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This is the most sensitive liver enzyme in detecting biliary obstruction, cholangitis, or cholecystitis. Therefore, it is very useful in the screening and evaluation of alcoholic patients. It may represent the associated hepatic insult (if elevation occurs in the first 7 days) or the proliferation of capil lary endothelial cells in the granulation tissue that replaces the infarcted myocardium. Increased levels Hepatitis Cirrhosis Hepatic necrosis Hepatic tumor or metastasis Hepatotoxic drugs Cholestasis Jaundice Myocardial infarction Alcohol ingestion Pancreatitis Cancer of the pancreas EpsteinBarr virus (infectious mononucleosis) Cytomegalovirus infections Reye syndrome notes G Abnormal findings 454 gastric emptying scan gastric emptying scan Type of test Nuclear scan Normal findings Normal values are determined by type and quantity of radio labeled ingested food. Time Lower normal limits Upper normal nimits 0 minutes 30 minutes 1 hour 2 hours 3 hours 4 hours 70% 30% 90% 60% 30% 10% Values lower than normal represent abnormally fast gastric emptying. Test explanation and related physiology In this study, the patient ingests a solid or liquid "test meal" containing a radionuclide such as technetium (Tc). This is helpful in the diagnosis of gastric obstruction secondary to gastroparesis or gastric obstruction. It is helpful in evaluating patients who have postcibal nausea, vomiting, bloating, early satiety, belching, or abdominal pain. Contraindications · Patients who are pregnant or lactating, unless the benefits outweigh the risk of fetal or newborn injury Interfering factors Drugs that decrease gastric emptying time include anticholin ergics, opiates, and sedativehypnotics. Tell the patient that smoking is prohibited on the day of examination because exposure to tobacco can inhibit gastric emptying. After ingestion of the test meal, the patient is imaged by a gamma camera that records gastric images. Images are obtained for 2 minutes every 30 to 60 minutes until gas tric emptying is complete. This may take several hours, although each particular timed scan takes only a few minutes. Child: 0125 pg/mL Test explanation and related physiology Gastrin is a hormone produced by the G cells located in the distal part of the stomach (antrum). In normal gastric physiology, an alkaline envi ronment (created by food or antacids) stimulates the release of gastrin. Gastrin then stimulates the parietal cells of the stomach to secrete gastric acid. By negative feedback, this lowpH environ ment suppresses further gastrin secretion. It is important to identify this latter group of patients to institute more appropriate, aggressive medical and surgical therapy. It is important to note that patients who are taking antacid peptic ulcer medicines, have had peptic ulcer surgery, or have atrophic gastritis will have a high serum gastrin level. Some may have top normal gastrin levels, which makes these patients difficult to differentiate from patients with routine peptic ulcer disease. Patients with these diseases have greatly increased serum gastrin levels associated with the infusion of these drugs. Drugs that may increase serum gastrin levels include antacids and H2blocking agents. Drugs that may decrease levels include anticholinergics and tricyclic antidepressants. A preinfusion serum gastrin level is then com pared with specimens taken every 30 minutes for 4 hours. Preinjection and postinjection serum gastrin levels are taken at 15minute intervals for 1 hour after injection. Finally, aspiration scans may be used to detect aspiration of gastric contents into the lungs. Contraindications · Patients who cannot tolerate abdominal compression · Patients who are pregnant or lactating, unless the benefits outweigh the risks Procedure and patient care Before Explain the procedure to the patient. The patient is placed in the supine position and asked to swal low a tracer cocktail. Aspiration scans · Delayed images are made over the lung fields 24 hours after injection of technetium to detect esophagotracheal aspiration of the tracer. Nuclear tracer films are then taken over the next hour, with 24hour delayed films as needed. After Assure the patient that he or she has ingested only a small dose of nuclear material. No radiation precautions need to be taken against the patient or his or her bodily secretions.

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The term copper in this profile not only refers to copper metal, but also to compounds of copper that may be in the environment. It is also found in many mixtures of metals, called alloys, such as brass and bronze. Many compounds (substances formed by joining two or more chemicals) of copper exist. Copper is extensively mined and processed in the United States and is primarily used as the metal or alloy in the manufacture of wire, sheet metal, pipe, and other metal products. Copper compounds are most commonly used in agriculture to treat plant diseases, like mildew, or for water treatment and as preservatives for wood, leather, and fabrics. For more information on the properties and uses of copper, please see Chapters 4 and 5. Copper can enter the environment through releases from the mining of copper and other metals, and from factories that make or use copper metal or copper compounds. Copper can also enter the environment through waste dumps, domestic waste water, combustion of fossil fuels and wastes, wood production, phosphate fertilizer production, and natural sources (for example, windblown dust, from native soils, volcanoes, decaying vegetation, forest fires, and sea spray). About 1,400,000,000 pounds (640,000,000,000 grams) of copper were released into the environment by industries in 2000. Copper is often found near mines, smelters, industrial settings, landfills, and waste disposal sites. When copper is released into soil, it can become strongly attached to the organic material and other components. Even though copper binds strongly to suspended particles and sediments, there is evidence to suggest that some water-soluble copper compounds do enter groundwater. Copper that enters water eventually collects in the sediments of rivers, lakes, and estuaries. Copper is carried on particles emitted from smelters and ore processing plants, and is then carried back to earth through gravity or in rain or snow. Indoor release of copper comes mainly from combustion processes (for example, kerosene heaters). Copper can be found in plants and animals, and at high concentrations in filter feeders such as mussels and oysters. Copper is also found in a range of concentrations in many foods and beverages that we eat and drink, including drinking water. You will find additional information on the fate of copper in the environment in Chapters 5 and 6. You may be exposed to copper by breathing air, drinking water, eating food, and by skin contact with soil, water and other copper-containing substances. Most copper compounds found in air, water, sediment, soil and rock are strongly attached to dust and dirt or imbedded in minerals. You can take copper into your body upon ingestion of water or soil that contains copper or by inhalation of copper-containing dust. Some copper in the environment is less tightly bound to soil or particles in water and may be soluble enough in water to be taken up by plants and animals. In the general population, soluble copper compounds (those that dissolve in water), which are most commonly used in agriculture, are more likely to threaten your health. When soluble copper compounds are released into lakes and rivers, they generally become attached to particles in the water within approximately 1 day. This could lessen your exposure to copper in water, depending on how strongly the copper is bound to the particles and how much of the particles settle into lake and river sediments. Therefore, at high fine particle concentrations, both exposure and uptake can be considerable even under conditions of tight copper binding to the suspended particulates. The concentration of copper in air ranges from a few nanograms (1 nanogram equals 1/1,000,000,000 of a gram or 4/100,000,000,000 of an ounce) in a cubic meter of air (ng/m3) to about 200 ng/m3. Near smelters, which process copper ore into metal, concentrations may reach 5,000 ng/m3. You may breathe high levels of copper-containing dust if you live or work near copper mines or processing facilities. You may be exposed to levels of soluble copper in your drinking water that are above the acceptable drinking water standard of 1,300 parts copper per billion parts of water (ppb), especially if your water is corrosive and you have copper plumbing and brass water fixtures.

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Any increase in one of the components will increase the intracranial pressure and compromise the other two components. In extreme circumstances, muscle relaxation can be used to decrease muscular resistance to venous outflow. The brain tissue compartment can be decreased by hypertonic saline or diuresis (usually osmotic diuresis with mannitol), which decreases intracellular fluid volume. As a last resort, a craniectomy, or removal of skull flap, can be performed to allow for controlled herniation out of the cranial vault. Half of the patients who make it to the hospital will be left with significant disabilities. Grading scales are used to estimate the risk for vasospasm and predicted morbidity. Other symptoms include: nausea, vomiting, meningismus, brief loss of consciousness and focal neurological deficits. The aneurysm needs to be secured as soon as possible, usually in the first 24 to 48 hours. Reversal Adapted from Rosen et al (4) Mortality increases drastically if the aneurysm re-bleeds, therefore, strict blood pressure control is pivotal. The benefit of blood pressure control must be balanced with the risk of decreased cerebral perfusion pressure. Many agents can be used to reach this blood pressure goal, but shorter acting agents are preferred. Nitrates cause vasodilatation, which may increase cerebral blood flow, can cause reflex tachycardia and headache, which may complicate care. The use of an antifibrinolytic for clot stabilization can also be used for 24 -48 hours while awaiting definitive intervention if the patient does not have coronary artery disease. The decision to clip (via craniotomy) or coil (endovascular) is based on aneurysm morphology [i. Vasospasm: the theorized mechanism is irritation to the arteries caused by blood products or inflammatory mediators in the subarachnoid space. The peak incidence of vasospasm is post bleed day 3­10, but patients remain at risk up to 21 days. Oral nimodipine has been shown to reduce the incidence and long-term morbidity from delayed cerebral ischemia caused by vasospasm. Other measures shown to reduce morbidity include: 3-7 days of antiepileptic medications, and maintenance of euvolemia (avoidance of hypovolemia). For both diagnoses, the goals of treatment are the same in this patient population, to maintain euvolemia and normonatremia via oral salt solutions, hypertonic saline and/or a mineralocorticoid administration. Intracerebral hemorrhage Hemorrhagic stroke is the second most common form of stroke. It is difficult to differentiate between hemorrhagic and ischemic 104 stroke based on physical exam. Increased risk for hematoma expansion is highest during the first three hours of symptom onset. Therefore, care is focused around early diagnosis and management to prevent expansion of hematoma and subsequent decline in neurological status. Management during these crucial hours includes; reversal of any anticoagulation, maintenance of ventilation and oxygenation, hemodynamic support and avoidance of hypertension. Hematoma evacuation is recommended for infratentorial hematoma volume >3 ml, brainstem compression, hydrocephalus, or supratentorial hematoma <1 cm from the cortex or >30 ml in volume with deteriorating neurological status. Hypertonic saline can be used to push serum sodium to 145­155 mEq/L in an attempt to reduce edema. Patients below the age of 55 are at increased risk of severe cerebral edema and herniation, termed malignant cerebral edema. Recently, an increasing number of clinical trials have demonstrated the efficacy of endovascular treatment for ischemic stroke.

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Practitioners should evaluate all potential fluoride sources and conduct a caries risk assessment before prescribing fluoride supplementation. Geme J, et al: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders. An analysis of the 2002­2003 El Salvador National Family Health Survey, Matern Child Nutr 5:49­63, 2009. Boschert S, Robinson T: Fight obesity with specific, countable goals, Pediatric News 1, Oct 2012. At puberty, the fat content of females increases more than that of males, who acquire more muscle mass than females. The blood volume, given a hematocrit of 40%, is usually 8% of body weight, although it is higher in newborns and young infants. The interstitial fluid, normally 15% of body weight, can increase dramatically in diseases associated with edema, such as heart failure, protein-losing enteropathy, liver failure, and nephrotic syndrome. The plasma osmolality is tightly controlled between 285 and 295 mOsm/kg through regulation of water intake and urinary water losses. Control of osmolality is subordinate to maintenance of an adequate intravascular volume. Volume depletion and volume overload may cause significant morbidity and mortality. The kidney determines sodium balance because there is little homeostatic control of sodium intake, although salt craving occasionally occurs, typically in children with chronic renal salt loss. The kidney regulates sodium balance by altering the percentage of filtered sodium that is reabsorbed along the nephron. The renin-angiotensin system is an important regulator of renal sodium reabsorption and excretion. The juxtaglomerular apparatus produces renin in response to decreased effective intravascular volume. Interstitial (15%) Extracellular (20­25%) Plasma (5%) Figure 32-1 Compartments of total body water, expressed as per- centage of body weight, in an older child or adult. In contrast, volume expansion stimulates the synthesis of atrial natriuretic peptide, which increases urinary sodium excretion. Daily water losses are measurable (urine and stool) and not measurable (insensible losses from the skin and lungs). Failure to replace these losses leads to a thirsty child and, ultimately, a dehydrated child. Sodium and potassium are given in maintenance fluids to replace losses from urine and stool. These guidelines assume that there is no disease process present that would require an adjustment in either the volume or the electrolyte composition of maintenance fluids. In children with complicated pathophysiologic derangements, it may be necessary to adjust the electrolyte composition and rate of maintenance fluids empirically based on electrolyte measurements and assessment of fluid balance. Along with maintenance fluids, children may require concurrent replacement fluids if they have excessive ongoing losses, such as may occur with drainage from a nasogastric tube. In addition, if dehydration is present, the patient also needs to receive deficit replacement (see Chapter 33). Maintenance fluids are composed of a solution of water, glucose, sodium, potassium, and chloride. This solution replaces electrolyte losses from the urine and stool, as well as water losses from the urine, stool, skin, and lungs. The glucose in maintenance fluids provides approximately 20% of the normal caloric needs of the patient. This percentage is enough to prevent the development of starvation ketoacidosis and diminishes the protein degradation that would occur if the patient received no calories. Maintenance fluids do not provide adequate calories, protein, fat, minerals, or vitamins. Sweating is not insensible and, in contrast to evaporative losses, sweat contains water and electrolytes. Evaporative skin water losses can be higher in neonates, especially premature infants who are under radiant warmers or undergoing phototherapy.

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Net ultrafiltration failure is the most important transport abnormality in patients undergoing long-term peritoneal dialysis. Ultrafiltration failure is defined as net ultrafiltration of less than 400 mL after a 4-hour dwell using 2 L of 4. This condition is associated with a large peritoneal vascular surface area and impaired aquaporin channel­mediated water transport. Because icodextrin is such a large molecule, its reabsorption is relatively unaffected by membrane permeability. It exerts colloid oncotic pressure and is able to maintain gradual but sustained ultrafiltration for 12 hours or longer. Improvement of peritoneal function can be brought about by minimizing glucose exposure. Mortality in this group is higher than for other patients on peritoneal dialysis, probably because of poor fluid control, which adds to the overall cardiovascular risk. Ultrafiltration failure also leads to increased protein loss in the dialysate, which compromises nutrition. Most diabetic patients require insulin while they are on peritoneal dialysis, even if they did not require it before the initiation of dialysis. This is partly the result of glucose absorption from the dialysate and associated weight gain. Insulin can be given to peritoneal dialysis patients via the intraperitoneal route, the subcutaneous route, or a combination of both. If given intraperitoneally, the total daily dose of insulin required must be increased because insulin adsorbs onto the polyvinylchloride bags. Injection of insulin into dialysis fluid bags confers a theoretical risk for bacterial contamination and subsequent peritonitis, although no evidence of this consequence has been reported. Nevertheless, it is a rarely used route of insulin administration for diabetic patients at present. Beginning with peritoneal dialysis maximizes the advantages that it confers during the first few years of dialysis in terms of preserving residual kidney function and better fluid control. If patient preference and medical conditions allow, peritoneal dialysis may well be the most appropriate initial dialysis therapy when a patient requires renal replacement therapy. The survival probabilities over the same periods for peritoneal dialysis have improved from 0. Risk factors for death among patients undergoing peritoneal dialysis include increasing age, presence of cardiovascular disease or diabetes mellitus, decreased serum albumin level, poor nutritional status as determined by anthropometric measurements, and inadequate dialysis. Patients transfer from peritoneal dialysis to hemodialysis for many reasons, including peritonitis or exit site infection, catheter malfunction, inability to perform the dialysis procedure, and inadequate clearance or ultrafiltration (particularly with loss of residual kidney function) (see. In many cases, the patient who loses a catheter because of peritonitis or a catheter infection elects to switch to hemodialysis permanently. The allograft and patient survival rates of transplanted peritoneal dialysis patients are similar to those of transplanted hemodialysis patients, but there is reduced delayed graft function in the peritoneal dialysis group. Delayed graft function, in combination with graft rejection, is a strong predictor of graft survival. If the transplant does not initially function, peritoneal dialysis may be continued provided that the peritoneal cavity was not breached during surgery. The peritoneal dialysis catheter is usually left in place for several weeks until the graft is functioning well. A decline in the use of peritoneal dialysis has been seen in many Western countries, partly related to lack of patient choice because there are fewer nephrologists and centers specializing in the delivery of peritoneal dialysis. However, interest in home-based therapies is on the rise as evidence of its superiority over incenter hemodialysis accumulates. In a lifetime, a patient is likely to utilize each of the three modalities, possibly more than once. In critical illness, bedside insertion of a Tenckhoff catheter using the Seldinger technique under local anesthesia is equally straightforward and carries a much smaller risk for infection. More frequent exchanges are unlikely to improve solute clearance, and they introduce a large "down time," when the peritoneum is mostly empty in between dwells. Although these procedures are extremely effective for volume control and are better tolerated in hemodynamically unstable patients than is hemodialysis, clearance of small solutes may be inadequate in catabolic patients or patients undergoing total parenteral nutrition who are receiving large protein loads. In addition, in the intensive care unit setting, the risk for peritonitis remains, although it should be remembered that central venous hemodialysis catheters also carry significant risks for bacteremia and other complications.

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Patients who have regained consciousness on arrival to the hospital will likely survive with intact neurologic function. The use of safety flotation devices in older children during water sport activities may be beneficial. Enhanced supervision is required to reduce the incidence of infants drowning in bathtubs. Burn injury releases inflammatory and vasoactive mediators resulting in increased capillary permeability, decreased plasma volume, and decreased cardiac output. The body then becomes hypermetabolic with increased resting energy expenditure and protein catabolism. Burns are the third leading cause of injury-related death for children ages 1 to 9 and are a major cause of morbidity. Overall, thermal burns secondary to scald or flame are much more common than electrical or chemical burns. Categories of first-degree, second-degree, and third-degree are commonly used; however, classification by depth (superficial, superficial partial-thickness, deep partialthickness, and full-thickness) conveys more information about the structures injured and the likely need for surgical treatment and may be more clinically useful. Commonly seen with sun exposure or mild scald injuries, these burns involve injury to the epidermis only. They heal in 2 to 5 days without scarring and are not included in burn surface area calculations. Superficial partial-thickness (second-degree) burns involve the entire epidermis and superficial dermis. After debridement the underlying dermis will appear erythematous and wet, will be painful, and will blanch under pressure. Healing is dependent on the uninjured dermis and usually occurs within about 2 weeks without the need for skin grafting and without scarring. Deep partial-thickness (also second-degree) burns involve the entire epidermis and deeper portions of the dermis. These burns may also have blistering, but the dermal base is less blanching, mottled pink or white, and less painful than superficial partial-thickness burns. They behave more like full-thickness burns and will often require excision and grafting. Fourth-degree burns involve underlying fascia, muscle, or bone and may require reconstruction in addition to grafting. Inhalation injuries should be suspected if there are facial burns, singed nasal hairs, or carbonaceous sputum. Inhalation injuries may result in bronchospasm, airway inflammation, and impaired pulmonary function. There are multiple methods and charts available for calculating the percentage of skin surface involved in a burn. One method that may be used for children of various ages is presented in Figure 44-1. The extent of skin involvement of older adolescent and adult patients may be estimated as 138 Section 8 u the Acutely Ill or Injured Child the first 8 hours. Controversy exists over whether and when to administer colloid during fluid resuscitation. Because burn injury produces a hypermetabolic response, children with significant burns require immediate nutritional support. Enteral feeds should be started early unless there is a specific contraindication. Children with critical burn injury may require parenteral nutrition if unable to tolerate full enteral feeds. Factors that may modify the hypermetabolic state such as beta blockers, androgenic steroids, and others are being investigated. Topical agents and dressings are then applied to control bacterial colonization, decrease evaporative losses, and aid in pain control. Commonly used topical agents include silver sulfadiazine (Silvadene) or, if the burn is shallow, polymyxin B/bacitracin/neomycin (Neosporin) ointment. Silver nitrate and mafenide acetate (Sulfamylon) are alternative antimicrobial agents. Sulfamylon has the benefit of penetrating eschar, but it is painful and can cause metabolic acidosis. Silver nitrate is used less commonly because of poor tissue penetration and potential for electrolyte abnormalities.


  • Nasal flaring
  • Medicine does not lower a high fever
  • Hallucinations
  • Eye exam every year during infancy
  • Is there any recent history of illness?
  • Notice any problems with the muscles in your face
  • Albuterol
  • Problems with the lungs
  • Painful bowel movements (tenesmus)
  • Infections in the abdomen and pelvis

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If cardiac troponins are normal, no myocardial injury has occurred, and there will be no lasting cardiac dysfunction. Revascularization may be indicated because this latter group is at great risk for a subsequent cardiac event (infarction or sudden death). A washout, or second peak of cardiac troponin levels, accurately indicates reperfusion by way of recanalization or coronary angioplasty. Late (4 weeks) cardiac troponin levels are inversely related to left ventricular ejection fraction. Elevated levels may indicate more severe disease and the need for thrombolytic therapy. Elevations of troponin T do not necessarily indicate the presence of an ischemic mechanism. Many other disease states are associated with elevations of troponin T via mechanisms different from those that cause injury in patients with acute coronary syndromes. Interfering factors · Severe skeletal muscle injury may cause false elevation of cTnT. If the immune system is nonfunctioning because of poor nutrition or chronic illness. Other skin tests used to test immune function include Candida, the mumps virus, and Trichophyton. Conventional culture techniques for growth, identification, and susceptibility of acid-fast mycobacteria take 4 to 6 weeks. After identification and growth of mycobacteria, antibiotic susceptibility testing is performed to identify the most effective antimycobacterial drugs. The culture specimen can be performed on sputum, body fluids, cerebrospinal fluid, and even biopsy tissue specimens. Other specimens, such as cerebrospinal fluid, tissue, and synovial tuberculosis culture 937 fluid, may be used. Interfering factors Antituberculosis drugs Procedure and patient care Before Explain the procedure to the patient. During · For sputum collection, it is best to induce sputum production with an ultrasonic or nebulizing device. These include contact investigations, evaluation of recent immigrants, and sequential-testing surveillance programs for infection control, such as those for health care workers. T Procedure and patient care Before Explain the procedure to the patient or the family. This distributes the stimulating antigens, allowing optimal processing and presentation of the antigens to T-cells, which causes release of interferon-. This test can be performed in conjunction with a barium swallow or a small bowel series (pp. The purpose of this examination is to detect ulcerations, tumors, inflammations, and anatomic malpositions. As the contrast descends, the lower esophagus is examined for position, patency, and filling defects. As the contrast enters the stomach, the gastric wall is examined for benign or malignant ulcerations, filling defects (most often in cancer), and anatomic abnormalities. The patient is placed in a flat or head-down position, and the gastroesophageal area is examined for evidence of gastroesophageal reflux of barium. As the contrast leaves the stomach, patency of the pyloric channel and the duodenum is evaluated. Benign peptic ulceration is the most common pathologic condition affecting these areas. The small intestine can then be studied (see discussion of small bowel follow-through, p. This is a chalky substance usually suspended in milk shake form and drunk through a straw. After drinking the barium, the patient is moved through several position changes. X-ray images are taken at the discretion of the radiologist observing the flow of barium fluoroscopically. The flow of barium is followed through the lower esophagus, stomach, and duodenum. This creates carbon upper gastrointestinal x-ray study 943 dioxide in the stomach, providing air contrast to the barium in the stomach and increased visualization of the gastric mucosa.


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The initial response to infection, especially in children, is usually a leukocytosis (increased number of circulating leukocytes) with an initial neutrophilic response to both bacterial and viral infections. With most viral infections, this response is transient and is followed quickly by a characteristic mononuclear response. In general, bacterial infections are associated with greater neutrophil counts than viral infections (Table 93-3). A shift-to-the-left is an increase in the numbers of circulating immature cells of the neutrophil series, including band forms, metamyelocytes, and myelocytes and indicates the rapid release of cells from the bone marrow. It is characteristic of the early stages of infection and, if sustained, bacterial infections. Transient lymphopenia at the beginning of illness and lasting 24 to 48 hours has been described with many viral infections. Atypical lymphocytes are mature T lymphocytes with larger, eccentrically placed, and indented nuclei classically seen with infectious mononucleosis caused by Epstein-Barr virus. Other infections associated with atypical lymphocytosis include cytomegalovirus infection, toxoplasmosis, viral hepatitis, rubella, roseola, mumps, and some drug reactions. Eosinophilia is characteristic of allergic diseases but may be seen with tissue-invasive multicellular parasites, such as the migration of the larval stages of parasites through skin, connective tissue, and viscera. High-grade eosinophilia (>30% eosinophils, or a total eosinophil count >3000/L) frequently occurs during the muscle invasion phase Clues from the History for Risk of Infection Fever-presence, duration, and pattern Previous similar symptoms Previous infections and other illnesses Previous surgeries, dental procedures Preceding trauma Presence of outbreaks or epidemics in the community Exposures to infected individuals Exposures to farm or feral animals and pets Exposures to ticks and mosquitoes Sexual history, including possibility of sexual abuse Illicit drug use Transfusion of blood or blood products Travel history Daycare or school attendance Sources of water and food. Chapter 94 of trichinellosis, the pulmonary phases of ascariasis and hookworm infection (eosinophilic pneumonia), and the hepatic and central nervous system phases of visceral larva migrans. Other common screening tests include urinalysis for urinary tract infections, transaminases for liver function, and lumbar puncture for evaluation of the cerebrospinal fluid if there is concern for meningitis or encephalitis (see Chapters 100 and 101). Various tests may help distinguish viral versus bacterial infection, but definitive diagnosis requires identifying the agent by culture or another test, such as polymerase chain reaction. Blood cultures are sensitive and specific for bacteremia, which may be primary or secondary to a focal infection (osteomyelitis, gastroenteritis, urinary tract, and endocarditis). Urine cultures are important to confirm urinary tract infection, which may be occult in young infants. Cultures should be obtained with every lumbar puncture, aspiration, or biopsy of other fluid collections or masses. Specific types of cultures (bacterial, fungal, viral, or mycobacterial) are guided by the clinical problem. Tissue culture techniques are used to identify viruses and intracellular bacterial pathogens. Antibiotics often are begun before a definitive diagnosis is established, complicating the ability to rely on subsequent cultures for microbiologic diagnosis (see Chapter 95). Although persistent or progressive symptoms, despite antibiotic treatment, may indicate the need to change the regimen, more frequently this indicates the need to stop all antibiotics to facilitate definitive diagnosis by obtaining appropriate cultures. Antibiotics should not be given before obtaining appropriate cultures unless there is a life-threatening situation. Rapid tests, such as antigen tests, are useful for preliminary diagnosis and are included in numerous bacterial, viral, fungal, and parasitic antigen detection tests. When an unusual infection is suspected, a microbiologist should be consulted before samples are obtained. In the absence of localizing signs and during an acute infection, imaging of the entire body is less productive. Ultrasonography is a noninvasive, nonirradiating technique well suited to infants and children for imaging solid organs. It also is useful to identify soft tissue abscesses with lymphadenitis and to diagnose suppurative arthritis of the hip. A voiding cystourethrogram may be used to evaluate for vesicoureteral reflux, a predisposing factor for upper urinary tract infections. Radionuclide scans, such as technetium-99m for osteomyelitis and dimercaptosuccinic acid for acute pyelonephritis, are often informative. Active immunization induces immunity through the administration of a vaccine or toxoid (inactivated toxin). Passive immunization includes transplacental transfer of maternal antibodies and the administration of antibody, either as immunoglobulin or monoclonal antibody.

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In addition, the proximal tubule is an important site of gluconeogenesis that parallels the liver (2). Space constraints do not permit a comprehensive account of proximal tubule function in this article. We will also briefly cover the reabsorption of glucose, amino acids, phosphate, and one organic anion, citrate, where the entire regulatory and absorptive function is confined to the proximal tubule. Whereas glucose and phosphate are primarily returned to the Copyright © 2014 by the American Society of Nephrology 1627 1628 Clinical Journal of the American Society of Nephrology circulation, citrate represents one substrate that is partially metabolized in the proximal tubule. Another organic substrate that is absorbed and metabolized is the amino acid glutamine. This process provides the nitrogen and carbon skeleton necessary to support renal gluconeogenesis and ammoniagenesis. Finally, the proximal tubule constantly adjusts its functions in response to needs, which is the hallmark of a stringent homeostatic system (6). Metabolic acidosis represents a state where there is concerted adaptations in multiple proximal tubule transport and metabolic functions aimed at minimization of the effect of the excess acid on the organism and rectification of the disturbance. The proximal tubule is the first nephron segment after the glomerulus where reabsorption commences. It is important to note that proximal solute and water reabsorption proceeds primarily in an isotonic fashion with very small changes in luminal osmolarity. Figure 1A shows the profile of changes in selected solutes along the length of the proximal tubule. Figure 1B shows a generic cell model of how transepithelial transport is achieved. Transporters can broadly be viewed from a thermodynamic standpoint as being driven primarily by changes in enthalpy or entropy. Entropy-based or secondary active transporters dissipate existing electrochemical gradients to move a solute against a concentration gradient. Thus, they use the downhill free energy change of one solute to energize the uphill movement of another solute. Transepithelial transport can occur via the paracellular or transcellular route, both of which are driven by electrochemical forces. It creates a low cellular [Na1] and negative voltage, which provides the Figure 1. Inorganic phosphate (Pi) reabsorption is more avid in the earlier parts of the proximal tubule. The presence of K1 conductance allows the [K1] gradient to increase the negative interior potential. The low cell [Na1] and negative voltage serve as the tertiary energy currencies that drive multiple secondary active apical transporters to achieve uphill movement of solutes coupled to downhill movement of Na1 (entropic transport). The transported solutes move in the same (symport or cotransport) or opposite (antiport, exchanger, or countertransport) direction as Na1. Movement of solute can also proceed via paracellular routes driven by electrochemical forces. Clin J Am Soc Nephrol 9: 1627­1638, 2014 Proximal Tubule Physiology and Response to Acidosis, Curthoys and Moe 1629 ultimate energy to transport a multitude of solutes across the proximal tubule (Figure 1B). Apical secondary active solute entry can proceed through Na1-dependent cotransporters (symporters), exchangers (antiporters), parallel transporter systems, or other Na1-independent facilitated transporters (6). NaCl Transport Approximately 60%­70% of the filtered NaCl and the accompanying water are reabsorbed by the proximal tubule in a near isotonic fashion. Basolateral Cl2 exit is mediated by Cl2 -carrying exchangers and cotransporters (Figure 2) (7­9). Na1-coupled transport is a general mechanism in the apical membrane so not all of the Na1 ions that enter the cell are devoted to NaCl transport (6). For example, a significant amount of glucose enters the apical membrane via Na1-glucose cotransport (10). This electrogenic process (net positive charge moving into the cell) contributes to a slight negative luminal potential. This combined electrochemical driving force in coalition with paracellular Cl2 permeability results in Cl2 movement from urine to blood, which is tantamount to essentially "Na1-glucose-Cl2 absorption" (Figure 2). Alternatively, Na1 can leak back from the paracellular space into the lumen, providing a recycling system for Na1-coupled transport of glucose. Conversely, natriuretic hormones, such as dopamine, inhibit proximal tubule NaCl reabsorption (15).


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