By C. Goose. Art Institute of Chicago.

These are adapted from the general biosecurity recommendations and the management guidelines issued by breeders cheap trental 400mg line. The intensity of disease prevention measures depends on the risks and consequences of infection discount trental 400mg fast delivery. The entire farm is surrounded by secure fencing and a high level of biosecurity is imposed to prevent introduction of disease which could be spread vertically to progeny buy trental 400 mg low cost. Maintaining multi-age farms or establishing units in close proximity creates problems relating to control and eradication of chronic diseases such as mycoplasmosis and coryza. Well-ventilated convection house using indigenous materials suitable for broiler growing. Delivery vehicles should be disinfected before entry to farms to avoid introduction of pathogens. Litter beetles (Alphitobius diaperinus) serve as reservoirs of Marek’s disease virus, Salmonella spp. If this is not possible, pullets should be obtained from a source known to be free of vertically transmitted infections or diseases characterized by a permanent carrier state such as coryza, salmonellosis or laryngotracheitis. Exposure to disease will lower egg production and reduce quality following transfer to laying units. In view of the high investment in facilities and flocks, it is recommended that appropriate biosecurity procedures should be implemented. Movement of personnel should be controlled, and where possible, bulk-delivered feed is recommended to obviate manual handling and delivery in bags. Plastic flats should be used, which can be decontaminated at the point of entry to the farm. Culled hens should be transferred from the production unit to a remote site for sale to live-bird dealers. Procedures include post- mortem examination of dead birds when mortality exceeds standard levels and periodic serum antibody assays to determine the immune status of flocks. Change-room and shower facilities are required and protective clothing should be provided to prevent introduction of disease onto farms by workers. Laborers invariably have contact with backyard chickens which are reservoirs of disease. Simple single-tier layer cage installed in open-sided house incorporating manual feeding and a trough drinker. These inexpensive systems are extensively used in Asia, but labor input is high and the system is associated with problems of manure disposal and houseflies. The facility should have a secure fence, and all entrances to the building should be located inside the fenced area. Hatchery design should allow for future expansion and incorporate provision for drainage, disposal of waste, washing of chick boxes and trays. To prevent movement of air from “dirty” to “clean” areas, positive pressure should be maintained in egg setter bays, cold room for eggs, and chick dispatch area. Potentially contaminated areas are the chick takeoff, processing, and washing areas. To prevent mold growth, all egg flats, trays, and metal boxes should be thoroughly dried after disinfection. Since fiber trays and cardboard boxes cannot be cleaned and disinfected, these should not be reused. Where possible, plastic egg flats and packaging material should be color-coded to the farm of origin. A log book should be kept for entry of visitors or deliveries to the hatchery, recording date and time and the previous farm or site visited. Broken eggs should be removed from setters daily, with appropriate action to prevent cross-contamination. Setter rooms should be disinfected daily under supervision and inspected to ensure compliance with standard procedures. Vaccination equipment should receive special attention according to manufacturers’ recommendations. Procedures should specify disinfectants, concentration, and the method and frequency of application. Routine tests should include incoming eggs, the egg room, setters, hatchers after disinfection, hatcher rooms, setters rooms, chick-processing rooms, vehicles, exhaust ducts, and the water supply. Correlations between the microbiological test results, hatchability, and chick livability should guide the choice of disinfectants and dilution rates. Setter bay in small hatchery showing high standards of surface finishes consistent with acceptable hygiene and decontamination. Suppliers of stock provide printed management guides incorporating nutrient specifications appropriate to the various ages and types of poultry. Nutritionists satisfy dietary requirements by blending available ingredients into diets on a least- cost basis. Generally, linear programming is used to develop formulations containing the most critical nutrients. These include; • Energy • Crude protein • Essential amino acids with specific reference to, - methionine - cystine - lysine - tryptophan - threonine • Fats and essential fatty acids (linoleic acid) • Macro Minerals - sodium - calcium - magnesium - potassium - chlorine as chloride - phosphorus as phosphate - sulphur as sulfate • Micro Elements - copper - cobalt - manganese - zinc - selenium - iron - iodine as iodized salt • Vitamins 7.

A low relative humidity aggravates the problem order 400 mg trental visa, as does repeated vigorous washing generic 400mg trental free shipping, especially in hot water with some soaps and cleansing agents discount 400 mg trental with mastercard. Presumably, the toilet procedures leach out important sub- stances that are vital to the integrity of the stratum corneum. Xeroderma tends to be worse in the wintertime and, when accompanied by itching, is known, logically enough, as ‘winter itch’. It has been sug- gested that this is a manifestation of ichthyosis, but there is more evidence in favour of the disorder being the result of the eczematous process itself. Xeroderma is also seen during the course of severe wasting diseases such as carcinomatosis, intestinal malabsorption and chronic renal failure, but should not be confused with acquired ichthyosis (Table 16. It is seen in ‘ordinary xeroderma’, in autosomal dominant ichthyosis, and sometimes in normal young women for no apparent reason. If the patient lives in centrally heated rooms, humidifiers should be employed to raise the rela- tive humidity. Emollients act for a short time only – up to 2–3 hours at most – and need to be frequently applied. Their action can be supplemented by bath oils, which deposit a film of lipid on the skin surface. It spares the flexures and is most notice- able over the extensor aspects of the limbs and trunk, being most noticeable over the back, the lateral aspects of the upper arms, the anterolateral thighs and par- ticularly the shins (Fig. Keratosis pilaris may be seen over the outer aspects of the upper arms in a few subjects. The condition is hardly noticeable in most people, but is quite marked and disabling in a few. It has been estimated that the gene occurs with a frequency of 246 Sex-linked ichthyosis Figure 16. Histologically, the only abnormality detectable is a much diminished granular cell layer (Fig. Ultrastructurally and biochemically, there is decreased content of a basic histidine- rich protein known as filaggrin, which is important in the orientation of the keratin tonofilaments. Patients who have very severe scaling may be helped by the use of topical keratolytic agents, including preparations containing urea (10–15 per cent) and salicylic acid (1–6 per cent). The latter is particularly effective in encouraging desquamation, but may not be used on large body areas for any length of time, as salicylic acid preparations when applied to abnormal skin may cause salicylate intoxication (sal- icylism). The reason for this appears to be a pla- cental deficiency of the steroid sulphatase and a consequent failure of the usual splitting of circulating maternal oestrone sulphate in the last trimester of pregnancy. The free oestrone is thought to have a role in priming the uterus to oxytoxic stimuli. It is also more marked over the extensor aspects of the body surface, but does not always spare the flexures and often affects the sides of the neck and even the face. The scales are often quite large, particularly over the shins and have a dark-brownish discoloration. Patients with sex-linked ichthyosis may be signifi- cantly disabled by their disorder. In fact, 248 Non-bullous ichthyosiform erythroderma the carrier female may demonstrate patchy scaling that is consistent with the ‘ran- dom deletion’ (or Lyon) hypothesis. The disorder is quite uncommon, having a gene frequency of approximately 1 in 6000. Histologically, there is a minor degree of epidermal thickening and mild hyper- granulosis. Biochemically, affected male subjects show a steroid sulphatase defi- ciency, but for diagnostic purposes, fibroblast, lymphocyte or epidermal cell cultures are tested. The steroid sulphatase abnormality results in excess quantities of cholesterol sulphate in the stratum corneum with diminished free cholesterol. This has been used as the basis of a diagnostic test and has been suggested as the underlying basis for the abnormal scaling. He had had it since birth, although it didn’t start to be a problem until he reached the age of 11. He complained of itchiness – especially in the wintertime, when, in addition to the itch, the skin of his hands became sore and ‘cracked’ in places. He had a brother who was affected and his maternal grandfather also had the disease. It was clear that he had sex-linked ichthyosis, which could be expected to persist, but the symptoms of which should be helped by emollients. It is probably heterogeneous, as, although the skin abnormality is similar in all patients, there are associations with abnormalities in other organ systems in some groups of patients. Ectropion, deformities of the ears and sparsity of scalp hair are common accompaniments. The con- dition persists throughout life, although the erythema tends to decrease. Severely affected patients may benefit from the use of long-term oral retinoid drugs.

Secondary prevention through diet and physical activity is a comple- mentary strategy in retarding the progression of existing chronic diseases and decreasing mortality and the disease burden from such diseases buy 400mg trental free shipping. From the above buy trental 400 mg cheap, it is clear that risk factors must be addressed throughout the life course trental 400 mg on-line. As well as preventing chronic diseases, there are clearly many other reasons to improve the quality of life of people throughout their lifespan. The intention of primary prevention interventions is to move the profile of the whole population in a healthier direction. Small changes in risk factors in the majority who are at moderate risk can have an enormous impact in terms of population-attributable risk of death and disability. By preventing disease in large populations, small reductions in blood pressure, blood cholesterol and so on can dramatically reduce health costs. For example, it has been demonstrated that improved lifestyles can reduce the risk of progression to diabetes by a striking 58% over 4 years (133, 134). Other population studies have shown that up to 80% of cases of coronary heart disease, and up to 90% of cases of type 2 diabetes, could potentially be avoided through changing lifestyle factors, and about one-third of cancers could be 43 avoided by eating healthily, maintaining normal weight and exercising throughout life (135--137). For interventions to have a lasting effect on the risk factor prevalence and the health of societies, it is also essential to change or modify the environment in which these diseases develop. Changes in dietary patterns, the influence of advertising and the globalization of diets, and widespread reduction in physical activity have generally had negative impacts in terms of risk factors, and presumably also in terms of subsequent disease (138, 139). Reversing current trends will require a multifaceted public health policy approach. While it is important to avoid inappropriately applying nutritional guidelines to populations that may differ genetically from those for whom the dietary and risk data were originally determined, to date the information regarding genes or gene combinations is insufficient to define specific dietary recommendations based on a population distribution of specific genetic polymorphisms. Guidelines should try to ensure that the overall benefit of recommendations to the majority of the population substantially outweighs any potential adverse effects on selected subgroups of the population. For example, population-wide efforts to prevent weight gain may trigger a fear of fatness and, therefore, undernutrition in adolescent girls. The goals are intended to reverse or reduce the impact of unfavourable dietary changes that have occurred over the past century in the industrialized world and more recently in many developing countries. Present nutrient intake goals also need to take into account the effects of long-term environmental changes, i. For example, the metabolic response to periodic famine and chronic food shortage may no longer represent a selective advantage but instead may increase susceptibility to chronic diseases. An abundant stable food supply is a recent phenomenon; it was not a factor until the advent of the industrial revolution (or the equivalent process in more recently industrialized countries). A combination of physical activity, food variety and extensive social interaction is the most likely lifestyle profile to optimize health, as reflected in increased longevity and healthy ageing. Some available evidence suggests that, within the time frame of a week, at least 20 and 44 probably as many as 30 biologically distinct types of foods, with the emphasis on plant foods, are required for healthy diets. The recommendations given in this report consider the wider environ- ment, of which the food supply is a major part (see Chapter 3). The implications of the recommendations would be to increase the consumption of fruits and vegetables, to increase the consumption of fish, and to alter the types of fats and oils, as well as the amount of sugars and starch consumed, especially in developed countries. The current move towards increasing animal protein in diets in countries in economic transition is unlikely to be reversed in those countries where there are increased consumer resources, but is unlikely to be conducive to adult health, at least in terms of preventing chronic diseases. Finally, what success can be expected by developing and updating the scientific basis for national guidelines? The percentage of British adults complying with national dietary guidelines is discouraging; for example, only 2--4% of the population are currently consuming the recommended level of saturated fat, and 5--25% are achieving the recommended levels of fibre. The figures would not be dissimilar in many other developed countries, where the majority of people are not aware of what exactly the dietary guidelines suggest. In using the updated and evidence-based recommendations in this report, national governments should aim to produce dietary guidelines that are simple, realistic and food-based. There is an increasing need, recognized at all levels, for the wider implications to be specifically addressed; these include the implications for agriculture and fisheries, the role of international trade in a globalized world, the impact on countries dependent on primary produce, the effect of macroeconomic policies, and the need for sustainability. The greatest burden of disease will be in the developing world and, in the transitional and industrialized world, amongst the most disadvantaged socioeconomically. In conclusion, it may be necessary to have three mutually reinforcing strategies that will have different magnitudes of impact over differing time frames. First, with the greatest and most immediate impact, there is the need to address risk factors in adulthood and, increasingly, among older people. Risk-factor behaviours can be modified in these groups and benefits seen within 3--5 years. With all populations ageing, the sheer numbers and potential cost savings are enormous and realizable. Secondly, societal changes towards health-promoting environments need to be greatly expanded as an integral part of any intervention. Ways to reduce the intake of sugars-sweetened drinks (particularly by children) and of high-energy density foods that are micronutrient poor, as well as efforts to curb cigarette smoking and to increase physical activity will have an impact 45 throughout society.

It is much more common in those with alcoholic liver disease generic 400 mg trental overnight delivery, but has also been seen in patients with liver tumours and those with hexachlorbenzene poisoning cheap trental 400 mg on-line. Metabolic basis There appears to be a defect in the action of the enzyme uroporphyrinogen decar- boxylase trusted 400mg trental, resulting in the accumulation of uroporphyrins and coproporphyrins in the blood, stools and urine. Clinical features When associated with alcoholic liver disease, the disorder is more often seen in middle-aged men. In the early stages of the disease, blistering and fragility of the skin on the face and backs of the hands are noted (Fig. The affected areas also develop an odd 259 Metabolic disorders and reticulohistiocytic proliferative disorders Table 17. Later, increased hair growth occurs on the involved skin and a sclerodermiform thickening of the skin develops. The diagnosis is made by finding increased uroporphyrins and coproporphyrins in the stools and urine. If available, monochromatic testing (to irradiate the skin with very narrow wavelength bands of light or ultraviolet radiation) will reveal photosensitivity at 404 nm. Histologically, the blistering is subepidermal and, in the long-standing case, fibrosis develops and deposits of immunoglobulin are found perivascularly. This is achieved by regular venesection – removing a pint of blood at a time – every 2 or 3 weeks, or by the use of chloroquine orally, resulting in the secretion of large amounts of porphyrins in the urine. The latter is caused by a deficiency of delta-aminolaevulinic acid synthetase and is pre- cipitated by certain drugs and anaesthesia, amongst other things. These protoporphyrins are detectable in the blood and this forms the basis of diagnostic tests. Clinically, the disorder often presents in childhood as episodes of skin soreness and extreme discomfort when exposed to the sun. This combi- nation of clinical features has suggested to some that these patients provoked the fable of ‘werewolves’. In the primary form, there is excessive gastrointestinal absorption of iron, resulting in iron deposition in the liver, testes, skin and pancreas. Involvement of the skin causes a brown-grey pigmentation due to both the iron and increased melanin in the skin. There is dia- betes due to deposition of iron in the pancreas, and cirrhosis from liver involve- ment. The condition seems to be inherited as a recessive characteristic, but is much more common in men. Secondary forms are found in conditions necessitating repeated blood transfu- sion and in conditions in which there is chronic haemolysis (e. The latter develops after long-standing inflammatory disease, including infections such as chronic tuberculosis and chronic osteomyelitis. In primary amyloidosis, the abnor- mal protein components are synthesized by clones of abnormal plasma cells and the condition is sometimes associated with multiple myeloma. In primary amyloid disease amyloid is deposited in various organs as well as in the skin. In the skin, it is deposited in and around the dermal capillary blood vessels, which become fragile and leaky. In the rare macu- lar amyloid, itchy, ‘rippled’, brown macular areas appear over the trunk (Fig. Lichen amyloidosis is another rare cutaneous form of amyloid in which lichen planus-like lesions occur. Amyloid can be detected in tissue using various histochemical tests, including birefringence with Congo red stain and fluorescence with thioflavine T, as well as by immunocytochemical tests. Xanthelasma Xanthelasma is a common form of xanthoma in which lesions appear as arcuate or linear plaques around the eyes (Fig. The condition is not associ- ated with hyperlipidaemia in 60–70 per cent of patients. The lesions can be removed by excision or by topical treatment with trichloracetic acid if the patient finds them a cosmetic nuisance. The area around the lesion should be protected with Vaseline and the surface of the lesion lightly wiped with a cotton-wool swab moistened with the acid. Xanthoma tuberosum The lesions of xanthoma tuberosum are large nodules containing lipidized histio- cytes and giant cells. The nodules develop around the tendons and extensor aspects of the joints in familial hyperlipidaemia (see Table 17. Eruptive xanthomata These mostly develop in diabetes, but are also seen in congenital deficiencies of lipoprotein lipase (Burger–Grütz disease: see Table 17.

Symptoms may include bone pain trental 400mg discount, low bone mineral density cheap trental 400 mg online, and an increased risk for fractures generic 400 mg trental free shipping. On the mild end of the spectrum, some people experience only a small drop in their bone mineral density. In more severe cases, blood supply to The Counsyl Family Prep Screen - Disease Reference Book Page 103 of 287 the bones is lost, leading to permanent damage. With fewer red blood cells (anemia), a person with the disease will often be tired and weak. Fewer platelets in the blood will make him or her more prone to bruising and excessive bleeding. Type 1 is distinct from other forms of Gaucher disease in that it usually does not afect the individual’s brain or spinal cord. Type 2 Type 2 is known as the infantile or acute neuropathic form of Gaucher disease. These may include enlarged liver and spleen, lowered number of red blood cells (anemia) leading to weakness and tiredness, lowered number of platelets leading to bleeding and bruising, and lung disease. While type 2 is distinct from types 1 and 3 in that it does not cause bone problems, type 2 does cause neurological problems. Neurological symptoms often include limited cognitive and motor development, brainstem abnormalities that can cause breathing problems and difculty swallowing, constant arching of the back and tilting back of the head, uncontrollable tightening and releasing of the muscles, and an inability to open the mouth. As the nervous system deteriorates, children with type 2 Gaucher may develop dementia and the inability to coordinate his or her own movement. Type 3 Type 3 Gaucher disease is known as the juvenile or chronic neuropathic form. Usually the symptoms associated with type 3 progress more slowly than with type 2. While some people with type 3 Gaucher disease die in childhood, others can live into their 30s or 40s. These may include enlarged liver and spleen, lowered number of red blood cells (anemia) leading to weakness and tiredness, lowered number of platelets leading to The Counsyl Family Prep Screen - Disease Reference Book Page 104 of 287 bleeding and bruising, lung disease, and bone problems including include pain, fractures, and arthritis. These may include seizures which worsen over time, progressive cognitive problems, and difculty controlling eye movement. Perinatal-Lethal Form The perinatal-lethal form is a rare but severe form of Gaucher disease. Infants with the disease have symptoms including enlarged liver and spleen, lowered number red blood cells and platelets, neurological problems, skin abnormalities, and often distinct facial features. Cardiovascular Form As the name implies, the cardiovascular form of Gaucher disease causes symptoms involving the heart, notably a hardening of the mitral and aortic valves. This type is particularly prevalent among people of Ashkenazi Jewish descent, of whom 1 in 855 is afected by the disease and 1 in 16 is a carrier. In the general population, researchers believe that about 1 in 50,000 will be afected. A form of type 3 is most common among people in the Norrbottnian region of Sweden, where 1 in 50,000 are afected. Additional treatments for the symptoms of Gaucher disease include blood transfusions for tiredness and excessive bleeding, joint replacement to relieve pain and restore movement, and medication to treat bone pain. Because symptoms of Gaucher disease vary widely in type and severity, both among the diferent types and among people with the same type, the outlook is similarly varied. The prognosis for an individual with Gaucher disease depends on the type of Gaucher, the severity in that particular individual, and the availability and efectiveness of treatment. Some individuals with severe cases of type 1 Gaucher may have debilitating symptoms that are more difcult to manage. Those with type 2 Gaucher disease often have signifcant developmental delays and die between the ages of 2 and 4. People with type 3 Gaucher disease usually develop symptoms in childhood which slowly worsen over time. For those with the cardiovascular form of the disease, the prognosis depends upon the success of valve replacement surgery. Detection Population Rate* <10% African American 84% Ashkenazi Jewish 73% Eastern Asia 79% Finland 79% French Canadian or Cajun <10% Hispanic 65% Middle East <10% Native American 79% Northwestern Europe <10% Oceania <10% South Asia <10% Southeast Asia 79% Southern Europe * Detection rates shown are for genotyping. The word “nonsyndromic” refers to the fact that there are no other symptoms or systems of the body involved with the disease. The degree of hearing loss is difcult to predict based on which genetic mutation one has. They may also want to consider enrolling in an educational program for the hearing impaired. The Counsyl Family Prep Screen - Disease Reference Book Page 108 of 287 Glucose-6-Phosphate Dehydrogenase Defciency Available Methodology: targeted genotyping.

Controlling outbreaks only rarely associated with any serious adverse and minimizing discomfort are two goals of antivi- effects cheap trental 400mg without prescription. The severity of a first episode of gen- shown no rise in birth defects or other problems in ital herpes can be dramatically minimized by the more than 10 years generic 400mg trental with amex. Similar safety is reported in use of an initial 10-day course of medication that the newer entries on the market—valacyclovir helps sores to heal faster buy trental 400mg fast delivery, reduces swollen glands, (Valtrex) and famciclovir (Famvir). For chronic suppression, Valtrex is sign of an outbreak; this serves to shorten dura- taken once daily. Famciclovir (Famvir) lasts longer genital herpes 55 in the body than acyclovir, and the herpes patient should be reported to the registry (800-722-9292, takes only twice-daily doses. Oral acyclovir may be taken by a woman who Recurrences has her first episode of genital herpes during preg- It has been seen that people having six or more nancy. Basically, though, the routine use of acy- episodes of herpes a year can reduce the rate of clovir during the pregnancy of a woman with recurrences by 75 percent by availing themselves recurrent infections is not recommended. The extent to disease; and 3 percent for those who have asymp- which this kind of therapy reduces the likelihood tomatic shedding. Abnormal strains seem more likely Understanding the circuitous route that herpes to flourish in these individuals. By the same token, often takes is key to coming to grips with having a no increase in drug-resistant strains of herpes in the disease for which there is no cure. In per- For episodic recurrent infection: sonal relationships, having herpes can feel like having leprosy, and, unfortunately, once it is con- Acyclovir: 400 mg orally three times a day for five tracted, there is little one can do other than try to days, or suppress the symptoms and frequency of bouts Acyclovir: 200 mg orally five times a day for five and take an honest approach with prospective days, or sexual partners. Famciclovir: 125 mg orally twice a day for five Decreased sense of self-worth is a huge problem days, or with herpes, in that many people, after recovering Valacyclovir: 500 mg orally twice a day for three from the initial feeling of betrayal and shock when days they realize they have contracted the disease, move into a state of malaise and inaction. During this Regimens for daily suppressive therapy: time, a redefinition of self can take place, as the individual assigns herself or himself the stigma of Acyclovir: 400 mg orally twice a day, or being “undesirable. In patients who experi- destructive thoughts, as the herpes sufferer experi- ence very severe bouts of herpes or complications ences relationship rebuffs over months and years that make hospitalization necessary (hepatitis, after the disease is contracted. The To combat the feeling of helplessness that often available creams are penciclovir (Denavir) and acy- accompanies this disease, the person with herpes clovir cream. Some have a supportive with infused oxygen to kill the herpesvirus because confidante who helps soothe them during bluesy viruses cannot live in an elevated-oxygen environ- periods; others are comforted by fellow sufferers in ment. In many people point out that episodic antiviral therapy can help to with herpes, the fear of rejection as a result of dis- shorten the duration of lesions and that suppressive closure of herpes is mixed with chagrin and anx- antiviral therapy can help prevent recurrent out- iety. At the same time, herpes sufferers learn, breaks of herpes or render them less frequent and sometimes the hard way, that establishment of an less severe. The first year after initial infection is intimate and satisfying relationship must be based marked by the most frequent outbreaks of herpes. Of course, no In succeeding years, most people experience fewer one should feel compelled to reveal personal outbreaks. However, some people have outbreaks health issues to someone with whom he or she is that are frequent and severe for many years. It is important to remember that those rejections Self-Care that follow on the heels of disclosure of herpes Attention to peace of mind is important for those status should be chalked up as “screening,” in dealing with the lifelong stress generated by having that partners who showed little promise for a herpes. Only those who have herpes can fully mutually beneficial, loving long-term relationship understand the burden of dealing with recurrences are eliminated. There usually are ongoing con- measures can help patients cope successfully with cern and worry about transmitting the disease to a this disease. Those who have distress and no confi- partner and about the necessity to have no sexual dante should be encouraged to seek help via hot- activity during active periods of the sores. Because this disease has asympto- matic shedding, it is extremely important for the • Keep the infected area clean and dry to prevent infected person to understand that sexual trans- development of secondary infections. During wash your hands after you do have contact with counseling, a doctor is likely to caution that it is the sores. Consistent use of condoms during sexual first have symptoms until complete healing has activity with new or uninfected partners should occurred. This can be defined as the time when be a rule of thumb for those with genital herpes. Periods of latency and activity vary with the Another key fact that should be shared in coun- individual, but it remains unclear what causes seling is the risk of neonatal infection. Some research suggests that women are reluctant to disclose that they have her- friction to the genitals can trigger herpes. Stress, pes when their doctors ask for their gynecologic fatigue, sunlight exposure, and menstruation are history, and it is very important that the doctor who also cited as causes. Condoms give some pro- Research tection, but their overall efficacy in curbing Areas of investigation are focusing on causes of transmission rates is dubious. It is rare (but possible) for genital warts to be transmitted by fomites (any nonliving genital secretion In respect to sexually trans- material such as surgical gloves) and by infected mitted diseases, genital fluids and secretions are mothers to newborns.