Non Hormonal Contraception - Sterilization, Barriers, and Natural Methods

by Philip Darney, MD MSc
Professor and Chief
Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco General Hospital Division, UCSF

Reshared Knol

Introduction

Many women who want to avoid pregnancy prefer not to use hormones. Male and female sterilization operations (vasectomy in men and various methods of closing the tubes or oviducts in women), vaginal barriers (condoms, diaphragms and crèmes or foams), and the “natural” methods (ovulation timing, abstinence, and breast feeding) all provide contraception without the use of hormones. In fact, these are the most frequently used methods around the world, including the USA, where sterilization and condoms provide protection against unintended pregnancy to more people than all the other methods combined.



Depending on the method chosen and how it is used, non-hormonal methods have a much wider range of effectiveness than the hormonal contraceptives (pills, patches, rings and implantable methods), but they avoid the side effects of taking hormones. The most effective of these methods (male and female sterilization) are not reversible; the reversible non-hormonal methods are usually much less effective than hormonal contraceptives, but some people achieve much greater success than “typical” users. Our description of these methods will begin with the most effective and proceed to the less effective ones.
Sterilization
Female Sterilization Operations (Tubal Ligation or Tubal Occlusion)
Key points:

* Tubal sterilization remains a popular and highly effective method of contraception worldwide.
* The 12 year U.S. Collaborative Review of Sterilization (CREST) study reported a 10 year cumulative pregnancy rate of 1.8%, with the lowest failure rate in post-partum partial salpingectomy and highest among bipolar electrocautery.
* Other large series suggest 10 year failure rates for interval sterilization of 0.23% - 0.9%, with the Filshie clip having the lowest failure rate.
* Successful bilateral placement of Essure coils occurs in 92-95% of procedures.
* On the day of the procedure, current pregnancy should be excluded prior to tubal sterilization.
* While no pregnancies were reported in Essure clinical trials, five year data suggest a failure rate of 2.6 per 1000, with no reported ectopic pregnancies; most of these pregnancies were in women who did not follow-up after the procedure. Confirmation of tubal occlusion is crucial, and this method should be reserved for patients who are likely to follow up and to use an interval method of contraception.

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Extraction of Iron from iron ore - Reshared Knol

Source Knol: Extraction of Iron from iron ore
by Partha Das Sharma, Hyderabad (India)

Extraction of Iron from iron ore - various basic steel:

Perhaps the most important element ever known to mankind and one of earth's most abundant, Iron (Fe), is extracted from Iron ore. The process of extracting iron - done either through ‘blast furnace’ route or by ‘direct reduction’ route - involves a number of steps.

A. Extraction of Iron using blast furnace:

Common iron ores are hematite (Fe2O3) and magnetite (Fe3O4). Since, iron is below carbon in the reactivity series, iron in the ore is reduced to iron metal by heating with carbon (coke). It is actually carbon monoxide which does the reducing in the blast furnace.

Iron ore is reduced to iron by heating them with coke (a form of carbon) in blast furnace. The iron ore contains impurities, mainly silica (silicon dioxide). Limestone (calcium carbonate) is added to the iron ore which reacts with the silica to form molten calcium silicate in the blast furnace. The calcium silicate (called slag) floats on the liquid iron.

The air blown into the bottom of the blast furnace is heated using the hot waste gases from the top. Heat energy is valuable, and it is important to conserve heat energy. The coke (produced by heating coal in the absence of air) burns in the blast of hot air to form carbon dioxide; exothermic reaction releases heat. This reaction is the main source of heat in the furnace.

C + O2 = CO2

At the high temperature at the bottom of the furnace, carbon dioxide reacts with carbon to produce carbon monoxide.

C + CO2 = 2CO

It is this carbon monoxide which is the main reducing agent in the furnace to produce iron.

Fe2O3 + 3CO = 2Fe + 3CO2

In the hotter parts of the furnace, the carbon itself also acts as a reducing agent. Notice that at these temperatures, the other product of the reaction is carbon monoxide, not carbon dioxide.

Fe2O3 + 3C = 2Fe + 3CO

The temperature of the furnace is hot enough to melt the iron which trickles down to the bottom as ‘pig iron’, where it can be tapped off.

The limestone is added to convert siliceous impurities into ‘slag’ ( as calcium silicate, CaSiO3), which melts and runs to the bottom. The calcium silicate melts and runs down through the furnace to form a layer on top of the molten iron.

CaCO3 + O2 = CaO + CO2. CaO + SiO2 = CaSiO3


B. Direct reduction of iron (DRI) –

(‘Sponge iron’, another method of producing iron):

All steelmaking processes require the input of iron bearing materials as process feedstock. For making steel in a basic oxygen furnace, the iron bearing feed materials are usually blast furnace hot metal and steel scrap. A broadly used iron source is also a product known as Direct Reduced Iron ("DRI") which is produced by the solid state reduction of iron ore to highly metallized iron without the formation of liquid iron. This solid state reduction of iron ore is also called ‘sponge iron’.

Sponge iron is the product created when iron ore is reduced to metallic iron, in the presence of coal, at temperatures below the melting point of iron. The external shape of the ore is retained with 30% reduction in weight due to oxide reduction resulting in change in true density from 4.4 gm/cc to 7.8 gm/cc in this product. This paves the way for 54% reduction in volume which is manifested in pore formation through out the interior of reduced product and hence the name “Sponge Iron”. This spongy mass sometimes called a bloom. This makes for an energy-efficient feedstock for specialty steel manufacturers which used to rely upon scrap metal. The advantage of this technique is that iron can be obtained at a lower furnace temperature (only about 1,100°C or so). Only small quantities of sponge iron can be made at a time as compare to blast furnace process, is the major disadvantage.

In this method, the iron ore along with coal is charged to the top portion of the reduction zone of a rotary kiln or furnace, wherein the bed of particles which descend by gravity is reduced by a hot reducing gas largely composed by carbon monoxide (CO) and hydrogen (H2). Finally, the product sponge iron is discharged from the bottom portion of the discharge zone of the furnace and conveyed (after cooling), for example, to be melted in an electric arc furnace or to be briquetted in a briquetting machine coupled to the reduction reactor. The evolution of sponge iron as a metallic feed in electric steel making has been mainly due to reduced availability of high quality scrap and its increasing cost.

Quality of sponge iron for steel making: There are several parameters to be monitored for improving the quality of sponge iron for steel making operation, such as – (a) Size, (b) Density, (c) Unit weight, (d) Crushing strength, (e) Weather resistance, (f) Carbon contents, (g) Metallization.

(a) Size - The size of sponge iron is very important especially with regard to continuous feeding. A very fine sized material (1 mm to 2 mm) would be quickly oxidized during falling to the slag or may be lost in fume extraction system. Extremely large size (exceeding 30 mm) poses problem during continuous feeding. The size fraction less than 2 mm needs to be limited for continuous feeding.

(b) Density - Sponge iron after falling should have the ability to penetrate into the slag layer and reside at the slag/metal interface for effective heat transfer and chemical reaction. Sponge iron with lower density tend to float on the slag while, high density material readily penetrates into the metal. Hence, it is desirable to have the density of sponge iron in the range 4 - 6 gm/cc.

(c) Unit weight – The transition time of the sponge iron pellets through the slag is dependant on the momentum. If the pellet stays in the slag layer for too long a time, the phenomenon of slag boiling occurs. Slag fluidity is highly important. However, a heavier sponge iron pellet does not require close control in slag fluidity.

(d) Crushing strength - Sponge iron should possess good crushing strength to prevent generation of large amounts of fines.

(e) Weather resistance - Sponge iron is prone to oxidation and heat builds up in contact with atmosphere. The storage of Sponge Iron for long periods of time affects its metallization, partially due to surface re-oxidation caused by the porous structure of sponge iron pellets or lumps.

(f) Carbon contents - During continuous feeding, an active carbon — oxygen boil is necessary to shield the arcs. It has been observed that to achieve the aforesaid, sponge iron should possess a minimum of 0.60% carbon.

(g) Metallization - High metallization helps in lower power consumption but severely reduces the bath activity and results in flat bath conditions. For low metallization levels, increased carburization is required to compensate for the extra oxygen in sponge iron.

C. Basic Iron and Steel products -

(i) Pig iron – The molten iron from the bottom of the blast furnace is pig iron. It contains 3.5 - 4.5% carbon and varying amount of contamination such as, sulfur, silicon and phosphorus. Pig iron is the intermediate step on the way to cast iron and steel.

(ii) Cast Iron – Some time pig iron from the blast furnace can be used as cast iron. It is very impure, containing about 4% of carbon. This carbon makes it very hard, but also very brittle.

(iii) Steel - Most of the pig iron is used to make one of a number of types of steel. There isn't just one substance called steel - they are a family of alloys of iron with carbon or various other metals after removal of impurities from molten iron.

D. Removal of impurities –

Impurities in the pig iron from the Blast Furnace include carbon, sulfur, phosphorus and silicon. Sulfur is removed by reacting with magnesium (Mg) as magnesium sulfate (MgS).

Mg + S = MgS

Carbon is removed by blowing oxygen in molten iron. The impure molten iron is mixed with scrap iron (from recycling) and oxygen is blown on to the mixture. The oxygen reacts with the remaining impurities to form various oxides. The carbon forms carbon monoxide. Since this is a gas it removes itself from the iron! This carbon monoxide can be cleaned and used as a fuel gas.

Elements like phosphorus and silicon react with the oxygen to form acidic oxides. These are removed using quicklime (calcium oxide), which is added to the furnace during the oxygen blow. They react to form compounds such as calcium silicate or calcium phosphate which form a slag on top of the iron.

E. Various basic steel products used –

The various steel products used include Wrought iron, Mild steel, High carbon steel and other specialized steel.

Wrought iron - When all the carbon is removed from the molten iron to give high purity iron, it is known as wrought iron. Wrought iron is quite soft and has little structural strength. It was once used to make decorative gates and railings, but these days mild steel is normally used instead.

Mild steel - Mild steel is iron containing up to about 0.25% of carbon. The presence of the carbon makes the steel stronger and harder than pure iron. The higher the percentage of carbon, the harder the steel becomes. Mild steel is used for lots of things - nails, wire, car bodies, ship building, girders and bridges amongst others.

High carbon steel - High carbon steel contains up to about 1.5% of carbon. The presence of the extra carbon makes it very hard, but it also makes it more brittle.

F. Environmental issues related to Iron making process –

(i) Loss of landscape due to the size of the chemical plant needed.

(ii) Noise.

(iii) Atmospheric pollution from the various stages of extraction. For example: carbon dioxide (greenhouse effect); carbon monoxide (poisonous); sulphur dioxide from the sulphur content of the ores (poisonous, acid rain).

(iv) Disposal of slag, some of which is just dumped – large scale land degradation.

(v) Iron-making uses up huge amounts of coal. The coal is not used directly, but is first reduced to coke which consists of almost pure carbon. The many chemical byproducts of coking are almost all toxic.

G Environment-friendly ‘ITmk3’ process plant for production of iron nuggets by Kobe Steel :

Please refer
(http://minmetandeqip.blogspot.com/2010/01/environment-friendly-itmk3-process.html )

References:

1. http://minmetandeqip.blogspot.com/2008/03/direct-reduction-of-iron-dri-sponge.html
2. http://minmetandeqip.blogspot.com/2008/02/extraction-of-iron-using-blast-furnace.html
3. http://www.chemguide.co.uk/inorganic/extraction/iron.html
4. http://www.tatasponge.com/Operations/Technology.htm
5. http://www.gcsescience.com/ex17.htm

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Source Knol: Extraction of Iron from iron ore

MRSA Methicillin Resistant Staphylococcus Aureus (MRSA) Infections of the Skin

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Source Knol: MRSA Methicillin Resistant Staphylococcus Aureus (MRSA) Infections of the Skin

by Bryan Cho MD, PhD, Board Certified Dermatologist

INTRODUCTION

Bacteria are microorganisms that are found almost everywhere. Most bacteria are harmless but some can cause infection. Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that has emerged as a major cause of skin infections among otherwise healthy adults and children in the community. This bacterium is dangerous because it causes infections that cannot be treated with commonly used antibiotics that in the past would destroy the bacteria and cure the infection. Moreover, left untreated these infections can have serious complications. This knol will discuss the risk factors for MRSA infections, what MRSA skin infections look like, and how they can be treated and avoided.



HEALTHCARE ASSOCIATED-MRSA

MRSA was first diagnosed in 1961 as bacteria associated with serious infections that occurred in hospitalized patients or patients in healthcare facilities such as nursing homes or dialysis centers. MRSA infections that occurred in healthcare facilities were termed healthcare associated-MRSA (HA-MRSA). These infections were often serious and potentially life-threatening and included bloodstream infections, surgical site infections or pneumonia. Since being discovered, the number of MRSA infections has increased dramatically. In 1974, MRSA infections accounted for 2% of the total number of Staphylococcus infections; in 1995 it was 22%; in 2004 it was 63%[1]



HA-MRSA risk factors include:[2],[3]

1. Weakened immune system and severe illness
2. Previous exposure to antimicrobial agents
3. Surgery or open wounds
4. Residence in a long term healthcare facility (nursing home, skilled nursing facility)
5. Underlying disease or conditions, particularly:
1. Chronic renal disease
2. Insulin-dependent diabetes mellitus
3. Peripheral vascular disease
4. Dermatitis or skin lesions
6. Invasive devices (Urinary catheterization, intravenous lines (IV), Dialysis, tracheotomies, G tubes)
7. Patients in the intensive care unit (ICU)
8. Male, age older than 65
9. Repeated contact with the healthcare system
10. Previous colonization by a multidrug-resistant organism



COMMUNITY ACQUIRED-MRSA

In the past few years, a separate strain of MRSA bacteria has developed that affects healthy members of the community. This community acquired MRSA (CA-MRSA) has caused outbreaks of disease among professional athletes, high school athletic teams, and in day care settings. Developing a CA-MRSA infection does not imply any impairment in immune system function. The average age of patients with CA-MRSA infections is age 23 compared to age 68 for HA-MRSA.[4] Unlike HA-MRSA, CA-MRSA rarely causes life threatening infections. CA-MRSA most commonly causes skin infections such as boils or pimples. Because these infections can occur abruptly on otherwise normal skin, CA-MRSA infections are frequently mistaken for spider bites.



CA-MRSA may occur in the following populations:

1. The young and healthy, especially those who live in crowded conditions or have close physical contacts with others, including:
1. Athletes
2. Prisoners
3. Soldiers
2. Selected ethnic populations
3. IV drug users








Table 1. CA-MRSA versus HA-MRSA. (not shown in this post. Visit source knol)

SKIN INFECTIONS CAUSED BY MRSA:

Roughly 85% of CA-MRSA infections develop in the skin.[5] Each year there are an estimated 12 million outpatient (e.g., physician offices, emergency and outpatient departments) healthcare visits for skin and soft tissue infections in the United States[6]. In one study, three out of four patients seen in the emergency room for skin infections had Staphylococcal aureus infections and over 50% had MRSA infections.[7]



Most MRSA skin infections look like (Described below.):



o Impetigo

o Many small pimple-like bumps (folliculitis)

o Large painful boils (furuncle or carbuncle)

o Spider or insect bites



Less common and more serious skin and soft tissue infection caused by MRSA include:



o Cellulitis

o Infected wounds



Impetigo is a superficial skin infection that occurs on open, exposed areas of skin. This infection occurs most commonly in children but usually does not cause serious illness. The infection starts at sites of minor skin trauma such as insect bites or abrasions. The affected skin may develop small (less than 5mm) fluid filled bumps that develop golden honey-crusting when bumps burst. Usually, multiple skin lesions are present. Impetigo is easily spread within families and close contacts. Other risk factors for infection include warm, humid conditions and poor hygiene. Impetigo is most commonly caused by a bacterium called Streptococcus, but more and more frequently, impetigo is caused by MRSA; CA-MRSA now accounts for 7-20% of impetigo infections.[8] Impetigo caused by Streptococcus and CA-MRSA look identical.





Figure 1: Impetigo



Folliculitis is a superficial infection of the hair follicle. Folliculitis typically starts when hair follicles are damaged by trauma from scratching or shaving, from friction due to tight fitting clothing, or due to blockage. As a result, damaged follicles become infected with bacteria that cause red bumps or pimples centered on hair follicles. Buttocks, thighs, back and upper arms are commonly affected sites. The lesions of folliculitis are often clustered in groups and itch is the most common symptom. Folliculitis does not cause systemic symptoms such as fever or chills. About 3-25% of cases of folliculitis are due to CA-MRSA[9] other cases of folliculitis may be caused by non-MRSA strains of S. aureus, Pseudomonas aeruginosa, or fungi such as Candida or Pityrosporum




Figure 2: Folliculitis

Boils (Furuncle/Carbuncle):

Boils are caused by an infection, usually by Staph aureus that occurs deep within the hair follicle. These infections start as red, tender areas of skin that form large circular tender bumps filled with pus. A soft, white/yellow area will often form at the center of the boil where the pus may drain. Boils are typically larger than five millimeters. A single boil is called a furuncle; a network of interconnected boils is called a carbuncle. Boils can frequently be confused with spider or insect bites because they occur abruptly on skin without previous trauma. Symptoms like fevers and chills rarely occur and if present may be suggestive of a more serious infection. A 2004 study found that approximately 76% of purulent (pus containing) skin and soft tissue infection in adults seen in emergency rooms were caused by Staph aureus. Of these infections, 78% were cause by MRSA[10].



Figure 3: Boil



Cellulitis:

Cellulitis is a rapidly spreading infection of the deep fat and connective tissue under the skin. Bacteria usually enter through breaks in the skin caused by trauma (cuts, scrapes, blisters, burns, surgery or insect/animal bites), infection (athlete’s foot, boils) or external medical devices (catheter). Characteristic findings associated with cellulitis include:

1. Swelling

2. Bright red skin, pain (erythyma)

3. Local warmth of the infected skin.

4. Pain

Cellulitis can also cause fever, chills, red streaks along draining lymph vessels (lymphangitis), and enlarged lymph nodes. Skin on the lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. Alcoholism, immunosuppression, diabetes mellitus, malignancy, intravenous drug abuse, and peripheral vascular disease are all risk factors for cellulitis. Cellulitis is rarely due to bacteria arriving from a distant source via the bloodstream (bacteremia).



Figure 4a: Cellulitis

Figure 4b: Lymphangitis



SERIOUS COMPLICATIONS

When MRSA infections are neglected or insufficiently treated, they may develop into serious infections that affect deeper underlying tissue (myositis, osteomyelitis), spread to the bloodstream (bacteremia, sepsis), or involve internal organs (pneumonia, endocarditis). Clinical presentations associated with invasive CA-MRSA include bacteremia (65.1%), pneumonia (14.0%), cellulitis (22.7%), osteomyelitis (8.1%), endocarditis (12.6%) and septic shock (3.8%).[11]



Patients with severe CA-MRSA infections requiring hospitalization and treatment include those who have fever, large abscesses, low blood pressure, blackened tissue (necrosis), severe bleeding and gas within infected tissue. In addition, other certain patient populations such as the immunocompromised, diabetic and infants younger than 6 months may require hospitalization. When serious systemic symptoms like fevers, chills or low blood pressure develop, you should be evaluated immediately by your physician.





TREATMENT

The treatment for MRSA skin infection depends on severity of the infection, the type of skin infection, and the patient’s risk factors for MRSA.



Impetigo:

For patients with a limited numbers of skin lesions, impetigo can be treated with the topical antibiotic mupirocin. When the disease is more severe, oral antibiotics should be used. The choice of antibiotic will depend on the resistance pattern of the infecting bacterium. For those cases of impetigo caused by CA-MRSA, sulfa drugs, tetracyclines, and clindamycin are usually effective. Once treatment is initiated, most cases of impetigo will resolve in 10-14days. Gentle washing of the affected skin to remove debris and crust is generally recommended. The American Academy of Pediatrics recommends that children with impetigo be with withheld from child care settings for the first 24-hours of antibiotic treatment. Precautionary measures that limit the spread of impetigo include hand washing, keeping the infected skin covered, and avoiding sharing common items (towels, clothing).



Folliculitis:

Treatment of CA-MRSA folliculitis varies but includes topical antibiotics, oral antibiotics and prophylactic use of antibacterial detergents. Many physicians start with topical antibiotics but may use oral antibiotics if topical antibiotics are ineffective, or the folliculitis is widespread. Most cases of folliculitis will respond to treatment and resolve in 10-14 days, however, a portion of patients may develop recurrent episodes. Recurrent folliculitis may suggest possible bacterial colonization (see below) and require decolonization treatment. Folliculitis can also evolve into deeper, larger lesions called furuncles (see below).



Boils (Furuncle/Carbuncle):

The most common presentation of CA-MRSA is as a boil, which is typically treated with incision and drainage. This treatment removes the source of infection and will cure most healthy people with no systemic signs of infection (e.g., fever, chills, elevated white blood cell count) when boils are less than five centimeters in diameter. In a recent randomized, placebo controlled trial in adult patients with deep skin abscesses, the majority of which were caused by MRSA, treatment success rates were over 90% for patients treated with incision and drainage alone.[12] Most recent Centers for Disease Control and Prevention (CDC) guidelines suggest that physicians should collect specimens for culture and antimicrobial susceptibility testing from all patients with abscesses or pus-containing skin lesions, particularly those with severe local infections, systemic signs of infection, or history suggesting connection to a cluster or outbreak of infections among epidemiologically linked individuals.



To perform an I&D, the skin is numbed with local anesthetic. A small incision is made on the skin overlying the boil and the pus is drained. Some abscesses have pockets of pus that must be broken up to release all of the pus. Packing material, such as gauze or gauze tape, may be placed in the drained abscess to keep the skin from closing and allow the wound to drain as it heals from the inside out. For patients with suspected MRSA, a sample of drained pus or of infected tissue will be sent for culture and susceptibility testing. If an I&D is not performed, your physician may remove fluid within a boil using a needle (aspiration) and send the fluid for culture. A culture can help confirm a case of suspected MRSA and guide the selection of an antibiotic when appropriate. In cases where a course of antibiotics was prescribed before culture results are available, the culture and sensitivity results help confirm or guide selection of the correct antibiotic.

Figure 5: Incision and Drainage



Patients with treated with I&D on an outpatient basis should contact their physician if they develop fevers/chills, worsening local symptoms or if their symptoms do not improve within 48 hours.



For some patients, an I&D may be the primary mode of therapy however, other patients may be treated with both an I&D and oral antibiotics. Factors which may influence a clinician to supplement I&D with antibiotics include:

* Severity and rapidity of progression of the skin infection or the presence of associated cellulitis
* An infected site more than five centimeters in diameter associated with failure of incision and drainage without effective antimicrobial therapy
* Signs and symptoms of systemic illness (fever, chills, elevated white blood cell count)
* Associated co-morbidities or immunosuppression (diabetes mellitus, neoplastic disease, HIV infection, transplantation, obesity, poor tissue oxygenation, nicotine use, poor nutritional status)
* Extremes of patient ages (very young or elderly)
* Location of abscess in area that may be difficult to drain completely
* Association with septic phlebitis or major vessels (central face)
* Lack of response to initial treatment with I&D alone



The choice of antibiotic therapy in treatment of CA-MRSA infections depends on the severity of the infection and the frequency of MRSA infections in the community. Local susceptibility data is often used to guide treatment.



Cellulitis:

Treatment of cellulitis consists of oral antibiotics and resting the affected limb or area. In severe cases, patients may require admission to a hospital for intravenous antibiotics and debridement of dead or infected tissue. Wounds or broken skin should be cleansed and bandaged. Wound dressings should be changed daily or when they become saturated or dirty.



With proper treatment most cases of cellulitis resolve in one to two weeks although more severe cases may take months to resolve. If untreated, cellulitis can result in severe debilitation or even death.





ANTIBIOTICS:

Both CA-MRSA and HA-MRSA are resistant to traditional anti-staphylococcal beta-lactam antibiotics, such as cephalexin. Sulfa drugs, tetracyclines, and clindamycin are usually effective at treating CA-MRSA; HA-MRSA is resistant even to these antibiotics. To treat HA-MRSA an intravenous administered antibiotic such as vancomycin or other newer oral medication such as linezolid are often required. A brief description of antibiotics that may be used to treat CA-MRSA or HA-MRSA is provided below.



Cephalosporins

Initial empiric antibiotic of choice in an uncomplicated skin infection in a community with higher rates of Methicillin sensitive Staph aureus than MRSA



Sulfa

Trimethoprim-sulfamethoxazole (Septra) remains the drug of choice for confirmed uncomplicated CA-MRSA especially when the rate of inducible clindamycin resistance is high. However, this class of medications does not provide coverage for beta-hemolytic streptococci which may also be the cause for erysipelas or cellulitis-like infections

These antibiotics are not recommended for women in third trimester of pregnancy or in infants less than two months of age.



Tetracyclines

Tetracyclines are effective on many strains of CA-MRSA. A small case series has demonstrated that doxycycline and minocycline were adequate for the treatment of MRSA soft tissue skin infections. This class of antibiotics is a good alternative treatment for confirmed CA-MRSA in cases where sulfa drugs are not tolerated or contraindicated.

However, they do not have activity against beta-hemolytic streptococcus and are contraindicated in children younger than age eight and during pregnancy



Clindamycin

Traditionally used for empiric therapy for uncomplicated skin infection alone or in combination with rifampin. A major advantage over trimethoprim-sulfamethoxazole (sulfa) is that when used empirically, clindamycin has better coverage for beta-hemolytic streptococci, another common cause of skin infections. Some strains of MRSA have developed inducible resistance to this class of antibiotics, therefore clindamycin not recommended in areas where inducible clindamycin resistant MRSA is present in greater than 10-15% of the local isolates. If clindamycin therapy is being considered, sensitivity testing for inducible clindamycin resistance should be performed using the D-zone disk-diffusion testing.



Rifampin

Because rifampin achieves high concentrations in mucosal surfaces, this antibiotic may promote eradication of MRSA colonization. However, because resistant strains of S. aureus develop rapidly when used as a single agent, rifampin should be used simultaneously with other antibiotics that target MRSA. Drug-drug interactions are common with rifampin and should be minimized prior to use. Women on contraception are recommended to use a second form of contraception as rifampin can decrease the effectiveness of oral contraceptives



Fluoroquinolones

Fluoroquinolones such as ciprofloxacin or levofloxacin are common first-line treatments for hospitalized patients with severe invasive S. aureus infection. Because of relatively high prevalence of resistance in the community and potential for rapid development of resistance, these antibiotics are not the optimal choice for the empiric treatment of CA-MRSA[13] Use of fluoroquinolones should be reserved for confirmed susceptible CA-MRSA infections when the use of other antibiotics is contraindicated. A major limitation of fluroquinolones for treatment of MRSA infections is that resistance can develop relatively quickly. Although many CA-MRSA strains remain sensitive to fluoroquinolones, resistance is emerging and overuse of these antibiotics favors the emergence of new CA-MRSA resistant strains



Macrolides/Azalides:

Erythromycin, clarithromycin and azithromycin are all FDA approved for the treatment o uncomplicated skin infections caused by S. aureus. Resistance to macrolides is common among CA-MRSA isolates which limits their usefulness as alternative agents for empiric treatment in areas with MRSA is high.



Vancomycin

Considered first line treatment for hospitalized patients with severe staphylococcal infections.



Linezolid

FDA approved for the treatment of complicated skin infections and hospital acquired pneumonia due to MRSA in adults. Has demonstrated superior tissue penetration in bone and muscle compared to vancomycin and has excellent penetration into skin and soft tissue. Available in a 100% bioavailable oral formulation, that can reduce hospital stays and duration of intravenous treatment. Due to the high bioavailability in oral form, linezolid can be used as an alternative treatment in patient with impaired renal function or poor venous access. This medication is expensive and has serious side effects that may include myelosuppression, peripheral and optic neuropathy and thrombocytopenia.





COLONIZATION

Rates of MRSA infection or recurrence are higher in people who are colonized with MRSA.

* Colonization means that the organism is present in or on the body but does not cause disease or symptoms.
* Infection means the organism is both present and causes disease.



The nostril and nasal passages (anterior nares) are the most common site of colonization by MRSA. Elimination of the bacteria at this site may prevent MRSA infections from recurring. However, MRSA colonization can also occur at sites other than the nose such as the throat, armpit, anus, and perineum. These sites may be important in development and transmission of the infection as well as in persistence or reappearance of colonization after use of nasal decolonization agents. Although having a MRSA infection raises the likelihood of having MRSA colonization, not all MRSA patients are colonized.[14] In a 2001-2002 US survey of non-institutionalized individuals, 0.8% of the U.S. population is colonized with MRSA.[15] Household or close contacts of MRSA colonized or infected patients are 7.5 times more likely to be colonized.[16]



Testing for Colonization

Testing for nasal colonization involves bacterial cultures of nasal swabs. Recent CDC guidelines suggest it is not necessary to routinely collect nasal cultures in all patients presenting with possible MRSA infection.



Decolonization Therapy

Decolonization is generally not recommended unless the patient has had recurrent infection; multiple infections recur within the same family or group of individuals; or if an individual is at higher risk for serious infection (e.g. diabetes, immunosuppressed). A number of different methods have been suggested with varying success. Most use a combination of oral antibiotics or an oral and topical antibiotic simultaneously. However, even the most intensive decolonization protocol results in eradication only about 66% of time. When attempting to eliminate MRSA colonization in a group, all members should receive the decolonization regimen simultaneously to decrease the risk of recolonization and to decrease the potential for emergence of resistance. Patients with indwelling lines, catheters, tracheostomies, G tubes, and other invasive devices are not good candidates for decolonization because such therapy is not likely to eradicate organisms from these surfaces.



Topical + Oral antibiotic

Mupirocin is the most effective among topical antibiotics for decolonization of the intranasal CA-MRSA. The antibiotic should be applied twice per day to both nostrils/nasal passages for five to10 days while on an appropriate oral antibiotic. For long term prevention, one study showed monthly use of mupirocin ointment applied intranasally twice per day for five days each month reduced nasal colonization and led to fewer cases of folliculitis or boils in 8/17 treated patients compared to 2/17 who received placebo.[17]



Rifampin + Other Oral Antibiotics

Rifampin is an oral antibiotic that achieves high concentrations in mucosal surfaces and is effective at reducing colonization by MRSA. However rifampin-resistant strains of MRSA develop rapidly when used as a single agent. Therefore, rifampin must be used in combination with another appropriate oral antibiotic that is active against MRSA for proper MRSA decolonization. Most courses of rifampin range from seven to 10 days with a daily dose of 600mg.



Rifampin should be used with caution because drug-drug interactions are common with rifampin. Women on oral contraception are recommended to use a second form of birth control because rifampin may decrease the effectiveness of oral contraceptives.





PREVENTION

The main mode of MRSA transmission is through direct physical contact, not through the air. Good hand cleansing is the single most important preventative measure to avoid for transmission of MRSA. Spread may also occur through contact with objects contaminated with MRSA infected skin or body fluids. Always clean hands immediately after touching infected skin or with any item that has come in direct contact with a draining wound. When washing hands, use an alcohol based hand gel or wash with an antibacterial soap for at least 15 seconds before rinsing with warm water. MRSA may survive on inanimate objects for up to 3 days. Clean equipment and other environmental surfaces than contact bare skin contact with an over the counter detergent/disinfectant that specifies Staphylococcus aureus on the product label and is suitable for the type of surface being cleaned





For caregivers of MRSA infected people, general recommendations are that caregivers should wash their hands with soap and water after physical contact with the infected or colonized person and before leaving the home.

· Towels used for drying hands after contact should be used once

· Disposable gloves should be worn if contact with body fluids is expected and hands should be washed after removing gloves

· Linens should be changed and washed routinely if they are soiled

· The infected person’s environment should be cleaned routinely
Controlling transmission

Infected or colonized patients should be able to participate in school/work or other social activities if draining wounds are covered, bodily fluids are contained, and the patients observe good hygienic practices.



Other MRSA prevention tips:[18]

§ Keep draining wounds covered with clean, dry, bandages.

§ Wash hands regularly with soap and water or alcohol-based hand gel (if hands are not visibly soiled). Always clean hands immediately after touching infected skin or any item that has come in direct contact with a draining wound.

§ Maintain good general hygiene with regular bathing.

§ Do not share items that may become contaminated with wound drainage, such as towels, clothing, bedding, bar soap, razors, and athletic equipment that touches the skin.

§ Launder clothing that has come in contact with wound drainage after each use and dry thoroughly.

§ If you are not able to keep your wound covered with a clean, dry bandage at all times, do not participate in activities where you have skin to skin contact with other persons (such as athletic activities) until your wound is healed.

§ Clean equipment and other environmental surfaces with which multiple individuals have bare skin contact. Use an over the counter detergent/disinfectant that specifies Staphylococcus aureus on the product label and is suitable for the type of surface being cleaned.




[1] Klevens RM, Edwards JR, Tenover FC, McDonald LC, Horan T, Gaynes R; National Nosocomial Infections Surveillance System. Changes in the epidemiology of methicillin-resistant Staphylococcus aureus inintensive care units in US hospitals, 1992-2003. Clin Infect Dis. 2006 Feb 1;42(3):389-91.

[2] Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S, Harrison LH,Lynfield R, Dumyati G, Townes JM, Craig AS, Zell ER, Fosheim GE, McDougal LK,Carey RB, Fridkin SK; Active Bacterial Core surveillance (ABCs) MRSA Investigators.Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007 Oct 17;298(15):1763-71.

[3] Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S, Harrison LH,Lynfield R, Dumyati G, Townes JM, Craig AS, Zell ER, Fosheim GE, McDougal LK,Carey RB, Fridkin SK; Active Bacterial Core surveillance (ABCs) MRSA Investigators.Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007 Oct 17;298(15):1763-71.

[4] Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J,Johnson SK, Vandenesch F, Fridkin S, O'Boyle C, Danila RN, Lynfield R. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003 Dec 10;290(22):2976-84.

[5] Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J,Johnson SK, Vandenesch F, Fridkin S, O'Boyle C, Danila RN, Lynfield R. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003 Dec 10;290(22):2976-84.

[6] McCaig LF, McDonald LC, Mandal S, Jernigan DB. Staphylococcus aureus-associated skin and soft tissue infections in ambulatory care. Emerg Infect Dis. 2006 Nov;12(11):1715-23.

[7] Abrahamian FM, Moran GJ. Methicillin-resistant Staphylococcus aureus infections.N Engl J Med. 2007 Nov 15;357(20):2090;

[8] Cohen PR . Community-acquired methicillin resistant Staphylococcus aureus skin infections: a review of epidemiology, clinical fetures, management and prevention. Int. J. Dermatol. 2007 Jan;46(1):1-11

[9] Cohen PR . Community-acquired methicillin resistant Staphylococcus aureus skin infections: a review of epidemiology, clinical fetures, management and prevention. Int. J. Dermatol. 2007 Jan;46(1):1-11

[10] Abrahamian FM, Moran GJ. Methicillin-resistant Staphylococcus aureus infections.N Engl J Med. 2007 Nov 15;3(20):2090;

[11] Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S, Harrison LH,Lynfield R, Dumyati G, Townes JM, Craig AS, Zell ER, Fosheim GE, McDougal LK,Carey RB, Fridkin SK; Active Bacterial Core surveillance (ABCs) MRSA Investigators.Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007 Oct 17;298(15):1763-71.

[12] Rajendran PM, Young D, Maurer T, Chambers H, Perdreau-Remington F, Ro P, Harris H. randomized, double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant Staphylococcus aureus infection. Antimicrob Agents Chemother. 2007 Nov;51(11):4044-8

[13] Gorwitz RJ, Jernigan, DB, Powers JH, Jernigan JA and Parcipants of the Centers for Disease Control and Prevention-Convened Experts Meeting on Management of MRSA in the Community. Strategies for Clinical Management of MRSA in the Community: Summary of Experts’ Meeting Convened by the Centers of Disease Control and Prevention, March 2006

[14] Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-Remington F. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections.Ann Emerg Med. 2005 Mar;45(3):311-20.

[15] Kuehnert MJ, Kruszon-Moran D, Hill HA, McQuillan G, McAllister SK, Fosheim G, McDougal LK, Chaitram J, Jensen B, Fridkin SK, Killgore G, Tenover FC. Prevalence of Staphylococcus aureus nasal colonization in the United States, 2001-2002. J Infect Dis. 2006 Jan 15;193(2):172-9.

[16] Calfee DP, Durbin LJ, Germanson TP, Toney DM, Smith EB, Farr BM. Spread of methicillin-resistant Staphylococcus aureus (MRSA) among household contacts of individuals with nosocomially acquired MRSA.Infect Control Hosp Epidemiol. 2003 Jun;24(6):422-6.

[17] Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y. A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection.Arch Intern Med. 1996 May 27;156(10):1109-12.

[18] Gorwitz RJ, Jernigan, DB, Powers JH, Jernigan JA and Parcipants of the Centers for Disease Control and Prevention-Convened Experts Meeting on Management of MRSA in the Community. Strategies for Clinical Management of MRSA in the Community: Summary of Experts’ Meeting Convened by the Centers of Disease Control and Prevention, March 2006

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Best Practices: Writing Good Knols - Tips for writing popular knols

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Source Knol: Best Practices: Writing Good Knols

by Knol Help, Helping authors since 2008 at Google Mountain View, CA

Overview
A knol is an introductory article about a specific subject. To write a successful knol, focus on the first things a reader would want to know about your topic. Remember that knols are openly available online, so you should aim to write for the broadest possible audience. For example, it’s best to avoid jargon and explain technical terms in straightforward language.

Length
There’s no ideal length for a knol, but as a general rule a good knol will be longer than a typical web page. Because knols are meant for readers who want more detail on a subject, they should be more in-depth than most web content. That said, be concise in your writing. Readers appreciate getting to the point no matter what type of information they’re looking for.

Tone
Knols aren’t blogs, and should avoid the informal conversational style common in blog entries. Use a more formal tone. Think of your knol as a statement more than as an ongoing conversation. A good tone to aim for would be similar to that of a textbook or a pamphlet: clinical and informative.

Dos and Don'ts

Do...

* Voice your opinion

Since knol authors receive attribution, knols are a great forum for expressing your opinions. Present the facts and argue your case. Readers can decide what’s valuable from your writing.

* Think about how to get your readers involved in your topic

Knol offers a simple and powerful way for authors to interact with readers, which we call "moderated collaboration." With moderated collaboration, you no longer have to rely solely on ratings and long strings of reader comments to improve your content. Now, your readers can edit your knols directly, making it easier to collaborate. At the same time you stay in control, accepting or rejecting any suggested edits before they’re published and become visible to readers. Moderated collaboration is great for things like soliciting feedback, sharing partial data and building collective lists. We encourage you to think about how to use the feature in your knols.

Also, be sure to check the comments to your knols regularly, and update content as needed. Addressing reader feedback will help improve your knols' ratings and relevance.

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If possible, ask other experts to write reviews of your knols. A positive review can show that your opinion is respected by others who are knowledgeable in your field.

* Focus on communicating clearly

Use headings to divide sections. Use lists and formatting to allow users to scan material quickly. A well-organized knol will be easier to read and engage more readers. Be sure to choose a relevant title for your article. Most search engines will give more importance to your knol title and subtitle, so a knol with a clear and informative title will have a head start when it comes to attracting readers.

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Insert relevant images to make your knol visually appealing. Use videos or slide-shows to bring your topic to life.


* Follow the rules

The Knol Terms of Service Agreement and Content Policy are in place to help ensure a good experience for all users and compliance with applicable laws. Please keep your knols in good taste. Don’t include spam or malware in your knols, and make sure to follow all copyright and other applicable laws.

Don'ts...

* Write a blog

Blogs are great for quickly and easily getting your latest writing in front of readers. Knols are better for when you want to write an authoritative article on a single topic. The tone should be more formal than that of a typical blog post. In addition, while it's easy to update your knols’ content to keep them fresh, knols aren't designed for continuously posting new content or threading. Recently mastered the process of fixing a leaky toilet, but don't want to write a blog about the weeks you spent repairing your bathroom? In that case, write a knol offering a step-by-step guide.


* Post advertisements

Teasers and sales pitches may work on the back of a book when readers can preview the content, but a Knol without real information will only frustrate readers and hurt an author's reputation. Make sure your knols include substantive content in order to build your reputation and encourage readers to come back for more.

On occasions, Google will take down knols which violate our Content Policy. The most common problems occur under this clause: "There are some commercial uses we don’t allow. We don’t allow pages that have the primary purpose of redirecting visitors, acting as a bridge page, or driving traffic to another website. We also don’t allow Knol pages that have the primary purpose of profiting from displaying ads from any publisher network, such as pages created with little or no unique content that exist only to display ads."

* Write for machines

Some authors are concerned about specifically including keywords so that search engines will index and return their pages for specific results. We recommend that you always write for humans first, not for machines. If there are keywords you specifically care about, let them occur in natural text, reader-friendly ways in the title, subtitle or summary areas of the document. Documents should not engage in keyword stuffing or other practices in violation of our Content Policy.

Examples of good knols

Want to see what a good knol looks like? Here are a few examples of knols that follow the guidelines we’ve set out above:

* The DTV Transition and You, by Lana Waters
* Arctic Exploration by Russel Potter
* Type 2 Diabetes by Anne Peters
* Creating a podcast by Nick Marino
* Rare Earths by Narayan Thakur
* Buttermilk Pancakes by Scott Jenson
* Kitchen Faucet Installation by The Family Handyman Magazine
* Snow skis buying guide by Scott Blair
* How to Backpack by Ryan Moulton
* Solar Energy by William Pentland
* Speed Costs Power, by Jeff Radtke
* Cancer Prevention by Graham Colditz, et al.
* The Physics of Giants and Dwarves, Julian G. Franco
* Chemistry Demos by Andy Sae


Advice from Other Knol Authors

Here is what a few other enthusiasts have to say about writing high quality knols

* How to write Knols that rank 'Top 10', How to Write an Article Review, and Knol Writing Tips, by Peter Baskerville
* How To Begin Writing a Knol, by Shatri JC Philip
* Scientific and Medical Writing by Amy Markowitz
* How to Write a Great Report, by Norman Creaney

Use of knols as an example is meant to highlight their apparent compliance with our best practices guidelines, and does not constitute endorsement of their content by Google.

Visit the source knol Source Knol: Best Practices: Writing Good Knols for links of example knols and also for updates.

How to Identify Symptoms of a Stomach Virus - Knol Reblogged

Source Knol: How to Identify Symptoms of a Stomach Virus

by eHowKnol, The eHow database is the world's most popular place to find clear instructions on how to do just about everything. at Demand Media

A stomach virus is also known as the stomach flu (viral gastroenteritis) and can affect people of all ages. It is a temporary health condition caused by an infection; the virus typically causes severe cramping and pain, but is commonly mistaken for the regular flu (influenza). A stomach virus is commonly caused by parasites such as cryptosporidium and giardia, as well as bacteria such as E.coli, Shigella and Salmonella.

Common Symptoms of a Stomach Virus

The most common symptoms of a stomach virus include:

* Watery diarrhea
* Extreme abdominal discomfort
* Vomiting
* Headache
* Ongoing fever
* Chills
* Excessive thirst
* Severe weakness
* Lethargy and fatigue
* Dizziness

The symptoms of a stomach flu typically occur within 4 to 48 hours of eating the contaminated food or being exposed to the bacteria. The symptoms can last for 2 – 4 days, but typically do not extend for longer than 10 days.

Common Causes of a Stomach Virus

Any type of infection that enters the gastrointestinal tract can trigger the spread of a stomach virus, and cause irritation or inflammation in the stomach or intestines. The virus may be caused by:

* Eating spoiled food
* Drinking contaminated water
* Inhaling or ingesting bacteria
* Having an allergic reaction to certain types of food
* Lactose intolerance
* Gluten intolerance

The most common types of viruses that cause stomach flu include:

* Caliciviruses – a virus that typically occurs between October and April, and results in diarrhea, vomiting and fatigue. The symptoms typically appear within 1-3 days of exposure to the contaminated foods or fluids, but most people can recover within 7 days.
* Adenovirus – a common ‘infant’ stomach virus that causes vomiting and diarrhea. This type of virus can occur any time of year and can be especially dangerous for infants with weak immune systems.
* Rotavirus – a virus that typically occurs in children who are 3 – 15 months old; this virus causes fever, diarrhea and abdominal pain and typically occurs between November and April.
* Astrovirus – a common type of stomach virus that occurs during the winter months. This one typically triggers vomiting, diarrhea, fatigue and abdominal discomfort.

Is It a Stomach Virus or the Flu?

Since many of the symptoms of a stomach virus are similar to those of influenza, it can be difficult to diagnose the problem. The average flu is a viral infection that begins with a high fever and congestion, and is often accompanied by fatigue. However, the flu cannot be treated with an antibiotic that is necessary to treat the stomach virus because it is not a bacterial infection.

In most cases, people suffering from the stomach flu will experience extreme dehydration, headaches and diarrhea. Overall, they will experience many of the common symptoms of the flu but also a number of digestive problems and gastrointestinal pain.

Recovering from a Stomach Virus

There is no specific treatment for recovering from a stomach virus. Sufferers must eat bland food, drink plenty of water and get enough rest to allow the body to recover naturally. Antibiotics are not very effective in treating viruses, because once the bacteria has reached the intestinal tract, it can be difficult for the body to absorb any type of medication.

The best strategy for recovering from the virus involves drinking clear liquids and eating easily-digestible foods. Oral rehydration solutions that contain minerals and salts such as potassium may be especially beneficial for young children and the elderly.

Individuals who are taking prescription medications may need to stop taking certain types of drugs until the symptoms disappear. Frequent episodes of vomiting and diarrhea can lead to malabsorption, making most medications ineffective and increasing the chances of toxicity.

Making an appointment with the doctor is recommended at the onset of a stomach virus, or if the symptoms do not disappear within 7-10 days. Extreme cases can become difficult to manage without oral rehydration solutions and supplements, and a doctor may be able to recommend certain foods and supplements for those who are not recovering from the stomach virus in an appropriate period of time.

Foods to Eat If You Have a Stomach Virus

Since the stomach will become especially sensitive to certain types of food and fluids after the initial stages of symptoms have settled down, the sufferer will need to drink extra fluids and eat a simple, easily-digestible diet. A bland diet comprised of simple carbohydrates can help the person with the stomach flu get the energy they need to recover and restore their body to good health. Foods that will not irritate the stomach lining or trigger a gastrointestinal reaction include:

* Dry toast
* Bananas
* Applesauce
* Cooked rice
* Puffed rice with lactose-free milk
* Soda crackers
* Boiled and mashed fruit
* Boiled and mashed vegetables

It’s also important to reduce the risk of extreme dehydration; drinking fresh water and flat, caffeine-free soda can help replenish the body with lost fluids and increase the chances of recovery.

Ways to Prevent a Stomach Virus

Eating properly-cooked food and making sure that hands are washed and cleaned thoroughly before handling fresh food are essential for preventing food borne illnesses. People who have a sensitive stomach should also avoid uncooked fish products and undercooked meats, as these may contain a significant amount of bacteria that can trigger the stomach virus.

Water-borne parasites are often found in third world countries, so anyone traveling to these areas should avoid drinking tap water and plan ahead to have a bottled water supply.

Any allergic reactions to seafood, shellfish, peanuts or even wheat products should be addressed by a doctor so that a healthy meal plan that does not contain these foods, or derivatives of these foods, can be arranged.

Exercising good hygiene is another way to protect yourself from a stomach virus. Washing hands thoroughly after going to the bathroom, keeping the nails clean and trim, and maintaining clean silverware and serving plates are simple ways to reduce the risk of contracting or spreading a stomach virus.

Piano Chords -- How They Are Formed & How They Work - Reshared Knol

Source Knol: Piano Chords -- How They Are Formed & How They Work

by Duane Shinn, I'm a keyboard instructor -- piano mostly. I also create books & courses about music theory and piano playing. at www.PlayPiano.com, Medford, Oregon

*
A chord is any group of 3 or more notes that are played at the same time. Broken chords, also known as arpeggios, are chords which are played one note at a time, but add up to 3 or more notes.



Chords are made from scales.



A scale is simply a row of notes in some consistent pattern. The word “scale” comes from a Latin word meaning “ladder” – notes ascend or descend the ladder rung by rung. The most-used scale is the major scale, which is a row of notes in alphabetical rotation in the following pattern:

The article has many images of scales.

Read further content in the original knol

Source Knol: Piano Chords -- How They Are Formed & How They Work

Female Sexual Function and Dysfunction - Knol

Source Knol: Female Sexual Function and Dysfunction

by Tom F. Lue, Professor and Vice Chair of Urology University of California, San Francisco
Alan Shindel, Assistant Professor of Urology, University of California, Davis, University of California Davis Medical Center
Irwin Goldstein, Director of Sexual Medicine, Alvarado Hospital; Clincial Professor of Surgery, UCSD, San Diego, California

Introduction

In 1893, the physician and sexual medicine specialist Edward Martin stated, “In the case of a woman, performance of the sexual act, at least insofar as her partner is concerned, requires only the presence of a sufficiently long and patulous (open) mucous canal.”[1] While this statement may seem shockingly misogynistic (hating or dismissive of women), when it was written it was fairly progressive to openly address women’s sexuality. Although our understanding of women’s sexual function and dysfunction has not progressed as rapidly as our understanding of men’s sexuality has, we have certainly made progress since Martin’s day.

Female Sexual Function
What are the phases of sexual response in women?

The famed sex researchers William Masters and Virginia Johnson derived a basic scheme for sexual response in men and women consisting of four distinct phases called excitement, plateau, orgasm, and resolution.[2] In the vast majority of men studied by Masters and Johnson these steps occurred in a fairly predictable pattern. In contrast, these researchers found much more variation among women with respect to sexual experience. In some women the sequence of events was similar to what was observed in men (blue line in graphic below). In other women a discrete orgasm phase did not occur (violet line in graphic below) and in some women there were multiple orgasms during a single sexual encounter (yellow line in graphic below). Helen Singer Kaplan, another prominent sex researcher, later elaborated on the Masters and Johnson schema by incorporating the concept of desire, defined as an interest in sexual activity that precedes actual sexual arousal.[3]

The paradigm created by Masters, Johnson, and Kaplan has been accepted for many years as representative of sexual response in both men and women. Recently, a leading expert in women’s sexual health (Rosemary Basson) has advocated a new model of female sexual function that stresses the interdependence of relationship factors and sexual function in women. In this new model, sexuality and sexual function in women follow a circular path in which emotional cues and relationship issues play a fundamental role and intrinsic sexual desire plays a much smaller role.[4]

No one model can adequately encompass the sexual experience for all individuals. In a recent study of 129 women, about 2/3 of respondents endorsed the Masters & Johnson model as most representative of their sexual response, while approximately 1/3 selected the Basson model. Interestingly, women who endorsed the Basson model were more likely to have sexual health concerns, particularly low sexual desire.[5]

What physical changes occur during the sexual response cycle in women?

During sexual arousal in women, numerous changes occur throughout the body. For the purposes of this review, we will focus on genital changes only. The attached diagrams demonstrate the anatomy of the female pelvis with a focus on the genital organs.

Vaginal lubrication

Prior to the 1960s, it was thought that the vaginal lubrication produced during sexual arousal was derived from glandular tissue. However, in a series of elegant experiments Masters and Johnson demonstrated that there were no discrete glands within the vagina and therefore vaginal lubrication could not be derived from glands.[2] It was subsequently discovered that vaginal lubrication is caused by the production of a transudate (a watery fluid with very low protein content) from the blood vessels supplying the vagina. Normally, the walls of blood vessels do not permit fluid to leak through. However, during sexual excitement, increased blood flow to the pelvic region causes pressure to build up in the small blood vessels around the vagina. This process is driven by nerves from the sacral portion of the spinal cord, which is part of the parasympathetic nervous system. This increased pressure forces fluid out of the blood vessels and into the vaginal canal, thus producing a slippery lubricant fluid. This fluid is the lubrication that a woman feels when she gets wet from sexual arousal.[6]

The clitoris is composed of inner-tube like cylinders of spongy tissue called corpora cavernosa. The internal portion (crura) of the clitoris attaches to the pelvic bones. During sexual excitement, blood flow to the corpora cavernosa increases, causing them to swell. Because the veins that drain blood from the clitoris are located to the side of the corpora cavernosa, compression from the swelling corpora will tend to obstruct these veins, causing blood to become trapped inside the clitoris. The overall process leads to engorgement (enlargement) and increased sensitivity of the clitoris.[7]

What about female ejaculation and the G spot?

During sexual climax, some women experience a spurting of fluid from the urethra; this is commonly referred to as female ejaculation. This is an atypical but not abnormal occurrence and should not be interpreted as a problem.

The G spot (or Grafenberg Spot, for the physician who first described it) is an anatomical area that can be a source of great pleasure during sexual stimulation for some women. It is most commonly located on the front wall of the vagina near the base of the bladder although the exact location may vary. The G Spot has been a source of great controversy in the medical community as some investigators contend that there is not enough evidence to prove its existence.[8] Other experts and many women very strongly maintain that the G spot does exist and can play an important role in sexual pleasure.[9]

The existence and importance of the “G spot” for a particular woman’s enjoyment of sex varies from woman to woman, like most aspects of sexuality. Interestingly, women who ejaculate at climax report sensitivity in the expected location of the G spot more frequently than women who do not ejaculate. [9] The G-spot has often been referred to as a “female prostate,” and recent evidence has supported the notion that the “G-spot” may indeed be a gland that surrounds the urethra and produces the fluid ejaculated at orgasm. The physical characteristics of female ejaculate have been not been well studied but there is good evidence that it is similar in some respects to semen, which is ejaculated by men at climax.[10] Further research is needed before definitive statements about the G spot and female ejaculation can be made. For the time being, G spot sensitivity and ejaculation can be considered normal variants of female sexual response.

It is a fairly long article and there is a lot of content on Female Sexual Disorders. There are images explaining anatomy of various organs. Visit source knol for more detailed content.

Source Knol: Female Sexual Function and Dysfunction

How to Tell If Your Car Alternator Is Bad - Reshared Knol

Source Knol: How to Tell If Your Car Alternator Is Bad

by eHowKnol

How a Car Alternator Works

An alternator takes advantage of the energy created by a gasoline car engine to move the vehicle. A serpentine belt is connected to the car's crankshaft. When the car engine moves, it turns the crankshaft and moves the serpentine belt. This is also connected to the alternator. As it turns it generates electricity. This electric current is used by the car while driving and is also transferred to the battery to store electricity. The power is used for things like the ignition coils, headlights, tail lights, brake lights, signal lights, interior lights, DVD player, radio, air conditioning and engine cooling fans. If the car alternator does not work properly, the car battery will eventually drain. When the battery is dead, the car wont start.

Why a Car Alternator Can Fail
There are two main reasons car alternators fail. The first is a reaction to high temperatures. Driving a car for a long time or in very hot weather can cause an alternator to stop charging. The second is a bad diode. These are vital to the charging process. As they wear out or burn out they charge the battery less and less.

Clues That Your Alternator is Bad
There are two tests you can perform at home that can give you an indication whether your alternator is working properly. Try one or both of these before spending any money on repairs:


•Try the headlight test. Turn your car headlights on while the car is running. Do this outside so carbon monoxide gas buildup doesn't become a problem. Press the accelerator while the car is in park. If the headlights dim or get brighter when you press the accelerator, your alternator could be bad. If the headlights remain the same, your alternator is probably fine.
•Try the battery test. Turn the car ignition on and open the engine hood. While the car is running, remove the negative cable on the battery. If the car suddenly stalls and dies, your alternator could be bad. This is because the alternator is not generating enough electricity to keep the car running. If the car keeps running, the battery might be the problem.

How To Confirm That You Have a Bad Alternator
The only way to confirm that you have a bad alternator is to have it tested. Any mechanic can do this but they will charge you for it. If you want your alternator tested for free, take it to an auto parts stores. Most stores will check it out for free. You will need to get your alternator to the auto service center or auto parts store to get it tested. If your car wont start, you can try to jump your battery with jumper cables and a fully charged car battery. If that does not work you will need to have your car towed. Of course, you can always push it there. The mechanic or auto parts salesperson will connect a voltmeter to the terminals of your battery. It should read between 12 and 13.5 volts. If it is less than that and falls even when the car is running, then the alternator is bad. If it reads higher than 14.5 volts, the battery is being overcharged. This could also be a problem with the alternator.

What To Do If You Have a Bad Alternator

It is very rare to have a bad alternator repaired. The work involved is not cost effective. It is less expensive to buy a new alternator than it is to replace the bad one. If you are trying to save some money, you can buy a rebuilt alternator. Just make sure that the shop that sells you the rebuilt alternator guarantees their work and its performance over a significantly long period of time. You could also buy a used alternator from a salvaged vehicle or junkyard. This can be risky since there is no guarantee how long it will work or whether it will work at all. It is also highly unlikely that a service shop mechanic will install a used alternator for you. Installing a replacement alternator yourself will save you a significant amount of money. Only attempt this if you are comfortable working on car engines and know what you are doing. An alternator is an important piece of equipment in a car engine. It must be installed properly.

What a Replacement Alternator Will Cost
Most of the cost of replacing a car alternator is labor. Most auto repair shops charge between $70 and $90 per hour for labor. Replacing a car alternator takes an average of 2 to 3 hours. This is in addition to the cost of the new alternator itself. A brand new alternator can cost between $200 and $400. A rebuilt alternator generally costs between $100 and $200. A used alternator can be acquired for as little as $50. However, you will probably have to install a used alternator yourself. For those who do not wish to do their own car repairs, an alternator replacement bill can range from $300 to $1000. The cost will vary from place to place, shop to shop and car type to car type.

What the Problem Can Be If It Is Not a Bad Alternator

It costs a lot of money to replace a car alternator. It pays to be sure that the alternator is really the problem before agreeing to the replacement. If the problem is really a bad battery, you can get a new one installed for less than $100. That's a big difference in cost. Also, check the wires connecting the alternator to the battery. If they are bad, it could impact the performance of the alternator. Check them for corrosion and make sure that they are attached securely and properly. The serpentine belt may also be loose or not properly connected to the alternator. This might prevent the charging of your battery or slow it down significantly.

By Kent Ninomiya


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BRAIN: CT, MRI - Noninvasive imaging of the central nervous system - Reshared Knol

Source Knol: BRAIN: CT, MRI

by Christopher Hess, Assistant Professor, Neuroradiology, University of California San Francisco, San Francisco, CA

Derk D Purcell, Radiologist at CPMC Radiology


Introduction
The complexity of the organ that determines how a person thinks, moves, feels and remembers is overshadowed only by its unique vulnerability. The brain is hidden from direct view by the protective bony covering of the skull, which not only shields it from injury but also hinders the study of its function in both health and disease. The cells in the arteries that supply the brain are so tightly bound that even most normal cells in the bloodstream are prevented from crossing the so-called “blood-brain barrier,” thereby rendering the normal chemistry of the brain invisible to the routine laboratory blood tests that are often used to evaluate the heart, liver or kidneys.

Computed tomography (CT) and magnetic resonance imaging (MRI) have revolutionized the study of the brain by allowing doctors and researchers to look at the brain noninvasively. Like other organs in the human body, the structure of the brain is highly organized according to its function. Different parts of the brain play specific roles that govern different activities, such as movement, cognition, and vision. These imaging techniques have allowed for the first time the noninvasive evaluation of brain structure, allowing doctors to infer causes of abnormal function due to different diseases.


How are brain images made with CT?
Computed tomography is based on the measurement of the amount of energy that the head absorbs as a beam of radiation passes through it from a source to a detector. Within a CT scanner, the radiation source and detector are mounted opposite one another along a circular track, or gantry, allowing them to rotate rapidly and synchronously around the table on which the patient lies. As the x-ray source and detector move around the patient’s head, measurements consisting of many projections through the head are obtained at prescribed angles and stored on a computer. The table moves horizontally in and out of the scanner in order to cover the entire head [1, 2].

The “tome” in tomography is the Greek word for “slice.” At the core of the scanner is a computer that not only controls the radiation source, the rotation of the x-ray tube and detector, and the movement of the table, but also generates anatomical slices, or tomograms, from the measured projections. The mathematical technique that allows an image of the head to be recovered from its projections is referred to as the backprojection algorithm [3]. Because the patient is positioned horizontally on the table, the backprojection algorithm yields slices that are transaxial, which means the slices are oriented at right angles to the long axis of the body.

The primary physical quantity that is captured with CT is density, or mass per unit volume. Prior to display and storage of CT images, pixel intensities are mapped to a standard numerical scale to allow reliable discrimination between different densities of tissue such as air, water, fat, bone, and various brain constituents. When the images are reviewed on a computer, the intensities are further modified by a process referred to as windowing in order to optimally depict the density of different tissues for visual display. Extremely dense material, such as metal or bone, appears bright on CT images, whereas tissue that is less dense, like fat or water, appears dark.

Magnetic resonance imaging relies upon signals derived from water molecules, which comprise between 70% and 80% of the average human brain. This ubiquitous biological molecule has two protons, which by virtue of their positive charge act as small magnets on a subatomic scale. Positioned within the large magnetic field of an MR scanner, typically 30 to 60 thousand times stronger than the magnetic field of the earth, these microscopic magnets collectively produce a tiny net magnetization that can be measured outside of the body and used to generate very high-resolution images that reveal information about water molecules in the brain and their local environment.

Protons placed in a magnetic field have the interesting property that they will absorb energy at specific frequencies, and then re-emit the energy at the same frequency. To measure the net magnetization, a coil placed around the head is used to both to generate electromagnetic waves and measure the electromagnetic waves that are emitted from the head in response. Unlike CT, which uses x-rays with very high frequency energy, MRI uses electromagnetic waves in the same portion of the electromagnetic spectrum as broadcast FM radio.

MRI is also a tomographic imaging modality, in that it produces two-dimensional images that consist of individual slices of the brain. Images in MRI need not be acquired transaxially, and the table or scanner does not move to cover different slices in the brain. Rather, images can be obtained in any plane through the head by electronically “steering” the plane of the scan. Precise spatial localization is achieved through a process termed gradient encoding [4]. The switching on and off of these magnetic field gradients are the source of the loud clicking and whirring noises that are heard during an MRI scan. While this process requires more time than CT scanning, imaging can be performed relatively rapidly using modern gradient systems [5].

Image intensity in MRI depends upon several parameters. These are proton density, which is determined by the relative concentration of water molecules, and T1, T2, and T2* relaxation, which reflect different features of the local environment of individual protons. The degree to which these parameters contribute to overall image intensity is controlled by the application and timing of radiofrequency energy through different pulse sequences. The most commonly used pulse sequences in brain imaging preferentially emphasize T1 relaxation, T2 relaxation, T2* relaxation or proton density. Specialized pulse sequences can sensitize images to flowing blood, minute changes in local brain oxygen content, or even to the microscopic movement of water molecules within the brain. Each pulse sequence confers a different contrast weighting to the image, such that when combined, the aggregate intensities from the different pulse sequences allow inference about the properties and local environment of the brain tissue being studied. For example, using MRI, one can infer the phase (solid or liquid), content (fat, water, air, blood) or movement (static or pulsatile) of a given structure in the brain

What is a contrast agent?
Contrast media, or “dyes” are used both in brain CT and MRI to provide another mechanism for modulating image intensity beyond what is possible using intrinsic tissue contrast. These are externally administered pharmaceutical agents given during an imaging examination to highlight normal or diseased brain structures. The additional information provided by a contrast agent may or may not be necessary to make an accurate diagnosis.

Contrast agents are most often administered by intravenous injection, but may in certain cases require intrathecal (spinal) injection using a lumbar puncture (spinal tap) procedure. Because they are water soluble they are normally removed from the body by the kidneys, though when the kidneys are diseased the liver may also contribute to their elimination. CT contrast agents are typically iodine-containing compounds that transiently increase the density of structures that they pass through. MRI contrast agents contain the heavy metal gadolinium, which changes the inherent T1 and T2 relaxation parameters of tissues.

The normal path of intravenously-injected contrast agents is through the heart, lungs and arteries of the chest and neck before entering the head. Once in the head, contrast passes first into the arterial system of the brain and its coverings, then through the cerebral microcirculation to supply the brain itself, ultimately passing into the intracranial venous system. Once it has passed into the large veins in the head, contrast is transmitted into the veins of the neck. From there, the contrast enters the heart for the second time, beginning the process of recirculation. The relative timing of the scan with respect to the location of the contrast agent within the blood pool allows detailed imaging of the arteries, brain, or veins.

Contrast agents in neuroimaging are usually given to evaluate blood vessels or to assess the integrity of the blood-brain barrier. In the former case, CT or MR angiography can diagnose cerebral aneurysms, vascular malformations, and narrowed or occluded arteries. In the latter, enhancement of the brain itself is used for the diagnosis of disease. The cells that line the capillaries of the normal brain are tightly bound together to form the “blood-brain barrier,” which allows the passage of oxygen and nutrients into the brain but prevents the transit of disease-causing organisms and large molecules, including contrast agents. Brain tumors, infections and inflammatory processes often disrupt the blood-brain barrier, giving rise to abnormal enhancement within the brain.

What do brain CT and MRI images show?
Interpretation of brain images requires a detailed knowledge of anatomy and a comprehensive understanding of how different diseases affect the brain and its supporting structures. Radiologists are medical doctors who specialize in acquiring and interpreting images; neuroradiologists focus specifically on imaging of the nervous system. These specialists work together with neurologists, neurosurgeons and primary care physicians to use CT and MRI to diagnose disorders of the brain and understand their significance for patients. Several different anatomical structures are routinely visualized with neuroimaging:

THE BRAIN. The gray matter of the brain consists of the cortex that lines the external surface of the brain and the gray nuclei deep inside of the brain, including the thalami and basal ganglia. Within the gray matter lie the cell bodies of the roughly 85 billion neurons that constitute the processing engine for the brain. White matter is comprised of the neuronal axons that interconnect different regions of the brain and serve as the interface between the brain and the rest of the body. Different diseases affect the gray and white matter in distinct patterns.

BLOOD VESSELS. The arterial supply to the brain arises from paired carotid and vertebral arteries in the neck. These four vessels continue into the head and divide into separate anterior, middle and posterior cerebral arteries that provide oxygen and nutrients to different regions of the brain. These vessels are interconnected at the base of the brain through a network of arteries called the circle of Willis. The principal veins within the head, the dural venous sinuses, collect blood that has passed through the brain. Blood vessels may cause symptoms by becoming enlarged or narrowed, occluded, or by supplying vascular malformations in or around the brain.

BRAIN COVERINGS. The brain is not rigidly adherent to the skull. It is surrounded by three layers of covering: the innermost pia mater, the middle arachnoid mater, and the outermost dura mater. Cerebrospinal fluid (CSF), a translucent liquid derived from blood and contained within the space between the pia and arachnoid mater, serves as a chemical and physical cushion for the brain. Blood from ruptured aneurysms, trauma or pus from infections such as meningitis may collect within the spaces between meningeal layers or within the CSF.

THE SKULL. The bones that surround the brain, including the calvarium, facial skeleton and skull base, are collectively referred to as the skull. These structures provide protection for the brain and a rigid frame to support the functions of the face. Because cortical bones contain very little water, they are evaluated reliably only with CT. The marrow within these bones, however, can be seen on MRI images. Bones can be the primary source of disease, or they can be secondarily involved by different infections and tumors, for example.

SURROUNDING TISSUES. The skull is surrounded not only by the scalp, but also fat, muscles, blood vessels, and various special glands. Importantly, the front of the head contains an array of muscles, salivary glands, and lymph nodes that may be primarily or secondarily affected by various disorders. The physical location of abnormalities in these regions often gives clues as to the source of disease.

Still there is lot more material in this long article and there are excellent images. There are references. For further reading visit:

Source Knol: BRAIN: CT, MRI

Ragnarok Online - Sniper Guide - Reshared Knol

Source Knol : Ragnarok Online - Sniper Guide
by Hans Christian


I. INTRODUCTION


Welcome to my first guide.I want to write this guide because i want to make sure everybody who loves
sniper job can masters his technique to beat everybody in the arena.Anyway,this guide contains
how to build a deadly Sniper based on my experience,non else.
And i hope this guide can help you to b e a feared killer character.^^

II. TYPES OF SNIPERS

There are many types of Status, each of them has their own special abilities,
Choose what suit you most.Personally,the most type that I used all the time
is the double strafing Sniper,since that's the most wicked sniper.

Double Strafing Sniper :
STR 1
AGI 99
VIT 21
INT 10
DEX 99
LUK 1

The most suitable type for me,since you can shoot your arrow like MG42,most of character can't move until they died,except if they are usingendure skill like knight.But,i will discover how to beat them later.Note that this type can't stand long if You get hit.So,be careful.


AGI LUK Sniper :
STR 1
AGI 98
VIT 30
INT 45
DEX 60
LUK 50
This type Rockz !! With This status,at least it will attack about 1100 per hit.
And the falcon will attack consecutively.With set of nice equip,This sniper is wicked !
You should attack fast enough,with medium arrow damaged,while u enjoying your
Nice High Damage From your Beloved falcon.So that's like a 3 way hit.
I've done this type when i was a hunter,it is so difficult to build.But you
will start enjoy it when your character reach level 80.Note that this type is
incredible when you are hunting,but it's sadly that this type is poor when you
put it into the PVP arena.

Falcon Assault Sniper :
STR 1
AGI 1
VIT 68
INT 98
DEX 74
LUK 1
This typed only depends from its INT ( for the damaged ).
This typed is hard to kill,because they have a lot of HP,and this type is
much on the Defense.And this type is quite good since FA does not
look at the opponent's defense.But you have to remember about skill delay too.

Hybrid Sniper :
STR 1
AGI 72
VIT 50
INT 45
DEX 97
LUK 1
This type is very common,because this type have some damaged with FA,
Nice damage with Double Strafe,and the Defense is not too bad,at least to avoid
being stun too long.And you will get a nice ASPD too.

III. ARCHER SKILL TREE

image in the original article

IV. HUNTER SKILL TREE

image in the original article

V. SNIPER SKILL TREE

image in the original article

VI. EQUIPMENTS


There are many types of equipment sets,but what i will write is sets of sniper equipment
that I know its greatness.And you know,You have to use them on the right places,or the effect
wouldn't work as we hope.

SNIPER EQUIPMENT SET
This is what I used all the time for PVP,and usually this set is feared in the server
by the drop rate item at 1x.

Apple of Archer
Binocular
Tights + Anolian card
Boots + Merman card
Composite bow ( make it +10 ) + Hydra card *2,Skel Worker card and Cruiser card.
Glove [1] + Alligator card.
Glove [1] + Zerom card.
Muffler + Dragon Tail Card

This sets is called sniper set because it contains cards combo that
only benefit for snipers,which is Anolian,Merman,Cruiser,Alligator and Dragon Tail.
Combo effects :
Inflict 20% more damage with Long Range Physical attack.
AGI + 5
DEX + 3
Seeking Attack (which never miss its target) + 20%.

Receive 5% more Experience Points from Brute monsters.
Add a chance of auto casting 'Coma' on Brute monster when attacking.

FALCON ASSAULT TYPE EQUIPMENT
For This type,there are no card combos to boost the attack.But,this is
The set of cards and equipments that slightly will increase your performance.

Crown
binoculars
Tights + Marc Card
Boots + Matyr Card
Muffler + Raydric Card
2 GLove [1] + 2 Zerom card
Main Gauche ( Make it + 10 )+ 4 Fabre Card
Guard + Thara frog card

Remember,this equipments only useful when you try to attack the target with FA.
Dont even attempt a Double Strafe skill or it will be crappy.Try to be fast for changing
better equipments for Double Strafe or normal attacks if you want to use it.

AGI LUK EQUIPMENT
This set of equipment is designed to prove your falcon auto blizt beat.
I really can't ensure you to use my recommended equipments.But,i suggest that
you should wear a bunny band,the rest is up to you.

FEARSOME EQUIPMENT SET
This is it,this equipment is the best from all the set.But,notice that you will have some
hard time to complete this set.Even you are playing in the server at the drop rate of 3000x.
And,don't forget to forge it at least into +7 to make it Even GREAT !!

Feather Beret or Alice Doll + Maya Purple or Ulle's Cap + Maya Purple
Masquerede or Binoculars
Sniping Suit + Ghostring Card or Sniping Suit + Angeling Card
Tidal Shoes + Matyr Card
Wool Scarf + Raydric Card or Wool Scarf + Deviling Card ( if you're up ONLY against a physical enemies )
Orleans Glove + Zerom Card
Orleans Glove + Zerom Card
Composite Bow ( Make it +10) + Lord of Death Card*2,Stormy Knight*2
or Composite Bow ( Make it +10) + Lord of Death Card*2,Stormy Knight,Valkyrie Randgris Card.
This is what i am talking about from the beginning,with this set of equipment,your sniper will be
a King in the court.But remember,keep your distance between you and your enemy,since you only have a little amount of defense.

VI. SNIPER'S ADVANTAGE

This is what Snipers can do in WOE :

1.Sniping : Attack enemies with DS or just with normal attack.Use DS to jobs such as Ass X,Champion,High Wizzard.If installed Lord of Death to your Bow,use normal attacks to Jobs with Bunch of Defense such as Paladin,Lord Knight,HP.

2.Trap : Use your ankle snare around the Emperium,and Don't forget to use your Shockwave trap,because it will be deadly for HW.

3.Status effect : You know,use your numbers of arrow like curse arrow,flash arrow,mute arrow,etc.

4.Wizzard supporter : these Sniper use wind arrow and breaks frost enemy in a running SG this is what makes being in an SG so painful,getting hit by SG with 2000++ damage,getting frost,then getting hit by an element SS for 5000++ then get frost back by SG.

5.Attacking Sniper : Use FA to a character that inflicted by Lex Aeterna so they will be eat at least 11k+++ damage.

6.usually Sniper are for defense,with their sniping skills and their various traps.

VI. SNIPER'S ENEMIES

Champion=
Yo can cancel asura by just locking them using normal shots.pneuma won't save against those status arrows.

High Wizard=
Use your double strafe as many as you can,they won't last long.

Assasins =
Just detect them if they're hiding,and quickly DS them.Their defense are poor.

Ninja =
Easy,Just use your FA to them.If they're using cicada skin shed,target FA to the enemy
so they can hit the wall and they can't dodge your attack anymore.

If you fight a VIT character,You have to use your Lord of Death Card*2,Stormy Knight*2 bow,so those character
will be Nothing.

VII. FINAL STATEMENT

Finally,this is the end of my word.Thanks for reading this guide.If you have any question or critics,
just give me some comment so I will know what you seek.And you may want to explore some of
my ads,if you want to.^^


2008 - Hans Christian

For images and some more links visit:

Source Knol : Ragnarok Online - Sniper Guide