Director of Oral and Maxillofacial Surgery Residency Program
University of Tennessee Graduate School of Medicine
University of Tennessee Cancer Institute
Knoxville, Tennessee
Residues from chemicals used to disinfect glassware erectile dysfunction estrogen quality 40 mg levitra super active, detergents used in washing erectile dysfunction in teenage purchase levitra super active with amex, or some aluminum foils and wrapping papers for autoclaving or dry heat sterilization can also leave potentially toxic deposits on pipettes impotence lisinopril buy levitra super active 40 mg on line, storage bottles and instruments erectile dysfunction doctor in karachi buy levitra super active visa. Because of their size and fast well as important sources of microbial contamination erectile dysfunction for young men purchase levitra super active in india. Warm rooms are growth rates erectile dysfunction fatigue best buy levitra super active, these microbes are the most commonly encountered cell common sites of infestation erectile dysfunction recovery buy levitra super active 40 mg free shipping. In the absence of antibiotics erectile dysfunction doctor new jersey purchase generic levitra super active pills, microbes can usually and sterile supplies as they search for food or shelter, they can randomly be readily detected in a culture within a few days of becoming contami spread a variety of microbial contaminants. Mites can be a serious problem in plant into slow growing, low level infections that are very difcult to detect cell culture facilities, especially those doing large scale plant propagation. These nearly as common as other culture contaminants, it is important to be alert cryptic contaminants may persist indefnitely in cultures causing subtle, to the presence of these invertebrates in culture areas. By the time these cryptic contaminants are discovered, many experiments and cultures may have Mycoplasmas been compromised. Mycoplasmas were frst detected in cell cultures by Robinson and coworkers in 1956. Their small size also makes them very dif other cell lines currently in use in their laboratory were also infected with cult to remove from media, sera, and other solutions of biological origin. Since many of these may be more common in cell cultures than many researchers realize, they cultures were from laboratories that test routinely for mycoplasma, the are usually not a serious problem unless they have cytopathic or other actual rates are probably higher in the many laboratories that do not test at adverse efects on the cultures. Thus, when cultures self-destruct for no apparent reason study had an interesting, but typical fnding: 100% of the cultures from labs and no evidence of common biological contaminants can be found, cryptic without mycoplasma testing programs were contaminated, but only 2% of viruses are often blamed. They are perfect culprits, unseen and undetect the cultures from labs that tested regularly. This is unfortunate, since the real cause 65% of the cultures in Argentina and 80% in Japan were reported to be of this culture destruction may be something else, possibly mycoplasma or 11 contaminated by mycoplasma in other studies. Special safety precautions should always be used 12 damage, and cytopathic efects including plaque formation. Contact your safety ofce for additional assistance if in doubt as to appropriate procedures for working with potentially hazardous tissues, What gives mycoplasmas this ability to readily infect so many cultures. Three basic characteristics: a) these simple, bacteria-like microbes are the smallest self-replicating organism known (0. Their small size and lack of a cell wall allow mycoplasmas to grow Both parasitic and free-living, single-celled protozoa, such as amoebas, 7 9 to very high densities in cell culture (10 to 10 colony forming units/ have occasionally been identifed as cell culture contaminants. Even careful microscopic occasionally from tissues, as well as throat and nose swabs of laboratory observation of live cell cultures cannot detect their presence. They can cause cytopathic efects resembling viral damage and two characteristics also make mycoplasmas, like viruses, very difcult to completely destroy a culture within ten days. In addition, their and morphological similarities to cultured cells, amoebas are somewhat 7 fastidious growth requirements (unfortunately, easily provided for by cell difcult to detect in culture, unless already suspected as contaminants. Thus, these three simple character important to be alert to the possibility of their occurrence. Technical Information 329 Understanding Cell Culture Contaminants: What Are the Sources of Biological Contaminants istics, combined with their ability to alter virtually every cellular function What Are the Sources of Biological Contaminants. This section will this is too benign a description for what are the most signifcant and wide detail some of the most common sources of biological contaminants. Unfortunately, even with the advances in detection methods (discussed in detail later) mycoplasma Nonsterile Supplies, Media, and Solutions infection rates have not changed noticeably since they were frst detected in cell cultures. Aggressive management against mycoplasma contamina Unintentional use of nonsterile supplies, media, or solutions during routine tion must be the central focus for any cell culture laboratory contamination cell culture procedures is a major source of biological contaminants. Cross-Contamination by Other Cell Cultures Glassware, including storage bottles and pipettes, is usually sterilized by With the advent of improved karyotyping methods in the late 1950s, it autoclaving or dry heat sterilization. Serious contamination outbreaks are soon became apparent that some cell lines were cross-contaminated by cells frequently traced to improper maintenance or operation of sterilization of other species. Packing too much into an autoclave or dry heat commonly used human cell lines were intraspecies contaminated by HeLa oven will cause uneven heating, resulting in pockets of nonsterile supplies. Unfortunately, of liquids greater than 500 ml per vessel or solutions containing solids or the scientifc community was slow to respond to this very serious problem. The size, Tests done at one research center on 246 cell lines over an 18 month mass, nature, and volume of the materials to be sterilized must always be considered and the cycle time appropriately adjusted to achieve sterility. Care must also be taken to avoid condensation on bottles of cell lines, and 12 cases of interspecies contamination. The validity of experimental results electron beam radiation source after they are sealed in their packaging. Furthermore, their use can lead to the embarrassment of and resealing the packaging to avoid contaminating the products within. Whenever the invading cell is better Most media, sera, and other animal-derived biologicals are not heat steriliz adapted to the culture conditions and thus faster growing than the original able and require membrane fltration (sometimes radiation is also used) to cells, it will almost always completely replace them. Products flter sterilized in your labora Because of the outward physical similarities of diferent cell lines and the tory should always be tested for sterility before use (discussed in detail later); wide morphological variations that can be caused by the culture environ commercially produced sterile products are tested by the manufacturer ment, it is impossible to rely only on microscopic observation to screen before being sold. Simple accidents are one of the most tive in removing most biological contaminants, it cannot guarantee the complete removal of viruses and mycoplasmas, especially in sera. In an excellent review of the rates and sources of mycoplasma contamina tion,25 Barile and coworkers reported that 104 out of 395 lots (26%) of Remember, the seriousness of any culture contaminant is usually directly proportional to the difculty of detecting it; those that go undetected commercial fetal bovine sera tested were contaminated by mycoplasma. Cultures containing They concluded in the early 1970s that animal sera were among the major nonlethal (but not harmless), cryptic chemical or biological contaminants sources of cell culture contamination by mycoplasma. This approach has been very successful at reducing the problem of mycoplasma in sera and other animal-derived products. Most cell culture laboratories airborne particles and aerosols generated during culture manipulations. As a result, the air in a sealed, draft-free room or laboratory (no people, other. Rooms containing open windows, air conditioners, microbiology open windows or doors, air handling units, air conditioners, etc. However as soon as people enter the discussed above, add to the potential hazards of moving cultures around room, particles that have settled out will be easily resuspended. This problem increases both with the distance traveled and certain equipment and activities can generate large amounts of microbial when the culture vessels are unsealed. Animal care facilities and the animals they house are especially serious particle and aerosol generators, and Unsealed culture plates and dishes, as well as fasks with loose caps to should always be kept as far from the culture area as possible. It is very easy for the space between the top and bottom McGarrity used a cell culture that was intentionally infected with myco sidewalls of a dish, or a fask and its cap to become wet by capillary action plasma as a model to study how mycoplasmas are spread in a laminar fow with medium or condensation. This thin flm of liquid then provides a hood during routine subculturing procedures. Live mycoplasma could even be successfully recovered from Accidents are often overlooked as a signifcant source of cell culture prob the surface of the laminar fow hood four to six days later!. Cell culture-related easy to understand from this study how the entry of a single mycoplasma accidents are one of the leading causes of cross-contamination by other infected culture into a laboratory can quickly lead to the infection of all the cell cultures. The following actual cases demonstrate how relatively simple other cultures in the laboratory. This explains the frequent fnding that if one accidents can result in serious cross-contamination problems: culture in a laboratory is mycoplasma contaminated then usually most if not all of the other cultures will be as well. The other lab worked with cultures derived from of aerosols that have been shown to contain mycoplasma. Some laboratory personnel shed Based on continuing reports in the literature7,8,19-22 many researchers have yeast-containing particles for several days following bread making or beer not been lucky enough to identify their mistakes. Attempts by these individuals at cell culturing during this period have routinely ended in failure due to yeast contamination. The information presented above is designed to provide you with an increased awareness and understanding of the nature of biological and Incubators, especially those maintained at high humidity levels, can be a chemical contamination, and its serious consequences. Dirty water sections will cover some basic ideas, techniques and strategies for reservoirs, and shelves or culture vessels soiled by spilled media, allow the actively detecting and combating cell culture contamination in your growth of spore-generating fungi. Some incubators humidify incoming gases by bubbling them through the water reservoirs at the bottom of the incubator; the aerosols generated by this will quickly spread any contami nants in the water. Technical Information 331 Understanding Cell Culture Contaminants: How Can Cell Culture Contamination Be Controlled How Can Cell Culture Contamination Use Good Aseptic Techniques Be Controlled. Aseptic technique is designed to provide a barrier between microorgan isms in the environment, and your cultures and sterile supplies, yet permit Cell cultures can be managed to reduce both the frequency and serious you to work with them. There are many successful techniques for achieving ness of culture-related problems, especially contamination. One solution is to actively manage your cultures to reduce 27,28 here is to review some of its basic tenets and present some suggestions for problems and if necessary set up a program for use in your laboratory. The reader is referred to Freshney for a basic introduction to this program should be designed to meet the needs of your specifc this very important area. Next, review the problems as a group to determine their nature, seriousness and frequency. This problem sharing the frst step in developing sound, rational aseptic techniques is a solid is often a painful process, but remember the goal is not to place blame, understanding of both the nature and potential sources of biological contami but to appreciate the extent and nature of the problems confronting the nation. A critical part of this process is understanding the seriousness many of the references. It is level of risk or danger to yourself and other laboratory personnel and then very important for everyone in the laboratory to know the answers to the design your culture techniques accordingly. This is especially true when following questions: working with cultures that are virally contaminated or derived from human 1. How much time, money and effort have been invested in your cultures and other primate sources. Basic problem solving tools2 can be used to help identify the redundancy if any, is required. Very valuable or irreplaceable cultures can source of problems; changes to minimize or prevent the problems from be carried by two or more workers using media from diferent sources and separate incubators to reduce the chance of their simultaneous loss. Evaluate whether workers need to be gloved, gowned and masked to the following suggestions, concepts and strategies, combined with basic reduce the potential for contamination. The nature of your working environment and any problems it may present must also be considered in choosing appropriate aseptic techniques. Certifed laminar fow hoods and safety cabinets are recommended for use whenever possible. Some of the aseptic techniques taught in intro ductory microbiology classes for use on the open bench, such as faming, while popular, are not appropriate or necessary in laminar fow hoods. Based on personal experi culture vessels whenever possible, especially for long-term cultures. The ence, accidents are far more likely on: multiple well plates can be sealed with labeling tape or placed in sealable bags, 35 and 60 mm dishes can be placed inside 150 or 245 mm dishes. These have hydrophobic flter b) the day before a vacation begins, membranes that allow sterile gas exchange, but prevent the passage of c) with new employees, or microorganisms or liquids. Using a disposable standing that cause many accidents to happen in the laboratory. If misunderstandings in crowded or busy labs by using a color coding pouring cannot be avoided, carefully remove any traces of media from system: assign each worker their own color for labeling tape and marking the neck of the vessel with a sterile gauze or alcohol pad. Square 245 mm dishes are excellent carriers for laboratory should understand and agree to their meaning. Storing unnecessary boxes, their use and makes it more likely that good records will be kept. Besides the risk of injury to laboratory personnel, and any special treatments that were done. These will both reduce the mouth pipetting has been implicated as the likely source of human potential for errors as well as provide a valuable aid in tracking down the mycoplasma species (M. Their use should be Environment restricted to the cell culture area to avoid exposure to dirt and dust from Reducing the amount of airborne particulates and aerosols in the labora other areas. Only turn them of materials in close proximity to the laminar fow hood and are a potential mycoplasma source. The cooling coils on refrigerators and freezers are a major source of micro bial laden airborne particulates that are often overlooked in otherwise very clean laboratories. These should be vacuumed at least yearly; besides removing a signifcant source of contamination, regular vacuuming will extend the life of the cooling units and allow them to run more efciently. Some laboratories may also need to consider a pest management program to reduce the presence of mice, ants, cockroaches, and other multilegged crea tures that can be sources of contamination. Potted plants, although attrac tive, can provide a home for these creatures and should not be kept in the culture vicinity. Care must be taken when using pesticides as part of a pest management program to prevent accidentally chemically contaminating the cultures in the laboratory. Technical Information 333 Understanding Cell Culture Contaminants: How Can Cell Culture Contamination Be Controlled Sterility Testing can then be calculated and analyzed. Besides giving an accurate level of the bioburden in that area, microscopic observation of the contaminants the best strategy for reducing contamination is to be proactive by routinely in the liquid test media also allows their morphological comparison with the monitoring supplies, media and solutions, work areas and, most impor microorganisms found causing problems in the cell cultures. Past experience tantly, cell cultures for contaminants before they are used in critical with this approach has shown it is a very useful tool when teaching aseptic applications and experiments. The key to developing a realistic contamina technique as it clearly demonstrates that the air in a room, or even inside a tion monitoring program is to keep it as simple as possible so that people humidifed incubator is usually not a major source of contamination in a use it, yet ensure that it can get the job done. It is also a useful tool in tracking down myste easy solutions: no single microbiological medium can detect all types of rious contamination outbreaks. The process of detection is made even more difcult by Detecting Mycoplasma in Cultures the presence of antibiotics. The techniques and concepts presented below ofer some practical approaches for monitoring contamination that can be No monitoring program is complete unless it can efectively detect readily adapted to meet the needs of most cell culture laboratories. Thermometers and chart recorders that at least 15% of all cell cultures in the United States are contaminated should be tested and calibrated periodically to ensure their accuracy. Because of these outrageously high levels of contamina Inexpensive (when compared to the cost of a single autoclave failure) tion and the proven ease with which mycoplasmas can be spread from autoclave thermometers, spore test strips and capsules, or other testing contaminated cultures,26 it is very important to quarantine all cultures devices can be placed inside autoclaves or into bottles of solutions or coming into the laboratory until they have been tested for mycoplasma. Samples of all in-house flter-sterilized solutions should be tested for sterility There are two basic testing methods for mycoplasma: direct culture in each time they are prepared and the solutions not used until testing is media, or indirect tests that measure specifc characteristics of myco complete. Additionally, although direct culture is the most sensitive method, it is the slowest Cell culture media, especially unopened bottles of media that are outdated (requiring up to 28 days) and it may not reliably detect some fastidious or no longer used in the lab (as long as they do not contain any antibiotics) strains of mycoplasma, making it less than 100% efective. Budget permit can provide a very rich, readily available and useful substitute for standard ting, direct culture testing is best contracted to an outside testing facility microbiological media. These tests are commercially available at a reasonable of either fltered solutions or cultures and products suspected of being cost from several cell culture testing companies. This sterility test media substitute is also very useful for evaluating the these tests are faster than direct culture, all are commercially available in kit amount or source of particulate contamination in an area, near a piece form, and they can detect the fastidious, difcult to cultivate strains that of equipment or by a technique. However they lack the sensitivity of frequently blamed by laboratory personnel as the source of their contami direct culture, requiring much higher levels of contamination for detection. Until these areas are methods, potentially leaving researchers who rely solely on a single indirect screened and eliminated as the source of the problem, the real problem, test with a false sense of security (Reviewed in references 11, 12, and 18). Not only will this test detect mycoplasma, but as an added beneft nants may take two weeks or longer to appear.
Diseases
Dysosteosclerosis
Radiation related neoplasm /cancer
Forbes disease
Hydrocephalus autosomal recessive
Marfan Syndrome type II
Chromosome 9, trisomy 9q
Otosclerosis
Brief psychotic disorder
Chromosome 8, monosomy 8p
Rhabdomyosarcoma
The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research erectile dysfunction treatment cream levitra super active 40mg low price. Accumulating evidence shows that many physiological processes require highly sophisticated events of chromatin remodeling erectile dysfunction nyc discount levitra super active 40mg visa. Recent ndings have linked cellular metabolism impotence uk order generic levitra super active line, epigenetic state erectile dysfunction while drunk 40mg levitra super active with visa, and the circadian clock erectile dysfunction generic drugs discount 40 mg levitra super active mastercard. The control of a large variety of neuronal erectile dysfunction medications online discount levitra super active 40 mg without prescription, behavioral erectile dysfunction trimix buy discount levitra super active 40 mg on-line, and physiological responses follows diurnal rhythms erectile dysfunction drugs and hearing loss buy levitra super active online. This is possible through a transcriptional regulatory network that governs a signi cant portion of the genome. The harmonic oscillation of gene expression is paralleled by critical events of chromatin remodeling that appear to provide speci city and plasticity in circadian regulation. Accumulating evidence shows that the circadian epigenome appears to share intimate links with cellular metabolic processes. These notions indicate that the circadian epigenome might integrate tissue speci city within biological pacemakers, bridging systems physiology to metabolic control. Keywords: circadian clock; epigenetics; metabolism Circadian rhythms: systems biology metabolic syndrome, and more recently an emerg ing role in tumorigenesis. One important rhythms represent one of the most clear examples 2 feature of the circadian clocks is that they are self of systems biology. Our understanding of circa sustained: circadian oscillations intrinsic to each cell dian rhythms indicates that these cyclic events are can occur autonomously, without any environmen self-sustained and centrally controlled, suggesting tal signals. However, because the period of oscilla a complex and intricate biological timing mecha tion is not exactly 24 h, the endogenous clock needs nism that governs our daily behavior. Disruption to be synchronized by external cues, a process called of circadian rhythms has been linked to numer entrainment. External cues (also known as zeitge ous diseases, including sleep disorders, depression, bers) reset the system daily and thereby prevent the endogenous clock from free-running out of phase. Re-use of this article is permitted in accordance with the predominant external cue of the central clock the Terms and Conditions set out at wiley is light. These gene expression events are as most prominent features of the circadian system as sociated with speci c histone modi cations leading it allows the integration of moderate variations in to chromatin remodeling. Restricted access to food can neurons: cultured cells from peripheral tissues, al reset the phase of peripheral oscillators, with little if though each has a sustained circadian cycle, do not 104 Ann. Several genome-wide ar lation), and chromosome condensation/segregation ray analyses have been centered on determining the (Ser10/Ser28 phosphorylation). Taking into consid acts as an enzyme that globally modi es genome eration the recent view of the mammalian circa functions, by inducing the opening of chromatin dian clock as a transcriptional network,2,35 through structure and allowing transcriptional activation. This notion has been demonstrated in the sine residue in position 537 of the protein and is way the circadian machinery interplays with other essential for circadian rhythmicity. Individual neurons dissociated from lites, a detailed analysis of such metabolites that are rat suprachiasmatic nucleus express independently phased currently not known to oscillate is needed. Time after time: inputs Concluding remarks to and outputs from the mammalian circadian oscillators. Resetting central and peripheral work of transcriptional, translational, and post circadian oscillators in transgenic rats. The intricate interrelationship reporting of circadian dynamics reveals persistent circadian between the central and peripheral clocks is a highly oscillationsinmouseperipheraltissues. The biological clock nucleus: a multiphasic oscillator network evidence suggests that the circadian clock machin regulated by light. Melanopsin in cells of origin of the also suggests that the metabolic state of the cell retinohypothalamic tract. Circadian rhythmicity restored and appreciate the scope of this network, how it is by neural transplant. Immunocytochemical characteriza regulated, and the extent to which it governs sys tion of the graft and its integration with the host brain. Prokineticin 2 transmits the be havioural circadian rhythm of the suprachiasmatic nucleus. Restricted feeding uncouples circa dian oscillators in peripheral tissues from the central pace 1. The circadian clock transcriptional complex positive limb of the mammalian circadian oscillator. Circadian cycling of the mouse liver emerging roles in physiology, aging, and calorie restriction. The physician should perform a more detailed clinical evaluation and/or refer to specialist when appropriate. Grade your answer by circling Grading Scale one number for each of the following questions: Never Rarely Occasionally Most Always Nights/Days 1 Do you have trouble falling 1 2 3 4 5 asleep. If they answer 3, 4 or 5 for two or more items and have significant daytime impairment the insomnia requires further evaluation and management. Question 8 refers to somatization and may reflect an underlying somatoform disorder which requires specific treatment. Further questioning about shift work or a preference for a delayed sleep phase should be done. Question 11 refers to restless legs syndrome and question 12 refers to periodic limb movement disorder. Grading above 3 on questions 14 and 15 or 14 and 16 is also suspicious for sleep apnea and further evaluation should be done. Being overly tired makes it Sdifficult to concentrate, which increases the possibility of errors or accidents. The stress of shiftwork also can aggravate health conditions, such as heart disease or digestive disorders. Sleep after night work usually is shorter and less refreshing or satisfying than sleep during the normal nighttime hours. This makes it more difficult to per form well, which increases the risk of accidents. Also, shiftwork can be stressful because of frequent switching from a day to night sched ule and because of separation from family and friends. Organizational or group approaches include redesigning the work schedule, redis tributing the workload, improving the work environment, and institut ing programs to improve worker awareness. Individual approaches include improved sleep strategies, exercise and diet programs, and relaxation techniques. This document gives basic facts about shiftwork and talks about ways to make shiftwork life easier. To prepare this document, we borrowed ideas and information from many people who have studied shiftwork or done shiftwork them selves. Some of our sources are mentioned in the recommended reading list at the end of this document. Shiftworkers might work in the evening, in the middle of the night, overtime or extra long workdays. This might happen at different times of the week or at different times of the month. Society and Em ployer Reasons for Shiftw ork There are several reasons for shiftwork. A major reason is that mod ern technology has made it possible to do many activities at any time of the day or night. Critical services include public safety, such as police and fire protection; military defense; health care; transportation; and public utilities, such as electrical power, water and telephone. Other industries must operate 24 hours per day because the production process is much longer than 8 hours and must be performed continuously. Also, manufacturing industries often have expensive machinery that needs to be operated continuously in order to be profitable. Because several occupations and industries operate around the clock, other services have expanded their hours to accommodate evening and nighttime workers. The increase in these expanded-time services in the past decade or two has opened up the job market for new shiftworkers. The Bureau of Labor Statistics reports that about five per cent of American adults work in the evening. Permanent night work ers and workers with irregular schedules make up another four per cent. A quick check of lists provided by the Bureau of Labor Statistics shows about 2 to 10 percent of almost any occupation working evening, night, or rotating shifts. These kinds of schedules happen quite often among police officers and firefighters. More than half of them work evenings and nights, and about a quarter of them rotate shifts. This practice has forced more truckers to take trips at all hours and at the last minute to make their deliveries on time. People W ho W ork Shifts If we look only at full-time jobs, men work more night and rotating shifts, while women work more evening shifts and do more part-time work. And more women are entering the workforce full time, so these numbers are changing quickly. If we look at married couples who each have paying jobs, about one-quarter to one-third of these couples have at least one partner who is a shiftworker. If we look at mothers with children at home, single mothers work shifts more often than married mothers. Em ployee Reasons to Do Shiftw ork Some workers actually prefer non-day work, but most do not seek out shiftwork. Reasons for employees choosing shiftwork include better pay, more available time during the day for child care, more daylight hours for recreation, and more time to attend school. Some workers prefer the night shift because it is quieter and there are fewer supervisors. They do it either because it is required of the job, or no other job is available. There is no simple answer to this question because there is no ideal schedule that fits every situation. In this section, we suggest ways to examine work schedules to identify their advantages and disadvan tages. However, it is difficult to accurately count the many shiftwork schedules being used. No thorough records are kept by the federal government, trade orga nizations, or labor unions. Different schedules might be used by the same occupation, the same industry, or even the same workplace. The most common shift schedule probably is five days on a single shift followed by two days off. If this is a rotating shift schedule, the worker will change to a new shift after the days off. Off shore oil rig workers, for example, might work two weeks out on the rig followed by two weeks off at home. Since so many different schedules exist, researchers have thought of ways to measure different features of the schedules. These features are used to study how work schedules might affect safety, health, or productivity. W ork Schedule Features W e already have mentioned the time of the shift and whether shifts are permanent (fixed) or rotating. If people experience too much stress and fatigue, then they might not do their jobs safely and efficiently. Tim e of Shift: Twenty-four hour operations usually are divided into two or three shifts. Because people who work in the late night or early morning hours often feel sleepy and fatigued during their shift. This happens because their body rhythm (also called a circadian rhythm) tells them to be asleep at those times. Night workers also must sleep during the day, when their circadian rhythm tells them to be awake. This might cause them to cut off their sleep, which makes them feel tired during the day. Many social events take place in the evening, which means they might be missed by evening or night workers. Parents who work the evening shift might not see their children during the week because they are at work when the kids return from school. W ith experi ence, many night workers figure out tricks or personal methods to fight off some of the nighttime fatigue. However, research tells us that most permanent night workers never really get used to the schedule. Fatigue occurs because most night workers go back to a day schedule on their days off. Also, many errands and chores (like getting the car fixed) must be done during the day. Because most night workers often return to a day schedule, they never completely allow their sleep and body rhythms to adapt to being awake at night. Because the shift times are always changing, they can never completely adapt to a set work schedule. Rotating schedules are often used because they are considered fairer to all workers. Everybody in the workforce takes their turn at both the popular and unpopular shifts. This is not easy, which is why rotating shiftworkers have more com plaints than other workers about physical health and psychological stress. Speed and Direction of Rotation: Adapting to rotating shifts can be affected by the speed of rotation and the direction of rotation. Speed of rotation means the number of consecutive day, evening, or night shifts before a shift change occurs. A backward rotation is in the counterclockwise direction, from day to night to evening shift. W e have already talked about the same situa tion under permanent versus rotating shifts. Longer rotations (for example, three to four weeks of working the same hours) are sup posed to allow workers more time to get used to night shifts. A fast rotation (every two days, for example) allows no time to get used to night work. Some researchers prefer the fast rotation, because the worker quickly gets through the tough shifts and then has a couple of days off. Direction of rotation can affect the ability of cir cadian (daily body) rhythms to adapt to the change in work times. Sleep, for example, is a circadian rhythm because each person sleeps for part of every day. Some researchers suggest that a forward, or clockwise, rotation is better for helping a worker adjust to new sleep times.
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S Clinical manifestations Generally after 7 to 9 cycles beta blocker causes erectile dysfunction purchase levitra super active 40 mg with mastercard, within minutes following infusion initiation erectile dysfunction treatment patanjali generic levitra super active 40 mg on line. S Management Pretreatment with intravenous calcium gluconate and magnesium sulfate erectile dysfunction doctor in dubai levitra super active 40 mg overnight delivery. Pretreatment with dexamethasone or methylprednisolone erectile dysfunction drugs free sample best levitra super active 40mg, dyphenydramine causes of erectile dysfunction and premature ejaculation buy levitra super active us, cimetidine 30 minu tes before oxaliplatin infusion erectile dysfunction 30s buy levitra super active 40 mg overnight delivery. Desensitization in 4 to 8 h erectile dysfunction causes emotional order levitra super active 40mg on line, starting at 1/10 erectile dysfunction drugs that cause discount levitra super active 40mg otc,000 to a cumulative goal dose of 175 mg (0. Standardization of skin tests for diagnosis and prevention of hyper sensitivity reactions to oxaliplatin Int Arch Allergy Immunol 2008;145:54-7. Successful desensitization protocol for hypersensitivity reactions caused by oxaliplatin. Ovarian cancer: mild cutaneous reactions in previous courses, respiratory dysfunction, obesity, post menopausal. Systemic and intra-stent (paclitaxel-eluting coronary stents) hypersensitivity reactions have been described, leading to thrombosis and death. Generation of reactive metabolites leading to complement activation or direct action on mast cells and basophils. Switch to Docetaxel (diluted and solubilized with tween 80); cross-sensitivity has been shown to be high, up to 90%. Paclitaxel-induced cutaneous lupus erythematosus in patients with serum anti-Ssa/Ro anti body. Paclitaxel hypersensitivity reactions : assessment of the utility of a test dose program. Rapid inpatient / outpatient desensitization for chemotherapy hypersensiti vity: standard protocol effective in 57 patients for 255 courses. Incidence and risk factors for paclitaxel hypersensitivity during ovarian cancer chemotherapy. Stevens-Johnson syndrome induced by paclitaxel in a patient with squamous cell carcinoma of the lung: a case report. Severe cutaneous toxicity after Pemetrexed as second line treatment for a refractory non small cell lung cancer (Article in French). It is widely used as an antineoplastic agent (lymphoid malignancies, mycosis fungoides, chronic lymphocytic leukemia). S Diagnostic methods Hypersensitivity vasculitis involving arteries and veins in the heart, spleen, cerebral cortex (seen at autopsy). S Mechanisms Concomitant administration of allopurinol to prevent hyperuricemia secondary to tumor lysis could enhance pentostatin toxicity. Hypersensitivity vasculitis associated with 2-deoxycoformycin and allopuri nol therapy. S Diagnostic methods No in vivo or in vitro method is currently available for diagnosis other than re-challenge, which is hazardous due to life-threatening pneumonitis (published). Anticonvulsant usage is associated with an increased risk of procar bazine hypersensitivity reactions in patients with brain tumors. Hypersensitivity reactions to procarbazine with mechlorethamine, vincris tine, and procarbazine chemotherapy in the treatment of glioma. Hypersensitivity to procarbazine associated with angioedema, urtica ria and low serum complement activity. Efficacy, tolerability and management of raltitrexed (Tomudex) mono therapy in patients with advanced colorectal cancer. Used to accelerate myeloid recovery following bone marrow transplantation or cytotoxic chemotherapy. Immediate hypersensitivity to human recombinant granulocyte-macrophage colony-stimula ting factor associated with a positive prick skin test reaction. Others: epis taxis, carcinoma, cutaneous and mucosal infections (viral and mycotic), nail alterations (onychopa thy and periungual infections). Cutaneous adverse events in renal transplants recipients receiving siroli mus-based therapy. Hand-foot syndrome (30 to 60% with sorafenib and 15 to 20% with sunitinib), preceeded or accom panied by dysesthesias, arising 2 to 4 weeks after the initiation of treatment. Lesions are localized, symmetrical, painful, hyperkeratotic and in peripheral erythematous, edematous and sometimes bullous. Subungual splinter hemorrhage: multiple, painless, more frequent with sorafenib (60% to 70%), than sunitinib (30%). Periorbital edema (5 to 10% with sunitinib), facial eruption (seborrheic derma titis like, with periorbital aspect), 50% with sorafenib; 1 to 2 weeks after beginning treatment; may be associated to scalp erythema, scalp dysesthesia (sorafenib), frequent in the first three weeks; disappears spontaneously, flushing (sorafenib), bullous dermatitis (sunitinib), stomatitis (sorafenib, sunitinib), yellow skin discoloration (sunitinib), hair depigmentation (sunitinib), hair modification and alopecia (sorafenib), kystic, hyperkeratosic papules, keratoacanthoma (sorafenib). Risk of hand-foot skin reaction with sorafenib: a systemic review and meta analysis. Hand-foot skin reaction in patients treated with sorafenib: a clinicopatholo gical study of cutaneous manifestations due to multitargeted kinase inhibitor therapy. Sunitinib: a cause of bullous palmoplantar erythrodysesthesia, periungual ery thema, and mucositis. Sytemic administration (transplantation): pruritus (7 to 36%), rash (10 to 24%), dyspnea (5 to 29%), cough (15 to 18%), pleural effusion (liver transplantation : 30 to 36%), atelectasis (5 to 25%), bron chitis (heart transplantation : 17 to 18%). S Management When possible, switch to non calcineurin inhibitor everolimus (mammalian target of rapamycin). S Diagnostic methods One case with a positive lymphocyte stimulation test and challenge test in allergic liver injury. Temozolomide-induced desquamative skin rash in a patient with metastatic mela noma. Successful treatment of palmo-plantar erythrodysesthesia possibly due to temozolomide with dexamethasone. Hypersensitivity reactions to epipodophyllotoxins in children with acute lym phoblastic leukaemia. Used in the treatment of ovarian, breast cancer and bladder tumors (intravesical instillation). Combined thiotepa and mitomycin C instillation therapy for low-grade superfi cial bladder tumor. Topotecan as a continuous infusion over 14 days in recurrent ovarian cancer patients. S Diagnostic methods One case of positive leukocyte migration test to vincristine. Vincristine-induced fever in a child with rhabdomyosarcoma: cellular hyper sensitivity to vincristine demonstrated by leukocyte migration test. Hand-foot syndrome associated with short infusions of combination che motherapy with gemcitabine and vinorelbine. Incidence and syndrome of acute shortness of breath following vinca alka loids in patients receiving mitomycin. Fatal acute respiratory failure following vinblastine and mitomycin administration for breast cancer. Acute bronchospasm after vinca alkaloids in patients previously treated with mitomycin. Maculopapular rash, occuring within the first weeks of treatment, often transitory, rarely a cause of discontinuation of treatment; pityriasis-rosea like rash, toxic erythema, exfoliative dermatitis, purpuric rash. S Diagnostic methods Skin tests (anaphylactic or cutaneous reactions) Intradermal: 0. Skin biopsy: vasculitis with leukocyte infiltration in patients with cutaneous lesions. Accumulation of bradykinin which stimulates the release of tachykinins including substance P and neurokinin A. Substance P is important in neurogenic inflammation and has a functio nal relationship via C fibers with mast cells in various tissues, including lung and skin. Bradykinin is known to activate afferent sensory C fibers via type J receptors which cause coughing. Conversely, bradykinin could increase the formation of prostaglandins and leukotrienes. In addition, a decrease in bradykinin degradation increases the synthesis of bradykinin and/or related kinins. Potential role of vasomotor effects of fibrinogen in bradykinin-induced angioedema. Acute adverse reactions associated with angiotensin-converting enzyme inhibi tors: genetic factors and therapeutic implications. Angioedema associated with angiotensin-converting enzyme inhi bitor use: outcome after switching to a different treatment. Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke. Biochemical basis of angioedema associated with recombinant tissue plasmino gen activator treatment: an in vitro experimental approach. S Mechanisms Pulmonary toxicity: direct toxicity or indirect/ inflammatory/ or immune process. Photodistribution of blue-gray hyperpigmentation after amiodarone treat ment: molecular characterization of amiodarone in the skin. The incidence of phlebitis with intravenous amiodarone at guideline dose recom mandations. Amiodarone-induced vasculitis and a review of the cutaneous side effects of amiodarone. The combination of clopidogrel and aspirin is considered essential in reducing the risk of stent thrombosis in patients undergoing coronary stenting. S Management Switch to ticlopidine but serious side effects may occur (diarrhea, neutropenia, thrombocytopenic purpura); cross-reactivity has been documented rarely between these two thienopyridines. Clopidogrel-induced hypersensitivity syndrome associated with febrile pancy topenia. Coumarin derivatives: warfarin, phenprocoumon, acenocoumarol the drugs are the therapeutic of choice for maintenance anticoagulation therapy. Patients with primary proteins C and S defi ciency or those with anticardiolipin syndrome are at greater risk for developing necrosis. S Management Replacement therapy with recombinant protein C concentrate appears to block progression of the lesion and enhances healing. Alternatively, longer overlapping periods with heparins during initiation of coumarin administra tion ensure a complication and necrosis-free treatment. Warfarin-induced skin necrosis and leucocytoclastic vasculitis in a patient with acquired protein C and protein S deficiency. Warfarin-induced skin necrosis and venous limb gangrene in the set ting of heparin-induced thrombopenia. Contrary to phenindione, which is also an indanedione derivative, very few cases of immunologic reactions have been described. Fluindione-induced acute generalised exanthematous pustulo sis confirmed by patch testing (Article in French). Immuno-allergic interstitial nephritis related to fluindione: first biopsy proven cases. Fluindione-induced acute exanthematous pustulosis with renal involve ment (Article in French). Heparin Heparins are important anticoagulants, used in the prophylaxis and treatment of throm boembolitic disorders. S Risk Factors Delayed allergic skin reactions: Female gender, obesity, and repetitive or long-lasting treatment. Hormonal factors, longer persistence of heparins in subcutaneous adipose tissue or a relationship to the lipase activity of heparins have been proposed to explain the gender difference. Often complicated by disseminated thrombosis of vessels in the skin and in other organs. Clinically hemorrhagic, sometimes bullous lesions and plaques with rapid evolution toward necrosis are present. After a sensitization or induction period of at least 7-10 days, but more often after weeks to months, patients develop pruritic erythematous lesions at the injection sites. Pruritus may be severe and hemorrhage can occur due to the anticoagulant action of the drug. Undiluted intradermal heparin causes irritant reaction Sometimes positive in immediate cutaneous reactions (urticaria). Skin biopsies: Presence of a dense lympho-histiocytic infiltrate with spongiosis of the epidermis, representing a contact dermatitis-type reaction. Challenge test: Performed with increasing doses up to one daily defined dose and should be followed from day 1 up to day 5-7, as a positive reaction may occur only after several days. These reactions were attributed to preservatives and contaminants such as proteins of animal origin. Heparin is a sulfated proteoglycan (mucopolysaccharide) with strong protein-binding capacity because of its highly negative charge. In allergic reaction, this negative charge seems to play an important pathogenic role, as the hepa rin molecule adheres to human proteins. However, the allergenic epitopes causing the different hypersensitivity reactions are still unknown. Danaparoid and pentosanpolysulfate, both low-sul fated mucopolysaccharides, may show cross-reactivity to some extent. In one study, 81% of patients with delayed heparin allergy showed cross-reactivity to danaparoid and 45% showed cross-reactivity to pentosanpolysulfate. Recently, several cases with erythematous plaques to heparins and also fondaparinux were reported. Use low molecular weight heparin or heparinoids (beware of cross-reactivity) Use hirudin. Hypersensitivity reactions to anticoagulant drugs: diagnosis and manage ment options. Tolerance to intravenous heparin in patients with delayed-type hypersensitivity to heparins: a prospective study. Delayed-type hypersensitivity to the ultra-low-molecular weight heparin fon daparinux. Tolerance of recombinant hirudins and of the new synthetic anticoagulant fondaparinux. Delayed cutaneous hypersensitivity reactions with polysensitivity to hepa rins and heparinoids (Article in French). Tolerance of Fondaparinux in patients with generalized contact der matitis to heparin. Fondaparinux is a safe alternative in case of heparin intolerance during pregnancy. Unexpected delayed-type hypersensitivity skin reactions to the ultra low-molecular-weight heparin fondaparinux. Delayed-type hypersensitivity to the ultra-low molecular-weight heparin fon daparinux. Fondaparinux: a suitable alternative in cases of delayed-type allergy to hepa rins and semisynthetic heparinoids. Hirudins Hirudins, proteins derived from the leech Hirudo medicinalis, specifically inhibit thrombin. Because of their completely dif ferent chemical structure compared with heparins, there in no cross-reactivity with heparins.
Christmas Flower (Poinsettia). Levitra Super Active.
Fever, pain, infection, warts, skin disorders, toothache, and other conditions.
