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The use of oxytocin for induction of labour is Menopausal symptoms are common in addition to decreased described in Chapter 41 order escitalopram 5 mg free shipping. Key points Pharmacokinetics Physiology of the pituitary Gonadorelin analogues are peptides and are given paren- Anterior pituitary terally cheap 5mg escitalopram overnight delivery. Tetracosactide is used as a diagnostic test in the Answer evaluation of patients in whom Addison’s disease (adrenal insuf- The most likely cause of his symptoms worsening in the first ficiency) is suspected buy escitalopram 5mg with amex. Thus this patient should be given adequate analge- and paraventricular hypothalamic nuclei and transported sia and an androgen receptor antagonist (e. Goserelin can then be restarted in for storage and subsequent release (neurosecretion). Corticotropin-releasing hormone and its receptors; an evaluation at the transcription level in vivo. Combined therapy with pharmacology of nonpeptide vasopressin receptor antagonists. The duration of therapy depends on the nature of the Bacteria are a common cause of disease, but have beneficial as infection and response to treatment. For example, the gastrointestinal bac- The British National Formulary provides a good guide to ini- terial flora of the healthy human assists in preventing colo- tial treatments for common bacterial infections. The widespread use of antibacterial regional variations in patterns of bacterial resistance, these drugs has led to the appearance of multiresistant bacteria may be modified according to local guidelines. Consequently, antibacterial therapy should not be information on local prevalence of organisms and sensitivities. It is the drugs that kill bacteria and bacteriostatic drugs that prevent minimal concentration of a particular agent below which bac- their reproduction, elimination depending on host defence terial growth is not prevented. This difference is relative, as bacteriostatic drugs useful information for comparing the susceptibility of organ- are often bactericidal at high concentrations and in the pres- isms to antibacterial drugs, it is an in vitro test in a homoge- ence of host defence mechanisms. In clinical practice, the dis- nous culture system, whilst in vivo the concentration at the tinction is seldom important unless the body’s defence mechanisms are depressed. Mechanism of action Antibacterial agent The choice of antibacterial drug, together with its dose and route of administration, depend on the infection (in particular Inhibition of cell wall synthesis Penicillins the responsible pathogen(s), but also anatomical site and Cephalosporins severity), absorption characteristics of the drug, and patient Monobactams Vancomycin Table 43. Yes No Yes No Treat with appropriate antibiotic Treat with most appropriate antibiotic No antibiotic according to predominant causative treatment organism(s) and sensitivities (including local sensitivity patterns) Consider other measures (e. Yes No Complete course Consider of treatment – alternative (or additional) diagnosis – poor penetrance of antibiotic to site of infection – possible change in antibiotic therapy Figure 43. Current guidelines therefore emphasize the following concentration which one might predict to be bactericidal (e. The dates on by spontaneous mutation) that exist within the bacterial tombstones in Victorian cemeteries should be required read- population by elimination of the sensitive strain by ing for over-enthusiastic prescribers and medical students! Thus the incidence of drug resistance is related to (Whole families of infants died in infancy, followed by their the prescription of that drug. In such patients, all dental (plasmids), or by passage of the information by procedures involving dento-gingival manipulation will require bacteriophage (transduction). In this way, transfer of antibiotic prophylaxis, as will certain genito-urinary, gastro- genetic information concerning drug resistance intestinal, respiratory or obstetric/gynaecological procedures. The latest guidelines (2006) by the Working Party of the British Society for Antimicrobial Mechanisms of drug resistance can be broadly divided into Chemotherapy can be found at http://jac. Prophylaxis should be restricted to cases where the or an altered organelle with reduced drug-binding procedure commonly leads to infection, or where properties (e. The antimicrobial agent should preferably be bactericidal and directed against the likely pathogen. The aim is to provide high plasma and tissue concentrations of an appropriate drug at the time of bacterial Most infections can be treated with a single agent. Intramuscular injections can usually be there are situations in which more than one antibacterial drug given with the premedication or intravenous injections at is prescribed concurrently: the time of induction. Many problems in this area arise because • to achieve broad antimicrobial activity in critically ill of failure to discontinue ‘prophylactic’ antibiotics, a patients with an undefined infection (e. Local hospital drug and therapeutics would affect all of the bacteria present; committees can help considerably by instituting sensible • to prevent the emergence of resistance (e. If continued administration is necessary, change to oral • to achieve an additive or synergistic effect (e. Penicillins are excreted it should be restricted to patients who have previously had in the urine. Adverse effects Adverse effects The adverse effects include: Rashes are common and may appear after dosing has stopped. It is acid labile and so must be given parenterally are susceptible to amoxicillin, most Staphylococcus aureus, 50% of (inactivated in gastric acid). Development of resistant β-lactamase-producing strains effects are similar to those of amoxicillin, but abdominal dis- can occur. This injection: is not usually a problem, as these organisms seldom cause dis- ease in otherwise healthy people. Procaine benzylpenicillin – this complex releases tion is important in neutropenic patients (e. Phenoxymethylpenicillin (‘penicillin V’) – this is acid oped and are particularly useful in these circumstances. These stable and so is effective when given orally (40–60% include piperacillin, azlocillin and ticarcillin. Although it is useful for mild infections, blood concentrations are variable, so it is not used in Uses serious infections or with poorly sensitive bacteria. Tablets are given on an empty stomach to improve Their efficacy against Gram-positive organisms is variable and absorption. They are useful against Gram-negative infections, partic- ularly with Pseudomonas and they are also effective against many anaerobes. Combinations of ticarcillin or of piperacillin with β-lactamase Flucloxacillin was developed to overcome β-lactamase-produc- inhibitors designed to overcome the problem of β-lactamase ing strains. Otherwise, it has a similar antibacterial spectrum to formation by Pseudomonas are commercially available. It is used for the treatment of staphylococcal infec- Adverse effects tions (90% of hospital staphylococci are resistant to benzylpeni- These drugs predispose to superinfection. It has a narrow spectrum of activity and cannot be They are given intravenously every 4–6 hours. Their half-lives used alone unless the organism’s sensitivity to aztreonam is range from 1 to 1. Their pharmacology is similar to that of the peni- Pharmacokinetics cillins and they are principally renally eliminated. Aztreonam is poorly absorbed after oral administration, so it is given parenterally. Uses Arguably the most generally useful member of the group is Imipenem, a carbapenem, is combined with cilastatin, which cefuroxime, which combines lactamase stability with activity is an inhibitor of the enzyme dehydropeptidase I found in the against streptococci, staphylococci, H. This enzyme breaks is given by injection eight-hourly (an oral preparation is also down imipenem in the kidney. It is expensive, although spectrum of activity against Gram-positive, Gram-negative and when used against Gram-negative organisms that would other- anaerobic organisms. It is β-lactamase stable and is used for treat- wise necessitate use of an aminoglycoside, this cost is partly ing severe infections of the lung and abdomen, and in patients offset by savings from the lack of need for plasma concentra- with septicaemia, where the source of the organism is unknown.
In pyrrole cheap escitalopram 10mg free shipping, there are four p electrons order escitalopram overnight, two short of the 2 Huckel¨ criteria for aromaticity order escitalopram on line. The nitrogen atom is sp -hybridized, formally containing a lone pair of electrons in the p orbital at right angles to the ring. However, the system delocalizes and pushes the lone pair of electrons into the ring to complete the sextet required for aromaticity. The nonbonding electrons on the nitrogen atom become a part of the aromatic sextet. However, biologically more signiﬁcant natural pyrroles are rather less simple; they are tetrameric pyrrole derivatives, known as porphyrins, e. Furan, also known as furane and furfuran, is an oxygen-containing ﬁve- membered aromatic heterocyclic compound that is usually produced when wood, especially pine wood, is distilled. Although it has a lone pair of electrons, these electrons cannot delocalize easily, and so the system is generally considered to be almost nonaromatic or weakly aromatic. The lone pair electrons of the sulphur are in the 3s orbital, and are less able to interact with the p electrons of the double bonds. S Acetylenic thiophene Physical properties of pyrrole, furan and thiophene Pyrrole is a weakly basic compound. However, as the nonbonding electrons on the nitrogen atom are part of the aromatic sextet, and no longer available for protonation, it has an extremely low basicity (pKa ¼$15). Pyrrole accepts a proton on one of the carbon atoms adjacent to the nitrogen atom, whereas the proton on the nitrogen atom can be removed by hydroxide ion to yield its conjugate base. The pair of nonbonding electrons on N in pyrrole is much less available for protonation than the pair on ammonia. While furan is extremely volatile and highly ﬂammable with a boiling point close to room temperature (31. Preparation of pyrrole, furan and thiophene A general way of synthesizing heterocyclic compounds is by cyclization of a dicarbonyl or diketo compound using a nucleophilic reagent that intro- duces the desired hetero-atom. Paal–Knorr synthesis It is a useful and straightforward method for the synthesis of ﬁve-membered heterocyclic compounds, e. Ammonia, primary amines, hydroxylamines or hydra- zines are used as the nitrogen component for the synthesis of pyrrole. In this reaction, a-haloketones react with 1,3-dicarbonyl compounds in the pre- sence of pyridine to yield substituted furan. However, the reactivity of this reaction varies signiﬁcantly among these heterocycles. The ease of electrophilic substitution is usually fur- an > pyrrole > thiophene > benzene. Clearly, all three heterocycles are more reactive than benzene towards electrophilic substitution. This reaction proceeds by formation of the electrophilic Vilsmeier complex, followed by electrophilic substitution of the heterocycle. H O S 2 S Me H 2-Formylthiophene Mannich reaction Pyrrole and alkyl substituted furan undergo the Man- nich reaction. Thiophene also undergoes this reaction, but, instead of acetic acid, hydrochloric acid is used. However, reaction rates vary considerably, and for pyrrole, furan and 8 2 thiophene the rates are 5. While unsubstituted ﬁve-membered aromatic heterocycles produce a mixture of bromo-derivatives, e. Thiophene reacts with benzoyl chloride in the presence of aluminium chloride to produce phenyl 2-thienyl ketone. Pyridine, a tertiary amine, has a lone pair of electrons instead of a hydrogen atom, but the six p electrons are essentially the same as benzene. A number of drug molecules possess pyridine or a modiﬁed pyridine skeleton in their structures, e. It is a polar aprotic solvent and is miscible with both water and organic solvents. The lone pair of electrons on the nitrogen atom in pyridine is available for bonding without interfering with its aromaticity. However, the pyridine ring can be synthesized from the reaction between pentan-2,4-dione and ammonium acetate. Cyclization of 1,5- diketones is also considered as a convenient method for the synthesis of corresponding pyridine derivatives. Thus, pyridine is less reactive than benzene towards electrophilic aromatic substitution. However, pyridine undergoes some electrophilic substitution reactions under drastic conditions, e. Nucleophilic aromatic sub- stitutions of pyridine occur at C-2 (or C-6) and C-4 positions. Reaction occurs by addition of the nucleophile to the CÀÀÀÀN bond, followed by loss of halide ion from the anion intermediate. The second hetero-atoms are oxygen, nitrogen and sulphur for oxazole, imidazole and thiazole systems, respectively. The aromatic characters of the oxazole, imidazole and thiazole systems arise from delocalization of a lone pair of electrons from the second hetero-atom. The increased basicity of imidazole can be accounted for from the greater electron-releasing ability of two nitrogen atoms relative to a nitrogen atom and a hetero-atom of higher electronegativity. The reaction involves initial nucleo- philic attack by sulphur followed by a cyclocondensation. Electrophilic substitutions Although oxazole, imidazole and thiazoles are not very reactive towards aromatic electrophilic substitution reactions, the presence of any electron-donating group on the ring can facilitate electrophilic substitution. Some examples of electrophilic substitutions of oxazole, imidazole and thiazoles and their derivatives are presented below. Some examples of nucleophilic aromatic substitutions of oxazole, imidazole and thiazoles and their derivatives are given below. In the reaction with imidazole, the presence of a nitro-group in the reactant can activate the reaction because the nitro-group can act as an electron acceptor. The aromaticity of these compounds is due to the delocalization of a lone pair of electrons from the second hetero-atom to complete the aromatic sextet. For example, the following drug used in the treatment of bronchial asthma possesses a substituted isoxazole system. However, these compounds are much less basic than their isomers, 1,3-azoles, owing to the electron-withdrawing effect of the adjacent hetero-atom. However, 1,2-azoles undergo elec- trophilic substitutions under appropriate reaction conditions, and the main substitution takes place at the C-4 position, for example bromination of 1,2- azoles. Nitration and sulphonation of 1,2-azoles can also be carried out, but only under vigorous reaction conditions. Cyto- sine, uracil, thymine and alloxan are just a few of the biologically signiﬁcant modiﬁed pyrimidine compounds, the ﬁrst three being the components of the nucleic acids.
The goal was to provide culture-speciﬁc and Another major tenet of the theory was that world- congruent care to people of diverse cultures view and social structure factors—such as religion (Leininger generic escitalopram 10mg without a prescription, 1978 cheap escitalopram 10 mg visa, 1984 generic 5 mg escitalopram free shipping, 1995). The central purpose (and spirituality), political and economic consider- ations, kinship (family ties), education, technology, The central purpose of transcultural nurs- language expressions, the environmental context, ing was to use research-based knowledge and cultural history—were important inﬂuences to help nurses discover care values and on health-care outcomes (Leininger, 1995). This practices and use this knowledge in safe, broad and multifaceted view provided a holistic responsible, and meaningful ways to care perspective to understand people and grasp their for people of different cultures. Data from this holistic research-based knowledge was predicted to guide nurses for the health and of transcultural nursing was to use research-based well-being of the individual or to help disabled or knowledge to help nurses discover care values and dying clients from different cultures. These social practices and use this knowledge in safe, responsi- structure factors inﬂuencing human care from dif- ble, and meaningful ways to care for people of ferent cultures would provide new insights to pro- different cultures. They need, however, has led to a wealth of research-based knowledge to be studied systematically by nurse researchers. They were focused on would also disclose ways clients would remain well ways to use theory data creatively to facilitate con- and prevent illnesses. The care had to be tailored to Discovering cultural care knowledge would ne- or ﬁt the client needs. Leininger believed that rou- cessitate entering the cultural world to observe, lis- tine interventions would not always be appropriate ten, and validate ideas. Transcultural nursing is an and could lead to cultural imposition, cultural ten- immersion experience not a “dip in and dip out” sions, and cultural conﬂicts. No longer could nurses rely only on bits shift from relying on routine interventions and and pieces of partial or fragmented medical and from focusing on symptoms to care practices de- psychological knowledge. It was these factors that were they had to use both generic and professional care important to understand cultural and care expres- data. Thus, nurses had to be taught the philosophy for the nurse and the client if thoughtfully done. It was the ing theory ﬁndings are in several published sources transcultural nursing courses and programs that (Leininger, 1995, 1999, 2002) and are presented in provided such instruction and mentoring. Since this theory has been used, new kinds of Professional and Generic Care transcultural nursing knowledge have been forth- Another major and predicted tenet of the theory coming. Culturally based care has been discovered was that there were care differences and similarities to prevent illness and to maintain wellness. Ways to with regard to two kinds of care, namely profes- help people throughout the life cycle (birth to sional and generic (traditional or indigenous folk), death) have been discovered. These differ- caring and health maintenance have also been dis- ences were also predicted to inﬂuence the health covered, with environmental and historical factors. These differences would Most importantly, cultural differences and simula- identify gaps in care, inappropriate care, and also rities have been discovered with the theory. These differences needed to be identiﬁed The theory’s overriding purpose was to discover, and resolved. The three modalities postulated knowledge in order to provide culturally congru- were (1) culture care preservation or maintenance, ent, safe, and beneﬁcial care to people of diverse or (2) culture care accommodation or negotiation, similar cultures for their health and well-being or and (3) culture care restructuring or repatterning for meaningful dying. Leininger’s Theory of Culture Care Diversity and Universality 315 the health and well-being of clients or to help 1. Culture care diversity: Refers to variability clients face disability or death in culturally mean- and/or differences in meanings, patterns, val- ingful and satisfying ways. Thus, the ultimate and ues, lifeways, or symbols of care within or primary goal of the theory was to provide culturally between cultures that demonstrate assistive, congruent care that was tailor-made for the life- supportive, or enabling human care expres- ways and values of people (Leininger, 1991, 1995). Culture care universality: Refers to the com- Theory Assumptions mon, similar, or dominant uniform care mean- Several assumptions or basic beliefs to the theory ings, patterns, values, lifeways, or symbols that were constructed by the theorist. They are as fol- are manifest with cultures and reﬂect assistive, lows (Leininger, 1970, 1977, 1981, 1984, 1991, supportive, facilitative, or enabling ways to 1997a): help people (Leininger, 1991, p. Care is essential for human growth, develop- ena related to assisting, supporting, or enabling ment, and survival and to face death or dying. Care is essential to curing and healing; there can or anticipated care needs to ameliorate or im- be no curing without caring. The forms, expressions, patterns, and processes refers generally to care actions and activities of human care vary among all cultures of the (Leininger, 1991, p. Culture: Refers to the learned, shared, and transmitted values, beliefs, norms, and lifeways Forms, expressions, patterns, and processes of a particular group that guides their thinking, of human care vary among all cultures of decisions, and actions in patterned ways the world. Culture care: Refers to subjectively and objec- tively learned and transmitted values, beliefs, 4. Every culture has generic (lay, folk, or naturalis- and patterned lifeways that assist, support, fa- tic) care and usually professional care practices. Culture care values and beliefs are embedded in to maintain well-being and health, to improve religious, kinship, social, political, cultural, eco- their human condition and lifeway, or to deal nomic, and historical dimensions of the social with illness, handicaps, or death (Leininger, structure and in language and environmental 1991, p. Therapeutic nursing care can only occur when learned, and transmitted professional care, client culture care values, expressions, and/or health, illness, wellness, and related knowledge practices are known and used explicitly to pro- and skills that are found in professional institu- vide human care. Differences between caregiver and care receiver are usually etic or outsiders’ views) (Leininger, expectations need to be understood in order to 1990, 1995, p. Culturally congruent, speciﬁc, or universal care tional, folk, lay, and home-based) knowledge modes are essential to the health or well-being of or skills used to provide assistive, supportive, people of cultures. Nursing is essentially a transcultural care profes- another individual or group (they are largely sion and discipline. Culture care preservation or maintenance: Refers actions toward the good or desired ways to to those assistive, supporting, facilitative, or en- improve one’s lifeways. Political factors: Refers to authority and power help people of a particular culture to retain over others that regulates or inﬂuences an- and/or preserve relevant care values so that other’s actions, decisions, or behavior. Technological factors: Refers to the use of elec- from illness, or face handicaps and/or death trical, mechanical, or physical (nonhuman) (Leininger, 1991, p. Education factors: Refers to formal and infor- Refers to those assistive, supporting, facilita- mal modes of learning or acquiring knowledge tive, or enabling creative professional actions about speciﬁc ideas or diverse subject matter and decisions that help people of a designated domains or phenomena. Economic factors: Refers to the production, dis- for beneﬁcial or satisfying health outcomes tribution, and use of negotiable material or (Leininger, 1991, p. Environmental factors: Refers to the totality of tive, or enabling professional actions and deci- factors within one’s geographic or ecological sions that help clients reorder, change, or living area. Culturally congruent care: Refers to the use of ferent, and beneficial health-care patterns culturally based care knowledge and action while respecting the client(s)’ cultural values modes with individuals or groups in beneﬁcial and beliefs to provide beneﬁcial and healthy and meaningful ways to assist or improve one’s lifeways (Leininger, 1991, p. Ethnohistory: Refers to past facts, events, in- rather than operational, in order to permit the re- stances, and experiences of individuals, groups, searcher to discover unknown phenomena or cultures, and institutions that have been pri- vaguely known ideas. Orientational terms allow dis- marily experienced or known in the past and covery and are usually congruent with the client which describe, explain, and interpret human lifeways. They are important in using the qualitative lifeways within a particular culture over short ethnonursing discovery method, which is focused or long periods of time (Leininger, 1991, p. Environmental context: Refers to the totality of their world using cultural knowledge and lifeways an event, situation, or particular experience (Leininger, 1985, 1991, 1997a, 1997b, 1999, 2000).
As with patients with seizure discount escitalopram 5 mg amex, failure to notify may expose the patient to both civil and criminal liability purchase escitalopram 10mg otc. Vision and Eye Disorders The two most important aspects of vision in relation to driving are visual acuity and visual fields discount escitalopram 5 mg with visa. Visual acuity may simply be defined as the best obtainable vision with or without spectacles or contact lenses. Most coun- tries require a binocular visual acuity greater than 6/12 for licensing pur- poses. In the United Kingdom, the eyesight requirements are to read a car number registration plate at 20. Ethical Considerations Although it is generally a patient’s responsibility to inform the licensing authority of any injury or medical condition that affects his or her driving, occasionally ethical responsibilities may require a doctor to inform the licens- ing authorities of a particular problem. If a patient has a medical condition that renders him or her unfit to drive, the doctor should ensure that the patient understands that the condition may impair his or her ability to drive. If patients continue to drive when they are not fit to do so, the doctor should make every reasonable effort to persuade them to stop, which may include informing their next of kin. If this still does not persuade the patient to stop driving, the doctor should disclose relevant medical information immediately, in confidence, to the medical adviser of the licensing authority. Before disclosing this information, the doctor should inform the patient of the decision to do so, and once the licensing authority has been informed, the doctor should also write to the patient to confirm that disclosure has been made (15). Absorption depends on many factors, including sex and weight of the individual, duration of drinking, nature of the drink, and presence of food in the stomach. Alcohol dehydrogenase in the gastric mucosa may contribute substantially to alcohol metabolism (gastric first-pass metabolism), but this effect is generally only evident with low doses and after eating. Studies of alcohol dehydrogenase activity in gastric biopsies of women suggest a significant decrease in activity in women compared with men, which could explain why women have higher peak blood alcohol levels and are more susceptible to liver damage after con- sumption of smaller quantities of alcohol when compared with men (16). Once absorbed, alcohol is eliminated at a fairly constant rate, with 90% being metabolized in the liver and the remainder excreted unchanged in urine, breath, and sweat. The rate of elimination in moderate drinkers may vary between 10 and 20 mg/100 mL blood/h, with a mean of 15 mg/100 mL blood/ h. Chronic alcoholics undergoing detoxification have elimination rates of 19 mg/100 mL blood/h or even higher (17). Even at low doses, there is clear evidence that alcohol impairs performance, especially as the faculties that are most sensitive to alcohol are 356 Wall and Karch those most important to driving, namely complex perceptual mechanisms and states of divided attention. In a review of more than 200 articles (18), sev- eral behavioral aspects were examined, including reaction time, tracking, concentrated attention, divided attention, information processing, visual function, perception, psychomotor performance, and driver performance. Most of the studies showed impairment at 70 mg/100 mL of blood, but approx 20% showed impairment at concentrations between 10 and 40 mg/ 100 mL of blood. The definitive study on the relationship between risk of accident and blood alcohol concentration is that conducted in the 1960s in Grand Rapids, Mich. Compari- son of the two groups disclosed that an accident was statistically more likely at blood alcohol levels greater than 80 mg/100 mL of blood, with accidents occurring more frequently as follows: Blood alcohol (mg/100 mL) Accident occurrence 50–100 1. On average, the risk doubles at 80 mg/ 100 mL, increasing sharply to a 10 times risk multiplier at 150 mg/100 mL and a 20 times risk multiplier at 200 mg/100 mL of blood. For inexperienced and infrequent drinkers, the sharp increase occurs at much lower levels, whereas for the more experienced drinking driver it may not occur until 100 mg/100 mL (Fig. Therefore, this research has encouraged some countries to have a lower blood alcohol level for legal driving; in Australia, Canada, and some states of the United States, different levels and rules are applied for younger and/ or inexperienced drivers (see Subheading 3. Further evidence of the rela- tionship between crash risk and blood alcohol levels has been shown by Compton and colleagues (21), who studied drivers in California and Florida. This recent research studying a total of 14,985 drivers was in agreement with previous studies in showing increasing relative risk as blood alcohol levels increase, with an accelerated rise at levels in excess of 100 mg/100 mL of blood. However, after adjustments for missing data (hit-and-run driv- ers, refusals, etc. Risk of road traffic accidents related to level of alcohol in the blood and breath. Road Traffic Legislation In the United Kingdom, this research led to the introduction of the Road Safety Act 1967, which set a legal driving limit of 80 mg/100 mL of blood (or 35 μg/100 mL of breath or 107 mg/100 mL of urine). This law also allows mandatory roadside screening tests and requires the provision of blood or urine tests at police stations. The Transport Act 1981 provided that quantitative breath tests, performed with approved devices, could be used as the sole evidence of drunk driving. In the United States, permissible blood levels vary from state to state and also by age. Many states have enacted “zero tolerance” laws, and the detection 358 Wall and Karch of any alcohol in an individual younger than 21 years old is grounds for license revocation. Some states permit levels as high as 100 mg/100 mL, but most enforce the same limit as in the United Kingdom, and legislation to reduce the 80 mg/100 mL level further is under consideration. Equivalent Limits in Other Body Fluids Statutes have been used to establish blood alcohol concentration equiva- lents in other tissues and breath. Not infrequently, alcohol concentrations will be measured in accident victims taken for treatment at trauma centers. How- ever, there are two important differences between alcohol measurements made in hospitals and those made in forensic laboratories; first, in hospitals, stan- dard international units are the norm, the mole is the unit of mass, the liter is the unit of volume, and alcohol concentrations are reported in mmol/L. In forensic laboratories, results are expressed as gram/deciliter or liter, or even milligrams per milliliter, and measurements are made in whole blood, not serum or plasma. There is another, even more important, difference between serum/plasma and whole blood. Because alcohol has a large volume of distribution, this difference in water content means that alcohol concentrations measured in serum/plasma will be higher than concentrations measured in whole blood by approx 14%. In practice, if plasma alcohol concentrations are to be intro- duced as evidence, they should be related back to whole blood concentrations using an even higher ratio (1. As mentioned, if whole blood is tested, drivers are not usually prosecuted at blood levels below 87 mg/100 mL of blood (17). The instruments used are cali- brated to estimate the concentrations of alcohol in whole blood, not plasma or serum. To estimate the serum or plasma alcohol concentration from breath measurements, a plasma/breath ratio of 2600:1 must be used (because, as explained, whole blood contains 14% less alcohol). In Europe, but not neces- sarily in the United States, two specimens of breath are taken for analysis, and the specimen with the lower proportion of alcohol should be used as evidence. Bladder urine, because it contains alcohol (or other drugs) that may have accumulated over a long period, is generally not considered a suitable speci- men for forensic testing, especially because the presence of alcohol in the Traffic Medicine 359 Table 1 Prescribed Blood Alcohol Levels in Various Jurisdictions Australia 50 France 50 Poland 20 Austria 80 Germany 80 Romania 0 Belgium 80 Greece 50 Russia 0 Bulgaria 0 Hungary 0 Sweden 20 Canada 80 Italy 80 Spain 80 Czechoslovakia 80 Luxembourg 80 Turkey 0 Denmark 80 Netherlands 50 United States 100a Ireland 80 Norway 50 Yugoslavia 50 Finland 50 aSome states in the United States have reduced the legal level to 80 mg/100 mL of blood. Alcohol concentrations in bladder urine cannot be used to infer the blood levels reliably. Under the new California provisions, police can still request a urine test if a suspect’s breath test is negative (22). Com- parison of alcohol concentrations in vitreous and blood can provide a good indication of whether concentrations were rising or falling at the time of death (alcohol is distributed mainly in water and the water content of vitreous is lower than that of blood). Urine obtained from the kidney pelvis can also be used, because its alcohol content can be precisely related to blood concentra- tion (23).