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By U. Campa. Central College. 2019.

I- The primary survey and resuscitation This part of management comprises a quick evaluation of the patient to detect immediately life threatening situations and institution of measures to correct them discount super viagra 160 mg with mastercard. In a trauma victim buy 160 mg super viagra mastercard, it may be compromised by the back fallen tongue buy generic super viagra online, broken tooth, vomitus, blood etc. If the air way is compromised, use suctioning, jaw trust, positioning, oropharyngeal tube or endotracheal tube to open it, taking care of the cervical spine. It may be compromised by pneumothorax, hemothorax or multiple rib fractures causing flail chest. Look for external hemorrhage and arrest it by pressure, bandaging or tourniquet if the other methods fail. Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound. E- Expose (undress) the patient fully for examination not to miss serious injuries. It includes the following aspects: A- Take History: The informant may be the injured patient, relatives, police or ambulance personnel. The history should include: • Time of injury, • Mechanism of injury, • Amount of bleeding, • Loss of consciousness, • Any intervention performed or drugs given should be asked for. C- Make necessary investigations such as hematocrite, cross-match, urinalysis, X-ray, ultrasound, etc. However, never send a patient with unstable vital signs for investigation or referral before resuscitation. These include poor condition and design of roads, traffic mix (sharing of road by vehicles of different speeds and pedestrians), poor condition of the vehicles and poor traffic rule enforcement. The incidence of this serious problem can be reduced by improving the public awareness and the quality of training given to the drivers and strict enforcement of traffic rules. Moreover, improving the design and quality of the roads and regular checkup of vehicle fitness would help alleviate the problem. In many developing countries like Ethiopia, the magnitude of the problem is big due to high distribution of firearms among civilians who have little or no knowledge on safe handling and usage. It is made worse by the presence of large number of land mines, which are remnants of repeated wars and conflicts in these poor nations. Generally, missile injuries may be caused by bullets from pistols, rifles, machine guns or fragments from exploded grenades and mines. The degree of injury sustained depends on the amount of energy transferred from the missile to the patient as formulated below. The extensive tissue injury with the high degree of contamination creates a perfect medium for life threatening infection to occur. Missile injuries are classified into: I- Low- velocity missile injuries • Comprise missiles fired from hand guns (<400m/s) • Injury is limited to the path of the bullet. All patients with missile injuries should receive broad spectrum antibiotics and tetanus prophylaxis. It is mostly seen in developing countries where there is overcrowding, poor housing designs and wide spread usage of open fire for cooking. Types of burns, according to the mechanism, include: • Flame burn • Scalding • Chemical burn • Electrical burn, etc. The severity of a burn injury is a function of the burn depth (degree) and the extent or percentage of the body surface that is burned. Determining the percentage of burn surface is important to calculate the amount of fluid requirement while determination of burn depth is important for burn wound management. Classification of Burn according to depth (degree) 1- First degree burn: It involves the epidermis only and manifests with erythema. The extent or percentage of burn is determined by the “rule of nine” in which the body surface is divided into eleven parts each constituting 9% of the total (fig. In children, the size of the hand may be used to estimate the burn surface, which is approximately 1%. Endotracheal intubation or tracheotomy may be needed in patients with burns involving the air way. Half of the calculated volume is given in the first 8 hours and the remaining half over the next 16 hours from the time of burn. The choice depends on the degree, size and site of the burn, and availability of facilities and expertise. Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk. Prevention of Infection: Burn patients have impaired resistance against infection. Prophylactic antibiotics (penicillin) are given for severe burns but, routine administration has no value. Nutrition: Naso-gastric tube should be inserted after admission for patients with more than 25% burn and those who have nausea and vomiting. Burn patients are in catabolic state and tend to lose weight very fast, thus special attention to their diet is important. Prophylaxis against tetanus: Tetanus prophylaxis should be supplemented as burn is potentially infected wound. Prevention of contractures and rehabilitation: Patients should constantly be urged and made to move all joints. Failure to do this results in contractures, which may be very disabling, unsightly and difficult to treat. Prevention The magnitude of burn injuries can be reduced by keeping the high risks, like children and epileptics, away from open fire or boiling pots and enforcing strict safety precautions in working places like factories etc. Investing in health research and development: Report of the ad-Hoc committee on health research relating to future intervention options. Craniocerebral trauma is consequently a source of major disability and huge financial and psychological burden. Trauma to the cranium can be either blunt or penetrating and involve the scalp, the skull or the brain. Scalp Injury Scalp lacerations are common and can result in severe hemorrhage if not controlled. Scalp lacerations can be sutured after ruling out possible associated skull or brain injuries. Skull Injury Different clinical forms of skull injury may follow trauma to the skull. These include: Simple Linear Fracture This is a line of fracture which usually marks of severe forces of injury. Depressed skull fracture This type of fracture is usually a result of blunt trauma.

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Lesion Number Total cardiopulmonary bypass 1 Partial left cardiac bypass * Atrio-aortic 6 * Atrio-arterial 1 * Aortic-arterial 1 30 30 Fig 160 mg super viagra free shipping. A 12-mm long rupture in the aortic wall (A) purchase discount super viagra on line, and 11x19 mm pseudoaneurysm located against the defect (B) are clearly illustrated best purchase for super viagra. It highlights the fact that certain entities with significant clinical implications are rare, and that the personal experience in managing these injuries are low among most Scandinavian surgeons. However, when a seriously injured patient is admitted to the emergency department, it is critical to quickly resuscitate the patient (141) and diagnose the full extent of all severe injuries (142, 143). The selection of priorities for the definite treatment of such injuries may tax the wisdom of even the most experienced surgeon, and may present a serious challenge to the less experienced ones. Pain is produced by the friction of one rib fragment against another at the site of fracture, stretching the periosteum with pain release. Reduction of the movement of a fractured rib reduces motion of the underlying lung parenchyma resulting in atelectasis that can lead to pneumonia and death. Chest wall defect which can produce an open pneumothorax, with collapse of the affected lung and impaired ventilation. Paradoxical motion described as flail chest is classically defined as two adjacent ribs fractured in two or more places. The external compression produced by the trauma forces the ribs inward enough to compress the lung and cause contusion. This underlying lung contusion plays a more important role in the pathophysiology of flail chest than does paradoxical movement (25). A simple etiological classification of extrapleural hematoma; spontaneous, iatrogenic and traumatic was presented (Table 2). Insertion of chest tubes is often ineffective and may be dangerous, especially if the pleural space is obliterated. This could be explained by the fact that clinical and laboratory findings of cardiac contusion are sometimes indistinguishable from those found in multiple injuries which were found in the majority of patients in this report (89. Cardiac contusion in this study probably was overshadowed by the overt manifestation of associated skeletal, abdominal, thoracic or cerebral injuries. The incidence of associated aortic rupture was nil in the cases with sternal fractures compared to one in the group of patients with chest trauma without sternal fractures. Postoperative pain was the salient complaint during follow-up visits, causing significant absence from work and even long-term disability (2/29). The retrosternal hematoma in patients with sternal fractures can be differentiated from real mediastinal widening using the features in Tables 3 and 35 35 4, which may aid in the management of sternal fractures and associated injuries. Sternal fractures with or without retrosternal hematomas in this study were not associated with cardiac or aortic injuries, while mediastinal widening is still a fairly reliable clue which should initiate further work-up. The majority of patients with penetrating lung trauma may be treated with chest tubes only (50, 112), while thoracotomy, if indicated, should be performed very soon after admission if it is to be an effective procedure (2, 50). Furthermore, acute thoracotomy is recommended for patients with penetrating chest trauma and in hemorrhagic shock, without evidence of cardiac, aortic, or major vessel injury (103). Chest physiotherapy and pain relief using intravenous analgesia, intercostal nerve blocks, intrapleural and epidural analgesia should be used as needed. Adequate and selective ventilatory support and frequent airway suction procedures to prevent pneumonia are important. This series differs from others (123) in that, the incidence of associated injuries in the chest was more severe and doubles the incidence of extrathoracic lesions. A similar observation has been reported from San Francisco (25) and showed that a higher morbidity and mortality included severe associated thoracic injuries. Patients who suffer pulmonary contusions are often victims of blunt trauma with multiple injuries (25, 56). The hospital mortality in patients with pulmonary contusion and extrathoracic lesions was 6/42 (19%) due to associated injuries, mostly central nervous system lesions (4/6). The nature of lung lesions (contusion with or without flail chest, lacerations, and lung hematomas) showed a tendency towards the group with extrathoracic lesions but this was not significant. Therefore, we consider the concomitant lung contusion in patients with chest trauma as a benign lesion. The diagnosis of penetrating cardiac injury should be considered in all patients with penetrating wound to the chest, neck or upper abdomen, with cardiovascular instability. Pericardial tamponade means the presence of bleeding into the pericardial sac, impairing heart function. These vital signs are cardinal in all patients with chest trauma and are usually documented, whether positive or negative. However, congested neck veins could be caused by tension pneumothorax and even in the presence of a cardiac tamponade this sign might be absent due to hypotension caused by bleeding from other injuries. Therefore, we have not relied just on muffled heart sound as a diagnostic criteria when it was the only sign found. When the patient presents with a weapon like a knife or any object penetrating the chest, this must not be disturbed since the object serves as a tamponade by sealing the cardiac wound (95, 144). This should be done only after making the appropriate incision, enabling the surgeon to perform the extraction under direct visual control. Aortic rupture is thought to occur either from traction or shear forces generated between relatively mobile portions of the vessel and points of fixation or, secondly, due to direct compression over the vertebral column or, thirdly, caused by an excessive increase of intraluminal pressure. However, our observations in patients with sternal fractures may make selection easier and avoid unnecessary angiograms (102). In a twenty-year meta-analysis study (136), the authors found only 1742 patients who reached the hospital alive. So it is useful in selected subacute patients particularly those patients subjected to delayed treatment. If treatment has to be delayed, patients are recommended to be kept on the lowest blood pressure that they can tolerate. Iatrogenic penetration of the descending thoracic aorta with a nail during a neurosurgical procedure was also reported in our material (104). However, no tracheobronchial injuries, air embolism or thoracic duct injuries have been detected in our series. Such a policy includes improvements in motor vehicle design, air bags and passive restraint devices which altogether have the greatest impact in reducing mortality (117). All penetrating injuries in this thesis were caused by different types of knives, and one would suggest and encourage the Swedish and Danish laws to mandate knife control legislation besides gun control legislation. The majority of trauma deaths take place in the prehospital phase, prior to initiation of resuscitation, and the only cure is to prevent them from occurring. Furthermore, the majority of surgeons - even those working with trauma - are not involved in injury prevention programs which are important for both the medical staff as well as the public (59). A thorough knowledge of trauma care (128, 129, 143), especially early recognition, rapid transport to hospital (20), aggressive resuscitation and expeditious surgical intervention are essential for successful management. Technology is also needed to improve the performance of chest protectors used in sports so as to decrease or prevent the incidence of cases with commotio cordis usually seen in young healthy athletes who die immediately on the scene (135).

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To treat patients with bone marrow transplants buy super viagra mastercard, it is first necessary to destroy the patient’s own diseased marrow through radiation and/or chemotherapy buy super viagra 160mg without prescription. As you can imagine discount super viagra 160 mg free shipping, they are quite small cells, with a mean diameter of only about 7–8 micrometers (µm) (Figure 18. The primary functions of erythrocytes are to pick up inhaled oxygen from the lungs and transport it to the body’s tissues, and to pick up some (about 24 percent) carbon dioxide waste at the tissues and transport it to the lungs for exhalation. Although leukocytes typically leave the blood vessels to perform their defensive functions, movement of erythrocytes from the blood vessels is abnormal. During the first day or two that it is in the circulation, an immature erythrocyte, known as a reticulocyte, will still typically contain remnants of organelles. These remnants, primarily of networks (reticulum) of ribosomes, are quickly shed, however, and mature, circulating erythrocytes have few internal cellular structural components. This means that they do not utilize any of the oxygen they are transporting, so they can deliver it all to the tissues. Erythrocytes do, however, contain some structural proteins that help the blood cells maintain their unique structure and enable them to change their shape to squeeze through capillaries. Erythrocytes are biconcave disks; that is, they are plump at their periphery and very thin in the center (Figure 18. Since they lack most organelles, there is more interior space for the presence of the hemoglobin molecules that, as you will see shortly, transport gases. The biconcave shape also provides a greater surface area across which gas exchange can occur, relative to its volume; a sphere of a similar diameter would have a lower surface area-to-volume ratio. In the capillaries, the oxygen carried by the erythrocytes can diffuse into the plasma and then through the capillary walls to reach the cells, whereas some of the carbon dioxide produced by the cells as a waste product diffuses into the capillaries to be picked up by the erythrocytes. Capillary beds are extremely narrow, slowing the passage of the erythrocytes and providing an extended opportunity for gas exchange to occur. However, the space within capillaries can be so minute that, despite their own small size, erythrocytes may have to fold in on themselves if they are to make their way through. Fortunately, their structural proteins like spectrin are flexible, allowing them to bend over themselves to a surprising degree, then spring back again when they enter a wider vessel. In wider vessels, erythrocytes may stack up much like a roll of coins, forming a rouleaux, from the French word for “roll. It consists of four folded chains of a protein called globin, designated alpha 1 and 2, and beta 1 and 2 (Figure 18. Each of these globin molecules is bound to a red pigment 794 Chapter 18 | The Cardiovascular System: Blood 2+ molecule called heme, which contains an ion of iron (Fe ) (Figure 18. Each iron ion in the heme can bind to one oxygen molecule; therefore, each hemoglobin molecule can transport four oxygen molecules. An individual erythrocyte may contain about 300 million hemoglobin molecules, and therefore can bind to and transport up to 1. The bright red, oxygenated hemoglobin travels to the body tissues, where it releases some of the oxygen molecules, becoming darker red deoxyhemoglobin, sometimes referred to as reduced hemoglobin. Oxygen release depends on the need for oxygen in the surrounding tissues, so hemoglobin rarely if ever leaves all of its oxygen behind. About 23–24 percent of it binds to the amino acids in hemoglobin, forming a molecule known as carbaminohemoglobin. From the capillaries, the hemoglobin carries carbon dioxide back to the lungs, where it releases it for exchange of oxygen. The primary drawback with polycythemia is not a failure to directly deliver enough oxygen to the tissues, but rather the increased viscosity of the blood, which makes it more difficult for the heart to circulate the blood. In patients with insufficient hemoglobin, the tissues may not receive sufficient oxygen, resulting in another form of anemia. In determining oxygenation of tissues, the value of greatest interest in healthcare is the percent saturation; that is, the percentage of hemoglobin sites occupied by oxygen in a patient’s blood. The device works by sending two different wavelengths of light (one red, the other infrared) through the finger and measuring the light with a photodetector as it exits. The machine calibrates the amount of light received by the photodetector against the amount absorbed by the partially oxygenated hemoglobin and presents the data as percent saturation. Oxygen levels are also directly monitored from free oxygen in the plasma typically following an arterial stick. When this method is applied, the amount of oxygen present is expressed in terms of partial pressure of oxygen or simply pO and is typically recorded in units of millimeters of2 mercury, mm Hg. The kidneys filter about 180 liters (~380 pints) of blood in an average adult each day, or about 20 percent of the total resting volume, and thus serve as ideal sites for receptors that determine oxygen saturation. In response to hypoxemia, less oxygen will exit the vessels supplying the kidney, resulting in hypoxia (low oxygen concentration) in the tissue fluid of This OpenStax book is available for free at http://cnx. Populations dwelling at high elevations, with inherently lower levels of oxygen in the atmosphere, naturally maintain a hematocrit higher than people living at sea level. Consequently, people traveling to high elevations may experience symptoms of hypoxemia, such as fatigue, headache, and shortness of breath, for a few days after their arrival. Everest and K2 in the Himalayas, many mountain climbers rely upon bottled oxygen as they near the summit. Lifecycle of Erythrocytes Production of erythrocytes in the marrow occurs at the staggering rate of more than 2 million cells per second. These include the same nutrients that are essential to the production and maintenance of any cell, such as glucose, lipids, and amino acids. Heme iron, from animal foods such as meat, poultry, and fish, is absorbed more efficiently than non-heme iron from plant foods. Ferroportin transports the iron across the intestinal cell plasma membranes and from its storage sites into tissue fluid where it enters the blood. Both enable the oxidation of iron from Fe to Fe , a form in which it can be bound to its transport protein, transferrin, for transport to body cells. In a state of copper deficiency, the transport of iron for heme synthesis decreases, and iron can accumulate in tissues, where it can eventually lead to organ damage. The trace mineral zinc functions as a co-enzyme that facilitates the synthesis of the heme portion of hemoglobin. Erythrocytes live up to 120 days in the circulation, after which the worn-out cells are removed by a type of myeloid phagocytic cell called a macrophage, located primarily within the bone marrow, liver, and spleen. The components of the degraded erythrocytes’ hemoglobin are further processed as follows: • Globin, the protein portion of hemoglobin, is broken down into amino acids, which can be sent back to the bone marrow to be used in the production of new erythrocytes. Hemoglobin that is not phagocytized is broken down in the circulation, releasing alpha and beta chains that are removed from circulation by the kidneys. Bilirubin binds to albumin and travels in the blood to the liver, which uses it in the manufacture of bile, a compound released into the intestines to help emulsify dietary fats. In the large intestine, bacteria breaks the bilirubin apart from the bile and converts it to urobilinogen and then into stercobilin.

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In fact purchase cheap super viagra on line, gene knock-out followed by transcript analysis and proteome definition seems to be the way to identify essential genes super viagra 160mg overnight delivery. Subsequently super viagra 160mg fast delivery, research derived from comparative genomic studies was directed towards the study of particular genes. Complementation and combination of in vitro and in vivo assay systems indicated the participation of the gene Rv1519 in the persistence and outbreak potential of this M. Thir- teen putative sigma (σ) factors and 192 regulatory proteins seem to be involved in the control of M. To date, consensus promoter sequences have been proposed for six σ factors, be- A sides the housekeeping σ factor, σ (for a review, see Rodriguez 2006). Gene ex- pression levels could be further modified by the action of transcriptional activators and repressors: regulatory proteins (Barnard 2004). These regulatory proteins in- clude 11 two-component systems, five unpaired response regulators, seven wbl genes, and more than 130 other putative transcriptional regulators (Cole 1998a). The differential expression of these regulatory gene products throughout different stages of the lifespan of M. In recent years, a number of reports have correlated the response of several of these transcriptional regulators to a variety of environmental stresses (for a summary, see Table 4-3 at http://www. However, the biological signals that stimulate the expression of the majority of them are still poorly recognized. Likewise, the connections between the different regulatory circuits of the complex network that controls gene expression in M. An example of the intricacy of this E network is the genetic regulation of sigB, which is induced by σ in response to H surface stress (Manganelli 2001) or by σ under heat shock and oxidative stress (Manganelli 2002). The regulation of sigB expression seems to be more complex F L than the above cited, given that σ - and σ -dependent promoters were identified in L the regulatory promoter region of sigB; and σ -dependent transcription was origi- H nated upstream to sigB (Dainese 2006). It has been shown that σ is also responsi- ble of the induction of sigE after heat shock and exposure to diamine (Raman 2001). Two-component signal transduction systems are composed of a histidine kinase sensor and a cytoplasmic response regulator that is activated by the cognate histidine kinase (West 2001). This regulon is responsible for the transcriptional changes during oxygen limitation, which is considered an important stimulus for the entry of M. Recently, the induction of sigB and sigE has been shown to depend on the two-component system MprA/MprB when the bacilli are subjected to surface stress (He 2006). The transcriptional regulator WhiB3 seems to positively regulate the expression of the housekeeping σ factor named sigA, by interacting with the subregion 4. Many of these anti-σ factors are located downstream of their cognate σ factor- encoding gene and both genes are usually co-transcribed (Bashyam 2004). Interestingly, RsbW, the σF-specific antagonist, is post-translationally regulated by two anti-anti- σ factors: RsfA and RskB (Beaucher 2002, Parida 2005). Although the function of many of these mycobacterial transcriptional regulators and signal transduction systems remains poorly defined, recent studies have begun to provide evidence of the biological role of these regulatory circuits throughout each stage of the lifecycle of M. The expression of sigA, sigE and sigG (Manganelli 2001, Capelli 2006, Volpe 2006), that of some 130 Genomics and Proteomics two-component systems (Ewann 2002, Haydel 2004, Walters 2006), as well as that of the transcriptional regulator whiB3 are induced during macrophage infection. The role of these transcriptional regulators in pathogenesis and virulence became even more evident in animal model experiments, where disruption or deletion of these genes was shown to affect M. These regulators can modify bacterial physiol- ogy and are able to modulate host-pathogen interactions in response to environ- mental signals. As mentioned previously, the tubercle bacillus adapts its transcriptome to the envi- ronment in which it replicates. The adaptation of a bacterium to harsh environ- ments involves the transcriptional activation of genes whose final products help the bacterium to reprogram its physiology, thus ensuring survival. Among the genetic determinants that the bacterium must modulate are those involved in intermediary and secondary metabolism, cell wall processes, stress responses and signal trans- duction pathways. Table 4-4 summarizes the most important genes whose expression is modulated by the transcriptional regulators mentioned previously (see section 4. On the contrary, the genes hspX (encoding the α-crystalline homologue), senX3 (sensor kinase), mtrA (response regulator), and fbpC (mycolyl transferase and fibronectine binding pro- tein or antigen 85C) were down-regulated in that mutant strain at different times of D the growth curve (Sun 2004). Genes induced by σ include the resuscitation pro- moting factor rfpC, several chaperone genes and genes involved in lipid metabo- lism and cell wall processes (Raman 2004). These include genes coding for some heat shock proteins 132 Genomics and Proteomics (hsp and clp), the trxB2C operon and some transcriptional regulators (Manganelli 2002). L At least four small operons appear to be directly regulated by σ : sigL-rslA, pks10- L pks7, mpt53-Rv2877c, and Rv1139c-Rv1138c, which clearly have a σ -consensus promoter sequence in their regulatory region (Hahn 2005, Dainese 2006). The pks genes are involved in the biosynthesis of phthiocerol dimycocerosate, a component of the cell envelope associated with virulence (Sirakova 2003); and the mpt operon contains genes involved in fatty acid transport (Sonden 2005). It was shown that the expression of this two-component system is highly induced under hypoxia (Sherman 2001b, Park 2003). A consensus dosR-specific binding motif was reported to be located up- stream of hypoxic response genes (Park 2003, Kendall 2004). The microarray ex- pression profiles of mutants in each of the components (dosR and dosS) showed that DosR is required for the expression of genes usually induced under oxygen limitation, such as hspX gene. However, it has not been clearly determined if the changes found in gene expression were directly or indi- rectly related to the lack of this two-component regulatory system (Parish 2003a). Recently, the global transcriptional profile of the two-component systems PhoP and MprA has been reported. One of these studies provided evidence that the PhoP/PhoR system is a positive transcriptional regulator of genes involved in the synthesis of the cell envelope of M. On the other hand, MprA regulates sigB and sigE and many other genes previously reported to be associated to various stress conditions (He 2006). In order to analyze the mechanisms involved in bacilli intracellular survival, myco- bacterial gene expression was determined in M. Macrophages have been investigated at different time points post-infection for the differential expression of various two-component system regulators (regX3, phoP, prrA, mprA kdpE, tcr, devR and tcrX) (Haydel 2004). In this work, the authors reported that ap- proximately one-third (32 %) of the genes upregulated by M. Interestingly, the authors observed high induc- tion of the sigma factor sigG and 13 other putative transcriptional regulators. Therefore, while significant work has been per- 134 Genomics and Proteomics formed on the gene expression profile of the host, information on M. So far, there is only one publication concerning global mycobacterial transcription expression in the animal model, using microarray as the analytical method (Talaat 2004). The same genes were also found to be induced 24 hours post-infection in murine bone marrow macrophages (Schnappinger 2003). Additionally, several genes were regulated up or down only in Balb/c mice, such as proZ (transport system permease protein), aceAa (probable isocitrate lyase involved in lipid metabolism), and genes encoding for regulatory proteins, such as sigK, sigE and kdpE. A gene required for extrapulmonary dissemination (hbhA) was also upregulated in the lung but not in the spleen during the early stages of infec- tion (Delogu 2006). Al- though some differences were observed when comparing human and murine lung, the authors admitted that it was difficult to ascertain whether the infection stage in the analyzed human lung specimens could be correlated with the persistent infec- tion in mice.

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