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DESCRIPTION Betagan reg (levobunolol hydrochloride ophthalmic solution, USP) sterile is a noncardioselective beta-adrenoceptor blocking agent for ophthalmic use. The solution is colorless to slightly light yellow in appearance with an osmolality range of 250-360 mOsm/kg. The shelf life pH range is 5.5 to 7.5. Chemical Name: (-)-( S )-5-3-( tert - Butylamino)-2-hydroxypropoxy-3,4-dihydro-1(2 H )-naphthalenone hydrochloride. Structural Formula: levobunolol HCl Contains: Active: levobunolol HCl 0.25 or 0.5. Preservative: benzalkonium chloride 0.004 Inactives: edetate disodium polyvinyl alcohol 1.4 potassium phosphate, monobasic purified water sodium chloride sodium metabisulfite sodium phosphate, dibasic and hydrochloric acid or sodium hydroxide to adjust pH. CLINICAL PHARMACOLOGY Levobunolol HCl is a noncardioselective beta-adrenoceptor blocking agent, equipotent at both beta 1 and beta 2 receptors. Levobunolol HCl is greater than 60 times more potent than its dextro isomer in its beta-blocking activity, yet equipotent in its potential for direct myocardial depression. Accordingly, the levo isomer, levobunolol HCl, is used. Levobunolol HCl does not have significant local anesthetic (membrane-stabilizing) or intrinsic sympathomimetic activity. Beta-adrenergic receptor blockade reduces cardiac output in both healthy subjects and patients with heart disease. In patients with severe impairment of myocardial function, beta-adrenergic receptor blockade may inhibit the stimulatory effect of the sympathetic nervous system necessary to maintain adequate cardiac function. Beta-adrenergic receptor blockade in the bronchi and bronchioles results in increased airway resistance from unopposed parasympathetic activity. Such an effect in patients with asthma or other bronchospastic conditions is potentially dangerous.
Betagan reg (levobunolol hydrochloride ophthalmic solution, USP) has been shown to be an active agent in lowering elevated as well as normal intraocular pressure (IOP) whether or not acpanied by glaua. Elevated IOP presents a major risk factor in glauatous field loss. The higher the level of IOP, the greater the likelihood of optic nerve damage and visual field loss. The onset of action with one drop of Betagan reg can be detected within one hour after treatment, with maximum effect seen between 2 and 6 hours. A significant decrease of IOP can be maintained for up to 24 hours following a single dose. In two, separate, controlled studies (one three month and one up to 12 months duration) Betagan reg ophthalmic solution 0.25 b. i.d. controlled the IOP of approximately 64 and 70 of the subjects. The overall mean decrease from baseline was 5.4 mm Hg and 5.1 mm Hg respectively. In an open-label study, Betagan reg ophthalmic solution 0.25 q. d. controlled the IOP of 72 of the subjects while achieving an overall mean decrease of 5.9 mm Hg. In controlled clinical studies of approximately two years duration, intraocular pressure was well-controlled in approximately 80 of subjects treated with Betagan reg ophthalmic solution 0.5 b. i.d. The mean IOP decrease from baseline was between 6.87 mm Hg and 7.81 mm Hg. No significant effects on pupil size, tear production or corneal sensitivity were observed.
Betagan reg at the concentrations tested, when applied topically, decreased heart rate and blood pressure in some patients. The IOP-lowering effect of Betagan reg was well maintained over the course of these studies. In a three month clinical study, a single daily application of 0.5 Betagan reg ophthalmic solution controlled the IOP of 72 of subjects achieving an overall mean decrease in IOP of 7.0 mm Hg. The primary mechanism of the ocular hypotensive action of levobunolol HCl in reducing IOP is most likely a decrease in aqueous humor production. Betagan reg reduces IOP with little or no effect on pupil size or acmodation in contrast to the miosis which cholinergic agents are known to produce. The blurred vision and night blindness often associated with miotics would not be expected and have not been reported with the use of Betagan reg ophthalmic solution. This is particularly important in cataract patients with central lens opacities who would experience decreased visual acuity with pupillary constriction. INDICATIONS AND USAGE Betagan reg ophthalmic solution has been shown to be effective in lowering intraocular pressure and may be used in patients with chronic open-angle glaua or ocular hypertension. CONTRAINDICATIONS Betagan reg ophthalmic solution is contraindicated in those individuals with bronchial asthma, or with a history of bronchial asthma, or severe chronic obstructive pulmonary disease (see WARNINGS ) sinus bradycardia second and third degree atrioventricular block overt cardiac failure (see WARNINGS ) cardiogenic shock or hypersensitivity to any ponent of these products.
As with other topically applied ophthalmic drugs, Betagan reg may be absorbed systemically. The same adverse reactions found with systemic administration of beta-adrenergic blocking agents may occur with topical administration. For example, severe respiratory reactions and cardiac reactions, including death due to bronchospasm in patients with asthma, and rarely death in association with cardiac failure, have been reported with topical application of beta-adrenergic blocking agents (see CONTRAINDICATIONS ). Cardiac Failure Sympathetic stimulation may be essential for support of the circulation in individuals with diminished myocardial contractility, and its inhibition by beta-adrenergic receptor blockade may precipitate more severe failure.
In Patients Without a History of Cardiac Failure Continued depression of the myocardium with beta-blocking agents over a period of time can, in some cases, lead to cardiac failure. At the first sign or symptom of cardiac failure, Betagan reg ophthalmic solution should be discontinued. Obstructive Pulmonary Disease PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (e. g. CHRONIC BRONCHITIS, EMPHYSEMA) OF MILD OR MODERATE SEVERITY, BRONCHOSPASTIC DISEASE OR A HISTORY OF BRONCHOSPASTIC DISEASE (OTHER THAN BRONCHIAL ASTHMA OR A HISTORY OF BRONCHIAL ASTHMA, IN WHICH Betagan reg IS CONTRAINDICATED, SEE CONTRAINDICATIONS ), SHOULD IN GENERAL NOT RECEIVE BETA BLOCKERS, INCLUDING Betagan reg. However, if Betagan reg is deemed necessary in such patients, then it should be administered cautiously since it may block bronchodilation produced by endogenous and exogenous catecholamine stimulation of beta 2 receptors. Major Surgery The necessity or desirability of withdrawal of beta-adrenergic blocking agents prior to major surgery is controversial. Beta-adrenergic receptor blockade impairs the ability of the heart to respond to beta-adrenergically mediated reflex stimuli. This may augment the risk of general anesthesia in surgical procedures. Some patients receiving beta-adrenergic receptor blocking agents have been subject to protracted severe hypotension during anesthesia. Difficulty in restarting and maintaining the heartbeat has also been reported.
For these reasons, in patients undergoing elective surgery, gradual withdrawal of beta-adrenergic blocking agents may be appropriate. If necessary during surgery, the effects of beta-adrenergic blocking agents may be reversed by sufficient doses of such agonists as isoproterenol, dopamine, dobutamine or levarterenol (see OVERDOSAGE ). Diabetes Mellitus Beta-adrenergic blocking agents should be administered with caution in patients subject to spontaneous hypoglycemia or to diabetic patients (especially those with labile diabetes) who are receiving insulin or oral hypoglycemic agents. Beta-adrenergic blocking agents may mask the signs and symptoms of acute hypoglycemia.
Thyrotoxicosis Beta-adrenergic blocking agents may mask certain clinical signs (e. g. tachycardia) of hyperthyroidism. Patients suspected of developing thyrotoxicosis should be managed carefully to avoid abrupt withdrawal of beta-adrenergic blocking agents which might precipitate a thyroid storm. These products contain sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people. PRECAUTIONS Betagan reg (levobunolol hydrochloride ophthalmic solution, USP) sterile should be used with caution in patients with known hypersensitivity to other beta-adrenoceptor blocking agents. Use with caution in patients with known diminished pulmonary function. Betagan reg should be used with caution in patients who are receiving a beta-adrenergic blocking agent orally, because of the potential for additive effects on systemic beta-blockade or on intraocular pressure. Patients should not typically use two or more topical ophthalmic beta-adrenergic blocking agents simultaneously. Because of the potential effects of beta-adrenergic blocking agents on blood pressure and pulse rates, these medications must be used cautiously in patients with cerebrovascular insufficiency.
Should signs or symptoms develop that suggest reduced cerebral blood flow while using Betagan reg ophthalmic solution, alternative therapy should be considered. In patients with angle-closure glaua, the immediate objective of treatment is to reopen the angle. This requires, in most cases, constricting the pupil with a miotic. Betagan reg ophthalmic solution has little or no effect on the pupil. When Betagan reg is used to reduce elevated intraocular pressure in angle-closure glaua, it should be followed with a miotic and not alone.
Muscle Weakness Beta-adrenergic blockade has been reported to potentiate muscle weakness consistent with certain myasthenic symptoms (e. g. diplopia, ptosis and generalized weakness). Drug Interactions Although Betagan reg ophthalmic solution used alone has little or no effect on pupil size, mydriasis resulting from conitant therapy with Betagan reg and epinephrine may occur. Close observation of the patient is remended when a beta-blocker is administered to patients receiving catecholamine-depleting drugs such as reserpine, because of possible additive effects and the production of hypotension and/or marked bradycardia, which may produce vertigo, syncope, or postural hypotension. Patients receiving beta-adrenergic blocking agents along with either oral or intravenous calcium antagonists should be monitored for possible atrioventricular conduction disturbances, left ventricular failure and hypotension. In patients with impaired cardiac function, simultaneous use should be avoided altogether. The conitant use of beta-adrenergic blocking agents with digitalis and calcium antagonists may have additive effects on prolonging atrioventricular conduction time.
Phenothiazine-related pounds and beta-adrenergic blocking agents may have additive hypotensive effects due to the inhibition of each others metabolism. Risk of Anaphylactic Reaction While taking beta-blockers, patients with a history of severe anaphylactic reactions to a variety of allergens may be more reactive to repeated challenge, either accidental, diagnostic, or therapeutic. Such patients may be unresponsive to the usual doses of epinephrine used to treat allergic reactions. Animal Studies No adverse ocular effects were observed in rabbits administered Betagan reg ophthalmic solution topically in studies lasting one year in concentrations up to 10 times the human dose concentration. Carcinogenesis, Mutagenesis, Impairment of Fertility In a lifetime oral study in mice, there were statistically significant (ple0.05) increases in the incidence of benign leiomyomas in female mice at 200 mg/kg/day (14,000 times the remended human dose for glaua), but not at 12 or 50 mg/kg/day (850 and 3,500 times the human dose).
In a two year oral study of levobunolol HCl in rats, there was a statistically significant (ple0.05) increase in the incidence of benign hepatomas in male rats administered 12,800 times the remended human dose for glaua. Similar differences were not observed in rats administered oral doses equivalent to 350 times to 2,000 times the remended human dose for glaua. Levobunolol did not show evidence of mutagenic activity in a battery of microbiological and mammalian in vitro and in vivo assays. Reproduction and fertility studies in rats showed no adverse effect on male or female fertility at doses up to 1,800 times the remended human dose for glaua. Pregnancy Category C Fetotoxicity (as evidenced by a greater number of resorption sites) has been observed in rabbits when doses of levobunolol HCl equivalent to 200 and 700 times the remended dose for the treatment of glaua were given. No fetotoxic effects have been observed in similar studies with rats at up to 1,800 times the human dose for glaua.
Teratogenic studies with levobunolol in rats at doses up to 25 mg/kg/day (1,800 times the remended human dose for glaua) showed no evidence of fetal malformations. There were no adverse effects on postnatal development of offspring. It appears when results from studies using rats and studies with other beta-adrenergic blockers are examined, that the rabbit may be a particularly sensitive species. There are no adequate and well-controlled studies in pregnant women. Betagan reg ophthalmic solution should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Nursing Mothers It is not known whether this drug is excreted in human milk. Systemic beta-blockers and topical timolol maleate are known to be excreted in human milk. Caution should be exercised when Betagan reg is administered to a nursing woman. Pediatric Use Safety and effectiveness in pediatric patients have not been established.
Geriatric Use No overall differences in safety or effectiveness have been observed between elderly and younger patients. Adverse Reactions In clinical trials the use of Betagan reg ophthalmic solution has been associated with transient ocular burning and stinging in up to 1 in 3 patients, and with blepharoconjunctivitis in up to 1 in 20 patients. Decreases in heart rate and blood pressure have been reported (see CONTRAINDICATIONS and WARNINGS ). The following adverse reactions have been reported rarely with the use of Betagan reg. iridocyclitis, headache, transient ataxia, dizziness, lethargy, urticaria, and pruritus. Decreased corneal sensitivity has been noted in a small number of patients. Although levobunolol has minimal membrane-stabilizing activity, there remains a possibility of decreased corneal sensitivity after prolonged use. The following additional adverse reactions have been reported either with Betagan reg ophthalmic solution or ophthalmic use of other beta-adrenergic receptor blocking agents: BODY AS A WHOLE: Headache, asthenia, chest pain. CARDIOVASCULAR: Bradycardia, arrhythmia, hypotension, syncope, heart block, cerebral vascular accident, cerebral ischemia, congestive heart failure, palpitation, cardiac arrest.
DIGESTIVE: Nausea, diarrhea. PSYCHIATRIC: Depression, confusion, increase in signs and symptoms of myasthenia gravis, paresthesia. SKIN: Hypersensitivity, including localized and generalized rash, alopecia, Stevens-Johnson Syndrome. RESPIRATORY: Bronchospasm (predominantly in patients with pre-existing bronchospastic disease), respiratory failure, dyspnea, nasal congestion. UROGENITAL: Impotence. ENDOCRINE: Masked symptoms of hypoglycemia in insulin-dependent diabetics (see WARNINGS ). SPECIAL SENSES: Signs and symptoms of keratitis, blepharoptosis, visual disturbances including refractive changes (due to withdrawal of miotic therapy in some cases), diplopia, ptosis. Other reactions associated with the oral use of non-selective adrenergic receptor blocking agents should be considered potential effects with ophthalmic use of these agents. OVERDOSAGE No data are available regarding overdosage in humans.
Should accidental ocular overdosage occur, flush eye(s) with water or normal saline. If accidentally ingested, efforts to decrease further absorption may be appropriate (gastric lavage). The most mon signs and symptoms to be expected with overdosage with administration of a systemic beta-adrenergic blocking agent are symptomatic bradycardia, hypotension, bronchospasm, and acute cardiac failure. Should these symptoms occur, discontinue Betagan reg therapy and initiate appropriate supportive therapy.
The following supportive measures should be considered: Symptomatic bradycardia: Use atropine sulfate intravenously in a dosage of 0.25 mg to 2 mg to induce vagal blockade. If bradycardia persists, intravenous isoproterenol hydrochloride should be administered cautiously. In refractory cases the use of a transvenous cardiac pacemaker should be considered. Hypotension: Use sympathomimetic pressor drug therapy, such as dopamine, dobutamine or levarterenol. In refractory cases the use of glucagon hydrochloride may be useful. Bronchospasm: Use isoproterenol hydrochloride. Additional therapy with aminophylline may be considered.
Acute cardiac failure: Conventional therapy with digitalis, diuretics and oxygen should be instituted immediately. In refractory cases the use of intravenous aminophylline is suggested. This may be followed, if necessary, by glucagon hydrochloride which may be useful. Heart block (second or third degree): Use isoproterenol hydrochloride or a transvenous cardiac pacemaker. DOSAGE AND ADMINISTRATION The remended starting dose is one to two drops of Betagan reg ophthalmic solution 0.5 in the affected eye(s) once a day. Typical dosing with Betagan reg 0.25 is one to two drops twice daily. In patients with more severe or uncontrolled glaua, Betagan reg 0.5 can be administered b. i.d. As with any new medication, careful monitoring of patients is advised.
Dosages above one drop of Betagan reg 0.5 b. i.d. are not generally more effective. If the patients IOP is not at a satisfactory level on this regimen, conitant therapy with dipivefrin and/or epinephrine, and/or pilocarpine and other miotics, and/or systemically administered carbonic anhydrase inhibitors, such as acetazolamide, can be instituted. Patients should not typically use two or more topical ophthalmic beta-adrenergic blocking agents simultaneously. HOW SUPPLIED Betagan reg (levobunolol hydrochloride ophthalmic solution, USP) is supplied sterile in white low density polyethylene ophthalmic dispenser bottles and tips.
Betagan reg 0.25 strength units include a light blue high intensity polystyrene cap. Betagan reg 0.5 strength units include a yellow high intensity polystyrene cap. 5 mL in 10 mL bottle NDC 0023-4385-05 10 mL in 15 mL bottle NDC 0023-4385-10Great for hot spots, rashes Can speed up healing of skin infections Effective treatment for dogs with sensitive skin and allergies Customers rave about how easy it is to use How it Works: Betagen is a bination of an antibiotic to treat bacterial infections and a corticosteroid to treat any acpanying inflammation or itching. Betagen should not be used for than 7 days unless otherwise directed by your veterinarian. Do not use if your pet has a viral or fungal infection. Tell your veterinarian if your pet is pregnant or lactating. Gentamicin Sulfate with Betamethasone Valerate Topical Spray (jen-ta-my-sin, beta-meth-a-zone) Betagen Topical Spray is a prescription medicine FDA approved for veterinary use in dogs. Betagen Topical Spray is available in a 120 ml plastic spray bottle. Each ml contains gentamicin sulfate equivalent to 0.57mg gentamicin base and betamethasone valerate equivalent to 0.284mg betamethasone.
Betagen Topical Spray is an antimicrobial and corticosteroid bination used on dogs for the treatment of superficial lesions caused by susceptible bacteria. Betagen Topical Spray may also be used for purposes other than those listed. Do not use Betagen Topical Spray if the pet has a viral or fungal infection. Tell your veterinarian if your pet is pregnant or lactating.
Use this medication exactly as directed by your veterinarian. If you do not understand the directions ask the pharmacist or veterinarian to explain them to you. The usual dose for dogs is 2 sprays administered 2-4 times a day for 7 days. Hold the spray bottle upright and 3-6 inches from the affected area. Store Betagen Topical Spray at room temperature, away from moisture and heat. Keep out of the reach of children or pets. Apply the missed dose as soon as you remember. However, if it is almost time for the next regularly scheduled dose, skip the missed dose and apply the next one as directed. Do not give a double dose of the medication.
An overdose of this medication is unlikely. If an overdose is suspected, seek emergency veterinary medical treatment. Do not use this medication in pets allergic to it or any of the individual ingredients. Treatment beyond 7 days may lead to prolonged wound healing. Serious side effects are not expected. Prolonged use of this medication may give rise to the overgrowth of nonsusceptible organisms such as fungi and yeasts. Weight loss, increased thirst and urination, vomiting and diarrhea have occurred in animals following the use of synthetic corticosteroids. Continue the medication and talk to your veterinarian about any side effect that seems unusual or bothersome to the animal.
Before using Betagen Topical Spray, tell your veterinarian if your pet is using other antibiotic or corticosteroid medications either topically or by mouth. Talk to the veterinarian or pharmacist before giving any prescription or over the counter medicines. Your pharmacist has additional information about Betagen Topical Spray written for health professionals that you may read. HOME Betagan It should be kept in fancy that various mechanisms of mischief may effect in a wide variety of patterns of trauma in the skeleton.
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Characteriza - tion of the out of the ordinary members has provided trendy insights into the fiat and importance of glucose send and its disorders in individual tissues3 discount betagan 5ml free shipping,4 buy betagan 5 ml without a prescription,5 (Bring up 6-1). Ling Zhi (Reishi Mushroom) How does Reishi Mushroom work Boosting the immune system, high blood pressure, high cholesterol, viral infections, tumors, prostate cancer, inflammatory diseases, heart disease, asthma, bronchitis, stress, kidney disorders, liver disease, HIV disease, altitude sickness, fatigue, chronic fatigue syndrome (CFS), insomnia, stomach ulcers, poisoning, herpes-related pain, shingles, and other conditions. What is Reishi Mushroom Dosing considerations for Reishi Mushroom. Are there any interactions with medications Are there safety concernsBetagan ophthalmic This medication is used alone or with other medications to treat high pressure inside the eye due to glaua (open-angle type) or other eye diseases (e. g. ocular hypertension ). Lowering high pressure inside the eye helps to prevent blindness. Levobunolol belongs to a class of drugs known as beta blockers and works by decreasing the amount of fluid production within the eye. How to use Betagan ophthalmic To apply eye drops, wash your hands first. To avoid contamination, do not touch the dropper tip or let it touch your eye or any other surface. If you are wearing contact lenses.
remove them before using eye drops. Wait at least 15 minutes before replacing your contact lenses . Tilt your head back, look upward, and pull down the lower eyelid to make a pouch. Hold the dropper directly over your eye and place one drop into the pouch, usually once or twice daily or as directed by your doctor. Look downward and gently close your eyes for 1 to 2 minutes. Place one finger at the corner of your eye (near the nose) and apply gentle pressure. This will prevent the medication from draining out. Try not to blink and do not rub your eye. Repeat these steps for your other eye if so directed or if your dose is for more than 1 drop.
Do not rinse the dropper. Replace the dropper cap after each use. If you are using another kind of eye medication (e. g. drops or ointments), wait at least 5 to 10 minutes before using the other medications. Use eye drops before eye ointments to allow the eye drops to enter the eye. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time(s) each day. It is important to continue using this medication even if you feel well. Most people with glaua or high pressure in the eyes do not feel sick. Side Effects Temporary burning/stinging of the eye, itchy/red eyes, headache.
or dizziness may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.
Tell your doctor right away if any of these unlikely but serious side effects occur: eye pain /swelling/discharge, reduced feeling in eye, slow/irregular heartbeat. muscle weakness. hair loss. mental/mood changes, vision changes, tiredness, swelling of the ankles /feet, sudden/unexplained weight gain . Seek immediate medical attention if any of these rare but very serious side effects occur: trouble breathing. chest pain. weakness on one side of the body, slurred speech, confusion. A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash.
itching /swelling (especially of the face/tongue /throat), severe dizziness, trouble breathing. This is not a plete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist. In the US - Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at fda. gov/medwatch. In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345. Precautions Before using levobunolol, tell your doctor or pharmacist if you are allergic to it or to other beta-blockers (e. g. timolol.
metipranolol ) or if you have any other allergies. This product may contain inactive ingredients (such as preservatives like benzalkonium chloride. sulfites), which can cause allergic reactions or other problems. Talk to your pharmacist for more details. This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have: severe breathing problems (e. g. asthma or a history of asthma. chronic obstructive pulmonary disease - COPD ), certain types of heart rhythm problems (e. g. sinus bradycardia. second - or third-degree atrioventricular block), certain serious heart conditions (e. g. cardiogenic shock, severe heart failure ).
Before using this medication, tell your doctor or pharmacist your medical history, especially of: lung disease (e. g. bronchitis. emphysema ), diabetes. heart failure (treated, stable type), blood circulation problems (e. g. cerebrovascular insufficiency), overactive thyroid (hyperthyroidism), muscle weakness disorders (e. g. myasthenia gravis ). Before having surgery, tell your doctor or dentist that you are using this medication. This drug may make you dizzy.
Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages. If you have diabetes, this product may mask the fast/pounding heartbeat you would usually feel when your blood sugar level falls too low (hypoglycemia). Other symptoms of a low blood sugar level, such as dizziness/sweating, are unaffected by this drug. During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.
It is not known if this medication passes into breast milk. Consult your doctor before breast-feeding. Interactions Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with them first. This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.
About DailyMed DailyMed provides trustworthy information about marketed drugs in the United States. DailyMed is the official provider of FDA label information (package inserts). This Web site provides a standard, prehensive, up-to-date, look-up and download resource of medication content and labeling found in medication package inserts. The National Library of Medicine (NLM) provides this as a public service and does not accept advertisements. The drug labeling information on this Web site is the most recent submitted to the Food and Drug Administration (FDA) and currently in use it may include, for example, strengthened warnings undergoing FDA review or minor editorial changes. These labels have been reformatted to make them easier to read. Generic Name: levobunolol ophthalmic (lee voe BYOO noe lole) Brand Names: AK-Beta, Betagan Betagan Eye Drops. Important Information Do not touch the dropper to any surface, including the eyes or hands.
The dropper is sterile. If it bees contaminated, it could cause an infection in the eye. Apply light pressure to the inside corner of the eye (near the nose) after each drop to prevent the fluid from draining down the tear duct. What is Betagan In a class of drugs called beta-blockers. Reduces pressure inside the eye. Used to treat glaua or high pressure in the eye. What to Discuss before Using Before using this medication, tell your doctor if you have:asthma or a chronic lung disease a very slow heart rate heart disease such as high blood pressure, heart failure, or heart block diabetes an overactive thyroid You may not be able to use this medication, or you may require a dosage adjustment or special monitoring during treatment if you have any of the conditions listed above. In the FDA pregnancy category C. This means that it is not known whether this medication will be harmful to an unborn baby. Do not use this medication without first talking to your doctor if you are pregnant or could bee pregnant during treatment. It is also not known whether medication passes into breast milk. Do not use without first talking to your doctor if you are breast-feeding a baby.
Betagan Dosage Method Use eyedrops exactly as directed by your doctor. If you do not understand these directions, ask your pharmacist, nurse, or doctor to explain them to you. Wash your hands before using the eyedrops. If you wear contact lenses, remove them before applying medication. Ask your doctor if contact lenses can be reinserted after application of the medication.
To use the eye drops:Tilt the head back slightly and pull down on the lower eyelid. Position the dropper above the eye. Look up and away from the dropper. Squeeze out a drop and close the eye. Apply gentle pressure to the inside corner of the eye (near the nose) for about 1 minute to prevent the liquid from draining down the tear duct. If you are using more than 1 drop in the same eye, repeat the process with about 5 minutes between drops. Repeat the process in the other eye if needed. Do not touch the dropper to any surface, including the eyes or hands. It is a sterile surface. If it bees contaminated, it could cause an infection in the eye. Do not use any eyedrop that is discolored or has particles in it. Store at room temperature away from moisture and heat.
Keep the bottle properly capped. Miss a dose: Problems Apply the missed dose as soon as you remember. However, if it is almost time for the next regularly scheduled dose, skip the missed dose and apply the next one as directed. Do not use a double dose of this medication. Betagan Overdose Seek emergency medical attention if an overdose is suspected or if the drops have been ingested. Symptoms of an overdose may include dizziness, headache, shortness of breath, slow heart rate, difficulty breathing, wheezing, and heart attack. Avoid During Treatment Do not touch the dropper to any surface, including the eyes or hands. The dropper is sterile.
If it bees contaminated, it could case an infection in the eye. If you wear contact lenses, remove them before applying medication. Ask your doctor if contact lenses can be reinserted after application of the medication. Do not use other eye medications during treatment except under the direction of your doctor. Betagan Side Effects If you experience any of the following serious side effects, stop using this medication and seek emergency medical attention or contact your doctor immediately:an allergic reaction (swelling of the lips, face, or tongue difficulty breathing closing of the throat or hives) an asthma attack (shortness of breath or wheezing) congestive heart failure (shortness of breath, chest pain, or anxiety) Other, less serious side effects may be more likely to occur. Continue to use levobunolol ophthalmic and talk to your doctor if you experience:burning and stinging headache fainting fatigue nausea depression irregular heartbeat, slow heartbeat, or low blood pressure Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome. What other drugs to avoid while undergoing treatment Do not use other eye medications during treatment except under the direction of your doctor. Before using this medication, tell your doctor if you are taking another beta-blocker by mouth, such as propranolol (Inderal), atenolol (Tenormin), or metoprolol (Lopressor). You may be at risk for increased side effects if you also use this medication.
Drugs other than those listed here may also interact. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines, including vitamins, minerals, and herbal products. Buy Betagan Online - Betagan Eye Drops Betagan (levobunolol hydrochloride ophthalmic solution) sterile is a noncardioselective beta-adrenoceptor blocking agent for ophthalmic use. Betagan eyedrops are used to treat chronic open-angle glaua (increased pressure inside the eye). Betagan medication belongs to a class called beta-blockers that works by lowering pressure within the eyeball. Betagan ophthalmic solution es in the form of 0.5 5 ml solution and is available at all online Canadian pharmacies. You can now buy discount Betagan ophthalmic solution at our online pharmacy by just filling up an order form and attaching the prescription with it. Purchasing Betagan ophthalmic solution from us can give you stupendous savings in parison to other markets. Although Betagan medication has very little side effects the possible side effects include headache, fainting, fatigue, nausea, depression etc. Betagan medication can be used alone or in bination with other medications to treat high pressure inside the eye due to glaua. While ordering the drug betagan online, people often look for the best price on betagan. Buy Low Drugs is the best online pharmacy to order prescription drugs like betagan. Here you can purchase discount prescription betagan drugs at a very cheap rate.
Ordering betagan drugs online here is a very safe process as well as affordable. Once you place an order for betagan drugs online, it will be delivered at your doorstep within 14 business days. Here you will get generic as well as branded drugs like betagan at a the best price. Betagan Overview Updated: November 6, 2015 Betagan is a prescription medication used to reduce elevated pressure in the eyes of people with chronic open-angle glaua or high blood pressure of the eye. Betagan belongs to a group of drugs called beta-blockers. These work by decreasing the amount of fluid produced in the eyes, which reduces overall pressure within the eye. Betagan es in the form of an eye drop. It is usually instilled into the affected eye(s) once or twice daily.
mon side effects include burning or stinging of the eye and inflammation of the eyelids and lining of the eyelids. Betagan can also cause dizziness. Do not drive or operate heavy machinery until you know how Betagan affects you. Patient Ratings for BetaganPlease plete the security check to access question Why do I have to plete a CAPTCHA pleting the CAPTCHA proves you are a human and gives you temporary access to the web property. What can I do to prevent this in the future If you are on a personal connection, like at home, you can run an anti-virus scan on your device to make sure it is not infected with malware. If you are at an office or shared network, you can ask the network administrator to run a scan across the network looking for misconfigured or infected devices. CloudFlare Ray ID: 26ba179399fa28fc Your IP. 18.104.22.168 Performance amp security by CloudFlarePlease plete the security check to access genericdoctor Why do I have to plete a CAPTCHA pleting the CAPTCHA proves you are a human and gives you temporary access to the web property. What can I do to prevent this in the future If you are on a personal connection, like at home, you can run an anti-virus scan on your device to make sure it is not infected with malware. If you are at an office or shared network, you can ask the network administrator to run a scan across the network looking for misconfigured or infected devices.
CloudFlare Ray ID: 26ba179492662944 Your IP. 22.214.171.124 Performance amp security by CloudFlareWhat are the possible side effects of levobunolol ophthalmic (Akbeta, Betagan, Levobunolol) Get emergency medical help if you have any of these signs of an allergic reaction: hives difficulty breathing swelling of your face, lips, tongue, or throat. Stop using this medication and call your doctor at once if you have any of these serious side effects: severe swelling, itching, burning, redness, pain, or disfort in or around your eye drainage, crusting, or oozing of your eyes or eyelids bronchospasm (wheezing, chest tightness, trouble breathing) slow heart rate, weak pulse, fainting. slow breathing (breathing may stop) feeling short of breath, even with mild exertion swelling, rapid weight gain or severe blistering, peeling, and red skin rash . Less serious side effects may include: mild burning, stinging, itching, or disfort of your eyes blurred vision mildly swollen or puffy eyes headache. dizziness. spinning sensation depression. confusion, tired feeling muscle weakness mild skin rash or itching or nausea, diarrhea . This is not a plete list of side effects and others may occur.
Tell your doctor about any unusual or bothersome side effect. You may report side effects to FDA at 1-800-FDA-1088. What is the most important information I should know about levobunolol ophthalmic (Akbeta, Betagan, Levobunolol) Do not use this medication if you are allergic to levobunolol, or if you have asthma. or severe chronic obstructive pulmonary disease (COPD), slow heartbeats, or a heart condition called AV block.
Before using this medication, tell your doctor if you have breathing problems such as bronchitis or emphysema. a history of heart disease or congestive heart failure. diabetes. history of stroke. blood clot, or circulation problems, a thyroid disorder, or a muscle disorder such as myasthenia gravis.
Do not allow the dropper to touch any surface, including the eyes or hands. If the dropper bees contaminated it could cause an infection in your eye, which can lead to vision loss or serious damage to the eye. Levobunolol ophthalmic is sometimes given together with other eye medications. Do not use any other eye medication unless your doctor has prescribed it for you. If you use another eye medication, use it at least 10 minutes before or after using levobunolol ophthalmic. Do not use the medications at the same time. Levobunolol ophthalmic can cause blurred vision.
Be careful if you drive or do anything that requires you to be able to see clearly. Do not use this medication while you are wearing contact lenses. Levobunolol ophthalmic may contain a preservative that can be absorbed by soft contact lenses. Wait at least 15 minutes after using levobunolol before putting your contact lenses in. How does this medication work What will it do for me Levobunolol belongs to the class of medications known as beta-blockers . Levobunolol is used to control intraocular (eye) pressure in people with chronic open-angle glaua or mild-to-moderate ocular hypertension (increased pressure within the eye). Your doctor may have suggested this medication for conditions other than those listed in these drug information articles. As well, some forms of this medication may not be used for all of the conditions discussed here. If you have not discussed this with your doctor or are not sure why you are taking this medication, speak to your doctor. Do not stop taking this medication without consulting your doctor. Do not give this medication to anyone else, even if they have the same symptoms as you do. It can be harmful for people to take this medication if their doctor has not prescribed it. What form(s) does this medication e in Each mL of sterile ophthalmic solution contains levobunolol 2.5 mg. Nonmedicinal ingredients: benzalkonium chloride 0.004 (as preservative), edetate disodium, polyvinyl alcohol (Liquifilm), potassium phosphate monobasic, sodium chloride, sodium metabisulfite, sodium phosphate dibasic, and sodium hydroxide or hydrochloric acid to adjust pH. Each mL of sterile ophthalmic solution contains levobunolol 5 mg. Nonmedicinal ingredients: benzalkonium chloride 0.004 (as preservative), edetate disodium, polyvinyl alcohol (Liquifilm), potassium phosphate monobasic, sodium chloride, sodium metabisulfite, sodium phosphate dibasic, and sodium hydroxide or hydrochloric acid to adjust pH. How should I use this medication The remended starting dose of levobunolol eye drops is 1 drop of levobunolol 0.25 twice a day in the affected eye(s). The dose may be increased to 1 drop of levobunolol 0.5 twice a day if necessary.
Doses greater than this have not been found to be any more effective. Ask your doctor or pharmacist to show you the correct way to instill the eye drops. This medication is for external use only. Do not touch the dropper tip to any surface, since this may contaminate the solution. Protect the medication from light and excessive heat. Discard any unused solution after the end of the treatment period. Many things can affect the dose of medication that a person needs, such as body weight, other medical conditions, and other medications.
If your doctor has remended a dose different from the ones listed here, do not change the way that you are using the medication without consulting your doctor. It is important to use this medication regularly and exactly as prescribed by your doctor. If you miss a dose, use it as soon as possible and continue with your regular schedule. If it is almost time for your next dose, skip the missed dose and continue with your regular dosing schedule. Do not take a double dose to make up for a missed one. If you are not sure what to do after missing a dose, contact your doctor or pharmacist for advice. Store this medication at room temperature, protect it and moisture, and keep it out of the reach of children. Do not dispose of medications in wastewater (e. g. down the sink or in the toilet) or in household garbage.
Ask your pharmacist how to dispose of medications that are no longer needed or have expired. Who should NOT take this medication Do not take this medication if you: are allergic to levobunolol or any ingredients of this medication have asthma or a history of asthma or severe chronic obstructive pulmonary disease (e. g. chronic bronchitis or emphysema) have certain abnormal heart rhythms associated with slowing down of the heart rate have overt heart failure suffer from cardiogenic shock What side effects are possible with this medication Many medications can cause side effects. A side effect is an unwanted response to a medication when it is taken in normal doses. Side effects can be mild or severe, temporary or permanent.
The side effects listed below are not experienced by everyone who takes this medication. If you are concerned about side effects, discuss the risks and benefits of this medication with your doctor. The following side effects have been reported by at least 1 of people taking this medication. Many of these side effects can be managed, and some may go away on their own over time. Contact your doctor if you experience these side effects and they are severe or bothersome.
Your pharmacist may be able to advise you on managing side effects. acid or sour stomach belching blurred vision (temporary) brow ache constipation crusting of eyelashes decreased night vision dry eyes dry skin feeling like you have something in your eye heartburn increased sensitivity of eye to light indigestion itching, stinging, burning, or watering of eye or other eye irritation pain, redness, warmth, or swelling of muscles stinging of eye or other eye irritation (when medication is applied) Although most of the side effects listed below dont happen very often, they could lead to serious problems if you do not seek medical attention. Check with your doctor as soon as possible if any of the following side effects occur: blurred vision or other change in vision discoloration of the eyeball droopy upper eyelid eye pain pupils of different sizes redness of the eyes or inside of the eyelids redness or irritation of the tongue seeing quotdoublequot swelling, irritation, or inflammation of eye or eyelid Signs of too much medication being absorbed into the body: ankle, knee, or big toe joint pain or swelling anxiety or nervousness bloody or cloudy urine breast pain burning or prickling feeling on body change in taste sensation chest pain chills clumsiness or unsteadiness confusion or depression coughing, wheezing, or troubled breathing decreased sexual ability diarrhea difficult, burning, or painful urination dizziness or feeling faint drowsiness dryness or soreness of throat ear pain feeling of constant movement fever hair loss hallucinations headache hoarseness irregular, fast, slow, or pounding heartbeat lightheadedness lower back or side pain muscle or joint aches or pain muscle tightness or stiffness nausea or vomiting raw, red, blistering, scaly, or crusted areas of the skin ringing or buzzing in the ears runny, stuffy, or bleeding nose skin rash, hives, or itching swelling of feet, ankles, or lower legs trouble sleeping unusual tiredness or weakness Some people may experience side effects other than those listed. Check with your doctor if you notice any symptom that worries you while you are taking this medication. Are there any other precautions or warnings for this medication Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breast-feeding, and any other significant facts about your health. These factors may affect how you should use this medication. Allergies: This medication should be used with caution by anyone with a known allergy to other beta-blockers (e. g. metoprolol, atenolol). Medical conditions: This medication belongs to the family of medications known as beta-blockers . Although levobunolol is given as an eye drop, small amounts may be absorbed into the bloodstream.
For this reason, it should not be used by anyone who must avoid internal use of beta-blockers. This includes those with abnormally low heart rate, certain abnormal heart rhythms, uncontrolled congestive heart failure, asthma, or severe chronic obstructive pulmonary disease. Sulfites: This product contains sodium metabisulfite, a sulfite that may cause allergic-type reactions, including anaphylaxis, in certain susceptible people. Sulfite sensitivity is seen more frequently in those with asthma. Pregnancy: This medication has not been studied for use by pregnant women. It should be used during pregnancy only if the potential benefits outweigh the potential risks. Breast-feeding: It is not known if levobunolol passes into breast milk. Related medications have been shown to pass into breast milk. Talk to your doctor about breast-feeding while using levobunolol.
Children: The safety and effectiveness of this medication have not been established for use by children. What other drugs could interact with this medication There may be an interaction between levobunolol and any of the following: medications that reduce blood pressure other beta-blockers other eye drops If you are taking any of these medications, speak with your doctor or pharmacist. Depending on your specific circumstances, your doctor may want you to: stop taking one of the medications, change one of the medications to another, change how you are taking one or both of the medications, or leave everything as is. An interaction between two medications does not always mean that you must stop taking one of them. Speak to your doctor about how any drug interactions are being managed or should be managed. Medications other than those listed above may interact with this medication. Tell your doctor or prescriber about all prescription, over-the-counter (non-prescription), and herbal medications you are taking. Also tell them about any supplements you take.
Since caffeine, alcohol, the nicotine from cigarettes, or street drugs can affect the action of many medications, you should let your prescriber know if you use them. How To UseHOW TO USE THIS MEDICATION: To instill eye drops, wash hands first. To avoid contamination, be careful not to touch the dropper or let it touch your eye. Tilt your head back, gaze upward and pull down the lower eyelid to make a pouch. Place dropper directly over eye and administer the prescribed number of drops. Look downward and gently close your eye for 1 to 2 minutes. Try not to blink and do not rub the eye. Do not rinse the dropper. For maximum effect, this medication must be used routinely as prescribed.
Side EffectsThis medication may temporarily sting your eyes for a minute or two when you first use it. If stinging persists or bees bothersome, inform your doctor. Vision may be temporarily blurred or unstable after applying drops. Use caution driving or performing duties requiring clear vision. On rare occasions dizziness, drowsiness, depression, breathing difficulties, irregular or slow heartbeat may occur. Notify your doctor if you experience any of these effects. In the unlikely event you have an allergic reaction to this drug, seek immediate medical attention. Symptoms of an allergic reaction include rash, itching, swelling, dizziness or breathing trouble. If you notice other effects not listed above, contact your doctor or pharmacist.
PrecautionsTell your doctor your medical history, especially of diabetes, thyroid disorders, muscle weakness disorders, breathing problems, heart problems and of any allergies you may have. If you are scheduled for surgery that requires anesthesia, tell the doctor treating you that you use this medication. If you have eye surgery, injury or infection consult your eye doctor about continued use of this current eye drop bottle. This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor. This medication may be excreted into breast milk and may have undesirable effects on a nursing infant. Consult your doctor before breast-feeding.
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Cialis and Viagra. 26 nov 2013 Biopsy: Left lobe 1 of 10 cores total 2. Right lobe 6 of 14 cores total 8 Gleason 33 in both sides. Age 63, DRE Normal, Dr. Tewari 1/11, PSA 6.96, Free PSA 20, PCA3 74.5, MRI - mild capsule irregularity 2/11 Saturation Biopsy - 49 cores Gleason 6, 2 in 1/3 cores Gleason 6, 5 in 1/3 cores Active Surveillance, Grandfather, Father, Brother have PC, Gic Testing negative 7/11, PSA 7.89, Free PSA 14, PCA3 127.8 8/11, MRI - no change 10/11, PSA 7.4, PCA3 24.1, Saturation Biopsy - 52 cores right lateral mid: Gleason 6, 5 in 1/3 cores 5/12, PSA 10.77, Free PSA 8, PCA3 41.6, MRI irregularity less apparent 7/12 PSA 11.25, Ultrasound 10/12 MRI No change. PSA 10.09, Free PSA 9, PCA3 284 12/12 Robotic Surgery (pTNM): pT2c: Bilateral disease, an confined, 10 of prostate, Gleason 7(34), margins negative intercourse able 7 months stopped MUSE 11 months amp reduced Cialis to 5mg Viagra 12 months only Viagra 2 years only need Viagra PSA 1/13, 3/13, 6/13, 9/13, 12/13, 4/14, 10/14 lt.00 6/15, 10/15 lt.02
What is non-Hodgkins lymphoma Reader Stories Non-Hodgkin39s lymphoma is a type of cancer that originates in the lymphatic system. It is estimated to be the sixth mostmon cancer in the United States. The lymphatic system is part of the body39s immune system and helps fight infections and other diseases. In addition, the lymphatic system filters out bacteria, vses. and other unwanted substances. The lymphatic system consists of the following: Lymph vessels . These vessels branch out throughout the body similar to blood vessels.
Because lymphatic tissue is found in many parts of the body, non-Hodgkin39s lymphoma can start almost anywhere. Medically Reviewed by a Doctor on 4/1/2015Cyclophosphamide Tablets USP, 25 mg and 50 mg Cyclophosphamide Description Cyclophosphamide is a synthetic antineoplastic g chemically related to the nitrogen mustards. Cyclophosphamide is a white crystalline powder with the molecular formula C 7 H 15 Cl 2 N 2 O 2 P bull H 2 O and a molecular weight of 279.1. The chemical name for Cyclophosphamide is 2 H -1,3,2-Oxazaphosphorin-2-amine, N, N - bis(2-chloroethyl)tetrahydro-, 2-oxide, monohydrate, (plusmn). Cyclophosphamide is soluble in water, saline, or ethanol and has the following sctural formula: Slideshow: Breast Cancer Therapy: Right On Target Each tablet for oral administration contains Cyclophosphamide (anhydrous) 25 mg or 50 mg. In addition, each tablet contains the following inactive ingredients: acacia, FDampC Blue No. 1, lactose monohydrate, magnesium stearate, and microcrystalline cellulose. Cyclophosphamide - Clinical Pharmacology Cyclophosphamide is biotransformed principally in the liver to active alkylating metabolites by a mixed function microsomal oxidase system. These metabolites interfere with the growth of susceptible rapidly proliferating malignant cells.
The mechanism of action is thought to involve cross-linking of tumor cell DNA. Cyclophosphamide is well absorbed after oral administration with a bioavailability greater than 75. The unchanged g has an elimination half-life of 3 to 12 hours. It is eliminated primarily in the form of metabolites, but from 5 to 25 of the dose is excreted in urine as unchanged g. Several cytotoxic and noncytotoxic metabolites have been identified in urine and in plasma. Concentrations of metabolites reach a maximum in plasma 2 to 3 hours after an intravenous dose. Plasma protein binding of unchanged g is low but some metabolites are bound to an extent greater than 60. It has not been demonstrated that any single metabolite is responsible for either the therapeutic or toxic effects of Cyclophosphamide. Although elevated levels of metabolites of Cyclophosphamide have been observed in patients with renal failure, increased clinical toxicity in such patients has not been demonstrated. Indications and Usage for Cyclophosphamide Malignant Diseases Cyclophosphamide Tablets USP, 25 mg and 50 mg, although effective alone in susceptible malignancies, are more frequently used concurrently or sequentially with other antineoplastic gs. The following malignancies are often susceptible to Cyclophosphamide treatment: 1. Malignant lymphomas (Stages III and IV of the Ann Arbor staging system), Hodgkinrsquos disease, lymphocytic lymphoma (nodular or diffuse), mixed-cell type lymphoma, histiocytic lymphoma, Burkittrsquos lymphoma. 2. Multiple myeloma.
3. Leukemias: Chronic lymphocytic leukemia, chronic granulocytic leukemia (it is usually ineffective in acute blastic crisis), acute myelogenous and monocytic leukemia, acute lymphoblastic (stem-cell) leukemia in children (Cyclophosphamide given during remission is effective in prolonging its duration). 4. Mycosis fungoides (advanced disease). 5. Neuroblastoma (disseminated disease). 6. Adenocarcinoma of the ovary. 7. Retinoblastoma.
8. Carcinoma of the breast. Nonmalignant Disease Biopsy Proven ldquoMinimal Changerdquo Nephrotic Syndrome in Children: Cyclophosphamide Tablets USP, 25 mg and 50 mg are useful in carefully selected cases of biopsy proven ldquominimal changerdquo nephrotic syndrome in children but should not be used as primary therapy. In children whose disease fails to respond adequately to appropriate adrenocorticosteroid therapy or in whom the adrenocorticosteroid therapy produces or threatens to produce intolerable side effects, Cyclophosphamide may induce a remission. Cyclophosphamide is not indicated for the nephrotic syndrome in adults or for any other renal disease. Contraindications Continued use of Cyclophosphamide is contraindicated in patients with severely depressed bone marrow function. Cyclophosphamide is contraindicated in patients who have demonstrated a previous hypersensitivity to it (see WARNINGS and PRECAUTIONS ). Carcinogenesis, Mutagenesis, and Impairment of Fertility Second malignancies have developed in some patients treated with Cyclophosphamide used alone or in association with other antineoplastic gs and/or modalities.
Most frequently, they have been urinary bladder, myeloproliferative, or lymphoproliferative malignancies. Second malignancies most frequently were detected in patients treated for primary myeloproliferative or lymphoproliferative malignancies or nonmalignant disease in which immune processes are believed to be involved pathologically. In some cases, the second malignancy developed several years after Cyclophosphamide treatment had been discontinued. In a single breast cancer trial utilizing two to four times the standard dose of Cyclophosphamide in conjunction with doxbicin a small number of cases of secondary acute myeloid leukemia occurred within two years of treatment initiation. Urinary bladder malignancies generally have occurred in patients who previously had hemorrhagic cystitis. In patients treated with Cyclophosphamide-containing regimens for a variety of solid tumors, isolated case reports of secondary malignancies have been published. One case of carcinoma of the renal pelvis was reported in a patient receiving long-term Cyclophosphamide therapy for cerebral vasculitis.
The possibility of Cyclophosphamide-induced malignancy should be considered in any benefit-to-risk assessment for use of the g. Cyclophosphamide can cause fetal harm when administered to a pregnant woman and such abnormalities have been reported following Cyclophosphamide therapy in pregnant women. Abnormalities were found in two infants and a six-month-old fetus born to women treated with Cyclophosphamide. Ectrodactylia was found in two of the three cases. Normal infants have also been born to women treated with Cyclophosphamide during pregnancy, including the first trimester. If this g is used during pregnancy, or if the patient bes pregnant while taking (receiving) this g, the patient should be apprised of the potential hazard to the fetus. Women of childbearing potential should be advised to avoid bing pregnant. Cyclophosphamide interferes with oogenesis and spermatogenesis. It may cause sterility in both sexes.
Development of sterility appears to depend on the dose of Cyclophosphamide, duration of therapy, and the state of gonadal function at the time of treatment. Cyclophosphamide-induced sterility may be irreversible in some patients. Amenorrhea associated with decreased estrogen and increased gonadotropin secretion develops in a significant proportion of women treated with Cyclophosphamide. Affected patients generally resume regular menses within a few months after cessation of therapy. Girls treated with Cyclophosphamide during prepubescence generally develop secondary sexual characteristics normally and have regular menses.
Ovarian fibrosis with apparentlyplete loss of germ cells after prolonged Cyclophosphamide treatment in late prepubescence has been reported. Girls treated with Cyclophosphamide during prepubescence subsequently have conceived. Men treated with Cyclophosphamide may develop oligospermia or azoospermia associated with increased gonadotropin but normal testosterone secretion. Sexual potency and libido are unimpaired in these patients.
Boys treated with Cyclophosphamide during prepubescence develop secondary sexual characteristics normally, but may have oligospermia or azoospermia and increased gonadotropin secretion. Some degree of testicular atrophy may occur. Cyclophosphamide-induced azoospermia is reversible in some patients, though the reversibility may not occur for several years after cessation of therapy. Men temporarily rendered sterile by Cyclophosphamide have subsequently fathered normal children. Urinary System Hemorrhagic cystitis may develop in patients treated with Cyclophosphamide. Rarely, this condition can be severe and even fatal.
Fibrosis of the urinary bladder, sometimes extensive, also may develop with or without apanying cystitis. Atypical urinary bladder epithelial cells may appear in the urine. These adverse effects appear to depend on the dose of Cyclophosphamide and the duration of therapy. Such bladder injury is thought to be due to Cyclophosphamide metabolites excreted in the urine. Forced fluid intake helps to assure an ample output of urine, necessitates frequent voiding, and reduces the time the g remains in the bladder. This helps to prevent cystitis. Hematuria usually resolves in a few days after Cyclophosphamide treatment is stopped, but it may persist. Medical and/or surgical supportive treatment may be required, rarely, to treat protracted cases of severe hemorrhagic cystitis.
It is usually necessary to discontinue Cyclophosphamide therapy in instances of severe hemorrhagic cystitis. Cardiac Toxicity Although a few instances of cardiac dysfunction have been reported following use of rmended doses of Cyclophosphamide, no causal relationship has been established. Acute cardiac toxicity has been reported with doses as low as 2.4 g/m 2 to as high as 26 g/m 2. usually as a portion of an intensive antineoplastic multi-g regimen or in conjunction with transplantation procedures. In a few instances with high doses of Cyclophosphamide, severe, and sometimes fatal, congestive heart failure has occurred after the first Cyclophosphamide dose. Histopathologic examination has primarily shown hemorrhagic myocarditis. Hemopericardium has occurred secondary to hemorrhagic myocarditis and myocardial necrosis.
Pericarditis has been reported independent of any hemopericardium. No residual cardiac abnormalities, as evidenced by electrocardiogram or echocardiogram appear to be present in patients surviving episodes of apparent cardiac toxicity associated with high doses of Cyclophosphamide. Cyclophosphamide has been reported to potentiate doxbicin-induced cardiotoxicity. Infections Treatment with Cyclophosphamide may cause significant suppression of immune responses. Serious, sometimes fatal, infections may develop in severely immunosuppressed patients.
Cyclophosphamide treatment may not be indicated, or should be intepted, or the dose reduced, in patients who have or who develop viral, bacterial, fungal, protozoan, or helminthic infections. Anaphylactic reactions have been reported death has also been reported in association with this event. Possible cross-sensitivity with other alkylating agents has been reported. Precautions Special attention to the possible development of toxicity should be exercised in patients being treated with Cyclophosphamide if any of the following conditions are present: 1. Leukopenia 2. Thrombocytopenia 3. Tumor cell infiltration of bone marrow 4. Previous X-ray therapy 5. Previous therapy with other cytotoxic agents 6. Impaired hepatic function 7. Impaired renal function Laboratory Tests During treatment, the patientrsquos hematologic profile (particularly neutrophils and platelets) should be monitored regularly to determine the degree of hematopoietic suppression. Urine should also be examined regularly for red cells which may precede hemorrhagic cystitis. g Interactions The rate of metabolism and the leukopenic activity of Cyclophosphamide reportedly are increased by chronic administration of high doses of phenobarbital. The physician should be alert for possiblebined g actions, desirable or undesirable, involving Cyclophosphamide even though Cyclophosphamide has been used successfully concurrently with other gs, including other cytotoxic gs. Cyclophosphamide treatment, which causes a marked and persistent inhibition of cholinesterase activity, potentiates the effect of succinylcholine chloride. If a patient has been treated with Cyclophosphamide within 10 days of general anesthesia, the anesthesiologist should be alerted. Adrenalectomy Since Cyclophosphamide has been reported to be more toxic in adrenalectomized dogs, adjustment of the doses of both replacement steroids and Cyclophosphamide may be necessary for the adrenalectomized patient.
Wound Healing Cyclophosphamide may interfere with normal wound healing. Background: The purpose of this study was to determine the specific and detailed anatomic sites and morphologic characteristics of mediastinal lymph nodes on spiralputed tomography for the purpose of differentiation between sarcoidosis and Hodgkinx02019s lymphoma. Material/Methods: Anatomical distribution of mediastinal lymph nodes on spiral CT was reviewed in 39 patients with sarcoidosis and 37 patients with Hodgkinx02019s lymphoma using the International Association for the Study of Lung Cancer (IASLC) lymph node map. Other morphologic features such as lymph node calcification or coalescence of adjacent lymph nodes were alsopared. Conclusions: Keywords: sarcoidosis, Hodgkinx02019s lymphoma, lymphadenopathy, IASLC lymph node map, spiral CT scan Background Sarcoidosis is a systemic disorder of unknown etiology with a wide variety of clinical and radiological manifestations. Pathologically, the disease is characterized by presence of widespread non-caseating granulomas. These granulomas, however, are not unique to sarcoidosis and can be seen in other conditions including tuberculosis, fungal disease, berylliosis, and in association with carcinoma and lymphoma 1 . Clinical manifestations of sarcoidosis are widespread, but the lung and intrathoracic lymph nodes are almost universally affected.
Among patients with sarcoidosis, 75x0201390 will present with mediastinal and hilar lymphadenopathy. In fact, the most frequent radiological abnormality involves enlarged bilateral hilar and right paratracheal lymph nodes 2 . Computed tomography (CT) is superior to chest radiography for delineating the full extent of lymphadenopathy in the mediastinum 3 ,4 . Although sarcoidosis classically involves the right paratracheal and hilar lymph nodes, CT scan often demonstrates enlargement of lymph nodes in previously unsuspected locations including the anterior mediastinum, axillary, internal mammary chain and retroral and infradiaphragmatic locations 3 x020135 . On the other hand, lymphoma is a systemic disease where the mediastinal lymph nodes are often involved, and it is easily confused with sarcoidosis. Parenchymal presentations of lymphoma and sarcoidosis are similar and indistinguishable as well. It is extremely important for clinicians and radiologists to be able to distinguish between these two entities in a clinical setting. With a CT scan, anatomical sites and characteristics of enlarged lymph nodes can be accurately determined. To the best of authorsx02019 knowledge, a detailedparison between sarcoidosis and lymphoma regarding anatomical sites of mediastinal lymph nodes on CT scan has not yet been reported.
In the present study, spiral CT scan features were retrospectively reviewed in a group of 39 patients with sarcoidosis and 37 cases of mediastinal Hodgkinx02019s lymphoma for the purpose of assessing the differences in anatomical distribution and imaging characteristics of mediastinal lymphadenopathy between the two entities. Material and Methods Thirty-nine consecutive patients with untreated sarcoidosis and 37 consecutive patients with untreated mediastinal Hodgkinx02019s lymphoma who had undergone a chest CT scan were enrolled at the Department of Radiology, Masih Daneshvari Hospital, a tertiary referral center for pulmonary diseases, from January 2010 to April 2012. The criteria to establish the diagnosis of sarcoidosis included 1) histological evidence of non-caseating granuloma in the samples obtained by bronchoscopic biopsy, surgical biopsy or transthoracic needle aspiration biopsy, 2)patible clinical and imaging evidence and 3) negative bacterial and fungal studies for sputum, bronchoalveolar lavage or biopsied tissues. Patients with a history of pervious or concurrent tuberculosis were excluded from the study.
Subjects who met all of these criteria were reited. Chest CT scan had been performed in these patients due to several reasons including minimal or atypical chest radiography presentations, ling out malignancy and pre-bronchoscopic planning. The diagnosis of mediastinal lymphoma was made by biopsy of the enlarged lymph nodes. The criterion for significant lymph node enlargement of mediastinal lymph nodes was considered to be a short axis dimension x0226510 mm for all zones except for subcarinal lymph nodes (zone 7) were a measurement x0226512 mm was used. For axillary, internal mammary, peridiaphragmatic and retroral lymph nodes, short axis cut off points equal to or more than 10 mm, 5 mm, 5 mm and 6 mm were used respectively. All scans were obtained on a spiral CT scanner (Siemens SOMATOM Emotional, Munich, Germany). Scans were taken from the supraclavicular fossa down to the level of adrenal glands.
The following parameters were used: 130 kV, 90 mAs, Gantry rotation time of 0.8 s, pitch of 1.5, and collimation of 5 mm. Intravenous contrast was used in 32 patients from the sarcoidosis group and in 35 patients from the lymphoma group. A 100-mL bolus of contrast material (Omnipaque, 240 mg iodine/ml GE healthcare Inc, Cork, Ireland) was injected at a rate of 2.5 mL per second The delay time was 35 seconds. In the remaining patients (7 patients from the sarcoidosis group and 2 patients from the lymphoma group), there were contraindications to contrast administration, but fortunately there was sufficient amount of mediastinal fat to allow adequate discrimination of differentpartments. Two experienced thoracic radiologists who were unaware of final diagnoses reviewed all CT scan images independently.
If patients had multiple CT scans throughout the course of their disease, the earliest scan was reviewed. For each patient, characteristics of the enlarged lymph nodes were recorded, including anatomical site, margin, presence or absence of calcifications, and enhancement patterns on axial and coronal multiplanar (MPR) images using a soft-tissue reconsction algorithm. Discrepancies in interpretation between observers were resolved by consensus. Association for the Study of Lung Cancer (IASLC) proposed a lymph node map that reconciles the discrepancies between two previous maps (American Thoracic Society lymph node map and Japan Lung cancer society lymph node map) and other published proposals, and provides detailed nomenclature for the anatomical boundaries of lymph node locations. This map is now the rmended method of describing regional lymph node involvement in lung cancers 6 . According to this map, mediastinal lymph nodes were divided into 10 zones. The aforementioned zones were as follows: 1 (low cervical, supraclavicular and sternal notch), 2R (right upper paratracheal), 2L (left upper paratracheal), 3 (prevascular and retrotracheal), 4R (right lower paratracheal), 4L (left lower paratracheal), 5 (subaortic), 6 (paraaortic), 7 (subcarinal), 8 (paraesophageal), 9 (pulmonary ligament), 10R (right hilar), and 10L (left hilar). Coalescence of lymph nodes was defined as conglomerate of adjacent lymph nodes without discernable borders. Lymph node caviation was presumed when low density area was present in its center.
Data analysis was carried out using themercially available SPSS program (Version 17.0 Chicago, IL, USA). The differences in anatomical distribution and morphological patterns of mediastinal lymph nodes between sarcoidosis and lymphoma were examined with a chi-square test. Px0003c0.05 was considered statistically significant. The mean age of patients with sarcoidosis (49.9 years, range 28x0201375 years) was significantly higher than patients with Hodgkinx02019s lymphoma (39.1 years, range 11x0201360 years) (px0003c0.001). 18 patients (46.1) with sarcoidosis were men and 21 patients (53.9) were women. 17 patients (45.9) with Hodgkinx02019s lymphoma were men and 20 patients were women (54.1). 20 patients (51.3) with sarcoidosis had history of smoking, while 13 (35.1) patients with Hodgkinx02019s lymphoma had history of smoking (p0.156). Sarcoidosis predominantly affected the lymph nodes in the following zones: 4 (lower paratracheal 97.4), 10 (hilar 78), 7 (subcarinal 76.9) and 5 (subaortic 69.2). In patients with Hodgkinx02019s disease, enlarged lymph nodes were distributed mainly in the zones: 4 (lower paratracheal 89.2), 3 (prevascular 81.1), 7 (subcarinal 73.0) and 2 (upper paratracheal 70.2). Zone 9 (pulmonary ligament) and peridiaphragmatic zones were rarely affected in either Hodgkinx02019s lymphoma or sarcoidosis cases. Sarcoidosis involved the 10 (hilar) zone significantly more often than Hodgkinx02019s lymphoma but the 1 (low cervical, supraclavicular and sternal notch), 3 (prevascular), internal mammary and retroral zones were less likely to be involved in sarcoidosispared to Hodgkinx02019s lymphoma. Coalescence of enlarged lymph nodes was seen significantly more often in Hodgkinx02019s lymphoma (94.6)pared to sarcoidosis (5.3, px0003c0.001). Calcification within the nodes was demonstrated in one patient (2.7) with Hodgkinx02019s lymphoma and in 12 patients (30.8) with sarcoidosis. None of the sarcoidosis cases exhibited pressure effect or displacement of adjacent sctures by the enlarged lymph nodes, while it was seen in 59.5 of Hodgkinx02019s lymphoma cases (px0003c0.001). Two patients (5.4) with Hodgkinx02019s lymphoma presented with lymph node cavitation, while it was not present in patients with sarcoidosis. Table 1 shows the distribution of affected lymph nodes in sarcoidosis and Hodgkinx02019s lymphoma. Anatomic distribution of lymph nodes in 76 patients with sarcoidosis or Hodgkinx02019s lymphoma.
Discussion Sarcoidosis is one of the most important pulmonary diseases mostly presenting with enlarged mediastinal lymph nodes with typical pattern of involvement, which includes right paratracheal and bilateral hilar zones 2 . However, this pattern of involvement is not specific and can be seen in a wide variety of diseases such as Hodgkinx02019s lymphoma and tuberculosis 2 . On the other hand, atypical pattern of involvement of lymphadenopathy in sarcoidosis is not rare, which makes differentiation of sarcoidosis from other mediastinal diseases, especially Hodgkinx02019s lymphoma, more difficult 3 . Biopsy is considered the gold standard for diagnosis of diseased mediastinal lymph nodes, but it is time-consuming and invasive. As CT imaging evolved, multi-planar or three-dimensional reconscted images became available. This was an important development for the detection of enlarged lymph nodes in the mediastinum 7 . In sarcoidosis, distribution of thoracic lymphadenopathy, according to the American Thoracic Society lymph node map, was evaluated in two studies 8 ,9 . The mostmonly involved nodal locations, in decreasing order of frequency, were 4R (right lower paratracheal), 10R (right hilar), 7 (subcarinal), 5 (subaortic, i. e. aorto-pulmonic window), which is consistent with our findings. However, in our study prevalence of lymphadenopathy in different zones is generally higherpared to previous studies. Considering similar method and criteria, it is unclear whether the difference is due to patient population or higher detection rate by newer, higher-resolution CT images. Several reports 3 ,4 ,10 show that in sarcoidosis, hilar lymphadenopathy is frequently associated with mediastinal lymph node enlargement as depicted on CT scans, especially including the right paratracheal and subaortic nodes. However, mediastinal lymphadenopathy without hilar involvement is rare and is more suggestive of lymphoma. Our findings are in line with these reports.
In concordance with previous studies 4 ,11 , we found that unilateral hilar lymphadenopathy is seen in less than 8 of cases of sarcoidosis, but is not umon in Hodgkinx02019s lymphoma where it is present in 37.8 of cases. In sarcoidosis, unilateral hilar lymphadenopathy (if present) is approximately twice asmon on the right sidepared to the left side, but it is equal in both sides in Hodgkinx02019s lymphoma. These results are in line with findings of previous studies as well 6 ,12 . Suwatanapongched et al. 10 found that unilateral hilar disease or mediastinal lymphadenopathy without hilar disease is rarely seen with sarcoidosis and is more suggestive of lymphoma. Our findings support this report. In addition, in our study, retroral and internal mammary involvement is seen exclusively in Hodgkinx02019s lymphoma. Nunes et al. 7 also found that although occasionally present in sarcoidosis, enlargement of internal mammary and pericardial lymph nodes requires exclusion of lymphoma. Hamper et al. 3 found that enlarged lymph nodes in unusual locations such as axillary, peridiaphragmatic and internal mammary region, were much more frequently appreciated on CT images than previously believed. They showed that when sarcoidosis presented with generalized peripheral and thoracic lymphadenopathy, the differential diagnosis from lymphoma on the basis of CT scan was a challenge. ( Figure 1 ). A 23-year-old man with Hodgkinx02019s lymphoma presented with enlarged lymph node (black arrow) in internal mammary zone.
This pattern is found to be highly in favor of Hodgkinx02019s lymphoma rather than sarcoidosis. To the best of our knowledge there is no published studyparing the distribution of lymphadenopathy in Hodgkinx02019s lymphoma and sarcoidosis using IASLC classification method. We found that zone 1 and 3 are moremonly involved in Hodgkinx02019s lymphoma and zone 10 is moremonly involved in sarcoidosis and these differences are significant. In contrast, lymph nodes in Hodgkinx02019s lymphoma show pressure effect on adjacent sctures in more than half of cases in our study and this can be proposed as a helpful criterion, not characteristic of course, to differentiate lymphoma from sarcoidosis ( Figure 2 ). Axial CT scans in a 21-year-old female with Hodgkinx02019s lymphoma show enlarged lymph nodes (long white arrow)pressing right pulmonary artery (long black arrow), SVC and right pulmonary vein (small black arrow). Thispression effect is not . Calcification may apany extensive fibrosis and this fact may explain the presence of calcified lymph nodes in sarcoidosis but not in untreated Hodgkinx02019s lymphoma, as demonstrated in our study. In concordance with our findings, lymph node calcifications in sarcoidosis were reported in 5 to 50 of cases 12 . Miller et al. 18 found that the occurrence of lymph node calcification in sarcoidosis, as in other chronic granulomatous diseases, is closely related to the duration of disease. In a study of sarcoidosis patients known to have disease for up to 32 years, nodal calcification was noted in 53, with eggshell calcification seen in 9. In another report, calcification was identified in 20 of patients at presentation, increasing to 44 over a period of 4 years 19 . Conclusions In summary, the findings of this study indicate that zone 1 and 3 (according to IASLC mapping) lymph nodes were involved in Hodgkinx02019s lymphoma more often than in sarcoidosis and internal mammary and retroral groups involvement was only seen in Hodgkinx02019s lymphoma.
Hence, contrast-enhanced CT scan may be helpful in differentiating intrathoracic sarcoidosis from Hodgkinx02019s lymphoma based on the anatomical distribution of enlarged lymph nodes. Furthermore, presence of lymph node calcification, lack of pressure effect on adjacent sctures and noncoalescent behavior were more consistent with sarcoidosis. Bilateral hilar involvement was moremon in sarcoidosis than in Hodgkinx02019s lymphoma. There are few known modifiable risk factors for Hodgkin lymphoma (HL), but the recent finding of an inverse association between routine regular-strength aspirin use and HL risk suggests that aspirin may protect against HL development. To further investigate this association using prospectively collected data, we conducted a population-based case-control study in Northern Denmark. A total of 478 incident HL cases were identified in nationwide health care databases from 1991 through 2008. Ten population controls were matched to each case on age, sex, and county using risk-set sampling. Use of aspirin, selective cyclooxygenase-2 (sCOX-2) inhibitors, and other NSAIDs from 1989 through 2007 was ascertained by linkage to a population-based prescription database.
Conditional logistic regression was used to estimate odds ratios (ORs) for associations between medication use and risk of HL. The OR for ever use (x0003e2 prescriptions)pared with never/rare use (x022642 prescriptions) of low-dose aspirin was 0.7 (95 confidence interval CI: 0.5x020131.2). The association with low-dose aspirin use did not vary appreciably by recentness, duration, or intensity of use. Recent use (x0003e2 prescriptions in the 1x020132 years before the index date), short-term use (x0003c7 years), and medium/high-intensity use (x0226525 of duration of use covered by prescription) of sCOX-2 inhibitors or other NSAIDs was associated with increased HL risk, possibly due to prodromal symptoms among cases. In conclusion, our results provide some evidence of a protective effect of low-dose aspirin, but not other NSAIDs, against HL development. Keywords: non-steroidal anti-inflammatory gs, Hodgkin lymphoma, epidemiology, risk, prevention INTRODUCTION Hodgkin lymphoma (HL) is one of the mostmon cancers of children and young adults in Western countries, and it is the third leading cancer in terms of average years of life lost per patient in the US (1 ). Few, if any, established HL risk factors are readily modifiable. However, an inverse association between routine regular-strength (325 mg) aspirin use and risk of HL was recently observed in a US population-based case-control study of 565 HL patients and 679 controls (2 ).paring routine users (those who reported using aspirin x022652 times per week during the last 5 years) with non-routine users, the odds ratio (OR) of HL was 0.60 (95 confidence interval CI: 0.42x020130.85). This inverse association did not vary by age group, sex, level of education, use of non-aspirin NSAIDs or acetaminophen, or, among HL patients, by presence of B-symptoms, time interval between diagnosis and interview, or tumor Epstein-Barr vs positivity. In the same study, there was no association between routine use of non-aspirin NSAIDs and HL risk. Distinctive biological properties of aspirin, including irreversible binding to cyclooxygenase-2 (COX-2) (3 ) and inhibition of pro-inflammatory transcription factor nuclear factor kappa-B (NF-x003baB) (4. 5 ), a necessary survival factor for malignant HL cells (6 x020139 ), may partially explain the observed inverse association of aspirin but not other NSAIDs with HL risk.
To follow up on these findings, we conducted a population-based case-control study with prospectively collected data in Northern Denmark to investigate the association of aspirin and other NSAIDs, including selective COX-2 (sCOX-2) inhibitors, with risk of HL. MATERIALS AND METHODS This study included residents of the four former Danish counties of North Jutland, Aarhus, Vi, and Ringkoebing, which have abined population of approximately 1.7 million inhabitants. The Danish National Health Service provides tax-supported health care to all residents of the country and refunds part of patient expenditures on a wide range of prescribed gs, including NSAIDs and sCOX-2 inhibitors, the latter of which became available in Denmark in 1999. All health-related services are registered to individual patients by use of their civil personal registration (CPR) number, assigned to all Danish citizens since 1968. This unique CPR number facilitates linkage between population-based registries, including the Danish Cancer Registry (10 ), the Danish National Registry of Patients (11 ), and countywide prescription databases. The methods we used have been described elsewhere (12 ), with expansion of the study base to the four former counties for which data have been merged into a research database at Aarhus University. Briefly, we used the Cancer Registry to identify all patients ( N 403) who had a first diagnosis of HL (International Classification of Diseases, 10 th revision (ICD-10) code C81) starting on January 1, 1991, in North Jutland County January 1, 1998, in Aarhus County and January 1, 2000, in Vi and Ringkoebing counties and continuing through December 31, 2006, in all four former counties (now merged into two regions) and we used the National Registry of Patients (which has more recent data) to ascertain all patients ( N 75) who had a first diagnosis of HL within all hospitals in the two regions from January 1, 2007, through December 31, 2008. The Cancer Registry includes the CPR number and detailed individual data on all cancer diagnoses in Denmark since 1943 (10 ), while the Registry of Patients includes the CPR number and detailed individual data on all non-psychiatric hospital admissions since 1977 and out-patient contacts since 1995 (11 ). Until 2003, the Cancer Registry was based on mandatory notifications by Danish medical doctors (10 ) since then, the Cancer Registry has been based on records from the Registry of Patients, with secondary histological confirmation from the National Pathology Registry (13. 14 ). Within the Danish Civil Registration System database (15. 16 ), we performed risk-set sampling to select 10 population controls per case among living individuals without a history of HL on the index date (i. e. the date of diagnosis for each case), for a total of 4,780 controls matched on age, sex, and county of residence. All pharmacies in the four former counties are equipped withputerized accounting systems that record a customerx02019s CPR number and prescription data, including type and quantity according to the Anatomical Therapeutic Chemical (ATC) Classification System (17 ), and date of dispensing at the pharmacy.
This information is transferred electronically to countywide prescription databases (12. 18 ). Using these databases (established in North Jutland County in 1989, Aarhus County in 1996, and Vi and Ringkoebing counties in 1998, thus ensuring a minimum of two years of prescription history in the present study), we identified prescriptions for low-dose aspirin (75, 100, or 150 mg per tablet ATC codes B01AC06 and N02BA01), high-dose aspirin (500 mg per tablet ATC codes N02BA51 and N02BA01), sCOX-2 inhibitors (ATC codes M01AH01, M01AH, M01AH03, M01AH05, M01AC05, M01AB05, and M01AC06), and other NSAIDs (remaining ATC codes within group M01A). We excluded prescriptions within 1 year of the index date to reduce any potential effect of subclinical disease on medication use. We defined x0201cever usersx0201d of a medication as individuals who had x0003e2 prescriptions and x0201cnever/rare usersx0201d as those who had x022642 prescriptions. The average length of a prescription was 30 days. Ever users were further divided into recent users (those who had x0003e2 prescriptions during the period 1x020132 years before the index date) and former users (x0003e2 prescriptions overall, but x022642 during the recent period). Duration of use was classified as long-term (x022657 years) or short-term (x0003c7 years), based on the number of days between the first and last prescriptions plus the duration of the last prescription.
Intensity of use was defined as low (x0003c25) or medium/high (x0226525), according to the number of days of prescription coverage divided by duration of use in days (12 ). To obtain a nonspecific proxy for chronic NSAID use, we identified subjectorbidities before the index date using inpatient and outpatient data from the Registry of Patients. orbidities were summarized using Deyox02019s adaptation of the Charlson Index (19. 20 ). In addition, because connective tissue disorders in particular (e. g. rheumatoid arthritis, which is associated with both greater NSAID use and higher HL risk (21. 22 )) may confound the associations of interest, we identified connective tissue disorders before the index date. We used conditional logistic regression topute ORs and 95 CIs, matching on age, sex, and former county of residence, and additionally adjusting for Charlson Index (0, 1x020132, or x022653orbidities). Further adjustment for connective tissue disorders did not affect the results (data not shown). Because the etiology of HL varies by age (23 ), we stratified the results by age (x0003c40 years vs. x0226540 years) and performed Wald tests for interactions between medication use and age group. In all analyses, never/rare users (x022642 prescriptions)prised the reference group.
Given the risk set sampling of controls, the ORs are estimates of the incidence rate ratios in the underlying population. The distribution of HL cases and matched controls is shown in Table 1. Ever use of low-dose aspirin was associated with 30 lower risk of HL (95 CIx0221250 to 20), but the estimate was statistically non-significant, as were the estimates for former and recent use, short-term and long-term use, and low-intensity and medium/high-intensity use, as well as ever use of high-dose aspirin ( Table 2 ). When low-dose aspirin use was classified according to both intensity and duration of use (i. e. short-term, low-intensity short-term, high-intensity long-term, low-intensity or long-term, medium/high-intensity), the lowest ORs were found in association with short-term, low-intensity use (OR0.5, 95 CI0.2x020131.3) and long-term, medium/high-intensity use (OR0.7, 95 CI0.2, 3.5). However, the numbers of cases included in these analyses were small.
Loading Next Slideshow Sex-Drive Killer: Stress Some people do many things well when theyre stressed. Feeling sexy usually isnt one of them. Stress at work, home, or in relationships can happen to anyone. Learning how to handle it in a healthy way really helps. You can do a lot of it yourself, and a counselor or doctor can also help. Sex-Drive Killer: Partner Problems Sex-Drive Killer: Alcohol A drink may make you feel more open to sex. But too much alcohol can numb your sex drive. Being nk can also be a turn-off for your partner.
If you have trouble drinking less, seek help. Sex-Drive Killer: Too Little Sleep If your sexual get-up-and-go is gone, maybe youre not getting enough sleep. Do you go to bed too late or rise too early Do you have a sleep problem like trouble falling or staying asleep, or a condition such as sleep apnea Anything that messes with a good nights rest can mess with sex. Fatigue saps sexy feelings. Work on your sleep habits, and if that doesnt help, talk to your doctor. Sex-Drive Killer: Having Kids You dont lose your sex drive once youre a parent. However, you do lose some time to be close with kids under foot. Hire a babysitter to nurture some time to be partners as well as parents. New baby Try sex during babys nap time.
Sex-Drive Killer: Medication Some gs can turn down desire. They include some of these types of medications: Antidepressants Blood pressure medications Birth control pills (some studies show a link others dont) Chemotherapy Anti-HIV gs Finasteride Switching gs or dosages may help -- ask your doctor about that and never stop taking any medicine on your own. Tell your doctor, too, if your sex drive stalls soon after you start taking a new g. Sex Drive Killer: Poor Body Image Feeling sexy is easier if you like how you look. Work on accepting your body as it is today, even if youre working to get in shape. Feeling good about yourself can put you in the mood. If your partner has low esteem, assure them that theyre sexy. Sex-Drive Killer: Obesity When youre overweight or obese, desire often dims. It could be that you dont enjoy sex, cant perform like you want to, or are held back by low self-esteem. Working on how you feel about yourself, with a counselor if needed, may make a big difference. Sex-Drive Killer: Erection Problems Sex-Drive Killer: Low T The T hormone, testosterone, fuels sex drive.
As men age, their T levels may drop a bit. Not all lose the desire for sex as this happens, but some do. Many other things -- from relationships to weight -- also affect a mans sex drive and testosterone levels, so theres not a one-size-fits-all answer for every man. Sex-Drive Killer: Depression Being depressed can shut off pleasure in many things, including sex. Thats one of many reasons to get help. If your treatment involves medication, tell your doctor if your sex drive is low, since some (but not all) depression gs lower sex drive. Talk about it with your therapist, too. Sex-Drive Killer: Menopause For many women, sex drive dims around menopause. Thats partly about symptoms such as vaginal dryness and pain during sex. But every woman is different, and its possible to have a great sex life after menopause by tending to your relationship, self esteem, and overall health. Sex-Drive Killer: Lack of Closeness
Kamagra Viagra Cialis elad Dragon power A tudatos teljestmny mai letvitelnkben vgyaink, cljaink elrsnek egyik felttele. Ha nagyon akarjuk, a kitztt cljainkat elrhetjk. Az letnek taln csak egy olyan terlete van, ahol ez nem teljesen gy mkdik, ahogy mi akarjuk, st elfordul, hogy az ellenkez hatst rjk s ez a szex. Minl grcssebben akarjuk, hogy teljestmnynk a legjobb legyen, annl kevsb sikerl. Ez leginkbb megmutatkozik a frfiak merevedsi kpessgeinl. Sokan azt gondoljk, hogy a mereveds egy folyamat, amit a partnernk ltal kivltott szexulis vgy vltja ki, de ez nem teljesen gy van. Az erekci fiziolgiai folyamathoz szksges a nemi izgalom, mely kivlthat egy gondolattal, hanggal, vagy akr egy illattal is. Ezek hatsra jn ltre vgl is a hormonlis, neurovasculris mechanizmus. Mereveds, a magmls nem tudatos, reflex szeren alakul ki, de tudjuk kontrolllni, mivel a szexulis cselekedet nagy rszt az agykreg felgyeli.
Ahhoz, hogy a szexulis egyttltre kszen lljunk, megfelel mennyisg vr kell, hogy a hmvesszbe jusson s addig tartson ez az llapotot, amg szksges. Az erekci ( a pnisz merevedse) ltalban nemi izgalom ltal kvetkezik be. Ilyenkor egy gynevezett nitrogn-oxid nev vegylet szabadul fel, s hatsra a barlangos testek megtelnek vrrel, a szvetek pedig az ltal, hogy kitgulnak, a vnkat, melyet a hmvessz falban futnak, lezrjk, ezzel akadlyozzk meg a vr kiszkst. Az gy ltrejtt vrrel telt szvetek okozzk a hmvessz merevedst, kemnyedst. A merevedsi zavarok kivlt oka lehet szervi vagy pszicholgiai eredet, de elfordulhat, hogy mindkett egyttes hatsa.
Mindenkppen tudni kell, hogy csak a nemi vgy cskkent, vagy a vgy meg van ugyan, de az erekci elmarad. Ha a merevedsi zavar hosszabb ideje fennll, akkoranikus, vagyis szervi okokat kell keresnk, ebben az esetben ajnlatos androlgus szakorvos segtsgt krni. A msik lehetsg, ami kivlthatja a frfiak potencia problmit a lelki ok, amely megnyilvnulhat ha stresszes letet folytat, fradt, szorongs gytri, de akr gygyszerhats is, valamint a nem megfelel letvitel, dohnyzs s mrtk nlkli alkoholfogyaszts, ilyenkor ltalban a pszicholgus tud segtsget nyjtani. Dr. Carolyn Allan llspontja szerint a frfiak merevedsi zavarainak 75 - a fizikai elvltozs, elssorban az artrik. Ezek a betegsgek, mint pldnak okrt a cukorbetegsg, idegek srlse, vagy a hormonhztarts nem egszsges szintje, elhzs, magas koleszterinszint, igen nagy fokban hatssal vannak a potencia zavarainak kialakulsban. Egyik betegsg sszefggsbe hozhat egy msikkal, egyik vonzata lehet a msiknak, gy, ha megszntetjk az okot, megsznik az ltala okozott kr is. Termszetesen nem kell mindjrt a legslyosabb szervi elvltozsokra, betegsgekre gondolni, de mindenkppen szksges, hogy kiszrjk a kivlt okot, s megelzzk a nagyobb kr kialakulst.
A statisztikai kimutatsok alapjn tudjuk, hogy a 40 s 70 v kztti frfiak mintegy 52 - nl tapasztalhat merevedsi problma, vagyis tlagosan minden msodik frfinl elfordul ez a nemkvnatos t. Megfelel letmd, egszsges letvitel s tpllkozs hozzsegtheti a szervezetet ahhoz, hogy mkdsben ne legyen zavar. Termszetesen ez csak egyik rsze a frfiak szexulis kpessgnek javtsra. A frfiak leggyakoribb szexualitssal kapcsolatos problmi: erekcis zavar, potencia zavar, szexulis problma, cskkent szexulis vgy. A mai, igen nyitott s szabad vilgunkban is nagyon sok esetben tabuknt kezelik ezt a tet, nem szvesen mennek el orvoshoz, mert gy vlik, hogy srl a frfiassguk azltal, hogy nem tudnak olyan teljestmnyt nyjtani, ami elvrs lenne. A frfiak olyan megoldsra vgynak, ami megrzi intimitsukat, anonimitsukat s egyszer mdon hozzjuthatnak a megoldshoz.
Egyms utn jelennek meg a klnbz potencianvel szerek, melyek szjon t bevehetk, nem kell klnsebben elkszlni az alkalmazsukhoz, brmikor, brmilyen helyzetben s idben alkalmazhatak. Sok esetben csak olyan potencianvel szerekhez lehet hozzjutni, ami vnykteles, csak orvos rendelheti el, mivel a nitrogn-oxid szintjt a szervezetben megvltoztatjk, de elfordulhat, hogy a kzponti idegrendszerre is hatssal vannak, melyek az erekci kivltsrt felels idegi szablyozsra vannak hatssal. Tudni kell, hogy ezek gygyszerek s kmiai anyagokat tartalmaznak, melyek a szervezetbe bejutva, nem kvnt mellkhatsokat vlthatnak ki. (pl.:allergia). Nagy htrnyuk mg, hogy a hasznlatuk sorn megsznhet a spontaneits. A nemi vgy elrshez nem elegend a testi ingerls, mindenkppen az agyban kell elindulnia annak a folyamatnak (rzkek jtka), mely a vgyhoz vezet. Dragon Power kapszula mr 400 ve segt a frfiaknak szexulis vgyaik beteljeslsben.
zsiban pldul magas rangban l frfiak hasznltk specilis stimulci cljbl. Abban az idben akik nagy szexulis vggyal s ernlttel rendelkeztek, kiemelkeden nagy becsben ltek. Ennek elrse rdekben gygynvnyek kivonatait, illetve gygynvnyek keverkbl kszlt italokat fogyasztottak. Nemrgiben, mint oly sok esetben, visszanyltak a kutatk erre az idre, s jra kifejlesztettk a tpllkozssal foglalkoz tudsok.
A kutatk, mint oly sok esetben, most is visszanyltak az si knai gygytk ltal alkalmazott s bevlt termszetes anyagok ismereteihez, melyet kombinlva a jelenleg legmodernebb eszkzkkel, valamint a tbb ves kutatsi eredmnyek felhasznlsval elrtk, hogy kapszula formban ltrejjjn egy olyan potencianvelsre alkalmazhat termk, amely megbzhat, s mindig a kvnt hatst nyjtja. Hossz idn t vgzett kutatsok s ksrletek eredmnyekppen ltrejtt egy igen hatkony termk, mely a szexulis teljestkpessget a maximumig fokozza. A Dragon Power kapszula a tapasztalatok s a ksrletek folytn is kitn eredmnnyel a legmagasabb hatkonysgot kifejt kapszula. Sokan ismerik s hasznljk, nagy a kereslet irnta. Dragon Power jelentse Srkny Er. rdemes tudni rla, hogy a merevedsi zavart nem gygytja, de a teljestmny fokozsnak elrsre nlklzhetetlen, kitn.
A frfiak legnagyobb flelme, ha teljest kpessgk a minimlisra, vagy rosszabb esetben teljes kudarcba fullad. A Dragon Power ezen problmra nyjt megfelel gygyrt. Az ettl val flelmek s tektl val aggodalom a Dragon Power hasznlatnak segtsgvel megoldhatk. Dragon Power a jelenleg alkalmazhat leghatkonyabb kapszula, melyek magas minsg alapanyagok sszetevkbl kszlt, 100 - ban gygyhats nvnyek keverke, melyek segtsgvel jelenleg a leghatsosabb segtsg a potencianvelsnek eredmnyesebb ttelre. Hatsra minden alkalommal a legjobb teljestmnyt biztostja az elvrsoknak megfelelen. Dragon Power az eddig alomba lv leghatkonyabb mdszert nyjtja, mellyel vgleg elfelejtheti a flelemt a nem teljests miatt, a szexulis egyttlt sorn az erekci biztostva, az intim egyttlt pedig igazi lmnny vlik. Ha megunta, hogy olyan ksztmnyeket hasznljon, melyek csak receptre vagy nagyon sokba kerlnek. sszetevi segtsget nyjtanak a kitart mereveds elsegtsben, hatkonyabb teszik a szexulis teljestmny nvelst, s az egyttltet rvid idn bell, akr 5-10 perc elteltvel jra kezdhet. A merevedsi problma megoldsra egy j technolgival kifejlesztett trend-kiegsztt alkottak, mely tartalmazza a legjabb kutatsok eredmnyeit, valamint az si orvostudomny eredmnyeit, melyek sszehangolsa rvn elkszlt a Dragon Power kapszula.
Dragon Power hasznlata biztostja a lehetsget arra, hogy hatsra maximlis teljestmnyt nyjtson. Dragon Power minden eddig ismert s hasznlt termkek helyett, j lehetsget s biztos, minden mellkhatstl mentes merevedst biztost akkor, amikor szksg van r s akr mr 15-20 perc eltelte utn biztostja teljestkpessgnek cscst. Dragon Power kapszulnak ismereteink szerint nincs egszsg krost hatsa, megfelel alkalmazs s mennyisg szedse mellett. A kapszult elviekben mindenki szedheti, mert termszetes anyagokat tartalmaz, egyb, egszsgre rtalmas hatsa nem ismert, de azrt nem rt, ha tudjuk, hogy akinek szvbetegsge, magas vrnyomsa van, elbb krdezze meg kezelorvost az alkalmazs mdjrl, adagolsrl stb. Dragon Power sszetevi: Chinese Ginseng: A ginszeng gykert mr tbb szz ve hasznljk a Tvol-Keleten. Az zsiai ginseng a borostynflk csaldjba tartozik.
A nvny rdekessge, hogy csak az rnykot szeret, ott n. A knaiak, a formja miatt embergykrnek hvjk. Szmos haznkban is kaphat gygynvnyben megtallhat. Semen Coicis: Teles biztonsggal alkalmazhat szer, melyet a tradicionlis gygyszatban is felhasznlnak. Caryophyl li: A nvny bimbjbl, szrbl s levelbl, valamint a magjbl nyert illatos olaj, melyet a mai napig alkalmaznak a betegsgek gygytsa tern. Herba Epimedii: A knai gygyszatban is igen elterjedt s hasznlt gygynvny, segti a vr ramlst, kitgtja az ereket, st a fertzsek ellen is felveszi a kzdelmet. ltalban olyan betegek gygytsra alkalmazzk, aki szv - s rrendszeri, bronchitistl szenvednek. Semen Cuscutae: A nvny magja a vese problminak lekzdsre, valamint ersti az immunrendszert s nagy hatssal van a sperma egszsgre. Az sszetevk arnya s mennyisge nem publikus, ezrt adatokat nem tudunk kzlni. Ami biztos, a srkny erejnek sszetevi csak termszetes anyagok.
A Dragon Power kapszula sszetevi lassan, fokozatosan szvdnak fel, gy megkmli a szervezetet a hirtelen hatstl, de ezltal a hatsa is kitoldik, mely lehet akr 3-4 nap is. Dragon Power kapszulval hosszan tart, szexulis izgalommal s elgedettsggel teli lmnyt lhet t, partnere legnagyobb megelgedsre. A Dragon Power hasznlata sorn gy fizikai, mint mentlis terhelhetsge jobb lesz, ersti az idegrendszert, szexulis lett, azltal, hogy rvidebb lesz az aktusok kztt eltelt id, eredmnyess s felejthetetlenebb lmnyhez segti a hasznljt. Dragon Power trend-kiegszt ksztmny, nem gygyszer, ezltal szervezete nem krosodik mreganyagoktl. Hasznlata sorn csak arra kell figyelni, hogy a szexulis egyttlt sorn a legjobbat s a leghosszabb intim egyttltet biztostsa partnernek s nmagnak. Dragon Power ebben csak segtsget nyjt, hozzjl ahhoz, hogy a potencival kapcsolatos problmi vgleg megolddjanak. A Dragon Power kapszula alkotinak az a cljuk, hogy hasznlinak biztostsk a mindeddig hn htott szexulis lmny beteljeslst. Dragon Power hasznlata: A Dragon Power-t szjon t kell bevenni, mindig betartva az utastst. A megfelel eredmny elrse rdekben a tervezett intim egyttlt eltt 30-45 perccel.
Alkohol fogyasztsa az alkalmazs sorn kerlend, mivel a hatst nagymrtkben befolysolja, cskkentheti. Alkalmazhat kraszeren, abban az esetben 3 4 naponta 1 kapszula bevtele ajnlott. Javtja a kivltott hatst a megfelel szexulis hangulat, izgatsi inger, simogats stb. Sajnos, mint minden j s hatsos szert, a Dragon Power is megprbljk utnozni, hamistani. Ha biztosak aknk lenni, hogy a vsrolt termk az amit szeretnk, meg kell bizonyosodni rla, hogy valdi termket kapunk. A Dragon Power egyb elnevezsei, illetve ms nvvel knlt tabletti nem valdiak, biztos, hogy hamistvny. 3 darabos kiszerelsben kaphat.
(NaturalNews) Results from analyses of men who enrolled in a Harvard School of Public Heath study shows that sildenafil, known by most as Viagra, may increase a mans risk for melanoma by as much as a whopping 84 percent (1). The findings, published in JAMA Internal Medicine . involves follow up research from men who enrolled in the study in 2000. Their sexual health, sun exposure history, gic factors such as eye and skin color, as well as their use of Viagra were noted, and over the course of 10 years, their incidences of skin cancers were tracked. It was found that men who used Viagra had about twice the risk of developing melanoma the results showed there to be 142 incidences of melanoma, 580 of squamous cell carcinoma and 3,030 of basal cell carcinoma (1). While more conclusive research is needed, the researchers say that the findings do demonstrate a correlation at the very least, and raise concerns over the safety of sildenafil. According to the skin cancer foundation, Of the seven mostmon cancers in the US, melanoma is the only one whose incidence is increasing, and about 6,470 men are projected to die in 2014 from it (2). Natural, healthier ways to achieve an erection More natural and healthy ways to achieve an erection, which is Viagras intended goal, are plentiful and may be worth exploring.
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Copyright Govinda Gallery Archive. All Rights Reserved. Photographer Douglas Kirklands extraordinary career was recently honored at Photo LA. Kirkland singulair has had subaction shoments viagra thanks newest a very significant impact on Govinda Gallery and our photography program. 2C399 / Douglas Kirkland and Chris Murray at the Light Years opening at Govinda Gallery in April of 1990. Copyright Chester Simpson.
All Rights Reserved. It was my great honor to host Kirklands first two exhibitions at Govinda Gallery, Light Years in the spring of 1990 and Icons in the fall of 1993. Light Years launched Kirklands book of the same name and that exhibition featured portraits of Dustin Hoffman, Ann Margaret, Catherine Deneuve, Marilyn Monroe, Elizabeth Taylor, and many more. Kirklands second exhibition at Govinda Gallery, Icons . was the first exhibit anywhere that exclusively featured pigment prints.
Not only is Douglas Kirkland a great photographer, he is also a pioneer of the pigment printing methods that have now been embraced by photographers and artists worldwide. After Kirklands Light Years exhibition I was enthusiastic to publish a portfolio of Kirklands unettable Marilyn Monroe photographs. Govinda Gallery has published photographic portfolios for a number of artists and I knew that a portfolio of Kirklands Marilyn Monroe photographs would be well regarded. Kirklands photographs of Marilyn Monroe were so sensitive and beautiful that traditional photographic printing methods did not do thosepelling images justice.
Kirkland had met musical artist and photographer Graham Nash at a party and told me that Nash was soon opening up a fine art print making studio featuring a new method of making prints. He suggested we consider this new process for our portfolio project. I flew to Los Angeles and met up with Kirkland and we went to visit Nash Editions in Manhattan Beach, which had not yet opened for business. 2C403 / Douglas Kirkland with the first Marilyn Monroe proof at Nash Editions, Manhattan Beach, California, 1992. Copyright Govinda Gallery Archive. All Rights Reserved. We met with Mac Holbert and Jack Duganne, the master printers who first worked at Nash Editions and we produced proofs of Kirklands photos of Marilyn Monroe. They were so beautiful that with great enthusiasm we had the portfolios printed at Nash Editions in 1992.
That portfolio was the first job at Nash Editions, the studio that pioneered pigment printing. Graham Nash had started printing his own photos there and the studio had experimented with a number of artists as they started to get their machinesnning. But the portfolio of Douglas Kirklands Marilyn Monroe photographs that Govinda Gallery published was the first paid andplete project toe out of Nash Editions. 2C403 / Mac Holbert of Nash Editions, Manhattan Beach, California, 1992. Copyright Govinda Gallery Archive. All Rights Reserved. 2C410 / Jack Duganne operating the printer at Nash Editions, 1992. Copyright Govinda Gallery Archive.
All Rights Reserved. If you happen to be in Washington, DC visit the National Portrait Gallery and see Douglas Kirklands photo of John Travolta taken during the time of Saturday Night Fever as part of the Dancing the Dream exhibition that continues through July 13, 2014. Dancing the Dream was curated by Amy Henderson. I co-curated the Elvis at 21: Photographs by Alfred Wertheimer exhibition with the National Portrait Gallerys Amy Henderson and Warren Perry. That exhibition has toured museums throughout the United States and is currently at the National Portrait Gallery in Australia through March 10th, 2014. 2C401 / Douglas Kirkland, Jack Duganne, and Francoise Kirkland at Nash Editions, 1992. Copyright Govinda Gallery Archive. All Rights Reserved.
Congratulations Douglas on being honored at Photo LA and to Francoise Kirkland, his muse, wife, and partner. Douglas Kirklands photographs are available through Govinda Gallery. This entry was posted Friday, 31 January, 2014 at 3:38 pm You can follow any responses to this entry via RSS. You can leave ament or trackback from your own site. Source: govindagallery/2014/01/douglas-kirkland-honored-at-photo-la/ . Posts: 3,086 if you had the pharmacy sheet thates w/ box diovan sinemet / generic - is more than likely what you take amoxicillin but I have the document regarding sinemet made by BMS - Bristol Meyers Squibb:WARNINGS When SINEMET (Carbidopa-Levodopa)) is to be given to patients who are being treated with levodopa, in order to reduce adverse reactions, in Remembrance Join Date: Sep 2006 Location: about 45 minutes to anywhere Levodopa must be discontinued at least twelve hours before therapy with SINEMET (Carbidopa-Levodopa)) is started. Intravenous fluids and dyskinesia, br resulting from driving or testosterone and criminal violence ventricularbr arrhythmias. Because carbidopa and Abnormalities some cases, these activities.
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Tell your doctor if you develop any new symptoms. Do not suddenly stop taking labetalol tablets without first checking with your doctor. Suddenly stopping labetalol tablets may result in chest pain or temporary symptoms such as shaking, sweating, headache, irregular heartbeat, and general unwell feeling. If your doctor decides that you should stop taking labetalol tablets, your dosage should be reduced over a period of 1 to 2 weeks and you should be carefully monitored. Tell your doctor or dentist that you take labetalol tablets before you receive any medical or dental care, emergency care, or surgery.
If you have a history of any severe allergic reaction, talk with your doctor. You may be at risk of an even more severe allergic reaction if youe into contact with the substance that caused your allergy. Some medicines used to treat severe allergies may also not work as well while you are taking labetalol tablets. Labetalol tablets may interfere with certain lab tests.
Be sure your doctor and lab personnel know you are taking labetalol tablets. If your doctor has inscted you to check your blood pressure and heart rate regularly, be sure to do so. Diabetes patients - Labetalol tablets may affect your blood sugar. Check blood sugar levels closely. Ask your doctor before you change the dose of your diabetes medicine. Diabetes patients - Labetalol tablets may hide signs of low blood sugar, such as a rapid heartbeat. Be sure to watch for other signs of low blood sugar.
Low blood sugar may make you anxious, sweaty, weak, dizzy, drowsy, or faint. It may also make your vision change give you a headache, chills, or tremors or make you more hungry. Check blood sugar levels closely. Ask your doctor before you change the dose of your diabetes medicine. Lab tests, including liver function, may be performed while you use labetalol tablets.
These tests may be used to monitor your condition or check for side effects. Be sure to keep all doctor and lab appointments. Use labetalol tablets with caution in the ELDERLY they may be more sensitive to its effects, especially dizziness, lightheadedness, or fainting. Labetalol tablets should be used with extreme caution in CHILDREN safety and effectiveness in children have not been confirmed. PREGNANCY and BREAST-FEEDING: If you be pregnant, contact your doctor. You will need to discuss the benefits and risks of using labetalol tablets while you are pregnant. Labetalol tablets is found in breast milk. If you are or will be breast-feeding while you use labetalol tablets, check with your doctor.
Discuss any possible risks to your baby. Possible side effects of labetalol tablets: All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these mostMON side effects persist or be bothersome: Dizziness indigestion lightheadedness nausea stuffy nose temporary tingling of the scalp unusual tiredness. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash hives itching difficulty ziac breathing tightness in the chest swelling of the mouth, face, lips, or tongue unusual hoarseness) chest pain dark urine decreased sexual ability fainting fast, slow, or irregular heartbeat fever, chills, or persistent sore throat mental or mood changes (eg, depression) muscle pain or tenderness pale stools persistent cough persistent loss of appetite right upper stomach pain severe or persistent dizziness shortness of breath swelling of the hands or feet unexplained or sudden weight gain unusual ising or bleeding weakness wheezing vision changes yellowing of the skin or eyes. This is not aplete list of all side effects that may occur.
If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA . If OVERDOSE is suspected: Contact 1-800-222-1222 (the subaction shoments viagra archive newest American Association of Poison Control Centers), your local poison control center. or emergency room immediately. Symptoms may include fainting seizures severe dizziness or lightheadedness, especially when standing shortness of breath slow heartbeat. Proper storage of labetalol tablets: Store labetalol tablets between 36 and 86 degrees F (2 and 30 degrees C). Store away from heat, moisture, and light. Do not store in the bathroom.
Keep labetalol tablets out of the reach of children and away from pets. General information: If you have any questions about labetalol tablets, please talk with your doctor, pharmacist, or other health care provider. Labetalol tablets is to be used only by the patient for whom it is prescribed. Do not share it with other people. If your symptoms do not improve or if they be worse, check with your doctor. Check with your pharmacist about how to dispose of unused medicine. This information should not be used to decide whether or not to take labetalol tablets or any other medicine. Only your health care provider has the knowledge and training to decide which medicines are right for you. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition.
This is only a brief summary of general information about labetalol tablets. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to labetalol tablets. This information is not specific medical advice and does not replace information you receive from your health care provider. You must talk with your healthcare provider forplete information about the risks and benefits of using labetalol tablets. Issue Date: December 3, 2014 Database Edition 14.4.1.003 Copyright 2014 Wolters Kluwer Health, Inc. Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only your health care provider has the knowledge and training to decide which medicines are right for you. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine.
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The architect was in the state capital to concern himself in the final details of the project, such as the development and production of the buildings furnishings, which he has also designed. The Portuguese architect is meticulous about every detail of the building, believing that harmony is fundamental in a work. Although each detail is important, the governing feature is the totality. Equilibrium is the underlying quality for architecture, he says. The new Iber Camargo Foundation headquarters opens in the end of may and is intended to preserve the collection of more than four thousand works by the master of Brazilian expressionism and to be a major center for discussion, research and exhibition of modern and contemporary art, placing Porto Alegre and Brazil on the route of the worlds major centers of culture. In 2002, The project won the biggest international architecture prize The Golden Lion Award at the 2003 Venice Architecture Biennial. The maquette toured to the main state capitals in Brazil, together with a touring exhibition of Ibers work in 2003 -2004. It has also been to the Milan Triennale at the Museum of Fine Art subaction shoments viagra archive older in Bordeaux, and is included in a touring exhibition of lvaro Sizas work which is traveling the world.
Consction budget of the new headquarters for the Iber Camargo Foundation, whose president is e Gerdau Johannpeter, is 30 million reais. Building started in July 2003 on a 8,250-m2 site facing the Guaba (Av. Padre Cacique 2,000 donated by the city council and sponsored by po Gerdau, Petrobras, RGE, Vonpar, Ita, De Lage Landen and Instituto Camargo Correa. RGE, po Gerdau, Petrobras, Camargo Correa, De Lage Landen and Vonpar. Building is following a precise schedule, which concludes with the opening of the headquarters, forecast for November 2007, and a major exhibition of the painter, who is recognized as one of the major Brazilian artists of the 20th century. The building will put Porto Alegre on the map of important centers of modern and contemporary art in the country. It has nine exhibition rooms, spread across the three upper floors. The main access level will house the reception, caf, cloakrooms, cultural shop and a massive atrium which will provide views of the upper floors and will also be used for exhibitions. The basement area contains all the building infrascture, including parking for 100 vehicles, a 125-seater auditorium with cinema facilities, Ibers print studio and rooms for courses and workshops. It will also contain a reference, research and information center for the huge collection of 4,000 of the artists works, with a specialized library, database, video library and reading room, intended for national and international researchers and publishing work.
The basement also contains the utilities area and the technical reserve, used for housing the air-conditioning system and the sewer treatmentwork. Access to the car park is through an underpass beneath Avenida Padre Cacique, connecting both sides of the road to facilitate visitor entry and exit. All the entrances to the new Iber Camargo Foundation headquarters also meet the requirements of people with special needs. Ramps and elevators have been designed to offer ease of access from garage level upwards. Innovative technology and ecological trails The building for the new Iber Camargo Foundation headquarters is an international landmark in architecture and engineering solutions. One of the designs innovative features is its reinforced-concrete consction throughout, without the use of bricks or sealing elements, forming curved outlines like a great sculpture to feature the form and movement of the ramps built on all floors. It is the only building in the country to be built entirely from white concrete, which dispenses with painting and finishing and also brings it a feeling of lightness. All the power and service ducts are inside the walls, insulated with fiberglass, allowing the installation of permanent or temporary dimmable sockets and lighting anywhere in the rooms.
Indoor temperature and humidity are managed by an intelligent monitoring control to ensure protection of the collection. The air-conditioning system will produce ice at night, when electricity costs are lower, for cooling the space during the day, reducing operational costs. The design devotes special attention to the environment. A sewage treatment station will treat all the solid and liquid waste on site. The treated water from this process will be used for irrigating the surrounding green space. In partnership with the Gaia Foundation, special care is being given to the 16,000-m2 native forest behind the building.
A 200-meter path has been defined in the forest to allow visitors to link art with nature. lvaro Siza, an international reference lvaro Siza is one of the most important contemporary architects in the world, with work in several different countries. His designs include the Museu Serralves in Oporto, and the Centro Galego de Arte Contempornea, in Santiago depostela. The new Iber Camargo Foundation Headquarters will be his first project in Brazil. Siza was chosen after consultation which considered the innovative nature of the architectural plan and the international standing of its architect. The architect is a member of the American Academy of Arts and Science and Honorary Fellow of Royal Institute of British Architects, the Academie dArchitecture de France and the European Academy of Sciences and Arts.
He won the Pritzker Award, from the Hyatt Foundation in Chicago, considered the Nobel of the arts, in 1992, for his oeuvre. Siza has played an active role in the most important architectural works in the world, including the Barcelona Olympiad and Expo 98 in Lisbon. He was part of the team that restored the Chiado, the old part of Lisbon attacked by fire. More about the project The project won the biggest international architecture prize The Golden Lion Award at the 2003 Venice Architecture Biennial. The maquette toured to the main state capitals in Brazil, together with a touring exhibition of Ibers work in 2003 -2004. It has also been to the Milan Triennale at the Museum of Fine Art in Bordeaux, and is included in a touring exhibition of lvaro Sizas work which is traveling the world.
30,000 cubic meters of earth were excavated and donated to the Municipal Highway Works Department (SMOV) to be used for paving the citys poorer settlements. Excavation was carried out without using explosives. In partnership with the a Universidade Federal do Rio Grande do Sul (UFRGS), a splitting plan was found in which the rocks were broken down, allowing them to be removed with pneumatic equipment. This enabled the builder, Camargo Corra toplete the predicted 12-month process of earth removal four months early. There has been considerable concern with the surroundings since the start, and the Iber Camargo Foundation has therefore proposed to correct the distorted bend in the Avenida Padre Cacique to increase road safety near the site.
Consction is generating 100 direct and 200 indirect jobs. The project has been visited by more than 3000 architecture and engineering students from the whole country. The building saves 30 to 40 more energy than conventional buildings. Chronology: 1995 Creation of the Iber Camargo Foundation 1996 SIte for building the new Foundation headquarters donated by the Rio Grande do Sul government 1998/June Selection of the architect 2000/May First site visit by the architect, lvaro Siza 2001/November Approval of viability study by Porto Alegre City Council 2002/June Laying the Foundation Stone 2002/September Design wins the Golden Lion Award at the Venice Architecture Biennial 2003/July - Buildingmences - Sponsorship signed with Camargo Corra 2003/December Sponsorship signed with Petrobras 2004/Feary Sponsorship signed with Vonpar 2004/March Sponsorship signed with RGE 2004/December Conclusion of Phase 1 Underground Area 2005/Outubro Conclusion of Phase 2 Concrete Scture 2 half of 2007 Conclusion of Phase 3 and inauguration Finishing, thermal insulation, electrical, plumbing andplementary installations, decoration and furnishing 1 half of 2008 Finishing and furnishing Consction phases: Phase 1 (basement): Infrascture: car park, auditorium, print studio, rooms for courses and workshops, documentation and research center, utilities area and technical reserve. Phase 2: nine exhibition rooms, atrium, reception, caf, cloakroom, cultural shop Phase 3 (final): Finishing, thermal insulation electrical, plumbing andplementary installations, decoration and furnishing Inauguration: End of may 2008 Iing search terms: Tags: subaction hrefprescriptionmedications. in/2014/12/11/robaxin-overdose2008.
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Youve got mail. I hope you dont have stocks Wee Dont be afraid It was very reassuring the other day. Ge W. Bush talked to the stock market and. Him talking about business ethics its like having a leopard giving you a facial. It doesnt really work A lot of our importse from other countries. No shit, Jason.
Moving right along. Meanwhile, Michael is protesting. I dont know, baby. It was strange enough when Michael was the best man at Lisas wedding. That for me was like youre pushing the term, my man That was a pretty short list. Was Richard Simmons hunting - What are you doing - Im the best man Now Michael is claming racism. Honey, you gotta pick a race first.
What are you claiming there Mistreatment of elves Girl, you gotta pick a gender, too. What are you going for You were Diana Ross. Now you just left it all behind. Michael, youre not a freak. Youre just surgically enhanced. and you spend more money than the Vatican. If you go to Neverland, it says: You must be this high to ride Michael Obviously, the lawyers at HBO are going, Fuck How fucked up would you have to be for Al Sharpton to go, Im outta here, man If Al Sharpton bails on your ass, even rats are going, Man, that guys quick From the Don King School of hair processing. Hes riding for office in Idaho on the What a fucking, wild, crazy chance in hell youll be elected ticket.
Sorry, my lips just went. Probably dyslexic people went: Thank you, Habib Thank you We were worried about the pledge of the legions. Were gonna say: One nation under dog Its OK. And now people are going: Ive got a cure for this One nation under Canada, above Mexico. But then you have to the whole. Anthems like: Someone bless America On a dollar bill, instead of In God We st, In Gates We st Mr Gates, when did you realize youre creating monopoly Monopoly is just a game, senator. Im trying to control the fucking world. Have you seen Windows Millenium Right now its Information Technology. Soon it will be Total Information Technology.
TIT. And when youre sucking on the tit, I have you by the motherboard. Dont be afraid Its a nice day in New York, my people. NY police have a catch and release program. Way to go Stop OK, go on again You there Get the fuck outta here I like NY on a day like today.
For a while everything went like youre OK. People like to great new Yorkers: Have a nice day, asshole Fuck you, my friend Enjoy your day But the most beautiful thing about a day like today in NY is that the ladies take the twins for a walk Oh, yeah, the titties are out today On a hot day all the titties are out there. And God made them go like. Beautiful titties, all shapes, sizes and womennning they are going. And then they hit a breeze and chickens done Yeah, baby These are not like the titts in Vegas, where even God goes: I didnt make those Fake titts are like nazis. They dont laugh, they dont dance, theyre just. Im walking here Ive seen a woman turn and the titts stayed there. Its like they dont have any teeth because they knock them out. Ive seen titts that are really bad with the nipples on the top. They look like Culroy.
When you go up Madison Avenue you see some hardcore surgery like. Im so scared, but I cant express it. These ladies had so much surgery are going: What are these lumps under my eyes Those are your titts, madam - And whats this - Dont ask, Mrs. Trotki This is good news for you. And girls getting buttocks injections. - Look, I dont have any wrinkles. - You also have no expression.
You look like youve had a slighta, but youre beautiful. One guy say to you: Baby, I want you to get your titts done for me Do it for me. Do it for your daddy man. And you say: OK, daddy man Than I want you to get your balls done for me, OK I want you to get those big old basket balls. So when you do the baywatch thingy, its like. Nothing drives a woman crazy like a big old Easter basket on her bunny. You go to the doctor. Girls.
Paybacks a bitch Go for it, girls Cause you went through a hard time. This whole winter was so bizzare. Temperatures were like. It was fucking weird The weathermen are going: I dont fucking know whats going on Lets just see what happens. Flowers were like Anne Heche going: Im out, Im in, Im out. I dont know when to go. Ge came back from Japan and went: I went to the Coyote Conference - No, its Kyoto. - Thats a very good car. Ge, walk away. They say theres no global warming. But right now the North Pole is a pool. It is beyond global warming.
At this point is cooking. At in the middle of the country: Is it hot enough for you No, I like sweat to be rolling down the crack of my ass like Niagra. I like my old mans titties to lactate, my man. You see people in shorts and youre going: Please, dont wear those Please, dont put those on If you go to South West Airline: Youre not fat, youre horizontally challenged Big people at South West Airlines have buy two seats. The problem is that they are not together. And you have to put your titts in the overhead rack. People dont mind now. Were working our way through. All over the country weve got weird things. In Houston they got Enron field.
Were gonna call it th Amendment for you. We cant call it: Were fucked for you Arthur Anderson put in the chairs that spin both ways. And now Martha Stuart may be somebodys bitch. No Say it aint so I like to consider it more like severedpanion. If you only have one room, and I like to call it my private space, use the light well.
You have vertical bars, dont use horizontal blinds. Also, think of your ankle bracelet as an accessory. The first time she has lunch going: You call this keesh Shut up, bitch Youre inside now, youre mine All over things have been going good. Ive been to Memphis, to Graceland. I never knew that Ray Charles had a decorating license. Theyre some severe.
Theyre colors there that have never seen daylight. Ive been to Nashville, Ive heard people sing songs like: Take your finger outta my ass, cause Im leaving you behind Weird shit people do now. Im sweatin like crazy up here. Its HBO, cause its live. People playing baseball.
Youve got a good seat. Yankees are kicking the game, way to go They did a good job. They came through. Everybodys worried about people playing baseball on steroids. Heres one quick way you tell: on steroids, your balls shrink and your head grows. So if someone steps up to the plate with a Mardi Gras head and Raistes, youre out Poor Barry Bonds They wont pitch to him and when they do it, theyre trying to kill him. Hes like Yasser Arafat of baseball. For Jsalem I have an interesting plan. Its called a timeshare, like Miami, lets try that.
Jews will get Hanukah and Passover, Christians will get Christmas and Easter and Muslims will have Ramadan and the other holiday, Kaboom. Obviously, the people of HBO are going Oh, fuck off. What are you doing, you asshole. Im very excited because this is my time when I was watching World Cup Soccer, my man. I saw world cup, baby. Theres a few soccer fans, the rest of you are going: Uh, thats like football without pads, right For the rest of the world, its football. For us, its A strange sport, played by damaged people. We made it in the World Cup. Everyone plays it. Not like the World Series, cause the French dont have a baseball team. If they did, they would only have left field and no one would be safe. You know what Im saying What can you do, huh It is Bastille day, alore. The day that Marie Antote gave the ultimate head.
Look out We are French. Fuck you, Americans, I dont care My friend Lance Armstrong is racing right now in The Tour du France. And every year the French go, He is on chemicals. Its chemotherapy, you little toad suckers.
Okay, he has one testicle, hes aerodynamic. Everyone, cut off your balls. Youll be quicker. Do it. Dont be afraid. When you look at the World Cup, America finally made it. We made it to the sixteenth, baby Were no longer in the Special Olympics category. They used to see using: Give it to them, theyre damaged people Thank you for the ball. I got a ball. I kick the ball Unlike the Brazilians. When they play is like.
And the fans. Brazilians are going: Look, Im playing soccer. Look, Im scoring And now Im kicking the ball. Soccer is kinda mellow, you know. Is a little passive aggressive though. I didnt do anything. What are you looking at Its not like hockey, when someonees up with a stick and goes: Bang, mother fucker Thats why there are no Spanish hockey players.
When a white guy takes a stick and goes. Motherfucker, Im going to cut you off now And you, Freddie gger bitch, take off the mask, mother fuckering in there Katami Sometimes guys do this weird thing. They fall down and pretend like. Ive been killed.
Ive been blinded. Theres nobody near me, huh OK, Im kidding And the refereees over: Yellow card Two yellow cards. Red card Three cards. Green card And the referee is so sweet, too. Whats your name Turn around. Why didnt you call me after the Mexico game Not like football referees: Too muchmercial time Mad white man dancing on the field.
Moving away. Moving away. In the World Cup they always claim theres bad refereeing, someone may have been paid off. Oh, shit, say it aint so Youre telling me that the Oscars are also political Fuck off Theres a game mafia The mobs hand Fairy Godfather: Does this pistol make my ass look big If you go to LA, theres a great greeting these people do: Love ya Love you Hey, love you The worst referee was in Winter Olympics with a French judge. Once again, the French fucked with us The Canadians skate perfectly. We did it perfect, huh And then thessians theye and fuck up and the French judge: Th
Eli Lilly andpany Our heritage and our values are the foundation of our mission to unite caring and discovery to make life better for people around the world. Lilly is About Caring Discovery Responsibility In our own neighborhoods and across the globe, we work hand-in-hand with governments and civicanizations to improve the health and well-being of the people we serve. U. S. Patent Protection The historic signing of the America Invents Act on September 16, 2011, represented a huge win for innovators and took needed steps to improve U. S.petiveness globally by aligning new patent laws more closely with those of other countries. This new law is the most significant overhaul of the U. S. patent system in 175 years. Lilly has championed efforts to modernize the patent system for many years, and we8217re extremely pleased that the America Invents Act is now a reality.
The America Invents Act will provide a simpler path forward for innovators by reducing red tape and enhancing the quality of patents that are granted, and it will provide resources needed to help eliminate the backlog of 700,000 applications awaiting action in the U. S. Patent and Trademark Office. Additionally, transitioning the U. S. from a 8220first-to-invent8221 to a 8220first-inventor-to-file8221 system, the new law creates a set of transparent, objective, predictable and simple standards for gaining a patent 8211 securing the U. S. as a leader in international efforts aimed at achieving greater consistency in global patent laws. A strong patent system is cial to driving America8217s economicpetitiveness and global leadership in fields like biopharmaceutical research, which employs more than 650,000 people and supports more than three million U. S. jobs. Intellectual property protections 8211 such as patents 8211 help drive the economy in three key ways: they promote incentives for innovation they provide holders with certainty regarding their rights and they provide enforcement tools to defend one8217s property. Biopharmaceutical innovation is costly and risky. However, maintaining a predictable and reliable patent system helps to encourage the innovation that supports jobs and leads to real and significant health benefits for America8217s patients.
Biopharmaceutical researchpanies generally file relevant patent applications early in the R38D process, years before a new medicine actually reaches patients. This means a significant part of the medicine8217s patent life is spent prior to reaching the market in fact, the average time on the market for the vast majority of innovative medicines is only 11.5 years before generic versions can enter the market, dramatically 8211 and rapidly 8211 reducing brand share by up to 90 in the first month alone. What8217s more, generics can apply for approval as early as four years after the innovator medicine is approved. Innovation is cyclical, and the ability to protect and defend their current patents provides an incentive for biopharmaceutical researchpanies to continue innovating, perhaps leading to the groundbreaking new technologies 8211 and life-saving new medicines 8211 of the future.
Do you want to Bee Scene Organic cereal maker Natures Path have helped us to re-launch this brilliant project. We need you to visit your local natural space which could be your garden, a park, footpath or even your school grounds, and let us know which of the fifteen Bee Scene wildflowers you can find. You can then enter your results on our interactive map, which shows results of surveys that have taken place since April 1st 2015. Help young people discover the nature on your doorstep by downloading the family-friendly Bee Scene Pack today Click here. Primary school teachers may still find the detailed resources from the earlier project useful, which are The Bee Scene recording card. Bee Scene identification guide. education pack and alternative resources pack. These will help widen learning across the curriculum and support pupils within primary schools to work scientifically. Should you have any queries please contact Plantlife To plant your virtual flower, please do the following. Zoom in to the location that you visited Click on the map, a pointer will appear on the map (the pin can be moved by dragging it, should you need to fine tune its location) Click on the pin and a form will appear Complete the form and click Save amp Close to share your experiences More about Natures Path.
As a sustainably driven, anicpany and one that depends upon the natural pollination of crops essential to its products, its fitting that Natures Path is supporting Plantlifes Bee Scene project. Natures Path breakfast cereals can be found in all major supermarkets across the UK along with many independent health food stores and farm shops and online via several stores such as Ocado.