Legionellosis – Legionnaires Disease
Legionellosis is a potentially fatal infectious disease caused by Gram negative, aerobic bacteria belonging to the genus Legionella.[1][2] Over 90% of legionellosis cases are caused by Legionella pneumophila, a ubiquitous aquatic organism that thrives in temperatures between 25 and 45 °C (77 and 113 °F), with an optimum around 35 °C (95 °F).[3]
Legionellosis takes two distinct forms:
- Legionnaires’ disease, also known as “Legion Fever“,[4] is the more severe form of the infection and produces pneumonia.[5]
- Pontiac fever is caused by the same bacteria but produces a milder respiratory illness without pneumonia that resembles acute influenza.[5]
Legionnaires’ disease acquired its name in July 1976 when an outbreak of pneumonia occurred among people attending a convention of the American Legion at the Bellevue-Stratford Hotel in Philadelphia. On January 18, 1977 the causative agent was identified as a previously unknown strain of bacteria, subsequently named Legionella. Some people can be infected with the Legionella bacteria and have only mild symptoms or no illness at all.
Outbreaks of Legionnaires’ disease receive significant media attention. However, this disease usually occurs as single, isolated cases not associated with any recognized outbreak. When outbreaks do occur, they are usually in the summer and early autumn, though cases may occur at any time of year. The fatality rate of Legionnaires’ disease has ranged from 5% to 30% during various outbreaks. “The death rate for patients who develop Legionnaire’s disease while in the hospital is close to 50%, especially when antibiotics are started late,” according to the NIH and U.S. National Library of Medicine service’s MedlinePlus. Most infections occur in those who are middle-age or older.
Signs and symptoms
Patients with Legionnaires’ disease usually have fever, chills, and a cough, which may be dry or may produce sputum. Some patients also have muscle aches, headache, tiredness, loss of appetite, loss of coordination (ataxia), and occasionally diarrhea and vomiting. Laboratory tests may show that patients’ renal functions, liver functions and electrolytes are deranged, including hyponatremia. Chest X-rays often show pneumonia with bi-basal consolidation. It is difficult to distinguish Legionnaires’ disease from other types of pneumonia by symptoms or radiologic findings alone; other tests are required for diagnosis.
Persons with Pontiac fever experience fever and muscle aches without pneumonia. They generally recover in 2 to 5 days without treatment.
The time between the patient’s exposure to the bacterium and the onset of illness for Legionnaires’ disease is 2 to 10 days; for Pontiac fever, it is shorter, generally a few hours to 2 days.
[edit] Cause
L. pneumophila is specifically considered as a pathogen of the respiratory tract. Other infections have also been reported, including haemodialysis fistulae, pericarditis, and wound and skin infections. Bacteraemia is often associated with Legionnaires’ disease. Intestinal infections may only occur as part of respiratory infections, and where gastrointestinal symptoms have on occasion been described.
No animal infections have been specifically recorded.
Infections of protozoa such as Hartmannella vermiformis and related protozoa have been shown to be able to support the growth of L. pneumophila in tap water. Also Acanthamoeba, Naegleria and Tetrahymena can be infected by L. pneumophila. This pathway may be how these organisms survive in the environment.[citation needed]
[edit] Transmission
Infection normally occurs after inhaling an aerosol (fine airborn particles) containing Legionella bacteria. Such particles could originate from any infected water source. When mechanical action breaks the surface of the water, small water droplets are formed, which evaporate very quickly. If these droplets contain bacteria, the bacteria cells remain suspended in the air, invisible to the naked eye and small enough to be inhaled into the lungs.[7] This often occurs in poorly ventilated areas such as prisons where a condensating air conditioner can spread it throughout the entire room, infecting anyone not immune to the strain of bacteria.
Potential sources of such contaminated water include cooling towers (some 40% to 60% of ones tested[8]) used in industrial cooling water systems as well as in large central air conditioning systems, evaporative coolers, hot water systems, showers, windshield washers[9], whirlpool spas, architectural fountains, room-air humidifiers, ice making machines, misting equipment, and similar disseminators that draw upon a public water supply.
The disease may also be transmitted from contaminated aerosols generated in hot tubs if the disinfection and maintenance program is not done rigorously.[10] Freshwater ponds, creeks, and ornamental fountains are potential sources of Legionella.[11] The disease is particularly associated with hotels, fountains, cruise ships and hospitals with old, poorly maintained pipework and cooling systems.
[edit] Prevention
A recent research study provided evidence that Legionella pneumophila, the causative agent of Legionnaires’ disease, can travel airborne at least 6 km from its source. It was previously believed that transmission of the bacterium was restricted to much shorter distances. A team of French scientists reviewed the details of an epidemic of Legionnaires’ disease that took place in Pas-de-Calais in northern France in 2003–2004. There were 86 confirmed cases during the outbreak, of whom 18 died. The source of infection was identified as a cooling tower in a petrochemical plant, and an analysis of those affected in the outbreak revealed that some infected people lived as far as 6–7 km from the plant.[12]
A study of Legionnaires’ disease cases in May 2005 in Sarpsborg, Norway concluded that: “The high velocity, large drift, and high humidity in the air scrubber may have contributed to the wide spread of Legionella species, probably for >10 km. “…[13]
In 2010 a study by the UK Health Protection Agency reported that 20% of cases may be caused by infected windscreen washer systems filled with pure water. The finding came after researchers spotted that professional drivers are five times more likely to contract the disease. No cases of infected systems were found whenever a suitable washer fluid was used.[14]
Temperature affects the survival of Legionella as follows:[15]
- 70 to 80 °C (158 to 176 °F): Disinfection range
- At 66 °C (151 °F): Legionellae die within 2 minutes
- At 60 °C (140 °F): They die within 32 minutes
- At 55 °C (131 °F): They die within 5 to 6 hours
- Above 50 °C (122 °F): They can survive but do not multiply
- 35 to 46 °C (95 to 115 °F): Ideal growth range
- 20 to 50 °C (68 to 122 °F): Growth range
- Below 20 °C (68 °F): They can survive but are dormant
Removing slime, which can carry legionellae when airborne, may be an effective control process.[16][17]
[edit] Action levels
The European Working Group for Legionella Infections (EWGLI)[18] was established in 1986 within the European Union framework to share knowledge and experience about potential sources of Legionella and their control. This group has published guidelines[19] about the actions to be taken to limit the number of colony forming units (i.e., the “aerobic count”) of micro-organisms per mL at 30 °C (minimum 48 hours incubation):
| Aerobic count | Legionella | Action required |
|---|---|---|
| 10,000 or less | 1,000 or less | System under control. |
| more than 10,000 up to 100,000 |
more than 1,000 up to 10,000 |
Review program operation. The count should be confirmed by immediate re-sampling. If a similar count is found again, a review of the control measures and risk assessment should be carried out to identify any remedial actions. |
| more than 100,000 | more than 10,000 | Implement corrective action. The system should immediately be re-sampled. It should then be ‘shot dosed’ with an appropriate biocide, as a precaution. The risk assessment and control measures should be reviewed to identify remedial actions. |
Almost all natural water sources contain Legionella and their presence should not be taken as an indication of a problem. The tabled figures are for total aerobic plate count, cfu/ml at 30 °C (minimum 48 hours incubation) with colony count determined by the pour plate method according to ISO 6222(21) or spread plate method on yeast extract agar. Legionella isolation can be conducted using the method developed by the US Center for Disease Control using buffered charcoal yeast extract agar with antibiotics.
Many other governmental agencies, cooling tower manufacturers, and industrial trade organizations have developed design and maintenance guidelines for preventing or controlling the growth of Legionella in cooling towers. However, in the US, there are no regulations requiring testing or maintaining any specified levels in these facilities.
[edit] Breeding ground
The bacteria grow best in warm water, like the kind found in hot tubs, cooling towers, hot water tanks, large plumbing systems, or parts of the air-conditioning systems of large buildings. Indoor ornamental fountains have been confirmed as a cause of Legionnaires’ disease outbreaks, in which submerged lighting as a heat source was attributed to the outbreak in all documented cases.[citation needed] Controlling the growth of Legionella in ornamental fountains is touched on in many of the listed guidelines. However, specific guidelines for ornamental fountains have also been published.[20]
Adding an antibacterial agent to the automobiles’ windshield system’s reservoir is also recommended.[21]
[edit] Regulations and ordinances
The guidance issued by the UK government’s Health and Safety Executive (HSE) now recommends that microbiological monitoring for wet cooling systems, using a dipslide, should be performed weekly. The guidance now also recommends that routine testing for legionella bacteria in wet cooling systems be carried out at least quarterly, and more frequently when a system is being commissioned, or if the bacteria has been identified on a previous occasion.[22]
The City of Garland, Texas requires yearly testing for legionella bacteria at cooling towers at apartment buildings.[23]
Malta requires twice yearly testing for Legionella bacteria at cooling towers and water fountains. Malta prohibits the installation of new cooling towers and evaporative condensers at health care facilities and schools.[24]
The Texas Department of State Health Services has provided guidelines for hospitals to detect and prevent the spread of nosocomial infection due to legionella.[25]
[edit] Limiting growth
Legionella bacteria themselves can be inactivated by UV light. However, Legionella bacteria that grow and reproduce in amoebae or that are sheltered in corrosion particles cannot be killed by UV light alone. An innovative way is the combination of ultrasonics and UVC light. This uses a two-stage process, where ultrasonic cavitation disrupts the amoebae or corrosion particles and leaves the Legionella bacteria exposed for UV radiation. Such combined system are used for example in hot water systems in sensitive areas, such as hospitals, where the inhabitants are more vulnerable than in normal environments.[26]
Legionella will grow in water at temperatures from 20 to 50 °C (68 to 122 °F). However, the bacteria reproduce at the greatest rate in stagnant water at temperatures of 35 to 46 °C (95 to 115 °F).
Legionella longbeachae, an organism in the Legionella family, is found in soils and compost.[27] Thus, the dust from purchased bags of soil, compost, or potting mix is a potential source of Legionella.
[edit] Diagnosis
People of any age may suffer from Legionnaires’ disease, but the illness most often affects middle-age and older persons, particularly those who smoke cigarettes or have chronic lung disease. Immunocompromised patients are also at elevated risk. Pontiac fever most commonly occurs in persons who are otherwise healthy.
The most useful diagnostic tests detect the bacteria in sputum, find Legionella antigens in urine samples (due to renal fibrosis), or the comparison of Legionella antibody levels in two blood samples taken 3 to 6 weeks apart. A urine antigen test which is simple, quick, and very reliable will only detect Legionella pneumophila serogroup 1. In addition the urine antigen test will not identify the specific subtypes; so it cannot be used to match the patient with the environmental source of infection.
[edit] Treatment
Current treatments of choice are the respiratory tract quinolones (levofloxacin, moxifloxacin, gemifloxacin) or newer macrolides (azithromycin, clarithromycin, roxithromycin). The antibiotics used most frequently have been levofloxacin and azithromycin. Macrolides are used in all age groups while tetracyclines are prescribed for children above the age of 12 and quinolones above the age of 18. Rifampicin can be used in combination with a quinolone or macrolide. Tetracyclines and erythromycin led to improved outcomes compared to other antibiotics in the original American Legion outbreak. These antibiotics are effective because they have excellent intracellular penetration and Legionella infects cells.
The mortality at the original American Legion convention in 1976 was high (34 deaths in 180 infected individuals) because the antibiotics used (including penicillins, cephalosporins, and aminoglycosides) had poor intracellular penetration. Mortality has plunged to less than 5% if therapy is started quickly. Delay in giving the appropriate antibiotic leads to higher mortality.
[edit] Prognosis
According to the journal Infection Control and Hospital Epidemiology, hospital-acquired Legionella pneumonia has a fatality rate of 28%, and the principal source of infection in such cases is the drinking-water distribution system.[28]
[edit] Epidemiology
“It is estimated that in the United States there are between 10,000 and 50,000 cases of Legionnaires’ disease each year”, according to OSHA from the U.S. Department of Labor.[29] Much has been learned about the epidemiology of Legionnaires’ disease since the organism was first identified in 1976. National surveillance systems and research studies were established early, and in recent years improved ascertainment and changes in clinical methods of diagnosis have contributed to an upsurge in reported cases in many countries. Environmental studies continue to identify novel sources of infection, leading to regular revisions of guidelines and regulations. Between 1995 and 2005 over 32,000 cases of Legionnaires’ disease and more than 600 outbreaks were reported to the European Working Group for Legionella Infections (EWGLI). In the future, there may be an increase in cases as the population becomes more elderly.[2] There is a shortage of data on Legionella in developing countries and it is likely that Legionella-related illness is underdiagnosed worldwide.[30] Improvements in diagnosis and surveillance in developing countries would be expected to reveal far higher levels of morbidity and mortality than are currently recognised. Similarly, improved diagnosis of human illness related to legionella species and serogroups other than legionella pneumophila would improve knowledge about their incidence and spread.[31]
[edit] Outbreaks
[edit] Philadelphia, United States, 1976
The first recognized outbreak occurred on July 27, 1976 at the Bellevue Stratford Hotel in Philadelphia, Pennsylvania, where members of the American Legion, a United States military veterans association, had gathered for the American Bicentennial. Within two days of the event’s start, veterans began falling ill with a then-unidentified pneumonia. They were tachypneic and complained of chest pain. As many as 221 people were given medical treatment, and 34 deaths occurred. At the time, the U.S. was debating the risk of a possible swine flu epidemic, and this incident prompted the passage of a national swine flu vaccination program. That cause was ruled out, and research continued for months, with various theories discussed in scientific and mass media that ranged from toxic chemicals to terrorism (domestic or foreign) aimed at the veterans.
This photograph shows Centers for Disease Control (CDC) laboratorian George Gorman at left, along side Dr. Jim Feeley, while they were examining culture plates, i.e., Petri dishes, upon which the first environmental isolates of Legionella pneumophils had been grown.
The U.S. Centers for Disease Control and Prevention mounted an unprecedented investigation and, by September, the focus had shifted from outside causes, such as a disease carrier, to the hotel environment itself. In January 1977, the Legionellosis bacterium was finally identified and isolated, and found to be breeding in the cooling tower of the hotel’s air conditioning system, which then spread it through the entire building. This finding prompted new regulations worldwide for climate control systems.[32]
[edit] United Kingdom, 1985
In April 1985, 175 patients were admitted to the District or Kingsmead Stafford Hospitals with chest infection or pneumonia. A total of 28 people died. Medical diagnosis showed that Legionnaires’ disease was responsible and the immediate epidemiological investigation traced the source of the infection to the air-conditioning cooling tower on the roof of Stafford District Hospital. A Government Inquiry was convened to investigate how the infection occurred and why it became Britain’s largest epidemic of Legionnaires’ disease. The infection was linked to one small zone in the hospital: the outpatients department. The initial investigation searched for engineering reasons to explain why this particular zone was the risk area. More detailed and wider epidemiological surveys subsequently showed that staff working in the whole area supplied with fresh air taken adjacent to the tower, had antibodies to the disease. The outpatients department was unique in having a very large transient population of susceptible individuals either receiving treatment or accompanying friends.
[edit] Netherlands, 1999
In March 1999, an outbreak in the Netherlands occurred during a flower exhibition in Bovenkarspel. 200 people became ill and at least 32 people died. There is a possibility that more people died from it, but these people were buried before the Legionella infection was recognized. The source of the bacteria were probably a whirlpool and a humidifier in the exhibition area.[33]
[edit] Melbourne, Australia, 2000
In April 2000, an outbreak of Legionella pnemophila serogroup 1 occurred in Melbourne, Australia. The outbreak resulted in 125 confirmed cases of Legionnaire’s disease, with 95 (76%) hospitalised. It is reported that 4 died from the outbreak. The investigation traced the source of the infection to the cooling tower at the newly opened aquarium.[34] Since this outbreak, legionella infection statistics are required to be reported by the state government as a notifiable disease.[35] Stringent Regulations were introduced by the State to control legionella in 2001.[36]
[edit] Spain, 2001
The world’s largest outbreak of Legionnaires’ disease happened in July 2001 (patients began appearing at the hospital on July 7), in Murcia, Spain. More than 800 suspected cases were recorded by the time the last case was treated on July 22; 636–696 of these cases were estimated and 449 confirmed (so, at least 16,000 people were exposed to the bacterium) and 6 died (a case-fatality rate of approximately 1%).[citation needed]
A case-control study matching 85 patients living outside the city of Murcia with two controls each was undertaken to identify the outbreak source; the epidemiological investigation implicated the cooling towers at the Morales Meseguer Hospital. An environmental isolate from these towers with an identical molecular pattern as the clinical isolates was subsequently identified and supported that epidemiologic conclusion.
[edit] United Kingdom, 2002
In 2002, Barrow-in-Furness in the U.K. suffered an outbreak of Legionnaires’ disease. Six women and one man died as a result of the illness; another 172 people also contracted the disease. The cause was found to be a contaminated cooling tower at the town’s Forum 28 arts centre.[37] Barrow Borough Council later became the first public body in the UK to be charged with corporate manslaughter but were cleared. They were, however, along with architect Gillian Beckingham, fined for breaches of Health and Safety regulations in a trial that ended in 2006.
[edit] Norway, 2005
In Fredrikstad, Norway, 56 people became ill and ten died from Legionnaires’ disease caused by bacteria growing in an air scrubber of a nearby factory.
[edit] Los Angeles, United States, 2011
In Los Angeles, CA, bacteria that causes Legionnaires’ disease was found in a hot tub at the Playboy Mansion where scores of people became ill after attending a fundraiser in February. Officials contacted 439 people and found that 123 had fevers and at least one other symptom with 69 falling ill on the same day.[38]
Source: http://en.wikipedia.org/
Anna Paquin
Date of Birth
24 July 1982, Winnipeg, Manitoba, Canada
Birth Name
Anna Helene Paquin
Height
5′ 5″ (1.65 m)
Mini Biography
Anna Paquin is the star of several major motion pictures, including her first Oscar winning performance in The Piano (1993), the role of the young Jane in the 1996 film Jane Eyre (1996), and the role of Amy Alden in the charming family film, Fly Away Home (1996). With a well-developed vocabulary and gentle sense of humor, Paquin proves herself to be the most enchanting young talent working today. Paquin’s rising stardom has often been a cause of charming media shyness, where it is obvious that she is an ordinary girl who happens to posses an extraordinary talent. She has two agents, Gail Cowan in New Zealand, and the William Morris agency in Los Angeles, but neither these nor her parents have much influence in deciding what she films. “In the end”, she says, “it’s my decision”. Paquin’s parents separated while she was filming Fly Away Home (1996) in Canada. On Oscar night in 1993, Anna Paquin was the surprise (and surprised) winner of the Academy Award for Best Supporting Actress. She stood, wide-eyed and gulping for breath at the microphone for a full twenty-something-odd seconds before delivering a gracious, though rather breathless thank-you speech.
IMDb Mini Biography By: Serg Pageen <akakii@chat.ru>
Mini Biography
Anna Paquin, the young Canadian who grew up in New Zealand and whose only acting experience was as a skunk at a school play, stunned movie-goers from all over the world with her performance as Holly Hunter‘s angry young daughter in the acclaimed film The Piano (1993). Anna, who received an Oscar for her performance (the second youngest Oscar winner ever), has proven that The Piano (1993) was only the beginning of a fabulous career.
She starred in Carroll Ballard‘s Fly Away Home (1996) and in Franco Zeffirelli‘s Jane Eyre (1996). After her parents’ divorce, she moved to Los Angeles with her mother and sister in order to pursue more actively a career in acting. Soon enough, she made the transition from child-actress to teenage actress with her performance in Hurlyburly (1998) alongside Sean Penn, Kevin Spacey and Meg Ryan and in A Walk on the Moon (1999) alongside Diane Lane, Viggo Mortensen and Liev Schreiber. Paquin, who has become an expert at portraying troubled teenagers, then starred in the popular science fiction film, the X-Men (2000). The same year, 2000, she also appeared in films such as Cameron Crowe‘s Almost Famous (2000) and Gus Van Sant‘s Finding Forrester (2000). Anna, who was a student at Columbia University, moved to New York City and began a new career as a stage actress appearing both in New York and London.
IMDb Mini Biography By: anonymous
Spouse
| Stephen Moyer | (21 August 2010 – present) |
Trade Mark
Trivia
She is a vegetarian.
While filming the movie Amistad (1997) in Montreal during the summer, she made a side-trip to Toronto to film 5 TV commercials for the telephone company of her old hometown in Winnipeg, Manitoba, Canada. She delivers the commercials in a variety of costumes in her Canadian accent rather than her New Zealand one. [1997]
She keeps her Oscar in her bedroom closet so her friends won’t see it and feel the need to comment on it.
She enjoys photography.
Family moved to New Zealand when Anna was 4.
Has an older brother, Andrew Paquin, a film producer, with whom she is working on Blue State (2007)), and a sister, Katya.
She plays the cello.
Father, Brian, is a physical education teacher. Mother, Mary, is an English teacher.
Her parents are divorced.
Hobbies: rugby; running; playing the piano; singing; gymnastics; swimming; downhill skiing; reading and knitting.
Enjoys listening to alternative music.
When she was younger, she wanted to be the Prime Minister of New Zealand, or a lawyer.
Is a fan of The Beatles.
She has 2 cats and 1 dog.
Speaks French.
Graduated from Windward School in West Los Angeles, California in June 2000; she completed the school’s community service requirement by working in an LA soup kitchen and at a special education center.
One of Teen People Magazine’s “25 Hottest Stars under 25”. [2002]
College classmate of Julia Stiles at Columbia University.
Is a fan of the alternative rock band Nine Inch Nails.
She was the original choice to play the character of Enola in Kevin Costner‘s Waterworld (1995) but, eventually, the role fell to Tina Majorino.
Attending Columbia University. [2005]
When on a talk show, the host told her he would give her $10,000 if she could shoot a basketball into a hoop. She did, but he refused to pay. After bad press he gave her the money which she donated to charity.
Played the daughter of Jeff Daniels in Fly Away Home (1996) and then his romantic partner in The Squid and the Whale (2005) nine years later.
Was number 93 on vh1’s “100 Greatest Kid Stars” (2005).
Has kept in close contact with Shawn Ashmore (Iceman/Bobby Drake) and Aaron Stanford (John Allerdyce/Pyro) after filming X2 (2003).
Though she was born in Canada she considers herself a Kiwi from New Zealand since she grew up there.
Ranked #50 on the Maxim magazine Hot 100 of 2008 list.
Announced her engagement to Stephen Moyer, having been in a relationship since February 2009 after meeting on the set of “True Blood” (2008), after he proposed to her on a beach in Hawaii (5 August 2009).
Among the guests at her wedding to Stephen Moyer were Alan Ball, Ryan Kwanten, Sam Trammell, Rutina Wesley, Carrie Preston and Elijah Wood.
Mentioned on “Late Show with David Letterman: Episode #16.176” (2009) that she had recently seen her first movie The Piano (1993) for the first time in her life.
Went to Columbia University in New York, but left after a year and did not graduate in order to pursue acting.
Step-mother of Stephen Moyer‘s children Billy and Lilac.
Was ranked #84 on Maxim magazine’s Hot 100 of 2010 list.
She ranked #84 on “Maxim’s Hot 100 of 2010”.
Personal Quotes
None of the characters I’ve played are really like me. That would be boring. It wouldn’t be acting.
Everything about being a teenager and not feeling like you fit in is just magnified by being a mutant!
If I don’t do laundry today, I’m gonna have to buy new clothes tomorrow.
There are very few films or plays or anything about really happy people with perfect lives. Everyone is usually screwed up in some way and that is usually where the work comes in – figuring out how to make it believable and make it real to present someone’s problems that you don’t necessarily actually know anything about. I mean it is not challenging to be happy all the time. I don’t think I could do it!
I just do what feels right. I think the great thing about getting to do what I do is that you can try out being a different person without having to screw up your life to do it.
I’m not very political. I’m also not American and I don’t get to vote so my feelings are not really relevant.
You’ll live a full and happy life if your pursue things you think are important and live the life you want to live
Where Are They Now
(January 2003) Returning to continue her studies at Columbia University in New York.
(May 2004) Starring in Neil LaBute‘s Off-Broadway play, “The Distance from Here.”
(February 2005) Starring in the Off-Broadway production of “After Ashley”.
(April 2006) Filming Blue State (2007) in Canada.
(2007) Working on “True Blood” (2008), an HBO series.
(February 2010) Working on “True Blood” (2008).
Source: http://www.imdb.com/
Jennifer Lopez and Marc Anthony to divorce
POP star Jennifer Lopez and husband Marc Anthony have announced they are to divorce after seven years of marriage.
The couple, who are parents to three-year-old twins Max and Emme, released a statement last night confirming their shock split.
“We have decided to end our marriage,” they said. “This was a very difficult decision. We have come to an amicable conclusion on all matters.”
Lopez, 41, and Anthony, 42, married in a secret ceremony at her lavish Beverly Hills home in June 2004.
It came just five months after her high-profile engagement to Ben Affleck ended. Lopez had been married twice before – to restaurateur Ojani Noa, whom she split from in 1998, and backing dancer Cris Judd, to whom she was hitched from 2001 to 2003.
Salsa star Anthony has two sons Cristin, 10, and Ryan, seven, from his first marriage to former Miss Universe Dayanara Torres.
The couple renewed their wedding vows in 2008 after their twins were born. They reaffirmed their love for one another again last year to mark their sixth anniversary on June 5.
Their statement added: “It is a painful time for all involved and we appreciate the respect of our privacy at this time.”
Singer J.Lo, who also starred in films including Maid in Manhattan and The Wedding Planner, was a judge on the last series of American Idol.
There may have been a clue something was wrong last week, when Lopez took her mother to meet William and Kate during their royal tour visit to Los Angeles.
Carmageddon
 |
It has been suggested that this article be split into a new article titled Carmageddon (series), accessible from a disambiguation page. (December 2010) |
| Carmageddon | |
|---|---|
 European cover art |
|
| Developer(s) | Stainless Games |
| Publisher(s) | SCi, Interplay |
| Series | Carmageddon |
| Engine | BRender |
| Platform(s) | DOS (1997), Macintosh (1997), PlayStation (1999), Nintendo 64 (2000), Game Boy Color (2001) |
| Release date(s) | June 30, 1997 |
| Genre(s) | Vehicular combat |
| Mode(s) | Single player, multiplayer |
| Rating(s) | ESRB: M, T (GBC) BBFC: 18 OFLC: MA15+ ELSPA: 15+ (cut) USK: 12 (cut) |
| Media/distribution | CD-ROM |
Carmageddon is the first of a series of graphically violent vehicular combat video games produced by Stainless Games, published by Interplay and SCi. It was inspired by the 1975 cult classic movie Death Race 2000.
Gameplay
Die Anna drives through the Coastal Carnage level
In Carmageddon, the player races a vehicle against a number of other computer controlled competitors in various settings, including city, mine and industrial areas. The player has a certain amount of time to complete each race, but more time may be gained by collecting bonuses, damaging the competitors’ cars or by running over pedestrians.
Races are completed by either completing the course as one would a normal racing game, “wasting” (wrecking) all other race cars, or killing all pedestrians on the level.
The game was notable for its realistic and ground-breaking physics and for its in-game movie making features. It was also one of the earliest examples of sandbox 3D driving games, and may have influenced other later games including Driver and the Grand Theft Auto series.
The game featured instrumental versions of songs from Fear Factory‘s album Demanufacture, with the song Zero Signal being used in the game’s intro. The other songs from the album that appear are Demanufacture and Body Hammer.
[edit] Development
The game that became Carmageddon started out as “3D Destruction Derby”, a Banger racing sim prototyped by Stainless Software. This was signed by SCi in 1995, but the banger-racing angle was soon dropped and for a while the game was to use the Mad Max license. This fell through, and was replaced by the Death Race 2000 license, as a sequel to the original film was at that time planned (it eventually emerged as a comic book).[1] This introduced the running-over of pedestrians into the game.
When this license also fell through, SCi and Stainless took the decision to proceed with the game anyway, creating their own IP. The name “Carmageddon” was coined, and development proceeded with the designers allowed unusually free rein with regard to the content of the game.
[edit] Reception
[edit] Sales
The Carmageddon series has sold around two million copies according to Patrick Buckland and Neil Barnden, co-founders of Stainless Games.[1]
[edit] Controversy
In many countries (including Germany and, for a short time, the UK), the first release of the game was censored. They contained zombies with green blood or robots with black oil instead of people, as running over the non-human figures was considered more acceptable by their respective ratings boards. In the UK, SCi wanted to gain publicity for the game by submitting it to the British Board of Film Classification (BBFC) to get an 18 rating, even though this was not necessary as the game contained no video footage. This backfired when the BBFC refused to certify the game unless all blood and gore was removed. After 10 months of appeal, the BBFC certified the original version.[2]
In some countries, the game was banned completely, including Brazil.[3] In Portugal and Australia the game was passed completely uncut with an +18 and MA15+ rating, respectively.[4]
[edit] Franchise
[edit] Expansion pack and compilation
Max Damage on the starting grid of Splat Pack level, Mayan Mayhem
Carmageddon Splat Pack is an official expansion pack released in 1997. The expansion pack included new tracks, vehicles, environments, network levels and 3Dfx support.
Carmageddon Max Pack, also released in 1997, bundled the original game and its expansion pack into one package. As a bonus, it also included a strategy guide, mousepad, and a leather car key chain with Carmageddon’s logo on it.
[edit] Sequels
The game was successful enough to become a trilogy. The other games in the main series are:
[edit] Ports
Carmageddon was originally released on the PC (for DOS) in 1997, but was eventually ported to Microsoft Windows (1997), Macintosh (1997), PlayStation (1999), Nintendo 64 (2000) and Game Boy Color (2001). The PlayStation and Nintendo 64 versions of Carmageddon are more similar to Carmageddon II. The Nintendo 64 port was ill-received, being N64 Magazine‘s lowest rated game at 8% from 1999 till 2004. A port of the first game was in development for the Gizmondo, but was never released due to the system’s demise.
[edit] Hiatus and revival
SCi had originally planned Carmageddon 4 for a late 2005 release. Little to no information was released about the game, then SCi (whom Eidos gained ownership of) putting development on hold for unspecified reasons. [5] SCi and Eidos went on to focus on other projects, while Square Enix Europe obtained the series IP rights.
On June 1st 2011, Stainless Games revealed that they had re-acquired the rights to Carmageddon. A new title, Carmageddon: Reincarnation, is in early development for a 2012 release.
Source: http://en.wikipedia.org/
Elin Nordegren
Early life
Nordegren was born in Stockholm, Sweden. Her mother, Barbro Holmberg, is a politician and the former Swedish migration and asylum policy minister, and the current Governor of Gävleborg County. Her father, Thomas Nordegren, is a radio journalist who served as a bureau chief in Washington, D.C.[2] She has an older brother, Axel, and a twin sister, Josefin.[3] Nordegren and her sister worked odd summer jobs and as cashiers in supermarkets to finance their studies.[4] She started modeling in 2000, and appeared on the cover of Cafe Sport magazine in the summer of 2000.
[edit] Marriage to Tiger Woods
Nordegren took a job in a Stockholm clothing store called Champagne, where she met Mia Parnevik, wife of Swedish golfer Jesper Parnevik, who hired Nordegren as the nanny to their children, a job that required her to move to the U.S.[5] He introduced her to Woods during the 2001 Open Championship.Parnevik also is being quoted as having said, “I’m kind of filled with sorrow for Elin since me and my wife are at fault for hooking her up with him, and we probably thought he was a better guy than he is.” [People Magazine] Previously, Woods had asked for a year to be introduced to Nordegren, who was seeing someone else at the time. “There was a big line of single golfers wanting to meet her. They were gaga over her.”[6] She had hopes of becoming a child psychiatrist at the time. In November 2003, Woods and Nordegren attended the Presidents Cup tournament in South Africa and became officially engaged when Woods proposed at the luxury Shamwari Game Reserve.
They were married in October 2004, by the 19th hole of the Sandy Lane resort in Barbados. The 150 guests included Oprah Winfrey, Michael Jordan, Charles Barkley and Bill Gates. Woods rented the entire complex for a week, including three golf courses and 110 rooms, costing almost $2 million.[7]
Shortly after Nordegren’s relationship with Woods became public, nude photographs purporting to be of Nordegren began circulating on the Internet, which were established to be fakes.[8][9] Despite the debunking, in 2006, Irish magazine The Dubliner published the nude photographs and stated they were of Nordegren.[10][11] On November 16, 2006, Nordegren filed a libel suit against The Dubliner.[12] Nordegren won the lawsuit, and as part of the settlement accepted by a Dublin court, The Dubliner was required to publish a lengthy apology in a variety of venues. Were the magazine to have failed to meet the conditions, the award would have been increased to $366,500 plus all of Nordegren’s legal expenses.[12][13]
On June 18, 2007, Woods announced the birth of the couple’s daughter, Sam Alexis Woods, a day after finishing second in the U.S. Open.[14] On September 2, 2008, Woods announced they were expecting another child in late winter.[15] Five months later it was announced that Nordegren had given birth to a boy, Charlie Axel, on February 8, 2009.[16]
In December 2009, her marriage to Woods was the subject of extensive media coverage after Woods admitted to infidelity, which had been revealed following his single-vehicle accident near the family’s Florida home.[17] Woods subsequently announced he would take an “indefinite break” from golf to work on his marriage.[17] These efforts were unsuccessful, however, as Nordegren and Woods finalized their divorce in the Bay County Circuit Court in Panama City, Florida, on August 23, 2010.[18] Nordegren’s legal team included her sister, Josefin (who is licensed to practice law in England and Sweden) and several of Josefin’s U.S. colleagues at international law firm McGuireWoods.[19]
[edit] Education
Nordegren has been enrolled part-time as a student at Rollins College in Winter Park, Florida, where she is studying psychology.[20][21]
[edit] References
^ Tiger Woods Update: Elin Nordegren’s Swedish hideway offers privacy, but no running water. Retrieved December 28, 2009.
^ a b “Five things you didn’t know about Elin Nordegren”. CNN. December 4, 2009. Retrieved December 28, 2009.
^ Article about Nordegren from the Swedish newspaper Aftonbladet. Retrieved December 28, 2009.
^ http://extratv.warnerbros.com/2009/12/17_facts_about_elin_nordegren.php
^ Bernstein, Jacob. The Mysterious Mrs. Woods, The Daily Beast, November 30, 2009. Accessed July 5, 2010.
^ Jesper Parnevik says sorry to Elin Nordegren: Should never have introduced you to Tiger Woods. Retrieved December 28, 2009.
^ Patteson, Jean. “Where’s Elusive Elin Woods?”, Orlando Sentinel, December 11, 2009. Retrieved December 28, 2009.
^ “That’s not her naked!”, playboy.com, URL retrieved September 22, 2006.
^ “Claim: Photographs show golfer Tiger Woods’ wife posing nude”, snopes.com, URL retrieved September 22, 2006.
^ “Wet Spots”, Fleshbot, September 21, 2006.
^ “Tiger Woods Blasts Mag Over Porn Jab at Wife”. Fox News. September 21, 2006. Retrieved December 28, 2009.
^ a b “Woods’s Wife Files Libel Suit”. New York Times. November 25, 2006. Retrieved December 28, 2009.
^ Pogatchnik, Shawn. Tiger Woods’ Wife Wins Libel Lawsuit, Huffington Post, December 7, 2007. Accessed July 5, 2010.
^ “Tiger Woods and Wife Elin Nordegren Have a Baby Girl – Birth, Tiger Woods: People.com”. People Magazine. June 18, 2007. Retrieved December 28, 2009.
^ “Woods announces his wife, Elin, pregnant with second child”. Associated Press. ESPN. September 2, 2008. Retrieved September 2, 2008.
^ “Tiger becomes dad for second time”. Associated Press (ESPN). February 9, 2009. Retrieved February 9, 2009.
^ a b Dorman, Larry (December 11, 2009). “Woods Says He’ll Take ‘Indefinite Break’ From Golf”. The New York Times. Retrieved December 14, 2009.
^ “Tiger Woods and wife Elin Nordegren are divorced”. BBC. August 23, 2010. Retrieved August 23, 2010.
^ Brian Baxter, “Family Ties Help McGuireWoods Land Tiger Woods Divorce Role”, The American Lawyer, 23 August 2010.
^ Back in the zone from The Guardian October 29, 2006
^ Can Tiger Save His Marriage? from People January 25, 2010
Source: http://en.wikipedia.org/
Kawasaki disease
Mucocutaneous lymph node syndrome; Infantile polyarteritis
Last reviewed: June 20, 2011.
Kawasaki disease is a rare condition in children that involves inflammation of the blood vessels.
Causes, incidence, and risk factors
Kawasaki disease occurs most frequently in Japan, where the disease was first discovered. In the United States, after congenital heart defects, Kawasaki disease is the leading cause of heart disease in children. Most of these patients are younger than age 5. The disease occurs more often in boys than in girls.
Kawasaki disease is a poorly understood illness. The cause has not been determined. It may be an autoimmune disorder. The disorder affects the mucus membranes, lymph nodes, walls of the blood vessels, and the heart.
Kawasaki disease can cause inflammation of blood vessels in the arteries, especially the coronary arteries. This inflammation can lead to aneurysms. An aneurysm can lead to a heart attack, even in young children, although this is rare.
Symptoms
Kawasaki disease often begins with a high and persistent fever greater than 102 °F, often as high as 104 °F. A persistent fever lasting at least 5 days is considered a classic sign. The fever may last for up to 2 weeks and does not usually go away with normal doses of acetaminophen (Tylenol) or ibuprofen.
Other symptoms often include:
Extremely bloodshot or red eyes (without pus or drainage)
Bright red, chapped, or cracked lips
Red mucous membranes in the mouth
Strawberry tongue, white coating on the tongue, or prominent red bumps on the back of the tongue
Red palms of the hands and the soles of the feet
Swollen hands and feet
Skin rashes on the middle of the body, NOT blister-like
Peeling skin in the genital area, hands, and feet (especially around the nails, palms, and soles)
Swollen lymph nodes (frequently only one lymph node is swollen), particularly in the neck area
Joint pain and swelling, frequently on both sides of the body
Additional symptoms may include:
Irritability
Diarrhea, vomiting, and abdominal pain
Cough and runny nose
Signs and tests
No tests specifically diagnose Kawasaki disease. The diagnosis is usually made based on the patient having most of the classic symptoms.
However, some children may have a fever lasting more than 5 days, but not all of the classic symptoms of the disease. These children may be diagnosed with atypical Kawasaki disease. Therefore, all children with fever lasting more than 5 days should be evaluated, with Kawasaki disease considered as a possibility. Early treatment is essential for those who do have the disease.
The following tests may be performed:
Chest x-ray
Complete blood count
C-reactive protein (CRP)
Echocardiogram
Electrocardiogram
ESR
Serum albumin
Serum transaminase
Urinalysis – may show pus in the urine or protein in the urine
Procedures such as ECG and echocardiography may reveal signs of myocarditis, pericarditis, arthritis, aseptic meningitis, and inflammation of the coronary arteries.
Treatment
Children with Kawasaki disease are admitted to the hospital. Treatment must be started as soon as the diagnosis is made to prevent damage to the coronary arteries and heart.
Intravenous gamma globulin is the standard treatment. It is given in high doses. The child’s condition usually greatly improves within 24 hours of treatment with IV gamma globulin.
High-dose aspirin is often given along with IV gamma globulin.
Even when they’re treated with aspirin and IV gamma globulin, up to 25% of children may still develop problems in their coronary arteries. Some research has suggested that adding steroids to the usual treatment routine may improve a child’s outcome, but more research is needed.
Expectations (prognosis)
With early recognition and treatment, full recovery can be expected. However, about 1% of patients die from complications of coronary blood vessel inflammation. Patients who have had Kawasaki disease should have an echocardiogram every 1 – 2 years to screen for heart problems.
Complications
Complications involving the heart, including vessel inflammation and aneurysm, can cause a heart attack at a young age or later in life.
Calling your health care provider
Call your health care provider if symptoms of Kawasaki disease develop. A persistent high fever that does not come down with acetaminophen or ibuprofen and lasts more than 24 hours should be evaluated by a health care provider.
Prevention
There are no known measures that will prevent this disorder.
References
Sakata K, Hamaoka K, Ozawa S, et al. A randomized prospective study on the use of 2 g-IVIG or 1 g-IVIG as therapy for Kawasaki disease. Eur J Pediatr. 2007;166(6):565-571. [PubMed]
Newburger JW, Sleeper LA, McCrindle BW, et al. Randomized trial of pulsed corticosteroid therapy for primary treatment of Kawasaki disease. N Engl J Med. 2007;356(7):663-675. [PubMed]
Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. St. Louis, Mo: WB Saunders; 2007.
Review Date: 6/20/2011.
Reviewed by: David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.; and Neil J. Gonter, MD, Assistant Professor of Medicine, Columbia University, NY and private practice specializing in Rheumatology at Rheumatology Associates of North Jersey, Teaneck, NJ. Review provided by VeriMed Healthcare Network.
Google Search Trends 