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The Baltimore Aircoil Company cooling tower “Operation and Maintenance Manual” and related documents can be found in Appendix D antibiotic resistance health care generic noroxin 400mg amex. Any part or equipment used in the cooling tower will comply with the manufacturer’s original design and performance specifications and any part or equipment used in the cooling tower system will comply with the New York City Construction Codes antibiotics via iv buy noroxin 400 mg with amex. As applicable antibiotic joint penetration best purchase for noroxin, replacement materials will be corrosion-resistant and effectively prevent the penetration of sunlight virus animation generic noroxin 400mg otc. A pre-startup cleaning is conducted for the seasonal systems and a shutdown cleaning is conducted at the end of the season. Cleanings require a complete system shutdown and will sometimes be completed in the evening or weekends. Areas where scale, debris and biofilm are likely to accumulate are paid special attention as well as water contact areas such as the basin, sump, fill, spray nozzles and fittings, drift eliminators, and air intake louvres are properly accessed or removed to facilitate cleaning. Power washing is also performed on the cooling tower to rid it of any debris as well as to clean fill sections that are present and cannot be removed. Protective equipment worn during cleaning includes googles, gloves, and coveralls. Drift eliminators are maintained, installed and inspected to ensure good working order and proper function. Visual inspections will be used to verify that they are not physically damaged or contaminated with scale or algae. All repairs will be in compliance with manufacturer’s recommendation in order to keep drift loss below the maximum allowable amount. Cleaning and disinfection will be done no later than 15 days before the first seasonal use of such tower. Start-Up for Drained Systems To be performed by a Certified and Licensed Water Treatment Contractor: Completely drain the cooling tower to protect it from offline contamination. While operating the condensing water pump(s) and prior to operating the cooling tower fans, execute one of the two alternative biocidal treatment programs* described below: 1) Treat with the biocide that had been used prior to shut down. Maintain the maximum recommended biocide residual (for the specific biocide) for a sufficient period of time (residual and time will vary with the biocide) to bring the system under good biological control. The chlorine residual must be held at 4 to 5 mg/L (ppm) for six hours, measurable with standard commercial water test kits. Start-Up for Undrained (Stagnant) Systems (If Applicable) To be performed by a Certified and Licensed Water Treatment Contractor: Remove accessible solid debris from the cooling tower sump and from any remote storage tank(s) that may be used. Do not circulate stagnant bulk cooling water over cooling tower fill or operate cooling tower fans during pretreatment. Otherwise add approved biocide directly to the bulk water source and mix with either manual or by side stream flow methods. Take care to prevent the creation of aerosol spray from the stagnant cooling water from any point in the cooling water system. When biocide residual is maintained at a 4 to 5 mg/L (ppm) level for at least six hours, the cooling tower fans may be operated. Note: All systems are required to be drained at the end of the Cooling Season as per Department of Education Requirements. Notice will include a statement that the cooling tower has been drained and sanitized. Shutdown, Startup and Idling Procedure Summary Seasonal Shutdown When the system is to be shut down for a period of more than three days, the entire system (cooling tower, system piping, heat exchangers, etc. Seasonal Startup Before cooling tower system startup, a cooling tower(s) that has been shut-down or idle for more than three days will be cleaned and disinfected. If seasonal startup a mechanical contractor will be onsite to make sure the tower is in operable condition. Idling A cooling tower(s) that has been shut-down or idle for more than three days will be cleaned and disinfected. The evaluation must describe the optimum level of chemicals to achieve the desired result in a manner which can be used as a system performance measure. Only biocide products registered with the New York State Department of Environmental Conservation may be used in disinfection. Provided that chemical treatment is demonstrated as adequate to control Legionella in the maintenance and management plan, non-chemical water treatment devices may also be installed as a part of the cooling tower system. Corrective Actions Run the system a few hours every day and adjust biocide levels 4. The shock treatment consists of sodium hyperchlorites that are circulated for 24 hours. As applicable, risk management procedures to mitigate the potential conditions listed in the below table should be undertaken, with additional sampling, measurement, and general observation to be implemented at high risk locations within the cooling tower system as identified by the risk management assessment conducted. Critical Risks and Hazards Risk Management Assessment and Management Dead legs or stagnant water in the recirculation Low Risk – Circulating pumps are used to provide system continuous water circulation Title 24, Chapter §8-03 (c)(1) Operating configurations and conditions that may Low Risk – Building checks are performed daily including occur after periods of extended inactivity lasting weekends where circulating pumps are turned on. System is offline and throughout the year making regular, periodic drained during the off season offline cleaning and disinfection difficult Title 24, Chapter §8-03 (c)(3) Any components that may add additional risk High Risk – Strainers and filters are found in the cooling factors for organic material buildup and microbial tower and are cleaned during preseason startup and growth such as strainers and out-of-use filters postseason shut down as well as if a full disinfection is Title 24, Chapter §8-03 (c)(4) required. Sources of elevated organic contamination, Low Risk – No such sources can contaminate the system. Title 24, Chapter §8-03 (c)(7) 5-20 Critical Risks and Hazards Risk Management Assessment and Management System components adversely affecting water Low Risk – No such components exist. All components are quality management procedures working as designed Title 24, Chapter §8-03 (c)(8) Other risk or limiting factors or constraints in the Low Risk – No other risk/limiting factors exist. The system is in operation with water circulating in the system for at least one hour prior to water quality measurements or collection of samples. Daily water quality parameters are measured by the Custodial Engineers, Building Managers, or Fireman from the cooling tower basin water. If any parameters are out of range and persist for an extended period of time without explanation, the Metro Group is contacted for help with resolving the problem. These samples are collected on Mondays each week from the tower basin and interpreted according to Table 2 of Chapter 8, while the cooling tower system is operating. When biocide applications are intermittent, indicators will be taken after the biocide application has had time to mix uniformly throughout the cooling tower system and reflect normal cooling tower operating conditions. Bacteriological Indicator Sampling Summary Responsible Party for the Custodial Engineer, Building Manager, and/or Fireman Indicator Collection Indicator Collection All samples will be taken from the basin of the Cooling Tower Location(s) Indicator Sample Using a dip slide the responsible party will remove the dip slide from the protective Protocol cover and dip it into the basin of the cooling tower for approximately 3 seconds. The excess water will be removed from the slide and the slide will then be covered again and the sample sealed. The results are reviewed by the Water Treatment Manager and any action that may be required will be ensue. All test results of all Legionella species at or above the magnitude of level 4, as indicated in Table 1 of Chapter 8, will be reported to the Department within 24 hours of receiving the test results. Collection Location(s) Legionella Sample Samples are collected by Triumvirate Environmental staff and staged in a cooler on Protocol ice. Responsible Party for Sample results will be interpreted by Triumvirate Environmental and the Water Corrective Action(s) Treatment Manager. The Water Treatment Manager will implement the required corrective action(s) if required. Corrective Action(s) the decision tree above displays the corrective action required caused by a high and Timeline colony density. Quarterly Activity Title (Rule Seasonal (every Description of Service (if applicable) Daily Weekly Biennial Section) Start-up 90 days in use) Check all wetted surfaces (safely visible during cooling tower operation), cooling tower basins and drift eliminators for the presence of organic material, Routine Monitoring biofilm, algae, scale, sediment and silt/dust deposits, X (8-04(a)(3)) organics (oil and grease), and other visible contaminants. Check sufficiency of chemical dosing and control equipment, of storage and delivery of treatment chemicals, and the bleed-off system. Inspect for the presence of visible contaminants, the general condition of the cooling tower, the basin packing material and drift eliminator; the quality of the water make-up connections and control; the proper Compliance functioning of the conductivity control; the proper Inspection X X functioning of all dosing equipment (pumps and strain (8-04(b)) gauges); and the review of routine maintenance records to ensure proper implementation of required activities (including those specified in 8-04(b)) and corrective actions as needed. Clean water contact areas such as the basin, sump, fill, spray nozzles and fittings, drift eliminators, air intake Cleaning louvres in accordance with manufacturer’s X (8-04(d)) recommendations, after properly accessing and/or removing equipment. Water Quality Measure the water quality parameters pH, conductivity, X* Monitoring (8-05(f)) temperature, and biocidal indicator. Bacteriological Sample bacteriological indicator at given point and time Indicator Sampling X of day. Building means any structure or premises used or intended for supporting or sheltering any use or occupancy.


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The laryngeal angioma represents a benign tuthe laryngeal lipoma represents 13% of the bemor antibiotics for bordetella dogs noroxin 400mg cheap, with an incidence of less than 1% of all the benign tumors of the fatty tissue discovered in the neck nign lesions discovered at this site antibiotic augmentin generic noroxin 400mg line. An indirect laryngoscopy reveals a sessile scopy reveals a yellow or yellow-grey mass infection gums cheap noroxin 400 mg with amex, of waxy or pedicled formation antibiotic resistance studies order discount noroxin line, frequently localized/situated at consistence and without ulcerations8. The pedicled tumors may lead to severe clude pathological types such as the epidermal cyst, shortness of breath with acute respiratory distress. Clinically, the most important sympnervous system are pretty rare at this level. In order to correctly the patient complains of persistent dysphonia in difdiagnose the disease, an indirect laryngoscopy, assoferent stages of severity. The diagnosis of certitude ciated with fibroscopy and videostroboscopy are reis based on the histopathological examination which quired. This mass determines a decrease in the vocal sheath and has a low laryngeal incidence. The gold standard for diagnosis is toms include dysphonia and shortness of breath. Sometimes, the lesions may be frequent localizations are on the ventricular bands, multiple and of variable sizes3. The size of the tumor determines the severity of of liquid generated by a glandular dilation; this is also the symptoms, which include dysphonia, foreign-body observed during the histopathological examination. Clinical mato giant structures that may induce acute respiratonifestations include persistent dysphonia, sometimes ry distress. The internal laryngocele causes dysphonia examination reveals a small, nodular, white-grey forwhich can sometimes associate shortness of breath, mation, covered by normal mucosa, which is situated depending on the size of the mass. It is chalaryngocele must be distinguished from other tumors racterized by a slow growth and it is frequently discoor latero-cervical swellings. The laryngocele usually vered in female gender, mostly on the right side, on contains liquid which may also become infected, thus the ventricular bands and/or the aryepiglottic folds. Fibroscopy reveals a cystic mass, reddish or bluish in the laryngeal myxoma represents an extremely color, smooth and well delimited. The clinical manifestations, mainly dysphonia tumor that appears isolated or in patients that suffer and dysphagia, are related to the localization and the of fibromatosis. The most frequent sites of the tumor sion, this tumor presents an aggressive potential. The are on the vocal cords, the aryepiglottic folds and the most common sites of discovery for this tumor are: epiglottis. Laryngeal endoscopy describes a spherical eosinophilic material and of fibrillar proteins in the mass, variable in size, mobile, with a rich blood supply supraglottic space. The diagnosis Differential diagnosis is made with all benign larynis established based on the clinical manifestations, geal lesions, especially with angioma, lipoma, fibroon the radioactive iodine uptake and on scintigraphy. According to the literature, malignization may be Benign tumors of the larynx represent patholopossible. These lesions derive from vascular endothelium without a vascular –conjunccomponents of the larynx or embryonic remnants. It is a rare subglottic pathology which affects Symptomatology depends on the location and size of especially children. Most of the lesions are unique, but in symptomatology (persistent hoarseness, shortness the literature have been reported also in Rendu-Osler of breath, sore throat, pharyngeal paresthesia), foldisease or Sturge-Weber disease3. Laryngeal papiLaryngeal lipomas are rare supraglottic patholloma is the most frequent benign tumor in children logical entities. Dyspnea is the most frequent sympand is determined by the infection of the larynx mutom which may evolve to acute respiratory failure. Lesions are multiple and Differential diagnosis of these lesions is mainly done diffuse, situated on the upper airways, where there with internal laryngocele or mucous retention cyst3. The illhas a high rate of recurrence, which in 10% of the ness has an extensive and recurrent character,which cases may become malignant, a neurofibrosarcoma3. Schwannoma originates from the internal branch of From the 90 subtypes of the virus, the most superior laryngeal nerve, it may also affect sensitive frequent ones are subtype 6 and 11. Histopathological diagnosis is esresponsible for the most agressive form of the diseatablished on three major criteria: the presence of capse, with frequent recurrences and extended lesions. Myoblastoma, described by Abrikossoff papilloma), rarely asociated with viral infection, and for the first time, appears extremely rare into the larpresent a high malignancy rate due to the association ynx, exclusively in the posterior area of the vocal folds. The thorough examination of the lesions in order to inmajority of these tumors are located at the supraglotcrease diagnostic accuracy. Vocal fold nodules are thickening of the mucosa Fibromas of the larynx are extremely rare tulining situated on the free edge of the fold. Their mors which can appear isolated or in the context of appearance is in direct correlation with vocal stress, fibromatosis. A careful endoscopic examination is rebeing frequently encountered on singers, actors, lawquired in order to differentiate them from vocal fold yers, teachers, priests etc5. Vocal rest Amyloidosis is a rare larynx affliction that most can partially alleviate the symptoms, while a high voof the time appears in a general context, but there cal effort can induce long periods of aphonia. Histologically, they the supraglottic level, most frequently in the laryngeal are angiofibromas, epithelial tumors with their own vestibule. The exact diagnosis will be esis low-pitched, high-pitched notes being frequently tablished by histological and immunohistochemical hard to transmit. An efficient and optimal therapeutic drainage, and the remaining lesions can affect the attitude depends on the accuracy of these investigavibrations of the vocal cord3. Otorhinolaryngology Head and Neck Surgery, Springer, the serous pseudo – cyst is a unilateral benign 2009; 487-497. Tratat de chirurgie, otoeffort, some professions like musicians are more likely laringologie si chirurgie cervico-faciala. Laryngeal papilomatosis: is often difficult, because of its high variability in dicorrelation between severity of desease and presence of mensions. J Clin inner larynx and the external type can exceed the Pathol, 1989; 42:694-698. Editura Viata Medicala Romaneasca, Bucuresti, 2001; 224-232, membrane and is exteriorized in the laterocervical 236-238. People’s Larynx myxoma can achieve great size that can Medical Publishing House Shelton, Connecticut, 2009; determine airway obstruction, with the necessity of 877-883. Laryngeal myxoma resembling a laryngeal Laryngeal benign tumors are pathological polyp: case report. See Principles of high-grade lesions, and intracranial extension (See Discussion). The role of proton versus acceleration of radiotherapy with or without concomitant therapy is being investigated. Proton therapy can be considered when normal tissue "Parotidectomy Surgery + neck dissection" constraints cannot be met by photon-based therapy. Reirradiation of head and neck cancers with intensity resection of a major salivary gland tumor. Int J Radiat • Adjuvant treatment options revised if adverse features after Oncol Biol Phys 2016;95:1117-1131. For primary subglottic tumors and mirror and fberoptic examination as clinically indicated)" or glottic cancers with signifcant subglottic extension, a • Imaging recommendations have been grouped together. The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for head-neck carcinomas. Molecular classification squamous cell carcinoma of the tonsil in clinical practice. J Clin Pathol 2011;64:308identifies a subset of human papillomavirus–associated oropharyngeal 312. Gy per fraction to a typical dose of 70 Gy in 7 weeks with single-agent cisplatin given every 3 weeks at 100 2Particular attention to speech and swallowing is needed during therapy. Human papillomavirus and survival of patients with oropharyngeal slightly modified (eg, <2. All current smokers distant metastases, and for select patients who smoke to screen for lung should be advised to quit smoking, and former smokers should be advised to remain cancer.

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Obesity-associated importance of large inter-individual that is unopposed by progestins virus vs disease discount noroxin 400 mg mastercard. A representative acinus is circled in red and indicated with increases in risk bacteria zinc order noroxin overnight delivery, depending on the an arrow antimicrobial zone of inhibition purchase noroxin 400mg amex. The related to most prescribed antibiotics for sinus infection order generic noroxin substantial reductions in est reductions in relative risks are effects of combination therapy may risk. Because of also be infuenced by how it is prerisk, and the reduction in risk persists these complexities, more meaningscribed (estrogens given sequentially for some time after discontinuation of ful insights can be derived by a focus vs continuously), but studies are only use [8]. Endometriosis is a well-established predictor of certain types of ovarian cancer, including clear cell and endometrioid cancers (Table 3. Unlike for breast cancer and endometrial cancer, body size is not strongly related to risk of ovarian cancer, although it may have some modest effect for certain tumour subtypes. However, use of menosumably because these parameters pausal hormones has been linked ther studies are needed to clarify the indicate an enhanced opportunity effects on endometrial cancer risk with increases in risk. In such studies, it will demonstrated for unopposed esrecent efforts have been made to be important to distinguish patterns trogen therapy, but there is growing develop individualized risk predicof risk according to specifc tumour evidence that combined estrogen tion models based on identifed risk subtypes. Age-standardized incidence of endometrial cancer by use of menopausal which there is growing evidence of hormone therapy and body mass index, from the United States National Institutes of etiological heterogeneity [14]. Error bars indicate 95% confidence interval on the age-standardized incidence rate. The relationship of risk with use of menopausal hormone therapy remains less clear. Data are also of prostate cancer by blocking the beginning to emerge that implicate conversion of testosterone to diHormonal factors play a role in the the importance of endogenous horhydrotestosterone; use has also etiology of testicular cancer, as evimones (particularly estrogens) in the been associated with increases denced by the rise in incidence startetiology of male breast cancer [19]. The Prostate ing at adolescence and a variety of Cancer Prevention Trial has shown risk factors, including height, subfersubstantial reductions in prostate tility, and possibly exposure to endoProstate cancer cancer incidence associated with crine disrupters (see Chapter 5. One large pooling interest in examining subgroup reies are needed to fully understand project showed no association belationships. However, the few one is converted in the prostate by from other studies on the role of available studies appear to implicate 5reductase. The both estrogens and androgens in several hormonally related risk faconly evidence of association obthe etiology of prostate cancer [22], Table 3. Relationship of anthropometric and hormonal risk factors with risk of male breast cancer: results from the Male Breast Cancer Pooling Project Factors Odds ratioa (95% confdence interval) Meta-analysis Case–control studies Cohort studies Adult body mass index (kg/m2) Lowest tertile, fi 24. Although some studies have sugand lung [25], are particularly difgested possible infuences of varifcult to decipher. Epidemiological Studies of Ovarian Cancer cancer: a collaborative analysis of 18 13(11):1141–51. A single measure a multiplicity of organic tricarboxylic acid cycle, and determination of the metabolome compounds in complex matrices bile acids. Although many meinformation on the mechanisms that new pathophysiological mechatabolites are shared between these link metabolism and diseases. In untargeted metabolomics, biomarkers for early detection their concentrations in any given thousands of metabolites can be of cancer and new risk factors condition. Currently, applications of metaboprognosis, and response to therapy Compared with fetoprotein, phelomics to cancer research are quite [9,10]. Two of metabolism, glutathione metabolism, Most of these metabolites are these fatty acids were good predictand fatty acid biosynthesis. A later study in the European 9 tumour types showed that several tors, such as other diseases, age, or Prospective Investigation into Cancer pathways were commonly affected body mass index (see Chapter 2. A combination before diagnosis, suggesting possicultures to identify metabolic alterof three serum metabolites differenble clinical applications as early bioations and adaptations, which are tiated with high accuracy between markers of disease. As an example, the syscancer and healthy controls, with prospective epidemiological studies tematic overexpression of individual a receiver operating characteristic are relatively recent. This fnding confrms results from the Framingham Offspring pathophysiological mechanisms that from earlier rat feeding studies that Study [16]. This tation of results from prospective creas, prostate, and breast have analysis showed that genetic variants studies on cancer. Arrows indicate the direction of the associations: cohort, 676 metabolites, including positive association (fi), negative association (fi), and inconsistent direction (fi In a nested of hundreds of these compounds, estrogen receptor-positive breast case–control study that included which together constitute the intercancer, enabling the generation of 621 postmenopausal breast cannal exposome [27,28]. Many of these novel hypotheses on the role of diet cer cases and 621 matched concompounds are direct indicators of in breast cancer risk [33]. Metabolomics data, once coldehydroepiandrosterone-3-sulfate, They have been measured in poplected in a prospective study, can be 3-methylglutarylcarnitine, allo-isoulation studies as proxy biomarkfurther mined to selectively examine leucine, and 2-methylbutyrylcarers of exposures to environmental associations of specifc markers of nitine) were associated with both factors. Detailed information on dietary exposures with cancer risk body mass index and risk of invathese biomarkers is curated in the [28]. Beyond endogenous metargeted metabolomics approaches doubt that metabolomics is emerging tabolites, a large array of exogenous to study their association with canas an essential tool, complementary compounds, directly derived from cer risk. Serum 27-nor-5 Explorer: a manually-curated database cholestane-3,7,12,24,25 pentol glucuro21. Histone modifcations although only a small fraction (~2%) the second main epigenetic mechaof the genome is established to enEpigenomic changes in nism encompasses various modifcode proteins [9]. Histone Experimental evidence sugepigenome is markedly dysregulatmodifcations include acetylation, gests that there is intimate and ed in almost all malignancies [1,2] methylation, phosphorylation, and mutually reinforcing cross-talk be. Dysregulation of epigenetic mechanisms may promote the development of abnormal phenotypes and cancer. There is cross-talk between epigenetic and genetic changes in the process of cancer development and progression. Given that epigenetic and genetic changes coexist in all cancers, it is important to identify the functionally important changes (“drivers”) that are pertinent to carcinogenesis, and to distinguish them from events that are not functionally important (“passengers”). This notion is pomethylation) and gene promotersuppressor genes and other cancersupported by recent studies showassociated (CpG island-specifc) related genes may occur through ing that recurrent mutations in the hypermethylation [11]. Ultimately, intervention this term is used for mutations, and tablished and suspected cancer risk studies in animals or humans are hence differentiate them from “pasfactors (including ageing, infammaimportant to establish causal assosenger” events, which are evident tion, tobacco smoking, alcohol conciations between environmental exbut not functionally important. Thus, epigenetic mechanisms may represent “sensors” of exposure and “mediators” of the outcomes, including cancer development. Cell death In vitro and animal models Twin cohort studies Optimized statistical approaches Epigenetic Transcription-dependent vs -independent inheritance Epidrivers Carcinogen evaluation the accumulation levels of aberrant methylation can be sensitively demixed results [31,32]. Measurement of methylation in normal-appearing tissues can be used as a biomarker of cancer risk. Methylation of specific genes that are associated with pathophysiology can be used as a biomarker of pathophysiology. Also, to beneft from effective chemoprecancer prevention by reversing it is now possible to identify individvention by balancing the beneft and epigenetic changes in the human uals at extremely high risk of some the potential adverse effects (see population, the specifcity of precancers by assessing accumulated Chapter 6. Epigenetic modulators, modifers and mediators in cancer aetiology and ylation and cancer: ghosts and angels above the genes. Hernandez-Vargas H, Castelino J, Silver for investigating epigenome deregulation and environmental origins of cancer. Asada K, Nakajima T, Shimazu T, Musulen E, Balana C, Estival-Gonzalez A, in a mouse model of prostate cancer. Mutator pathterm epigenetic therapy with oral zebuways unleashed by epigenetic silencing in larine has minimal side effects and pre29. In the context of fi Innate and adaptive immunity Immunity in all its diversity and interferon-driven type 1 immune in the tumour microenvironment plasticity acts as a double-edged responses, macrophages acquire are double-edged swords. In contrast, infammatory cells (elimination) phase in the natural fammation orchestrated by inand myeloid cells – in particular, history of carcinogenesis [8]. Single-cell analysis has mechanisms, has opened up a immunity, and cancer added a new dimension to the disnew frontier in oncology, repreA connection between infammasection of myeloid cell diversity in sented by tumour immunology tion and cancer. Pathways connecting inflammation and cancer at the tissue level and at the systemic level. Oncogene activation Intrinsic Components of innate pathway immunity drive tumourObesity promoting infammation. Lifestyle T cells eliminate and edit Extrinsic (diet, physical exercise) cancer cells. Cytokines are a key component T-cell-orchestrated type 1 immune unleash antibody-dependent cellular cytotoxicity and phagocytosis of tumour-promoting infammation.

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