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The objects will frequently be seen in one of three locations along the length of the esophagus medicine uses best order for bimat. In the pediatric population 60 80% of objects get caught at the level of the cricopharyngeus muscle in the proximal esophagus symptoms testicular cancer order bimat online from canada, 10-20% become trapped at the level of the aortic crossover medications 512 buy bimat 3 ml lowest price, and 5-20% are found at the level of the lower esophageal sphincter (3) medicine to induce labor order bimat visa. Radiographically medicine 5 rights best purchase bimat, a coin in the esophagus is seen as a disk in the anteroposterior projection and from the side on lateral films as it is lodged in the easily compressed esophagus medications that cause tinnitus buy discount bimat, which lies posterior to the trachea. Conversely, a coin in the trachea is seen from the side on anteroposterior films and as a disk on lateral films as its orientation conforms to that of the vocal cords en route to the trachea (however, most coins cannot fit in a pediatric trachea). Radiolucent objects in the esophagus, such as plastic, wood, or aluminum can tabs, are difficult to detect on plain films. Management of an esophageal foreign body depends on the type and location of the object. Objects in the proximal and mid esophagus should also be removed endoscopically since they usually do not pass spontaneously into the stomach (5). A single blunt object located in the distal esophagus for less than 24 hours in an asymptomatic, otherwise healthy patient may be allowed to pass spontaneously into the stomach if close follow up can be assured. However, if passage is not seen on radiographs obtained 24 hours after ingestion, the object should be removed endoscopically since objects allowed to remain in Page 354 the esophagus for more than 24 hours are associated with mucosal inflammation (6). Patients with respiratory difficulties or those showing signs of esophageal perforation should be immediately referred for endoscopy. Several other removal techniques have been described for blunt esophageal foreign bodies in an asymptomatic or minimally symptomatic patient. The Foley catheter method, done by experienced personnel, involves inserting the deflated catheter orally, past the object. The balloon is then inflated and the catheter is slowly withdrawn, pulling the foreign body ahead of it. The use of glucagon to relax the smooth muscle of the lower esophageal sphincter and allow passage of the object into the stomach has also been described. Asymptomatic patients with foreign bodies in the stomach may be observed for spontaneous passage of the object. If movement from the stomach is not detected on follow up radiographs in 7 days or if the patient becomes symptomatic, referral for endoscopic removal is required (4). As mentioned previously, long objects should also be removed endoscopically since these might not be able to navigate through the duodenal sweep. If a sharp object passes beyond the pylorus, endoscopic removal is more difficult so the patient should be followed with daily radiographs and observed for signs of perforation and bleeding. If complications do develop, the patient should be referred for surgical removal of the object. These include airway compromise, abrasions, perforation with resultant abscess formation, obstruction, ulceration, fistula formation, or vascular injuries. With the advent of endoscopy, more foreign bodies are successfully removed resulting in less complications. Disk or button batteries are small, coin-shaped batteries used in hearing aids, watches, and calculators. As the use of these small electronic gadgets have increased, the problem of disk battery ingestion has become more common. Seventy percent of disk battery ingestions occur in children aged 6 to 12 years (1). The danger of disk batteries is that they contain mercury, silver, zinc, manganese, cadmium, lithium, sulfur oxide, copper, and sodium or potassium hydroxide. As little as one hour of contact between the battery and esophageal mucosa may result in injury (4). Because of the damage that can occur in the esophagus, endoscopic removal should be done immediately after localization by radiographic imaging. On the anteroposterior projection, disk batteries can be distinguished from coins by the double-density shadow of its bilaminar structure (4). As the battery is allowed to pass, patients should be monitored for signs of perforation or bleeding. If these complications become evident or if the battery has not moved beyond the stomach in 3-4 days, endoscopic removal should be performed. Batteries that pass into the intestine are generally eliminated without consequence. Bezoars are accumulations of exogenous material in the stomach and small intestine. Ninety percent of patients with trichobezoars are females aged 10-19 years with trichotillomania and trichophagia (4). Persimmons, celery, pumpkin, grapes, leeks, and grass have all been known to form phytobezoars if they are ingested in great amounts. Though the reasoning is not clear, the majority of lactobezoars are found in premature, low birth weight infants (7). Factors associated with lactobezoar formation may include rapid advancement in feedings, high calcium and protein content of specialized formulas, or the unique gastric physiology of premature infants. Antacid bezoars are accretions of dehydrated antacids, commonly seen in patients with poor gastric motility or patients receiving high dose antacid therapy. Bezoars, regardless of composition, often present with symptoms of abdominal pain, anorexia, nausea, and vomiting. Bezoars may be visible on plain films but computed tomography with contrast is the imaging technique of choice since it allows for estimation of the size of the bezoar, which often directs management. Endoscopy allows direct visualization of the bezoar and also provides information on its content. Phytobezoars are frequently dissolved using a clear liquid lavage and metoclopramide or endoscopic fragmentation. If a coin is seen as a disk on the anteroposterior film, is it in the esophagus or trachea True/False: A sharp object in the distal esophagus may be observed for 7 days if the patient is asymptomatic. If an 12 month old swallows a penny, is there any possibility that it is in the trachea Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, second edition. The level of the cricopharyngeus muscle in the proximal esophagus, the aortic arch crossover in the midesophagus, and the lower esophageal sphincter. A sharp object in the esophagus should be endoscopically removed immediately to prevent perforation. More gadgets which use disc batteries increases the likelihood that these batteries will be left around the house for young children to put into their mouths. She had been breast feeding well during the first week, but her intake has been declining and she has begun spitting up. Physical examination finds lethargy, pallor with diaphoresis, tachycardia, distended loops of bowel, and rectal examination finds a narrow anus, and further insertion gives the impression of putting on a glove two sizes too small. The narrow canal extends for two centimeters, then widens into a pool of loose stool. When the examining digit is withdrawn, it is followed by a sudden spurt of particularly foul-smelling stool laden with mucus and streaked with blood, accompanied by a moderate amount of flatus. Questioning the parents identifies the failure to pass stool or flatus without stimulation with a rectal thermometer, having received instruction to do so from her aunt who is a nurse. An abdominal series is obtained which demonstrates dilated bowel loops and a pattern resembling an acute bowel obstruction. All of these definitions are used in medical and/or everyday communication, but it is preferable to use specific terms to describe the symptoms of the patient. The specific findings and their clinical significance will be described in this chapter. Infantile constipation: Per the guidelines, this does not include neonatal delays in defecation since the structural anomalies (imperforate anus, cloacal exstrophy, and other perineal anomalies, as well as intestinal atresia, stricture or web, volvulus, duplication, or perforation) and genetic diseases. However, this criterion should not be relied on in isolation since pathologic conditions will not necessarily present this way. The above alarm indicators are searched for, as are signs of other structural anomalies. The rectal examination is key, with careful assessment of the anal location, anal neurologic function (the anal wink, which assesses both the sensory afferent and motor efferent pathways), anal structure (looking for distention of the internal anal sphincter), anal tone (looking for spasticity or patulousness), function of the muscles of the pelvic floor (which provide additional help with control of defecation), and rectal diameter and tone (looking for signs of chronic distention even if no stool is present on the day of exam). The anal location should be halfway between the posterior border of the scrotum or posterior fourchette and the tip of the coccyx. Anything outside of the middle third of this region should raise the suspicion for a "perforate imperforate anus" (a structure resembling an Page 356 anus is visible externally, but it is not contiguous with the rectum). If benign constipation is found, treatment is stratified based on age and developmental state. Exclusively breast fed infants are permitted a longer interval between stools if they show no signs of distress or distention and if they are not prone to becoming impacted. In exclusively formula-fed infants, my favorite strategy is the substitution of a commercially available partially hydrolyzed formula, which may produce suitable loosening of the stools. Malt soup extract (a dehydrated powder derived from an effusion of malted barley used in the brewing industry) has been advocated by the committee, as have corn syrup, lactulose or sorbitol, while the use of mineral oil was cautioned against due to the risk of aspiration posed by the frequency of gastroesophageal reflux and swallowing incoordination in this age group. Impaction is most commonly dislodged by glycerin (non-stimulant) suppositories for which the commercially pre-softened versions sold in soft plastic applicators (glycerin gel) have been my personal favorite, as they provide more immediate relief (the traditional refrigerated suppositories require a wait while they melt in situ). Older infants who are of an age where pureed foods would be appropriate should have the fiber content of their diet optimized. Another personal favorite in the older formula fed infant is the use of undiluted apple juice (not apple drink) for its sorbitol content, titrating the amount administered to the stool texture while making certain that formula intake remains adequate. Case #2: this 6 year old male presents with fecal soiling on a daily basis, which began in late October. His parents report multiple bouts daily of fecal urgency where he rushes to the toilet, only to pass small amounts of diarrheal stool. His toilet sitting behavior is peculiar in that he sits far back on the toilet seat with his knees extended and his toes pointed, straining at defecation. Once or twice weekly he will pass a very large caliber formed stool, which has on occasion plugged the plumbing. This pattern was not thought to be a problem by his parents as it began shortly after they began potty training him at two years old so that he could enter preschool earlier than rest of the neighborhood children. The dietary history finds that he eats the school breakfast and lunch, and will often not touch his vegetables at supper. Closer questioning indicates he does not pick fruit or vegetables from the salad bar at school, and the school typically offers only sweet buns or a burrito for breakfast. Physical examination finds a midline mass in the lower abdomen, with a rectal examination that shows a normally placed anus with an intact anal wink and a perineum coated with stool. The anus is shortened with the internal anal sphincter dilated by a massive boule (little football) of formed stool. You are unable to accurately assess the diameter of the rectum as the stool appears to fill the pelvic bowl. This lack of inflammation is an important differentiating factor that permits immediate identification of the older child with chronic constipation. The primary cause is voluntary fecal withholding, usually due to fear of pain on defecation, giving rise to the term "Psychogenic Constipation". The often accompanying overflow diarrhea or involuntary soiling arising from passage of looser chyme above and around the impaction is termed Encopresis in verbal analogy to enuresis. The withholding behavior most often arises from a pattern of passage of large caliber stool as was the case with our illustration, but it can arise in response to a single traumatic event, such as a particularly large stool resulting in a traumatic fissure, a too-rapid transition from diarrhea with a raw perineum to fully formed stools, perianal cellulitis (more properly erysipelas, an intensely painful superficial infection of the anus and surrounding structures with Group A streptococcus identifiable by culture of the affected area), or least frequently but most insidious: overt trauma of physical or sexual abuse. The above historical markers are useful in establishing an understanding of the process by the patient and his or her caregivers. Dietary issues must also be explored, as well as the pattern of toileting (it is amazing how little time and opportunity school age children seem to have for sitting on the toilet, with some schools having policies of allowing only two minutes per bathroom break). The issues on the physical examination of the older child are the same as those of the infant, particularly those regarding the rectal examination. If suspicion is high (inability to spontaneously pass flatus or a strict requirement of stimulation to pass stool which when triggered tends to be foul, loose, and voluminous), an unprepped barium radiographic colon examination is indicated. This study should specifically look for a transition zone, to and fro peristalsis in the unobstructed segments, or uniform mixing of the contrast material throughout the colon (rather than concentration of the remaining barium in the rectum) on the 24 hour delayed film (hence the stipulation for barium rather than water soluble contrast which would tend to be absorbed by the next morning). If simple constipation without impaction or soiling is identified, therapy begins with education regarding the need for a more regular defecation pattern to prevent progression of the problem. Dietary intervention is advocated, emphasizing fiber and fluid in accordance with proper nutritional guidelines. More importantly, the need for regular toileting in the already potty-trained is emphasized, and I ask that they sit on the commode twice daily after meals to take advantage of the gastrocolic reflex to promote more regular rectal emptying. As in our illustration above, there must be an immediately preceding meal for the process to be most effective, and I have found that eating two fruits before toileting to Page 357 be helpful. Suppers eaten out should be followed by a trip to the restaurant toilet to avoid missing the increased post-prandial peristaltic activity. Encopresis on the other hand is an indicator of repeated impaction, and usually is accompanied by enough dilatation as to render the rectal musculature patulous. Here again, education is key, and to simplify the biophysics (the wall tension is proportional to the fourth power function of the bowel lumen diameter), a quick analogy to a balloon that has been repeatedly inflated to the point of flaccidity is readily within the experience of most 4 or 5 year olds. Likewise an analogy to repeatedly compacting the trash over a 3-4 day period rather than dumping it daily will usually trap a kindergartner into admitting such behavior is likely to lead to a heavier, harder and bigger trash bag (and stool). Most importantly, education and discussion is important which should center on the cycle of pain at defecation leading to withholding which results in larger, firmer stools which in turn leads to more pain at defecation, perpetuating the cycle. This helps create understanding in the patient and the parent as to the origin of the process and its ultimate eradication. A thorough discussion of the mechanics of impaction and overflow passage of the as-yet unformed stool around the obstruction helps explain why distention of the rectum and internal anal sphincter and distortion of the levator structures of the pelvic floor result in inadvertent passage of loose stool whenever voluntary control of the external anal sphincter is relaxed. A thorough understanding is important in defusing the animosity that often arises between the patient and caregivers (parents, school, babysitters, etc.

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In the case of Morocco medications bad for kidneys 3 ml bimat visa, 70 per cent of Moroccan women in Spain arrived under formal or informal family reunifcation processes medications errors cheap bimat 3 ml fast delivery, compared with only 20 per cent of men treatment zoster ophthalmicus generic 3 ml bimat visa. In contrast treatment hemorrhoids buy bimat 3 ml amex, 70 per cent of males and only 20 per cent of females reported that they had migrated with the intention of working ad medicine cheap bimat online american express, although 49 per cent of the migrant women now did so (a 22 per cent increase) treatment dynamics order bimat canada. As for remittances, only 40 per cent of Moroccan immigrants send remittances home, of whom 80 per cent are men. More than three-fourths send remittances to their parents, and 15 per cent to their spouse. The funds are used to cover household needs such as food, housing, health and education, to attend to the needs of dependent family members such as elder parents or other dependants, or to pay for construction or renovation of a home. The studies from Morocco fnd that migration is causing domestic problems, especially since womens absence from their communities is not considered socially acceptable: there is a sense of shame incurred when women must work outside of the home to help sustain the household. For example, it is increasingly dif fcult for young men to fnd work at home, and their international migration is giving rise to a lack of available men of marriageable age, causing a gradual delay in the age of marriage. In this case, the studys authors note that mens contributions to households have become less and less important over the years, and their role has be come increasingly secondary and marginal. The vast majority of the Dominican woman who went abroad to work left their households in the charge of another woman, a mother or a sister, or a Haitian woman hired to help out; men did not take on more tasks at home when their wives migrated, nor were they expected to do so. In the vast majority of cases, women working abroad sent remittance funds to be managed by other women (usually to a mother or a sister); women had remitted money to their husbands when migratory fows frst began, but many of the husbands were reported to have used the money unwisely, considering it a personal asset rather than one for the collective good. The authors note that when men migrate and send money home, they are seen as fulflling their paternal responsibility, which is to provide for their families, and their absence is not perceived as traumatizing for the children. When women migrate, on the other hand, their contribu tion may be admired, but at the same time they are blamed for not respecting traditional gender norms and fulflling traditional maternal roles. Their absence is perceived as an abandonment of their families, an abandonment that may well result in the disintegration of the home and have catastrophic efects on the children. Indeed, several problems were evoked among the children involved, including low educational achievement, school abandonment, early pregnancy, and drug use (Garcia and Paiewonsky, 2006). The country has a long history of male migration for work in goldmines in South Africa, but recently female migration has also increased, driven by a decrease in work available for men in mines and agricultural decline. Both male and female migrants send money home to their families, but signifcant gender diferences emerge: male mi grants, especially those who are still employed in the mining industry, usually send more than twice as much as female migrants, who receive far lower and less reliable incomes as informal traders or domestic workers. Remittances are crucial to the survival of the recipi ent households: the greatest portion has been spent on basic necessities such as food, fuel, clothes, transportation and medical expenses. As for family repercussions of migra tion, hardly any of the survey respondents recognized any positive aspects; instead, they mentioned loneliness and separation from spouses or from parents and children. Mens migration, especially to the mines in South Africa, used to be temporary: it was regarded as a rite of passage and also as a means for a young man to earn money to marry. Those who could get such jobs kept them, making working in the mines more of a long-term career. Migrant men spent less and less time at home, and repeated separations strained relationships. In particular, female migrant workers are in demand, and labour migration of women is increasingly common. However, it still represents a departure from what is regarded as proper behaviour, and is perceived as a last resort and a source of shame and embarrassment to the household, especially if it is related to a mans perceived failure to earn a living for his family. The report refers to an increase in domestic violence in contexts of male loss of employment, and also damage to mens sense of identity, masculinity and self-esteem. These efects may be exacerbated when women take over the role of family breadwinner, inducing feelings of envy, resentment and failure in their male partners (Crush and others, 2010). Migration, families and men in families 145 (or were rumoured to have begun) new relationships. Some said they were uncomfort able sending money to a household that now included another male, and others justifed their remittance behaviour as a response to the womens moral character (Abrego, 2009). He found that although gender diferences in remittance behav iour are not always statistically signifcant, when they are, men with some exceptions are generally more likely to remit, and to remit larger amounts, although women may remit a substantially larger proportion of their wages. He noted that such diferences must be understood in the context of family migration histories (involving such factors as whether one or both spouses are abroad, time since migration and family structure) and household structures (that is, remittances tend to be positively associated with house hold size at the origin and negatively associated with household size at the destination). In addition, households headed by women tend to be more likely to receive remittances than those that are headed by men, a fnding that, usually, simply refects the nature of separation through migration. On the other hand, many such fnancial transfers (for example, to children or elderly par ents) would have taken place between the same individuals even without migration. More importantly, remit tance behaviour in circumstances where migration is to be temporary (that is, when the migrant intends to return and maintains a frm home base in country of origin) is quite diferent from remittance behaviour in a context where the migrant is permanently settled in the new country, and sends money mainly to elderly parents (Carling, 2008). The chapter has sketched 146 Men in Families and Family Policy in a Changing World the way in which migration patterns have become increasingly complex over the past generation, with notable increases in short-term and circular migration, migration of skilled workers, and of female labour migration. It has also stressed that such migra tion is usually a family afair: families organize to send one or more of their promising members abroad on behalf of the entire group. Many move with their partners and children, while many others leave them behind, usually because they feel their families will be better cared for in the home community. Studies from many diferent countries report that the mother usually takes care of the children when a man becomes a labour migrant; but when it is a woman who migrates, the children are most often cared for by other family members, such as grandparents, or by another woman hired to do so. Today, families with one or more of their members working abroad often maintain close contact, helped by increased ease of travel and of communication. Indeed, transnational families have arisen, in which members remain closely connected while living in places geographically quite separated. The chapter has sketched the ways in which migration can lead to signifcantly increased economic and social well-being for families and communities, and may also bring about subtle and not-so-subtle changes in family relations. The following section formulates recommendations for policies and programmes concerning development, emigration and immigration, conditions for migrant workers and their families in destination countries, and strengthening resilience of families and the men in them. Improving migration data, and recognizing families and men Today it is possible to systematically measure cross-border movements of toys and textiles, of debt, equity, and other forms of capital, but not cross-border movements of people. Our patchy statistics on international migration amount to an enormous blind spot. Difculties with respect to migration data include lack of agreement on defni tions, failure to collect, tabulate or publish information on people who enter countries and especially on those who depart, and inadequacy of information on gender, age and family status of those who do enter and depart. Numerous calls have been made for bet ter migration data, ever since the 1890s, in fact, whose defcit precipitated the creation of a blue-ribbon expert panel to formulate specifc, simple and feasible recommenda tions for improving general migration data. Countries have, inter alia, been requested to ask about country of citizenship, country of birth, and country of previous residence during every population census and then publish cross-tabulations of this information by age and sex. They have also been asked to better exploit administrative data sources and surveys containing migration data. Important backup roles have been assigned to specifc United Nations organizations with respect to setting standards, providing Migration, families and men in families 147 capacity-building, coordinating and also funding census projects (Center for Global Development, 2009). Better data will help better ground policy discussions, and are also essential to correcting popular beliefs and misconceptions and to building public knowledge and understanding of the economic, social and cultural impacts of migra tion (Organization for Economic Cooperation and Development, 2010). Related to the need for better data is that of recognizing families and men in rela tion to the migration process within research and knowledge-production, as in policy dialogue. In the individualistic societies from which most research and policy dialogue originate, the extent to which migration is very often a family afair has generally not been adequately recognized. As regards men in the context of migration, after a period in which they were the unique focus in migration discussions, followed by an interval in which the importance of women in migration was at last rightly recognized, it has become apparent that men have rather systematically faded from the picture. In addition to Governments and international organizations whose roles were just mentioned, researchers and academ ics also have an important role to play: they must conceptualize and generate data and carry out specifc studies that take families and men into account. Non-government organizations, in addition, must also advocate for, request and generate better data. Including migration, and the gender aspects thereof, in development discourse and policy Several of the very basic themes of this chapter come under the heading of develop ment, and have already been the object of extensive discussion elsewhere. One such theme is poverty reduction and support of families: migration should be an option that a family chooses freely, to improve its livelihood, rather than simply to make a livelihood possible. Men and women should not have to seek work in other countries simply so that their families at home will have enough to eat (United Nations Devel opment Programme, 2009). Similarly, migration should not have to be undertaken in order to secure basic social services that are ofered by well-functioning States, such as unemployment, retirement, education and decent health care. Other themes from development discussions that were invoked in this chapter include the migration of the highly skilled, and the question whether or not such migra tion may drain resources in the countries of origin (cf. Global Commission on Inter national Migration, 2005; International Organization for Migration, 2008; Dumont, Martin and Spielvogel, 2007), as well as that of global care chains, that is, the market for women from poorer communities hired to take care of the children of profession ally active women in richer communities. The point made by this chapter is that each of these development issues must also be viewed in the context of its repercussions for men and for families. Many of the policy implications are complex, and many of the possible repercussions are the result of individual decisions, but there are nevertheless measures that can be taken to increase the likelihood that labour migration will lead to increased well-being for men and for families. The recommendations are directed at destination-country Governments, as well as those of countries of origin and at other key actors such as the private sector, unions, non-governmental organizations and individual migrants themselves. They include liberalizing and simplifying regular channels that allow people to seek work abroad, ensuring basic rights for migrants, and address ing discrimination and xenophobia. For example, while recognizing that countries have the sovereign right to determine who is to enter their territory, the Human Development Report 2009 (United Nations Development Programme, 2009) proposes that regular channels of entry into countries be opened up in two major ways, by expanding schemes for truly seasonal work in sectors such as agriculture and tourism (an intervention that should involve unions and employers, as well as desti nation and source-country Governments) and by increasing the number of visas for low skilled people. Mechanisms for deciding desired numbers of entrants, based on employer demand and economic conditions in destination countries, should be transparent and pub lic. Establishing fair and clear-cut mechanisms ensuring that migrants have the right to enter and to leave countries freely would facilitate the establishment not only of their right to work abroad, but also of their right to travel home to visit their families while doing so. As for ensuring basic rights for migrants, the report calls for Governments to ensure that migrants have, inter alia, right to equal pay for equal work, to decent working conditions and to collective organization. It also calls for Governments to act quickly to stamp out discrimination and, in this regard, it points out that while some situations will require active eforts to combat discrimination, address social tensions and prevent outbreaks of violence against immigrants, civil society and Governments do have a wide range of positive ex periences upon which to draw as models for such eforts (United Nations Development Programme, 2009). A more general but particularly important point to be emphasized in these dis cussions is that policy and scholarly discourses celebrating migration, remittances and transnational engagement as embodiments of self-help development from below must not distract attention from the structural constraints involved and the limited albeit real ability of individuals to overcome such constraints. States must continue to play a role in shaping the general conditions favourable for the achievement of human devel opment (de Haas, 2010); and international organizations and civil society must play a signifcant role when the welfare of the groups in question involves the responsibilities of several States, as is the case with migrants. Making emigration and immigration more friendly to families Some sending countries, such as the Philippines, have deliberately promoted emigra tion as a way of improving their economies. Since its inception in 1974, indeed, the Overseas Employment Programme has been instrumental in lifting many Filipino households out of poverty, and providing steady employment even during times of economic crisis (World Bank, 2010). The Philippines is often regarded as having created a prototype for sending country migration policies inasmuch as overseas employment Migration, families and men in families 149 is regulated by legislation, there is widespread acknowledgement of and respect for the social contribution of migrant workers, and migrant workers receive a number of very tangible benefts and services, such as access to special express lanes and lounges in airports and favourable rates on bank loans. As for destination countries, immigration policy determines which members of a family can enter the country, in what order, and, to some extent, their living condi tions, especially in the case of irregular migrants (Glick, 2010). Would-be migrants are currently confronted with growing legal and administrative barriers, established in the light both of fears that migrants will take jobs from nationals in a context of economic crisis, and of countries fears concerning possible links between migration and security. Such barriers feed clandestine migration, a phenomenon that leaves the door open to abuses, and can have the very negative efects on families discussed throughout this chapter, such as when their irregular status prevents migrant workers from visiting their families, or prevents their children from going to school. On the other hand, it would be naive not to recognize the darker sides of migra tion, which also bring out some of the complex policy issues. In addition to the very positive aspects of increasing economic wellbeing and reuniting separated families, migration may also encompass such abuses as trafcking in persons and exploitation of migrant workers and children. A strong role exists for non-governmental organizations and for international organiza tions in identifying and advocating against cruel policies, and abuses. At the level of the individual migrant, and as has also been discussed in this chapter, some men and women decide to migrate not only because they wish to improve the well-being of their families, but also to increase distance in troubled relationships. Others may feel that conditions for their partners and children are better at home than in the destination community. Tus any policy promoting family reunifcation must navigate among numerous options, some of which imply delicate issues about which those involved may prefer not to speak. The relevant Government institutions include two agencies specifcally created to develop overseas labour markets, regulate and monitor recruitment, ensure the well-being of work ers, and provide welfare assistance to registered overseas workers and their families. There have been many eforts to disseminate information about the risks and opportunities of international migration in the Philippines. Examples include, inter alia, a mass audience awareness-raising campaign which targets young people; inclusion of migration issues in the curricula of elementary and secondary schools; public service advertisements and radio programmes; face-to-face meetings; pamphlets, comics, cartoons and posters; country-spe cifc cards listing numbers to call in case of emergency; and up-to-date information web sites. In destination countries, embassies and resource centres make themselves available to overseas workers, a 24-hour helpline is maintained, and Filipino migrants have created associations that use the media (including text messaging on mobile phones) to help over seas workers keep in contact with home, and also share their experiences. The Philippines has established itself as a pioneer in pre-departure orientation and training programmes run by the Government, non-governmental organizations and the private sec tor. Workers who have been identifed as especially vulnerable or who have special needs (for example, domestic workers, entertainers, those travelling to particular countries, and workers who have not gone through recruitment agents) attend special sessions. There are also special sessions for those engaged in seafaring, a profession said to enjoy model recruitment, training and handling as a result of strong union presence. Filipinos migrating as fance(e)s or spouses of foreign nationals are also required to attend guidance and counselling programmes which discuss migration laws afecting emigrants, welfare and support services available abroad, the rights of migrants overseas, and how to cope with problematic domestic situations. The trainers in such programmes, many of whom were formerly welfare ofcers abroad, have been trained and accredited by the Government, and are periodically assessed. Many non-governmental organizations also provide training programmes of their own, for example, to migrants and their families, community leaders, and local government ofcials. One example is a programme for returning migrants on reintegration and entrepreneur ship.

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These findings have led agencies and researchers to suggest an increase in recommended vitamin D intakes for the elderly from the suggested 2 medicine remix order bimat with mastercard. The increased requirements are justified mainly on the grounds of the reduction in skin synthesis of vitamin D symptoms zithromax buy 3ml bimat with visa, a linear reduction occurring in both men and women 97140 treatment code cheap bimat 3 ml with amex, that begins with the thinning of the skin at age 20 years (24) symptoms 4 days post ovulation discount generic bimat canada. Pregnancy and lactation Elucidation of the changes in calciotropic hormones occurring during pregnancy and lactation has revealed a role for vitamin D in the former but probably not the latter medications you can give dogs order bimat. The concern that modest vitamin D supplementation might be deleterious to the foetus is not justified treatment ulcerative colitis best order bimat. Furthermore, because transfer of vitamin D from mother to foetus is important for establishing the newborns growth rate, the goal of ensuring adequate vitamin D status with conventional prenatal vitamin D supplements probably should not be discouraged. Consequently, there is no great drain on maternal vitamin D reserves either to regulate calcium homeostasis or to supply the need of human milk. Because human milk is a poor source of vitamin D, rare cases of nutritional rickets are still found, but these are almost always in breast-fed babies deprived of sunlight exposure (17-20). Furthermore, there is little evidence that increasing calcium or vitamin D supplements to lactating mothers results in an increased transfer of calcium or vitamin D in milk (38). Thus, the current thinking, based on a clearer understanding of the role of vitamin D in lactation, is that there is little purpose in recommending additional vitamin D for lactating women. The goal for mothers who breast-feed their infants seems to be merely to ensure good nutrition and sunshine exposure in order to ensure normal vitamin D status during the perinatal period. Accurate food composition data are not available for vitamin D, accentuating the difficulty for estimating dietary intakes. Skin synthesis is equally difficult to estimate, being affected by such imponderables as age, season, latitude, time of day, skin exposure, sun screen use, etc. Previously, many studies had established 27 nmol/l as the lower limit of the normal range. However, a recent editorial in a prominent medical journal attacked the recommendations as being too conservative (45). This came on the heels of an article in the same journal (46) reporting the level of hypovitaminosis D to be as high as 57 percent in a population of ageing (mean 62 years) medical in-patients in the Boston area. Of course, such in-patients are by definition sick and should not be used to calculate normal intakes. Nevertheless, in lieu of additional studies of selected human populations, it would seem that the recommendations of the Food and Nutrition Board are reasonable guidelines for vitamin D intakes, at least for the near future. In most situations, approximately 30 minutes of skin exposure (without sunscreen) of the arms and face to sunlight can provide all the daily vitamin D needs of the body (24). Because not all of these problems can be solved in all geographic locations, o particularly during winter at latitudes higher than 42 where synthesis is virtually zero, it is 116 Chapter 8: Vitamin D recommended that individuals not synthesising vitamin D should correct their vitamin D status by consuming the amounts of vitamin D appropriate for their age group (Table 21). There are some suggestions in the literature that these outbreaks of idiopathic infantile hypercalcemia may have been multifactorial with genetic and dietary components and were not just due to technical problems with over-fortification as was assumed (49,50). This is all the more cause for concern because hypovitaminosis D is still a problem worldwide, particularly in developing countries at high latitudes and in countries where skin exposure to sunlight is discouraged (51). The vitamin D story: a collaborative effort of basic science and clinical medicine. Induction of monocytic differentiation and bone resorption by 1a,25 dihydroxyvitamin D3. Specific high affinity receptors for 1,25-dihydroxvitamin D3 in Human peripheral blood mononuclear cells: presence in monocytes and induction in T lymphocytes following activation J. In: "High Performance Liquid Chromatography and its Application to Endocrinology". Subclinical vitamin D deficiency in neonates: definition and response to vitamin D supplements. Plasma concentrations of vitamin D metabolites at puberty: Effect of sexual maturationand implications for growth. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. Vitamin D supplementation and fracture incidence in elderly persons: a randomised, placebo-controlled clinical trial. Influence of the vitamin D-binding protein on the serum concentration of 1,25-dihydroxyvitamin D3. In vitro metabolism of 25-hydroxycholecalciferol by isolated cells from Human decidua. Elevated parathyroid hormone related peptide associated with lactation and bone density loss. Maternal-Foetal calcium and bone metabolism during pregnancy, puerperium, and lactation. Dietary calcium and vitamin D intake in elderly women: effect on serum parathyroid hormone and vitamin D metabolites. International Perspective: Basis, need and application of recommended dietary allowances. Williams syndrome: an historical perspective of its evolution, natural history, and etiology. Therefore, a complex antioxidant defence system normally protects cells from the injurious effects of endogenously produced free radicals as well as from species of exogenous origin such as cigarette smoke and pollutants. Should our exposure to free radicals exceed the protective capacity of the antioxidant defence system, a phenomenon often referred to as oxidative stress (2), then damage to biologic molecules may occur. There is considerable evidence that disease causes an increase in oxidative stress; therefore, consumption of foods rich in antioxidants, which are potentially able to quench or neutralise excess radicals, may play an important role in modifying the development of such diseases. Vitamin E is the major lipid-soluble antioxidant in the cell antioxidant defence system and is exclusively obtained from the diet. The term vitamin E refers to a family of eight naturally occurring homologues that are synthesised by plants from homogentisic acid. All are derivatives of 6-chromanol and differ in the number and position of methyl groups on the ring structure. The four tocopherol homologues (d-, d-, d-, and d-) have a saturated 16 carbon phytyl side chain, whereas the tocotrienols (d-, d-, d-, and d-) have three double bonds on the side chain. There is also a widely available synthetic form, dl tocopherol, prepared by coupling trimethylhydroquinone with isophytol. This consists of a mixture of eight stereoisomers in approximately equal amounts; these isomers are differentiated by rotations of the phytyl chain in various directions that do not occur naturally. Any of the synthetic all-rac-tocopherol (dl-tocopherol) should be multiplied by 0. On donating the hydrogen, the phenolic compound itself becomes a relatively unreactive free radical because the unpaired electron on the oxygen atom is usually delocalised into the aromatic ring structure thereby increasing its stability (3). Elevated levels of lipid peroxidation products are associated with numerous diseases and clinical conditions (4). Although vitamin E is primarily located in cell and organelle membranes where it can exert its maximum protective effect, its concentration may only be one molecule for every 2000 phospholipid molecules. Absorption of vitamin E from the intestine depends on adequate pancreatic function, biliary secretion, and micelle formation. Conditions for absorption are like those for dietary lipid, that is, efficient emulsification, solubilisation within mixed bile salt micelles, uptake by enterocytes, and secretion into the circulation via the lymphatic system (6). Emulsification takes place initially in the stomach and then in the small intestine in the presence of pancreatic and biliary secretions. The resulting mixed micelle aggregates the vitamin E molecules, solubilises the vitamin E, and then transports it to the brush border membrane of the enterocyte probably by passive diffusion. Within the enterocyte, tocopherol is incorporated into chylomicrons and secreted into the intracellular space and lymphatic system and subsequently into the blood stream. Tocopherol esters, present in processed foods and vitamin supplements, must be hydrolysed in the small intestine before absorption. Vitamin E is transported in the blood by the plasma lipoproteins and erythrocytes. Chylomicrons carry tocopherol from the enterocyte to the liver, where they are incorporated into parenchymal cells as chylomicron remnants. The catabolism of chylomicrons takes place in the systemic circulation through the action of cellular lipoprotein lipase. Although the process of absorption of all the tocopherol homologues in our diet is similar, the form predominates in blood and tissue. This is due to the action of binding proteins that preferentially select the form over the others. This form also accumulates in non-hepatic tissues, particularly at sites where free radical production is greatest, such as in the membranes of mitochondria and endoplasmic reticulum in the heart and lungs (10). Other proteinaceous sites with apparent tocopherol-binding abilities have been found on erythrocytes, adrenal membranes, and smooth muscle cells (12). These may serve as vitamin E receptors which orient the molecule within the membrane for optimum antioxidant function. These selective mechanisms explain why vitamin E homologues have markedly differing antioxidant abilities in biologic systems and illustrates the important distinction between the in vitro antioxidant effectiveness of a substance in the stabilisation of, for example, a food product and its in vivo potency as an antioxidant. From a nutritional perspective, the most important form of vitamin E is tocopherol; this is corroborated in animal model tests of biopotency which assess the ability of the various homologues to prevent foetal absorption and muscular dystrophies (Table 22). Kinetic studies with deuterated tocopherol (15) suggest that there is rapid equilibration of new tocopherol in erythrocytes, liver, and spleen but that turnover in other tissues such as heart, muscle, and adipose tissue is much slower. This presumably reflects an adaptive mechanism to avoid detrimental oxidative reactions in this key organ. The primary oxidation product of tocopherol is a tocopheryl quinone that can be conjugated to yield the glucuronate after prior reduction to the hydroquinone. This is excreted in the bile or further degraded in the kidneys to tocopheronic acid and hence excreted in the bile. Table 22 Approximate biological activity of naturally occurring tocopherols and tocotrienols compared with d-tocopherol Biological activity compared with Common name d-tocopherol, % d-tocopherol 100 d-tocopherol 50 d-tocopherol 10 d-tocopherol 3 d-tocotrienol 30 d-tocotrienol 5 d-tocotrienol not known d-tocotrienol not known Defining populations at risk of vitamin E deficiency There are many signs of vitamin E deficiency in animals most of which are related to damage to cell membranes and leakage of cell contents to external fluids. Muscle and neurological problems are also a consequence of human vitamin E deficiency (20). Early diagnostic signs of deficiency include leakage of muscle enzymes such as creatine kinase and pyruvate kinase into plasma, increased levels of lipid peroxidation products in plasma, and increased erythrocyte haemolysis. The assessment of the vitamin E requirement for humans is confounded by the infrequent occurrence of clinical signs of deficiency because these usually only develop in adults with fat malabsorption syndromes or liver disease, in individuals with genetic anomalies in transport or binding proteins, and possibly in premature infants (19, 21). This suggests that diets contain sufficient vitamin E to satisfy nutritional needs. Evidence suggests that oxidized lipoprotein is a key event in the development of the atheromatous plaque which may ultimately occlude the blood vessel (23). Likewise, the few randomised double-blind, placebo-controlled intervention trials with human volunteers which focused on the relationship between vitamin E and cardiovascular disease have given inconsistent results. There was a marked reduction in non-fatal myocardial infarction in patients with coronary artery disease (as defined by angiogram) who were randomly assigned to take pharmacologic doses of vitamin E (400 and 800 mg/day) or placebo in the Cambridge Heart Antioxidant Study involving 2000 men and women (25). However, the incidence of major coronary events in male smokers who received 20 mg/day of vitamin E for approximately 6 years was not reduced in the Alpha-Tocopherol, Beta-Carotene study (26). Epidemiologic studies suggest that dietary vitamin E influences the risk of cardiovascular disease. In the United States both the Nurses Health Study (28) involving 87000 females in an 8-year follow-up and the Health Professionals Follow-up Study in 40000 men (29) concluded that persons taking supplements of 100 mg/day or more of vitamin E for at least 2 years had approximately a 40 percent lower incidence of myocardial infarction and cardiovascular mortality than did those who did not use supplements. A possible explanation for the significant relationship between dietary vitamin E and cardiovascular disease in European countries but not in the United States may be found in the widely differing sources of vitamin E in European countries. It is reported that sunflower seed oil, which is rich in tocopherol, tends to be consumed more widely in the southern European countries with the lower cardiovascular disease risk than in northern European countries where soybean oil, which contains more of the form, is preferred (30) (Table 24). However, a study carried out which compared plasma and tocopherol concentrations in middle-aged men and women in Toulouse (southern France) with Belfast (Northern Ireland) found that the concentrations of tocopherol in Belfast were twice as high as those in Toulouse; tocopherol concentrations were identical in men in both countries but higher in women in Belfast than in Toulouse (P<0. However, very high doses may also induce adverse pro-oxidant effects (33), and the long-term advantages of such treatments have not been proven. Delineation of dietary sources and possible limitations to its availability worldwide Because vitamin E is naturally present in plant-based diets and animal products and is often added by manufacturers to vegetable oils and processed foods, intakes are probably adequate to avoid overt deficiency in most situations. Exceptions may be during ecologic disasters and cultural conflicts resulting in food deprivation and famine. Analysis of the Food and Agriculture Organization of the United Nations country food balance sheets indicates that about half the tocopherol in a typical northern European diet such as in the United Kingdom is derived from vegetable oils (30). Animal fats, vegetables, and meats each contribute about 10 percent to the total per capita supply and fruit, nuts, cereals, and dairy products each contribute about 4 percent. There are marked differences in per capita tocopherol supply among different countries ranging from approximately 8-10 mg/head/day. This variation can be ascribed mainly to the type and quantity of dietary oils used in different countries and the proportion of the different homologues in the oils (Table 25). For example, sunflower seed oil contains approximately 55 mg tocopherol/100 g in contrast to soybean oil that contains only 8 mg/100 ml (34).

The average iodine content of foods (fresh and dry basis) as reported by Koutras et al medications xl order generic bimat on line. Thus treatment interstitial cystitis order online bimat, the average iodine content of foods shown in Table 35 can not be used universally for estimating iodine intake symptoms pink eye buy bimat 3ml low price. However medicine hat mall cheap 3ml bimat with mastercard, more recent data indicate that the iodine content of human milk varies markedly as a function of the iodine intake of the population medicine runny nose buy generic bimat on-line. The iodine requirement of pre-term infants is twice that of term infants because of a 50 percent lower retention of iodine by pre-term infants treatment of diabetes order bimat master card. Such values have been observed in iodine-replete infants in Europe (11), Canada (12), and the United States (12). Table 36 Iodine content of the inorganic world Location Iodine content Terrestrial air 1. These requirements are based on the body weight of Mexican children who participated in this study. The average body weight of a 10-year-old child, as per the Food and Agriculture Organization references, is 25 kg. It also provides the iodine intake necessary to maintain the plasma iodide level above the critical limit of 0. Moreover, this level of iodine intake is required to maintain the iodine stores of the thyroid above the critical threshold of 10 mg, below which an insufficient level of iodisation of thyroglobulin leads to disorders in thyroid hormone synthesis (18). Data reflecting either iodine balance or its effect on thyroid physiology can help to define optimal iodine intake. In adults and adolescents in equilibrium with their nutritional environment, most dietary iodine eventually appears in the urine, so the urinary iodine concentration is a useful measure for assessing iodine intake. For this, casual samples are sufficient if enough are collected and if they accurately represent a community (19). Correction of the iodine deficiency will bring all these measures back into the normal range. Recent data from the Thyro-Mobil project in Europe have confirmed these relations by showing that the largest thyroid sizes are associated with the lowest urinary iodine concentrations (20). In practice such maximal efficiency is never obtained and therefore considerably more iodine is necessary. Data from controlled observations associated a low urinary iodine concentration with a high goitre prevalence, high radioiodine uptake, and low thyroidal organic iodine content (23). These requirements have been derived from studies of thyroid function during pregnancy and in the neonate under conditions of moderate iodine deficiency. Thyroid volume progressively increases and is above the upper limit of normal in 10 percent of the women by the end of pregnancy. T4 with iodine was probably administered to the pregnant women to rapidly correct sub-clinical hypothyroidism, which would not have occurred if iodine had been administered alone. Upper limit of iodine intake for different age groups An iodine excess also can be harmful to the thyroid of infants by inhibiting the process of synthesis and release of thyroid hormones (Wolff-Chaikoff effect) (28). The threshold upper limit of iodine intake (the intake beyond which thyroid function is inhibited) is not easy to define because it is affected by the level of iodine intake before exposure to iodine excess. Indeed, long-standing moderate iodine deficiency is accompanied by an accelerated trapping of iodide and by a decrease in the iodine stores within the thyroid (18). In addition, the neonatal thyroid is particularly sensitive to the Wolff-Chaikoff effect because the immature thyroid gland is unable to reduce the uptake of iodine from the plasma to compensate for increased iodine ingestion (29). Iodine intake in areas of moderate iodine deficiency In a study in Belgium, iodine overload of mothers (cutaneous povidone iodine) increased the milk iodine concentration and increased iodine excretion in the term newborns (mean weight about 3 kg). These data indicate that modest iodine overloading of term infants in the neonatal period in an area of relative dietary iodine deficiency (Belgium) also can impair thyroid hormone formation. Iodine intake in areas of iodine sufficiency Similar studies have not been conducted in the United States, where transient hypothyroidism is rarely seen perhaps because iodine intake is much higher. Table 38 summarises the recommended dietary intake of iodine for age and approximate level of intake which appear not to impair thyroid function in the European studies of Delange in infants, in the loading studies of adults in the United States, or during ingestion of the highest estimates of dietary intake (just reviewed) in the United States (34). Excess consumption of salt has never been documented to be responsible for excess iodine intake. Occasionally each of these may have significant thyroid effects, but generally they are tolerated without difficulty. This adaptation most likely involves a decrease in thyroid iodide trapping, perhaps corresponding to a decrease in the thyroid sodium-iodide transporter recently cloned (36). Some people, especially those with long-standing nodular goitre who live in iodine deficient regions and are generally ages 40 years or older, may develop iodine-induced hyperthyroidism after ingestion of excess iodine in a short period of time. Iodine fortification Iodine deficiency is present in almost all parts of the developed and developing world, and environmental iodine deficiency is the main cause of iodine deficiency disorders. Iodine is irregularly distributed over the earths crust, resulting in acute deficiencies in areas such as mountainous regions and flood plains. Thus, the food grown in iodine-deficient regions can never provide enough iodine for the people and livestock living there. The iodine deficiency results from geologic rather than social and economic conditions. It cannot be eliminated by changing dietary habits or by eating specific kinds of foods but must be corrected by supplying iodine from external sources. It has, therefore, been a common practice to use common salt as a vehicle for iodine fortification for the past 75 years. Salt is consumed at approximately the same level throughout the year by the entire population of a region. Universal salt iodisation is now a widely accepted strategy for preventing and correcting iodine deficiency disorders. For example, in Congo, Africa, as a result of cassava diets there is an overload of thiocyanate (37). To overcome this problem, appropriate increases in salt iodisation are required to ensure the recommended dietary intake. Both of these forms of iodine are absorbed as iodide ions and are completely bio-available. Other methods of iodine prophylaxis are also used: iodised oil (capsule and injections), iodised water, iodised bread, iodised soya sauce, iodoform compounds used in dairy and poultry, and certain food additives (38). Iodine loss occurs as a result of improper packaging, Humidity and moisture, and transport in open trucks and railway wagons exposed to sunlight. To compensate for these losses, higher levels of iodine are used during the production of iodised salt. Losses during the cooking process vary from 20 percent to 40 percent depending on the type of cooking used (39). To ensure the consumption of recommended levels of iodine, the iodine content of salt at the production level should be monitored with proper quality assurance programmes. Regular evaluation of the urinary iodine excretion pattern in the population consuming iodised salt or exposed to other iodine prophylactic measures would help the adjusting of iodine intake (40). The use of iodised oil and other alternatives for the elimination of iodine deficiency disorders. Physiopathology of iodine nutrition during pregnancy, lactation and early postnatal life. Regional variations of iodine nutrition and thyroid function during the neonatal period in Europe. Anomalies in physical and intellectual development associated with severe endemic goitre. Relation between serum thyrotropin and thyroglobulin with urinary iodine excretion. Maternal and neonatal thyroid function at birth in an area of marginally low iodine intake. A randomized trial for the treatment of excessive thyroidal stimulation in pregnancy: maternal and neonatal effects. Development of the regulatory mechanisms in the thyroid: failure of iodide to suppress iodide transport activity. Increased recall rate at screening for congenital hypothyroidism in breast-fed infants born to iodine overloaded mothers. Iodinated skin disinfectants in mothers at delivery and impairment of thyroid function in their breast-fed infants. Indicators for assessing Iodine Deficiency Disorders and their control through salt iodisation. Delange which appeared in the chapter Thyroid Hormone and Iodine Requirements in Man During Brain Development from the book Iodine In Pregnancy, edited by John B. It serves as a carrier of oxygen to the tissues from the lungs by red blood cell haemoglobin, as a transport medium for electrons within Icells, and as an integrated part of important enzyme systems in various tissues. Most of the iron in the body is present in the erythrocytes as haemoglobin, a molecule composed of four units, each containing one heme group and one protein chain. The structure of haemoglobin allows it to be fully loaded with oxygen in the lungs and partially unloaded in the tissues. The iron-containing oxygen storage protein in the muscles, myoglobin, is similar in structure to haemoglobin but has only one heme unit and one globin chain. Several iron-containing enzymes, the cytochromes, also have one heme group and one globin protein chain. These enzymes act as electron carriers within the cell and their structures do not permit reversible loading and unloading of oxygen. Their role in the oxidative metabolism is to transfer energy within the cell and specifically in the mitochondria. Iron is reversibly stored within the liver as ferritin and hemosiderin whereas it is transported between different compartments in the body by the protein transferrin. Iron requirements Basal iron losses Iron is not actively excreted from the body in urine or in the intestines.

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