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  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

A high index of suspicion is required to order lioresal 25 mg with visa muscle relaxant jaw pain prevent missed diagnosis and to lioresal 25 mg without a prescription muscle relaxant ointment reduce mortality 25mg lioresal overnight delivery muscle relaxant veterinary. Natural medicine Indications for use Mechanism of kidney injury St John’s wort discount lioresal 25 mg without prescription muscle relaxant sciatica, Depression and anxiety Induces cytochrome P450 activity. In almost all cases, treatment of underlying disease and providing supportive care are critical in alle viating the renal damage. Appropriate referral and judicious use of fiuids, elec trolytes, and renal replacement therapy are major contributory factors towards an uneventful recovery in most cases. Elsevier, Inc, Philadelphia Jha V, Rathi M (2008) Natural medicines causing acute kidney injury. Trop Med Int Health 12(9):1037–1050 Sarah L, Larry P, Charles P (eds) (2008) Principles and practice of pediatric infectious diseases, 3rd edn. Lippincott Williams & Wilkins, Philadelphia Sitprija V (2006) Snakebite nephropathy. Nephrology (Carlton) 11(5):442–448 World Health Organization (2009) Dengue guidelines for diagnosis, treatment, prevention and control. The age of onset of renal disease is variable and may be found in children as young as 2 years of age. Other presenting features include haematuria, hypertension or manifestations of renal tubular acidosis and acute kidney injury. Marked podocyte hyperplasia may sometimes cause obliteration of the urinary space, forming “pseudocrescents”. Tubular changes include microcystic tubular dilation with interstitial cellular infiltrates. Clinical Vignette A 4-year-old girl presented with fever, facial swelling and abdominal disten sion during the previous month. Her urine albumin was 3+ on three occasions and her urine protein/creatinine ratio was 1. Her father has passed away 2 years ago due to a “lung infection”, but no records were available. A renal ultrasound showed bilateral enlarged echogenic kidneys, and a renal biopsy showed mesangial hyperplasia and microcystic tubular dilatation. A month after starting this treatment, proteinuria had disappeared and ascites had resolved. There are features of renal insufficiency, microangiopathic haemolytic anaemia and thrombocytopenia. Renal pathology consists of thrombotic microangiopathic glomerular lesions with accumulation of fibrin and accompanying microcystic tubular changes. Although these are very rare in children, some common examples reported among adults include disseminated tuberculosis with renal involvement leading to acute kidney injury, renal cryptococcosis, infiammatory interstitial nephritis and even immune reconstitution sarcoidosis presenting with hypercalce mia and acute kidney injury. If a previously untreated quiescent infection has manifested, then treatment of the specific infec tion is also warranted. Crystallization: indinavir, saquinavir and nel fi navir have been implicated in nephrolithiasis, causing dysuria, renal colic, urinary obstruction and interstitial nephritis. Drug interactions: ritonavir, when combined with tenofovir and indinavir, can cause acute kidney injury. Regular monitoring of urinalysis and serum creatinine Ritonavir Acute kidney injury May potentiate nephrotoxicity of other agents (indinavir, tenofovir) (continued) 486 A. Renal impairment is usually reversible after discontinuing drug Antibacterial drugs Aminoglycosides Acute kidney injury Monitoring of peak and trough drug levels recommended Cipro fi oxacin Allergic interstitial nephritis Sulphonamides Azotemia, obstructive nephropa thy, allergic interstitial nephritis 14. Improved neonatal care has created a new set of complications such as neonatal nephrocalcinosis and catheter-related thromboembolic disease. Managing complex neonatal renal prob lems is a challenge for the team of neonatologists and nephrologists. Diseases affecting the newborn kidney may be inherited or congenital or related to certain key events occurring in the perinatal period. It is completed by 35 weeks of gestational age, forming about one million nephrons in one kidney. In the preterm infant, nephrogenesis continues after birth but is subject to dam age by diseases and drugs. Low birth weight infants (both preterm infants and intrauterine growth-restricted infants) have reduced number of nephrons at birth. Reduced glomerular number may be associated with hypertension and chronic kidney disease in later life. The excretory and homeostatic functions of the kidneys begin only in the postnatal period. The maximal urine osmolality is 500 mOsm/l in premature infants and 800 mOsm/l in term infants. A delay in urination for up to 48 h should not be a cause for immediate concern in the absence of a palpable bladder, abdominal mass or other signs or symptoms of renal disease. As gestational age increases, total body water and extracellular water decrease and intracellular fi uid content increases. This physiologic weight loss is largely the result of a reduction in the extracellular compartment of body water. Perturbations of this normal transitional physi ology can lead to imbalances in sodium and water homeostasis.

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The book has many line drawings lioresal 10 mg line muscle relaxant cephalon, photos order lioresal 10mg muscle relaxant renal failure, scans 10mg lioresal sale spasms colon, tables and key points which help to buy lioresal 25 mg cheap muscle relaxant drugs cyclobenzaprine illustrate the text. It is a single author book, written in an easy style with clear and comprehensive explanations. He has worked for almost 20 years in Africa and combines an interest in patient care teaching and research. He obtained a PhD titled “Neurological Disorders in Tanzania” in 1995 from the University of Bergen, Norway. As you may recall from the introduction of this syllabus, viruses and bacteria are the smallest organisms that we will discuss. We will now shift our focus to larger organisms that can be seen using light microscopy and even (in some cases) the naked eye. Parasites are organisms that live within or on another organism (this other organism is called the host). They are a diverse group of eukaryotes that are composed of protozoa and helminths. Protozoa are single celled eukaryotes which are divided into four traditional groups – amebae, sporozoans (a. These groups are based on motility and morphology and do not necessarily indicate genetic relatedness (see diagram below). Amebae move using pseudopods, flagellates move using flagella, ciliates move using cilia, and sporozoans are non-motile. As we describe each protozoan, we will state which of these four groups they belong to. It is also important to note that protozoa often exist in two forms: trophozoites are a mobile stage in which they can ingest food, while cysts are an immobile, protected stage in which they cannot ingest food and are surrounded by a chitinous external wall. They have differentiated tissues and nervous, excretory, and reproductive systems. Helminths are divided into nematodes (roundworms), cestodes (tapeworms), and trematodes (flukes). The defining features of each of these groups will be described in the relevant sections below. As a side note, the “Tree of Life” that contains parasites, fungi, bacteria, and all other organisms has changed significantly over the past 20 years with advances in genetics. The below is the most up-to-date view of how different life forms are thought to be related based on their genes (note: you are not responsible for knowing this diagram). Plasmodium Leishmania Trypanosoma Entamoeba Helminths, Humans Giardia Trichomonas Microspora Adapted from: Simpson & Roger 2004. There are facultative parasites (which can live with a host or can live separately) and obligate parasites (which cannot live free of the host for any part of their lives). There are also commensal organisms (parasites that don’t cause disease) and pathogens that are capable of causing disease. The term Ectoparasites refers to parasites that live or feed on the outside of the body, such as ticks, fleas, mites (such as scabies), and lice. Vectors are the systems by which parasites are spread from one host to the next and can be either biological or mechanical. The best way to comprehend how each parasite causes disease and how we detect its presence is to understand its life cycle. As a result, the life cycle of each organism will be described before going into the clinical symptoms of each disease. The host in which the parasite undergoes asexual reproduction or in which the larvae develop are called intermediate hosts. For both “intestinal” protozoa and helminths, the host’s immune response to these pathogens is vigorous but largely ineffective. For example, the immune system generates IgE antibodies against intestinal helminthic invaders. The Fc portions of these antibodies bind to Fc receptors on mast cells and basophils and trigger the release of histamine from these immune cells. IgG binds to Fc receptors on eosinophils and triggers release of major basic protein onto the worm. Despite these mechanisms, intestinal helminths evade the immune system by their location in the gastrointestinal tract and their ability to continually change their surface antigens, mask themselves with host antigens, and/or destroy the mediators generated by the host immune system. Parasite diagnosis classically relies on traditional techniques such as detection of an organism or its progeny in the stool, urine, blood or tissue by light microscopy. For stool specimens, this is referred to as the stool “Ova and Parasite” or “O&P” exam. Because of the intermittent shedding of intestinal parasites (both protozoa and helminths) in stool, at least 3 stool exams collected on alternate days should be examined. In addition to microscopic methods, serology (detection of antibodies in serum) or antigen detection tests are also sometimes used. Helminths that migrate outside of the intestinal tract are commonly associated with eosinophilia and this may cause the physician to suspect a parasitic organism and order the appropriate tests. This is because parasitic infections tend to be rarer in the United States than bacterial, viral, or fungal infections and thus have less of an impact on the United States medical system. However, parasitic infections are a major cause of disease in many parts of the world and therefore it is important for all physicians to have some familiarity with major parasitic species. Some, like malaria, can be deadly, and cause a tremendous number of deaths worldwide. Also, some parasites such as pinworm and Giardia (lamblia) intestinalis are very common in the United States. Hence we will describe parasites that impact human health both in the United States and in the rest of the world.

Some women are at an increased risk for having a baby with an open neural tube defect buy lioresal 25 mg low cost spasms under right rib cage. There are natural sources of folic acid: green leafy veg etables purchase lioresal 25mg free shipping spasms under left rib, nuts discount lioresal 10mg with visa muscle relaxant 303, beans 25 mg lioresal back spasms 20 weeks pregnant, and citrus fruits. While a daily vitamin supplement is no substitute for a healthy diet, most pregnant and lactating women need supplements to make sure they get adequate levels of these minerals. All rights reserved 13 Medicine Guidelines During Pregnancy Although some medicines are considered safe during pregnancy, the effects of other medicines on your unborn baby are unknown. Prescription medicine guidelines If you were taking prescription medicines before you became pregnant, please ask your health care provider about the safety of continuing these medicines as soon as you find out that you are pregnant. With some medicines, the risk of not taking them might be more serious than the potential risk associated with taking them. Be sure to discuss the risks and benefits of the newly prescribed medicine with your health care provider. Ask your health care provider about the safety of taking other vitamins, herbal remedies, and supple ments during pregnancy. The following medicines and home remedies have no known harmful effects during pregnancy when taken according to the package directions. Your decision whether to get tested and/or the test result itself will not prevent you from getting health care. Therefore, if you have a neg ative test during your pregnancy, it will likely prevent testing on your baby after birth. All rights reserved Index# 4849 20 Screening for Chromosome Abnormalities in Pregnancy Cleveland Clinic offers options for women who are interested in determining the risk for chromosome abnormalities and certain birth defects in their baby during a pregnancy. While the risk for having a baby with a chromosome abnormality increases with a women’s age at the time of delivery, the majority of these babies are born to younger women. Having this testing performed is optional and should only be done after a thorough discussion of available tests. In some instances, your provider may refer you for genetic counseling to see which, if any, test is best for you. Sequential Screening the sequential screen combines ultrasound and blood tests to determine the risk for chromosome abnormalities, including Down syndrome (Trisomy 21) and Trisomy 18. The nuchal translucency is a fiuid filled space behind the neck, which is typically increased in size in fetuses with Down syndrome, other chromosome abnormalities, and birth defects. Blood tests, which measure the levels of certain hormones in the mother, are drawn at the time of the nuchal translucency measurement and later in the second trimester between 15 and 21 weeks’ gestational age. This test detects ultrasound 75 to 80 percent of cases of Down -Previous history of a syndrome and 60 to 75 percent of chromosome abnormality cases of Trisomy 18, with a 5 to 7 percent false positive rate. The sound waves are recorded and changed into video or photographic images of your baby. The idea for ultrasonography came from sonar technology, which makes use of sound waves to detect underwater objects. Transvaginal ultrasound Most prenatal ultrasound procedures are performed on the surface of the skin, using a gel as a conductive medium to aid the quality of the image. However, a transvaginal ultrasound is performed using a probe that is in serted into the vaginal canal. It may also be used to get a clearer view of the uterus or ovaries if a problem is suspected. Be sure to tell the ultrasound doctor whether or not you want to know the gender of your baby. There is a chance that 25 the ultrasound images can be During the test misinterpreted. An ultrasound You will lie on a padded examining might be performed earlier in your table during the test. A small device, called a transducer, Later in pregnancy, ultrasound is gently applied against the skin on might be used to determine: your abdomen. The transducer • Fetal well-being sends high-frequency sound waves • Placenta location into the body, which refiect off • Amount of amniotic fiuid around internal structures, including your the baby baby. Even though ultrasound There is virtually no discomfort is safe for mother and baby, it is a during the test. If a full bladder is test that should be done only when required for the test, you might feel medically necessary. If you have an some discomfort when the probe is ultrasound that is not medically nec applied. You might be asked to hold essary (for example, to simply see the your breath briefiy several times. This will help interpreted by a board-certified the doctor view the baby better on physician. You will be allowed to go to the bathroom right after the test has ©Copyright 1995-2015 the Cleveland Clinic Foundation. Every woman’s pregnancy is unique, and some of these discomforts might not affect you. Round • Apply a hot water bottle or heating pad, or take a ligament pain is consid warm bath or shower. Irregular, Regular tightening or pain in your back or infrequent contrac lower abdomen tions are called Pressure in the pelvis or vagina Braxton Hicks Menstrual-like cramps contractions. Bleeding Fluid leakage Flu-like symptoms such as nausea, vomiting, and diarrhea Backaches • Wear low-heeled (but not flat) shoes. The increase in your • Get a dental checkup early in your pregnancy to make sure volume of circulation your teeth and mouth are healthy.

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One cuff cheap 10 mg lioresal free shipping muscle relaxant withdrawal, pulse oximetry buy generic lioresal 10mg on-line muscle spasms 6 letters, capnography and temperature) for every must keep in mind the potential for prolonged duration of ac patient 10 mg lioresal for sale muscle relaxant valium. This means the patient should maintain at least one pre tool that allows anesthesiologists another gauge of anesthetic tetanic twitch in a train of four buy lioresal 25 mg lowest price muscle relaxant brands. During the maintenance depth (in addition to vital signs, akinesis, pupillary response). Aminoglyciodes terial lines and central lines, should be dictated by the pa may be administered for perioperative infection or infection tient’s other comorbidities and the complexity of the case, not prophylaxis. These drugs can lead to weakness by themselves simply because the patient is myasthenic. These drugs would include phenytoin, lithium, ha ing surgery that may inhibit muscular strength or depress res loperidol, droperidol and amitriptyline that may have been ad piratory function. The struggle is to combine optimum preopera tive treatment with effective intraoperative management such 4. Effec tive postoperative analgesia is an important link in this chain Narcotics have a blanket warning for myasthenic patients. There is some evidence that cholin esterase inhibitor medications can exacerbate the depressant 4. This combined effect, to During Anesthesia gether with the baseline neuromuscular dysfunction in myas thenic patients, makes it critical that narcotics be given in a As previously mentioned anesthesia is accomplished with no monitored setting. Regardless of the method used, prudent administra ing for these complex patients. What Regional anesthetics (nerve blocks, epidurals, spinals) might is emerging from the data, though, is that what is given for an be useful for certain procedures and can often be both the an esthesia is not as important as how anesthesia is administered esthetic and postoperative mode of analgesia. Della Rocca, et al these modalities need to be weighed against the unique risk of (Della Rocca G, 2003) demonstrated that patients maintained myasthenic patients. This is due to some of the accessory respiratory mus erative complications were both minimal and similar in both cles being impaired by neuromuscular blockade to the T4 spi groups. The bottom line is that the exact agent used isn’t ever, may cause outright respiratory failure due to the spinal’s as important as the conduct of anesthesia, namely goal di effect and the already impaired function (weakness) of the pri rected anesthesia designed to affect respiratory function and mary and secondary muscles of respiration. The foundation (as emphasized throughout of thoracic epidurals for thymectomy in myasthenics have this text) is to avoid muscle relaxants and preserve ventilatory been linked to profound bradycardia. Objective data for successful extuba Anesthesia Issues 92 tion would include the ability to follow commands (“open Patients presenting for thymectomy need to be prepared maxi your eyes,” “stick out your tongue”), regular respiratory pat mally for surgery. Symptomatic patients should take their cho tern (>10 and <24 breaths per minute), tidal volumes of 5 linesterase inhibitor medications up to the point of surgery. Muscle relaxants should be (Banoub M, 2001) state that pyridostigmine doses of >750 avoided, if possible, or titrated closely with the use of neuro mg/day place a patient at highest risk for postoperative venti muscular twitch monitoring. Following surgery, these patients lation, while Mori et al (Mori T,2003) showed risk of postop should be followed in an intensive care setting to allow close erative reintubation and ventilatory support to be strongly re respiratory monitoring, surgical blood loss recording and to lated to a dose of only 240mg/day. Thymectomy has been shown to Myasthenia gravis patients face numerous challenges in the either cure or reduce symptoms in a significant number of pa perioperative period. Banoub and Kraenzler (Banoub ther physically or pharmacologically, respiratory function. M, 2001) more generally state that thymectomy, in combined Postoperative pain management and neuromuscular monitor age reporting, produces 20% remission, 40% marked clinical ing require specialized and intensive care. A strong under improvement with reduced cholinesterase inhibitor use, 20% standing of medication pharmacology, myasthenia gravis pa clinical improvement with no change in preoperative medica thophysiology and teamwork will allow these patients to be tion dosage, while 6% have no benefit. Putting our egos aside and ask ing for assistance when caring for these patients is of utmost Anesthesia Issues 93 importance. Changes in respiratory condition after thymec ward nurses and the anesthesiologist are a team that must tomy for patients with myasthenia gravis. AnnThorac Cardio dedicate themselves in an integrated fashion to the care of vasc Surg, 2003;9(2): 93-97. Vecuronium dose response and main tenance requirements in patients with myasthenia gravis. Propofol or sevoflurane anesthesia with out muscle relaxants allow the early extubation of myasthenic patients. The prevalence of disease is about 20 per 100000 sents a diagnostic challenge for the emergency practitioner population, and the incidence is 2 to 5 cases that can be answered by careful history taking, evocative physi / yr / 1000000 population. Many cases are undiagnosed (Har cal examination techniques, and bedside confirmatory testing. In myasthenia gravis, auto-antibodies are formed against the nicotinic acetylcholine 5. The examiner must elicit this Emergency department encounters with the myasthenic pa key element of the history through directed questions to re tient typically involve one of three scenarios: veal symptoms that are worse at the end of the day, following exertion, or after prolonged activity. The stable myasthenic patient with unrelated issues the most common symptoms of myasthenia include ptosis or 2. The myasthenic patient with an acute exacerbation of my diplopia, which together account for two thirds of all present asthenic symptoms ing complaints. Ptosis often begins as a unilateral or asymmet ric problem that can be unnoticed by the patient but revealed 3. Diplopia is usually variable and worse with ac onset of symptoms tivities requiring sustained gaze (watching television, driving, reading). Limb weakness may be frank, sub available, screening can be done at the bedside by having the tle (such as stumbling when walking over rough and uneven patient count slowly upwards from 1. Elevation of the head toms and respiratory failure are uncommon presenting symp of the bed to 30 degrees or more may reduce aspiration risk, toms, although many patients have measurable respiratory intrathoracic pressure, and work of breathing.

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Anal swabs (cellophane tape preparations such as used for pinworm diagnosis) are often helpful due to order 25 mg lioresal visa back spasms 39 weeks pregnant squeezing of segments on the outside of the stool as it passes through the anus buy lioresal 10 mg otc muscle relaxants knee pain. Hymenolepis nana – the Dwarf Tapeworm Hymenolepis nana adult Hymenolepis nana scolex Hymenolepis nana egg (1) Frequency most common of tapeworm infections in humans trusted 25mg lioresal infantile spasms 4 year old. It measures 45 to generic 25 mg lioresal with amex muscle relaxant and pain reliever 50 microns in diameter and exhibits polar filaments lying between the egg shell Cestodes. Grain weevils are the most important intermediate host (other intermediate hosts include earwigs, larval fleas, various beetles). Taenia two species infect humans (1) Life cycle (a) infective eggs (from human feces) are ingested by a suitable intermediate host (cow or pig). It is delivered to various parts of body via the circulatory or lymphatic systems. As the oncosphere hatches, it penetrates the intestinal wall and larvae (cysticerci) lodge in body tissues, commonly the lung, brain, eyes, connective tissues, and especially in muscles. Diphyllobothrium latum – the Broad Fish Tapeworm Life cycle Diphyllobothrium latum scolex D. Children are at risk of being infected when licked in the mouth after a dog has nipped a flea. Adults killing fleas with fingernails can infect themselves if they bite their nails; cats can spread larvae over fur while grooming following their nipping fleas. The Administrative Panel on Biosafety and the Biosafety & Biosecurity Program have revised this document based on the latest government regulatory requirements, guidelines and current professional standards. Safety is a core value at Stanford and the University is committed to continued advancement of an institutional safety culture. Research excellence and safety are inextricably intertwined and the protection of researchers, the environment, and the broader community are an integral part of the responsible conduct of research. The Environmental Health & Safety Ofice, through the Biosafety Manager, is responsible for monitoring individual principal investigators and laboratory facilities for adherence to the practices and procedures described in this manual. However, it is the responsibility of each principal investigator to ensure that all lab workers are familiar with the contents of this manual and that these workers and employees are trained to recognize potential related hazards prior to initiation of the research work. Your cooperation with the Administrative Panel on Biosafety and the Environmental Health & Safety Ofice is essential to comply with the regulatory requirements that our University must follow in order to continue the success of our research endeavors. If you have any questions regarding this document, please call the Research Compliance Administrator at 723-4697 or the Biosafety & Biosecurity Manager at 725-1473. If you have questions regarding this manual, please contact the Biosafety & Biosecurity Program at (650) 725-1473 or email biosafety-owner@lists. Chair, Administrative Panel on Biosafety Lawrence Gibbs Associate Vice-Provost, Environmental Health & Safety Russell Furr Director of Research Safety and Deputy Director, Environmental Health & Safety Ellyn Segal, Ph. Biosafety & Biosecurity Manager, Environmental Health & Safety Chapter 1: Introduction 13 Safe Research at Stanford e As an academic institution, safety culture is part of the educational foundation that will accompany our s students into their future careers, preparing them to + be skilled scientists in academia or industry. Safety’s intrinsic value is seen in better reproducibility and productivity of research, as well as preventing tragic lab accidents that cost lives and knowledge. This chapter is part of a larger conversation about shaping and defining a shared cultural approach, which integrates safety and health seamlessly with the work of our laboratories and classrooms. Encourage reporting by members when identifying and reviewing lessons learned afer an incident and using these as Chapter 2: teaching opportunities. Culture of Safety To some degree, as researchers, we all have experienced rules, regulations, compliance What is Safety Culturefi It is generally As this manual addresses biosafety, it should understood that these are part of an established be stated that a Safety Culture is not a secured research environment. Safety culture is a part experience, it is easy to incorrectly equate safety of organizational culture and is ofen described by rules with safety and come to believe that adhering the phrase “the way we do things around here”. According to the American Chemical Society, safety In science, researchers think according to the culture at an academic institution is a “reflection of principles: mathematical, physical and chemical the actions, attitudes, and behaviors” demonstrated laws; biological paradigms. Safety should have led to the realization that ensuring excellence be no diferent. This starts with recognizing that in research requires a strong, positive safety culture safety is a fundamental part of the scientific process, throughout the University. This means that safety adding value by exerting greater control, reducing is viewed as an operational priority, because of the uncertainty, and increasing the safety and quality of benefits thoughtful, safe procedures and attitudes your results or product. Chapter 2: Safety Culture Elements and Attributes 15 While reading information on Safety Culture I came across an article published in Occupational Health & Safety entitled Stop Trying to Create a Safety Culture. The article began with: Safety culture has become the new catch phrase, program focus, and desire of global executives, verbalized in the ofen expressed, “We need a safety culture! Researchers just need to do what they are supposed to be doing, what they are told to do, and we will all be safe. Safety practices, risk perceptions, and mitigation techniques have been and always will be a part of human conversation, probably more so among those who are more successful in navigating life’s risks and able to pass this knowledge to their ofspring and descendants. Cultures are not a program; they are the interconnectedness that explains why eforts work, don’t work, succeed, and fail. All researchers know that safety trainings, classes, guidance’s, regulations, compliance approvals, and inspections currently exist and are part of the established research environment. We – researchers, laboratories, Universities have safety attributes but they have been traditionally broken up into pieces, some more obvious than others, some not totally acknowledged and some just ignored. We must have a Safety Culture gestalt, a whole that is perceived as more than the sum of its parts, that is second nature to all participants, one that will influence the individual decisions carried out when no one is watching the most important part of cultural reality, safety or otherwise. For this transition to succeed we all need to be aware of the issues, be open to suggestions, communicate, and work together to change beliefs and behaviors. The following elements (Fig 1) help Execution lay the foundation to build and support a safe and Take action to control your risks. Make sure you productive research environment: have the right protective equipment, engineering controls are working correctly, and researchers are training to safety perform their work. Principal Leadership investigators must enforce the established controls in their lab.

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