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Collectively this space is referred to as the interstitium and the fluid contained within the space is referred to as the interstitial fluid 200mg flagyl for sale antibiotic resistance webquest. These large cells engulf and destroy foreign particles buy cheap flagyl 500 mg on line antibiotic resistance research paper, including bacteria and cellular debris generic flagyl 500mg amex virus zona. The lymph nodes also contain B lymphocytes buy discount flagyl 400mg on line antibiotic during pregnancy, white blood cells capable of initiating antibody production in response to the presence of viruses, bacteria, yeast, and other organisms. Weighing about 7 oz, the spleen is a fist-sized, spongy, dark purple organ that lies in the upper left abdomen behind the lower ribs. The spleen’s functions include producing white blood cells; engulfing and destroying bacteria and cellular debris, and destroying worn-out red blood cells and platelets. During times of demand, such as hemorrhage, the spleen can release its stored blood and prevent shock. Like the thymus, the spleen also releases many potent immune-system-enhancing compounds. For example, tuftsin and splenopentin, two small proteins secreted by the spleen, have been shown to exert profound immune-enhancing activity. White Blood Cells There are several types of white blood cells, including neutrophils, eosinophils, basophils, lymphocytes, and monocytes. Neutrophils These cells actively phagocytize—engulf and destroy—bacteria, tumor cells, and dead particulate matter. They secrete histamine and other compounds designed to break down antigen-antibody complexes, but they also promote allergic mechanisms. Lymphocytes There are several types of lymphocytes, including T cells, B cells, and natural killer cells. These cells orchestrate many immune functions and are the major components of cell-mediated immunity (discussed above). There are different types of T cells, including helper T cells, which help other white blood cells to function; suppressor T cells, which inhibit white blood cell functions; and cytotoxic T cells, which attack and destroy foreign tissue, cancer cells, and virus-infected cells. The ratio of helper T cells to suppressor T cells is a useful determinant of immune function. If the ratio of helper T cells to suppressor T cells is high, most often allergies or autoimmune disorders such as rheumatoid arthritis or lupus are present. B cells are responsible for producing antibodies, which are large protein molecules which bind to foreign molecules (antigens) on bacteria, viruses, other organisms, and tumor cells. After the antibody binds to the antigen it sets up a sequence of events that ultimately destroys the infectious organism or tumor cell. The level of activity of natural killer cells in chronic fatigue syndrome, cancer, and chronic viral infections is usually low. These large white blood cells are responsible for cleaning up cellular debris after an infection. Special Tissue Cells Macrophages As stated earlier, the lymph is filtered by specialized cells known as macrophages. Macrophages are actually monocytes that have taken up residence in specific tissues such as the liver, spleen, and lymph nodes. These large cells phagocytize or engulf foreign particles including bacteria and cellular debris. Macrophages are essential in protecting against invasion by microorganisms as well as against damage to the lymphatic system. Mast Cells Mast cells are basophils that have taken up residence primarily along blood vessels. The mast cell, like the basophil, is responsible for releasing histamine and other compounds involved in allergic reactions. Special Chemical Factors There are a number of special chemical factors that enhance the immune system (interferon, interleukins, complement, etc. These compounds are produced by various white blood cells—for example, interferon is produced primarily by T cells, interleukins are produced by macrophages and T cells, and complement fractions are manufactured in the liver and spleen. These special chemical factors are extremely important in activating the white blood cells to destroy cancer cells and viruses. Supporting the Immune System There really isn’t any single magic bullet that can immediately restore immune function. The immune system is a complex integration of parts that are continuously protecting the body from microbial and cancerous attack. The immune system is truly holistic, as evidenced by the close association of psychological, neurological, nutritional, environmental, and hormonal factors with immune function. The best approach to supporting immune function is a comprehensive plan involving lifestyle, stress management, exercise, diet, nutritional supplementation, avoidance of toxins, and the use of botanical medicines. Emotional State and Immune Function The first step in supporting immune function is employing the healing power of the mind and attitude. Our mood and attitude have a tremendous bearing on the function of our immune system. Employing measures outlined in the chapter “A Positive Mental Attitude” can be quite useful in improving the immune system. It was easily accepted by conventional medical authorities that negative emotional states adversely affect the immune system, but for some reason the medical community initially scoffed at the notion that positive emotional states can actually enhance immune function. Although a stressor does not have to be a major life event to cause depressed immune function, it is safe to say that the more significant the stressor, the greater the impact on the immune system. The loss of a spouse, perhaps the most stressful life event, was strongly associated with increased sickness and death well before a link between the mind and immune function was documented. In fact, it was not until 1977 that a study of 26 bereaved spouses documented that grief led to a significant depression in immune function (natural killer cell activity was significantly reduced). But in 1979, Norman Cousins’ popular book Anatomy of an Illness caused a significant stir in the medical community. Cousins’s book provided an autobiographical anecdotal account that positive emotional states can cure the body of even a quite serious disease. But they soon demonstrated in numerous studies that laughter and other positive emotional states can in fact enhance the immune system. Stress Many clinical and experimental studies have clearly demonstrated that stress, personality, attitude, and emotion are etiologic or contributory in suppressing the immune system as well as leading to the development of many and diverse diseases. The variations in response help account for the wide diversity of stress-induced illnesses. Stress causes increases in blood levels of the adrenal hormones adrenaline and cortisol, leading to an immune-suppressed state and leaving the host susceptible to infectious and carcinogenic illnesses. This immune suppression is proportional to the level of stress, and although the effects are numerous, they appear to involve a common mechanism: increases in cortisol, pro-inflammatory compounds known as cytokines, and adrenaline, resulting in significant decrease in white blood cell function, thymic function, and the formation of new white blood cells. More than 150 clinical studies have now shown that stress can alter immune function and contribute to the development of significant disease and poor health. Research studies often use the response to a vaccine to simulate the response to an infectious organism as a measure of immune system function. For example, the chronic stress associated with caring for a spouse with Alzheimer’s disease or, for younger people, experiencing stressful life events was associated with a poorer antibody response to an influenza virus vaccine than was the case in well-matched control subjects.
The berberine alkaloid of goldenseal exerts antibiotic activity against streptococci and buy flagyl 200 mg otc antibiotics for uti or kidney infection, perhaps more important discount flagyl 200 mg fast delivery antibiotic resistance stewardship, has been shown to inhibit the attachment of group A streptococci to pharyngeal epithelial cells purchase 200mg flagyl amex infection definition. To promote the spread of colonies flagyl 250mg for sale can antibiotics for acne cause weight gain, streptococci secrete large amounts of hyaluronidase. Echinacea also inactivates group A streptococci and reduces the pro-inflammatory response to strep infection10 as well as promoting greater ability of white blood cells to identify and destroy bacteria. South African Geranium Extracts of this African plant (Pelargonium sidoides) have been shown to exert a number of effects beneficial in upper respiratory tract infections, particularly acute bronchitis, an indication for which it is an approved drug in Germany (see the chapter “Bronchitis and Pneumonia”). A stroke can be the result of a lack of blood flow (ischemia) caused by blockage from a blood clot (embolism) or a hemorrhage (leakage of blood). Without oxygen, the nerve cells become damaged or die, and the affected area of the brain becomes unable to function. A stroke may result in an inability to move one or both limbs on one side of the body, inability to understand or formulate speech, or an inability to see on one side of the visual field. If the stroke is severe enough or occurs in a certain location, such as parts of the brainstem, it can result in coma or death. Stroke is the leading cause of adult disability in the United States and the third-leading cause of death. It must be administered within a few hours of a stroke to produce significant benefit. The results of stroke can affect patients physically, mentally, or emotionally, or in any combination of the three ways, and can vary widely depending on size and location of the lesion. The physical disabilities that can result from stroke include muscle weakness, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, speech loss, vision loss, and pain. Emotional problems after a stroke can result from direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. Poststroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express emotions), mania, apathy, and psychosis. Almost half of stroke survivors suffer poststroke depression, which is characterized by lethargy, irritability, sleep disturbances, lowered self-esteem, and withdrawal. Emotional lability, another consequence of stroke, causes the patient to switch quickly between emotional highs and lows and to express emotions inappropriately, for instance with an excess of laughing or crying with little or no provocation. While these expressions of emotion usually correspond to the patient’s actual emotions, a more severe form of emotional lability causes patients to laugh and cry pathologically, without regard to context or emotion. Some patients show the opposite of what they feel, such as crying when they are happy. Cognitive deficits resulting from stroke include perceptual disorders, speech problems, dementia, and problems with attention and memory. A stroke sufferer may be unaware of his or her own disabilities, a condition called anosognosia. In a condition called hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere. Up to 10% of all stroke patients develop seizures, most commonly in the week subsequent to the event; the severity of the stroke increases the likelihood of seizures. Therapeutic Considerations For most stroke patients who suffer from poststroke disability, recovery is a concerted effort that involves physical therapy, occupational therapy, and speech-language therapy. We recommend taking advantage of these services, as they can greatly aid the rehabilitation process. Medical care is often focused on preventing another stroke and most often utilizes anticoagulant therapy with warfarin (Coumadin) or antiplatelet therapy with aspirin or clopidogrel (Plavix), ticlopidine (Ticlid), and so on. These drugs are designed to prevent blood clots from forming and lodging in the brain, where they can produce another stroke. From a natural medicine perspective the goals are similar, but more focused on maximizing blood flow and nutrition to the damaged areas. The general guidelines offered in the chapter “Cerebral Vascular Insufficiency” are valid here. Ginkgo biloba extract increases blood flow to the brain, improves the production of energy within nerve cells, and favorably affects blood viscosity (thickness), resulting in improved blood flow characteristics within the brain. Natural Antiplatelet and Fibrinolytic Therapy There are a number of dietary and supplements to reduce the aggregation of platelets as well as reduce the formation of fibrin and thereby prevent blood clots from forming. The general dietary factors that reduce platelet aggregation and promote fibrin breakdown (fibrinolysis) are discussed in the chapter “Heart and Cardiovascular Health. Fish oil supplementation can definitely be used in combination with aspirin and other platelet inhibitors,2 but if several natural antiplatelet agents are used at the same time or if nattokinase is used, it is important to avoid the use of antiplatelet drugs (including aspirin). There are case reports of hemorrhagic strokes that occurred when a natural agent (e. Precautions with Coumadin The drug Coumadin works by blocking the action of vitamin K. Since green leafy vegetables and green tea contain high levels of vitamin K, you should avoid increasing your intake of these foods while taking Coumadin. You can usually eat the same levels you’re accustomed to—just don’t increase your consumption. Your physician will monitor your blood clotting ability and will change your dose up or down as needed. In addition to foods high in vitamin K, other natural remedies may interact with Coumadin. For example: • Coenzyme Q10 and Saint-John’s-wort (Hypericum perforatum) may reduce Coumadin’s efficacy • Proteolytic enzymes, such as nattokinase and bromelain, and several herbs, including Chinese ginseng (Panax ginseng), devil’s claw (Harpagophytum procumbens), and dong quai (Angelica sinensis), can increase Coumadin’s effects. We generally tell people taking Coumadin to avoid these products at higher dosages (more than the equivalent of one clove of garlic per day for garlic or more than 240 mg per day of ginkgo extract) but not to worry if they are just on the typical support dose of garlic or ginkgo. Take Coumadin and products that contain iron, magnesium, or zinc products at least two hours apart. To reduce the likelihood of bleeding and easy bruising with Coumadin, we recommend taking 150 to 300 mg of either grape seed or pine bark extract per day. In double-blind studies both have been shown to be useful in promoting recovery from a stroke. In all cases, citicoline was begun within 24 hours after stroke onset and continued for six weeks. At the three-month check-up, results indicated that citicoline improved by 29% the probability that the patient would recover the ability to participate in activities of daily living and by 42% the probability of recovering functional capacity. Nonetheless, these results are very encouraging, as any improvement over a placebo can have profound real-life benefits. The single largest trial was conducted at 176 centers in Italy and included 2,044 patients. Acupuncture There is some clinical research showing that acupuncture can facilitate recovery from a stroke. Specifically, acupuncture can often help stroke patients perform self-care better, can mean that patients require less nursing and less rehabilitation therapy, and can possibly cut health care costs. Possible mechanisms of its effects include stimulation of nerve cell regrowth, facilitation of improved nerve cell function, reduction of poststroke inflammatory reactions, and prevention of nerve cell death. Given its safety and possible benefits, acupuncture is very much worth the effort.
The plant extracts were prepared from the powdered leaves cheap 400mg flagyl amex treatment for feline uti, stems and roots by using polar and non-polar solvents generic 200 mg flagyl with amex antimicrobial overview. The preliminary phytochemical tests showed thar the roots of (Kyetsu-kanakho) (Cotton leaves purchase 200mg flagyl with amex antibiotic quiz pharmacology, Bellyache bush) plant contained terpenoids and phenolic conpounds purchase flagyl 500 mg without a prescription virus that causes rash. Jatrophone (terpernoids), arylnaphthalene and gadain lignans (phenolic compounds) were isolated from the roots. Then extracts obtained by using ethanol, acetone, petroleum-ether (60-80˚C), chloroform extracts and Jatrophone compound were tested on six microorganisms by using agar-well diffusion method. It was found that roots extract was more effective than the extracts of leaves and stems. The acute toxicity of the aqueous, 95% and 50% ethanol extracts of Kyetsu-kanako root was evaluated on mice. Aqueous 95% and 50% ethanolic extracts did not show any toxic effect even with maximum permissable dose of 24g/kg of aqueous extract and 12g/kg of ethanolic extracts at the dosages tested. It was found that the, extract produced relaxation activity on oxytocin induced contraction in the isolated rat uterus. The plant is a crude drug which is known as Pongu-hteik-peik and has been used for snake bite, jaundice, fever and scabies. It is an indigenous Indian plant sacred to Hindus, where is used in folk medicine. Investigation of morphological and histological characters have been carried out for identification and its use as standard drug: Qualitative and quantitative analysis of relative abundance elements and mineral elements, nutritional values, extraction and isolation of active constituent compounds. The biological properties of this plant, preliminary pharmacological and clinical studies with Leucas cephalotes Spreng. In this research a detailed study of the morphological and histological characters of Leucas cephalotes Spreng. This plant is a stout, annual herb, inflorescence verticillate, leaves opposite and decussate, simple. Flowers bilabiate, bisexual and zygomorphic with upper and lower lips, gynobasic style and disc present. Basal midribs are two to three separate vascular bundles; small vascular bundle is present in petiolar wing. Calcium oxalate crystals in the form of (small needle) occur in parenchyma cells of all aerial plant parts as well as in the root. The preliminary phytochemical examination showed the presence of alkaloids, α-amino acid, carbohydrate, starch, reducing sugar, glycoside, tannin, saponin, phenolic compound, steroid, terpene, flavonoid and cyanogenic glycoside was not detected. In physicochemical properties, moisture content, total ash, acid insoluble as well as water insoluble ash, polar and non polar soluble matter were found in leaves and whole plant to determine the extract was more soluble using ethyl acetate than other solvents. Mineral elements Ca, K, P, Cl, Fe, S, Ti, Zn, Cu and Zr were common in Leucas cephalotes Spreng. In the present work, the active organic compounds were isolated from the whole plant of Leucas cephalotes Spreng. The examination of nutritional values of the whole plant showed carbohydrate was the highest. Evaluating data were obtained from research to determine the amount of carbohydrate, fat, fibres, proteins and vitamins. There are six main classes of nutrients that the body needs: carbohydrate, proteins, fat, vitamins, minerals and water. It is important to consume these six nutrients on a daily basis to build and maintain healthy bodily function. In antimicrobial activity, the leaves and whole plant crude extracts and isolated compounds (sitosterol and flavonoid) were tested by agar- well diffusion method with six microorganisms. The ethyl acetate crude extract leaves and the whole plant showed the highest activity except against E. The isolated compounds such as β-sitosterol and luteolin 7-O-glucoside also indicated antimicrobial activity. The present study of acute toxicity examination, the aqueous and 50% ethanolic extracts of whole plants were administered on albino mice; the maximum permissible dose was 12kg/kg. The aqueous and 50% ethanolic extracts of Pingu-hteik-peik have the significant antipyretic effect when tested on yield induced pyrexia in albino rats. The 50% ethanolic extract of the whole plant was more effective than aqueous extract of wholeplant. Cv (Parr-ni-thayet) have been studied and identified by using available literatures. The epidermal cells of upper and lower surface were more or less silicified cell and anomocytic stomata type. Separate collateral bundle are consistently with the resin canals in the phloem, It was one of the most important features of the genus were present in continuousing elongated tannins sac and sclereids are abundant in mature stem. The preliminary phytochemical examination of the powdered leaves and bark of Mangifera indica L. In physicochemical properties, moisture content, total ash, acid insoluble as well as water insoluble ash, polar and nonpolar soluble percentage were tested in powdered leaves and bark. Mineral elements Si, Ca, K, Fe, Mn, Zn, Cu and Al were common in leaves and bark powder of Mangifera indica L. Confirmation test of terpene and steroid in powdered leaves and bark were carried out and averaage percent of crude yield of steroid were determined. Extraction and isolation of active constituents from the leaves and bark of Mangifera indica L. Isolated compound V (mangiferin) was identified by detection with successive reagent (phenolic and flavone test) (Kokate, 1993). The decolorization in phenolic compound and flavone, xanthone assumed as mangiferin. Phenolic and polyphenolic compound constitute the main class of natural antioxidant present in plants, food and beverages. Bioassay test was carried out determined the effect of antimicrobial and antioxidant activity of isolated compound V (mangiferin). The susceptibility of the microorganisms on the basis of zone of growth in inhibition varied. Powder of leaves, stems and roots were also examined which can be used to ascertain their identification and standardization for traditional medicine. In morphological study, the plants were evergreen shrubs, up to 3m tall; leaves simple, opposite and decussate, palmately 5-nerved; flowers showy pentamerous; Inflorescences corymbose cymes; Fruits were fleshy capsules and opening irregularly transversely at maturity. In histological study, the lower surface of the lamina were wavy, anomocyticrpe type of stomata were abundant in lower surface only. In transverse section of the lamina, the hypodermal layer was present below the epidermis. Scale-like multicellular shaggy hairs were occurred interface view of midrib and petiole. In transverse section of petiole, midrib and stem, intraxylary phloem was observed.
Syndromes
- Crater-like ulcers between the teeth
- Certain birth defects of the heart
- Crushing injuries
- Increased bone fractures
- Weakness
- Giardiasis
- Infection of the shunt or brain
- Infants
- Methylene hydrochloride
- Infection
The catheter allows pretreatment blood collection and “slow” administration of fluids buy flagyl 400 mg overnight delivery antibiotic resistance effects on society, antibiotics or other medications with one venipunc- ture trusted 250 mg flagyl bacteria 4. The amount of fluid that can be administered at one time depends on the size of the bird discount flagyl 500 mg with amex antibiotics for dogs for bladder infection. The area of the base of the neck should be avoided because of the cervico- repeated every three to four hours for the first twelve cephalic air sacs order flagyl 500 mg overnight delivery treatment for sinus infection in pregnancy. Subcutaneous fluids are generally ineffective in hours, every eight hours for the next 48 hours, and cases of severe dehydration or shock. Subcutane- Intravenous catheters (24 ga in medium to large ous fluids may pool in the ventral abdominal area birds) can be placed in the ulnar or medial metatar- causing hypoproteinemia, overhydration or poor ab- sal veins of some birds for continuous fluid admini- sorption. For placement in the ulnar vein, the cathe- taneous fluid administration should be decreased or ter is inserted using sterile technique, secured discontinued. Intraosseous cannulas the tongue depressor are then firmly incorporated in or use of the right jugular vein are the best access a wing wrap to stabilize the catheter. Dyspneic birds hematoma formation is probably greater using the and those with distended, fluid-filled crops should be ulnar vein than with the metatarsal vein. Many or metatarsal veins is difficult and frequently results birds will chew at the catheter, tape or extension set in hematoma formation. Isoflurane anesthesia is sometimes necessary for cannula place- ment in fractious birds. For placement in the ulna, the feathers from the distal carpus are removed and the area is aseptically prepared. Using sterile technique, the needle is in- troduced into the center of the distal end of the ulna parallel to the median plane of the bone (Figure 15. The needle is ad- vanced into the medullary cavity by applying pres- sure with a slight rotating motion. The needle should advance easily with little resistance once the cortex is penetrated. The mated to be ten percent dehydrated (reduced ulnar refill time, tacky mucous membranes, dull sunken eyes). Admini- Ineffective for shock stration of hypertonic or alkaline solutions can be painful and should be avoided. The advantages of Subcutaneous Fluids intraosseous cannulas include the ease of placement Primarily used for mild dehydration and maintenance, cannula stability, tolerance by Effective for providing maintenance fluids most birds and reduced patient restraint once the Given in axilla or lateral flank cannula is placed. Continuous fluid administration Divide dose among several sites by intraosseous cannula is less stressful than re- Intravenous or Intraosseous Fluids peated venipunctures. Rapidly expands circulatory volume Rapidly perfuses kidneys It has been shown in pigeons that 50% of the fluids Indicated in shock administered in the ulna enters the systemic circula- Indicated with severe dehydration tion within 30 seconds. Initial fluids should be administered slowly to check for subcutaneous swelling, which would indi- cate improper placement of the cannula. If the can- nula is properly placed, fluid can be visualized pass- ing through the ulnar vein. The cannula is secured in place by wrapping a piece of tape around the end and suturing the tape to the skin or by applying a sterile tissue adhesiveb at the point of insertion (Figure 15. A gauze pad with a small amount of antibact- erial ointment is placed around the cannula at the insertion site, and a figure-of-eight bandage is used to secure the wing. One to two loops of the extension tube should be incorporated into the bandage to de- crease tension on the cannula. Tibial cannulas are seated in the tibial crest and passed distally, similar to the technique used for obtaining a bone marrow aspirate. A light padded bandage or lateral splint is used to secure the can- nula in place (see Figure 39. Fluids are administered through the cannula using an infusion pump, buretrolc or Control-a-Flow regu- lator. In small mammals, fluids can be given at shock doses (90 ml/kg) at a pressurized flow rate of 2 l/hr. Excessively rapid infu- sion of the fluids may cause signs of discomfort or edema of the soft tissue in the area of the cannula. Fluid extravasation may occur if the infused volume is too large, or if several holes were made in the cortex while attempting to place the cannula. Intraosseous cannulas are most successful in birds if used during the first 24 to 48 hours for initial rehy- dration and shock therapy. Cannulas can remain in place for up to 72 hours without complications if placed aseptically and maintained with heparinized flushings every six hours. If fluid or drug administration will be restricted to a sponse when fluids are given through an in- single dose or a short period (eg, surgery), it is easier to place a traosseous cannula. No portion of the catheter is externally ex- itial treatment of birds that are weak, sick, debili- tated or in shock. Intrave- for long-term intravenous chemotherapy and total nous administration is recommended if septicemia is parenteral nutrition. Intravenous drugs can be given devices have been used in dogs and laboratory ani- 2,37 during the initial fluid bolus or through an indwell- mals. Intravenous drugs cess port include thrombosis, sepsis, local infection 2 should be given slowly to avoid circulatory shock. Intramuscular administration of antibiotics is used Vascular access devices have been used experimen- routinely for maintenance therapy. A small gauge tally in pigeons and geese and clinically in an auk- 20 needle (26 to 30 ga) is used to minimize muscle let. The pectoral muscles should be used for limited by the size of the animal and absence of an most injections (see Chapter 17). Other disadvan- tages of the device in birds include the necessity of The major disadvantage to intramuscular injection is surgical placement and removal and the difficulty of the potential for muscle damage. The catheter is secured in place in the vein with sutures above and below a Subcutaneous administration of drugs is less trau- retention ring on the catheter. A tunnel is made matic to the muscle and is often used for mainte- through the subcutaneous tissue to a site dorsal to nance therapy. Subcutaneous injections may be pre- the catheter where the port is sutured to the under- ferred in very small or cachectic birds with limited lying muscle fascia. The extravascular portion of the muscle mass and in birds with suspected coagulopa- catheter is left in a short loop to prevent tension thies. The catheter is flushed with clude the possibility of leakage from the injection site heparinized saline at regular intervals to ensure and poor absorption. The initial choice of an antibiotic depends on the Antibiotics clinical signs and history of the bird. Birds with Septicemia and bacteremia should be considered in suspected gram-negative septicemia should be any bird that is severely depressed. Prophylactic treated with a bactericidal antibiotic effective antibiotics are frequently used in birds that are im- against the most common avian pathogens, including munocompromised from a noninfectious disease.
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