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Thomas H. Strong, Jr., MD

• Director, Maternal-Fetal Medicine
• Banner Thunderbird Samaritan Medical Center
• Glendale, Arizona
• Clinical Professor, Obstetrics and Gynecology
• University of Arizona School of Medicine
• at the Arizona Health Sciences Center
• Tucson, Arizona
• Associate Director, Phoenix Perinatal Associates
• Phoenix, Arizona

Babies with reduced conjugation or elimination of bilirubin are at risk for hyperbilirubinemia erectile dysfunction treatment vancouver discount tadalafil 10mg free shipping. Several laboratory techniques have been developed for measuring the serum bilirubin concentration erectile dysfunction drugs associated with increased melanoma risk buy tadalafil 10 mg with visa. The specific technique used has implications for the interpretation of serum values erectile dysfunction and high blood pressure order genuine tadalafil on-line. Direct or conjugated bilirubin: concentration of bilirubin conjugated with glucuronic acid impotence losartan best 5mg tadalafil. Indirect or unconjugated bilirubin: the lipid-soluble form of bilirubin that circulates in loose association with the plasma proteins men's health erectile dysfunction causes order generic tadalafil canada. Cases of extremely high levels of serum bilirubin in infants with no apparent sequelae have been reported how is erectile dysfunction causes purchase tadalafil 10mg mastercard. Conversely, infants without documented high serum 3 bilirubin levels have been found to have kernicterus. The majority of these affected infants are term and late-preterm infants who are discharged from the hospital as healthy newborns, yet subsequently develop extreme hyperbilirubinemia and the neurodevelopmental findings associated with kernicterus. Establish nursery protocols for the identification and evaluation of hyperbilirubinemia. Recognize that visual estimation of the degree of jaundice can lead to errors, particularly in darkly pigmented infants. Recognize that infants less than 38 weeksgestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring. Perform a systematic assessment on all infants before discharge for the risk of severe hyperbilirubinemia. Provide appropriate follow-up based on the time of discharge and the risk assessment. TcB Measurement TcB or transcutaneous bilirubin measurement is being performed more frequently in hospitals and outpatient settings. Serial measurements of bilirubin concentrations are recommended to monitor the effectiveness of phototherapy treatment. The performance characteristics of the most commonly used phototherapy devices are summarized in 14 Table 2. Immediate exchange transfusion is recommended if the infant with hyperbilirubinemia shows signs of acute bilirubin encephalopathy: hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry. Several pharmaceutical agents have been investigated for their ability to prevent or treat neonatal hyperbilirubinemia. It is currently being investigated for 16 use in infants with severe hyperbilirubinemia. Parent Education and Resources Before the infant is discharged from the hospital, parents should be given both written and verbal information about newborn jaundice, including risk factors, identification and treatment. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 74 Appendix 18 1. Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: recommendation statement. Loss of concern about jaundice and the reemergence of kernicterus in full-term infants in the era of managed care. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. Hyperbilirubinemia in the newborn infant >35 weeksgestation: An update with clarifications. A new transcutaneous bilirubinometer, BiliCheck, used in the neonatal intensive care unit and the maternity ward. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy-term and near-term newborns. Evaluation of transcutaneous jaundice meter following hospital discharge in term and near-term neonates. Screening and early postnatal management strategies to prevent hazardous hyperbilirubinemia in newborns of 35 or more weeks of gestation. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 75 Appendix 18 Table 1: Risk Factors for the Development of Severe Hyperbilirubinemia in Infants of 35 or More WeeksGestation (In Approximate Order of Importance). Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 76 Appendix 18 Figure 1: Nomogram for Designation of Risk. Reprinted with permission from the American 8 Academy of Pediatrics Nomogram for designation of risk in 2840 well newborns at 36 or more weeksgestational age with birth weight of 2000 g or more or 35 or more weeksgestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values. The serum bilirubin level was obtained before discharge, and the zone in which the value fell predicted the likelihood of a subsequent bilirubin level exceeding the 95th percentile (high-risk zone) as shown in 31 Appendix 1, Table 4. See Appendix 1 for additional information about this nomogram, which should not be used to represent the natural history of neonatal hyperbilirubinemia. Figure 2: Guidelines for phototherapy in hospitalized infants of 35 or more weeks8 gestation. Reprinted with permission from the American Academy of Pediatrics Note: these guidelines are based on limited evidence and the levels shown are approximations. Note that irradiance measured below the center of the light source is much greater than that measured at the periphery. Measurements should be made with a radiometer specified by the manufacturer of the phototherapy system. See Appendix 2 for additional information on measuring the dose of phototherapy, a description of intensive phototherapy, and of light sources used. If total serum bilirubin levels approach or exceed the exchange transfusion Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 77 Appendix 18 50 line4), the sides of the bassinet, incubator, or warmer should be lined with aluminum foil or white material. If the total serum bilirubin does not decrease or continues to rise in an infant who is receiving intensive phototherapy, this strongly suggests the presence of hemolysis. Infants who receive phototherapy and have an elevated direct-reacting conjugated bilirubin level (cholestatic jaundice) may develop the bronze-baby syndrome. Figure 3: Guidelines for exchange transfusion in infants 35 or more weeksgestation. Blood for exchange transfusion is modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant. Reprinted with permission from the American Academy of Pediatrics Provide lactation evaluation and support for all breastfeeding mothers. Follow-up recommendations can be modified according to level of risk for hyperbilirubinemia; depending on the circumstances in infants at low risk, later follow-up can be considered. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 80 Appendix 18 Table 2: Phototherapy Devices Commonly Used in the United States and Their Performance Characteristics. For precision based device assessment, the spectral bandwidth (*), which is defined as the width of the emission spectrum in nm at 50% of peak light intensity, is the preferred method to distinguish and compare instead of the total range emission spectrum (data usually provided by manufacturers). Emission peak values are also used to characterize the quality of light emitted by a given light source. The devices have been found exceptionally stable during several years of use and agree closely after each annual calibration. The footprint of a device is that area which is occupied by a patient to receive phototherapy. The irradiance footprint has greater dimensions than the emission surface, which is measured at the point where the light exits a phototherapy device. The minimum and maximum values are shown to indicate the range of irradiances encountered with a device and can be used as an indication of the uniformity of the emitted light. Most devices conform to an international standard to deliver a minimum/maximum footprint light ratio of no lower than 0. All of the reported devices are marketed in the United States except the PortaBed, which is a non-licensed Stanford-developed research device and the Dutch Crigler-Najjar Association (used by Crigler-Najjar patients). Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 82 Appendix 19 Appendix 19. Fetal effects of illicit substances include teratogenesis, intrauterine growth retardation, prematurity, low birth weight, birth complications, and central nervous system damage. Exposed newborns are at risk for neonatal abstinence effects and developmental and behavioral abnormalities. Increasing rates of substance abuse during pregnancy translate into higher numbers of drug exposed infants. However, this number is lower than the expected 1500-1750 newborns based on ~ 37,000 infants being delivered in Iowa annually. The unrecognized infants are discharged to their homes where mothers are likely to continue to use/abuse illegal substances. These infants continue to be exposed to illegal substances and the associated chaotic life style, health degradation, violence, child abuse and neglect, and family dysfunction. Treatment also has a positive effect on fetal outcome (fewer intensive care admissions due to greater gestational age and birth 6 weight). A screening and intervention protocol developed by a panel of experts from across Iowa will help medical care providers to make objective decisions regarding their screening/testing/intervention practices for 7,8 substance abuse in women during pregnancy and for their offspring. Purpose Develop a community practice guideline for perinatal illicit substance use screening and testing Identify illicit substance using patients during pregnancy and their exposed infants Provide a screening tool to identify the patients and infants at risk for use and exposure Provide guidelines for referral and intervention both for the mother and the infant Increase secondary and tertiary prevention efforts to reduce pregnancy related illicit drug use/abuse Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 83 Appendix 19 the sole goal of identification is to provide early access to assessment and treatment for the mother/infant dyads without application of punitive measures. Screening for maternal substance abuse must begin with a thorough but non-judgmental and compassionate interview. Consent for Testing Specific consent should be sought from the pregnant woman to perform urine toxicology testing if any risk factor is recognized via risk assessment form. Urine testing history including testing offer dates, maternal responses (consented versus declined), test dates, results, and positive testing drug(s) should be documented in the chart. Any concerning result should be shared with the hospital social worker and the pediatric team. Urine/meconium or umbilical cord testing with testing dates and results should be documented in the chart. Risk assessment in Prenatal Clinic, Labor & Delivery, and Neonatal Units this tool consists of two assessments; one to assess the risk status of the pregnant/delivering woman, the other of the infant. This risk assessment should take place at the first encounter with the pregnant woman and at delivery. If prenatal care and delivery take place at different hospitals, the delivery hospital should request maternal consent to obtain the prenatal records from where prenatal care was obtained. Prenatal clinic/labor and delivery staff, hospital substance abuse management team, hospital social worker(s), psychiatry staff, and pediatric team should review these forms in their assessment of their client (infant and/or the mother). Test specimens Urine: 10 ml urine; if submission to the lab is to be delayed it should be kept refrigerated until testing. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 84 Appendix 19 Umbilical Cord: 6-8 inch segment; cord blood should be drained from the cord segment and discarded, rinse exterior with normal saline, place cord segment in specimen container; sample is shipped to testing laboratory without preservative at room temperature. Institutional response to addiction in Prenatal Clinic/Labor & Delivery Unit Hospitals are recommended to establish an in-house team to respond to the needs of pregnant women using illicit drugs. This team may include staff from prenatal clinic, newborn unit, hospital social services, hospital/community chemical dependency unit/agency, and psychiatry department. Staff becoming aware of substance abuse or positive test results should have this team or the hospital social worker involved to improve the referral process for treatment at any time during pregnancy. Information on referral centers for substance abuse treatment can be found at, Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 85 Appendix 19 1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The National Survey on Drug Use and Health Report, Substance Use During Pregnancy: 2002 and 2003 Update. The relationship between parental substance abuse and child maltreatment: findings from the Ontario Health Supplement. Obstetrics Clinic and Labor and Delivery Unit >Risk Factors Related to Current Pregnancy Maternal urine drug screen positive. Yes No Unexplained discrepancy between delivery/prenatal care facilities (hospital hopping). Yes No Untreated maternal depression or major psychiatric illness within the last 3 yearsYes No Ever used illegal drugs during any pregnancy. Yes No >Risk Factors Related to Maternal Social History History of illicit drug use by mother or partner within the last 3 years. Yes No History of illicit drug rehabilitation by mother or partner within the last 3 years. Yes No History of child abuse, neglect, or court ordered placement of children outside of home.

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Add the fruit and let it come to a boil; the next day drain off the liquor and boil again; do this three times and your pickles are delicious; add cinnamon to the liquor and stick two or three cloves in each peach. While the prunes are soaking, boil together for ten minutes two pounds sugar, one pint vinegar, one ounce each of cloves and cinnamon and one-fourth of an ounce of ginger. After the prunes have been strained, pour the hot vinegar over them and boil all together until the prunes are soft. Let this come to a boil and pour over the tomatoes; after they get cold tie strong paper over them. Let these stand while you boil for a few minutes the following: 2 pounds sugar, 1 ounce cinnamon, 1/2 ounce cloves, 1 pint vinegar. Be sure and skim this while it is boiling, then put in the cucumbers, letting them cook until tender. Then add 3 green peppers, chopped, 1 teacup of grated horseradish, 2 quarts of vinegar, 1 teacupful of sugar. Let this all boil, stirring occasionally, gently, until the tomatoes are tender, then add a large spoonful of cinnamon and cloves. Be sure and use plenty of spices, cover carefully and let stand for a month before using. Keep this in stone jars and tie closely and it will keep nicely for a year or more. Drain and put them in weak vinegar on the stove and let them get hot; drain and pack in glass jars. Then bring to a boil, one quart vinegar, a few slices of onions, sugar and spices to taste. Cover with water and an inverted plate; place a brick on the plate to keep all under water. The next morning put tomatoes in kettle after draining them, with five pounds of brown sugar, 1/4 cup cloves, ten cents worth cinnamon stick, two quarts vinegar. Pour over the pulp another pint of vinegar with two tablespoonfuls brown sugar, 2 or 3 ounces mixed spices. Pick them over carefully and add to five pounds of grapes, half as much sugar (by weight), 1 pint vinegar, two or three ounces of mixed spices, and salt to taste. Fill a wide-mouthed glass bottle or jar with them, then add two tablespoons of salt, and fill the jars with cold vinegar. Then take six green tomatoes, three large white onions, one large red pepper, (taking out the seeds) three sour apples, one small cupful of tender string beans, and finally the carrots treated in the same manner; place all these ingredients together in the preserving kettle in which they are to be cooked, adding salt and a very little paprika and allow them to stand for twelve hours. When ready to cook drain off the water that will have formed, adding sufficient vinegar to well moisten, one cupful of sugar, a tablespoon olive oil and two teaspoonfuls of celery seed tied in a piece of muslin, for about five minutes. Remove from the fire and mix in quickly half a teaspoonful ground English mustard blended with a little vinegar; seal immediately in small well-closed jars. The cucumbers are to be soaked in salt and water over night and drained in the morning, put in the vinegar and let come to a boil, then add your onions and cauliflower. Take the flour, mustard and tumeric powder, work to a cream with a little vinegar, then gradually stir into the boiling vinegar to thicken it. Fill into wide mouthed bottles, lay a paper wet with vinegar over the currants and tie up the mouth of the bottle with paper. Add two-thirds as much sugar as you have fruit, the juice of a lemon, two-thirds cupful of water and a desertspoonful of ginger. Allow one pound of sugar, one fourth pound whole white mustard seed, one ounce ground black pepper, one teaspoonful ginger and one of cinnamon. Put a layer of tomatoes and onions in a kettle and sprinkle with spices, then tomatoes and so on until all are used. Cover with vinegar and let boil two hours, after which pack in jars and set in cool place. Add five tablespoonfuls of brown sugar, three tablespoonfuls of salt and eight cupfuls of vinegar. Cook until tender, when nearly done, add one pound of sugar, put in cans and seal. When all are pared, put into a pan of clear, cold water, and boil until almost tender. Make a syrup of the water in which the pears were boiled, allowing one pound of sugar to each half pint of water. Drop the pears into the syrup and cook them slowly until they can be pierced with a silver fork. After the stones have been taken out, allow them to stand in a stone jar over night; in the morning put them in a preserving kettle and cook until clear. Put in glass tumblers and cover the tops when cool with melted paraffin, before putting on covers. Use just enough water to keep them from sticking, and put fruit, sugar and water all on at the same time, and let them cook twenty minutes. Then spread on flat dishes and set in sun for three or four days, and then put in glass jars. When the apples are done, boil the syrup down thick, then pour boiling hot over the apples and cover closely. Place the fruit in a porcelain or granite kettle, first a layer of fruit, then a layer of sugar, using pound for pound of sugar. The following day pour the liquor into a quart of codlin liquor, this being made by boiling and straining a pound of fine sugar with just enough water to make a syrup. To every pound of fruit allow a half pound of loaf sugar; put the citron on to cook until it is quite clear, then remove it from the kettle where it can drain, and pour out the water it was cooked in. Then put on the sugar you have weighed, with water enough to wet it through; let it boil until very clear, and before putting in the citron again add to the syrup two large lemons sliced, and a small piece of ginger root, to give it a fine flavor; then add the citron and let all cook together about fifteen minutes; fill the jars with citron and pour over the hot syrup, then seal up. Put a little over one quart of granulated sugar into your preserving kettle; add just water enough to moisten the sugar; when warm put into this two quarts of pears; let them cook very slowly several hours; when the syrup is thick put your fruit in jars. The next morning take the apples out of the syrup, cook the syrup until it thickens, replace the apples and boil fifteen minutes; remove the pineapple from the syrup and let them cool, then put in jars and pour the syrup over them. Let this stand over night, then pour off the juice into a preserving kettle and boil until it is a thick syrup, clarifying it with the white of an egg; add the tomatoes and boil until they look transparent. One lemon to a pound of fruit, sliced thin and cooked with the fruit, together with a piece of ginger root, will improve it. Drop the berries into this and allow them to boil rapidly for twenty minutes, removing all scum that rises, but do not stir the fruit. Pour into tumblers, and when you are done cook your syrup and juice to a jelly and fill up your jelly glasses. Place in a kettle on the back of the stove until the sugar is dissolved into syrup; then let it come to a boil, stirring from the bottom. Spread on platters, not too thickly and set out in the hot sun till the syrup thickens-it may take two or three days. Boil currants one hour, then add sugar, spices and a half pint vinegar, boil a half hour longer. Put the tomatoes in and boil gently twenty minutes; remove fruit again and boil until the syrup thickens. Make a syrup of sugar and water, allowing a teacupful of sugar to a jar and fill the jars to the brim; put on the covers, without rubbers and place in a kettle of cold water over the fire. Note carefully when the water comes to a boil, and let it boil twenty minutes or more, according to ripeness of the fruit. Take the jars from the water, adjust the rubbers and screw on the tops tighter and tighter as the jars cool. A plated knife should be used in peeling the fruit as a steel one discolors the fruit. Make a syrup of half a pound of sugar and half a teacupful of water for each pound of peaches. Skim as the scum rises in boiling, then put in the peaches and boil them gently until tender, no longer. Remove the syrup from the fire, and add to it half a pint of best brandy to every pound of peaches. When the syrup boils, put in the fruit, set back on stove and cook very slowly for an hour or more if not too tender, as the longer it cooks the brighter will be the color. Cut each grape with a knife and extract the seeds; add sugar to the fruit, pound for pound; cook slowly for half an hour or longer until the syrup and pulp of the grape are perfectly clear and transparent. First a layer of fine granulated sugar, then the plums and so on until the jar is filled. Let them stand in the boiling water all day, filling up the kettle as the water boils away. After the pulps are thoroughly cooked, strain through a sieve, then add to it three pounds of sugar, two teaspoonfuls of cinnamon and allspice, and half teaspoonful of cloves. When done remove them from the liquid, and add one ounce each of cinnamon, cloves and mace. Boil the liquid for some time after the spices have been added, then place the fruit in jars and pour this over them. Boil the fruit and sugar together until soft, then add the lemon, a half pound green ginger root scraped and cut into small pieces. To every four pints of juice use three pints of sugar; heat the sugar very warm in the oven. Boil the juice fourteen minutes, stir in warm sugar, and boil altogether three to five minutes, then turn into moulds or jelly glasses. When they are quite soft, strain all through a coarse muslin bag, pressing hard to extract all the flavor of the fruit. Put a pound of loaf sugar to every pint of juice and the juice of one lemon, and put the liquor over the fire in a preserving kettle. When the juice has boiled twenty minutes stir in the sugar until it dissolves; then put into glasses and keep in a cool place. Return the juice to the stove and cook fifteen minutes more; pour into glasses and seal when cool. Let the juice boil half an hour, then add the sugar and let it boil five or ten minutes longer. All jellies to be good, should have nearly all the boiling done before the sugar is added. Boil hard for twenty minutes, turn into glasses and set in the sun, if possible, for half a day. Take equal quantities of juice and sugar; to each quart of juice add one-half teaspoonful of cloves and one tablespoonful cinnamon. Cook very hard for twenty minutes, then remove from the stove and pour into glasses. To each pint of juice add a pound of sugar; boil until it jellies on the skimmer, then remove and place in glasses. Then cut the shells of the oranges in two, scrape out the white lining and put the skins on to boil; weigh the pulp, take half as much sugar, and simmer together fifteen minutes. When the skins are transparent and tender, take up, putting several pieces together, cut it quickly into the narrowest possible strips. Crush the whole well in a preserving kettle; add one pint of currant juice and boil gently until it jellies upon a cold plate; put into a small jar and cover with brandied paper. Place in a porcelain kettle and boil the berries and currant juice first, then add the sugar and boil up again, skimming well. Dry and heat the sugar in a separate pan and let the peach liquor boil twenty minutes. From the Following Recipes and Formulae, Hundreds and Even Thousands of Candies Can Be Made. Hundreds of tons of candy are annually consumed, and fortunes have been made in the business. The range of price is from ten cents to a dollar a pound, with some specially wrapped and boxed bon-bons exceeding the latter price, not because of intrinsic excellence, but because of the ornamental form in which they are presented. Delicious candy may be made at home at much less cost, and some famous candies, like the "Mary Elizabeth" and others, had their beginnings in a home kitchen and grew into popular favor because of their known purity and uniform excellence. Any girl can prepare bon-bons for a luncheon or a party at home, if she is willing to take the trouble,-which is, after all, a pleasure to many. She may save her own candy boxes and by getting a supply of paraffin paper, fill them again with candies quite as good as those they originally contained; or buy new boxes of the paper box manufacturers at two or three cents apiece. The first of these is the "thread" at about 215 degrees, by the sugar thermometer, when a short thin thread forms when thumb and forefinger are separated with a drop of syrup between them. This passes very quickly into a second stage, known as the large or long thread, when it can be drawn out to a considerably greater length without breaking. In a moment more it can be extended as far as the thumb and forefinger can be separated. The next stage is the "pearl," shown when the surface of the syrup is covered with bubbles, and is the stage at which much candy is made. To discover when the boiling has progressed to this stage, drop a little of the syrup on to ice water, or dip the tips of the thumb and forefinger into ice water and then into the syrup and instantly into the ice water again with the syrup between. If the syrup can be rolled into a soft, but not sticky ball, it is in the soft ball stage; half a minute more of boiling will convert it into the "hard ball," if tested in the same manner. The next is the "crack" or brittle stage, at about 300 degrees; when testing as above the syrup remains dry and hard on the fingers. At the caramel stage the syrup begins to brown, and must be quickly taken from the fire or it becomes "burnt sugar;" dropped in water it crackles and snaps. An endless number of varieties may be made from it in combination with other material.

It may be used in diarrhea erectile dysfunction symptoms treatment discount 20 mg tadalafil, dysentery impotence for males order generic tadalafil canada, leucorrhea erectile dysfunction first time buy cheap tadalafil on line, but as stated it is better for cystitis weak erectile dysfunction treatment tadalafil 5mg on line, urinary trouble erectile dysfunction gel treatment cheap tadalafil 5 mg amex, etc erectile dysfunction injections videos purchase discount tadalafil on-line. For decoction use one ounce of the leaves and boil in one and one-half pints of distilled water. This is also good for ulcers and wounds, and for skin affections applied locally; or a poultice can be used. A poultice of this remedy, poke and white oak, equal parts, is very good for old sores. Useful locally also for sore mouth and throat, and as an injection for leucorrhea. Use one to one and one-half ounce of root to a pint of boiling water for infusion. For dysentery and diarrhea boil one ounce in a pint of milk and use two ounces every two to four hours. Powdered root, given in hot water, may be used in doses of one-half to one teaspoonful three times a day, instead of infusion. Taken after confinement, use the infusion four times a day, smell of the red bethroots. This is used once daily for leucorrhea, gleet, gonorrhea, falling of the womb and bowel. Prepare infusion by adding one ounce of bark of the root to a pint of boiling water. For bleeding from the womb take ten to twenty drops, four times daily, a few days before the time for the flow. Dose of infusion as an emetic one to four teaspoonfuls: For ringworm, tetter and warts, it is applied locally, freely. As a tonic for the stomach, the dose should be small, one to one and one-half teaspoonful of the infusion four times daily, and for sick headache it should be half as much and not repeated oftener than twice, a half hour apart. Make a tincture immediately or dry it quickly before the fire, clean, powder, and bottle tight for use. Following is good for indigestion and biliousness: Fluid extract of blue flag and golden seal each; one-half ounce, simple elixir, one ounce. It is used in decoction to regulate menstruation, and should be taken freely and warm and begun a day before the menstrual period. In irritable bladder and urethra, due to increased sand in the urine, inflammation. Used as an ointment for skin diseases; the juice, of the leaves, is mixed with lard, cream or vaselin. This remedy is used frequently in combination with other blood remedies, for the above named diseases and is very beneficial. When the infusion is made from the seeds the dose is only about one-third of a teaspoonful four times daily. For external use for troublesome ulcers, scrape or grate the root and apply to the ulcers. It is frequently used for colic in babies in doses of half to one teaspoonful, warm. The expressed juice of the plant is good for amenorrhea in one to two teaspoonful doses five times daily. Use one and one-half ounces of the herb in a pint of warm water and allow it to steep for two hours. Also equal parts of cleavers, maidenhair, and elder blows, steeped in warm water for two or three hours and drank freely when cold forms an excellent drink in erysipelas, scarlet fever and measles. An infusion made with cold water is good to remove freckles; wash the parts several times daily for two or three months. When used in acute disease, the dose should not be more than one-fourth as much and given every one or two hours. For rheumatism it is especially valuable, when small joints like the fingers and toes are involved. Fluid extract, ten to thirty drops three times daily; for afterpains give half as much about every three hours. For the diseases named it is best to take it in smaller doses and oftener, say four teaspoonfuls every hour or two; children in proportion. Congested kidney, dropsy from heart disease, chronic nephritis, suppression of the urine, renal colic, haematuria, cystitis. For hysteria attacks, asthma spasms, less should be used and taken oftener for a few doses. The following combination is effective for the spasmodic attacks, above named: Cramp bark two ounces, scull cap and skunk cabbage one ounce each, cloves one-half ounce, capsicum two even teaspoonfuls. Dose: one or two ounces two or three times a day; oftener and smaller doses for hysteria, etc. For piles:-Inject a strong decoction and retain as long as possible; or apply an ointment of two ounces of the root to tobacco ointment seven ounces, and apply three or four times a day. Nose-bleed and bleeding from teeth extraction:-Apply the powder or strong decoction to the part. Bleeding from the womb: -Inject strong decoction or apply on gauze or cotton to inner womb. Decoction, two parts to one part blood root, forms a good injection for leucorrhea and gonorrhea. Good in latter stages of diarrhea and dysentery of children, boiled in milk, given in teaspoonful doses, every one to three hours. To make decoction, use one ounce of the powdered root to one pint of water and let boil. If you use the green root put one ounce in cold water, and let it remain there for one hour. Good also for indigestion, in this form when due to inactive liver and costive bowels. It should be taken often enough, when the liver is torpid, to move the bowels once or twice a day. If the infusion is used, begin with a half ounce and take every three hours; increase or decrease as necessary. Infusion of the bark of the root may be taken in doses of half ounce twice daily, to act as a cathartic. Local, use inner bark of the limbs and steep with cream and apply freely and often for burns, sores, etc. For sweating and painful menses take two teaspoonfuls of the hot decoction every two hours until relieved. Oil is very good, in doses of one to five drops every three hours for acute diseases, or three times a day for chronic cases. For retention of urine, place a poultice in the perineum or over bladder on the abdomen. Infusion made by adding half ounce of the powdered or bruised root to a pint of boiling water. It tones up the stomach and bowels temporarily, but should not be used long or frequently. When it is called for, the tongue is generally coated whitish; it will soon clear that. Two parts of the decoction of golden seal and one of cranesbill used as an injection is good for gonorrhea, gleet, and leucorrhea. Good in this form, mixed with cranesbill, for diarrhea and dysentery; taken in two teaspoonful doses every three hours. Use one ounce of the leaves to one pint of boiling water and let it steep to make an infusion. For nervous troubles, take one ounce of the infusion, or one dram tincture, every hour or two until quiet; same for sleeplessness. In delirium tremens, infusion drank with some red pepper in it settles the stomach and quiets the craving for drink. Decoction made of the bark by using one and one-half ounces to a pint of water and boiling. Infusion used hot for sweating, freely and often; cold and chest troubles about every two to four hours; or use fluid extract. It can be made more effective by adding half ounce of cream of tartar to the infusion. The oil can be bought and used in doses of five to twenty drops, three or four times a day. Pour on a pint of boiling water and steep for fifteen minutes, and take half ounce every half hour, for three or four hours. In menorrhagia-too much flow-cinnamon and raspberry leaves can be combined with it. In small doses and given often in infusion it produces sweating and relaxation of the tissues, thus helping in asthma and lung diseases; For asthma, dose:- Ten drops of tincture every ten minutes at the onset until better or until there is a little nausea, and then lengthen the interval. Take an ounce of the herb to a pint of boiling water and boil to make a decoction. To make tincture: Gather the fresh root before the fruit is ripe, chop and pound to a pulp, and weigh. Then take two parts of alcohol by weight, mix the pulp thoroughly with one-sixth of the alcohol and then add the rest of the alcohol. Stir all, pour into a well stoppered bottle, let stand eight days, in a cool place. To make tincture: Take the fresh leaves at the top of the plant with the blossoms and buds, chop and pound to a pulp, enclose in a piece of new linen and press. Shake the expressed juice, with an equal part of alcohol by weight, allow it to stand eight days in a well stoppered bottle, in a dark cool place and then filter. Decoction is made by using three ounces of the root to one quart of water, and boil. Smaller doses can be used for nervous women every hour, and when there are painful menstruations, suppressed lochia, hysteria, sleeplessness, etc. For apoplexy and convulsions, mustard poultices of the seeds to feet, and mustard foot baths, handful of ground mustard to hot water. Hiccough: Teaspoonful of mustard in four ounces of boiling water, steep for twenty minutes, and take in four doses. It contains many constituents, such as citrate of lime, allyl sulphide, volatile oils, sulphur. Roasted Spanish onion is good, eaten at bedtime, as a laxative; fried in lard and applied locally it makes a splendid poultice. Roasted in coals it makes a good poultice for earache, toothache, sore throat and sore chest. Then take two parts, by weight, of alcohol; mix pulp with one-sixth part of it thoroughly and rest of alcohol added, stir all well, pour into a well stoppered bottle and let stand eight days in a dark cool place; pour off, strain and filter. To tone the womb and make labor easier, the Indians used to take it several weeks before confinement. For sore nipple: two ounces (fresh, if possible) and make a strong decoction in a pint of boiling water. For bladder and urinary troubles and leucorrhea, put four ounces of the kernels in a quart of brandy; dose,-teaspoonful three or four times a day. For bowel troubles use half ounce of the flowers and half ounce of the kernels to a pint of water; boil to make a decoction and sweeten; dose,-teaspoonful occasionally, until relieved; for teething children and for worms use about five doses. For menstrual troubles, checked lochia and perspiration, take a hot foot bath in bed and drink freely of the tea until sweating occurs. The bruised leaves or the tea may be used for other diseases mentioned as poultice or wash. For falling womb use one ounce pleurisy root and one-half ounce unicorn root (true), mix powder and give in twenty to thirty grain doses three times daily; and an injection of the same, in infusion, may be given once a day. Following is good for diarrhea and dysentery: Tincture pleurisy root two ounces, brandy one ounce, syrup of raspberry three ounces. Juice of plant, half teaspoonful three times a day, for same diseases can be used. For caked breasts one to three drops of the tincture every one to three hours, at same time applying the root (roasted in ashes until soft) mashed and applied as a poultice; good also for a felon or can apply a hot fomentation of the leaves instead. Drug stores keep the fluid extract, which can be bought and given in doses of fifteen to thirty drops every three or four hours. Some claim it relieves the pain in the kidney stone colic; the Indians used it for that purpose. Extract; dose, ten to thirty drops; smaller doses given every two or three hours; larger dose three or four times daily. Decoction, use four ounces of the dried leaves to one quart of boiling water and boil. Fluid extract is the best form, can be bought and given in doses of half to one teaspoonful three or four times a day. For sore mouth, sore throat, tonsilitis and quinsy, use hot infusion strong as a gargle. The mucilage is good for chest disorders, bowels, kidneys and for inflammation after poisoning, as a bland demulcent drink. For decoction use one ounce of the dried root to a pint of boiling water and let boil. A saturated tincture of the fresh root is much better, of which half a teaspoonful can be given everyone to four hours for above diseases.

Users of radioactive materials are responsible for compliance with the requirements of their national nuclear regulatory body (in the United States impotence in a sentence cheap 2.5 mg tadalafil mastercard, the Nuclear Regulatory Commission)1 and/or related state regulations erectile dysfunction causes medscape purchase tadalafil 10 mg without a prescription. In addition erectile dysfunction urban dictionary buy generic tadalafil, administrative or local requirements may apply at specific facilities impotence bicycle seat cheap tadalafil 2.5 mg on-line. Radionuclides are used in laboratories to develop and evaluate analytical methods impotence emotional causes generic 20 mg tadalafil overnight delivery, to prepare counting standards erectile dysfunction age 40 order tadalafil 20 mg amex, and to calibrate detectors and counting instruments (see Part 7000). Sealed sources, such as the nickel-63 detector cell used in electron capture gas chromatograph units, also are common. The exposure limits may be adjusted proportionately (upward) for a period where the exposure is less than 40 h. However, the limit must be adjusted proportionately (downward) for periods where the exposure period is greater than 40 h. Limiting exposure to ionizing radiation includes providing engineering (physical safeguards) and administrative (procedural) controls for using radioactive materials. Engineering controls include shields, barriers, and interlocks to limit external exposure, and exhaust ventilation systems and personal protective equipment to limit internal contamination. Administrative controls include conducting periodic surveys and reviews of activities, training in the use of radioactive materials, and documented procedures (see below). Monitoring procedures and equipment: Radiochemical exposure monitoring may be done by collecting and analyzing wipe samples, using portable survey instruments, and/or by collecting and analyzing air samples. Survey procedures generally use wipe tests for removable contamination and/or portable measurement devices for locating or measuring fixed and removable radioactivity. Electron capture detectors using 63Ni or 3H require counting wipes by liquid scintillation or windowless gas-flow proportional counters to measure low-energy beta radiation effectively. The frequency of the surveys is dictated by the documented contamination record for the laboratory. Usually the radioactivities presented using the methods of Part 7000 are not measurable with routine survey instruments. Therefore use blanks in the analytical process in determining the presence of low-level contamination. Personnel surveys and monitoring: Conduct and document surveys after routine use of unsealed radionuclide sources to confirm that personnel and the work area have not been contaminated by the process. Wear monitoring devices if there is a reasonable probability of exceeding 25% of the occupational exposure dose equivalent limit. Personal monitoring devices include film badges, thermoluminescent dosimeters, and solid state electronic dosimeters. The length of time the personal monitoring badges are worn before evaluation depends on the ability of the device to integrate the exposure over long periods, the probability and magnitude of the exposure, and the need to assure that the device is available and used. Personnel performing procedures in Standard Methods would not be expected to receive exposures approaching 1. Personal (external radiation) exposure is evaluated by using a personal dosimeter, preferably the film dosimeter (badge). Pocket ionization chambers, thermoluminescent dosimeters, and thimble chambers also may be used to supplement the film dosimeter. Whole body or gamma spectrometry radiation detectors may be used to determine the presence of radioactive substances in the body, but these instruments are expensive and require the operator to be specially trained. Evaluate equipment and supplies that have been, or are suspected to have been, in contact with radioactive substances to determine if contamination is present. Because body waste may contain radioactive contaminants evaluate it also for the presence of contamination where personal exposures have been confirmed. Emergency procedures should include notifications required, containment methods, clean-up procedures, and survey techniques. Contamination is typically prevented through proper use of laboratory facilities and procedures. Procedures include the use of gloves, aprons, safety glasses, and other protective clothing to eliminate the possibility of skin contamination and transfer. Learn proper pipetting and weighing techniques before working with radioactive sources. Conduct work with unsealed radioactive sources in unobstructed work areas with adequate means of containing and absorbing potential spillage of liquids. Procedures Develop and implement a radiation safety plan and provide a copy to all persons working with radioactive materials or radiation-producing machines, and provide both lecture and practical training to all employees. Safety plan elements: the recommended minimum plan should include procedures for obtaining authorization to use, order, handle, and store radionuclides; safe handling of unsealed radioactive material; safe response to radiation accidents; decontamination of personnel and facilities; personnel monitoring; laboratory monitoring; and disposal of radioactive materials. Handling radioactive materials: Become knowledgeable about the hazards associated with the materials to be used. Plan work activities to minimize the time spent handling radioactive materials or in using radioactive sources. Work as far from radioactive sources as possible, use shielding appropriate for the materials to be used, and use radioactive materials only in defined work areas. Use appropriate personal hygiene and self-monitor after using radioactive materials and after each decontamination procedure. Training of users: Train personnel working with radioactive materials in radiation safety as part of the overall occupational health program. Address at least the following topics: characteristics of ionizing radiation and radioactive contamination; radiation dose limits; environmental radiation background; acute and chronic effects; internal and external modes of exposure; basic protective measures; responsibilities of employer and employees; radiation protection program responsibilities; posting, warning signs, and alarms; radiation monitoring programs; and emergency procedures. Waste Disposal Generalized disposal criteria for radioactive wastes have been developed by the U. Noble gases can be removed by absorption; standard techniques can be used for particulate. Intermediate levels may be treated by various physical-chemical processes to separate the waste into a nonradioactive portion that can be disposed of by dilution and a high-activity portion to be stored. Dispose of all waste in conformance with the requirements of the regulatory authority having jurisdiction. Standard operating procedures or work practices: Include procedures and practices relevant to safety and health considerations. These are to be followed when laboratory work involves the use of hazardous chemicals. Exposure hazard criteria and procedures: these will be used to determine and implement control measures for reducing employee exposure to hazardous chemicals while conducting laboratory operations. They include engineering controls, the use of personal protective equipment, and hygiene practices. Pay particular attention to the selection of control measures for work activities that involve chemicals known to be extremely hazardous. Protective equipment performance procedures: these include procedures for evaluating the performance of fume hoods and other protective equipment and specific measures to be taken to ensure proper and adequate performance of such equipment. Employee information and training: this training must be timely, be refreshed periodically, evaluated for effectiveness, and documented. Approval procedures: the plan must state the circumstances under which a specific laboratory operation, procedure, or activity requires prior approval before implementation. This should include the formal assignment of a Chemical Hygiene Officer and, where appropriate, the establishment of a Chemical Hygiene Committee. Additional employee protection: the plan should include provisions for working with particularly hazardous substances. Introduction Waste minimization and disposal are part of integrated hazardous materials management. It is important to become familiar with federal regulations regarding the use and disposal of hazardous materials prior to their purchase, storage, and use for water and waste-water analysis. Proper management of hazardous materials will reduce the amount of hazardous waste and associated disposal costs. General Considerations Waste minimization or pollution prevention in the laboratory is the preferred approach in managing laboratory waste. Minimizing waste makes good economic sense: it reduces both costs and liabilities associated with waste disposal. Waste Minimization Methods Waste minimization methods include source reduction, recycling, and reclamation. While large-volume purchases may seem economical, the costs of disposing of expired-shelf-life materials also must be considered. Commercial laboratories and chemical users in general can return samples or unopened chemicals to sender or supplier for recycling or disposal. Wherever possible use methods that do not require the use of hazardous chemicals or use micro-scale analytical methods. Improving laboratory procedures, documentation, and training will increase awareness of waste minimization and proper disposal practices, and may allow different sections within a laboratory to share standards and stock chemicals. Evaluate hazardous materials storage and use areas for potential evaporation, spills, and leaks. Segregate waste streams where possible to keep nonhazardous waste from becoming hazardous waste through contact with hazardous waste. Transfer of unused stock chemicals to other areas of the laboratory where they may be used or to other institutions is a way to minimize waste. Recycling/reclamation has limited potential in water and waste-water laboratories. Volumes generated are generally too small for economical reclamation and purity requirements are often too great. However, organic solvents often can be distilled and recovered for reuse and mercury and silver can be recovered. General Considerations Stringent penalties exist for the improper disposal of hazardous wastes. Potential criminal and civil liability exists for both organizations and individuals. Specific requirements vary by state and local jurisdiction and are subject to change. Many activities, in particular treatment, storage, and disposal of hazardous wastes, require a permit or license. Plan should address the proper transport, storage, treatment, and disposal of hazardous waste. Refer to Section 1090 on Safety with regard to protective equipment in the handling of hazardous materials. Waste Treatment and Disposal Methods Treatment can be used to reduce volume, mobility, and/or toxicity of hazardous waste where expertise and facilities are available. Waste treatment methods include thermal, chemical, physical, and biological treatment, and combinations of these methods. Thermal treatment: Thermal treatment methods include incineration and sterilization. They involve using high temperatures to change the chemical, physical, or biological character or composition of the waste. Incineration is often used to destroy organic solvents and is preferred for infectious wastes, although sterilization through autoclaving and/or ultraviolet light also may be allowed. Chemical treatment: Methods include chemical reaction (oxidation/reduction, neutralization, ion exchange, chemical fixation, photolysis, coagulation, precipitation) of the waste material. Neutralization of acidic or alkaline wastes is the most common form of chemical treatment. The oxidation of cyanide to cyanate with a strong chemical oxidant is an example of a toxicity-reducing chemical treatment. Physical treatment: Methods include solidification, compaction, photo-induced reaction, distillation, flocculation, sedimentation, flotation, aeration, filtration, centrifugation, reverse osmosis, ultrafiltration, gravity thickening, and carbon or resin adsorption. Biological treatment: Methods include using biosolids to destroy organic compounds, composting organic-rich wastes, and using bioreactors to promote decomposition. Ultimate disposal: After waste minimization and treatment, remaining waste streams require disposal. Nonhazardous wastes that cannot be treated further can be discharged as wastewater, emitted to the atmosphere, or placed on or in the ground. With extreme caution, it may be permissible to dispose of limited quantities (at certain concentrations) of laboratory wastes to the sanitary sewer system or to evaporate volatile wastes in chemical ventilation hoods. Obtain written permission of local, state, and federal authorities to dispose of waste in this manner. Wastes disposed of in this manner may contact other substances in the sewer or ventilation systems and produce hazardous reactions. Most hazardous wastes generated in laboratories must be sent off site for further treatment and disposal. Ensure that the laboratory receives a copy of the completed manifest and certificate of treatment and/or disposal. If possible, visit the disposal facility in advance to observe how it will manage a waste.

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