Dan E. Berkowitz, MD

• Professor, Department of Anesthesiology and Critical Care Medicine
• Professor, Department of Biomedical Engineering
• Johns Hopkins Medicine
• Baltimore, Maryland

The three leading causes of cancer death are lung (27%) spasms meaning in english cheap rumalaya liniment 60 ml on-line, liver (14%) spasms with broken ribs cheap rumalaya liniment 60ml on-line, and colorectum (11%) among males spasms in your sleep purchase discount rumalaya liniment, and lung (21%) spasms lower left side discount rumalaya liniment 60ml without prescription, breast (14%) spasms brain rumalaya liniment 60ml, and colorectum (11%) among females spasms or twitches 60 ml rumalaya liniment fast delivery. As a result, comparisons of survival between racial/ethnic groups should be interpreted with caution. First, data are limited for racial and ethnic subpopulations, so many statistics are presented for Asian Americans, Native Hawaiians, and Pacific Islanders in aggregate, masking important differences within this heterogeneous group. Second, much of the demographic information in health records, such as place of birth and racial/ethnic identity, is often incorrect or incomplete for minority patients. This can occur when information is assigned by a health care worker instead of obtained directly from the patient or their family. The resulting misclassification leads to inaccurate, often underestimated cancer rates. Third, there are challenges when calculating statistics for racial/ ethnic subgroups, especially those that are rapidly growing and changing. For example, population size, which is necessary for computing rates, is often difficult to estimate. For information on data sources and methodology, please see Sources of Statistics on page 64. These differences are thought to be related to extent of adoption of western behaviors that increase breast cancer risk, such as a later age at childbirth, fewer births, and higher body weight. This may be attributable to exposure to cooking oils at high heat, secondhand smoke, genetic susceptibility, or other unknown risk factors. Estimates are rounded to the nearest 10, and cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. All sites excludes basal and squamous cell skin cancers and in situ cancers except urinary bladder. These declines are attributed to early detection and improvements in treatment, although the relative contribution of each is debated. The percentage of cancers attributable to infection in Asia ranges from 17% in central Asia to 26% in China, compared to 4% in North America. For example, a California study documented increasing colorectal cancer incidence rates in Koreans, Filipinos, and South Asians between 1988 and 2007. Stomach cancer rates in Korea are the highest in the world for both males and females. The reasons for the elevated rates in Filipinos are not well understood, but are thought to include dietary or environmental factors. However, national trends do not necessarily reflect those among specific groups or localities. For instance, there was no decline in smoking among Asian males in New York City from 2002 to 2010. Moderate: 12+ drinks in lifetime and (male) 3-14 drinks/week in past year or (female) 3-7 drinks/ week in past year. Heavy: 12+ drinks in lifetime and (male) >14 drinks/week in past year or (female) >7 drinks/week in past year. Aerobic activity recommendations: includes 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity each week. Source: 1990-2013: Health, United States, 2014: With Special Feature on Adults Aged 55-64. In addition, screening for colorectal, cervical, and breast cancer can detect cancers at an earlier stage when more treatment options are available. Please see page 66 for screening recommendations for people at average cancer risk. Either a fecal occult blood test within the past year, sigmoidoscopy within the past five years, or a colonoscopy within the past 10 years. Note: Percentages for cancer screening hepatitis testing are age adjusted to the 2000 U. Notably, this disparity is almost entirely driven by the low screening rate among Asian American women. Among Native Hawaiians in Hawaii, 8% were uninsured and 16% had no regular source of medical care. Influence of American acculturation on cigarette smoking behaviors among Asian American subpopulations in California. Immigration and generational trends in body mass index and obesity in the United States: results of the National Latino and Asian American Survey, 2002-2003. The role of medical interpretation on breast and cervical cancer screening among Asian American and Pacific Islander women. Cancer research in Asian American, Native Hawaiian, and Pacific Islander populations: accelerating cancer knowledge by acknowledging and leveraging heterogeneity. Tufts University Selected Patient Information Resources in Asian Languages: spiral. Recent trends in breast cancer incidence among 6 Asian groups in the Greater Bay Area of Northern California. Hidden breast cancer disparities in Asian women: disaggregating incidence rates by ethnicity and migrant status. Female breast cancer incidence among Asian and Western populations: more similar than expected. Asian American women in California: a pooled analysis of predictors for breast and cervical cancer screening. Disparities in breast cancer survival among Asian women by ethnicity and immigrant status: a population-based study. Comparative analysis of clinicopathologic features, treatment, and survival of Asian women with a breast cancer diagnosis residing in the United States. Asian ethnicity and breast cancer subtypes: a study from the California Cancer Registry. Deaths Due to Cigarette Smoking for 12 Smoking-Related Cancers in the United States. Adult tobacco use among racial and ethnic groups living in the United States, 2002-2005. Cancer incidence, mortality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. Lung cancer incidence trends by histology type among Asian American, Native Hawaiian, and Pacific Islander populations in the United States, 1990-2010. Cancer-specific mortality of Asian Americans diagnosed with cancer: a nationwide populationbased assessment. Colorectal cancer incidence in Asian populations in California: effect of nativity and neighborhoodlevel factors. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Going against the tide: increasing incidence of colorectal cancer among Koreans, Filipinos, and South Asians in California, 1988-2007. Longitudinal, population-based study of racial/ethnic differences in colorectal cancer survival: impact of neighborhood socioeconomic status, treatment and comorbidity. Global burden of cancers attributable to infections in 2008: a review and synthetic analysis. Cancer incidence and mortality patterns among specific Asian and Pacific Islander populations in the U. Chronic hepatitis B and liver cancer risks among Asian immigrants in New York City: Results from a large, community-based screening, evaluation, and treatment program. Changing hepatocellular carcinoma incidence and liver cancer mortality rates in the United States. Survival differences by race/ethnicity and treatment for localized hepatocellular carcinoma within the United States. Racial differences in survival of hepatocellular carcinoma in the United States: a population-based study. Thyroid cancer incidence attributable to overdiagnosis in the United States 1981-2011. Benign and Malignant Thyroid Incidentalomas Are Rare in Routine Clinical Practice: A Review of 97,908 Imaging Studies. Continued rapid increase in thyroid cancer incidence in california: trends by patient, tumor, and neighborhood characteristics. Cervical human papillomavirus prevalence in 5 continents: meta-analysis of 1 million women with normal cytological findings. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. Cervical cancer incidence among 6 asian ethnic groups in the United States, 1996 through 2004. Cancer Incidence Trends Among Asian American Populations in the United States, 1990 to 2008. Trends in the incidence rates of nasopharyngeal carcinoma among Chinese Americans living in Los Angeles County and the San Francisco metropolitan area, 1992-2002. Secular trends of nasopharyngeal carcinoma incidence in Singapore, Hong Kong and Los Angeles Chinese populations, 1973-1997. What proportion of cancer deaths in the contemporary United States is attributable to cigarette smoking Cancer preventability estimates for food, nutrition, body fatness, and physical activity. Smoking among Asian Americans: acculturation and gender in the context of tobacco control policies in New York City. Appropriate bodymass index for Asian populations and its implications for policy and intervention strategies. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Body-mass index and cancer mortality in the Asia-Pacific Cohort Studies Collaboration: pooled analyses of 424,519 participants. Association between bodymass index and risk of death in more than 1 million Asians. Dramatic increases in obesity and overweight prevalence and body mass index among ethnic-immigrant and social class groups in the United States, 1976-2008. Obesogenic Dietary Practices of Latino and Asian Subgroups of Children in California: An Analysis of the California Health Interview Survey, 2007-2012. Seroprevalence and ethnic differences in Helicobacter pylori infection among adults in the United States. The incidence of gastric carcinoma in Asian migrants to the United States and their descendants. Global Epidemiology of Hepatocellular Carcinoma: An Emphasis on Demographic and Regional Variability. Final recommendation statement: Hepatitis B, nonpregnant adolescents and adults: Screening, May 2014. Global burden of hepatitis C: considerations for healthcare providers in the United States. Hepatitis C testing, infection, and linkage to care among racial and ethnic minorities in the United States, 2009-2010. Hepatitis C-related hepatocellular carcinoma in the United States: influence of ethnic status. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. Prevention of hepatocellular carcinoma in chronic viral hepatitis B and C infection. Human papillomavirus infection and cervical cytology in women screened for cervical cancer in the United States, 2003-2005. Understanding suboptimal human papillomavirus vaccine uptake among ethnic minority girls. Ethnic differences and predictors of colonoscopy, prostate-specific antigen, and mammography screening participation in the multiethnic cohort. Each year, cigarette smoking results in an estimated 480,000 premature deaths, 42,000 of which are due to secondhand smoke exposure. As of 2014, there was a 2 percentage point difference in smoking prevalence between white men (19%) and women (17%), a 9 percentage point difference between non-Hispanic black men (23%) and women (14%), a 7 percentage point difference between Hispanic men (15%) and women (8%), and a 9 percentage point difference between Asian men (14%) and women (5%). In 2014, smoking prevalence was 23% among adults 25 years and older with less than a high school diploma and 5% among those with graduate degrees. However, this progress differs by subgroup, and poor individuals remain substantially more likely to be exposed than those who are more affluent. Regular cigar smoking is associated with an increased risk of cancers of the lung, oral cavity, larynx, esophagus, and probably pancreas. Some studies have shown lower levels of toxic chemicals in aerosol from e-cigarette products than in smoke from combustible cigarettes, and e-cigarettes are promoted as a less harmful alternative to traditional cigarettes and a way to bypass smoke-free laws. However, the long-term health risks of using these products, or being exposed to them secondhand, are unknown and likely vary depending on the specific e-cigarette product and how it is used. While the health risks of e-cigarettes are not fully known, there is growing concern that e-cigarette use will normalize cigarette smoking and lead to the use of other forms of tobacco products with known health risks. Indeed, a recent study indicates that adolescent e-cigarette users are much more likely to initiate cigarette, cigar, or hookah smoking than nonusers. E-cigarettes have been gaining in popularity, particularly among high school students. In addition, there is strong evidence that smoke-free policies decrease the prevalence of both adult and youth smoking.

Patients usually have painful vaginal bleeding with uterine contraction and tenderness muscle relaxant used for migraines quality rumalaya liniment 60ml. Estimated blood loss may be underestimated because it may be concealed inside the uterus muscle relaxant gi tract buy discount rumalaya liniment 60ml. Severe abruption is a life-threatening emergency that requires an emergency cesarean section and typically massive blood transfusion spasms upper back quality rumalaya liniment 60 ml, including replacement of coagulation factors and platelets muscle relaxant voltaren cheap rumalaya liniment 60ml on line. Uterine rupture: Also in the differential diagnosis and can occur during labor as a result of (1) dehiscence of a scar from a previous (usually classic) cesarean section spasms left side under rib cage buy generic rumalaya liniment on-line, extensive myomectomy spasms pelvic floor purchase 60 ml rumalaya liniment with mastercard, or uterine reconstruction; (2) intrauterine manipulations or use of forceps (iatrogenic); or (3) spontaneous rupture after prolonged labor in patients with hypertonic contractions (particularly with oxytocin infusions), fetopelvic disproportion, or a very large, thin, and weakened uterus. It can present as frank hemorrhage, fetal distress, loss of uterine tone, or hypotension with occult bleeding into the abdomen. Even when epidural anesthesia is utilized for labor, uterine rupture is often heralded by the abrupt onset of continuous abdominal pain and hypotension. Ligation of the internal iliac arteries, with or without hysterectomy, may be necessary. Risk factors include prior cesarean section or uterine myomectomy, multiparity, advanced maternal age, or a large placenta. It is usually initially confined to the T11 to T12 dermatomes during the latent phase but involves the T10 to L1 dermatomes as the active phase begins. Perineal pain signals the beginning of fetal descent and the second stage of labor. Lumbar epidural: Concerns about increasing the likelihood of oxytocin augmentation, operative delivery, or cesarean sections are unjustified, and in the setting of an emergency cesarean section, an epidural may make it possible to avoid general anesthesia. Use of dilute concentrations of local anesthetics generally does not lead to a motor blockade (typically bupivacaine or ropivacaine with either fentanyl or sufentanil is used). Optimal placement is at the L3 to L4 or L4 to L5 interspace to achieve a T10 to S5 neural blockade. A multiorificed epidural catheter is ideal; it is associated with fewer unilateral blocks and reduces the incidence of falsenegative aspiration for intravascular placement. Air or sterile water may be used to test for loss of resistance; large amounts of air may lead to patchy or unilateral analgesia and headache. If unintentional dural puncture occurs, either the catheter can be placed into the subarachnoid space or the needle can be removed and replaced at a higher level. Intrathecal opioid and local anesthetic are injected, and an epidural catheter is left in place. The risk of advancing the epidural catheter into the dural hole is negligible; however, the epidural catheter should be aspirated carefully, and drugs should be given in small doses to avoid unintentional intrathecal injections. When spinal or epidural opioids are used alone, high doses must be given to provide adequate analgesia during labor, placing the patient at higher risk for respiratory depression. Pure spinal opioids are most useful if the patient will not tolerate a sympathectomy. With the exception of meperidine, spinal opioids do not cause a motor blockade or hypotension. Possible complications include intravascular injection, retroperitoneal hematoma, and retropsoas or subgluteal abscess. Paracervical blocks are not performed because they are associated with a high risk of fetal bradycardia; the close proximity of the injection site may lead to uterine artery vasoconstriction, uteroplacental insufficiency, and high amounts of local anesthetic in the fetal blood. Caudal injection: Not often performed in obstetrics because it is limited mostly to coverage of perineal analgesia, requires high volumes of local anesthetic, and may cause early paralysis of the pelvic muscles, and the injection carries a small risk of puncture of the fetus. Fetal monitoring may detect fetal distress, requiring correction of maternal hypotension, providing supplemental oxygen, or decreasing uterine contractions. Sustained decreased baseline variability is a prominent sign of fetal asphyxia, but it can also be decreased by central nervous system depressants, parasympatholytics, prematurity, fetal dysrhythmias, and anencephaly. A sinusoidal pattern that resembles a smooth sine wave is associated with fetal depression (hypoxia, drugs, and anemia secondary to Rh isoimmunization). Accelerations decrease with fetal sleep, some drugs (opioids, magnesium, and atropine), and fetal hypoxia. Early (type I) decelerations: Thought to be secondary to a vagal response during compression of the fetal head or stretching of the neck with uterine contractions. Early decelerations are usually not associated with fetal distress and occur during descent of the head. One-minute Apgar scores of 5 to 7 usually require only stimulation and 100% oxygen blown across the face. Scores of 3 to 4 require assisted positive-pressure ventilation with mask and bag. Neonates with scores of 0 to 2 should be immediately intubated, and chest compressions may be required. Sign Heart rate (beats/ m in) Respiration Muscle tone Reflexes Color 0 Po in ts Absent Absent Flaccid No response Blue or pale 1 Po in t <100 Slow, irregular Som e flexion Grim ace Body pink; extrem ities blue 2 Po in ts >100 Good, crying Active m otion Crying All pink Meconium-stained neonates: Unless the neonate has absent or depressed respirations, thin, watery meconium does not require suctioning beyond careful bulb suctioning of the oropharynx. When thick meconium is present in the amniotic fluid, however, some clinicians intubate and suction the trachea immediately after delivery but before the first breath is taken. If the baby is not vigorous, tracheal suctioning is recommended when meconium is present. Differential diagnosis: the most common cause of neonatal depression is intrauterine asphyxia; therefore, the emphasis in resuscitation is on respiration. Hypovolemia may also occur as a result of early clamping of the umbilical cord, holding the neonate above the introitus before clamping, prematurity, maternal hemorrhage, placental transection during cesarean section, sepsis, and twin-to-twin transfusion. Also consider pneumothorax, congenital anomalies of the airway, and congenital diaphragmatic hernia. Assisted ventilation with a bag and mask should be at a rate of 30 to 60 breaths/min with 100% oxygen. If after 30 seconds the heart rate is above 100 beats/min and spontaneous ventilation becomes adequate, assisted ventilation is no longer necessary. If the heart rate is below 60 beats/min or is 60 to 80 beats/min and not rising, the neonate is intubated and chest compressions are started. If the heart rate is 60 to 80 beats/min and rising, assisted ventilation is continued, and the neonate is observed. If the heart rate does not rise above 80 beats/min, chest compressions should be performed. Chest compressions: Indications for chest compressions are heart rate below 60 beats/min or 60 to 80 beats/min and not rising after 30 seconds of adequate ventilation with 100% of oxygen. They should be provided at a rate of 120/min, and the two-thumb encircling hands technique is preferred. The depth of compressions should be one third of the anterior-posterior diameter of the chest and enough to generate a palpable pulse. Compressions should be interposed with ventilation in a 3:1 ratio, such that 90 compressions and 30 ventilations are given per minute. If can also be given down the endotracheal tube if venous access is not available. The risk of morbidity in pediatric anesthesia is generally inversely proportional to age. Fewer, smaller airways and alveoli result in reduced lung compliance, increased airway resistance, and increased work of breathing. A cartilaginous ribcage increases chest wall compliance, promoting collapse during inspiration and low residual lung volumes at expiration, limiting O2 reserve during apneic periods and predisposing neonates and infants to atelectasis and hypoxemia. Respiratory rate is increased in neonates and falls to adult values by adolescence. Tidal volume and dead space per kilogram remain nearly constant during development. Airway anatomy: Neonates and infants have proportionately larger heads and tongues, narrower nasal passages, anterior and cephalad larynxes (glottis is at a C4 vertebral level vs. The cricoid cartilage is the narrowest point of the airway in children younger than 5 years of age; in adults, the narrowest point is the glottis. Although basal heart rate is greater than in adults, activation of the parasympathetic nervous system, anesthetic overdose, or hypoxia can quickly trigger bradycardia and profound reductions in cardiac output. Sick infants undergoing emergency or prolonged surgical procedures are particularly prone to episodes of bradycardia that can lead to hypotension, asystole, and intraoperative death. The sympathetic nervous system and baroreceptor reflexes are immature, and the infant cardiovascular system displays a blunted response to exogenous catecholamines. The immature heart is more sensitive to depression by volatile anesthetics and to opioid-induced bradycardia. The vascular tree is less able to respond to hypovolemia with compensatory vasoconstriction. Intravascular volume depletion in neonates and infants may manifest as hypotension without tachycardia. Normal ranges may include measurements that deviate from these as much as 25% to 50%. Premature neonates often have multiple forms of renal deficiency, including decreased creatinine clearance; impaired sodium retention, impaired glucose excretion, and impaired bicarbonate reabsorption; and reduced diluting and concentrating ability. These abnormalities underscore the importance of appropriate fluid administration in the early days of life. Anatomic and Physiological Development: Glucose Homeostasis Neonates have relatively reduced glycogen stores that predispose them to hypoglycemia. The neonates at greatest risk for hypoglycemia are premature or small for gestational age, receiving hyperalimentation, or born to mothers with diabetes. Pharmacologic Differences Pediatric drug dosing is typically adjusted on a per-kilogram basis. The blood/gas coefficients of volatile agents are lower in neonates than in adults, contributing to faster induction times and potentially increasing the risk of accidental overdose. This clinical observation has been attributed to immature compensatory mechanisms. Airway irritation: Halothane and sevoflurane are less likely to irritate the airway or cause breath holding or laryngospasm during induction than other volatile agents. Respiratory depression: In general, volatile anesthetics appear to depress ventilation more in infants than in older children. Emergence delirium: Emergence is fastest after use of desflurane or sevoflurane, but both agents are associated with a greater incidence of agitation or delirium upon emergence, particularly in young children. Because of the latter, some clinicians switch to isoflurane for maintenance of anesthesia after a sevoflurane induction. Sevoflurane: There are no reported instances of renal toxicity attributed to inorganic fluoride production during sevoflurane anesthesia in children. Overall, sevoflurane appears to have a greater therapeutic index than halothane and has become the preferred agent for inhaled induction in pediatric anesthesia. Children have a shorter elimination half-life and higher plasma clearance for propofol. Although recovery from a single bolus is not noticeably different from that in adults, recovery after a continuous infusion may be more rapid. Children may require increased weight-adjusted rates of infusion for maintenance of anesthesia. Propofol is not recommended for prolonged sedation of critically ill pediatric patients because of an association with greater mortality than other agents. Its features include rhabdomyolysis, metabolic acidosis, hemodynamic instability, hepatomegaly, and multiorgan failure. Opioids: Opioids appear to be more potent in neonates than in older children and adults. Sufentanil, alfentanil, remifentanil and (possibly) fentanyl clearances may be greater in children than in adults. Ketamine: Neonates and infants may be more resistant to the hypnotic effects of ketamine, requiring slightly higher doses than adults (but the "differences" are within the range of error in studies); pharmacokinetic values do not significantly differ from those of adults. Midazolam: Midazolam has the fastest clearance of all the benzodiazepines; however, midazolam clearance is significantly reduced in neonates compared with older children. With the exclusion of succinylcholine and possibly cisatracurium, infants require significantly smaller muscle relaxant doses than older children. Variable response to nondepolarizing muscle relaxants: the response of neonates to nondepolarizing muscle relaxants is variable. The explanations for this include "immaturity of the neuromuscular junction (in premature neonates) tending to increase sensitivity" (unproven) and a disproportionately larger extracellular compartment reducing drug concentrations (proven). The relative immaturity of neonatal hepatic function prolongs the duration of action for drugs that depend primarily on hepatic metabolism. When a child experiences cardiac arrest after succinylcholine administration, immediate treatment for hyperkalemia should be instituted. For this reason, succinylcholine is avoided for routine, elective paralysis for intubation in children and adolescents. Unlike adults, children may have profound bradycardia and sinus node arrest after the first dose of succinylcholine without atropine pretreatment. Some clinicians advocate midline intralingual succinylcholine (2 mg/kg) as an emergency route. Atracurium and cisatracurium: Atracurium and cisatracurium may be preferred in young infants, particularly for short procedures, because these drugs consistently display short to intermediate durations. Approximately 6% children had permanent injury, but the majority (68%) had either no or an only temporary injury.

A Risk Group 4 pathogen is one that usually causes serious human or animal disease and that can be readily transmitted from one individual to another muscle relaxant id purchase rumalaya liniment 60ml with mastercard, directly or indirectly muscle relaxant for bruxism buy rumalaya liniment 60ml with mastercard, and for which effective treatments and preventive measures are not usually available muscle relaxant 5658 buy rumalaya liniment overnight delivery. Follow the procedures below when mailing Category B substances iphone 5 spasms proven rumalaya liniment 60 ml, exempt patient specimens and non-regulated items spasms piriformis buy rumalaya liniment 60 ml with mastercard. Quantity limits and form of substance (liquid or solid) determine the packaging requirements for nonregulated materials muscle relaxant yoga generic rumalaya liniment 60ml without a prescription. Medical or clinical equipment and laboratory products may be transported aboard the same vehicle provided they are properly packaged and secured against exposure or contamination. Note, in order for the vehicle to be "dedicated," the vehicle can not be utilized for other purposes at the same time. Although no specific packing instructions are required by law, packages should be prepared in accordance with the packaging guidelines outlined in Section 10. All those transporting materials must be licensed drivers and comply with all applicable driving laws and accepted safety standards. Biological materials should not be transported in any area where food/beverages are transported and these areas should be fully decontaminated prior to transport of food/beverages. Packages with dry ice or liquid nitrogen should never be transported in the passenger compartment of the vehicle due to the suffocation hazards (see Section 10. Any material transported in an open truck must be secured to prevent loss via jostling of the vehicle during transport. Transport via privately-owned vehicle is discouraged as many private insurance companies do not cover this activity. Check with your insurance company to verify the terms of your policy prior to transport. Medical College of Georgia 10-33 Biosafety Guide- June 2008 Appendix A: Biosafety Protocol Application Forms Avialable in fillable *. This can be done either by simply updating the appropriate form or schedule and re-submitting those pages to the Biosafety Office or you may fully detail the amendment in an email to the Biosafety Office. If you have any questions, please contact the Biosafety Officer at (706) 721-2663 or kraemers@mcg. These are a list of rules and procexpected to be followed by those working in your laboratory, and therefore should address the specific hazards and risks in your laboratory. Principal Investigators bear responsibility for ensuring that all research personnel understand and comply with these rules at all times. This form should be completed and answered accurately to reflect the situation in the laboratory. Certificates for Dangerous Goods Transport Training (if applicable) If you intend to ship or transport to/from campus any biological material, including diagnostic specimens, cells, tissues, infectious substances, genetically modified organisms, toxins of biological origin or anything on dry ice or in liquid nitrogen, you will need to include a copy of the certificate of completion of the Shipping of Dangerous Goods (Saf-T-Pak) training course for the person(s) assuming the responsibility of shipping/transport. If you and/or personnel on the protocol need to register for this class, please contact Ken Erondu (kerondu@mcg. This training can be satisfied in two manners: A didactic refresher training course is available for departments, centers, or large laboratory groups (to schedule a training session, please contact the Biosafety Office). Please contact Jenny Whitlock in the Laboratory Animal Services office at jwhitlock@mcg. Please contact Angela Randazzo in the Office of Human Research Protection at arandazzo@mcg. This includes: human or primate blood, tissues or fluids; cell, tissue or organ cultures of human or non-human primate origin. If "yes", please complete & attach Biosafety Schedule B Yes Yes No No Any large-scale cultures (> 10 liters at any one time) Note: this excludes any material previously described in either Schedule A or B (recombinant viral vectors or materials exposed to recombinant viral vectors or mammalian tissues/cultures/fluids which might be potentially contaminated with microbial. If "yes", please complete & attach Biosafety Schedule C If "yes", please complete & attach Biosafety Schedule D Yes No the use of biological materials in association with live animals (other than human or non-human primates) If "yes", please complete & attach Biosafety Schedule E Yes Yes Yes Yes No No No No Yes No Human gene transfer/therapy2 Shipping, extramural transport, or importation or exportation of any biological material (including diagnostic/clinical specimens, cell cultures, tissues, genetically modified organisms and/or infectious agents, toxins of biological origin) or items on dry ice or liquid nitrogen4 High civil and criminal liability and fines may be associated with non-compliance with these laws. Experiments using more than 2/3 of the genome of infectious animal or plant viruses or defective viruses grown in the presence of helper virus or complementing helper virus components. Please contact the Biosafety Office (x1-2663) as soon as possible if your experiments fall into these categories for assistance. Amendments to the personnel list can be submitted as an updated version of this form or via email to the Biosafety Office (kraemers@mcg. Name List biological agents/techniques with which this person has experience Where was this experience obtained I attest that the information contained in the attached application and supplements is accurate and complete. I will ensure that before entering my laboratory, any person is advised of the potential hazards. I agree to amend this protocol to include any changes in agents, personnel, locations, applications or major equipment. I agree to immediately report any high hazard spills (large volumes, high risk group agents) or spills in public (nonlaboratory) areas to the Biosafety Officer (x1-2663). Yes Yes Yes Yes Yes No No No No No Name of Packaging Cell line(s) or Helper plasmids used in co-transfect ion to produce viral particles Source(s) of cells. What is the gene source (species and/or strain) What is the nature of the insert(s). Have these agents been previously passaged through animals or other cells or cell lines Yes No If "yes", please describe methods and stage in your experiment at which these assays will be performed. How will these constructs be utilized (what are the target cells and/or animals for these constructs) List approximate maximum volume(s) of cultures of these agent(s) generated at any one time. Will these experiments result in acquisition of new characteristics of any infectious agents, such as altered virulence or infectivity, or changes in resistance/susceptibility to drug therapy or changes in host range For established cell lines, provide examples of cell lines within each grouping-comprehensive lists are not required unless they may present additional risk considerations. List approximate maximum volume(s) of these agents handled or cultured at any one time. Describe any procedures to be performed which may be associated with an increased potential risk of exposure of personnel. Method of delivery and health status of the patients Frequency of administration the anticipated effect of the introduction of the agent upon the patient (if known) the expected persistence of the agents after administration (if known) How long after administration will you obtain specimens to be analyzed Indicate whether this is a closed system, and whether seals are available to prevent leakage enclosed in ventilated housings. Describe how you intend to transfer material from your growth chambers and how this material will be decontaminated: 3. Describe how your system exhaust gases will be treated to prevent release of viable organisms: 4. Describe potential risk of infection of personnel while using the agents indicated. Yes Yes Yes Yes Yes Yes No No No No No No Risk Group2 No No No No No No for a list of Select Agents, please see. Describe any procedures that will be performed with this material which may be associated with an increased potential risk of exposure of personnel. The nature of the potentially infectious material to be introduced into the patients. The anticipated effect of the introduction of the agent upon the patient (if known) vi. At what stage of your experiments will the infectious agent(s) be inactivated or lysed What biosafety precautions will be taken to avoid inadvertent exposure to other patients, researchers, or health care providers. Will these experiments result in acquisition of new characteristics of these infectious agents, such as altered virulence or infectivity, or changes in resistance/susceptibility to drug therapy or changes in host range The anticipated effect of the introduction of the biological agent upon the animal (if known). The expected persistence of the infectious material, cells, toxins and/or heterologous gene expression after administration (if known) vi. At what point in your experiments will your biological agents be inactivated or lysed Are you preparing to create a new strain of genetically engineered (transgenic or knock-out) animals Will the delivery of any biological material or genetic modification cause the animal to potentially shed infectious material, toxins or potentially create a hazard to animal handlers, research staff or other animals in the facility Yes No If "yes", describe any procedures that researchers or animal care givers may perform which would be associated with an increased potential risk of exposure. Yes If "yes", indicate location (building/rooms #) or the animals will be housed after return. Do you intend to perform any safety tests or pathogen screening prior to introduction of biological agents into animals (eg. Please note that this definition would also include research involving ex vivo transduction of cells for human application. Describe below what evidence exists to suggest that the vector-encoded immunogen expression is not expected to persist in the patient Random reviews will be performed by the Biosafety Office, and grant material may be requested for review at that time. Random reviews may be performed by the Biosafety Office, and protocol material may be requested for review at that time. This appendix includes those biological agents known to infect humans as well as selected animal agents that may pose theoretical risks if inoculated into humans. Included are lists of representative genera and species known to be pathogenic; mutated, recombined, and non-pathogenic species and strains are not considered. This appendix reflects the current state of knowledge and should be considered a resource document. Included are the more commonly encountered agents and is not meant to be all-inclusive. Further guidance on agents not listed in Appendix B may be obtained through: Centers for Disease Control and Prevention, Biosafety Branch, Atlanta, Georgia 30333, Phone: (404) 639-3883, Fax: (404) 639-2294; National Institutes of Health, Division of Safety, Bethesda, Maryland 20892, Phone: (301) 496-1357; National Animal Disease Center, U. Animal Viral Etiologic Agents in Common Use the following list of animal etiologic agents is appended to the list of human etiologic agents. None of these agents is associated with disease in healthy adult humans; they are commonly used in laboratory experimental work. The purpose of containment is to reduce or eliminate exposure of laboratory workers, other persons, and the outside environment to potentially hazardous agents. Secondary containment, the protection of the environment external to the laboratory from exposure to infectious materials, is provided by a combination of facility design and operational practices. Therefore, the three elements of containment include laboratory practice and technique, safety equipment, and facility design. The risk assessment of the work to be done with a specific agent will determine the appropriate combination of these elements. Persons working with infectious agents or potentially infected materials must be aware of potential hazards, and must be trained and proficient in the practices and techniques required for handling such material safely. The director or person in charge of the laboratory is responsible for providing or arranging for appropriate training of personnel. Each laboratory should develop or adopt a biosafety or operations manual that identifies the hazards that will or may be encountered and that specifies practices and procedures designed to minimize or eliminate risks. Personnel should be advised of special hazards and should be required to read and to follow the required practices and procedures. A scientist trained and knowledgeable in appropriate laboratory techniques, safety procedures, and hazards associated with handling infectious agents must direct laboratory activities. When standard laboratory practices are not sufficient to control the hazard associated with a particular agent or laboratory procedure, additional measures may be needed. The laboratory director is responsible for selecting additional safety practices, which must be in keeping with the hazard associated with the agent or procedure. Laboratory personnel, safety practices, and techniques must be supplemented by appropriate facility design and engineering features, safety equipment, and management practices. An example of another primary barrier is the safety centrifuge cup; an enclosed container designed to prevent aerosols from being released during centrifugation. Safety equipment also may include items for personal protection such as gloves, coats, gowns, shoe covers, boots, bouffant head covers, respirators, face shields, safety glasses, or goggles. Personal protective equipment is often used in combination with biological safety cabinets and other devices that contain the agents, animals, or materials being worked with. In some situations in which it is impractical to work in biological safety cabinets, personal protective equipment may form the primary barrier between personnel and the infectious materials. Examples include certain animal studies, animal necropsy, agent production activities, and activities relating to maintenance, service, or support of the laboratory facility. For example, the exposure risks for most laboratory work in Biosafety Level 1 and 2 facilities will be direct contact with the agents, or inadvertent contact exposures through contaminated work environments. As the risk for aerosol transmission increases, higher levels of primary containment and multiple secondary barriers may become necessary to prevent infectious agents from escaping into the environment. Such design features could include specialized ventilation systems to assure directional air flow, air treatment systems to decontaminate or remove agents from exhaust air, controlled access zones, airlocks as laboratory entrances, or separate buildings or modules for isolation of the laboratory. Each combination is specifically appropriate for the operations performed, the documented or suspected routes of transmission of the infectious agents, and for the laboratory function or activity. Bacillus subtilis, Naegleria gruberi, and infectious canine hepatitis virus are representative of those microorganisms meeting these criteria. Many agents not ordinarily associated with disease processes in humans are, however, opportunistic pathogens and may cause infection in the young, the aged, and Medical College of Georgia C-2 Biosafety Guide-June 2008 immunodeficient or immunosuppressed individuals. Vaccine strains which have undergone multiple in vivo passages should not be considered avirulent simply because they are vaccine strains. Biosafety Level 1 represents a basic level of containment that relies on standard microbiological practices with no special primary or secondary barriers recommended, other than a sink for hand-washing. With good microbiological techniques, these agents can be used safely in activities conducted on the open bench, provided the potential for producing splashes or aerosols is low. Biosafety Level 2 is appropriate when work is done with any human-derived blood, body fluids, or tissues where the presence of an infectious agent may be unknown. Primary hazards to personnel working with these agents relate to accidental percutaneous or mucous membrane exposures, or ingestion of infectious materials. Extreme precaution with contaminated needles or sharp instruments must be emphasized. Other primary barriers should be used as appropriate such as splash shields, face protection, gowns, and gloves. Secondary barriers such as hand-washing and waste decontamination facilities must be available to reduce potential environmental contamination. Louis encephalitis virus, and Coxiella burnetii are representative of microorganisms assigned to this level. Primary hazards to personnel working with these agents relate to autoinoculation, ingestion, and exposure to infectious aerosols. At Biosafety Level 3, more emphasis is placed on primary and secondary barriers to protect personnel in contiguous areas, the community, and the environment from exposure to potentially infectious aerosols.

Relative survival adjusts for normal life expectancy by comparing survival among cancer patients to that of people not diagnosed with cancer who are of the same age muscle relaxant 771 discount rumalaya liniment, race spasms face discount rumalaya liniment 60 ml fast delivery, and sex muscle relaxant renal failure buy rumalaya liniment 60 ml low price. In addition to 5-year relative survival rates spasms below breastbone order discount rumalaya liniment, 1- spasms lower right abdomen rumalaya liniment 60 ml with visa, 10- spasms pregnancy generic rumalaya liniment 60 ml on line, and 15-year survival rates are presented for selected cancer sites. Probabilities of developing cancer were calculated using DevCan (Probability of Developing Cancer) software version 6. For example, the estimate of 1 man in 14 developing lung cancer in a lifetime underestimates the risk for smokers and overestimates the risk for nonsmokers. More information on the methods used to generate the statistics for this report can be found in the following publications: A. Women should have the opportunity to begin annual screening between the ages of 40 and 44. Transition to biennial screening, or have the opportunity to continue annual screening. Continue screening as long as overall health is good and life expectancy is 10+ years. Women, ages 55+ Cervix Women, ages 21-29 Women, ages 30-65 Women, ages 66+ Pap test Screening should be done every 3 years with conventional or liquid-based Pap tests. Single stool testing during a clinician office visit is not recommended, nor are "throw in the toilet bowl" tests. In comparison with guaiac-based tests for the detection of occult blood, immunochemical tests are more patientfriendly and are likely to be equal or better in sensitivity and specificity. Every 5 years Every 10 years Every 5 years Women should be informed about risks and symptoms of endometrial cancer and encouraged to report unexpected bleeding to a physician. Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about annual lung cancer screening with apparently healthy patients ages 55-74 who have at least a 30 pack-year smoking history, and who currently smoke or have quit within the past 15 years. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation Men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the potential benefits, risks, and uncertainties associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. All positive tests (other than colonoscopy) should be followed up with colonoscopy. Microbiological laboratories are special, often unique work environments that may pose identifiable infectious disease risks to pe rson s in or near them. Infec tions have been cont racte d in the laboratory throughout the history of microbiology. In 1949, Sulkin and Pike3, published the first in a series of surveys of laboratory-associated infections. In 1951, Sulkin and Pike4, published the second of the series, bas ed on a que stion naire sent to 5,0 00 lab orato ries. Brucellosis outnumbered all other reported laboratory-acquired infections and, together with tuberculosis, tularemia, typhoid, and streptococcal infection, accounted for 72% of all bacterial infections and for 31% of infections caused by all agents. The majority of these were related to mouth pipetting and the use of needle and syringe. This survey was updated in 1965,5, addin g 641 new or pre viously unreported cases, and again in 1976,6, summarizing a cumulative total of 3,921 cases. Brucellosis, typhoid, tularemia, 1 Introduction tuberculosis, hepatitis, and Venezuelan equine encephalitis were the m ost c om mo nly rep orted infec tions. Exp osure to infectious aerosols was considered to be a plausible but unconfirmed source of infection for the more than 80% of the reported cases in which the infected p erson h ad "work ed with the agent. In some instances, the ability of a given arbovirus to produce human disease was first confirmed as the re sult of uninte ntional infec tion of labor atory pers onnel. Exposure to infectious aerosols was considered the most common source of infection. In 19 74, S kinh olj 8, published the results of a survey which showed that personnel in Danish clinical chemistry laboratories had a reported incidence of hepatitis (2. Similarly, a 1976 survey by Harrington and Shannon9, indicated that medical laboratory workers in England had "a five times increased risk of acquiring tuberculosis compared with the general population. Along with tuberculosis, these were the three most commonly reported occupation-associated infections in Britain. Although these reports suggest that laboratory personnel were at increased risk of being infected by the agents they handle, a ctual rates of infection are typically not av ailable. However, the studies of Harrington and Shannon9 and of Skinhoj10, indicate that laboratory personnel had higher rates of tuberculosis, shigellosis, and hepatitis B than does the general population. In contrast to the documen ted occurrence of laboratory-acquired infections in laboratory personnel, laboratories working with infectious agents have not been shown to represent a threat to the community. For example, although 109 laboratory-associated infections were recorded at the Centers for Disease Control and Prevention from 1947-1973,11, no secondary 2 Introduction cases were rep orted in fam ily mem bers or c omm unity contac ts. The National Anim al Disease Center reported a sim ilar experience,12, with no secondary cases occurring in laboratory and non-laboratory contacts of 18 laboratory-associated cases occurring from 196 0-1975. A seconda ry case of Marburg disease in the wife of a primary case was presumed to have been transmitted sexually two months after his dismissal from the hos pital. In his 1979 review,20, Pike concluded that "the knowledge, the techniques, and the equipment to prevent most laboratory infections are a vailab le. Guidelines were also prom ulgated for health care workers under the rubric of Universal Precautions. A thorough risk assessment must be 4 Introduction conducted when addressing these activities and their inherent unknowns. Exper ience ha s dem onstrate d the pru dence of the Bios afety Level 1-4 practices, procedures, and facilities described for manipulations of etiologic agents in laboratory settings and animal facilities. Although no national reporting system exists for reporting laboratory-associated infections, anecdotal information suggests that strict adherence to these guidelines does contribute to a healthier and safer work environment for laboratorians, their co-workers, and the surrounding community. To further reduce the potential for laboratory-associated infections, the guidelines presented here should be considered minimal guidance for containment. They must be customized for each individual laboratory and can be used in conjunction with other available scientific information. Incidence of tuberculosis, hepatitis, brucellosis and shigellosis in British medical laboratory workers. Report of the Committee of Inquiry into the Smallpox Outbreak in London in March and April 1973. B Virus (Herpesvirus simiae) Infection in Humans: Epidemiologic Investigation of a Cluster. National Cancer Institute, Office of Research Safety, and the Special Committee of Safety and Health Experts. Biosafety in the Laboratory: Prudent Practices for the Handling and Disposal of Infectious Materials. Meeting the Challenge of Multidrug-Resistant Tuberculosis: Summary of a Conference. The purpose of containment is to reduce or eliminate ex posure of laboratory workers, other persons, and the outside environment to potentially hazardous agents. Primary containment, the protection of personnel and the immediate laboratory environment from exposure to infectious agents, is provided by both good microbiological technique and the use of appropriate safety equipment. Therefore, the three elements of containm ent include laboratory practice and tech nique, sa fety equipm ent, and fa cility design. Persons working with infectious agents or potentially infected materials must be aware of potential hazards, and must be trained and proficient in the practices and techniqu es requ ired to han dle such mate rial safely. The direc tor or pers on in c harg e of th e labo rator y is res pon sible for p rovid ing or arran ging t he ap prop riate tr aining of pe rson nel. Each laboratory should develop or adopt a biosafety or operations manual that identifies the hazards that will or may be encountered, and that specifies practices and procedures designed to minim ize or elimin ate exp osures to these h azards. Personnel should be advised of special hazards and should be required to read and follow the required practices and proced ures. This individual should consult with biosafety or other health and safety pro fession als with reg ard to risk asses sme nt. When sta ndard lab oratory pra ctices are not suffic ient to control the hazards associated with a particular agent or laboratory procedure, additional measures may be needed. The laborator y director is res ponsible for selec ting additiona l safety practices, which must be in keeping with the hazards associated with the agent or procedure. An example of another primary barrier is the safety centrifuge cup, an enclosed container designed to prevent aerosols from being released during centrifugation. Safety equipment also may include items for personal protection, such as gloves, coats, gowns, shoe covers, boots, respirators, face shields, safety glasses, or goggles. Personal protective equipm ent is often used in c omb ination with bio logical safe ty cabinets and other devices that contain the agents, animals, or ma terials being hand led. In som e situ ation s in wh ich it is impractical to work in biological safety cabinets, personal protective equipment may form the primary barrier between personnel and the infectious materials. Examples include certain animal studies, animal necropsy, agent production activities, and activities relating to maintenance, service, or support of the labor atory f acility. The recommended secondary barrier(s) will depend on the risk of transmission of specific agents. For example, the exposure risks for most laboratory work in Biosafety Level 1 and 2 facilities will be direct contact with the agents, or inadvertent contac t expos ures thro ugh co ntam inated wo rk enviro nme nts. Secondary barriers in these laboratories may include separation of the laboratory work area from pu blic access, availability of a decontamination facility. When the risk of infection by exposure to an infectious aerosol is present, higher levels of primary containment and multiple secondary barriers may become necessary to prevent infectious agents from escaping into the environment. Such 10 Principles of Biosafety design features include specialized ventilation systems to ensure directional air flow, air treatment systems to decontaminate or remove agents from exhaust air, controlled access zones, airlocks as laboratory entrances, or separate buildings or modules to isolate the laboratory. Each combination is specifically appropriate for the operations performed, the documented or suspected routes of transmission of the infectious agents, and the laboratory function or ac tivity. The laboratory director is specifically and primarily responsible for assessing the risks and appropriately applying the recommended biosafety levels. When specific information is available to suggest that virulence, pathogenicity, antibiotic resistance patterns, vaccine and treatment availability, or other factors are significantly altered, more (or less) stringent practices may be specified. Biosa fety Le vel 1 practices, safety equipment, and facility design and construction are appropriate for undergraduate and secondary educational training and teaching laboratories, and for other laboratories in which work is don e with defin ed an d cha racte rized s trains of via ble mic roor gan ism s not kno wn to cons isten tly cau se dis eas e in healthy adu lt huma ns. M any agen ts not ordinarily associated with disease processes in humans are, however, opportunistic pathogens and may cause infection in the young, the aged, and immunodeficient or immunosuppressed individuals. Vaccine strains that have undergone multiple in vivo passages should not be considered avirulent simply because they are vaccine strains. Biosafety Level 1 represents a basic level of containment that relies on standard microbiological practices with no special primary or secondary barriers recommended, other than a sink for handwashing. Biosa fety Le vel 2 practices, equipm ent, and fa cility design and construction are applicable to clinical, diagnostic, teaching, and othe r laborator ies in which work is d one with the broad spectrum of indigenous moderate-risk agents that are present in the community and associated with human disease of varying severity. Biosafety Level 2 is appropriate when work is done with any human-derived blood, body fluids, tissues, or primary human cell lines where the presence of an infectious agent may be unknown. Other primary barriers should be used as appropriate, such as splash s hields, fac e protec tion, gown s, and glo ves. Secondary barriers such as handwashing sinks and waste decontamination facilities must be available to reduce potential environmental contamination. Biosa fety Le vel 3 practices, safety equipment, and facility d esig n and cons truct ion ar e app licable to clinic al, diagn ostic, teac hing, rese arch, or pr odu ction facilitie s in which work is done with indigenous or exotic agents with a potential for respiratory transmission, and which may cause serious and pote ntially lethal infection. Louis encephalitis virus, and Cox iella burn etii are repre sentative of the m icroorga nism s assign ed to this level. Primary hazards to personnel working with these agents relate to au toinocula tion, ingestion, and exp osure to infectious aerosols. At Biosafety Level 3, more emphasis is placed on primary and secondary barriers to protect personnel in contiguous areas, th e com mun ity, and the en vironm ent from expos ure to potentially infectious aerosols. Secondary barriers for this level include controlled access to the laboratory and ventilation requirements that minimize the release of infectious aerosols from the labor atory. Biosa fety Le vel 4 practices, safety equipment, and facility design a nd con struction a re applica ble for wo rk with dangerous and exotic agents that pose a high individual risk of life-threatening disease, which may be transmitted via the aerosol route and for which there is no available vaccine or thera py. Ag ents with a close or ide ntica l antig enic relationship to Biosafety Level 4 agents also should be handled at this level. Viruses such as Marburg or Congo-Crimean hem orrhagic fever are man ipulated at B iosafety Le vel 4. All manipulations of potentially infectious diagnostic materials, isolates, and naturally or experimentally infected animals, pose a high risk of exposure and infection to laboratory personnel, the commun ity, and the en vironm ent. The Bios afety L evel 4 facility its elf is genera lly a separate building or c omp letely isolated zon e with com plex, spe cialized ventilation requirem ents an d waste man agem ent system s to preve nt release of viable ag ents to the enviro nme nt. The labor atory d irecto r is sp ecific ally and prim arily responsible for the safe operation of the laboratory. His/her knowledge and judgment are critical in assessing risks and appropriately applying these recommendations. The recommended biosafety level represents those conditions under w hich the a gent ca n ordinar ily be safely han dled. Special characteristics of the agents used, the training and experience of personnel, and the nature or function of the laboratory may further influence the director in applying these recommendations. Four biosafety levels are also described for activities involving infectious disease work with experimental animals. These four combinations of practices, safety equipment, and facilities are designated Animal Biosafety Levels 1, 2, 3, and 4, and provide increasing levels of protection to personnel and the e nvironm ent. Clinic al labo rator ies, e spe cially those in h ealth care facilities, rece ive clinical spe cime ns with reques ts for a var iety of diagno stic and c linical suppo rt services. Typically, the infectious nature of clinical material is unknown, and specimens are often submitted with a broad request for micro biological ex amin ation for m ultiple agen ts. It is the responsibility of the laboratory director to establish standard procedures in the laboratory which realistically address the issue of the infec tive hazard of clinical spe cime ns. This requires the use of specific precautions with all clinica l spec ime ns of blood or oth er po tentia lly infectious material (Universal or Standard Precautions). Biological safety cabinets also should be used for the initial processing of clinical specimens when the nature of the test requested or other information suggests the likely presence of an agent re adily transm issible by infec tious aero sols.

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