the play with characters like Goody Putnam or Danforth who represent Millers personalisation of judgement by both society and individuals. People convicted of witchcraft belonged to the Puritan society which is known for its severity and its devotion to Christianity. The environment is thus propitious to all sorts of judgements. It is for example the case when John Proctor is asked why he does not attend Church every Sunday: In the book of records that Mr Parris keeps, I note that you are rarely in the church on Sabbath Day (Miller 53). Hale here makes an assumption that Proctor is not a good Christian since he is rarely at the church. He does not ask whether John is a good father or if he helps his neighbours, all he cares about is whether he is physically present at the office every week. This emphasizes the importance of the social environment on ones reputation. Nowadays, in liberal countries like France for example, the factors that determine whether a person is good or not might be his frequentations, his generosity or his involvement in the community. In the Salem of the 17th century, what makes someone a good pe rson is first of all Christianity and the attendance at the Church. Judgement by society depends on the social standards and conventions that create an ideal citizen to which everyone tries to resemble as much as possible. In this precise historical context, this ideal would be a married man with children, all baptized, that would go to the Church every Sunday, respect all of the commandments and work hard on his piece of land without necessarily being rich. Since no one in Salem completely corresponds to this portrait, people judge and accuse each other of not being good Christians. It is in this context propitious to judgement of others that Miller decided to install his plot. During the Cold War, a terror campaign was led through the United States to demonize communism and the USSR. A Manichean myth was blossoming showing the ideological war that opposed both superpowers as us versus them, good versus evil. The exact same situation is present in The Crucible when in the testimonies and questions from the judge there is absolutely no space for someone like John Proctor who is neither totally good nor evil. From the judges point of view, you are either on God of the Devils side. People convicted of witchcraft usually confess under torture or because they just dont want to die. The latter case is usually a lie that permits to escape death but involves someone elses name. This is for example the case of Tituba who, under the pressure of Hales questions names other women who she says she saw with the Devil: Aye, sir, a good Christian (37) and I dont know, sir, but the Devil got him numerous witches (39). This example shows all the hypocrisy of people who call themselves good and permit judging others, but when the situation gets warm, they are capable of anything that would save them, including buying their freedom with someone elses life. It is the same for Goody Putnam whose role in the play is to make a relation to witchcraft to everything she sees. She wants to convict someone for her babies death and the arrival of Reverend Hale is a good way to prove herself it is not her fault if she cannot give birth to a vigorous baby. She thus tries to get involved in the inquiry and does not hesitate to give evidence of the guilt of whoever is named by Abigail and the girls: I knew it! Goody Osburn were midwife to me three times. I begged you, Thomas, did I not? I begged him not to call Osburn because I feared her. My babies always shrivelled in her hands! (39). Goody Putnam never mentioned Goody Osburns name before Tituba in the play. This quote shows how some people dare judge others and try to hammer them down for personal satisfaction. Tho se who like Goody Putnam are not suspected of being evil because they are at the Church every Sunday are, at least in this play, the ones whose soul is the most blackened. This situation can be compared to Millers period of time, when people like Senator McCarthy who was far from being exemplar still convicted artists for un-American activities. The author fustigates this attitude by giving the reader the impression that Goody Putnam for example or Judge Danforth are simple minded people. Those they convict, like John Proctor or Rebecca Nurse are not perfect but are at least honest with themselves until proven otherwise. Throughout the play, we never see either of them spitting on someone else or trying to bring trouble to anyone. This kind of character might represent Arthur Millers ideal; someone that does not permit himself to judge others since no one is perfect. John and Rebeccas death at the end of the play might symbolise the authors wish to represent them as martyrs who died for the ideas and moral values they defended and thus bring the sympathy of the reader. The Crucible is a way for the playwright to bring the readers attention on how judgements may be dangerous and end up like a snowball effect. The judges Danforth and Hathorne already had their idea on John Proctor when he came to try to save his wife, which means nothing could have twisted his fate. He was condemned to death the minute he entered the court because of Parriss record of attendance at church. The judiciary system is represented as obsolete and totally subjective in The Crucible in the sense that the judges do not show any subjectivity and that people are sent to death with no proof of their affiliation to devilish activities. Considering this play is an allegory of what happened in the United States during the Cold War, Miller explicitly criticizes the trials of all those who were convicted of un-American activities. The reason that took Giles wife to prison for example shows how arbitrary the decisions taken by the judges were. The judgements were not based on the quality and veracity of evidence or testimonies like for Elizabeth. Had they thought more of it for a second, Hathorne and Danforth could have guessed Abigail might have seen Mary put a needle in the poppet and thus created the whole masquerade that followed. Starting from the point that Mr Parris is a minister and that John Proctor is not considered a good Christian, there is ninety percent of chance that Proc tor will lose his trial. The characters of Danforth and Hathorne represent justice as Arthur Miller sees it; a group of pretentious old men who believe almost anything as long as it fits to their opinion. When Hale asks Danforth to postpone John and Rebeccas execution, all he can answer is that its impossible since other people before them have been executed. This example shows Danforths incompetence and his lack of arguments which he compensates with a complex of superiority. The judges know their decision cannot be questioned and they do not refer to anyone about what they decided so they are the supreme authority of the court and thus, can decide whatever pleases them. John and Giles wish to save their wives with testimonies are vain in the sense that all that appeals to the judges about this list is more names of people who can be convicted of witchcraft. It seems that Hathorne and Danforth want to give ampleness to their trial and thus to their reputations of good Christian jud ges that do not show pity for Gods enemies. The hypocrisy of this religious centred society arises in the whole play and through many different characters, like the judges who, instead of praying for their soul and truly follow the love messages in the Bible, prefer to execute people who are thought of dealing with the Devil but against whom no concrete proof can be held, for the sake of the Lords power. Right before the execution, Rebecca throws a warning at the judges who she knows care more about their glory than following what the Bible says: Let you fear nothing! Another judgement waits us all!  Ãƒâ€šÃ‚ ». According to the holy book, God will decide who goes to Heaven and Hell on Judgement Day, and Rebecca tells John she is confident that because justice was not made in this world, it will be in the other. She is more afraid of Gods punishment than an execution decided by judges who trample His name. This last sentence brings solemnity and a heroic touch to John and Rebe ccas execution. It is thrown like a prophecy, which considering what happened to those who were responsible of their deaths and how history remembers of the Salem witch trials, can be compared to Jacques de Molays curse over Pope Clement V and King Philippe le Bel right before his execution. This shows Millers will to prove that true justice always triumphs, no matter in what form. The Crucible can be considered as a radiography of the American society during the Cold War. Fear and terror promoted by the government disturbed the balance of justice in the United States in the sense that according to Arthur Miller, it had reached the level of freedom women who were accused of witchcraft in the 17th century had. The historical context of the play is a metaphor of what Miller really wishes to criticize, and his choice to postpone his problems to another period of time might be a constraint due to censorship. However, the playwright indignation towards judgements, either by society or individuals is highly palpable throughout the story. Miller openly criticizes the hypocrisy of religious people and politics but also everyone who wishes to enhance others problems but not theirs. Whether he treats the theme of judgement through personifications or by pointing out the whole paradox of this attitude, Miller does not hide his disgust for insincerity and mockery.

In An Inspector Calls J.B. Priestley has a message to deliver, what :: English Literature

In An Inspector Calls J.B. Priestley has a message to deliver, what is this message and how does he deliver this message? In the play 'An Inspector Calls' the playwright John Boynton Priestley, uses real people in artificial situations to create the well-rounded performance, he does this so effectively because the people of the time could relate to these situations, setting and the issues raised but could also place themselves in the play with each person in the audience becoming an actors. We are constantly kept on the edge, never knowing what to expect next. He does this by using many complex dramatic devices in order to give the correct information to the audience and actors and deliver it with pinpoint timing. In this family situation the inspector is able to manipulate it by knowing the significant weaknesses and personalities of the individual family members. He shows the family cannot communicate with each other when put in a tense or uneasy situation. One of the devices he uses is the constant use of small climaxes where the audience believe they have found the major culprit then the line of enquiry jolts off into another direction this makes the play both captivating and interesting. This is shown in the way it holds the audience all the way through, building up slowly with peaks, gathering the complex plot as it goes along, then finally ends in a stunning climax with a twist. Throughout the play the inspector is extracting small threads of information from each member of the family and slowly interweaves the small threads to form one big picture, once the picture is formed the audience can narrow it down to the main culprit this acts as the first conclusion of the play, but once the audience have realised that there isn't one culprit but instead the whole family are guilty for her death this really drives the message home. The inspector uses a photograph very cleverly because the family believe that the inspector is showing the same pictures to everyone, as an alternative these could be pictures of different people. After the inspector has carried out all his investigations the family is split into two sections, one being the people who are sorry for all the hurt and pain they have caused, these are the people that have taken in Priestley's and the inspectors message, the socialists. On the other hand the other group are the elders that are stuck in there old fashioned ways and believe that society functions better as individuals and not a team these are the people that Priestley is rebelling against, the capitalists, the money driven people who don't

NHL Players Moving West :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   NHL Players Moving East   Ã‚  Ã‚  Ã‚  Ã‚  It was deemed official this past weekend that the NHL will be on lockout due to the new salary cap the league wants to enforce. The players in the league have a different outlook this year as well and it involves moving east. Hockey players in the NHL get 75% of the revenue the league makes and it is very obvious that this current situation is not going to last. There is no way to fund the league if the players are making all of the money. So what happens now? Ratings are very low, the league is not m   Ã‚  Ã‚  Ã‚  Ã‚  September 21, 2004   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Current Events Paper arketable right now, and expansion has hurt rather than cured many of the problems in the NHL. That is why the NHL is trying to come to an agreement to place a cap in the league in order to make some much-needed revenue. The players are not having this new idea, and they are now welcoming a different home.   Ã‚  Ã‚  Ã‚  Ã‚  More than 150 players have signed to play in the European leagues. Jaromir Jagr has agreed to play in the Czech Republic for a team named Kladmo. Marcus Naslund has agreed to play in Sweden for Modo. Llya Kovalchuk has signed with AK Bars Kazan in Russia. These are just a few names, but other players are already signed as well and are playing games as we speak. The Russian league has signed 33 NHL players, the Swedish league has signed 30 NHL players, the Czech league has signed 47 NHL players, and the Finnish and Slovakia leagues both signed nine NHL players apiece.   Ã‚  Ã‚  Ã‚  Ã‚  So how can this current situation be resolved? There are few options right now, which makes it seem like this is really going to hurt the league economically. Most of the players in the league have a lockout clause in their contracts making this problem easy for them to deal with. All they have to do is wait out this lockout while being involved with a different league and when the lockout is over they can automatically resume their previous positions in the NHL. This situation however, is not going to be resolved that easily. If the players do not agree to have a salary cap in the NHL then there is not quite an alternative. Where can the league make up this money? If there were a bigger demand for the sport than there would not be a problem.

CT scan of abdomen and pelvis without contrast Essay

ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous structures of the abdomen appeared unremarkable. No free air was seen. PELVIS: Good quality, non contrasted actual CT examination of the pelvis with coronal reconstructions. Prostate, seminal vesicles and urinary bladder appeared WNL. The bowels seen on the study appeared WNL, except for inflammatory changes of the appendix and seccum with acute appendicitis. Osseous structures of the pelvis appeared in tract with evidence of bilateral hip degenerative changes. IMPRESSION: 1. Findings consistent with acute appendicitis 2. Degenerative changes of the hips Paula Reddy NN:EF D: T: DISCHAGE SUMMARY Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05/Age: 46Sex: M Date of Admission: 11/14/2012 Date of Discharge: 11/17/2012 Admitting Physician: Benard Kester, MD General Surgery Procedures Performed: Laparoscopic appendectomy with placement of RLQ drain on 11/14/2012 Complications: None. Discharge Diagnosis: Acute subapperative appendectomy perforated. DIAGNOSTIC/IMAGING LABS: Lab results at the time of admission showed a WBC count of 13. CT scan done in the ED revealed an acute appendicitis with fleggon. HOSPITAL COURSE: The 46 years old Caucasian gentleman presented to the ED with a 3 day history of abdominal pain, however in the last 24 hours and it has________ migrated to the RLQ with anneorixia, guarding and elevated WBC of 13 and CT scan consistent with appendicitis. The patient was taken to the operating room where he underwent a laparoscopic appendectomy that revealed appendix perforation and phlegmon. The appendix was removed in toto with an intact stable line. A drain was placed in the RLQ due to the fleggmonous material. Patient did well over the successive 2-3 days postoperatively with resumption of an oral diet having past flatus with having bowel movement with minimal drain output. However his WBC lowered to 6. His drain has been left intact. Patient is being discharged on the post operative day 3 on a 1 week course of PO gentamicin. The drain left in place. The drain will be removed in my office on 11/24/2012 if the drain output is minimal. Patient is on a PO diet. He was given a script for both antibiotics and PO narcotics. (Continued) PLAN: Post operative visit in my office in 1 week for evaluation and possible removal of JP drain. No heavy lifting for 4 weeks following surgery. Patient is to complete his full course of post operative antibiotics. DISCHAGE SUMMARY Patient is to report to the ED or my office earlier if any redness or foul smelling drainage out of the wound sit. Any swelling, fever, pain or any other concerns. Patient and his wife verbalized the understanding of the agreement with the above plan. Bernard Kester CC: Max Hirsch, MD D:11/14/2012 T:11/14/2012 HISTORY AND PHYSICAL EXAMINATION Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05Age: 46 Date of Admission: 11/14/2012 Emergency Room Physician: Alex McClure, MD Admission Diagnosis: Acute Appendicitis HISTORY OF PRESENT ILLNESS: 46 year old gentlemen with past medical history significant only for degenerative disease with bilateral degenerative disease of the hips. Secondary to arthritis. Presents to the Emergency room after having had 3 days of abdomen pain. It usually started 3 days ago and was generalized vague abdomen complaint. Earlier this morning the pain localized and radiated to the RLQ. He had some nausea without amesis. He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. ‘he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy. PAST MEDICAL HISTORY: Significant for arthritis of bilateral hips seen by Dr. Hersch. PAST SURGICAL HISTORY: Negative MEDICATIONS: Piroxicam for degenerative joint disease of bilateral hips ALLERGIES: No known drug allergies SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married. FAMILY HISTORY: No history of cancer or inflammatory bowel disease in his family. REVIEW OF SYSTEMS;;12 point ROS was preformed and is negative except noted in above HIP, PMH and PSH. Careful attention was paid to endocrine, integumentary, pulmonary, renal and neurological exam PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical,  subclavicular, axilarry or lingual lymphinalpathy. HEART: Regular rate and rhythm. No thrills or murmur heard. LUNGS: Clear to aspiration bilateral. ABDOMEN: Obese with minimal bowel sounds, slightly distended there is RLQ tenderness with guarding and pinpoint rebound. Positive _____. Actuator signs with negative psoas side. RECTAL: No evidence of blood or masses. PROSTATE: WNL. EXTREMITIES: No clubbing, cyanosis, clots or edmea. 1+ pedal pulses bilaterally. NUERO: Cranial nerves 2-12 grossly intact. DIAGNOSTIC DATA: WBC was 13.4, Hemoglobin and hematocrit 15.4 and 45.8, platelets 206 with 89% shift. Sodium 133, Potassium 3.7,Chorlide 99, Bicarbonate 24, BUM and Creatine 18 and 1.1, Lukeuos 146, adermin 4.3, total bulliru,1.7, remainder of the LFTs is WNL. Urinary analysis reveals trace keytones with 100 mg per decimeter with small amount of blood. CT scan was preformed revealing evidence of acute appendicitis with parasitical inflammation as well as facilitation of appendix inflammation and haziness in aperparacifiacal dilation. There is evidence of degenerative joint disease in bilateral hips on the cat scan as well. ASSESTMENT PLAN: This 46 year old Caucasian gentleman has signs and symptoms and radiographical findings consistent with acute appendicitis without evidence of abscesses. The plan is to take him to the operating room for laproscopic possible open appendectomy and possible large bowel dissection should the case resisitated. Plan was discussed with patient with his wife. Risk, benefits and alternatives were discussed. There was no barriers to communication and all questions were answered appropatily The patient understands the plan and desires to proceed . (Continued) The plan was discussed with Dr. Keslerof general surgery who agrees and will take patient to operating room . Alex McClure, MD D:11/14/2012 T:11/14/2012 PATHOLOGY REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/Age: 46Sex: M Pathology Report No: 10-S-9044 Date of Surgery: 11/14/2012 Attending Physician: Bernard Kester, MD general surgery Preoperative Diagnosis: Acute appendicitis Postoperative Diagnosis: Necrotizing acute appendicitis Specimen Received: Appendix other than incidental Date specimen received: 11/14/2012 Date reported: 11/16/2012 CLINICAL HISTORY: Acute appendicitis. GROSS DESCRIPTION: The specimen was received in formily? With patient name, ID and appendix. It consist of a appendix measuring 6 x1.5Ãâ€"1.5 cm there periepdesial fat attached to it measuring 6Ãâ€"4 by1 cm. The cirrosal surface is hemmoraggric. Upon opening the appendix there is percudent exudates material. The wall thickness measures 0.3cm. Representive sections are present is 1 cassettes. MICROSCOPIC DESCRIPTION: Performed MICROSCOPIC DIAGNOSIS: Appendix appendectomy, Necrotizing acute appendicitis. ICD Diagnosis Code: 540.9 (Continued) CPT Code: 8-88304 Georgia Tamato,MD ALW: D:11/14/2012 T:11/14/2012 OPERTIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05Age: 46Sex: M Date of Admission: 11/14/2012 Date of Procedure: 11/14/2012 Admitting Physician: Bernard Kester, MD General Surgery Surgeon: Bernard Kester, Assistant: Jason Wangner, PAC Circulating nurse: Jimmy Dale Jet, RN Preoperative diagnosis: Acute appendicitis. Post operative diagnosis: Perforated appendicitis. Operative Procedure: 1: Laparoscopic Appendectomy. 2: Placement of RLQ drain. Anesthesia: General endotracheal. Specimen Removed: 1 Necrotic appendix. IV Fluids: 1700 crystalloid. Estimated Blood Loss: 10mL. Urine Output: 300mL. Complications: None. INDICATIONS: This gentleman is a 46 year old Caucasian male that came in with a 3 day history of abdominal pain, however the pain worsened after 24 hours to the RLQ and caused a significant amount of anorixia. He presented to the ER department. CT scan to abdominals and pelvis showed acute appendicitis. Labs showed WBC at 13. Laparoscopic appendectomy procedure was explained along with the risk, benefits and possible complications. Patient voiced his desire to proceed. Patient was started on preoperative gentamicin. DESCRIPTION OF PROCEDURE: Patient was ID’d times 2 in the pre op holding area. A final timeout was held in the nursing area, anesthesia and surgical service during in which the patient ID was confirmed and the surgical site was initialed. He was given preoperative antibiotics. He was taken back to the OR and placed in the supine position. General endotracheal anesthesia was induced. SEDs were placed on his lower extremities. His Left arm was tucked to the side. Foley Catheter was placed. His abdomen was shaved and prepped with betadine solution, and draped in the usual standard fashion. A small semicircular umbilical incision was made to the subcutaneous tissue down to the fascia. And was gasped at either side and was incised. Kelly clamped was easily inserted. Stay sutures made a _____on either side the Hasson trocar was placed and pneumoperitoneum was easily  achieved. 10 mL port was placed in Left abdomen and a 5 mL was placed in the LLQ. Inspection of RLQ showed a significant amount of adhesions and the small bowel trying to wall off perforated appendix. Milky purulent exudates was noted in surrounding area. The small bowel was carefully peeled off the RLQ side wall. Fibrous exudate the vermiform appendix was identified. It was neurotic perforated in appearance The cecum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal illium through the pelvis were significant, attempts at this time were not made to free them. There was no evidence of obstruction. The base of the appendix was Identified and dissected and lifted free. Stapler loaded with___ was used to transect the base______however again inflammation extended to the level of the cecum. Though the cecum itself was also inflamed. The remainder of the mesoappendix was divided with a Endo GIA loaded with a _____. Appendix was placed into a endo catch bag was brought out through the umbilical cord site and sent to pathology for routine processing. Inspection of the RLQ and the area was irrigated coupsuley, there was no further evidence of purulent exudate. The appendicualr stump remained and doesn’t appear to be inflamed. However____wasn’t bl eeding. There was some fibrous exudate in the area. Consequently I felt like we had 2 options, we either perform a right epicolodectomy, given the intent of the adhesions in the pelvis would likely require a laparotomy or place a drain with antibiotics possibly controlling the fistula until the inflammation resolves. But hopefully it will heal on its own spontatensouly. Consequently we placed a19 French round Blake drain in the RLQ and brought it out through the LLQ in the 5mm port site. It was secured to the skin using a micro suture. Nuenopartiumeum was then desufflated the fascia of the umbilical port site was closed using a 2,o vicro that had been previously placed. All wounds were enthsitized using 1/2% marking solution and was coupsley irrigated. Skin edges approximated using 4 or monocro. The wounds were dressed with beatdine spray and steri strips. Drain sponge was placed around the drain, Foley catheter was removed. The patient was awakened, exubated then taken to recovery PAR in stable condition. Having tolerated the procedu re well. No complications were observed. DISPOSISTION: 1: The patient will be transferred to the floor. 2: He will be kept at least overnight. 3: He will be taught drain care. 4: He will go home with the drain on place. 5: He may require a fistulagram in the future. Benard Kester, MD D:11/14/2012 T:11/14/2012

Poetry Ducle Et Decorum Est Essay

Wilfred Owen was a poet born in 1893, and the poem Dulce et Decorum Est was probably his most famous one. Owen wrote this poem in hospital after suffering from both physical and mental injuries of the First World War. Having experienced war himself, he had a realistic view of the war and tried to convey this to others before he died at twenty-five years old. Dulce et Decorum Est focuses on a gas attack, and portrays that war is not honourable and sweet, as the title suggests in Latin. The poem begins by describing the physical state of the soldiers. The poet uses similes to convey the ill-health of the men. The soldiers are described as being â€Å"Bent double, like old beggars† which characterizes soldiers as being prematurely old, and extremely weak for their young age. Metaphors are also used to draw attention to their weak state of mind, â€Å"Men marched asleep† is used to imply the exhaustion of the fighters, not only the soldiers are here physically but suggests also as they are mentally and â€Å"Drunk with fatigue†. The poet uses the personification of bombs when he writes â€Å"disappointed shells† which suggests the soldiers from the enemy side had thrown bombs and grenades unsuccessfully. This implies that in war, soldiers had a lot of chances to be bombed easily. From the second stanza, we experience war through the naked eyes of a soldier during a sudden gas attack. The tone of the poem changes from a pessimistic calm with the slow walk of soldiers through the â€Å"sludge† to a tone of panic due to the gas attack. â€Å"GAS! Gas! Quick, boys! † these exclamatory sentences create urgency, which shows how the soldiers had to live in fear every day. From the gas attack, the poet uses again a personification by using â€Å"clumsy helmets† to explain that the gas masks provided were inefficient, and that soldiers almost had no chance of surviving. During that time, the simile â€Å"floundering like a man in fire or lime† is used to show a panicking soldier because gas has got infected his body. This creates a sense of pity because the soldier sees his comrade die in front of him, through the â€Å"misty panes† which are the masks. From this, readers understand that war doesn’t only have physical effects, but also terrible mental effects. The emotional impact of war is well shown in Owen’s poem when in the third stanza, he describes how in all his â€Å"dreams†, he sees his â€Å"friend† who died â€Å"guttering, chocking, drowning†. These three verbs are used as the rule of three, they all are connotations of suffering and death. The fact that he couldn’t help this â€Å"helpless† soldier because gas had already got into his body haunts him every night since. When Owen describes the death of his mates in war, he remembers how badly treated they looked and he uses negative connotations to show that seeing these images hurt him mentally. Owen writes about his friend having a â€Å"hanging face† which suggests that he was exhausted, and uses the simile â€Å"like a devil’s sick of him† that implies Owen comparing his comrade’s face to a devil’s appearance. Seeing his partner suffering, the poet uses the verb â€Å"gargling† to define his †forth-corrupted lungs†. These words submit a sense of sound in the poem which is another way the poet has created pity and also put forward the fact that soldiers die in horrific conditions. On the next line, two similes are used to explain how Owen felt by the scene at this time. Obscene as cancer† and â€Å"bitter as the cud† both suggest death and the darkness of war. â€Å"Of vile, incurable sores on innocent tongues† shows it is unfair that young soldiers have to live in this misery, instead of having a normal and pleasant life. Readers obviously imagine after this stanza, the memories the survivors still have in their mind is most of the time worth dying, and this affects readers to feel some pity for these young men. In the very last stanza, Wilfred Owen involves the reader by using the second person. If you could hear† reminds the sound sense again but also asks readers between the lines : if you were in this situation, how would you react. Talking directly to the readers gives a bigger chance to Owen to emphazize pity in his poem. He continues with â€Å"My friend, you would not tell with such a high zest to children† to create guilt in the readers minds, because soldiers were highly encouraged or even forced to go to war by propaganda and the country’s government. All the people who pushed young men to go to war by saying how great and adventurous it is feel guilty in this last stanza. The word â€Å"Children† also emphazises pity, and points out that Owen has himself been a kid pushed to war and now as a survivor knows the lies behind it. In my opinion, I think that this poem was directed to all the people who formed propaganda for war, but it was also written to tell young men who were going to war in the future aware of the reality. In the end, after pointing out that society shouldn’t lie about war, and after earing that these children desire glory, he states â€Å"The old Lie: Dulce and decorum est pro patria mori†, which is the title of the poem. Here, Wilfred Owen made a rime, and he also has used irony in this one sentence. This whole poem is about expressing how bad war is and when he writes this which means ‘it is honourable and sweet to die for your country’ in Latin perfectly summarises the poem using irony. From this poem, I can obviously see that, after years, Owen still suffers from the physical and mental injuries that war caused him. Lots of strong words have been used by the poet to express what it was like and how he felt, which creates pity in the readers mind. I find Wilfred Owen very brave and courageous for writing this poem that explains how millions of young soldiers have felt, being in war.