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Otras funciones La envoltura o tripa a base de colageno representa probablemente una de las peliculas comestibles comerciales con mas exito desde un punto de vista comercial acne- cheap 20gm cleocin gel fast delivery, ya que se emplean como sustitutos de las tripas naturales en la elaboracion de productos carnicos tipo salchicha o embutido skin care summer cheap cleocin gel 20 gm mastercard. Estas envolturas se utilizan sobre todo para mantener la integridad estructural de los productos carnicos (Chapman y Potter acne gone cheap 20gm cleocin gel with amex, 2004) skin care 50 year old woman purchase cleocin gel 20 gm on-line, pero tambien tienen otras funciones beneficiosas como la de retrasar la perdida de humedad acne jeans sale order 20gm cleocin gel otc, oxidacion lipidica acne out active order cleocin gel online, decoloracion, mejora de la apariencia del producto o como portador de aditivos alimentarios (Catherine Nettles, 2006; Gennadios, Hanna y Kurth, 1997; Veronique, 2008). Otra aplicacion de los envases comestibles consiste en su empleo como pegamento para adherir determinados condimentos o diferentes componentes de un alimento. Como ejemplo los tentempies tipo barrita y snacks de cereales (Kramer, 2009), en los que se requiere unir diferentes componentes entre si (cereales, semillas, frutos secos). Todas estas funciones a las que hace referencia este capitulo pueden desarrollarse en menor o mayor medida, dependiendo de los componentes, estructura y composicion de los envases comestibles. Ademas, en funcion del alimento interesara potenciar unas acciones frente a otras, ya que no todos los alimentos tienen las mismas necesidades en cuanto al mantenimiento de su calidad o de su seguridad. Esta capacidad la poseen algunos biopolimeros y lipidos, y por tanto, suelen ser la base de los envases comestibles. Muchas veces resulta imprescindible la adiccion de aditivos como los plastificantes a la formulacion de estos envases, puesto que sin ellos la pelicula resultante seria excesivamente fragil y muy poco flexible. Ademas de los plastificantes se pueden incluir otros aditivos, tal vez no tan estrictamente necesarios como los anteriores pero que su inclusion en la formula supone una mejora en las propiedades tecnologicas y funcionales de las envolturas. Por lo tanto, la presente memoria se centrara en los principales componentes de las peliculas (biopolimeros, lipidos y plastificantes), aunque tambien se hara mencion a otros aditivos que resultan interesantes en la formulacion de los envases comestibles. Materiales formadores de peliculas y recubrimientos comestibles Los materiales utilizados en la preparacion de recubrimientos y peliculas proceden de diversas fuentes del reino animal y vegetal, tanto terrestre como marino, y asi como procedente de los microorganismos (Tharanathan, 2003). Algunos de estos biopolimeros se obtienen a partir de los residuos generados de la pesca, de la agricultura o de la ganaderia. Desde un punto de vista medio ambiental, el aprovechamiento de residuos resulta de gran interes puesto que se consigue obtener un rendimiento y valorizar estos desechos, reducir su cantidad y por lo tanto los costes y problemas de su eliminacion. La naturaleza de estos compuestos es muy variada, siendo principalmente de origen proteico (gelatina, proteina del suero de la leche, zeina, gluten, proteina de soja, etc. Las caracteristicas de las peliculas y recubrimientos vienen determinadas, en parte, por la naturaleza de estos compuestos y por esta razon, para explicar de forma simplificada las propiedades de los envases comestibles, se han clasificado en tres categorias en funcion del material de base utilizado en su formulacion: ? Peliculas y recubrimientos constituidos a base de hidrocoloides La capacidad de los biopolimeros para interaccionar entre si y con el resto de los componentes durante la formacion del recubrimiento viene dado por su naturaleza, peso molecular, cargas, etc. En lineas muy generales, la formacion de una red macromolecular de un biopolimero tipo hidrocoloide requiere de algunas etapas: en primer lugar la solubilizacion (parcial o total) que permita una ruptura de enlaces intermoleculares de baja energia que estabilicen a los polimeros en su estado nativo; de esta manera se facilita un reordenamiento y orientacion de las cadenas polimericas y una interaccion con el resto de componentes que forman la pelicula (esta estructura se estabiliza durante el secado) (Cuq, Gontard, Cuq y Guilbert, 1998; Mauri y Anon, 2008). Peliculas y recubrimientos constituidos a base de proteinas Para la elaboracion de peliculas y recubrimientos comestibles a base de proteina se han utilizado proteinas de diferente origen, tanto animal como vegetal. Asi se pueden encontrar en la literatura peliculas de gelatina (Gimenez, Gomez-Estaca, Aleman, Gomez-Guillen y Montero, 2009), caseina, proteina aislada o concentrada del suero lacteo (Banerjee y Chen, 1995), gluten de trigo (Gontard y Ring, 1996) y proteina de soja (Brandenburg, Weller y Testin, 1993), entre otras. Los biopolimeros proteicos forman redes macromoleculares tridimensionales que se estabilizan mediante diversos tipos de enlaces (interacciones electrostaticas, puentes de hidrogeno, fuerzas de Van der Waals, enlaces covalentes y puentes disulfuro), los cuales dependen de su composicion aminoacidica. Los enlaces se pueden favorecer durante el procesado, tanto por las soluciones en las que se encuentra como por el tratamiento termico y modo de secado. Asi, por ejemplo, una pelicula a base de proteina de huevo, que contiene gran cantidad de cisteina, puede favorecer la formacion de enlaces covalentes tipo puentes disulfuro en condiciones termicas adecuadas, lo cual favorece la insolubilizacion de la pelicula (Gimenez, Gomez-Guillen, Lopez-Caballero, Gomez-Estaca y Montero, 2012). Asimismo, la forma de la proteina es de gran importancia para la formacion de estas redes que conforman la matriz. Las proteinas de alto peso molecular y fibrilares -como el colageno, la gelatina y las proteinas miofibrilares pueden formar redes mas amplias con buenas propiedades mecanicas (Guillbert y Graille, 1994). En cambio, las proteinas globulares, frecuentemente de bajo peso molecular (como las proteinas aisladas de soja y proteinas sarcoplasmicas), hacen redes mas compactas y menos elasticas, con menor resistencia (Mauri y Anon, 2008). Tambien se puede modificar la estructura de la proteina por desnaturalizacion y agregacion, pudiendo ofrecer de esta manera variaciones en las propiedades que generan al constituir la red filmogenica. Todas estas variables y la gran diversidad de caracteristicas de las distintas proteinas permiten obtener un amplio abanico de posibilidades y propiedades de las peliculas constituidas a partir de estos biopolimeros. En general, si bien las peliculas a base de proteinas presentan buenas propiedades de barrera frente al oxigeno y dioxido de carbono, son susceptibles a la humedad (Cha y Chinnan, 2004; Krochta y De Mulder-Johnston, 1997). La capacidad antioxidante que poseen determinadas proteinas aporta un valor anadido a las peliculas y recubrimientos elaborados a partir de ellas. Varios estudios describen las propiedades antioxidantes de las proteinas tanto de origen animal como vegetal tales como las proteinas de la leche (Cervato, Cazzola y Cestaro, 1999), zeina de maiz (Wang, Fujimoto, ~ 9 ~ Introduccion Miyazawa y Endo, 1991), gliadina del trigo (Iwami, Hattori y Ibuki, 1987) o gelatina de pescado (Aleman, Gimenez, Montero y Gomez-Guillen, 2011). Entre la gran variedad de proteinas utilizadas para la elaboracion de envases comestibles, la gelatina posee excelentes propiedades fisicas y facil manejo, por lo que se selecciono para la elaboracion de las peliculas y los recubrimientos comestibles de la presente memoria. Gelatina La gelatina se obtiene a partir de la hidrolisis parcial del colageno, el cual se encuentra ampliamente distribuido en la naturaleza formando parte de la piel, tendones, sistema vascular, huesos, espinas, escamas y tejido conectivo de los animales. Esta proteina se obtiene principalmente a partir de la piel y huesos de mamiferos terrestres, fundamentalmente vacuno y porcino. Sin embargo recientemente se ha incrementado la produccion de gelatina a partir de productos de la pesca. Este aumento se debe a la sustitucion de la gelatina de origen vacuno y porcino por la gelatina de origen marino. Las razones inicialmente han sido socio culturales (productos kosher y del islam) o sanitarias (ej. La gelatina se utiliza ampliamente en la industria farmaceutica, cosmetica y alimentaria debido a sus excelentes propiedades gelificantes, hidratantes, formadora y estabilizadora de emulsiones y espumas, propiedades viscoelaticas o filmogenicas. La gelatina es rica en aminoacidos tales como la prolina, hidroxiprolina, lisina e hidroxilisina, los cuales interaccionan durante la preparacion de las peliculas y como consecuencia de ello, forman enlaces cruzados intra e intramoleculares entre las cadenas proteicas (Dangaran, Tomasula y Qi, 2009). Las peliculas o recubrimientos basadas en gelatinas se han disenado para recubrir los alimentos con el fin de reducir el transporte de agua, oxigeno y grasas en productos carnicos (Gennadios, McHugh, Weller y Krochta, 1994). Si bien este tipo de peliculas presentan buenas propiedades de barrera a los gases (oxigeno y al dioxido de carbono), sus valores de permeabilidad al vapor de agua suele ser altos debido a que la gelatina es altamente hidrofilica (Ioannis, 2002), al igual que la mayoria de las proteinas y otros hidrocoloides. Por esta razon, para la formulacion de peliculas o recubrimientos se recurre a la combinacion de la gelatina con otras proteinas para mejorar las propiedades mecanicas y de permeabilidad al vapor de agua de la gelatina. Estos autores observaron que la formulacion que contenia un 25% de proteina aislada de soja y 75% de gelatina de piel de bacalao mostro una mejora de la fuerza a la rotura hasta 1,8 o 2,8 veces mayor que la obtenida por las formulaciones con solo gelatina o proteina de soja, respectivamente, mientras que la elevadisima elasticidad que presentan las peliculas de gelatina de bacalao y la relativa baja permeabilidad al vapor de agua de las peliculas de aislado de soja se mantuvo. Las propiedades de las peliculas varian en funcion de la procedencia de la gelatina puesto que la composicion de aminoacidos de gelatinas de distintas especies es diferente, especialmente en lo que respecta a los aminoacidos mayoritarios de la gelatina (glicina, prolina e hidroxiprolina) (Gomez-Guillen y cols. Asi se ha visto recientemente que las peliculas a base de gelatina de atun, que contienen un bajo numero de residuos de prolina e hidroxiprolina, presentaron valores de deformacion a la ruptura aproximadamente 10 veces mayores que los obtenidos por las peliculas a base de gelatina de piel bovina (Gomez-Estaca, Gomez-Guillen, Fernandez-Martin y Montero, 2011). Peliculas y recubrimientos constituidos a base de polisacaridos Los polisacaridos son polimeros hidrosolubles de cadena larga, que se emplean en la industria alimentaria para compactar, espesar y gelificar o bien para proporcionar dureza y textura crujiente a los alimentos (Catherine y Susan, 2002). Entre los polisacaridos utilizados en la preparacion de peliculas y recubrimientos se encuentran la celulosa y sus derivados, almidon, pectinas, alginatos, carragenatos, quitosano, entre otros. Los polisacaridos pueden ser lineales o ramificados y se componen de la repeticion de un mismo monosacarido o varios. Estas caracteristicas estructurales determinan las diferencias entre un polimero y otro en cuanto a su solubilidad, propiedades gelificantes, emulsificantes, espesantes, sinergia o ~ 11 ~ Introduccion incompatibilidad entre polisacaridos o entre diferentes componentes (ej. Las caracteristicas de las peliculas preparadas a partir de este tipo de materiales vienen determinadas tambien por la estructura del polisacarido, ya que influye el numero de enlaces de hidrogeno intermoleculares establecidos entre las cadenas del polimero. El peso molecular del polisacarido tambien juega un papel importante en las propiedades finales de las peliculas. Los polimeros lineares de alto peso molecular y no ionico forman peliculas fuertes, como es el caso del agar y la metilcelulosa. En cambio, los polisacaridos mas ramificados, con o sin carga anionica, forman peliculas mas debiles (Nieto, 2009). Como ejemplos de biopolimeros polisacaridos en este capitulo se describiran solo el quitosano y el agar por ser los materiales utilizados para la elaboracion de los recubrimientos y peliculas en la presente memoria. El quitosano se selecciono principalmente por sus conocidas propiedades antimicrobianas y antioxidantes, mientras que el agar se eligio por ser un biopolimero de carga neutra, relativamente inerte, por lo que presenta menos interaccion con los componentes del alimento o del envase. Quitosano como polimero con capacidad filmogenica El quitosano es un polimero lineal derivado de la N-desacetilacion parcial de la quitina (vease Figura 2). La quitina se localiza en el exoesqueleto de los crustaceos, en la pared de los hongos y en otros materiales biologicos (algas verdes) y representa uno de los biopolimeros mas abundantes de la naturaleza, despues de la celulosa. La estructura del quitosano esta formado por unidades de glucosamina y N-acetil D-glucosamina unidos por enlaces? Estos tres parametros son basicos en la caracterizacion de los quitosanos ya que sus caracteristicas o propiedades vienen determinadas en parte por ellos. Debido a las excelentes propiedades funcionales y biologicas que posee, el quitosano se ha empleado tanto solo como en combinacion con otros polimeros naturales (almidon, gelatina, alginatos y otros), en la industria alimentaria, farmaceutica, textil, agraria, tratamiento de aguas y cosmetica (Kong, Chen, Xing y Park, 2010). En los ultimos anos este polimero se ha aplicado en la elaboracion de peliculas y recubrimientos comestibles por ser un material biodegradable, no toxico y biocompatible y con capacidad filmogenica. En general, las peliculas y recubrimientos de quitosano son claros, fuertes, flexibles y con buenas propiedades de barrera al oxigeno y dioxido de carbono, pero como biopolimero polisacarido presentan una alta permeabilidad al vapor de agua. Sin embargo, algunos autores describen que las propiedades de las peliculas varian en funcion del grado de acetilacion y peso molecular del quitosano utilizado para la formacion de las mismas. En este sentido, Park, Marsh y Rhim (2002) observaron que los quitosanos con pesos moleculares altos forman peliculas mas fuertes. Las propiedades mecanicas de las peliculas tambien aumentaron en este estudio cuando el acido acetico se utilizo como solvente para la preparacion de las mismas (Park y cols. Por otra parte, Ki Myong, Jeong Hwa, Sung-Koo, Weller y Hanna (2006) demostraron que los quitosanos con un grado de acetilacion alto forman peliculas con valores bajos de permeabilidad al vapor de agua, los cuales no se modificaron por la variacion de pH producida por la utilizacion de acido acetico como solvente. Pero ademas de los factores intrinsecos del propio quitosano como peso molecular promedio, grado de desacetilacion y viscosidad, son otros muchos los factores a tener en cuenta para evaluar su efecto sobre las ~ 13 ~ Introduccion propiedades fisico quimicas de los recubrimientos y peliculas, y sobre sus propiedades activas como antimicrobianos y antioxidantes; entre estos factores extrinsecos caben destacar, por ejemplo: pH, acido utilizado para solubilizar el quitosano, presencia de plastificantes, grado de humedad de la cobertura, etc. Los recubrimientos de quitosano se aplican en su mayor parte en frutas y vegetales (Davis D. Este tipo de coberturas al ser semi-permeables pueden alterar la atmosfera interna, de tal modo que producen un retraso de la maduracion y una disminucion en la velocidad de transpiracion en frutas y vegetales (Bourtoom, 2008; Nisperos-Carriedo, 1994). Estas peliculas y recubrimientos tambien se han utilizado para aumentar la calidad y extender la vida util de otros alimentos, como por ejemplo, el pescado (Lopez-Caballero, Gomez-Guillen, Perez-Mateos y Montero, 2005), principalmente por las propiedades antioxidantes y antimicrobianas que el quitosano posee, y no tanto por las propiedades fisicas (ej. El quitosano como ingrediente activo con propiedades antioxidantes y antimicrobianas se describe en el apartado 1. Agar El agar (tambien denominado agar-agar) se obtiene a partir de dos algas rojas: Gelidium sp. La proporcion de cada una de las fracciones varia en funcion de la especie de alga y las condiciones ambientales. El agar de uso alimentario se compone primordialmente por agarosa puesto que la agaropectina es eliminada durante su fabricacion. La agarosa es un polimero lineal con un peso aproximado de 120 kDa y esta constituida por unidades repetitivas del disacarido agarobiosa, cuya estructura es (1>4)-? El agar se utiliza en microbiologia, principalmente para la preparacion de medios de cultivo, pero tambien como laxante, como espesante para sopas, gelatinas vegetales, helados y algunos postres o como agente aclarador de la cerveza. Ademas de estos usos, recientemente se ha empleado en la preparacion de peliculas y recubrimientos comestibles debido a las interesantes caracteristicas que posee (Catherine y Susan, 2002). Las peliculas de agar son ~ 14 ~ Introduccion claras y fuertes en general, aunque son fragiles y poco flexibles. Ademas tiene la particularidad de ser insolubles en agua en condiciones ambientales, al igual que el agar solo. La naturaleza lineal y no ionica del agar permite que las moleculas hidratadas se asocien mas estrechamente, formando una red que se estabiliza por enlaces de hidrogeno intermoleculares durante el secado de la pelicula (Nieto, 2009). La incorporacion de antimicrobianos a este tipo de coberturas alarga la vida util de la carne de ave y ternera (Ayres, 1959; Meyer, Winter y Weiser, 1959), aunque por otro lado, no evita las perdidas de humedad (Catherine y Susan, 2002). Peliculas y recubrimientos constitudios a base de lipidos Las ceras y las grasas fueron los primeros materiales utilizados para cubrir los alimentos. Hoy en dia, los lipidos solos o en combinacion con otros compuestos, se aplican como envases comestibles en carnes, pescados, frutas, vegetales, semillas, caramelos, quesos, alimentos frescos, curados, congelados o procesados (Rhim y Shellhammer, 2005). En la actualidad, para la preparacion de peliculas con caracteristicas hidrofobicas se utilizan, en orden de eficacia como peliculas de barrera: ceras, lacas (shellac), acidos grasos y alcoholes, gliceridos acetilados y compuestos a base de cacao y sus derivados. La mayor o menor eficacia para actuar como barrera depende de la composicion quimica de la molecula, es decir, de la presencia de elementos polares, longitud de la cadena hidrocarbonada y el grado de insaturacion o acetilacion (Debeaufort y Voilley, 2009). Peliculas y recubrimientos constituidos a base de mezclas de biopolimeros Los biopolimeros de diferente naturaleza o estructura se pueden combinar entre si de tal manera que se compensen las ventajas y desventajas de cada uno de ellos. Asi se han descrito peliculas y recubrimientos basados en mezclas de proteinas y polisacaridos, proteinas y lipidos o polisacaridos y lipidos. Estas combinaciones se consiguen: a) incorporando el componente inmiscible (lipido) dentro de la solucion filmogenica (hidrocoloide) mediante la formacion de ~ 15 ~ Introduccion una emulsion, suspension o dispersion, b) incorporando los diferentes componentes en sucesivas capas (peliculas y recubrimientos multicapa), o por ultimo c) mezclando los compuestos con un disolvente en el que los diversos biopolimeros sean miscibles (Bourtoom, 2008; Kamper y Fennema, 1985; Krochta y De Mulder-Johnston, 1997). De este modo las propiedades mecanicas, de barrera a gases y humedad o la adhesion de las coberturas se mejoran con la combinacion de varios biopolimeros (Baldwin, Nisperos-Carriedo y Baker, 1995). Las posibilidades son infinitas y en la literatura existe una gran variedad de copolimeros con diferentes propiedades (Bourtoom, 2008). En este sentido, la adicion de lipidos a las peliculas y recubrimientos constituidos a base de hidrocoloides (carbohidrato o proteinas) mejora las propiedades de barrera a la humedad y al oxigeno de las mismas. Asi, por ejemplo, la incorporacion de aceite de girasol (2 g/L) a peliculas basadas en almidon disminuye los valores de permeabilidad al vapor de agua debido a la hidrofobicidad que aporta (Garcia, Martino y Zaritzky, 2000). Otras veces, para mejorar las propiedades mecanicas de las peliculas y recubrimientos se recurre a la combinacion de varios hidrocoloides. Esto es el caso de las peliculas basadas en quitosano, a las que se han anadido otros agentes formadores de peliculas y recubrimientos tipo hidrocoloide, con el proposito de incrementar sus propiedades mecanicas, como por ejemplo, almidon (Vasconez, Flores, Campos, Alvarado y Gerschenson, 2009; Xu, Kim, Hanna y Nag, 2005), proteinas sericas (Ferreira, Nunes, Delgadillo y Lopes-da Silva, 2009) o gelatina (Arvanitoyannis, Nakayama y Aiba, 1998), entre otros. Aditivos Los aditivos son componentes que se anaden a las peliculas o recubrimientos para proporcionarles las caracteristicas o cualidades de las que carecen o para mejorar las que poseen. El grupo mas importante dentro de los aditivos lo conforman los plastificantes puesto que su adiccion resulta a veces imprescindible para la formacion de un envase comestible, especialmente en el caso de las peliculas y por esta razon merece una seccion aparte. Plastificantes Las peliculas a base de polisacaridos o proteinas suelen ser quebradizas y poco flexibles por lo que requieren de la adiccion de plastificantes (Gennadios y cols. Los plastificantes son compuestos de pequeno peso molecular que se anaden a las coberturas para mejorar su flexibilidad y propiedades mecanicas (Dangaran y cols. La adicion de ~ 16 ~ Introduccion plastificantes modifica la organizacion polimerica de la red proteica tridimensional, disminuyendo las fuerzas de atraccion intermoleculares, incrementando el volumen libre y favoreciendo la movilidad de las cadenas (Banker, Gore y Swarbrick, 1966). El efecto plastificante se evidencia mas cuando la molecula empleada es mas pequena y mas hidrofilica. Hay que restringir su uso, ya que un exceso puede tener efectos negativos sobre las propiedades de barrera de las peliculas. Entre los plastificantes mas frecuentes se encuentran los polioles (sorbitol, glicerol, polietilenglicoles y los derivados del glicerol), azucares y acidos grasos. Los polioles son particularmente efectivos como plastificantes, siendo el glicerol el mas comunmente empleado en las formulaciones de peliculas de proteinas.

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Neurologic fndings such as tremor acne light therapy cleocin gel 20gm sale, reveals elevated transaminase levels acne under skin discount cleocin gel 20 gm, mild hyperbilirubinemia acne pregnancy cheap cleocin gel 20 gm free shipping, fne motor incoordination acne in your 30s buy cleocin gel online from canada, clumsy gait skin care equipment suppliers discount cleocin gel 20 gm overnight delivery, and chore form move hypergammaglobulinemia acne location meaning generic cleocin gel 20gm on line, and auto-antibodies (antinuclear ments suggest Wilson disease. A workup specifcally for jaundice may also be elevated, although it is usually associated with pri may not be necessary when an underlying diagnosis such as mary biliary cirrhosis. Mycoplasma pneumonia, Epstein-Barr infant 35 or more weeks of gestation, Pediatrics 114(1): 297?316, 2004. Most cases of hemolytic anemia associated healthy term and near-term newborns, Pediatrics 103: 6?14, 1999. Other causes include Brumbaugh D, Mack C: Conjugated hyperbilirubinemia in children, Pediatr lymphoproliferative disorders, systemic lupus erythematosus, Rev 33: 291?302, 2012. Liver function is better as sessed by serum albumin and prothrombin time because they rely on the synthetic function of the liver. Infammatory bowel disease can be associated with hepa 3 tobiliary disease through a variety of mechanisms. Tese The presence of a palpable liver does not always indicate include autoimmune (autoimmune hepatitis), infammatory hepatomegaly. Liver span may be measured by percussing the upper fbrosis (nonalcoholic steatohepatitis). It used to be an adult margin of dullness and by palpating the lower edge in the disease but is increasingly described in children. Other infections that cause hepatosplenomeg 1 as well as underlying conditions that may contribute to aly and anicteric hepatitis include cat-scratch disease, typhoid, liver disease. Ask about episodic brucellosis, tularemia, syphilis, Lyme disease, leptospirosis, Rocky vomiting, associated neurologic changes, travel, and drug or Mountain spotted fever, Q fever, tuberculosis, and actinomycosis. Metabolic disease is suggested by symptoms Fitz-Hugh?Curtis syndrome is a perihepatitis associated with pel of failure to thrive, vomiting, loss of developmental mile vic infammatory disease due to Neisseria gonorrhoeae or Chla stones, new seizures, or hypotonia. A 6 should be suspected in infants with hepatomegaly, hypotonia, family history of hepatic, neurologic, and psychiatric symp and loss of developmental milestones. Tese include amino acid toms should be elicited, as well as a history of neonatal deaths. Diagnosis is apy, other medication and toxins, malnutrition, and obesity are typically made early in life owing to a characteristic phenotype, also risk factors. Ascites and tender hepatomegaly are common presenting 12 Wilson disease is in the diferential diagnosis of acute symptoms of hepatic venous outfow obstruction. Kayser-Fleischer transaminases and bilirubin levels are minimally afected rings and neurologic symptoms. Diagnosis is by low serum ceruloplasmin venous outfow obstruction occurring in conditions predispos levels, high urinary copper excretion, and increased hepatic ing to thrombosis. Practical strategies in pediatric diagnosis and therapy, ed 2, Philadelphia, 2004, Saunders, pp 333?344. Sudden spleno megaly in a child with sickle cell disease suggests acute splenic In children, a palpable spleen may or may not be enlarged, be sequestration, a life-threatening condition. The abdominal ex cause the volume of the spleen may be relatively larger com amination should include attention to the liver and the possibility pared with the volume of the abdomen. Up to 15% of teristic notch on the medial or inferior border of the spleen may newborns, 10% of children, and 5% of adolescents have palpa help identify it, although other nodular masses may be present. A splenic edge felt more than 2 cm below the lef Pain occurs secondary to stretching of the splenic capsule and costal margin is usually abnormal. A persistently palpable may occur as lef upper quadrant pain or referred pain to the lef spleen may be normal, but some workup is necessary before shoulder. A careful H and P will usually suggest stretched acutely, such as in an acute infection or hemolysis. Examples of other infections that may cause splenomegaly 2 A neonatal history of an umbilical catheter is a risk factor include spirochetal, rickettsial, parasitic, fungal, mycobac 1 for portal vein thrombosis and subsequent venous obstruc terial, and protozoal. Certain ethnic backgrounds suggest a risk of Viral infection is the most common cause of splenomeg 3 certain disorders, mostly hemolytic or storage disorders. Milder variants of the disease may 6 kemia requiring referral for bone marrow examination. Pulmonary hyperinfation due to asthma, bronchiolitis, or 7 12 It may be seen in congenital spherocytosis or other congeni a pneumothorax may cause splenic displacement. Extracorporeal membrane oxy Practical strategies in pediatric diagnosis and therapy, ed 2, Philadelphia, genation, prosthetic heart valves, and burns may cause hemoly 2004, Elsevier, pp 345?352. It is the preferred diagnostic test in neonates and is also appropriate in older Abdominal masses represent a varied group of entities, many of children. Because the abdominal cav ity allows considerable room for growth, there may be few or Hydronephrosis is the most common cause of an abdomi 3 nonspecifc symptoms. In male infants, posterior urethral valves For infants, a perinatal and birth history may reveal risk 1 are the most common cause of hydronephrosis. A thorough re In infants, a history of polycythemia, dehydration, diabetic 4 view of symptoms and social history, including a sexual history, mother, asphyxia, sepsis, or coagulopathy are risk factors recent travel, and infectious contacts, should be obtained. Hematuria, hypertension, and The abdominal examination should note the location, size, thrombocytopenia are ofen present. Neuroblastoma is one of the most common malignancies 5 Hepatosplenomegaly is the cause of more than half of child in infants. The tumors occur as precocious puberty owing to the production of normal spleen is usually nonpalpable, although it may be felt in estrogen. Renal masses usually extend downward The etiology of a hepatic mass includes tumors, hemangio 7 from the kidney location, do not tend to cross the midline, and mas, cysts, and abscesses. Abdominal distention due to as plasia, and hamartomas can occur as solitary lesions. Malignant cites must be distinguished from abdominal distention due to a hepatic tumors include hepatoblastoma and hepatocellular mass. The fuid shifs with movement of the Wilms tumor is the second most common malignancy in patient and causes a percussion wave or shifing dullness. Wet saline mount of vaginal secretions with microscopy, including use of potassium hydroxide, and Gram stain can be used to detect Dysuria is pain or burning occurring with urination. It is ofen Trichomonas, as well as bacterial vaginosis and vaginal candi associated with urinary symptoms such as frequency, urgency, diasis. Constipation, not being circumcised, mydia, herpes simplex, Trichomonas vaginalis). Dark or tea-colored urine may in Nonspecifc urethritis is ofen seen in premenarchal girls dicate hematuria. A history of penile or vaginal discharge as well 6 and is associated with poor hygiene, tight nonbreathing? as sexual abuse should be elicited. Anal pruritus nal palpation of the kidneys, pelvic exam when indicated, and a may indicate pinworms, which can cause urethral irritation and careful neurologic exam in children with voiding dysfunction can be confrmed by examination with a tape slide test. Urethral prolapse method, correlates with infection, particularly in an older child. Bleed Dipstick methods test for leukocyte esterase (an enzyme present ing and dysuria are common. Microscopic analysis of unspun urine for 3 glass-shaped area of atrophy and scarring with depigmentation. Sexual abuse is ofen associated with rectal or vaginal casts, when present, are associated with upper tract infections. Gross hema 5 8 catheterization, or more than 10 colonies by clean-catch mid turia is seen with hemorrhagic cystitis (adenovirus, cyclo stream urine indicate infection. In 9 circumcised boys, it may result from recurrent meatal in In older children, pyelonephritis may be clinically difer 3 fammation from moist diapers. Trauma, hypospadias repair, entiated from cystitis by the presence of systemic features catheterization, and balanitis xerotica obliterans are other causes. In infants and young children, the clinical picture dysuria, and occasional bleeding. Phimosis is when the foreskin may be nonspecifc, with fever and other symptoms present in cannot be retracted because of scarring or narrowing of the pre upper or lower tract disease. Paraphimosis is the also show pyelonephritis but is not as sensitive; however, it is incarceration of the prepuce behind the glans, ofen afer forcible adequate to detect obstructive uropathy or high-grade refux retraction of the foreskin. Balanitis is an infammation of the pre that may be associated with pyelonephritis. Chapters 114, 116 Neurogenic bladder may develop secondary to a lesion of 4 the central or peripheral nervous system. A careful neuro Chapter 31 logic examination should be included, assessing strength, tone, sensation and refexes of the lower extremities, and anal wink. The voiding cystourethrogram demonstrates a trabeculated bladder with a Christmas tree? or pine cone? Enuresis is urinary incontinence at an age when most children appearance. Nocturnal enuresis, the most common form, is malities when the cause of the neurogenic bladder has not the involuntary passage of urine during sleep. Primary nocturnal enure 5 ful examination may indicate labial fusion in which there sis refers to a child who has never been continent at night and is retention of urine behind the fused labia. Secondary enuresis refers to a child cially obese or preschool-aged girls who do not open the labia who was successfully toilet trained for at least 3 to 6 months and when voiding, there may be refux? of the urine into the va becomes incontinent once again. Some girls who have postvoid (new sibling, school trauma, physical or sexual abuse). Urethral obstruction may appear as abnormal urinary symp 6 It is most important to distinguish between monosymp toms such as dribbling, poor stream, needing to push, or 1 tomatic nocturnal enuresis (which is usually benign) and weak thin stream. Chil urethritis) or trauma (traumatic catheterization, urethral foreign dren with overactive bladder (pediatric unstable bladder) may body. Hinman syndrome (detrusor-sphincter dyssynergia) is enuresis associated with giggling, laughing, coughing, strain an extreme form of this in a child without neurologic abnor ing, or physical activity may indicate the cause. In children with nocturnal enuresis, lated bladder, a signifcant amount of residual urine afer void a history of snoring and mouth breathing may indicate sleep ing, and may show vesicourethral refux, upper urinary tract apnea. In Overactive bladder (urge syndrome, pediatric unstable bladder) 8 patients with urethral obstruction, the bladder and kidneys may is a common cause of daytime wetting. A frst morning urine sample with specifc gravity above Giggle incontinence is associated with laughing and is 9 1. Hematuria may be noted in children with hypercalcuria or common in preschool-aged children who are engrossed in ac sickle cell disease or trait. Constipation is ofen associated with bladder dysfunction, Ectopic ureter is a rare congenital anomaly. Incontinence 3 10 because anorectal and lower urinary tract function are in occurs when the ureter is inserted distal to the external terrelated. It is more common in girls, and there is constant der function is known as dysfunctional elimination syndrome. It is more common in boys and ofen shows sis, constant wetness, neurologic signs or symptoms, or abnor a familial pattern. Tese children have a normal examination mal urine stream may indicate an organic cause and prompt (including careful neurologic exam), no associated daytime further evaluation, as in the case of diurnal enuresis. A lateral neck x-ray may be helpful to document textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders, Chapters 21, 537. Neveus T, Eggert P, Evans J, et al: Evaluation of and treatment for monosymp large adenoids, and a sleep study to evaluate for obstructive sleep tomatic enuresis: A standardization document from the International apnea. Gross hematuria is vis ation, trauma due to catheterization, and sexual abuse may ible to the naked eye. Injury to the bladder and posterior urethra may be History should include urinary symptoms such as dysuria, associated with pelvic fractures and may be diagnosed by retro 1 frequency, and urgency, as well as fank or abdominal pain. A history of exercise or trauma, including a foreign body, cath eterization, or sexual/physical abuse, may indicate the cause of Idiopathic hypercalciuria most ofen occurs as persistent 6 the hematuria. A medication, drug, and dietary history should microscopic hematuria or as recurrent gross hematuria or be obtained. If this is sion, as well as systemic illnesses ofen associated with renal present, a 24-hour urine collection for calcium should be ob disease. Autosomal dominant polycystic kidney disease ofen include renal abnormalities, hematuria, deafness, renal failure, appears as gross hematuria. Symptoms may begin in childhood hypertension, nephrolithiasis, sickle cell disease or trait, dialysis, but more ofen occur in adulthood. Stress hematuria occurs af A positive reagent strip (dipstick) in the absence of ter exercise. Patients with benign familial hematuria (thin base moglobinuria occurs with hemolysis. It may occur in hemo ment membrane nephropathy) have an excellent prognosis but lytic anemias, hemolytic-uremic syndrome, mismatched must be followed. Nutcracker syndrome is due to carbon monoxide, fava beans, venoms, mushrooms, naphtha the compression of the distal segment of the lef renal vein be lene, quinine, and many other substances. Papillary will ofen show fragmented cells, and the reticulocyte count necrosis may result in hematuria in patients with sickle cell may be elevated. Myoglobinuria occurs with rhabdomyolysis afer viral myo sitis and in children with inborn errors of energy metabolism, Acute postinfectious glomerulonephritis occurs 4 days to 7 ofen afer exercise. The clinical picture as well as elevated 3 weeks afer a febrile illness just with hematuria, but also muscle enzyme levels may aid in distinguishing myoglobinuria with oliguria, edema, and hypertension. If needed, Hgb and myoglobin may be mea infection causing either pharyngitis or impetigo is the most sured in the urine. Laboratory fndings include a decrease in C3 and C4 levels and laboratory evidence of a preceding group A Microscopic hematuria is ofen found on routine screen 3 streptococcal infection (Streptozyme, antistreptolysin, antihyal ing. If proteinuria is present, the port syndrome is associated with a family history of renal dis evaluation is the same as for gross hematuria (see algorithm). Proteinuria suggests glomerular involve may be due to associated renal cysts and angiomyolipomas. Chapter 163 122 Part V u Genitourinary System particularly in focal segmental sclerosis and membranopro Bibliography liferative glomerulonephritis. It may also Pediatrics textbook of pediatric care, Elk Grove Village, Ill, 2009, American be associated with other diseases, such as systemic lupus Academy of Pediatrics, pp 1566?1569.

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Primary headaches: Migraines acne needle purchase 20gm cleocin gel fast delivery, tension type acne keloidalis nuchae icd 10 order 20 gm cleocin gel, cluster or other trigeminal etiologies b skin care korea yang bagus order genuine cleocin gel on line. Secondary headaches: Caused by other underlying pathologies skin care 70 discount cleocin gel 20gm with visa, such as trauma acne tool buy cleocin gel 20gm, substance use or withdrawal skin care 4men wendy trusted cleocin gel 20gm, vascular malformations, infection, mass effect, referred pain from teeth, sinuses, and/or eyes, or psychiatric. For the purpose of pediatric headache it is benefcial to differentiate headache based on onset and duration 2. History and physical examination: It is important to distinguish those who require specifc or immediate treatment vs. Quality, site, and radiation of pain (focal occipital pain is concerning for secondary headaches) 8. Triggers and relieving and worsening factors (triggers: foods, environmental factors, etc. Meningeal infammation: Meningitis, leukemia, subarachnoid or subdural hemorrhage 4. Vascular: Vasculitis, arteriovenous malformation, hypertension, cerebrovascular accident 5. Bone, soft tissue: Referred pain from scalp, eyes, ears, sinuses, nose, teeth, pharynx, cervical spine, temporomandibular joint 6. Characteristics as defned by the International Headache Society: Chronic recurrent (at least two attacks with aura and fve attacks with no aura); throbbing, pulsatile, or pressure-like in children; usually bifrontal in children, unilateral in adolescents and adults, lasting from 1?72 hours; relieved by sleep; many potential triggers. Associated symptoms include nausea, vomiting, abdominal pain, motion sickness in smaller children, photophobia, phonophobia, paresthesias, and dizziness; rare associated symptoms include focal weakness, aphasia, ataxia, and confusion 2. Associated reversible neurologic defcits (rare): Paresthesia, visual-feld cuts, aphasia, hemiplegia, ophthalmoplegia, vertigo, ataxia, confusion. These children typically receive neuroimaging due to the complicated nature of their migraines 4. Treatment6: Includes reassurance and education regarding lifestyle modifcation (sleep, exercise, stress reduction, fuids, not missing meals). The acute and chronic pharmacologic treatment of migraine headaches in the pediatric population is well studied; however, these recommendations have not yet been incorporated into national guidelines for children a. Chapter 20 Neurology 511 (3) For >12 years of age: Objective data support nasal sumatriptan. Chronic treatment (if >3 per month and if migraines interfere with daily functioning or school): (1) Avoid triggers and stress, improve general health with balanced diet restrictive of certain migraine-causing foods, suggest headache journal to help identify potential triggers. Offer counseling when appropriate; also consider biofeedback, acupuncture, yoga, massage therapy if parents are interested (3) Consider medications. See Table 20-4 for summary of preventive therapies, doses, and adverse effects (4) the natural history of chronic headache includes spontaneous improvement. Differential Diagnosis of Recurrent Events that Mimic Epilepsy in Childhood (Table 20-5) B. Seizure: Paroxysmal synchronized discharge of cortical neurons, resulting in alteration of function (motor, sensory, cognitive) 2. Diffuse brain dysfunction: Fever, metabolic compromise, toxin or drugs, hypertension, idiopathic epilepsy b. Focal brain dysfunction: Stroke, neoplasm, focal cortical dysgenesis, trauma, focal idiopathic epilepsy 3. Short duration (no more than 10 minutes) and rapid recovery (if not meningitis should be high on the differential) 4. Paroxysmal vertigo Patient frightened and crying; no loss of awareness; staggers (toddler) and falls, vomiting, dysarthria. Breath-holding spells Loss of consciousness and generalized convulsions, always (18 mo?3 yr) provoked by an event that makes child cry. Syncope Loss of consciousness with onset of dizziness and clouded or tunnel vision; slow collapse to foor; triggered by postural change, heat, emotion, etc. Cough syncope Prolonged cough spasm during sleep in asthmatic, leading to loss of consciousness, often with urinary incontinence. Paroxysmal May be precipitated by sudden movement or startle; not dyskinesias accompanied by change in alertness. Night terrors (4?6 yr) Brief nocturnal episodes of terror without typical convulsive movements. Tics/habit spasms Involuntary, nonrhythmic, repetitive movements not associated with impaired consciousness; suppressible. Starting as simple partial seizures (a) Without automatisms (b) With automatisms (such as lip smacking and drooling, dazed eyes look) 2. With impairment of consciousness at onset (a) Without automatisms (b) With automatisms C. Absence seizures: Brief lapse in awareness without postictal impairment (atypical absence seizures may have the following: mild clonic, atonic, tonic, automatism, or autonomic components) B. Overall recurrence of seizure varies from 14%?65%, with most recurrences occurring in the frst 2 years after initial event. Recommend that child participate in activities, but have supervision during bathing or swimming. Pharmacotherapy (Table 20-7): Weigh risk for more seizures without therapy against risk for treatment side effects plus residual seizures despite therapy. Monotherapy may reduce complications; polytherapy increases risk of complications and side effects more than effcacy d. Ketogenic diet11: High-fat, low-carbohydrate therapy used for intractable seizures. Special Seizure Syndromes12,13,14 See Table 20-6 for seizure types, etiologies, evaluations, and treatments of many common seizure syndromes. Slowly progressive hydrocephalus: Acetazolamide may be effective in children age 2 weeks to 10 months with slowly progressive communicating hydrocephalus (see Formulary for dosing) 2. Ventriculoatrial and pleural shunts are associated with cardiac arrhythmias, pleural effusions, and higher rates of infection b. Shunt complications: Shunt dysfunction may be caused by infection, obstruction (clogging or kinking), disconnection, and migration of proximal and distal tips. Yes puncture, given that absence of meningeal signs in a child <1yr of age No does not rule out meningitis Has child received Strongly consider performing a lumbar antibiotics before Yes puncture, given that prior antibiotic seizure treatment could mask meningeal signs presentation? No No Yes No Do not routinely perform Child with Evaluate and treat lumbar puncture, given that simple febrile seizure (if appropriate) clinical signs of meningitis are other abnormal more reliable in a child findings >18 mo of age Yes Is patient 1 Discharge patient to routine care medically 2 Educate parents concerning stable? Miller-Fisher variant of Guillain-Barre syndrome (ataxia, ophthalmoplegia, and arefexia). Warning: If bulbar signs present, disease is likely progressive; patient may lose ability to protect airway and/or ability to breathe 12. Urine vanillylmandelic acid and homovanillic acid radiographs) to look for kinking or disconnection. Referral to a neurosurgeon is then warranted to test shunt function and for possible percutaneous shunt drainage. Etiology Risk factors for childhood stroke: Include, but are not limited to , congenital heart disease, cerebral arteriopathies, hematologic disorders (most commonly sickle cell disease) including prothrombotic state, serious systemic infection (meningitis, sepsis), head or neck trauma causing arterial dissection, and drugs. Differential Diagnosis (Box 20-13) Stroke should be considered in the differential diagnosis for any child who presents with acute-onset focal neurologic defcit, focal seizures with prolonged postictal paralysis, new-onset refractory focal status epilepticus, altered mental status, or unexplained encephalopathy. On a case-by-case basis, consider: A fasting lipid panel, rheumatologic and metabolic studies, hemoglobin electrophoresis, and human immunodefciency virus testing D. There are three published evidence based guidelines that address the evaluation and management of children with stroke. The most comprehensive guidelines are the American Heart Association Guidelines (Roach et al. Supportive care: Critical and should proceed rapidly and parallel with initial workup. Optimize cerebral perfusion pressure: Assure adequate fuid volume and maintenance of median blood pressure for age. Antiplatelet and anticoagulation therapy: If there is no evidence of hemorrhage, aspirin is typically recommended at a dose of 1?5 mg/kg/ day. Anticoagulation with either unfractionated heparin or low molecular weight heparin may be considered on a case-by-case basis, particularly if cardioembolism or arterial dissection is suspected as the etiology of stroke 6. Children with sickle cell disease: Hydration and urgent exchange transfusion to reduce sickle hemoglobin to <30% is recommended. Urgent neurology consultation: Along with transfer to a tertiary care center with expertise in childhood stroke 8. Practice parameter: evaluation of children and adolescents with recurrent headaches. Practice parameter: pharmacological treatment of migraine headache in children and adolescents. Committee on Classifcation and Terminology of the International League against Epilepsy. Classifcation of epilepsia: its applicability and practical value of different diagnostic categories. Practice parameter: the neurodiagnostic evaluation of the child with a frst simple febrile seizure. Stroke in childhood: clinical guidelines for diagnosis, management and rehabilitation, 2004. Professional and Government Organizations Growth Charts and Nutrition Information. Infant and Pediatric Formula Company Websites for Obtaining Complete and Up-to-Date Product Information Information regarding more specialized and metabolic formulas can be found using these websites: Enfamil, EnfaCare, Nutramigen, and Pregestimil. Clinical assessment (general appearance, including hair, skin, oral mucosa, and gastrointestinal symptoms of nutritional defciencies) 3. Growth: Ideally, should be evaluated over time, but one measurement can be used for screening. The smoothing of the disjunction between the pre and post term sections 0 generally occurs between 36 and 45 weeks. The Childhood Obesity Action Network has also developed an implementation guide for the assessment and management of childhood obesity based on expert committee opinions5 6. Waist-height ratio is calculated as a ratio of waist circumference (cm) and height (cm). For most healthy infants and children, the equations here can be used to determine energy needs. Ideally, energy expenditure should be measured in critically ill patients, but this requires expensive equipment and may not always be practical. Appropriate changes should be made as indicated by real (not fuid) weight gain and signs and symptoms of overfeeding. Catch-up Growth Requirement for Malnourished Infants and Children (<3 years)8,9 1. Growth failure (also known as failure to thrive): Condition of undernutrition generally identifed in the frst 3 years of life. Approximately 20%?30% more energy may be required to achieve catch-up growth in children. The daily nutrient intake level estimated to meet the requirement of 97%?98% of healthy individuals in a particular life stage and gender group 3. Generally, an A, D, C multivitamin, such as Tri-Vi-Sol or Poly-Vi-Sol, can be used (Table 21-8) B. Consider supplementation for those patients who use bottled water and home fltration systems. To avoid fuorosis, children should not use fuoridated toothpaste until age 2 years, and then only a small pea-sized amount up to age 6 years. Full-term breast-fed infants: ~1 mg/kg/day is recommended after age 4?6 months, preferably from iron-fortifed cereal or alternatively, elemental iron b. Preterm or low-birth-weight breast-fed infants: Iron supplement of 2 mg/kg/day should be given from age 2?12 months c. Full-term formula-fed infants: Iron-fortifed formula containing 4?12 mg/L of iron from birth to age 12 months b. Preterm formula-fed infants: An additional 1 mg/kg/day, administered either as iron drops or in a vitamin preparation with iron D. Mixing Instructions for Full-term Standard and Soy-based Infant Formulas (Table 21-10) B. Common Caloric Modulars For the child who needs additional protein, carbohydrate, fat, or a combination (Table 21-11) C. Enteral Formulas, Including Their Main Nutrient Components (Table 21-12) A comprehensive (but not complete) list. Clinical Conditions Requiring Special Diets, and Suggested Formula(s) (Table 21-13) A comprehensive (but not complete) list of special clinical conditions. Recommended Parenteral Formulations (Table 21-16) Based on age groups; includes recommendations for electrolytes, elements, and minerals D. An estimate of the osmolarity of parenteral nutrition can be obtained with the following formula: Estimated osmolarity = (dextrose concentration? Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. The Childhood Obesity Action Network Expert Committee recommendation implementation guide. The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What clinicians need to know. Consider rasburicase (recombinant urate oxidase, converts uric acid to allantoin) for higher risk patients, especially those with uric acid >7. Check K+, Ca2+, phosphate, uric acid and urinalysis frequently, as often as every 2 hours. Consider stopping alkalinization soon after starting chemotherapy (if uric acid is normal) to facilitate calcium phosphate excretion C. Occurs most commonly with brain tumors, sarcomas, leukemia with lymphomatous involvement, lymphoma, and neuroblastoma 2. Presentation: Back pain (localized, radicular), weakness, sensory loss, change in bowel or bladder function. Prognosis for recovery based on duration and level of disability at presentation 3.

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Adolescents skin care tips in urdu order cleocin gel paypal, aged care with overwhelmed new caregivers who cannot 11-17 years skin care after 30 order cleocin gel without prescription, are made vulnerable by the poverty that bring all children to a doctor when needed acne 2004 discount 20 gm cleocin gel with mastercard. However acne zyme discount cleocin gel 20 gm mastercard, the two groups diferentiated with their long-term outcomes in terms of weight gain skin care khobar cheap cleocin gel 20 gm, with the Approximately 15 acne jawline cheap cleocin gel 20 gm mastercard. When the family loses a primary caregiver new caregiver does not notice the adjustment difculties who provided economically for the family, the efects of the orphan in the frst 6 months because the child may can be widespread. The family may be forced to move to be well behaved with a new caregiver or too traumatized a diferent region to help earn additional income. In Institutions often fail to provide adequately for the Northern Africa, the Middle East, Latin America, Asia, physical and psychosocial needs of children, and they and sub-Saharan Africa, young women have a harder actually cost more than direct monetary assistance to time fnding employment because of poorer educational families that foster orphans. Some of these will lose property or inheritance when the relatives of constraints include restriction from extensive traveling the deceased come to claim items such as cars, work for employment and lack of available jobs for young equipment, or electronics. Educational opportunities are lacking the loss felt by the surviving children in the family. For example, in India more than half of addition to economic hardship, educational opportunities women aged 15-19 years have no primary education. New caregivers cannot Sub-Saharan Africa also has a dearth of young girls in pay school fees, and often orphans have to work to help school. This lack of education for young women has a maintain the family fnancial stability or care for younger ripple efect throughout their lives, afecting their ability siblings. The American Academy of Pediatrics states that young girls in the family because they are then made adolescents should know their diagnosis in all cases. They may need so that they can make informed decisions regarding to fetch water daily from the community well, which their actions and life choices. The youth will often need takes away from their ability to leave the homestead for repetitive education around daily living with the virus and education or outside work and often exposes them to how it will mold decisions that they make in their social opportunities for exploitation. Tese decisions involve managing their own health, disclosing to friends and signifcant others, and sexual Worldwide, young women are at greater risk of choices. Coercion can include forced themselves against negative reactions and social isolation. Many feel that they being kept out of school and tracked into informal simply do not have the skills to disclose with positive employment. Clinic staf can role-play diferent scenarios with patients so that they can practice what they are Adolescents are an increasingly important population comfortable saying and how they can also provide that deserves special attention. The youth can no longer be passive in their health care decisions, and physicians must learn to share control over medical decisions with the youth themselves. But many youth feel a moral obligation to directly with their health care providers. Adolescents feel a strong need to be similar to Often, adolescents may need to transition to a new their peers and feel accepted. Many pediatric fear of rejection can even be stronger than their fear of clinics do not have funding or capacity to keep youth as potentially infecting their sexual partner. Many youth feel that the clinic bring his or her partner to the clinic if the patient would staf are the keepers of their health history? and do like additional medical education and support. Medical Independence When meeting with a new provider, some youth may For adolescents living with a chronic illness, transitioning feel unsure regarding which components of their health into adulthood includes an important shift toward history are important to share with these new providers. Peer relationships have a stronger may have a family history of?for example, cancers or infuence on behaviors during adolescence than in any high blood pressure. For teens who are switching to a new other period in life, including childhood and adulthood. Peers have a member of the pediatric ofce staf can accompany them strong infuence not only on adolescent social behaviors to their frst visit with their new provider or go with but also on health-related behaviors. Tese infuences them on a tour of the new clinic and meet the staf prior can be negative, such as smoking tobacco, or positive, to the frst visit. It is benefcial to have a strong working such as encouraging medication adherence in support relationship with the adult clinic/provider in your area to groups. Connecting with a peer group allows caregivers help ensure a smooth transition and prevent adolescents and clinic staf to understand their adolescent patients. The adolescent years are one of the most important developmental stages prior to adulthood. They afect their views of caregivers, afect the role of medical also gain awareness of others and their relationships. Developing an identity is a difcult in physical development, including pubescent changes. As youth develop, they will systematically begin experience physical changes as a result of their illness, to organize their lives around who they feel they are as including wasting and opportunistic infections that individuals and how this afects where they ft in the may cause noticeable physical symptoms. In turn, this perception of their place in society bonding with them, adversely afecting the adolescents? then shapes the personal and professional choices that peer attachments and making it difcult for them to they make, which belief system they align with, and which separate from their parents. Individuals develop much of their their perceptions of their place in the world can be hugely identity, the sense of who they are, on the basis of how damaging. This sense of identity comes from actions within a social context and is based on whether Sexuality their decisions are accepted or rejected by others in Sexuality is an important topic for adolescents, who are the group. Rejection from the group can have a serious at the age when sexual exploration begins. Many youth are poorly educated about sex and safe sex Adolescents developmentally are at a point where they methods. This lack of education on practicing safe sex want to be similar to their peer group. Youth extra lengths to reduce the diferences that they have are also engaging in sexual exploration at younger ages between themselves and their peers. This trend is of great concern because engaging in sexual practices without protection. Second, younger groups are even less likely to be educated about education can sometimes be hard to fnd in a society sexual protection. Sexuality in many societies is not openly A study conducted in 1999 showed that if youth perceived discussed for fear that youth will then engage in sexual themselves as more mature than their chronological activity too early or because conversations regarding age, they were more likely to engage in sex earlier than sex are traditionally held privately within families. Teir premature transition into adulthood However, despite these broadly held beliefs, one study also was a major factor in their remaining sexually active found that 82% of 45 television shows most watched after their frst sexual encounter. Many care for younger siblings, and this situation highlights that even if family members some are the sole providers for their families. With these or clinicians do not discuss sexual behaviors, youth are responsibilities, youth may feel greater autonomy and still being exposed to them through the media. The ability to A group that requires special attention within the express oneself sexually and the opportunity to one day adolescent population is homosexual and bisexual youth. Clinicians involved with public stigma and discrimination toward homosexuals youth must educate them on ways to have safe sexual and bisexuals. Tese teens feel diferent from their experiences for themselves and their partners, as well peers and experience the gay-related stress? of growing as on ways to have their own children without fear of up homosexual or bisexual in a hostile environment. All teens and adults experience Symptoms of gay-related stress can include anxiety about prevention fatigue. Tese youth must learn to integrate their homosexuality However, in many places females are not in a position of into their greater identity. Stress increases if the teen power to protect themselves during sexual intercourse. First, provide them with the tools to protect themselves and some may not seek out safe sex education or tools for fear others. More young people often use Educating teens on the adverse efects of substance use tobacco products and consume alcohol socially. Tobacco, alcohol, Conclusion and marijuana are sometimes referred to as gateway Education and support are the most efective tools that drugs. Drugs such as cocaine and heroin are used less children recover from the devastating loss of parents frequently, but their presence on the adolescent scene and loved ones. Youth who Trough education, children and adolescents can learn begin using substances early tend to use more substances to take charge of their own medical care and protect with increased frequency as time goes on. Trough the many multiple studies have found an increased prevalence of changes and challenges of childhood and adolescence, the substance abuse-related disorders in this population. Combining the two Hospital Learning Support Center Continuing may lengthen the time that an illegal substance stays Education Series. Disclosure of illness status behavioral inhibitions and increase other risky behaviors. Personal and social clinical and educational experiences with end-of-life factors infuencing age at frst sexual intercourse. Variation Phenomenology and correlates of complicated in health and risk behavior among youth living with grief in children and adolescents. Orphanhood and childcare Custody plans among parents living with human patterns in sub-Saharan Africa: an analysis immunodefciency virus infection. The broken heart: anticipatory grief in the Switzerland: Joint United Nations Programme on child facing death. A framework for the protection, symptoms in parentally bereaved children and care and support of orphans and vulnerable children adolescents. Identify and describe appropriate resources for care the patient; it is associated with a profound and authentic and support. Identify sources of stigma and discrimination and Psychologists conceptualize the disease developing discuss ways of educing their negative efects on based not only on an individual relationship with the patients and health care workers. Developmental psychology described these the new life situation, as much as concrete, practical stages decades ago, and we should consider them when we support. Sexuality is important during adulthood; questioning goals however, having a sexually transmitted disease that is. Tere are social, economic, and cultural reasons Research Report, 1997) why such events occur? (Vignette 4). Stigma can be defned as an Prevention behaviors are also stigmatized, and people act of identifying, labeling, or attributing undesirable are reluctant to introduce behaviors that could associate qualities targeted towards those who are perceived as them with the virus, such as use of condoms, certain being shamefully diferent and deviant from the social medications, and infant formula when appropriate. The loss of social support Discrimination can be defned as an action or treatment results in isolation for the family, which may also fear loss based on the stigma and directed toward the stigmatized? of employment, denial of school admission, or denial of and as sanction, harassment, scapegoating, and violence adequate housing. As a result, appropriate care or are segregated from the general young people may lack information to prevent the spread hospital population. Only 27% reported using a condom nurses in West Africa in 2002 found that 20% of them during their frst sexual experience. Stigma may even lead to violence must minimize the efects of stigmatization to improve against those blamed for introducing the disease. Anal sex is a more At the same time, providers can take steps to reduce common practice in Africa than previously thought: in a the efects of stigma on their patients. Stigma may cause a support system for the patient and educate family people not to talk about risk behaviors and risk reduction. They often avoid testing, and if they are tested, they avoid following up on results, as if avoiding a clinical diagnosis might prevent the disease. Having a disease is discouraging, growth inhibiting, and However, there is a crucial interaction between the fosters hopelessness and helplessness. Where regression are the frst processes that take place in the stigma is high, people may be unlikely to progress into psychological life of persons newly disclosed to . Early in the disease, people somatic symptomatology through psychogenic factors often see themselves as being persecuted? by the virus? that are activated by the awareness of the disease an external, alien, bad object. Health psychology suggests that psychological anxieties and fears about death are common. As the disease progresses, control (or power) issues emerge as patients face increasing loss of physical control. Nilsson Schonnesson and Ross found that often perceive a chronic disease as being developed existential issues invariably emerged in response to from within, as being part of the body (this creates a threats to physical and psychological survival. Patients? paradoxical situation, because the confict comes from sense of the meaning of life may be shattered, and they wanting to avoid something that is inside and by this very will need to reconstruct new meanings that incorporate nature it is a state that cannot be avoided). Existential isolation?a uncertainties related to the disease prognosis, enhances fear of being rejected or abandoned?may lead to these feelings. For many, the existential issues by the patient with chronic disease (versus the trust that involve spirituality, often manifesting as a rediscovery of one experiences for an acute condition). Denial is most Suicidal impulses appear as complications of depression and typical in the early stages of infection. Splitting (always present, to a lesser or greater extent tioned processes and help patients overcome denial and because it allows some degree of dissociation and splitting, improve self-esteem, and restore the symbolic denial). This comes in contrast to recognize the unpleasant reality of the disease while with at least one intense feeling?beyond the usual keeping hope and goals in life, to ofer a safe mode of expected intensity?that the client displays toward expressing fury and fear while keeping the love and some other problems such as school problems/grades support of signifcant ones, and fnally integrating the or relationship conficts. Projecting bad? parts of self associated with illness Nilsson Schonnesson and Ross note that with successive (infuenced by internalized stigma). The self-concept health crises, people may regress briefy to earlier stages is altered: I am bad, I am without control, I anticipate as they adapt to new health circumstances. All these cognitions create high levels of doubt and uncertainty regarding iden Professional counselors, social workers, health care tity and self-efectiveness. One practices?for example, when patients are looking of the frst steps in providing adequate assistance for for quasimedical cures. It is about reframing and fnding a new, supportive counseling can help patients come to terms positive meaning in difcult, existential issues. One useful tool to use is the self-report scale Meaning of Reduced illness questionnaire? that helps evaluate illness-related Stigma and Quality Discrimination of life meaning appraisals in fve domains. However, this approach is usually not a complexity and variability of unique constellations of good idea until the person has been able to accept the psychosocial factors that come together in the life of each diagnosis enough to come to the group and communicate patient. Group support can help patients cope with psychosocial services that involve a multidisciplinary team. Counseling and support can also help people consider how their own The multidisciplinary team should have clear standards behaviors can promote health and well-being, such as of care and intervention that will guide their actions seeking resources for adequate nutrition, shelter, proper (Figure 2).

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In some cases the processing artifact acne x-ray treatments cheap cleocin gel generic, and such cilia are generally pre identification of the organism involved is prelimi sumed to be normal skin care natural discount 20 gm cleocin gel mastercard, care must be taken to identify nary or tentative acne emedicine best buy for cleocin gel. The eye is particularly susceptible skin care japanese product buy cleocin gel 20 gm cheap, especially if the use of topical steroids creates a locally immunocom promised state (Chan et al skin care facts cleocin gel 20gm generic. Light microscopy is the primary technique for confirming the presence of microsporidia which are visible using a wide range of stains (Ramanan & Prit acne mechanica buy 20 gm cleocin gel, 2014). The (2009) have suggested that staining with oolong outer microtubule pairs (arrowhead) lack dynein arms. A tea extract may enhance the visibility of the single extra displaced microtubule is also present (arrow). Microtubular discontinuities as acquired British Journal of Ophthalmology, 57, 669?674. The ultrastructure of paraffin noproliferative glomerulonephritis: a good start embedded sections. Journal of basement membrane thinning is acquired in mini Protozoologyy, 40, 101?112. The ultrastructural pathology of malignant associated with pathology in invertebrates and pleural mesothelioma. Glomerular basement membrane abnor Corneal microsporidioses: characterisation and malities associated with apparently idiopathic identification. Journal of Eucaryotic Microbiology, 38, hematuria: ultrastructural morphometric analysis. Fine structure of a new drums over risk estimates and whither electron human microsporidian, Encephalitozoon hellem, in microscopy for diagnosis? F1000Research 2017, 6 (F1000 microsporidia and free-living amebae at the 10th Faculty Rev), 248. Inherited epidermolysis bullosa: Bangladesh infection by an insect parasite from updated recommendation on diagnosis and the genus Nosema. Journal of Protozoology, of the genus Brachiola (Microsporidia) to the genus 32, 250?254. Diagnostic electron microscopy human microsporidian, Encephalitozoon hellem of tumors (2nd ed. British Journal of and classification of human neoplasia by electron micros Haematology, 99, 245?256. Journal of Biophysical and Biochemical Cytology, 4, New York: Churchill Livingstone. The pathology of malignant mesothelioma, men preparation for transmission electron microscopy. Preparation of buffers for use in an ultrastructural study of two cases, includ enzyme studies. A clinicopathologic review approach to classification and clinicopathologic and molecular pathogenetic update. Archives of Pathology and Laboratory Pathology and Laboratory Medicine, 139, 1211?1214. Development and ultrastructure of terisation of the microsporidian Septata intestinalis Trachipleistophora hominis n. Principles and techniques of types with normal values for 24 parameters in electron microscopy, biological applications (4th ed. Archives of Dermatological Research, 289(11), Cambridge: Cambridge University Press. Modern acryl Allergic contact dermatitis from dental composite ics for post-embedding immunostaining tech resins due to aromatic epoxy acrylates and ali niques. Resin micros hyde fixative of high osmolarity for use in electron copy and on-section immunocytochemistry. Concurrent infection of the urinary tract with Ultrastructural features of diffuse malignant meso Encephalitozoon cuniculi and Enterocytozoon bieneusi theliomas. The role of electron microscopy in evaluating Archives of Pathology and Laboratory Medicine, 119, ciliary dysfunction: report of a workshop. Journal of Embedding in epoxy resins for ultrathin sectioning Eukaryotic Microbiology, 42, 158?165. A practical ogy today paradigm change and the impact guide to interpretation and technique. Role of transmission electron Isolation of Nosema algarae from the cornea of an microscopy in tissue diagnosis. Ultrastructural distinc copy in tissue diagnosis: diseases of the kidney, tion from adenocarcinoma. Ultrastructural ing and embedding for transmission electron pathology of cilia in the immotile cilia syndrome. Methods in Molecular Biology, 1117, Perspectives in Paediatric Pathology, 8, 133?161. Brain Pathology, 24, uranyl acetate for the ultrathin sections of bacterial 525?544. Unlike a physical object, a digital image file magnifications comparable to that achievable with a can be moved from one physical location to another conventional light microscope. With appropriate data-security ners typically include slide loading mechanisms, arrangements, digital images should be more durable a motorized stage, a light path, image capture than glass slides which are physical, fragile and prone device and software to create the composite image. The overhead of sorting, filing, storing and Although the data files which represent these retrieving glass slides is particularly burdensome images are large, software techniques enable these on larger laboratories and a fully digital workflow images to be viewed on screen in a manner analo has the potential to significantly reduce this. Finally, gous to how a slide may be viewed on a physical digital images are a prerequisite for automated image microscope. Digital representation of slides enables histology images to be distributed, viewed and shared over Digital images computer networks rather than relying on physical handling of the glass slide. This is likely to represent Images can be represented in numerical form in a the future of histology and cytology departments. The text on this page, for example, is ultimately represented by the printing software, Introduction not as letters and words but as collections of lines and curves. The commonest method for represent Whole-slide imaging refers to the creation of a digi ing complex real world scenes, including histology tal representation of the image presented by a glass images, is to consider the image as a grid of individual histology slide, at a level of detail comparable to that points, each with brightness and, for color images, seen with a light microscope. These individual points are referred to as pixels, is a broader term encompassing related processes the term pixel being a contraction of picture element? which maximize the practical utility of such images, and the smallest resolvable detail. In all commonly including the storage, viewing, annotation and use encountered digital image formats pixels are square, in applications including educational, research and although other shapes, in particular hexagons, are in clinical practice. The term lossless compression? refers slide image is defined by the original absolute size to techniques which allow for the extraction or of the area represented by each pixel. This is deter decompression? of the exact original image with mined by the quality of the slide scanner optics and no loss of detail. Lossless compres by downstream variables such as monitor resolution sion techniques are typically only able to reduce and viewing distance (Sellaro et al. Broadly image file sizes around 2-3 fold, whereas lossy? however, when viewed under appropriate conditions, techniques can achieve 50-fold or higher compres images in which each pixel represents a square of side sion ratios, albeit with noticeable artifact. The the term pixel depth? refers to the extent to which required file size may be compressed up to 30-fold subtly different colors can be distinguished. The using compression techniques without impact on crude but recognizable image in Fig. It is worth noting that discernable arti required to capture this for each pixel. Most formats facts may be introduced into the images at lower for the realistic representation of real life images use levels of compression without necessarily impacting 24 bits, 8 to represent the intensity of each of the 3 on the diagnostic utility of the image (Foran, 1997). This enables 256 different Moreover, greater degrees of compression may be intensity levels to be represented for each of these possible for non-H&E tinctorial stains than for H&E colors, a total of 16,777,216 different tones. File size compression the way in which pathologists interact with the simplest format for representing a digital image images also influences the way image data are is a matrix of pixels, each pixel represented by an stored. Files may include the senting an image of 1000 x 1000 pixels at 24-bit color same image at multiple resolutions to support rapid depth, requires 3 million bytes, i. Medium resolution the slide is moved by the motorized stage and images are captured by the camera. Two commonly used methods of image acquisition are line scan High ning and tile scanning. In line scanning, the slide is resolution moved in a linear fashion so that the camera cap tures strips of the image. Multiple separate images are stored at different mag strobe light source and high frame rate camera are nifcations and resolutions. A pathologist viewing a low power typically employed to reduce movement, the blur overview image only needs to access the top? tier. This mechanism avoids the need to algorithm is then applied to assemble the strips or send entire image fles across networks. Files tationally more complex but modern multi-core may also store metadata such as a timestamp, image processors negate the effect this has on overall scan file type, image size, pixel depth, make and model of time. An image scanned using one focal analyzed, either manually or by an image analysis plane would appear blurry in places, making it algorithm as all measurements are calculated from diagnostically useless. This requires the generation of a focus map either by Image acquisition the operator or automatically from the overview scan image. The scanner could apply autofocus on A slide scanner essentially comprises an optical a tile-by-tile basis in the case of tile scanning or at microscope with a mechanized stage control and several points along a strip of image in line scan focusing, coupled to a digital image capture device, ning. Additional hardware may in a trade-off between speed and image fidelity, typically include mechanical apparatus to sequen the scanner generates a representative autofocus tially load slides, operator controls, a visual display map, or focuses on every third or fifth tile of an area and computer control hardware. A typi Large blocks cal 15 x 15 mm tissue area may take 30 to 60 seconds these mega or jumbo blocks can also be scanned, to scan using a 40x objective at 25 m/pixel. Prior to acquisition time and file size owing to the larger image acquisition, the slide scanner may register the tissue area which needs to be scanned. Large slides sample number by reading a barcode printed on the may interrupt the workflow of a digital laboratory glass slide. A scanner may also perform a low reso as they may require loading in separate batches to lution overview scan to determine where the tissue the standard size slides. One alternative to scanning 480 Digital pathology 22 mega blocks is to create composite blocks of a sam ple then scan these as standard sized slides. Image stitching software can be used to create a virtual mega block from the composite blocks. Cytology preparations the 3-dimensional nature of a typical cytology slide presents challenges. Using a conventional glass slide, a pathologist manually adjusts the microscope to bring different depths? of the preparation into focus. This problem is addressed by acquiring multiple images of the cytology slide at different focal points which are treated as a stack of 2-dimensional images, a pro Fig. Additionally, the scanner operator should ite z-stack images on a monitor, additional image re-check and if necessary clean or re-coverslip slides processing is required to allow the smooth transition prior to scanning. If a laboratory is situated close to a major road or rail Fluorescent slides line or other source of vibration it may be prudent Acquiring digital images of slides stained with fluo to consider installing a scanner on a vibration-proof rescent stains will typically require additional hard table (Fig. The slide scanner should be regularly serviced Some vendors supply the fluorescence modules, or and cleaned to ensure consistent lighting and a dedicated scanner may be required. A daily test slide should be scanned to assess the basic function of the scanner and detect Measures to ensure good quality digital major errors such as poor sample detection and images abnormal color profiles. This procedure will also generate diagnostic information such as scanner the quality of the virtual image depends upon the temperature, time-to-focus and time-to-scan, all of production of a high quality physical slide and which can create variance in digital image consis quality control processes relating to the scanner tency and laboratory throughput. When using a conventional light microscope, tion of the scanner has been shown to increase a pathologist can work around artifacts including diagnostic confidence and produce digital slides tissue folds, wax on the coverslip, air bubbles and which are subjectively similar to slides viewed tissue not covered by the coverslip. This is achieved by ner will faithfully reproduce all of these artifacts, scanning a standardized color patch affixed to a potentially diminishing the quality of the scanned slide. An adjustment to the color reproduc should ensure the production of the highest qual tion is then made by the scanner. This procedure ity slides and the presence of artifacts need to be is important to ensure day-to-day consistency of Accessing and viewing whole slide images 481 a b Fig. Using a glass slide a pathologist may be able to compensate for this by focusing up and down through the depth of the tissue but such compensation is not possible on a digitally acquired image. The rapid trans tency between scanners in the same department mission of image data is achieved by only sending (Fig. This allows smooth transition between magnifica Accessing and viewing whole slide tions and when panning without preloading the images entire file, which would otherwise require a prohibi tively large amount of network bandwidth. Image streaming Client software the sheer size of virtual slide images raises signifi cant technical challenges around distributing image this term refers to the software used by individual data over networks. A key challenge in developing client soft this process is referred to as streaming. The same ware has been to provide zooming and panning in approach is used in viewing films over the internet a manner which is intuitive for pathologists accus rather than sending an entire movie file of perhaps tomed to physical microscopes. A pyramidal image format assists with the able lag between operating the panning controls and image streaming process, with deeper subsections the ultimate refreshing of the image will impact on of the image transmitted as the pathologist increases the usability of the system. A similar mechanism is used for the Many manufacturers have developed interfaces Google Earth image viewing system, in which a sin which only require a web browser to view and navi gle low resolution image of the planet is first sent, gate images, although relatively fast computers with with subsequent image data for higher magnifica capable graphics cards are required. Arrangements for such access should be established in advance, taking into account institu tional network security policies. The initial acquisition of a slide image ity only, which may be all that is required for many requires the highest drive speeds as the entire image applications (Fig. Unreported images should be stored on high performance disks with the fastest available Hardware installation and image file data-read times on servers able to deliver images to storage multiple pathologists at the same time. However, once reported, the images for these cases could be Installation of a digital pathology system may be moved to a cheaper, less highly specified medium. Even for such a simple arrangement however, can be accessed, but with some minor lag in image adequate space, computer network access, a power availability. The initial image scanning process gener drives may provide the most cost-effective solution. If it is accepted scale digitization is anticipated, multiple scanners that a digital image must be held for a period of may be needed to achieve the required throughput.

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