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A live attenuated varicella virus vaccine is currently recommended as part of routine childhood immunization (Table 30 12) and its use has been associated with decreased mortality due to varicella across all age ranges Although only 10% of adults remain susceptible, varicella in adolescents and adults is a more serious disease Only about 2% of all cases of varicella occur in adults, but almost 50% of all deaths are in adults Thus, all susceptible adolescents and adults should be immunized, with special emphasis on certain high-risk groups, ie, health care workers; household contacts of immunosuppressed individuals; persons who live or work in environments where transmission can occur, eg, teachers in day care centers or elementary schools, residents and workers in institutional settings such as military and correctional institutions, college students; nonpregnant women of childbearing age; and international travelers The role of the present vaccine in postexposure prophylaxis has not been widely studied, but it has been suggested that it is 90% effective in preventing varicella in an outbreak, particularly when given within 3 5 days after exposure The ACIP recommends vaccination in susceptible persons following exposure The vaccine is very immunogenic Seroconversion occurs in 95% of children after a single dose In adolescents (older than 12 years of age) and adults, seroconversion is seen in 78% after one dose and 99% after two doses For this reason, two doses given 4 8 weeks apart are recommended in persons 12 years of age and older The duration of immunity is not known but is probably 10 years Although the vaccine is very effective in preventing disease, breakthrough infections do occur but are much milder than in unvaccinated individuals (usually less than 50 lesions, with milder systemic symptoms) Although the vaccine is very safe, adverse reactions can occur as late as 4 6 weeks after vaccination Tenderness and erythema at.

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Getting Started. This section explains how to add and use a PDF viewer control in your web application with ASP . NET MVC .

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Pemphigus is characterized by an insidious onset of flaccid bullae, crusts, and erosions in crops or waves In pemphigus vulgaris, lesions often appear first on the oral mucous membranes These rapidly become erosive The scalp is another site of early involvement Rubbing a cotton swab or finger laterally on the surface of uninvolved skin may cause easy separation of the epidermis (Nikolsky s sign)

The diagnosis is made by light microscopy and by direct and indirect immunofluorescence microscopy Indirect immunofluorescence microscopy detects circulating pemphigus autoantibodies that correspond with disease activity and help in management

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Blistering diseases include erythema multiforme, drug eruptions, bullous impetigo, contact dermatitis, dermatitis herpetiformis, and bullous pemphigoid, but flaccid blisters are not typical of these diseases, and acantholysis is not seen All of these diseases have clinical characteristics and different immunofluorescence test results that distinguish them from pemphigus Paraneoplastic pemphigus is clinically, histologically, and immunologically distinct from other forms of the disease Oral erosions and erythematous plaques resembling erythema multiforme are seen Survival rates are low because of the underlying malignancy

Relapsing crops of bullae (Plate 21) Often preceded by mucous membrane bullae, erosions, and ulcerations Superficial detachment of the skin after pressure or trauma variably present (Nikolsky s sign) Acantholysis on biopsy Immunofluorescence studies are confirmatory

Secondary infection commonly occurs; this is a major cause of morbidity and mortality Disturbances of fluid, electrolyte, and nutritional intake can occur as a result of painful oral ulcers

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Pemphigus is an uncommon intraepidermal blistering disease occurring on skin and mucous membranes It is caused by autoantibodies to adhesion molecules expressed in the skin and mucous membranes The cause is unknown, and in the preantibiotic, presteroid era, the condition was usually fatal within 5 years The bullae appear spontaneously and are tender and painful when they rupture If the lesions become extensive, the compli-

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When the disease is severe, hospitalize the patient at bed rest and provide antibiotics and intravenous feedings as

If Word were available under an open source license, it would come with its source code You would be legally entitled to modify any code you wished, in this case creating a new version of the program that consumes less resources If the original Word program was licensed under the GPL and you decided to distribute your program, you would be required to distribute all source code, including your additions, along with the program If Word was licensed under a BSD -like license, you would be required to retain the original copyright notice with the program The actual licensing agreements are far more inclusive and detailed than indicated in these examples..

Pemphigus very often requires systemic therapy as early in its course as possible However, the main morbidity in this disease is due to the side effects of such therapy Initial therapy is with systemic corticosteroids: prednisone, 60 80 mg daily In all but the most mild cases, a steroid-sparing agent is added from the beginning, since the course of the disease is long and the steroid-sparing agents take several weeks to exert their activity Azathioprine (100 200 mg daily) or mycophenolate mofetil (1 15 g twice daily) is used most frequently, the latter seeming to be the most reliable and recommended for most cases In refractory cases, monthly IVIG at 2 g/kg intravenously over 3 days is useful and has replaced high-dose corticosteroids plus cyclophosphamide and pulse intravenous corticosteroids as rescue therapy Increased risk of thromboembolism is associated with IVIG therapy in these doses Rituximab may be added to IVIG therapy in refractory cases

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