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See Sleep pools cheap lansoprazole 30 mg fast delivery gastritis symptoms getting worse, 279 food in order 30 mg lansoprazole gastritis hiccups, 191�192 Safety Sensory table materials generic 15 mg lansoprazole fast delivery gastritis symptom of celiac disease, 275�276 Registration of facility purchase 15 mg lansoprazole amex gastritis diet 0 cd, record of valid, 384 strangulation hazards, 129 Separation, helping families cope with, 53�54 Regulations, xxi sun, 126�127 Separation of operations from child care rational basis of, 398 Safety covers areas, 202 Regulatory agency, provision of caregivers/ for electrical outlets, 219 Service plan, developing, for children with teachers and consumer training and sup for swimming pools, 279 special health care needs and disabilities, port services, 414�416 Safety guards for glass windows/doors, 205 337�340 Regulatory enforcement, state statute support Safety straps for diaper changing table, 106 Services, planning for child�s transition to new, of, 397 109 351�352 Regulatory policy Salmonella, See Exclusion for illness; food Sewage systems, on-site, 225 adequacy of staff and funding for en safety; animals Sex offender registries, 401, 408 forcement, 397 Salmonellosis, 190, 315 in background screening, 10 regulation of all out-of-home child care, St. See Child abuse and neglect Sand Shading of play areas, 267�268 state statute support of enforcement, as a surfacing material, 274 Shaken baby syndrome/abusive head trauma 397 type used in sandboxes, 274 preventing and identifying, 125 Rehabilitation Act (1973), Section 504 of, ac cessibility of facilities and, 199 Sandboxes, 274 prevention of, 18 Reimbursement for children with special Sanitation Shelter-in-place, 366-368* health care needs and disabilities, 340 of objects intended for mouth, 118 Shelter-in-place drills Relationships, developing, for school-age policies and procedures, 360�361 evacuation and records of, 385 children, 64 routine, 116�117 Shigella. See Space 399�400 swaddling and, 99 Stackable cribs, 254�255 State health department Sleep and rest areas Staff. See also Cough and informing, regarding presence of toxic Streptococcal pharyngitis, temporary exclu sneeze substances, 229�230 sion of children and, 133 Socialization during meals, 179�180 maintenance of attendance records for, Streptococcus pneumoniae, 308�309 Social policies, efforts to strengthen, 8 who care for children, 393 informing public health authorities of Social Security Act (1935), social policies notifcation of parents/guardians about invasive, 309 and, 8 varicella-zoster (chickenpox) virus, Stress for caregivers/teachers, 42�43 Social security trace in background screen 328�329 Strings on children�s clothing as strangulation ing, 10 nutritionist/registered dietitian as mem hazard, 129 Stroller requirements, 242 *Corrected page number in second printing, August 2011 **Corrected to �of� from �by� in second printing, August 2011 Index 580 Caring for Our Children: National Health and Safety Performance Standards Structurally sound facility, 201 water temperature, 282 limiting time in crib, high chair, car seat, Structure maintenance, 261 Swings, clearance space for, 273 etc. See preventing entry to toilet rooms by Expulsions Supervision during transportation, child-staff infants and toddlers, 245 ratio and, 6 Therapeutic equipment, 244 prohibited uses of handwashing sinks, Supplies Therapy services, space for, 255�256 248 for bathrooms and handwashing sinks, Thermometers ratios of toilets, urinals, and hand sinks 258�259 for taking human temperatures, 135�136 to children, 246 frst aid and emergency, 257�258 type and placement of room, 214 waste receptacles in child care facility microfber cloths, rags, and disposable Threatening incidents, written plan and train and in child care facility toilet rooms, towels and mops used for cleaning, ing for handling urgent medical care or, 247 259 364�365 Toilet learning/training equipment, 246�247 single service cups, 258 Three-to-fve year olds. See Evening care 209�210 Training designated, 209 of caregivers/teachers, 414�416 Walls, 240�241 U Warm weather, outdoor play in, 93 on administering medications, 143�144 Underwear, changing soiled, 108�110 Waste containers, labeling, cleaning, and Uniform categories and defnitions, 407�408 disposal of, 226 on care of children with special health care needs, 22 Unimmunized children, 298�299 Waste receptacles in child care facility and in Universal precautions. See Immunizations location of electrical devices near, 220 Transitions, 351�353 Varicella-zoster (chickenpox) virus, 328�329 location of play areas near bodies of, 267 *Corrected page number in second printing, August 2011 Index 582 Caring for Our Children: National Health and Safety Performance Standards supervision near bodies of, 68�69 supply of, for disaster, 192�193 Water (cont. See also Pertussis Wind chill advisory, 93 Wind chill temperature, 93 Windows covering cords as strangulation hazard, 129 possibility of exit from, 204�205 Wireless communication device, availability and use of, 243 Wood/corn pellet stoves, 215�216 Wood frame construction, buildings of, 201 Written daily activity plan and statement of principles, 49 Written discipline policies, 351 Written plan and training for handling urgent medical care or threatening incidents, 364�365 Z Zoning, 384 583 Index. It was developed as a tool to encourage common understanding among caregivers, teachers, families, and healthcare professionals about infectious diseases and to aid with efforts for reducing illnesses, injuries and other health problems in childcare settings. This guide explains the health history of immunizations, ways to prevent and control the spread of communicable diseases, symptoms of common infections seen in childcare settings, how infections are spread, when to seek medical care, inclusion/exclusion criteria, fact sheets, and sample letters to give to parents. DuPont Highway Dover, Delaware 19901Dover, Delaware 19901 302-744-1033302-744-1033 888-295-5156888-295-5156 5 Childcare Manual Chapter 1Chapter 1 Introduction: Keeping Children HealthyIntroduction: Keeping Children Healthy Delaware�s early care providers, teachers, families and health professionals are committed to keeping all children healthy. As families enter the workforce, they must rely on childcare centers to provide a safe, healthy and caring environment for their child. These children are very susceptible to contagious diseases because they have not been exposed to many infections. A variety of infections have been documented in children attending childcare, sometimes with spread to caregivers and to others at home. In addition, wherever there are children in diapers, the spread of diarrheal diseases may readily occur as the result of poor or inadequate handwashing, diaper changing and environmental sanitation measures. In general, sending home (excluding) mildly ill children is not an effective way to control the spread of most germs. All of these factors make infections in childcare settings common and fast spreading. This manual contains disease fact sheets specifically meant for childcare settings. These fact sheets may be distributed to parents and staff; fact sheets will help staff determine when children should be sent home or readmitted to your facility. When a child enrolls in your childcare facility, you should find out: � Contact information for parents with names, addresses, work, home and cell phone numbers. Any child who has not had a well baby or well child examination recently (within the past 6 months) should be examined within 30 days of entering your childcare facility. You should assure that all children admitted to your facility are up to date on their vaccinations. Children attending childcare especially need all of the recommended vaccinations to protect themselves, the other children, the childcare provider, and their families. Several diseases that can cause serious problems for children and adults can be prevented by vaccination. These diseases are chickenpox, diphtheria, Haemophilus influenzae certain types of meningitis, hepatitis A and B, influenza, measles, mumps, pneumococcal disease, polio, rubella (German measles or 3-day measles), tetanus, and whooping cough (pertussis). Many of these diseases are becoming less common because most people have been vaccinated against them. However, cases still occur and children in childcare are at increased risk for many of these diseases because of the many hours they spend in close contact with other children. Children who are not up to date on their vaccinations should be taken out of childcare (excluded) until they have begun the series of shots needed. Each child in your care should have an Immunization certificate on file at the facility. Each child shall also have a current health appraisal on file signed by a licensed healthcare provider. This health appraisal should include a description of any disability or impairment that may affect adaptation to childcare. Date: Printed Name: Telephone: 8 Childcare Manual Health History & Immunization Policy for Childcare ProvidersHealth History & Immunization Policy for Childcare Providers Children, especially those in groups, are more likely to get infectious diseases than are adults. As a childcare provider, you will be exposed to infectious diseases more frequently than will someone who has less contact with children. To protect yourself and the children in your care, you need to know what immunizations you received as a child and whether you had certain childhood diseases. If you are not sure, your healthcare provider can test your blood to determine if you are immune to some of these diseases and can vaccinate you against those to which you are not immune. Childcare providers shall also have a health appraisals signed by a licensed healthcare provider on file at the facility. Providers are considered immune to rubella if they have received at least one does of rubella vaccine on or after their first birthday. A blood test indicating immunity to rubella or one dose of rubella vaccine is required. Tetanus, Diphtheria & Pertussis Childcare providers should have a record of receiving a series of 3 doses of Tetanus, Diphtheria and Pertussis containing vaccine (usually given in childhood) and a booster of tetanus given within the past 10 years. Those who have not received the Tdap vaccine (available only since 2005) should receive a single dose.

Food and Drug be made in consultation with the parents/guardians and Administration requires a warning on the dangers of harmful the child�s primary care provider 15 mg lansoprazole amex gastritis no appetite. Food sensitivity includes a range of condi ship between the consumption of sweetened beverages tions in which a child exhibits an adverse reaction to order lansoprazole 30mg overnight delivery gastritis symptoms dizziness a food and tooth decay lansoprazole 30mg with amex gastritis diet ice cream. Drinks with high sugar content should be that generic 15mg lansoprazole otc symptoms of gastritis and duodenitis, in some instances, can be life threatening. Modifcation avoided because they can contribute to childhood obesity of a child�s diet may be related to a food allergy, inability to (2,5,6), tooth decay, and poor nutrition. Excess fruit instructions from the child�s parent/guardian and the child�s juice consumption by preschool-aged children is associated with primary care provider should be provided in the child�s short stature and obesity. These written instructions must identify: Policy statement: the use and misuse of fruit juice in pediatrics. Regular to be substituted; sugar-sweetened beverage consumption between meals increases f) Limitations of life activities; risk of overweight among preschool-aged children. Safe handling of raw should be used to develop individual feeding plans and, produce and fresh-squeezed fruit and vegetable juices. A number of children Facilities should develop, at least one month in advance, with special health care needs have diffculty with feeding, written menus showing all foods to be served during that including delayed attainment of basic chewing, swallow month and should make the menus available to parents/ ing, and independent feeding skills. The facility should date and retain these menus utensils, and equipment, including furniture, may have to be for six months, unless the state regulatory agency requires adapted to meet the developmental and physical needs of a longer retention time. Some children have diffculty with slow weight gain and need their caloric intake monitored and supplemented. To avoid problems of food sensitivity in very young children Others with special needs, such as those with diabetes, under eighteen months of age, caregivers/teachers should may need to have their diet matched to their medication obtain from the child�s parents/guardians a list of foods that (insulin if they are on a fxed dose of insulin). Some children have already been introduced (without any reaction), and are unable to tolerate certain foods because of their allergy then serve some of these foods to the child. In children, foods are considered for serving, caregivers/teachers should share are the most common cause of anaphylaxis. Nuts, seeds, and discuss these foods with the parents/guardians prior to eggs, soy, milk, and seafood are among the most common their introduction. Parents/guardians need to be low, as well as their designated roles during an emergency. If a child advance whether a child has food allergies, inborn errors of has diffculty with any food served at the facility, parents/ metabolism, diabetes, celiac disease, tongue thrust, or spe guardians can address this issue with appropriate staff cial health care needs related to feeding, such as requiring members. Some regulatory agencies require menus as a special feeding utensils or equipment, nasogastric or gastric part of the licensing and auditing process (2). Posting menus In some cases, dietary modifcations are based on religious in a prominent area and distributing them to parents/guard or cultural beliefs. Detailed information on each child�s spe ians helps to inform them about proper nutrition. Sample cial needs whether stemming from dietary, feeding equip menus and menu planning templates are available from ment, or cultural needs, is invaluable to the facility staff in most state health departments, the state extension service, meeting the nutritional needs of that child. Par the parents/guardians is essential for successful feeding, in ents/guardians may have to provide food on a temporary general, including when introducing age-appropriate solid or, even, a permanent basis, if the facility, after exploring all foods (complementary foods). The decision to feed specifc community resources, is unable to provide the special diet. It is recommended that the caregiver/teacher be Family Child Care Home given written instructions on the introduction and feeding of foods from the parents/guardians and the infant�s primary care provider. Caregivers/teachers should use or develop a 159 Chapter 4: Nutrition and Food Service Caring for Our Children: National Health and Safety Performance Standards take-home sheet for parents/guardians on which the care specifc symptoms that would indicate the need to giver/teacher records the food consumed each day or, for administer one or more medications; breastfed infants, the number of breastfeedings, and other b) Based on the child�s care plan, the child�s caregivers/ important notes on the infant. Caregivers/teachers should teachers should receive training, demonstrate continue to consult with each infant�s parents/guardians competence in, and implement measures for: concerning foods they have introduced and are feeding. Caregivers/teach 3) Treating allergic reactions; ers should let parents/guardians know what and how much c) Parents/guardians and staff should arrange for their infant eats each day. Consistency between home and the facility to have necessary medications, proper the early care and education setting is essential during the storage of such medications, and the equipment and period of rapid change when infants are learning to eat age training to manage the child�s food allergy while the appropriate solid foods (1,4,6). Making food healthy and safe for children: How to meet the national health and safety performance the child�s primary care provider be notifed if the standards � Guidelines for out-of-home child care programs. Menus in child care: A h) Parents/guardians of all children in the child�s class comparison of state regulations to national standards. Pass the sugar, pass the salt: care and education setting; Experience dictates preference. Feeding infants: A guide for use in the child nutrition prominently in the classroom where staff can view programs. Nutrition in infancy and proper medications for appropriate treatment if the childhood. Infant routinely carried on feld trips or transport out of the feeding and feeding transitions during the frst year of life. Food allergic reac tions can range from mild skin or gastrointestinal symptoms Food Allergies to severe, life-threatening reactions with respiratory and/ When children with food allergies attend the early care and or cardiovascular compromise. Hospitalizations from food education facility, the following should occur: allergy are being reported in increasing numbers (5). A major a) Each child with a food allergy should have a care plan factor in death from anaphylaxis has been a delay in the prepared for the facility by the child�s primary care administration of life-saving emergency medication, particu provider, to include: larly epinephrine (6). Intensive efforts to avoid exposure to 1) Written instructions regarding the food(s) to which the offending food(s) are therefore warranted.

Country in which there are precipitous cliffs with torrents running between buy 30mg lansoprazole mastercard diet gastritis kronis, deep natural hollows 15 mg lansoprazole for sale gastritis diet ���������, con 34 Sun Tzu on the Art of War fined places buy cheap lansoprazole 30 mg on line gastritis symptoms with back pain, tangled thickets discount lansoprazole 30 mg mastercard gastritis chronic symptoms, quagmires and crevass es, should be left with all possible speed and not approached. While we keep away from such places, we should get the enemy to approach them; while we face them, we should let the enemy have them on his rear. If in the neighborhood of your camp there should be any hilly country, ponds surrounded by aquatic grass, hollow basins filled with reeds, or woods with thick undergrowth, they must be carefully routed out and searched; for these are places where men in ambush or insidious spies are likely to be lurking. When the enemy is close at hand and remains quiet, he is relying on the natural strength of his position. When he keeps aloof and tries to provoke a battle, he is anxious for the other side to advance. The appearance of a number of screens in the midst of thick grass means that the enemy wants to make us suspicious. When there is dust rising in a high column, it is the sign of chariots advancing; when the dust is low, but spread over a wide area, it betokens the approach of infantry. When it branches out in different directions, it shows that parties have been sent to collect firewood. Humble words and increased preparations are signs that the enemy is about to advance. Violent language and driving forward as if to the attack are signs that he will retreat. When the light chariots come out first and take up a position on the wings, it is a sign that the enemy is forming for battle. When there is much running about and the soldiers fall into rank, it means that the critical moment has come. When the soldiers stand leaning on their spears, they are faint from want of food. If those who are sent to draw water begin by drink ing themselves, the army is suffering from thirst. If the enemy sees an advantage to be gained and makes no effort to secure it, the soldiers are exhausted. When an rmy feeds its horses with grain and kills its cattle for food, and when the men do not hang their cooking-pots over the camp-fires, showing that they will not return to their tents, you may know that they are determined to fight to the death. The sight of men whispering together in small knots or speaking in subdued tones points to disaffec tion amongst the rank and file. Too frequent rewards signify that the enemy is at the end of his resources; too many punishments betray a condition of dire distress. To begin by bluster, but afterwards to take fright at 37 Sun Tzu on the Art of War the enemy�s numbers, shows a supreme lack of intelli gence. When envoys are sent with compliments in their mouths, it is a sign that the enemy wishes for a truce. If the enemy�s troops march up angrily and remain facing ours for a long time without either joining battle or taking themselves off again, the situation is one that demands great vigilance and circumspection. If our troops are no more in number than the enemy, that is amply sufficient; it only means that no direct attack can be made. What we can do is simply to con centrate all our available strength, keep a close watch on the enemy, and obtain reinforcements. He who exercises no forethought but makes light of his opponents is sure to be captured by them. If soldiers are punished before they have grown attached to you, they will not prove submissive; and, unless submissive, then will be practically useless. If, when the soldiers have become attached to you, pun ishments are not enforced, they will still be unless. Therefore soldiers must be treated in the first instance with humanity, but kept under control by means of iron discipline. If in training soldiers commands are habitually enforced, the army will be well-disciplined; if not, its discipline will be bad. If a general shows confidence in his men but always insists on his orders being obeyed, the gain will be mutual. Sun Tzu said: We may distinguish six kinds of ter rain, to wit: (1) Accessible ground; (2) entangling ground; (3)temporizing ground; (4) narrow passes; (5) precipitousheights; (6) positions at a great distance from the enemy. With regard to ground of this nature, be before the enemy in occupying the raised and sunny spots, and carefully guard your line of supplies. From a position of this sort, if the enemy is unpre pared, you may sally forth and defeat him. But if the enemy is prepared for your coming, and you fail to defeat him, then, return being impossible, disaster will ensue. When the position is such that neither side will gain by making the first move, it is called temporizing ground. In a position of this sort, even though the enemy should offer us an attractive bait, it will be advisable not to stir forth, but rather to retreat, thus enticing the enemy in his turn; then, when part of his army has come out, we may deliver our attack with advantage. With regard to narrow passes, if you can occupy them first, let them be strongly garrisoned and await the advent of the enemy. Should the army forestall you in occupying a pass, do not go after him if the pass is fully garrisoned, but only if it is weakly garrisoned. With regard to precipitous heights, if you are beforehand with your adversary, you should occupy the raised and sunny spots, and there wait for him to come up. If the enemy has occupied them before you, do not follow him, but retreat and try to entice him away. If you are situated at a great distance from the enemy, and the strength of the two armies is equal, it is not easy to provoke a battle, and fighting will be to your disadvantage. Now an army is exposed to six several calamities, not arising from natural causes, but from faults for which the general is responsible. These are: (1) Flight; (2) insubordination; (3) collapse; (4) ruin; (5) disorganization; (6) rout.

Royal Society of Chemistry (1977) Code of Practice for Chemical Laboratories buy lansoprazole 30mg without a prescription gastritis dieta en espanol, London proven lansoprazole 30 mg gastritis vitamin c. St John Ambulance Association (1982) First Aid lansoprazole 30 mg gastritis diet advice, 3rd edn lansoprazole 15mg fast delivery gastritis kefir, St Andrews Ambulance Association and the British Red Cross Society, London. Additional guidance on Regulation 6 of the Ionizing Radiations Regulations 1985 (superseded by L 121: 2000) L 8 the Prevention or Control of Legionellosis (including Legionnaires� Disease) Approved Code of Practice L 9 Safe use of pesticides for non-agricultural purposes � Control of Substances Hazardous to Health Regulations 1994 Approved Code of Practice L 10 A guide to the Control of Explosives Regulations 1991 L 11 A guide to the Asbestos (Licensing) Regulations 1983 L 13 A guide to the Packaging of Explosives for Carriage Regulations 1991 L 21 Management of health and safety at work. Approved Code of Practice and Guidance (revised) L 24 Workplace health, safety and welfare. Approved Code of Practice and Guidance L 25 Personal protective equipment at work � Guidance on Regulations L 27 the control of asbestos at work. Approved Code of Practice and guidance L 80 A guide to the Gas Safety (Management) Regulations 1996 L 82 A guide to the Pipelines Safety Regulations 1996 L 83 A guide to the Installation, Verification and Miscellaneous Aspects of Amendments by the Offshore Installations and Wells (Design and Construction, etc) Regulations 1996 to the Offshore Installations (Safety Case) Regulations 1992 L 84 A guide to the well aspects of amendments of the Offshore Installations and Wells (Design and Construction, etc. Critical assessments of the evidence for agents implicated in occupational asthma 1997. Part 21: Methods for determination of the fire resistance of loadbearing elements of construction. Part 22: Methods for determination of the fire resistance of non-loadbearing elements of construction. Method 140B: Determination of the burning behaviour of flexible vertical specimens in contact with a small-flame ignition source. Method 140C: Determination of the combustibility of specimens using a 125 mm flame source. Method 140D: Flammability of a test piece 550 mm 35 mm of thin polyvinyl chloride sheeting (laboratory method). Determination of hydrogen sulfide, mercaptan sulfur, and carbonyl sulfide sulfur by potentiometry. Part 3: Classification of groups of environmental parameters and their severities. However, regulatory obligations forcing compliance with national and/or local requirements should be consulted. General health and safety the minimum standards for health and safety are those outlined in numerous pieces of statutory legislation. Act 1974 Management of Health and Safety at Work Regulations 1992 Management of Health and Safety at Work (Amendment) Regulations 1994 Manual Handling Operations Regulations 1992 All of these contain requirements of relevance to work with hazardous chemicals. Selected legislation relevant to the control of hazardous chemicals the following legislation is of direct relevance. Asbestos (Prohibitions) Regulations 1992 Cover the prohibition of the importation, supply or new use of amphibole asbestos or products containing it. Also prohibit the supply and use of a range of products containing chrysotile asbestos. Carriage of Dangerous Goods by Rail Regulations 1996 the scope includes carriage of dangerous substances by wagons, large containers, small containers and tanks. Carriage of Dangerous Goods by Road Regulations 1996 Cover the carriage of dangerous goods by road in bulk, in tanks and in containers. The requirements for documentation, information, loading/unloading, and emergencies and parking are included. Carriage of Dangerous Goods by Road (Driver Training) Regulations 1996 Cover the instruction, training and certification of drivers of motor vehicles engaged in the carriage of dangerous goods. Carriage of Dangerous Goods (Classifications, Packaging and Labelling) and Use of Transportable Pressure Receptacles Regulations 1996 Cover the classification, packaging and labelling of dangerous goods. The requirements for design, manufacture, modification, repair, approval, certification and marking of transportable pressure containers are included. Carriage of Explosives by Road Regulations 1996 Prohibit the carriage of certain explosives. Concerned with the carriage of explosives in vehicles used to carry passengers and carriage in bulk. The suitability of both vehicle and container, vehicle approval, types of vehicles, and quantity limits for loads are regulated. This includes route of carriage, parking, load integrity, equipment, precautions against fire and explosion, and the requirements in the event of accidents and emergencies. Chemicals (Hazard Information and Packaging for Supply) Regulations 1994 Regulate the classification, provision of safety data sheets, labelling and packaging of substances and preparations dangerous for supply. Confined Spaces Regulations 1997 Requirements for work in confined spaces, including avoidance of entry if reasonably practicable, provision of a safe system of work and establishment of adequate emergency arrangements. Control of Asbestos at Work Regulations 1987 (amended 1992 and 1999) Requirements for the control of asbestos exposures at work. Exposure is to be prevented or, if this is not reasonably practicable, reduced to the lowest level reasonably practicable by measures other than the use of respiratory protective equipment. Control of Explosives Regulations 1991 Concerned mainly with the security of explosives and restricted substances. Control of Lead at Work Regulations 1980 Requirements for protecting the health of workers exposed to lead including lead alloys, lead compounds and lead containing substances. Provision of adequate information, instruction and training; control against exposures by measures other than the use of personal protective equipment; provision of adequate washing facilities; prohibition of eating, drinking and smoking in contaminated areas; and health surveillance are covered. Control of Major Accident Hazard Regulations 1999 Regulate the design and operation of defined major hazard installations. All necessary measures are required to prevent and limit the consequences of major accidents. Operators of upper-tier sites must produce a detailed Safety Report; those of lower-tier sites must prepare a Major Accident Prevention Policy. Control of Pesticides Regulations 1986 Prohibit the advertisement, supply, storage and use of pesticides unless they have been approved. Competence training and certification is required for commercial use in agriculture generally.

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This additional probe is called the secondary antibody effective 30 mg lansoprazole gastritis diet example, as its sole purpose is to cheap 30mg lansoprazole gastritis diet espanol deliver the measurable signal tag by binding to buy lansoprazole 30 mg overnight delivery gastritis lemon the detection (primary) antibody buy lansoprazole 15 mg fast delivery gastritis kas tai per liga. Direct detection is generally faster than indirect detection and potential background signal from secondary antibody cross-reactivity with the coating antibody is also eliminated. Even in the best of circumstances however, direct detection cannot provide the signal amplification gained from the use of a secondary antibody or avidin/biotin systems. Consequently direct detection is generally less sensitive than indirect detection and is best used only when the target is relatively abundant. Avidin and streptavidin are proteins that originate from different sources but have nearly identical functions in binding very strongly and specifically to the biotin molecule. Hereafter in this document, �avidin� and �streptavidin� will be used interchangeably to mean any one of these biotin-binding proteins. A common adaptation of indirect detection is to amplify the signal using avidin-biotin chemistry. First, biotinylation (biotin-labeling) typically results in multiple biotin tags per antibody molecule, thus allowing more than one streptavidin molecule to bind to each antibody. Binding is aided by the fact that avidin-type proteins are tetrameric and have four biotin-binding sites per molecule. Second, the process of either labeling the streptavidin molecule with enzymes or using a pre-incubated mixture of streptavidin plus biotinylated enzyme results in conjugates having more than one enzyme. This increases the catalysis of appropriate substrate and gives a stronger signal compared to a conventional enzyme-labeled secondary antibody. This kind of approach is common when performing multiplex arrays, as more than one antigen can be detected simultaneously with antibodies conjugated to different fluorophores. In fluorescence assays, the detection antibody is either labeled directly or the secondary antibody (or occasionally avidin) is labeled for indirect detection. When multiplexing using labeled secondary antibodies it is essential to use detection antibodies from different species in order to distinguish the separate signals. The detection limit is typically around 100pg/well which is less sensitive than colorimetric or chemiluminescent detection. In this case, twelve different capture antibodies are coated as an array of printed spots on a glass slide. Each antibody captures a different analyte and is detected by its matched detection antibody, which is biotinylated. Finally, all spots are detected through a fluor-labeled streptavidin conjugate (in this case, the Thermo Scientific DyLight� 649 Fluorophore). Substrates Enzymatic signal generation requires the catalysis of a substrate to produce a colored or fluorescent compound or chemiluminescence (visible light). The signal is measured using a spectrophotometric plate reader, a fluorometer with the appropriate filters or a luminometer set to read total light output. Each type of substrate is discussed below; more information about specific products can be found at our website. Colorimetric substrates form a soluble, colored product that accumulates over time relative to the amount of enzyme present in each well. When the desired color intensity is reached, the product absorbance is either measured directly or in some cases a stop solution is added to provide a fixed end point for the assay. The signal is measured using a fluorometer with the appropriate excitation and emission filters. Chemifluorescence reactions are either measured over time in kinetic assays or halted using a stop solution for direct measurement. Chemiluminescence is a chemical reaction that generates energy released in the form of light. The luminol is oxidized and forms an excited state product that emits light as it decays to the ground state. Light emission occurs only during the enzyme-substrate reaction, therefore when the substrate becomes exhausted the signal ceases. Chemiluminescent detection is generally considered to be more sensitive than colorimeteric detection. The method involves the assembly of a large immune complex with multiple components, therefore failure to capture signal can potentially be caused by any of these factors and optimization is essential. A list of such factors and associated variables is described in Table 1, followed by a discussion of several pertinent issues. The protocol section at the end of this guide includes specific instructions and suggestions about optimization procedures. If the standard curve displays the correct sensitivity, range and linearity, the researcher can proceed with confidence to process the samples. Factor Variable Characteristic Assay Plate material, well shape, pre-activation Coupling Buffer composition, pH Capture Antibody specificity, titer, affinity, incubation time and temperature Blocking Buffer composition, concentration, cross-reactivity Target Antigen conformation, stability, available epitope(s), matrix effects Detection Antibody specificity, titer, affinity, incubation time & temperature, cross-reactivity Enzyme Conjugate type of enzyme, type of conjugate, activity, concentration, cross-reactivity Washes buffer composition, volume, duration, frequency Substrate sensitivity, manufacturer lot, age Signal Detection filters, imaging instrument, exposure time A. Other materials such as polypropylene, polycarbonate and in some instances nylon are occasionally used; many plates are now gamma-irradiated to impart a positive charge, which aids coating procedures. The absorbances of colorimetric substrates are measured by shining a laser up through the base of each well, so it is essential to use a flat bottomed plate with a clear base. Fluorescent detection requires the use of an opaque black or white plate, and fluorometric plate readers measure either from above or below the plate. Chemiluminescent detection requires the use of a black or white opaque plate and may also be measured from the top or the bottom. For this reason both fluorescent and chemiluminescent assays must be performed in plates with a clear bottom.