Clonidine has also been used as a preanaesthetic because of its anxiolytic properties without having re- spiratory depressant activity and therefore may be potentially useful during that period [15 generic ampicillin 500mg mastercard treatment for uti in female dog, 80–89] buy ampicillin american express antibiotic you can't drink alcohol. Premedication with clonidine reduced the requirement for volatile agents during general anaesthesia  buy ampicillin from india 3m antimicrobial gel wrist rest, whereas clonidine 2. However, 5 mcg/kg-1 clonidine orally was associated with prolonged recovery from propofol/fentanyl anaesthesia [86, 87]. After oral premedication with either clonidine 3 mcg/kg-1 or placebo in patients un- dergoing vascular surgery, Morris et al. Therefore, it is possible that the reduced cardiac output of these patients resulted in altered propofol disposition so that slower infusion rates were required to achieve the same blood concentrations. Induction of anaesthesia, tracheal intubation, surgical incision and surgery under regional anaesthesia and mergence from anaesthesia are associated with dramatically increased sympathetic activity. Alpha-2-adrenoceptor agonists at appropriate doses reliably control heart rate and blood pressure in patients undergoing surgery [3, 4, 69, 75, 78, 81, 90–101], including neurosurgery [24, 70, 81, 93, 102–104]. The incidence of perioperative myocardial ischaemia was signi¿cantly reduced with clonidine. In addition, clonidine reduced the in- cidence of postoperative mortality for up to 2 years. However, these patients were dispro- portionately present in the placebo group, and the mortality difference was thus considered to be due to the presence of a subset of high-risk patients in the placebo group . The lack of widespread use of clonidine by anaesthesiologists probably reÀects [108, 109]: 1. Aantaa R, Jalonen J (2006) Perioperative use of alpha2-adrenoceptor agonists and the cardiac patient. Fletcher D, Aubrun F, Adam F et al for the Comité douleur-anesthésie locorégion- ale et le comité des référentiels de la Sfar (2008) Formalized recommendations of experts 2008. Gordh T, Jansson I, Hartvig P et al (1989) Interactions between noradrenergic and cholinergic mechanisms involved in spinal nociceptive processing. Noyer M, de Laveleye F, Vauquelin G et al (1994) Mivazerol, a novel compound with high speci¿city for alpha 2 adrenergic receptors: binding studies on different human and rat membrane preparations. Sallinen J, Haapalinna A, Viitamaa T et al (1998) Adrenergic alpha-2C-receptors modulate the acoustic startle reÀex, prepulse inhibition, and aggression in mice. Tank J, Jordan J, Diedrich A et al (2004) Clonidine improves spontaneous barore- Àex sensitivity in conscious mice through parasympathetic activation. Tibirica E, Feldman J, Mermet C et al (1991) An imidazoline-speci¿c mechanism for the hypotensive effect of clonidine: a study with yohimbine and idazoxan. Koppert W, Sittl R, Scheuber K et al (2003) Differential modulation of remifenta- nil-induced analgesia and postinfusion hyperalgesia by S-ketamine and clonidine in humans. Polarz H, Bohrer H, Martin E et al (1993) Oral clonidine premedication prevents the rise in intraocular pressure following succinylcholine administration. Bonhomme V, Maquet P, Phillips C et al (2008) The effect of clonidine infusion on 288 C. Delaunay L, Bonnet F, Liu N et al (1993) Clonidine comparably decreases the thermoregulatory thresholds for vasoconstriction and shivering in humans. Joris J, Banache M, Bonnet F et al (1993) Clonidine and ketanserin both are effec- tive treatment for postanesthetic shivering. Marinangeli F, Ciccozzi A, Donatelli F et al (2002) Clonidine for treatment of postoperative pain: a dose-¿nding study. Gowing L, Ali R, White J (2006) Opioid antagonists with minimal sedation for opioid withdrawal. Anesthesiology 24 Of-label Drugs in Perioperative Medicine: Clonidine 289 82:741–748 56. Klimscha W, Chiari A, Krafft P et al (1995) Hemodynamic and analgesic effects of clonidine added repetitively to continuous epidural and spinal blocks. Roelants F (2006) The use of neuraxial adjuvant drugs (neostigmine, clonidine) in obstetrics. Elia N, Culebras X, Mazza C et al (2008) Clonidine as an adjuvant to intrathecal local anesthetics for surgery: systematic review of randomized trials. Gentili M, Juhel A, Bonnet F (1996) Peripheral analgesic effect of intra-articular clonidine. Ghignone M, Calvillo O, Quintin L (1987) Anesthesia and hypertension: the effect of clonidine on perioperative hemodynamics and isoÀurane requirements. Nishina K, Mikawa K, Shiga M et al (1997) Oral clonidine premedication reduces minimum alveolar concentration of sevoÀurane for tracheal intubation in children. Viggiano M, Badetti C, Roux F et al (1998) Controlled analgesia in a burn patient: fentanyl sparing effect of clonidine. Mikawa K, Nishina K, Shiga M (2002) Prevention of sevoÀurane-induced agita- tion with oral clonidine premedication. Higuchi H, Adachi Y, Dahan A et al (2002) The interaction between propofol and clonidine for loss of consciousness. Higuchi H, Adachi Y, Arimura S et al (2002) Oral clonidine premedication reduces the awakening concentration of propofol. Br J Anaesth 95:183–188 24 Of-label Drugs in Perioperative Medicine: Clonidine 291 89. Gregoretti C, Decaroli D, Piacevoli Q et al (2008) Analgo-sedation of patients with burns outside the operating room. Quintin L, Bouilloc X, Butin E et al (1996) Clonidine for major vascular surgery in hypertensive patients: a double-blind, controlled, randomized study. Nishina K, Mikawa K, Uesugi T et al (2002) Ef¿cacy of clonidine for prevention of perioperative myocardial ischaemia: a critical appraisal and meta-analysis of the literature. Gregoretti C, Moglia B, Pelosi P, Navalesi P (2009) Clonidine in perioperative medicine and intensive care unit: more than an anti-hypertensive drug. An- aesthesia International (in press) Cost Efectiveness of Spinal Cord Stimulation 25 in the Management of Severe Angina M. However, there is a group of patients that continues to suffer from lasting and severe and disabling angina pectoris despite optimum drug treatment and who are not suitable candidates for surgery. Patients with refractory angina generally have poor quality of life due to inadequate symptom relief, frequent hospitalisations, and limited physical activity with negative con- sequences for their quality of life. Due to the challenging pain problem, refractory angina is clinically important not only for the cardiologist, but also for other specialists, such as those in acute medicine, anesthesiology, and pain treatment . Additional treatment modalities for severe angina pectoris, including refractory angina, are therefore needed. The ¿rst spinal cord stimulator was implanted in 1967 , and toward the end of the 1970s, the method was tried in patients with severe peripheral arterial circulatory insuf¿ciency of the lower extremities, with favourable effects, both on peripheral arterial circulation and pain . Via an incision at the T 6–8 level, an electrode is inserted into the epidural space and guided via X-ray monitoring up to the T 1–2 vertebrae level.
We encourage a strong and collegial relationship between faculty residents and all members of the department purchase ampicillin 250mg free shipping antibiotic biogram. We believe when our residents finish this program they should have outstanding skills and knowledge and we will help them obtain the fellowship buy discount ampicillin 500 mg line antibiotics for uti bladder infection, faculty or hospital position that they choose purchase on line ampicillin antibiotics for uti cefdinir. Competencies that are specific to individual rotations are included with each sub-discipline. Residents will be given graduated responsibilities and will be evaluated at two general skill levels. Specific goals and learning objectives (Skill Levels) are described under each sub-discipline. Objectives: Learning Evaluation Activities Activities Demonstrate the ability to critically assess the scientific literature. In addition, there are 1-3 cytopathology fellows, 1-2 Surgical Pathology Fellows, and 1-3 post-sophomore fellows. The faculty works with the residents to design an elective program that will provide a sound educational experience in the resident’s chosen area of concentration, as well as to flexibly adapt to the resident’s level of expertise and career goals. During the elective time residents are encouraged to spend time carrying out basic or applied research and/or time pursuing subspecialty training. In addition, the following list of year-specific goals defines specific goals either in skills, knowledge, or professionalism that are appropriate for each year of training. Residents must strive to achieve these goals as well as the overall educational goals described in the previous pages. Goals may vary somewhat between levels depending on individual rotation schedules. The resident must demonstrate a prioritization of educational mission, with the willingness and appreciation of teaching from attending staff, fellows and senior residents and other para-health professionals. They should demonstrate understanding in what is told to them by appropriate and timely follow-up on assigned duties. Attendance is required for all residents, except for those residents on vacation or on a rotation outside of Kansas City. Depending upon the conference, attendance is required at 80% of the conferences depending upon the resident rotation. Residents must be present prior to or within 10 minutes after the beginning of each conference or lecture in order to fulfill the attendance requirement. Conference attendance will be recorded by the Chief Residents and reviewed on a quarterly basis by the Program Director. Failure to achieve the required attendance level will result in disciplinary action including loss of educational funds for the next academic year. Publishing a peer-reviewed article is considered as important educational experience and all residents are expected to publish a minimum of one manuscript during their training or present at least one abstract at a national meeting. Pathology Resident Manual Page 17 Resident Travel Funds Each resident may apply for funding to attend up to two regional/national scientific meetings during the four-year residency program contingent upon availability of funds as determined by the Chair of the Department of Pathology. Funding will be contingent upon the resident being in good standing by the Program Director. If the resident is on a rotation that requires resident service, it is the responsibility of the resident to find coverage for the service (as approved by the Chief Residents and Program Director). In such cases, the strength of the scientific project will be reviewed by the Department of Pathology Research Committee or Resident Education Committee and final approval will be determined by the Department Chair based upon availability of funds. Resident Educational Funds Each academic year each resident will be allocated $750 for educational development. Additionally, these funds may be applied to cover expenses related to attending pre- approved medical conferences and workshops. American Board of Pathology application fees and permanent license fees are not covered. Funding will be contingent upon the resident being in good standing (including adequate conference attendance) as deemed by the Program Director. During the year that a resident serves as Chief Resident, the allocation is increased to $1,250. Funding will also be provided for travel expense, lodging, food, and meeting registration, not to exceed $1,200 (receipts are required for reimbursement) for each resident to attend a board review course during either the third or fourth year of the residency program. Such residents may petition the residency education committee for consideration of extension of contract to allow them time to take the examination again. Initial Application Screening The initial screening of applicants is done by the residency program coordinator or program directors. If greater than 10 years, the type of work the candidate has been engaged in since graduation from medical school is noted. Experience, either by education or work experience, in the field of pathology is noted. The program directors read the applicant’s personal statement and evaluate it based on the following: • Command of the English language • Stated genuine interest in Pathology • Overall quality of the statement • Dean’s Letter • Medical Transcripts • Letters of reference • Any potential items for concern Additional Screening If the program director is unable after the secondary screening to make a decision on whether or not to invite a candidate, the application will be sent to one of the other program director or another member of the Resident Education Committee for their review. After receiving feedback from the committee reviewer, the program director will decide whether or not to extend an invitation to the candidate. Each candidate that is selected for interview will be invited via email by the residency program coordinator. Once the applicant is schedule, they will be sent an email with an interview confirmation and instructions for the interview day. Interview Process Six to 8 interview dates are selected and up to 8 candidates may be interviewed per interview day. At the beginning of each interview day an overview of the institution and program is presented. Five faculty members, including the two program directors and one chief resident interview the applicants. Each interviewer is given all application materials for each applicant to be interviewed in their scheduled day. Each interviewer is asked to complete a resident candidate evaluation form and also an individual ranking Pathology Resident Manual Page 20 form for each candidate they interview. Interviewers are asked to assign them a quartile based on every applicant they have ever interviewed. In February an annual ranking meeting is held with all faculty and resident interviewers and any other faculty who wish to attend. After initial grouping into ‘Upper, Middle, or Lower Thirds’, the final rank list determined by the committee. A list of faculty members who will evaluate residents on each rotation has been developed and a tracking mechanism is used to insure that all evaluations have been obtained. Resident evaluations are reviewed by the Program Director and are summarized for the Resident Education Committee Meeting and at least annually at a meeting attended by all clinical faculty members. If a problem with performance is identified for any resident, the Program Director or designee immediately meets with the resident to discuss the issues and develop a plan of action. If there are no problems with the performance, the residents review and sign their evaluations at the time of evaluation release or at the six- month review meeting with the Program Director. Clinical faculty members meet at the end of the academic year to decide on promotion for each resident.
This proved to be safe and feasible and was achieved without delaying door-to- balloon time  buy ampicillin uk antibiotic prophylaxis joint replacement. Possible side effects must be kept in mind to prevent or counteract them in a timely manner but should not prevent the use of hypothermia when indicated purchase ampicillin with american express infection yellow pus. The European multicentre trial did not report a signi¿cant difference in complication rate buy ampicillin in united states online bacteria webquest, but there was a trend towards more infections and sepsis in the hypothermia group . Other studies did not report a higher rate of infections after treat- ment with hypothermia [36, 37]. A meta-analysis of three randomised trials showed a trend towards a higher incidence of sepsis, whereas the incidence of pneumonia did not differ between hypothermia and normothermia groups . A high level of vigilance towards infection seems advisable in cooled patients after cardiac arrest. However, in none of the clinical trials have major bleeding complications attributable to hypothermia been observed. A trend towards a higher incidence of bleeding episodes is reported in an observational study by Wolfrum et al. They found platelet function unaltered by mild hypothermia, and platelet inhibition by clopidogrel was even attenuated. Further studies seem necessary to determine the optimal antiplatelet therapy in hypothermic patients undergoing coronary intervention, more so because patients after cardiac arrest due to myocardial infarction show pronounced platelet hyperfunction . Patients randomised to hypothermia had more premature ventricular beats but showed no increased incidence of clinically relevant ar- rhythmias compared with the normothermia group . Patients who were in cardiogenic shock after cardiac arrest also seem to substantially pro¿t from therapeutic hypothermia. They observed a rise in mean arterial pressure after cooling, and despite the expected higher mortality rate, a neurologic recovery comparable with patients without shock . Of 17, ¿ve in the hypothermia group survived vs none of 14 in the control group (p = 0. Of 50 pa- tients, 23 were treated with an intra-aortic balloon pump, and 14 of those (61%) survived to favourable neurological recovery. Although drug levels might rise because of reduced me- tabolism, the potency and ef¿cacy of certain drugs are diminished by hypothermia. Dur- ing rewarming, these processes might be reversed, further enhancing the risk of over- or underdosing of drugs. In the normothermic patients, a steady state of 1,500 ng/ml was achieved, whereas in hypothermic patients, a ¿vefold increase in concentration was observed. Fentanyl concentration has been found to rise at body temperatures below mild hy- pothermia. At 29°C, plasma concentrations were increased twofold compared with nor- mothermia in piglets . Propofol concentration has been shown to rise by 28% at 34°C compared with 37°C in healthy volunteers . Duration of action of the neuromuscular blocking agents vecuronium, rocuronium and atracurium is prolonged, so monitoring of the neuromuscular function seems advisable . During hypothermia, the clearance of many more drugs is altered, as a recent comprehensive review demonstrates . It should also be considered for out-of-hospital cardiac arrest from a nonshockable rhythm or cardiac ar- 124 T. It is thus far the only therapy that improved neurological outcome after cardiac arrest in a randomised controlled trial. Lloyd-Jones D, Adams R, Carnethon M et al (2009) Heart disease and stroke statis- tics – 2009 update: a report from the American Heart Association Statistics Com- mittee and Stroke Statistics Subcommittee. Hypothermia After Cardiac Arrest Study Group (2002) Mild therapeutic hypo- thermia to improve the neurologic outcome after cardiac arrest. Hachimi-Idrissi S, Van Hemelrijck A, Michotte A et al (2004) Postischaemic mild hypothermia reduces neurotransmitter release and astroglial cell proliferation during reperfusion after asphyxial cardiac arrest in rats. Horiguchi T, Shimizu K, Ogino M et al (2003) Postischaemic hypothermia inhibits the generation of hydroxyl radical following transient forebrain ischaemia in rats. Lei B, Tan X, Cai H et al (1994) Effect of moderate hypothermia on lipid peroxida- tion in canine brain tissue after cardiac arrest and resuscitation. Fukuda H, Tomimatsu T, Watanabe N et al (2001) Post-ischaemic hypothermia blocks caspase-3 activation in the newborn rat brain after hypoxia-ischaemia. Eberspacher E, Werner C, Engelhard K et al (2005) Long-term effects of hypo- thermia on neuronal cell death and the concentration of apoptotic proteins after incomplete cerebral ischaemia and reperfusion in rats. Yanagawa Y, Ishihara S, Norio H et al (1998) Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest. Nagao K, Hayashi N, Kanmatsuse K et al (2000) Cardiopulmonary cerebral resus- citation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital. Zeiner A, Holzer M, Sterz F et al (2000) Mild resuscitative hypothermia to improve 126 T. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardio- vascular Care Science with Treatment Recommendations (2005) Part 4: Advanced life support. Arrich J (2007) Clinical application of mild therapeutic hypothermia after cardiac arrest. Holzer M, Mullner M, Sterz F et al (2006) Ef¿cacy and safety of endovascular cool- ing after cardiac arrest: cohort study and Bayesian approach. Skulec R, Kovarnik T, Dostalova G et al (2008) Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome. Acta Anaes- thesiol Scand 52(2):188–194 11 Mild Therapeutic Hypothermia after Cardiac Arrest 127 46. Fukuoka N, Aibiki M, Tsukamoto T et al (2004) Biphasic concentration change during continuous midazolam administration in brain-injured patients undergoing therapeutic moderate hypothermia. Koren G, Goresky G, Crean P et al (1984) Pediatric fentanyl dosing based on phar- macokinetics during cardiac surgery. Anesth Analg 80(5):1007–1014 Nasopharyngeal Cooling 12 During Cardiopulmonary Resuscitation F. Patients success- fully resuscitated following cardiac arrest in fact often present with what is now termed “postresuscitation disease” . Most prominent among these diseases are postresuscita- tion myocardial failure and ischaemic brain damage. Severe postresuscitation heart con- tractile failure has been implicated as one of the most important mechanism causing these fatal outcomes [6–9]. Up to 30% of survivors of cardiac arrest man- ifest permanent brain damage [10–12], and in some instances, only 2–12% of resuscitated patients are discharged from hospital without neurological dysfunction . The greatest postresuscitation emphasis has therefore been on minimising postresus- citation myocardial dysfunction and achieving long-term neurologically intact survival . Among all postresuscitation-care interventions suggested and/or recommended as the most persuasive bene¿ts both for the brain and the heart is the use of hypothermia [15–18].
Diagnostic terms should be as specific as possible and yet be general pathological terms (for example: "arteriosclerosis cheap ampicillin 250 mg mastercard antibiotic upset stomach, cerebral arteries" rather than "cerebral sclerosis") discount ampicillin 500 mg online narrow spectrum antibiotics for sinus infection. There are many situations in which the whole course of a disease depends upon a relatively innocuous lesion being located in a particular site buy ampicillin 250mg mastercard 51 antimicrobial agents 1. A subcutaneous abscess of the upper lip, however, carries considerably more danger because of its location. In the diagnoses the order should be as follows: (1) disease process (noun); (2) organ, tissue or cells, and (3) modifier (e. The list of diagnoses should be as complete as possible, but should not include abnormalities of no significance. Pathology Resident Manual Page 103 With regard to the major diagnoses, the first diagnosis should always be the fundamental disease, and should be similar to the wording on the death certificate. Example • Acute gangrenous appendicitis, with: • Appendiceal abscess • thrombosis of appendiceal vein • pylephlebitis • multiple liver abscesses Other diagnoses should include any other concomitant conditions such as hyperplasia of prostate, arteriosclerosis, etc. This arrangement of specific terms and specific sites will give the reader at a glance a fairly good summary of the patient’s illness and death. Where there have been surgical pathology specimens, they should be cross referenced in the diagnosis, the accession number given, described in the autopsy protocol where applicable, and duplicate slides filed with the autopsy slides. The Provisional Anatomical Diagnosis will, in most cases, be modified considerably in the light of subsequent studies and should be re-worked thoroughly to result in the Final Anatomical Diagnosis before the case is presented for final checking. For file card purposes, check the one principal or most important disease process or anatomical diagnosis on both the provisional and final anatomical diagnosis. Opinion Use the opinion section of the report to synthesize the clinical and pathologic findings. Most autopsies already have a history contributed by the clinician and one dictated by the pathologist. Similarly, since a diagnosis sheet is present elsewhere in the autopsy protocol, a re-listing of diagnoses is inadvisable. An opinion can be based on a clinical problem list, or better, one that the pathologist generates after reading the chart and performing the gross autopsy. It should be principally a clinical- pathological correlation, discussion of significance of the principal findings and a resume of the prosector’s correlation of the case with the literature and departmental files of similar cases. Surprises, fulfilled predictions, interesting or unusual conditions, significant negative findings should be mentioned. The opinion is not the place to criticize the clinical care, yet the autopsy still remains the best instrument of quality control. Gross and Microscopic Description Because data are obtained essentially at two different times, two descriptive reports are written. The first embodies the data obtained from the clinical history, the gross examination and such chemical, bacteriological or frozen section data as are available at the completion of gross dissection. The most complete and accurate description Pathology Resident Manual Page 104 is made at the time of dissection not by relying on memory afterwards. The second is written after microscopic examination and all chemical, bacteriological, viral, histochemical and other studies have been completed. The first report is made to preserve the detailed data of the clinical record and gross examination until the final report can be written, and is used in selecting case material and specimens for conferences, classes, etc. Autopsy Photographs Color photographs should be taken at the time of autopsy of the overall body, the facial features, injuries, and significant anatomic abnormalities. Clinical Summary The clinical record is available at the time the autopsy is done, but must be returned to the record room via the secretary within 24 hours from the completion of the autopsy. Therefore, the first draft of the clinical summary should be reasonably complete since the data provided may well be used in the final interpretation. The rough draft of the clinical summary should include dates, laboratory data, opinions of various examiners, results of special examinations and any other relevant data. The clinical summary should be chronological and should include clinical opinions and diagnoses. The clinical summary should include certain calendar dates: date of onset of the important illness, date of admission to the hospital, date of operation (for that illness), and date and time of death. Important incidents in the past history (before the present illness) may be referred to by date. The train of events in the last illness, however, should be tied together by a few reference points and liberal use of days, weeks, months, years, etc. Example: Third postoperative day, sixth week of hospitalization, tenth year of disease etc. One need not catalog every symptom so that the reader views the patient’s story exactly as the clinician did. Generally it is necessary to state if the patient was treated with antibiotics, with transfusions, antimetabolites, diuretics, corticosteroids, etc. Supportive treatment such as vitamins, sedatives or tranquilizers need not be listed specifically. Pathology Resident Manual Page 105 • Within 24 hours further dissection completed and gross autopsy checked by senior staff supervisor. The pathology resident should be able to perform a competent medicolegal examination and document the findings with sufficient detail to aide in the administration of justice. The resident will dictate autopsies in which they are the primary prosector within 24 hours. The resident shall follow up on microscopic, radiographic and toxicologic examinations, and observe court proceedings. Further, it prepares the resident for additional training for career specializing in clinical transfusion medicine, transfusion medicine research, blood center operations, histocompatibility hematopoietic stem cell transplants or organ banking. After the training period, the resident will be knowledgeable and experienced with red cell antigens, compatibility testing, component therapy, adverse effects of transfusion, transfusion appropriateness review, blood donor evaluation and donation, therapeutic apheresis, peripheral blood stem cell collection, stem cell processing and infusion. Transfusion medicine clinical training and experience is provided at two major teaching sites. Community Blood Center of Kansas City is a state-of-the-art blood collection and processing center. They also provide apheresis services, and conduct both clinical and basic science research related to Transfusion Medicine. The resident will take a 2-week bench-oriented course, as an introduction to the science of Transfusion Medicine as part of their training. The attending physician spends one to three hours each week day with the resident. The resident carries out the provision of clinical blood bank services but with close overview. The attending physician also sees therapeutic apheresis patients and inpatient consults and countersigns notes made by the resident in the patient’s medical record (consults, stem cell infusions, therapeutic procedures). Individual decisions to approve components not meeting guidelines and deviations from blood bank procedures (e. In addition to daily mentoring by the attending physician, the resident receives scheduled didactic learning sessions (one-on-one) from the physician in charge of the apheresis/donor center, the blood bank laboratory and the cell therapy laboratory.
M. Tragak. Dawson College.