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Mechanical injuries In: the Essentials of Forensic Medicine and Toxicology, 22nd edn. Medicolegal conclusions on the form of the knife used bare on the shape of the stab wounds received. Proximal (internal) ballistics: It includes the study of firearms and projectiles used. Intermediate (external) ballistics: It includes the study of movement or motion of the projectile after it exits from the firearm till the time it hits the target. Terminal (wound) ballistics: It includes the study of injuries produced by firearm. Classification of Firearms Firearms are classified by various ways as: A) According to condition of barrel 1. High velocity (> 3000 ft/s) for example machine gun 197 Structure of Firearm In 1. Grip or Butt this is the rear part of firearm and is held either in hand (for example in case of pistol or revolver) or can be supported by shoulder (for example in case of military rifle). When trigger is pulled, it causes striker or hammer to strike on the posterior part of cartridge and causes bullet/pellet to eject from muzzle end of barrel. Trigger guard: It is a metallic rim that surrounds trigger to prevent accidental firing. The part, which incorporates the firing pin, spring and trigger, is called as bolt. Striker or hammer: At the posterior part of chamber, there is a hammer with a pointed pin (firing pin) and a spring. Mechanism: When the trigger is pulled, the spring action causes to move the hammer and advance or protrude the firing pin to the chamber from the central hole of breech plate. The striking of firing pin over cartridge produces heat and ignites the primer present in the cartridge. The action of pin is similar to matchstick which when rubbed or strike on surface of matchbox produces heat and then ignites. The front end of tube is known as muzzle end and the posterior end or rear end is known as breech end. Chamber is the posterior most (rear) part of the barrel and is wider than rest part of tube or cylinder and accommodates or houses the cartridge to be fired. Indirect method: In this method, the gauge or bore of shotgun is indirectly determined by a known number of spherical balls of uniform size prepared from 1 lb (1 pound, 454 gm) of lead and each ball is fitting exactly in the barrel.

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The musical tinkling sounds produced by escaping gas bubbles can sometimes be heard by simple auscultation using a stethoscope and are probably produced in response to adjacent ruminal movements. Alternatively, gentle ballottement of the abdomen using a clenched fist or by gentle rocking may evoke them. It is suggested that clinical evaluation should be focused along a line drawn from the left elbow to the left tuber coxae, although it can be found much higher or lower than this. Ultrasonography can be used to identify the displaced abomasum as the folds of the abomasal mucosa contrast with the papilliform mucosa of the rumen. Conditions producing pings include abomasal dilatation, caecal dilatation or torsion, gas in the rectum and pneumoperitoneum. Splashing sounds caused by excessive fluid in the intestines may be detected by ballottement and succussion. Sometimes large lumps of fat present in fat necrosis and impactions of the abomasum may also be detected in this way. Prehepatic causes of jaundice, such as haemolytic anaemia, are more common in cattle. Transudates or urine in the peritoneum can be identified as non-echogenic fluid images. The rectal examination the contents of the posterior abdomen should be checked in a set order to avoid missing any organ. In the normal animal it is possible to palpate the caudal surface of the dorsal sac of the rumen to the left of the pelvic brim. A left displaced abomasum cannot be felt per rectum unless the gas-filled viscus is displaced very high and caudal in the left flank, which is exceptional. The invagination of one part of the intestine into another can sometimes be felt as a large hard sausage-like structure on the right. Focal pain may be provoked on palpation of an intussus97 Method Examination per rectum requires care and patience with good restraint. However, on raising the tail a rectal prolapse will present with inflamed oedematous rectal mucosa protruding through the anus. If air is allowed to enter the rectum the wall may balloon and make palpation of internal structures impossible. Dysenteric faeces occur in salmonellosis, mucosal disease and winter dysentery, and are composed of a mixture of undigested blood, mucus and watery faeces, usually with an offensive smell. Faecal samples can be colleced for laboratory analysis which may include bacteriology, virology and examination for parasitic gastroenteritis, fascioliasis, coccidiosis and Cryptosporidium. The detailed examination begins with observations of the calf from a distance and is followed by a physical examination of the abdomen to assess the developing rumen, abomasum, intestines, umbilicus and peritoneum. They have a poorly adapted rumen or abnormal, usually incoordinate, rumen movements. They may also present with chronic recurrent distension of the left dorsal quadrant caused by free gas bloat.


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Navigational Note: Feminization acquired Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition: A disorder characterized by the development of secondary female sex characteristics in males due to extrinsic factors. Navigational Note: Also consider Reproductive system and breast disorders: Premature menopause, Amenorrhea. Lactation disorder Mild changes in lactation, not Changes in lactation, significantly affecting significantly affecting breast production or expression of production or expression of breast milk breast milk Definition: A disorder characterized by disturbances of milk secretion. Navigational Note: Oligospermia Sperm concentration > 0 to < 15 million/ml Definition: A disorder characterized by a decrease in the number of spermatozoa in the semen. Navigational Note: Ovarian hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the ovary. Symptoms may include hot flashes, night sweats, mood swings, and a decrease in sex drive. Testicular hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the testis. Navigational Note: Uterine obstruction Asymptomatic; clinical or Symptomatic; elective Severe symptoms; invasive diagnostic observations only; intervention indicated intervention indicated intervention not indicated Definition: A disorder characterized by blockage of the uterine outlet. Navigational Note: Vaginal discharge Mild vaginal discharge Moderate to heavy vaginal (greater than baseline for discharge; use of perineal pad patient) or tampon indicated Definition: A disorder characterized by vaginal secretions. Mucus produced by the cervical glands is discharged from the vagina naturally, especially during the childbearing years. Navigational Note: Vaginal dryness Mild vaginal dryness not Moderate vaginal dryness Severe vaginal dryness interfering with sexual interfering with sexual resulting in dyspareunia or function function or causing frequent severe discomfort discomfort Definition: A disorder characterized by an uncomfortable feeling of itching and burning in the vagina. Navigational Note: Vaginal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the vagina. Navigational Note: Apnea Present; medical intervention Life-threatening respiratory or Death indicated hemodynamic compromise; intubation or urgent intervention indicated Definition: A disorder characterized by cessation of breathing. Navigational Note: Bronchial fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the bronchus and another organ or anatomic site. Navigational Note: Bronchopulmonary Mild symptoms; intervention Moderate symptoms; invasive Transfusion indicated; hemorrhage not indicated intervention not indicated invasive intervention indicated; hospitalization Definition: A disorder characterized by bleeding from the bronchial wall and/or lung parenchyma. Navigational Note: Epistaxis Mild symptoms; intervention Moderate symptoms; medical Transfusion; invasive Life-threatening Death not indicated intervention indicated. Navigational Note: Hoarseness Mild or intermittent voice Moderate or persistent voice Severe voice changes change; fully understandable; changes; may require including predominantly self-resolves occasional repetition but whispered speech understandable on telephone; medical evaluation indicated Definition: A disorder characterized by harsh and raspy voice arising from or spreading to the larynx. Navigational Note: Mediastinal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; not indicated; radiologic intervention indicated invasive intervention evidence only indicated; hospitalization Definition: A disorder characterized by bleeding from the mediastinum. Navigational Note: Oropharyngeal pain Mild pain Moderate pain; altered oral Severe pain; severely altered intake; non-narcotics eating/swallowing; narcotics initiated; topical analgesics initiated; requires parenteral initiated nutrition Definition: A disorder characterized by a sensation of marked discomfort in the oropharynx. Navigational Note: Pharyngeal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; not indicated intervention indicated invasive intervention indicated; hospitalization Definition: A disorder characterized by bleeding from the pharynx.

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Dosimetric considerations to determine the optimal technique for localized prostate cancer among external photon, proton, or carbon-ion therapy and high-dose-rate or low-dose-rate brachytherapy. Patient-reported outcomes after 3-dimensional conformal, intensity-modulated, or proton beam radiotherapy for localized prostate cancer. Clinical outcomes and late endocrine, neurocognitive, and visual profiles of proton radiation for pediatric low-grade gliomas. Comparison of the effectiveness of radiotherapy with photons, protons and carbon-ions for non-small cell lung cancer: a meta-analysis. Clinical outcomes and patterns of disease recurrence after intensity modulated proton therapy for oropharyngeal squamous carcinoma. Dosimetric advantages of proton therapy over conventional radiotherapy with photons in young patients and adults with low-grade glioma. Postoperative intensity-modulated proton therapy for head and neck adenoid cystic carcinoma. A multidisciplinary orbit-sparing treatment approach that includes proton therapy for epithelial tumors of the orbit and ocular adnexa. Proton radiation therapy for head and neck cancer: a review of the clinical experience to date. Proton therapy reduces treatment-related toxicities for patients with nasopharyngeal cancer: a case-match control study of intensity-modulated proton therapy and intensitymodulated photon therapy. Dosimetric advantages of intensity-modulated proton therapy for oropharyngeal cancer compared with intensity-modulated radiation: a case-matched control analysis. Proton therapy with concurrent chemotherapy for non-small-cell lung cancer: technique and early results. Comparative effectiveness study of patient-reported outcomes after proton therapy or intensity-modulated radiotherapy for prostate cancer. Proton therapy patterns-of-care and early outcomes for Hodgkin lymphoma: results from the Proton Collaborative Group Registry. Second cancer risk and mortality in men treated with radiotherapy for stage I seminoma. Comparing the dosimetric impact of interfractional anatomical changes in photon, proton and carbon ion radiotherapy for pancreatic cancer patients. Comparative treatment planning between proton and xray therapy in pancreatic cancer. Comparative treatment planning between proton and x-ray therapy in esophageal cancer. Favourable long-term outcomes with brachytherapy-based regimens in men 60 years with clinically localized prostate cancer.

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Women who become pregnant should be advised of the possibility of harm to the fetus. If oligohydramnios occurs, fetal testing should be done that is appropriate for gestational age and consistent with community standards of care. Animal reproduction studies revealed no evidence of impaired fertility or harm to the fetus. The exposure to trastuzumab in utero and the presence of trastuzumab in the serum of infant monkeys was not associated with any adverse effects on their growth or development from birth to 1 month of age. As human IgG is excreted in human milk, and the potential for absorption and harm to the infant is unknown, a decision should be made whether to discontinue nursing, or discontinue drug, taking into account the elimination half-life of trastuzumab and the importance of the drug to the mother. The risk of hematologic toxicities (leukopenia and thrombocytopenia) may be increased in geriatric patients. To ensure accurate and reproducible results, the protocol described in the package insert of an appropriate diagnostic test needs to be strictly followed. However, based on the current scientific knowledge, no standard test can be recommended at this time. There is no standard method of staining and no standard for the type of antibodies used. The grading for overexpression is subjective, and the signal may fade with time on stored slides. Patients classified as staining 2+ or 3+ were included, while those staining 0 or 1+ were excluded. In the studies, an investigative clinical trial assay was employed which utilized a 0 to 3+ scale. A reading of 3+ with HercepTest is likely to correspond to that of a 2+ or 3+ with the investigative clinical trial assay. A 2+ reading with the HercepTest would likely incorporate a significant number of patients who were scored as 1+ by the investigative clinical trial assay. Test methods having increased sensitivity, relative to the investigative clinical trial assay, may alter the benefit-to-risk ratio compared to that seen in the clinical trials. The testing should be done in experienced laboratories that have validated the test. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates. Table 10 displays adverse events which were reported after 8 years of median follow up in 1% of patients, by study treatment. Table 11 Adverse Events of Any Grade with Incidence 1% in Study B-31 (Final Analysis after Median Follow-up of 8.

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Additionally, the parathyroid hormones stimulate the kidneys to release vitamin D which then enhances absorption of calcium from the Gl tract. It is the hormone calcitonin which helps to lower the calcium concentration in blood by improving the concentration of calcium in the bones. Also of consideration is the possibility of a chronic depletion of calcium in the urine. Some other causes of hypocalcemia include the following: acute pancreatitis, magnesium depletion, septic shock, parathyroidism, vitamin D deficiency, renal failure, hypoproteinemia, hyperphosphatemia, and excessive release of calcitonin. However, memory loss, depression, confusion, delirium, and/or hallucinations may result if low calcium levels are left untreated. Fortunately, if calcium levels are replenished, these symptoms can be reversed in due time. The healthcare provider should be aware that severe cases of hypocalcemia could possibly result in: seizures, tetany (prolonged contraction of muscles, mainly of the face and extremities), or muscle spasms in the throat, often affecting the ability to breath. This may result from someone using excessive amounts of calcium or with those who take calcium containing antacids. If hypercalcemia does occur, typical symptoms include: constipation, loss of appetite, nausea and vomiting, and/or abdominal pain. Severe hypercalcemia may induce weakness, confusion, emotional disorders, delirium, hallucinations, or coma. With chronic conditions of hypercalcemia, permanent damage may occur from kidney stones or calcium-containing crystals forming. Potassium: this electrolyte plays a major role in cell metabolism and in nerve and muscle cell performance. Too high or low levels of blood potassium can cause serious effects such as an abnormal heart rhythm or cardiac arrest. With the assistance of intracellular potassium, the potassium concentration in the blood is properly maintained. Similar to other electrolytes, potassium balance is regulated by Gl tract absorption of potassium from food, and by the removal of potassium by the kidneys. High sources of dietary potassium are: melons, sweet potatoes, most peas and beans, bananas, tomatoes, and green leafy vegetables such as: spinach, turnip greens, collard greens, kale, also salt substitutes (potassium chloride), potatoes, oranges, and K Supplements. Hypokalemia is most frequent in the elderly and the most common causes are during acute illness, with nausea and vomiting, and during treatment with thiazide or loop diuretics. Because many foods contain potassium, hypokalemia is not typically a result of low intake. Those individuals with heart disease must be careful regarding hypokalemia (especially when taking Digoxin), because they are prone to developing abnormal heart rhythms. Potassium typically can be restored easily by eating foods rich in potassium or by taking potassium salts (potassium chloride). Organs that assist with Fluid Regulation: the Kidneys: reabsorb and excrete fluids, and regulate electrolyte and pH balance.

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However, a significant proportion of patients experience the first attack in childhood, adolescence, or early adult life. Blazer and Williams, who studied 997 persons over the age of 65 in North Carolina, found symptoms of a major depressive illness in 3. There is no known explanation for this gender difference, but some have speculated that just as many men are depressed, only they deny it or turn to alcohol. Patients in the bipolar group have an earlier age of onset, more frequent and shorter cycles of illness, and a greater prevalence of affective disorder among their relatives than do patients with unipolar depression (Winokur). Clinical Presentation Fully developed endogenous depression may evolve within a few days, or, more often, it emerges more gradually, on a background of vague prodromal symptoms that had been present for months. Here it need only be repeated that the patient expresses feelings of sadness, unhappiness, discouragement, hopelessness, and despondency, with loss of self-esteem. Reduced energy and activity, typically expressed as mental and physical exhaustion, is almost always present, to the point of catatonia in the most severe cases. Indeed, the most common cause of symptoms relating to reduced psychic and physical energy and drive (connation) is depression. There is heightened irritability as well as a lack of interest in most activities that formerly were pleasurable. The mental life of such an individual may narrow to a single-minded concern about physical or mental decline or both. Consciousness is clear, and though there is no evidence of a schizophrenic type of thought disorder, delusional ideas and less often hallucinations may be prominent in some patients, justifying the term depressive psychosis. In our experience, delusions are more common in older patients and tend to appear only after weeks or months of more typical symptoms of depression. Frequently, agitation and irascibility rather than physical inactivity and mental slowness are the principal behavioral abnormalities. Pacing the floor and wringing the hands, particularly in the early morning hours, are characteristic. Such patients tend to be overly talkative and vexed in their manner of expression, irritable, shorttempered, impatient, and intolerant of minor problems- changes noted mainly by family members. Attempts at reassurance may meet with initial success, only to be dispelled in the next rush of doubts. These patients remain impervious to reason and logic with respect to their symptoms, even though they are reasonable and logical to a variable degree in other areas of their lives. At its worst the illness takes the form of a depressive stupor; the patient becomes mute, indifferent to nutritional needs, and neglectful even of bowel and bladder functions (anergic depression). The most important concern in patients with mid- and latelife depression is the risk of suicide. Such patients should be questioned forthrightly on this subject: Do they feel that life is not worthwhile? These questions relate to features that have been shown to put depressed individuals at risk of suicide.

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If relevant, has the applicant submitted information to assess the abuse liability of the product? Has the applicant submitted a rationale for assuming the applicability of foreign data in the submission to the U. Has the applicant submitted datasets in a format to allow reasonable review of the patient data? Has the applicant submitted datasets in the format agreed to previously by the Division? Are all datasets for pivotal efficacy studies available and complete for all indications requested? For the major derived or composite endpoints, are all of the raw data needed to derive these endpoints included? Has the applicant submitted all required Case Report Forms in a legible format (deaths, serious adverse events, and adverse dropouts)? Has the applicant submitted all additional Case Report Forms (beyond deaths, serious adverse events, and adverse drop-outs) as previously requested by the Division? Yes If the Application is not fileable from the clinical perspective, state the reasons and provide comments to be sent to the Applicant. Please identify and list any potential review issues to be forwarded to the Applicant for the 74-day letter. From a clinical perspective, there were no major review issues identified at this time. When the balance between the production and reabsorption of this fluid deteriorates, it becomes pleural effusion [1]. However, malignant effusions are more common in women due to breast and gynecological cancers, while malignant mesothelioma and pancreatitisassociated effusions are more frequent in males [3]. Ventilation/perfusion imbalance and/or ventricular diastolic collapse may occur depending on the amount of atelectasis caused by effusion. Depending on the underlying disease, night sweats, weight loss, hemoptysis and high fever can also be seen. However, when this amount is exceeded; less participation this article is available in: insightsinchestdiseases. This results in a physical examination of the trachea as a counter-deviation to the opposite side. Depending on the underlying disease, peripheral edema, swelled neck veins, S3 rhythm, cutaneous findings or lymphadenopathies may be detected [4-7]. Radiological approach the first procedure to be performed in a patient with suspicion of pleural effusion on physical examination is to evaluate the patient with radiological examinations. Approximately 50 ml of fluid can be seen on the lateral chest radiograph and 200 ml of fluid can be seen on posterior-anterior chest radiograph. However, in radiographs taken in a supine position, the fluid does not cause significant blunting of the sinuses while it spreads to the entire thorax (Figure 1). It helps to distinguish solid structures, to locate locular or small amount of pleural effusion or to perform thoracentesis safely.

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The syndrome is largely reversible, but neuropsychologic tests given long after apparent recovery demonstrate defectsinexecutive function, affect, and language. He had been operated on twice 2 years before with a vermis splitting operation that removed most of the lesion, but left residual tumor in the lateral wall of the fourth ventricle. The surgeon did not invade the vermis but lifted the cerebellar tonsil to successfully resect the residual tumor. Neurologic consultation was sought in the immediate postoperative period when the patient appeared to be ``unresponsive. The hyperintensity in the vermis is more marked and there is new hyperintensity in the right posterior lobe of the cerebellum. Comment: the cerebellar cognitive affective syndrome is rare in adults and can easily be mistaken for catatonia or psychogenic unresponsiveness. Interestingly, the surgeon noted that when she first interviewed him his affect seemed ``flat. Although historically we have used Amytal, clinical evidence suggests that a benzodiazepine such as lorazepam works just as well and is more available. The Amytal interview is conducted by injecting the drug intravenously at a slow rate while talking to the patient and doing repeated neurologic examinations. Patients with structural or metabolic disease of the nervous system usually show immediately increasing neurologic dysfunction as the drug is injected. Neurologic signs not present prior to the injection of amobarbital (such as extensor plantar responses or hemiparesis) may appear after only a small dose has been introduced, and behavioral abnormalities, especially confusion and disorientation, grow worse. On the other hand, patients with psychogenic unresponsiveness or psychogenic excitement frequently require large doses of amobarbital before developing any change in their behavior, and the initial change is toward improvement in behavioral function rather than worsening of abnormal findings. An excited patient may calm down and demonstrate that he or she is alert, is oriented, and has normal cognitive functions. In a few instances, even the Amytal interview does not make a distinction between organic and psychologic delirium. In such instances, the patient must be hospitalized for observation while a meticulous search for a metabolic cause of the delirium is made.

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Special Considerations/Preparation Intravenous solution: Available as a powder for injection in 250-mg, 500-mg, 1-g, and 2-g vials. Prepared by reconstituting powder with compatible solution (sterile water for injection, D5W, or D10W) to a concentration of 100 mg/mL. Reconstituted solution is stable for 2 days at room temperature, 10 days refrigerated. Acyclovir, amikacin, amiodarone, aztreonam, clindamycin, famotidine, gentamicin, heparin, linezolid, metronidazole, morphine, potassium chloride, propofol, remifentanil, sodium bicarbonate, and zidovudine. Terminal Injection Site Incompatibility Aminophylline, azithromycin, calcium chloride, calcium gluconate, caspofungin, fluconazole and vancomycin. Avoid administration of calcium-containing solutions or products within 48 hours of the last administration of ceftriaxone. Intramuscular: To reduce pain at the injection site, reconstitute with 1% lidocaine without epinephrine to a final concentration of 250 mg/mL or 350 mg/mL. Uses Treatment of neonatal sepsis and meningitis caused by susceptible gram-negative organisms. Contraindications/Precautions Not recommended for use in neonates with hyperbilirubinemia. Dosage adjustment is necessary only for patients with combined hepatic and renal failure. Uses Treatment of serious infections caused by susceptible gram-negative organisms (eg, E coli, H influenzae, Enterobacter, Klebsiella,Morganella, Neisseria, Serratia,and Proteus species), especially Pseudomonas aeruginosathat are resistant to 3rd generation cephalosporins. Treatment of serious infections caused by susceptible Gram-positive organisms (eg, Strep pneumoniae, Strep. Pharmacology Cefepime is a fourth-generation cephalosporin with treatment efficacy equivalent to third-generation cephalosporins. Special Considerations/Preparation Available as powder for injection in 500-mg and 1-g, and 2-g vials. Amikacin, ampicillin, aztreonam, bumetanide, calcium gluconate, clindamycin, dexamethasone, fluconazole, furosemide, gentamicin, heparin, hydrocortisone succinate, imipenem/cilastatin, lorazepam, methylprednisolone, metronidazole, milrinone, piperacillin-tazobactam, potassium chloride, ranitidine, remifentanil, sodium bicarbonate, ticarcillin/clavulanate, trimethoprim/sulfamethoxazole, and zidovudine. Capparelli E, Hochwald C, Rasmussen M, et al: Population pharmacokinetics of cefepime in the neonate. Potential advantages include: more rapid penetration through the cell wall of Gram-negative pathogens; enhanced stability to hydrolysis by -lactamases; and enhanced affinity for penicillin-binding proteins. Protein binding is low (approximately 20%), and it is primarily excreted unchanged in the urine. Adverse Effects Safety has been documented to be the same as commonly used second- and thirdgeneration cephalosporins. Reconstitute 500mg vial with 5 mL of sterile water for injection to a concentration of 100 mg/mL. Amikacin, ampicillin, aztreonam, bumetanide, calcium gluconate, clindamycin, dexamethasone, fluconazole, furosemide, gentamicin, heparin, hydrocortisone succinate, imipenem/cilastatin, lorazepam, methylprednisolone, metronidazole, milrinone, piperacillin-tazobactam, potassium chloride, ranitidine, 180 Micormedex NeoFax Essentials 2014 remifentanil, sodium bicarbonate, ticarcillin/clavulanate, trimethoprim/sulfamethoxazole, and zidovudine.


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