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The first time gastritis diet meals discount 400 mg sevelamer mastercard, the audience is asked to gastritis chronic nausea buy 800 mg sevelamer otc look at it carefully and (a) analyse if the scene relates to gastritis ginger ale buy cheap sevelamer 400 mg on line him/her, and (b) analyse how the person can overcome the oppressive situation. This time, the audience can stop the scene at any given time to (a) substitute the protagonist, (b) substitute the oppressor but only to make it worse, or (c) substitute one of the third figures for realistic solidarity actions. At the end, the original protagonist accepts or not the proposed solution, and the audience does as well. A variant If the oppression is more an internalized feeling than a socioeconomic or sociocultural one than in step 4, the audience analyses if the scene relates to him or her, but also which feeling/attitude is provoking the weakness of the protagonist. Step 6: the audience members who feel so inclined transform the identified weak point in an image, which is brought on stage. Step 8: Whenever the protagonist is falling in the weak point identified by the audience, the participant who made the respective image advances on stage to make it visible to the protagonist. If the "image" thinks this is happening successfully, it goes back, ready to come back visible if the problem occurs again. At the end, the protagonist speaks out his/her feelings and whether changing attitudes and winning certain identified weak points may help her in life, based on what happened on the stage. This is even truer for migrant and refugee adolescents, who are not used to be given a choice. Once the problems are identified, it is not the facilitator who should tell them the solutions, but the peers, according to their own personal experiences. Each participant creates his/her own, by folding four A4 papers in half and drawing the cover page. The diary is absolutely personal, and at no point will the participants be requested to read it to others, unless they feel like doing so. At the end of each session of work, the facilitator gives 2 to 10 minutes to the participants to express their feelings, uneasiness, doubts and such in the diary. Moreover, the facilitator poses some questions to direct the reflection on particular games. The modality may change according to the activity of the day, so that feedback could be given with one word, one sentence, a body image, and the like. However, others maintain that ritual has always been social and has regulated the social functioning of not only human groups, but also groups of animals from the prehuman era (Bonino 1987; Eibl-Eibesfeld 1989; Schechner 1993). Among those who believe the latter view are those scholars who think that the origin of ritual is biological. Paul Ekman, with his comparative analysis of the facial expressions of emotions in the human face stresses the bioneurological origin of these expressions and claims that these are not determined by cultural, historical, environmental, and social specificities (1982). Those were the theoretical tendencies of the theatre at the beginning of my theatre experience. During my fieldwork, I arrived at the conclusion that the value of theatre does not lie in its capacity to emphasize what unifies human beings, but rather in its potential to emphasize their differences and to create bridges between them. I believe the theatre should work at the limits and the borders-and not at the center-of what is defined as "humanity. Even if there are elements human beings have in common, there are, at any level even the biological one-big differences. If we concentrate on the unifying factors, we create elites who do not act in history; we position them as somehow existing "above" or removed from the social and relational dynamics of identity formation. If we work on the differences among and within all people, we might be able to turn conflicts into peaceful contrasts and exchanges-into ways of relating. Evolution 397 What theatre scholars do agree on is that at a certain point, either following its development, or recuperating its original characteristics, social ritual became independent from religion. This process helped the theatre become, after many centuries, an autonomous form of human action. According to Turner, industrialization prompted the disintegration of the former integrity of the well-organized and all-encompassing religious gestalt that was the ritual of liminal societies. As societies modernized a space opened for a number of performance arts such as theatre, ballet, opera, cinema, the novel, poetry, music carnivals, processions, popular theatre, sporting events, and many others that Turner dubbed "liminoid" (1982). Thus, there was a transition from a collective and compulsory ritual that was a self-representation of communities and an enforcement of shared and common values through the symbolic inclusion of dissent and marginality in the system, as in Greek tragedy, to the theatre as part of the set of individual, optional activities operating in spare time and by means of the entertainment and arts industries. The economic revolution of industrialization led to a professionalization of the theatre and the specialization of the theatre artists, who could only be admired by those able to buy tickets. The primary socioeconomic "draw" to attend the theatre varied from century to century, from the actor to the playwright, and then to the director and then back again. They were and are organized by the different social "confraternities or professional associations. The Catholic Church often considers them to be pagan, even when it is deeply involved in the process. Therefore, I know from experience that the divisions between religious and social ritual, between symbol and representation, and the strict evolution of ritual into commercial theatre do not necessarily apply to all the cultures and communities in the Western world. I have traveled enough to understand that these divisions do not apply to other cultures and continents, certainly not to most of the African cultures. What we are describing here is only the mainstream of what has been "globally" defined as theatre in the last century in the Western academic and cultural environments. This search would give back to the theatre its fundamental role and heritage of political intervention, peaceful redefinition of the rules of the society, cultural discussion, and social therapy. In the meantime, anthropologists such as Erving Goffman (1959) began to study the importance of representation, with its ritual and performative aspects, in everyday life. Numerous other experiences seemed to corroborate those of the founders of this new theatre movement. In the 1970s, the search for new forms of social and political participation found in this transitional theatre one of the strongest means of communication and symbolic selfrepresentation, as well as a powerful cultural arm. Therefore, from a theatre perceived as part of show business, a widely disseminated theatricality evolved and infused schools, institutions, political groups, marginal communities, suburbs, and cities, while new models of dramaturgy emerged, such as collective (ensemble) work and the workshop-theatre. The first trend took the name "community-based theatre" in the States (see Schechner 1998); and in Italy, France, and neighboring countries, a similar trend was known as "theatre animation" (Rostagno 1980). This latter definition includes all decentralized, educational, recreational, and community-based social activities using theatricality and performance. These two trends have much in common, since they both refer to what Peter Brook calls the "third culture" (1987). As Bernardi pointed out (1996), according to Brook three cultures exist: the collective, the individual, and the culture of the relationship. Inclusion the relationship between the visible and the invisible in the 20th century has been culturally defined by the relation between the visible and the repressed.

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A trial application of this method of analysis suggested that certain sites had far fewer conflicts than others chronic gastritis message boards discount 400mg sevelamer visa, but the authors cautioned that many variables that could be important to gastritis diet 2000 order 800mg sevelamer visa siting decisions were not included in the study gastritis diet forum sevelamer 400 mg amex. First, we review federal regulation of wind energy: most narrowly, federal regulation of wind-energy development on federal lands; then federal regulation of wind-energy development that has a federal "nexus" via federal funding or permitting; then, most broadly, federal regulation of wind-energy development regardless of land ownership. To better understand regulation of wind-energy development, we review regulatory frameworks for a number of states. Because the focus of this document is the Mid-Atlantic Highlands, we include all four states in this region (Pennsylvania, Maryland, Virginia and West Virginia). These four states vary in the intensity of their review processes, thus giving a picture of the range of regulatory oversight in the United States today. We also review wind-energy regulation for states outside the Mid-Atlantic Highlands, choosing some from northeastern states that share many landscape, social and wind-energy characteristics with the Mid-Atlantic Highlands, and some from contrasting landscapes. In reviewing regulatory frameworks at all levels, we emphasize regulations that are likely to be particularly salient for wind-energy projects, and especially regulations that are likely to affect wind development in the Mid-Atlantic Highlands region. We give rather little attention to regulations that apply equally to any type of construction or industrial operation, wind energy or other. National Forests operate under the guidance of Land and Resource Management Plans, which form the basis for review of all proposed actions. Recent updates of Forest Land and Resource Management Plans address wind-energy projects. In most cases a project would require a "special use authorization" (Patton-Mallory 2006). No offshore windenergy project was operational or even under construction in the United States at the end of 2006. Otherwise, socioeconomic/cultural impacts of wind-energy projects are given little explicit attention at the federal level. Federal Regulation of Wind-Energy Development in General Federal regulation of wind-energy facilities is minimal if the facility does not receive federal funding or require a federal permit; this is the situation for most energy development in the United States. The Migratory Bird Treaty Act applies to all migratory birds native to the United States, Canada, and Mexico; this includes many species that use the Mid-Atlantic Highlands, including for migration. Bald eagles nest in isolated parts of the Mid-Atlantic Highlands whereas golden eagles are mainly migrants or winter residents, although a few may nest in the region (Hall 1983). Violations are identified in several ways, including receiving citizen complaints and self-reporting by individuals or industry. Planning for and Regulating Wind-Energy Development Prepublication Copy 133 Like other construction and operation activities, wind-energy projects are subject to federal regulations protecting surface waters and wetlands, such as the Clean Water Act. Section 404 of the Clean Water Act may also apply if the waters of the United States are potentially affected. Before construction begins, the developer also must ensure that the requirements of various federal laws and regulations protecting historic and archeological resources are met. Provisions such as these apply to all types of construction, not just wind energy, and we will not consider them in any detail here. State and Local Regulation of Wind-Energy Development Most regulatory review of wind-energy development takes place at the state or local level, or some combination of them, and most energy development has been on private land, although a few states have anticipated that wind-energy projects could be proposed for state-owned land. In reviewing state and local regulatory frameworks, the committee found it difficult to be sure that we understood these frameworks and their implementation accurately. Because of the rapidly changing nature of regulation of wind-energy development, the committee examined records from several recent wind-energy proposals to see how the regulatory process is working in practice, as well as reviewing the regulations themselves. State-Owned Lands Some states have developed policies with regard to the use of state-owned lands for wind-energy development. Privately-Owned Lands All of the federal regulations described in the previous section as applying to wind-energy developments or other construction activities, regardless of ownership or funding, apply in addition to the state and local regulations discussed here. In some cases, there are state and local regulations that parallel federal requirements. Many states have their own regulations for endangered species, water quality, and so forth. States assemble their own lists of species protected under these laws and may include species not listed at the federal level. These local ordinances will not be discussed in detail, unless they are the only level of review or when the local provisions are particularly salient for wind-energy projects. State and local regulations that govern construction and development projects typically apply to wind-energy projects as well. Rather than summarize the regulatory process for particular state or local jurisdictions, we concentrate on several recurring themes, some of which came to our attention during public presentations to our committee and some of which we identified as we examined the regulations for numerous states and municipalities. These themes are: (1) the locus of regulatory review (state, local, or mixed); (2) separation or integration of utility and environmental issues in the review process; (3) the information required for review; (4) the procedures for public participation in the review process; and (5) balancing the positive and negative effects of wind-energy development. In the following sections, we describe these themes using examples from the Mid-Atlantic Highland states and elsewhere. Then we critique and interpret some of the same themes, along with some others, in order to identify potential improvements to regulatory processes. Locus of Regulatory Authority: State, Local, Mixed Regulatory review of wind-energy development varies considerably. It tends to follow one of three patterns: (1) all projects are handled entirely at the state level, (2) larger projects are handled at the state level and smaller projects at the local level (with the size cutoff varying among states), or (3) all projects are handled primarily at the local level. Many states have some state-level permitting of electrical generation facilities, especially transmission lines. Three of the four states in the Mid-Atlantic Highlands have state utility commissions that oversee proposals for electricity generation and transmission. Other states are in the process of incorporating specific language concerning wind-energy projects into regulatory rules and guidelines. In some cases, the developer must obtain a variety of state permits before final review by a local planning or governing body. Sometimes the state regulatory authority coordinates or consolidates these permits. The Oregon Office of Energy encourages developers of smaller wind-energy facilities to obtain permits through the Energy Facility Siting Council rather than dealing separately with the variety of state and local permits otherwise required. They argue that at the state-level siting process there is "a defined set of objective standards," while "local-level siting is subject to local procedures and ordinances that vary from county to county and city to city" (White 2002, P. In addition, the Oregon Energy Office states, "Most local land use ordinances address energy facility siting in a superficial way, if they address it at all. It may not be clear what standards the local jurisdiction will apply in deciding whether or to issue a conditional use permit" (P. It notes that "most planning departments around the state have no experience siting large electric generating facilities" (White 2002, P. Local governments (counties and towns or cities) regulate wind-energy development via local ordinances that apply to any construction proposal. Local regulations, such as zoning of land uses, rightsof-way, building permits, and height restrictions, may constrain wind-energy development. In Pennsylvania, local regulations constitute the only review, and county governments that issue zoning recommendations and permits for land development and subdivision plans are the regulatory authorities.

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Patients who have predominantly intraperitoneal or retroperitoneal fat have improved visualization of internal organ structures compared with patients with less intraperitoneal fat due to gastritis purchase 400 mg sevelamer overnight delivery increased delineation of internal organ structures by the fat gastritis lymphoma order sevelamer us. Solutions to chronic gastritis meaning buy sevelamer 800mg lowest price decrease noise involve increasing kVp to 140 and increasing the effective mAs. Appropriate emergency equipment and medications must be immediately available to treat adverse reactions associated with administered medication. The equipment, medications, and other emergency support must also be appropriate for the range of ages and/or sizes in the patient population. A written policy should be in place for dealing with emergency situations such as cardiopulmonary arrest. Additional information concerning radiation protection is provided later in this course. Magnetic Resonance Imaging Felix Bloch of Stanford University and Edward Purcell of Harvard University conducted the first successful nuclear magnetic resonance experiment to study chemical compounds in 1956. In the early 1980s, the first "human" magnetic resonance imaging scanners 4 1 130 became available, producing images of the inside of the body. The basic types of pulse sequences are: proton (spin) 131 2 density, T1 relaxation time, and T2 relaxation time. For a complete diagnostic evaluation, a combination of these pulse sequences is usually required. Those who are claustrophobic may require high doses of weight-based sedative medications, which may put certain individuals at risk for respiratory depression. These devices may move or undergo a torque effect in the magnetic field, overheat, produce an artifact on the image, or become damaged or functionally altered. Nuclear Medicine Imaging In 1896, Henri Becquerel was investigating phosphorescence in uranium salts when he discovered a new phenomenon, which came to be called radiosensitivity. He 133 along with Marie and Pierre Curie began investigating the new discovery, which today plays a significant role in nuclear medicine imaging. Nuclear medicine imaging procedures use pharmaceuticals that have been labeled with radionuclides. In diagnosis, radioactive substances are administered to patients and the radiation emitted is detected by using a gamma camera or positron emission tomography. The physiologically mapped image allows skeletal changes to be detected earlier than demonstrated by conventional radiography. Abnormal images illustrate "hot spots" produced by an increase in uptake of the radionuclide that is directly proportional to the emission of gamma radiation or "cold spots" reflecting a decrease in uptake of the radionuclide. Tc-99m is absorbed by bone and provides a survey study of the skeletal system for evaluation of abnormal musculoskeletal conditions such as stress fracture, injuries, and metastases. Uptake is greater in the axial skeleton (pelvis and spine) than in the appendicular skeleton (skull and extremities). The ability of a scintigram to demonstrate trauma precedes conventional radiography detection of fracture healing by approximately 10 days. Two of the many indications for bone scintigraphy are to detect bone lesions and impacts of metabolic diseases on the skeleton. On bone scintigraphy images, osteomalacia is usually demonstrated as a random distribution of intense activity with looser zones and pseudofractures. The pathology of looser zones relates to areas of poorly mineralized woven bone occurring at sites of mechanical stress. Looser zones are frequently associated with osteomalacia, Paget disease, osteogenesis imperfecta tarda, fibrous dysplasia, renal disease, congenital hypophasphatasia, vitamin D malabsorption, and neurofibromatosis. Common locations of looser zones are the scapula, medial femoral neck, femoral shaft, pubic and ischial rami, ribs, lesser trochanter and the proximal one third of the ulna, and 134 the distal one third of the radius. Looser zones are generally visualized as a two to three millimeter wide stripe of lucency at a right angle to the cortex of the bone. Images of tracer concentration in three dimensional or four dimensional space with the body are then reconstructed by computer analysis. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. Also, three dimensional information may be provided as cross-sectional slices through the part and can be freely reformatted or manipulated as required. The increase is partially attributed to utilization by nonradiologists and may be driven by "self-referral". A high level of skill and experience is needed to acquire diagnostic quality images; and, There are no scout images so once an image has been acquired there is no exact way to tell which part of the body was imaged. Arthrography Arthrography is imaging the joint space and its surrounding structures. Conventional radiography is the most common imaging modality used in arthrography; however, magnetic resonance imaging, computed tomography, and ultrasonography may also be used. The joint space and its surrounding structures can be the site of many different types of pathologies and arthrography may be helpful in the diagnosis, treatment, and monitoring of the condition. Patients who are taking the drug Plavix (clopidogrel) should be advised to discontinue the drug 136 for at least five days prior to certain invasive diagnostic and interventional imaging examinations. Arthrography may be performed with a negative or a positive contrast agent, or both. A disadvantage to this method is that the use of negative contrast agents such as air, requires injection of a sufficiently large quantity, which produces distention of the area and results in patient discomfort. Positive contrast arthrography has increased diagnostic accuracy compared to pneumoarthrography. A double-contrast arthrogram examination combines the use of smaller quantities of both a negative and a positive contrast agent. Fluoroscopy is used throughout the procedure to localize the landmarks in the joint space and to obtain spot film images that provide documentation of areas of pathology. Scout film images of the area to be examined are taken and viewed by the imaging team. There has been recent concern about the radiation exposure received by patients and staff when fluoroscopy is used in diagnostic and interventional imaging procedures. Bone Mass Measurement Technologies In this section the term operator is used when referring to the person who operates bone densitometry equipment. Bone loss diseases drain the skeleton of essential minerals that comprise the bony matrix, thus leaving a porous, weakened skeletal framework. Many of the consequences of bone loss diseases can be diminished or halted if therapeutic interventions are initiated in the early stages. Bone mass measurement technologies along with advanced laboratory tests have helped to recognize these diseases. The introduction of new technologies to measure bone mass was critical since ordinary x-ray 137 techniques cannot detect less than 30% loss in bone mass. Using bone mass measurement technologies, as little as 1% change in bone mass is detectable. Over 100 years ago, dentists used crude instruments to measure the density of the mandible.

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Although signs and symptoms of specific nutrient deficiencies commonly overlap and multiple deficiencies are frequently encountered gastritis oatmeal order sevelamer mastercard, a judicious approach to gastritis diet kolesterol purchase 800mg sevelamer otc ordering laboratory tests is recommended gastritis diet mayo purchase sevelamer with a visa. While a rather comprehensive list of laboratory tests is presented here, clinical suspicion should guide the selection of specific investigations. Depending on the clinical laboratory facilities, turnaround time on certain tests may preclude their usefulness in the acute setting. Familiarity with these limitations will help to avoid ordering tests that do not contribute meaningfully to the management of a child. Table 1 provides a summary of the laboratory tests discussed here, including their normal values, signs and symptoms of the deficiency state, and pitfalls to avoid in their interpretation. Laboratory tests may aid in the diagnosis of primary childhood malnutrition (resulting from inadequate intake) and are invaluable in guiding therapeutic decisions in secondary malnutrition (resulting from conditions of increased need for or losses of substrate). Because nutritional status is an independent predictor of outcome in the sick child, strict attention to indicators of visceral Protein Assessment of visceral protein stores is commonly made by measuring serum proteins (table 2), most commonly albumin, prealbumin (transthyretin) and retinol-binding protein. Generally, serial measurements of protein status are more meaningful than single values and an understanding of their biological half-lives will dictate the frequency of assessment (table 2). Appreciating the positive and negative acute-phase reactants will help avoid misinterpretation of data. Another limitation of measuring serum proteins is that their manufacture is tied to hepatic synthetic function. Therefore, in a child with advanced liver disease, low serum protein may not necessarily reflect a lack of substrate but rather a lack of synthetic function. Finally, their concentrations are also susceptible to changes in hydration status and fluid shifts, and these changes may occur rapidly. Serum proteins used in the assessment of vis- ceral protein stores Protein Albumin Prealbumin (transthyretin) Retinol-binding protein Half-life 20 days 2 days 12 h Table 3. Serum proteins in the acute-phase response Positive acute-phase reactants 1-Antitrypsin C3 complement C-reactive protein Ceruloplasmin Fibrinogen Negative acute-phase reactants Albumin Prealbumin (transthyretin) Retinol-binding protein Transferrin Thyroxin-binding globulin Vitamins and Minerals the decision to evaluate vitamin and mineral stores should take into account the suspected underlying pathophysiology. Frequently, signs and symptoms of nutrient deficiency overlap with one another, underscoring the importance of an informed approach to laboratory investigation. An exhaustive list of these interactions is beyond the scope of this text; however, some important nutrientspecific examples are shown in table 1. A fecal smear with Sudan staining gives a rough qualitative estimate of steatorrhea and may be useful for screening purposes (2) Pancreatic insufficiency: in addition to fecal fat measurement, determination of fecal elastase can be used as a measure of exocrine pancreas sufficiency. Although reliable for detecting severe pancreatic insufficiency, it is less so for mild-to-moderate pancreatic insufficiency; it will not identify other isolated enzyme deficiencies. Testing should be done on the most liquid portion of the stool and can be done at the bedside using the same test strips used to measure pH and glucose in urine (4) Hydrogen breath testing: this test detects the passage of carbohydrate into the colon. Breath hydrogen is measured at baseline and after the child is given an oral load of the carbohydrate of interest. Additionally, a positive test does not always correlate with symptoms of intolerance (5) Small-bowel bacterial overgrowth syndrome may be assessed in an analogous manner using lactulose or glucose. Based on the assumed sta- the concept of a near-normal, symmetrical distribution of nutrient requirements (fig. Examples are the nutrient needs for iron, vitamin D and polyunsaturated fatty acids. Iron requirements are not normally distributed, with high needs in menstruating women, particularly in those with substantial blood losses. This is unfortunate because infants, children and adolescents have relatively large nutrient needs due to their growth and development, and adequate substrate supply is of utmost importance to support their short- and long-term health, well-being and performance [5]. However, this approach is weak, because it assumes that the subjects are in good health and are achieving their full genetic potential and that their diets are quantitatively and qualitatively appropriate and free from adverse long-term effects. However, this approach has major limitations because the actual metabolizable substrate intakes of breastfed infants are not well determined. The volume of milk consumed varies between about 550 and 1,100 ml/ day, and milk composition differs between women and with changes during the course of lactation, during the day and even during a single feeding. Therefore, human milk composition and the nutrient supply to breastfed infants may not always provide useful guidance for infants that are not exclusively breastfed. Examples of extrapolation methods that are used include body size (weight or metabolic weight), energy intakes for age, or factorial estimates of requirements for growth [8]. It is important that the rationale or scientific basis for the method chosen should be completely transparent and thoroughly described for each nutrient and life stage group. Extrapolation is always the second choice, and the use of innovative, non-invasive methods or of existing methods. Unlike recommendations for other nutrients, which meet or exceed the requirements of practically all individuals in the population, recommendations for energy intake are based on the average requirement of the population to avoid energy intakes that exceed requirements. Recommendations for energy intake and physical activity are intended to support and maintain the growth and development of well-nourished and healthy infants, children and adolescents. The energy cost of growth was derived from average growth velocities and the composition of weight gain. Basal metabolism is defined as that energy expended to maintain cellular and tissue processes fundamental to the organism. Thermic effect of feeding refers to the energy required for the ingestion and digestion of food and for the absorption, transport and utilization of nutrients. Thermoregulation can constitute an additional energy cost when exposed to temperatures below and above thermoneutrality; however, clothing and behavior usually counteract such environmental influences. Physical activity is the most variable component of energy requirements, and entails both obligatory and discretionary physical activities. The energy cost of growth as a percentage of total energy requirements decreases from around 35% at 1 month to 3% at 12 months of age, and remains low until the pubertal growth spurt, at which time it increases to about 4% [2]. The composition of weight gained was assumed to be 10% fat with an energy content of 38. Recommendations for Physical Activity A minimum of 60 min/day of moderate-intensity physical activity is recommended for children and adolescents [1], although there is no direct experimental or epidemiological evidence on the minimal or optimal frequency, duration or intensity of exercise that promotes health and wellbeing of children and adolescents [13]. Regular physical activity is often associated with decreased body fat in both sexes and, sometimes, increased fat-free mass at least in males. Energy requirements must be adjusted in accordance with habitual physical activity. Torun [14] compiled 42 studies on the activity patterns of 6,400 children living in urban, rural, industrialized and developing settings from around the world. Protein in the body is in a dynamic state referred to as protein turnover, which involves continuous degradation to free amino acids and resynthesis of new proteins.

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Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation gastritis symptoms loose stools generic sevelamer 800mg on-line. His parents inform you that he was recently evaluated by his school and determined to chronic gastritis what to eat order generic sevelamer canada qualify for an Individualized Education Program under intellectual disability gastritis diet игри discount sevelamer on line. His adaptive skill scores are 65 in communication, 62 in daily living skills, 67 in motor skills, and 66 in socialization. Intellectual disability, previously known as mental retardation, is a chronic condition with onset during the developmental period. Significant impairment in both cognitive abilities and adaptive functioning are required for diagnosis. Adaptive functioning can be divided into the conceptual domain (eg, reasoning, practical knowledge), social domain (eg, social judgment, interpersonal communication skills), and practical domain (eg, personal care, vocational skills, accessing transportation). It is measured by standardized tests such as the Vineland Adaptive Behavior Scales and the Adaptive Behavior Assessment System. Test scores have been de-emphasized in the latest version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Adaptive functioning in real-life situations does not always correspond with intellectual capacity; therefore, clinical assessment with a greater focus on adaptive functioning has been stressed. Severity is determined by deficits in adaptive functioning, and treatment plans should be developed to address those needs. They require assistance and supervision for their self-care, daily needs, and safety during childhood and adulthood. He would read up to the sixth grade level and be able to accomplish his daily living and self-care tasks without need for support or supervision for his safety. Severity is determined by deficits in adaptive functioning and treatment plans should be developed to address those needs. Her friends reported to the paramedics that she "seemed normal" at the beginning of the concert. When the paramedics arrived, she was actively seizing, with stiffening of all extremities, generalized twitching of her face, and drooling. Her heart rate is 150 beats/min, blood pressure is 160/95 mm Hg, respiratory rate is 22 breaths/min, rectal temperature is 38. The substance most likely to be responsible for these findings is synthetic cathinone ("bath salt"), an amphetamine analog. All pediatric providers should recognize the major physiologic and behavioral consequences associated with amphetamine use, including the clinical findings associated with acute intoxication. Historically, amphetamines have been utilized in medicine to treat conditions including nasal congestion, fatigue, narcolepsy, attention deficit/hyperactivity disorder, and obesity (to promote weight loss). Though they have played a significant role in medicine over the years, these substances have also had a long history of being abused in the United States and worldwide. Specifically, abuse of synthetic cathinones (ie, "bath salts") emerged in Europe around 2009 and spread to the United States in 2010. These compounds are typically sold as tablets or white powders, marketed as "bath salts" or "plant food," in a variety of venues, including "head shops," gas stations, and convenience stores. Despite the disclaimer on their packaging that these substances are "not intended for human consumption," they are widely sold and used as "legal" drugs of abuse in the United States. Amphetamines and amphetamine-like substances are potent activators of adrenergic receptors in both the central and peripheral nervous system. These signs include tachycardia, hypertension, hyperpyrexia, mydriasis, and diaphoresis. Central nervous system effects may include anxiety, agitation, combativeness, and even seizures. Other clinical effects may include the musculoskeletal system (myoclonus, tremors), kidneys, and gastrointestinal system. In severe cases of amphetamine intoxication, lethal arrhythmias, hyperthermia, and intracranial hemorrhage may occur. Clinical management of acute amphetamine intoxication should focus on supporting and protecting the airway, maintaining adequate ventilation and oxygenation, and ensuring adequate perfusion to the brain and other vital organs. While there is no specific antidote available to reverse amphetamine toxicity, benzodiazepines such as diazepam or lorazepam are first line for treating psychomotor agitation and seizures arising from amphetamine toxicity; these agents are also beneficial in alleviating amphetamine-induced hypertension and hyperthermia. Furthermore, hypertension and hyperpyrexia are not typical clinical features of ethanol intoxication. Classic clinical features of intoxication with heroin, an illicit opioid, would include central nervous system depression, respiratory depression, and miosis ("pinpoint pupils"). Central nervous system effects may include anxiety, agitation, combativeness, and seizure activity. Clinical experience with and analytical confirmation of "bath salts" and "legal highs" (synthetic cathinones) in the Unites States. She recently returned from Pakistan where she travelled with her parents to visit family. Laboratory data are shown: Laboratory test Laboratory test White blood cell count Hemoglobin Platelet count Segmented neutrophils Lymphocytes Aspartate aminotransferase Alanine aminotransferase Result 17,000/L (17. In a traveller returning from Pakistan, typhoid fever must be considered as an etiology, given that Salmonella typhi infections are endemic in resource-limited countries, especially in Asia. In typhoid fever, stool cultures are often negative, thus negative stool tests do not exclude this diagnosis. Infections due to Salmonella typhi are distinct compared to nontyphoidal Salmonella infections. Nontyphoidal Salmonella typically cause enteritis, though invasive infections including bacteremia, osteomyelitis and meningitis can occur. In contrast, Salmonella typhi is more likely to cause invasive infections than enteritis. The main reservoirs for non-typhoidal Salmonella include birds, mammals, reptiles, or amphibians. Infections occur either via food contamination or direct contact with infected animals. Abdominal ultrasonography may reveal hepatosplenic enlargement in the setting of typhoid fever, among other etiologies of fever of unknown origin, though this would not specifically identify the diagnosis. In cases of fever of unknown origin suspected to be due to cat scratch disease, however, abdominal ultrasonography can aid with diagnosis, given that characteristic hepatosplenic lesions can often be seen. Given that the child in the vignette has transaminitis, infection due to a hepatitis virus is a consideration. However, the clinical scenario is more fitting with typhoid fever given the prolonged fever and absence of emesis, diarrhea, and jaundice. Urine should be evaluated in cases of fever of unknown origin, though there is nothing in this scenario to invoke the urinary tract. Likewise, the child in the vignette has not demonstrated respiratory symptomatology, therefore, a nasal wash for a virus is unlikely to prove useful. Of note, the patient in this vignette should have received pre-travel vaccinations, including typhoid vaccine. While not completely protective, typhoid vaccine certainly enhances resistance against infection. His vomiting has decreased in the past 24 hours, but his diarrhea continues with 7 to 9 large, liquid bowel movements daily.

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Are there potential risks linked with supporting and stimulating games and sports (such as cultural divisions gastritis diet играть purchase discount sevelamer on line, human rights violations gastritis symptoms for dogs purchase generic sevelamer from india, gender issues gastritis diet гогл cheap sevelamer 800 mg line, among others) How is the emergency impacting the set-up and implementation of the planned activity (for example, see chapter on Integration of mental health and psychosocial support in conflict transformation and mediation) Finally, the relation between sport and play, and theatre and other arts-based activities, is clearcut, since they all refer to the action of playing, of which they represent different forms and manifestations. Additional information, including the definition and operational framework for the use of sports in post-disaster settings, can be found here. Non-meaningful participation, especially in emergency situations, would be the one that derives from focusing on antagonism. In emergency situations, these skills may need to be refreshed or taught, since the challenges of the emergency context bring the need for new per-sonal, social and technical capacities, as well as new sport practices. Sport activities should be sensitive to the cultural and spiritual dimensions of individuals and families, the socioeconomic and political contexts of the emergency, and to subcultural and conflict dynamics. In sports, inclusion is programmatically translated in a series of practices aiming at "increasing access to, participation within, and reducing exclusion from, any arena that provides sport and physical activity". Therefore, proactive initiatives should be taken to ensure the participation of marginalized or segregated individuals, such as persons with disabilities, including children with mental, cognitive and physical impairments; women and girls; and elders and youths belonging to different subgroups. But regardless of how one chooses to classify them, it is critical that sports and activities aim to support psychosocial well-being, and are selected and implemented in ways that consider all ranges of motions and abilities, and include considerations of age, gender, economic situation and culture, among other factors. In each session, the goal is discussed and agreed, then there will be a warm-up, core exercises and trainings, a cool-down, and a debate/discussion. Which sports activities to select should be primarily based on what is already existing within the community. However, sport and play should also be seen as an opportunity to innovate and listen to the needs and requests coming from the community. The suggestions below aim at complementing the information from a programmatic point of view and adding links to relevant tools. These generated sport and play activities can include: can be introductory or specialized, based on (i) Sport materials; needs and pre-existing capacity. Training should (ii) Sport equipment; always be accompanied by ongoing support and (iii) Other in-kind support; supervision. The latter mechanism; (vii)Creating occasions for networking between represent a prerequisite to reinforce the skills of others. In addition, training can vary for levels sport activities, such as leagues, common of complexity, according to the existing capacity trainings and forums. In parallel, a group (e) Sport activities proposed by the programme of sport coaches was identified and trained manager that are not part of the usual sport to organize specific sport activities for people and play activities used in a community, but with amputations and new to the use of that respond to specific psychosocial objectives prostheses. Since the coaches were proficient in or emergency generated needs: In this case, their own sport domains and as sport trainers, objectives should reflect and be reflected in the training focused on psychosocial skills, the type of sport, the local context, the stage rehabilitation skills and very specific exercise of emergency, and the psychosocial needs that and inclusion practices. The project aimed at have been identified and prioritized through supporting the amputees in regaining faster the assessments. They should be determined control over their movements, as well as a with a participatory approach. Encourage coaches and facilitators to form peer-to-peer groups as part of ongoing support to the coaches and the activities they are implementing with the community. Conduct on-the-job trainings with frequent follow-up rather than one-off longer trainings. These refugees live in precarious conditions, and their children suffer the effects of forced displacement. Since October 2017, a new project called "Sport for community-based protection and social inclusion" has been implemented and aims at providing sustainable sport as well as psychosocial and life skills activities that increase social inclusion and community-based protection for vulnerable children and youth. Some no longer remember their homes, but still have trouble adjusting to their new culture. Activities should be culturally appropriate and respect non-discriminatory principles. For instance, girls may be at risk of bullying by taking part in a certain activity or sports that imply force and physical confrontation. It is important to offer different kinds of sports and to adapt rules and practices to make games and sports, even highly physical ones, accessible. Communicating the objectives of the programmes to the community is essential, and illusions or disproportionate expectations should not be created to stay realistic. While sports are important, it is essential to consider food and other basic needs of participants. If food insecurity is a grave issue, one should consider delaying the start of programmes and partnering with those who are able to engage in mitigating food insecurity. Coaches are in a unique position to be role models and mentors for young participants, but there are also stories of coaches misusing their Animators use football as a tool to support the children. We use activities to show them that they can get back on their feet and still make something of the situation. This applies to football and real life", explains Pasant Aly Mokhtar, who is in charge of those running the activities. It is widely recognized that safeguards are necessary, and this includes putting into place safeguard policies. It is therefore important to associate planning of sport activity with a conflict-sensitive approach. Sport Inclusion Network 2012 Inclusion of Migrants in and through Sports: A Guide to Good Practice. In situations of forced or mass displacement, the integration of newly arrived communities in the formal education system of the country of destination can be hampered by logistical and administrative constraints. Moreover, in displacement and migration, students, even if integrated in the education system of the host country, can struggle due to the adaptation to different curricula and pedagogical models from the ones they were used to. Therefore, such contexts call for programmes facilitating either non-formal education and/or informal learning responses, as a bridge towards or a complement to formal education. Formal education, non-formal education and informal learning are all fundamental cultural activities having to do with the consolidation of a cultural canon and the organic integration in a community. They are also an important venue to create relations and to learn how to relate to others. Table 6: Common framework for education in emergencies Education in emergencies - Quality of learning opportunities for all ages in situations of crisis, including early childhood development, primary, secondary, non-formal, technical, vocational, higher and adult education. It is consequently less organized and structured than either formal or non-formal education. Curricula are more or less formalized, but with no certification process nor diploma at the end.


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Any legislation reintroducing the criminal responsibility would come in conflict with general principles of the Swedish judicial system uremic gastritis symptoms sevelamer 400 mg overnight delivery. Since Sweden has no possibility of reintroducing the criminal responsibility for these crimes gastritis duodenitis buy sevelamer line, no accusations against individuals can be tried by the Swedish judicial bodies gastritis or anxiety cheap 400 mg sevelamer with amex. The Government has therefore decided not to take further action in response to your request to establish an official governmental investigation concerning crimes against humanity during the Second World War. However, during this year the Government will establish a commission with the task to deliberate the Swedish legislation as to war-crimes, crimes against humanity and genocide. The commission will also be charged with the issue of abolishing the statute of limitations for the future for these very serious crimes. Yet, as powerful and as incisive as these responses may have been, they did not achieve any concrete result and thus it is almost one hundred percent certain that no Holocaust perpetrator living in Sweden will ever be held accountable for their crimes. Postscript On 19 April 2001, the Simon Wiesenthal Center issued its first Annual Status Report on the Worldwide Investigation and Prosecution of Nazi War Criminals, which graded the performances regarding this issue over the past few years of eighteen different countries that were either the site of Holocaust crimes or the current domicile of suspected perpetrators. Office of Special Investigations was awarded the former grade for its outstanding successes, Sweden and Syria were the only two countries to receive a failing grade. Six weeks later the author of this article utilized the publication of a report by an international commission of historians appointed by Estonian president Lennart Meri to investigate the crimes committed during the Nazi-and communist-occupation of Estonia that named Oskar Angelus, who escaped to Sweden and lived there for many years, as one of those personally responsible for the murder of Estonian Jewry39 to once again raise the issue of unprosecuted Nazis in Sweden. In summation, Sweden remains one of the few countries in the world that refuse, in principle, to investigate suspected Holocaust perpetrators, regardless of their being Swedish citizens or not, and the places where they are suspected of having committed their wartime crimes. By comparison, three of the other countries to which the Simon Wiesenthal Center submitted lists of suspected Nazi war criminals in the fall of 1986 passed special legislation to enable the prosecution of the Holocaust perpetrators living in those countries: Canada in 1987, Australia in 1989, and Great Britain in 1991. Faced with a similar-albeit not exactly identical-legal obstacle to prosecution, Sweden opted to ignore the problem, thereby granting a safe haven to those who least deserve such largesse. For an account of American efforts to identify and prosecute Nazi war criminals resident in the United States, see Allan A. Arklans, Political Refugees Unmasked (Riga: Latvian State Publishing House, 1965), 17, 20-21, 62, 67-69, 133, 134, 137-138, 156, 192, 194. Among the Nazi war criminals mentioned are Helmut Rauca, who was extradited from Canada to West Germany and Kaunas (Lithuania) mayor Kazys Palciauskas, who was stripped of his American citizenship in the United States. Don Shannon, "Nazi Hunters Give Sweden 12 Names from Data Bank," Los Angeles Times, 19 November 1986. See, for example, Eliyahu Zehavi, "Shvedya: Lo Nasgir Poshim Natzim," Haaretz, 20 November 1986. The journalist who broke the story was Arne Lapidus, the Israeli correspondent of the Swedish daily Expressen. According to Lapidus the list contained fourteen names-our original list of Latvian suspects-but we subsequently uncovered the names of seven Estonian suspects and removed the names of those who were obviously already dead. According to community spokesperson Lena Posner-Korosi, there were about twenty thousand Jews living in Sweden. The war crimes, which were committed during the Second World War, constitute one of the darkest chapters in the history of mankind. I am convinced that you understand that an amendment of the Swedish law would be contrary to fundamental principles which have been of guidance in legislation in our country for a long time. Shortly before the conference, Swedish radio journalist Bosse Lindquist broadcast a documentary report on the complicity of Swedish officials in the escape from Sweden of Estonian Nazi war criminal Evald Mikson. See Efraim Zuroff, "The Impact of Contemporary Political Issues on Holocaust Education," speech delivered at "Tell Ye Your Children," conference on the Holocaust, Stockholm, May 1998, 32-33. Belinda Goldsmith, "Sweden Urged to Admit Links to Nazi Germany," Reuters, 4 January 2000. Appendix Correspondence between Simon Wiesenthal Center Officials and Swedish Prime Ministers on the Nazi War Criminals Issue (1986-2000) 1. Ingvar Carlsson Prime Minister of Sweden Statsradsberedningen S-10333 Stockholm, Sweden Dear Mr. Prime Minister: the Simon Wiesenthal Center has intensified its worldwide hunt for suspected Nazi war criminals. As a result of our investigations, our Jerusalem office headed by Efraim Zuroff, a Holocaust historian and formerly with the Office of Special Investigations U. Enclosed is a preliminary list of twelve suspected Nazi war criminals who, based on archives drawn from various places of the world, are suspected of having committed crimes against Jews in Latvia and Estonia during the Nazi occupation. This list of suspects contains varying degrees of culpability ranging from crimes against humanity, mass murder and torture, collaborators and those aiding the Nazi cause. During the period in question, of a population of 95,000 Latvian Jews only a few hundred managed to survive the brutal genocide carried out by Lithuanian, Latvian and Estonian collaborators and supervised by the Germans. The biological clock is running out on Nazi war criminals and the record of history should not read that those who committed unspeakable crimes against humanity had the final victory by depriving justice of its due course. Future generations must learn that the crime of genocide has no time limit and that even forty-five years after the event, governments will overcome any impediment in Efraim Zuroff 121 exercising their responsibility to bring those who committed such crimes before the bar of justice. We look forward to hearing from you on the contents of this letter at your earliest convenience. The Government immediately charged a group of lawyers (the UnderSecretaries for Legal Affairs, Mr. Hans Corell, at the Ministry for Foreign Affairs) to examine the material submitted to the Government and to review the legal position with regard to war crimes. The group has now completed its work and submitted a memorandum to the Government. The memorandum is presently being translated into English, and you will be provided with a copy of this translation as soon as possible.

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He has a long history of atopic dermatitis and asthma diagnosed at 3 years of age gastritis symptoms treatment mayo clinic quality 400 mg sevelamer. His asthma has required numerous visits to gastritis diet 2 weeks cheap 400 mg sevelamer overnight delivery the local emergency department gastritis quick fix buy sevelamer 800mg without prescription, but no hospitalizations. During this time, he has been treated with 3 courses of antibiotics, including azithromycin, as well as leukotriene receptor antagonists and a short course of systemic corticosteroids without any clear impact on his fevers or cough. He reports malaise, a productive cough with brown mucus, and occasional hemoptysis. His mucosa are moist and pink, and his nares are clear without rhinorrhea or discharge. He has no retractions, his heart and abdominal examinations are normal, and his skin is warm and well-perfused. Aspergillus is a group of aerobic saprophytic fungi that are ubiquitous in the environment. Aspergillus species are molds, that grow in multicellular filaments called hyphae and produce asexual nonmotile spores (conidia) that people routinely inhale. The genus Aspergillus consists of multiple subgenera, which are then further divided into sections and species. Mycologists often refer to isolates as a member of an Aspergillus species complex because of the hundreds of Aspergillusspecies that exist without available molecular typing or phenotypic differentiating features. Aspergillus is found in the air, water, soil, and on decomposing organic material. It grows well on carbon-rich surfaces, such as monosaccharides and polysaccharides, and frequently grows on bread or potatoes. However, some of these same Aspergillus species, such as A niger, and A terreus can cause invasive disease in immunocompromised patients. Aspergillus flavus produces carcinogenic aflatoxins, which can contaminate chili peppers, corn, wheat, rice, peanuts, tree nuts, sunflower seeds, and spices, resulting in severe hepatic necrosis. AspergilIosis primarily occurs in patients with underlying lung diseases such as asthma or cystic fibrosis, or immunocompromised patients. Although the lung is the usual origin of local disease, invasive disease can originate in the skin and gastrointestinal tract. Allergic bronchopulmonary aspergillosis results from Aspergillus fumigatus conidial colonization creating a hypersensitivity reaction in the airway of patients with either asthma or cystic fibrosis. Eosinophilic inflammation, combined with proteolytic enzymes and mycotoxins released by the Aspergillus, cause damage to the airway, which leads to mucus plugging, central bronchiectasis, bronchocentric granulomatosis, and eosinophilic pneumonias. Precipitating immunoglobulin G (IgG) antibodies (precipitins) to Aspergillus and also specific IgE and IgG antibodies to Aspergillus on immunoassay may help pinpointing the actual etiology. Chest radiographs may show upper lobe parenchymal opacities and atelectasis from mucus plugging. Central bronchiectasis of the medial half to two-thirds of the chest is common, as seen in the radiograph in the vignette. Since the patient in this vignette does not have a history of a significant immunocompromised condition or medications, it would be highly unlikely for him to have invasive or disseminated aspergillosis. The chest radiograph does not show any cavities where an aspergilloma might be present. While this clinical picture could be consistent with chronic pulmonary aspergillosis, disease has not been present for more than 3 months. Furthermore, patients with chronic pulmonary aspergillosis often have cavities present on chest radiograph, with or without aspergillomas. Extensive fibrosis, progressive segmental areas of consolidation with or without adjacent pleural thickening, and multiple radiopaque nodular areas may also be seen. His respiratory rate is 19 breaths/min, heart rate is 80 beats/min, and blood pressure is 100/60 mm Hg. His physical examination is significant for bilateral periorbital edema, ascites, and diffuse severe pitting edema. Urine microscopy shows 5 to 10 red blood cells per high-power field, and no white blood cells, crystals, or bacteria. You inform his parents that you suspect that the boy has idiopathic nephrotic syndrome and begin a discussion about treatment options, as well as prognostic factors for renal function. Nephrotic syndrome is characterized by the triad of edema (facial puffiness or generalized anasarca), proteinuria, and hypoalbuminemia. Serum chemistry will demonstrate hyperlipidemia (elevated cholesterol and low-density lipoprotein cholesterol). Often, on initial presentation with facial puffiness, children are thought to be having an allergic reaction. Boys are more frequently affected than girls, however this predominance does not persist into adolescence. Nephrotic syndrome is categorized as primary/idiopathic, secondary, or congenital/infantile (Item C220). Urinalysis will demonstrate nephrotic range proteinuria, defined as a spot urine (preferably a first-morning sample) protein-to-creatinine ratio greater than 2 (< 0. Cyclophosphamide, an alkylating agent, is used as a steroid-sparing agent and can induce longterm remission. Patients resistant to cyclophosphamide may be treated with other steroid-sparing therapies such as calcineurin inhibitors (cyclosporine, tacrolimus), mycophenolate mofetil, or rituximab. Microscopic hematuria is seen in nearly 20% of children with minimal change disease, and does not predict steroid sensitivity. The mother is a 26-year-old gravida 3, para 2 woman with no significant past medical or prenatal history. The neonate was delivered vaginally at 38 weeks of gestation with a birthweight of 2. Laboratory data are shown: Laboratory test Result White blood cell count 18,600/L (18. It is common in newborns during the first 24 to 48 hours after birth and may be exacerbated by hypothermia or polycythemia. Thus, cyanosis may be more difficult to identify in an anemic neonate and more prominent in a neonate with polycythemia. Though the pathophysiology of peripheral cyanosis is not completely understood, it may be related to immature vasomotor control. With vasodilation, there may be slow blood flow with a large difference between the arterial and venous oxygen content. In this situation, the amount of deoxygenated blood present may be high enough to appear cyanotic, though arterial oxygen content remains normal. In comparison, central cyanosis is usually associated with hypoxemia, which is low levels of dissolved oxygen in the blood.

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Levels of Significant Exposure to gastritis symptoms nhs discount sevelamer line Fluoride - Oral (Continued) Intermediate (15-364 days) Systemic 1000 0 16m 016m 100 @27m 021r 10 Q21r @30h @28m a27m 029111 @29m 1 @26m Q24m @17r 0 gastritis diet ulcerative colitis purchase sevelamer paypal. Z E n 9 P 061111 10 C g 0 n r 0 056m 055r 056rn 055r 056rn @57h 055r 056rn 82% 858kQ55r 055r 056m 05sr 056rn 055r 056m 055r @60h 066n 062h gastritis garlic order sevelamer on line amex. No studies were located regarding respiratory effects in humans after oral exposure to fluoride, hydrogen fluoride, or fluorine. Congestion, the presence of edema fluid, and desquamation of respiratory epithelium were observed in the lungs of rabbits exposed to 4. Inflammatory cell infiltrates, congestion, and desquamated epithelium were also observed in the large bronchi and trachea of rabbits fed 9 mg fluoride/kg/day. Necrosis of the lung parenchyma was also observed in two high-dose rabbits that died before the end of the study. The cardiovascular effects of fluoride have been attributed to hypocalcemia I and hyperkalemia caused by high fluoride levels. Fluoride can bind with serum calcium if the dose is sufficient and cause hypocalcemia. Calcium is necessary for the functional integrity of the voluntary and autonomic nervous systems. Hypocalcemia can cause tetany, decreased myocardial contractility, and I1 possibly cardiovascular collapse (Bay less and Tinanoff 1985). Hyperkalemia has been suggested as the - cause gf the repeated episodes of ventricular fibrillation and eventual death that are often encountered in cases of fluoride poisoning (Baltazar et al. Approximately 2 hours after ingestion of 120 g of roach powder (97% sodium fluoride) in an unsuccessful suicide attempt, a 25-year-old male had severe toxic reactions that included tetany, multiple episodes of ventricular fibrillation, and esophageal stricture (Abukurah et al. Within 14 hours following exposure, the patient experienced 63 episodes of ventricular fibrillation. In a study of adults with skeletal fluorosis living in an area of China with high levels of fluoride in the drinking water (4. In two epidemiological studies, fluoride in the drinking water did not increase the mortality rates from cardiovascular effects. One of these studies was a report of 428,960 people in 18 areas of "high" natural fluoride (0. The water supply for 52% of the "high" fluoride population had average fluoride levels of 21 ppm (Heasman and Martin 1962). A positive relationship between heart disease and water fluoridation was reported, but these authors did not adjust for a doubling of the members of this population over 75 years old during the period of fluoridation under study (Jansen and Thomson 1974). In addition, this study lacked statistical analysis and drew conclusions regarding trends that were not obvious from the data presented. Doses of fluoride are difficult to estimate for large populations, however, because most people are potentially exposed to fluoride through a variety of sources, such as food, beverages, medicine, and dental products. Similarly, no significant alterations in the rate of cardiovascular system abnormalities were observed in a community with 8 ppm fluoride in the water supply, as compared to a community with 0. The results of other studies have suggested a role for fluoride in reducing cardiovascular disease. This effect was not due solely to differences in age distribution, because the incidence in the 55-64-year-old, high-fluoride group was lower than the incidence in th:e 45-54-year-old, low-fluoride group. In a study of four towns in Finland, Luoma (1980) found that incidence of cardiovascular disease correlated negatively with water fluoride concentration. Taves (1978) likewise found that standard mortality ratios decreased to a greater extent in fluoridated cities from 1950 to 1970 as compared to non-fluoridated control cities. Both studies, however, relied on population-summary information for disease rates. A mechanism for this potential reduction in cardiovascular disease could be the ability of fluoride to inhibit the calcification of soft tissue such as the aorta, as demonstrated in i vitro n studies (Taves and Neuman 1964; Zipkin et al. The primary gastrointestinal effects following both acute and chronic oral exposure to fluoride consist of nausea, vomiting, and gastric pain. The irritation of the gastric mucosa is attributed to fluoride (as sodium fluoride) forming hydrofluoric acid in the acidic environment of the stomach (Hoffman et al. The uncharged hydrogen fluoride molecule can then penetrate cell membranes and enter the neutral environment of the cytoplasm where it dissociates to release both fluoride and hydrogen ions. Thirty-four students (kindergarten through third grade) exhibited acute gastrointestinal effects after drinking water from school water fountains that provided a fluoride supplement designed to raise the water level to a range of 1-5 pprn (Hoffman et al. An accident with the delivery system resulted in the water levels reaching 375 ppm; specific doses could not be calculated, but were estimated to range from 1. In two other cases, individuals vomited and had abdominal pain immediately after accidentally consuming 1 tablespoon of sodium fluoride (used as a dusting powder for poultry) (Rao et al. Of the 150 cases involving fluoride intake reported to a poison control center from 1978 to 1979, most of the cases involved ingestion of <1 mg/kg fluoride, although exact doses could not be determined (Spoerke et al. Endoscopies were performed and biopsy samples were taken from healthy volunteers either after no treatment (control), or 2 hours after drinking 20 mL, of a solution containing 20 mg fluoride (1,000 ppm) I as sodium fluoride (Spak et al. Fluoride treatment resulted in petechiae (minute hemorrhages) or erosions in most of the subjects. Nausea was present in one-third of the subjects drinking the sodium fluoride solution, suggesting that nausea may not be the first sign of fluoride irritation of the gastric mucosa. While high levels of fluoride clearly can cause gastrointestinal irritation, it is unclear whether there are any gastrointestinal effects of chronic exposure to fluoride in drinking water. The sole evidence of an effect comes from a study of 20 non-ulcer dyspepsia patients at an outpatient clinic in India and 10 volunteers without gastrointestinal problems from the surgical clinic (Susheela et al. While none of the drinking water supplies of the controls had fluoride levels >1 ppm, the water supplies of 55% of the dyspepsia patients were at this level. In addition, all of the dyspepsia patients and 30% of the controls had serum fluoride levels >0. The study was compromised by small treatment size, undetermined total fluoride doses, undetermined nutritional status of the subjects, and lack of statistical comparisons. Seventy-eight workers engaged in the crushing and refining of cryolite, a mineral compound composed of sodium, aluminum, and fluoride, were examined (Moller and Gudjonsson 1932). Although an average exposure period was not presented, no workers with <2 years of exposure were included; 18 workers had been exposed for >10 years. The study authors stated that the effects were due only to cryolite dust being swallowed (either due to dust being deposited in the mouth during mouth-breathing, or due to deposition on the bronchial tree followed by mucociliary action bringing the material to the epiglottis) and absorbed through the gastrointestinal tract. They based this conclusion on the fact that 21 enamel-, glass-, and sulphuric acid-industry workers exposed by inhalation to fluorine gas (some for up to 40 years) revealed no evidence of any effect on the stomach. In light of what is now known about the absorption of fluorides ~ through the lung, the cryolite workers probably were exposed by both the oral and inhalation routes. Decreased appetite, congestion of the duodenum, and mild diarrhea were reported in sheep given a single intragastric dose of 28.


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