The hard core of the ground power in being would come from Europe erectile dysfunction nerve best dapoxetine 60mg, aided by other nations erectile dysfunction raleigh nc purchase dapoxetine 60 mg on-line. England erectile dysfunction at 25 dapoxetine 60mg cheap, France impotence yoga 90 mg dapoxetine with amex, and the closer countries would have the bulk of short-range attack bombardment and air defense. The United States would, of course, maintain its own defense and tactical air support forces for its ground and naval arms. But with no warning in July 1949, Truman called defense officials to his office and told them to reduce the fiscal 1951 request to $13 billion, a reduction that by plan or circumstance equaled the military assistance package. Navy this cut promised further aircraft carrier reductions in addition to the United States. From April through August, a Navy propaganda office attacked the B-36 program and the growing reliance on long-range strategic bombing. In this same season, sometime between 26-29 August, the Soviet Union exploded an atomic device several years before U. The committee quickly exonerated Air Force leaders of insinuations of irregularity in B-36 procurement, but in regard to strategy, the final committee report advocated preservation of a plural defense establishment. The committee held that "military air power consists of Air Force, Navy, and Marine Corps air power, and of this, strategic bombing is but one phase. Short-range plans that gained approval were typically and admittedly infeasible and hardly more than a beginning was made on intermediate and long-range plans, or on mobilization plans. Although the Korean War was perhaps not foreseeable, its planning had to proceed virtually from scratch, barely ahead of implementing actions and operation^. Samford, Director of Air Force Intelligence, had an additional thought: "Since it has been stated that military men are unable to reach any fundamental agreement on the art of war, it seems very probable that civilian thought will go to work to help them. That same day, he directed the Secretaries of State and Defense to prepare a basic review of the national political and military strategy of the United States in the light of the Soviet atomic explosion. The National Security Council handled the paper for costing and estimated that the expanded military program would come to about $50 billion annually for a number of years. President Truman had been attempting to limit total military spending to not more than $15 billion a year and preferably less. The year 1954 looked like a year of maximum danger to the Un-ted States and Western Europe because 26 1 Soviet production of new weapons would peak. For one moment, when the Chinese Communist armies were attacking in mass, it appeared that President Truman might authorize emergency use of an atomic weapon. Given this stock and the need to maintain deterrence of the Soviet Union, it is easy to see why the Joint Chiefs of Staff were not eager to use atomic bombs in Korea or against China. General Vandenberg described his organization as a shoestring air force in view of its global commitments. It could not sacrifice its deterrent capabilities for the sake of pecking at the periphery of Communist power in Manchuria and China. Early in October 1951, the Joint Chiefs of Staff were able to complete planning for stabilized forces. The program projected an army with 20 divisions; a navy with 409 major combat ships, including 12 modem aircraft carriers, 3 marine divisions, and 3 marine air wings; and an air force with 143 wings, including 126 combat and 17 troop carrier wings. President Truman approved this military buildup on 28 December 1951, but he directed the program be stretched out in order that the armed forces budget, including military assistance for fiscal 1953, would fall below $60 billion. New technology was turning out bombs of small and convenient design that could be carried by fighter aircraft. Taking into consideration the 262 growing nuclear weapons availability, European allies were less enthusiastic about large conventional defenses. The British chiefs of staff argued that the advent of nuclear weapons justified a primary reliance on atomic air power and a substantial reduction in expensive surface forces. On a visit to Washington in July 1952, Air Chief Marshal Sir John Slessor argued that the Lisbon force goal placed too great a strain on fragile European economies and recommended a strategy of nuclear deterrence based upon American and British nuclear air power. During the spring of 1953, the Eisenhower administration was able secretly to threaten to use atomic weapons if the United Nations did not soon get an honorable military armistice in Korea. The armistice came on 27 July 1953, and Secretary of State John Foster Dulles offered a cogent reason why the Communists agreed to the armistice: "The fighting was stopped on honorable terms because the aggressor, already thrown back to and behind his place of beginning, was faced with the possibility that the fighting might, to his own great peril, soon spread beyond the limits and methods he had se:e~ted. The goal of the Air Force was trimmed from 143 to 137 wings, which parenthetically it reached for one brief moment thanks to some programming legerdemain in mid-1956, only to find that it could not program support for a force of this size. In statements during 1953, Eisenhower referred to the need for the services to integrate new weapons more effectively into their planning. Goodpaster, writing on the basis of six and one-half years in the White House as staff assistant to President Eisenhower and a later tour as Supreme Allied Commander in Europe, has set forth some better judgmental standards to evaluate both the Eisenhower defense policy and indeed any military policy-this by pointing to the importance of military power in terms of defense, deterrence, or detente. Defense equals employment of armed forces in combat operations or the preparation of such forces. At this meeting, Eisenhower pointed out that the two categories of military force that he was emphasizing-forces for retaliation and continental defense-would not be sufficient to give the United States a war winning capability if deterrence failed and a major war broke out. Eisenhower believed that the New Look would deter the Soviets and since lowered defense spending was of utmost importance, the New Look`s admitted operational shortcomings were an acceptable risk. Air Force and its essentially simplistic concept of air power as massive strategic bombing. At the National Press Club on 29 November 1957, Air Force Chief of Staff General Thomas D. Air Force wing strength peaked at 137 wings in mid-1956 and then had to be reduced, mostly in tactical fighter wings to meet financial constraints. In the several years after 1956 the 11-wing B-52 force expanded to 14 wings, with a compensatory reduction of shorter range B47s. By all military standards the Strategic Air Command under General LeMay stood at a state of readiness, discipline, and efficiency seldom before known in world history. The development of strategic striking power was accompanied by a denigration of tactical air forces and air mobility forces. Under extreme financial pressure in 1957, a cold war conference of senior Air Force commanders agreed that the Air Force should cross the nuclear Rubicon: it should measure its high-explosive ordnance capability and retain it, should not increase it, and should eliminate it when national policy permitted. The movie, Milton recalled, showed "in a wonderfully simplistic way, how a bomber or two made superfluous all the other excessive paraphernalia of war: the troops, the ships, the fighter planes, were all neatly crossed out. Army ought to provide its own organized firepower support within a combat zone and that the Strategic Air Command and Tactical Air Command should be reorganized into one "Air Offensive Command" under a single commander. One factor overlooked in airpower thought, moreover, was that aerial technology and weapons effects do not necessarily provide overweening utility in a war if one follows the premise of Air Marshal Slessor that to win a war means to create "world conditions more favorable for oneself than would have been possible if there had not been a war. The growing reluctance to depend on actual usage of nuclear weapons was evidenced in the Lebanon-Taiwan Straits Crisis in 1958. In the Taiwan area, the contingency war plan called for use of nuclear bombs against Chinese Communist airfields in Fukien Province in case Taiwan was forces were gathering toward Taiwan, President invaded. Eisenhower doubtlessly noted a Soviet threat; a nuclear strike against China would be the same as an attack on Russia. In any event, Eisenhower directed that nuclear weapons would not be used at the outset of a Chinese Communist attack. McNamara would explain that in the 267 early 1960s he already believed-using italics for emphasis-that "nuclear weapons serve no military purpose whatsoever. The test of the Kennedy defense strategy came in the Cuban missile crisis of October 1962, when the United States was able to flex far superior strategic power over the Soviets and was also able to ready general purpose invasion forces in Florida for movement to Cuba. To General LeMay the Cuban crisis was an outstanding example where superior strategic power, coupled with a manifest willingness to employ it, was decisive. The choice was made that it was not necessary to go because the Russians removed the missiles. What I have said here reflects a new environment of interservice cooperation forced in no small part by the strategic necessity of raising the nuclear threshold while simultaneously coping with the military power of the Soviet Union. But even though it may be unsporting to scoff at the past, it goes without saying that the historical 1940s and 1950s 268 laid the groundwork for the 1960s and thereafter. Thus if this survey of air planning is to be more than mere buff-stuff, some observations drawn from the past yet possibly of ongoing pertinence deserve mention, as much to get thought as anything else. Air Force planning in 1945-1962 was partly produced and partly drawn from national military planning. The plans of the era were not based upon the whole aspect of war as an institution that comes in many different characterizations. The emphasis of air planners was in making war fit a weapon-nuclear air powerrather than making the weapon fit a war. Theirs was a weapons strategy wherein the weapons determined the strategy rather than strategy determining the weapons. The pertinent observation here is that sound military planning must be based on a study and appreciation of war in its broadest aspects, not only in modern times but throughout history. We know that all plans are inevitably based upon assumptions, either stated or implicit.
Although in many tropical areas there is continuous breeding throughout the year erectile dysfunction kolkata purchase dapoxetine 60mg free shipping, there may nevertheless be dramatic increases in population size during the rainy season erectile dysfunction medicine reviews cheap dapoxetine 60mg visa. Nuisance In both tropical and non tropical areas of the world black flies can cause a very serious bitting problem icd 9 erectile dysfunction nos buy dapoxetine 90mg line, since there bites can be painful erectile dysfunction best treatment dapoxetine 90 mg otc. Although the severity of thereaction to bites is different in different individuals, localized swelling and inflammation frequently occurs, accompanied by in tense irritation lasting for several days or even weeks. Onchocerciasis Onchocerciasis / river blindness is the disease transmitted by the female black fly. Rarely life threatening, the disease causes chronic suffering and severe disability. It is often called river blindness because of its most extreme manifestation and because the black flies that transmit the disease abound in riverside areas, where they breed in fast-flowing waters. Causative agent A parasitic worm, Onchocerca volvulus, of the family filariidae, which lives in the human body for up to 14 years. Each adult female worm produces millions of microscopic larvae (microfilariae), that migrate throughout the body to cause a variety of symptoms. Transmission Transmission of the disease is via the bite of infected black flies (Simulium spp. The life-cycle begins when a parasitized female black fly takes a blood-meal from a human host. After mating, eggs formed inside the female worm, develops into microfilariae and leave the worm one by one. When the microfilariae die, they cause skin rashes, lesions, intense itching and skin depigmentation. Immature worms move through the body and after dying, cause a variety of conditions including serious visual impairment and blindness, skin rashes, lesions, intense itching and 97 depigmentation of the skin, lymphadenitis (resulting in hanging groins and elephantiasis of the genitals) and general debilitation. Prevention and control of Onchocerciasis Drug treatment: the development of ivermectin in the 1980s provided a safe, effective drug for killing microfilariae in infected people. Vector control: insecticide spraying to control black flies has proved successful in certain areas. Simulium larvae are killed by applying insecticides via aerial spraying over breeding sites in fastflowing rivers. Following interruption of transmission, the reservoir of adult worms dies out in humans after 14 years. The objective is to create, by 2007, sustainable community-directed distribution systems using ivermectin. Mansonella Ozzardi Mansonella ozzardi is a filarial parasite of humans that is usually regarded as non-pathogenic, although it has been reported as causing morbidity in Colombia and Brazil. Although insecticidal fogging or spraying of vegetation though to harbour resting adult blackflies has occasionally been undertaken, this approach results in very temporary and localized control. The only practical method at present available fro the control of blackflies is the application of insecticides to their breeding places to kill the larvae. Insecticides need be applied to only a few selected sites on watercourses for some 15-30 min, because as the insecticide is carried downstream it kills simuliid larvae over long stretches of water. The flow rates of the water and its depth are used to calculate the quantity of insecticide to be released. If treatment is not repeated at intervals throughout the year, gravid female adult dispersing into the area from untreated areas will probably cause recolonization. Under these conditions aerial applications from small aircraft or helicopters have been used. Considerable information has been gained in North America on the chemical control of pestiferous blackflies. This programme originally involved seven west African countries but has now expanded to cover 11 countries. Because of the appearance of temephos resistance (in 1980) in some populations and species of the S. Larviciding will continue in the newer areas covered by the programme until the year 2000, thus giving insecticidal control in these areas fro 14 years, the period required to eliminate O. Alternata There are some 700 species of phlebotomine sandflies in five genera within the subfamily phlebot00 ominae of the family psychodidae. Species in three genera, phlebotomus, Lutzomyia and Sergentomyia, suck blood from vertebrates, the former two are the more important medically as they contain disease vectors. The genus phlebotomus occurs only in the Old World, especially in southern parts of the northern temprate areas such as the Mediterranean region. The genus also occurs in the Old world 102 tropics, but there are not many species in tropical Africa, especially West Africa. Most phlebotomus species inhabit semiarid and savannah areas in preference to forests. Lutzomyia species by contrast are found only in the New World tropics, occurring mostly in the forested areas of Central and South America Sergentomyia species are also confined to the Old World, being especially common in the Indian subregion, but also occurring in other areas such as Africa and Central Asia. The only other blood-sucking flies which are as small as this are some species of biting midges (Ceratopogonidae), but these have non-hairy wings and differ in many other details. Phlebotomine sandflies have the head, thorax, wings and abdomen densely covered with long hairs. The antennae are are long and composed of small bead-like segments with short hairs; they are similar in both sexes. At their base are pair of five-segmented maxillary palps 103 which are relatively conspicuous and droop downwards. Wings are lanceolate in outline and quite distinct from the wings of other biting flies. The phelebotominae can be distinguished from other subfamilies of the family psychodidae, which they may superficially resemble, by the wings. In sandflies the wings are held erect over the body when the fly is at rest, whereas in non-biting psychodid flies they are folded, roof like, over the body. In phlebotomine sandflies, but not in the other subfamilies of psychdidae, vein 2 branches twice, although this may not be apparent unless most of the hairs are rubbed from the wing veins (Figure 4. Although it usually lasts less than 45 days, Breeding is in the soil independent of surface water. Sand flies usually rest in the day time in dark and humid sites such as termite hills, animal burrows, cracks in mud walls and masonry, on decaying vegetations etc 104 Figure 4. Adult Behavior Both sexes feed on plant juices and sugary secretions but females in addition suck blood from a variety of vertebrates, including livestock, dogs, urban and wild rodents, snakes, lizards and amphibians; a few species feed on birds. In the Old World many phletobomus species bite people whereas most species of sergentomyia feed mainly on reptiles and rarely bite humans. In the tropical Americas Lutzomyia species feed on a variety of mammals including humans. Biting is usually restricted to crepuscular and nocturnal periods but people 105 may be bitten during the day in darkened rooms, or in forests during overcast days. Most species feed out of doors (exophagic) but a few also feed indoors (endophagic). Adults are weak fliers and do not usually disperse more than a few hundred metres from their breeding places. Sandflies have a characteristic hopping type of flight so that there may be several short flights and landings before females settle on their hosts. During the day adult sandflies rest in sheltered, dark and humid sites, but on dry surfaces, such as on tree trunks, on ground litter and foliage of forests, in animal burrows, termite mounds, tree-holes, rock fissures, caves, cracks in the ground and inside human and animal habitations. Species that commonly rest in houses (endophilic) before or after feeding on humans are often referred to as domestic or peridomestic species. Examples are phlebotomus papatasi in the Mediterranean area and Lutzomyia longipalpis in South America. In temperate areas of the Old World sandflies are seasonal in their appearance and adults occur only in the summer months. In tropical areas some species appear to be common more or less throughout the year, but in other species there may be well marked changes abundance of adults related to the dry and wet seasons. Nuisance Apart from their importance as disease vectors, sand flies may constitute a serious, but usually localized bitting nuisance. In previously sensitized people their bite may result in severe and almostintolerable irritations, a condition known in the middle east as harara. Leishmaniasis this is a term used to describe a number of closely related diseases caused by several distinct species, subspecies and strains of Leishmania parasites. Distribution Leishmaniasis is wide spreaded in 22 countries in the New World and in 66 nations in the Old World, it is not found in South-east Asia.
Items 33-37 Hospital Information Enter the appropriate information to identify the birth center or nurse midwife completing the form erectile dysfunction treatment penile injections dapoxetine 90mg low cost. Handle this admission as a late pick-up when the newborn is assigned a beneficiary number erectile dysfunction alcohol purchase dapoxetine 90mg mastercard. The hyperlinked version of these special forms and instructions are located in Appendix D injections for erectile dysfunction treatment cheap 60 mg dapoxetine, Special Forms erectile dysfunction homeopathic treatment dapoxetine 60mg low cost, of this handbook. Medicaid-funded home and community based services available in Pennsylvania are: Personal Support Services: Assistance needed for the person to plan, organize, and manage community resources. Residential Habilitation Services: Assistance with acquisition, retention, or improvement in skills related to activities of daily living. Day Habilitation Services: Assistance with acquisition, retention, or improvement in selfhelp, socialization and adaptive skills which take place in a non-residential setting, separate from where the person resides. Prevocational Services: Services aimed at preparing an individual for paid or unpaid employment. Supported Employment: Paid employment services for people who need intensive ongoing support to perform in a work setting. Homemaker/Chore Services: General household activities provided by a trained homemaker when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself and others in the home. Adaptive Appliances and Equipment: Specially designed appliances and equipment needed for the person to live as independently as possible. Transportation: Transportation needed to enable persons to gain access to waiver and other community services. Respite Care Services: Services provided to individuals unable to care for themselves; furnished on a short-term basis because of the absence or need for relief of those persons normally providing care. The services are provided to adults, children, adolescents, and their families who exhibit an acute problem of disturbed thought, behavior, mood or social relationships. The services provide rapid response to crisis situations, which threaten the wellbeing of the individual or others. The variance of the crisis intervention program that services can be rendered include telephone crisis service, walk-in crisis service, mobile individual crisis service, mobile team crisis service, medical mobile crisis team service, and crisis residential service. It is designed to insure access to community agencies, services, and people whose functions are to provide the support, training and assistance required for a stable, safe, and healthy community life. Services will be offered within parameters imposed by funding and other resources. Resource coordination is similar to intensive case management in that the activities are the same. However, caseload limits are larger and there is no requirement for 24-hour service availability. Resource coordination is established as an additional level of case management and is not intended to replace intensive case management. Payment for sterilizations, abortions, and hysterectomies will only be made if the appropriate form(s) are completed and accurate, and the procedures were performed within any time frames specified within the regulations. It is therefore important that providers be aware of the regulations surrounding sterilizations, abortions, and hysterectomies, as well as how to complete the federally required forms accurately. Providers frequently experience rejections for claims submitted with federally required forms, which were incomplete or incorrect. This problem is made more difficult because providers do not know specifically why a form has been rejected. The following details which services require submission of a claim form and its applicable federal form: 5. Under certain circumstances, beneficiaries may be hospitalized for extensive periods of time. After the hospital is paid for the initial interim bill (using Type of Bill 112), additional interim bills (using Type of Bill 117), may be submitted after each 30-day period. These additional bills for continued hospitalization must be submitted as a claim adjustment for the preceding paid bill. Type of Bill 117 is an accumulation of the total stay from the date of admission to the date specified in the "through" section of Form Locator 6 Statement Covers Period. Payments made as a result of the interim billing will be adjusted up or down based upon the final review determination of allowable days. After the initial interim claim (Type of Bill 112) is submitted and paid, additional interim claims must be completed as "Replacements of Prior Claims" using Type of Bill 117. Each replacement is an accumulation of the total stay appearing in the Statement Covers Period and should be billed in 30-day increments reflecting all ancillary information for covered days during the identified Statement Covers Period. Remember to show the same admission date on both claims (admission date, Form Locator 17). When straddle billing at the beginning of a new fiscal year, Type of Bill 112 must be used. If the patient remains in the hospital (Patient Status 30) and you submit an interim or straddle bill, it is not necessary for you to subtract a discharge day since the patient has not been discharged. Upon receipt of Edit Code 4261, you must submit a properly completed claim, using Type of Bill 117, and Condition Code 60 with the following information: 1. Any days denied by the coordinator must be identified by the date in the comments section. An agency or independent provider cannot provide services to a child without this referral. Service coordination is not a reimbursable service with any third party insurer in Pennsylvania. Travel time related to eligible activities provided to the child/family is eligible for reimbursement. The plan should document the outcome expected from the service and any other specific needed to understand what this service is intended to do for the child. Progress notes provide a summary of activities provided the child/family response to the treatment/intervention, and progress/purpose of each visit/interaction. Out-of-state practitioners must be licensed and currently registered by the appropriate agency in their state. Other providers must be approved, licensed, issued a permit or certified by the appropriate State agency and, if applicable, certified under Medicare. It is to be used by currently enrolled providers to request changes to their provider information. In addition, each provider will be assigned one or more 4-digit service locations that identify the physical address where service is provided, the provider type and at least one specialty. Pertinent information is printed on the front and back of the letter for provider verification. As an approved provider, you may submit claims for reimbursement under the medical programs within the scope of coverage of your services for eligible individuals. The nine (09) digit identification provider number, and four (04) digit service location listed above have been assigned to you for billing purposes. For additional information regarding the Pennsylvania Department of Human Services Programs, please access our website at. Once read, the message can be marked "read" and will no longer appear on the initial window. Maintain passwords and, if authorized, can create and manage user accounts for others in their organizations. Although this response will be available upon submission, the claim will be held in a "Suspend" status for later processing. This prompt response to the claim submission will significantly reduce the time required for providers to submit properly completed claims and allow faster processing. A parent, legal guardian, relative, or friend may sign his or her own name on behalf of the beneficiary. When billing for services which are paid in part by another third party resource, such as Medicare, Blue Cross, or Blue Shield. When billing for services provided to a beneficiary who is unable to sign because of a physical condition such as palsy. When billing for services provided to a beneficiary who is physically absent, such as laboratory services or the interpretation of diagnostic services. Prior authorization is also required when a single item costing under $100 per item is requested in quantities totaling more than $100.
Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States impotence klonopin order dapoxetine 60 mg. The fraction of cancer attributable to modifiable risk factors in England treatment erectile dysfunction faqs buy cheap dapoxetine 30mg online, Wales impotence causes cures order 30mg dapoxetine visa, Scotland erectile dysfunction surgery options purchase 30 mg dapoxetine with mastercard, Northern Ireland, and the United Kingdom in 2015. A global cancer surveillance framework within noncommunicable disease surveillance: making the case for population-based cancer registries. Esta definiciуn no es totalmente correcta ya que a) algunas levaduras se reproducen por fisiуn, b) algunas levaduras producen micelio verdadero bajo ciertas condiciones nutricionales (dimorfismo) y c) ciertos hongos filamentosos pueden existir en forma unicelular o levaduriforme (dimorfismo). Son heterуtrofas, que viven a expensas de otros seres vivos (levaduras parбsitas) o sobre materia orgбnica muerta (levaduras saprуfitas). Estбn ampliamente distribuidas en la naturaleza; se las encuentra en las frutas, granos, miel y otros alimentos que contienen azъcar, en el suelo, aire, mar, piel y mucosa de mamнferos. Muchas de ellas son ъtiles para el hombre, como las que se emplean en la producciуn de cerveza, vino y pan; otras son perjudiciales ya que descomponen alimentos, deterioran fibras textiles o causan enfermedades en las plantas, los animales y el hombre. Existen mбs de 600 especies conocidas de levaduras, distribuidas en 60 gйneros taxonуmicos, de las cuales solo unas pocas especies son capaces de producir enfermedades en humanos y animales. Dentro de ellas, las mбs aisladas como agentes causales de infecciones en el hombre son: Candida albicans y otras especies del gйnero (se han descripto mбs de 190 especies): Candida parapsilosis, Candida tropicalis, Candida glabrata, Candida krusei, Candida dubliniensis, etc. Agentes etiolуgicos: El principal agente es Candida albicans, pero pueden estar implicadas otras especies de Candida, como, Candida dubliniensis, Candida glabrata, Candida famata, Candida krusei; C. Levaduras de otros gйneros distintos de Candida como Saccharomyces, Pichia, Rhodotorula pueden dar cuadros clнnicos similares a la Candidiasis. Clasificaciуn taxonуmica: Teniendo en cuenta la reproducciуn sexuada de las levaduras se las incluye en las subdivisiones Ascomycotina, Basidiomycotina y Deuteromycotina (cuando no se conoce la reproducciуn sexuada). Dominio: Eucarya Reino: Fungi Divisiуn: Eumycota Subdivisiуn: Deuteromycotina Clase: Blastomycetes Familia: Cryptoccocaceae Gйnero: Candida Especies: C. Las levaduras son causantes del 7,45% de las micosis, el 25% de las micosis superficiales y entre el Candidiasis-4 75 y 88% de las infecciones fъngicas nosocomiales. Afecta a individuos de cualquier edad, sexo o grupo йtnico Las levaduras del gйnero Candida existen en la naturaleza, en el suelo y agua dulce, vegetales, frutas, exudado de бrboles, granos y en general toda sustancia rica en hidratos de carbono simples. Ademбs, son habitantes habituales del aparato digestivo, respiratorio y regiones muco cutбneas del hombre y animales domйsticos. El sistema gastrointestinal humano tiene una poblaciуn pequeсa pero constante de C. En el adulto, dos factores regulan el nъmero de levaduras en el intestino: 1- otros miembros de la flora intestinal que ejercen un control sobre la densidad de poblaciуn de las levaduras (principalmente lactobacilos y bacterias anaerobias) a travйs de factores antimicrobianos, inhibidores de la adherencia, potenciales de уxido-reducciуn y competencia por los nutrientes disponibles y 2- la dieta, ya que la ingestiуn excesiva de frutas frescas, dulces u otros materiales fermentables darбn lugar a un aumento considerable en el nъmero de levaduras intestinales, particularmente de C. La piel normal tambiйn puede presentar flora de levaduras residentes, que incluye C. Patogenia El delicado balance o equilibrio que existe entre comensal (levaduras) y hospedero podrнa romperse y dar lugar al parasitismo o desarrollo de una infecciуn oportunista. El desarrollo de la enfermedad por Candida depende de la interacciуn de ciertos factores: Candidiasis-5 * Factores predisponentes para la infecciуn. Factores predisponentes Los factores desencadenantes de la enfermedad son generalmente modificaciones en los mecanismos de defensa del huйsped, los cuales, secundariamente, inducen transformaciones en el comportamiento del hongo. Las manifestaciones clнnicas y la severidad de la infecciуn estбn en relaciуn con la naturaleza y el grado de compromiso de las defensas normales del huйsped. Las causas predisponentes se pueden agrupar en: Locales: maceraciуn, contacto con agua, mala higiene. Enfermedades hematolуgicas: linfomas, leucemias, anemia aplбsica, agranulocitosis, neutropenia, hipo y agamaglobulinemia. Factores iatrogйnicos: uso prolongado de corticoides, quimioterбpicos, inmunosupresores, agentes citotуxicos, alimentaciуn parenteral, transplantes, cirugнa abdominal, utilizaciуn de sondas y catйteres, radioterapia, prуtesis, hemodiбlisis, cateterismo. Factores de patogenicidad El potencial patogйnico de las levaduras varнa considerablemente. Йstas no son un componente pasivo del proceso infeccioso, sino que poseen una serie de factores de virulencia. No existe un Candidiasis-6 ъnico factor que pueda ser considerado por sн solo como responsable de la patogenicidad, sino que se ha propuesto una combinaciуn de diferentes factores que contribuyen a una o mбs etapas de la infecciуn. Los principales factores de virulencia, que han sido estudiados en profundidad para C. Candidiasis-7 Mecanismos de defensa del huйsped a- No inmunes: 1- La interacciуn con otros miembros de la flora microbiana. En un paciente inmunocompetente esta invasiуn es limitada por macrуfagos y/o polimorfonucleares. En cambio en pacientes neutropйnicos, al fallar la respuesta celular innata (disfunciуn de la inmunidad), la levadura puede invadir el torrente sanguнneo y diseminarse. Otra vнa de diseminaciуn podrнa ser a travйs del ingreso directo de la levadura al torrente sanguнneo introducido por un catйter, que puede estar contaminado o que puede arrastrar las levaduras presentes en la piel del paciente o del personal mйdico o paramйdico que lo manipula. Formas Clнnicas de Candidiasis Grandes y pequeсos pliegues 1- Cutбnea Uсas: Onixis blastomicйtica Granuloma candidiбsico Mucosa oral: muguet, glositis, queilitis Mucosa genital: vaginitis y balanitis 2- Mucocutбnea Mucosa digestiva: esofagitis, gastritis, enteritis y lesiones perianales Mucosa bronquial Candidiasis mucocutбnea crуnica - Candidemia: Transitoria o persistente 3- Candidiasis Invasiva - Candidiasis Sistйmica o Diseminada 4- Alйrgica -Crуnica - Candidiasis Localizada (en diferentes уrganos) -Aguda 1-Cutбnea: Candidiasis de los pliegues (intertrigos blastomicйticos): cualquier pliegue del cuerpo puede ser atacado. Una de las causas predisponentes mбs frecuentes de esta afecciуn es la diabetes (modifica el estado bioquнmico de la piel, produce aumento del glucуgeno y de la acidez). Otros factores que favorecen esta afecciуn son el calor, la humedad y la maceraciуn de la Candidiasis-9 piel (es muy comъn en las personas obesas cuyos pliegues tienen mayor superficie de contacto y en estos pacientes aparecen otros pliegues como el suprapъbico que no existen en personas delgadas). En los lactantes, la regiуn perianogenital, de epidermis frбgil y delicada, irritada por las deyecciones o por el uso de los paсales, es una zona muy atacada por las levaduras. Candidiasis de los grandes pliegues (axilar, interglъteo, inguinal, submamario, suprapъbico): La lesiуn inicial se caracteriza por la presencia de una o varias vesнculas superficiales, que se rompen y dejan al descubierto un fondo rojo erosionado que no sangra. Cuando se abre el pliegue, se observa un fondo mбs o menos extendido rojo brillante y hъmedo; en el fondo se encuentra una grieta que puede estar cubierta por un magma blanquecino de piel macerada. Los pacientes pueden sentir un prurito mбs o menos acentuado y sensaciуn de ardor o quemazуn. Si se raspa la lesiуn con una hoja de bisturн o canto de un portaobjetos, se recoge unas especies de viruta hъmeda y pastosa. Lesiуn por Candida en pliegue inguinal Candidiasis-10 Lesiуn por Candida en pliegue submamario Lesiуn por Candida en pliegues inguinales que se extiende a abdomen y muslos (candidiasis del paсal) Candidiasis de los pequeсos pliegues (espacio interdigital de pies y manos, pliegues retroauriculares): estas lesiones se extienden en forma de arco gуtico entre las dos caras Candidiasis-11 laterales de los dedos que estбn en contacto y cuyos bordes estбn rodeados por colgajos de piel macerada, hъmeda y blanquecina. En los pies pueden ser atacados todos los espacios pero el 4є espacio es el mбs frecuentemente atacado. Lesiуn por Candida en espacios interdigitales de pie Lesiуn por Candida en espacios interdigitales de mano Paroniquia y Onicomicosis candidiбsica (Onixis blastomicйtica): Paroniquia: es inflamaciуn del pliegue ungueal tras la destrucciуn de la cutнcula, que aparece rojo, hinchado y doloroso, ocasionalmente con pus. Candidiasis-12 Onicomicosis: es una infecciуn causada por hongos en las uсas de pies y/o manos. Es comъn en la mujer adulta por dedicarse a los quehaceres domйsticos (mantienen sus manos mojadas o hъmedas gran parte del dнa) y el contacto con detergentes y sustancias abrasivas favorecen aъn mбs la maceraciуn. En los hombres estб relacionado con ciertas profesiones (pasteleros, cocineros, carniceros, lavacopas, etc. Otros factores predisponentes: diabetes, dermatitis crуnica, inmunosupresiуn, uso de corticoides, uso permanente de guantes oclusivos, manicurнa, uсas esculpidas, ancianos. La infecciуn comienza generalmente por el pliegue periungueal, que se inflama y enrojece y pueden producir dolor (paroniquia). Cuando la levadura invade la uсa, la placa ungueal cambia de color, se vuelve parduzca, engrosada, endurecida y se forman estrнas o surcos. La uсa no se hace friable como en el caso de la onixis producida por dermatofitos. Paroniquia y Onicomicosis candidiбsica Candidiasis-13 Granuloma candidiбsico: es una infecciуn rara que afecta a niсos, preferentemente con trastornos endocrinos (hipotiroidismo, hipoparatiroidismo) y produce lesiones en piel, uсas y cuero cabelludo, con caracterнsticas diferentes a las descriptas. Se describen como pбpulas vascularizadas primarias cubiertas de una costra gruesa, adherente, pardo amarillento, que pueden convertirse en callosidades o protuberancias. Es comъn en los bebйs hasta los 3 meses de edad (falta de factor candidostбtico del suero, acidez de la mucosa de los bebйs, etc. La lesiуn se puede presentar con la mucosa roja y brillante (forma eritematosa), o pueden aparecen lesiones como placas blanquecinas que pueden confluir formando verdaderas membranas, muy adherentes como engastadas en el epitelio (forma pseudomembranosa aguda o crуnica). La glositis por Candida se presenta como una lengua muy aumentada de volumen y con surcos y grietas transversales. La queilitis (es rara) es la inflamaciуn de los labios que se presentan cubiertos por gruesas escamas y grietas. Candida albicans es la especie mбs frecuentemente aislada; las especies de Candida no C.
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