Nitrofurantoin

Kelley R. Branch, MD, MS

• Assistant Professor in Cardiology
• University of Washington
• Seattle, Washington

The confluence of two other peoples laying claim to the land (the Ngizim and Karekare) has developed into a complex history of plot and counter-plot over the twentieth century antimicrobial journal articles order 50 mg nitrofurantoin otc, and this continues to create rivalries into the present bacteria mod 164 buy nitrofurantoin 100 mg low price. Mai Yari was Fulfie and was concerned that a Karekare would replace him as District Head on antibiotics for sinus infection generic nitrofurantoin 50mg with amex. With the connivance of the State Police Commissioner he instigated his subjects to go on the rampage antibiotics for acne when pregnant purchase nitrofurantoin cheap online. In another case in 1994 virus treatment nitrofurantoin 100 mg with amex, 19 Churches were burnt by the Izala sect and the Emir acted promptly to prevent reprisals antibiotic resistant viruses best order for nitrofurantoin. Given the political connotation of the name, minority ethnic groups of southern Kaduna, Bauchi and Gombe are included. Before the coming of British rule in 1903, Islam had deep roots in these areas, excluding Plateau, Benue and Taraba states. Kontagora is noted for its ethno-religious and political violence, but there are also clashes between crop farmers and pastoral groups. In 44 Kontagora Emirate council efforts began in 1995 to reduce the violence in the area. The council tried to organise a committee of leaders representing the various ethnic groups resident in Kontagora. In February 2006, ethno-religious conflicts erupted in Kontagora leaving many people dead. Although the Emir summoned emergency meetings and appealed to the subjects to end the violence this was largely ineffective. Political wrangling and interference in Kontagora Emirate has reduced the authority of the Emir. The district head of Igede flouted the order of the Emir not to allow encroachment in Bobi Grazing Reserve and argued with the Emir in public. Similarly, Kainji National Park in New Bussa has been a flashpoint for clashes between pastoralists and the National Park guards. The ruler of New Bussa has intervened several times to stop the violence between Kainji National Park guards and pastoralists. The pastoralists claimed that the park had been their traditional halting point en route to dry season grazing. The National Park used armed force to stop them from passing through with their herds. The mediation of the Bussa traditional ruler succeeded in minimising the conflict in a situation that both the government and the administration of the National Park found difficult to handle. The Emir of Borgu Alhaji Haliru Dantoro, used chieftaincy titles to reconcile two former Heads of state General Ibrahim Babangida and Major-General Muhammadu Buhari. However, the turbaning ceremony of the duo provided a meeting point for the two men who decided to bury the hatchet after the Emir had a meeting with them before the installation ceremony. General Buhari was the first to be invited to the podium for the turbanning as protocol demanded but immediately the master of ceremony invited the former military leader to the stand, Gen. Buhari was appointed Maje of Borgu kingdom (Strong Pillar of Borgu Kingdom) while Gen. Babangida was made Mayaki of Borgu 45 kingdom (Invisible War Commander of Borgu Kingdom). The Nupe were converted to Islam at the end of the eighteenth century by Mallam Dendo, a wandering preacher, and were incorporated into the Fulfie kingdoms established by the Jihad after 1806. However, the traditions of Nupe were retained, hence the ruler of Nupe is the Etsu Nupe rather than being called Emir. Nupe fell to the British forces in 1897, the Etsu Abubakar was deposed and replaced by the more pliable Muhammadu (Vandeleur 1898). More detail on the history of the Nupe kingdoms can be found in Burdon (1909), Nadel (1942), Hogben & Kirk-Greene (1966:261-282) and Mason (1981). One arrangement that developed following disputes over accession to the position of Etsu was the post be circulated among three ruling houses, all of whom maintain bases in Bida. This tradition has been maintained, although not without dispute, and it provides an opportunity for the houses not in power to stir up popular agitation to try and get rid of an unpopular Etsu. The turbanning of the new Etsu, Alhaji Yahaya Abubakar took place in September 2003 in Minna rather than Bida, presumably reduce controversy. Although the realm of the Etsu Nupe is dominated by the Nupe people, these are divided into a number of groups, some of whom speak languages very distinct from standard Nupe. In addition, although the main Nupe towns are dominated by Islam, traditional religion remains very strong in many rural areas and the Nupe are well-known for their masquerades. Christianity has made some impact in rural areas but without any allegiance from the ruling group will remain weak. Although there are five other first class Emirs (the Emirs of Suleja, Kontagora, Agaie and New-Bussa), the president of the council of chiefs in Bida is the most powerful and respected by subjects and government authorities and has been appointed to many national and state assignments. The late Etsu Nupe was twice a member of Local Government Reforms Committee established by the Federal Government in 1988 and 2003. Nupeland, where the Etsu Nupe reigns, has been relatively peaceful and the majority of conflicts arise in 46 Suleja and Kontagora Emirates. The credit for low levels of conflict in the domain of the Etsu Nupe is attributed to the good governance of the traditional rulers. Regular meetings with senior councillors and District Heads is one strategy adopted by the ruler. The district heads in turn meet with village and ward heads to discuss issues affecting insecurity, banditry and conflicts within their domains. The dominant cases recorded during the fieldwork were marriages, witchcraft, and farmer/pastoralist conflicts. However, the Etsu Nupe being the president of the state council of chiefs has been involved in mediating crises outside Bida Emirate. Etsu Umaru Sanda was chosen by the 36 traditional rulers that met the then Head of State, General Abdulsalami Abubakar in their individual capacity; as the Chairmen of the various State Council of Chiefs to speak on their behalf following their exclusion from the 1999 constitution. The Etsu was called to advise in the Suleja chieftaincy crisis, the Kontagora uprisings and also the Kainji National Park Crisis. Most of them were surprised to hear that these roles are not entrenched in the constitution of the Federal Republic of Nigeria. They noted that it does not matter whether their role is entrenched in the constitution or not, since nobody can perform the role of peace builders better than traditional rulers. Staff of the Bida and Mokwa Local Governments observed that they had been assisted by traditional rules in revenue collection. The royal bodyguards (Dogarai) were dispatched to markets, motor-parks, villages and roadblocks on several occasions to assist in tax collections. Some respondents had expressed the need for a fourth tier of government, which should purely be manned by Emirate councils. As of now the traditional institution is performing several functions without due recognition or legal backing. However, they felt all these roles should be properly harmonized and entrenched in the constitution so that the former powers of the rulers can be restored. Hunters paying homage to the Territory from Lagos to Abuja in the 1980s, the principal Gomo of Kuje subjects of the Gomo of Kuje were Gade, Gbagyi, Nupe, and a few Hausa. However, once the capital moved to Abuja, it brought an influx of settlers and traders of very different backgrounds and thus less religious and ethnic uniformity. New disputes emerged and the traditional council had to be proactive to cope with these new issues. The Gomo had to expand his council to include leaders of the ethnic groups settled within his chiefdom. The representation of these groups gave the Gomo the opportunity to gain respect and allowed his authority to flourish (Photo 2). While the council was able to handle different kinds of dispute, the problem of cultism was one of the areas still to be tackled effectively. Cases of child abuse, rape, unwanted pregnancies and land disputes are some of the issues being handled by the traditional institution. Being relatively close to Abuja, Kuje was also being watched; the Federal Government would clearly be unhappy if there were serious disturbances in Kuje and furthermore they had be sure the ruler would follow their instructions. Senior councillors and district heads interviewed reported that there is currently more recognition of the traditional institution by government than in the past. The chief of Kuje (Gomo) was interviewed; likewise the district head, Sarkin Kasuwa (Market Leader), Sarkin Wanzamai (Leader of Local Barbers), the Chief Imam and others. The rulers are also well funded to support them in performing their traditional roles. This might suggest to an external observer that this is not a reflection of greater government respect for a traditional institution but rather a need to control closely activities in areas close to the seat of the Government. However, historical records all focus on the kingdom of fiyfi as the most important political entity from the seventeenth century onwards. By the end of the eighteenth century, the region was politically extremely complex and the development of walled towns throughout the region suggest a highly militarised culture. Islam came relatively late to the Yoruba area and was only of significance in the northernmost kingdoms. Further important syntheses of Yoruba history can be found in Johnson (1921), Biobaku (1973) and Law (1977). However, the literature is now extremely voluminous and only the Emirate of Ilorin is relevant to the present topic. It was founded following disputes in the ruling house of fiyfi, when one of the claimants to a title invited Mallams representing the Jihad to support the establishment of Ilorin. Although the early rulers of Ilorin were converted Yoruba, the Fulfie eventually took over the Emirate and their descendants remain in power. Ilorin was brought under British rule following a treaty between the Emir and Sir George Goldie in 1897. The mixed Yoruba/Fulfie heritage of Ilorin has been a source of tension since this era and the numerous political quarrels of the colonial era made Ilorin a difficult place to govern. In February 2002, a major crisis erupted when the State Governor upgraded the traditional title, Magaji Ilorin, to first class status and thus to a level equal to Emir. This move was resisted by the Fulfie dynasty and several lives were lost in the ensuing conflict. The Governor lost the elections in 2003 and the aged ruler passed away, so the post has not been filled. Despite the religious overtones, the underlying basis of these conflicts is undoubtedly ethnic. The Emir of Ilorin is a powerful Northern traditional ruler respected by his non-Yoruba subjects, State Government and Federal Authorities. Within his domain, conflict prevention and mediating committees have been established from the Emirate council to the district, village and ward levels. The committees are called to resolve conflicts between communities, such as boundary issues or farmer/pastoralist disputes. The intervention of the peace committee set up by the Emir facilitated the 2002 and 2004 settlement of the conflicts between pastoralists and crop farmers in Lata Grazing Reserve in Edu Local Government. From the lessons learned, the Emir set up to handle the Lata crisis, efforts were made to replicate the strategy and efforts to resolve the Offa and Erin Ille communal clashes. A committee comprising some councillors of the Emirate Council and District Heads in the affected areas is already making efforts to resolve the matter. At least fighting has stopped and discussions have commenced with the warring factions. The Emir of Ilorin despatched his peace and reconciliation committee under the auspices of the Ilorin Traditional Council to deal with the matter. The State Committee worked with Local Government and District Peace Committees to bring the crisis under control in just two days. Two weeks later, students in the College of Education in Offa wanted to stir up trouble but again the Peace Committee went into action and the crisis was headed off. All the above listed groups are always represented and are given opportunity to express their views. Monthly meetings are held among religious leaders of the two major 52 religions in the country.

Figure 3: Invasive Haemophilus influenzae Incidence Rates* by Age Group p11-002 antibiotic discount nitrofurantoin 100mg line, Indiana antibiotic knee spacers discount nitrofurantoin 100 mg with visa, 2014 14 antibiotic resistance database order nitrofurantoin mastercard. Table 2: Percent of reported Haemophilus influenzae cases by serotype antibiotic mouthwash over the counter cheap 100 mg nitrofurantoin free shipping, 2014 Type Number Percent a 5 4 antibiotics for sinus infection while breastfeeding order nitrofurantoin with mastercard. The main route of transmission for humans is breathing air contaminated with the virus natural antibiotics for sinus infection purchase 50 mg nitrofurantoin with amex. The disease was first described as a clinical syndrome, and the causative agent was identified as the Sin Nombre virus in the Four Corners area (Utah, New Mexico, Colorado and Arizona) in 1993. However, 12 states east of the Mississippi have reported cases, including Indiana. Since 1993, two hantavirus cases have been reported in Indiana, resulting in one death. Public Health Significance the initial symptoms of hantavirus include fever, tiredness, headache and fatigue. As the disease progresses, symptoms may include shortness of breath and coughing due to lungs filling with fluid (pneumonia). People most at risk for becoming infected with hantavirus include those who visit or reside in closed spaces where infected rodents live, including campers and hikers and those who work or play outdoors. In addition, housecleaning activities such as sweeping or vacuuming areas that rodents inhabit can release contaminated particles into the air. Epidemiology and Trends No hantavirus cases were reported in Indiana in 2014 or during the five-year reporting period 2010-2014. You can learn more about hantavirus by visiting the following Web site. Persons are at risk for hepatitis A infection if they have: fi Exposure to contaminated food or water, such as: o Consuming untreated water. Symptoms of hepatitis A usually occur suddenly and may include diarrhea, nausea, vomiting, tiredness, stomach pain, fever, dark urine, pale or clay-colored stool, loss of appetite and sometimes jaundice. People are most contagious from about two weeks before symptoms begin until two weeks after. Some people, especially children, may have no symptoms but can still spread the virus to others. Symptoms usually begin 28 days (range of 15-50 days) after exposure and usually last less than two months. About 10 percent to 15 percent of symptomatic people can recover and become ill again (relapse) for as long as 6 months. However, people will eventually recover, and hepatitis A infection has no longterm carrier. People who have had hepatitis A develop lifelong immunity and cannot get hepatitis A again. Beginning with the 2014-2015 school year, two doses of hepatitis A vaccine were required for all incoming kindergarten students. Candidates for vaccination also include persons at increased risk for hepatitis A infection or its consequences including: fi Persons with chronic liver disease or clotting factor disorders fi Men who have sex with men fi Injecting drug users fi Persons traveling to or working in countries where hepatitis A infection is endemic fi Persons who work with hepatitis A virus in a research setting fi Children who live in communities with consistently elevated rates of infection Post-exposure prophylaxis with hepatitis A vaccine or hepatitis A immune globulin is effective if received within two weeks of exposure. This goal was met in Indiana in 2010, 2012 and 2014 for the five-year reporting period 2010-2014 (Figure 1). Table 1: Hepatitis A case rate by race and sex, Indiana, 2014 Cases Rate* 2009 2014 Total Indiana 20 0. Figure 2: Hepatitis A Cases by Year, Indiana, 2010-2014 35 30 32 25 20 24 15 20 10 11 11 5 0 2010 2011 2012 2013 2014 Year Incidence of disease was greatest in April and May (Figure 3). Figure 3: Hepatitis A Cases by Month, Indiana, 2014 5 4 4 4 3 3 2 2 2 2 1 1 1 1 0 0 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Figure 4 shows age-specific rates were greatest for adults aged 80 years and over (0. You can learn more about hepatitis A by visiting the following Web sites. This serious viral disease of the liver is transmitted through parenteral or mucosal exposure to blood or body fluids of an infected person. Acute hepatitis B virus infection is a short-term illness that occurs within the first six months after someone is exposed to the hepatitis B virus. An acute hepatitis B illness can range in severity from a very mild illness with few or no symptoms, to a serious condition requiring hospitalization, characterized by multiple symptoms such as nausea, anorexia, fever, malaise, headache, myalgia, right upper quadrant abdominal pain, dark urine, skin rash and jaundice. The time variation is related to the amount of virus transmitted, the mode of transmission and host factors. Most adult acute hepatitis B infections result in complete recovery and immunity from future infection. Many individuals with chronic hepatitis B do not have symptoms and do not know they are infected. Clinical and laboratory definitions must be met to classify a case of hepatitis B. Although changes were made to the definition in 2012, no changes were made in 2013 or 2014. Risk for hepatitis B infection varies with occupation, lifestyle or environment where there is contact with blood from infected persons. Populations at intermediate risk include: prisoners, health care workers, staff caring for developmentally disabled individuals, and heterosexuals with multiple partners. After three intramuscular doses of hepatitis B vaccine, more than 90 percent of healthy adults and more than 95 percent of infants, children and adolescents will develop adequate immunity. Hepatitis B vaccination programs addressing each of these priorities will ultimately eliminate domestic hepatitis B transmission. Control measures used to prevent exposures to blood and body fluids, another mechanism for the transmission of hepatitis B, include the use of universal precautions and disinfection of contaminated equipment. Hospitals and healthcare providers must report their findings within 72 hours, and positive laboratory results must be reported at least weekly. Healthy People 2020 Goal the Healthy People 2020 objective for hepatitis B is to reduce both new and chronic infections in a variety of populations. The first goal toward addressing that objective is to reduce new infections in adults age 19 years and older to 1. Also included in Figure 1 is the reference level for the Healthy People 2020 goal for reducing new infections in adults ages 19 and older. As evidenced in the table, during 2014, Indiana only met the Healthy People 2020 goal for the 60-69 and 70-79 year age groups. Overall for 2014, an increase in the incidence rate of infection was noted in each age group, with the exception of the 40-49 age group, as compared to 2013. This overall increase in number of acute hepatitis B cases continues to be the trend and is likely attributed to an increase in the reporting and surveillance of hepatitis B throughout the state. Although improved reporting and surveillance can be reason for an increase in incidence of disease, significant work needs to continue to be accomplished in each of the goal areas in order to meet the Healthy People 2020 objective for hepatitis B. However, the most notable increase was seen in the race category of white individuals (Table 1). Table 1: Acute Hepatitis B case rate by race and sex, Indiana, 2014 Cases Rate* 2010-2014 Total Indiana 126 1. Figure 2 shows reported cases of acute hepatitis B for the five-year period 2010-2014. In 2014, the number of reported cases of acute hepatitis B increased compared to 2013 (101). The consistent increase in reported cases since 2011 can be attributed to increased reporting, investigating and treatment that is being provided by local health departments, laboratories, hospitals and physicians throughout the state. This increase can also be attributed to the rise in awareness of the public of the need for testing. Figure 2: Acute Hepatitis B Cases by Year, Indiana, 2010-2014 140 120 126 100 80 101 90 60 75 70 40 20 0 2010 2011 2012 2013 2014 Year Acute hepatitis B cases occurred and were reported during each month in 2014 without specific seasonality (Figure 3). Figure 3: Acute Hepatitis B Cases by Month, Indiana, 2014 20 16 14 15 13 13 12 11 11 9 10 8 8 8 5 5 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month the number of reported cases of hepatitis B varied with age. Figure 4 shows acute hepatitis B incidence rates by age group per 100,000 population. In Indiana, as well as nationally, higher rates of hepatitis B disease continue among adults, particularly males 30-39 and 40-49 years of age, and persons with identified risk factors. All of this data also emphasizes the need for continued vaccination of adults and young people, and the provision of preventative counseling; especially for those who are at higher risk for acquiring hepatitis B infection. Table 2 highlights the identified risk factors in 2014 for the acute hepatitis B cases in Indiana. This represents a decrease in the number of counties reporting acute cases in 2013 (45 counties). The incidence rates, per 100,000 population, were highest among the following counties reporting five or more cases: Fayette (29. Figure 5 shows acute hepatitis B incidence rates by county per 100,000 population. Individuals with chronic hepatitis B infection may be asymptomatic and unaware of their infection for many years before developing clinical evidence of illness. Serologic testing identifies infected persons, allowing for treatment and the identification and vaccination of their contacts. In 2014, the testing and reporting of the hepatitis B status of refugees residing in Indiana continued, especially in Marion and Allen counties, where refugee centers are located. The provision of education and counseling regarding the testing and vaccination for household contacts is also a part of the perinatal program. Infections may range from asymptomatic or mild illness lasting several weeks to serious, lifelong illness. The number of reported cases is determined by the number of positive hepatitis C tests reported for the first time during a given year. Acute cases were reportable in 2014, but data are also collected and reported on chronic cases to assess risk factors when feasible. Investigation of chronic hepatitis C cases contributes to the reduction in the spread of disease by increasing the percentage of persons aware they have a hepatitis C infection and educating infected individuals. This eventually led to the implementation and screening of both blood products and organs for donation and increased detection of the disease. The number of acute hepatitis C cases decreased from 140 cases in 2013 to 122 cases in 2014. Between 15 percent and 20 percent of these acute cases will spontaneously clear the virus, and individuals will no longer be considered infected. The remaining infected individuals may be asymptomatic for years or even decades, becoming chronic cases. Symptoms that may be present during infection include abdominal pain, fatigue, fever, joint pain, jaundice, loss of appetite, dark urine, light stool and nausea and/or vomiting. Populations most at risk include injection drug users and recipients of blood transfusions and organ transplants prior to 1992. Twenty percent of cases will develop serious liver damage from hepatitis C, and 25 percent of those will need a liver transplant, develop liver cancer or die. Antibodies can be found in 7 out of 10 persons when symptoms begin and in 9 out of 10 people within three months after symptoms begin. There is no vaccine for hepatitis C; treatment for hepatitis C is available and is becoming increasingly more effective. New treatments with higher success rates than those seen in previous years have been developed. However, these treatments often carry adverse side effects and can be very costly. New treatment technologies available and their duration of use should be discussed thoroughly with a healthcare provider. Use of this rapid test, along with the counseling and education of those infected with the disease, will reduce the spread of hepatitis C. Aspire Indiana, a non-profit comprehensive community mental health center, is assisting with these efforts. Laboratory reporting enables identification of asymptomatic persons infected with the virus as well as those displaying symptoms, and positive results must be reported at least weekly. Surveillance capacity to monitor both acute and chronic viral hepatitis is limited at the state and local levels, resulting in underreporting and incomplete variable quality data that is insufficient for understanding the magnitude of hepatitis C in Indiana. To see the most current national statistical summary of data, which includes Indiana, go to . Epidemiology and Trends In 2014, 122 cases of acute hepatitis C infection were reported, for an incidence rate of 1. For chronic hepatitis C infection, 6,506 cases were reported during 2014 for a prevalence rate of 98. Table 2 highlights the most common risk factors identified in 2014 for acute hepatitis C cases in Indiana. Table 1: Hepatitis C cases by race and sex, Indiana 2014 Acute Chronic 2010-2014 Cases Rate Cases Rate Total Cases Indiana 122 1. Table 2: Acute Hepatitis C risk factors, Indiana, 2014 Risk Factor Number of Cases (%) Injected drugs not prescribed by doctor 60 (49. The number of total reported cases of hepatitis C infection for the five-year period 2010-2014. Figure 1: Hepatitis C Cases* by Year, Indiana, 2010-2014 7000 6000 6628 5000 5826 5636 5356 4000 4934 3000 2000 1000 0 2010 2011 2012 2013 2014 Year * Includes Chronic and Acute Cases Figure 2. Age-specific prevalence rates for total acute and chronic reported cases of hepatitis C infection during 2014. Offenders are tested for bloodborne diseases, such as hepatitis C, at these facilities, but likely reside in other Indiana counties. In 2014, at least one case of hepatitis C infection was reported in each of the 92 counties.

For example antibiotics yellow stool discount 100mg nitrofurantoin fast delivery, one area of great potential in advancing current knowledge of the effects of diet on health is the study of genetic markers of disease susceptibility (especially polymorphisms in genes that encode metabolizing enzymes) in relation to dietary exposures what causes antibiotic resistance yahoo purchase cheap nitrofurantoin online. This development is expected to provide more accurate assessments of the risk associated with different levels of intake of nutrients and other food constituents antibiotic 200 mg buy nitrofurantoin 100mg free shipping. While analytic epidemiological studies (studies that relate exposure to disease outcomes in individuals) have provided convincing evidence of an associative relationship between selected nondietary exposures and disease risk antibiotics kidney infection proven 100mg nitrofurantoin, there are a number of other factors that limit study reliability in research relating nutrient intakes to disease risk (Sempos et al inflection point order genuine nitrofurantoin on line. First antibiotic lupin buy generic nitrofurantoin on-line, the variation in nutrient intake may be rather limited in the population selected for study. This feature alone may yield modest relative risk across intake categories in the population, even if the nutrient is an important factor in explaining large disease-rate variations among populations. Third, many cohort and case-control studies have relied on self-reports of diet, typically from food records, 24-hour recalls, or diet history questionnaires. Repeated application of such instruments to the same individuals shows considerable variation in nutrient consumption estimates from one time period to another with correlations often in the 0. In addition, there may be systematic bias in nutrient consumption estimates from self-reports, as the reporting of food intakes and portion sizes may depend on individual characteristics such as body mass, ethnicity, and age. For example, some have demonstrated more pronounced and substantial underreporting of total energy consumption among obese persons than among lean persons (Heitmann and Lissner, 1995; Schoeller et al. Such systematic bias, in conjunction with random measurement error and limited intake range, has the potential to greatly impact analytical epidemiological studies based on self-reported dietary habits. Cohort studies using objective (biomarker) measures of nutrient intake may have an important advantage in the avoidance of systematic bias, though important sources of bias. Finally, there can be the problem of multicollinearity, in which two independent variables are related to each other, resulting in a low p value for an association with a dependent variable, when in fact each of the independent variables have no relationship to the dependent variable (Sempos et al. Randomized Clinical Trials By randomly allocating subjects to the nutrient exposure level of interest, clinical trials eliminate the confounding that may be introduced in observational studies by self-selection. The unique strength of randomized trials is that, if the sample is large enough, the study groups will be similar not only with respect to those confounding variables known to the investigators, but also to other unknown factors that might be related to risk of the disease. Thus, randomized trials achieve a degree of control of confounding that is simply not possible with any observational design strategy, and thus they allow for the testing of small effects that are beyond the ability of observational studies to detect reliably. Although randomized controlled trials represent the accepted standard for studies of nutrient consumption in relation to human health, they too possess important limitations. Specifically, individuals agreeing to be randomized may be a select subset of the population of interest, thus limiting the generalization of trial results. In addition, the follow-up period will typically be short relative to the preceding time period of nutrient consumption; the chronicity of intake may be relevant to the health outcomes under study, particularly if chronic disease endpoints are sought. Also, dietary intervention or supplementation trials tend to be costly and logistically difficult, and the maintenance of intervention adherence can be a particular challenge. Many complexities arise in conducting studies among free-living human populations. The totality of the evidence from observational and intervention studies, appropriately weighted and corroborated by an understanding of the underlying mechanisms of action, must form the basis for conclusions about causal relationships between particular exposures and disease outcomes. Weighing the Evidence As a principle, only studies published in peer-reviewed journals have been used in this report. However, raw data or studies published in other scientific journals or readily available reports were considered if they appeared to provide important information not documented elsewhere. For estimating requirements for energy, doubly labeled water data was collected from various investigators and subject to statistical analysis (see Appendix I). On the basis of a thorough review of the scientific literature, clinical, functional, and biochemical indicators of nutritional adequacy and excess were identified for each nutrient. The characteristics examined included the study design and the representativeness of the study population; the validity, reliability, and precision of the methods used for measuring intake and indicators of adequacy or excess; the control of biases and confounding factors; and the power of the study to demonstrate a given difference or correlation. For example, biological plausibility would not be sufficient in the presence of a weak association and lack of evidence that exposure preceded the effect. Data Limitations Although the reference values are based on data, the data were often scanty or drawn from studies that had limitations in addressing the various questions that arose in reviewing the data. Therefore, many of the questions raised about the requirements for, and recommended intakes of, these nutrients cannot be answered fully because of inadequacies in the present database. Apart from studies of overt deficiency diseases, there is a dearth of studies that address specific effects of inadequate intakes on specific indicators of health status, and thus a research agenda is proposed (see Chapter 14). For many of these nutrients, estimated requirements are based on balance, biochemical indicators, and clinical deficiency data because there is little information relating health status indicators to functional sufficiency or insufficiency. Thus, after careful review and analysis of the evidence, including examination of the extent of congruent findings, scientific judgment was used to determine the basis for establishing the values. The reasoning used in developing the values is described for each nutrient in Chapters 5 through 11. Using the infant exclusively fed human milk as a model is in keeping with the basis for earlier recommendations for intake. It also supports the recommendation that exclusive intake of human milk is the preferred method of feeding for normal, full-term infants for the first 4 to 6 months of life. In general, this report does not cover possible variations in physiological need during the first month after birth or the variations in intake of nutrients from human milk that result from differences in milk volume and nutrient concentration during early lactation. The use of formula introduces a large number of complex issues, one of which is the bioavailability of different forms of the nutrient in different formula types. This volume was reported from studies that used test weighing of full-term infants. In this procedure, the infant is weighed before and after each feeding (Allen et al. Because there is variation in both the composition of milk and the volume consumed, the computed value represents the mean. It is assumed that infants will consume increased volumes of human milk during growth spurts to meet their needs for maintenance, as well as for growth. There is little evidence, however, of markedly different needs for carbohydrate, fat, and n-6 and n-3 polyunsaturated fatty acids. However, for the energy-yielding nutrients, these methods were not appropriate because the amount of energy required per body weight is significantly lower during the second 6 months, due largely to the slower rate of weight gain/kg of body weight. The amounts of fat and carbohydrate consumed from complementary foods were determined by using data from the Third National Health and Nutrition Examination Survey. One problem encountered in deriving intake data in infants was the lack of available data on total nutrient intake from a combination of human milk and solid foods in the second 6 months of life. Most intake survey data do not identify the milk source, but the published values indicate that cow milk and cow milk formula were most likely consumed. For determining estimated energy requirements using a doubly labeled water database, equations using stepwise multiple linear regressions were generated to predict total energy expenditure based on age, gender, height, and weight. Methods to Determine Increased Needs for Pregnancy It is known that the placenta actively transports certain nutrients from the mother to the fetus against a concentration gradient (Hay, 1994). In these cases, the potential for increased need for these nutrients during pregnancy is based on theoretical considerations, including obligatory fetal transfer, if data are available, and on increased maternal needs related to increases in energy or protein metabolism, as applicable. Methods to Determine Increased Needs for Lactation For the nutrients under study, it is assumed that the total requirement of lactating women equals the requirement for the nonpregnant, nonlactating woman of similar age plus an increment to cover the amount needed for milk production. To allow for inefficiencies in use of certain nutrients, the increment may be greater than the amount of the nutrient contained in the milk produced. While data regarding total fat, cholesterol, protein, and amino acid content of various foods have been available for many years, data for individual fatty acids have only recently been available. For nutrients such as energy, fiber, and trans fatty acids, analytical methods to determine the content of the nutrient in food have serious limitations. Methodological Considerations the quality of nutrient intake data varies widely across studies. The most valid intake data are those collected from the metabolic study protocols in which all food is provided by the researchers, amounts consumed are measured accurately, and the nutrient composition of the food is determined by reliable and valid laboratory analyses. It is well known that energy intake is underreported in national surveys (Cook et al. Estimates of underreporting of energy intake in the Third National Health and Nutrition Examination Survey were 18 percent of the adult men and 28 percent of the adult women participating (Briefel et al. In addition, alcohol intake, which accounted for approximately 4 percent of the total energy intake in men and 2 percent in women, is thought to be routinely underreported as well (McDowell et al. Adjusting for Day-to-Day Variation Because of day-to-day variation in dietary intakes, the distribution of 1-day (or 2-day) intakes for a group is wider than the distribution of usual intakes, even though the mean of the intakes may be the same (for further elaboration, see Chapter 13). However, no accepted method is available to adjust for the underreporting of intake, which may average as much as 18 to 28 percent for energy (Briefel et al. A second recall was collected for a 5 percent nonrandom subsample to allow adjustment of intake estimates for day-to-day variation. Survey data from 1990 to 1997 for several Canadian provinces are available for energy, carbohydrate, fat, saturated fat, and protein intake (Appendix F). Food Sources For some nutrients, two types of information are provided about food sources: identification of the foods that are the major contributors of the nutrients to diets in the United States, and the food sources that have the highest content of the nutrient. The determination of foods that are major contributors depends on both nutrient content of a food and the total consumption of the food (amount and frequency). Therefore, a food that has a relatively low concentration of a nutrient might still be a large contributor to total intake if that food is consumed in relatively large amounts. Feinleib M, Rifkind B, Sempos C, Johnson C, Bachorik P, Lippel K, Carroll M, Ingster-Moore L, Murphy R. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. The relation between energy intake derived from estimated diet records and intake determined to maintain body weight. The Copenhagen Cohort Study on Infant Nutrition and Growth: Breast-milk intake, human milk macronutrient content, and influencing factors. Food and nutrient exposures: What to consider when evaluating epidemiologic evidence. Reproducibility and validity of a semiquantitative food frequency questionnaire. The fact that diets are usually composed of a variety of foods that include varying amounts of carbohydrate, protein, and various fats imposes some limits on the type of research that can be conducted to ascertain causal relationships. The available data regarding the relationships among major chronic diseases that have been linked with consumption of dietary energy and macronutrients (fats, carbohydrates, fiber, and protein), as well as physical inactivity, are discussed below and are reviewed in greater detail in the specific nutrient chapters (Chapters 5 through 11) and the chapter on physical activity (Chapter 12). Early studies in animals showed that diet could influence carcinogenesis (Tannenbaum, 1942; Tannenbaum and Silverstone, 1957). Cross-cultural studies that compare incidence rates of specific cancers across populations have found great differences in cancer incidence, and dietary factors, at least in part, have been implicated as causes of these differences (Armstrong and Doll, 1975; Gray et al. In addition, observational studies have found strong correlations among dietary components and incidence and mortality rates of cancer (Armstrong and Doll, 1975). Many of these associations, however, have not been supported by clinical and interventional studies in humans. Increased intakes of energy, total fat, n-6 polyunsaturated fatty acids, cholesterol, sugars, protein, and some amino acids have been thought to increase the risk of various cancers, whereas intakes of n-3 fatty acids, dietary fiber, and physical activity are thought to be protective. The major findings and potential mechanisms for these relationships are discussed below. Energy Animal studies suggest that restriction of energy intake may inhibit cell proliferation (Zhu et al. A risk of mortality from cancer has been associated with increased energy intakes during childhood (Frankel et al. Excess energy intake is a contributing factor to obesity, which is thought to increase the risk of certain cancers (Carroll, 1998). To support this concept, a number of studies have observed a positive association between energy intake during adulthood and risk of cancer (Andersson et al. Dietary Fat High intakes of dietary fat have been implicated in the development of certain cancers. Early cross-cultural and case-control studies reported strong associations between total fat intake and breast cancer (Howe et al. Evidence from epidemiological studies on the relationship between fat intake and colon cancer has been mixed as well (De Stefani et al. Howe and colleagues (1997) reported no association between fat intake and risk of colorectal cancer from the combined analysis of 13 case-control studies. Epidemiological studies tend to suggest that dietary fat intake is not associated with prostate cancer (Ramon et al. Giovannucci and coworkers (1993), however, reported a positive association between total fat consumption, primarily animal fat, and risk of advanced prostate cancer. Numerous mechanisms for the carcinogenic effect of dietary fat have been proposed, including eiconasanoid metabolism, cellular proliferation, and alteration of gene expression (Birt et al. Experimental evidence suggests several mechanisms in which n-3 fatty acids may protect against cancer. Epidemiological studies have shown an inverse relationship between fish consumption and the risk of breast and colorectal cancer (Caygill and Hill, 1995; Caygill et al. Monounsaturated fatty acids have been reported as being protective against breast, colon, and possibly prostate cancer (Bartsch et al. However, there is also some epidemiological evidence for a positive association between these fatty acids and breast cancer risk in women with no history of benign breast disease (Velie et al. There may be protective effects associated with olive oil (Rose, 1997; Trichopoulou et al. Dietary Carbohydrate While the data on sugar intake and cancer are limited and insufficient, several case-control studies have shown an increased risk of colorectal cancer among individuals with high intakes of sugar-rich foods (Benito et al. Additionally, high vegetable and fruit consumption and avoidance of foods containing highly refined sugars were shown to be negatively correlated to the risk of colon cancer (Giovannucci and Willett, 1994). Dietary Fiber There is some evidence based on observational and case-control studies that fiber-rich diets are protective against colorectal cancer (Lanza, 1990; Trock et al. There is also some epidemiological evidence of a protective effect of cereals and cereal fiber against colon carcinogenesis (Hill, 1997).

Syndromes

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• Skin changes: moist, warm, thin, pale (occasionally)

Most commonly used stains include auraminerhodamine infection skin purchase nitrofurantoin 100mg online, a modified acid-fast stain virus x 1948 buy nitrofurantoin 100mg free shipping, and safranin-methylene blue antibiotics for chest infection buy discount nitrofurantoin 50 mg on line. A fiuorescein-tagged monoclonal antibody is useful for detecting oocysts in stool and in environmental samples bacteria diagram purchase nitrofurantoin 100mg on line. Infection with this organism is not easily detected unless looked for specifically antibiotics yellow tongue generic 100 mg nitrofurantoin free shipping. Serological assays may help in epidemiological studies bacteria 600x cheap 100mg nitrofurantoin with visa, but it is not known when the antibody appears and how long it lasts after infection. Cryptosporidium oocysts have been identified in human fecal specimens from more than 50 countries. Children under 2, animal handlers, travellers, men who have sex with men and close personal contacts of infected individuals (families, health care and day care workers) are particularly prone to infection. Outbreaks have been reported in day care centers around the world, and have also been associated with: drinking water (at least 3 major outbreaks involved public water supplies); recreational use of water including waterslides, swimming pools and lakes; and consumption of contaminated beverages. The parasite infects intestinal epithelial cells and multiplies initially by schizogony, followed by a sexual cycle resulting in fecal oocysts that can survive under adverse environmental conditions for long periods of time. Oocysts are highly resistant to chemical disinfectants used to purify drinking water. Immunodeficient individuals generally clear their infections when factors of immunosuppression (including malnutrition or intercurrent viral infections such as measles) are removed. In communities with modern and adequate sewage disposal systems, feces can be discharged directly into sewers without preliminary disinfection. If waterborne transmission is suspected, large volume water sampling filters can be used to look for oocysts in the water. If the individual is taking immunosuppressive drugs, these should be stopped or reduced wherever possible. Epidemic measures: Epidemiological investigation of clustered cases in an area or institution to determine source of infection and mode of transmission; search for common vehicle, such as recreational water, drinking water, raw milk or other potentially contaminated food or drink; institute applicable prevention or control measures. Control of person-to-person or animal-to-person transmission requires emphasis on personal cleanliness and safe disposal of feces. Diarrhea in the immunocompetent can be prolonged but is self-limited; mean duration of organism shedding was 23 days in Peruvian children. It has also been associated with diarrhea in travellers to Asia, the Caribbean, Mexico and Peru. Produce should be washed thoroughly before it is eaten, although this practice does not eliminate the risk of cyclosporiasis. Cyclosporiasis can be treated with a 7-day course of oral trimethoprimsulfamethoxazole (for adults, 160 mg trimethoprim plus 800 mg sulfamethoxazole twice daily; for children, 5 mg/kg trimethoprim plus 25 mg/kg sulfamethoxazole twice daily). In patients who are not treated, illness can be protracted, with remitting and relapsing symptoms. Treatment regimens for patients who cannot tolerate sulfa drugs have not been identified. Health care providers should consider the diagnosis of Cyclospora infection in persons with prolonged diarrheal illness and request stool specimens so that specific tests for this parasite can be made. In jurisdictions where formal reporting mechanisms are not yet established, clinicians and laboratory workers who identify cases of cyclosporiasis are encouraged to inform the appropriate health departments. Serious manifestations of infection vary depending on the age and immunocompetence of the individual at the time of infection. Lethargy, convulsions, jaundice, petechiae, purpura, hepatosplenomegaly, chorioretinitis, intracerebral calcifications and pulmonary infiltrates may occur. Survivors show mental retardation, microcephaly, motor disabilities, hearing loss and evidence of chronic liver disease. Death may occur in utero; the neonatal case-fatality rate is high for severely affected infants. Fetal infection may occur during either primary or reactivated maternal infections; primary infections carry a much higher risk for symptomatic disease and sequelae. Seronegative newborns who receive blood transfusions from seropositive donors may also develop severe disease. Infection acquired later in life is generally inapparent but may cause a syndrome clinically and hematologically similar to Epstein-Barr virus mononucleosis, distinguishable by virological or serological tests and the absence of heterophile antibodies. It is the most common cause of mononucleosis following transfusion to nonimmune individuals; many posttransfusion infections are clinically inapparent. The situation in developing countries is not well described, but infection generally occurs early in life and most intrauterine infections are due to reactivation or reinfection of maternal infection. Persistent excretion may occur in infected newborns and immunosuppressed individuals. Virus can be transmitted to infants through infected breastmilk, an important source of infection but not of disease, except when milk from a surrogate mother is given to seronegative infants. Transmission through sexual intercourse is common and is refiected by the almost universal infection of men who have many male sexual partners. Adults appear to excrete virus for shorter periods, but the virus persists as a latent infection. Preventive measures: 1) Take care in handling diapers; wash hands after diaper changes and toilet care of newborns and infants. Workers in day care centers and preschools (especially those dealing with mentally retarded populations), should observe strict standards of hygiene, including handwashing. Minor bleeding phenomena, such as petechiae, epistaxis or gum bleeding may occur at any time during the febrile phase. Differential diagnosis includes chikungunya and other epidemiologically relevant diseases listed under arthropod-borne viral fevers, infiuenza, measles, rubella, malaria, leptospirosis, typhoid, scrub typhus and other systemic febrile illnesses, especially those accompanied by rash. Laboratory confirmation of dengue infection is through detection of virus either in acute phase blood/serum within 5 days of onset or of specific antibodies in convalescent phase serum obtained 6 days or more after onset of illness. Virus is isolated from blood by inoculation to mosquitoes, or by culture in mosquito cell lines, then identified through immunofiuorescence with serotype-specific monoclonal antibodies. These procedures provide a definitive diagnosis, but practical considerations limit their use in endemic countries. A positive test result in a single serum indicates presumptive recent infection; a definitive diagnosis requires increased antibody levels in paired sera. Since these assays are costly, demand meticulous technique, and are highly prone to false-positives through contamination, they are not yet applicable for wide use in all settings. Dengue viruses of several types have regularly been reintroduced into the Pacific and into northern Queensland, Australia, since 1981. In large areas of western Africa, dengue viruses are probably transmitted epizootically in monkeys; urban dengue involving humans is also common in this area. Successive introduction and circulation of all 4 serotypes in tropical and subtropical areas of the Americas has occurred since 1977; dengue entered Texas in 1980, 1986, 1995 and 1997. As of the late 1990s, two or more dengue viruses are endemic or periodically epidemic in virtually all of the Caribbean and Latin America including Brazil, Bolivia, Colombia, Ecuador, the Guyanas, Mexico, Paraguay, Peru, Suriname, Venezuela, and central America. Dengue was introduced into Easter Island, Chile in 2002 and reintroduced into Argentina at the northern border with Brazil. Epidemics may occur wherever vectors are present and virus is introduced, whether in urban or rural areas. This is a day biting species, with increased biting activity for 2 hours after sunrise and several hours before sunset. Patients are infective for mosquitoes from shortly before the febrile period to the end thereof, usually 3 5 days. The mosquito becomes infective 8 12 days after the viraemic blood-meal and remains so for life. Recovery from infection with one serotype provides lifelong homologous immunity but only short-term protection against other serotypes and may exacerbate disease upon subsequent infections (see Dengue hemorrhagic fever). Preventive measures: 1) Educate the public and promote behaviours to remove, destroy or manage mosquito vector larval habitats, which for Ae. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidemics; case reports, Class 4 (see Reporting). Until the fever subsides, prevent access of day biting mosquitoes to patients by screening the sickroom or using a mosquito bednet, preferably insecticide-impregnated, for febrile patients, or by spraying quarters with a knockdown adulticide or residual insecticide. If dengue occurs near possible jungle foci of yellow fever, immunize the population against yellow fever because the urban vector for the two diseases is the same. Acetylsalicylic acid (aspirin) is contraindicated because of its hemorrhagic potential. Epidemic measures: 1) Search for and destroy Aedes mosquitoes in sites of human habitation, and eliminate or apply larvicide to all potential Ae. Disaster implications: Epidemics can be extensive and affect a high percentage of the population. International measures: Enforce international agreements designed to prevent the spread of Ae. Prompt oral or intravenous fiuid therapy may reduce hematocrit rise and require alternate observations to document increased plasma leakage. In severe cases, findings include accumulation of fiuids in serosal cavities, low serum albumin, elevated transaminases, a prolonged prothrombin time and low levels of C3 complement protein. Viruses can be isolated from blood during the acute febrile stage of illness by inoculation to mosquitoes or cell cultures. In outbreaks in the Americas, the disease is observed in all age groups although two-thirds of fatalities occur among children. Such antibodies may enhance infection of mononuclear phagocytes through the formation of infectious immune complexes. Geographic origin of dengue strain, age, gender and human genetic susceptibility are also important risk factors. Control of patient, contacts and immediate environment: 1), 2), 3), 4), 5) and 6) Report to local health authority, Isolation, Concurrent disinfection, Quarantine, Immunization of contacts and Investigation of contacts and source of infection: See Dengue fever. The rate of fiuid administration must be judged by estimates of loss, usually through serial microhematocrit urine output and clinical monitoring. Blood transfusions are indicated for massive bleeding or in cases with unstable signs or a true fall in hematocrit. The use of heparin to manage clinically significant hemorrhage occurring in the presence of well-documented disseminated intravascular coagulation is high-risk and of no proven benefit.

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