Former Senior Managing Director of Whitehall Asset Management, Inc. Former President and Director of Whitehall Funds.
Toradol lidocaine
Phenol is fairly unstable at room temperature. It lasts at least one year when refrigerated and kept away from light. Phenol can be used in 3-15 % concentration and with saline, water, and glycerol or radiological dye. It is relatively insoluble in water, and as a result concentration in excess of 6.7 % cannot be obtained at room temperature without adding glycerine to increase its solubility in water. Phenol with glycerine is hyperbaric versus alcohol being hypobaric ; in CSF, but is so viscid that even when warmed, it is difficult to inject through needles smaller then 20 gauge. Phenol has a biphasic action-its initial local anesthetic action produces subjective warmth and numbness that usually give way to chronic denervation over a day's time. Hypoalgesia after phenol typically is not as dense as after alcohol, and quality and extent of analgesia may fade slightly within the first 24 hours of administration. Subarachnoid intrathecal ; injections of alcohol or phenol continue to play an important role in the management of intractable cancer pain in carefully selected patients. Neurolytic neuraxial block produces pain relief by chemical rhizotomy. Since alcohol and phenol destroy nervous tissue indiscriminately careful attention to the selection of the injection site, volume and concentration of injectate, and selection and positioning of the patient are essential to avoid neurological complications 139141 ; . Most authorities agree that neither alcohol nor phenol offers a clear advantage except insofar as variations in baric properties facilitate positioning of the patient 142, 143 ; . Except for perineal pain, alcohol is usually preferred, since most patients are unable to lie on their painful side, as is required for intrathecal phenol neurolysis. In one of the analysis of 13 published series documenting treatment with intrathecal rhizolysis of more than 2500 patients Swerdlow reported that 58% of patients obtained "good" relief; "fair" relief was observed in an additional 21%, and in 20% of patients "little or no relief" was noted 142 ; . Average duration of relief is estimated at 3 to.
Large-scale randomized placebo-controlled clinical trials conducted within the last few years show the value of ARBs in low LVEF HF, both in patients intolerant to standard therapies and as part of a combination treatment strategy. On the basis of data from these trials, the revised 2005 ESC CHF guidelines now provide stronger recommendations for the use of ARBs in CHF management, indicating that these agents represent effective alternative or additional therapies to ACE-inhibitors to optimize patient outcomes.
130 MR. FASS: And that is having a significant effect on prices in the United States. Now, we can talk about the policy of that. But I do think it's interesting to be really focusing on this as an issue in a time where we have some of the highest food prices in the world right now, including this country. But I'm not -- in terms of its definition as an export subsidy, it is not a great area of expertise of mine. COMMISSIONER MULLOY: I was very interested in your granddad or great-grandfather started this company. I'm sure it was all domestic oriented in the beginning. When did it reach the crossover point from being a marketer for domestic seafood to a marketer of imported seafood. What percentage of your seafood do you market now that is foreign? MR. FASS: The vast majority. Over 95 percent. Maybe more. COMMISSIONER MULLOY: When did you cross over from domestic to -MR. FASS: There were a couple of -- I don't want to say tipping points, but they were over the course of a hundred years. Obviously, it started out as just a one person show, being a domestic oysterman. When my father and his brother at the time were running a company which was called Fass Brothers, it was probably one of the largest fresh fish operations in the Eastern Seaboard. Still, they had boat owners, processors, actually, a chain of restaurants. But this was back in the 1950s, '40s, '60s. Even at that time, they were some of the first to start importing both fresh and frozen fish from other countries. So we were a pioneer in imports in certain ways. So it certainly started long before the last 5, 10 or 15 years. Now, there have definitely been waves of significant growth. Maritime, as an entity, really focused more on imports in the early '80s. My father split off from his brother and started what was predominantly an import company, recognizing that that was where -- we didn't have enough seafood here. And it has grown since then to be more and more focused on it. COMMISSIONER MULLOY: Miss Chauvin, you talked about the communities in decline and people angry. I can relate to that. I'm from a small town in Pennsylvania. And Senator Obama referred to people up there having the same sentiment. They're bitter or angry about what's happened to the industrial base in this country and jobs and other things in this era of globalization.
These are not all the side effects with NSAID medicines. Talk to your healthcare provider or pharmacist for more information about NSAID medicines. Other information about Non-Steroidal Anti-Inflammatory Drugs NSAIDs ; Aspirin is an NSAID medicine but it does not increase the chance of a heart attack. Aspirin can cause bleeding in the brain, stomach, and intestines. Aspirin can also cause ulcers in the stomach and intestines. Some of these NSAID medicines are sold in lower doses without a prescription over-the-counter ; . Talk to your healthcare provider before using overthecounter NSAIDs for more than 10 days. NSAID medicines that need a prescription Generic Name Celecoxib Diclofenac Diflunisal Etodolac Fenoprofen Flurbiprofen Ibuprofen Indomethacin Ketoprofen Ketorolac Mefenamic Acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin Tradename Celebrex Cataflam, Voltaren, ArthrotecTM combined with misoprostol ; Dolobid Lodine, Lodine XL Nalfon, Nalfon 200 Ansaid Motrin, Tab-Profen, Vicoprofen combined with hydrocodone ; , CombunoxTM combined with oxycodone ; Indocin, Indocin SR, Indo-LemmonTM, IndomethaganTM Oruvail Foradol Ponstel Mobic Relafen Naprosyn, Anaprox, Anaprox DS, EC-NaprosynTM, Naprelan, Naprapac copackaged with lansoprazole ; Daypro Feldene Clinoril Tolectin, Tolectin DS, Tolectin 600.
Linical-trial data have shown that reduction of LDL-C levels significantly reduces the incidence of coronary heart disease CHD ; , decreases the occurrence of cardiac events, and slows atherosclerotic progression. Based on this evidence, the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III ; identifies LDL-C as the primary target of cholesterol-lowering therapy.1 However, a substantial number of individuals still experience cardiac events or exhibit evidence of atherosclerotic progression despite achieving significant LDL-C reduction with treatment. An inadequate response in some patients may be related to metabolic abnormalities that cannot be fully modified by LDL-C reduction. This article reviews the latest clinical-trial data related to the primary and secondary prevention of CHD via strategies that go beyond LDL-C reduction, with a focus on increasing HDL-C levels and decreasing TG levels, or both and carisoprodol.
Abnormalities result from: 1. Decreased K + due to dilution, intracellular shifts & or diuretics 2. Decreased Na + , Ca mg + - dilutional, fluid shifts or diuresis 3. Increased capillary permeability fluid shifts, interstitial edema leading to intravascular hypovolemia Treatment: 1. Replace K + keep K + 4.5 5.5 2. Na + - treatment or free water restriction 3. Replace mg + - keep 2-3 & Ca + - keep ionized Ca + 1.15. Narcotics: If intravenous doses of an opioid analgesic are required, fentanyl, hydromorphone & Analgesia morphine are the recommended agents Grade C ; . Scheduled opioid does or a continuous infusion is preferred over an "as Needed" regimen to ensure consistent analgesia. A PCA device may be utilized to deliver opioids if the patient is able to understand and operate the device Grade B ; . Morphine and hydromorphone are preferred for intermittent therapy because of their longer duration of effect. Grade C ; NSAIDs or acetaminophen may be used as adjuncts to opioids in selected patients. Grade B ; In combination with an opioid, acetaminophen produces a greater analgesic effect than higher doses of the opioid alone. NSAID's: Toradoll can lead to renal failure & increased risk of bleeding. Hypovolemia or hypoperfusion, elderly patients & those with preexisting renal impairment may be more susceptible to NSAID-induced renal injury ; . Propofol or Dexmedetomidine are the preferred sedatives when rapid awakening for neurologic assessment or extubation ; is important. Grade B ; Triglyceride concentrations should be monitored after two days of propofol infusion and total caloric intake from lipids should be included in the nutrition support prescription. Grade B ; . Ace Inhibitors can be used in conjunction with or in lieu of B-Blockers in patients with coronary artery Ace Inhibitor disease. Contraindications include clinically relevant renal failure, history of bilateral renal artery stenosis or angioedema, cardiogenic shock, hyperkalemia, and pregnancy ; . Angiotensin receptor blockers ARB's ; should be used in intolerant patients. Ace inhibitors have shown benefit reduction in vascular events, mortality, and ventricular dilation ; from early use. Use of an Ace Inhibitor was also associated with a reduction in CV mortality, MI, stroke, all cause mortality, cardiac arrest, revascularization procedures, and heart failure. This benefit was observed without HTN and with normal LVEF. Class I recommendation, Evidence A. 1. All patients undergoing CABG should receive lipid lowering Lipid therapy unless contraindicated. 2. Decreases progression of disease in SVG's 3. Decreases Management revascularization rates. Low Density Lipoprotein LDL ; cholesterol is the primary target of lipid lowering therapy as elevated levels are a major cause of coronary disease. These agents should be started in all patients, regardless of baseline LDL cholesterol. Baseline LFTs should be obtained before initiation of these agents and rechecked in two weeks for patients with chronic liver disease and in three months for all other patients. Statins should be stopped if there is a threefold elevation above the upper limit of normal of AST or ALT on two occasions. Creatine phosphokinase levels should be determined in patients presenting with persistent symptoms of myalgia during statin therapy. Withdrawal of the drug should be considered if significant elevations are observed. Rare cases of rhabdomyolysis with acute renal failure have been reported in patients receiving statins. Rhabdomyolysis may occur after a single dose. In the majority of cases reported, rhabdomyolysis abated after withdrawal of the drug. Target levels in patients with coronary, other vascular disease, or diabetics: LDL 70mg dl; HDL 45mg dl; Triglycerides 150mg dL. If HDL is 45mg dl, education should focus on exercise, weight loss, and smoking cessation, all of which will help to increase HDL. Benefits are seen in patients with cholesterol and LDL of all levels, thus it is not necessary to await lipid levels prior to starting. Use of these agents lowers the risk of recurrent events, need for revascularization, hospitalizations, strokes, and mortality. Anticoagulation 1. Long term 3-6 months ; anticoagulation is probably indicated for patients with recent anteroapical infarct and persistent wall-motion abnormality after CABG IIA, evidence C ; 2. Patients with severely depressed LV function should be considered for long-term anticoagulation to reduce the incidence of thromboembolic events. Patient Education Class I recommendation, evidence B. Current smoking status and all smoking cessation Smoking interventions must be documented in the medical record. Both physicians and nurses should Cessation counsel current smokers through strong encouragement and smoking cessation information in the form of verbal instruction, smoking cessation packets, and videos. Patients should also be told to avoid secondhand smoke. Family members who live in the same household should also be encouraged to quit smoking and help to reinforce the patient's effort to quit. Pharmacological therapy including nicotine replacement and bupropion should be offered to select patients indicating a willingness to quit. Evidence B ; In patients with Coronary Artery Disease, smoking cessation is associated with a 36% reduction in all-cause mortality irrespective of patient age, sex or cardiac event. Electrolytes.
First trimester diagnostic pregnancy care ultrasound scans Second or third trimester diagnostic pregnancy care ultrasound scans Gynecologic scans Emergency scans performed for acutely ill patients in labor and delivery, the emergency department and the office 5 . Ultrasound guided procedures e.g., amniocentesis, external cephalic version, paracentesis, thoracentesis, organ biopsy, mass biopsy, dilation and curettage, intrauterine contraceptive device retrieval and insertion ; 6 . Specific small parts and surface anatomy ultrasonographic scans A number of continuing medical education courses presented by family physicians extensively review the clinical applications, indications and clinical settings in which diagnostic ultrasonography in the hands of family physicians is useful. Obstetrical ultrasound courses organized and presented by family physicians and sponsored through the American Academy of Family Physicians have been presented since 1989. SECTION II - CLINICAL INDICATIONS3 Maternal factors: a. b. c. Evaluation of pelvic mass Evaluation of hydatidiform mole Evaluation for ectopic pregnancy Evaluation for uterine anomaly and trental.
Flammation by B. burgdorferi and are usually associated with other signs and symptoms of disease.105, 106 The eye may also be affected by extraocular manifestations of Lyme disease, such as cranial nerve pareses and orbital myositis. Findings in other organ systems gastrointestinal, lymphatic, respiratory, urinary, and genital ; have been reported, but the associations with borrelial infection are loose. PERINATAL LYME DISEASE Studies in both human and animal models indicate that B. burgdorferi can cross the placenta during the initial spirochetemia, but evidence of a fetal immune response or an adverse neonatal outcome are not definitively established.107 LYME DISEASE IN CHILDREN Other than differences in localization of EM lesions more typically in the head and neck ; , pediatric Lyme disease is similar to that of adults. Of note, however, in children optic nerve involvement may lead to blindness.108.
Ancef 1 gm IVPB every 8 hours x 2 doses. If history of anaphylaxis with Penicillin or allergy to Ancef, give Clindamycin 600 mg IVPB every 8 hours x 2 doses. B. THERAPEUTIC ANTIBIOTIC Antibiotic coverage ordered for greater than 24 hours post-op, REQUIRES documentation of appropriate antibiotic and indication. DOCUMENT RATIONALE: Ancef 1 gm IVPB every 8 hours x doses. If history of anaphylaxis with Penicillin or allergy to Ancef, give Clindamycin 600 mg IVPB every 8 hours x doses. C. PAIN MANAGEMENT May Only Choose ONE Injectable and TWO 2 ; Oral PRN Medications Notify Physician if analgesia is inadequate. q Morphine Sulfate 4-6 mg IV every hour s ; PRN moderate to severe pain or for breakthrough pain q Morphine Sulfate 6-10 mg IV every hour s ; PRN moderate to severe pain or for breakthrough pain q Oxycodone 5 mg 1-2 tabs PO every 3 hours PRN when tolerating PO ; for moderate to severe or breakthrough pain q Ultram 25-50 mg PO every 6 hours PRN moderate pain for breakthrough pain. Do not use if patient is on a SSRI Selective Seretonin Re-Uptake Inhibitor ; or if patient is allergic to Codeine. q Tpradol 30 mg IV x 1 dose in PACU Toadol 15 mg IV x 1 dose for patients 65 years of age or older ; q Goradol 30 mg IV every 6 hours x 24 hours for patient under the age of 65 OR Toradol 15 mg IV every 6 hours x 24 hours for patients 65 or older Do not use if allergic to Aspirin q Celebrex 100 mg PO twice daily start after Toradol is completed q Oxycontin 10 mg PO twice daily Post-Op q Oxycontin 20 mg PO twice daily Post-Op Tylenol 650 mg PO every 4 hours PRN for mild pain or temperature 101F or greater ROOM #: continued on page 3 and artane.
Abstr. 549, 2003 ; have recently reported that when UIC-94017 is coadministered with RTV by use of dosing regimens of 200 mg of UIC-94017 plus 100 mg of RTV once a day and 1, 200 mg of UIC-94017 plus 200 mg of RTV once a day, the levels of UIC-94017 in the plasma of patients with AIDS rose to 2.6 and 9.6 M, respectively, and the trough levels were 0.65 and 1.8 M, respectively. These pharmacokinetic data from a clinical trial show that the levels of UIC-94017 in plasma do not go below 15- and 43-fold above the AAG-adjusted IC50s 0.042 M; Table 5 ; with the low and high dosing regimens, respectively. Indeed, it should be noted that Arasteh et al. K. Arasteh, et al., 10th Conf. Retrovir. Opportunistic Infect., abstr. 8, 2003 ; most recently reported the early results of an open, randomized phase IIa clinical trial with 50 multiple PI-experienced patients with AIDS in which patients receiving various combination regimens of UIC-94017 and RTV had a significant reduction in the number of HIV-1 RNA copies in their plasma range, 0.47 to 2.5 log10; median reduction, 1.35 log10 ; . Treatment with UIC-94017 plus RTV was generally well tolerated. It was recently reported that certain PIs can exert potent activities against clinical HIV-1 strains which acquired high levels of resistance to multiple PIs 2, 30, 31 ; . One such agent, JE-2147, represents a dipeptide PI which, like UIC-94017, is potent in vitro against a wide spectrum of HIV-1 strains, including HIV-1 variants highly resistant to multiple PIs 31 ; . JE-2147, unlike UIC-94017, possesses a P2 benzylamide group that has two rotatable bonds between the amide and the phenyl ring. This flexible P2 substituent, which can adapt to structurally altered active sites of mutant HIV-1 proteases and maintain its tight binding to protease, is believed to be responsible for the potent activity of JE-2147 against multi-PI-resistant HIV-1 variants 31 ; . In contrast, the observed extreme potency of UIC-94017 seen in the present in vitro study appears to stem from the formation of strong hydrogen bonds between the two oxygens of UIC-94017's bis-THF and the main chains of Asp-29 and Asp-30 in the S2 subsite Fig. 2 ; . More importantly, the reason that UIC-94017 exerts potent activity against multi-PI-resistant variants is also presumably due to its interaction with the main chains not the side chains, with which other PIs interact ; of these two aspartic acids. Indeed, the Asp-303Asn substitution emerges as a primary substitution in HIV-1 following long-term exposure to NFV, which is known to interact with the side chain of Asp-30, and presumably alters the NFV-protease interaction and confers on the virus resistance to NFV 19, 20 ; . Although HIV-1 selection experiments with UIC-94017 are under way in H.M.'s laboratory, it is worth noting that HIV-1 strains exposed to UIC-94003 30 ; , an analog of UIC-94017, did not undergo a substitution at codon 30, probably because side chain changes do not confer on the virus resistance to UIC-94003, as described previously 30 ; . Instead, HIV-1 strains exposed to UIC-94003 acquired a unique Ala3Ser substitution at residue 28 at the active site of the enzyme, which can produce a steric and electrostatic expulsion and which may alter the conformation of the enzymatic active site composed of Asp-29 and Asp-30 30 ; . The unique characteristics exhibited by the bisTHF group of UIC-94017--namely, its close position and tight binding to the main chains of the active-site amino acids, Asp-29 and Asp-30, which differ from the profiles of other.
Although tobacco smoke contains several substances, nicotine appears to be the critical reinforcing component of tobacco smoke.710 Therefore, for simplicity, we will consider here that nicotine is responsible for most of the effects of tobacco smoke in humans. A large body of evidence implicates 42nicotinic acetylcholine receptors in the reinforcing effects of nicotine.11, 12 The initial effect of nicotine is probably to activate 42-nicotinic acetylcholine receptors located on dopamine neurons in the ventral tegmental area; however, it is likely that these receptors are rapidly desensitized, whereas nicotine produces a sustained effect on dopamine release in the nucleus accumbens Figure 1 ; . According to the "dopamine hypothesis" of drug dependence, the increase in dopamine levels in the nucleus accumbens produced by drugs of abuse is critical to the drugs' ability to induce motivational and reinforcing properties.13 Although the nucleus accumbens plays a pivotal role in drug-seeking behaviour, the influence of the prefrontal cortex, the amygdala and the hippocampus which, through the glutamate and -aminobutyric acid [GABA] neurons, mediate the drive to take drugs, the influence of drug-associated cues and the memory of drug taking ; is critical Figure 1 ; . Therefore, medications that act on glutamate or -aminobutyric acid systems probably hold the promise of reducing drug cravings or avoiding relapse.14 Several other promising approaches are currently under investigation.1517 Tobacco withdrawal triggers a range of unpleasant and stressful signs and symptoms, 18 including headache, nausea, constipation or diarrhea, falling heart rate and blood pressure, fatigue, drowsiness or insomnia, irritability, difficulty concentrating, anxiety, depression, increased hunger and energy inFrom the Translational Addiction Research Laboratory Le Foll ; and Addiction Psychiatry George ; , Centre for Addiction and Mental Health, University of Toronto, Toronto, Ont and celebrex.
Extremely likely to eventually return to your drug of choice because this will short-circuit your ability to control impulsive action. You have to be very cautious when you become physically ill, even with respiratory diseases colds, flu, or pneumonia ; because many of the drugs used to treat these conditions cause mood changes and decreased ability to control impulses. There are many compounds that will cause you to crave a drink drug.many cough syrups have narcotics in them. It is difficult to remember which drugs to avoid and so this list of medications has been prepared for you.what you can take and what you must avoid. You have to take responsibility for all of your future drug use because not every physician, pharmacist, or dentist knows about the nature of your condition and what you have learned. If you have a particular problem, be sure and discuss it with your case manager. No drug of any kind is to be taken without prior notice to your treatment provider. LET YOUR PHYSICIANS, DENTISTS, PHARMICISTS, AND ALL OTHER PERSONS THAT WILL BE INVOLVED IN YOUR RECEIVING MEDICATIONS KNOW THAT YOU ARE IN RECOVERY. THIS IS EXTREMELY IMPORTANT IN THE MAINTENANCE OF YOUR RECOVERY! In the following pages will be lists of drugs you can and cannot take safely. Please pay close attention to the medications that you receive to insure long-term health and recovery from addiction. DRUGS THAT CAN BE TAKEN Do not use any amount beyond what is recommended. Advil Aleve Aspirin Tylenol Ibuprofen Toradol Clinoril Feldene Meclomen Motrin Nalfon Naprosyn Robitussin DM 5cc every 4 hrs. for cough ; Tessalon Perles for cough Ecotrin Sudafed Medipren.
U.S. Community Right-to-Know Act, 21: 831 U.S. Defense Logistics Agency DLA ; , titanium sponge solicitation by, 24: 848. See also United States U.S. Department of Agriculture USDA ; , 12: 3334; 21: See also Department of Agriculture DOA ; U.S. Department of Energy DOE ; , radioactive waste management by, 25: 852, 855, See also Department of Energy DOE ; U.S. Department of Labor Safety Standards, 15: 768 U.S. Department of Transportation, nitric acid categories, 17: 188 U.S. Department of Transportation DOT ; , 21: 568, 25: See also Department of Transportation DOT ; labeling regulations of, 21: 115t radioactive waste transport regulation by, 25: 855 United States Enrichment Corporation USEC ; , 25: 413, 416 U.S. Environmental Protection Agency USEPA ; , biotechnology regulation by, 13: 285, 18: See also Environmental Protection Agency EPA ; U.S. Environmental Protection Agency USEPA ; , pesticide tolerance levels and, 14: 337 U.S. Environmental Protection Agency Toxic Substances Control Act U.S. EPA TSCA ; Chemical Inventory and Test Submission Data Base, 13: 694 U.S. EPA Tier 2 specification, gasoline sulfur content, 10: 54. See also Environmental Protection Agency EPA ; U.S. Food and Drug Administration FDA ; , 21: 571580. See also FDA entries approval and enforcement centers within, 21: 572 consumer protection function of, 21: 572573 Defect Action Levels DALs ; of, 23: 160 organization and roles of, 21: 571573 regulation of biological products, 21: 576 regulation of cosmetics, 21: 579580 regulation of drug products, 21: 573576 regulation of food products, 21: 578579 and imitrex.
MEASUREMENT People with type 2 diabetes should have ongoing structured evaluation of microvascular and cardiovascular risk and the C development of complications. Haemoglobin A1c HbA1c ; should be measured at 26 monthly intervals; the interval should depend on.
These are serious side effects. You may need urgent medical attention. Serious side effects are rare. If any of the following happen, stop taking TORADOL and tell your doctor immediately or go to Accident and Emergency at your nearest hospital: * vomiting blood or material that looks like coffee grounds * bleeding from the back passage rectum ; , black sticky bowel motions stools ; or bloody diarrhoea * swelling of the face, lips or tongue which may cause difficulty in swallowing or breathing * asthma, wheezing, shortness of breath * sudden or severe itching, skin rash, hives * fainting, seizures or fits * pain or tightness in the chest These are very serious side effects. You may need urgent medical attention or hospitalisation. These side effects are rare. Other side effects not listed above may also occur in some patients. Tell your doctor if you notice anything else that is making you feel unwell. Ask your doctor or pharmacist if you don't understand anything in this list. Do not be alarmed by this list of possible side effects. You may not experience any of them and naprosyn!
MEDICAL CHEMISTRY 1st semester 15 weeks ; LECTURE 3 hrs week ; Basic terms. The mole concept. Basic structure of atoms. Electronic structure of atoms. Atomic theories. The periodic table. Explanation of periodic properties. Chemical bonding. Octet rule. Ionic, covalent and metallic bondings. Intermolecular forces: hydrogen bonding, van der Waals forces dipole-dipole and London forces ; . Introduction to inorganic chemistry. Properties of the most important elements and their compounds. Biological importance and usage. States of matter. The gaseous state: gas laws, Avogadro's law. The liquid state: properties of liquids, dependence of phase changes on pressure and temperature. The solid state: properties of solids, types of crystalline SEMINAR 1 hr week ; Important terms: atomic mass, molar mass, moles, chemical formulas. Chemical reactions, stoichiometry, SI units, simple chemical calculation involving Avogadro's number and moles. Atomic models, electronic configuration of atoms. Chemical calculations: concentration of solutions. PRACTICE 2 hrs week ; Review of laboratory requirements. Fire and safety precautions. Demonstration of laboratory equipments. Background of volumetric analysis. Using a pipette and a burette. Titration calculations!
72. Neitzel H. A routine method for the establishment of permanent growing lymphoblastoid cell lines. 73. Girardin SE, Boneca IG, Viala J, Chamaillard M, Labigne A, Thomas G, et al. Nod2 is a general sensor of 74. Yamamoto Y, Gaynor RB. Therapeutic potential of inhibition of the NF-kappaB pathway in the treat75. Rioux JD, Abbas AK. Paths to understanding the genetic basis of autoimmune disease. Nature 2005; 76. Schreiber S, Rosenstiel P, Albrecht M, Hampe J, Krawczak M. Genetics of Crohn disease, an archetypal 77. Zhou Z, Lin XY, Akolkar PN, Gulwani-Akolkar B, Levine J, Katz S, et al. Variation at NOD2 CARD15 in 2002; 97: 3095-3101. inflammatory barrier disease. Nat Rev Genet 2005; 6: 376-388. ment of inflammation and cancer. J Clin Invest 2001; 107: 135-142. peptidoglycan through muramyl dipeptide MDP ; detection. J Biol Chem 2003; 278: 8869-8872 and maxalt.
AMREV1ATE0 PRESCRIBING INFORMATION: TORADOL' tor intramuscular injection 30mo ml TORADOL' lor oral administration 10mg tablet Please refer to both data sheets before prescribing USES: Intramuscular injection - relief of pain associated with surgical procedures Onl tablets - short-term management of moderate pain associated with surgical procedures DOSAGE: Intramuscular injection Adults initially 30mg im followed by 10 to 30mg im every 4-6 hours as required. A total daity dose greater than 120mg is not recommended In the initial postoperative period. TORADOL may be given as often as every 2 hours t required Continuous im usage should not exceed 5 days. Elderly: A lower total daily dose is recommended. Onl tablets Adults 10mg every 4-6 hours as required Doses exceeding 40mg per day are not recommended. Intended for short-term use only Elderly A longer dosing interval e g 6-8 hourly nay be advisable Intnimoalar hifedkM and onl tablets For patients who nave received parenteral TORAOOL and are converted to oral tablets, a total combined daily dose of all forms should not exceed 120mg on the day the change of formulation is made. Not recommended for children under 16 years Reduce daily dose in renal impairment. Opiate analgesics may be used concomitants if required The following information refers to both the intramuscular and oral dosage forms CONTRAINOICATIONS: History of peptic ulcer coagulation disorders hypefsensitwty to ketorolac trometamol: NSAID-mduced allergy; treatment with lithium salts; asthma. severe renai insufficiency WARNINGS AND PRECAUTIONS: Use with care in the etderty, in patients with a history of Gl disease, those with cardiac, renal, hepatic or allergic disease hypertension, those who are hypovoiaemic and those taking diuretics NSAIDs have been associated with renal disease Fluid retention may occur TORADOL inhibits platelet aggregation and may prolong bleeding time Caution is advised where stnct haemostasis is cntical Prothrombin time should be monitored in patients recewng orai anticoagulants Renal clearance of ketorolac is decreased by probenecid NSAIDs decrease renal clearance ol mettiotrexate TORADOL reduces the diuretic response to frusemide. Concomitant use of other NSAIDs is not recommended. Not recommended in pregnancyflabour or in breast-feeding women SIDE-EFFECTS: see data sheets ; Gl Nausea, vomiting, dyspepsia diarrhoea, peptic ulcer, haemorrhage, perforation constipation CNS Drowsiness dizziness, headache, convulsions Renal Acute renal failure, flank pain haematuna, raised Wood urea Other Hypersensrnvity reactions anaphylaxis. bronchospasm. laiyngeal oedema, hypotension flushing, rash ; , purpura, oedema, abnormal liver function tests, postoperative wound haemorrhage Iniectran site pain has occurred following administration of the intramuscular injection PRESENTATION: TORADOL intramuscular injection Single-dose ampoules containing ketorolac trometamol 30mg, ethanol, sodium chloride and water in a 1ml solution PL 0286 0111, 10 ampoules 1314 ; TORADOL tablets White creamy-white round film-coated tablet each containing ketorolac trometamol 10mg. PL 0286 0125. 100 tablets 3343 ; Further information is available on request from Syntex Pharmaceuticals Limited. Syntex House. St Ives Road Maidenhead, Berkshire. SL6 1RD "TORADOL is a trademark. References: 1. O'Hara DA. Fragen RJ Kiruer M, Pemberion D Clm Pharmacol Ther 1987: 41: 556-61 Yee JP, Koshiver JE, Allbon C. Brown CR Pharmacotherapy 1986; 6 253-61 Data on Syntex file CL5724.
F. Perna 1 , L. Gatta 1 , N. Figura 2 , J. Holton 3 , J. Osborn 4 , C. Ricci 1 , A. Tampieri 1 , M. Miglioli 1 , D. Vaira 1 . 1 Dept of Internal Medicine and Gastroenterology, Bologna, Italy, 2 Dept of Internal Medicine, Siena, Italy, 3 Dept of Microbiology, University College, London, United Kingdom, 4 Department of Public Health Science, La Sapienza University, Rome, Italy Aim: to compare M susceptibility testing by agar dilution AD ; , epsilometer test E-t ; and disk diffusion DD ; in Hp isolates; Methods: Biopsies from 90 Hp positive patients were streaked onto Pylori Agar BioMerieux ; the same day of the endoscopy. All plates were incubated in a microaerobic environment, at 37 C, for seven days, and inspected daily from the third day. The isolates were identified by Gram stain and by oxidase, catalase and urease tests. All susceptible tests were carried out on Mueller-Hinton agar with 5% aged sheep 3 2 week old ; blood freshly prepared. AD was performed as described by the approved NCCLS and serial log2 concentrations were obtained range 0.016 to 256 mg ml ; , DD was carried out using M-disk 5 mg ; and E-t AB Biodisk, Solna, Sweden ; , was performed according to manufacturers' guidelines. For AD and E-t, isolates were considered M-R if the MIC was 3 8mg ml, whilst for DD an inhibitory zone diameters of less than 20 mm was regarded as resistant. Hp ATCC 43504 was used as quality control reference strain. Results: 44 90 isolates 48.9% ; were M-R with AD, whilst E-t and DD found 42 90 isolates 46.7% ; M-R, with no significative difference between the proportions p 0.88 ; . Inter-test variability among AD and E-t showed that 34.4% n 31 90 ; of MICs were equivalent within 1 log2 ; and 65.6% n 59 90 ; were major errors 1 log2 ; . Among the 65.6%, 3.38 n 2 ; had a change in susceptibility pattern very major errors ; for both comparisons. Overall discordance was found in 2.2% 95%CI: 0.6% to 7.7% ; when E-test and DD were compared to AD. No discrepancy between E-test and DD as pattern susceptibility. Conclusions: Our data showed a good agreement among the tests used. The use of fresh biopsies and plates for all susceptibility tests may explain this high agreement and cafergot.
Jason G Whalen, B.S.; University of Pittsburgh School of Medicine, 559 Robin Drive, Pittsburgh, PA Background: The "ABCD" mnemonic for cutaneous melanoma CM ; A-Asymmetry; B-Border Irregularity; C-Color Variegation; D-Diameter of 6 mm or greater ; is a summary message that is being used on a national level in an attempt to reduce mortality. Tumor diameter is directly proportional to tumor thickness, and tumor thickness is directly correlated with the age of diagnosis. Hence, younger patients have smaller, thinner, and hence more curable tumors as compared to older patients. Therefore, the current ABCD's of CM may be focusing on more advanced tumors. Objective: The purpose of this study was to assess the proportion of CM's less than 6 mm and to compare the age of diagnosis with both tumor diameter and thickness. Methods: A retrospective review was conducted of consecutive patients with intact primary CM from 1993-99 in a university dermatology ambulatory setting. The largest diameter LD ; , obtained from either the dermatopathology report or patient record, was recorded for each case. In addition, age, sex, race, tumor thickness, anatomic level of invasion and anatomic site of the primary tumor was recorded. Results: 196 cases of CM were accessioned, of which 97 had a LD recorded. The proportion of CM's, as assessed by the LD, that were 6 mm and 6 mm was 29 97 29.9% ; and 41 97 42.3% ; respectively. For CM's 6 mm, the majority were seen in ages 25-34, while the preponderance of CM's 6 mm were in the 45-54 year range. 81.3% of patients 55 years had a Breslow Thickness 0.76 mm, while 57.9% of patients 55 years had a Breslow Thickness 0.76 mm. Of the 196 total cases of primary CM reported that had a median tumor thickness of 0.6 mm, the majority were melanoma in-situ, involved whites and males, were located on the trunk, and invaded no deeper than Clark's level II. Conclusion: This analysis has found that approximately 30% of primary CM's have a tumor diameter less than 6 mm and 40% of CM's have a tumor diameter equal to or less than 6 mm. In addition, patient age was found to be directly proportional to both tumor thickness and diameter, as the smaller & thinner CM's were seen in the younger population. Hence, these findings do not apply to the ABCD mnemonic propagated by the American Academy of Dermatology and the American Cancer Society. This message may have adverse health consequences if used by the general public in the selfdetection of CM since smaller diameter tumors tend to be thinner and more curable than large diameter tumors. P421 AN EARLY DIAGNOSED BUT LATE TREATED SUBUNGUAL MELANOMA: THE IMPORTANCE OF PUBLIC AWARENESS.
Commonwealth Edison experienced numerous simultaneous extended outages among the eight units at its Dresden, LaSalle, Quad Cities, and Zion nuclear stations. For example, during the first six months of 1996, the utility had at least three units shut down at any one time for extended outages of longer than three months in duration. Commonwealth Edison had at least four units shut down at any one time for extended outages during the last six months of 1996, except for a short period at the end of August and early September. The utility also experienced simultaneous outages of at least six months in length at its two unit Zion nuclear station from October 1993 through April 1994 and at its two unit LaSalle Station from September 1996 through 1998. Both units at the D.C. Cook Nuclear Plant in Michigan were shutdown from September 1997 through June 2000. Both units at the Salem Nuclear Station were shutdown for more than two years between July 1995 and August 1997. Both units at the Brunswick nuclear plant were shutdown for the twelve month period April 1992 through April 1993. Both units at the Calvert Cliffs nuclear plant were shut down at the same time for more than one year starting in May 1989 and pyridium and Buy toradol.
Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Pain severity 0-10 ; is a vital sign to be recorded pre and post IV or IM medication delivery and at disposition. Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications. Contraindications to Morphine use include hypotension, head injury, respiratory distress or severe COPD. Ketorolac Toradol ; and Ibuprofen should not be used in patients with known renal disease or renal transplant, GERD, PUD, patients who have known drug allergies to NSAID's non-steroidal anti-inflammatory medications ; , or patients who may need surgical intervention such as open fractures or fracture deformities. Also, Toradol SHOULD NOT be administered if there is an aspirin allergy, asthma, head injury or if anticoagulants have been administered. All patients should have drug allergies documented prior to administering pain medications. All patients who receive IM or IV medications must be observed 15 minutes for drug reaction.
A second study of Schering's betaferon in patients with secondary progressive MS has failed to reach its primary endpoint, time to confirmed disease progression. The company put the result down to "the surprisingly low progression rate in the study population", associated with the recruitment of patients with more advanced disease. Patients in the betaferon group did have a lower rate of relapses and a reduction in inflammatory activity in the brain. The results were presented at a recent American Academy of Neurology meeting and diclofenac.
Role of RAAS modulation continues to evolve Several major ongoing trials are assessing the effects of RAAS modulation on CV events and diabetes. Results are anticipated beginning in 2007.
Problem with case: Nursing concern that splint was applied to swollen ankle; the patient was transferred with vascular compromise. Case summary: 51 year old presented with displaced fracture dislocation of an ankle. He was treated with PO Toradol and splinted then referred to orthopedics. At CBRH the ER physician reduced the ankle prior to seeing orthopedics. Standard of care below Comment: This ankle required fairly urgent reduction, which is something an experienced ER physician, should have carried out. He should have been given morphine prior to transfer, which does not appear to have been done. Oral Toradol is completely inadequate. It is unclear if there was vascular compromise to me and even if there was the best thing that could have been done, and was done, was to transfer to orthopedics. As for waiting for the swelling to go down prior to splinting, as seems to be the complaint is completely without foundation. The lack of immediate reduction and adequate pain management is regrettable and reflects a minimal level of care and is not in keeping with an experience physician." 206. Dr. Sutton considered that R.M.'s care was marginal after noting that there was "no.
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6. Liebeskind JC. Pain can kill. Pain 1991; 4 Lillemoe KD, Cameron JL, Kaufman HS, Yeo CJ, Pitt HA, et al. Chemical splanchnicectomy in patients with unresectable pancreatic cancer. Ann Surg 1993; 217: 447-57. Bonica JJ, Ekstrom JL. Systemic opioids for the management of cancer pain: an updated review. Adv Pain Res Ther 1990; 14: 425-46. Silverberg E, Boring CC, Squires TS. Cancer statistics, 1990. CA Cancer J Clin 1990; 40: 9. American Cancer Society. Cancer facts and figures: 1994. Atlanta: ACS, 1994. 11. Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330: 592-6. Higginson, I.J. Innovations in assessment: epidemiology and assessment of pain in advanced cancer. In: Jensen TS, Turner JA, Wiesenfeld-Hallin, Z, editors. Proceedings of the 8th World Congress on pain, Progress in Pain Research and Management Vol. 8. Seattle, IASP Press 1997; p. 707-11 13. American Cancer Society. Cancer facts and figures: 1989. Atlanta: ACS, 1989. 14. Walsh TD. Oral morphine in chronic cancer pain. Pain 1984; 18: 1-11. Bruera E. Malnutrition and asthenia in advanced cancer. Cancer Bull 1991; 43: 387. Bonica JJ. Management of Cancer pain. Rec Res Cancer Res 1984; 89: 13. Daut RL, Cleeland CS. The prevalence and severity of pain in cancer. Cancer 1982; 50: 1913-8. Mumford JW, Mumford SP. The care of cancer patients in a rural South Indian hospital. Pall Med 1988; 2: 157. World Health Organization. Cancer Pain Relief. Geneva: WHO, 1986. 20. Portenoy RK. Cancer pain: epidemiology and syndromes. Cancer 1989; 63 11 Suppl ; : 2298-307 21. Brescia FJ, Adler D, Gray G, Ryan MA. A profile of hospitalized advanced cancer patients. J Pain Symptom Manage 1990; 5: 221-6.
The Guild was looking for evidence that a reduction in Pharmacy numbers will reduce distribution costs. The Guild was looking for the Government's long term social objectives for the PBS and its perceptions of the ideal system. My view is that this has been researched time and time again, and the proof is there that we do have the best system in the world. The problem for pharmacy lies with the fact that each time a new Agreement is hatched that the intellectual knowledge on the Government's side is lost, and the profession has to start all over again with a group that holds a view that small business is a blot on.
Levels of endogenous opioid peptides Cheng, Pomeranz, & Yu, 1980; Clement-Jones, McLoughlin, Lowry, Besser, Rees, & Wen, 1979. Stimulating specific acupuncture points on the ears, hands, and the back of the neck may reduce alcohol craving and decrease withdrawal symptoms in alcoholics however acupuncture probably does not reduce craving and relapse after treatment is discontinued Konefal, Duncan, & Clemence, 1994; Richard, Montoya, Nelson, & Spence, 1995 and buy carisoprodol.
1. Endovascular repair of infrarenal aortic and or common iliac aneurysms may be considered in patients at low or average surgical risk. Level of.
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All patients anticipating surgery must stop the use of aspirin, aspirin-containing, and anti-inflammatory compounds 714 days prior to surgery. These drugs interfere with normal platelet function and can lead to bleeding problems in normal individuals during surgery. You may take acetaminophen Tylenol ; as needed prior to surgery. If you need another medicine for pain control prior to surgery, notify your doctor. You must not be on any diet pills especially Redux ; prior to surgery. You should also be off of "St. John's Wart" and high dose garlic for at least one week prior to surgery. The following list contains a few of the most common aspirin-containing or aspirin-like products to be avoided: Advil Alka Seltzer Alleve Anacin Anaprox Arthrotec Ascriptin Aspirin Bayer BC Powder Bextra Bufferin Darvon Compound Daypro Diclofenac Ecotrin Empirin Etodolac Excedrin Excedrin Migraine Feldene Fiorinal Goody's Headache Powder Ibuprofen Indocin Ketoprofen Ketorolac Lodine Midol Mobic Motrin Naprosyn Naproxen Norgesic Novasen Nuprin Orudis Oruvil Pediprofen Percodan Piroxicam Redux Relafen Soma Compound Sulindac Synalgos DC Toradol Vicoprofen Voltaren.
TEMODAR PA ; TEMOVATE * TENEX * TENORETIC * TENORMIN * TERAZOL * TERNAMAR * TESLAC TESSALON PERLES 100mg * 200mg NF ; TEST STRIPS - LIFESCAN ONLY TESTIM PA ; THALOMID PA ; THEO-24 * THEOCHRON * THEO-DUR * THEOLAIR 80 * THEO-VENT * THIOGUANINE * THORAZINE * TICLID * TIGAN * TIMOPTIC XE * TIMOPTIC * TINACTIN * OTC ; TOBI TOBREX * TOFRANIL * TOLECTIN, DS * TOLINASE * TOPAMAX TOPICORT * TOPROL XL TORADOL * QL ; T-PHYL * TRACLEER PA ; TRANDATE * TRANXENE * TRAVATAN 2.5ml only ; TRENTAL * TRIAVIL * TRIGLIDE TRILAFON * TRILISATE * TRIMO-SAN GEL * OTC ; TRIMOX * TRIMPEX TRI-NORINYL * TRIPHASIL * TRI-VI-SOL WITH IRON * TRI-VI-SOL * TRIVORA * TRIZIVIR TRUVADA T-STAT * TUMS * OTC ; TUSSI-12 S * TWINJECT TYLENOL #2, 3, 4 * capsules NF ; TYLENOL * TYLOX * 5 325 and 5 500 only.
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Containing 0.5g acetaminophen and a 100ml bottle containing 1g acetaminophen. Both are labeled for administration via a 15-minute intravenous infusion. In Europe, IVAPAP was initially launched in France in mid-2002, followed by Germany and Spain in 2003 and Italy and the United Kingdom in 2004. Despite this country-by-country launch, IV APAP achieved a 44% dollar share 20% vial share ; as of the fourth quarter of 2006. In 2006, IV APAP sold more than 64 million vials, which represents a 17% increase over 2005. Total sales of IV APAP exceeded 9 million U.S. dollars ; in 2006 according to IMS. We believe the United States represents a substantially larger market opportunity for IV APAP than Europe with respect to the number of surgical procedures and potential pricing. For example, the United States accounts for nearly 50% of worldwide hip and knee replacement surgeries; whereas, Europe only accounts for approximately 30% of such surgeries, according to Datamonitor. More significantly, pharmaceutical pricing continues to be higher in the United States on average. Each country in the European Union currently employs direct and other forms of price controls, including reference systems where prices for new drugs are based upon the prices of existing drugs that provide similar therapeutic benefit or prices of drugs in other European countries. According to IMS, the average selling price in Europe was approximately .50 U.S. dollars ; per vial of IVAPAP. In contrast, the price of Toradol ketorolac ; in the United States in 1997, prior to the entry of generic competitors, was approximately .00 U.S. dollars ; per vial according to the American Journal of Health-System Pharmacy. We believe that the key product attributes that will drive adoption include the proven efficacy and established safety profile of acetaminophen, the potential ability to reduce concomitant use of morphine and other opioids, a more convenient dosage form for some patients and a more rapid onset of action. Clinical Development History Clinical Overview. There have been 2, 241 subjects, including 1, 780 subjects that received IVAPAP, studied in nine clinical trials completed by BMS, largely submitted to support the Marketing Authorization Application, or MAA, that resulted in European approval. These trials included two Phase I trials, six Phase III trials and one large Phase IV trial. Overall, we believe that the results of these nine studies demonstrate that IV APAP is safe and effective in the treatment of post-operative pain in adults and children. These trials have also demonstrated that IV APAP reduces the consumption of opioids when used in combination. Clinical Studies for Post-Operative Pain in Adults. One Phase III study evaluated 152 adult subjects with moderate-to-severe pain following total hip and total knee replacements. Subjects were randomized to receive IV APAP, intravenous propacetamol or placebo. We believe this study best demonstrates the efficacy of IVAPAP since the patients in the trial were undergoing surgical procedures with more severe levels of pain. On the primary efficacy endpoint, pain relief scores in the patients treated with IVAPAP were statistically higher p-value 0.05 ; than those treated with placebo and not statistically different than those treated with intravenous propacetamol from 15 minutes to six hours, at which point patients received a second dose. P-values indicate the likelihood that clinical trial results were due to random statistical fluctuations rather than a true cause and effect. The lower the p-value, the more likely there is a true cause-and-effect relationship. Therefore, p-values provide a sense of the reliability of the results of the study in question. Typically, the FDA requires a p-value of less than 0.05 to establish the statistical significance of a clinical trial.
Department of Health Program Document No.: 6621.01 Subject: Splinting Extremity Type: Procedure.
Heartmind Nutrition has carefully considered two rat studies, conducted by the same authors, on the pharmacologic regulation of "serum N-acetylserotonin" levels which reported behavioral changes in rats characteristic of the "serotonin syndrome" Burns et al. 1982 ref. 14. ; and Brown and Burns et al. 1984 Ref.15. ; . These studies are of questionable relevance to the use of low oral dosages of N-acetylserotonin normelatonin ; as a dietary ingredient in humans. Serum levels of N-acetylserotonin are lo-100 times higher than melatonin in humans Wolfer et al.1999 ref. 6!
| Toradol pricesThe otc nsaids, aspirin, ibuprofen, naproxen, and ketoprofen are classified as either nonselective cox inhibitors, or as slightly selective for cox- the other prescription drugs are either nonselective cox inhibitors— diflunisal dolobid ; , fenoprofen calcium nalfon ; , mefenamic acid ponstel ; , meclofenamate sodium meclomen ; , oxaprozin daypro ; , piroxicam feldene ; , salsalate disalcid ; , sulindac clinoril ; , tolmetin sodium tolectin ; — or selective for cox-1— flurbiprofen ansaid ; and ketorolac tromethamine toradol ; — or cox-2— celecoxib celebrex ; , etodolac lodine ; , meloxicam mobic ; , nabumetone relafen ; , nimesulide not available in the united states ; , rofecoxib vioxx ; , valdecoxib bextra.
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Most extrapolations from animal experimental data in the risk assessments require the utilization of uncertainty factors. This is because we are not certain how to extrapolate across species, with species for the most sensitive population, and across duration. To account for variations in the general population and to protect sensitive subpopulations, an uncertainty factor of 10 is used by EPA and ATSDR. The value of 10 is derived from a threefold factor for differences in toxicokinetics and for threefold factor for toxicodynamics. To extrapolate from animals to humans and account for interspecies variability between humans and other mammals, an uncertainty factor of 10 is used by EPA and ATSDR, and as with intraspecies extrapolations, this 10-fold factor is assumed to be associated with in toxicodynamics and toxicokinetics. An uncertainty.
There was suddenly a loud explosion, which sent Radulf and Janekin flying across the open counter. It had come from the other side of the street, where a hermit's oratory stood. The hermit himself had died some three months before, and the adjacent parishes were arguing over the appointment of his successor; but the oratory had remained a well-known place of prayer on behalf of those who had departed into purgatory. The loud explosion sent people shrieking into the street. The walls of the oratory had been blown out, and its thatched roof demolished. Radulf could not rise to his feet, and he lay among the hats and purses as wisps of straw floated through the air. Janekin had roused himself, and was brushing the dust off his taffeta jacket when he thought he saw a tall figure running towards the city. He was too shaken to raise the hue and cry. Instead he helped to support Radulf as he struggled upright, murmuring, `Christ and His tree save us!' All those around them were shrieking `Fire!' Some were wrapped in cloaks, some had quickly pulled on hose and jacket, while others were already dressed for the day's work. They clustered around the smouldering oratory, where a wooden image of the Virgin lay in fragments among the blackened stones. The air smelled of sulphur, as if the smoke of hell itself had ascended into the outer world. Radulf walked unsteadily towards the ruin, and noticed traces of dark powder on the earth floor. `They have used Greek fire, ' he said to no one in particular.
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