Mark Corson

By R. Gnar. Barrington University.

While one form of energy can be converted to another cheap 200 mg celecoxib with mastercard, heat energy 100mg celecoxib with visa, because of its random nature celecoxib 200mg on-line, cannot be completely converted to other forms of energy. First, let us examine how heat is converted to work in a heat engine (for example, the steam engine). Heat flows into the gas; this increases the kinetic energy of the gas molecules and, therefore, raises the internal energy of the gas. The molecules moving in the direction of the piston collide with the piston and exert a force on it. The heat added to the gas causes the molecules in the cylinder to move in random directions, but only the molecules that move in the direction of the piston can exert a force on it. Therefore, the kinetic energy of only the molecules that move toward the piston can be converted into work. For the added heat to be completely converted into work, all the gas molecules would have to move in the direction of the piston motion. The odds against the complete conversion of 1 cal of heat into work can be expressed in terms of a group of monkeys who are hitting typewriter keys at random and who by chance type out the complete works of Shakespeare without error. Although some of the random thermal motion can be ordered again, the ordering of all the motion is very improbable. Because the probability of completely converting heat to work is vanishingly small, the Second Law of Thermodynamics states categorically that it is impossible. Heat can be partially converted to work as it flows from a region of higher temperature T1 to a region of lower temperature T2 (see Fig. A quanti- tative treatment of thermodynamics shows (see, for example, [11-5]) that the maximum ratio of work to the input heat is Work T2 1 − (10. From this equation, it is evident that heat can be completely converted into work only if the heat is rejected into a reservoir at absolute zero temperature. Although objects can be cooled to within a very small fraction of absolute zero, absolute zero cannot be attained. In fact, the first law could lead us to the erroneous conclusion that animals should be able to function without a source of external energy. The body takes in energy that is in the chemical bonds of the food molecules and converts it to heat. If the weight and the temperature of the body remain constant and if the body performs no external work, the energy input to the body equals exactly the heat energy leaving the body. We may suppose that if the heat outflow could be stopped—by good insulation, for example—the body could survive without food. The need for energy is made apparent by examining the functioning of the body in the light of the Second Law of Thermodynamics. A single protein molecule in the body may consist of a million atoms bound together in an ordered sequence. Their specialized functions within the body depend on a specific structure and location. We know from the Second Law of Thermodynamics that such a highly ordered system, left to itself, tends to become disordered, and once it is disordered, it ceases to function. For example, the blood circulating in veins and arteries is subject to friction, which changes kinetic energy to heat and slows the flow of blood. The concentration of minerals inside a cell differs from that in the surrounding environment. Finally, cells that die must be replaced, and if the animal is growing, new tissue must be manufactured. For such replacement and growth, new proteins and other cell constituents must be put together from smaller, relatively more random subcomponents. Thus, the process of life consists of building and maintaining ordered structures. The situation is somewhat analogous to a pillar made of small, slippery, uneven blocks that tend to slide out of the structure. The work necessary to maintain the ordered structures in the body is obtained from the chemical energy in food. Except for the energy utilized in external work done by the muscles, all the energy provided by food is ulti- mately converted into heat by friction and other dissipative processes in the body. Once the temperature of the body is at the desired level, all the heat generated by the body must leave through the various cooling mechanisms of the body (see Chapter 11). The heat must be dissipated because, unlike heat engines (such as the turbine or the steam engine), the body does not have the ability to obtain work from heat energy. Even if the body did have mechanisms for using heat to perform work, the amount of work it could obtain in this way would be small. The temperature differences in the body are small—not more than about 7 C◦ between the interior and the exterior. With the interior temperature T at 310 K (37◦C) and the exterior 1 temperature T1 at 303 K, the efficiency of heat conversion to work would be (from Eq. Of all the various forms of energy, the body can utilize only the chemical binding energy of the molecules which constitute food. The body does not have a mechanism to convert the other forms of energy into work. A person could bask in the sun indefinitely, receiving large quantities of radiant energy, and yet die of starvation.

This disclosure should also be documented in the medical record in a clear and concise manner cheap 100mg celecoxib with visa. It is extremely impor- tant that the physician emphasizes to the patient that the use of social or illicit sub- stances is totally contraindicated during the course of pregnancy discount celecoxib 200 mg overnight delivery. These are not theoretical concerns because we have assisted in the defense of physicians sued for adverse pregnancy outcomes caused by substance abuse celecoxib 100mg sale, despite the physician’s appropriate counseling that the patient chose to ignore. The risk–benefit ratio for substance abuse during pregnancy is easily explained to be increased risk with no benefit. The patient consultation, particularly this aspect, must be documented in the medical record to show that the risk was recognized and patient appropriately advised. Patients have been asked to initial or sign counseling notes regarding substance abuse during pregnancy to acknowledge that they received and understood counseling. Patient consultation Pregnant women usually admit to some use of a substance, but rarely do they admit that they have a ‘problem’ with social or illicit substance. Once some substance use is admit- 298 Substance abuse during pregnancy ted, two tandem approaches to the history-taking process are suggested. Differences in substance use between weekdays and weekends are important to ascertain, because it is common for the user’s pattern of use to differ greatly between these two time periods. The patient should describe her daily activities, including any substances used, from awaken- ing to going to sleep at night on a normal weekday. The patient should be asked when she begins drinking or using drugs during the course of a day and the duration of such use. For example, does the patient use the sub- stance as an ‘eye-opener’ in the morning (Sokol et al. The patient should be asked to disclose how much of the substance is used in an average day and approximately how much would be consumed in an hour. Combined with information about the weekly pattern (weekend versus weekday), a semiquantita- tive estimate of the amount and frequency of substance use can be made. Alcohol use during pregnancy is well studied and crude risks of fetal alcohol syn- drome can actually be made by estimating the average daily dose. With other less well- researched substances used during pregnancy, daily dose information can be used only to assess the severity of maternal addiction. Very serious dependencies are, of course, associated with more severe adverse effects. At the outset, the physician should explain to the patient that the purpose of obtaining this personal and private informa- tion is to better manage the pregnancy, i. The author’s spouse is an attorney, and states that no release should ever be signed and that each person must protect their individual rights to privacy assertively. Another important aspect of patient consultation is to provide information regarding specific risks from substance use (Tables 16. The most ethical and legally sound approach is to provide information that may be verified directly with the medical litera- ture. Ultimately, the clinical conclusion/treatment is that social and illicit substance use during pregnancy is contraindicated because of the associated maternal and embryo fetal risks. The need for services to assist pregnant substance users is being recognized, and pro- grams exist in most areas. For assistance in locating such a treatment program, the physi- cian can contact their local substance abuse service, or their state’s commission on sub- stance abuse that accredits treatment facilities. Ideally, the pregnant substance user should be managed by the obstetrician in conjunction with a program designed to promote absti- nence or at least to reduce the substance use during pregnancy. The medical positions of abstinence and treatment are the only appropriate ones clinically and legally. One’s medical mal- practice insurance provider is often the most economical and efficient source of legal infor- mation as this service is often included as a provision of a medical malpractice policy. Drug injec- tion sites on the upper forearm (‘track marks’) are strong evidence of a serious substance use problem, but this is not frequently observed. Substances of abuse usually have an anorectic effect and often result in poor weight gain during pregnancy. Other possible signs of substance use during pregnancy include new-onset ‘spontaneously arising’ heart murmur and hypertension not associated with preeclampsia. Heart murmurs occur with increased frequency among women who are Clinical evaluation 301 chronic substance users. Heart murmurs also occur in association with bacterial endocarditis or a history of this disease. Chronic substance use can induce hypertension in the nonpregnant adult, although not all have been studied for hypertensive effects dur- ing pregnancy. Cocaine, heroin, and tobacco use is known to be associated with hyper- tension during pregnancy (Abel, 1980a,b; Little et al. In addition, abruptio placentae or a history of this serious complication is also an indication that substance use may be a factor. Risk of abruptio placentae may be as high as 1–2 percent among substance abusers compared to 0. A history of stillbirths may, along with other risk fac- tors, be a clue to the obstetrician that substance abuse is a complicating factor. Hidden risks of substance abuse: impurities All substances of abuse, even alcohol, may be contaminated by certain impurities. Amphetamine and methampheta- mines may contain impurities, such as lead oxides (Allcott et al. Leaded gasoline is sometimes used as the solvent, resulting in lead contamination in the extraction of cocaine paste from cocoa leaves. If not fully reacted, cyanide may be contained in the final product because illicit laboratories are usually crudely equipped for purification, with no quality control.

Doomed are all Salmonellas; doomed also are eggs of parasites that might be in the stomach (cysts) quality celecoxib 100 mg. In the past cheap celecoxib 200 mg on-line, 2/3 of a teaspoon (60 drops) of Lugol’s was the standard dose of iodine given to persons with thyroid disease trusted 100 mg celecoxib. The concept of supplementing the diet is excellent, but the pollution problem makes it prohibitive. Use only supplements and brands recommended in Sources, although the best approach is to test them yourself with your Syncrometer. Home Clean-up This is the easiest task because it mostly involves throwing things out. Your Basement To clean your basement, remove all paint, varnish, thinners, brush cleaners, and related supplies. You may keep your laundry supplies: borax, washing soda, white distilled vinegar, bleach and homemade soap. Also move any car tires and automotive supplies like waxes, oil, transmission fluid, and the spare gas can (even if it is empty) into your garage or discard them. Tack a sheet of plastic over it to slow down the rate of fume entrance into the house. Your house is taller and warmer than the garage so garage-air is pulled in and up as the warm air in the house rises. But what of the gasoline and motor fumes we are getting now due to parked vehicles? If your garage is under your house, you cannot keep the pollution from entering your home. Remove window air condi- tioners or test the dust in your home (page 485) for Freon. Would Freon react with ozone supplied to your body and thereby become biodegradable? Other ozone routes, as intravenous or rectal, have not been observed to be as effective. If you are following your progress with the Syncrometer, you will see that Freon now appears in the liver for the first time. A combination of herbs (Liver Herb Drink in Recipes, page 552) rescues the liver from its plight, and prevents the indiges- tion. After drinking liver herbs you will see that the Freon now appears in the kidneys. Take the kidney cleanse to assist the kidneys so they can finally excrete the Freon into the urine. Although toxic, at least I observe it in the liver directly, suggesting that your body is capable of handling it. Special Clean-up for Fiberglass Fiberglass insulation has microscopically small bits of glass that are free to blow into the air. They cut their way through your lungs and organs like millions of tiny knives, spreading through your body, since there is no way out for them. Your body, though, recognizes these sharp, pointed bits and tries to stop their spread by sequestering them in cysts. Most solid malignant tumors contain fiberglass or asbestos, another glass-like particle. In nearly all cases a hole can be found in the ceiling or walls, leading to fiberglass insulated parts of the house. When these holes are sealed in an air-tight manner the house air no longer is positive for fiberglass. Search for small screw holes intended for pictures, or electric outlet plates that are missing. Also remove fiberglass jackets from water heater and fiber- glass filter from furnace. Best of all, hire a crew to remove it all from your home, and replace in- sulation with blown-in shredded paper or other innocuous sub- stance. Special Clean-up for Asbestos The biggest source of asbestos is not building materials! It is especially hazardous to be aiming a stream of hot asbestos right at your face! If you have cancer or are ill, no one in the house should use an unsafe hair dryer. Turn off radiators and electric heaters and cover them with big plastic garbage bags, or paint them, or remove them. Remove every- thing that has any smell to it whatever: candles, potpourri, soaps, mending glue, cleaners, repair chemicals, felt markers, colognes, perfumes, and especially plug-in air “fresheners”. Since all vapor rises, they would come back up if you put them in a downstairs garage or basement. If other rooms have paneling or wallpaper, close their doors and spend no time in them. Remove all cans, bottles, roach and ant killer, moth balls, and chemicals that kill insects or mice. For cockroaches and other insects (except ants) sprinkle handfuls of 34 boric acid (not borax) under your shelf paper, behind sink, stove, refrigerator, under carpets, etc. A sick person should not be in the house while house cleaning or floor waxing is being done.

It actively chelates iron within cells celecoxib 100mg line, thus preventing the formation of the anthracycline--iron complex that is thought to cause cardiotoxicity order celecoxib 200mg. The first infusion should be initiated as soon as possible and within the first 6 hours after extravasation 100mg celecoxib fast delivery. Treatment on the remaining days should start at the same hour as on the first day. Dose in renal impairment: in patients with creatinine clearance <40mL/minute the Cardioxane dose should be reduced by 50%. There is no experience of such reduced doses in the treatment of extravasation therefore use of Savene in renal impairment is not recommended. Withdrawtherequireddoseandfurtherdiluteeach500mgwith25--100mLofHartmann’s(larger volumes are preferred as the infused solution is then less acidic). Inspect visually for particulate matter or discoloration prior to administration and discard if present. Remove cooling measures such as ice packs from the affected area at least 15 minutes before administration to allow sufficient blood flow. Withdraw the required dose of dexrazoxane and add to the 500mL of the Savene diluent provided. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Technical information Incompatible with No information, but do not mix dexrazoxane with other drugs during infusion. Sodium content Cardioxane: Nil Savene: Diluent contains 70 mmol/500mL Storage Store below 25 C in original packaging. Displacement value Negligible Special handling Dexrazoxane should not be handled by pregnant staff and it is recommended that gloves and other protective clothing are worn to prevent skin contact. Any contact with skin or mucous membranes should be washed immediately and thoroughly with water. Renal function and * Dose may need reducing if renal impairment serum Na and K develops. Cardiac function: If symptoms warrant * Dexrazoxane does not eliminate the risk of * left-ventricular concern cardiotoxicity. Symptoms of If symptoms warrant * Combination of dexrazoxane with chemotherapy thromboembolic concern may "risk of thromboembolism. Other: The following may be due to concurrent cytotoxic therapy: nausea, vomiting, dyspepsia, abdominal pain, diarrhoea, stomatitis, dry mouth, anorexia, dizziness, syncope, asthenia, paraesthesia, tremor, fatigue, drowsiness, pyrexia; myalgia; bone-marrow suppression, conjunctivitis; alopecia, pruritus, peripheral oedema. Significant * Dexrazoxane may "levels or effect of the following drugs (or "side-effects): interactions live attenuated vaccines including yellow fever vaccine (avoid combination), oral anticoagulants ("monitoring), phenytoin (avoid combination), dimethyl sulfoxide (avoid combination). Counselling Both sexually active men and women should use effective methods of contraception during treatment. Additionally, men should use contraception for at least 3 months after treatment has ceased. This assessment is based on the full range of preparation and administration options described in the monograph. It exerts a colloidal osmotic pressure similar to that of plasma proteins and in comparison with crystalloids, smaller volumes are required to produce the same expansion of blood volume. Pre-treatment checks (not all are necessary in an emergency situation) As this product is often used in acute, emergency settings, e. Aggressive fluid resuscita- tion can, however, dilute blood clotting factors to such an extent that a bleeding diathesis occurs). Inspect visually for particulate matter or discoloration prior to administration and discard if present. Follow immediately by the administration of appropriate isotonic replacement fluids. Technical information Incompatible with No information Compatible with Flush: NaCl 0. Serum osmolarity * Hyperosmolarity can occur particularly with hypertonic solutions and in diabetic patients. After infusion of 250mL, serum Na increases by 9--12 mmol and returns to normal in less than 4 hours. Significant * Dextran may affect the following tests: interactions blood cross-matching, biochemical measurements (glucose, bilirubin, or protein). This assessment is based on the full range of preparation and administration options described in the monograph. Diam orphine hydrochloride (diacetylm orphine hydrochloride, heroin) 5-mg and 10-mg dry powder in ampoules * Diamorphine hydrochloride is a potent opioid analgesic. It is more potent than morphine with a faster onset and shorter duration of action. It is also more water-soluble, which is useful in palliative care as high doses can be given in a relatively small volume. Pre-treatment checks * Do not use in acute respiratory depression, where there is a risk of paralytic ileus, in raised intracranial pressure and in head injury, in comatose patients, in acute abdomen, in delayed gastric emptying, in chronic constipation, in cor pulmonale, in acute porphyria and in phaeochromocytoma. Subcutaneous injection Preparation and administration Check that you have selected the correct strength of ampoule. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving the initial dose, especially elderly patients or those of low bodyweight. Intramuscular injection Preparation and administration Check that you have selected the correct strength of ampoule. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving the initial dose, especially elderly patients or those of low bodyweight.