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M. Mannig, M.B.A., M.D.

Professor, Universidad Central del Caribe School of Medicine

Encopresis is the regular hiv transmission statistics top bottom buy 400 mg zovirax with visa, voluntary or involuntary passage of feces into a place other than the toilet after 4 years of age hiv viral infection symptoms zovirax 800 mg on line. Encopresis without constipation is uncommon and may be a symptom of oppositional defiant disorder or other psychiatric illness hiv infection symptoms in pregnancy 800 mg zovirax fast delivery. Soiling is the involuntary passage of stool and often is associated with fecal impaction hiv infection long term effects purchase 800mg zovirax amex. The normal frequency of bowel movements declines between birth and 4 years of age, beginning with greater than four stools per day to approximately one per day. Etiology the etiology of functional constipation and soiling includes a low-fiber diet, slow gastrointestinal transit time for neurologic or genetic reasons, and chronic withholding of bowel movements, usually because of past painful defecation experiences. Approximately 95% of children referred to a subspecialist for encopresis have no other underlying pathologic condition. Constipation with overflow soiling occurs in 1% to 2% of preschool children and 4% of school-age children. The incidence of constipation and soiling is equal in preschool girls and boys, whereas there is a male predominance during school age. Parents may report that the child has diarrhea because of soiling of liquid stool. On further questioning, the clinician learns that the child is passing large-caliber bowel movements that may occasionally block the toilet. Children younger than 3 years of age often present with painful defecation, impaction, and withholding. The history should include a complete review of systems for gastrointestinal, endocrine, and neurologic disorders and a developmental and psychosocial history. Stool impaction can be felt on abdominal examination in about 50% of patients at presentation. A rectal examination allows assessment of sphincter tone and size of the rectal vault. Evaluation of anal placement and existence of anal fissures also is helpful in considering etiology and severity. A neurologic examination, including lower extremity reflexes, anal wink, and cremasteric reflexes, may reveal underlying spinal cord abnormalities. It can be helpful to show to the family the degree of colonic distention and fecal impaction. In general further studies, such as barium enema and rectal biopsy, are indicated only if an organic cause for the constipation is indicated by history or physical examination (see Chapter 129). Similarly although endocrinologic conditions such as hypothyroidism can cause chronic constipation, laboratory studies are not indicated without history or physical examination suggesting such a disorder. Table 14-1 u Control of Elimination 45 Education about Chronic Constipation and Soiling Constipation affects 16% to 37% of children. Until then, dilated rectal musculature may be less able to expel stool effectively. Paradoxical anal sphincter contraction may occur when the urge to defecate is felt; it can lead to incomplete emptying of stool at defecation attempt. Many children do not recognize their soiling accidents owing to olfactory accommodation. Effective management of functional constipation requires a substantial commitment of the child/family, usually for 6­24 mo. Differential Diagnosis the differential diagnosis for functional constipation and soiling includes organic causes of constipation. A child with chronic constipation and soiling who had delayed passage of meconium and has an empty rectum and tight sphincter may have Hirschsprung disease (see Chapter 129). Chronic constipation may be a presenting sign of spinal cord abnormalities, such as a spinal cord tumor or a tethered cord. Physical examination findings of altered lower extremity reflexes, absent anal wink, or a sacral hairy tuft or sacral sinus may be a clue to these anomalies. Hypothyroidism can present with chronic constipation and typically is accompanied by poor linear growth and bradycardia. The use of opiates, phenothiazine, antidepressants, and anticholinergics also may lead to chronic constipation. Developmental problems, including mental retardation and autism, may be associated with chronic constipation. Treatment Treatment begins with education and demystification for the child and family about chronic constipation and soiling, emphasizing the chronic nature of this condition and the good prognosis with optimal management.

Is there an implemented procedure for direct service health professional training that includes the following? Orientation to the facility hiv infection in young adults generic 800 mg zovirax with amex, program and equine-assisted activities and therapies in general? Health professionals should be aware of the responsibilities given to them and aware of the performance expected of them structure and infection cycle of hiv zovirax 800mg otc. Compliance Demonstration: Personnel and health professional explanation of training procedure hiv transmission risk statistics generic zovirax 400 mg without prescription. Is there an implemented written procedure to train personnel specifically for driving? Personnel should be trained in offering assistance to the equine and participant as needed throughout the driving lesson the infection cycle of hiv includes buy zovirax 200 mg with amex. Personnel should be trained in procedures to handle the equine and quickly release him/her from the harness and vehicle in an emergency. Personnel should be instructed in the operation of all securing mechanisms and procedures for entering and exiting the vehicle. Is there an implemented procedure for volunteer and personnel training specific to the needs of interactive vaulting? These skills are in addition to the training for equine-assisted activities and therapies and may include but are not limited to instructions in vaulting exercises, gymnastics, group dynamics, emergency response and spotting. Compliance Demonstration: Visitor interview with personnel; observation of the interactive vaulting session. Yes Interpretation: Personnel may be certified through a recognized agency such as American Red Cross, American Heart Association, Canadian Red Cross, or other international equivalent. Copies of the current certification documentation should be maintained by the center. Compliance Demonstration: Center representative identifies certified persons at the activity site during participant activities. Yes No Interpretation: this standard applies to personnel and volunteers while engaged in mounted, driving or vaulting in center activities. Staff and volunteer assignments Yes No Interpretation: these assignments should be based on the size of the participant, needs of the participant, type of movement provided by the equine, size of the equine and plan for the appropriate activity or therapy. The implemented system may include a posted written list of the required information that is readily available to the team at the activity site. Compliance Demonstration:Visitor observation and personnel description of procedures. Is there an implemented procedure to ensure the proper fit of equipment to the following: 1. Personnel responsible for adjusting equipment must be instructed in proper fit and adjustment. For example: Stirrups should allow the rider to place the widest part of the foot on the tread but should not be so small as to entrap the foot or so large as to allow the foot to easily slip through the stirrup. The well-fitted helmet should stay on the head when harnessed without rocking or moving. It should rest so there could be two fingers placed between the eyebrows and the edge of the helmet. Compliance Demonstration: Visitor observation; personnel explanation of the procedure. Yes No Interpretation: the instructor is responsible to ensure that the equipment safety checks are conducted for any mounted or hitched activity. Are there written guidelines to determine the ability of personnel to perform the tasks of leader and/or sidewalker? Is there an implemented maintenance routine throughout the center facility resulting in the following: 1. Stalls, fencing, gates, paddocks, tack rooms, office, toilet facilities, classrooms, riding areas, waiting areas, mounting areas, observation areas and electrical wiring are examples of items that should show signs of regular maintenance and repair.

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