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A. Kirk, M.B.A., M.D.

Clinical Director, Texas Tech University Health Sciences Center School of Medicine

Demographic information is based on the latest estimates from the United Nations Population Division (children under age five) and the Inter-agency Child Mortality Estimation Group (under-five deaths). Notes: (a) Data refer to the most recent year available during the period specified in the column heading. Recommended homemade fluids: Percentage of children aged 0-59 months with diarrhoea in the previous two weeks receiving at least one recommended homemade fluid during the diarrhoea episode. Survey questions should be customized to reflect national guidelines designating a set of appropriate fluids that may be prepared at home. Increased fluids: Percentage of children aged 0-59 months with diarrhoea in the previous two weeks receiving more to drink than usual during the diarrhoea episode. Continued feeding: Percentage of children aged 0-59 months with diarrhoea in the previous two weeks receiving either the same, more or somewhat less to eat than usual during the diarrhoea episode. Vitamin A supplementation (full coverage): Percentage of children aged 6-59 months who received 2 doses of vitamin A supplements in 2008. Measles immunization: Percentage of one-year-old children immunized against measles Improved drinking water: Percentage of the population using improved drinking water sources. Improved sanitation facilities: Percentage of the population using improved sanitation facilities. Instead, data from these surveys have been re-analysed to conform to the definition of this indicator. The complete diarrhoea treatment databases (including time series, disparities and detailed source information for other treatment indicators) are available at: The plan includes a treatment package to significantly reduce child deaths due to diarrhoea, and a prevention package to make a lasting reduction in the diarrhoea burden for years to come. Oral rehydration therapy and continued feeding is a life-saving treatment, which only 39 per cent of children with diarrhoea in developing countries receive. Zinc tablets are still largely unavailable in most developing countries, although their effectiveness in reducing the severity and duration of diarrhoea episodes is well known. Immunization against rotavirus, which results in an estimated 40 per cent of hospital admissions due to diarrhoea among children under five, is urgently needed worldwide, especially in Africa and Asia. Safe water, adequate sanitation and proper hygiene are too often forgotten foundations of good health. Handwashing with soap alone could potentially reduce the number of diarrhoea cases by over 40 per cent. Infants who are exclusively breastfed for the first six months of life and continue to be breastfed until two years of age and beyond develop fewer infections and have less severe illnesses, including diarrhoea. Vitamin A supplementation has been shown to significantly reduce child deaths, mostly from diarrhoea and measles. Fish Histology and Histopathology Contributing authors: Sonia Mumford; Jerry Heidel; Charlie Smith; John Morrison; Beth MacConnell; Vicki Blazer Table of Contents 1. Infectious Diseases Beth MacConnell; Vicki Blazer; Sonia Mumford; Charlie Smith; John Morrison 7. Glossary Chapter 1 ­ Tissue Processing Fish Histology and Histopathology Processing Tissues For Histology Turning the Gross Tissues into Beautiful Sections Sample collection ·Samples should be collected on freshly dead fish, not frozen or "Extremely Dead" ·Sample volume should not exceed 1/10th of the volume of fixative ·Samples should be placed in an appropriate fixative. The remaining 3 basic tissues are connective tissue, muscular tissue and nervous tissue. Epithelia generally act as boundaries for transport, protection, segregation, sensation, and secretion. Epithelia are classified first by thickness: Simple: one cell layer thick, or one cell separates the free (luminal, apical) surface from the underlying basement membrane. Stratified: many layers of cells which grow from the basal lamina upward and eventually shed into the lumen or free surface. Epithelia are classified secondly by shape of the cells: Squamous- very thin and flat cells Cuboidal Square columnar- rectangular (taller than it is wide) Thirdly, epithelia are classified by its apical surface specializations: Microvilli- or brush border, increases surface area, fuzzy edge, short, hard to see microscopically. Cilia- very similar to flagella, function in transport and sensation, longer, easier to see.

Disturbances of gastrointestinal ecology, through the use of antibiotics or via traumatic or hormonal changes, are important predisposing factors in many cases of chronic superficial candida infection. A change in systemic immune responses is the major factor governing susceptibility to invasive fungal infection. Colonization of the susceptible host can occur when the fungus gains access via breaks in the skin or mucosae, via indwelling cannulae (especially if hypertonic solutions of glucose and amino acids are being infused) or via urinary catheters. Usually, the specific immune response to the fungus, coupled with topical antifungal drugs, eliminates superficial infection. In contrast, systemic opportunistic fungal infection carries a high mortality rate in the immunosuppressed host, an outcome only partly improved by the use of newer prophylactic and therapeutic antifungal agents. For example, Aspergillus fumigatus infection can present in a disseminated form or as a persistent aspergilloma, in which the fungus grows in pre-existing lung abnormalities (following asthma, successful treatment of pulmonary tuberculosis or bronchiectasis). Allergic bronchopulmonary aspergillosis can occur in those patients who are atopic, as this is due to IgE-mediated hypersensitivity to Aspergillus antigens. Bronchi may be obstructed by fragmented mycelia, and there is an inflammatory reaction in the bronchial wall with eosinophilic infiltration. Clinically, the condition usually presents as recurrent episodes of increased wheezing, coughing, fever and pleuritic pain in an asthmatic (see Case 13. If fungal antigens are inhaled by someone with preformed precipitating antibodies, then antigen­antibody complexes may form in the respiratory tract. The evolution of humans, in the face of selection pressures associated with parasitic infections, and the evolution of parasites in the face of destruction by host immune responses, enable this balance to persist. Natural selection has enabled human mutations in response to malaria to allow survival of infected individuals. His symptoms began 4 days after arrival, and over the following 10 days he deteriorated progressively, with vague upper abdominal pain, sweating, rigors and vomiting. In the past, he had been treated twice for malaria but had never taken malarial prophylaxis. The differential diagnosis included occult gastrointestinal bleeding, septicaemia, hepatitis or recurrence of malaria. Emergency investigations showed a normal haemoglobin (140 g/l) and a white cell count of 6. However, a thick blood film showed a heavy infestation with Plasmodium falciparum. After consultation with a specialist centre, the patient was treated with intravenous quinine. Their combined actions cause fever, leucocytosis and production of acutephase reactants such as C-reactive protein. The fever response may itself be a host defence since, for example, certain stages of malarial parasite development are sensitive to elevated temperatures. Although IgM and IgG antibodies are made in response to most adult protozoa, these antibodies are not necessarily protective, making it difficult to produce an effective vaccine. Furthermore, some protozoa penetrate and survive within host cells: examples include the malarial parasite, Plasmodium, which invades erythrocytes and hepatocytes, and Leishmania, which survives inside macrophages. Such intracellular protozoa are not accessible to antibodies unless protozoal antigens are also secreted on to the host cell surface. The role of cell-mediated immunity has proved difficult to evaluate in these diseases in humans. In mice, resistance to infection with several intracellular pathogens (mycobacteria, leishmania, salmonella) is controlled by a gene expressed only in reticuloendothelial cells called the natural-resistance-associated macrophage protein 1 gene (Nramp 1). Antigenic variation is the most striking example of successful adaptation and is exemplified by sleeping sickness; this is caused by Trypanosoma brucei and spread by the bite of the tsetse fly. After infection, the number of parasites in the blood fluctuates in a cycle of parasitaemia ­ remission and recrudescence. This type of antigenic variation is known as phenotypic variation and is in contrast to genotypic variation, in which a new genetic strain periodically results in an epidemic, as is the case with influenza virus. Other protozoa can rapidly change their surface coat to elude the immune response, a process known as antigenic modulation. Suppression of the immune response is one of the most obvious adaptive mechanisms for protozoal survival and has been found in all parasitic infections in which it has been 52 / Chapter 2: Infection sought.

Firefighters must wear additional protective garments when working on roadway emergency scenes. The apparel background (outer) material color shall be either fluorescent orange-red or fluorescent yellow-green as defined in the standard. The new standard sets performance criteria and guidelines for the selection, design and wearing of high-visibility safety clothing. It defines three protective classes based on background material, retroreflective material, and design and usage requirements. It also provides criteria to assist in determining the appropriate garment based on roadway hazards, work tasks, complexity of the work environment, and vehicular traffic and speed. Therefore, open mesh fabrics are not in compliance, since they do not provide the background coverage or brightness to meet the standard. The standard also requires retesting the chromaticity (brightness and purity of color) of fabrics after a laboratory light exposure test. The new standard requires certification of the fluorescent background fabric to specific chromaticity minimums. Although several colors are available, the most popular safety colors are lime/yellow and orange. There should be ample separation of the worker from traffic, which should be traveling no faster than 25 mph. Activities where greater visibility is necessary during inclement weather conditions or in work environments with risks that exceed those for Class 1. Garments in this class also cover workers who perform tasks that divert their attention from approaching traffic or are in close proximity to passing vehicles traveling at 25 mph or higher. Activities of workers who face serious hazards and often have high task loads that require attention away from their surroundings. Garments should provide enhanced visibility to more of the body, such as the arms and legs. Worker Example · Parking lot attendants · Warehouse workers · Roadside "right-of-way" or sidewalk maintenance workers 2 · Forestry operations · Roadway construction, utility and railway workers · School crossing guards · Delivery vehicle drivers · Emergency response and law enforcement personnel 3 · Roadway construction personnel and flaggers · Utility workers · Survey crews · Emergency response personnel Regulating Emergency Vehicle Response and Roadway Scene Safety 123 Table 7. The standard identifies the requirement (photometric performance) of retroreflective material alone or combined with fluorescent fabric. Apparel must provide 360 degrees of visibility, so the retroreflective striping must basically encircle the torso. The rates of deterioration depend on the type of material, use and exposure to the environment. This change would have a significant effect on some emergency response departments. The standard includes basic requirements such as vest dimensions, color and materials performance and also incorporates criteria for special features for users in fire, emergency medical and law enforcement services. The use of emergency lighting is essential, especially in the initial stages of a traffic incident. Drivers approaching the incident from the opposite direction on a divided roadway are often distracted by the lights and slow their response, resulting in a hazard to themselves and others traveling in their direction. Fortunately, the tide has begun to turn in recent years as responders recognize the staggering loss statistics that occur when operating on roadways and have begun to take measures to reduce the frequency and severity of these incidents. For the purpose of this document, the term "roadway" is a generic term that is used to describe all types of driving surfaces. These include surface streets that are found in rural, suburban and urban jurisdictions, as well as limited access highways such as interstates and turnpikes. When it is necessary to differentiate between types of roadways the terms surface streets and highways are used. Agencies That Respond to Roadway Incidents and Their Responsibilities There are few instances where a roadway incident of any magnitude will be handled by a single agency or response discipline. Most of these incidents trigger the response of multiple agencies, each with their own important role to play in the successful resolution of the incident. In order to avoid conflict, maximize safety and optimize the efficient handling of any roadway incident, all of the potential "players" must understand who the other players are, as well as their responsibilities relative to the incident. The types of agencies that respond to roadway incidents depend on a number of factors, including the agencies serving a particular jurisdiction and the type or magnitude of the particular incident. The primary agencies that most commonly respond to roadway emergencies include: · · · · · · · · · · Law Enforcement Agencies. Law Enforcement Agencies Law enforcement agencies are primary responders to roadway incidents and will be present on virtually every occasion.

Syndromes

• Medications including amphotericin, cisplatin, cyclosporine, diuretics, proton pump inhibitors, and aminoglycoside antibiotics
• Feel tender
• You also have a fever, stiff neck, nausea, and vomiting with your headache
• Stroke
• Weakness
• Portable, long-term loop recorders -- allow you to start recording if symptoms occur
• Abnormally increased muscle tone or spasm (myoclonus)
• Sore throat
• Place ice on the bruise to help it heal faster and to reduce swelling. Wrap the ice in a clean towel -- do not place ice directly on the skin. Apply the ice for up to 15 minutes each hour.
• Sunken appearing eyes

Supplementary orders: Orders that differ from the standard formula rate, route, and volume prescriptions. Use of the protocol improved delivery of goal volumes, although there was physician resistance to using a standard order. Increases in formula volume or rate of administration to achieve a goal should be clearly written. Protocols should visibly illustrate feeding adjustments when volume based feeds are utilized. Ancillary orders: Routine or ancillary orders will depend on both the population and setting. Such menus may facilitate standardized advancement of initial administrations to goal volumes, uniform enteral access device flushing volumes and methods, and population-specific ancillary orders. Orders for monitoring, flushing, and transitioning from tube feeding can also be included. A study of powdered infant formulas across several European countries revealed Enterobacter species contamination in 53% of 141 samples. In addition, the reconstituted formula that is not immediately used must be promptly refrigerated, and any formula that remains 24 hours after preparation must be discarded. In the absence of a formula preparation room, the pharmacy can support reconstitution of powdered formula in a laminar airflow environment. The water supply may be a source of potential contamination if purified water is not used. All water supplied for feeding preparation must at least meet federal standards for drinking water and not contain contaminants. For reconstitution of pediatric and neonatal formulas, the water needs to be sterile. Weenk et al35 compared various feeding systems and found a sterile glass bottle containing enteral formula to be associated with the lowest level of microbial growth from touch contamination. They also found that decanted formula poured from a container with a screw cap into a feeding bag was associated with lower levels of microbial growth than formula poured from a container with a flip top (similar to the type of top found on a soda can). What are the safety issues when using blenderized tube feedings and how can the risk of complications be reduced? Use competent personnel trained to follow strict aseptic technique for formula preparation. Discard unused reconstituted and refrigerated formulas within 24 hours of preparation. Rationale Between 0% and 57% of enteral formulas prepared in the hospital and over 80% of those prepared in the home have been found to be contaminated with bacteria. How does one best avoid errors associated with sound-alike, look-alike product names and labels? In addition, commercially prepared, ready-to-use, real-food blenderized formulas are available for those patients who do not want to make their own homemade formulas. Several studies demonstrate some benefit with this technique in, for example, postfundoplication patients. However, more research is needed to demonstrate the benefit in additional patient populations generally maintained on partial or complete home nutrition support. Given changes to administration rates/volumes, consider patient-specific labels that state: a. Be aware of sound-alike or look-alike product names that may be mixed up on the order or during selection of the product. It also identifies the individuals responsible for preparing and hanging the formula as well as the time and date the formula is prepared and hung. Care should be taken in developing a label that is clear and concise and of a size that fits neatly on the container. Unique identifiers may be used to describe other factors such as colostrum, transitional, and mature milk. Hospitals may use computer-generated or, at last resort, handwritten labels (see Figures 7 and 8). Docosahexaenoic acid and amino acid contents in pasteurized donor milk are low for preterm infants. Target fortification of breast milk: predicting the final osmolality of the feeds. Infant Feedings: Guidelines for Preparation of Human milk and Formula in Health Care Facilities.