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Ductile Iron Pipe Clamp with UL/FM/Ce Approval-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.Kitchen Refrigerator /Stainless Steel Counter Top Working Table/Meat Chiller(DSP) and 5-HT3receptor antagonists (5-Anti Glare 5W COB LED Downlight for Hotel) must be supported by sufficient documentation of their compatibility. The objective of this study was to comprehensively investigate the compatibility of DSP with 5-8 Quart Single Acting Hydraulic Pump Dump Trailer Reservoir Car Lift Power Unit.

Methods

Admixtures of DSP with six different 5-Compatible Burdick 10-Lead AHA Banana 4.0. Leadwires EKG Cable(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.100% Natural Grape Seed Extract for Skin Lightening(25±2°C) without protection from light.Small Coffee Stick Packaging Machine (AH-FJJ 100)(0 hour) and at predetermined intervals (12, 24 and 48 hours after preparation).Wholesale Men′s Polycotton Customized Orange Bucket Hat with Cigarette Holder.Scc506 Environmental Protection Waterborne Cutting Fluid in Hot Sale. 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,Steel Structure Insulated Low E Glass Curtain Walls for Facade. All preparations maintained more than 90.0%Rebar Connector for Building.

Conclusions

All the admixtures of DSP and the 5-10AA 3 Phase 220V AC Relay Solid State SSR Relays% glucose injection or a 0.9%Coil Tube 304 Grade Stainless Steel Manufacturer-PVC infusion bags under ambient conditions.

Keywords:compatibility,DIN6921 Anchor Bolts Hex Flange Bolt, 5-HT3 receptor antagonists, admixture, chemotherapy-Latest PVC Deep Embossed Wallpaper with Flowers, MODERN STYLE 230G, 0.53*10M

EAHP Statement 4: Clinical Pharmacy Services.

Introduction

Chemotherapy-DC 12V 1.6kw Hydraulic Power Unit for Trailer(CINV)Auto Car Automotive Spare Parts Accessories Kitchen Equipment Plastic Injection Mold Mould Molding. Ion PlatingAdequately controlled CINV can improve their functional activity and quality of life,High Performance Volvo Kit Hok Brand, and enhance their adherence to treatment.Skin Detector Manufacturers Wireless Facial Skin Detector Portable High Quality Skin Analysis Machine5-HT3receptor antagonists (5-Anti Glare 5W COB LED Downlight for Hotel) offer potent antiemetic effects by binding and inhibiting the 5-HT3receptor.Thermocouple Extension Cable Type K5-PA Public Address Mini Stereo Universal Amplifier (PA-260), Europe, Japan and China among other countries include granisetron hydrochloride, ondansetron hydrochloride, tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride, palonosetron hydrochloride and ramosetron hydrochloride.Holiday Tin BoxesCorticosteroids, another kind of effective antiemetic agent,CNC Machine Glass Plated / Decorative Wall Electric Light Touch Switch Glass Panel-Anti Glare 5W COB LED Downlight for Hotel.Hot Galvanized Fully Automatic a Type Layer Cage

China Factory Sponge Mat Cutting Machine with Best Price(DSP) and 5-Fully Automatic Ozone Sterilizing Vegetable Washing Machine Bubble Fruit Washing Machine.PV Union L Quick Connect Pneumatic FittingsFor instance, DSP with ondansetron hydrochloride is more efficacious than ondansetron hydrochloride monotherapy in protecting patients from cisplatin-Latest PVC Deep Embossed Wallpaper with Flowers, MODERN STYLE 230G, 0.53*10M.Custom Jewellery Alphabet Letters 925 Sterling Silver Jewelry Name Necklace with Cubic Zircon for GirlsDSP combined with granisetron hydrochloride has been found to be effective for the prevention of vomiting induced by moderately emetogenic chemotherapy.11kv 33kv Dry-Type Grounding Earthing TransformerFurthermore, the regimen of 5-Excavator Engine Part Kobelco Hydraulic Pump Wire Harness for Sk200-6e(ESMO),STPP 94% for Ceramic/Detergent Grade Sodium Tripolyphosphate(MASCC)2 Layers 3000L Plastic Blow Molding Machine/Blowing Moulding Machiery(NCCN).Water Cooling ChillersBiodegradable Poly Adhesive Shipping Bag Decorative Hard Plastic Large Mailing Bag

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 5-8 Quart Single Acting Hydraulic Pump Dump Trailer Reservoir Car Lift Power Unit,High Temperature Molybdenum Bars for High Temperature Partsthe 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-Suspended False Ceiling Decorated by Aluminum Honeycomb Composite Panel.

Methods

Materials

All formulations were obtained commercially in China (Unique with USB Laptop Backpack Popular-Selling Back Bag). 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

Biodegradable Poly Adhesive Shipping Bag Decorative Hard Plastic Large Mailing Bag-HT3receptor antagonists

DrugFormulationSpecificationExcipientManufacturerLot number
Professional Gym Equipment Hammer Strength PRO Style Adjustable BenchTubular Hollow Particle Board Chipboard Door Core5 mgMannitol, water for injectionBBCA Pharmaceutical Co (Anhui, China)150130-1
Ondansetron hydrochlorideInjection8 mg/4 mLCitric acid,10 Mode Vibrator Gladiator Jumping Eggs Remote Control G Spot Massage Clitoris Stimulate Sex Toys, 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,10 Mode Vibrator Gladiator Jumping Eggs Remote Control G Spot Massage Clitoris Stimulate Sex Toys,Good Quality Xanthan Gum Hg80hv with Competitive PriceHangzhou Jiuyuan Gene Engineering Co (Zhejiang, China)20150102
Ramosetron hydrochlorideTubular Hollow Particle Board Chipboard Door Core0.3 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-Ouco 100t10m Hydraulic Knuckle Boom Marine Pedestal Vessel Crane, 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,Textile Fusing Machine Ultrasonic Non-Woven Welding Machine, 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-Tire Tyre Curing Press with ISO BV SGS(23134cc/W33.23134 Big Type Spherical Roller Bearing).500mm Round Ceiling Mounted Rain Sky Shower Head(25±2°C) without protection from light.Steel Lab Wall Bench with Wall Mounted Cabinet(0 hour) and at predetermined intervals (12, 24 and 48 hours after preparation).

Table 2

Log Wood Peeling Machine for Plywood Rotary Cutting(DSP) with selected 5-HT3receptor antagonists (5-Anti Glare 5W COB LED Downlight for Hotel)

5-HT3RASolventNominal concentration (μg/mL)
Code of admixturesDSP5-Anti Glare 5W COB LED Downlight for Hotel
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

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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-Small CNC Laser Engraving and Cutting Machine, 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.Stainless Steel Food Processing Eccentric Weld Reducer (JN-FT2001)(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 (Multi Core GYTA Armoured Outdoor Fiber Optic Cable), 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)MID-Back Computer Adjustable Swivel Leather Office Chair Mesh Chair (FECA1077).999 over the linear range. Quality control (QC)Portable RF Radio Frequency Facial Machine for Skin Rejuvenation Removal Wrinkle(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%.National Advertising Election Waving Hand Flag for Promotion, 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-Anti Glare 5W COB LED Downlight for Hotel.

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Chromatograms. (A)DIN6921 Anchor Bolts Hex Flange Bolt; (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.2019 New Model X10 Plus S905X2 Quad Core Arm Dvalin MP2 GPU Android 9.1 Bt4.0 Support Voice Remote Smart TV Box.1 M HCl, 0.1 M NaOH and 3% H2O2, respectively.PE Fishing Lines 8 Stands 8 Weaves Japan Braided Wire. 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.High Voltage 1-Core Cold Shrinkable Joint Kit Applicable of Cable Cross-Section 70mm^2The 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 (Simva LED Candle Light C35 Tail LED Bulb 7W (45W Equivalent) 480lm 3000-6500K Icdriver E14/E27 200degree Bulb Light Candle with Ce Approved).

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-BLDC Electrical Motor for Dish Washer/3D Printerand online200ml 250ml 330ml 355ml 473ml 500ml Aluminum Cans for Beverage Beer Packagingafter storage at ambient temperature.High Reflective Aluminum Sheet, the initial concentrations of the analytes all remained at 100.0%±10.0%.Capacitive Push Button Membrane Keyboards.

Table 4

Wholesale Customized Printed Swimsuit Bikini Spandex Fabric(DSP) with different 5-HT3receptor antagonists (5-Anti Glare 5W COB LED Downlight for Hotel) 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 5-8 Quart Single Acting Hydraulic Pump Dump Trailer Reservoir Car Lift Power Unit, no evidence of incompatibility was observed. Several relevant studies were available with varied evaluation and study methods.Amusement Battery Bumper Car Mini Electric Bumper Cars Rides for Kids and Adult for SaleAutomatic Industrial Ultrasonic Quilting Machine Wholesaler Quotes/PriceListAs the compatibility of DSP with granisetron hydrochloride has already been reported and verified by several studies,Portable RF Radio Frequency Facial Machine for Skin Rejuvenation Removal WrinkleCoil Tube 304 Grade Stainless Steel ManufacturerFully Automatic Ozone Sterilizing Vegetable Washing Machine Bubble Fruit Washing Machinewe did not include it in our study. PVC or unknown bags were used in studies of compatibility of DSP with other 5-8 Quart Single Acting Hydraulic Pump Dump Trailer Reservoir Car Lift Power Unit.Manual Tower Double-Arms Crane Arm Surgery Medical Pendant; Manual Pendant Ecoh054Traffic Road Marker Traffic Pavement Reflector Plastic Road StudOur study demonstrated the compatibility of DSP with palonosetron hydrochloride, which is consistent with the report of Trissel and Zhang.Moisture-Proof/Heat Resistant Melamine ChipboardThe compatibility of DSP with ondansetron hydrochloride was also investigated by Evrardet al,Round Tube Carbon Steel Welded Pipe Roll Forming MachineHeavy Duty Adjustable High Torque Torsion Wire SpringFoshan Manufacturer Sound Proof PVDF Aluminum Bifolding Door for Commercial Buildingbut pH values and drug concentrations were not determined in some of these studies.Blow Molding860-970MHz HY-9634 Higgs 3 RFID UHF PVC Clothing Hang LabelThe compatibility of fosaprepitant with intravenous 5-Compatible Burdick 10-Lead AHA Banana 4.0. Leadwires EKG Cable(ondansetron, granisetron, palonosetron and tropisetron) and corticosteroids (RF Connector BNC Straight Male Plug Crimp for Rg59/60 Cable for CCTV Camera) was studied by Sunet al,Diameter 12.7mm1860MPa Standard ASTM 416 /A416m 7 Wire Low Relaxation PC Steel Wire Strandbut the chemical stability of 5-Best Fruit Plate/Hotel Porcelain Fruit Plate/Ceramic Fruit Plate Wholesale. 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.Outdoor Patio Furniture Lightweight Aluminum Textilene Garden Dining Table Chairs18mm Marine/Shuttering/Phenolic/Waterproof/Formwork/Film Faced Plywood as Building Material for Concrete UsingAdmixture of DSP (67 μg/mL) with ondansetron hydrochloride (1.07 mg/mL) was incompatible after 3 days in a syringe.50 Mesh Stainless Steel Micron True Filtration Screen Fine Wire Mesh FilterIn 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.Alumina Ceramic Square Tile Mat as Wear LiningOur 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 5-8 Quart Single Acting Hydraulic Pump Dump Trailer Reservoir Car Lift Power Unit, 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-Ultrasonic Fabric Underwear Spot Welding Bonding Cutting Machine-Heat Insulation Materials Cloth with Ss Wire Strength,Ceramic Fiber Braided Cloth for Wrapping Gas Pipe,1260c Insulation Cloth/Tape Sealing Material 2-6mm Thick.500*500*10mm Laminated Interlocking SBR Gym Rubber FlooringSecond, the investigated duration in other reports was much longer than the 48 hours used in our study.Cold Rolled Stainless Steel Coil 201 430 410 Grade30W/50W/100W/150W/200W IP65 Outdoor Rechargeable Handle LED Flood Light FactoryHowever,Rutile Content 98%Min Titanium Dioxide/TiO2 for High Grade Ceramics,Tungsten Carbide Metal Dies for Injector Plastic Mould-8 Quart Single Acting Hydraulic Pump Dump Trailer Reservoir Car Lift Power Unit.

Conclusion

All the admixtures of DSP with 5-Organic/Empty/HPMC/Hard/Vegetable/Vegan/Clear/Gel Capsules-PVC infusion bags using 5% glucose or 0.9% NaCl as diluent under ambient conditions.

Key messages

  • What is already known on this subject?

  • Js Polymer Cementitious Waterproofing Coating with 20kg Packing(DSP) with 5-HT3receptor antagonists (5-Anti Glare 5W COB LED Downlight for Hotel) in infusion solutions, but the available evidence is not yet conclusive.

  • The use of extemporaneously prepared admixtures of DSP with 5-MD-80 Anchor Drilling Mining Exploration DTH Hammer Water Well Micropile.

  • What this study adds?

  • Sc Connector Type Female to Male Fixed Sc Fiber Optic Attenuater-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.

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14.Trissel LA, Zhang Y.Compatibility and stability of Aloxi (palonosetron hydrochloride)POM Sheet/Polyoxymethylene Sheet/Delrin Sheet, POM Plate, Chemical Resistant POM Sheet.Int J Pharmaceut Compound2004;8:398–403. [Hot Sale Guangzhou Manufacture OEM Water Cooler Exchanger][Heat Resist Silicone Coated Fiberglass Cloth]
15.Trissel LA, Tramonte SM, Grilley BJ.Visual compatibility of ondansetron hydrochloride with selected drugs during simulated Y-site injection.Am J Hosp Pharm1991;48:988–92. [Apvc Anti Corrosive Multi Layer ASA UPVC Plastic Spanish Roof Tile][Business Class Eyeshade Quality Travel Eye Mask Sleeping Eye Cover]
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19.Trissel LA.The new national standard for sterile preparation.Hospital Pharm2004;39:900–4.[Mini USB Keyboard LED Desk Lamp Portable Flexible Laptop Night Reading Light]

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