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In some patients, surgical separation under local or general anaesthesia will be required, particularly where dense fibrous adhesions have formed. The condition tends to resolve spontaneously at puberty, however, and surgery should only be under taken if the condition is symptomatic. Dysuria, pain with activities, urinary retention and almost complete oc clusion of the vestibule leading to a pinpoint opening with abnormal urinary stream are indications for such treatment. Infantile pyramidal perineal protrusion Although this has only recently been labelled as an entity in the medical literature [11], it is probably not rare. It is noticed in infancy as an asymptomatic soft protrusion of the median raphe, mostly in girls. Some cases have been seen in association with lichen sclerosus[12] and chronic constipation [13]. Idiopathic calcinosis cutis presenting as labial adhesions in children: report of two cases with literature review. Significance of topical estrogens to labial fu sion and vaginal introital integrity. Retro spective comparison of topical treatments: estrogen only, betamesthasone only, and combination estrogen and betamethasone. Topical estrogen therapy in labial adhesions in children: therapeutic or prophylactic? Infantile pyramidal protrusion as a manifestation of lichen sclero sus et atrophicus. Genital signs of systemic disease Crohn’s disease Crohn’s disease, a chronic and relapsing inflammatory bowel disorder, is often associated with skin findings. Erythema nodosum and pyoderma gangrenosum may occur as non-specific associations, but the same granulo matous process that affects the bowel may be found in the skin and can be confirmed histologically. The biopsy will demonstrate giant cells, macrophages, lymphocytes and plasma cells in sarcoidal granulomas. This can be contiguous with the bowel, with perianal lesions or on the genitalia [2,3]. The usual presentation is with discomfort and soreness, associated with firm oedema and hypertrophy of the labia in girls and the penis and scrotum in boys. Perianal erosions and fissures, swelling, fistulae, skin tags and erythema are commonly found where there is genital involvement. The condition must be differentiated from other processes that cause painless induration of the genital area, including filiariasis and lymphogranuloma venereum. The skin lesions tend to be resistant to treatment with oral antibiotics such as metronidazole and sulphasalazine, and prednisone is usually required to induce a remission. Orofacial granulomatosis In this group of children, painless induration of the lips associated with a similar induration of the penis, scro tum and perianal area occurs without bowel disease. Treatment with topical and intrale sional corticosteroids in association with dietary restriction is considered first-line treatment [8]. A recent report documents three children with granulomatous periorificial dermatitis who also had involve ment of the labia majora [9]. In these children, histopathology demonstrated non-caseating perifollicular granu lomas. This condition presents with an erythematous papular eruption, rather than swelling and fissuring that is typical of Crohn’s disease but may need to be differentiated from it because of the histological appearance. Behcets’ Disease Behcet’s disease is a systemic vasculitis affecting arterioles and venules. It is characterized by recurrent oral ulcers, genital ulcers and ocular inflammatory disease. Joints, gastrointestinal tract, central nervous system and skin are other sites commonly involved in this multisystem disease. A recent review showed that oral ulcers are present in all childhood cases and genital aphthous ulcers in over 90%. Familial clustering was found in 45 % of cases, significantly higher than in adult cases, however in other ways childhood Behcet’s disease presents similarly to adult cases and is treated in the same way. The appearance is with an eroded bilateral vul val rash with a very well-demarcated edge. Crohn’s disease of the prepuce in a 12-year-old boy: a case report and review of the literature. Crohn’s disease with metastatic cutaneous involvement and granulomatous cheilitis.

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In zation regarding structural integrity and patient our opinion, an across-the-board recommendation of 6 weeks outcomes2,31,53,58,59,65,88 (Table I). Although recalcitrant postoperative stiffness ties, if there are concerns regarding tissue healing. Those survey results have been incorporated into (Appendix S1) as a starting point for communication among the recommendations to provide a rationale for rehabilita the surgeon, physical therapist, and patient, and this should tion decisions not commonly studied in the literature. Our document is not intended to substitute for international consensus rehabilitation statement developed communication between therapist and surgeon. This statement is intended to foster Methods of development matched expectations among patient, surgeon, and therapist to provide a patient-centered rehabilitation strategy. Anatomic failure is associated with increasing resulted in 4714 articles; then abstracts were reviewed to merit age, poor tissue quality, fatty infiltration, atrophy, inclusion as supporting evidence related to rehabilitation after smoking, hypercholesterolemia, and diabetes. After review of the evidence, articles were divided into to occur in the first 3-6 months after surgery. However, numerous authors have assessed muscle performance using a hand Appendix S1 contains the detailed rehabilitation guideline. Thus, it is reasonable to begin assessing tionale for each phase of rehabilitation. Function of the periscapular mus of time from surgery, there are many other important vari culature can be screened with visual observation of active ables that need to be considered to properly advance a patient’s elevation or rehabilitation exercises76,102,109. A protocol that offers flexibility of progres the periscapular muscles can be used to help make sense of sion based on when patients reach specific clinical goals or an abnormality detected with visual observation. Most rotator cuff tears arise In addition to monitoring impairment-based milestones, not from an acute injury but as a result of gradual degener it is important to collect patient-rated outcome measures to ation of the tendon. Given the fact then that rotator cuff tissue comprehensively assess response to treatment. The does not approach normal levels of elasticity or strength until disease-specific Western Ontario Rotator Cuff Index pro at least 6 months postoperatively10,37. Patient-rated outcome quality, atrophy of muscles24,38,40,43,52,97,104, associated shoul measures should be assessed every 2-4 weeks to ensure symp der pathology, and method of surgical repair10,11,35,37,57,106. These Perhaps no component of postoperative management is more phases comprise phase 1, in which exercises are generally con important than patient education. The first step in this process sidered to be passive exercises that minimize loads across the is open communication between the rehabilitation provider repair; phase 2, in which expanded flexibility exercises, as and the patient, family, and surgeon. Thorough and timely well as the transition from active-assistive exercises to active patient education is important to help empower patients so exercises to very light resistive exercises, begin in a way that that they can share responsibility for rehabilitation deci gradually increases but maintains controlled loads to the repair; sions. Furthermore, patients receiving cryotherapy in the first 10 days postoperatively reported diminished shoul tension on the repair. Whereas all these factors are impor der pain and swelling, less pain during therapy, and a more tant, exercise prescription (passive and active) for the patient tolerable rehabilitation87. Therefore, transcutaneous electrical neuromuscular able estimate of stress placed on the rotator cuff stimulation or neuromuscular electrical stimulation may be tendon7,22,30,41,47,51,78,92,93,108. Therefore, we recommend per and progress in a manner consistent with the suggested phases forming all exercises with only as many repetitions as of rehabilitation. In the early part of this progression, the patient is generally in the upright During the postoperative time frame of 6-12 weeks, animal position, moving the upper limb with assistance and then ad studies have shown that Sharpey fibers, which bind the healing vancing to independent, unsupported elevation later in this tendon to the bone, are not present in any considerable number. Because the repair is still not biome Therefore, repair strength is likely only 19%-30% of normal chanically mature, we suggest avoiding excessively loading at 6 weeks and 29%-50% of normal at 12 weeks39. Al the healing tendon, as indicated by fatigue, pain, or altered though tendon-bone healing is thought to be sufficient to patterns of movement. Clin pensation; and the ability to perform light, nonrepetitive ically, we believe the wall slide or wall walk is not appropriate activities of daily living or work tasks below shoulder level to use in the early stages of phase 2 but, instead, is more ap without difficulty or pain. For example, active ele and positions are thought to place tension directly on the vation against gravity produces 16%-29% supraspinatus repair, these stretches are typically included only in the latter activity if 0-1 lb of resistance is used but ≥50% supraspi half of phase 2 (after week 9), should be prescribed judi natus activity if 3-4 lb of resistance is added to the ciously, and should be performed only to the level of a light arm3,36,73,107,110. Therefore, we recommend caution ing exercises likely apply a progressive continuum of passive when prescribing these exercises during phase 2 rehabilita and active stresses on the repair based on the applied load. We advocate using the muscle activity level) use slow-speed motions in an aquatic thumb-up “full can” position for assistive, active, and re environment55, gravity-minimized positions such as supine or sisted elevation exercises because it provides better subacromial side lying, and/or short lever arms to promote rotator cuff and clearance33, better scapular mechanics103, and equal rotator deltoid balance21,22,67.

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Cheilitis due to Retinoids Several side effects may appear during retinoid administration. The most common are dryness During the last decade, synthetic retinoids (13-cis with scaling of the lips and dryness of the oral retinoic acid and the aromatic analogue of retinoic mucosa (Fig. Hair loss, palmoplantar scal acid, etretinate) have been introduced as new ing, thinning of the skin, pruritus, epistaxis, agents in the modern therapy of skin diseases. No They are extremely effective drugs in various severe complications have been observed after disorders of keratinization. Synthetic retinoids have recently been treatment and one year thereafter because of the used in the treatment of psoriasis, acne vulgaris, teratogenic and embryotoxic action of these ichthyosis, lichen planus, parapsoriasis en drugs. Metal and Other Deposits Amalgam Tattoo the differential diagnosis includes pigmented nevi, malignant melanoma, normal pigmentation, Amalgam deposition develops either as a result of and hematoma. Histopathologic examination and fragments in the oral tissues during dental filling radiographs are necessary on occasion to differen or surgical operations. In addition, during tooth tiate amalgam tattoo from other lesions of the oral extraction, fragments of amalgam restorations are mucosa with dark discoloration. Amalgam tattoo appears as a well defined flat area with a bluish-black or brownish discoloration of varying size (Fig. Amalgam deposits usually occur in the gingiva, the alveolar mucosa, and the buccal mucosa. Metal and Other Deposits Bismuth Deposition Materia Alba of the Attached Gingiva Bismuth compounds were formerly used in the Materia alba is the result of accumulation of bac treatment of syphilis. It is antibiotics have replaced these compounds in the usually found at the dentogingival margins of per treatment of syphilis. However, materia bismuth are now rarely encountered except in alba presenting as a white plaque along the ves patients who have been treated for syphilis in the tibular surface of the gingiva and the alveolar preantibiotic era and have poor oral hygiene. Less detached after slight pressure, leaving a red sur frequently, bismuth may be deposited in other face. Phleboliths Phleboliths are calcified thrombi that occur in veins and blood vessels. It is accepted that thrombi are produced by a slowing of the peripheral blood flow, and become secondarily organized and mineralized. Clinically, it appears as a hard, pain less swelling of the oral soft tissues typically associated with hemangiomas, although in some cases there are no signs of hemangiomas (Fig. The differential diagnosis includes salivary gland calculi, calcified lymph nodes, and soft-tissue tumors. White plaques on the attached gingiva and the alveolar mucosa caused by materia alba accumulation. If the salivary glands are irradiated, xero treatment of oral and other head and neck can stomia is one of the earliest and most common cers. Spontaneous remission of oral lesions ionizing radiation, delivered by an external may occur gradually after termination of the radi source, or radioactive implants (gold, iridium, ation treatment. Late manifestations are usu Ionizing radiation, in addition to its therapeutic ally irreversible and result in extremely sensitive effect, can also affect normal tissues. The teeth, in the absence of mucosal side effects after radiation are mainly salivary protection, rapidly develop caries and dependent on the dose and the duration of treat finally are destroyed (Fig. These radiation-induced mucosal reactions crosis is a serious complication and occurs in cases may be classified as early and late. Early reactions of high-dose radiation, especially if inadequate appear at the end of the first week of therapy and measures are taken to reduce the radiation dosage consist of erythema and edema of the oral delivered to the bones. During the second week, erosions and osteomyelitis with bone necrosis and sequestra ulcers may appear, which are covered by a whit tion and, rarely, formation of extraoral fistulas ish-yellow exudate (Figs. The mandible is more frequently complaints include malaise, xerostomia, loss of affected than the maxilla. The risk of this compli taste, burning, and pain during mastication, cation is increased particularly if teeth within the speech, and swallowing.

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Recommendation: High Voltage Galvanic Therapy, H-Wave Stimulation, Interferential Therapy, Microcurrent, or Iontophoresis for Trigger Points/Myofascial Pain There is no recommendation for or against high voltage galvanic, H-wave stimulation, interferential therapy, microcurrent, or iontophoresis for the treatment of trigger points/myofascial pain. Strength of Evidence  No Recommendation, Insufficient Evidence (I) Rationale for Recommendation There are no quality trials for these electrical therapies. Electrical therapies are not invasive, have low adverse effects and are moderately costly. As there is no quality evidence, there is no recommendation for or against these treatments. Evidence for the Use of High Voltage Galvanic, H-Wave Stimulation, Interferential Therapy, Microcurrent, or Iontophoresis There are no quality studies evaluating the use of high voltage galvanic, H-wave stimulation, interferential therapy, microcurrent, or iontophoresis for trigger points/myofascial pain. However, it is high cost and with absence of evidence of efficacy, it is not recommended. Through these mechanisms, it is theorized that there may be a mechanism for increased © Copyright 2016 Reed Group, Ltd. Strength of Evidence  No Recommendation, Insufficient Evidence (I) Rationale for Recommendation There are no quality studies for trigger points/myofascial pain. Recommendation: Trigger Point Injections Using Local Anesthetic Trigger point injections consisting solely of a topical anesthetic such as bupivacaine are recommended as a second or tertiary option for subacute or chronic trigger points that are not resolving. Frequency/Duration – Up to 4 injections a session with a follow-up appointment to assess subjective and objective measures of efficacy. If there are not subjective and objective improvements at that point, further injections are not recommended. Repeated injections should be linked to subjective and objective functional improvements. The use of therapeutic injections without participation in an active exercise or rehabilitation program is not recommended. Recommendation: Trigger Point Injections Using Glucocorticosteroids Glucocorticosteroids are not recommended for use in trigger point injections. Study designs, health outcomes assessed, interventions performed all differ widely across these studies. There is no evidence that a steroid is required for efficacy of these injections, particularly those that are tender point injections. A study evaluated injection with 1% lidocaine versus lidocaine/water mixture and suggested that the lidocaine/water mixture had less injection site pain and better pain outcomes at 14 days after injection, (Iwama 00) however, another report by the same author found no differences among 4 injection mixtures. An injectable anesthetic, typically either lidocaine or bupivacaine are recommended. Author/Title Score Sample Comparison Results Conclusion Comments Study Type (0-11) Size Group Collée 1991 8. The difference is evident in the rheumatology setting but not in the general practice setting. After 3 injections months, 19 of 20 in include severe sterile water group pain requiring assessed their pre-medication condition as in some generally improved; individuals and 6 in saline group muscle spasm felt they were lasting 10 better. Whether pain on injection is helpful or harmful for treatment of trigger point patients unclear. However, these injections have primarily been used for numerous non-occupational conditions such as cervical dystonia (Lew 97,00; Benecke 05; Brans 96, 98; Brashear 98; Brin 99; Tassorelli 06; Poewe 98; Pappert 08; Ostergaard 94; Odergren 98; Laubis-Herrmann 02; Ranoux 08; Naumann 02; Lu 95; Comella 05; Truong 05), torticollis (Tsui 86; Blackie 90; Lorentz 91; Moore 91; Koller 90; Greene 90; Gelb 89), strabismus, migraine prophylaxis (Evers 04), blepharospasm, (Charles 04) neuropathic pain after neck dissection, (Wittekindt 06) and severe primary axillary hyperhidrosis (see Chronic Pain Guidelines). These injections are thought to directly treat a taut muscle band and to have analgesic properties. Strength of Evidence  Moderately Not Recommended, Evidence (B) Rationale for Recommendation Botulinum toxin A to treat trigger points/myofascial pain has been evaluated in multiple quality studies with nearly all studies finding a lack of benefit when compared with saline. Within this body of evidence, there are five high-quality studies with the four largest studies all finding a lack of clear benefit. Botulinum does not appear superior to bupivacaine (Graboski 05) and the latter has a much lower adverse effect profile. Those studies that evaluated botulinum injections for the management of neck pain or tension headaches did not demonstrate benefits greater than placebo.

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Be sure to give yourself enough time to teach the girls camping skills at home before their camping adventure. Be sure to give yourself enough time to teach them the expected behavior, etiquette, and other expectations before your trip. Staying at hotels and hostels involves a different knowledge and skill set to ensure girls have a fun and safe experience. Extended Travel: If you are planning a trip of more than three days and two nights, your trip is an extended trip and the Domestic Troop Travel class is required. For extended trips, Troops/groups must submit an Extended Travel/High Risk Application eForm. International Travel: If you are planning on traveling internationally, then the International Travel class is required before you and the girls plan their international travel trip. Troops/groups must submit an Extended Travel/High Risk Application eForm. Use this handy chart to determine which classes to take in order to give your girls the best and safest experiences. If girls are not able to choose the what/when/where/who and how of a trip, it may not be age-appropriate! As you help girls choose and plan their trips, be sure they use these Trip Guidelines established for troop and other pathways in Girl Scouts of Greater Los Angeles: Girl Scout Daisies Start out with short, local trips. Girl Scout Daisies in 1st grade may participate in an of several hours in duration. May take local overnight troop trips of one or two Brownies nights once progressive day trips have been successfully completed. May take overnight trips of two or more nights based on previous troop travel experiences. May take overnight trips of three nights based on previous troop Cadettes, travel experiences. International Travel Training Ambassadors is required at least one year in advance before applying for this type of trip. When is a girl ready for a day trip or one-night overnight at an indoor facility with kitchen and bathrooms? As troop leader, you must decide if the trip or overnight activity is appropriate for the maturity of the girls and their basic skill level. Here are some things to consider: ➢ Be ready emotionally and physically for the planned trip. Communicate with girls and/or with their caregivers, to assess any special needs or accommodations related to health issues or disabilities. Learn more about adaptive camping resources and information from Global Explorers ( As a troop or other pathway leader, you are not only supervising activities yourself, you help the other adults accompanying you on trips understand what supervision means when activities are girl-led: ➢ Teaching, watching, guiding, and directing girls as they take part in activities, but not taking over and doing things for the girls ➢ Encouraging girls to try new things and learn new skills ➢ Giving girls real responsibility for finishing a job, so they can see themselves as useful and competent. Every chaperone, driver, and first-aider must be screened and cleared (To determine how many volunteer chaperones the girls will need with them on the trip, see the adult-to-girl ratios in this handbook. Getting fit (appropriate to the trip) ➢ Creating an experience for and with girls, by understanding the plans the girls have made for the trip, plus realizing all adults on the trip should be acting as coaches (watching, guiding, and not doing). It is suggested that members should wear closed toed shoes when participating in outdoor activities unless engaging in water sports. Be sure every chaperone reviews the Safety-Wise and Troop Chaperone online training modules found at: gsglaonlinetraining. Keep this in mind before participating in any activities with the girls that may distract your attention from this critical responsibility. How parents decide to transport girls between their homes and Girl Scout meeting places is each parent’s decision and responsibility. For planned Girl Scout field trips and other activities—outside the normal time and place—in which a group will be transported in private vehicles: ➢ Every driver must be an approved* adult volunteer, at least 21 years of age, and have a good driving record, a valid license, and a registered/insured vehicle. For more about driving, see the “Transporting Girls” section of “Chapter 4: Safety-Wise” in this handbook. Girl Scouting helps girls discover how to stay healthy and have a feeling of well-being, and adult volunteers provide supervision and model healthy behavior, but ultimately the health of a girl is the responsibility of herself and her parent or caregiver. They are filled out by the girl’s parent or caregiver to give an updated record of the girl’s health status. Form should be reviewed and updated before each trip if any information has changed or new medications are being used, and must be updated at least once a year.

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Diffusion several different mechanisms, in to normalize the tumour vasculature limited hypoxia refers to limitations in cluding upregulation of reactive and improve drug uptake. Epidemiological re limited hypoxia results from non-uni outcomes in patients with head ports indicate that chronic infamma form blood fow patterns caused by and neck carcinomas and cervical tion in select organs increases the structural and functional alterations cancer. For example, a Studies evaluating the genetic that non-steroidal anti-infammatory rapidly expanding tumour may im stability of the stromal compart drugs reduce the incidence of, and pinge on its vasculature and tem ment have yielded conficting results. An infammatory component is fow, thereby creating areas defcient affn-embedded archival tumours also present in the microenvironment in oxygen. In circulation; approximately one third of certain loci in cancer-associated general, cancer-associated infam of arterial blood can pass through fbroblasts, whereas studies per mation parallels disease progres tumours without taking part in the formed on fresh-frozen tissues failed sion and contributes to cancer cell microcirculatory exchange process. A re metastasis, subversion of adaptive mours has important clinical im cent genome-wide copy number and immunity, and reduced response to plications. Hypoxia acts as a ber alterations are extremely rare represented innate immune cells physiological selective pressure for in cancer-associated fbroblasts [7]. A variants with diminished apoptotic There is no debate about the im correlation exists between high mac potential, enhanced genetic instabil portance of infammation to carcino rophage content and poor prognosis ity, and increased invasive capacity. Circulating monocytes traffc to tumours in re sponse to chemokines including Fig. A compilation of data from multiple assays, including measuring angiogenic factors in and vasoactive peptides including serum, plasma, and urine; tumour biopsy analysis; radiological imaging; and, recently, endothelins. Cancer cell-derived fac ex vivo analyses of isolated peripheral blood cells (labelled circulating endothelial cells) tors mediate the differentiation and may facilitate defining the optimal biological dose for subsequent clinical studies of orientation of incoming monocytes. Results from clinical and experimental studies suggest that the functional proper ties of M2 macrophages favour tu mour progression. M2 macrophages possess limited antigen-presenting capacity and suppress Th1 adaptive immunity while actively promoting angiogenesis and tissue remodel ling processes. Disseminating and correlate with advanced tumour carcinoma cells reactivate this de stage, increased invasion and me Microenvironment in velopmental programme and re tastasis, and shortened survival [10]. The process of metastasis consists of sequential, interlinked, and selective steps. Each step of the metastatic process is considered rate-limiting in that failure of a tumour cell to complete any step effectively terminates the process. The formation of clinically relevant metastases represents the survival and growth of a unique subpopulation of cells that pre-exist in primary tumours. See the text for a detailed description of the individual steps of the metastatic process. Reciprocal brain metastases, 80% of which are the intermediate flament protein signalling between cancer cells and located in the cerebral hemispheres. Invading cancer molecular mechanisms that medi infltrate brain metastases, and the cells gain access to the systemic cir ate breast cancer cell arrest and magnitude of astrogliosis parallels culation by penetrating thin-walled extravasation in the brain. Extravasated cancer the passage of breast cancer cells cancer cells from chemotherapeutic cells are thought to undergo mes through the blood–brain barrier [13]. Bone metastasis is also a signif the process of metastasis is ex Results from real-time imag cant public health concern; it oc tremely ineffcient in that less than ing studies suggest that survival of curs in up to 70% of individuals with 0. That system is dependent on their abil prostate and in approximately 40% certain tumours have a tendency to ity to communicate with vascular of patients with carcinomas of the form metastases in specifc organs endothelial cells. The pathophysiology provided the foundation for the “seed late angiogenesis leads to regres of bone metastasis involves several and soil” hypothesis, which was pro sion of lung adenocarcinoma cell different cell populations and a va posed well over a century ago. Bone essence, Paget’s hypothesis states ability to locate cerebral vessels for metastases are classifed as either that tumour cells (“seed”) grow pref co-option leads to activation of cell osteoblastic or osteolytic, depending erentially in the microenvironment death programmes in melanoma on whether the pathology involves of select organs (“soil”). Brain en bone formation or bone destruc cluding sections of this chapter, the dothelial cells also protect brain me tion. Pathological bone remodelling discussion focuses on the microen tastases from the cytotoxic effects results in signifcant skeletal compli vironment of the brain and bone, two of chemotherapy. Unlike endothelial cations, including pain, hypercalcae frequent target organs of metastasis. The bone is enriched in temic cancers develop brain metas tine, doxorubicin, and etoposide.

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Primary data: Residents’ concerns Quantitative: Survey Human Trafficking was not covered in the 2011 community survey. Qualitative: Focus Group In the focus group conversations, human trafficking was not discussed. These teams coordinate medical, mental health, housing, law enforcement, legal, and basic needs for the victim. The taskforce that has been establishing this team has recently lost the support of a grant-funded coordinator at the Wake County Legal Aid, but is optimistic that the team can finalize its structure and function soon. At that time it will start advertising its availability providing direct, coordinated 10 services to victims. If someone suspects trafficking, local law enforcement departments can be contacted. The statewide North Carolina Stop Human Trafficking coalition brings together community and civic groups, faith-based organizations, and interested individuals working together to end trafficking. Interpretations: Disparities; Emerging Issues; Gaps and Unmet Needs; and Strategies Children are highly desired in both sex and labor trafficking and are often exploited in the commercial sex trades, performing the same jobs as adults in prostitution, pornography, and sex tourism. Outside of the illicit sex trade, children are regularly found in domestic service, migrant farm work, hotel or restaurant work, and sweat shops. Many of the victims of sex trafficking within the United States are runaways or women who have been kidnapped. Victims of labor trafficking, like sexual trafficking victims, are often kept isolated to prevent them from seeking advice or help. Traffickers “coach” them to answer questions with a cover story about 12 being a student or tourist and they are constantly escorted and watched. Victims are often Blackmailed using their status as an undocumented alien or participating in an “illegal” industry. People who are trafficked often come from unstable and economically devastated places as traffickers frequently take advantage of vulnerable populations characterized by oppression, high 13 rates of illiteracy, little social mobility, and few economic opportunities. Trafficking is a large, global problem, but it often remains an invisible issue at both global and local levels. There are numerous barriers that contribute to identifying victims, including, but not limited to:  Trafficking victims can be very hidden  Victims are kept moving by traffickers  Lack of awareness of trafficking among general public and health, legal, and human service professionals  Law enforcement often detains and removes possible victims before they can be interviewed, 14 identified, and assisted by legal counsel 15 Most important next steps include:  Build awareness of human trafficking (among both service providers and the general public) to increase identification;  Develop services for victims. Currently the services being developed are based on services for trauma victims and some on victims of torture and refugees. Victims of human trafficking have overlap with all of these, but do not fall completely in any of these categories; and,  Research and evaluation on what is being done and if it is effectively working. Department of Justice, Civil Rights Division, Anti-Trafficking News Bulletin, July, 2004 4 U. Department of Justice, Civil Rights Division, Anti-Trafficking News Bulletin, July, 2004 5 International Labor Organization, A global alliance against forced labor: 2005. Department of Justice, Civil Rights Division, Anti-Trafficking News Bulletin, July, 2004. Department of Justice, Federal Bureau of Investigation, April, 2007 15Personal communication with Patrice Patterson-Garling Child Abuse Social Worker. Individuals who already have health risks will be most affected by environmental issues through the exacerbation of current disease. Efforts to improve environmental health must address those factors that are most likely to impact an individual’s risk of 3 exposure and disease. The excellent quality of life within Orange County continues to attract new persons to the area. As the County experiences continued expansion, one challenge is accommodating this growth while maintaining the high quality of life that current residents enjoy. This chapter discusses the current state of Orange County’s environment and its impact on human health. Three determinants and indicators of health—Air Quality, Drinking Water, and Lead Hazards—are highlighted below in light of their potential impact and relevance for Orange County and its residents.


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If you have the standard citrus press you may need to cut the pomegranates into quarters and then press out the juice. When you have finished juicing your pomegranates let the juice set in the refrigerator a few hours. There will be a small amount of cloudy material in the bottom of the container that needs to be discarded and you will then have beautiful tasty pomegranate juice ready for drinking or any use. A warning: Do not use a citrus reamer as it will get some of the tannin from the skin and partition material into the juice and that is not desirable. Take the pomegranate and roll it around a little, until it gets soft, then cut apart the pomegranate under water. Wrap them in cheesecloth or jelly sack then use your hands to squeeze out the juice into a bowl, squeezing gently as you do not want to squirt yourself. Follow the instructions for removing the arils and then process the seeds in a food processor or blender. Let the juice settle a few hours and remove any cloudy material from the bottom of the juice container. Another method that is used in Iran: Roll the pomegranate around, giving good pressure, but not enough to break the skin. It’s an art to push hard enough to break the arils inside without breaking the skin. When soft, carefully open a hole in the pomegranate and place a straw in and suck the juice out or just bite a bit of the skin out, spit it out and suck out the juice. The partition material and most of the skin will float to the top and the arils will go to the bottom. Another method is to cut the pomegranate in half over a large bowl then place half the fruit in the palm of your hand and squeeze gently (try not to squirt yourself). Then take a heavy wooden spoon or pin or other clean wooden object and tap the half where you have the arils loosened (it may take a hard tap); tapping the loosened arils into a bowl. The simple fact is that most pomegranate recipes for using the juice are based on two basic recipes – heavy and light pomegranate syrup. But you can get creative with some very special recipes of your own by using these basics and then adding your own ingredients. If you are using fresh pomegranates for these recipes, you can usually count on one pomegranate making about 1/2 cup of juice, depending on size of fruit. We would like to note that there seems to be some confusion of just how pomegranate grenadine is made. First, grenadine that is used in drinks nowadays is not made from pomegranates as it was; it is artificially flavored. In the Mediterranean area and the Middle East where the heavy and light pomegranate syrups are used frequently, they are referred to as Pomegranate Molasses and Pomegranate Concentrate. You can also buy this 79 Plant and Fruit already made in most Middle Eastern markets; the syrup was used in Middle Eastern cooking in much the way that wine is used in western cooking. That’s how simple it is to make pomegranate syrup yourself and it will keep in your refrigerator in a sealed jar for about four months. Pour in clean jars and use prepared clean canning rings and lids, then process in a water bath canner for 15 minutes. Pomegranate Concentrate – Light pomegranate syrup the difference between this and pomegranate molasses is that you do not use any sugar in this recipe and you have a more intense pomegranate taste. It can be used for many of the same things as pomegranate molasses— it is just a question of flavor, this being the less sweet and more tart of the two. Ingredients:  Pomegranate Juice (that’s all) If you want 2 cups of syrup start with 4 cups of pomegranate juice, as it reduces by about ½ of the amount you start with. Pour juice into sauce pan and bring to boil over high heat, then reduce heat to maintain boiling action for about 25 minutes or until it thickens, stirring to prevent sticking. When juice starts to thicken, check it to see if it is ready by lifting out the spoon. This can be canned and processed the same way that you would can 80 the Incredible Pomegranate pomegranate molasses, or it can be frozen. When bottled and stored, the syrup stays good in a refrigerator for up to 2 weeks.


  • http://www.scielo.br/pdf/abd/v79n3/v79n3a10.pdf
  • https://urology.weillcornell.org/sites/default/files/cv_schlegel_2_website.pdf
  • https://arup.utah.edu/media/kidney/051313%20kidney%20function.pdf
  • https://www.biolifesolutions.com/wp-content/uploads/2017/06/Mathew-et-al-1.pdf