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Vasotec is used for treating high blood pressure, heart failure, and other heart problems.

Active Ingredient: Enalapril

Vasotec (Epril) as known as: Acepril, Acetensil, Alapren, Alicante, Alphapril, Amprace, Analept, Anapril, Angiotec, Antiprex, Atens, Auspril, Bagopril, Bajaten, Baripril, Baypril, Benalapril, Bidinatec, Biocronil, Bitensil, Bql, Calnate, Carlon, Cetampril, Cinbenon, Ciplatec, Clipto, Controlvas, Convertase, Converten, Convertin, Corodil, Corprilor, Corvo, Cosil, Crinoren, Dabonal, Daren, Defluin, Denapril, Dentromin, Dilvas, Dinid, Ditensil, Ditensor, Docenala, Ecaprilat, Ecaprinil, Ednyt, Ekaril, Elpradil, Ena, Ena-puren, Enabeta, Enacard, Enacodan, Enacor, Enadigal, Enadura, Enafril, Enal, Enalabell, Enaladex, Enaladil, Enalafel, Enalagamma, Enalaprili maleas, Enalaprilmaleat, Enalaprilo, Enalaprilum, Enalaprol, Enalart, Enalbal, Enaldun, Enalek, Enalich, Enalin, Enalind, Enalten, Enam, Enap, Enap r, Enaprel, Enapren, Enaprex, Enapril, Enapril-h, Enaprotec, Enarenal, Enaril, Enatec, Enatral, Enazil, Encardil, Enecal, Enetil, Enpril, Envas, Ephicord, Epril, Eril, Eritril, Eupressin, Fabotensil, Feliberal, Fibrosan, Gadopril, Glenamate, Glioten, Gnostocardin, Grifopril, Hasitec, Herten, Hiperpril, Hiperson, Hipertan, Hipertin, Hipoartel, Hipopril, Hypace, Iecatec, Ileveran, Imotoran, Innovace, Innozide, Insup, Intonis, Invoril, Istopril, Jutaxan, Kalpiren, Kaparlon-s, Kinfil, Kintec, Konveril, Korandil, Lapril, Laprilen, Lariludon, Lenaberic, Lenimec, Leovinezal, Lerite, Linatil, Lotrial, Lowtril, M-enalapril, Maxen, Megapress, Meipril, Mepril, Minipril, Myoace, Nacor, Nalabest, Nalapril, Naprilene, Narapril, Neotensin, Norpril, Nuril, Octorax, Ofnifenil, Olinapril, Olivin, Pharmapress, Pharpril, Pms-enalapril, Pralenal, Pres, Presopril, Pressitan, Presuren, Prilace, Prilan, Prilenap, Prilenor, Priltenk, Pulsol, Rablas, Raserpril, Reca, Reminal, Renacardon, Renapril, Renaton, Renil, Renipril, Renistad, Renitec, Reniten, Renivace, Reniveze, Renopent, Revinbace, Selis, Silverit, Spaciol, Stadelant, Stadenace, Sulocten, Supotron, Tenace, Tenaten, Tencas, Tensapril, Tensazol, Tesoren, Ulticadex, Unipril, Vapresan, Vasolapril, Vasopren, Vasopril, Vexopril, Vimapril, Virfen, Vitobel, Xanef, Zacool

Cat Scratch Disease Update April 2006; 146-6

Cat Scratch Disease Update

Cat-scratch disease has never been foremost in Bandolier's thoughts. For one thing it is relatively uncommon, is usually seen in children, and has a relatively straightforward diagnosis and treatment. There are a few hostages to fortune there, but that's the way it is oftentimes. Cat-scratch disease in older people wasn't even on the radar, but reports from a new study from Israel suggests that it has a different presentation than in younger people [1,2].


This was a surveillance study began in Israel in 1991, and involved clinicians sending specimens from patients suspected to have cat-scratch disease to a single laboratory. If they met case definition criteria, they were enrolled into the study and demographic and clinical data collected prospectively with a structured questionnaire, supplemented by medical records if necessary.

A case was defined as at least one positive test, including PCR, antibodies, or culture, with a compatible clinical syndrome. Typical disease was defined as regional lymph node involvement without ocular, cutaneous, or visceral problems. Atypical included one of several problems, including ocular, encephalitis, endocarditis, fever of unknown origin, erythema nodosum, hepatitis, splenitis, or osteomyelitis.


The group of 846 patients with confirmed cat-scratch disease formed the cohort. Typical disease was present in 85%. Overwhelmingly patients were young, with 80% of cases in under 40s, and 70% in under 30s. The average age was 18 years, with the highest number of cases between four and 14 years, and a smaller peak between 22 and 28 years (Figure 1, for age to 50 years).

Figure 1: Age distribution of presenting cases, up to age 50 years

Cat scratch disease was diagnosed in 52 patients at least 60 years or older [1]. Their presentation was different (Table 1). There were generally more women, but fewer with lymph node involvement. More of the older patients had atypical presentation, fever of unknown origin, encephalitis, and especially endocarditis. Diagnosis took longer in the over 60s, and fewer received antibiotics.

Table 1: Presentation in older patients

A second report of the same study [2] identified 24 patients with arthropathy, not usually associated with cat scratch disease. These patients were aged between 23 and 54 years, and were more likely (5/24; 21%) to have erythema nodosum than in patients without arthropathy (2%).

These patients with arthropathy had frequent involvement of knee, wrist, or ankle. All had regional lymph node involvement, and in 22/24 arthropathy developed within a week of appearance of lymph node involvement.

Average duration of arthropathy was 13 weeks, but that encompassed the enormous range of one to 240 weeks. Nineteen (74%) recovered, and in these recovery came within 24 weeks (median six weeks). In the other five patients the disease became chronic, persisting for 16-53 months at the latest follow up.


It is comforting that we can continue to learn using good quality observation. Diagnosing cat scratch disease in older people may be made easier by the increasing availability of genetic methods like PCR, especially of tissue for the causative agent, bartonella henselae. An interesting, though not extensive, study of patients with lymph node involvement [3] tells us that PCR is 100% specific – meaning that a negative test is a rule out. Using PCR, and the starting point of superficial lymph node involvement in one isolated area, the paper has what looks to be a useful, if untested, diagnostic algorithm.

  1. R Bewn-Ami et al. Cat-scratch disease in elderly patients. Clinical Infectious Diseases 2005 41: 969-974.
  2. M Giladi et al. Cat-scratch disease – associated arthropathy. Arthritis & Rheumatism 2005 52: 3611-3617. 3 Y Hansmann et al. Diagnosis of cat scratch disease with detection of bartonella henselae by PCR: a study of patients with lymph node involvement. Journal of Clinical Microbiology 2005 43: 3800-3806.

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Chronic Diseases Summit (3-4 April 2014) - European Commission

European Commission
Public health
Chronic Diseases Summit (3-4 April 2014) Brussels, 3-4 April 2014 About the Conference

This first EU summit on chronic diseases discussed medical, social and economic benefits of sustainable investments in health, ways to reduce the burden of chronic diseases, and how to strengthen the prevention and management of chronic diseases, with a focus on EU added value and action.


The first EU summit on chronic diseases brought together key policymakers, stakeholders and interest groups to explore ways to address chronic diseases effectively in the EU and to develop recommendations along the following questions:

  1. How does the expanding burden of chronic diseases affect the quality of life of citizens, the competitiveness of economies and the cohesion of societies and what can the EU do about it?
  2. How can the pressure of the expanding burden of chronic diseases on health systems be reduced and how can available resources be invested in the most efficient way?
  3. Which prevention measures are the most cost-effective in the short and in the long term, and how could they be implemented? How should the EU and its Member States promote their implementation? Which risk factors need to be addresses more efficiently?
  4. How do the health and care systems need to change to respond to the ageing challenge and growing phenomena of frailty and multi-morbidity?
  5. How to best reach, include and empower the most vulnerable and marginalised people successfully in prevention and care strategies?
  6. How could the European Union support Member States’ attempts towards containing the chronic disease burden? Which EU action would provide most added value – in economic, social and political terms?

The summit will develop Conference conclusions and a set of policy recommendations for action clarifying on how the medical, social and economic burden of chronic diseases should be tackled in the European Union now and in the years to come.


The number of participants was around 450. The conference brought together representatives of Member States, non-governmental organisations and other relevant stakeholders, professional groups, business operators, academics, and EU institutions.

Video recordings

The Conference was broadcast online:

Watch the video recordings.


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Epril Side Effects

Epril Side Effects Track Your Side Effects

Note Your Observations

It is really important to keep track of your health symptoms, right from the time you start a new medicine. You can do it any way you prefer: in a notebook, in a computer file or using our online tool. You should also note down any other medicines you are taking at the same time, because there could be an interaction between these medicines.

Why Your Notes are Important

Your notes could be helpful in several ways:

  • You can use them to remind you of details that may alert your health care professional(s) to a problem
  • You will have a record to refer to in the future, in case you are ever prescribed the same medicine again

    You can use the following log form to write down important information, like the date and time you experienced a side effect and your symptoms, how strong the symptoms were, and any other medicines you were using.

    Medicine Name and Dosage:

    Other Medicine(s) or Treatment(s)

    Scale: 1 = very mild to 10 = very bad

    Side effects reports are analyzed to discover potential health product safety signals. Some important reactions may take an extremely long time to develop or occur infrequently. Continued monitoring of adverse reactions is thus essential to maintain a comprehensive safety and effectiveness profile of health products.

    You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.

    Epril reports list potential signals of serious risks and new safety information that were identified using the FDA Adverse Event Reporting System (FAERS).
    FAERS is a database that contains information on adverse event and medication errors reports submitted to FDA by healthcare professionals (such as physicians, pharmacists, nurses and others), consumers (such as patients, family members, layers and others) and manufacturers.

    Discuss Epril Side Effects Did You Have a Epril Side Effect? View Results How Effective is Epril for You? View Results Epril Safety Alerts, Active Ingredients, Usage Information


    On market since

    Teva Pharmaceuticals USA Inc

    Angiotensin Converting Enzyme Inhibitor [EPC],Angiotensin-converting Enzyme Inhibitors [MoA],Decreas

    Side Effects reported to FDA: 1

    Epril safety alerts: No

    Reported hospitalizations: 1

    Epril Reviews

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  • Disease по Мальтийский - Английский-Мальтийский Словарь

    mt Għandu jsir eżami għal speċi ta

    en The harmful event referred to in Article ‧ of the Law of ‧ March ‧ making certain adjustments to military pensions and granting free medical care and prescriptions to servicemen invalided in peacetime shall constitute an accident at work or occupational disease within the meaning of Chapter ‧ of Title ‧ of the Regulation

    mt L-inċident dannuż imsemmi fl-Artikolu ‧ tal-Liġi tad-‧ ta

    en Aid to compensate farmers for the costs of prevention and eradication of animal or plant diseases or pest infestations incurred for the costs of health checks, tests and other screening measures, purchase and administration of vaccines, medicines and plant protection products, slaughter and destruction costs of animals and costs of destruction of crops is compatible with the internal market

    mt L-għajnuna li tingħata bħala kumpens għall-ispejjeż li l-bdiewa jġarrbu minħabba l-kontrolli tas-saħħa, t-testijiet u l-miżuri l-oħrajn għall-għarfien minn kmieni, ix-xiri u l-użu tat-tilqim, tal-mediċini u tal-prodotti tas-saħħa tal-pjanti, il-qtil u l-qerda tal-annimali kif ukoll il-qerda tal-uċuħ tar-raba’ b’rabta mal-evitar u mal-qerda tal-mard tal-annimali, tal-mard tal-pjanti u tal-impestazzjonijiet mill-annimali u l-insetti li jagħmlu l-ħsara, hija kompatibbli mas-suq intern

    en Concerning health claims referring to the reduction of disease risk, no transitional measure was needed

    mt Fir-rigward ta' indikazzjonijiet dwar is-saħħa li jirreferu għat-tnaqqis ta' riskju ta' mard, ma huma meħtieġa l-ebda miżuri tranżitorji

    en In advanced Parkinson s disease. doses higher than ‧ mg (‧ mg of salt) per day can be useful in patients where a reduction of the levodopa therapy is intended

    mt Fil-marda ta ’ Parkinson fl-istadju avvanzat, dożi ogħla minn ‧. ‧ mg (‧. ‧ mg ta ’ melħ) kuljum jistgħu jkunu utli f’ pazjenti fejn it-tnaqqis tat-terapija ta ’ levodopa jkun intenzjonat

    en This differentiation is important for disease surveillance and control

    mt Din id-differenzjazzjoni hija importanti għas-sorveljanza u l-kontroll tal-mard

    en for fish diseases. the Technical University of Denmark, National Veterinary Institute, Department of Poultry, Fish and Fur Animals, Hangøvej ‧, ‧ Århus, Denmark

    mt Għall-mard tal-ħut: it-Technical University of Denmark, National Veterinary Institute, Department of Poultry, Fish and Fur Animals, Hangøvej ‧, ‧ Århus, id-Danimarka

    en The OIE is planning an International Conference on foot and mouth disease

    mt L-OIE qed tippjana Konferenza Internazzjonali dwar il-marda tal-ilsien u d-dwiefer

    en The late-onset form of Pompe disease manifests during infancy, childhood, adolescence or even adulthood and is much less rapidly progressive than the infantile-onset form

    mt Il-forma tal-marda ta ’ Pompe li tibda aktar tard fil-ħajja tkun osservata matul l-infanzja, it-tfulija, l-adolexxenza jew meta persuna ssir adulta, u hi ħafna inqas progressiva b’ mod mgħaġġel mill-forma tal-marda li tibda fl-infanzja

    en The medicine is used to help in the diagnosis of: movement disorders such as those seen in Parkinson s disease and other related diseases. where a loss of striatal nerve cells in the brain leads to tremor (shaking), gait disturbance and stiffness of muscles

    mt Il-mediċina tintuża biex tgħin fid-dijanjożi ta ’: • Problemi tal-moviment bħal dawk li jseħħu fil-marda ta ’ Parkinson u f’ mard ieħor relatat, fejn ikun hemm rogħda, tfixkil fil-mixi u għebusija tal-muskoli minħabba telfien fiċ-ċelloli tan-nervituri fl-istriatum tal-moħħ

    en If a holding located in a region not subject to restrictions within the meaning of this Directive has one or more animals suspected of being infected with bluetongue, Member States shall ensure that the official veterinarian immediately implements official methods of investigation to confirm or rule out the presence of the disease

    mt Jekk azjenda li tkun f’reġjun li ma jkunx suġġett għar-restrizzjonijiet skond is-sens ta’ din id-Direttiva jkollha annimal wieħed jew aktar suspettati li jkunu infettati bil-bluetongue, l-Istati Membri għandhom jiżguraw li l-veterinarju uffiċjali jimplimenta minnufih il-metodi uffiċjali għall-investigazzjoni tal-konferma jew iċ-ċaħda tal-preżenza tal-marda

    en Instructs its President to forward this Decision and the resolution that forms an integral part of it to the Director of the European Centre for Disease Prevention and Control, the Council, the Commission and the Court of Auditors, and to arrange for their publication in the Official Journal of the European Union (L series

    mt Jagħti istruzzjonijiet lill-President tiegħu biex jgħaddi din id-Deċiżjoni u r-riżoluzzjoni li hi parti integrali minnha lid-Direttur taċ-Ċentru Ewropew għall-Prevenzjoni u l-Kontroll tal-Mard, lill-Kunsill, lill-Kummissjoni u lill-Qorti tal-Awdituri, u biex jiżgura li tiġi ppubblikata f'Il-Ġurnal Uffiċjali tal-Unjoni Ewropea (serje L

    Emerging Infectious Diseases journal

    Emerging Infectious Diseases journal

    Country-wide planning and coordination can improve sustainability of vectorborne disease control.

    Arthropod vectors transmit organisms that cause many emerging and reemerging diseases, and their control is reliant mainly on the use of chemical insecticides. Only a few classes of insecticides are available for public health use, and the increased spread of insecticide resistance is a major threat to sustainable disease control. The primary strategy for mitigating the detrimental effects of insecticide resistance is the development of an insecticide resistance management plan. However, few examples exist to show how to implement such plans programmatically. We describe the formulation and implementation of a resistance management plan for mosquito vectors of human disease in Zambia. We also discuss challenges, steps taken to address the challenges, and directions for the future.


    K. L. Herrick et al.

    The likely vector was Amblyomma triste. a Neotropical tick species only recently recognized in the United States.

    In the United States, all previously reported cases of Rickettsia parkeri rickettsiosis have been linked to transmission by the Gulf Coast tick (Amblyomma maculatum ). Here we describe 1 confirmed and 1 probable case of R. parkeri rickettsiosis acquired in a mountainous region of southern Arizona, well beyond the recognized geographic range of A. maculatum ticks. The likely vector for these 2 infections was identified as the Amblyomma triste tick, a Neotropical species only recently recognized in the United States. Identification of R. parkeri rickettsiosis in southern Arizona demonstrates a need for local ecologic and epidemiologic assessments to better understand geographic distribution and define public health risk. Education and outreach aimed at persons recreating or working in this region of southern Arizona would improve awareness and promote prevention of tickborne rickettsioses.

    • Plasmodium falciparum K76T pfcrt Gene Mutations and Parasite Population Structure, Haiti, 2006–2009 PDF Version [PDF - 714 KB - 8 pages]

    M. Charles et al.

    Low genetic diversity and low levels of chloroquine resistance among parasites suggest exogenous origin of reported cases.

    Hispaniola is the only Caribbean island to which Plasmodium falciparum malaria remains endemic. Resistance to the antimalarial drug chloroquine has rarely been reported in Haiti, which is located on Hispaniola, but the K76T pfcrt (P. falciparum chloroquine resistance transporter) gene mutation that confers chloroquine resistance has been detected intermittently. We analyzed 901 patient samples collected during 2006–2009 and found 2 samples showed possible mixed parasite infections of genetically chloroquine-resistant and -sensitive parasites. Direct sequencing of the pfcrt resistance locus and single-nucleotide polymorphism barcoding did not definitively identify a resistant population, suggesting that sustained propagation of chloroquine-resistant parasites was not occurring in Haiti during the study period. Comparison of parasites from Haiti with those from Colombia, Panama, and Venezuela reveals a geographically distinct population with highly related parasites. Our findings indicate low genetic diversity in the parasite population and low levels of chloroquine resistance in Haiti, raising the possibility that reported cases may be of exogenous origin.

    D. L. Hastings et al.

    Infection probably was transmitted in the emergency department, inpatient areas, and dialysis unit.

    During March–May 2014, a Middle East respiratory syndrome (MERS) outbreak occurred in Jeddah, Saudi Arabia, that included many persons who worked or received medical treatment at King Fahd General Hospital. We investigated 78 persons who had laboratory-confirmed MERS during March 2–May 10 and documented contact at this hospital. The 78 persons with MERS comprised 53 patients, 16 healthcare workers, and 9 visitors. Among the 53 patients, the most probable sites of acquisition were the emergency department (22 patients), inpatient areas (17), dialysis unit (11), and outpatient areas (3). Infection control deficiencies included limited separation of suspected MERS patients, patient crowding, and inconsistent use of infection control precautions; aggressive improvements in these deficiencies preceded a decline in cases. MERS coronavirus transmission probably was multifocal, occurring in multiple hospital settings. Continued vigilance and strict application of infection control precautions are necessary to prevent future MERS outbreaks.

  • Expansion of Shiga Toxin–Producing Escherichia coli by Use of Bovine Antibiotic Growth Promoters PDF Version [PDF - 738 KB - 8 pages]

    These growth promoters facilitate transfer of Shiga toxin–encoding phages in E. coli .

    Antibiotics are routinely used in food-producing animals to promote growth and prevent infectious diseases. We investigated the effects of bovine antibiotic growth promoters (bAGPs) on the propagation and spread of Shiga toxin (Stx)–encoding phages in Escherichia coli. Co-culture of E. coli O157:H7 and other E. coli isolated from cattle in the presence of sublethal concentrations of bAGPs significantly increased the emergence of non-O157, Stx-producing E. coli by triggering the SOS response system in E. coli O157:H7. The most substantial mediation of Stx phage transmission was induced by oxytetracyline and chlortetracycline, which are commonly used in agriculture. bAGPs may therefore contribute to the expansion of pathogenic Stx-producing E. coli .

    N. Putkuri et al.

    Most cases appeared to be subclinical, but a few patients, usually children, required hospitalization.

    Inkoo virus (INKV) and Chatanga virus (CHATV), which are circulating in Finland, are mosquitoborne California serogroup orthobunyaviruses that have a high seroprevalence among humans. Worldwide, INKV infection has been poorly described, and CHATV infection has been unknown. Using serum samples collected in Finland from 7,961 patients suspected of having viral neurologic disease or Puumala virus infection during the summers of 2001–2013, we analyzed the samples to detect California serogroup infections. IgM seropositivity revealed 17 acute infections, and cross-neutralization tests confirmed presence of INKV or CHATV infections. All children ( < 16 years of age) with INKV infection were hospitalized; adults were outpatients with mild disease, except for 1 who was hospitalized with CHATV infection. Symptoms included fever, influenza-like illness, nausea or vomiting, disorientation, nuchal rigidity, headache, drowsiness, and seizures. Although many INKV and CHATV infections appear to be subclinical, these viruses can cause more severe disease, especially in children.

  • Differences in Genotype, Clinical Features, and Inflammatory Potential of Borrelia burgdorferi sensu stricto Strains from Europe and the United States PDF Version [PDF - 806 KB - 10 pages]

    Strains from the United States are more virulent and have greater inflammatory potential.

    Borrelia burgdorferi sensu stricto isolates from patients with erythema migrans in Europe and the United States were compared by genotype, clinical features of infection, and inflammatory potential. Analysis of outer surface protein C and multilocus sequence typing showed that strains from these 2 regions represent distinct genotypes. Clinical features of infection with B. burgdorferi in Slovenia were similar to infection with B. afzelii or B. garinii. the other 2 Borrelia spp. that cause disease in Europe, whereas B. burgdorferi strains from the United States were associated with more severe disease. Moreover, B. burgdorferi strains from the United States induced peripheral blood mononuclear cells to secrete higher levels of cytokines and chemokines associated with innate and Th1-adaptive immune responses, whereas strains from Europe induced greater Th17-associated responses. Thus, strains of the same B. burgdorferi species from Europe and the United States represent distinct clonal lineages that vary in virulence and inflammatory potential.

    J. Reefhuis et al.

    A modifiable spreadsheet tool will enable health officials to plan for these births.

    The marked increase in infants born with microcephaly in Brazil after a 2015 outbreak of Zika virus (Zika virus) disease suggests an association between maternal Zika virus infection and congenital microcephaly. To project the timing of delivery of infants born to mothers infected during early pregnancy in 1 city in Bahia State, Brazil, we incorporated data on reported Zika virus disease cases and microcephaly cases into a graphical schematic of weekly birth cohorts. We projected that these births would occur through February 2016. Applying similar projections to a hypothetical location at which Zika virus transmission started in November, we projected that full-term infants at risk for Zika virus infection would be born during April–September 2016. We also developed a modifiable spreadsheet tool that public health officials and researchers can use for their countries to plan for deliveries of infants to women who were infected with Zika virus during different pregnancy trimesters.

    Genetic relationships between bunyaviruses from Australia and pathogenic bunyaviruses from elsewhere indicate emergence potential.

    To better understand the diversity of bunyaviruses and their circulation in Australia, we sequenced 5 viruses (Gan Gan, Trubanaman, Kowanyama, Yacaaba, and Taggert) isolated and serologically identified 4 decades ago as members of the family Bunyaviridae. Gan Gan and Trubanaman viruses almost perfectly matched 2 recently isolated, purportedly novel viruses, Salt Ash and Murrumbidgee viruses, respectively. Kowanyama and Yacaaba viruses were identified as being related to members of a large clade containing pathogenic viruses. Taggert virus was confirmed as being a nairovirus; several viruses of this genus are pathogenic to humans. The genetic relationships and historical experimental infections in mice reveal the potential for these viruses to lead to disease emergence.

  • Plasmodium falciparum In Vitro Resistance to Monodesethylamodiaquine, Dakar, Senegal, 2014 PDF Version [PDF - 342 KB - 5 pages]

    In vitro and in vivo surveillance of all artemisinin-based combination therapy partners is warranted.

    We successfully cultured 36 Plasmodium falciparum isolates from blood samples of 44 malaria patients admitted to the Hôpital Principal de Dakar (Dakar, Senegal) during August–December 2014. The prevalence of isolates with in vitro reduced susceptibility was 30.6% for monodesethylamodiaquine, 52.8% for chloroquine, 44.1% for mefloquine, 16.7% for doxycycline, 11.8% for piperaquine, 8.3% for artesunate, 5.9% for pyronaridine, 2.8% for quinine and dihydroartemisinin, and 0.0% for lumefantrine. The prevalence of isolates with reduced in vitro susceptibility to the artemisinin-based combination therapy partner monodesethylamodiaquine increased from 5.6% in 2013 to 30.6% in 2014. Because of the increased prevalence of P. falciparum parasites with impaired in vitro susceptibility to monodesethylamodiaquine, the implementation of in vitro and in vivo surveillance of all artemisinin-based combination therapy partners is warranted.

    This virus is an unrecognized cause of central nervous system infection, particularly among immunocompromised patients.

    Next-generation sequencing has identified novel astroviruses for which a pathogenic role is not clearly defined. We identified astrovirus MLB2 infection in an immunocompetent case-patient and an immunocompromised patient who experienced diverse clinical manifestations, notably, meningitis and disseminated infection. The initial case-patient was identified by next-generation sequencing, which revealed astrovirus MLB2 RNA in cerebrospinal fluid, plasma, urine, and anal swab specimens. We then used specific real-time reverse transcription PCR to screen 943 fecal and 424 cerebrospinal fluid samples from hospitalized patients and identified a second case of meningitis, with positive results for the agent in the patient’s feces and plasma. This screening revealed 5 additional positive fecal samples: 1 from an infant with acute diarrhea and 4 from children who had received transplants. Our findings demonstrate that astrovirus MLB2, which is highly prevalent in feces, can disseminate outside the digestive tract and is an unrecognized cause of central nervous system infection.

    R. Kariyawasam et al.

    Over a 2-year period, common and emerging viruses were documented in >20% of these travelers.

  • Expanded Geographic Distribution and Clinical Characteristics of Ehrlichia ewingii Infections, United States PDF Version [PDF - 352 KB - 4 pages]

    R. M. Harris et al.

    This bacterium should be considered as an etiologic agent of tickborne illness that might be missed by serologic testing.

    Ehrlichiosis is a bacterial zoonosis, spread through the bites of infected ticks, that is most commonly caused in the United States by infection with the bacterium Ehrlichia chaffeensis. We retrospectively reviewed samples from an 18-month study of ehrlichiosis in the United States and found that E. ewingii was present in 10 (9.2%) of 109 case-patients with ehrlichiosis, a higher rate of infection with this species than had previously been reported. Two patients resided in New Jersey and Indiana, where cases have not been reported. All patients with available case histories recovered. Our study suggests a higher prevalence and wider geographic distribution of E. ewingii in the United States than previous reports have indicated.


    We genetically characterized 32 canine rabies viruses isolated in Mali during 2006–2013 and identified 3 subgroups that belonged to the Africa 2 lineage. We also detected subgroup F rabies virus. This information should be useful for development of mass vaccination campaigns for dogs and eventual large-scale control programs in this country.

    C. G. Sosa-Gutierrez et al.

    Human monocytic ehrlichiosis is a febrile illness caused by Ehrlichia chaffeensis. an intracellular bacterium transmitted by ticks. In Mexico, a case of E. chaffeensis infection in an immunocompetent 31-year-old woman without recognized tick bite was fatal. This diagnosis should be considered for patients with fever, leukopenia, thrombocytopenia, and elevated liver enzyme levels.

    F. K. Jones et al.

    Flooding on 1 of the Solomon Islands precipitated a nationwide epidemic of diarrhea that spread to regions unaffected by flooding and caused >6,000 cases and 27 deaths. Rotavirus was identified in 38% of case-patients tested in the city with the most flooding. Outbreak potential related to weather reinforces the need for global rotavirus vaccination.

    E. Angelakis et al.

    To further characterize human infections caused by Rickettsia sibirica mongolitimonae. we tested skin biopsy and swab samples and analyzed clinical, epidemiologic, and diagnostic characteristics of patients with a rickettsiosis. The most common (38%) indigenous species was R. sibirica mongolitimonae. Significantly more cases of R. sibirica mongolitimonae infection occurred during spring and summer.

    A. N. Maina et al.

    To increase knowledge of undifferentiated fevers in Kenya, we tested paired serum samples from febrile children in western Kenya for antibodies against pathogens increasingly recognized to cause febrile illness in Africa. Of patients assessed, 8.9%, 22.4%, 1.1%, and 3.6% had enhanced seroreactivity to Coxiella burnetii. spotted fever group rickettsiae, typhus group rickettsiae, and scrub typhus group orientiae, respectively.

    During 2011–2013, a nationwide outbreak of chikungunya virus infection occurred in the Philippines. The Asian genotype was identified as the predominant genotype; sporadic cases of the East/Central/South African genotype were detected in Mindanao. Further monitoring is needed to define the transmission pattern of this virus in the Philippines.

    During a 2014 outbreak, 450 patients with confirmed chikungunya virus infection were admitted to the University Hospital of Pointe-à-Pitre, Guadeloupe. Of these, 110 were nonpregnant adults; 42 had severe disease, and of those, 25 had severe sepsis or septic shock and 12 died. Severe sepsis may be a rare complication of chikungunya virus infection.

    We investigated a dengue outbreak in Dar es Salaam, Tanzania, in 2014, that was caused by dengue virus (DENV) serotype 2. DENV infection was present in 101 (20.9%) of 483 patients. Patient age and location of residence were associated with infection. Seven (4.0%) of 176 patients were co-infected with malaria and DENV.

    R. Nielsen et al.

    We describe 2 fatal cases of methicillin-resistant Staphylococcus aureus (MRSA) clonal complex 398 septicemia in persons who had no contact with livestock. Whole-genome sequencing of the isolated MRSA strains strongly suggest that both were of animal origin and that the patients had been infected through 2 independent person-to-person transmission chains.

    V. Pommier de Santi et al.

    To assess the prevalence of malaria among illegal gold miners in the French Guiana rainforest, we screened 205 miners during May–June 2014. Malaria prevalence was 48.3%; 48.5% of cases were asymptomatic. Patients reported self-medication with artemisinin-based combination therapy. Risk for emergence and spread of artemisinin resistance among gold miners in the rainforest is high.

    We identified a 41.4% prevalence of hepatitis C virus, absence of HIV, and unexpectedly high frequency of hepatitis C virus genotype 3 among suburban New Jersey heroin users 17–35 years of age during 2014–2015. Despite 2 clinicians prepared to engage these users, few were successfully linked to care and treated.

  • ODIN-23 Dogwood Diseases

    Dogwood Diseases
    L. F. Grand, Plant Pathologist
    C. S. Hodges, Professor Emeritus
    R. K. Jones, Professor Emeritus

    Flowering dogwood (Cornus florida ) is widely planted in home and commercial
    landscapes across North Carolina. Although popular for its early season display of flowers, and for its bright red berries in the fall, this plant is susceptible to a large number of diseases that vary in severity from those that merely disfigure the flowers and foliage to those than can kill the tree. This publication describes the most common diseases of dogwood, factors influencing their infection and spread, and where known, means of control.

    Dogwood anthracnose, caused by the fungus Discula destructiva. was first reported in New York and Pennsylvania in the late 1970's. Since that time it slowly moved south along the Appalachian Mountains through Maryland, West Virginia and Virginia, and reached western North Carolina in 1987. Currently the disease is found in all counties to the west of, and including, Rockingham, Wilkes, Alexander, Burke and Cleveland.

    Initial symptoms are small purple-bordered leaf spots or larger tan blotches, especially on leaf margins. These initial symptoms can be confused with leaf spots caused by Elsinoe corni and Septoria cornicola. or other foliage diseases. Blighted leaves do not abscise in the fall and frequently remain on the twigs until spring. The fungus can spread to the twigs and, in some cases, to the trunk, causing brown, elliptical, annual cankers. Epicormic branches may develop on the trunk and larger branches, and also may become infected. Multiple cankers can girdle branches or the trunk, and may result in the death of the tree. The disease is most severe in cool moist forested areas above 1800 feet elevation. It is less of a problem in the landscape than in the forest.

    The fungus produces masses of spores (conidia) on infected leaves or bark and presumably spreads by splashing rain and possibly by birds. Disease spread and development are favored by cool, moist weather.

    Control is centered around cultural practices and fungicidal sprays. Maintenance of healthy, vigorous dogwoods is recommended (see section on planting and cultural practices at end of note). Pruning and disposal of diseased twigs and branches, removing epicormic branches that develop on the trunk, and raking and disposal of leaves may be of some value. Pruning low branches on taller trees and thinning other understory plants to improve air movement may also help.

    Fungicides should be used as a supplement to the cultural control program at elevations above 3000 feet; or below 3000 feet elevation if the plants occur in full shade on north-facing, moist slopes. Chlorothalonil (Daconil 2787), mancozeb + thiophanate methyl (Cleary's 3336 or Domain) or propiconazole (Banner) will protect against leaf infections. Apply 3 or 4 sprays during leaf expansion in the spring at 10-14 day intervals. Additional fungicide applications may be necessary later in the growing season if weather conditions are favorable for infection.

    Leaf and Flower Diseases

    Spot anthracnose, caused by Elsinoe corni. affects the flower bracts (petals), leaves and young shoots. The most conspicuous symptoms are small (1/25 to 1/16 inch in diameter), circular to elongate reddish-purple spots on the bracts in early spring. The spots may become numerous and merge, losing the distinctive characteristics of individual spots. Severely infected bracts may be stunted and disfigured and fall prematurely.

    Spots on leaves are very small and dark purple in color, but the centers may turn pale yellow-gray and drop out. Heavily infected leaves are smaller than normal, distorted and often killed. Infected young shoots and berries develop elongated, scabby lesions with a purplish margin. The causal fungus produces spores on the lesions, and overwinters on infected twigs and fruit.

    Ascochyta blight, caused by Ascochyta cornicola. usually appears in June after a wet spring. The disease is characterized by round to irregular spots that have a gray-to-tan center and a dark border. If several of these spots develop on a leaf, the entire leaf may suddenly collapse, shrivel and turn black.

    Septoria Leaf Spot

    Septoria leaf spot, caused by Septoria cornicola. usually does not become severe until mid to late summer, but this may vary depending on spring weather conditions. The spots are angular and are bordered by veins. At first, they are a uniform, purplish color, but later in the season the centers become grayish, while keeping the dark purple border. The centers rarely drop out. The spots are much larger than those caused by spot anthracnose.

    Powdery Mildew
    Powdery mildew, caused by Microsphaera pennicillata. produces a whitish growth over leaves, buds and young shoots. Young plants and actively growing plant tissues are more severely damaged than older plants or tissues. Infected leaves may be dwarfed, curled, or otherwise deformed. The disease may occur throughout the growing season.

    An effective spray schedule to control of leaf and flower diseases must start before disease appears, usually when the flower buds are beginning to open. A second spray should be made when the leaves are unfolding, a third spray about the last week in July, and a fourth before leaf drop in the fall. Full coverage of the plant is necessary. Fungicides containing azoxystrobin (Heritage), propiconazole (Banner), and myclobutanil (Systhane, Eagle, Immunox) are effective in controlling all the leaf and flower diseases. Fungicides containing mancozeb (Dithane, Fore, Mancozeb DG and Protect) will control spot anthracnose and septoria leaf spot. Spraying may not be necessary unless leaf or flower diseases were a problem the previous year. However, newly planted trees should be protected by fungicides until they are well established in the landscape.

    Crown canker, caused by Phytophthora cactorum. is characterized by a slowly developing canker on the main trunk near the soil line. The disease usually occurs on newly transplanted trees or those that have injuries to the roots, and is more common on poorly drained areas. Cankers appear as constricted or sunken areas that may eventually girdle the stem and kill the top of the tree. Leaves on diseased trees may be smaller than normal, become chlorotic and be shed prematurely. Trees with cankers often produce numerous sprouts at or below the soil line. Treatment with metalaxyl (Subdue 2E, Subdue 2G) at 2-3-month intervals will prevent the disease.

    This disease, of unknown cause, results in the production of cankers on the main trunk and larger branches. Cankers may be of two types; a) sunken areas in the bark that may girdle the trunk and result in the death of the tree above the canker, or b) swollen areas with roughened bark on the trunk or main branches. These roughened areas are often invaded by insects. Trees with cankers often produce sprouts from the base of the tree. No control measures are known. Only canker-free plants should be purchased.

    Phytophthora root rot causing defoliation and dieback.

    Dogwoods are susceptible to several root and crown rot fungi. These fungi may be present in the soil and attack the roots when the vigor of the tree is reduced by unfavorable soil conditions or by some type of injury. Often the first symptom observed is the drying of the leaf margins followed by death of the plant during the summer months. This is the final stage of a disease that began with an infection of one or more of the lateral roots. After infecting a part of the root system, the fungus spreads along the roots to the basal portion of the tree, which is often girdled. As the fungus progresses, the tree may show symptoms of decline, such as yellowing of the foliage, dying of the leaf margins, branch dieback, and a general unthriftiness. One of the most common root rots on dogwood is caused by Armillaria sp. This disease is characterized by a relatively thick, white, fan-shaped mass of fungal tissue (mycelium) beneath the bark at the base of the tree or on large roots, and by black, shoestring-like structures (rhizomorphs) that can be found on or under the bark and in the adjacent soil. Another root rot, caused by Phytophthora cinnamomi. usually affects the smaller roots and occurs most commonly in poorly drained soils. This disease can be diagnosed only by laboratory tests.

    To prevent root rot, plant only in well-drained soils where root rot has not been known to occur, preferably away from areas where large trees have been removed. Fertilize and water during dry periods and control foliage diseases to maintain the vigor of the tree. By the time a general decline of the tree is observed, it is too late to save it. Remove the tree and all roots possible from the soil, since the fungi can persist in dead roots and infect nearby shrubs or other plants set in the same site.

    Other Dogwood Problems

    The poor appearance of dogwood trees is often due to factors or conditions other than diseases, with symptoms the same as might be expected with a damaged or inefficient root system. These include stunting or slow growth, light green to yellow foliage, dead leaf margins, dieback of branches or even death of the plant. Marginal leaf burn and premature reddening of the leaves are common symptoms on dogwoods during the summer months when rainfall is below normal. Any situation in which the leaves are losing water faster than the plant can take it up can result in these types of symptoms.

    Proper planting and maintenance are the best way to avoid these problems. Some of the most important factors to consider are presented below:

    Know the diseases and other problems commonly affecting dogwood.

    Select healthy trees to plant. Avoid purchasing or moving diseased plants from one area to another. Purchase trees from a reputable, inspected nursery. Avoid transplanting trees from the "wild", especially from mountainous areas.

    Select good planting sites to promote vigor and rapid drying of foliage. Avoid sites where prolonged high moisture situations prevail.

    Use proper planting techniques. Dogwoods grow best in a soil high in organic matter. Prepare a hole about 18 inches deep and 3 feet in diameter, and fill it with a mixture containing one-third organic matter and two-thirds soil. Organic matter, such as leaf mold or pine bark, is especially important in heavy clay soils. Set the tree at the same soil level as in the container.

    Use a maximum of 3-4 inch deep mulch in an approximate 3-foot radius around established trees, ensuring that mulch does not contact the trunk. Avoid using dogwood chips and leaves as mulch, since they may harbor disease organisms.

    Prune and completely remove dead wood and leaves yearly. Avoid flush cuts! Prune out and destroy epicormic growth (trunk or water sprouts) in late summer.

    Water weekly in the morning during dry periods. Caution: Do not wet foliage.

    Fertilize according to need based on soil analysis. Do not overfertilize!

    Use proper insecticides/fungicides where and when appropriate and legal. Consult extension personnel for currently labeled pesticides.

    Avoid mechanical and chemical injuries to trees, especially lawnmower and string-trimmer wounds to the tree base. These can provide entry for pathogenic fungi. Also manage any insect pest that is potentially damaging.

    For assistance with a specific problem, contact your local North Carolina Cooperative Extension Service

    Recommendations of specific chemicals are based upon information on the manufacturer's label and performance in a limited number of trials. Because environmental conditions and methods of application by growers may vary widely, performance of the chemical will not always conform to the safety and pest control standards indicated by experimental data. All recommendations for pesticide use were legal at the time of publication, but the status of registration and use patterns are subject to change by actions of state and federal regulatory agencies. Last printed 04/91

    Published by North Carolina Cooperative Extension Service
    Distributed in furtherance of the Acts of Congress of May 8 and June 30, 1914. Employment and program opportunities are offered to all people regardless of race, color, national origin, sex, age, or disability. North Carolina State University at Raleigh, North Carolina A&T State University, U.S. Department of Agriculture, and local governments cooperating.

    Vasotec (Epril) Delivery

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