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Private decision makers can take advantage of multiple benefits in decision making if tools are available Refrigera on 3000 that facilitate complex, integrated assessments of costs and benefits. Oven 2000 Washing this section focuses on demonstrating the significance of co-benefits to Machine Fan sustainable energy action in buildings in several areas to illustrate that 1000 they are sufficient enough for offering alternative avenues for decisionEficiency Scenario and policymaking. One classification is proposed by significance, co-benefits can often present attractive entry points to polSkumatz and Dickerson (1997). They group non-energy benefits dependicymaking, and point to the crucial importance of policy integration. However, only a limbenefits in the buildings sector in a similar way adding improved social ited portion of such opportunities has been taken up by individuals as welfare and poverty alleviation. Once quantified, and with certain caution, many of these efficiency in developed countries. However, strong policy commitment to figures could be monetized and integrated into cost-benefit assessclimate change mitigation only exists in a few countries and even there ments of energy efficiency and saving actions. The following sections energy efficiency policies still fall very short of capturing the potential elaborate on a selection of co-benefits, avoiding repetitions of previous for cost-effective efficiency. This section demonstrates that co-benefits are very significant in the building sector and offer new entry points into policyand decision mak10. In jurisdictions where environmental benefits do not play a strong role in public policy, other benefits, such as poverty alleviation, employthe existing links between public health and the use of energy at home ment creation, or improved energy security may be important enough to have been explored and quantified following two main directions: the motivate such policies. For private decision makers, for whom energy cost health impacts of indoor and outdoor (regional) pollution, and the health savings are not sufficient to take steps, other benefits, such as improved impacts of inadequate access to energy, mostly heating in regions with comfort and health or corporate productivity gains, can unlock action. That way, it is likely that the most important health nonenergy benefit of providing more energy-efficient solutions in buildings While a single benefit, such as climate change mitigation, energy cost is the large number of lives that could be potentially saved through the saving, or energy security gains, may not be sufficient to motivate provision of safe, clean, and energy-efficient cooking plus heating and action to capture saving potentials or to fare positive in a cost-benefit lighting equipment in developing countries for population segments not 719 Energy End-Use: Buildings Chapter 10 Table 10. Lower water consumption and sewage production Percentage of reduction in water consumption and sewage production, Economic effects Lower energy prices1 Inverse price elasticity of supply. Employment creation2 Employments per unit of investment, multiplier effect, working age population relying on unemployement benefits, New business opportunities New market niches Rate subsidies avoided3 Decrease in the number of subsidized units of energy sold, percentage of the energy price subsidized, Enhanced value of the buildings capital stock. Service provision benefits Transmission and distribution loss reduction Value of eliminated energy losses. Fewer emergency service calls Saving staff time and resources necessary for attending the calls. Lower bad debt write-off5 Decrease in the average size of bad debt written off, decline in the number of such accounts. Social effects Fuel poverty alleviation Reduced expenditures on fuel and electricity; reduced fuel / electricity households debt; reduced excess winter deaths. Increased comfort Mean household temperature,reduction of outdoor noise infiltration (dB). Increased awareness (Conscious) reductions in energy use, higher demand for energy efficiency measures. However, it is unlikely that initiatives at local, regional or even national scales bring sufficient reductions in the overall energy demandto affect prices set internationally. To be incorporated as a benefit into cost-benefit analysis, only net employment creation can be accounted for. Rate subsidies can be defined as lower, subsidized rates provided by utilities for their low-income customers (Schweitzer and Tonn 2002). Reducing gas leaks and repair of faulty appliances (as a part of weatherization programs) decreases the insurance costs of utility companies. Writing off the portion of a bad debt which is not paid by customers to the utilities (Schweitzer and Tonn 2002). Improving building ventilation and the inefficient indoor burning of traditional biomass and other solid insulation allows the control of air exchange rates and reduces indoor air fuels is thoroughly discussed in Chapter 4; it could translate into avoidpollution and outdoor noise infiltration (Jakob, 2006). Many studies (Aunan sumption will bring about reduced amounts of embodied energy and et al. Also other co-benefits, such as the increased value and impaired mental health (Morrison and Shortt, 2008). Therefore, of real estate and lower energy prices, have welfare implications for improving building capital stocks for fuel poverty alleviation is also households. Such weatherization proinfluence rates of communicable respiratory illness, allergy and grams are especially beneficial in countries with poor housing condiasthma symptoms, sick building symptoms, and worker performance tions, where the problem of fuel poverty is especially acute (Clinch (Fisk, 2000). The experience has pointed on recreational fisheries, as well as a reduction in noise pollution, visat spatial overlaps of fuel poverty and high unemployment. Promoting ual amenity disruption, and major accident risks (European Commission, energy-efficient renovations in fuel poverty affected areas will bene1995). A growing body of literature on the economic value of ecosysfit fuel-poor households by also providing additional income-earning tem services (Costanza et al. This category of co-benefits include, inter alia, houses could reduce construction and demolition wastes over 50%, transmission and distribution (T&D) loss reduction, fewer emergency and up to a maximum of 99%, as compared to an average practice. Even tions in water consumption and sewage production over the lifetime though these are mostly related to the functioning of utility companof energy-efficiency measures, i. Since building construction, operation, and decommissionfare changes, as long as similar comfort and service provision levels are ing are energy-using activities, as is water provision and treatment achieved with fewer resources. Energy efficiency in the buildings sector can also contribute to tackling social issues, such as poverty and fuel poverty. High-efficiency retrofitting of the existing building stock or the construction of near-zero10. This, in turn, saves large amounts of public funds that are being spent on relief for those in fuel or energy poverty. Particular attention should also be paid to addressing non-compliance related to building codes. Policy instruments to encourage deep retrofits should be implemented, including performance standards, performance conWhen societal interests are considered, many of the identified co-bentracting, energy audits and incentive mechanisms. Taxation provides an impetus for a more rational justified on a societal basis or not. Similarly, non-energy benefits, espeuse of energy sources, but especially in poor regions or population cially those obtained at micro (household or firm) level, are important segments, subsidies of highly efficient capital stock can be more determinants of private decision making. The survey revealed that different types of co-benefits have been examined to different extents. The authors were unable to locate research on the quantification of cothe previous sections, in addition to earlier work, have demonstrated benefits such as new business opportunities and costs avoided due to that there is a very broad spectrum of technologies and know-how that increased awareness. A global aggregation would be barriers can be removed or lowered by appropriate policies, programs, especially challenging, because ideally such an effort applies a uniform and measures. Policy instruments clasIn this section, the final effects of key categories of policy instruments sified in this group include appliance standards, building codes, proused in the building sector to improve energy efficiency are reviewed and curement regulations, energy efficiency obligations, quotas, etc. Experts agree that even a brilliantly designed policy tool may schemes that aim to inform energy users about energy efficiency. However, the greatest attention is these comprise mandatory labeling and certification programs, usually given to policy design, whereas implementation and enforcement mandatory audit programs, utility demand-side management proprocesses are often neglected (Khan et al. These are: (a) the degree to which a policy tool achieves ciency certificate schemes, the Kyoto flexible mechanisms, regional the target, often referred to as policy effectiveness; (b) the extent to carbon trading platforms and carbon offset programs, etc. These which a tool has made a difference compared to the situation without are directly or indirectly aimed at steering economic actors toward it, referred to as net impact of the policy tool; and (c) the relationships improved energy efficiency. Also, the best either the implementation of taxes, tax exemptions or reductions, attempt has been made to identify limitation and success factors.


  • EKG (heart tracing)
  • 4-ounce serving of meat
  • 1 hour: greater than 180 mg/dL
  • Nausea and vomiting continue beyond your 4th month of pregnancy. This happens to some women and is usually normal, but have it checked out.
  • Difficulty walking
  • Take over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB) or acetaminophen (Tylenol).
  • Complete blood count

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Hepatitis B Virus X Protein: A Key Regulator of the Virus Life Cycle 153 Quasdorff, M. Lipid-mediated introduction of hepatitis B virus capsids into nonsusceptible cells allows highly efficient replication and facilitates the study of early infection events. Virus replication and virion export in X-deficient hepatitis B virus transgenic mice. Phosphorylation and rapid turnover of hepatitis B virus X-protein expressed in HepG2 cells from a recombinant vaccinia virus. Primary human hepatocytes-a valuable tool for investigation of apoptosis and hepatitis B virus infection. Hepatitis B virus infection initiates with a large surface protein-dependent binding to heparan sulfate proteoglycans. Cytosol is the prime compartment of hepatitis B virus X protein where it colocalizes with the proteasome. Transfer of hepatitis B virus genome by adenovirus vectors into cultured cells and mice: crossing the species barrier. Identification of a structural motif crucial for infectivity of hepatitis B viruses. Isolation and molecular characterization of hepatitis B virus X-protein from a baculovirus expression system. Long-term efficacy of tenofovir monotherapy for hepatitis B virus-monoinfected patients after failure of nucleoside/nucleotide analogues. Regulation of Toll-like receptor-2 expression in chronic hepatitis B by the precore protein. Structural and functional characterization of interaction between hepatitis B virus X protein and the proteasome complex. X-deficient woodchuck hepatitis virus mutants behave like attenuated viruses and induce protective immunity in vivo. A theoretical model successfully identifies features of hepatitis B virus capsid assembly. The virion consists of an envelope and prM-M dimers surrounding an icosahedral capsid of approximately 50 nm in size (Beasley, 2005). The structural proteins are not only essential for virion assembly and release, but they are also the major targets for virus neutralizing antibodies. They do not develop prolonged high-level viremia, so the concentration of the virus in blood is insufficient to infect a feeding mosquito. The severity of symptomatic cases ranges from flu-like illness (~20% of infections) to severe neurological disease (~ 1%) (Hayes & Gubler, 2006). The virus can be also transmitted from human to human by blood transfusion and by solid organ transplantation. A significant geographical expansion occurred starting from 1999 when the virus was introduced into North America. In 2002, the virus spread westward and the number of reported human cases increased dramatically. The spread of the virus and intensity of the outbreak was correlated with the appearance of a new genotype with higher virulence and ability to disseminate in mosquitoes (Beasley, 2005). The pattern of yearly reoccurring outbreaks in North America differs from that of sporadic outbreaks observed in Europe and Africa. The speed with which the virus spread over the world triggered great interest and prompted a detailed investigation of the genetic evolution of the virus in search of the cause of its rapid adaptability. Lineage 1 included viruses circulating in Europe, Israel, United States, India, Russia, and Australia, while the Lineage 2 contained strains that circulated in sub-Saharan Africa and Madagascar. The highest rate of nucleotide sequence divergence among viruses isolated from 2002-2010 varies in the range of 0. It is noteworthy that 80% of the nucleotide changes are observed in the structural regions represented by U<->C transitions; 75% among them are silent mutations (Grinev et al. Positive selection of these two amino acid substitutions potentially could impact viral fitness, phenotype and virulence (McMullen et al. Application of a Microarray-Based Assay for the Study of Genetic Diversity of West Nile Virus 161 1. It provides a significant advantage for the field of clinical microbiology and molecular epidemiological studies. The efficiency of hybridization is monitored through measurement of the fluorescent signal from each spot by using a laser microarray scanner equipped with two lasers: 632 nm and 543 nm for excitation of Cy5 and Cy3 dyes respectively. The double-stranded probes must be denatured prior to hybridization, either using a special printing buffer or after immobilization on the glass surface (Tomiuk et al. Use of shorter probe lengths increases the microarray specificity and enables efficient detection of minor genetic changes between the probe and target (Chou et al. Microarray technology has been used to study gene expression in clinical and biological samples, detect and genotype pathogens (Honma et al. The microarrays consisting of multiple individual short oligoprobes were shown to be an efficient and sensitive genetic method for detection of single point mutations in viral and bacterial genomes (Chizhikov et al. In general, microarray technology can be easily implemented for detection and genotyping of any pathogen. Recently a pan-Microbial Detection Array was designed to detect all known viruses and bacteria (Gardner et al. Although further improvements, optimizations, and automation are still needed to fully implement the microarray technique in routine research and clinical practices, the potential role of these robust technologies in rapid diagnostics of multiple viral and bacterial pathogens is indisputable (Miller, 2009). Passage P1 indicates first isolation in Vero cells; P2 and P3 indicates subsequent virus passages. These samples were collected in different geographic locations of the continental U. In addition to 23 previously published isolates, which were used for structural region investigation (Grinev et al. Vero cells were incubated with the viral inoculum for 2 hours, either at room temperature under gentle rocking or at 37oC with mixing every 10-15 min. Application of a Microarray-Based Assay for the Study of Genetic Diversity of West Nile Virus 165 Table 2. The Cy3 image shows the design of array and the results of hybridization experiment. Atypical and empty spots were manually flagged and excluded from further analysis. A signal intensity ratio threshold from reference spots, specific to each microarray printing lot, was defined as an average ratio plus two standard deviation values. Any spots showing a ratio greater than the threshold value for a particular printing lot. In fact, optimization of an oligonucleotide microarray assay is a multi-parametric task.

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Nearly, if not quite, all the fbres decussate in the superior medullary velum and are distributed to the superior oblique muscle of the opposite side. The sixth nerve nucleus is situated much further caudally in the brainstem (Fig. Hence, vascular and other lesions of the sixth nucleus are very liable to be accompanied by facial paralysis on the same side. All the fbres of the sixth nerve are distributed to the ipsilateral lateral rectus. So long as the fixation point (F) is imaged on are also interrelated through this bundle so that coordinaeach macula, the fixation reflex maintains the posture of the eyes steady tion of the two eyes is maintained. The afferent path is: (a) retinae n optic nerve n chiasma n right optic tract; (b) lateral geniculate body n right optic radiations n striate area of occipital cortex; (c) peristriate occipital cortex. The frontal cortex has an area which controls quick fxational eye movements to the opposite side. Both supranuclear areas send the abducens nuclei and the oculomotor nuclei by way of the medial impulses to the brainstem to the centres which control conlongitudinal fasciculus. The centres controlling eye movements in the fbres control conjugate movements, vertical and horizonbrainstem are the fnal common pathway conveying imtal, of both eyes; movements of individual muscles are not pulses for movement in a particular direction, irrespective represented in the cortex. Stimulation of the cortex or the of whether the movement is voluntary or involuntary, a sactracts unilaterally therefore produces horizontal conjugate cade or a pursuit, or a vestibular refex eye movement. These pathways are tested clinically and it controls conjugate horizontal movement to the by asking the patient to look to the right, left, upwards or ipsilateral side. A destructive lesion in the right prefrontal lobe An area controlling vertical movements lies just above would lead to an inability to look conjugately to the left. Vertical movethe centre for convergence (Perlia nucleus) is associated ments are generated by bilateral simultaneous stimuli from with the third nerve nucleus and lies in the region of the both sides. All refexes is the visual pathway; the efferent runs down voluntary movements are initiated by the cerebral cortex the optic radiations to the posterior longitudinal bundle which sends impulses to the specifc centres for a particular (Fig. The cerebral cortex represents a movepathways are tested by asking the patient to follow an object, ment of gaze involving both eyes and not individual muswhich is passed horizontally and vertically so that the concles. If a lesion affects an individual muscle or group of jugate following movements of the eyes may be elicited. An elaborate system of statokinetic refexes coordinates Voluntary ocular movements are initiated in the pyrathe position of the eyes when the head is moved in space; midal cells of the motor area of the frontal cortex in their afferent path runs from the semicircular canals of the the second and third frontal convolutions of both sides inner ear to the mid-brain centres. The fbres enter the knee of the internal capmovements of both eyes, a slow tonic movement in the sule as part of the pyramidal tract close to the fbres governdirection of equilibration and a quick return (nystagmus). If the chin is depressed the eyes normally elevate if fxation is maintained, and if the head is rotated on a vertical axis the eyes maintain fxation as a result of the statokinetic refexes. Optokinetic movements are initiated by rotation or movement of the environment or the visual target. A tentative localization of the ments of the eyes in respect to movements of the head upon main ocular motor areas in part transferred from the brain of primates the body. It is to be noted that the apparently accurate localization pulses from the neck muscles, which are linked with the of certain areas is by no means factual or constant. Points on the two retinae, which are Fixation and Projection not corresponding points in this sense of the term, are We have already seen that the location of the image of an called disparate points, and if an object forms its retinal external object on the retina is determined by a line passing images on these, it will be seen double (binocular diplopia). ConIf the disparity is slight there is a tendency to move the eyes versely, an object is projected in space along the line passing so that the images may be fused by means of the fusion through the retinal image and the nodal point. When a distant object is looked at the visual axes are practically Fixation, Fusion and Refex Movements parallel; the object forms an image upon each fovea centralis. Since the most accurate vision is attained by the foveae it is necessary that the eyes be rapidly orientated so that the imCorrespondence age of an object of interest falls upon them or that of a Any object to one side of the fxation target forms its retinal moving object be retained on them. This ascendancy of the images upon the temporal side of one retina and upon the foveae is maintained by the fxation refex (Fig. The peristriate, posterior temporal both eyes horizontally in opposite directions. The system and dorsal prefrontal cortex are regions is required to maintain foveal position of the image of an which send convergence and divergence object which may be moving away or towards the observer impulses or may be located near or far away Fixation Maintaining the image of the object of regard on Supplementary eye feld maintains fxation the fovea with the eyes in specifc orbital locations and also inhibits visually evoked saccadic refexes. The frontal eye feld is involved in changing fxation (disengaging) VestibuloPrevents slipping of the retinal images when the head Otolith receptors and semicircular canals. Optokinetic nystagmus is evoked during head and cerebral hemispheres, parts of the striate motion with the environment stable and with the head still, and extrastriate visual cortex, parietal, but the visual image in motion. If the target is small and posterior temporal, prestriate and lateral attention voluntarily guided, smooth pursuit is induced occipital cortex followed by opposite quick phases. Each frontal eye feld or superior colliculus can generate horizontal saccades to the opposite side. Vertical saccades are generated by simultaneous stimuli from bilateral frontal eye felds or superior colliculi. The object moves outside the binocular feld of vision and the strongest prism whose deviating effect can be tolerated eyes then refxate on another object. The activity of this without developing diplopia or double vision is a measure refex is demonstrated by the rapid to-and-fro movements of the refex fusional capacity (Fig. A prism bar of the eyes of a person watching passing objects such as consists of a battery of prisms of increasing strength and is trees or electric poles while looking out of the window of a a convenient instrument in clinical testing (Fig. The latter phenomenon can be used as a test to demonstrate the In view of the distance between the two eyes, it is obvious integrity of the refex paths. If the object is a solid body the right eye may be demonstrated clinically by placing a small prism in sees a little more of the right side of the object, and vice front of one eye while the patient regards a distant light. The images of the fixation point (F) fall on each fovea (f); those of an object near the eye (T) will fall on t, giving rise to crossed diplopia. It will thus be found that near objects suffer a crossed (heteronymous) diplopia; distant objects an uncrossed (homonymous) diplopia. This diplopia is physiological and is perceptually suppressed in actual vision, but produces a psychological impression, which is translated into appreciation of distance. It follows that accuracy of stereoscopic vision depends upon good sight with both eyes simultaneously. If, however, a near object is regarded, the eyes converge upon it and an effort of accommodation corresponding to the distance of the object is made. These movements are refex and are controlled, as we have seen, by a centre in the occipital cortex (Fig. Suppose an object is situated in the Even with one eye a person can appreciate depth by median line between the two eyes at a distance of one metre monocular clues such as contour overlay, distant objects from them. Then the angle which the line joining the object appearing smaller, motion parallax with far objects moving with the centre of rotation of either eye makes with the faster, etc. If the object is 50 cm away the angle point is continued to the retina, it is seen that the images will be 2 m. If a person fxates (and accommodates for) a near object, the amount of positive convergence is mea2 m sured by the strongest prism, base out, which can be borne without causing diplopia; the amount of negative convergence (or relative divergence) by the strongest prism, base in (Fig. The amplitude of convergence, therefore, consists of a negative portion and a positive portion, which vary with each distance of the object fxated. The convergence synkinesis is so coordinated that the energy exerted is accurately divided between the two medial recti. Hence, it is found that the effect is the same in the above 1m experiments whether the prism is placed before only one eye, or a prism of half the strength is placed before each eye. Cr, Cl: centres of rotation of control of the extraocular muscles is important for the clinithe right and left eyes, respectively. All four recti originate from the annulus of with an emmetropic person, the amount of convergence, Zinn and insert on the sclera 5. Just as the difference in noid superomedial to the annulus of Zinn and the inferior the amount of accommodation between the far point and oblique muscle from the orbital floor at a location vertically the near point is called the amplitude of accommodation, below the trochlea. Both oblique muscles have an oblique the difference in convergence between the far points and the insertion behind the equator of the eye in the superotemnear point is called the amplitude of convergence.

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The most frequent underlying systemic disorders are arterial hypertension and diabetes mellitus; the most frequent underlying ocular disorder is glaucoma. Etiology: Occlusion of the central vein of the retina or its branches is frequently due to local thrombosis at sites where sclerotic arteries compress the veins. In central retinal vein occlusion, the thrombus lies at the level of the lamina cribrosa; in branch retinal vein occlusion, it is frequently at an arteriovenous crossing. Symptoms: Patients only notice a loss of visual acuity if the macula or optic disk are involved. Diagnostic considerations and findings: Central retinal vein occlusion can be diagnosed where linear or punctiform hemorrhages are seen to occur in all four quadrants of the retina (Fig. In branch retinal vein occlusion, intraretinal hemorrhages will occur in the area of vascular supply; this bleeding may occur in only one quadrant (Fig. Cotton-wool spots and retinal or optic-disk edema may also be present (simultaneous retinal and optic-disk edema is also possible). One differentiates between non-ischemic and ischemic occlusion depending on the extent of capillary occlusion. Differential diagnosis: Other forms of vascular retinal disease must be excluded, especially diabetic retinopathy. An internist should be consulted to verify or exclude the possible presence of an underlying disorder. Laser treatment is performed in ischemic occlusion that progresses to neovascularization or rubeosis iridis. Focal laser treatment is performed in branch retinal vein occlusion with macular edema when visual acuity is reduced to 20/40 or less within three months of occlusion. Prophylaxis: Early diagnosis and prompt treatment of underlying systemic and ocular disorders is important. Clinical course and prognosis: Visual acuity improves in approximately onethird of all patients, remains unchanged in one-third, and worsens in onethird despite therapy. Complications include preretinal neovascularization, retinal detachment, and rubeosis iridis with angle closure glaucoma. Bleeding occurs only in the affected areas of the retina in branch retinal vein occlusion. Epidemiology: Retinal artery occlusions occur significantly less often than vein occlusions. Symptoms: In central retinal artery occlusion, the patient generally complains of sudden, painless unilateral blindness. In branch retinal artery occlusion, the patient will notice a loss of visual acuity or visual field defects. In the acute stage of central retinal artery occlusion, the retina appears grayish white due to edema of the layer of optic nerve fibers and is no longer transparent. Patients with a cilioretinal artery (artery originating from the ciliary arteries instead of the central retinal artery) will exhibit normal perfusion in the area of vascular supply, and their loss of visual acuity will be less. Atrophy of the optic nerve will develop in the chronic stage of central retinal artery occlusion. In the acute stage of central retinal artery occlusion, the fovea centralis appears as cherry red spot on ophthalmoscopy. There is not edema of the layer of optic nerve fibers in this area because the fovea contains no nerve fibers. In branch retinal artery occlusion, a retinal edema will be found in the affected area of vascular supply (Fig. Perimetry (visual field testing) will reveal a total visual field defect in central retinal artery occlusion and a partial defect in branch occlusion. The paper-thin vessels and extensive retinal edema in which the retina loses its transparency are typical signs. Treatment: Emergency treatment is often unsuccessful even when initiated immediately. Ocular massage, medications that reduce intraocular pressure, or paracentesis are applied in an attempt to drain the embolus in a peripheral retinal vessel. Calcium antagonists or hemodilution are applied in an attempt to improve vascular supply. Lysis therapy is no longer performed due to the poor prognosis (it is not able to prevent blindness) and the risk to vital tissue involved. Prophylaxis: Excluding or initiating prompt therapy of predisposing underlying systemic disorders is crucial (see Table 12. The prognosis is better where only a branch of the artery is occluded unless a macular branch is affected. Epidemiology: Arterial hypertension in particular figures prominently in clinical settings. Vascular changes due to arterial hypertension are the most frequent cause of retinal vein occlusion. Pathogenesis: High blood pressure can cause breakdown of the blood-retina barrier or obliteration of capillaries. This results in intraretinal bleeding, cotton-wool spots, retinal edema, or swelling of the optic disk. Symptoms: Patients with high blood pressure frequently suffer from headache or eye pain. Diagnostic considerations: Hypertensive and arteriosclerotic changes in the fundus are diagnosed by ophthalmoscopy, preferably with the pupil dilated (Tables 12. Differential diagnosis: Ophthalmoscopy should be performed to exclude other vascular retinal disorders such as diabetic retinopathy. Diabetic retinopathy is primarily characterized by parenchymal and vascular changes; a differential diagnosis is made by confirming or excluding the systemic underlying disorder. Treatment: Treating the underlying disorder is crucial where fundus changes due to arterial retinopathy are present. The column of venous blood is constricted by the sclerotic artery at an arteriovenous crossing. Clinical course and complications: Sequelae of arteriosclerotic and hypertensive vascular changes include retinal artery and vein occlusion and the formation of macroaneurysms that can lead to vitreous hemorrhage. In the presence of papilledema, the subsequent atrophy of the optic nerve can produce lasting and occasionally severe loss of visual acuity. Prognosis: In some cases, the complications described above are unavoidable despite well controlled blood pressure. Epidemiology: this rare disorder manifests itself in young children and teenagers. Pathogenesis: Telangiectasia and aneurysms lead to exudation and eventually to retinal detachment. Symptoms: the early stages are characterized by loss of visual acuity, the later stages by leukocoria (white pupil; see Fig. Diagnostic considerations and findings: Ophthalmoscopy will reveal telangiectasia, subretinal whitish exudate with exudative retinal detachment and hemorrhages (Fig. Treatment: the treatment of choice is laser photocoagulation or cryotherapy to destroy anomalous vasculature.

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This automatically improves the positive predictive values when another test is used. Class-specific immune reactions differ greatly between primary infections and those which occur in connection with reinfections and reactivation. The primary antibody response of most viral infections is characterized by a certain regularity in the immune response, with IgM reactivity followed by an IgG response and rapid abatement of the IgM response. In contrast, the immune response in bacterial infections is often considerably delayed. Furthermore, reinfections with Bordetella pertussis or Treponema pallidum, for example, can trigger a significant increase in the titers or test results of traditional titer tests, such as complement-fixation tests. For example, in the case of syphilis or borreliosis reinfections, a renewed increase in the specific IgM response normally occurs with a considerable temporal latency. When a viral infection is reactivated, for example as part of the reactivation of varicella zoster or herpes simplex, there is usually no renewed specific IgM response or else it is very weak. On the other hand, a significant increase in the specific IgG response (booster effect) can come about through the expansion of the corresponding memory cell clone. These antibodies can persist for a long time after the infection, or be induced through vaccinations, not only through infections. The importance of determining IgA is now viewed critically for many indications or only recommended as an additional test. It is no longer recommended in Chlamydia pneumoniae serology particularly since IgA assays in evaluation studies and in the framework of external quality assurance have frequently been shown to be less than reproducible. Comparing the immune response of the mother and the child enables a determination to be made as to whether it is a case of an autochthonous specific immune response of the child, or surrogate immunity through antibodies passively passed on from the mother. These frequently occur temporarily when blood and blood products are used, for example, with intensive care patients, poly-transfused individuals and after the application of immunoglobulins. They are then falsely interpreted as an expression of an infection that has occurred in the meantime, particularly when there is a lack of sera during the course of the infection. Conversely it should be noted that, in addition to specific IgG antibody titers after vaccinations, a specific IgM or IgA response can temporarily occur. In the vast majority of cases additional clinical information or a discussion on the findings with the attending physician are required in order to conclusively interpret the findings of serological infectious disease testing and, here in particular, of meaningful results of individual sera. When possible, progression should be monitored to enable a more precise characterization and establishment of the point of infection through significant changes in the findings during the course of the infection. This also allows interpretations to be made about the primary infection, reinfection, or surrogate immunity. In order to assess qualitative and/or quantitative serological test results with respect to treatment success, serological monitoring of progression and the categorization of the quantitative immune response specific to the immunoglobulin class and antigen are required in the clinical context. While monitoring the treatment success of viral infections through serological testing plays a less significant role, this type of progression monitoring makes sense and is recommended for monitoring the successful treatment of a syphilis infection. It is understood that result constellations, in terms of a negation of findings or a significant decrease in the test result in a parallel assay with the previous serum, can indicate that the infection is abating or has been sufficiently treated. At the same time, 30 specific immune responses can persist for months or even years after effectively treated infections. In order to detect intrathecal pathogen-specific antibody formation, liquor and serum should be tested in parallel, and the quotient scheme should be calculated according to Reiber (after determining albumin, and total IgG and, if necessary, IgM and IgA in serum and liquor). Solely determining IgG antibodies in liquor without a parallel serum value is of no value since IgG antibodies can pass through the blood-brain barrier when the meninges is inflamed. In special diagnostic cases, the testing of cadaver blood or intraocular fluid can be useful (endophthalmitis diagnostic testing). The latter is gaining in importance, particularly in the context of tests that are subject to the Medicines Act, such as tests for cornea donors, amnion donors, bone banks etc. Antibody determination in joint punctate is not standardized and of dubious value. The commercially available tests have usually not been validated for these samples. Detailed information about the serological diagnostic testing of the individual infectious agents can be found in the sections on the respective pathogens. The serum and plasma samples are prepared in the same way as for antibody detection tests. The indications for and the value of the specific antigen detection tests are discussed in the sections on the respective pathogens. When antigen detection tests are positive, it should be noted that this positive test result frequently needs to be confirmed after inactivating (heat-activating) the sample, depending on the test manufacturer. They can be sent at room temperature by post, in their separated form, within 2 days. Sample tubes without additives or with clot activators can be used (with or without a separating gel). Plasma tubes also have to be centrifuged and the plasma separated from its cellular components. Repeated freezing and thawing, as well as storing serum and plasma samples over a longer period, can affect the quality and quantity of IgM detection. When measuring several parameters from one sample using different analysis systems it is useful to generate sample aliquots or secondary sample tubes. In particular, analysis equipment that uses steel needles and not disposable tips for pipetting has been known to cross contaminate samples. However, when dividing samples, it should be noted that the creation of secondary sample tubes is accompanied by the risk of interchanging the samples. This risk can be considerably lowered through the use of automated sample sorters. The granular or flaky structures can already be detected macroscopically or when magnified with a magnifying glass or microscope/agglutinoscope. Agglutination reactions are therefore unsuitable for differentiating between these classes of antibodies. The agglutination reaction is influenced by temperature, pH value and electrolyte content of the reaction environment. Agglutination tests can be conducted on microscope slides (qualitative antibody detection), in tubes, or on microtiter plates (semi-quantitative antibody detection). The optimal antigen and particle concentration must be determined after a batch change. A dilution series of the immunoserum is produced to quantitatively analyze the agglutination. The serum dilution, which continues to produce agglutinates, is called the endpoint titer. Furthermore, sera with a known specificity can also be used to test a questionable bacterial strain (Gruber reaction). When direct agglutination is used to detect antibodies, the antigen determinates of the pathogens are a natural component of the antigen carrier. Examples include bacterial agglutination (Widal reaction), heterohemagglutination (Paul Bunnell reaction) and the hemagglutination assay (for determining blood group, detecting certain types of bacteria or viruses). In bacterial agglutination, dead or inactivated bacteria suspensions are used as antigens. Antigen binding sites are components of the cell wall (O-antigens) or flagellum (H-antigens). O-agglutination usually has a granular reaction pattern, Hagglutination a flaky one. Flawless H-agglutination is generally only observed in bacteria with multiple flagella. Every antigen is to be accompanied by one negative and one positive serum control. An acute infection can only be identified by a clear quadrupling or more of the titer.

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In addition to features of chronic blepharitis, it is characterized by presence of nits at the lid margin and at roots of eyelashes Symptoms and signs: itching and lacrimation; the parasite is seen on the lashes and the black nests of eggs are also seen. The use of yellow mercurial ointment, sulphur ointment, camphorated oil, crotamiton, choline esterase inhibitors, sulfacetamide, steroids, antibiotics, as well as antimycotic drugs offers some improvement. A good response has been observed after oral application of ivermectin along with topical application of cream permethrin. However, the best results were obtained after applying 2 % metronidazole gel or ointment treatment. The inward turning of lashes along with the lid margin (seen in entropion) is called pseudotrichiasis. Etiology Common causes of trichiasis are: cicatrizing trachoma, ulcerative blepharitis, healed membranous conjunctivitis, hordeolum externum, mechanical injuries, burns, and operative scars on the lid margin. Complications these include recurrent corneal abrasions, superficial corneal opacities, corneal vascularization and non-healing corneal ulcer. Treatment A few misdirected cilia may be treated by any of the following methods: 1. In this technique, infiltration anesthesia is given to the lid and a current of 2 mA is passed for 10 seconds through a fine needle inserted into the lash root. The loosened cilia with destroyed follicles are then removed with epilation forceps. Surgical correction: when many cilia are misdirected operative treatment similar to cicatricial entropion should be employed. Symptoms and signs Occur due to rubbing of cilia against the cornea and conjunctiva and are thus similar to trichiasis. Complications these are similar to trichiasis Treatment Surgical treatment Ectropion It is outward rolling of the lid margin, so that the posterior lid margin will not be in contact with the surface of the eyeball. This malposition will disturb tear spreading over the surface of cornea and conjunctiva. Also the lacrimal 89 punctum will not be in contact with tears, so that epiphora will occur. The posterior lid margin is seen to be rolled outward away from the globe, so that the punctum can be seen. Complication Prolonged exposure may cause dryness and thickening of the conjunctiva and corneal ulceration (exposure keratitis). Treatment Surgical treatment Symblepharon In this condition lids become adherent with the eyeball as a result of adhesions between the palpebral and bulbar conjunctiva. Fibrous adhesions between palpebral conjunctiva and the bulbar conjunctiva and/or cornea may be present only in the anterior part (anterior symblepharon), or fornix (posterior symblepharon) or the whole lid (total symblepharon). During the stage of raw surfaces, the adhesions may be prevented by sweeping a glass rod coated with lubricant around the fornices several times a day. A largesized, therapeutic, soft contact lens also helps in preventing the adhesions. The raw area created may be covered by mobilising the surrounding conjunctiva in mild cases. Ankyloblepharon It refers to the adhesions between margins of the upper and lower lids. It may occur as a congenital anomaly or may result after healing of chemical burns, thermal burns, ulcers and traumatic wounds of the lid margins. Treatment Lids should be separated by excision of adhesions between the lid margins and kept apart during the healing process. When adhesions extend to the angles, epithelial grafts should be given to prevent recurrences. Blepharophimosis In this condition the extent of the palpebral fissure is decreased. Lagophthalmos this condition is characterized by inability to voluntarily close the eyelids. Etiology It occurs in patients with paralysis of orbicularis oculi muscle, cicatricial contraction of the lids, symblepharon, severe ectropion, proptosis, following over-resection of the levator muscle for ptosis, and in comatose patients. Physiologically some people sleep with their eyes open (nocturnal lagophthalmos) Clinical picture It is characterized by incomplete closure of the palpebral aperture associated with features of the causative disease. Treatment To prevent exposure keratitis artificial tear drops should be instilled frequently and the open palpebral fissure should be filled with an antibiotic eye ointment during sleep and in comatose patients. Blepharospasm It refers to the involuntary, sustained and forceful closure of the eyelids. It is a rare idiopathic condition involving patients between 45 and 65 years of age. It usually occurs due to reflex sensory stimulation through branches of the fifth nerve, in conditions such as: phlyctenular keratitis, interstitial keratitis, corneal foreign body, corneal ulcers and iridocyclitis. It is also seen in excessive stimulation of retina by dazzling light, stimulation of facial nerve due to central causes and in some hysterical patients. Clinical features Persistent epiphora may occur due to spasmodic closure of the canaliculi which may lead to eczema of the lower lid. Spastic entropion (in elderly people) and spastic ectropion (in children and young adults) may develop in long-standing cases. Blepharophimosis may result due to contraction of the skin folds following eczema. Treatment In essential blepharospasm botulinum toxin, injected subcutaneously over the orbicularis muscle, blocks the neuromuscular junction and relieves the spasm. In reflex blepharospasm, the causative disease should be treated to prevent recurrences. Congenital ptosis It is associated with congenital weakness (maldevelopment) of the levator palpebrae superioris. As a part of blepharophimosis syndrome, comprising congenital ptosis, blepharophimosis, telecanthus and epicanthus inversus. In this condition there occurs retraction of the ptotic lid with jaw movements, i. Acquired ptosis Depending upon the cause it can be neurogenic, myogenic, aponeurotic or mechanical. Neurogenic ptosis: it is caused by innervational defects such as third nerve palsy, Hornerfis syndrome, ophthalmoplegic migraine and multiple sclerosis. Myogenic ptosis: it occurs due to acquired disorders of the levator palpebrae superioris muscle or of the myoneural junction. It may be seen in patients with myasthenia gravis, dystrophia myotonica, ocular myopathy, oculo-pharyngeal muscular dystrophy and following trauma to the levator palpebrae superioris muscle. Aponeurotic ptosis: it develops due to defects of the levator aponeurosis in the presence of a normal functioning muscle. It includes involutional (senile) ptosis, postoperative ptosis (which is rarely observed after cataract and retinal detachment surgery), ptosis due to aponeurotic weakness 94 associated with blepharochalasis, and in traumatic dehiscence or disinsertion of the aponeurosis. Mechanical ptosis: it may result due to excessive weight on the upper lid as seen in patients with lid tumours, multiple chalazia and lid oedema. It may also occur due to scarring (cicatricial ptosis) as seen in patients with ocular pemphigoid and trachoma.

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Where residual concentrations are high, undesirable colour and turbidity may ensue. Concentrations of aluminium at which such problems may occur are highly dependent on a number of water quality parameters and operational factors at the water treatment plant. Aluminium intake from foods, particularly those containing aluminium compounds used as food additives, represents the major route of aluminium exposure for the general public. The contribution of drinking-water to the total oral exposure to aluminium is usually less than 5% of the total intake. It has been hypothesized that aluminium exposure is a risk factor for the development or acceleration of onset of Alzheimer disease in humans. However, strong reservations about inferring a causal relationship are warranted in view of the failure of these studies to account for demonstrated confounding factors and for total aluminium intake from all sources. But, because the risk estimates are imprecise for a variety of methodological reasons, a population-attributable risk cannot be calculated with precision. Such imprecise predictions may, however, be useful in making decisions about the need to control exposures to aluminium in the general population. The Committee therefore based its evaluation on the combined evidence from several studies. The relevance of studies involving administration of aluminium compounds by gavage was unclear because the toxicokinetics after gavage were expected to differ from toxicokinetics after dietary administration, and the gavage studies generally did not report total aluminium exposure including basal levels in the feed. The studies conducted with dietary administration of aluminium compounds were considered most appropriate for the evaluation. The defciencies are counterbalanced by the probable lower bioavailability of the less soluble aluminium species present in food. Overall, an additional uncertainty factor of three was considered to be appropriate. However, there remain uncertainties as to the extent of aluminium absorption from drinking-water, which depends on a number of parameters, such as the aluminium salt administered, pH (for aluminium speciation and solubility), bioavailability and dietary factors. The benefcial effects of the use of aluminium as a coagulant in water treatment are recognized. These include use of optimum pH in the coagulation process, avoiding excessive aluminium dosage, good mixing at the point of application of the coagulant, optimum paddle speeds for focculation and effcient fltration of the aluminium foc. However, as also noted above, practicable levels based on optimization of the coagulation process in drinking-water plants using aluminium-based coagulants are less than 0. In view of the importance of optimizing coagulation to prevent microbial contamination and the need to minimize deposition of aluminium foc in distribution systems, it is important to ensure that average residuals do not exceed these values. Intensive rearing of farm animals can give rise to much higher levels in surface water. Ammonia in water is an indicator of possible bacterial, sewage and animal waste pollution. Exposure from environmental sources is insignifcant in comparison with endogenous synthesis of ammonia. Toxicological effects are observed only at exposures above about 200 mg/kg body weight. Ammonia in drinking-water is not of immediate health relevance, and therefore no health-based guideline value is proposed. However, ammonia can compromise disinfection effciency, result in nitrite formation in distribution systems, cause the failure of flters for the removal of manganese and cause taste and odour problems (see also chapter 10). Antimony is used in solders as a replacement for lead, but there is little evidence of any signifcant contribution to drinking-water concentrations from this source. Total exposure from environmental sources, food and drinking-water is very low compared with occupational exposure. As the most common source of antimony in drinking-water appears to be dissolution from metal plumbing and fttings, control of antimony from such sources would be by product control. The form of antimony in drinking-water is a key determinant of the toxicity, and it would appear that antimony leached from antimony-containing materials would be in the form of the antimony(V) oxo-anion, which is the less toxic form. The subchronic toxicity of antimony trioxide is lower than that of potassium antimony tartrate, which is the most soluble form. Animal experiments from which the carcinogenic potential of soluble or insoluble antimony compounds may be quantifed are not available. Although there is some evidence for the carcinogenicity of certain antimony compounds by inhalation, there are no data to indicate carcinogenicity by the oral route. In water, it is mostly present as arsenate (+5), but in anaerobic conditions, it is likely to be present as arsenite (+3). However, in waters, particularly groundwaters, where there are sulfde mineral deposits and sedimentary deposits deriving from volcanic rocks, the concentrations can be signifcantly elevated. Arsenic is found in the diet, particularly in fsh and shellfsh, in which it is found mainly in the less toxic organic form. There are only limited data on the proportion of inorganic arsenic in food, but these indicate that approximately 25% is present in the inorganic form, depending on the type of food. Apart from occupational exposure, the most important routes of exposure are through food and drinking-water, including beverages that are made from drinking-water. In circumstances where soups or similar dishes are a staple part of the diet, the drinkingwater contribution through preparation of food will be even greater. Metabolism is characterized by 1) reduction of pentavalent to trivalent arsenic and 2) oxidative methylation of trivalent arsenic to form monomethylated, dimethylated and trimethylated products. Methylation of inorganic arsenic facilitates the excretion of inorganic arsenic from the body, as the end-products monomethylarsonic acid and dimethylarsinic acid are readily excreted in urine. There are major qualitative and quantitative interspecies differences in methylation, but in humans and most common laboratory animals, inorganic arsenic is extensively methylated, and the metabolites are excreted primarily in the urine. There is large interindividual variation in arsenic methylation in humans, probably due to a wide difference in the activity of methyltransferases and possible polymorphism. Ingested organoarsenicals are much less extensively metabolized and more rapidly eliminated in urine than inorganic arsenic. The acute toxicity of arsenic compounds in humans is predominantly a function of their rate of removal from the body. Arsine is considered to be the most toxic form, followed by the arsenites, the arsenates and organic arsenic compounds. Acute arsenic intoxication associated with the ingestion of well water containing very high concentrations (21. Signs of chronic arsenicism, including dermal lesions such as hyperpigmentation and hypopigmentation, peripheral neuropathy, skin cancer, bladder and lung cancers and peripheral vascular disease, have been observed in populations ingesting arsenic-contaminated drinking-water. Dermal lesions were the most commonly observed symptom, occurring after minimum exposure periods of approximately 5 years. Effects on the cardiovascular system were observed in children consuming arsenic-contaminated water (mean concentration 0. Numerous epidemiological studies have examined the risk of cancers associated with arsenic ingestion through drinking-water. Many are ecological-type studies, and many suffer from methodological faws, particularly in the measurement of exposure. However, there is overwhelming evidence that consumption of elevated levels of arsenic through drinking-water is causally related to the development of cancer at several sites. These effects have been demonstrated in many studies using different study designs. The effects have been most thoroughly studied in Taiwan, China, but there is considerable evidence from studies on populations in other countries as well.

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Watery diarrhea may be osmotic due to carbohydrate malabsorption or secretory due to Food protein-induced enterocolitis syndrome due to cow 5 toxins, gastrointestinal peptides, bile acids, or laxatives. Steatorand/or soy milk allergy or intolerance may present with rhea (greasy stools) indicates fat malabsorption. Mucus and blood in stools indicate intestinal ment with a trial of a casein or whey hydrolysate formula or infammation. Early in infancy, food protein-induced enteropathy may Overfow incontinence secondary to constipation and rectal present with diarrhea, occult blood loss, and hypoproteinemia. Hematuria and abRotavirus is primarily a wintertime virus that afects infants normal renal function suggest an enterohemorrhagic strain of 6 and small children most ofen. The social history should inquire about recent travel, Fever commonly occurs; gross or occult blood is uncommon. Giardiasis (from infection with Giardia lamblia) ofen 7 A diet history that includes seafood, unwashed vegetables, results from contaminated food or water, but person-tounpasteurized milk, contaminated water, or uncooked meats person spread is common, especially in daycare centers and may suggest a foodborne or waterborne agent in acute cases of other crowded institutions. In chronic cases, assessing type and quantity of oral ogy in acute cases of diarrhea, although it is most frequently intake, especially fuid selection, is helpful because certain seconsidered a pathogen in chronic diarrhea. Sensitivity of addition of jar foods or cereals, addition of sugar-free or other stool examination for ova and parasites increases with a greater sorbitol containing compounds). Antigen tests are more sensitive but Sudden vomiting and explosive diarrhea within several 2 will not aid in identifying other protozoans. Small intestinal hours of ingestion of a contaminated food suggests food biopsy or aspiration of duodenal or jejunal contents for examipoisoning from pre-formed toxins produced by Staphylococcus nation are other more sensitive means of diagnosis. Other causes of foodborne illness inridium may cause an acute diarrheal illness, including large clude other bacteria (Salmonella, Campylobacter, E. It causes a severe, chronic diarand mushrooms may cause paresthesias, paralysis, or mental rheal illness in immunocompromised patients. Diarrhea is frequently precedes the grossly bloody stools; abdominal cramping with associated with upper respiratory infections, otitis media, and minimal or absent fevers is characteristic. Many causes of chronic diarrhea demonstrate 9 ducing substances; pH testing with Nitrazine paper should an acidic pH or positive reducing substances consistent with be performed on a fresh stool specimen. Be aware of two caveats: (1) the test for reducing substances 13 smelling fatty stools not classic loose, watery diarrheal is only reliable when the child is being fed adequate amounts of stools. When accompanied by a history of recurrent respiratory carbohydrates, and (2) sucrose is not a reducing sugar and must infections and failure to thrive, a sweat chloride test should be be digested or split by bacteria to produce a positive test. Infants younger than 6 months tend to present with failhydrochloric acid before the analysis should have the same result. Postinfectious enteritis afer acute enteritis is a common 10 cause of prolonged diarrhea. Low-grade mucosal injury is Pancreatic insufciency, chronic neutropenia, and short 14 responsible for the malabsorption. Immune-mediated damage of the small intestine in reApproximately 10% of children with Hirschsprung disease 16 11 sponse to gluten occurs in celiac disease (gluten-sensitive develop enterocolitis. Symptoms of malabsorption and failure to thrive of delayed passage of meconium, preceding constipation, Down classically develop between 6 months and 3 years; symptom syndrome, and a positive family history. A rectal suction biopsy demonstrating the disorder, which may also include failure to thrive, anorexia, absent ganglion cells is necessary for diagnosis. Biopsy is considered necesdoes not specify whether the abnormality is of bowel, pancreatic, sary for defnitive diagnosis. Stool elastase-1 can help evaluate for pancreatic in cases being diagnosed in older children. Breath colitis is more common than Crohn disease in the toddler age hydrogen testing afer an oral lactose load may make the diaggroup. Weight loss and growth retardation are the cardinal sympnosis, although resolution of symptoms afer dietary restriction toms. Gastrointestinal manifestations include diarrhea, abdominal of lactose is strongly suggestive. Postinfectious secondary pain, bloody stools, perianal disease, and malabsorption. Multiple lactase defciency can occur in older children but is not as extra intestinal manifestations. In others the diarrhea may alternate with Practical strategies in pediatric diagnosis and therapy, ed 2, Philadelphia, periods of constipation. Gastroenterology, Hepatology and Nutrition: Evaluation and treatment of constipation in infants and children: Recommendations of the North American Previously, most of these cases were probably due to excessive Society for Pediatric Gastroenterology, Hepatology and Nutrition. As the role of fruit juices has been increasingly Gastroenterol Nutr, 43(3) 43:e1-e13, 2006. In chronic cases, stool retention results in a vicious cycle of retained stool, painful defecation, resisting the urge to defecate, further retaining of stool, and so on. A response usually occurs to organic or anatomic causes is encountered most commonly. Encopresis, also known as fecal incontinence, is fecal soiling that occurs in the presence of chronic functional constipation. Constipation can occur because of multiple classes of drugs, 5 When the constipation is severe and if it has been a longincluding anticonvulsants, anticholinergics, antacids, iron1 standing problem since early infancy, it is necessary to rule containing medications, calcium channel blockers, psychoout an underlying organic disorder. Toxins intermittent large stools, because some children with constipamay include metal intoxication. Parents may Laboratory studies are not normally contributory on a describe stool withholding maneuvers of gluteal tightening and 6 routine basis unless there is some suggestion in the history posturing, which are sometimes interpreted as attempts to or physical examin ation of a metabolic disturbance. Occasionally, a parent will misinterpret the genital hypothyroidism is generally diagnosed through newsigns of encopresis as diarrhea. Concerns about possible abuse should Abdominal x-rays are not usually useful in the initial 7 be addressed in the social history. Rectal motility reveal risk factors for Hirschsprung disease, such as the disorstudies (manometry) will demonstrate physiologic abnormalider itself or certain syndromes. The fndings in A careful spine and neurologic examination should be done Hirschsprung disease are so characteristic that many centers are to rule out spinal disorders that could be contributing to the now using manometry to establish the diagnosis. An anal wink elicited by stroking the perianal skin useful in children with constipation starting very early in life. A digital may also be helpful in cases in which constipation has failed to rectal examination may be helpful. In very young infants, a biopsy stipation have a dilated rectal ampulla and a large, hard stool may be preferred over manometry because the latter is technimass unless they had a recent large bowel movement. Further evaluation by a spechildren with Hirschsprung disease will not have any palpable cialist is necessary to arrive at the remaining possible diagnoses. It may 2 presumptively treat the patient with education, dietary be congenital or acquired and may be due to a neuropathy or changes, and medication. Attention to family dynamics and 40% of afected infants, followed by lower intestinal obstruction the response of both the parents and child to the problem should in young infants. If there is inadequate response or there is concern tion since birth, narrow-caliber stools, abdominal distention, for organic etiology, further investigation is suggested. Fecal soiling is almost unheard of in Situational constipation is usually short-lived and situaHirschsprung cases. Patients with short segment disease may 3 tional in response to a recent change or stress, such as startnot present until older childhood, adolescence, or even adulting daycare, travel, or the birth of a sibling. A rectal mucosal suction biopsy revealing an absence of the transition to all-day school and the associated loss of privacy ganglion cells is ofen necessary for diagnosis of Hirschsprung will contribute to withholding behaviors. The anteriorly located anus must be distinguished from an ectopic anus, condition may occur in the infant of a diabetic mother and in in which the anal canal and internal anal sphincter are displaced ancystic fbrosis, rectal aganglionosis, maternal drug abuse, and teriorly; the external anal sphincter remains in its normal posterior afer maternal magnesium sulfate therapy for preeclampsia. An ectopic anus should be suspected if an anal wink can be Gastrografn enema is usually diagnostic and therapeutic.

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Functional abdomigastroesophageal refiux clinical practice guidelines: nal pain: All roads lead to Rome (criteria). Infectivity is highest in catarrhal stage and the severe neck swelling (bull neck), myocarditis, first 2 weeks after onset of cough Guillain-Barre type neuritis, and paralysis 6. Evaluation of sensitivity to horse serum; if fever negative, single dose of equine antitoxin 2. Identification of contacts for follow-up care, cyanosis, absence of whoop, unexpected immunization, and treatment according to death, and then followed by a prolonged current American Academy of Pediatrics Red convalescence Book recommendations; includes surveillance for 7 days, culture for C. Children less than 7 years of age, with bronchi and evidence of atelectasis and close contact with infected individual, bronchopneumonia who are unimmunized or have received 2. Children who have not received a vaccine culture is continued for 10 days; positive in within past three years or those fi 6 years initial phase of illness but not in paroxysmal of age should receive a booster dose of stage pertussis vaccine at time of exposure; this 4. A negative culture does not exclude diagnosis can be given as Tdap of pertussis. Epidemic infiuenza caused by types A and B; threatening complications far outweighs the recent subtypes have included H1N1, H1N2, potential risk of pyloric stenosis that has been and H3N2 viruses associated with erythromycin; trimethoprim2. Transmission occurs by direct person-tosulfamethoxazole is the alternative for patients person contact, via airborne droplet, or by unable to tolerate macrolides or who may have articles contaminated with nasopharyngeal a macrolides-resistant strain; dosing at trimethsecretions oprim 8 mg/kg/day, twice a day for 14 days 3. Hospitalized children should remain in isomost frequently infected and infect household lation until they have received five days of contacts erythromycin 4. Children receiving oral erythromycin at home onset of symptoms and while symptoms are should not attend childcare or school until most severe; viral shedding peaks first 3 days they have received five days of therapy of illness with direct correlation to height of 5. Supportive treatment for children who cannot fever tolerate oral intake due to paroxysmal cough5. Infiuenza season mid-October through midsupplementation, ventilatory support February 6. Management of infiuenza is primarily for close contacts of severely immunocomprosupportive mised individuals a. Infected children should limit contact with nasopharyngeal secretions susceptible persons, including women of 3. Incubation period ranges from 14 to 23 days childbearing age; out of school for 5 days after 4. Rash starts on forehead and face and spreads auditory with hearing loss, and neurologic over trunk and extremities during the 1st day; systems facial exanthem fades by 2nd day, disappears 5. Educate caretakers regarding complications by 3rd day of arthritis, and rarely thrombocytopenia and 3. Medical referral if meningeal signs appear or if fever; antitussive therapy fever persists 4. Outbreaks occur most often during late winter febrile episode, prior to appearance of the rash and spring months 5. Spreads to upper arms, legs, trunk, buthalf of the pregnancy, but Parvo B 19 has not tocks, hands, and feet been proven to cause congenital anomalies; c. Can cause aplastic crises in young chilprodrome and usually a sequential rash consisting dren, patients with hemolytic diseases, or if of papules, vesicles, pustules, and crusts immunocompromised 5.

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There is sudden onset of intense unbearable pain in the eye due to stretching of the sensory nerves. It is mainly due to ischaemia due to optic neuropathy and partially due to corneal oedema stasis and increased permeability of the capillaries. Redness, lacrimation and photophobia are present due to corneal oedema erosion and conjunctival and ciliary congestion. Peripheral anterior synechiae (organized exudates) occur as a result of prolonged and repeated acute congestive attack. The perfusion of optic nerve head is affected due to decreased blood flow in the capillary and in annulus of Zinn which supplies nutrition to the laminar and post-laminar optic nerve head. It usually passes into the stage of chronic primary angle-closure glaucoma as the angle becomes slowly and progressively closed. Treatment Although the treatment of primary angle-closure glaucoma is essentially surgical, the initial treatment is medical in order to control the raised tension. Medical Treatment It is useful in lowering the raised tension particularly in the acute congestive attack preoperatively. The patient should be positioned supine (lying straight) to allow the lens to shift posteriorly. Acetazolamide 500 mg intravenously and 500 mg orally and/or intravenous mannitol is given after making sure that the patient is not suffering from cardiovascular disease. Pressure with moist cotton swab can be applied on the central part of the cornea if the pupil remains blocked. Initially pilocarpine is instilled every 30 minute and later hourly till maximum miosis is achieved. This is effective in pulling the iris away from the angle and opening the drainage channels. However, the tension is lowered by medical treatment before surgery to prevent occurrence of expulsive haemorrhage. Technique A drop of topical pilocarpine is instilled frequently 30 minutes before laser therapy. The laser with an anterior offset is then used to make an opening measuring 150-200 microns in size is made in the periphery of iris. By making a hole in the periphery of iris, pupillary block is relieved permanently. A partial thickness of a part of limbus (trabecular meshwork and canal of Schlemm) is excised under a scleral flap. The superficial flap of the sclera measuring 5 fi 5 mm is dissected anteriorly upto the limbus. The aqueous seeps out from the anterior chamber into the scleral window > It passes in between the two scleral flaps > It flows into the subconjunctival space. Postoperative management Topical broad spectrum antibiotic drops and ointment, cycloplegic and corticosteroids are given for a period of 2-3 weeks. Circumcorneal ciliary congestion is present around the limbus as reddish blue zone. Intraocular pressure is permanently raised when about two-third or more circumference of the angle is closed by peripheral anterior synechiae. Therefore after lowering the raised intraocular pressure with fi-blockers, acetazolamide and hyperosmotic agents; a filtration surgery (trabeculectomy) should be done. The iris is atrophic (white patches) and may have a broad zone of pigment around the pupil (ectropion of the uveal pigment) due to fibrosis of the iris tissue. Ocular structures like cornea, iris, anterior chamber can be easily identified unlike in phthisis bulbi. Essentially it is a histopathologial diagnosis, whereby the cytoarchitecture of the eye is maintained in the blind eye. In phthisis bulbi, in addition to atrophy there is disorganisation of the ocular cytostructure in the blind eye. Cyclodiathermy using surface electrodes may result in necrosis of scleral tissue and staphyloma formation ii. It causes tissue necrosis and often results in patients discomfort and ocular inflammation. Application of intense ultrasound to produce focal lesions of the sclera (over the pars plana). It is a more desirable procedure as it is effective, more predictable and pain free iv. Blockage at the angle of anterior chamber by the peripheral anterior synechiae and organised exudate. Neovascular glaucoma results commonly due to thrombosis of the central retinal vein and rubeosis iridis in diabetes mellitus.


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