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By D. Cronos. Bard College.

These include The dorsal fragment almost always remains in place sec- torus fractures buy cleocin gel 20gm without prescription, which can be identified by a buckling of ondary to its strong attachments (Bennett’s fracture); the cortex (usually dorsal) of the distal radius order cleocin gel 20gm without prescription. The de- tures buy generic cleocin gel 20gm, that is, those not demonstrable on conventional radi- gree of displacement is best appreciated on this image. The so-called baseball finger or mallet finger abnormalities about the hip that are responsible for the is a fracture of the dorsal aspect of the base of the distal symptoms. Volar plate fractures are quite (fatigue fractures) or in the elderly with osteoporosis or common and are seen at the volar aspect of the base of other underlying disease (insufficiency fractures) [15]. Others will have no joints may be seen in association with volar plate injuries; findings on conventional imaging and the presence of the a dislocation may have been reduced prior to imaging. This is often accompanied by a fracture at the site the hip are not uncommon, particularly in athletes. The of avulsion and may require stress views for evaluation most common of these include avulsion fractures from when the injury is purely ligamentous. If the adductor the site of origin of the hamstring muscles (the ischial aponeurosis is entrapped within the joint (Stenner lesion), tuberosity), avulsions from the straight or reflected heads then surgery may be necessary. Dislocations of the hip are most commonly posterior Specific Sites - Lower Extremity and are frequently associated with fractures of the poste- rior wall of the acetabulum. Osteochondral or shear frac- Hip tures of the femoral head (Pipkin fractures) occur where the femoral head strikes the acetabulum at the time of Fractures of the femoral neck may be displaced, with re- posterior dislocation [16]. In a posterior dislocation, the sultant shortening and external rotation of the lower ex- hip is displaced posteriorly and often slightly superiorly; tremity. Much less common are an- tional imaging, at times there is an apparent radiolucen- terior dislocations of the hip, in which the femoral head cy in the femoral neck, suggesting that the fracture is is seen in a medial and inferior position; the thigh is held pathologic. Tangential views of the patella and tunnel views may bands of density extending across the femoral neck or by be used to supplement these, particularly when joint ef- a “squared-off ” contour to the head-neck junction along fusions are demonstrable. If a lipohemarthrosis is demonstrable on hori- tertrochanteric region; the lesser trochanter may represent zon-beam images, this is presumptive evidence for an in- a separate bony fragment in these cases. Osteochondral injuries of the femoral condyles displacement of the medial fragment [19]. Avulsion fractures at process of the calcaneus occur and must be distinguished the insertion of the posterior cruciate ligament are often from normal variants in this location. Asymmetry in the width of the growth plate or small fracture fragments on The Forefoot the metaphyseal side of the growth plate should be suffi- cient to establish the diagnosis in most cases. This injury is easily over- question and also allows evaluation of ligamentous struc- looked, and a careful examination of the relationships of tures about the knee. Ankle and Hindfoot In the forefoot, stress and other fractures of the metatarsals are not uncommon. Fractures oneus brevis muscle, should be distinguished from of the malleoli are common ,and careful examination for “dancer’s fracture” or Jones fracture. These occur near the presence of posterior malleolar fracture is necessary the base of the fifth metatarsal, approximately 2. If a tal to the base, in a relatively avascular area of the shift of the talus in the ankle mortise has occurred and no metatarsal and may go on to non-union. Fractures of the lateral malleolar fracture is demonstrated, examination of phalanges in the foot are quite common. It is important the entire length of the fibula is necessary to demonstrate to evaluate all images so that these are not overlooked. Isolated Fractures of the sesamoids may also occur; most com- fractures of the posterior malleolus do occur and may on- monly at the first metatarsal phalangeal joint. Careful evaluation for fractures of the lateral process The degree of separation of the parts is usually sufficient of the talus is necessary. Avulsion fractures from the neck of the talus occur at the site of insertion of the capsule. Pilon fractures represent comminuted fractures of the tibial pla- Summary fond secondary to axial compression forces. They are of- ten associated with supra-malleolar fibular fractures and Fractures and dislocations in the appendicular skeleton they commonly exhibit depressed tibial fragments. There are common and careful examination of the appropriate is typically a posterior tibial fragment that remains at- images obtained from each site is required for diagnosis. Radiology 192:477-480 tance of the internally rotated oblique projection for diagnosis. Radiology Demonstration of Instability of the Shoulder: The Apical 1097:263-267 Oblique Projection. Am J Roentgoenol 155:1049- amination for trauma be a four-view study, including a semi- 1052 supinated oblique view? Therefore this age group is particularly like- Infective spondylitis represents 2-4% of all cases of ly to develop discitis. Men are tion vascular invasion of the disc space may occur, affected more frequently than women (2-3 to 1), therefore primary discitis is possible in older patients as usually in the fifth and six decades of the life, but in- well. In adults, arteries are distributed equatorially, with fective spondylitis may appear in all age groups. The the richest networks of nutrient arterioles in the sub- most common causative pyogenic organisms are chondral “metaphyseal” region of the vertebral bodies, Staphylococcus aureus, followed by streptococcus and which is the most common site of initial inflammation.

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Testing for the following is offer more benefit during acute infection when a recommended: patient’s immune system is still nearly intact generic 20 gm cleocin gel mastercard. Pets generic cleocin gel 20gm visa, food discount 20 gm cleocin gel visa, and water also bear risks, so comes and in need of more targeted hospital regular vigilant handwashing and avoidance of any resources. Secondary prophylaxis, then, pharmacy or syringe-exchange program; using is meant to prevent recurrence of an infection the sterile water to prepare drugs (or fresh tap water if patient has already had. The latter is often used for sterile water is not available); preparing drugs long-term suppressive treatment of incurable with a new or disinfected “cooker” and a new fil- infections (toxoplasmosis). It is believed this information is always interpreted as a death that condom use can decrease one’s risk of super- sentence. On the other also avoid oral–anal contact, which gives them a hand, it is important to emerge from the reaction heightened risk of development of intestinal infec- to become proactive in fighting the disease. Some people do using single-drug therapy are less effective than inform, and others keep it to themselves. Most the multidrug approach people do better psychologically when they share • That if the viral load continues to increase, their grief and are reassured to find that friends despite the drug regimen, one’s health care and family are supportive. It may take a number of these mutations to either drug-resistant strains evolve during therapy allow the virus to produce high-level resistance to or drug-resistant strains exist in the virus popula- a certain drug, but consider the fact that the body tion before therapy is even begun. But if the resistant strains drug is no longer being used; adding insult to are preexisting entities, the drug’s effect on the injury, the virus adds a layer of cross-resistance to wild-type virus is basically irrelevant because a drugs that are similar. The upshot is that the viral potent drug will make resistant mutants escalate load must be suppressed in order to prevent resist- quickly and wild-type virus decline quickly, ance. Experts tell us, however, that even at viral whereas the opposite—a weak drug—will do the loads of 500 copies/mL, there is enough viral reverse. In the case of preexisting strains that are reproduction to allow development of resistance. As more resistance is diminishing the likelihood that any virus strain developed, the antiretroviral drugs are rendered could have resistance to all drugs. An obser- going on and off drug therapy, a practice that has vational cohort study by Douglas Richman, Sam been shown to lead to drug mutations. Of course, a donation detected with either is with 38 percent of the other patients. This was excluded from clinical use, and the donor cannot after six months of standard treatment as recom- donate again. Complaints of dis- example of new thinking in this respect is pro- comfort are also fewer. Hav- must seek frequent updates on treatment and care ing opened its doors in 2001, this facility is Sal- information from the person’s doctor. The patient is kept comfortable bedroom transitional housing, which residents and the family is provided support. The community also Medicare, Medicaid, and some health insurance has permanent housing: 28 two- and three-bed- plans, hospice care is provided in a facility, in the room townhouses. The team of health Rounding out the convenience of the neighbor- care professionals may include a social worker, a hood is a licensed 60-space day care center that nurse, a physician, and a spiritual adviser. Many serves residents and families in the surrounding people who have been through the experience of community. Services for those who live in transi- caring for a relative who had a terminal illness tional housing are medical support, treatment for view hospice care as the most humane way to substance abuse, vocational services, meals, and handle the final months of life of a person with medications. I idiopathic thrombocytopenic purpura An auto- through the placenta or through breast-milk. The person’s body vidual, the immune system capably protects the forms antibodies that bind to platelets. High-dose body from toxins, cancer cells, microorganisms, steroid therapy is usually the initial treatment, and other elements. Antibodies ring infections, faulty response to treatment, serve to neutralize toxins and microorganisms. Immunity is induced when fall prey to opportunistic infections—the term for an individual is given a vaccine (immunization) or ordinarily controllable infections that can turn has exposure to the antigenic marker on an organ- severe in those with a compromised immune sys- ism that invades the body. Passive immunity occurs have contagious diseases and avoid those who when a mother passes her fetus immunities have had recent immunizations. If a disease is 115 116 immunosuppression contracted, it must be treated aggressively. Pre- someone who is experiencing dementia related to ventive treatments may be necessary. The human immunodeficiency virus can cases, bone marrow transplantation is the best affect the brain in a way that diminishes the sensa- option for treating immunodeficiency disorders.

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The biblical approach is to consider the possibility that a demon may be involved and act appropriately order cleocin gel 20 gm without a prescription. The Man with the Spirit of Lust I once gave a short exhortation at a church in Stone Mountain buy cleocin gel 20 gm without prescription, Georgia buy cleocin gel 20gm on-line. At the end of the mini- sermon, just before the church fellowship meal, an elderly guy approached me and asked me to pray for him. I could have taken the path of least resistance and told the man what thousands of preachers would have told him. He was simply a child of God who loved the Lord with his whole heart, and had never learned how to be set free from this terrible demon of lust. There are multitudes of dear saints, preachers included, who are totally bound by demon power. They fear they will be rejected by the church should their problem ever become known. Just because a person appears to have everything together does not mean he or she has everything together. In light of this I urge you to consider that if you have a sin, a mental problem, a condition, or a sickness that doesn’t respond to prayer, fasting, and the sort, you should consider the possibility that Satan has directly attacked you (remember Job). If the idea of you having a demon is repulsive, I solemnly warn you to humble yourself. If you submit yourself to God for His deliverance in His way, you will be delivered. Conversely, if you let pride or fear talk you out of accepting all that God has for you, you will probably never be set free. Choose this day what you will have: Life or death, health or sickness, peace or torment. The subject of who can have a demon is probably the most controversial topic of demonology. Although Satan is lord and father to those who have not genuinely repented of their sins, and have submitted to the lordship of Jesus Christ, he does not literally own them. His rulership is limited to acting within the framework of God’s plan for humanity. If people, families, churches, companies, cities, states, or nations choose life and blessing, Satan’s actions are tremendously limited. A scripture that concisely says this is Romans 6:16: “Know ye not, that to whom ye yield yourselves servants to obey, his servants ye are, to whom ye obey; whether of sin unto death, or of obedience unto righteousness? Since the great majority of people choose death and cursing rather than life and blessing, the Bible calls Satan: • The prince of this world. It’s a very basic doctrine of the Bible that there are only two spiritual families in existence. Jesus was most emphatic when He said, “No man can serve two masters: for either he will hate the one, and love the other; or else he will hold to one, and despise the other. He said, “In this the children of God are manifest, and the children of the devil: whosoever doeth not righteousness is not of God, neither he that loveth not his brother. Satan’s children are identified by their lifestyle of disobedience to God, and lack of love (unless it benefits them). As Romans 3:14-18 states so descriptively: “Whose mouth is full of cursing and bitterness: Their feet are swift to shed innocent blood: Destruction and misery are in their ways: And the way of peace they have not known: There is no fear of God before their eyes. They see themselves as basically good people, especially if they are moral or religious. He sees them as murderous rebels totally absorbed in themselves; as people who lie when it’s convenient; as people who hate when done wrongly (or rightly); as people who willingly destroy their bodies through drugs and alcohol; as people who commit adultery; as people who commit whatever sexual sin their bodies crave; as people who steal; as people who speak evil of those who do right; as people who serve false gods; as people who deliberately hurt others; as people who love pleasures more than God; as people who dishonor their parents; as people who kill their babies through abortion; as manipulators of the gullible; as exploiters of the weak and poor; as people with filthy mouths; as people who despise authority; as people who justify the ungodly; as people who are ungrateful; as people who are full of pride; as people who break agreements; as people who are selfish. It’s unrealistic to suppose that sinners, whom the scriptures refer to as “children of the devil” can be anything other than influenced, controlled, or full of demons. How can one live totally for the devil, and have one’s mind filled with his thoughts, and have one’s actions controlled by him, and not be filled with demons? I know of no possible way to be a slave of Satan and not be simultaneously demonized. Sinners are demonized to one extent or another due to their service and allegiance to Satan. Ephesians 2:1-2 supports this observation: “And you hath he quickened, who were dead in trespasses and sins. Wherein in time past ye walked according to the prince of the power of the air, the spirit [Satan] that now worketh in the children of disobedience. Nothing can start a holy war quicker than perhaps the subject of tongues or women preachers.

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Conducting or storing drinking water in containers of metal is as foolish a practice as eating food off the floor generic cleocin gel 20gm fast delivery. You may not see what it picked up any more than you can see if it has picked up sugar or salt discount 20gm cleocin gel. If you find cadmium in your hot or cold water order cleocin gel 20 gm without a prescription, you will never be able to filter it out. The amount of cadmium in your clothing from doing laundry with this water is already too much for your adrenals and kidneys. If you believe you already have plastic pipes or all copper (which leads to leu- kemia, schizophrenia and fertility problems) you will need to search every inch of plumbing for a very short piece of galva- nized pipe left in the system! The toxicity of cadmium, in fact, the high blood pressure connection, has been known a long time. All (100%) cases of high blood pressure I have seen could be easily cured by eliminating cadmium and other pollutants, followed by cleansing the kidneys. To test whether you still need your blood pressure medicine, wait until your pressure is down to 140/90 or better. If it has climbed back up you are not ready; go back to ¾ or a full dose of medicine. If your blood pressure stays down, cut your medicine in half again (you are now down to ¼ the regular dose) and see if your blood pressure stays improved. Better yet, make a salt that is a mixture of sodium and potassium chlorides (see Sources). The sodium portion could be sterilized sea salt (test and make sure it has no alumi- num silicate in it first). Rinse these thoroughly first, throw away shriveled ones, and add vitamin C to the cooking water. Bala Cuzmin, age 72, had high blood pressure for ten years but the upper (systolic) pressure remained high in spite of various medi- cines that were tried. She stopped using caffeine, switching to arginine tablets to get over the let-down. Her diet was changed to reduce phosphate and add calcium, and she took magnesium and Vitamin B6 to assist the kidneys. She killed parasites, cleansed kidneys but saw no drop in blood pressure which stayed at 150 to 170 systolic. She had all the metal in her mouth replaced and promptly saw a blood pressure drop to 145-1 50. She had phosphate crystals in her kidneys and was started on kidney herbs and a diet change to include milk and exclude soda pop. She was feeling so much better after the kidney cleanse that she decided to remove her last fillings and replace her bridge, too, since it was shedding ruthenium. On her way home from the dentist, her ears stopped ringing and soon her blood pressure was down to 126/68. She was still on half a dose of drugs because she was too afraid to go off entirely. This gave her the energy she wanted to play basketball with the grandchildren again. Then he could cut back on his medicines, measuring his blood pressure daily to guide him. After seven weeks it was down to 140/85, so he decided to do without medicine, a bit early. His next chore, which he approached gladly, was removal of all metal from his mouth. He still had some Ascaris and other health problems but was highly motivated to clean them up, too. Glaucoma In glaucoma the pressure in the eyeball gets too high, putting pressure on fragile retina cells that do your seeing. It is your tip-off, though, that something is not right and you should correct it now, when it is easy, and before other damage is done. Read the section on high blood pressure (page 210) to learn how to reduce it by going off caffeine, checking for cadmium poisoning from your water pipes, and cleansing the kidneys (page 549). Simply getting your blood pressure to normal is sufficient help for beginning glaucoma. Antonia Guerrero, age 51, had glaucoma for five years and was dete- riorating rapidly. She cleansed her kidneys, killed parasites and changed her diet to the anti-arthritic one since she also suffered from arthritis in her hands for ten years with painful enlarged knuckles. She got rid of her asbestos toxins by bringing her own hair blower with her to the hairdresser.

The second edition of Infectious Diseases in Critical Care Medicine has been streamlined proven cleocin gel 20gm, maintaining the clinical focus in a more compact volume generic cleocin gel 20 gm without a prescription. The contributors to the book are world-class teacher/clinicians who have in their writings imparted wisdom accrued from years of clinical experience for the benefit of the critical care unit physician and their patients order cleocin gel 20gm. The second edition of Infectious Diseases in Critical Care Medicine remains the only book dealing with infections in critical care. Cunha Preface to the Third Edition Infectious disease aspects of critical care have changed much since the first edition was published in 1998. Infectious Diseases in Critical Care Medicine (third edition) remains the only book exclusively dedicated to infectious diseases in critical care. Importantly, Infectious Diseases in Critical Care Medicine (third edition) is written from the infectious disease perspective by clinicians for clinicians who deal with infectious diseases in critical care. The infectious disease perspective is vital in the clinical diagnostic approach to noninfectious and infectious disease problems encountered in critical care. The third edition of this book is not only completely updated but includes new topics that have become important in infectious diseases in critical care since the publication of the second edition. The hallmark of clinical excellence in infectious disease consultation is the diagnostic experience and expertise of the infectious disease consultant. The clinical approach should not be to arrive at a diagnosis by ordering a bewildering number of clinically irrelevant tests hoping for clues from abnormal findings. The optimal differential diagnostic approach depends on the infectious disease consultant carefully analyzing the history, physical findings, and pertinent nonspecific laboratory tests in critically ill patients to focus diagnostic efforts. Before a definitive diagnosis is made, the infectious disease consultant’s role as diagnostician is to correctly interpret and correlate nonspecific laboratory tests in the correct clinical context, which should prompt specific laboratory testing to rule in or rule out the most likely diagnostic possibilities. As subspecialist consultants, infectious disease clinicians are excellent diagnos- ticians. For this reason, infectious disease consultation is of vital importance for all but the most straightforward infectious disease problems encountered in critical care. Another distinguishing characteristic of infectious disease clinicians is that they are both diagnostically and therapeutically focused. Many noninfectious disease clinicians often tend to empirically “cover” patients with an excessive number of antibiotics to provide coverage against a wide range of unlikely pathogens. Currently, most of resistance problems in critical care units result from not appreciating the resistance potential of some commonly used antibiotics in many multidrug regimens, such as ciprofloxaxin, imipenem, and ceftazidime. Some contend this approach is defensible because with antibiotic “deescalation” the unnecessary antibiotics can be discontinued subsequently. Unfortunately, except for culture results from blood isolates cultures with skin/soft tissue infections, or cerebrospinal fluid with meningitis, usually there are no subsequent microbiologic data upon which to base antibiotic deescalation, such as nosocomial pneumonia, abscesses, and intra-abdominal/pelvic infec- tions. The preferred infectious disease approach is to base initial empiric therapy or covering the most likely pathogens rather than clinically unlikely pathogens. Should diagnostically valid data become available, a change in antimicrobial therapy may or may not be warranted on the basis of new information. Because infectious disease consultation is so important in the differential diagnostic approach in critical care, this book’s emphasis is on differential diagnosis. If the diagnosis is inaccurate/incorrect, empiric therapy will necessarily be incorrect. To assist those taking care of critically ill patients, chapters on physical exam clues and their mimics, ophthalmologic clues and their mimics in infectious disease, and radiologic clues and their mimics in infectious disease have been included in this edition. In addition, several chapters notably, “Clinical Approach to Fever’’ and ‘‘Fever and Rash,” also emphasize on physical findings. Another important topic has been added on infections related to immunomodulating/ immunosuppressive agents. The widespread introduction of immune modulation therapy has resulted in a recrudescence of many infections due to intracellular pathogens, which are important to recognize in patients receiving these agents. Because miliary tuberculosis is so important and is not an infrequent complication of steroid/immunosuppressive therapy, a chapter on this topic also has been included in the third edition. As mentioned, antibiotic resistance in the critical care unit is a continuing problem with short- and long-term clinical consequences. Currently, methicillin-resistant Staphylococcos aureus and vancomycin-resistant enterococci are the most important gram-positive pathogens in critical care, and a chapter has been added on antibiotic therapy of these pathogens. Among the multidrug-resistant aerobic gram-negative bacilli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii continue to be difficult therapeutic problems, and a chapter has been included on this important topic. The contributors to the third edition of Infectious Diseases in Critical Care Medicine are nationally or internationally acknowledged experts in their respective fields. They are teacher-clinicians also known for their ability to effectively distill the key points related to their topics. Guideline followers may not agree with this book’s clinical approach which is evidence based, but tempered by clinical experience. Especially in critical care, the key determinant of optimal patient care is experienced based clinical judgment which the clinician contributors have provided.

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A teaspoon is about 5 grams discount cleocin gel 20gm without a prescription, a cup is about 230 ml (milliliters) discount 20gm cleocin gel, therefore the starting concentration is about 2½ (2 purchase cleocin gel 20 gm without a prescription. Label one clean plastic spoon “water” and use it to put nine spoonfuls of filtered water in a clean glass bottle. The glass bottle now has a 1 in 10 dilution, and its concentration is one tenth the original, or. Use a new spoon to transfer a spoonful of salt solution from bottle #1 to bottle #2 and stir briefly (never shake). If you want to calculate how many salt molecules you can detect, select the concentration at the limit of your detection, and put 2 drops on a square inch of paper towel and rub into your skin. If you can detect water -15 from bottle #13, you have detected 510,000 molecules (10 23 fg/ml divided by 58. Water in bottle #12 would therefore have 10 times as many molecules in one drop, and so forth. Even if your error is as much as a factor of 2 (100%), you can still get a good idea of what you can measure. Atomic absorption standards start at exact concentrations; it is easy to make a more exact dilution series with them. When testing for iridium chloride by this skin test method, I was able to detect 3025 molecules! Troubleshooting: Always extend your set until you get a negative result (this should happen by at least bottle #18). Sensitivity of Pollutant-In-Product Testing Get some slides of Salmonellas and Shigellas and find some milk that tests positive to at least one. Make a dilution series of the milk up to bottle #14, being careful not to shake the bottles. It was the same for toxic elements starting with standard solutions, about 1000 µg/ml, showing this method is less sensitive than skin testing. Microscopy Lesson Purpose: To observe fluke stages in saliva and urine with a microscope. A total of 100x magnification is satisfactory for the four common flukes, Fasciolopsis, sheep liver fluke, human liver fluke and pancreatic fluke. For sanitation purposes (wiping table tops, slides, micro- scope and your hands) a 50% to 70% alcohol solution (not rubbing alcohol! Dilute this with equal parts of filtered water to get 18½%, which is close enough to 20%, for the purpose of “fixing” (killing) the specimens. Ask a pharmacist to prepare Lugol’s Iodine Solution for you, as follows: • 44 grams (1½ oz) iodine crystals • 88 grams (3 oz) potassium iodide crystals Dissolve both in 1 liter (quart) filtered water. Pour the 20% formaldehyde into a small amber bottle or other receptacle to a depth of about 1/8 inch. The person to be tested is asked to salivate into the bottle so the organisms are immediately “fixed” without under- going cooling first. Compare objects you observe with specimens obtained on slides from bio- logical supply companies. Persons with terminal untreated cancer have many more fluke stages than relatively well persons. Cancer victims with cervical or prostate cancer will show higher numbers of stages in urine than other cancer types. Slides may be stained in either of these two ways: • Put a drop of “fixed” urine on a slide. Taking Pictures Of What You See You may be unsure of what you see even if you have the microscope slides of labeled flukes and their stages to study and compare. In real life, they vary so much in shape and size that absolute identification is difficult without experience. Unfortu- nately in a few hours, just as you are getting proficient, your magnificent specimens will be drying out and unfit for observa- tion. To preserve them longer you can seal the edges by painting around the coverslip with fingernail clear enamel. Or dribble hot sealing wax along the edges and then place them in sealed plastic bags (one per bag). Make an applicator from a piece of coat hanger wire bent in the shape of a small square to fit around the coverslip and a handle. To take pictures of what you see under the microscope you will need a photomicrographic camera, which costs $200. Even photographs do not scientifically prove identity of parasite stages, but it is very good evidence.

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