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Cystic hygromas are spongy medications quizlet buy rivastigimine paypal, mobile 97110 treatment code order 4.5mg rivastigimine with mastercard, nontender lesions located in the posterior triangle of the neck medicine nobel prize purchase rivastigimine 6 mg otc, most frequently on the left side medicine 6mp medication cheap rivastigimine 4.5 mg on-line. If a large cystic hygroma is detected prenatally, delivery should be performed at a center capable of managing the airway and lesion at the time of birth. Fine needle aspiration should be avoided when diagnosing cystic hygromas because hemorrhage into the lesion may cause rapid expansion. An ectopic thyroid gland may be located anywhere along the path of descent of the thyroid during its embryologic development, most commonly at the base of the tongue. Although these are often midline, they can occur in many locations and present far less commonly as a midline mass compared with a thyroglossal duct cyst. In most cases ultrasonography is necessary to identify the location of an ectopic thyroid gland in a child with hypothyroidism, because there are usually no external signs of the thyroid’s location. However, they have a high potential for malignancy, estimated to range anywhere from 9% to 50%. Because many children and adolescents with thyroid cancer have metastatic lesions in the cervical lymph nodes at presentation, they most often present with a lateral neck mass. Thyroid masses: approach to diagnosis and management in childhood and adolescence. He was admitted for fever, neutropenia, and septic shock 5 days ago and has improved after receiving fluid resuscitation, stress dose steroids, intravenous vancomycin and cefepime, and a dopamine infusion. His indwelling central line culture grew Pseudomonas aeruginosa, and after 48 hours, based on sensitivity results, the vancomycin was discontinued. Pseudomembranous colitis is caused by Clostridium difficile infection of the colon. C difficile is a gram-positive anaerobic bacillus capable of producing a toxin that affects intracellular signaling pathways of colonic epithelium, resulting in inflammation and cell death. Infants younger than 1 year may not develop pseudomembranous colitis from C difficile infection because they may lack the toxin receptor. Any process that disrupts normal gastrointestinal flora, alters immunity, or impairs motility can lead to an infection with a C difficile toxin-producing strain. This can include inflammatory bowel disease, ileus, broad-spectrum antibiotic usage, immunosuppression, and chronic illness. Both the incidence and clinical severity of pseudomembranous colitis have been rising in recent years, especially in the pediatric population. Classic pseudomembranous colitis was strictly a hospital-acquired infection, but its incidence in the community is increasingly recognized. Broad-spectrum antibiotic use is a common cause of pseudomembranous colitis, though the absence of this history does not rule it out. Antibiotics can kill the normal gastrointestinal flora, leading to selection of resistant organisms and colonization with C difficile. The clinical presentation of pseudomembranous colitis begins within days of colonization, and can range from mild, self-limited diarrhea and cramping to more severe manifestations such as fever, bacteremia, sepsis, abdominal distention, toxic megacolon, and even death. For the patient in the vignette, risk factors for pseudomembranous colitis include the antecedent history of broad-spectrum antibiotics and immunocompromise. Either oral metronidazole or oral vancomycin is the best therapy for pseudomembranous colitis. Discontinuation of cefepime is not advisable because treatment of his central line infection is necessary. Fluconazole and ganciclovir will not be helpful, because the cause of the diarrhea is not likely to be fungal or viral. Oral linezolid is effective against gram-positive bacteria, but it is not a first-line therapy for C difficile infection because its spectrum is too broad, and it is a bacteriostatic agent. Fever has not been documented, but she has been on scheduled ibuprofen since the onset of illness. On physical examination, she has warmth, a notable effusion, and limited range of motion of the left knee. Of the answers listed, cefotaxime is the correct antibiotic choice for the patient in this vignette. Additional antibiotics with activity against Kingella include aminoglycosides, macrolides, tetracyclines, chloramphenicol, and fluoroquinolones. Approximately 40% of Kingella are resistant to clindamycin and all are resistant to glycopeptide antibiotics, including vancomycin. Clindamycin, linezolid, and vancomycin have good gram-positive activity and would be considered in osteoarticular infections caused by gram-positive pathogens such as Staphylococcus aureus; however, these antibiotics have no activity against Kingella. However, the combination of trimethoprim with sulfamethoxazole would be effective against Kingella. Kingella can be an asymptomatic colonizer of the posterior pharynx in 9% to 12% of children between 12 and 24 months of age. Frequently, patients with invasive Kingella infections have viral infections including upper respiratory tract symptoms, gingivostomatitis, or oral ulcers that may allow for invasion of bacteria into the respiratory epithelium and subsequent translocation into the bloodstream. Kingella is increasingly recognized as a cause of osteoarticular infections, including septic arthritis, osteomyelitis, spondylodiscitis, and tenosynovitis in young children. In comparison with other pathogens that can cause osteoarticular infections and bacteremia, constitutional symptoms, including fever, can be mild or absent in patients with Kingella infection. In young children, in comparison with older children and adults, disease occurs in healthy individuals without underlying conditions. His review of systems is significant for an upper respiratory tract infection-like illness 3 weeks ago. He has a respiratory rate of 18 breaths/min, heart rate of 94 beats/min, and blood pressure of 130/90 mm Hg. Serum chemistries will likely reveal azotemia and electrolyte abnormalities, depending on the severity of renal failure. The timing of infectious illness and acute nephritis can provide clues to the presenting nephritis. The streptozyme test measures different streptococcal antibodies and is positive in nearly 95% of patients with pharyngitis, and around 80% of patients with skin infections because of group A, β-hemolytic streptococcus preceding acute nephritis. Initial urine microscopy shows hematuria, pyuria (glomerular inflammation), and red blood cell casts. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. He was delivered by spontaneous vaginal delivery at 27 weeks of gestation due to maternal preeclampsia. He has been growing and developing normally with no significant medical issues to date. On physical examination, he is alert and energetic without scleral icterus or jaundice. Abdominal examination is notable for hepatomegaly, with his liver edge palpable 4 cm below the right costal margin. Abdominal ultrasonography with Doppler will confirm a hepatic mass and, of the studies listed, would be the best next step in evaluation. Hepatomegaly is a nonspecific finding and not a reliable predictor of liver disease. If an enlarged liver is suspected, physical examination should assess the liver span at the mid-clavicular line using palpation and percussion. The liver edge should be less than 2 cm below the costal margin at the mid-clavicular line, with the exception of children younger than 2 years of age, when it may be palpable to 3. The normal values for liver span are based on gender, age, and body weight, with a variability of +/ 2 to 3 cm. An abdominal ultrasonography can be used to confirm the size of the liver and provides some assessment of density and evaluation for a liver mass, if present. Laboratory studies may include a complete blood cell count, comprehensive metabolic panel, total and direct bilirubin, γ-glutamyl transferase, and an assessment of synthetic function with a prothrombin time and partial thromboplastin time. Evaluations for infectious etiologies and storage disease should be considered based on the history. The differential diagnosis for hepatomegaly is quite broad and is summarized in Item C247. Splenomegaly occurs with portal hypertension, storage disease, inflammation, infection, and malignancy. Magnetic resonance cholangiopancreatography is used to assess bile ducts and anatomy, and may be useful in the evaluation of hepatomegaly, but it is not the first imaging modality in the evaluation. Similarly, nuclear medicine liver and spleen scans and positron emission tomography may be used in the evaluation of hepatomegaly to assess blood flow or for tumor evaluations, but are not used to confirm hepatomegaly or as the initial screen for a mass. Pathophysiology, epidemiology, classification and treatment options for polycystic liver diseases.

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In the event that all laboratory testing is normal medicine stick buy genuine rivastigimine on line, or the symptoms are so minor that testing is not indicated medicine quotes quality 4.5mg rivastigimine, the diagnosis of premature adrenarche can be made medicine 4 you pharma pvt ltd generic 1.5mg rivastigimine. With premature adrenarche there is isolated pubic hair development without breast budding or other estrogen effects symptoms 9dpo buy rivastigimine with mastercard. She has continued to require 2 L of oxygen via nasal cannula to maintain oxygen saturations greater than 91%. A chest tube was placed on admission and an exudative pleural fluid collection was confirmed by laboratory analysis. Despite confirmed adequate placement of the chest tube, radiographic imaging reveals a persistent dense opacity and fluid collection in the inferior aspect of the right lung. Fibrinolytic therapy is instilled into the pleural space without resolution of the airspace disease. In children with pneumonia, parapneumonic effusion or empyema complicates the clinical course in 28% to 53% of cases. Pneumonia causes an inflammatory response in the pleura and in the pulmonary parenchyma. A pleural exudative response to this irritation may result in the development of a parapneumonic effusion or an inflammatory fluid collection between the parietal and visceral pleura. Initially, this pleural fluid is likely to be clear with a low number of white blood cells. With persistence and transition to a complicated parapneumonic effusion, there is an influx of inflammatory mediators, development of purulence, and deposition of fibrin. It is important to recognize the complicated parapneumonic effusion prior to the development of fibrotic change with irreversible lung restriction. The Light criteria have been used to characterize pleural fluid as exudative if at least 1 of the following criteria are met: o the ratio of pleural fluid protein to serum protein is greater than 0. While the Light criteria are commonly utilized in clinical care, they have not been validated in pediatric patients. Of note, recent data have shown that serum C-reactive protein levels are significantly higher in children with empyema, as compared to children with uncomplicated pneumonia. In the imaging of pneumonia and parapneumonic effusions, it is often challenging to differentiate between lung consolidation and pleural fluid with the use of plain radiographs. While a lateral decubitus radiograph may demonstrate “layering” with free flowing pleural effusions, the same is not expected with a complex or loculated parapneumonic fluid collection. Ultrasonography involves no exposure to ionizing radiation and is a useful modality in differentiating between a pleural and parenchymal process. In general, small and moderate uncomplicated parapneumonic effusions can be treated with antibiotics and do not routinely require chest tube drainage. Drainage with chest tube insertion is warranted when parapneumonic effusions are large in size or when purulence has been demonstrated; drainage is also indicated if the effusion is associated with respiratory compromise or distress. Chest thoracotomy tube drainage is an effective intervention for free flowing effusions. When effusions are complex or loculated, they may respond to instillation of fibrinolytic agents (such as tissue plasminogen activator or urokinase) through the indwelling thoracostomy tube. The patient in the vignette has now failed antibiotic therapy, chest thoracotomy tube drainage, and fibrinolysis. Hypertonic saline draws fluid into the airway after nebulized inhalation and may provide symptomatic relief in cystic fibrosis or bronchiolitis by rendering secretions less tenacious. The fluid collection in this case is not in the airway and would not respond to this therapy. Continued observation, repeat instillation of fibrinolytic therapy, and lung biopsy are not indicated. Timely management of the complicated effusion is warranted in order to prevent late complications, including restrictive lung disease. The mother is trying to determine which feeding practices will fit with her lifestyle as a biology graduate student. She has heard that breastfeeding promotes a healthier immune system compared to formula feeding and asks what the mechanism of this protection is. Most of the immune supporting components of breast milk exert their effects within the gastrointestinal tract at the mucosal level. The primary immunoglobulin in breast milk, and the most studied bioactive component, is secretory immunoglobulin A (sIgA); immunoglobulin M and immunoglobulin G occur in much smaller amounts. The sIgA exerts its effects by binding to microbial antigens, inhibiting their adhesion to host cells and preventing their penetration of the mucosal barrier. In addition, sIgA promotes phagocytosis and is active in regulating local immune response. In addition, several of these protein components, along with oligosaccharides (a carbohydrate component of breast milk) promote the growth of beneficial bacteria. While less clear, there is evidence that breastfeeding results in enhanced neurodevelopment. The bacterial microflora of the gut is also critical in the development of local immunity. Oligosaccharides are important for creating a healthy microflora, and cow milk-based formula contains much lower levels of oligosaccharides than human milk does. In human milk-fed infants, Lactobacillus bifidus and Bifidobacterium are the predominant organisms, while for formula fed-infants, the most common organisms are gram negative. This difference in microflora likely contributes to differences in immune response. Adding probiotics to formula may improve the gastrointestinal microflora, but does not provide the other immune benefits of human milk. While breastfeeding helps protect the infant against various pathogens, breast milk can be the vehicle to transmit some viruses from mother to infant. You remind the residents of the top causes of adolescent and young adult (age 15-24 years) mortality and stress the importance of thorough psychosocial risk assessments during adolescent preventive care visits. Of the following, the top 3 leading causes of death for this age group are unintentional injury, A. The mortality rate of males between 15 to 19 years of age was more than twice that of females in 2010. Additionally, non-Hispanic, American Indian/Alaska Native adolescents had the highest rate of mortality among both males and females. Non-Hispanic black males had the second highest rate; non-Hispanic, Asian/Pacific Islander females had the lowest rate. Unintentional injury was the leading cause of death for adolescents of all racial and ethnic groups, except non-Hispanic black males, for whom homicide was the leading cause of death. The major causes of adolescent mortality are largely preventable, therefore routinely reviewing and counseling on issues such as driving and personal safety with adolescents are important in the provision of adolescent preventive services. She was running down the court during a game, came to a sudden stop, and felt “a pop” in her knee. The patient was seen at an urgent care clinic on the day of injury, where radiographs were performed and were unremarkable. The urgent care clinician fitted her with a knee immobilizer and recommended follow-up with her primary care physician. The patient is guarding, and therefore you are unable to adequately assess for ligamentous laxity. Another reasonable option would be to recommend protected ambulation with crutches, gentle range-of motion exercises, application of ice to reduce swelling and a return visit to the clinic for repeat examination in about 2 weeks. Common mechanisms of injury include sudden deceleration, landing from a jump, and twisting or changing direction. To perform a Lachman maneuver, the examiner flexes the patient’s knee to 30 degrees, stabilizes the femur with 1 hand, and attempts to pull the tibia anteriorly with the other hand. Surgical reconstruction is preferred for athletes who wish to return to sports involving jumping or direction change. The surgical technique for skeletally mature individuals involves drilling through the bone in the area where the physis is located. Exercise programs emphasizing balance, strength, and landing mechanics have been shown to reduce rates of injury. Athletes in sports with high injury rates, for example, soccer and basketball, appear to derive the largest benefits from neuromuscular training programs. For the athlete in the vignette, a return to sports is inappropriate because her history and physical examination are suggestive of intra-articular injury.

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Many thrombotic adverse events could be linked to pretreatment order rivastigimine online presence of trace amounts of clotting factors that copurify with IgG and occur more commonly (but not exclusively) in patients with risk factors for thrombosis symptoms kidney problems buy rivastigimine with paypal. Determining the precise cause and how to treatment hpv purchase rivastigimine cheap online prevent thrombotic complications is an area of active investigation medicine bow order rivastigimine cheap online. Anaphylactic reactions induced by anti-IgA can occur in patients with primary immune defciency who have a total absence of circulating IgA and develop IgG anti bodies to IgA. These reactions are rare in patients with panhypogammaglobulinemia and potentially are more common in patients with selective IgA defciency and subclass IgG defciencies. Because of the extreme rarity of these reactions, however, screening for IgA defciency and anti-IgA antibodies is not recommended routinely. For patients with repeated severe reactions unresponsive to these measures, hydrocortisone (Solu-Cortef, 5–6 mg/kg in children or 100–150 mg in adults; or Solu-Medrol, 2 mg/kg) can be given intravenously 30 minutes before infusion. Smaller doses, administered more frequently (ie, weekly), result in less fuctuation of serum IgG concentrations over time. Antibodies of Animal Origin (Animal Antisera) Products of animal origin used for neutralization of toxins or prophylaxis of infectious diseases are derived from serum of horses or sheep immunized with the agent/toxoid of interest. These animal-derived immunoglobulin products are referred to here as “serum,” for convenience. These products are derived by concentrating the serum globulin fraction with ammo nium sulfate. Some, but not all, products are subjected to an enzyme digestion process to decrease clinical reactions to administered foreign proteins. Patients with a history of asthma or allergic symptoms, espe cially from exposure to horses, can be dangerously sensitive to equine sera and should be given these products with the utmost caution. People who previously have received animal sera are at increased risk of developing allergic reactions and serum sickness after admin istration of sera from the same animal species. Nevertheless, any sensitivity test must be performed by trained personnel familiar with treatment of acute anaphylaxis; necessary medications and equipment should be available readily (see Treatment of Anaphylactic Reactions, p 67). Positive (histamine) and negative (physiologic saline solution) control tests for the scratch test also should be applied. A positive test result is a wheal with surrounding erythema at least 3 mm larger than the negative control test area, read at 15 to 20 minutes. Positive and negative control tests, as described for the scratch test, also should be applied. For people with nega tive history for both animal allergy and previous exposure to animal serum, the 1:100 dilution may be used initially if a scratch, prick, or puncture test result with the serum is negative. Positive test results not attributable to an irritant reaction indicate sensitivity, but a negative skin test result is not an absolute guarantee of lack of sensitivity. Therefore, ani mal sera should be administered with caution even to people whose test results are nega tive. Immediate hypersensitivity testing is performed to identify IgE-mediated disease and does not predict other immune reactions, such as serum sickness. If history and sensitivity test results are negative, the indicated dose of serum can be given intramuscularly. In these instances, serum should be diluted and slowly administered intravenously according to the manufacturer’s instruc tions. The desen sitization procedure must be performed by trained personnel familiar with treatment of anaphylaxis and with appropriate drugs and available equipment (see Treatment of Anaphylactic Reactions, p 67). If signs of anaphylaxis occur, aque ous epinephrine should be administered immediately (see Treatment of Anaphylactic Reactions, p 67). Administration of sera during a desensitization procedure must be continuous, because if administration is interrupted, protection achieved by desensiti zation will be lost. Of these, only anaphylaxis is mediated by IgE antibodies, and thus, occurrence can be predicted by previous skin testing results. Severe febrile reactions should be treated with antipyretic agents or other safe, available methods to decrease temperature physically. Manifestations, which usually begin 7 to 10 days (occasionally as late as 3 weeks) after primary exposure to the foreign protein, consist of fever, urticaria, or a maculopapular rash (90% of cases); arthritis or arthralgia; and lymphadenopathy. Local edema can occur at the serum injection site a few days before systemic signs and symp toms appear. Angioedema, glomerulonephritis, Guillain-Barré syndrome, peripheral neu ritis, and myocarditis also can occur. However, serum sickness may be mild and resolve spontaneously within a few days to 2 weeks. People who previously have received serum injections are at increased risk after readministration; manifestations in these patients usu ally occur shortly (from hours to 3 days) after administration of serum. Antihistamines can be helpful for management of serum sickness for alleviation of pruritus, edema, and urticaria. Fever, malaise, arthralgia, and arthritis can be controlled in most patients by administration of aspirin or other nonsteroidal anti-infammatory agents. Corticosteroids may be helpful for controlling serious manifestations that are controlled poorly by other agents; prednisone or prednisolone in therapeutic dosages (1. Anaphylaxis usually begins within minutes of exposure to the causative agent, and in general, the more rapid the onset, the more severe the overall course. Major symptomatic manifestations include (1) cutaneous: pruritus, fushing, urticaria, and angio edema; (2) respiratory: hoarse voice and stridor, cough, wheeze, dyspnea, and cyanosis; (3) cardiovascular: rapid weak pulse, hypotension, and arrhythmias; and (4) gastrointesti nal: cramps, vomiting, diarrhea, and dry mouth. Medications, equipment, and compe tent staff necessary to maintain the patency of the airway and to manage cardiovascular collapse must be available. Mild symptoms, such as skin reactions alone (eg, pruritus, erythema, urticaria, or angioedema), may be the frst sign of an anaphylactic reaction but intrinsically are not dangerous and can be treated with antihistamines (Table 1. However, using clinical judgment, an injection of epi nephrine may be given depending on the clinical situation (Table 1. Epinephrine should be injected promptly for anaphylaxis, which is likely (although not exclusively) occurring if the patient has: (1) skin symptoms (generalized hives, itch-fush, swollen lips/tongue/uvula) and respiratory compromise (dyspnea, wheeze, bronchospasm, stri dor, or hypoxemia); or (2) 2 or more organ systems involved, including skin symptoms or respiratory compromise as described above, plus gastrointestinal tract symptoms (eg, persistent gastrointestinal tract symptoms, such as crampy abdominal pain or vomiting) or cardiovascular symptoms (eg, reduced blood pressure, syncope, collapse, hypotonia, incontinence). If a patient is known to have had a previous severe allergic reaction to the biologic product/serum, onset of skin, cardiovascular, or respiratory symptoms alone may warrant treatment with epinephrine. When the patient’s con dition improves and remains stable, oral antihistamines and possibly oral corticosteroids (1. Severe or potentially life-threatening systemic anaphylaxis involving severe broncho spasm, laryngeal edema, other airway compromise, shock, and cardiovascular collapse necessitates additional therapy. Maintenance of the airway and administration of oxygen should be instituted promptly. Administration of epinephrine intra venously can lead to lethal arrhythmia; cardiac monitoring is recommended. A slow, continuous, low-dose infusion is preferable to repeated bolus administration, because the dose can be titrated to the desired effect, and accidental administration of large boluses of epinephrine can be avoided. Second Symposium on the Defnition and Management of Anaphylaxis: Summary Report-Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. Mixing 150 mg of dopamine with 250 mL of saline solution or 5% dextrose in water will produce a solution that, if infused at the rate of 1 mL/kg/h, will deliver 10 μg/kg/min. This dilution can be made using 1 mL of the 1:1000 dilution in 9 mL of physiologic saline solution. One milligram (1 mL) of 1:1000 dilution of epinephrine added to 250 mL of 5% dextrose in water, resulting in a concentration of 4 μg/mL, is infused initially at a rate of 0. Corticosteroids should be used in all cases of anaphylaxis except cases that are mild and have responded promptly to initial therapy (see Table 1. However, no data support the usefulness of corticosteroids in treating anaphylaxis, and therefore, they should not be administered in lieu of treatment with epinephrine and should be considered as adjunctive therapy. All patients showing signs and symptoms of systemic anaphylaxis, regardless of sever ity, should be observed for several hours in an appropriate facility, even after remission of immediate symptoms. Although a specifc period of observation has not been established, a period of observation of 4 hours would be reasonable for mild episodes, and as long as 24 hours would be reasonable for severe episodes. Anaphylaxis occurring in people who already are taking beta-adrenergic–blocking agents can be more profound and signifcantly less responsive to epinephrine and other beta-adrenergic agonist drugs. More aggressive therapy with epinephrine may over ride receptor blockade in some patients. Immunization in Special Clinical Circumstances Preterm and Low Birth Weight Infants Preterm infants born at less than 37 weeks’ gestation and infants of low birth weight (less than 2500 g) should, with few exceptions, receive all routinely recommended childhood vaccines at the same chronologic age as term infants.

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The 28B has not been occur naturally in environment nor in feaces but it is used as model organism in several studies (Höglund et al medicine 3202 purchase rivastigimine 3mg with visa. Фx174 bacteriophage is non-enveloped with simple icosahedral structure (Dika et al symptoms depression generic 3 mg rivastigimine amex. The animal model organisms used are canine adenovirus symptoms underactive thyroid buy rivastigimine 3mg otc, murine norovirus symptoms 2 dpo effective 4.5mg rivastigimine, porcine enterovirus and mammalian orthoreovirus. The reovirus is responsible for mild illness such as cold and diarrhea mostly in children’s. Mammalian orthoreovirus type 3 is used as model organism in the present study, the mammalian orthoreovirus type 3 Dearing strain is currently used as naturally onco-lytic virus used in clinical trails (Kim, 2015). All these model viruses are used because they share most of the biological properties with the human viruses and are cultured according to the protocol mentioned in methodology section. The different characteristics of the viruses and model organisms used in the experiment are shown in the table 3 below. The surface water typically contains highly suspended solid particles and microbial contamination with viruses, bacteria, algae and organic matter. In order to reduce organic and microbial content, the water must be treated through several stages to provide complete safe drinking water. The most commonly used methods by water treatment plants for surface water are filtration, flocculation, sedimentation, and disinfection. Primary treatment is a type of treatment in which suspended solids are removed from the raw water. In Primary treatments of drinking, water viruses are less efficiently removed so disinfection is the critical process for reduction of viruses in surface water. To produce safe drinking water generally the water treatment plants removes and -6 inactivate viruses to acceptable levels (approx. The treatment need for moderately contaminated surface water is normally 6-log reduction, which produces 99. Log reduction: Log reduction is defined as number of microbes removed from the surface by disinfection or by cleaning. If the surface having 1,000,000 pathogenic microbes, the reduction of these pathogenic microbes to one gives a six log reduction (Vries and Hamilton, 1999). The relationship between log reduction and percent reduction is as follows 1 log reduction = 90% reduction 2 log reduction = 99% reduction 3 log reduction = 99. Log reduction can be calculated using the formula 13 Log reduction = log10(A) – log10(B) (or) log reduction = log10(A/B) Where A = Number of viable microorganisms before treatment, B = Number of viable microorganisms after treatment. The treatment of the surface water by the water treatment plants that remove contaminants are as follows, 1. The floc and dirt becomes heavy to sink at the bottom during sedimentation to clear water flow to filtration. The water passes through filters such as gravel, charcoal and layers of sand helps in removal of smaller particles. Coagulation conditions such as dose, pH, temperature and turbidity affect the efficiency of removal of microbes. The average microbial removal of this treatment process is 27 to 74% for viruses, 32 to 87% for bacteria and 0 to 94% for algae. In sedimentation process, coagulated and flocculated particles are removed physically (Fewtrell et al. Since, only 1-2 log reduction is done in conventional treatment, disinfection is a crucial in order to remove the viruses to provide safe drinking water. These disinfectants also remove organic contaminants for microorganisms and these organic contaminants serve as nutrients or shelters. These disinfectants remain actively in 14 water even after disinfection because they must have a residual effect. The chlorine gas is hazardous and impractical, so based on this calcium and sodium hypochlorite are widely used disinfectants because they are easy to distribute, cheap and safe use and they are effective against most bacterial and viral pathogens. The factors affecting the disinfection process are pH, temperature, contact time, and concentration of the disinfectant used and physical and chemical parameters of the water. According to Swedish legislation, the amount of free chlorine allowed to add is not more than 1 mg/L. Free chlorine can be used as primary disinfectant and also can be used as secondary disinfectant in distribution systems in water treatment plants. Monochloramine is also used as a disinfectant but not so effective, it is used to prevent the bacterial regrowth in water pipes. When sodium hypochlorite reacts with water gives hypochlorous acid and this will give hypochlorite ion. The knowledge of virus functions is necessary to understand and to predict the inactivation mechanisms, which are unclear. The mode of entry of viruses into the host organism is important, which is different from bacteriphages. Modifications in viral proteins and nucleic acids occur when exposed to inactivating oxidants and radiation. A systematic understanding of virus inactivation losses to functionalities such as host recognition, genome replication would develop understanding and optimization of treatments (Wigginton et al. Generally the microbes will be inactivated after addition of disinfectants, which means the initial reduction will be seen within vey less time. These disinfectants will get into contact with the pathogens at certain time and at a particular concentration. Aim of the study the specific goals of this project were as follows,  To study the efficiency of chlorination (free chlorine) on viruses in waters from Scandinavian drinking water treatment plants in laboratory scale. Then, the virus was 2 inoculated onto cells in 25 cm cell culture bottles, and after absorption for about 1 h, cell culture medium was added. After 80-100% cytopathogenic effect was evident, the cells were frozen and thawed 2-3 times at centrifugation for 2500×g for 20 min to get rid of the cell debris. The phages were added in 1:1 volumes to 18 bacterial solution to obtain the same concentration of phages and bacteria in the solution and cultured for 24 hours at 37˚C. To filter out the bacteriophages, the culture medium was centrifuged at 2000×g for 15-20 minutes until clear supernatant was obtained. Now, the supernatant was filtered and concentration of bacteriophages was determined. Pre-studies were performed to know the appropriate amount of hypochlorite that should be added to the water. All the glasswares used in the experiment were soaked overnight in diluted hypochlorite solution to avoid contamination. Soak all the glassware to be used in the solution overnight or for at least 1hour before starting the experiment and rinse the glassware to be used 5 times in deionized water, and let it dry. Two glass beakers, one with 150 ml of water (for Chlorine inactivation) and the other with 50 ml of water (positive control) were taken. Chlorine Inactivation: 9 ml of virus and 300 µl of bacteriophages were added to chlorine inactivation beaker. After allowing for 2 minutes, the appropriate amount of hypochlorite solution was added to the chlorine inactivation and chlorine readings were noted immediately and after 2, 4, 10, 30 and 60 minutes. The readings were measured by placing the sample in the kit and readings were noted. A bag of total chlorine was added to the other sample, shaken for 20 sec and after 6 minutes readings were noted again. Positive control Inactivation: 3 ml of virus and 100 µl of bacteriophages were added to positive control beaker. For one sample free chlorine bag was added and shaken for 20 seconds upside down for allowing the chlorine residuals to react with viruses and bacteriophages and after 1 minute reading was taken by using chlorine kit. To the other sample total chlorine bag was added and shaken for 20 sec and after 6 minutes the reading was taken down. The glass beakers were immediately placed in 5˚C incubator after measuring every sampling point. Now the sodium thiosulphate test tubes containing samples were aliquoted into 1 ml tubes and stored in the 70˚C freezer. The aliquoted virus samples (obtained after chlorine inactivation procedure) were titrated in cell culture medium to tenfold dilution (100+900 µl), 50 µl virus dilutions were inoculated with the above-prepared cells in 8 wells per dilution. For positive control, 50 µl virus was added in 8 wells as cell control in order to compare with the virus dilutions. The analysis was done by preparing particular host strain to each bacteriophage to determine the plaque count.

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