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Alternative scores asthma symptoms mayo best purchase serevent, incuding pediatric scores asthmatic bronchitis and pneumonia buy serevent uk, have been proposed as well; their value also remains to asthma zenhale buy serevent without a prescription be proven asthmatic bronchitis 37 purchase serevent amex. Diagnosis: Laboratory Tests Some advocate lab tests as part of the initial diagnostic process asthmatic bronchitis vs pneumonia buy serevent 25 mcg free shipping, others find it only useful in case of diagnostic uncertainty asthmatic bronchitis 11 generic 25mcg serevent with visa. However, there is evidence33 that the inflammatory parameters are strongly discriminative if they are combined, especially in case of perforated appendicitis. Thus, since the clinical diagnosis of acute appendicitis remains difficult, it seems reasonable to advocate the use of combined inflammatory parameters in the initial evaluation of every patient. Also, these data might support the practice of repeating labs in cases of uncertainty about the diagnosis. Approximately 10% of patients with abdominal pain who are seen in the emergency department have urinary tract disease71 An urinalysis may confirm or rule out urologic causes of abdominal pain. Although the inflammatory process of acute appendicitis may cause pyuria, hematuria or bacteriuria in as many as 48 % of patients, but if clearly abnormal. There are insufficient data to determine sensitivity and specificity of an urinalysis in the diagnosis of appendicitis. On the other hand it is well-known that the diagnosis in female patients is more difficult, and it has been noted in a retrospective multi-centre study that females had a 2. Last (but not least), no literature was found which addressed the need of preoperative lab assessment in view of anesthetic risks in case of acute appendicitis. The expected diagnostic accuracy in these circumstances approaches 95% and is probably not improved by imaging. If the diagnosis of appendicitis cannot be readily made nor excluded based on history, physical examination and inflammatory parameters, imaging procedures are generally believed to contribute to the diagnostic process. Plain radiography is not specific and can even be misleading in this situation since in fewer than 5 percent of patients an opaque fecalith may be apparent. Nevertheless, due to failure to visualize the appendix the study is inconclusive in up to 10% of the cases. This is attributed to superimposed air or feces, or an atypical appendiceal location. Also, diagnostic accuracy is highly dependent on operator skill and subject-dependent as well. There are only limited data about newer techniques including color Doppler and hydrocolonic ultrasonography. The most common protocol was helical scanning with enteric (rectal) contrast material, limited to the periappendiceal area. Concern has been raised about the increased time interval between admission and surgery in case of additional examinations. However, no increase in perforated appendicitis (in several studies even a decrease) could be noted 69. However, many studies seem to point towards a decrease of negative appendectomy, as well in adults 41 42, mixed populations, as in children43 69. Differential reference standard bias was encountered in almost all included studies. These two biases might have led to an overstimation of the diagnostic value of the evaluated imaging techniques. Concerning Magnetic Resonance Imaging, there are still insufficient data to establish sensitivity and specificity for diagnosing appendicitis 52. Diagnostic laparoscopy and Surgical Treatment Diagnostic laparoscopy has been advocated to clarify the diagnosis in equivocal cases (after classical diagnostic work-up) and has been shown to reduce the rate of unnecessary appendectomy since it makes it possible to visualize other pathologies as well. It is most effective for female patients, since a gynecologic cause of pain is identified in approximately 10 to 20 percent of such patients54. However, diagnostic laparoscopy still is an invasive procedure with approximately a 5 percent rate of complications, mostly due to general anesthesia71. Concerning surgical treatment, in a Cochrane meta-analysis of 54 randomised clinical trials by Sauerland et al. In the same meta-analysis, five studies on children were included, the results didnEt seem to be much different when compared to adults. Previous meta-analyses including less studies and presenting less data on quality of included papers and/or on data extraction usually could already present the same results as Sauerland et al. Postoperative Management One meta-analysis 58concludes that systematic drains for any stage of appendicitis do not reduce complications after appendectomy. Another meta-analysis60 supports the use of primary and not delayed wound closure for complicated (gangrenous or perforated) appendicitis. Several retrospective reports on the necessity of a systematic intra-operative culture in all cases of appendectomy emphasize that this practice can be abandoned since it does not influence the initial choice of antibiotics 61 59 62. The use of incentive spirometry hourly (5 to 10 breaths per session) while awake for the first 48 to 72 hours post extubation is recommended in the Cincinnatti group based on the statement that respiratory complications including atelectasis, pneumonia and respiratory failure are frequent causes of postoperative morbidity and mortality following major abdominal surgery. The rate of postoperative respiratory complications in case of appendicitis in the literature varies but seems to be only a fraction of the total complication rate, except for very young children or persons over 50 as well as persons with other co-morbidities63 64 65 66. The efficacity of postoperative respiratory physiotherapy, like (among others) incentive spirometry, is not known in case of appendectomy. However, the efficacy of prophylactic respiratory physiotherapy after cardiac surgery was summarized in a systematic review and the usefulness remained unproved. Critical Appraisal of the Pathways Content: Conclusion In conclusion, it is clear that each element of clinical and laboratory examinations taken alone is of weak discriminatory and predictive capacity in the diagnostic process of acute appendicitis. Since the clinical diagnosis of acute appendicitis remains difficult, it seems reasonable to advocate the use of combined inflammatory parameters in the initial evaluation of every patient. Urinalysis may help in discriminating with urinary tract pathology, but there are insufficient data to determine sensitivity and specificity in the diagnosis of appendicitis. Because it is simple to perform and if clearly abnormal can help to avoid an unnecessary appendectomy, it can be done in every patient with suspected appendicitis. If the diagnosis of acute appendicitis is possible but not sure, the presented evidence might also support the practice of repeating inflammatory parameters after some hours. Although lists of differential diagnostic possibilities are readily available in the literature, no clear recommendations about additional laboratory examinations were found. Although still some debate is going on in the literature, especially the meta-analysis of Terasawa et al. For the role of clinical scoring systems like the Alvarado-score to perform risk-stratification (who needs imaging, who not) evidence is still insufficient. If the results of the imaging are indeterminate, watchful waiting and repeated clinical examination is advised71. Nowadays, many patients prefer to go home and to come back the next day on the outpatients clinic for reevaluation and repeat blood tests. Evidence so far does not support the systematic use of intra-operative cultures and drains or delayed wound closure in case of complicated appendicitis. There are many questions about the usefulness of systematic postoperative incentive spirometry after appendectomy. Translation into financing the cost of the 3 international and the Belgian pathways described above were calculated by using the corresponding billing codes. Secondly, based on the critical appraisal of the key interventions, the theoretical minimal costs for a strictly evidence-based scenario and the reasonable costs taking into account defendable interventions where evidence is limited or absent were calculated. For the pathways as well as for minimal and reasonable costs, two different scenarioEs were calculated: one based on the scenario where after the doctorEs clinical examination of the patient, there is no doubt about the diagnosis of acute appendicitis (Typical or clinically unequivocal); the other scenario where the patient presents with clinical signs and symptoms that might point towards acute appendicitis but other diagnoses are still possible as well, so further evaluation and/or exploration is necessary (Atypical or clinically equivocal). Hence, to calculate the minimal and reasonable cost for atypical cases based on evidence in the literature it was taken into account that 3/4 of the total appendectomy group consists of adults and 1/4 of children (see introduction). Note that all the international pathways are outlined for children; the Belgian pathway however has been set up for both children and adults. Finally, to merge the Typical and the Atypical scenario into one final cost for each included pathway and for minimal and reasonable cost, it was considerd fair, based on data in the literature (see introduction), that on average about 50% of cases are typical and 50% atypical. Average costs of a hospital stay for the clinical pathways in function of costgroup for typical (clinical diagnosis of appendicitis is obvious) patients. Clinical path Clinical Imaging Other Surgery + Total biology reimbursed anesthesiology (without activities surgery) boston 0. Average costs of a hospital stay for the clinical pathways in function of costgroup for atypical (clinical diagnosis of appendicitis is possible but not sure) patients (25% children and 75% adults; international pathways: children only). Clinical path Clinical Imaging Other Surgery + Total biology reimbursed anesthesiology (without activities surgery) boston 1. Average costs of a hospital stay for the clinical pathways in function of cost-group for typical (50%) and atypical patients (50%). As already explained in chapter 3, the possibility that patients (typical or atypical) develop complications after surgery has not been taken into account when calculating the cost for international and Belgian pathways nor for the theoretical minimal or reasonble cost. The calculated cost for the Belgian pathway is still higher than the foreign pathways but within the theoretical reasonable costs. This is explained by the frequency tables for clinical biology for appendectomy in Belgium (2001), which show that chemistry and coagulation are used in more than 50% of cases in the Belgian hospitals, whereas, as shown above, it is assumed to be reasonable to consider 50% of the cases as Typical. Only one pathway (Cincinnati) systematically includes this type of costs, due to the included postoperative respiratory rehabilitation for which little evidence is available. The latter is due to higher costs for clinical biology and even more to the use of other reimbursed activities for which little evidence exists. Discussion the abundant use of clinical biology in Belgium, and more specificially pre-operatively, is not unique for appendectomy. The category other reimbursed activities shows the largest difference between pathways, theoretical reasonable cost and the Belgian Reference values. Although definite conclusions about necessity for certain prestations can only be drawn if additional details about co-morbidity and/or complications are known (which was beyond the scope of this paper), we draw attention especially to electrocardiography (also a frequently found unnecessary technical prestation in other surgical interventions, since it often is included as a routine preoperative examination) as well as physiotherapy (peak-incidences for appendectomy are the second and third decade of life). The pitfalls in the exercise for Appendectomy are generally speaking the same as the pitfalls for the other studied interventions. The time for this study was limited, and some literature, more difficult to find, about key interventions in the pathways might have been missed. The costs of complications are not included, although complications are not rare and can augment expenses a lot. Key messages x the content of the Belgian pathway for adult patients was to a large extent in accordance with our critical appraisal based on evidence. Whether the difference in costs related to the paediatric pathways is justified or not cannot be judged. Discrepancies were present especially for routine pre-operative tests, like laboratory tests (chemistry: in 80% of hospitalisations, coagulation: in 61%), and in the category AotherE: electrocardiography (in 20%). Cholecystectomy and appendectomy utilisation rates in Belgium: trends 1986-1996 and impact of laparoscopic surgery. Ultrasonography to evaluate adults for appendicitis: decision making based on meta-analysis and probabilistic reasoning. Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts. Active observation of children with possible appendicitis does not increase morbidity. Standardized patient care guidelines reduce infectious morbidity in appendectomy patients. Are incentive spirometry, intermittent positive pressure breathing and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Accuracy in diagnosis of acute appendicitis by comparing serum Creactive protein measurements, Alvarado score and clinical impression of surgeons. The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Prospective evaluation of modified Alvarado score for diagnosis of acute appendicitis. Continuing diagnostic challenge of acute appendicitis: evaluation through modified Alvarado score. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. Comparison of ultrasound and the Alvarado score for the diagnosis of acute appendicitis. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. The accuracy of C-reactive protein in diagnosing acute appendicitisa meta-analysis. Urinalysis, ultrasound analysis, and renal dynamic scintigraphy in acute appendicitis. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. An economic evaluation of sonographic examination of children with suspected appendicitis. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. The clinical role of noncontrast helical computed tomography in the diagnosis of acute appendicitis. Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Computed tomography and ultrasonography in the diagnosis of appendicitis: when are they indicated

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It is important to asthma step therapy order serevent 25mcg free shipping employ a variety of means to asthma pictures order serevent on line amex actively review information obtained from communities asthma definition 2-fold serevent 25mcg mastercard. Not all cases or deaths are seen at a health facility and may be left unnoticed and not included in the alert system asthma bronchitis natural treatment generic serevent 25 mcg visa. Action 4: Describe the epidemic Regular and timely epidemiologic updates are necessary to asthma related bronchitis cheap serevent 25 mcg otc describe the progress and trends of the cholera outbreak and to asthma 5 year old buy serevent 25mcg fast delivery monitor response actions. Updates can be performed daily (especially at the beginning of an 16 outbreak), weekly or monthly, depending on the progression of the outbreak. It should be monitored at the lowest administrative level to update response interventions and at national or regional levels to support advocacy and fundraising, predict spread, estimate resource needs and signal neighbouring countries of epidemic proximity. Data should be analysed and reported using a mix of numbers, graphs and maps to describe: Person: who is affected (data broken down by sex, age, or risk factor; Time: trends over time (see Action 4B); Place: location/place (see Action 4C). The analysis of these trends should be conducted at the lowest administrative level to allow immediate adjustment of the prevention and case management interventions. Information for daily reporting of cases and deaths can be drawn from alerts and facility-reported data from line listing. Action 4B: Conduct weekly reporting Weekly reporting involves more analysis than daily reporting and provides a more robust picture of an epidemics time trends, which can be illustrated in tables, line graphs or histograms. Weekly data can also be described by age or gender to yield a more detailed analysis of trends. For an example, please refer to Zimbabwe weekly epidemiologic bulletins at. Epidemic curves (see Annex 3I) are used to determine whether cases are clustered in time, place or by person, i. Each facility should establish an epidemic curve, as well as district, provincial, and national epidemic curves, and they should be updated frequently and regularly. Spot maps or hand-drawn maps can show where, how and why the outbreak is moving and the locations of cases, roads, water sources and health facilities in more than larger country-level maps. Action 4D: Identify sources of transmission Analysis of the information gathered or estimated in Actions 2, 3 and 4 should help identify the source of transmission through the observation of common patterns among reported cholera cases. Assessments of cholera transmission from particular bodies of water, food outlets or other sources may rely on case control studies, sanitary surveys around water points, inspections of food hygiene and safety at food outlets, and testing of thermo-tolerant coliform, such as E. Additional studies, including laboratory tests and environmental studies, can be conducted as necessary, although they can be time and resource consuming and the capacity limited in low-income countries. Action 5: Estimate the populations at risk and number of expected cases the estimation of risk is based on a number of combined factors that include water, sanitation and hygiene coverage; environmental factors such as seasonality or flooding; levels of crowding; population displacement and movement; systemic capacity to respond; population immunity; and other factors such as marginalization, economic stress and water supply limits faced by populations. Action 5A: Estimate the populations at risk Estimates of at-risk populations will reflect broad numbers in locations based on pre-determined risk factors (see Section 2. Risk assessment methods can include: reviews of existing data on coverage, use and knowledge of safe water, sanitation and hygiene services and health services, observation, sanitary surveys, measurement of residual chlorine, key stakeholder interviews and focus group discussions. Targeted prevention interventions to reduce the spread of disease including water, sanitation and hygiene efforts, communications measures and oral cholera vaccines where indicated should be focussed on populations at risk of exposure. Action 5B: Estimate the expected number of cases the number of new cases expected and ultimately the magnitude of an outbreak is very difficult to predict and depends on many different factors. It is often a best guess and should be rounded up to ensure there are adequate supplies (which can be used to address other diarrhoeal disease efforts after the outbreak). See Annex 3H for a planning excel spread sheet that can help in calculating how many cholera treatment centres, staff, supplies, etc. Regular supervision of health staff is also necessary to make sure the case definition is applied, the line listing is 19 completed properly, data are being used for analysis and shared with key partners for action, reporting forms are available and the number of alerts that were not reported and the reasons are known. Monitoring when there are no cases Monitoring epidemiologic data when there is no outbreak of cholera is important and should be incorporated into the existing surveillance system with an early warning and alert component. Overview of Chapter 4 this chapter covers outlines the individual and community behaviours and practices that can help to prevent cholera infection and transmission. How to prevent cholera through improved water, sanitation and hygiene the single most important principle for preventing cholera transmission Keep faecal matter away from water and food and kill cholera bacteria that have contaminated food or water prior to consumption. The following table identifies specific actions, which if implemented by a large proportion of the population and by supporting practitioners, can prevent the transmission of cholera. In the longer term, eliminating cholera 9 transmission will require sustained efforts on making water and sanitation services accessible and used, appropriate hygiene practices adopted (which usually requires changing personal and social behaviours) and health care services accessible and of good quality. While the table indicates specific actions and outcomes to be achieved, Section 4. Target outcome Household, community and institutional practices Actions Practitioners Actions required required (may involve sustained behaviour change) Infants are Babies under 6 months are exclusively breastfed Advocacy, communication and social mobilisation exclusively breastfed Older infants continue to be breastfed and are also given sessions, including mothers support group and if needed, given complementary foods prepared hygienically sessions, for and promotion of exclusive safe fluids and food Where formula milk is used it is prepared hygienically using breastfeeding for infants under 6 months of age and boiled water that remains hot enough to kill bacteria in the promotion of breastfeeding with complementary formula (but cooled before serving) feeding for older infants (including education on food hygiene for caregivers) the environment is Latrines with functional hand-washing facilities are used and Advocacy for and facilitation of processes to free from excreta kept clean encourage community led sanitation action because people People do not defecate in the open (if people dont have access Support to government authorities to ensure dispose of it safely to a latrine they always bury their faeces) institutions and public places have adequate Childrens faeces are disposed of safely in a latrine or buried accessible latrines with functional hand-washing Excreta disposal facilities are provided in markets, other public facilities as well as systems to ensure they are places and institutions with functional and well managed handcleaned and maintained washing facilities Communication for behaviour and social change Excreta disposal facilities are culturally appropriate and a interventions for latrine use and maintenance and sustainable cleaning and a maintenance system is established free open defecation communities. People wash their Hands are washed with water and soap at the critical times Behaviour and social change communication, hands with soap and (after defecation or handling faeces, before preparing food, education and social mobilisation activities on the water at critical times feeding a child or eating) importance of handwashing with soap at critical If soap is not available then ash or another appropriate times are undertaken disinfectant is used Construction, operation and maintenance (including Because a shared cloth or towel can become contaminated provision of soap) of handwashing facilities is hands should be dried in the air supported in all public places, particularly next to Particular care is taken at funerals and other gatherings to public latrines and in food preparation and serving ensure facilities for hand-washing with soap are available and areas. Use of cholera vaccines Vaccination is becoming increasingly important to cholera control for a number of reasons, including: the availability of new, improved, less expensive and prequalified vaccines; growing awareness of large and protracted epidemics receiving extensive response operations and media coverage; increased interest by partners and donors in new technologies to address the worrisome growth in incidence of cholera worldwide; and, closer collaboration with technical vaccine experts and partners who implement traditional cholera control efforts. Both offer the major advantage of being relatively easy to administer in a short time and of depending more reliably on functioning health systems and their partners than on the actions of families or individuals. In all contexts, the decision-making process must be based on a sound risk assessment. It should also not be allowed to detract from necessary on-going attention to diarrhoeal diseases of other origin, which remain a major cause of childhood mortality in all developing countries. It has become increasingly clear that the appropriate implementation of a mass cholera vaccination program should be considered as a potentially important element of any cholera prevention and control effort, together with the other areas of intervention discussed in this Toolkit. They are intended to prevent the spread of cholera and to reduce mortality through preventing infection. Incorporating cholera prevention into development / regular programming the risk of cholera is the highest among the most marginalized populations, where water, sanitation and health related services are at the lowest coverage. Preventing cholera demands an overall strengthening of measures towards reduction of diarrhoeal diseases improving access to the above mentioned services and hygiene related behaviours and putting in place cholera specific measures in the most at risk areas. Increasing emphasis and bringing additional resources to existing diarrheal disease programs so they can scale up should be part of any cholera prevention strategy. Nevertheless elimination of cholera will only be possible if the gains are sustained over the time. The following interventions have been identified as key for control and reduction of diarrhoeal diseases. Advocacy and support of national efforts, including resource mobilization, to scale up and expand them to cover cholera prone areas will contribute to the prevention and elimination of cholera in endemic and high risk settings: Community based approaches to stop open defecation and increase sanitation demand. Integrate cholera as an overt consideration into existing development programs: For endemic areas, cholera should be a specific consideration of the planning and delivering of any development programme. The list below highlights areas where the inclusion of cholera would be necessary as a mean to eliminate cholera transmission / prevent it to occur and improve health outcomes: In all concerned sectors. All work plans and collaboration with governmental institutions and partners (including project cooperation agreements for the implementation of regular programmes) should consider the opportunity to incorporate the actions mentioned in Section 4. Overview of this chapter this chapter covers the rationale and structures for cholera outbreak prevention, preparedness and response, including the role of task forces and co-ordination committees. It also considers the meetings, sources of information and the importance of information management to understanding and containing cholera risks. The need for communications and the challenges presented by situations when cholera is present but not declared are reviewed, as are stakeholder roles and responsibilities overall. Summary of Annexes Annex 5A Comparison of co-ordination structures Ethiopia & Zimbabwe 5. Purpose of co-ordination for cholera prevention, preparedness and response Effective prevention, preparedness and response for cholera require co-ordination and communication across multiple sectors and at different levels. The speed of response has significant bearing on the containment and impact of an outbreak. The purpose of co-ordination is to: Ensure coherence of the prevention, preparedness or response activities through the development of collaborative plans and agreement on technical standards Avoid both gaps and duplication, and promotes complementarity Make the most effective use of all actors, including government partners, resources, funding and supplies Undertake collaborative assessments, leading to aligned planning and response assumptions Effectively share information Build capacities Mobilise resources Instigate timely monitoring, reporting and decision making Increase the efficiency and timeliness of early warning system Establish common thresholds for triggering interventions. Co-ordination structures for prevention, preparedness and response Activities that will lead to the prevention of cholera (and infectious diarrhoeal diseases of all varieties) over the longer term should be undertaken as part of developmental efforts to build systems, structures and services. Cholera-specific prevention activities and advocacy may be justified in high to medium risk countries and wherever possible should be considered a focus area for attention in existing co-ordination platforms. Ideally, these pre-existing co-ordination structures can also ensure the incorporation of appropriate preparedness actions to be taken in advance of any possible cholera outbreak, thereby building sustainable capacity among national stakeholders and facilitating collaborative programming between development and emergency focussed actors. An explosive National (with Primarily high-level liaison, Action might justify initiating either outbreak in a country additional strategic decision making, national disaster management or which usually only support at setting standards and delivering cholera-specific co-ordination has small outbreaks sub-national guidance, developing strategies mechanisms at national, regional or a country which level as for prevention and response, and district levels. International has not experienced required) advocacy and resource support is also likely to be needed. International Health associated transmission risks Regulations should be respected and international authorities duly notified. Establishment of co-ordination structures Support existing government-led national, regional and district co-ordination mechanisms wherever possible. Outbreak task forces or co-ordination committees the Ministry of Health coordinates all departments responsible for preventive health and epidemiology and is usually the overall lead agency in cholera prevention, preparedness and response. Engagement is required from Ministries and Departments responsible for emergency/disaster preparedness, water, sanitation, education, community development, social protection, local government, public information, communication and finance. In a country that has experienced large-scale outbreaks, the existence of a stand-alone cholera task force is more likely. For cholera endemic countries, which do not tend to face large outbreaks, or in countries which have not had cholera for some years, cholera is more likely to be covered by a more general outbreak task force or coordination mechanism. A National Disaster Preparedness and Management Agency (or the like) may exist in addition to a cholera task force and may or may not have epidemic control as part of its mandate. Irrespective of format and name, the core functions of a cholera co-ordination unit will be: Preparing for epidemic Co-ordinating among sectors and sharing information Collaborating at regional and international levels Conducting risk and needs assessments Collecting and reporting of information on cholera cases and deaths Organising any relevant training Procuring, storing and distributing of essential supplies Implementing, supervising, monitoring and evaluating control activities. Co-ordination arrangements may necessitate the creation of sub-committees, advisory or technical working groups tasked with the following focus areas: Overall co-ordination (usually an strategic advisory group) Surveillance and information exchange Case management and laboratory services Environmental health / water, sanitation and hygiene Advocacy, communication for behaviour and social change and social mobilisation Communication and resource mobilisation Distribution and utilisation of supplies and associated logistics Membership composition of a national cholera task force A national cholera task force should be broadly representative. The size should balance inclusivity against the need for rapid decision making for quick and effective implementation. Some of them can be operational all the time, some of them can be activated for outbreak response only; Country B some areas might be merged in one committee, and more committees can be created as per the existent needs Sub-national coordination platform Sub-national coordination platform Coordination between local authorities Province/District A Province/District B for cross-border interventions Sub-committees could be different from one province/district to another, depending on the specific needs. Fig 5 Example of coordination arrangements for cholera preparedness and response Membership composition may change by context. For reference, see the co-ordination structures utilized in two major epidemics with different contexts in Ethiopia and Zimbabwe shown in Annex 5A: Comparison of Coordination Structures, with some observations on their relative strengths and weaknesses. During a cholera outbreak it is very important to identify organizations that have significant proven experience in responding to cholera and can help lead and guide other stakeholders in the response. A number of international institutions, agencies and organisations may be able to provide technical support. Unqualified individuals or organizations should not be allowed to manage cholera control activities, especially those relating to health care, until they have received adequate training. In epidemic situations where cholera outbreaks have not occurred before, training of national personnel will be a critical priority. These guides provide a range of useful information for supporting government-led sectoral and inter-sectoral co-ordination efforts. However, the high level of commitment required for participation in the task force is difficult to sustain due to: Inconsistent representation by stakeholders, both in terms of changing personnel and of sustained priority given to engagement, not to mention a perceived domination of the group by Health professionals Perceptions by civil society representatives of being overlooked or limited either in number of agency representatives or ability to contribute. Meetings and information required to manage cholera risks A cholera task force or co-ordination mechanism should meet periodically during periods before seasonal outbreaks in which attention is focussed on prevention and preparedness. During the response period, stakeholders should meet frequently (at least weekly) during the outbreak period. At the peak of an outbreak, the task force or committee managing the direct response, for example at district level, will need to meet daily to discuss the progression of the cholera outbreak and, the status of and gaps in the response, and to prioritise actions and disseminate data. The coordinator chairing any meeting should possess technical knowledge and co-ordination skills regardless of his/her normal work sector. Meetings should have a prepared agenda and stated objective and be kept as short and focussed as possible. Actions points arising from the meeting should be disseminated as fast as possible and followed up Information is critical for stakeholder engagement and actions, but it is only useful if shared with those stakeholders who are responsible for acting on it. In cholera outbreaks, these stakeholders include: General public who require information to protect themselves Media who disseminate information widely to the general public Responders at local, national, regional, sub-regional levels. The following table identifies the types of information required to effectively manage cholera outbreaks. Table 4 Types of information required for managing cholera outbreaks Types of information needed in cholera Where is it discussed Why it is needed outbreaks in this Toolkit Contextual information and the basics of cholera: 31 How to prevent cholera and what to do To inform the public about what if a person is infected they need to do to protect Chapters 2, 4, 8 and 9 How and where to obtain assistance themselves effectively. Co-ordination and communication when cholera is present but not declared A cholera outbreak can have significant political ramifications. Governments may decide, for political and/or economic reasons, not to declare an outbreak when it occurs. If a cholera outbreak has potential international implications, it must be reported under the terms of the International Health Regulations. Even when a government is not declaring the outbreak, practitioners on the ground are often working hard to do their best to respond within the limitations. If they trust that you will not put them in a difficult or dangerous position with the political authorities, they will welcome support for improving the response. Also, highlight the likely impacts if the outbreak becomes extensive, including the costs to the country, and share examples of other large outbreaks. Stakeholder responsibilities related to cholera the stakeholders outlined in the following table may be involved in cholera prevention, preparedness and response. Table 5: Potential stakeholders in cholera prevention, preparedness and response and their responsibilities / actions Stakeholder category / Description Possible responsibilities / actions level of importance Primary Including: Girls, boys, women, men, Community cholera preparedness planning and stakeholders: i. Data and Information Management Accurate and consistent, systematically collected data needs to be collated, analysed and evaluated prior to being presented to decision makers for action.

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Dona Blanca asthma symptoms rib pain serevent 25mcg sale, his mother asthma symptoms rapid heart beat buy 25mcg serevent visa, smothered by mourning that was considered eternal asthma symptoms headache 25 mcg serevent free shipping, had substituted evening novenas for her dead husbands celebrated lyrical soirees and chamber concerts asthma treatment 0f discount serevent 25 mcg amex. His two sisters asthma 2014 soundtrack discount serevent 25mcg on-line, despite their natural inclinations and festive vocation asthma definition gina purchase 25mcg serevent with mastercard, were fodder for the convent. Juvenal Urbino did not sleep at all on the night of his return; he was frightened by the darkness and the silence, and he said three rosaries to the Holy Spirit and all the prayers he could remember to ward off calamities and shipwrecks and all manner of night terrors, while a curlew that had come in through a half-closed door sang every hour on the hour in his bedroom. He was tormented by the hallucinating screams of the madwomen in the Divine Shepherdess Asylum next door, the harsh dripping from the water jar into the washbasin which resonated throughout the house, the longlegged steps of the curlew wandering in his bedroom, his congenital fear of the dark, and the invisible presence of his dead father in the vast, sleeping mansion. Juvenal Urbino commend ed himself body and soul to Divine Providence because he did not have the heart to live another day in his rubble-strewn homeland. But in time the affection of his family, the Sundays in the country, and the covetous attentions of the unmarried women of his class mitigated the bitterness of his first impression. Little by little he grew accustomed to the sultry heat of October, to the excessive odors, to the hasty judgments of his friends, to the Well see tomorrow, Doctor, dont worry, and at last he gave in to the spell of habit. This was his world, he said to himself, the sad, oppressive world that God had provided for him, and he was responsible to it. He kept in place the hard, somber English furniture made of wood that sighed in the icy cold of dawn, but he consigned to the attic the treatises on viceregal science and romantic medicine and filled the bookshelves behind their glass doors with the writings of the new French school. He took down the faded pictures, except for the one of the physician arguing with Death for the nude body of a female patient, and the Hippocratic Oath printed in Gothic letters, and he hung in their place, next to his fathers only diploma, the many diverse ones he himself had received with highest honors from various schools in Europe. He tried to impose the latest ideas at Misericordia Hospital, but this was not as easy as it had seemed in his youthful enthusiasm, for the antiquated house of health was stubborn in its attachment to atavistic superstitions, such as standing beds in pots of water to prevent disease from climbing up the legs, or requiring evening wear and chamois gloves in the operating room because it was taken for granted that elegance was an essential condition for asepsis. They could not tolerate the young newcomers tasting a patients urine to determine the presence of sugar, quoting Charcot and Trousseau as if they were his roommates, issuing severe warnings in class against the mortal risks of vaccines while maintaining a suspicious faith in the recent invention of suppositories. He was in conflict with everything: his renovating spirit, his maniacal sense of civic duty, his slow humor in a land of immortal pranksters-everything, in fact, that constituted his most estimable virtues provoked the resentment of his older colleagues and the sly jokes of the younger ones. He appealed to the highest authorities to fill in the Spanish sewers that were an immense breeding ground for rats, and to build in their place a closed sewage system whose contents would not empty into the cove at the market, as had always been the case, but into some distant drainage area instead. The well-equipped colonial houses had latrines with septic tanks, but two thirds of the popula tion lived in shanties at the edge of the swamps and relieved themselves in the open air. The excrement dried in the sun, turned to dust, and was inhaled by everyone along with the joys of Christmas in the cool, gentle breezes of December. Juvenal Urbino attempted to force the City Council to impose an obligatory training course so that the poor could learn how to build their own latrines. He fought in vain to stop them from tossing garbage into the mangrove thickets that over the centuries had become swamps of putrefaction, and to have them collect it instead at least twice a week and incinerate it in some uninhabited area. The mere idea of building an aqueduct seemed fantastic, since those who might have supported it had underground cisterns at their disposal, where water rained down over the years was collected under a thick layer of scum. Among the most valued household articles of the time were carved wooden water collectors whose stone filters dripped day and night into large earthen water jars. To prevent anyone from drinking from the aluminum cup used to dip out the water, its edges were as jagged as the crown of a mock king. Juvenal Urbino was not taken in by these appearances of purity, for he knew that despite all precautions, the bottom of each earthen jar was a sanctuary for waterworms. He had spent the slow hours of his childhood watching them with an almost mystical astonishment, convinced along with so many other people at the time that waterworms were animes, supernatural creatures who, from the sediment in still water, courted young maidens and could inflict furious vengeance because of love. As a boy he had seen the havoc they had wreaked in the house of Lazara Conde, a schoolteacher who dared to rebuff the animes, and he had seen the watery trail of glass in the street and the mountain of stones they had thrown at her windows for three days and three nights. And so it was a long while before he learned that waterworms were in reality the larvae of mosquitoes, but once he learned it he never forgot it, because from that moment on he realized that they and many other evil animes could pass through our simple stone filters intact. For a long time the water in the cisterns had been honored as the cause of the scrotal hernia that so many men in the city endured not only without embarrassment but with a certain patriotic insolence. When Juvenal Urbino was in elementary school, he could not avoid a spasm of horror at the sight of men with ruptures sitting in their doorways on hot afternoons, fanning their enormous testicle as if it were a child sleeping between their legs. It was said that the hernia whistled like a lugubrious bird on stormy nights and twisted in unbearable pain when a buzzard feather was burned nearby, but no one complained about those discomforts because a large, well-carried rupture was, more than anything else, a display of masculine honor. Juvenal Urbino returned from Europe he was already well aware of the scientific fallacy in these beliefs, but they were so rooted in local superstition that many people opposed the mineral enrichment of the water in the cisterns for fear of destroying its ability to cause an honorable rupture. He was just as concerned with the lack of hygiene at the public market, a vast extension of cleared land along Las Animas Bay where the sailing ships from the Antilles would dock. An illustrious traveler of the period described the market as one of the most varied in the world. It was rich, in fact, and profuse and noisy, but also, perhaps, the most alarming of markets. Set on its own garbage heap, at the mercy of capricious tides, it was the spot where the bay belched filth from the sewers back onto land. The offal from the adjoining slaughterhouse was also thrown away there-severed heads, rotting viscera, animal refuse that floated, in sunshine and starshine, in a swamp of blood. The buzzards fought for it with the rats and the dogs in a perpetual scramble among the deer and succulent capons from Sotavento hanging from the eaves of the market stalls, and the spring vegetables from Arjona displa yed on straw mats spread over the ground. Urbino wanted to make the place sanitary, he wanted a slaughterhouse built somewhere else and a covered market constructed with stained-glass turrets, like the one he had seen in the old boquerias in Barcelona, where the provisions looked so splendid and clean that it seemed a shame to eat them. That is how they were: they spent their lives proclaiming their proud origins, the historic merits of the city, the value of its relics, its heroism, its beauty, but they were blind to the decay of the years. Juvenal Urbino, on the other hand, loved it enough to see it with the eyes of truth. The epidemic of cholera morbus, whose first victims were struck down in the standing water of the market, had, in eleven weeks, been responsible for the greatest death toll in our history. Until that time the eminent dead were interred under the flagstones in the churches, in the exclusive vicinity of archbishops and capitulars, while the less wealthy were buried in the patios of convents. The poor were sent to the colonial cemetery, located on a windy hill that was separated from the city by a dry canal whose mortar bridge bore the legend carved there by order of some clairvoyant mayor: Lasciate ogni speranza voi chentrate. After the first two weeks of the cholera epidemic, the cemetery was overflowing and there was no room left in the churches despite the fact that they had dispatched the decayed remains of many nameless civic heroes to the communal ossuary. The air in the Cathedral grew thin with the vapors from badly sealed crypts, and its doors did not open again until three years later, at the time that Fermina Daza saw Florentino Ariza at close quarters as she left Midnight Mass. Clare was full all the way to its poplarlined walks, and it was necessary to use the Communitys orchard, which was twice as large, as a cemetery. There graves were dug deep enough to bury the dead on three levels, without delay and without coffins, but this had to be stopped because the brimming ground turned into a sponge that oozed sickening, infected blood at every step. Then arrangements were made to continue burying in the Hand of God, a cattle ranch less than a league from the city, which was later consecrated as the Universal Cemetery. From the time the cholera proclamation was issued, the local garrison shot a cannon from the fortress every quarter hour, day and night, in accordance with the local superstition that gunpowder purified the atmosphere. The cholera was much more devastating to the black population, which was larger and poorer, but in reality it had no regard for color or background. It ended as suddenly as it had begun, and the extent of its ravages was never known, not because this was impossible to establish but because one of our most widespread virtues was a certain reticence concerning personal misfortune. Marco Aurelio Urbino, the father of Juvenal, was a civic hero during that dreadful time, as well as its most distinguished victim. By official decree he personally designed and directed public health measures, but on his own initiative he intervened to such an extent in every social question that during the most critical moments of the plague no higher authority seemed to exist. Juvenal Urbino confirmed that his fathers methodology had been more charitable than scientific and, in many ways, contrary to reason, so that in large measure it had fostered the voraciousness of the plague. He confirmed this with the compassion of sons whom life has turned, little by little, into the fathers of their fathers, and for the first time he regretted not having stood with his father in the solitude of his errors. But he did not dispute his merits: his diligence and his self-sacrifice and above all his personal courage deserved the many honors rendered him when the city recovered from the disaster, and it was with justice that his name was found among those of so many other heroes of less honorable wars. When he recognized in himself the irreversible symptoms that he had seen and pitied in others, he did not even attempt a useless struggle but withdrew from the world so as not to infect anyone else. Locked in a utility room at Misericordia Hospital, deaf to the calls of his colleagues and the pleas of his family, removed from the horror of the plague victims dying on the floor in the packed corridors, he wrote a letter of feverish love to his wife and children, a letter of gratitude for his existence in which he revealed how much and with how much fervor he had loved life. It was a farewell of twenty heartrending pages in which the progress of the disease could be observed in the deteriorating script, and it was not necessary to know the writer to realize that he had signed his name with his last breath. In accordance with his instructions, his ashen body was mingled with others in the communal cemetery and was not seen by anyone who loved him. Juvenal Urbino received a telegram during supper with friends, and he toasted the memory of his father with champagne. But three weeks later he received a copy of the posthumous letter, and then he surrendered to the truth. All at once the image of the man he had known before he knew any other was revealed to him in all its profundity, the man who had raised him and taught him and had slept and fornicated with his mother for thirty-two years and yet who, before that letter, had never revealed himself body and soul because of timidity, pure and simple. Juvenal Urbino and his family had conceived of death as a misfortune that befell others, other peoples fathers and mothers, other peoples brothers and sisters and husbands and wives, but not theirs. They were people whose lives were slow, who did not see themselves growing old, or falling sick, or dying, but who disappeared little by little in their own time, turning into memories, mists from other days, until they were absorbed into oblivion. His fathers posthumous letter, more than the telegram with the bad news, hurled him headlong against the certainty of death. And yet one of his oldest memories, when he was nine years old perhaps, perhaps when he was eleven, was in a way an early sign of death in the person of his father. One rainy afternoon the two of them were in the office his father kept in the house; he was drawing larks and sunflowers with colored chalk on the tiled floor, and his father was reading by the light shining through the window, his vest unbuttoned and elastic armbands on his shirt sleeves. Suddenly he stopped reading to scratch his back with a long-handled back scratcher that had a little silver hand on the end. Since he could not reach the spot that itched, he asked his son to scratch him with his nails, and as the boy did so he had the strange sensation of not feeling his own body. More than twenty years had gone by since then, and Juvenal Urbino would very soon be as old as his father was that afternoon. He knew he was identical to him, and to that awareness had now been added the awful consciousness that he was also as mortal. He did not know much more about it than he had learned in a routine manner in some marginal course, when he had found it difficult to believe that only thirty years before, it had been responsible for more than one hundred forty thousand deaths in France, including Paris. But after the death of his father he learned all there was to know about the different forms of cholera, almost as a penance to appease his memory, and he studied with the most outstanding epidemiologist of his time and the creator of the cordons sanitaires, Professor Adrien Proust, father of the great novelist. So that when he returned to his country and smelled the stench of the market while he was still out at sea and saw the rats in the sewers and the children rolling naked in the puddles on the streets, he not only understood how the tragedy had occurred but was certain that it would be repeated at any moment. In less than a year his students at Misericordia Hospital asked for his help in treating a charity patient with a strange blue coloration all over his body. But they were in luck: the patient had arrived three days earlier on a schooner from Curacao and had come to the hospital clinic by himself, and it did not seem probable that he had infected anyone else. Juvenal Urbino alerted his colleagues and had the authorities warn the neighboring ports so that they could locate and quarantine the contaminated schooner, and he had to restrain the military commander of the city who wanted to declare martial law and initiate the therapeutic strategy of firing the cannon every quarter hour. A short while later, the Commercial Daily pub lished the news that two children had died of cholera in different locations in the city. It was learned that one of them had had common dysentery, but the other, a girl of five, appeared to have been, in fact, a victim of cholera. Her parents and three brothers were separated and placed under individual quarantine, and the entire neighborhood was subjected to strict medical supervision. One of the children contracted cholera but recovered very soon, and the entire family returned home when the danger was over. Eleven more cases were reported in the next three months, and in the fifth there was an alarming outbreak, but by the end of the year it was believed that the danger of an epidemic had been averted. Juvenal Urbino, more than the efficacy of his pronouncements, had made the miracle possible. From that time on, and well into this century, cholera was endemic not only in the city but along most of the Caribbean coast and the valley of the Magdalena, but it never again flared into an epidemic. Juvenal Urbinos warnings were heard with greater serious ness by public officials. They established an obligatory Chair of Cholera and Yellow Fever in the Medical School, and realized the urgency of closing up the sewers and building a market far from the garbage dump. Urbino was not concerned with proclaiming victory, nor was he moved to persevere in his social mission, for at that moment one of his wings was broken, he was distracted and in disarray and ready to forget everything else in life, because he had been struck by the lightning of his love for Fermina Daza. A physician who was a friend of his thought he detected the warning symptoms of cholera in an eighteen-year-old patient, and he asked Dr. He called that very afternoon, alarmed at the possibility that the plague had entered the sanctuary of the old city, for all the cases until that time had occurred in the poor neighborhoods, and almost all of those among the black population. From the outside, the house, shaded by the almond trees in the Park of the Evangels, appeared to be in ruins, as did the others in the colonial district, but inside there was a harmony of beauty and an astonishing light that seemed to come from another age. The entrance opened directly into a square Sevillian patio that was white with a recent coat of lime and had flowering orange trees and the same tiles on the floor as on the walls. There was an invisible sound of running water, and pots with carnations on the cornices, and cages of strange birds in the arcades. The strangest of all were three crows in a very large cage, who filled the patio with an ambiguous perfume every time they flapped their wings. Several dogs, chained elsewhere in the house, began to bark, maddened by the scent of a stranger, but a womans shout stopped them dead, and numerous cats leapt all around the patio and hid among the flowers, frightened by the authority in the voice. Then there was such a diaphanous silence that despite the disorder of the birds and the syllables of water on stone, one could hear the desolate breath of the sea. He followed Gala Placidia along the arcaded corridor, passed by the window of the sewing room where Florentino Ariza had seen Fermina Daza for the first time, when the patio was still a shambles, climbed the new marble stairs to the second floor, and waited to be announced before going into the patients bedroom. But Gala Placidia came out again with a message: The senorita says you cannot come in now because her papa is not at home. There he remained, sitting in a dark corner with his arms folded, and making futile efforts to control his ragged breathing during the examination. It was not easy to know who was more constrained, the doctor with his chaste touch or the patient in the silk chemise with her virgins modesty, but neither one looked the other in the eye; instead, he asked questions in an impersonal voice and she responded in a tremulous voice, both of them very conscious of the man sitting in the shadows. Juvenal Urbino asked the patient to sit up, and with exquisite care he opened her nightdress down to the waist; her pure high breasts with the childish nipples shone for an instant in the darkness of the bedroom, like a flash of gunpowder, before she hurried to cover them with crossed arms. Imperturbable, the physician opened her arms without looking at her and examined her by direct auscultation, his ear against her skin, first the chest and then the back. Juvenal Urbino used to say that he experienced no emotion when he met the woman with whom he would live until the day of his death.

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These investigators were unable to asthma treatment india order serevent 25 mcg without prescription show any effect of prior adaptation to asthma definition 3g buy serevent with a mastercard these two different phenylalanine intakes on the rates of phenylalanine oxidation at changing phenylalanine intakes asthma definition revenant buy 25mcg serevent amex, where the adaptation to asthma treatment inhaler proven serevent 25 mcg the test level was about 4 hours bronchitis asthma like symptoms discount serevent 25 mcg without prescription. Clearly asthma definition socialism 25mcg serevent fast delivery, from this study, adaptations in amino acid metabolism appear to take place much more quickly than do adaptations in urinary nitrogen excretion and are (at least for leucine [Motil et al. For the regression models to work, ranges of intake (particularly at the low end) have to be fed. In practical terms, this has greatly hampered studies in infants, children, and other vulnerable groups. On the other hand, if the individual only needs to be on a low or even zero intake of the test amino acid for a matter of 8 hours, then it becomes feasible to study indispensable amino acids in these and other vulnerable groups. Such a minimally invasive indicator oxidation model has been developed (Bross et al. In this model the oxidation study is conducted after only 6 hours of adaptation to the level of the test amino acid, which is administered every 30 minutes. For amino acid oxidation measurements, two-phase linear crossover regression analysis was introduced during the validation of indicator amino acid oxidation in piglets (Kim et al. Later, this approach was transferred to humans in a direct oxidation study (Zello et al. As pointed out above, the drawbacks of the indicator method are the short period of measurement in the fed state only, and the lack of a period of adaptation to the test diets. To avoid these drawbacks, a 24-hour indicator method has been developed (Kurpad et al. On theoretical grounds, this method has advantages over other methods for estimating amino acid requirements, and is the chosen method for estimated amino acids requirements where data are available. There are no reports of apparently healthy, full-term infants, exclusively fed human milk, who manifest any signs of protein deficiency (Heinig et al. The protein content of human milk at various stages of lactation is shown in Table 10-7. Nonprotein nitrogen contributes 20 to 27 percent of total milk nitrogen (Atkinson et al. These nonprotein nitrogenous components include free amino acids, pyrimidine nucleotides, creatine, and glutathione, but the large majority is urea. Using data from 13 lactating mothers of term infants, Butte and coworkers (1984a) reported that the protein content of human milk was 1. However, higher human milk protein content has been reported by Nommsen and coworkers (1991): 1. These latter investigators attribute the higher values to their utilization of the modified Lowry assay for total protein, which tends to result in slightly higher values (Nommsen et al. This is the average protein content of human milk during the first six months of lactation from studies (Butte et al. This value is in the range of protein content reported in other studies (Table 10-7). As expected, gains in weight and lean body mass are higher in the formula-fed than breast-fed infants, but when controlled for energy intake, protein intake is not associated with weight or length gain within the breast-fed infants (Heinig et al. Several studies have shown that infants fed formula with a true protein level ([total nitrogen nonprotein nitrogen] multiplied by 6. It is recognized that casein and whey in cow milk is not the same as human casein and whey and that the absorption and digestibility of amino acids from formula is different than that of human milk. Later Fomon (1991) recommended a conversion estimate of 90 percent for infants receiving infant formula as the only source of dietary protein and suggested that infant formula should contain a minimum of 1. Thus in determining the level of protein to be included in infant formula based on various possible protein sources, it is important to evaluate the digestibility and comparative protein quality (see Protein Quality) as indicated above. Although limited data are available for typical protein intakes from foods by infants fed human milk, mean protein intake from complementary foods for infants aged 7 through 12 months was estimated to be 7. Heinig and coworkers (1993) reported slightly higher values for nonmilk protein intake during the second 6 months of life. Based on their data, the average volume of human milk consumed during the second 6 months of life would be about 0. It should be noted that this is greater than that derived from the studies of content of milk from earlier lactation periods, primarily due to the use of the Lowry methods by both of these reports and the small number of studies available from this lactation period. Method Used to Estimate the Average Requirement Published data on the relationship between protein (nitrogen) intake and nitrogen balance were utilized to estimate protein requirements by the factorial method for infants 7 through 12 months of age as well as for children and adolescents through 18 years of age. The factorial method includes: (1) estimates of the maintenance requirement, which is determined by regression analysis of the relationship between nitrogen intake and nitrogen balance, (2) measurement of the rates of protein deposition, which are derived from body composition analysis, and (3) estimates of the efficiency of protein utilization, which is derived from the slope of the line relating intake and balance from the available data on infants and children. Several nitrogen balance studies that involved children in the age range of 9 months to about 14 years were identified and analyzed (Table 10-8). Included in the analysis were studies in which the children consumed diets containing milk/egg, legume/cereal, and mixed vegetable/animal protein sources. The results, summarized in Table 10-8, were obtained in mostly boys and include a number of different ethnic groups including European, African, Central American, and Chinese. A critical aspect of the analysis is the inclusion of an estimate for integumental and unaccounted losses that were based on direct measurements in children, mostly boys, aged 7 months through 14 years. In deriving the protein requirement, this estimate of miscellaneous losses was included as an adjustment to the reported nitrogen balances for the studies included in Table 10-8. The miscellaneous losses from both boys and girls are assumed to be the same since data from girls were limited. Individual maintenance protein requirements were estimated by first regressing nitrogen balance on nitrogen intake for the individuals studied at several different intake levels, and then using these individual regression equations to interpolate the intakes that would be expected to produce zero nitrogen balance (adjusting for 6. Table 10-8 contains seven studies that permit estimation of individual requirements and three studies that were used to estimate pooled requirements. As shown in the table, the average individual maintenance requirement was estimated as the median of the individual nitrogen requirements (108 mg/kg/d). For each study, an estimate was calculated as the median of the individual studies or the study pooled nitrogen requirement for those studies without individual data, and was 110 mg/kg/d. Since data for girls were sparse and could not be separated from that for boys, the protein maintenance requirement for both boys and girls is set at the same level. In addition, the maintenance protein requirement was not adjusted for age, as the requirement per kg of body weight for children 8 years of age and above appeared to be similar to that of younger children ranging in age from 9 months to 5 years (Table 10-8). Supporting this decision are the data of Widdowson and Dickerson (1964), which demonstrated that around 4 years of age, body protein concentration reaches the adult value of 18 to 19 percent of body weight. Estimates of rates of protein deposition for infants from 9 months through 3 years of age (Butte et al. To obtain protein deposition rates since the data in young children were longitudinal (Butte et al. The gradients at specific ages in the range 4 through 17 years were determined by differentiation of the regression equation. Hence, the gradients at specific ages in the age range 4 through 18 years were determined by differentiation of the regression equation, whereas for ages 9 months through 2 years, the growth rates given by Butte and coworkers (2000) were employed. The variation in requirements is based on both the variation in maintenance needs and the variation in the rate of protein deposition (protein for growth). Median requirement for ages 14 through 18 years = 656 mg protein/kg/d (105 mg N/kg/d [Table 10-12] 6. A coefficient of variation for growth of 43 percent was determined in a study of whole body potassium-40 content in children (Butte et al. The mean of the nitrogen intake for nitrogen equilibrium (thus measuring maintenance requirement only) is derived from all of the individual estimates for children and is 110 mg nitrogen/kg/d or 688 mg protein/kg/d (110 6. This is multiplied by the mean protein deposition (Table 10-9) for boys and for girls for each age group. While the nitrogen balance method for estimation of protein requirements has serious shortcomings (see Nitrogen Balance Method), this method remains the primary approach for determining the protein requirement in adults, in large part because there is no validated or accepted alternative. Nitrogen Balance Studies Over the last 40 years, a number of analyses of available data on adult nitrogen balance studies have been utilized to estimate adult protein requirements; some reports are listed in Table 10-10. This was considered important so that estimates of individual requirements could be interpolated. In addition, 9 studies of individuals fed a single level of nitrogen intake or that only provided group data for multiple levels of intake (n = 174 individuals) were used to assess the fit of the analyses conducted (Rand et al. The studies used were classified on the basis of age of the adults (young: 19 through 52 years of age; old: 53 years of age and older); protein source (animal [animal sources provided > 90 percent of the total protein], vegetable [vegetable sources provided > 90 percent of the total protein], or mixed), as well as gender and climatic origin (temperate or tropical area), and corrected for skin and miscellaneous losses when not included in the nitrogen balance data (Rand et al. Estimates of endogenous loss from some of the various analyses of protein requirements are included in Table 10-11. However, as discussed in earlier sections, the efficiency of utilization of dietary protein declines as nitrogen equilibrium is reached. With additional data it is possible to estimate requirements using regression analysis. Linear regression of nitrogen balance on nitrogen intake was utilized to estimate the nitrogen intake that would produce zero nitrogen balance in the most recent carefully done analysis available (Rand et al. In adults, it is generally presumed that the protein requirement is achieved when an individual is in zero nitrogen balance. To some extent, this assumption poses problems that may lead to underestimates of the true protein requirement (see Nitrogen Balance Method). In this range there is no indication, either visually or statistically, for the utilization of an interpolation scheme other than linear (Rand et al. It was also recognized that while the use of more complex models would improve the standard error of fit, these models did not statistically improve the fits, in large part because of the small number of data points (3 to 6) for each individual (Rand et al. Estimation of the Median Requirement Utilizing the recent analysis of nitrogen balance data (Rand et al. Because of the non-normality of the individual data, nonparametric tests were used (Mann-Whitney and Kruskal-Wallis) to compare requirements between the age, gender, diet, and climate subgroups (Table 10-13). Where nonsignificant differences were found, Analysis of Variance was used for power calculations to roughly estimate the differences that could have been found with the data and variability. Statistical Analysis of Nitrogen Balance Data to Determine the Protein Requirement Data Analysis. The relationship between nitrogen balances, corrected for integumental and miscellaneous losses, and nitrogen intake from Rand and coworkers (2003) is shown in Figure 10-6. This figure includes individual data from the linear regression of nitrogen balance in adults examined (Rand et al. The authors noted that positive nitrogen balance was found in some individuals at nitrogen intakes as low as 60 mg/kg/d, and in other individuals negative balance was noted at nitrogen intakes as high as 200 mg/kg/d. This suggests that at least some of these individuals were not at constant nitrogen balance equilibrium. In addition, while the nitrogen balance response to increasing nitrogen intake is theoretically expected to be nonlinear, the primary individual data points near the equilibrium balance point demonstrate a linear relationship, which appears to become nonlinear at high intakes. This can be attributed to different study designs in the test data included in Figure 10-6. The data points from only the estimation studies show a linear response over the relatively narrow range of intakes studied, while data points from the test studies also show a response that is not different from linear, although more variable and with a lower slope. Much variability is noted in the response data because the studies differ in methodology, individuals differ from each other, and an individuals response differs from day to day. Table 10-12, a summary of the nitrogen requirement for all the data points included in the analysis by Rand and coworkers (2003), shows a nitrogen requirement of 105 mg/kg/d or 0. When only the individual data points in the primary estimation studies are considered, the nitrogen requirement is 102 mg/kg/d (0. As shown in Table 10-13, expected climate in the country of the study had a significant effect (p < 0. The effect of age, as shown in Table 10-13, was a nonsignificant difference of 27 mg N/d (0. Although the young individuals had a lower nitrogen requirement than the older individuals, the requirement of young individuals was more variable and more positively skewed than that for the older individuals. Ninety-five percent confidence intervals for these estimates are 104 and 114 mg N/kg/d (0. Finally, the source of protein (90 percent animal, 90 percent vegetable, or mixed) did not significantly affect the median nitrogen requirement, slope, or intercept. It should be noted that almost all of the studies included as 90 percent vegetable were based on complementary proteins. For further discussion on this aspect of the data analysis and for information on vegetarian diets see later sections on Protein Quality and on Vegetarians. Other Approaches to Determine the Protein Requirement Based on the Recent Meta-Analysis In addition to the linear statistical approach to determine protein requirements described in detail above, the authors considered three other statistical approaches to the nitrogen balance analysis (Rand et al. All data from the studies in the meta-analysis were fitted to the following models: linear, quadratic, asymptotic exponential growth and linear biphase (see Table 10-12). Since the above analyses used all of the available data points without linking the individuals or restricting the range of intakes, the authors made the decision to use nitrogen equilibrium as the criterion and individual linear regressions, using only those individuals in the primary data set to determine the protein requirement (Rand et al. However, due to the shortcomings of the nitrogen balance method noted earlier, it is recommended that the use of nitrogen balance should no longer be regarded as the gold standard for the assessment of the adequacy of protein intake and that alternative means should be sought. Although the data indicate that women have a lower nitrogen requirement than men per kilogram of body weight, this was only statistically significant when all studies were included, but not when the analysis was restricted to the primary data sets. This difference may be due to differences in body composition between men and women, with women and men having on average 28 and 15 percent fat mass, respectively. When controlled for lean body mass, no gender differences in the protein requirements were found. For example, the intake that is estimated to be adequate for 80 percent of a healthy population is exp [0. Because the distribution of individual requirements for protein is log normal, and thus skewed, the calculated standard deviation and coefficient of variation of requirement itself does not have the usual intuitive meaning (that the mean plus two standard deviations exceeds all but about 2. However, because this skewing is not extreme, an approximate standard deviation can be calculated as half the distance from the 16th to the 84th percentile of the protein requirement distribution as estimated from the log normal distribution of requirements. These have been analyzed and evaluated in various publications (Campbell and Evans, 1996; Campbell et al.


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