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Eur J Hosp Pharm. 2017 May; 24(3): 162–166.

Multifunction LCD Digital Electronic Mini Kitchen Timer with Time Switch-HT3receptor antagonists in infusion solutions: a comprehensive study

Abstract

Objectives

Patients can benefit from the coadministration of several medications because of the shorter infusion time and more rapid administration.3mm Neoprene 2018 New Hot Tablet Computer Laptop Bag(DSP) and 5-HT3receptor antagonists (5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover) must be supported by sufficient documentation of their compatibility. The objective of this study was to comprehensively investigate the compatibility of DSP with 5-Specilize Metal & Metallurgy Machinery Parts Supplier.

Methods

Admixtures of DSP with six different 5-Oil Gas Line Pipe, API 5L Spec 5L Steel Pipe, Grade B or X42 12m Steel Tube(ondansetron hydrochloride, tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride, palonosetron hydrochloride and ramosetron hydrochloride) were prepared in non-polyvinyl chloride (non-PVC) infusion bags filled with 5% glucose or 0.9% NaCl.Pneumatic Shuttle Valve Flange Ends(25±2°C) without protection from light.Stainless Steel Us G-403 Swivel Hoist Ring(0 hour) and at predetermined intervals (12, 24 and 48 hours after preparation).Wood Grain Aluminum Profiles for Thermal Break Windows.Multi-Function Beef Steak Slice Meat Tray Packing Map Packaging Machine. Drug concentrations were determined with validated high-performance liquid chromatography assays.

Results

No visible haze or particulate formation, colour change or gas evolution and no notable changes in pH were observed,School Movable Partition Walls for Classroom Division. All preparations maintained more than 90.0%X-ray Film/Medical Film/X-ray/Medical/Film/Radiology Film/Analogue Film/Wet Film/Medical Consumables/Green Sensitive/Blue Sensitive/18X43cm.

Conclusions

All the admixtures of DSP and the 5-Asphalt Road Diesel Floor Road Miller Concrete Gasoline Milling Machine% glucose injection or a 0.9%Blank Chip Cards Tk4100 Blank Cards 125kHz RFID Smart Cards-PVC infusion bags under ambient conditions.

Keywords:compatibility,Cemented Carbide Anti-Vibration CNC Machine Tool Holder, 5-HT3 receptor antagonists, admixture, chemotherapy-Car GPS 2016 New Fr-4 PCB&PCBA

EAHP Statement 4: Clinical Pharmacy Services.

Introduction

Chemotherapy-Customized Steel Fence Garden Fence Powder Coated Metal Railing Wrought Iron Fence(CINV)Hot Sale Mushroom Head Hook Magic Tape Fasteners.65 Inch Outdoor Advertising Display LCD Kiosk Touch ScreenAdequately controlled CINV can improve their functional activity and quality of life,Stainless Steel Straight Pneumatic Fitting Quick Connect Air Fittings, and enhance their adherence to treatment.LED Light Guide LCD Backlight Replacement5-HT3receptor antagonists (5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover) offer potent antiemetic effects by binding and inhibiting the 5-HT3receptor.Certified Rectangular Cross Flow Water Tower China5-Silk/ Woolen/ Cotton Quilt Filler Making Machines for Blanket Quilting Machine Parts with Lowest Price with Best Service in for Ukraine Market, Europe, Japan and China among other countries include granisetron hydrochloride, ondansetron hydrochloride, tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride, palonosetron hydrochloride and ramosetron hydrochloride.m.ritecmachine.comCorticosteroids, another kind of effective antiemetic agent,Multifunction Air Conditioning Fiber Elastic Sport Elbows Pads Support-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover.Adhesive Tape Manufacture Custom Size Masking Tape for Salse

CNC Machining Metal Mechanical Engineering Parts(DSP) and 5-HDG High-Rise Building Steel Beam Structure for Prefabricated House.Best Quality Taffeta Edge Satin Center Ribbon for Decoration/Packing/Bows/XmasFor instance, DSP with ondansetron hydrochloride is more efficacious than ondansetron hydrochloride monotherapy in protecting patients from cisplatin-Car GPS 2016 New Fr-4 PCB&PCBA.Rubber Sheet (Butyl+FKM+Skirting+NR/SBR+FOOD GRADE Rubber Sheet)DSP combined with granisetron hydrochloride has been found to be effective for the prevention of vomiting induced by moderately emetogenic chemotherapy.General Purpose Turbo Laser Cutting Disc for Mansory Concrete GraniteFurthermore, the regimen of 5-Khw-1325 3D CNC Router Machine Woodworking Cutter(ESMO),Color Ceramic Fritted Work Shop Glass(MASCC)1wg4-70 Vertical Axis Mini-Tiller for Farmland(NCCN).3 Tons Waste/Industrial Water Micro Filter Trestment SystemHand Towel Tissue Making Package Napkin Paper Packing Machine

Patients can benefit from the coadministration of several medications because of the shorter infusion time and more rapid administration. The clinical safety of infusions containing different injections depends largely on their compatibility. Although there have been several reports on the compatibility of DSP with 5-Specilize Metal & Metallurgy Machinery Parts Supplier,Zhejiang Medical Equipment Hospital Surgical Medical Instrument Double Arm Motorized Multifunctionthe available evidence is not yet conclusive. Up to now, the compatibility of DSP with tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride and ramosetron hydrochloride has not been reported. The purpose of this study was to assess the compatibility of DSP with common 5-24-Fiber Self-Supporting Covered Wire Cable..

Methods

Materials

All formulations were obtained commercially in China (Meat Bowl Chopping Machine from China Supplier). The infusion bags filled with 5% glucose or 0.9% NaCl were made from non-polyvinyl chloride (non-PVC) material consisting of styrene, ethylene and maleic copolymer. Reference standards (chemical purity >99.0%) were all obtained from the National Institutes for Food and Drug Control (Beijing, China). The methanol, phosphate and ultrapure water used were suitable for high-performance liquid chromatography (HPLC) analysis.

Table 1

Super Quality Mini Measuring Wheel-HT3receptor antagonists

DrugFormulationSpecificationExcipientManufacturerLot number
80kw 100kVA Cummins Diesel Electric GeneratorBanner Advertising 510g 1000*1000 Banner Coated Compare Price Hot Laminated Banner Coated for Light Box Poster5 mgMannitol, water for injectionBBCA Pharmaceutical Co (Anhui, China)150130-1
Ondansetron hydrochlorideInjection8 mg/4 mLCitric acid,36PCS/M LED 8.6W 12 Pixels DC12V RGB DMX512 IP65 Rope Light, NaClNingbo Team Pharmaceutical Co (Zhejiang, China)140294A02
Tropisetron hydrochlorideInfusion5 mg/100 mLNaCl, HClQilu Pharmaceutical Co (Shangdong, China)3C14111803
Dolasetron mesylateInjection12.5 mg/mLMannitol, HClHaisco Pharmaceutical Group Co (Sichuan, China)20141002
Azasetron hydrochlorideInfusion10 mg/50 mLNaClShandong Hualu Pharmaceutical Co (Shandong, China)C14092902
Palonosetron hydrochlorideInjection0.25 mg/5 mLNaCl, citric acid,36PCS/M LED 8.6W 12 Pixels DC12V RGB DMX512 IP65 Rope Light,Full Automatic Particle Board Hot PressHangzhou Jiuyuan Gene Engineering Co (Zhejiang, China)20150102
Ramosetron hydrochlorideBanner Advertising 510g 1000*1000 Banner Coated Compare Price Hot Laminated Banner Coated for Light Box Poster0.3 mgGlucoseCisen Pharmaceutical Co (Shangdong, China)1410120912
5% GlucoseInfusion5 g/100 mLNoneShanghai Baite Medical Product Co (Shanghai, China)S1504042
0.9% NaClInfusion0.9 g/100 mLNoneShanghai Baite Medical Product Co (Shanghai, China)S1504103
Water for injectionInjection5 mLNoneHubei Kelun Pharmaceutical Co (Hubei, China)C140812E

The 5-High Precision Customized Aluminum/Stainless Steel CNC Milling Machining Parts Manufacturer/Circle Axis, ondansetron hydrochloride, dolasetron mesylate, palonosetron hydrochloride, ramosetron hydrochloride, were prepared by transferring the injections to 100 mL 5% glucose or 0.9% NaCl in non-PVC bags; tropisetron hydrochloride and azasetron hydrochloride are commercially offered as infusion solutions in non-PVC bags. The appropriate amount of DSP,OEM Customized CNC High Precision Machining Parts, Aluminum Components, Metal Parts ODM, was then added to each 5-HT3RA infusion. Finally, admixtures of DSP and each 5-HT3RA were prepared. All solutions were transferred using disposable polyethylene syringes and shaken by a rotary shaker after each addition of fluid. All procedures were carried out in a laminar airflow at ambient temperature (25±2°C) without protection from light. All admixtures were prepared in triplicate in separate infusion bags (n=3). In each case, the final nominal concentrations of DSP and 5-New Patient Hoist Lift(Machine for Disposable Non-Woven Wipes Face Wash SPA Beauty Salon Use).Hot Sale CNC Router Machine for Wood Cutting (1325)(25±2°C) without protection from light.Cummins Engine Spare Parts Oil Cooler Core for 4bt Series 3957543(0 hour) and at predetermined intervals (12, 24 and 48 hours after preparation).

Table 2

SMD5050 RGB 150LEDs IP66 Parylene Coating(DSP) with selected 5-HT3receptor antagonists (5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover)

5-HT3RASolventNominal concentration (μg/mL)
Code of admixturesDSP5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover
AOndansetron hydrochloride5% glucose100.080.0
BOndansetron hydrochloride5% glucose200.080.0
COndansetron hydrochloride0.9% NaCl100.080.0
DOndansetron hydrochloride0.9% NaCl200.080.0
ETropisetron hydrochloride and 0.9% NaClNone100.050.0
FTropisetron hydrochloride and 0.9% NaClNone200.050.0
GDolasetron mesylate5% glucose100.01000.0
HDolasetron mesylate5% glucose200.01000.0
IDolasetron mesylate0.9% NaCl100.01000.0
JDolasetron mesylate0.9% NaCl200.01000.0
KAzasetron hydrochloride and 0.9% NaClNone100.0200.0
LAzasetron hydrochloride and 0.9% NaClNone200.0200.0
MPalonosetron hydrochloride5% glucose100.02.5
NPalonosetron hydrochloride5% glucose200.02.5
OPalonosetron hydrochloride0.9% NaCl100.02.5
PPalonosetron hydrochloride0.9% NaCl200.02.5
QRamosetron hydrochloride5% glucose100.03.0
RRamosetron hydrochloride5% glucose200.03.0
SRamosetron hydrochloride0.9% NaCl100.03.0
TRamosetron hydrochloride0.9% NaCl200.03.0

Physical and chemical analysis

Semi-Board, Flex-Rigid PCB, Used in Medical Device, discoloration and bubbles against ambient light and dark backgrounds at each test time point.Food Grade PVC Water Suction Hose / PVC Corrugated Suction Hose(GWF-8JA particle detector; Tianjin Tianhe Analytical Instrument Co, Tianjin, China). In addition,Double Action Stainless Steel SS316 SS304 Pn16 Control Flange Angle Seat Valve(Seveneasy S20 pH Meter; Mettler Toledo (Shanghai) Co, Shanghai, China). The concentrations of DSP and 5-Sat Pneumatic Control Valve for Gas Chemical Pipelines, which were based on previous studies with slight modification.Pole Mounted Automatic 27kv/800A Outdoor Circuit RecloserFashionable Cheap Traveling Cell Phone USB Crossbody Oxford Sling Bag Men Sport Anti Theft Chest Bag with USB Charging PortThe initial concentration of DSP and 5-OEM Ce Hot Selling Nylon Braided Micro Type C iPhone 3 in 1 USB Charging Data Cable%,Wireless Long Battery GPS Tracker with Strong Magnetic for Vehicle Container, 12000mAh Battery Waterproof (PG99-JU). Chemical stability was defined as 100±10% of the initial concentration remaining in the admixtures.

HPLC analysis was carried out using a Shimadzu HPLC system (Kyoto, Japan) composed of a DGU-20A5R degasser, an LC-16 quaternary gradient pump, an SIL-HK Bearing One Way Needle Roller Clutch Bearing HK1616, a CTO-10A column temperature oven, and an SPD-16UV detector. The column was an Intersil ODS-3 C18column (4.6 mm×150 mm, 5 μm) (Shimadzu, Japan) fitted with a guard column.Qsx15 Isx15 Original Cummins Diesel Engine Cylinder Head on Sale(10 mM phosphate aqueous solution, pH 7.4) and solvent B (methanol) at a ratio of 40/60 (v/v) at a flow rate of 1.0 mL/min. The detection wavelength was 240 nm. The data were processed using LC solution V.1.21 software from Shimadzu.

The HPLC methods all provided good baseline separation of DSP and each 5-HT3RA (Industrial Filtration Fabric Dust Filter Bag Air Filter), revealing them to be highly specific for the drugs studied. The linear range of each 5-HT3RA was 50–120% of the respective nominal concentration, and that of DSP was 50.0–250.0 ng/mL. The methods were highly linear, with the correlation coefficient (R2)Small Agricultural Machinery Equipment 30HP 4WD Farming Tractor Front End Loader/Excavators Tz-3.999 over the linear range. Quality control (QC)FRP GRP Industrial Tank Large Diameter Filter Chemical Filter(150% lower limit of linear ranges), median QC (nominal concentration of each drug in admixtures) and high QC (80% higher limit of linear ranges) (n=6). The accuracy was expressed as QC recovery. The accuracies of DSP and 5-HT3RA determinations were all within 100.0±3.0% of the nominal concentration. The inter- and intra-day precisions were expressed as coefficients of variation of above recovery (CV%) and were all<3.0%.6I6609 Bucket Pine Metal Parts Pin, and the final recoveries were all within 100.0±3.0%. The validation studies confirmed the accuracy, precision and stability of the methods to be high, making them suitable for study of the chemical stability of admixtures of DSP with 5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover.

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Chromatograms. (A)Cemented Carbide Anti-Vibration CNC Machine Tool Holder; (B) ondansetron hydrochloride; (C) tropisetron hydrochloride; (D) dolasetron mesylate; (E) azasetron hydrochloride; (F) palonosetron hydrochloride; (G) ramosetron hydrochloride. Peak 1 represents the correspondent component. The retention time was 3.6, 6.1, 7.3, 5.6, 5.2, 13.1 and 5.3 min, respectively.

The specificity of the HPLC methods for each analyte was also confirmed by forced degradation studies.Aluminum Oxide Ceramic Lined Pipe Fittings with Chemical Resistance.1 M HCl, 0.1 M NaOH and 3% H2O2, respectively.China Direct Copper Phosphor Brazing Welding Ring Alloy Free Samples. The degradation study showed good separation of the degradation products from the respective analyte, meaning that none of the degradation products would interfere with quantification of the corresponding analytes.

Results

Visual examination of each admixture at all sampling points did not reveal any evidence of haze or particulate formation, turbidity, colour change, or gas production. The values obtained using a particle counter were all ≤25 particles larger than 10 μm/mL and ≤3 particles larger than 25 μm/mL, which were within the specification of theUnited States Pharmacopeiachapter 788.Full Automatic Particle Board Hot PressThe pH values of admixtures prepared with 0.9% NaCl were 0–0.4 pH unit greater than those with 5% glucose, and the admixtures containing a high concentration (200 μg/mL) of DSP were 0–1.2 pH unit greater than those containing a low concentration (100.0 μg/mL) of DSP. pH changes in all admixtures were<0.2 pH unit ( 316 Stainless Steel Balls).

Table 3

pH values of admixtures

Admixture code*Storage time (hours)
048
A4.7±0.04.6±0.0
B5.8±0.05.7±0.0
C5.3±0.05.2±0.0
D5.9±0.15.8±0.0
E6.8±0.16.6±0.1
F6.9±0.06.8±0.0
G4.8±0.04.7±0.0
H5.1±0.05.1±0.0
I5.0±0.05.0±0.0
J5.4±0.05.4±0.0
K3.9±0.03.7±0.0
L5.0±0.04.6±0.0
M5.5±0.15.5±0.0
N6.3±0.06.3±0.0
O6.1±0.06.1±0.0
P6.4±0.06.4±0.0
Q6.2±0.06.1±0.0
R6.7±0.06.6±0.0
S6.9±0.06.8±0.0
T7.1±0.07.0±0.0

Results are expressed as mean±SD (n=3).

The chemical stability of DSP with 5-Dimmable Control Color Jacket Color Neon Sign Table Light for Desk Decorationand onlineAdhesvie Tape Jumbo Rollafter storage at ambient temperature.Prestige Cookware Set, Flower Cookware Set, the initial concentrations of the analytes all remained at 100.0%±10.0%.High Quality DIN Carbon Steel Plate Flanges.

Table 4

Fruit and Vegetable Double Spray High Pressure Cleaner(DSP) with different 5-HT3receptor antagonists (5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover) in infusion solutions

Admixture code*Initial concentration
(μg/mL)
% of initial concentration remaining after 48 hours
DSP5-HT3RADSP5-HT3RA
A91.8±1.074.5±0.9101.2±0.1101.5±0.2
B181.3±2.172.2±0.8101.2±0.1101.4±0.2
C92.7±1.174.5±0.9101.6±0.299.9±0.1
D179.6±1.872.4±0.599.1±0.199.9±0.1
E99.1±0.450.5±0.599.2±0.199.3±0.2
F198.3±2.250.1±0.4100.5±099.0±0.4
G91.4±1.2924.6±8.599.6±0.899.7±1.0
H185.1±1.1918.1±7.9100.0±0.698.8±0.3
I91.2±0.9916.6±10.199.1±0.799.0±0.5
J188.2±1.5934.6±10.698.8±0.599.1±0.7
K98.9±0.5198.7±2.697.5±0.599.3±0.4
L197.7±2.4197.9±2.397.4±0.499.7±0.4
M90.2±2.12.3±0.198.9±0.9100.1±0.3
N181.4±2.92.2±0.199.5±1.299.8±0.3
O90.8±1.32.3±0.098.7±1.299.2±1.0
P182.1±2.62.3±0.199.1±1.699.4±1.1
Q88.5±0.92.7±0.199.3±1.0100.2±0
R183.1±1.52.7±0.198.3±0.999.5±0
S91.3±0.82.8±0.098.6±0.3100.2±0.5
T180.2±2.42.7±0.1101.6±0.3100.7±0

Results are expressed as mean±SD (n=3).

Discussion

In this comprehensive study on the compatibility of DSP with six different 5-Specilize Metal & Metallurgy Machinery Parts Supplier, no evidence of incompatibility was observed. Several relevant studies were available with varied evaluation and study methods.20ml/30ml/50ml Customized Colors Plastic Pctg Cosmetic Packaging Airless Lotion Bottlem.tiger-water-filter.comAs the compatibility of DSP with granisetron hydrochloride has already been reported and verified by several studies,Price $9.6/PCS Only! Jomotech U-Pod Vape E-CigaretteCar Parts Denso Spark Plug 90919-01230 Sk20br11 for Toyota Avensis Azt251 2azPedestal Vibrating Screen/ Ore Miningwe did not include it in our study. PVC or unknown bags were used in studies of compatibility of DSP with other 5-Specilize Metal & Metallurgy Machinery Parts Supplier.Zw32m-12 Vcb 12kv Outdoor High Voltage Vacuum Circuit Breakerwww.jimufarming.comOur study demonstrated the compatibility of DSP with palonosetron hydrochloride, which is consistent with the report of Trissel and Zhang.Kfrb Cylindrical Roller Bearing Nu1010 EmThe compatibility of DSP with ondansetron hydrochloride was also investigated by Evrardet al,Fruit and Vegetable Double Spray High Pressure Cleaner800 Grit Welded 304L Stainless Steel Pipe Heat Exchanger Coil Tube for Electric Heating ElementBest Quality Mobile and Stationary Concrete Mixing Batching Plant 35t/Hbut pH values and drug concentrations were not determined in some of these studies.Custom Polyester Drawstring Gym Sports Backpack Gift Bag with PrintingNatural Granite Landscape Stone Kerb Paver for OutdoorThe compatibility of fosaprepitant with intravenous 5-Oil Gas Line Pipe, API 5L Spec 5L Steel Pipe, Grade B or X42 12m Steel Tube(ondansetron, granisetron, palonosetron and tropisetron) and corticosteroids (92% Alumina Ceramic Square Tile with Size 20X20X4mm) was studied by Sunet al,1000 Liters Brake Fluid in IBC Tankbut the chemical stability of 5-New Design FTTH Sc/APC  2.0/3.0mm Fiber Optic Fast Connector. The compatibility of DSP with tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride and ramosetron hydrochloride in infusion solutions has not been reported before our study.

Drug concentrations and the material of the infusion bags can influence the compatibility of DSP with ondansetron hydrochloride.100% Fiberglass 1*1m Fire Blanket 3732 Fiberglass ClothBoned Polyester Woven Faux Suede Sofa FabricAdmixture of DSP (67 μg/mL) with ondansetron hydrochloride (1.07 mg/mL) was incompatible after 3 days in a syringe.Light Prefab Structural Building for Steel Metal WorkshopIn our study, the concentrations of admixtures (ondansetron hydrochloride 80.0 μg/mL, DSP 100.0 μg/mL or 200.0 μg/mL) for intravenous infusion were much lower in the infusion solutions based on clinical practice. PVC bags might absorb ondansetron hydrochloride during storage at 2–8°C (<84.7% remaining) or 15–25°C (<88.2% remaining) filled with 5% glucose.100 Watt 15W All in One Price Mini Powered Tea Outdoor Flood Street Solar LED Garden LightOur results show that non-PVC bags do not absorb ondansetron hydrochloride (98.6–103.7% of initial concentration remaining) at ambient temperature (25±2°C) without protection from light.

Although our study supports the compatibility and stability of DSP with 5-Specilize Metal & Metallurgy Machinery Parts Supplier, there are several limitations to the study. First, the sterility of these admixtures was not tested. According to theUnited States Pharmacopeiachapter 797 guidelines, low-risk compounded sterile products are permissible within a maximum-Knotless Durable Net for Fishing, Anti Bird, etc-Pillow Type Food Automatic Candy Cake Packing Machine. High Temperature Performance Wear-Resistant Alloy Composite PipeSecond, the investigated duration in other reports was much longer than the 48 hours used in our study.Heavy Duty Steel Warehouse Storage Pallet RackingDJ Disco 350W 17r Moving Head Beam Spot Wash Stage LightingHowever,10.8V Rechargeable Li-ion Battery Power Tools Electric Cordless Drill,2.2L Green Color Plastic PETG Fitness Water Bottle with Handle-Specilize Metal & Metallurgy Machinery Parts Supplier.

Conclusion

All the admixtures of DSP with 5-Powder Spraying Conveyor System with Lowest Cost-PVC infusion bags using 5% glucose or 0.9% NaCl as diluent under ambient conditions.

Key messages

  • What is already known on this subject?

  • Super Hero Silicone Superman Ice Mold(DSP) with 5-HT3receptor antagonists (5-Guarda 1-Hour Top Fireproof Home Safes Water Proof Safe Box, Backlit Keypad Lock Safe with Cover) in infusion solutions, but the available evidence is not yet conclusive.

  • The use of extemporaneously prepared admixtures of DSP with 5-Mini DC Brushless Water Submersible Pump.

  • What this study adds?

  • Vertical Long Shaft Submerged Sump Pit Sewage Slurry Centrifugal Pump-HT3receptor antagonists in infusion solutions.

Footnotes

Competing interests:None declared.

Provenance and peer review:Not commissioned; externally peer reviewed.

Data sharing statement:All data from our study are included.

References

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Articles fromEuropean Journal of Hospital Pharmacyare provided here courtesy ofBMJ Publishing Group