"Generic diarex 30 caps overnight delivery, gastritis yahoo answers."

By: Cristina Gasparetto, MD

  • Professor of Medicine
  • Member of the Duke Cancer Institute


Performance of the assay with endocervical swab and urine specimens from pregnant females was assessed in the clinical study chronic gastritis message boards 30 caps diarex otc. Specificity for endocervical swab and urine specimens was 100% (26/26) and 100% (26/26) gastritis symptoms in elderly purchase 30 caps diarex with amex, respectively gastritis with duodenitis discount diarex 30 caps online. Of the 646 asymptomatic subjects enrolled in the study gastritis information buy 30caps diarex with amex, two were less than 16 years of age gastritis diet buy diarex mastercard, 158 were between the ages of 16 and 20 gastritis for 6 months purchase generic diarex pills, 231 were between the ages of 21 and 25, and 255 were more than 25 years of age. Of the 818 symptomatic subjects enrolled in the study, 160 were between the ages of 16 and 20, 324 were between the ages of 21 and 25, and 334 were more than 25 years of age. Five specimens were collected from each eligible subject; one urine specimen, one patient-collected vaginal swab, one cliniciancollected vaginal swab, and two randomized endocervical swabs. Aptima Combo 2 Assay results were generated from the two vaginal swabs, one of the endocervical swabs, and an aliquot of the urine specimen. Specimen testing was conducted either at the site of subject enrollment or at an external testing site. All performance calculations were based on the total number of Aptima Combo 2 Assay patient-collected and clinician-collected vaginal swab results compared to a patient infected status algorithm. Culture was not used as a reference test since the Aptima Combo 2 Assay has already been evaluated against culture for other specimen types (refer to the Endocervical Swab, Male Urethral Swab, and Urine Specimen Clinical Study for details). Samples that were Aptima Combo 2 Assay positive and infected patient status negative. Subjects were designated with an unknown patient infected status if results were missing that prevented conclusive determination of infected status. Of the 5,782 Aptima Combo 2 Assay vaginal swab results from the multi-center clinical study, there was a small percentage (28, 0. Of the 1,647 available subjects, 1,288 were asymptomatic subjects and 359 were symptomatic subjects. Two specimens were collected from each eligible subject: one PreservCyt Solution liquid Pap specimen and one endocervical swab. PreservCyt Solution liquid Pap specimens were processed in accordance with the Aptima Combo 2 Assay 46 502487 Rev. After processing the PreservCyt Solution liquid Pap specimen with the ThinPrep 2000 Processor, the specimen was transferred into the Aptima Specimen Transfer Kit for testing with the Aptima Combo 2 Assay. The PreservCyt Solution liquid Pap specimens and endocervical swab specimens were tested with the Aptima Combo 2 Assay. Sensitivity and specificity for PreservCyt Solution liquid Pap specimens were calculated by comparing results to a patient infected status algorithm. The distribution of cervical sampling devices used in this clinical study according to clinical site is summarized in Table 4. Table 4: Summary of Cervical Sampling Devices Used in the PreservCyt Solution Liquid Pap Specimen Study Clinical Collection Site Cervical sampling device Total 1 2 3 4 5 6 Spatula/Cytobrush 0 124 475 287 57 364 1307 Broom-type Device 100 0 0 0 240 0 340 Aptima Combo 2 Assay 47 502487 Rev. Table 7c: PreservCyt Solution Liquid Pap Specimen Clinical Study Patient Infected Status Results for C. Precision studies were conducted as part of the Endocervical Swab, Male Urethral Swab, and Urine Specimen Clinical Study and the PreservCyt Solution liquid Pap Specimen Clinical Study. Two (2) operators at each of the three sites performed one run per day on each of three days, totaling three valid runs per operator. Reproducibility when testing swab, urine, or PreservCyt Solution liquid Pap clinical specimens containing target organism has not been determined. Samples with discordant and equivocal results were included in the signal variability analysis. See Panther System Analytical Performance for Panther System-specific analytical performance. Neisseria gonorrhoeae analytical sensitivity was determined by directly comparing dilutions of 57 different clinical isolates in culture and in the Aptima Combo 2 Assay with swab and urine specimens and 20 clinical isolates with PreservCyt Solution liquid Pap specimens. The analytical sensitivity claim for the assay is 50 cells/assay (362 cells/swab, 250 cells/mL urine, 488 cells/mL PreservCyt Solution liquid Pap). Analytical Specificity A total of 154 culture isolates were evaluated using the Aptima Combo 2 Assay. The Chlamydia and Neisseria organisms were tested in 5 PreservCyt solution medium. Interfering Substances the following interfering substances were individually spiked into Swab and PreservCyt Solution liquid Pap specimens: 10% blood, contraceptive jelly, spermicide, moisturizer, hemorrhoidal anesthetic, body oil, powder, anti-fungal cream, vaginal lubricants, feminine 6 spray and leukocytes (1. The following interfering substances were individually spiked into urine specimens: 30% blood, urine analytes, protein, glucose, ketones, bilirubin, nitrate, urobilinogen, pH 4 (acidic), pH 9 (alkaline), leukocytes 6 (1. Endocervical Swab Specimens Data to support the recommended shipping and storage conditions for endocervical swab samples were generated with pooled negative swab samples. PreservCyt Solution Liquid Pap Specimens Data to support the recommended shipping and storage conditions for PreservCyt Solution liquid Pap samples were generated with pooled negative PreservCyt Solution liquid Pap samples. The PreservCyt Solution liquid Pap samples were placed at 30C for 7 days, after which 1. Samples stored at 4C and 10C were tested in duplicate at days 0, 6, 13, 26, 30 and 36. Four spiked PreservCyt Solution liquid Pap sample pools were added to Aptima Transfer Tubes and placed at 30C for 14 days before being stored at either -20C or -70C. The -20C samples and the -70C samples were tested in duplicate after 0, 30, 60, 90 and 106 days of storage. Vaginal Swab Specimens Data to support the recommended shipping and storage conditions for vaginal swab samples were generated with pooled negative swab samples. Urine Specimens Data to support the recommended shipping and storage conditions for urine samples were generated with ten female and ten male negative urine samples. All spiked specimens met the acceptance criteria of 95% agreement with expected results. The clinical specimen agreement study evaluated agreement between the two systems using swab and urine specimens from 485 male and 576 female subjects. Overall percent agreement and percent positive and negative agreements were calculated. The vaginal swab specimens were transferred directly to Hologic for testing while the PreservCyt Solution liquid Pap specimens were processed at 2 cytopathology laboratories before being transferred. One hundred seventy (170) vaginal swab and 170 PreservCyt Solution liquid Pap specimens from 181 female subjects were tested on both systems. The majority of specimens (110 vaginal swab and 107 PreservCyt Solution liquid Pap specimens) selected for comparison testing Aptima Combo 2 Assay 70 502487 Rev. The instrument had loose Detect 1 and 2 fittings that could have allowed air into the lines or incorrect amounts of detect reagents to be injected. Aptima Combo 2 Assay precision was evaluated across three Tigris Systems, two study sites, two Aptima Combo 2 Assay kit lots and four operators. Reproducibility when testing swab and urine specimens containing target organism has not been determined. Note: Variability from some factors may be numerically negative, which can occur if the variability due to those factors is very small. Concentrations ranged from 150 cells per assay to 5 cells per assay, which is one log below the analytical sensitivity claim for the assay of 50 cells/assay (362 cells/swab, 250 cells/mL urine). These organisms included those known to cross-react in other amplification assays. All samples containing target nucleic acid were positive when tested at a level of 10% (vol/vol) blood in swab specimens, vaginal swab specimens, post-processed PreservCyt Solution liquid Pap specimens and 30% (vol/ vol) blood in urine specimens. The overall carryover rate, including both false positive and equivocal results, averaged 0. The carryover rate for this subset of the population, including both false positive and equivocal results, averaged 1. Testing was performed over six days using two lots of assay reagents and a total of six operators (two at each site). These panels were tested on three Panther Systems using two lots of reagents over four days for a total of 60 replicates per panel member. Analytical Specificity Study Analytical specificity was not tested on the Panther System. Interfering Substances Interfering substances were not tested on the Panther System. The runs included clusters of high positive samples with clusters of negative samples as well as single high positives dispersed within the run. Screening Tests to Detect Chlamydia trachomatis and Neisseria gonorrhoeae infections. Performance of the Aptima Combo 2 Assay for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in female urine and endocervical swab specimens. Cumitech Guide on Verification and Validation of Procedures in the Microbiology Laboratory. User Protocol for Evaluation of Qualitative Test Performance: Approved Guideline for additional Guidance on Appropriate Internal Quality Control Testing Practices. Performance of transcription-mediated amplification and Ligase chain reaction assays for detection of chlamydial infection in urogenital samples obtained by invasive and noninvasive methods. Nucleotide and deduced amino acid sequences for the four variable domains of the major outer membrane proteins of the 15 Chlamydia trachomatis serovars. All other trademarks that may appear in this package insert are the property of their respective owners. These partnerships are essential components to ensure that students and their families can successfully access needed services either through referral to appropriate community services or via enhanced on-site services at a school. These partnerships will help to link youth with sexual health services through school-based or community-based organizations. The sections in this document outline the key concepts to establishing organizational partnerships and build upon one another. Sections also contain tools that can be used individually or with a team to guide you through the process of establishing organizational partnerships. This guidance was developed as a companion to the resource entitled, Developing a Referral System for Sexual Health Services: An Implementation Kit for Education Agencies. An organizational partnership is an intentional effort to create and sustain relationships between organizations that agree to work together to address common goals. Formal Versus Informal7 Most education agencies and schools already have informal partnerships with community-based organizations like local health departments, youth-serving organizations, and mental health agencies. In addition, informal relationships may not include clearly defined roles, responsibilities, and processes which are necessary for building strong relationships. By gaining organizational buy-in and support through formal means, partnerships can be strengthened and provide better coordination for youth services, i. A formal agreement between two organizations may also help sustain a partnership in times of staff turnover. Other examples of more informal partnerships could include provision of workshops to students or assistance with reimbursement. This would require coordination between the school and healthcare provider in terms of space, supplies, staff and additional financial support as needed. Depending on the relationship and history between the two organizations and the overall goal of the partnership, this process may take a year or more. Different partnership models use similar language and characteristics to describe a continuum in which two organizations can move from weaker to stronger partnerships. Figure 1 showcases various levels of partnerships starting at networking or communication and ending with collaboration. In general, the dimensions listed below can be used to determine the level of partnership and determine if its feasible to move along the continuum to a higher level of partnership. They usually involve a group of organizations that can also support each others goals or causes. Formal agreements are established between the organizations with clearly defined roles and responsibilities. Organizational roles are defined and a formal agreement between agencies is important. This level of partnership may involve coordination of planning and regular joint activities. Both organizations support each others mission and work together to create a system that is easy to navigate for clients. This type of partnership is usually at the individual level, informal, and requires little support. One can monitor the success of such awareness-building activities by tracking data related to the number of clinic visits as well as the student reason for visit. Connect with the School Based Health Alliance10 and state affiliate for assistance. Additional medical and mental health services are available at each center as well as referrals for outside medical treatment. They also provide an opportunity to deliver educational and prevention counseling messages to young people. Districts and schools in high prevalence areas may consider school-based screening programs when partnerships are strong and when capacity and interest are high. The schools support the program by promoting the event to students and staff, providing space and storage, and determining the need and handling details regarding parental consent/notification of testing event. Healthcare providers are included in the guide following a clinical self-assessment based on criteria identified in the Best Practices in Sexual and Reproductive Healthcare for Adolescents11 as well as a youth led mystery shopper screening. Often teachers, counselors, and other school staff may be identified by youth as a trusted adult to ask about sexual health. Health agencies in the community may be able to provide technical assistance to schools and districts interested in exploring thirdparty billing for school health services. This may begin by assessing what the district is already doing related to billing and reimbursement.


  • You have concerns about jaw alignment
  • Chest x-ray
  • Blood pressure that falls when a person rises or suddenly changes position (orthostatic hypotension)
  • Breathing tube
  • Double vision
  • Recording of the electrical activity in muscles (EMG)

order diarex with a visa

A wide range of neurological symptoms and signs can occur in the context of paediatric oncology gastritis symptoms nausea buy 30 caps diarex mastercard. It is always tempting to gastritis diet generic 30 caps diarex with visa blame the chemotherapy gastritis jello buy discount diarex line, but consider also: Metabolic derangements gastritis hemorrhoids purchase cheap diarex. Drug-induced encephalopathy Methotrexate neurotoxicity Relatively common complication of intrathecal or systemic methotrexate treatment gastritis diet trusted 30caps diarex. Note that in this case changes are relatively asymmetric and not confined to gastritis prevention discount diarex american express occipital cortex (c. Paraesthesia Pressure palsy mononeuropathy causing immobility in a debilitated child. The characteristic distribution of the sensory disturbance and (if relevant) the motor deficit corresponding to the involved nerve should be sought (see b p. Anticoagulate with low molecular weight heparin once a secondary haemorrhage into a venous infarct has been excluded. Oto-toxicity Carboplatin, cisplatin; cytosine arabinoside (with vestibular involvement). Peripheral neuropathy Vincristine, cisplatin, cytosine arabinoside Neurotoxicity with vincristine is dose-related and cumulative. A poor nutritional state may exacerbate the severity: numbness and tingling are a common early sign; muscle cramps; mild symptoms (loss of ankle refiexes, slapping gait) are common even at conventional dosages; reduction in dose of vincristine may be necessary if symptoms are severe, symptoms and signs are slowly reversible on discontinuation of the drug. Treatment in all cases is supportive, with consideration of reduction or discontinuation of the responsible agent in conjunction with the oncology team. Unusual infections arise due to impaired host defence as a result of: Aggressive anti-cancer therapy. Diagnosis can be difficult, with a wide range of possible agents including many organisms normally of low pathogenicity. Diagnostic pointers Clinical setting Children receiving chemotherapy causing marked lymphopaenia. Specific management requires close liaison with oncologists, microbiologists, and virologists. A significant number of children will have an unexplained or cryptogenic encephalopathy despite extensive investigations. Further/subsequent investigations to consider It is not intended that this list be slavishly followed in all cases. Hyponatraemia in a neuro-intensive care setting Hyponatraemia commonly occurs following neurological disease. It is an important preventable cause of secondary neurological insult, aggravating cerebral oedema, precipitating seizures, and sometimes causing irreversible white matter change. Evaluation of hyponatraemia If measured plasma osmolality is 2 [Na]plasma in the absence of uraemia, consider hyperglycaemia or mannitol as the cause of hyponatraemia. Diagnostic criteria for brainstem death Profound coma of known cause with total unresponsiveness to noxious stimuli. Spinal refiexes, including deep tendon refiexes; and spinal myoclonus may (rarely) be preserved. Timing is at the discretion of medical staff (typically 24 h apart), but should take the familys needs into account. Cranial nerve refiex testing Pupillary light refiexes Test in a dark room with a bright source. The legal time of death is when the first set of tests is completed, not when intensive care is withdrawn. Prognostication after acquired brain injury Neurologists are often requested to assist in assessing prognosis for recovery for a child in a coma. Traumatic injury Predictors of mortality Age (mortality is high in infants and young children, lowest in midadolescence then rising again), but this is confounded by injury mechanisms and severity. Non-traumatic coma Cardiopulmonary arrest Rare, usually in-hospital Outcome is poor. Near-drowning Outcomes after cold water immersion can be remarkably good: thought to be protective effect of hypothermia; intact survival reported after 60 min pulse-less immersion under ice. Clinical assessment Motor response to pain is the best clinical predictor of morbidity. Withdrawal of care decisions Your job as consulting neurologist is to try objectively to describe future levels of neurodisability, as well as the (often considerable) width of the confidence interval on that forecast. Decisions as to whether such outcomes are acceptable are highly value-laden, and family and professional views on these issues will be infiuenced by many factors. Specific investigations to consider As well as specific tests for the conditions already listed: Tensilon test. Understanding the pathophysiology of the event, particularly in relation to its onset, is invaluable. If the latter, is this caused by hypoventilation, obstruction or right-to-left shuntingfi This question is often centred on displays of temper or other erratic/ inappropriate behaviour. History the typical story is of gradual emergence of unusual behaviour and/or social withdrawal together with falling school performance. Main differentials of primary psychiatric psychosis are behavioural problems (particularly at school) due to unrecognized learning difficulties (see b p. Examination the presence of motor signs (pyramidal, extrapyramidal, or cerebellar) is incompatible with a diagnosis of primary psychosis. Unwanted drug effects Tardive dyskinesia this is most often associated with neuroleptics (phenothiazine, haloperidol), atypical antipsychotics (olanzapine) and, more rarely, with anti-emetics (metaclopromide or prochlorperazine), but it can also occur with theophylline. It may present with an altered level of consciousness or behaviour, progressing to muscle rigidity, hyperthermia rhabdomyolysis, and autonomic dysfunction. Examples include: the adolescent with dyskinetic cerebral palsy who presents with loss of weight, food refusal, and a fiuctuating affect (due to increasing insight into the disability). Areas of joint management Tics and Tourette syndrome Neurologist Establishing diagnosis of tics after consideration of differentials, such as myoclonus or seizure disorder. Behavioural management in difficult to control epilepsy Children with poorly-controlled seizures may have difficulties with behaviour and attention interictally. Episodic behavioural episodes may be mistaken for seizures and (for example) lead to excessive and inappropriate use of emergency seizure medication. The role of the neurologist is to: Define seizure events where possible (reviewing video telemetry data). Psychiatrists may play a role in addressing some of the emotional and social (axis 5) effects of severe epilepsy (see b p. Aggression, conduct disorder, and oppositional defiant disorder Precise diagnostic criteria for these conditions are established, but their practical value is debated. The main concern with conduct dis-order is that the younger the onset of difficulties, the worse the outcome in terms of risk of serious offending in later life. Described as occurring in two age groupsmiddle childhood/early adolescence, and adolescence. In the latter, a distinction between socialized (with preservation of peer relationships) and socialized (offending alone with little guilt or concern) is useful. Physical aggression is less common in adolescencetruancy becomes more common; drug taking, sexual offences and prostitution can occur and gang fighting occurs in large cities. Consider assessment for occult learning difficulties, sensory and perceptual difficulties, and autism. Autism and epilepsy Epilepsy is common in children with autism (one of the strongest pieces of evidence for a neurobiological, rather than psychosocial basis for autism), and many general epilepsy management principles apply. Autistic regression Setback autismthe onset of social and communicative withdrawal after apparently normal acquisition of the first few wordsis relatively common. For most children with autism and epilepsy, antiepileptic therapy should be long term even if seizure freedom has been achieved. Typically foodborne, initially though person-to-person spread, a risk as it may be shed in the stool for several weeks after resolution of symptoms. Sudden drops in blood pressure risk focal infarction particularly of the optic nerve. Posterior reversible encephalopathy syndrome A relatively common cause of encephalopathy with seizures and motor signs. Idiopathic (benign) intracranial hypertension Secondary to prolonged steroid use for renal disease. Rhabdomyolysis/myoglobinuria Rarely presents primarily to the renal team, although nephrological input may be required for fiuid management and/or acute secondary renal failure. Neurological complications of renal transplantation Essentially the risks of chronic immunosuppression. Poorly controlled seizures may warrant investigation for other causes (LaurenceMoonBiedl syndrome has been associated with hypothalamic hamartoma). Decisions on the use of long-term ventilation must be preceded by clear discussions with the child and family, on the aims of treatment and a frank exchange of views on end of life issues (see b p. Functional factors predisposing to ventilatory failure Inspiratory failure due to: poor central drive, poor co-ordination, or weakness of diaphragm, external intercostals, or accessory muscles. The respiratory/long-term ventilation team will advise on mask fitting and ventilator type. An inspiratory positive airway pressure is set together with a back-up rate for when the child does not trigger a breath. Volume-type ventilators may be used to supply higher pressures when needed but cannot compensate for leaks like pressure-support devices. Mask or mouthpiece used with a portable volume ventilator, set in the assist-control mode. The respiratory rate is set on the lowest possible to allow the child to take breaths as needed. A breath is activated by drawing air through the mouthpiece, thus creating a small negative pressure in the circuit by sipping or inhaling. Disordered breathing patterns Central apnoea Central hypoventilation syndrome is defined as persistent alveolar hypoventilation and/or apnoea during sleep, and impaired ventilatory responses to hypercapnia. Cessation of breathing occurs for >20 seconds, at times accompanied by bradycardia and cyanosis. Generally, a problem of infancy, but may be seen later in childhood due to acquired brain injury. Physiological causes Inefficient central control of respiration seen in preterm babies (periods of regular, irregular or periodic breathing predominate), diminishing as term approaches; worse if ill. Idiopathic congenital central hypoventilation syndrome Unexplained by any of the listed possible causes. Seen with autonomic dysfunctionvery low heart rate and respiratory rate variability, abrupt asystole, abnormal pupillary reactivity, temperature dysregulation, profuse sweating, swallowing difficulties, and/or oesophageal dysmotility. Late-onset central hypoventilation syndrome Presents following respiratory infection or anaesthesia, which may trigger the need for nocturnal ventilator support. Often preceded by chronic pulmonary hypertension, right heart failure, or respiratory infections with seizures or need for mechanical ventilation. Counsel parents Consider acetazolamide, non-invasive/long-term ventilation as appropriate. History and examination give diagnostic clues, but endoscopy is usually, and imaging may be required. Inspiratory stridor suggests a laryngeal obstruction, expiratory stridor implies tracheobronchial obstruction, and a biphasic stridor suggests a subglottic or glottic abnormality. Most neurological stridor is chronic; other causes include congenital or acquired stenosis or other compressive abnormalities, including webs, rings aberrant vessels, etc. Dystonia/dyskinesia of vocal cords/larynx Occasionally seen in older children as a focal dystonia or as part of a more generalized dystonia. Whereas autoimmune disorders typically involve cross-reactivity between a host and a target antigen, autoinfiammatory disorders are genetically-determined disorders of regulation of infiammation. Kawasakis disease Diagnosis Unexplained fever for 5 days and four of the following: Non-purulent conjunctivitis. Haemophagocytic lymphohistiocytosis A rare syndrome of multi-system involvement with widespread activity of infiammatory mechanisms, particularly activation of macrophages. Parenteral haloperidol can cause acute oculogyric crisis or dystonia (treat with procyclidine). Identify and treat the cause Delirium has a large number of possible causes many of which are life threatening. Drug treatment Drug treatment of delirium should only be used when essential and then with care, especially in children. Antipsychotics and benzodiazepines can aggravate delirium, exacerbate underlying causes (for example, benzodiazepines worsening respiratory failure) and cause significant unwanted effects. Benzodiazepines Usually preferred when delirium is associated with withdrawal from alcohol or sedatives. Antipsychotic drugs Antipsychotics are the most commonly used drugs in adults, but are less popular in children because of extrapyramidal effects. In severe behavioural disturbance, haloperidol may be given intramuscularly or intravenously. Note resting pupil size and symmetry, and briskness and symmetry of the response to light. Do not mistake a dilated non-reactive pupil due an afferent pupillary defect (optic nerve involvement in fracture of the bony orbit) for a fixed dilated pupil due to third cranial nerve involvement in a herniation syndrome (the consensual response is present in the former, absent in the latter. Oculocephalic (dolls eye) refiex Exclude cord injury then turn the head from side to side, watch the eyes. The normal response is to maintain eye orientation in space (eyes move relative to the head and orbits). Intubation and ventilation of the unconscious child will be either for the purpose of securing a safe airway due to an inadequate cough and gag refiex, or for the management of raised intracranial pressure. Borderline cases should be discussed urgently with an intensivist or anaesthetist. If an inborn error of metabolism is suspected Usually occurs in a neonate, but occasionally a urea cycle disorder can present in later childhood with coma and hyperammonaemia. Management of raised intracranial pressure Basic measures Nurse head in midline and tilted up 30.

order diarex with paypal

In the test gastritis zoloft discount diarex amex, track gastritis diet 7 up nutrition cheap diarex, treat initiative gastritis colitis cheap 30caps diarex with amex, it is recommended that every suspected malaria case is tested gastritis and gerd buy diarex online now, that every confrmed case is treated with a quality-assured antimalarial medicine and that the disease is tracked by timely gastritis diet 90x generic diarex 30caps online, accurate surveillance systems gastritis symptoms remedy purchase diarex 30 caps amex. Surveillance and treatment based on confrmed malaria cases will lead to better understanding of the disease burden and enable national malaria control programmes to direct better their resources to where they are most needed. An antimalarial medicine that is recommended in the national malaria treatment policy should be changed if the total treatment failure proportion is 10%, as assessed in vivo by monitoring therapeutic effcacy. A signifcantly declining trend in treatment effcacy over time, even if failure rates have not yet fallen to the 10% cut-off, should alert programmes to undertake more frequent monitoring and to prepare for a potential policy change. However these early relapses (or any newly acquired infections) should be suppressed by therapeutic doses of slowly eliminated antimalarial drugs such as chloroquine, mefoquine and piperaquine. Reappearance of parasitaemia within 28 days of treatment (whether relapse, recrudescence or re-infection) can therefore still be used as a proxy measure of resistance. Resistance to antimalarial drugs arises because of selection of parasites with genetic changes (mutations or gene amplifcations) that confer reduced susceptibility. Resistance has been documented to all classes of antimalarial medicines, including the artemisinin derivatives, and it is a major threat to malaria control. Widespread inappropriate use of antimalarial drugs exerts a strong selective pressure on malaria parasites to develop high levels of resistance. Resistance can be prevented or its onset slowed considerably by combining antimalarial drugs with different mechanisms of action and ensuring high cure rates through full adherence to correct dose regimens. If different drugs with different mechanisms of resistance are used together, the emergence and spread of resistance should be slowed. Clinical and parasitological assessment of therapeutic effcacy should include: confrmation of the quality of the antimalarial medicines tested; molecular genotyping to distinguish between re-infections and recrudescence and to identify genetic markers of drug resistance; studies of parasite susceptibility to antimalarial drugs in culture; and measurement of antimalarial drug levels to assess exposure in cases of slow therapeutic response or treatment failure. Good practice statement When possible: use fxed-dose combinations rather than co-blistered or loose, singleagent formulations; and for young children and infants, use paediatric formulations, with a preference for solid formulations. Good practice statement these guidelines provide a generic framework for malaria diagnosis and treatment policies worldwide; however, national policy-makers will be required to adapt these recommendations on the basis of local priorities, malaria epidemiology, parasite resistance and national resources. Broad, inclusive stakeholder engagement in the design and implementation of national malaria control programmes will help to ensure they are feasible, appropriate, equitable and acceptable. Transparency and freedom from fnancial conficts of interest will reduce mistrust and confict, while rigorous evidence-based processes will ensure that the best possible decisions are made for the population. In some countries, the group adapting the guidelines for national use might have to re-evaluate the global evidence base with respect to their own context. Failure to implement the basic principles of combination therapy and rational use of antimalarial medicines will risk promoting the emergence and spread of drug resistance, which could undo all the recent gains in malaria control and elimination. High-quality light microscopy requires welltrained, skilled staff, good staining reagents, clean slides and, often, electricity to power the microscope. It requires a quality assurance system, which is often not well implemented in malaria-endemic countries. In many areas, malaria patients are treated outside the formal health services. Where possible, however, blood smears should be examined by microscopy, with frequent monitoring of parasitaemia. Although there are minor differences in the oral absorption, bioavailability and tolerability of the different artemisinin derivatives, there is no evidence that these differences are clinically signifcant in currently available formulations. It is the properties of the partner medicine and the level of resistance to it that determine the effcacy of a formulation. Nevertheless, the combination with artesunate is very effective, unless there is also resistance to artemisinin. Elsewhere, the dihydroartemisinin + piperaquine combination is currently highly effective. Fixed-dose artesunate + amodiaquine performs better than loose tablets, presumably by ensuring adequate dosing. Although there are some minor differences in the oral absorption and bioavailability of different artemisinin derivatives, there is no evidence that such differences in currently available formulations are clinically signifcant. It is the pharmacokinetic properties of the partner medicine and the level of resistance to it that largely determine the effcacy and choice of combinations. Paediatric formulations should allow accurate dosing without having to break tablets and should promote adherence by their acceptability to children. Paediatric formulations are currently available for artemether + lumefantrine, dihydroartemisinin + piperaquine and artesunate + mefoquine. The impact in reducing transmission at a population level depends on high coverage rates and the transmission intensity. A strategy for ensuring full access (including community management of malaria in the context of integrated case management) must be based on analyses of national and local health systems and may require legislative changes and regulatory approval, with additional local adjustment as indicated by programme monitoring and operational research. To optimize the benefts of effective treatment, wide dissemination of national treatment guidelines, clear recommendations, appropriate information, education and communication materials, monitoring of the deployment process, access and coverage, and provision of adequately packaged antimalarial drugs are needed. Community case management should be integrated into community management of childhood illnesses, which ensures coverage of priority childhood illnesses outside of health facilities. Clear guidelines in the language understood by local users, posters, wall charts, educational videos and other teaching materials, public awareness campaigns, education and provision of information materials to shopkeepers and other dispensers can improve the understanding of malaria. They will increase the likelihood of better prescribing and adherence, appropriate referral and unnecessary use of antimalarial medicines. Prescribers, shopkeepers and vendors should therefore give clear, comprehensible explanations of how to use the medicines. Effectiveness of artemisinin-based combination therapy used in the context of home management of malaria: a report from three study sites in sub-Saharan Africa. This method ensures a transparent link between the evidence and the recommendations. The Technical Guidelines Development Group, co-chaired by Professor Fred Binka and Professor Nick White (other participants are listed below), organized a technical consultation on preparation of the third edition of the Guidelines. A review of data on pharmacokinetics and pharmacodynamics was considered necessary to support dose recommendations, and a subgroup was formed for this purpose. After the scoping meeting, the Cochrane Infectious Diseases Group at the Liverpool School of Tropical Medicine in Liverpool, England, was commissioned to undertake systematic reviews and to assess the quality of the evidence for each priority question. When insuffcient evidence was available from randomized trials, published reviews of non-randomized studies were considered. The data had either been included in peer-reviewed publications or been submitted to regulatory authorities for drug registration. Population pharmacokinetics models were constructed, and the plasma or whole blood concentration profles of antimalarial medicines were simulated (typically 1000 times) for different weight categories. At various times during preparation of the guidelines, sections of the document or recommendations were reviewed by external experts and users who were not members of the group; these external peer reviewers are listed below. Treatment recommendations were agreed by consensus, supported by systematic reviews and review of information on pharmacokinetics and pharmacodynamics. Areas of disagreement were discussed extensively to reach consensus; voting was not required. Barnes, Division of Clinical Pharmacology, University of Cape Town, South Africa Professor F. Binka, (co-Chair), University of Health and Allied Sciences, Ho, Volta Region, Ghana Professor A. Bjorkman, Division of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden Professor M. Garner, Liverpool School of Tropical Medicine, Liverpool, United Kingdom Professor O. Gaye, Service de Parasitologie, Faculte de Medicine, Universite Cheikh Anta Diop, Dakar-Fann, Senegal Dr S. Juma, Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya Dr A. McCarthy, Tropical Medicine and International Health Clinic, Division of Infectious Diseases, Ottawa Hospital General Campus, Ottawa, Canada Professor O. Mokuolu, Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria Dr D. Sinclair, International Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom Dr L. Tjitra, National Institute of Health and Development, Ministry of Health, Jakarta, Indonesia 126 Dr N. White (co-Chair), Faculty of Tropical Medicine, Mahidol University, A Bangkok, Thailand 1 Members of the sub-group on dose recommendations Professor K. Barnes, (co-chair), Division of Clinical Pharmacology, University of Cape Town, South Africa Professor F. Juma, Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya Professor O. Mokuolu, Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria Dr S. Tarning, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Dr D. Terlouw, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi Professor N. White (co-Chair), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Guideline Steering Group Dr A. McGready, Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Professor F. Nosten, Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand External contributors to Annex 5 (Pharmacology of Antimalarial Drugs) C. Brunschwig, Department of Chemistry, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa. Chigutsa, WorldWide Antimalarial Resistance Network, University of Cape Town, South Africa L. Barnes reported being a recipient of grants from the Malaria Medicine Venture to undertake clinical trials to evaluate novel antimalarial medicines. Valecha reported serving as an investigator for clinical trial supported by the Department of Science and Technology India, and Ranbaxy Laboratories Limited. White reported being an advisor to all pharmaceutical companies developing new antimalarial medicines. This is done on a pro-bono basis, it does not include consultancy fees nor any form of remuneration. The female mosquito is infected by gametocytes, the sexual stages of the malaria parasite, when they take a blood meal from an infected person. Male and female gametocytes then fuse to form zygotes (ookinetes), which embed in the gut wall A as oocysts and then undergo further development in the insect for 612 days. The intensity of malaria transmission in an area is the rate at which people are inoculated with malaria parasites by infected mosquitoes. The proportion of infected mosquitoes in a locality refects the capacity of the vectors to transmit malaria (vectorial capacity) and the number of infected and infectious humans in the area. Lowering the infectivity of infected persons to mosquito vectors contributes to reducing malaria transmission and eventually to reducing the incidence and prevalence of the disease. Experience with major interventions, such as use of insecticide-treated nets and artemisinin-based combination therapy, suggests that effective transmission-reducing interventions reduce mortality and even morbidity in most situations (14). Relation between entomological inoculation rate and parasite prevalence (on the assumption that no infections are treated) Parasite prevalence (%) 100 80 60 40 20 0 0. Early, effective treatment of a malaria blood infection with any antimalarial medicine will reduce gametocytaemia by eliminating the asexual blood stages from which gametocytes derive. The faster the clearance of asexual blood parasites, the greater the reduction in infectivity. The potent anti-infective properties of artemisinins result partly from rapid clearance of parasites. Effective treatment of the asexual blood infection alone abolishes infectivity to mosquitoes. Infectivity can be lowered either by a direct effect on gametocytes (gametocytocidal effect; primaquine) or on the parasite developmental stages in the mosquito (sporontocidal effect; antifols, atovaquone) or by killing feeding mosquitoes (endectocidal effect; avermectins). Sulfadoxinepyrimethamine in fact increases gametocyte carriage, but it also reduces the infectivity of drug-sensitive parasites. Artemisinins are the most potent gametocytocidal drugs of those currently used to treat acute malaria (611). They kill young gametocytes, preventing new infective gametocytes from entering the circulation, but they have less effect on mature gametocytes that may 130 be present in the circulation at the time of treatment (6). The 8-aminoquinoline primaquine acts on mature gametocytes rapidly, reducing their transmissibility to mosquitoes and accelerating gametocyte clearance (1220). Doseresponse relations for primaquine in reducing the infectivity of Plasmodium falciparum-infected individuals to anopheline mosquitoes A 2 Oocyst positive (%) Assessed < 48 hrs 100 29 after primaquine 80 7 60 15mg 30mg 40 10 45mg 20 48 13 4 13 26 0 6 0 0. Vertical axes show the proportions of fed anopheline mosquitoes that were infected. Oocyst formation (upper graph) and sporozoite formation (lower graph) assessed from blood sampled 48 h after a dose of primaquine. Primaquine given with an artemisinin derivative is shown in green, and primaquine given with no antimalarial medicine or a non-artemisinin derivative is shown in red. The size of the circle is proportional to the number of patients in each group (shown within). In areas of low-to-moderate transmission the most direct consequences of lowering parasite infectivity by the use of medicines are seen in areas of low transmission, where symptomatic patients contribute signifcantly to the infectious reservoir. Reducing infectiousness has a signifcant impact on malaria transmission and thus the prevalence of infection and the incidence of disease. In areas of high-transmission In high-transmission areas, infected but asymptomatic people constitute an important part of the infectious reservoir.

order diarex 30caps fast delivery

Prominent examples include poststreptococcal disease gastritis diet ice cream order generic diarex on line, Goodpasture syndrome gastritis diet generic diarex 30 caps with amex, and others gastritis esophagitis diet purchase 30 caps diarex with mastercard. This disease is focal and segmental but differs from focal segmental glomerulosclerosis in that the changes are inflammatory and proliferative rather than sclerotic gastritis zungenbelag purchase cheap diarex. This disease is hereditary nephritis associated with nerve deafness and ocular disorders gastroenteritis flu buy generic diarex 30 caps on-line, such as lens dislocation and cataracts gastritis symptoms nih buy diarex 30caps low cost. Clinical characteristics include the nephritic syndrome, often progressing to endstage renal disease by 30 years of age. Irregular glomerular basement membrane thickening with foci of splitting of the lamina densa is seen. Iga nephropathy (Berger disease) is an extremely common entity defined by deposition of IgA in the mesangium. Most frequently, the disease is characterized by benign recurrent hematuria in children, usually following an infection, lasting 1 to 2 days, and usually of minimal clinical significance. The glomeruli classically show mesangial expansion on light microscopy with granular mesangial IgA and lambda light chain deposition by immunofluorescence. Histologic characteristics include both basement membrane thickening and cellular proliferation. Disease is marked by reduplication of glomerular basement membrane into two layers due to expansion of mesangial matrix into the glomerular capillary loops; this results in a characteristic tram-track appearance best seen with silver stains. Disease occurs in two forms: (1) type I is an immune complex nephritis associated with an unknown antigen. Incidence of infection of the urinary tract and kidney is greatly increased in women, presumably because of the shorter length of the female urethra; the incidence is increased during pregnancy. This condition can be caused by hematogenous bacterial dissemination to the kidney or by external entry of organisms through the urethra into the bladder; in the latter case infection can spread upward from the bladder into the ureters (vesicoureteral reflux) and through the ureters to the kidney (ascending infection). Most frequently, the infection involves the normal flora of the colon, most often Escherichia coli. The most common pathogen in young, sexually active women is Staphylococcus saprophyticus. Obstruction of urinary flow, such as that occurring with urethral obstruction in benign prostatic hyperplasia 2. Urinary frequency: a compelling necessity to void small amounts of urine at frequent intervals 2. Bacteriuria: usually defined as more than 105 organisms per milliliter of urine; must be distinguished from contamination of urine specimens by external flora D. Characteristics include pyuria and often hematuria, but urinary white cell casts are not found. Most often the trigger is penicillin derivatives, such as methicillin, and other drugs, such as nonsteroidal anti-inflammatory drugs and diuretics. This form of necrosis is most often associated with diabetes mellitus, in which it is related to renal infection and coexisting vascular disease. Renal papillary necrosis is also associated with long-term persistent abuse of phenacetin, most often in association with aspirin and other analgesics. This can lead to chronic analgesic nephritis, a chronic inflammatory change characterized by loss and atrophy of tubules and interstitial fibrosis and inflammation. Necrotic renal tubular cells are replaced by new cells in approximately 2 weeks, with complete return of renal function to normal if the patient is maintained on dialysis. Proper medical management results in complete recovery; otherwise the syndrome is potentially fatal. This condition can also lead to cardiac standstill from hyperkalemia, most often during the initial oliguric phase. Oliguria from acute tubular necrosis must be distinguished from oliguria due to prerenal causes, such as reduced blood volume or dehydration. The acute condition is most frequently precipitated by renal ischemia, which is often caused by prolonged hypotension or shock, most often induced by gram-negative sepsis, trauma, or hemorrhage. Myoglobinuria also can be observed after intense exercise, but this is not of clinical consequence. Other causes may include direct injury to the proximal renal tubules from mercuric chloride, gentamicin, and several other toxic substances. Ethylene glycol (antifreeze) is extremely toxic when ingested and can result not only in acute tubular necrosis but also in renal oxalosis with massive intratubular oxalate crystal deposition that can be visualized with polarized light. This manifestation of generalized dysfunction of the proximal renal tubules may be hereditary or acquired. Impaired reabsorption of glucose, amino acids, phosphate, and bicarbonate is characteristic. Clinical manifestations include glycosuria, hyperphosphaturia and hypophosphatemia, aminoaciduria, and systemic acidosis. The protein-filled, dilated renal tubules are reminiscent of the appearance of the thyroid. This finding, frequently observed in chronic pyelonephritis, is referred to as thyroidization. Coarse, asymmetric corticomedullary scarring and deformity of the renal pelvis and calyces occurs; these findings are essential to diagnosis. Characteristics include interstitial inflammatory infiltrate in the early stages and interstitial fibrosis and tubular atrophy as the disease progresses; atrophic tubules often contain eosinophilic proteinaceous casts, resulting in an appearance reminiscent of thyroid follicles (thyroidization of the kidney). Causes almost always include chronic urinary tract obstruction and repeated bouts of acute inflammation. This disease is acute generalized ischemic infarction of the cortices of both kidneys; the medulla is spared. Diffuse cortical necrosis is also associated with septic shock and other causes of vascular collapse. It is thought that the cause is a combination of end-organ vasospasm and disseminated intravascular coagulation. This diffuse deposition of calcium in the kidney parenchyma can lead to renal failure. This condition is caused by hypercalcemia, such as occurs in hyperparathyroidism or in the milk-alkali syndrome (nephrocalcinosis and renal stones resulting from self-medication for peptic ulcer with milk and absorbable antacids). This is usually the cause of the nephrocalcinosis that occurs as a component of renal failure. It is of note that nephrocalcinosis can be both a cause and an effect of renal failure. UrolIthIasIs this condition is characterized by calculi (stones) in the urinary tract. These stones are formed in alkaline urine, which is caused most often by ammoniaproducing (urease-positive) organisms, such as Proteus vulgaris or Staphylococcus. They can form large staghorn (struvite) calculi (casts of renal pelvis and calyces). Uric acid stones are associated with hyperuricemia in approximately half of the patients; hyperuricemia can be secondary to gout or to increased cellular turnover, as in the leukemias or myeloproliferative syndromes. This disease manifests clinically between 15 and 30 years of age, even though the genetic defect is present at birth. This kidney disease is often associated with berry aneurysm of the circle of Willis. It is also frequently associated with cystic disease of the liver or other organs. Multiple small medullary cysts and impaired tubular function, usually without renal failure, are characteristic; renal stones may form in the dilated ducts. Renal failure can be acute or chronic and can result from any of the glomerular or tubulointerstitial lesions discussed in the preceding sections. In advanced stages, renal failure results in uremia; the term uremia denotes the biochemical and clinical syndrome characteristic of symptomatic renal disease. An early characteristic is the inability to concentrate urine; a later manifestation is the inability to dilute urine. It is characterized Chapter 17 Kidney and Urinary Tract 275 by increased tubular reabsorption of sodium and water, resulting in oliguria, concentrated urine, and decreased urinary sodium excretion. Oliguria may be caused by decreased renal blood flow with consequent decreased glomerular filtration rate, in which case tubular reabsorption of sodium is maximally increased and urinary sodium is low. Oliguria may be a manifestation of acute tubular necrosis, in which case tubular reabsorption is greatly impaired and urinary sodium is not decreased. This tumor is comprised of cells with abundant granular acidophilic cytoplasm replete with mitochondria, as is the case in oncocytomas elsewhere in the body. In some instances, it is associated with gene deletions in chromosome 3; renal cell carcinoma can also be associated with von Hippel-Lindau disease, which is caused by alterations in a gene localized to chromosome 3. The clear cell appearance of these neoplastic cells derived from proximal tubular epithelial cells is reminiscent of the adrenal cortex. A rare variant occurring most often in young patients is associated with translocations involving Xp11. These tumors are notable because they are among the first epithelial tumors to be found to have reproducible translocations (in contrast, translocations have long been recognized in many hematologic malignancies). Frequently the tumor invades renal veins or the vena cava and can extend up the vena cava. It is grossly bright orange-yellow and microscopically demonstrates clear cells containing abundant lipids and glycogen. Renal cell carcinoma may be manifested clinically by any of the following additional findings: (1) fever (2) secondary polycythemia (results from erythropoietin production) (3) ectopic production of various hormones or hormone-like substances. It can also be associated with hemihypertrophy (gross asymmetry due to unilateral muscular hypertrophy), macroglossia, organomegaly, neonatal hypoglycemia, and various embryonal tumors. This syndrome is an example of genomic imprinting because the abnormal alleles are always of maternal origin. This cancer is the most common tumor of the urinary collecting system and can occur in renal calyces, pelvis, ureter, or bladder. In the renal pelvis, transitional cell carcinoma has been associated with phenacetin abuse. This cancer may result from chronic inflammatory processes, such as chronic bacterial infection or Schistosoma haematobium infection. The most likely diagnosis is (Reprinted with permission from Rubin R, Strayer D, et al. A 3-year-old girl presents with general(C) Immune complexes at the dermalized edema shortly after recovery from an epidermal junction in skin upper respiratory infection. Laboratory stud(D) Perivascular fibrosis in the spleen ies reveal marked albuminuria, as well as (e) Pleuritis hypoalbuminemia and hyperlipidemia. The most likely diagnosis is bout of pharyngitis, an 11-year-old girl is (a) focal segmental glomerulosclerosis. A 22-year-old woman presents with fever, (C) Marked hypoalbuminemia malaise, generalized arthralgias, and a skin (D) Polyuria rash over the nose and malar eminences. Expected findings on electron microscop(C) Hyperglycemia ic examination of the glomerulus from the (D) Hypocalcemia patient in question 4 demonstrate (e) Increased blood urea nitrogen (a) marked subendothelial immune complex deposition. A 28-year-old woman presents with (B) marked thickening of the glomerular fever, dysuria, urinary frequency, and flank basement membrane with numerous tenderness. The urine contained numerous intramembranous and epimembranous neutrophils and many white cell casts. A quantitative urine culture revealed more than 105 (C) no changes except for fused epithelial foot processes. The most likely caus(D) normal-appearing glomerular baseative organism is ment membrane with electron-dense (a) Escherichia coli. A 78-year-old man with long-standing and the nephrotic syndrome undergoes a prostatic nodular hyperplasia dies of a renal biopsy. Of the strate coarse asymmetric renal corticofollowing possible additional laboratory medullary scarring, deformity of the renal findings, which one is most characteristipelvis and calyces, interstitial fibrosis, and cally associated with this lesionfi A 2-year-old boy with visible abdominal distention is found to have an enormous left-sided flank mass apparently arising from, but dwarfing, the left kidney. A syndrome that includes the lesion found in the patient in question 9 has which of the following additional characteristicsfi Baltimore, Lippincott Williams & (B) Hemihypertrophy Wilkins, 2012, figure 16-26, p. A glomerular immunofluorescent pattern for IgG similar to that shown in the figure would be expected in which of the following patientsfi Enormously enlarged kidneys similar to the one shown in the figure are found at autopsy in a 65-year-old woman. Which of the following is a well-known association or characteristic of this disease processfi A 4-year-old boy presents with severe (C) Lupus nephropathy proteinuria, hypoalbuminemia, generalized (D) Membranous glomerulonephritis edema, and hyperlipidemia. The patient (e) Minimal change disease Chapter 17 Kidney and Urinary Tract 281 14. A 60-year-old woman dies of a tumor that had invaded the renal vein and entered the inferior vena cava. A 55-year-old man presents with paininvolves only some glomeruli and only less hematuria. On cystoscopy, a papillary parts of affected glomeruli on light mass is found in the bladder. A 50-year-old woman with a 20-year (D) Occurrence only in the bladder and history of type 2 diabetes mellitus presnowhere else in the urinary tract ents with proteinuria, hypoalbuminemia, (e) Usual presence of distant metastases at edema, and hyperlipidemia. She has the time of diagnosis not monitored her serum glucose levels over the past several years. Blood tests reveal severe classic morphologic finding in diabetic proteinuria, hypoalbuminemia, and hypernephropathyfi

Order diarex with a visa. 11 Powerful Home Remedies for Acid Reflux.


  • https://www.europeanreview.org/wp/wp-content/uploads/327.pdf
  • https://www.jimmunol.org/content/jimmunol/198/1/40.full.pdf
  • http://s3-eu-west-1.amazonaws.com/files.crohnsandcolitis.org.uk/Publications/Steroids.pdf
  • https://www.nordic-myeloma.org/filer/Protokoller/Silvennoinen_K_Elo_d_protocol_FINAL_07022017.pdf

Quienes Somos

El mercado español del videojuego ocupa una posición de liderazgo en el sector del ocio audiovisual e interactivo, por ello la industria desarrolladora española ...

Leer más...


C/ Velázquez 94 1ª planta, 28006 MADRID


twitter_icon   facebook   linkedin_icon



Utilizamos cookies para mejorar nuestro sitio web y su experiencia al usarlo. Ya se han establecido cookies utilizadas para el funcionamiento esencial del sitio.

Acepto las cookies del sitio.