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I begin with evidence on the relative impact of personal m edi­ cal care and a set of socioenvironmental factors cheapest generic cialis super active uk erectile dysfunction drugs with the least side effects. It is here order cialis super active toronto erectile dysfunction estrogen, in C hapter 2, that m uch of the research and literature on the “effectiveness” of medical care is compiled. T hen I turn to a history o f the “crisis” in health care, together with a discus­ sion o f its evolutionary features, to show where and how it is evolving. Next I turn to some “social futures” for the United States and their implications for health. This is done dialec- tically, by contrasting the evolution of medicine with a pro­ jection of the future, to dem onstrate the divergence between the medical care system and the larger society of which it is a part. T he end of medicine is coming both because of inter­ nal contradictions within the present system and because the system does not correspond with an em erging Zeitgeist. In C hapter 6, I attem pt to state what health is, having spent five chap­ ters spelling out what it is not. In C hapter 7, through a brief historical analysis o f the eras of medicine, I propose some o f the elements of a new paradigm for health. In this last chapter I also resurrect the question of national health in­ surance, because it is on this question that the public debate about health care will turn. If a comprehensive program of national health insurance is prom ulgated in the next few The Arguments 5 years, as is almost certain, the structure, prerogatives, and style of practice of the existing medical care system will be frozen for decades. If the outcome is simply m ore medical care, our health will be worse and our well-being as a popu­ lation will be in jeopardy. Finally, in an epilogue I draw the broad outlines o f a new medicine, which must be calibrated with the future and specifically with the health care needs o f the future. Although most of the points are docum ented, the ultimate test is their theoretical strength. T hree characteristics of medical practice are particularly perplexing to the uninitiated. First, determ inations of the quality of care are made with­ out reference to the actual outcomes of care to the patient. To use a homely example, most of us judge a restaurant on the basis of the taste and quality o f the food. Seldom do we inquire as to the chefs lineage or education, or visit the kitchen to inspect the ovens and utensils. The quality of means and the results of health care are m atters of different im portance and m agnitude, but the analogy fits. Unlike the quality of food, the regulatory measures traditionally em­ ployed to control the quality of medical care have focused on who renders it and how, m ore often than on what the results have been. T here is one notable exception, although Florence Night­ ingale should get similar kudos. Codm an, a surgeon at Massachusetts General Hospital, sought to orient assessment o f the quality of medical care from structural or input evaluation—who did it—to process 6 The Impact of Medicine 7 and end-result evaluation—how and why. T he results revealed shock­ ingly low quality of care; only 89 of the 692 hospitals could meet the standards established for the study. Limited circu­ lation of the results aroused so much controversy that Cod- man could not at first get his findings published and then could not find sponsors for further research. He argued that patients should be required to pay only for good results, and that people should be aware of the results of their care. This is a slight variation on the practice in Babylon o f severing the physician’s hand if he failed to cure. He published annual reports that docum ented the results of his care and his methods o f accounting for the results. Cod­ m an concluded that 183 (or 54 percent) were managed without undue complications. For the rem aining 154 cases that were not satisfactorily managed in his judgm ent, 204 separate judgm ents were m ade to determ ine why problems arose. In most cases (roughly 76 percent), the problems were found to be due to errors in physician care, including surgi­ cal misjudgment, use of faulty equipm ent, or misdiagnosis. Second, and m ore puzzling than the failure of the medical care enterprise to examine its results, is the paucity of re­ search on the impact of care on the health of populations. Controlled clinical trials have been used to measure the impact of medical cures for individual patients. But, histori­ cally, with the surrender of medicine to the scientific m ethod, “population” medicine was relegated to the schools of public health, while medicine went to work on the indi­ vidual. Consequently, we know something about medicine’s impact on individual patients but very little about the impact of medical care on populations. T hird, there is even less research on the relative impact of 8 The Impact of Medicine personal medical care services and other socioenvironmental factors such as education, housing, air, water, seat belts, and Muzak. In other words, other than some anecdotal and impressionistic evidence, we have virtually no inform ation on the relative weight to assign to the various factors that bear on health, including medical care. First, evidence about the outcomes of medical care, when it is presum ed to be efficacious, is examined. T hen the obverse is examined—when the outcomes are adverse as a result of iatrogenesis, or disease “caused” by the medical care system itself. Next, the placebo effect is assessed, followed by a discussion of the im portance o f caring. The balance of the chapter examines the slender research on the impact of medical care on the health of populations and concludes with a review o f the even m ore sparse work on the relative impact o f medical care and other factors on health. To grapple with this subject, the following definitions de­ veloped by the W orld Health Organization can be used. T here is also evidence that it is poor in a surprisingly high num ber of instances. The Impact of Medical Care on Patients 9 T he Center for the Study of Responsive Law incorporated much of the research that has been done in its publication, One Life— One Physician. Lewis reviewed the records of the Kansas Blue Cross Association over a one- year period (only two hospitals in the state failed to partici­ pate in the review). He tabulated the num ber o f elective operations for removal of tonsils, hem orrhoids, and varicose veins, and the operations for hernia repair, in all the hospi­ tals in each of the state’s 11 regions. Variations for the average rate o f these four elective surgical procedures ranged from a low of 75 operations per 10,000 persons in one region to a high of 240 operations per 10,000 persons in another. Striking variations were also found between regions within each elective surgical category. T he high and low regional incidences (rounded off) per 10,000 persons were: for tonsillectomy, 153 and 432; for hem orrhoidectom y, 11 and 35; for varicose veins, 3 and 7; and for hernia repair, 18 and 43. T here is little doubt, however, that part of the variation is due to the relationship between the medical care provided and the num ber and type o f providers providing it.

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In these early stages cardiac output and blood pressure are maintained and the shock is considered Patient Group Caution compensated order cialis super active online now doctor for erectile dysfunction in ahmedabad. It is important to recognize that although the systolic Elderly The elderly have less physiological reserve and will blood pressure is maintained order cialis super active online from canada erectile dysfunction and diabetes type 2, perfusion of the peripheral tissues is decompensate earlier impaired and continued lactate formation and progressive systemic Drugs Drugs such as Beta blockers will limit the ability for acidosis result. Pathological vasodilatation Pacemakers A pacemaker with a fixed rate will limit the ability may prevent compensatory vasoconstriction, resulting in flushed for the patient to mount a compensatory and warm peripheries in the early stages. Tachycardia may also be tachycardia and lead to earlier decompensation absent in neurogenic shock due to unopposed vagal tone. The Athlete The resting heart rate of an athlete may be in the By assessing the respiratory rate, feeling the pulse rate and region of 50bpm. This should be taken into strength, and by looking and feeling the patient’s peripheries, the account when assessing for relative tachycardia prehospital practitioner can rapidly assess for signs of compensated Pregnancy In pregnancy the normal physiological changes of shock (Box 8. Delayed capillary refill Penetrating A vagal response (relative bradycardia) stimulated Pale / cool / clammy peripheries Reduced pulse pressure trauma by intra-peritoneal blood may lead to Poor SpO2 trace. Decompensated shock A point will be reached at which the compensatory mechanisms Aids to identifying shock fail to compensate for the reduction in cardiac output or systemic A lack of plethysmography trace may reinforce suspicions of poor vascular resistance. At this point decompensation will occur and peripheral perfusion; however, hypothermia may have the same perfusion to the vital organs becomes compromised. Direct measurement of tissue oxygen saturation (StO2)pro- relies on a constant blood flow to maintain function, and as blood vides a more accurate indication of peripheral perfusion, with flow is compromised the conscious level drops. Loss of the radial values <75% corresponding to inadequate perfusion in haemor- pulse indicates a critical reduction in blood flow to the peripheries rhagic shock. The size and weight of StO2 monitors limits their and correlates with impaired perfusion of the vital organs. I-Stat) will allow direct mea- actions of the sympathetic nervous system, will also drop. Haem- Loss of Radial Pulse orrhage is the most common cause of shock following trauma and Drop in Systolic Blood Pressure. Prehospital ultrasound can be a useful adjunct to help localize the site of bleeding and aid management decisions. Useful findings include free fluid within the abdominal or thoracic cavity and increased pubic diastasis. Control of external haemorrhage In most circumstances external haemorrhage can be controlled by the stepwise application of basic haemorrhage control techniques – the haemostatic ladder (Figure 8. Modern dress- ings now come in a variety of sizes with elasticated bandages and integral pressure bars or caps to aid in the application of pressure. These Tourniquets may also be used immediately in cases where haemorrhage is so When used tourniquets should be placed as distally as possible on severe that if not immediately controlled, would lead rapidly to the affected limb and should be tightened until all bleeding ceases death (e. They can often be more painful than the injury itself and judicious use of ketamine and opioids can be useful. It is vital that tourniquets are reassessed regularly during Haemostatics the resuscitation process as they may require adjustment. Indirect Pressure Direct Pressure & Elevation Haemostatic dressings Haemostatic dressings are particularly useful for controlling Wound Dressing bleeding at junctional zones (e. A number of impregnated Circulation Assessment and Management 39 (a) First 15° log-roll Factor concentrators Mucoadhesive agents • Granules absorb water • Chitosan-based products • Concentrates coagulation factors • Anionic attraction of red cells • Promotes clotting • Adherence to wound surface (b) Second 15° log-roll e. Early recognition and rapid evacuation to a major Greater Greater trauma centre is therefore essential. A clear appreciation of the trochanter trochanter mechanism of injury, pattern of physical injury and temporal changes in physiology will allow the prehospital practitioner to identify those patients at risk. The only exception to rapid evacua- tion is when a massive haemothorax compromises ventilation and oxygenation, whereupon intercostal drainage should be performed prior to transfer. Re-expansion of the lung on the affected side may also control pulmonary bleeding. Knees and feet bound Control of skeletal haemorrhage Following significant trauma conscious patients with pelvic pain, Figure 8. Under no circumstances should the pelvis to overcome the contractile forces of the thigh muscles. The early application of a pelvic binder will reduce bleeding through bone end apposition and limit further movement which could Control of maxillofacial haemorrhage disrupt established clot. Binders should be applied to skin as part Severe maxillofacial trauma may result in significant haemorrhage of skin-to-scoop packaging. The binder should be folded into from damaged branches of carotid artery (usually maxillary artery). After securing the airway, second limited logroll the folded end is pulled through and when haemorrhage control can be achieved through a combination of supine the binder is tightened to achieve anatomical reduction facial bone splinting and intranasal balloon tamponade. It is important to ensure the feet and knees are bound collar is applied to fix the mandible before the maxillae are manually to limit rotational forces at the hip joint. Prior to insertion, a venous tourniquet should be placed no more than 10 cm away from the insertion point and sufficient time allowed for it to work. When only a small vein can be cannulated, keeping the tourniquet on then infusing 50–100 mL of fluid dilates larger veins allowing larger gauge access. Care should be taken to secure cannulae and intravenous lines with dressings and tape prior to any patient movement. There are situations where peripheral intravenous access may be difficultorevenimpossible(Figure8. Any drug, fluid or blood product that can be given intravenously can be given via the intraosseous route. In addition to the standard Cook® needle there are a number of mechanical intraosseous devices that allow needle insertion into both adult and paediatric patients, e. In most cases (Vidacare) (Waismed) access can be gained quickly by the insertion of an intravenous can- Figure 8. Standard access for fluid resuscitation for use granted by Cook Medical Incorporated, Bloomington, Indiana. The dorsum of the hand, right hand image – Permission for use granted by Pyng Medical. Bottom left antecubital fossa, and medial ankle (long saphenous) are good hand image – Permission for use granted by Vidacare. Ideally two points of venous access in separate image – Permission for use granted by Waismed). Circulation Assessment and Management 41 Humeral Head • Adduct arm to body and flex elbow to 90° • Internally rotate arm so hand over umbilicus • Greater tubercle now lies anterior on shoulder • Insert needle perpendicular to bone • Splint limb to side to prevent dislodgement Proximal tibia Adult • One finger breadth medial to tibial tuberosity Child • One finger breadth below and medial to tibial tuberosity • Two finger breadth below patella and one finger medial Distal tibia Adult • Three finger-breadths above tip of medial malleolus Child • Two finger-breadths above tip of medial malleolus Figure 8. The humeral head and sternal insertion sites permit Fluid resuscitation flow rates five times higher than those in the tibia. Care should be Fluid resuscitation following trauma may be indicated to replace taken to splint limbs and secure needles with commercial stabiliz- lost blood volume and optimize haemodynamics in order to main- ers or dressings to prevent dislodgement.

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The ligament injury was treated with and randomized controlled trials’ (Rabago et al prolotherapy at 14 days and at 21 days generic 20 mg cialis super active with visa erectile dysfunction doctor cape town. Results • A study in Pain Physician concluded: ‘This demonstrated that the mechanical properties of single blinded buy cheap cialis super active medical erectile dysfunction pump, randomized and cross-over the ligaments were of greater strengthening, study of prolotherapy was described as being a stiffening, enlargement and decrease of laxity. Alternatives Human studies Dry needle tissue irritation may be an effective alternative for stimulation of inflammation and new • A study at the University of Kansas (Reeves & growth. The acupuncture technique of ‘bone-pecking’ Hassanein 2003) concluded: ‘Dextrose injection or ‘osteopuncture’ involves needle irritation at bony prolotherapy at 2- to 3-month intervals resulted attachments of tendons and ligaments (Helms 1985, in elimination of laxity by machine measure in Lowenkopf 1976, Mann 1971). The use of taping, tensor bandages or devices injections, sustainable through 3 years with and splints to stabilize weakened ligaments may be periodic injection. Exercise for joints or core strengthening results in knees and finger joints (Reeves & for the spine are effective in reducing pain and are Hassanein 2000a, 2003). There are forms of electrotherapy (Harvard 60% sustained reduction in pain and disability Medical School 2006) and friction massage (Cyriax & after 12-month follow-up (Klein et al 1993, Coldham 1984) that strengthen ligaments. Surgery has been a standard for chronic groin pain in this group of elite medical practice and, more recently, growth factors rugby and soccer athletes. Many injuries and degenerative chronic spinal pain showed that 91% of processes do not fully heal on their own because of patients reported reduction in level of pain, the inhibition of the initial inflammation phase by the 84. The prolotherapy 260 Naturopathic Physical Medicine Inflammation Granulation tissue Matrix formation Box 7. To get a sense of the ligament diagnosis, find a patient with an unresolved sacroiliac pain. Consider that the problem may not be the restricted joint but perhaps a hypermobility in the other joint caused by ligament laxity. See if the symptom picture matches the indications outlined earlier in this section. This initi- ates a 3- to 5-day inflammatory cascade, followed by Hypothesis 2–4 weeks of fibroblast activity (Cockbill 2002, Reeves Form and force closure tests are also useful in & Hassanein 2000b). In the of localized inflammation and tissue repair is the basis Vleeming/Lee model the force closure problem is of how injuries self-repair. Prolotherapy, by irritating addressed by increasing articular compression through the injured site, initiates the natural inflammatory the strengthening of specific muscle groups (Lee cascade that allows the body to bring fibroblasts and 1997). These tests might also assist in prioritizing • Diffuse myofascial pain – prolotherapy is treatment strategies. The integration with the suboccipital region naturopathic methods may enhance the effectiveness • Areas that have been repaired by screws, plates of prolotherapy as a stand-alone therapy. By combin- or other hardware ing prolotherapy with manipulation, other manual • Needle phobic or high anxiety patient therapies and exercise the patient should receive a Chapter 7 • Modalities, Methods and Techniques 261 more comprehensive treatment approach. The nutri- Methodology tional, lifestyle, biochemical and energetic aspects of Lymphatic pump method description (Sleszynski & the naturopathic practice will ensure that all perspec- tives of joint and tissue healing are addressed. Kelso 1993) • The patient lies supine, knees and hips [Manual] pump techniques: lymphatics, flexed. Indications for the use of lymphatic pump techniques The arms should be more or less straight for include all conditions that involve congestion, lym- ease of transmission of force from the shoulder phatic stasis and infection (apart from those listed to the hands. Note: This is one example only; there are many other methods for enhancing lymphatic drainage, including direct ‘pumping’ of the lower thorax, exaggerated repetitive dorsiflexion during deep breathing by the Venous patient, etc. Safety If normal precautions are observed there seem to be no contraindications to use of lymphatic pump methods. Venous flow is down the pressure osteopathic), as outlined in Chapter 8, puts their clini- gradient. Appropriately trained and Further reading licensed practitioners might also use injection or acupuncture in order to deactivate trigger 1. Lederman E 2005 Science and practice of exercise and rehabilitation methods, such as manual therapy, 2nd edn. Livingstone, Edinburgh, p 87–224 • Proprioceptive re-education utilizing physical therapy methods (e. In this section two • Postural and breathing re-education (see common dysfunctional conditions are briefly below) using physical therapy approaches as outlined: well as Alexander, yoga, tai chi and other similar systems (Mehling et al 2005). Rehabilitation implies returning the individual • Psychotherapy, counseling or pain toward a state of normality which has been lost management techniques such as cognitive through trauma or ill-health. Richard (1978) external rotation again, and the same process of notes that a working muscle will mobilize up to 10 times relaxation and movement to internal rotation is the quantity of blood mobilized by a resting muscle. A few cycles of muscle contraction against resistance can be used to initiate vascular changes • Practitioner stands with a hand on the lateral aspect (hyperemia) which will transiently ‘open up’ the of the ankle, resisting the patient’s effort to externally blood flow in the muscle. Passive technique rotate the hip using minimal but sustained effort for immediately follows, taking advantage of the 7–10 seconds. This adds a degree of rotation Active fascial stretch of the anterior body surface. Internal • This repetitive process continues for several minutes Active to encourage lymphatic flow throughout the body. The patient actively oscillates the limb External Active pump Passive pump Active + resistance rotation Increased blood Transient hyperemia Internal Passive flow in the muscle rotation Method B. Reproduced Reproduced with permission from Lederman (2005d) with permission from Lederman (2005d) 264 Naturopathic Physical Medicine • Occupational therapy (see earlier in this Shiatsu, acupressure, etc. Methodology • Appropriate exercise strategies to overcome Shiatsu application includes point and meridian stim- deconditioning (Liebenson 1996b). Abdominal palpation is seen as Breathing rehabilitation an important aspect of diagnosis, with abdominal See Chapters 2, 4, 6, 9 and 10 for notes on additional massage as required. Liebenson C (ed) 2006 Rehabilitation of the Whether or not ‘energy’ impedance exists in reality, spine, 2nd edn. Chaitow L, Bradley D, Gilbert C 2002 ischemic compression (also known as inhibitory Multidisciplinary approaches to breathing pressure in osteopathic medicine) has a number of pattern disorders. Somatic psychotherapies are based on the belief that Mechanoreceptor stimulation affecting pain transmis- the mind and body continuously inform one another, sion also occurs (Melzack & Wall 1994). A combina- and they are primarily interested in this mind–body tion of circulatory, endocrine and neurological interface. The field of somatic psychology incorpo- changes therefore follow in response to applications rates several basic concepts (Caldwell 1997): of focused compressive loading of tissues. Any experience impacts the system at all Cautions levels: physical, emotional, cognitive and • Deeply applied compression is contraindicated spiritual. Pathology experienced at one level of the or that are inflamed system is also experienced at the other levels. The body is viewed as the blueprint for all conditions (contraindicated during acute experience. Treatment consists of working experientially • Aneurysm with the body in the present moment.

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If an animal producing good antibodies becomes ill quality 20 mg cialis super active erectile dysfunction age graph, it should be carefully observed and purchase 20 mg cialis super active visa erectile dysfunction just before intercourse, if there is any likelihood of it dying, it should be sacrificed by exsanguination under anaesthesia. At each bleed, blood should be collected in glass tubes and allowed to clot for one to two hours at room temperature and two to six hours at 4ºC. The tubes should not be disturbed during the clotting process as haemolysis may result. Where storage at –20ºC is convenient, the antiserum may be diluted in the ratio 1:10 in buffer containing 0. If freeze drying equipment is available, antisera may be lyophylized and stored in aliquots for reconstitution immediately before use. Protocol 4: Production of immunogens from haptens using the mixed anhydride reaction (a) Activation of hapten (steroid) The following procedure is used: —Add 40 mmol (5 mL) of N-methylmorpholine to 40 mmol of the steroid derivate in 250 mL non-aqueous solvent (e. Protocol 6: Antibody purification methods (a) Preparation with ammonium sulphate The following procedure is used: —Dilute 3 mL of antiserum to 10 mL with 0. Protocol 7: Direct iodination of protein using chloramine T 125 125 (a) Preparation of I-T4 and I-T3 The following procedure is used: (1) Suspend 2 mg of T3 in a few millilitres of phosphate buffer of pH7. Count each fraction and plot the counts against fraction number, to derive the chromatographic profile. Calculate the proportion of radioactivity in each peak eluted (see the examples shown in Fig. Dilute each to a radioactive concentration of 5–10 mCi/mL, adding also phosphate buffer (pH7. The procedure described above incorporates 40–60% of the initial 125I 125 into T4 and 25–40% into T3, with only about 5% of the I remaining unreacted. Protocol 8: Radioiodination using solid phase lactoperoxidase The following procedure is used: (a) Add to 10 mg antigen in an iodination vial: —10 mL 0. Protocol 11: Iodination of antibodies (rabbit IgG) by the N-bromosuccinimide method The antibodies must be pure for iodination. The final specific activity of the product can be altered by adjusting the 125 amount of protein added, the amount of Na I added, the amount of N-bromo- succinimide added and the reaction time: (a) Equilibrate a small Sephadex G-25 column with 0. Calculate the specific activity of the label: labelled counts ¥ µCi Na125I Specific activity = = mCi/mg. Transfer the column outlet back to the wastewater outlet and the eluent back to water, continue washing with water for at least 30 min, and open the sample loop so that this is also washed. There should be approximately (25 000 counts)/(10 s · 10 mL) (= 10 mCi/mL at 70% efficiency) but no less than 20 000 counts. Protocol 13: Antibody coated tubes and wells The following procedure is used: —Dispense 300 mL per tube or 200 mL per well of a 1, 10 and 100 mg/mL IgG solution in phosphate buffer of pH7. Protocol 14: Antibody coated cellulose Activation procedure Five grams of Sigmacell are weighed into a 50 mL conical flask fitted with a ground glass stopper. The activated imidazole-carbamate, cellulose, is recovered by filtration over a glass microfibre filter, washed with three 100 mL aliquots of acetone and allowed to air dry. The procedure is as follows: —Weigh 200 mg of activated cellulose into a polystyrene tube. Protocol 15: Antibody coated magnetic particles The activation procedure is as follows: —Roll the bottle containing the magnetic particles for 30 min at room temperature at 30 rev. Wash the particles three times with 20 mL water, by mixing gently with water, sedimenting and aspirating the supernatant. Day 3: —Pipette 5, 10, 20, 50, 100 and 200 mL magnetic cellulose suspensions in duplicate into assay tubes (adding assay buffer for constant volume). Wash the particles with a further 1 mL wash solution and count the magnetic pellets. Introduction Cell anatomy can be studied by several distinct methods using microscopy but, although revealing cellular architecture, very little information is provided about cell physiology. The biochemistry and molecular biology perspective is to identify molecules involved in a specific pathway and to determine where and why the pathway occurs. In the 1970s, several technical approaches were described bringing sensitive methodological advantages that drastically altered the amount of data generated in this field of research. To monitor the molecular aspects of cell physiology, radioisotopes are routinely used, for example, in tracing chemical pathways, evaluating the dynamic behaviour of compounds in cytosol and nucleus, and identifying and typing molecules. Radioisotopic methods are specific and sensitive, capable of detecting a particular molecule sample present in small amounts in complex mixtures. The most developed are in the molecular diagnosis of infections, genetic diseases and cancer. Molecular techniques can be applied to the diagnosis of diseases such as human papilloma virus infection and Chagas’ disease (infective diseases), Fragile X syndrome (a genetic disease) and the mutated p53 gene (cancer). Besides improving diagnosis, molecular methods can also be used to address the control of disease through: —Identification of common transmission sources; —Assessment of drug resistance; —Follow-up of treatment efficacy; —Strain typing to distinguish more pathogenic organisms. Specificity is further enhanced by molecular hybridization using probes, making these approaches ideal tools for diagnostic purposes. Furthermore, they allow detection of pathogens, such as the human papilloma virus, that are refractory to in vitro propagation. Antibodies used in a direct search for a given pathogen typically recognize antigens found in multiple copies on the microorganism and thus circumvent the need to replicate the agent. Unfortunately, the cross- reactivity of these antibodies with host antigens and other pathogens has compromised the convenient and broad use of these diagnostic reagents for some pathogens. In addition, some viruses establish latent infections in which active viral replication is substantially attenuated, thereby preventing detection by antigen based methods. For example, in visceral Leishmaniasis, the parasitological diagnosis can be performed using peripheral blood instead of bone marrow or spleen aspirates. Similarly, in chlamydia infections, urine can be used instead of urethral scrapings. This approach is in contrast to the traditional xenodiagnosis method, where 40 insects starving for 45 days are applied to the patient’s arms. In cutaneous Leishmaniasis, the invasiveness is reduced from regular biopsies to needle aspirates. Examples of pathogens that can be detected using these approaches are listed below. Pathogens with an asterisk represent those for which molecular based methods are the gold standard: Adenovirus Legionella pneumophila Bartonella henselae and Bartonella quintana * Leishmania sp. Borrelia burgdorferi Microsporidia * Chlamydia pneumoniae Mycobacterium avium * Chlamydia trachomatis Mycobacterium bovis Cytomegalovirus Mycobacterium leprae Epstein–Barr virus Mycobacterium tuberculosis Helicobacter pylori Mycobacterium ulcerans Hepatitis B virus Mycoplasma pneumoniae * Hepatitis C virus * Neisseria gonorrhoeae Hepatitis G virus Onchocerca volvulus Herpes viruses 6 and 8 Parvovirus B19 412 5. The virus site of latency is the epithelium, where most of the clinical presentations are encountered. The distinct virus genetic groups present different cellular tropisms and therefore present distinct clinical features (skin warts, benign head and neck tumours, genital warts and cervical carcinoma).