Joanna Chikwe, MD

• Assistant Professor
• Department of Cardiothoracic Surgery
• Mount Sinai Medical Center
• New York, New York

Very permeable fill materials should be avoided to prevent surface exposure of inadequately treated wastewater from too rapid movement through the fill erectile dysfunction treatment exercise order avana paypal. Slowly permeable fill material should also be avoided to prevent impeded wastewater movement through the fill erectile dysfunction statistics age purchase avana 50mg with amex. If the in-situ unsaturated soil has a percolation rate faster than one (1) minute per inch impotence over 70 purchase avana 200mg online, sufficient stabilized soil with a percolation rate between five (5) and thirty (30) minutes per inch is required to maintain at least two (2) feet separation between the proposed bottom of the absorption trenches and in-situ soil erectile dysfunction treatment in kl buy cheap avana line. The edge of the fill material beyond the basal area shall be tapered at a slope no greater than one (1) vertical to three (3) horizontal with a minimum taper length of twenty (20) feet erectile dysfunction doctors jacksonville fl purchase avana 50 mg overnight delivery. All minimum horizontal separation distances as described in Table 2 shall be measured from the outer edge of the taper since the fill is considered a system component causes of erectile dysfunction in 60s discount 100mg avana otc. The fill must be stabilized prior to conducting final percolation tests and construction of the absorption trench system. Soils whose permeability characteristics could change significantly upon stabilization (soils containing clay and/or silt) shall be allowed to settle naturally for a period of at least six (6) months and include one freeze-thaw weather cycle. Soils whose permeability characteristics will not change significantly upon stabilization (sand and sandy loam) may be mechanically compacted or 78 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems allowed to settle naturally as indicated above. Mechanical compaction shall be achieved via track type machines (bulldozer or front-end loader with downward blade/bucket pressure) or steel wheeled roller. Mechanical compaction shall be accomplished in shallow lifts [approximately six (6) inches] to the approximate density of the undisturbed borrow pit soil. Compaction must be carried out carefully to avoid creating layers of different density. Distribution to the absorption trench system shall incorporate dosing, unless: (a) the system is to be installed under the jurisdiction of a local health department which has a program incorporating site evaluation, system design approval and construction inspection/certification, and (b) a minimum of two (2) feet of fill material with a percolation rate of five (5) to thirty (30) minutes/inch shall be placed between the bottom of the trenches and the existing ground. Curtain drains may be used on the uphill side of proposed fill areas on sloped sites to intercept and control ground water where high ground water levels exist. Non-perforated pipe constructed to convey ground water from the perforated drain pipes to the ground surface should be installed on in-situ soil bedding at least five (5) feet from the toe of the slope of the fill material. Excavated soil shall be used as backfill around and above the non-perforated pipe. The drainpipe surface outlet shall be protected from water infiltration, soil erosion and animal entry. This method of controlling groundwater level should be monitored to confirm effectiveness to ensure the absorption area maintains the two (2) foot separation to groundwater year-round. On sloped sites, a diversion ditch or curtain drain shall be constructed uphill from the fill to prevent surface runoff from entering the fill area. The topsoil surface of the fill shall be graded to enhance runoff of precipitation. The receiving soil will act as a final polishing media and distribute the treated wastewater into the soil. A conventional absorption trench shall be designed to distribute effluent evenly over the fill material basal area. Extreme care must be taken to assure that construction techniques do not compromise the integrity of the receiving soils or fill material. Heavy construction equipment must not be allowed within the area where the raised system is to be installed. Generally, sites with large trees, numerous small trees, or large boulders are unsuitable for a raised system because of the difficulty in preparing the surface and the reduced infiltration area beneath the system. Consideration should be given to increasing the size of the system to provide sufficient soil 79 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems to accept the effluent when tree stumps and/or boulders occupy a significant amount of the soil surface area. In areas that are suitable, all trees and stumps shall be cut at grade and removed. Plowing the area where the fill is to be placed turns over the soil without destroying the soil structure or infiltrative capability of the receiving soils. When the surface is plowed, a plow with at least a double bottomed blade/furrow plow with the furrow turned upslope is recommended. If other equipment (such as teeth from the bucket of a backhoe) or another method is used it must not destroy soil structure and cause smearing or compaction of receiving soils. Rototilling or soil scarification with construction equipment should always be avoided. After the site has been cleared and plowed all traffic shall be excluded from the area. Fill material can be deposited on the site with a front-end loader or pushed on from the side, preferably the upslope side, using a track type machine with at least six (6) inches of fill beneath the tracks. Fill should be placed on the site immediately after it is prepared to avoid undesirable changes to the native soil (traffic, compaction, erosion, etc. The fill shall be properly stabilized and the absorption trench system shall be constructed in the fill material. After the absorption trenches have been constructed in the stabilized fill (including backfilling the trenches), the entire surface of the raised system including the tapers shall be covered with a minimum of six (6) inches of topsoil, slightly mounded to enhance runoff of precipitation from the system (1% slope) and seeded to grass. Appropriate curtain drains and diversion ditches shall be constructed uphill from the absorption system on sloped sites to prevent ground water from interfering with absorption system operation or surface runoff from entering the fill. Mounds are a variation of the raised system except a specified and analyzed (sieve analysis) sandy fill material is utilized. The type of soil used does not require a stabilization period (freeze-thaw) prior to construction of the absorption trenches or bed in the fill. For sites with permeable soils of insufficient depth to groundwater, creviced rock or porous bedrock for a conventional absorption system, the specified fill material in the mound provides the necessary treatment of wastewater. The overall size of a mound system will usually be substantially smaller than a raised system because of the combination of using a specified fill material, the improved solids retention of the required multi-compartment septic tank or tanks in series and the required pressure distribution. Installation of water saving devices such as; faucets, showerheads, toilets and clothes washers are recommended for any residence using a mound system to minimize wastewater flow. When mound systems are proposed as replacement systems for existing homes, water saving fixtures should replace older household plumbing fixtures. Siting and design experience indicates that a mound should be long and narrow and should follow the site contour. At least one deep hole test at least four (4) feet deep or to bedrock shall be dug at the proposed location of the mound system to verify boundary conditions. On 1% to 12% sloping sites the basal area includes only the area under the absorption trenches or bed and the lower or downhill taper only. All minimum vertical separation distances depicted in Figure 30, 31 shall be met, and dimension D in Figures 32A and 32B must be at least one (1) foot. The required basal area is dependent upon the daily design flow rate and soil percolation test results of naturally occurring soil. Trench lengths listed in Table 6A or calculated from Table 6B for trenches, and basal areas listed in Tables 7A or calculated from Table 7B for absorption beds, shall be used when the percolation rate is between one (1) and sixty (60) minutes per 81 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems inch. Percolation test holes shall be approximately twelve (12) inches deep to determine the percolation rate of the upper foot of naturally occurring soil. Percolation tests should be conducted near each end of the proposed mound and the expansion area. The slowest percolation test results (worst case observed within the selected basal area) shall be used to design the basal area required. At least one (1) deep hole test should be performed at the proposed location of the reserve area to verify boundary condition separation, if available. The recommended separation distance between two (2) or more mound systems (toe of slope of fill to toe of slope of fill), perpendicular to ground contours is at least thirty (30) feet. Heavy construction equipment shall not be allowed within the basal area and a recommended minimum 20 feet wide area downslope of the basal area, which acts as a dispersal area for the mound. Percolation tests for the fill material shall be conducted at the borrow pit in areas representative of the soil to be obtained. Only uniform medium to course sand with a percolation rate between five (5) and thirty (30) minutes per inch shall be used for the fill material. A sieve analysis is recommended and may be necessary to verify compliance with the soil specifications. The percolation rate should be verified and take precedence to the fill gradation requirements when a mound is placed over very slow percolating soil to avoid rapid weeping of fluids at the ground surface. A pressure distribution network shall be utilized and timed dosing is recommended to control discharge to the mound. The width of the system shall be kept to a minimum and, in no case, shall the absorption area be wider than 20 feet. A mound shall not be expanded greater than 20 feet wide to satisfy absorption system expansion. In a distribution network using a central-manifold, distribution lines shall have a maximum total length of 200 feet (end cap to end cap) as depicted in Figure 16. In a distribution network using an end-manifold, distribution lines shall have a maximum length of 100 feet (manifold pipe to end cap) as depicted in Figure 15. The overall size of absorption facilities in a mound (bed or trenches) shall not exceed 20 feet by 205 feet for a central manifold distribution network or 20 feet by 105 feet for an end manifold distribution network. B = absorption trench or bed total length and shall not exceed 205 feet for a central manifold or 105 feet for an end manifold. C = downslope setback and shall be the larger of: (1) approximately three (3) times the height of the mound at the downslope edge of the absorption facility ([3] [E + F+ G]); or, (2) the dimension calculated from percolation tests on the naturally occurring soil plus flow rates to meet the required basal area. D = depth of fill at the upslope edge of the absorption facility between the top of the plowed surface and the bottom of the absorption facility and shall be at least one (1) foot. E = depth of fill at the downslope edge of the absorption facility between the top of the plowed surface and the bottom of the absorption facility and shall be equal to [D + (slope of site) (A)]. Gravelless absorption products may be used in place of aggregate in accordance with the manufacturers recommendations on a 1:1 basis only (mound and absorption area dimensions shall remain the same). G = depth of permeable soil cover plus topsoil at the upslope and downslope edges of the absorption facility and shall be at least one (1) foot [i. H = depth of permeable soil cover plus topsoil at the width center of the absorption facility and shall be at least 1. J = upslope setback and shall be at least: [3(D + F + G)] [Slope of Site] [(3) (D + F+ G)] = [1 Slope of Site] [(3) (D + F + G)]. K = side slope setback and shall be at least three (3) times the total height of the mound: D E [3][() + F+H]. Mound dimensions shall be consistent with Figures 30, 30A, 31, 31A, 32, 32A and 32B and meet or exceed those required by the local health department having jurisdiction. The required absorption area of the trenches or bed shall be based upon the daily design flow rate and the percolation rate of the in-situ fill material (at the borrow pit). Trench lengths are listed in Table 6A or calculated from Table 6B for trench systems, and basal areas are listed in Table 7A or calculated from Table 7B for absorption beds. A dual chamber septic tank or two tanks in series in addition to the dosing tank (with pump storage) shall be provided. An effluent filter or other outlet modification that enhances solids retention in the tank(s) is recommended. The in-situ soil beneath the mound basal area must be capable of absorbing the filtered effluent of the mound. Extreme care must be taken to assure that construction techniques do not compromise the integrity of the mound system or receiving soils. Heavy construction equipment must not be allowed within the fill area of the system or immediately downslope of the system. Placement of fill material or construction of absorption facilities in fill shall not occur when the soil moisture content is high. Generally, sites with large trees, numerous small trees or large boulders are unsuitable for a mound system because of the difficulty in properly preparing the surface and the reduced infiltration area available beneath the system. Other vegetation (brush, vines, weeds and grass) shall be cut as close to grade as possible and removed. The proposed mound area shall be plowed to a depth of about seven (7) to eight (8) inches preferably with a double-bottomed blade/furrow plow with the furrow turned upslope or a backhoe equipped with plowing blades. Other methods that will promote infiltration and not destroy soil structure may also be used. Fill should be placed on the site immediately after it is prepared to avoid undesirable changes to the plowed native soil, (traffic, compaction, erosion). Fill material can be deposited on the site with a front-end loader or pushed on from the side (preferably the upslope side) using a track type machine with at least six (6) inches of fill beneath the tracks. Construction of the absorption system in the fill material shall be in accord with Figures 30, 30A, 31, 31A, 32, 32A and 32B, including distribution laterals being installed parallel to the contour lines of the native soil prior to installing fill. The bottom and sidewalls of the absorption trenches or bed shall be raked prior to installing. The 84 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems aggregate in the trenches or bed shall be completely covered with a permeable non-woven geotextile to prevent infiltration of soil into the aggregate. The tapered slopes of the fill shall not exceed one (1) vertical to three (3) horizontal. The entire mound including the tapers shall be covered with six (6) inches of topsoil and seeded to grass. Appropriate curtain drains and diversion ditches shall be constructed uphill from the mound on sloped sites to prevent ground water from interfering with absorption system operation or surface water from entering the mound. Effluent is intermittently spread across the surface of a bed of specified sand (at least 24 inches thick) via perforated distribution lines installed in an upper layer of aggregate. A three (3) inch layer of 1/8 to 1/4 inch diameter washed crushed stone or washed gravel is placed beneath the sand layer and above a layer of 3/4 to 1-1/2 washed aggregate (at least ten (10) inches thick). Perforated collector pipes are installed in the bottom layer of aggregate to collect filtered wastewater for distribution to a subsurface soil absorption area for final treatment. Sand filter effluent shall be discharged to a subsurface absorption facility (to a downstream absorption mound or modified shallow trench system). Intermittent sand filters and downstream absorption systems should only be used on large lots. These systems are not intended for use where the surface soil is impermeable since the absorption system would exhibit continuous weeping. The downstream absorption system may exhibit some weeping of double-filtered wastewater during the wet season.

Laboratory tests should include a presence of constitutional symptoms even with localized disease erectile dysfunction lubricant avana 50 mg amex. Several small case reports have also reported favorable for patients in the high-risk group male erectile dysfunction pills review avana 50mg line. It is recommended that patients with recommended when used alone as primary treatment and 45 to 50 impotence at 43 order avana 100mg on-line. Most of the available data are from were initially partially involved erectile dysfunction treatment options uk discount avana, all adjacent paranasal sinuses what causes erectile dysfunction in males order avana 100mg fast delivery, as well as a 0 erectile dysfunction protocol pdf download free generic avana 100 mg overnight delivery. Pegaspargase-based combination chemotherapy alone may be extranasal disease at presentation and then by the stage of the disease. Recent reports from options for refractory disease with no response to induction therapy. Patients with a positive biopsy should be managed as described below for refractory disease. Diagnostic cues for natural killer cell lymphoma: primary nodal presentation and the role of in situ 3. Blood Cancer J with advanced stage natural killer/T-cell lymphoma: elucidating the effects 2017;7:e608. Extranodal natural killer T-cell lymphoma, nasal-type: a prognostic model from a retrospective 28. Available at: regimen improved prognosis in elderly patients with early-stage extranodal. A prognostic index for natural killer cell lymphoma after non-anthracycline-based treatment: a multicentre, 29. Available at: concurrent chemoradiotherapy for localized nasal natural killer/T-cell. Available at: chemoradiotherapy for localized nasal natural killer/T-cell lymphoma: an. Efficacy and tolerance of pegaspargase, gemcitabine and oxaliplatin with sandwiched radiotherapy 37. Ann Oncol transplantation for extranodal natural killer/T-cell lymphoma, nasal type: a 2003;14:1673-1676. Allogeneic hematopoietic transplantation for natural killer-cell lineage neoplasms. Bone Marrow stem cell transplant following chemotherapy containing l-asparaginase as Transplant 2006;37:425-431. Available at: a promising treatment for patients with relapsed or refractory extranodal. Autologous hematopoietic stem cell transplantation in extranodal natural killer/T cell lymphoma: a 55. Allogeneic hematopoietic stem cell multinational, multicenter, matched controlled study. Biol Blood Marrow transplantation for advanced extranodal natural killer/T-cell lymphoma, Transplant 2008;14:1356-1364. Allogeneic haematopoietic stem cell Factors of Up-Front Autologous Stem Cell Transplantation in Patients with transplantation as a salvage strategy for relapsed or refractory nasal Extranodal Natural Killer/T Cell Lymphoma. Modern radiation therapy for extranodal lymphomas: field and dose guidelines from the International Lymphoma Radiation Oncology Group. Therefore, the choice of terminal method, the handling of ani that the processes and method be respectful, be con mals, and the disposal of animal carcasses should ad ducted with minimal pain and distress to the animal, here to strong ethical standards and procedures and and be informed by species-specifc expertise. Urgency and risk to the public, For example, where the goal is to save as many ani human safety and public health, animal welfare, and mals as possible and protect signifcant public inter environmental factors recommend the use of profes ests by rapidly curtailing the spread of disease, pain sional judgment. The circumstanc light of availability of resources and best outcomes of es surrounding depopulation are unusual and will all considered to judiciously address a crisis situation. The veterinarians primary responsibility is ations affecting the sustainability of animal agriculture, doing what is in animals best interest under emergen the care and management of food animals, and food se cy circumstances (ie, ensuring the most respectful and curity, will infuence the recommendations in this and humane depopulation process possible). These Guidelines represent ence during a crisis situation, personal value commit more than 2 years worth of deliberation by more than ments of veterinarians, their commitment to profes 70 individuals, including veterinarians, animal scien sional codes of conduct, and fnding the best outcome tists, and an animal ethicist. The range of expertise included veteri mals that have been designated for depopulation in narians, nonveterinarians, and experts from animal accordance with clinical standards of care and local, welfare and animal science, emergency management, state, and federal regulatory bodies and to ensure disease control, epidemiology, agricultural engineer a quick and effective depopulation process that re ing, and ethics. Appointments were made by welfare during depopulation, it is important to under the Animal Welfare Committee, and chairs of work stand that public health and safety are priorities and ing groups made up the Panel. Species-specifc information is provided plethora of complicated problems and risks and can for terrestrial and aquatic species. In addition to delineating appropri different affected parties and deserve careful consider ate methods and agents for depopulation, the Guide ation and sensitivity in an emergency situation. Veteri lines recognize the importance of considering and narians take part in a disaster or emergency response applying good predepopulation and animal-handling team to offer clinical expertise in disease control, be practices. Planning gency situations like zoonoses, pandemics, large-scale for preparedness and response is essential to remove feed contamination and natural disasters affect ani barriers that could frustrate a swift and effective de mals, emergency workers, and caregivers of animals population and to ensure that crisis team members and to raise awareness and consider the full range of have adequate training to respond in an emergency. Crisis or depopulation veterinary infrastructure in Interdisciplinary research will enable policy makers, cludes competencies in animal health and welfare, ap crisis management teams, and other stakeholders to propriate knowledge of zoonotic diseases, ability to develop effective strategies to address animal welfare provide crisis standard of care for animals displaced concerns in emergency preparation and response during natural and human-caused disasters, and the plans at local, national, and international levels. Doing so will ensure that concerns and needs and must be able to partner well there is adequate training, equipment, and support with other responders. Good coordination animals and to prevent or limit human injury before between veterinarians, local veterinary medical asso and during depopulation, methods and agents should ciations, emergency preparedness and crisis manage be selected that maintain calm animals. Veterinarians performing or overseeing depopula More importantly, it will enable the timely deployment tion should assess the potential for species-specifc of emergency response plans to reduce suffering and distress secondary to physical discomfort, abnormal deaths of animals. Thoughtful integration of animal facilities, options for carcass disposal, and the poten welfare and husbandry practices within formal policy tial for secondary toxicity. Human safety is of utmost and planning for emergency response for ethical, psy importance, and appropriate safety equipment, pro chological, cultural, economic, and ecological reasons tocols, and expertise must be available before ani are necessitated by our respect for animals and our mals are handled. The publics attachment to or regulatory agencies to apply preferred methods in a special affnity with certain species should be consid timely manner. Using less than ideal methods that re ered when employing a terminal method, as should sult in a quick death for animals and support disease public sentiment to the ways in which carcasses will containment may become necessary. Once an animal has been killed in Decisions to implement alternatives that are not the course of a depopulation, death must be carefully recommended must be made on a case-by-case basis, verifed. Making ethics a priority and basing decisions sponse plans (including rapid diagnosis, decision and regarding the termination of animal lives in disasters risk communication, and management), biosecurity, or emergencies on supporting reasons and evidence depopulation techniques, and facility design should will enhance the professional credibility of veteri occur in normal or ordinary times before an emer narians during these circumstances. Some depopulation methods require physi veterinarians should consider whether 1) the proce cal handling of the animal. Each facility where depopula congruent with euthanasia methods since they involve tion is performed is responsible for appropriately train the mass termination of large populations of animals. Personnel must be suffciently trained to recognize the cessation of vital but be adjusted for situational considerations. Examples of such situations and knowledge of clinically acceptable techniques in include, but are not limited to , structural collapse or selecting a method of depopulation or euthanasia (if compromise of buildings housing animals, large-scale required). Reaching out to colleagues with relevant radiologic events, complete inability to safely access experience may be necessary. The perception of pain is defned as a con scious experience6 and requires nerve impulses from Unconsciousness, and Pain peripheral nociceptors to reach a functioning con these Guidelines acknowledge that a humane ap scious cerebral cortex and the associated subcortical proach to the depopulation of animals is warranted, brain structures. Because loss of conscious fed as being less aversive in some species (eg, Ar in ness resulting from these mechanisms can occur at pigs8 or N gas mixtures) can still produce overt signs 2 different rates, the suitability of a particular agent of behavioral distress (eg, open-mouth breathing) for or method will depend on the species and whether extended periods of time before loss of conscious an animal experiences pain or distress before loss of ness under certain conditions of administration (eg, consciousness. In ani changes in heart rate, sympathetic nervous system mals, loss of consciousness is functionally defned by activity, hypothalamic-pituitary axis activity). Although any physical initiate adaptive responses that are benefcial to the movement occurring during anesthesia, euthanasia, animal. If the cerebral functional the brain regions responsible for cortical cortex is nonfunctional because of physical disrup integration (eg, gunshot, captive bolt, cerebral induc tion, hypoxia, generalized epileptic seizure, or neu tion of epileptiform activity in the brain [eg, electric ronal depression, pain cannot be experienced. Purposeful escape behaviors should not be ob and restraint methods associated with it must be served during the transition to unconsciousness. Clear outcomes should be delineated tress and suffering before loss of consciousness. As regarding mitigation, preparedness, response and best as possible, acceptable husbandry and proper emergency relief, and recovery in an emergency situ handling techniques should be maintained until the ation and the potential impact of depopulation on animals are terminated. Considering the human dimension as with humane standards of care principles and with sociated with depopulation, such as whether veteri minimal stress. Operational procedures should be narians have suffcient training and education in the adapted to the premises and should consider animal area, is important. An effective depopulation plan should include wild, zoos, or aquariums, and provisions regarding a priority system of which animals to depopulate frst animal welfare have not been well considered within or save or spare, training for members in the case of the evacuation plans for their human caregivers. This such a contingency, well-designed communication lack of proper planning and trained individuals can methods, and clear provisions for animals and staff. Rather, it is a shared responsibil tion will alleviate some of the stress of the recovery ity that may involve government agencies, communi period, minimize burnout, and facilitate staff reten ties, businesses, professions, and individuals. Stress counseling is most effective when and transparency in decision-making between all it has been incorporated as part of regular disaster the relevant parties. The cyclic nature of emergen ment of emergency management and depopulation of cies and cross-relation of all four phases confrms that animals should be a signifcant concern if not para planning does not end with the publication of a plan. Effective biosecurity measures and new are constantly being anticipated, reviewed, and im technologies that have the potential to improve the proved. Suffcient planning for the evacuation of and safety, and bolster humane performance of de animals together with their owners is necessary as population procedures. It is also the role of the temperament that does not lead to callousness and lead veterinarian to ensure adherence to mandated abuse. Self-awareness when it comes to mass destruc animal welfare and biosecurity standards, federal and tion of animals will help to mitigate compassion fa state laws, and professional codes of conduct. People may have individual differences to communicate risks to the public (and through in how they psychologically react to the job of killing mass or social media to ensure balanced reporting animals. Every effort lation personnel and the public in general, especially must be made to share the welfare-protection mea if there is any underestimation of the toll of killing sures undertaken. It should also population may result in fear, anxiety, helplessness, include targeted public education and options for the anger, frustration, a sense of defeat, and distrust. Veterinarians are en titudes among the general public and veterinary com couraged to increase their awareness of euthanasia munity toward depopulation of different species of and depopulation methods and to enhance under animals will go a long way in promoting healthier and standing of the science behind the methods current more respectful human-animal relationships. Doing so will help to engender pub Personnel performing depopulation must be techni lic support for a diffcult decision and is an important cally profcient. While public Animal Welfare Principles3) will provide valuable trust and support will likely be bolstered by greater frameworks for planning for animals in emergency transparency regarding the defensibility of method, contexts and ensure that ethical commitments are for example, all members of the public may not desire upheld. The situations can be punctuated by failures in mass or event given impact (local, state or regional, national, electronic communication and disruptions in acces or international) will determine the access. Thus, a depopulation plan must be informed A central component of veterinary ethics in a cri by disposal. All state and federal laws need to be fol sis situation is determining which animals we ought lowed during carcass disposal, and coordination may to care about and how we ought to care about them. An vary in their priorities, interests, and views about the emergency situation that involves depopulation is moral and economic value of animals. The hard decisions certain biological group membership (eg, whether that need to be made during this extraordinary situ a species or individuals are considered nuisances or ation should be based on sound ethical grounding or pests) and disagreement about whether to consider standards. Ethical reasoning cannot be suspended animals interests for their own sake or indirectly or ignored, and it is important that preparation plan in an emergency situation could initially frustrate a ning and response planning for emergency situations crisis management process. For instance, depopula occur within normal times (ie, when there is no ur tion of species with a charismatic appeal can create gency) and be guided by commonly shared moral val public objections regardless of the methods used, ues. In the wake of effective and humane depopulation, since veterinar divergent views of which animals should matter and ians will be challenged to be sensitive to a plurality of how we ought to consider their interests, a general views about the ethical value and killing of animals,37 commitment to animal welfare (eg, that we should be and to address ethical problems and situations that mindful of their capacities, feelings, and functions) affect not only animals, but also the environment and can be a common starting point for ethical and prac a variety of human agents and their value systems. When adjudicating depopulation Depopulation, as a method of containment for and disposal techniques and, more generally, policies effective emergency or disaster management and and actions regarding treatment of animals in a crisis response, should account for human well-being, ani situation, thoughtful consideration should be given to mals and their welfare, and the importance of spe different social, cultural, and emotional human-ani cifc human-animal bonds and relationships. The priorities of reducing tion ahead of time with other crisis team members suffering or saving lives during an emergency situa will likely result in respect and a good outcome. Alongside a nexus of actors and agen Problem-seeing also invites veterinarians and others cies tasked with bringing about the best outcome for to begin refecting on their personal ethical values all those affected, veterinarians may face planning or commitments and to distinguish them from the that is complicated by conficts of duties, scarcity of values of the organizations or constituents that they resources, limited and evolving information, uncer represent. Veterinarians are obliged pro the third step involves considering the context fessionally to protect or promote animal welfare and of the emergency or depopulation, which includes health. Veterinarians expertise in discerning clini benefts and risks associated with the depopulation cally related issues will be important in moving for method or alternative solutions. The diagnosis what is at stake, and can they give consent for the of the situation may involve reducing suffering of in depopulation or alternative responses It may also is not tolerable as well as 8) make transparent lines of include investigating the circumstances surrounding accountability. Clinically related issues intersect with disasters like fooding, fres, or earthquakes on the those involving quality of life/death issues when vet welfare of stranded animals. For example, vet ded in both preparation and response planning to an erinarians may raise the following important consid emergency is an important next step in ethical deci erations: What are the prospects for the animals for sion-making. What that the impacts of response (be it depopulation or physical and mental defcits are the animals likely to not) on animals, human agents such as clients, and the experience if treatment succeeds These principles may refect Besides clinical issues, considering other stake whether, for example, consequences, rights, or vir holders preferences and interests will be key in tues of character are motivating various responses. Thus, it is important to consult other mon principles or values that can be distinguished as potential sources of information. Substan clinical considerations could include whether own tive principles express philosophical and normative ers and caregivers or affected members of the public commitments that emphasize consequences, con or depopulation operators have been informed of straints or conduct. The focus of this approach is future impacts quickly and effciently and to ensure that the best care of an action, for all those who may be affected by is available to those who need it the most, while bal it. Veterinarians who are part of a being can be based on efforts to either ensure nonma crisis response team will beneft from having the sup lefcence (eg, to refrain from doing harm to animals, port of an informed public that is aware of necessary caregivers, or members of the general public) or pro procedures to address the calamity and from making mote benefcence (eg, to do good for others either by the desired outcome transparent. Are actors at various levels; highlight clear indicators of the depopulation outcomes consistent with public success; and delineate lines of responsibility and pro conceptions of justice

They should be stored in such a way as to avoid breakage and scratching of the counting surface erectile dysfunction in diabetes type 1 buy generic avana pills. Performance of the Count the counting chamber is surveyed with the low power objective to ascertain whether the cells are evenly distributed impotence spell buy avana online. Calculation If N is the number of leucocytes in four large squares erectile dysfunction drugs not working order avana on line amex, then the number of cells per mm3 is given by: No impotence and alcohol order genuine avana line. The corrected leucocyte count Nucleated red cells will be counted and can not be distinguished from leucocytes in the total leucocyte count erectile dysfunction statistics uk order discount avana online. If their number is high as seen on the stained smear erectile dysfunction vitamin deficiency order 100 mg avana fast delivery, a correction should be made according to the following formula: 99 Hematology Corrected leucocyte count = Uncorrected count 100 No. Example the blood smear shows 25 nucleated red cells per 100 white cells in the differential count. Using a capillary, Pasteur pipette, or plastic bulb pipette held at an angle of about 450C, fill one of the grids of the chamber with the sample, taking care not to overfill the area. Leave the chamber undisturbed for 2 minutes to allow time for the white cells to settle. Count as described in thomma white cell count method * When a count is higher than 50 x 109/l, repeat the count using 0. Total leucocyte counts are commonly increased in infections and when considered along with the differential leucocyte count can be indicators as to whether the infecting agent is bacterial or viral. Red Cell Count Although red cell counts are of diagnostic value in only a minority of patients suffering from blood diseases, the advent of electronic cell counters has enormously increased the practicability of such counts. Their value, too, has been increased now that they can be done with a degree of accuracy and reproducibility comparable to that for hemoglobin estimation. Although clearly an 104 Hematology obsolete method (because the combined error of dilution and enumeration is high), visual counting will still has to be undertaken for some years to come in the smaller laboratories. Principle A sample of blood is diluted with a diluent that maintains (preserves) the disc-like shape of the red cells and prevents agglutination and the cells are counted in a Neubauer or Burker counting chamber. Diluting Fluid 1% formal citrate Dilution Thomma Red Cell Pipette Take a well mixed blood or blood from a freely flowing capillary puncture to the 0. It is important to count as many cells as possible for the accuracy of the count is increased thereby; 500 cells should be considered as the absolute minimum. Platelet counts are also performed when patients are being treated with cytotoxic drugs or other drugs which may cause thrombocytopenia. Method using formal-citrate red cell diluent Diluent should be prepared using thoroughly clean glassware and fresh distilled water. Then fill a Neubauer counting chamber and allow the platelets to settle for 20 minutes. To prevent drying of the fluid, place the chamber in a petri dish or plastic container on dampened tissue or blotting paper and cover with a lid. Count the number of platelets which will appear as small refractile bodies in the central 1mm2 area with the condenser racked down. If the count is less than 100, it is preferable to repeat the count with a lesser dilution of blood. Method Using Ammonium Oxalate (10g/l; 1%w/v) this diluent causes erythrocyte lysis. Not more than 500ml should be prepared at a time using thoroughly clean glassware and fresh distilled water. The preparation is mixed, the chamber filled and the cells allowed to settle in a similar fashion as Method 1. The cells are counted in 5 small squares in the central 1mm2 of the improved Neubauer counting chamber. Rough estimation of platelet number from a stained blood film Normally there are 10-20 platelets per oil immersion field. Interpretation of platelet counts In health there are about 150-400 x 109 platelets/liter of blood. Platelet counts from capillary blood are usually 111 Hematology lower than from venous blood and are not as reproducible. Principle Blood is diluted with a fluid that causes lysis of erythrocytes and stains eosinophils rendering them readily visible. Diluting Fluid Hinklemans fluid It has the advantage of keeping well at room temperature and not needing filtering before use. Method Make dilution of blood using thomma pipette or tube dilution as described for the white cell count. Reference range 40 440 106/l Interpretation of eosinophil counts Eosinophilia is common in allergic conditions. How do you calculate the number of cells per unit volume of blood after you count the cells in a sample of diluted blood The count is usually performed by visual examination of blood films which are prepared on slides by the wedge technique. For a reliable differential 117 Hematology count the film must not be too thin and the tail of the film should be smooth. This should result in a film in which there is some overlap of the red cells diminishing to separation near the tail and in which the white cells on the body of the film are not too badly shrunken. If the film is too thin or if a rough-edged spreader is used, 50% of the white cells accumulate at the edges and in the tail and gross qualitative irregularity in distribution will be the rule. The polymorphonuclear leucocytes and monocytes predominate at the edges while much of smaller lymphocytes are found in the middle. Methods of Counting Various systems of performing the differential count have been advocated. The problem is to overcome the differences in distribution of the various classes of cells which are probably always present to a small extent even in well made films. Of the three methods indicated underneath for doing the differential count, the lateral strip method appears to be the method of choice because it averages out almost all of the disadvantages of the two other methods. Multiple manual registers or 118 Hematology electronic counters are used for the count. The Longitudinal Strip Method the cells are counted using the X40 dry or X100 oil immersion objectives in a strip running the whole length of the film until 100 cells are counted. If all the cells are counted in such a strip, the differential totals will approximate closely to the true differential count. The Exaggerated Battlement Method In this method, one begins at one edge of the film and counts all cells, advancing inward to one-third the width of the film, then on a line parallel to the edge, then out to the edge, then along the edge for an equal distance before turning inward again. It should be related to the total leucocyte count and the results reported in absolute numbers. The fact that a patient may have 60% polymorphs is of little use itself; he may have 60% of a total leucocyte count of 8. If they are included, they are expressed as a percentage of the total nucleated cell count. Myelocytes and metamyelocytes, if present, are recorded separately from neutrophils. Band (stab) cells are generally counted as neutrophils but it may be useful to record them separately. An increase may point to an inflammatory process even in the absence of an absolute 122 Hematology leucocytosis. The Cook-Arneth Count Arneth attempted to classify the polymorphonuclear neutrophils into groups according to the number of lobes in the nucleus and also according to the shape of the nucleus. The procedure was too cumbersome for routine used and was modified by Cooke, who classified the neutrophils into five classes according to the number of lobes in the nucleus. The lobes can not be said to be separated if the strand of chromatin joining them is too thick. Some workers suggest that the strand must be less than one quarter of the width of the widest part of the lobe. That means if the figures were to be plotted on graph paper, the peak of the graph would move to the left hand side of the normal curve. It occurs in infections since new cells are released into the circulation from the marrow. They are primarily seen in infectious mononucleosis which is an acute, self-limiting infectious disease of the reticuloendothelial tissues, especially the lymphatic tissues. What is the importance reporting the differential leucocyte counts in absolute terms What other elements of the blood film should be evaluated while doing the differential leucocyte count The most immature reticulocytes are those with the largest amount of precipitable material and in the least immature only a few dots or strands are seen. The number of 130 Hematology reticulocytes in the peripheral blood is a fairly accurate reflection of erythropoietic activity assuming that the reticulocytes are released normally from the bone marrow and that they remain in the circulation for the normal period of time. Complete loss of basophilic material probably occurs as a rule in the blood stream after the cells have left the bone marrow. The ripening process is thought to take 2-3 days of which about 24 hours are spent in the circulation. Although reticulocytes are larger than mature red cells and show diffuse basophilic staining (polychromasia) in Romanowsky stained films, only supravital staining techniques enable their number to be determined with sufficient accuracy. Better and more reliable results are obtained with new methylene blue than brilliant cresyl blue as the former stains the reticulo-filamentous material in the reticulocytes more deeply and more uniformly than does the latter. Deliver 2-3 drops of the dye solution into 75 X 10mm glass or plastic tube using a Pasteur pipette. The exact volume of blood to be added to the dye solution for optimal staining depends upon the red cell count. A larger proportion of anemic blood and a smaller proportion polycythemic blood should be added than normal blood. After incubation, resuspend the cells by gentle mixing and make films on glass slides in the usual way. In a successful preparation, the reticulofilamentous material should be stained deep 132 Hematology blue and the non-reticulated cells stained diffuse shades of pale greenish blue. Counting An area of the film should be chosen for the count where the cells are undistorted and where the staining is good. To count the cells, the oil immersion objective and if possible eye pieces provided with an adjustable diaphragm are used. If such eyepieces are not available, a paper or cardboard diaphragm in the center of which has been cut a small square with sides about 4mm in length can be inserted into an eyepiece and used as a substitute. The counting procedure should be appropriate to the number of reticulocytes as estimated on the stained blood film. Very large numbers of cells have to be surveyed if a reasonably accurate count is to be obtained when the reticulocyte number is small. When the reticulocyte count is expected to be 10% a total of 500 red cells should be counted noting the number of reticulocytes. If less than 10% reticulocytes are expected, at least 1000 red cells should be counted. This is an eyepiece giving a square field in the corner of which is a second ruled square one-ninth of the area of the total square. Reticulocytes are counted in the large square and red cells in the small square in successive fields until at least 300 red cells are counted. For example, a reticulocyte 135 Hematology percentage of 10% in a patient with a hematocrit of 0. This is equivalent to calculating the absolute reticulocyte count in terms of red cell number. Another correction is made because erythropoietin production in response to anemia leads to premature release of newly formed reticulocytes and these stress reticulocytes take up to two days rather than one to mature into adult erythrocytes. In hemolytic anemia with excessive destruction of red cells in the peripheral blood in a functionally normal marrow, this index may be 3-7 times higher than normal. Identifying reticulocytosis may lead to the recognition of an otherwise occult disease such as hidden chronic hemorrhage or unrecognized hemolysis. Fox example, after doses of iron in iron deficiency anemia where the reticulocyte count may exceed 20%; Proportional increase when pernicious anemia is treated by transfusion or vitamin B12 therapy. Decreased levels this means that the bone marrow is not producing enough erythrocytes. A decrease in the reticulocyte number is seen in iron deficiency anemia, aplastic anemia, radiation therapy, untreated pernicious anemia, tumor in marrow. How could the number of reticulocytes in the peripheral blood be a fairly accurate reflection of erythropoietic activity in the bone marrow

Angiogenesis Inhibitors in Cancer Therapy: Mechanistic perspective on classification and treatment rationales erectile dysfunction drugs and melanoma generic avana 200 mg visa. The ketogenic diet reverses gene expression patterns and reduces reactive oxygen species levels when used as an adjuvant therapy for glioma impotence blood circulation cheap avana 100 mg. The ketogenic diet is an effective adjuvant to radiation therapy for the treatment of malignant glioma what food causes erectile dysfunction order avana 50mg without prescription. The ketogenic diet potentiates radiation therapy in a mouse model of glioma: effects on inflammatory pathways and reactive oxygen species erectile dysfunction pills generic order avana with mastercard. A decade of exploring the cancer epigenome biological and translational implications erectile dysfunction devices order cheap avana. Suppression of oxidative stress by beta-hydroxybutyrate erectile dysfunction support groups purchase on line avana, an endogenous histone deacetylase inhibitor. Fasting cycles retard growth of tumors and sensitize a range of cancer cell types to chemotherapy. Mechanistic studies of the ketogenic diet as an adjuvant therapy for malignant gliomas. Ketogenic Diets Enhance Oxidative Stress and Radio-Chemo-Therapy Responses in Lung Cancer Xenografts. Starvation-dependent differential stress resistance protects normal but not cancer cells against high-dose chemotherapy. Is the restricted ketogenic diet a viable alternative to the standard of care for managing malignant brain cancer Drug/diet synergy for managing malignant astrocytoma in mice: 2-deoxy-D-glucose and the restricted ketogenic diet. The ketogenic diet and hyperbaric oxygen therapy prolong survival in mice with systemic metastatic cancer. Effects of a ketogenic diet on tumor metabolism and nutritional status in pediatric oncology patients: two case reports. Metabolic management of glioblastoma multiforme using standard therapy together with a restricted ketogenic diet: Case Report. Effects of a ketogenic diet on the quality of life in 16 patients with advanced cancer: A pilot trial. Long-term ketogenic diet causes glucose intolerance and reduced beta and alpha cell mass but no weight loss in mice. The impact of the ketogenic diet on arterial morphology and endothelial function in children and young adults with epilepsy: A case-control study. When I was a student, I drifted away from science and math, preferring instead subjects I considered less demanding. After a brief career suing people (never a doctor, though), I stumbled upon fiction and wrote a couple of books. Because the books have done well, I have been lucky enough to dabble in philanthropy. Once you get the reputation of being generous, a lot of opportunities present themselves. Seven years ago, my friend and neighbor, Neal Kassell, gave a PowerPoint presentation on focused ultrasound therapy. Neal is a prominent neurosurgeon whos spent his career drilling through skulls and making repairs to brains. During the PowerPoint, Neal, with great enthusiasm, explained that focused ultrasound therapy could one day alleviate the need for conventional brain surgery. Tumors would be destroyed using beams of ultrasound energy, and afterward the patient would walk out of the operating room and go home. Not only would the treatment be non-invasive, painless, quick, and relatively inexpensive, it could also save the patients life. Focused ultrasound therapy is still in its early stages, still experimental, but there is enough research to date to be very optimistic. Tumors in the breast, prostate, pancreas, liver, kidneys, and bones could be treated on an out-patient basis. Neal loves to use the example of a man with prostate cancer undergoing focused ultrasound therapy, then driving himself back to the office for a few hours. Around the world, more than 70,000 men with prostate cancer have been treated with focused ultrasound. Nearly 100,000 women with uterine fibroids (benign tumors of the uterus) have been treated, thus avoiding hysterectomies and infertility. Clinical trials for tumors of the brain, breast, pancreas, and liver, as well as Parkinsons disease and arthritis, are inching forward at over 360 research sites around the world. Though focused ultrasound technology is in its infancy, there is great enthusiasm for its potential to improve quality of life and decrease cost of care. For this potential, to be fully demonstrated, additional laboratory research and clinical trials are necessary. There are barriers from regulators, insurance companies, even many in the medical field. I have found no other cause, issue, non-profit, or charity that can potentially save so many lives. One day in the not-too-distant future, you or someone you love will be diagnosed with a tumor. Paul gets a complete physical once a year, jogs twenty miles a week, plays golf and tennis at a nearby club, and avoids extra pounds. He has a tumor in the right frontal lobe of his brain, about the size of a hens egg. Looking back, the first symptom was a gradual decrease in his ability to concentrate at work. Naturally curious and active, he noticed an uncharacteristic tendency to procrastinate. On a Wednesday morning, as Paul is in the bathroom shaving, Karen hears a loud thump. In the emergency room, he is still drowsy and confused and complains of weakness on his left side. Upon examination, his left hand is very weak and he has difficulty lifting his left arm and leg. He is admitted to the hospital and started on anticonvulsant medication to prevent further seizures, as well as steroids to decrease the swelling in his brain around the tumor. The doctor explains that Paul indeed has a tumor in his brain and it appears to be the type known as a glioma. Surgery is needed to remove as much of it as possible and to obtain tissue to determine the type of tumor. The surgery will take about three hours, and if all goes well, Paul can expect to go home in three days. Left untreated but managed with pain medication only, the patient can expect to live several months. About 22,000 Americans are diagnosed each year with glioblastomas; 15,000 die within 12 months. After the doctor leaves, Paul and Karen attempt to come to grips with whats happening. They like their neurosurgeon and a quick search online proves hes one of the best. She refuses to believe the tumor is malignant and is convinced the surgery will go well. She spends hours online gathering frightening and depressing information about brain tumors. At 6:30, Paul is prepped for surgery and two orderlies arrive with a gurney for the short ride to the operating room. As they settle in for a long morning, the room begins to fill with other anxious families. A question-mark-shaped incision is made from the midpoint of his forehead just below the hairline to a point in front of his right ear. Burr holes are made in the skull, and a power saw is used to fashion a bone flap more or less like the top of a cookie jar (fig. The surface of the frontal lobe is 1 discolored and distorted because of the tumor. Under the magnification of an operating microscope, an incision is made into the brain, and just beneath this the abnormal tissue is identified. A portion is cut out and sent to the pathology lab for a preliminary diagnosis (fig. The tumor is removed by suction and the bleeding is controlled with coagulation (fig. Early Monday evening, Paul and Karen meet with the neurosurgeon, who has a preliminary pathology report; the final one is a few days away. As for the weakness in Pauls left side, the doctor says it is undoubtedly the result of surgical manipulations and should get better. Paul is able to lift his arm but movements of his fingers are slow and his grip is weak. She tells him that a lot of friends are eager to stop by for a visit, but he says no. Early Wednesday morning, one week after his seizure, they meet again with the neurosurgeon. Although the tumor has been removed, it left behind microscopic portions that extend into the normal brain and cannot be surgically removed. These remnants of the tumor will almost certainly regrow, and must be treated with radiation and chemotherapy. With as much professional sympathy as possible, the doctor tells them that, according to statistics, Paul can expect to live 12 to 14 months. He describes radiation therapy and explains that it will be administered five days a week for the next six weeks. Among other side effects, Paul will lose his hair and his face will swell and become disfigured from the steroids hell be given. Later, the neuro-oncologist stops by and they discuss chemotherapy, which has its own set of unpleasant side effects. Later, alone and in a dark room, Paul opens his laptop and pulls up a calendar for the next 12 months. Its all there, all planned: the school year, their upcoming vacation, the holidays and birthdays, a golfing trip with his friends, several business trips, his parents 40th anniversary. Later that afternoon, he is transferred to a rehabilitation facility to address the weakness in his left side. Two weeks after surgery, Karen drives him to the office where hes greeted like a hero. He is determined to work at least half a day until he regains his strength, and he assures his colleagues hell be back. His hair falls out rapidly from the radiation and, worse, his face begins to swell from the steroids (opposite). He is constantly fatigued, and his thinking becomes slow and dull from the damage to his brain caused by the radiation. His neurosurgeon offers the option of another surgery to remove the recurrent tumor. The visible portions of the tumor are removed, and Pauls skull is put back together. He bravely accepts the fact that his days are numbered, and he wishes to say farewell on his terms. In a heart-wrenching scene, he and Karen finally tell the children that their father is about to leave them. Hes left with only some powerful narcotics to deaden the horrible headaches, which occur with increasing severity. Karen sleepwalks through the days and nights, thoroughly drained, but trying gamely to shield his condition from the children as much as possible. Eight months after his seizure, Paul has completely checked out, but his heart still manages to beat. Had he been born in 1990 and diagnosed with a brain tumor at the age of 35, in 2025, his story could be rewritten as follows: That same Wednesday morning, Karen hears a crash in the bathroom, and she finds Paul on the floor in a grand mal seizure. Based on the scan, the neurosurgeon, with virtual certainty, makes a diagnosis of a glioblastoma and explains the prognosis and the treatment options, including focused ultrasound therapy. The size and location of Pauls tumor make it amenable to treatment with focused ultrasound therapy, which is what the neurosurgeon recommends. He explains that the tumor in all probability cannot be cured and will return, but it can be controlled with repeated treatment, giving Paul additional years with a high quality of life. Opposite, the focused ultrasound brain transducer fits over the head and emits beams of energy that penetrate the skull to target a tumor. He changes into a gown, takes a light sedative, and is positioned on his back on a table.

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