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Store unopened vials in the original packaging, which facilitates inventory management and rotation of vaccine by expira tion date. Review vaccine time and temperature indicators, both chemical and electronic, if included in the vaccine shipment. Store suspect vaccine under proper conditions and label it “Do Not Use” until the viability has been determined. A minimum-maximum thermometer is preferred to record extremes in temperature fuctuation and reset to baseline. The refrigerator temperature should be maintained between 2°C and 8°C (35°F and 46°F) with a target temperature of 40°F, and the freezer temperature should be –15°C (5°F) or colder. A “Do Not Unplug” sign should be affxed directly next to the refrigerator electrical outlet. Predrawing vaccine increases the possibility of medication errors and causes uncertainty of vaccine stability. All reconstituted vaccines should be refrigerated during the interval in which they may be used. Offce personnel should have a written and easily accessible procedure that outlines vaccine packing and transport. Vaccines that have been exposed to temperatures outside the recommended storage range may be ineffective. Vaccines should be packed in an appropriate insulated storage box and moved to a location where the appropriate storage temperatures can be maintained. Offce personnel need to be aware of alternate storage sites and trained in the correct techniques to store and transport vaccines to avoid warming vaccines that need to be refrigerated or frozen and to avoid freezing vaccines that should be refrigerated. After a power outage or mechanical failure, do not assume that vaccine exposed to temperature outside the recommended range is unusable. Gloves are not required when administering vaccines unless the health care professional has open hand lesions or will come into contact with poten tially infectious body fuids. To pre vent inadvertent needlesticks or reuse, a needle should not be recapped after use, and disposable needles and syringes should be discarded promptly in puncture-proof, labeled containers placed in the room where the vaccine is administered. Changing needles between drawing a vaccine into a syringe and injecting it into the child is not necessary. Different vaccines should not be mixed in the same syringe unless specifcally licensed and labeled for such use. Because of the rare possibility of a severe allergic reaction to a vaccine component, people administering vaccines or other biologic products should be prepared to recognize and treat allergic reactions, including anaphylaxis (see Hypersensitivity Reactions After Immunization, p 51). Facilities and personnel should be available for treating immediate allergic reactions. This recommendation does not preclude administration of vaccines in school-based or other nonclinic settings. Syncope may occur following any immunization, particularly in adolescents and young adults.

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Call your healthcare provider or get emergency medical care if you get any of the following symptoms of a serious allergic reaction: o rash o swelling of your face, mouth, and tongue o hives o breathing problems. Symptoms of acute narrow-angle glaucoma may include: o eye pain or discomfort o nausea or vomiting o blurred vision o seeing halos or bright colors around lights o red eyes If you have these symptoms, call your healthcare provider right away before taking another dose. Medicines are sometimes prescribed for purposes not mentioned in a Patient Information leaflet. If you would like more information, talk with your healthcare provider or pharmacist. The lost dose will be held in the inhaler, but it will no longer be available to be inhaled. It is not possible to accidentally take a double dose or an extra dose in 1 inhalation. To avoid wasting doses after the inhaler is ready, do not close the cover until after you have inhaled the medicine. Figure C Prepare your dose: Wait to open the cover until you are ready to take your dose. Remove the inhaler from your mouth and hold your breath for about 3 to 4 seconds (or as long as comfortable for you). Michael Neary, Extension Small Ruminant Specialist, Purdue University Terry Hutchens, Extension Goat Specialist, Univ. Patty Scharko, Extension Veterinarian, University of Kentucky A sound management program to keep animals Animals should exhibit a healthy hair coat or feece, healthy is basic to production of both sheep and while maintaining a body condition score appropriate goats. Both coat and body condition keep individual animals and the whole herd or fock score are good indications of nutritional adequacy and healthy and productive. Signs of an unhealthy animal include compromised, that operation will not be as effcient as isolation from the rest of the herd/fock, abnormal possible. A biosecurity plan must take into account While there are some important differences between all modes of transmission, including direct animal the species, this publication gives a broad overview of contact within a herd, contact with wild animals or diseases and health problems. For further information other domesticated species, airborne transmission, on specifc diseases, references and sources of contaminated feed or water, and visitors or vehicles additional information are available at the end of this that come onto the farm. The most basic method of disease control in individual herds/focks is to avoid introduction of Evaluating Animal Health Status disease agents. If possible and practical, producers To recognize clinical signs of diseases common to should keep a closed herd/fock. Most diseases of sheep and goats, it is important to be familiar with a contagious nature are introduced into operations what is normal. Disease agents can fock’s general health on a regular basis, including be introduced when breeding animals are added vital signs, body condition, and coat. The respiration rate for closed herd/fock is not feasible, then use an animal sheep and goats is about 12 to 15 breaths per minute quarantine program.

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Studies indicate that subtle hormonal abnormalities do exist in women 153, 154 with unexplained infertility. These changes (elevated gonadotropins and estradiol in the follicular phase and decreased luteal phase progesterone) have been 154 attributed to a reduction in ovarian reserve as usually seen in older women. In andomized, controlled clinical trials, the monthly pregnancy rates in couples with unexplained infertility is increased 2–3-fold (a monthly fecundity rate of 9%) with 156, 157 and 158 clomiphene treatment, and with human gonadotropins, the monthly fecundity rate is approximately 10–15%. Although some studies have failed to yield 137, 159 increased pregnancy rates with the empiric use of clomiphene, we believe couples with unexplained infertility should be offered superovulation or one of the assisted reproductive technologies. As with almost all infertility, success is age-related, with pregnancy rates 3–4-fold greater 160 in women under age 20. Thus, there exist a number of options for the empiric treatment of unexplained infertility before considering the more complex and costly assisted reproductive technologies (Chapter 31). These options and the timing of their use should always be considered in the context of the known spontaneous cure rate for unexplained infertility. Approximately 60% of couples with unexplained infertility of less than 3 years duration will become pregnant within 3 years of expectant management. For older women, decreasing the time to achieve a pregnancy is an important objective. In a meta-analysis of methods used to treat unexplained infertility, pregnancy rates were estimated to be as follows: 169 Pregnancy Rate per Cycle No treatment 1. Patient demand for this treatment is substantial, and it is not unreasonable to respond to that demand with 3–4 clomiphene cycles. Once this baseline is surpassed, increasing the number of sperm inseminated does not increase the pregnancy rate; although one study achieved higher pregnancy rates with 172, 173 inseminations of greater than 10 million motile sperm. Once the percentage of normal forms exceeds 5–10%, there is no 174, 175 influence on success. In one series of 136 treatment cycles, no pregnancies were achieved in women who 176 were 43 or older. Adoption With proper assessment and therapy, the majority of couples evaluated for infertility will become pregnant. For those who are refractory to the usual treatments, consideration of assisted reproductive technologies or adoption is appropriate. Couples thinking about adoption have a range of choices including social agency adoptions, private adoptions, and international adoptions. In some states, private adoption is not legal; however, where it is legal, it can provide an effective, more rapid alternative to adoption through a social agency. In most cases the biologic mother has the opportunity to know the adopting parents, and this lack of anonymity may direct some individuals away from private adoption. In addition, there is a short time period during which the biologic mother can reclaim the baby. In our experience, this devastating event occurs in approximately 5% of private adoptions. To facilitate private adoption, patients should be encouraged to “spread the word” that they are interested in adoption.

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Because of this capacity for autoinfection, people can remain infected for decades after leaving a geographic area with endemic infection. At least 3 consecutive stool specimens should be examined microscopically for character istic larvae (not eggs), but stool concentration techniques may be required to establish the diagnosis. The use of agar plate culture methods may have greater sensitivity than fecal microscopy, and examination of duodenal contents obtained using the string test (Entero Test), or a direct aspirate through a fexible endoscope also may demonstrate larvae. Eosinophilia (blood eosinophil count greater than 500/μL) is common in chronic infec tion but may be absent in hyperinfection syndrome. Serodiagnosis is sensitive and should be considered in all people with unexplained eosinophilia. Gram-negative bacillary meningitis is a common associated fnding in disseminated disease and carries a high mortality rate. Alternative agents include thiabendazole and albendazole, although both drugs are associated with lower cure rates (see Drugs for Parasitic Infections, p 848). Prolonged or repeated treatment may be necessary in people with hyperinfection and disseminated strongyloidiasis, and relapse can occur. Examination of stool for larvae and serum for antibod ies to S stercoralis is recommended in patients with unexplained eosinophilia, especially for those who are immunosuppressed or for whom administration of glucocorticoids is planned. If possible, patients should be treated for strongyloidiasis prior to initiation of immunosuppressive therapy. Intrauterine infection with Treponema pallidum can result in stillbirth, hydrops fetalis, or preterm birth or may be asymptomatic at birth. Infected infants can have hepatosplenomegaly, snuffes (copious nasal secretions), lymphadenopathy, mucocu taneous lesions, pneumonia, osteochondritis and pseudoparalysis, edema, rash, hemolytic anemia, or thrombocytopenia at birth or within the frst 4 to 8 weeks of age. Skin lesions or moist nasal secretions of congenital syphilis are highly infectious. However, organ isms rarely are found in lesions more than 24 hours after treatment has begun. Some consequences of intrauterine infection may not become apparent until many years after birth, such as interstitial kera titis (5–20 years of age), eighth cranial nerve deafness (10–40 years of age), Hutchinson teeth (peg-shaped, notched central incisors), anterior bowing of the shins, frontal boss ing, mulberry molars, saddle nose, rhagades (perioral fssures), and Clutton joints (sym metric, painless swelling of the knees). The primary stage appears as one or more painless indurated ulcers (chancres) of the skin or mucous membranes at the site of inoculation. Lesions most commonly appear on the genitalia but may appear elsewhere, depending on the sexual contact responsible for transmission (ie, oral). These lesions appear, on average, 3 weeks after exposure (10–90 days) and heal spontaneously in a few weeks. The secondary stage, beginning 1 to 2 months later, is characterized by rash, mucocutaneous lesions, and lymphadenopathy. The polymorphic maculopapular rash is generalized and typically includes the palms and soles. This stage also resolves spontaneously without treatment in approximately 3 to 12 weeks, leaving the infected person completely asymp tomatic. A variable latent period follows but sometimes is interrupted during the frst few years by recurrences of symptoms of secondary syphilis.