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Tumours destroy man in a unique and appalling way allergy testing and zantac buy fml forte 5 ml free shipping, as flesh of his own flesh allergy treatment vancouver order fml forte 5 ml with amex, which has somehow Romanian proverb been rendered proliferative allergy medicine 0025-7974 fml forte 5 ml purchase with mastercard, rampant allergy medicine for juniper order fml forte us, predatory If you wish to die soon allergy testing symptoms buy fml forte 5 ml online, make your physician and ungovernable. Report of the Special Health Commission, transmitted to the A Discourse Upon the Origin and the Foundation of the New York Legislature,  February () Inequality Among Mankind Pt  () It is common sense to take a method and try it. If Teach him to live rather than avoid death: life is it fails, admit it frankly and try another. Isabel the birth tenderly and with her annointed hands, Hapgood) so that it may be reduced again to a natural birth. Everybody knows how to bring up Letter to Dr David Hosack,  August () other people’s children. Address at a Hernia Conference, Newport, Wales, May The Crown of Wild Olive () The work of science is to substitute facts for appearances, and demonstrations for impressions. If I were a medical man, I should prescribe a holiday to any patient who considered Saki (H. British novelist and short story writer The Autobiography of Bertrand Russell Vol. Oxford University Press, Oxford () Robert, Marquis of Salisbury – English statesman and author Frederick Saunders – Doctors are a social cement. The language of the men of medicine is a fearful Science :  () concoction of sesquipedalian words, numbered by H. British Journal of Surgery : – () The physician that bringeth love and charity to the sick, if he be good and kind and learned and George Santayana – skilful, none can be better than he. Sayers – Science is nothing but developed perception, British crime writer interpreted intent, common sense rounded out If accidents happen and you are to blame, take and minutely articulated. Medical historian Santorio Santorio – Italian physician, Capodistria, and inventor of the clinical Integrity and rectitude in our profession are thermometer paramount. Archives of Internal Medicine :  () Obviously this method I have discovered is of great importance, since it enables us to ascertain the precise amount of that insensible perspiration interference which, according to Hippocrates and Richard Schatzki –? The development of ideas of what constitutes a good death can even be Surgery is the endeavor where intellect and traced to prehistory. Oxford University Press, Oxford () Book Review of Stapling in Surgery   ·    Béla Schick – Pain is a more terrible lord of mankind than even Austrian paediatrician death himself. Wolf) It is our duty to remember at all times and anew that medicine is not only a science, but also the Children are not simply micro-adults, but have art of letting our own individuality interact with their own specific problems. Wolf) Sir Walter Scott – First the patient, second the patient, third the Scottish author patient, fourth the patient, fifth the patient, and then maybe comes science. We first do everything There is no harder worker in all Scotland, and for the patient; science can wait, research can none more poorly requited, than the village wait. The practice of Professor of philosophy and author medicine is like heart muscle contraction – it’s all The hunt has run its course, and the fox will die. His death will be quick—quicker by far than the Aphorisms and Facetiae of Béla Schick ‘Early Years’ (I. Wolf) death of a mouse in the paws of a cat, of a rat in the jaws of a terrier or of a human in the hands of The physician’s best remedy is Tincture of Time! Yellow Jersey Press, London () Johann Christoph Friedrich von Frank Scully Schiller – You are not crippled at all unless your mind is in a German poet, philosopher, and physician splint. Bartlett’s Unfamiliar Quotations (Leonard Louis Levinson) All significant diseases, especially those issuing from a malignancy of the abdomen, are heralded Sir Harry Secombe – by a greater or lesser upheaval of personality. Welsh comedian and singer Prosaïsche Schriften (Erste Periode) My advice if you insist on slimming: Eat as much as you like—just don’t swallow it. Johann Lukas Schönlein – Attributed German-born Zurich physician We return to those foundations, to those pillars David Seegal –? Dover Publications, New York practice would find it difficult to single out a dull () (original W. Journal of the American Medical Association :  () Albert Schweitzer – French Protestant theologian and medical missionary The involved student may thus come to appreciate that work, work, and more work plus a sense of Here, at whatever hour you come, you will find proportion will ease him over the unexpected and light and help and human kindness. Lambaréné Journal of Medical Education :  ()    ·  The sound clinician attacks the core of the I was instantly struck with the close resemblance problem and avoids being mousetrapped by of the malady from which Kolletschka died to that tangential data. On the death of his friend the professor of Jurisprudence after being pricked by a needle during a post-mortem. The Pharos of Alpha Omega Alpha :  () Aetiologie, Begriff und Prophylaxis der Kindbettfiebers The proper study of geriatrics begins with pediatrics. Journal of Pediatrics :  () Progress in medical science depends chiefly on the Seneca c. Journal of Pediatrics :  () Hercules Oetaeus An increasing worship of the instrument for its Time heals what reason cannot. Agamemnon  Journal of Pediatrics :  () At the beginning no one tries extreme remedies. Agamemnon  John Selden – Nothing hinders a cure so much as frequent English historian changes of medicine. Chatto & Windus, London () quality: if prolonged it cannot be severe, and if Who can gaze on so much misery and feel no hurt? That alone should am old, I shall try to die well; but dying well make him kinder to strangers. His shelves are lined with Not even medicine can master incurable rolls of skin, each with its subtleties of texture and diseases. Chatto & Windus, London () of inn which is to be left behind when one perceives that one is a burden to the host. It is owing to the doctors that there is so high a Attributed mortality in childbed. Aetiologie, Begriff und Prophylaxis der Kindbettfiebers Attributed    ·     Marie de Sévingé – The miserable have no other medicine. For there was never philosopher Letter to her daughter That could endure the toothache patiently. For in that sleep of death what dreams may come – When we have shuffled off this mortal coil, Irish-born playwright Must give us pause. Take utmost care to get well born and well If the cook help to make the gluttony, you help brought up. Therefore much drink may be said to From his Preface on Doctors published with The Doctor’s be an equivocator with lechery. From his Preface on Doctors published with The Doctor Macduff was from his mother’s womb Dilemma () Untimely ripp’d. No man can be a pure specialist without being in From his Preface on Doctors published with The Doctor’s the strict sense an idiot. Dilemma () Attributed To give a surgeon a pecuniary interest in cutting An asylum for the sane would be empty in off your leg, is enough to make one despair of America. Attributed From his Preface on Doctors published with The Doctor’s Youth is a wonderful thing. He may be hungry, weary, sleepy, run down by Attributed several successive nights disturbed by that Science is always wrong. It never solves a problem instrument of torture, the night bell; but who ever without creating ten more. We think no more of the condition of a doctor attending a case than the condition of a fireman at a fire. From his Preface on Doctors published with The Doctor’s Percy Bysshe Shelley – Dilemma () English poet If I refuse to allow my leg to be amputated, its There is no disease, bodily or mental, which mortification and my death may prove that I was adoption of vegetable diet and pure water has not wrong; but if I let the leg go, nobody can ever infallibly mitigated, wherever the experiment has prove that it would not have mortified had I been been fairly tried. Operation is therefore the safe side for Queen Mab Notes the surgeon as well as the lucrative side. From his Preface on Doctors published with The Doctor’s Dilemma () William Shenstone – It does happen exceptionally that a practising English poet doctor makes a contribution to science... John Shepherd – From his Preface on Doctors published with The Doctor’s Dilemma () British surgeon A serious illness or a death advertises the doctor Every surgeon should be something of a physician. From his Preface on Doctors published with The Doctor’s Dilemma () Richard Brinsley Sheridan – When men die of disease they are said to die from natural causes. When they recover (and they mostly Irish-born British dramatist do) the doctor gets the credit of curing them. I had rather follow you to your grave than see you From his Preface on Doctors published with The Doctor’s owe your life to any but a regular-bred physician. Sir Bloomfield Bonnington’s cry in The Doctor’s Dilemma () Charles Scott Sherrington – There is no love sincerer than the love of food. The then we are supposing the brain to be much more sound body is a product of the sound mind. The man with toothache thinks everyone happy Man on his nature whose teeth are sound. Cancer, Diagnosis, Treatment and Prognosis, Ackerman and Misalliance Preface, ‘Parents and Children’ del Regato Mosby ()    ·  . Our doctor would never really operate unless it American Journals of Obstetrics and Gynecology :  () was necessary. They must want it and Attributed be prepared to do their share and to cooperate fully in whatever health program a country develops. Medical and Surgical Practitioner’s Memorandum Proceedings of the American Philosophical Society :  () Disease creates poverty and poverty disease. These are highly social not only to the mothers and ancestors but also to functions and we must look at medicine as the obstetricians and midwives. Phoenix Books, New York Oxford () () We must also keep in mind that discoveries are At all times disease isolated its victims socially usually not made by one man alone, but that because their lives are different from those of many brains and many hands are needed before a healthy people. Oxford University Press, Most dangerous to society was an unskilled Oxford () surgeon. In pre-Hitler Oxford () Germany it was estimated that the country lost No doctors live on in the memory save the more women from septic abortion than from exceptional beings who enriched the healing art tuberculosis. Phoenix Books, New York Quoted in Journal of the History of Medicine and Allied () Sciences :  () Illness, in general, is not a good literary subject. The Death of Humane Medicine () Men leave arms and legs behind, severed by the frost, and the cruel cold cuts off the limbs already The pursuit of health is a symptom of unhealth. In: Cured to Death, Arabella Pure water is the world’s first and foremost Melville and Colin Johnson. London () Adam Smith – Scottish economist Viscount Simon – Science is the great antidote to the poison of Lord Chancellor of England enthusiasm and superstition. Medicolegal judgment () Alexander Smith – Scottish poet To have to die is a distinction of which no man is James Young Simpson – proud. Allen and Unwin, London () Italians used to find their mate at a distance, on average, of 600 yards. British anaesthetist Quoted in The Human Pedigree George Allen and Unwin, London () My hands are then henceforth, washed of chloroform and devoted to ether. Sunday Times  July (), commenting on the case of Whilst a disease can be described and diagnosed, Dr Harold Shipman, mass murderer we can dare not to suspect to cure it by any manner of means. Homer William Smith – Quoted in: Dictionary of Medical Eponyms (nd edn), p. The Death of Humane Medicine () All Trivia ‘Last Words’   ·    Sydney Smith – A Frenchman will sooner part with his religion British churchman and essayist and wit than with his hair, which indeed, no consideration will induce him to forego. Travels through France and Italy, ‘Letter from Paris, October , Letters to Arthur Kinglake ’ There is only one rule of professional conduct. To know what kind of a person has a disease is as A Memoir of the Revd Sydney Smith (quoted by Lady Holland) essential as to know what kind of disease a person has. Death must be distinguished from dying, with Journal of Medical Education :  () which it is often confounded. Crito (quoted by Plato) Letter to Dr Holland, June () Base men live to eat and drink, and good men eat One evil in old age is, that as your time is come, and drink to live. Apoplexy is an affection of the Everyone who is born holds dual citizenship in the head; paralysis is nervousness; gangrene is pain kingdom of the well and in the kingdom of the sick. Illness as Metaphor Letter to Mrs Holland, January () What is childhood but a series of happy delusions? Storr) Great discoveries which give a new direction to currents of thought and research are not, as a Merrill C. Boston Medical and Surgical Journal :  () One look is worth a thousand listens. Since appeared all the uncouth gravity and supercilious illness is man’s reaction to disease, it is a time self-conceit of a physician hot from his studies. Bartlett’s Unfamiliar Quotations (Leonard Louis Levinson) Spanish Proverbs David Spodick Bleed him and purge him; if he dies, bury him. We alter physiology, arrest inflammation, and remove Science is madness if good sense does not cure it. For the past  years, British doctors have had Hospital Doctor  November () privileged arrangements for accounting for themselves; privileged not only among other health care workers but also among all other Sir James Calvert Spence – occupations. Quoted in The Great Doctors—A Biographical History of Principles of Biology Pt I, Ch. Few seem exercise will sooner or later have to find time for conscious that there is such a thing as physical illness. The Conduct of Life, Address at Liverpool College, Attributed  December ()   ·     Issac Starr –? A corporate sector in health care is also likely to aggravate inequalities in access to health care. Too much emphasis on standards is a cause of Profit-making enterprises are not interested in decay; often it is a psychological defense treating those who cannot pay. The voluntary mechanism set up by persons no longer hospital may not treat the poor the same as the rich, productive. Journal of Clinical Investigation :  () The Social Transformation of American Medicine Introduction, p. Basic Books, New York () Paul Starr – Sir Richard Steele – Professor of Sociology, Harvard University Irish-born English essayist and dramatist Modern medicine is one of those extraordinary There are so few who can grow old with a good works of reason: an elaborate system of grace. The Social Transformation of American Medicine Introduction, Gertrude Stein – p.


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In fact allergy treatment providers generic fml forte 5 ml buy on line, it should be embraced allergy forecast dallas today buy fml forte overnight delivery, as it reflects a true connection with the child you once were and his or her attempts to survive in this world allergy forecast euless tx purchase generic fml forte pills. It’s a connection to your past and a window into how you functioned at that time allergy treatment brand buy 5 ml fml forte with mastercard, which is still influencing your present behaviour allergy testing lawrenceville ga purchase fml forte 5 ml without prescription. Your response is then directed by your need to stay within the parameters of this system. The upshot of this is that you’re often being controlled by your inner four-year-old child’s need for love, security, and acceptance. The legacy of these coping techniques may be that you have a set of behavioural tendencies that fit the common stereotypes of the perfectionist, the caregiver, the clown, or the renegade. You originally developed these tendencies in response to emotional childhood events. As a child you responded to these events in a manner that made you feel less threatened and more comfortable, safe and accepted. As an adult your actions are still based on the same patterns that you developed as a child. The inner voice actually brings you back to your childhood and how you experienced life at that time. The inner voice is really a child’s response to events that are occurring now and how that child feels it measures up to its internalized parental values under the circumstances. Your belief system doesn’t change very easily, especially if it seems to still be working for you. The belief system that you have in place now, that gives rise to the inner voice, was most likely first established in your childhood and has persisted into adulthood unchanged because it worked. Everything that occurs now is interpreted from a point, which is fixed in the past when the belief was first developed. So even though an event is occurring now and you have much more, knowledge, wisdom and experience that could help you cope, you’re still habitually relying Inner Child • 161 on the coping mechanisms that worked for the child you once were. That inner child is still reacting to current events with the emotional, psychological and physical responses of your past. A belief-system pattern that arose out of a core-wounding childhood experience produces physical sensations when triggered. This is in response to the fear and anxiety you felt at the time of the original experience. You have a characteristic way of physically responding to your emotions that is entirely unique to you. This could be headaches, neck tension, shoulder pain, chest or abdominal pain, diarrhea, nausea, constipation or muscle spasms. When you experience a physical reaction to something stressful, you’re actually feeling the original physical memory pattern from your childhood, in response to a threatening episode from your past. Accompanying this is the general physiological response to stress, which includes rapid heartbeat, breath-holding, sweating, sleep disorders and fatigue. In Larry’s inner- voice dialogue, there was the obvious surface fear of being late for work and the potential consequences that being late might cause for him as an adult. However, the true fundamental fear, resided in his inner child’s response to this event. The most significant point here is that you have to dive deeper to truly understand what’s motivating your behaviour. For Larry, what actually was underlying his fear of being late for work was an earlier fear of not being good enough. His parents were very demanding and critical and nothing that Larry did was “good enough. By being ‘perfect’ and controlling himself and his surroundings as best he could, Larry was able to minimize being yelled at or punished back when he was a child. The possibility of arriving late for work triggered Larry’s fear surrounding childhood events that occurred relating to the completion of a task in a perfect way. You can see that the thoughts and actions he expresses, in his internal conversation, reflect learned behaviour from his childhood. You yourself, are also not operating entirely from an adult perspective, but carry your own inner child. If you can come to understand your own core-wounding experiences through a mindful dialogue with your inner child, you can see how these experiences and their aftereffects are manifested in all of your stress responses. A common roadblock to meaningful change is that you probably believe that you’re making conscious adult choices about how to act in this world. However, to a large extent, your behaviour is controlled by unrecognized, conditioned, habitual, childhood coping-strategies. You’re not truly present to the events in your life, but to your inner child’s interpretation of how the event fits with your internalized, parental belief system. You judge everything you experience in order to position yourself in relation to the world so as to ultimately feel loved and safe. Talking with your inner voice is a wonderful way to understand what’s truly driving your “adult” behaviour. You have the ability to connect with your inner child through dialogues with that inner voice. Engaging in the dialogues will allow you to discover the true motives underlying how you operate in this world. The inner child’s belief system is the origin of the automatic responses and stories that you tell yourself about internal and external sensations, perceptions, experiences and events. With additional insight, you can bring empathy, support and love to the process of trying to change. You can thereby diminish the power that your inner child has over your present day-to-day experiences. It will give you more control, more perspective and that elusive peace of mind that we all dream about. The next time you become aware of an inner voice or conversation with yourself that’s going something like, “Oh I shouldn’t have done that…” look for clues that it’s really a child talking. When you become aware of your inner child, extend compassion and understanding to the child you once were and use the occasion as an opportunity to explore why you think and act the way you do. Summary • You have an inner voice that’s always commenting to you during times of stress and directing the action to be taken next. This refers to childhood events, which were very emotionally traumatic and may have related to loss, rejection, abandonment, humiliation, betrayal and/or a sense of having been overwhelmed. If you were to develop mindfulness in relation to your own thoughts, you would Adiscover that you have an inner voice that is always talking to you, usually criticizing, comparing and judging everything that arises internally and externally. In this chapter, you’ll learn a helpful stress-reducing technique, which is how to talk to your inner voice. The purpose of the inner-child dialogue is to: • discover the underlying core belief system of the inner child • examine if the core belief system is true • identify the inner child’s feelings This is an important progression that ultimately helps you to change the limiting and painful belief system of the inner child. The inner-child dialogue is a useful technique for really understanding yourself and your stress, but if you’re new to it, it’s going to seem a little strange at first. Remember, you can’t continue to handle things the way you always have and expect a different result. The other advantage of the inner-child dialogue is that, through this technique, you can truly understand that your inner voice is your inner child just trying to be safe. This understanding makes it easier to allow your thoughts to pass through your mind without taking any ownership of their content. The inner voice is really your protector, the voice that recognizes when you have strayed from your created belief system. You should view the voice as that of your beautiful inner child who is trying to help you. If you keep this in mind, it may be easier to bring a sense of self-compassion to any conversations that you have with your inner child. There is the surface level on which you, as an adult, have numerous worries and concerns in response to stressful events. However, it’s the underlying realm of the inner child that truly gives a stressful event its motivational drive. Have you ever noticed that in some situations there’s an emotional or psychological intensity that appears disproportionate to what’s actually happening? This is why connecting with the inner child, and truly understanding the experience from the inner child’s perspective, can be so useful. Talking to Yourself You’re directly and intimately feeling the emotions and physical sensations that the inner child is experiencing and so you can authentically understand and express support to the inner child. The initial process of dialoguing follows this sequence: Dialogue: A Friendly Chat with Your Inner Child • 167 1. Inquire: Time to ask some questions Mindfulness: Bring Awareness to Your Inner Voice Initially, to start an inner-child dialogue, you’ll want to bring mindful- ness into play. When practicing mindfulness, you bring your attention to the present moment without trying to change it and are simply present to whatever is being experienced. You’re bringing awareness to what’s being said, and what’s felt emotionally and physically. When a more emotionally charged thought arises and you notice your inner voice commenting, create some space around that sensation. Just observe it; notice what it’s saying to you from a place of awareness, acceptance, non-judgment, non-attachment and compassion. It can be very difficult not to identify with what the inner voice is saying and you may want to even amplify, or add to , what you’re hearing. The initial ability to let the voice say what it needs to say, for as long as it needs to say it, without interfering, is the first step. When you’re upset, you probably feel like talking to a friend and sharing with him or her what it is that you’re experiencing. The opportunity just to be heard is likely more helpful than necessarily having your friend offer a solution. You can truly experience mentally, emotionally and physically what the inner child is experiencing first hand, without having to guess at what’s happening. In many situations, just listening and allowing the mind to speak will bring a stressful moment to a close without needing to do anything further. The child has normally felt neglected, marginalized and unimportant and finally there’s some recognition. This starts with really listening to the child, without interrupting, as it talks to you. Be completely open to feeling the emotional state 168 • Mindfulness Medication of the child mentally and physically. Actively bring your attention to feeling the mental trauma and anxiety conveyed by your inner child, as well as any accompanying physical sensations, such as rapid or shallow breathing, racing heart rate, twisting sensations in the abdomen, shaking of the head or body, etc. Sitting in the fire of the emotional trauma of the child, and not running from it or avoiding it, will allow a transformation to occur. By directly experiencing what the child is feeling, you will be able to really determine, and then express, what it is that the child needs. When you first begin the inner-voice conversations, you will tend to view the inner voice as completely “who you are. It helps to create some space, away from the intensity of the inner voice, by clarifying the fact that who you are is not the voice. Remember that it’s the voice of your inner child and this will allow you to keep your distance and listen to the inner voice with a sense of compassion. What happens typically is that when the inner child starts to talk to you about its anxieties and concerns, your present-day awareness identifies with what’s being said and amplifies what’s being expressed. You react to the initial thoughts and have additional reactive thoughts that in-turn create more tension. Dialogue: A Friendly Chat with Your Inner Child • 169 To avoid this, be careful not to identify with your inner voice by saying to yourself, “It’s just my mind. This gives your mind a job to occupy itself so that it doesn’t have the chance to react and get more emotionally and/or actively involved. Engage: Start a Conversation with Yourself So you’ve observed that your inner voice (the voice of your inner child) has something to say. It’s used to being the one in charge and you don’t usually challenge it, especially during times of stress when you function on autopilot and are very reactive rather than responsive. Inquire: You’re in the Driver’s Seat, Ask the Questions • Remind yourself, once again, of the fact that this is a conversation with your inner child by opening the inquiry with, “My dear child…” • The questions you pose to your inner child should be in the form of an open-ended question. Open-ended questions are just questions that can’t be answered with a straight ‘yes’ or ‘no’ response. You can base your next question on the dominant word in your inner voice’s response. The original experience that caused this belief system and behavior pattern to enter your repertoire was probably a core-wounding experience. Remember that core-wounding experiences most likely involved an event perceived by the inner child to have been emotionally traumatic and were likely related to loss, rejection, humiliation, abandonment, betrayal and/or a sense of having been overwhelmed. There can also be the physical memory of how the inner child felt at that original time when this response pattern was first used in your childhood. This physical memory may produce hand wringing, head turning or bobbing, shallow breathing or holding of the breath, and/or tightness in the chest or abdomen. Bring awareness to the associated physical component as a way of Dialogue: A Friendly Chat with Your Inner Child • 171 fully becoming aware of what the inner child is experiencing in the moment. You can further cultivate your inner-child connection by imagining that you’re talking to yourself as a young child who is suffering. If that proves difficult to imagine, hold an image in your mind of a young child you deeply care for e.

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Hierbij moeten detectiegrenzen zo laag mogelijk zijn en is het gebruik van andere matrices mogelijk relevant, zoals mest, haar, veren, veegmonsters (alle niet-invasief) en botten. Op basis van het onderzoek gepresenteerd in dit proefschrift, kunnen we de volgende vraag beantwoorden: “Hoeveel selectiviteit is vereist? Normaal gesproken bestaat er een wisselwerking tussen 337 selectiviteit en het aantal componenten dat met één methode geanalyseerd kan worden. Voor screeningsmethoden zou derhalve een lagere selectiviteit volstaan, terwijl de selectiviteit van bevestigingsmethoden hoog moet zijn. Hieruit wordt geconcludeerd dat bij methodeontwikkeling en –validatie, het van groot belang is de parameter selectiviteit in detail te bestuderen. Deadlines, mislukte experimenten, lastige reviewers… Gelukkig heb ik de afgelopen jaren de druk die ik voelde enigszins weten te beperken. Echter, zodra de promotiedatum bekend werd, ontstond toch een licht gevoel van spanning in mijn onderbuik. Het gaat nu echt gebeuren… Zoals zo vaak de laatste maanden, zit ik weer eens in de voorkamer achter de laptop aan tafel. De hond ligt snurkend op de bank en op de achtergrond hoor ik zacht het geluid van de televisie. Een documentaire of zoiets… Het grootste deel van het proefschrift ligt gelukkig al lang klaar, de opmaak is gedaan. Op tafel liggen verschillende proefschriften, alle opengeslagen op één van de laatste pagina’s. Terwijl ik inspiratie probeer te krijgen herinner ik me ineens de woorden van Ingrid: “Het dankwoord mag best met een beetje humor geschreven worden”. Ik voel ineens die enorme last op mijn schouders; meer druk dan ik tijdens het gehele onderzoek en het schrijven van dit proefschrift heb ervaren. Ik kijk op en zie dat de hond echt eerst nog even naar buiten moet en ik loop een rondje dat net iets langer is dan normaal. Eenmaal terug, de hond weer op de bank, tuur ik afwisselend naar het scherm en naar de opengeslagen proefschriften. Onderweg zie ik de modderpoten en haren van de hond op de vloer; daar moet toch echt eerst iets aan gebeuren, anders kan ik me niet concentreren. Een kwartier later zit ik weer aan tafel, een kop thee rechts en een handje rozijnen links van de laptop. Het belangrijkste is dat ik niemand vergeet te noemen en iedereen in passende volgorde laat passeren, wat dat dan ook moge ijn. Toen Michel na het behalen van mijn diploma informeerde of ik interesse had in een PhD-traject, vond ik dat een grote eer. Vanaf dat moment hebben Michel en Linda zich volledig ingezet om mij in dit traject te ondersteunen. Wat misschien nog wel het belangrijkste is, is dat jullie beiden altijd hebben uitgestraald vertrouwen in 340 Dankwoord mij te hebben. Jullie hebben me alle ruimte gegeven mijn onderzoek zelfstandig uit te voeren, maar waren er altijd als ik reflectie nodig had. Michel, ik moet eerlijk eggen dat ik even moest wennen aan jouw kritische blik en je ‘advocaat- van-de-duivel-aanpak’, maar ik ben er wel veel verder mee gekomen. Het heeft me gedwongen beter na te denken over keuzes die ik maakte en me geleerd mijn standpunten helderder te beargumenteren. Ook wil ik jullie beiden bedanken voor jullie feedback op manuscripten en teksten voor dit proefschrift. Ondanks dat jullie enorm druk zijn, kreeg ik toch altijd onverwacht snel een uitgebreide reactie op mijn concepten. Allereerst degenen die een belangrijke bijdrage geleverd hebben aan het onderzoek dat in dit proefschrift beschreven staat. Ik vind het leuk dat er o veel collega’s meegewerkt hebben aan mijn onderzoek; het blijkt toch maar weer dat je samen veel verder komt. Wat hebben we lopen zoeken naar een goede opwerking om die isomeerpieken op hun plek te houden. Martien, bedankt voor je hulp bij het optimaliseren van de opwerking van de urinemonsters. Robin, door jouw inzet en enthousiasme heb ik me altijd extra gemotiveerd gevoeld. Jij wilde altijd precies weten wat er binnen het onderzoek speelde, zodat je je eigen ideeën kon vormen. Echt jammer dat we niet hebben kunnen aantonen dat chlooramfenicol in maïskuil gevormd wordt, maar dank ij ‘jouw’ maïskuil konden we de e hypothese met grote waarschijnlijkheid verwerpen. Ook bedankt voor je hulp in de begeleiding van Mathilde en Ralph, leuk dat je paranimf wilt zijn en nogmaals dank dat je 52 pagina’s door bent gegaan op oek naar fouten. Henk, jij ook bedankt voor je hulp in de begeleiding van Ralph en je bijdrage aan de ß-lactammethode. Jouw kennis van de Q-Trap 6500 heeft ervoor gezorgd dat we last-minute de overstap konden maken en dat we toch tijdig de validatiedata konden produceren. Je hebt er zeker aan bijgedragen dat er weer financieel draagvlak kwam voor vervolgonderzoek naar chlooramfenicol en de ß-lactamanalyse. Ingrid, bedankt dat je er altijd bent om even 341 inhoudelijk mee te sparren en om af en toe wat persoonlijke zaken te bespreken. Hoe eenvoudig deze gesprekken misschien lijken, ze helpen wel om zaken wat te relativeren. Echt heel fijn om jou als collega te hebben en top dat jij als routinier paranimf wilt zijn. Ook jij bedankt dat je de proefversie van dit proefschrift hebt gecontroleerd; knap dat je nog zoveel kleine inconsistenties en taalfoutjes hebt weten te vinden. Sinds ik erachter kwam dat we zelf ook een Streptomyces venezuelae kunnen opkweken, hebben jullie je enorm flexibel opgesteld (een preparaat stond klaar wanneer ik maar wilde) en waren jullie enorm betrokken bij het onderzoek. Toch jammer dat het zo verdomd lastig is ervoor te zorgen dat die bacterie chlooramfenicol gaat produceren. Ooit gaat het ons lukken… Het is erg leuk om met jullie samen te werken, juist omdat onze achtergronden zo verschillend zijn. Mede daardoor ga ik iedere dag (nou ja, bijna iedere dag) met plezier naar mijn werk. Iedereen is altijd bereid om bij te springen waar nodig en o klaren we met ’n allen toch steeds weer iedere klus. Ook wil ik alle studenten bedanken die een bijdrage hebben geleverd aan het werk in dit proefschrift. Jullie hebben met ’n allen o ont ettend veel werk verzet dat ik niet anders kan dan concluderen dat dit proefschrift zonder jullie een stuk dunner was geweest. Ik heb het altijd leuk gevonden jullie te begeleiden en te zien hoe jullie je ontwikkelden. Richetti, bedankt voor het uitzoeken van goede condities om die nare chlooramfenicolisomeren op de chirale kolom te scheiden. Vooral de reproduceerbaarheid viel in het begin nogal tegen, maar het is toch gelukt. Cynthia, super dat je de methode voor de analyse van ceftiofur met behulp van de hydrolyse met ammoniak hebt geoptimaliseerd. Later is weliswaar overgestapt op piperidine, maar jij hebt de basis van de monstervoorbewerking. Sven, bedankt voor het implementeren van de verschillende methodes voor de analyse van ceftiofur en de analyse van al die vleesmonsters. Mathilde, bedankt voor het onderzoek naar de invloed van de 342 Dankwoord maalprocedure op de vorming van degradatieproducten van ceftiofur. Hoewel jouw werk niet direct in dit proefschrift is opgenomen (ik zou het misschien nog eens moeten publiceren), vormt het wel een heel belangrijke basis van het onderzoek. Ik ben blij dat je hebt kunnen aantonen dat er wel degelijk metabolieten gevormd worden na injectie van kippen met ceftiofur. Jouw werk vormde een mooie basis om de uiteindelijk gerapporteerde methode op te zetten. Het was een enorme klus: ik denk dat het je nog steeds duizelt als je bedenkt dat je meer dan 15000 pieken hebt geïntegreerd gedurende je stage. Ik schrik er elf een beetje van… In dit dankwoord uiteraard ook een mooie plek voor Freek. Iedereen weet wel dat dat niet waar is, maar uiteraard houd ik dat gerucht graag in stand. Met name tussen 2008 en 2010, de jaren waarin ik hele avonden en weekenden heb gestudeerd, heb jij alle andere taken uit handen genomen, zodat ik me op mijn opleiding kon concentreren. Hele weekenden zat ik opgesloten in de voorkamer te werken en ik heb jou daar niet één keer over horen mopperen. Hetzelfde geldt voor de laatste fase van mijn PhD: ik kon me volledig focussen op mijn proefschrift, omdat jij altijd voor me klaar staat en me steunt. Als ik na mijn promotie in het bekende zwarte gat val, zal ik jullie allemaal weer wat vaker gaan vervelen. Hoewel, de puzzel die ik van Sinterklaas heb gekregen met duizend stukjes uitsluitend grijskleurige olifant houdt me nog wel even van de straat (moet ik dat als subtiele hint van Sinterklaas beschouwen? Bjorn 343 344 Curriculum Vitae th Bjorn Berendsen was born on the 10 of March 1978 in Bemmel, The Netherlands. He started his Bachelor study, Higher Laboratory Education, at Hogeschool van Arnhem en Nijmegen. Nielen, The occurrence of chloramphenicol in crops through the natural production by bacteria in soil, J. Nielen, Comprehensive analysis of ß-lactam antibiotics including penicillins, cephalosporins and carbapenems in poultry muscle using liquid chromatography coupled to tandem mass spectrometry, Anal. Nielen, The (un)certainty of selectivity in liquid chromatography tandem mass spectrometry, J. Nielen, Assessment of liquid chromatography–tandem mass spectrometry approaches for the analysis of ceftiofur metabolites in poultry muscle, Food Add. Nielen, Quantitative trace analysis of eight chloramphenicol isomers in urine by chiral liquid chromatography coupled to tandem mass spectrometry, J. Nielen, Discrimination of eight chloramphenicol isomers by liquid chromatography tandem mass spectrometry in order to investigate the natural occurrence of chloramphenicol, Anal. Elliott, Evidence of natural occurrence of the banned antibiotic chloramphenicol in herbs and grass, Anal. Stolker, Newly identified degradation products of ceftiofur and cephapirin impact the analytical approach for quantitative analysis of kidney, J. Stolker, Determination of the stability of antibiotics in matrix and reference solutions using a straightforward procedure applying mass spectrometric detection, Food Add. Van Rhijn, Residue analysis of tetracyclines in poultry muscle: Shortcomings revealed by a proficiency test, Food Add. Brinkman, Liquid chromatographic–tandem mass spectrometric determination of selected sulphonamides in milk, J. Berendsen, Polymyxin E-1 (colistin sulphate) (neuro-)intoxication in young ostriches (Struthio camelus spp. Course Advanced Chromatography, Wageningen University, Organic Chemistry, Wageningen, the Netherlands (2011). Symposium Recent Advances in Food Analysis, Institute of Chemical Technology, Prague, Czech Republic (2011). Training School for Advanced Residue Analysis: group A6 antibiotics, Cochin, India. The validation of methods for the analysis of veterinary drugs in food products (2010). Training School for Advanced Residue Analysis: group A6 antibiotics, Kiev, Ukraine. Jagannadham A ntibiotic esistance of acteria BioM ed Research International A ntibiotic esistance of acteria Guest Editors: M adhab K. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Antibiotic resistance of bacteria and other microorganisms methods for the detection of resistance. Te omnipresent is one of the most serious and grievous challenges of the nature of the resistant organisms is revealed in a number twenty-frst century. Khalilreportonthe great deal of promises during the 1940s to eradicate all occurrence of antibiotic resistance among bacteria (predom- the infectious life-threatening diseases in the world, have inantly skin commensal coagulase-negative staphylococci) ceased to work, because of the increasing emergence of isolated from allogenic bone samples for grafing, collected microbial strains invulnerable to them. Food materials are ously efcacious antibiotics are no longer usable because of believed to serve as a vehicle for transmission of resistance. Te trepidation that we might similarity in the genotype pattern of the isolates obtained be pushed back to a situation analogous to the preantibiotic from vegetables and humans indicates transmission. Te articles contributed by investigators from from nasal swabs of pigs, collected from two slaughter houses various research laboratories with diferent scientifc back- of Poland. Some meat samples bought from the shops were grounds have not only portrayed the width of the problem also included into their studies. Rapid detection of the profle of resistance typhimurium for resistance genes in an area of southern Italy is essential for timely application of the right antibiotic to by pulsotyping and phage typing.

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The pain often radiates anteriorly allergy testing st cloud mn order 5 ml fml forte overnight delivery, but it also may be referred to the inguinal allergy symptoms of rheumatoid arthritis generic 5 ml fml forte with visa, labial allergy testing tampa purchase discount fml forte on line, penile allergy blood test zyrtec fml forte 5 ml buy lowest price, or testicular areas allergy forecast madison wi proven fml forte 5 ml. It is not uncommon for a man with a ureteral calculus to complain of pain at the tip of the penis or for a women with the same problem to experience labial pain. Flank pain that originates from urinary tract pathology may be caused by obstruction, inflammation, or mass. Hydronephrosis occurs when there is obstruction of the urinary tract that results in dilation of the renal collecting system. Dilation of the renal collecting system leads to distention of the renal capsule, and this distention results in flank pain. In the case presented above, flank pain accompanied by crystals in the urine is suggestive of hydronephrosis due to an obstructing renal calculus. When evaluating a patient with flank pain, the severity of the pain generally correlates inversely with the duration of the problem. That is, chronic, gradual distention of the renal capsule over a long period of time due to a slowly enlarging ureteral tumor often is associated with mild to moderate flank pain. The pain is mild or dull because it results in gradual but possibly severe distention of the renal collecting system and capsule. In contrast, the acute flank pain that is associated with an obstructing renal calculus often is severe, since it results in sudden distention of the renal collecting system and capsule. In the case presented, it is likely that an obstructing calculi is causing the patient’s symptoms. Severe flank pain caused by an acute urinary tract obstruction is termed renal colic. It is important for the clinician to determine if the pain represents an emergency or if the problem can be managed in the outpatient setting. In this regard, it is important to determine if there is associated fever, dehydration, nausea, or vomiting. Comorbid medical conditions, such as diabetes, immunocompromise, or pregnancy, also need to be considered. When flank pain presents in association with any one of these factors, hospital admission may be necessary to prevent possible complications, such as pyelonephritis or urosepsis, from developing. In the case presented, none of these factors are present, so this patient can be managed in the outpatient setting. Since a prime objective for the clinician is to determine if the flank pain represents an emergent medical problem, it is helpful to consider the differential diagnosis of flank pain (see Algorithm 38. Differential Diagnosis of Flank Pain Urinary Calculi One of the most common causes of acute, severe flank pain is sudden distention of the renal collecting system and capsule secondary to an 672 J. Algorithm for the clinical evaluation of the patient presenting with acute flank pain. Most urinary calculi cause pain only when they obstruct the flow of urine from the kidney into the bladder. Since the patient in the case presented has pain, it is prob- able that obstruction is present. Typically, the stone becomes caught in the renal pelvis or ureter and causes obstruction of urine flow. Types of Urinary Calculi The most common type of urinary tract calculus is composed of calcium oxalate. Oxalate is found in many green leafy vegetables and teas, and it is considered to be an inducer of stone formation. When urine becomes supersaturated with calcium or oxalate, precipitation of crystals can result in stone formation. Causes for supersaturation with calcium or oxalate include excess bone resorption of calcium from immobility, intestinal hyperabsorbtion of calcium from sarcoidosis, and renal leak of calcium seen with renal tubular acidosis. However, most individuals who form calcium oxalate stones do not drink enough fluids, which results in concentrated urine. Even though the patient in the case pre- sented has a family history of calcium oxalate calculi, dehydration is the most likely cause of her stone formation. For this reason, calcium oxalate stones are more common in the summer months and in the 38. Evaluation of Flank Pain 673 southern United States “stone belt,” where it is hot and where dehy- dration is more likely to occur. Other common types of stones include magnesium ammonium phosphate and carbonate apatite stones. These stones sometimes are called infection stones, since they form secondary to urinary tract infections with urea splitting bacteria. Urea splitting bacteria raise the pH of the urine, and this facilitates the formation of infection stones by lowering the solubility of magnesium-ammonium and phosphate. Infectious stones can enlarge quickly and sometimes can fill the entire renal collecting system to form a staghorn calculus. The term staghorn calculus indicates that the stone is a large stone, but it does not imply stone composition. All urinary calculi have the potential to form staghorn calculi; however, infection stones result in staghorn formation most often. Some stones, including uric acid and cystine stones, form sec- ondary to metabolic abnormalities. These stones are seen less com- monly in clinical practice, but they should be suspected in patients with a history of gout or homozygous cystinuria. Hyperuricosuria may be seen in gout, myelo- proliferative disorders, idiopathic hyperuricosuria, and patients with increased dietary purine. Uric acid stones are clinically unique, since they cannot be seen on a standard abdominal x-ray. Since the formation of uric acid stones is very dependent on the pH of the urine, they generally form only if the urine pH is consistently below 5. Typically, an oral urinary alkalin- izing agent, such as potassium citrate, is used to raise urine pH and dissolve uric acid stones. Cystine stones are uncommon and form only in patients who are homozygous for cystinuria. Cystinuria is an inher- ited defect of the renal tubule causing loss of cystine, ornithine, arginine, and lysine. The loss of cystine is the only clinical problem patients suffer, since they excrete over 250mg of cystine per liter of urine. This high urinary cystine level is problematic, since stone for- mation results in urinary cystine levels of 170mg per liter of urine at pH 5. Patients who are heterozygous for cystinuria excrete less urinary cystine and generally do not suffer from cystine stone formation. Risk Factors Some of the common risk factors for developing urinary calculi include inadequate fluid intake, excess sodium intake, metabolic abnormalities, inflammatory bowel disease, dehydration, and family history. Patients with inflammatory bowel disease form stones composed of calcium oxalate by a unique mechanism. Fat malabsorption caused by the inflammatory bowel disease results in excess fats in the gut, which bind to calcium. This creates a situation in the gut in which oxalate, which normally binds to calcium, enters the bloodstream in its ionic 674 J. Since oxalte is a stone inducer, it binds with urinary calcium and facilitates calcium oxalate stone formation. Other medical conditions increase the risk for stone formation by causing hypercalciuria, which is excess calcium in the urine. These medical problems include renal tubular acidosis, sarcoidosis, hyper- parathyroidism, chronic immobility, and paralysis. In these condi- tions, hypercalciuria results when excess calcium is absorbed from bone or the gut and ultimately is excreted by the kidneys. In renal tubular acidosis, the renal tubule leaks calcium directly into the urine. Chronic urinary tract infection also can lead to stone formation due to urea splitting bacteria, which lead to an elevated urine pH. These end products cause a rise in urinary pH, which facilitates infec- tious stone formation. These bacteria raise the pH of the urine, and this allows the precipitation of magnesium-ammonium-phosphate or apatite stones. Patients with infected urine and flank pain due to an obstructing calculi may require hospitalization to prevent urosepsis. Management As illustrated in the case presented, most patients who present with flank pain secondary to acutely obstructing urinary calculi can be managed on an outpatient basis. Cornerstones of therapy include adequate hydration, pain relief, and control of any associated nausea or vomiting. If the pain is severe enough to require intravenous morphine sulfate or if there is associated fever or dehydration due to nausea or vomit- ing, hospital admission may be necessary. Again, one of the most important decisions the clinician has to make is to determine if the patient can be treated as an outpatient or if the patient needs hospital admission. There are several indications for hospital admission, and fever is a common indicator for admission (Table 38. Fever in the pres- ence of obstructing urinary calculi can be an ominous clinical find- ing that suggests an accumulation of purulent urine proximal to an obstructing stone. This is an especially serious situation if the patient has comorbid medical conditions, such as diabetes. Emergent intra- venous antibiotics, aggressive intravenous fluid hydration, and per- cutaneous or transureteral drainage of the infected urine usually are necessary in these situations. Patients with fever and obstructing urinary calculi should not be discharged from the emergency room, as urosepsis and septic shock can develop quickly. Following the acute event, it is suggested that all patients who form urinary stones undergo a metabolic evaluation consisting of a com- plete blood count, urinalysis, serum chemistry profile, and a 24-hour urine collection for calcium, phosphorus, uric acid, creatinine, citrate, and oxalate levels. Evidence-based practice management guideline for the evaluation of fever in critically ill adult patients. The nosocomial spread of pathogens must be avoided when using temperature measurement devices. Laboratory testing for the evaluation of fever should be individualized for each patient. Blood cultures Level I: For skin preparation, povidone-iodine should be allowed to dry for 2min, or tincture of iodine for 30s. Alcohol skin preparation, an acceptable alternative for iodine- allergic patients, need not be allowed to dry. Additional cultures should be based on high clinical suspicion of bacteremia or fungemia, and not instituted automatically for each temperature elevation. If two peripheral sites are not available, one pair of cultures may be drawn through the most recently inserted catheter, but the diagnostic accuracy is reduced. Any expressed purulence from an insertion site should be collected for culture and Gram stain. The catheter should be removed and cultured for evidence of a tunnel infection, embolic phenomena, vascular compromise, or sepsis. Two blood cultures should be drawn peripherally, or one may be drawn from the most proximal port (if a multilumen catheter). Both the introducer and the catheter itself should be cultured for suspected pulmonary artery catheter infection. Posteroanterior and lateral films or computed tomography of the chest can offer more information. Respiratory secretions should be transported to the laboratory within 2h of collection. Pleural fluid should be obtained for culture and Gram stain if there is an adjacent infiltrate or another reason to suspect infection. A second sample should be sent if the first is negative and suspicion remains high. If illness is severe and rapid testing is unavailable or nondiagnostic, consider flexible sigmoidoscopy. If illness is severe, consider empiric therapy with metronidazole until the results of studies are available. Empiric therapy (especially with vancomycin) is not recommended if two stool evaluations have been negative for C. If the patient has an indwelling Foley catheter, urine should be collected from the urine port and not the drainage bag. The specimen should be transported rapidly to the laboratory, or refrigerated if transport will exceed 1h. Puncture and aspiration of the sinuses should be performed using sterile technique if mucosal thickening or an air–fluid level is present in the sinus. Culture and Gram stain should be obtained from purulent material if from deep within the wound. A computed tomographic study is usually required before lumbar puncture, which may need to be deferred if a mass lesion is present. Consider lumbar puncture for new fever with unexplained alteration of consciousness or focal neurologic signs. In febrile patients with an intracranial device, cerebrospial fluid should be sent for culture and Gram stain. Stop all nonessential medications, or substitute medications for treatments that cannot be stopped. Task Force of the Society of Critical Care Medicine and the Infectious Diseases Society of America.

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Frillock, 32 years: Vera Vigneault, age 32, came mainly for help in getting pregnant but she already had lower back pain and mid-back pain.

Ilja, 47 years: Note: Colonies from a mannitol salt agar culture are not suitable for coagulase testing.

Tufail, 44 years: A urine Answers to Questions 41–44 specimen obtained by catheterization also showed gram-negative rods, 100,000 col/mL.

Reto, 52 years: Changes in acid–base balance also may require special alkalotic or acidotic solutions to correct these abnormalities (Tables 4.

Asaru, 51 years: Hemorrhoids are found in the subepithelial tissue above and below the dentate line.

Chris, 48 years: A patient who seems sick and shows a swollen tonsil near the midline may have a peritonsillar abscess, which requires urgent drainage.

Tom, 28 years: Pharmacology 333 rently with many diuretics to counteract potassi- Pharmacology um depletion.

Mamuk, 39 years: The baseline measures of the groups should be specified so that the reader can determine whether or not the groups were similar in their initial baseline mea- sures.

Felipe, 26 years: What component(s) is (are) indicated for patients centrifuge and plasma can be removed.

Dargoth, 56 years: Microfilariae of the various species can be differen- tiated morphologically in stained blood smears (Table 10.

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