title: Sterilization (microbiology)

text: Biological indicators can also be used to independently confirm autoclave performance. Simple biological indicator devices are commercially available, based on microbial spores. Most contain spores of the heat-resistant microbe "Geobacillus stearothermophilus" (formerly "Bacillus stearothermophilus"), which is extremely resistant to steam sterilization. Biological indicators may take the form of glass vials of spores and liquid media, or as spores on strips of paper inside glassine envelopes. These indicators are placed in locations where it is difficult for steam to reach to verify that steam is penetrating there.


title: Sterilization (microbiology)

text: For autoclaving, cleaning is critical. Extraneous biological matter or grime may shield organisms from steam penetration. Proper cleaning can be achieved through physical scrubbing, sonication, ultrasound, or pulsed air.


title: Sterilization (microbiology)

text: Pressure cooking and canning is analogous to autoclaving, and when performed correctly renders food sterile.


title: Sterilization (microbiology)

text: To sterilize waste materials that are chiefly composed of liquid, a purpose-built effluent decontamination system can be utilized. These devices can function using a variety of sterilants, although using heat via steam is most common.


title: Sterilization (microbiology)

text: Dry heat was the first method of sterilization and is a longer process than moist heat sterilization. The destruction of microorganisms through the use of dry heat is a gradual phenomenon. With longer exposure to lethal temperatures, the number of killed microorganisms increases. Forced ventilation of hot air can be used to increase the rate at which heat is transferred to an organism and reduce the temperature and amount of time needed to achieve sterility. At higher temperatures, shorter exposure times are required to kill organisms. This can reduce heat-induced damage to food products.


title: Sterilization (microbiology)

text: The standard setting for a hot air oven is at least two hours at . A rapid method heats air to for 6 minutes for unwrapped objects and 12 minutes for wrapped objects. Dry heat has the advantage that it can be used on powders and other heat-stable items that are adversely affected by steam (e.g. it does not cause rusting of steel objects).


title: Sterilization (microbiology)

text: Flaming is done to inoculation loops and straight-wires in microbiology labs for streaking. Leaving the loop in the flame of a Bunsen burner or alcohol burner until it glows red ensures that any infectious agent is inactivated. This is commonly used for small metal or glass objects, but not for large objects (see Incineration below). However, during the initial heating, infectious material may be sprayed from the wire surface before it is killed, contaminating nearby surfaces and objects. Therefore, special heaters have been developed that surround the inoculating loop with a heated cage, ensuring that such sprayed material does not further contaminate the area. Another problem is that gas flames may leave carbon or other residues on the object if the object is not heated enough. A variation on flaming is to dip the object in a 70% or more concentrated solution of ethanol, then briefly touch the object to a Bunsen burner flame. The ethanol will ignite and burn off rapidly, leaving less residue than a gas flame


title: Sterilization (microbiology)

text: Incineration is a waste treatment process that involves the combustion of organic substances contained in waste materials. This method also burns any organism to ash. It is used to sterilize medical and other biohazardous waste before it is discarded with non-hazardous waste. Bacteria incinerators are mini furnaces that incinerate and kill off any microorganisms that may be on an inoculating loop or wire.


title: Sterilization (microbiology)

text: Named after John Tyndall, Tyndallization is an obsolete and lengthy process designed to reduce the level of activity of sporulating bacteria that are left by a simple boiling water method. The process involves boiling for a period (typically 20 minutes) at atmospheric pressure, cooling, incubating for a day, and then repeating the process a total of three to four times. The incubation periods are to allow heat-resistant spores surviving the previous boiling period to germinate to form the heat-sensitive vegetative (growing) stage, which can be killed by the next boiling step. This is effective because many spores are stimulated to grow by the heat shock. The procedure only works for media that can support bacterial growth, and will not sterilize non-nutritive substrates like water. Tyndallization is also ineffective against prions.


title: Sterilization (microbiology)

text: Glass bead sterilizers work by heating glass beads to . Instruments are then quickly doused in these glass beads, which heat the object while physically scraping contaminants off their surface. Glass bead sterilizers were once a common sterilization method employed in dental offices as well as biological laboratories, but are not approved by the U.S. Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) to be used as a sterilizers since 1997. They are still popular in European and Israeli dental practices, although there are no current evidence-based guidelines for using this sterilizer.


title: Sterilization (microbiology)

text: Chemicals are also used for sterilization. Heating provides a reliable way to rid objects of all transmissible agents, but it is not always appropriate if it will damage heat-sensitive materials such as biological materials, fiber optics, electronics, and many plastics. In these situations chemicals, either in a gaseous or liquid form, can be used as sterilants. While the use of gas and liquid chemical sterilants avoids the problem of heat damage, users must ensure that the article to be sterilized is chemically compatible with the sterilant being used and that the sterilant is able to reach all surfaces that must be sterilized (typically cannot penetrate packaging). In addition, the use of chemical sterilants poses new challenges for workplace safety, as the properties that make chemicals effective sterilants usually make them harmful to humans. The procedure for removing sterilant residue from the sterilized materials varies depending on the chemical and process that is used.


title: Sterilization (microbiology)

text: Ethylene oxide (EO, EtO) gas treatment is one of the common methods used to sterilize, pasteurize, or disinfect items because of its wide range of material compatibility. It is also used to process items that are sensitive to processing with other methods, such as radiation (gamma, electron beam, X-ray), heat (moist or dry), or other chemicals. Ethylene oxide treatment is the most common chemical sterilization method, used for approximately 70% of total sterilizations, and for over 50% of all disposable medical devices.


title: Sterilization (microbiology)

text: Ethylene oxide treatment is generally carried out between with relative humidity above 30% and a gas concentration between 200 and 800 mg/L. Typically, the process lasts for several hours. Ethylene oxide is highly effective, as it penetrates all porous materials, and it can penetrate through some plastic materials and films. Ethylene oxide kills all known microorganisms, such as bacteria (including spores), viruses, and fungi (including yeasts and moulds), and is compatible with almost all materials even when repeatedly applied. It is flammable, toxic, and carcinogenic; however, only with a reported potential for some adverse health effects when not used in compliance with published requirements. Ethylene oxide sterilizers and processes require biological validation after sterilizer installation, significant repairs or process changes.


title: Sterilization (microbiology)

text: The traditional process consists of a preconditioning phase (in a separate room or cell), a processing phase (more commonly in a vacuum vessel and sometimes in a pressure rated vessel), and an aeration phase (in a separate room or cell) to remove EO residues and lower by-products such as ethylene chlorohydrin (EC or ECH) and, of lesser importance, ethylene glycol (EG). An alternative process, known as all-in-one processing, also exists for some products whereby all three phases are performed in the vacuum or pressure rated vessel. This latter option can facilitate faster overall processing time and residue dissipation.


title: Sterilization (microbiology)

text: The most common EO processing method is the gas chamber method. To benefit from economies of scale, EO has traditionally been delivered by filling a large chamber with a combination of gaseous EO either as pure EO, or with other gases used as diluents; diluents include chlorofluorocarbons (CFCs), hydrochlorofluorocarbons (HCFCs), and carbon dioxide.


title: Sterilization (microbiology)

text: Ethylene oxide is still widely used by medical device manufacturers. Since EO is explosive at concentrations above 3%, EO was traditionally supplied with an inert carrier gas, such as a CFC or HCFC. The use of CFCs or HCFCs as the carrier gas was banned because of concerns of ozone depletion. These halogenated hydrocarbons are being replaced by systems using 100% EO, because of regulations and the high cost of the blends. In hospitals, most EO sterilizers use single-use cartridges because of the convenience and ease of use compared to the former plumbed gas cylinders of EO blends.


title: Sterilization (microbiology)

text: It is important to adhere to patient and healthcare personnel government specified limits of EO residues in and/or on processed products, operator exposure after processing, during storage and handling of EO gas cylinders, and environmental emissions produced when using EO.


title: Sterilization (microbiology)

text: The U.S. Occupational Safety and Health Administration (OSHA) has set the permissible exposure limit (PEL) at 1 ppm – calculated as an eight-hour time-weighted average (TWA) – and 5 ppm as a 15-minute excursion limit (EL). The National Institute for Occupational Safety and Health's (NIOSH) immediately dangerous to life and health limit (IDLH) for EO is 800 ppm. The odor threshold is around 500 ppm, so EO is imperceptible until concentrations are well above the OSHA PEL. Therefore, OSHA recommends that continuous gas monitoring systems be used to protect workers using EO for processing.


title: Sterilization (microbiology)

text: Nitrogen dioxide (NO) gas is a rapid and effective sterilant for use against a wide range of microorganisms, including common bacteria, viruses, and spores. The unique physical properties of NO gas allow for sterilant dispersion in an enclosed environment at room temperature and atmospheric pressure. The mechanism for lethality is the degradation of DNA in the spore core through nitration of the phosphate backbone, which kills the exposed organism as it absorbs NO. This degradations occurs at even very low concentrations of the gas. NO has a boiling point of at sea level, which results in a relatively highly saturated vapour pressure at ambient temperature. Because of this, liquid NO may be used as a convenient source for the sterilant gas. Liquid NO is often referred to by the name of its dimer, dinitrogen tetroxide (NO). Additionally, the low levels of concentration required, coupled with the high vapour pressure, assures that no condensation occurs on the devices being sterilized. This means that no aeration of the devices is required immediately following the sterilization cycle. NO is also less corrosive than other sterilant gases, and is compatible with most medical materials and adhesives.


title: Sterilization (microbiology)

text: The most-resistant organism (MRO) to sterilization with NO gas is the spore of "Geobacillus stearothermophilus", which is the same MRO for both steam and hydrogen peroxide sterilization processes. The spore form of "G. stearothermophilus" has been well characterized over the years as a biological indicator in sterilization applications. Microbial inactivation of "G. stearothermophilus" with NO gas proceeds rapidly in a log-linear fashion, as is typical of other sterilization processes. Noxilizer, Inc. has commercialized this technology to offer contract sterilization services for medical devices at its Baltimore, Maryland (U.S.) facility. This has been demonstrated in Noxilizer’s lab in multiple studies and is supported by published reports from other labs. These same properties also allow for quicker removal of the sterilant and residual gases through aeration of the enclosed environment. The combination of rapid lethality and easy removal of the gas allows for shorter overall cycle times during the sterilization (or decontamination) process and a lower level of sterilant residuals than are found with other sterilization methods.


title: Sterilization (microbiology)

text: Eniware, LLC has developed a portable, power-free sterilizer that uses no electricity, heat or water. The 25 liter unit makes sterilization of surgical instruments possible for austere forward surgical teams, in health centers throughout the world with intermittent or no electricity and in disaster relief and humanitarian crisis situations. The four hour cycle uses a single use gas generation ampoule and a disposable scrubber to remove nitrogen dioxide gas.


title: Sterilization (microbiology)

text: Ozone is used in industrial settings to sterilize water and air, as well as a disinfectant for surfaces. It has the benefit of being able to oxidize most organic matter. On the other hand, it is a toxic and unstable gas that must be produced on-site, so it is not practical to use in many settings.


title: Sterilization (microbiology)

text: Ozone offers many advantages as a sterilant gas; ozone is a very efficient sterilant because of its strong oxidizing properties (E=2.076 vs SHE) capable of destroying a wide range of pathogens, including prions, without the need for handling hazardous chemicals since the ozone is generated within the sterilizer from medical-grade oxygen. The high reactivity of ozone means that waste ozone can be destroyed by passing over a simple catalyst that reverts it to oxygen and ensures that the cycle time is relatively short. The disadvantage of using ozone is that the gas is very reactive and very hazardous. The NIOSH's immediately dangerous to life and health limit (IDLH) for ozone is smaller than the IDLH for ethylene oxide. NIOSH and OSHA has set the PEL for ozone at , calculated as an time-weighted average. The sterilant gas manufacturers include many safety features in their products but prudent practice is to provide continuous monitoring of exposure to ozone, in order to provide a rapid warning in the event of a leak. Monitors for determining workplace exposure to ozone are commercially available.


title: Sterilization (microbiology)

text: Glutaraldehyde and formaldehyde solutions (also used as fixatives) are accepted liquid sterilizing agents, provided that the immersion time is sufficiently long. To kill all spores in a clear liquid can take up to 22 hours with glutaraldehyde and even longer with formaldehyde. The presence of solid particles may lengthen the required period or render the treatment ineffective. Sterilization of blocks of tissue can take much longer, due to the time required for the fixative to penetrate. Glutaraldehyde and formaldehyde are volatile, and toxic by both skin contact and inhalation. Glutaraldehyde has a short shelf-life (<2 weeks), and is expensive. Formaldehyde is less expensive and has a much longer shelf-life if some methanol is added to inhibit polymerization to paraformaldehyde, but is much more volatile. Formaldehyde is also used as a gaseous sterilizing agent; in this case, it is prepared on-site by depolymerization of solid paraformaldehyde. Many vaccines, such as the original Salk polio vaccine, are sterilized with formaldehyde.


title: Sterilization (microbiology)

text: Hydrogen peroxide, in both liquid and as vaporized hydrogen peroxide (VHP), is another chemical sterilizing agent. Hydrogen peroxide is a strong oxidant, which allows it to destroy a wide range of pathogens. Hydrogen peroxide is used to sterilize heat- or temperature-sensitive articles, such as rigid endoscopes. In medical sterilization, hydrogen peroxide is used at higher concentrations, ranging from around 35% up to 90%. The biggest advantage of hydrogen peroxide as a sterilant is the short cycle time. Whereas the cycle time for ethylene oxide may be 10 to 15 hours, some modern hydrogen peroxide sterilizers have a cycle time as short as 28 minutes.


title: Sterilization (microbiology)

text: Drawbacks of hydrogen peroxide include material compatibility, a lower capability for penetration and operator health risks. Products containing cellulose, such as paper, cannot be sterilized using VHP and products containing nylon may become brittle. The penetrating ability of hydrogen peroxide is not as good as ethylene oxide and so there are limitations on the length and diameter of the lumen of objects that can be effectively sterilized. Hydrogen peroxide is a primary irritant and the contact of the liquid solution with skin will cause bleaching or ulceration depending on the concentration and contact time. It is relatively non-toxic when diluted to low concentrations, but is a dangerous oxidizer at high concentrations (> 10% w/w). The vapour is also hazardous, primarily affecting the eyes and respiratory system. Even short term exposures can be hazardous and NIOSH has set the IDLH at 75 ppm, less than one tenth the IDLH for ethylene oxide (800 ppm). Prolonged exposure to lower concentrations can cause permanent lung damage and consequently, OSHA has set the permissible exposure limit to 1.0 ppm, calculated as an eight-hour time-weighted average. Sterilizer manufacturers go to great lengths to make their products safe through careful design and incorporation of many safety features, though there are still workplace exposures of hydrogen peroxide from gas sterilizers documented in the FDA MAUDE database. When using any type of gas sterilizer, prudent work practices should include good ventilation, a continuous gas monitor for hydrogen peroxide and good work practices and training.


title: Sterilization (microbiology)

text: Vaporized hydrogen peroxide (VHP) is used to sterilize large enclosed and sealed areas, such as entire rooms and aircraft interiors.


title: Sterilization (microbiology)

text: Peracetic acid (0.2%) is a recognized sterilant by the FDA for use in sterilizing medical devices such as endoscopes. Peracetic acid which is also known as peroxyacetic acid is a chemical compound often used in disinfectants such as sanitizers. It is most commonly produced by the reaction of acetic acid and hydrogen peroxide with each other by using an acid catalyst. Peracetic acid is never sold in unstabilized solutions which is why it is considered to be environmentally friendly. Peracetic acid is a colorless liquid and the molecular formula of peracetic acid is CHO or CH3COOOH. More recently, peracetic acid is being used throughout the world as more people are using fumigation to decontaminate surfaces to reduce the risk of Covid-19 and other diseases.


title: Sterilization (microbiology)

text: Prions are highly resistant to chemical sterilization. Treatment with aldehydes, such as formaldehyde, have actually been shown to increase prion resistance. Hydrogen peroxide (3%) for one hour was shown to be ineffective, providing less than 3 logs (10) reduction in contamination. Iodine, formaldehyde, glutaraldehyde, and peracetic acid also fail this test (one hour treatment). Only chlorine, phenolic compounds, guanidinium thiocyanate, and sodium hydroxide reduce prion levels by more than 4 logs; chlorine (too corrosive to use on certain objects) and sodium hydroxide are the most consistent. Many studies have shown the effectiveness of sodium hydroxide.


title: Sterilization (microbiology)

text: Sterilization can be achieved using electromagnetic radiation, such as ultraviolet light, X-rays and gamma rays, or irradiation by subatomic particles such as by electron beams. Electromagnetic or particulate radiation can be energetic enough to ionize atoms or molecules (ionizing radiation), or less energetic (non-ionizing radiation).


title: Sterilization (microbiology)

text: Ultraviolet light irradiation (UV, from a germicidal lamp) is useful for sterilization of surfaces and some transparent objects. Many objects that are transparent to visible light absorb UV. UV irradiation is routinely used to sterilize the interiors of biological safety cabinets between uses, but is ineffective in shaded areas, including areas under dirt (which may become polymerized after prolonged irradiation, so that it is very difficult to remove). It also damages some plastics, such as polystyrene foam if exposed for prolonged periods of time.


title: Sterilization (microbiology)

text: The safety of irradiation facilities is regulated by the International Atomic Energy Agency of the United Nations and monitored by the different national Nuclear Regulatory Commissions (NRC). The radiation exposure accidents that have occurred in the past are documented by the agency and thoroughly analyzed to determine the cause and improvement potential. Such improvements are then mandated to retrofit existing facilities and future design.


title: Sterilization (microbiology)

text: Gamma radiation is very penetrating, and is commonly used for sterilization of disposable medical equipment, such as syringes, needles, cannulas and IV sets, and food. It is emitted by a radioisotope, usually cobalt-60 (Co) or caesium-137 (Cs), which have photon energies of up to 1.3 and 0.66 MeV, respectively.


title: Sterilization (microbiology)

text: Use of a radioisotope requires shielding for the safety of the operators while in use and in storage. With most designs, the radioisotope is lowered into a water-filled source storage pool, which absorbs radiation and allows maintenance personnel to enter the radiation shield. One variant keeps the radioisotope under water at all times and lowers the product to be irradiated in the water in hermetically-sealed bells; no further shielding is required for such designs. Other uncommonly used designs use dry storage, providing movable shields that reduce radiation levels in areas of the irradiation chamber. An incident in Decatur, Georgia, US, where water-soluble caesium-137 leaked into the source storage pool, requiring NRC intervention has led to use of this radioisotope being almost entirely discontinued in favour of the more costly, non-water-soluble cobalt-60. Cobalt-60 gamma photons have about twice the energy, and hence greater penetrating range, of caesium-137-produced radiation.


title: Sterilization (microbiology)

text: Electron beam processing is also commonly used for sterilization. Electron beams use an on-off technology and provide a much higher dosing rate than gamma or X-rays. Due to the higher dose rate, less exposure time is needed and thereby any potential degradation to polymers is reduced. Because electrons carry a charge, electron beams are less penetrating than both gamma and X-rays. Facilities rely on substantial concrete shields to protect workers and the environment from radiation exposure.


title: Sterilization (microbiology)

text: High-energy X-rays (produced by "bremsstrahlung") allow irradiation of large packages and pallet loads of medical devices. They are sufficiently penetrating to treat multiple pallet loads of low-density packages with very good dose uniformity ratios. X-ray sterilization does not require chemical or radioactive material: high-energy X-rays are generated at high intensity by an X-ray generator that does not require shielding when not in use. X-rays are generated by bombarding a dense material (target) such as tantalum or tungsten with high-energy electrons, in a process known as "bremsstrahlung" conversion. These systems are energy-inefficient, requiring much more electrical energy than other systems for the same result.


title: Sterilization (microbiology)

text: Irradiation with X-rays, gamma rays, or electrons does not make materials radioactive, because the energy used is too low. Generally an energy of at least 10 MeV is needed to induce radioactivity in a material. Neutrons and very high-energy particles can make materials radioactive, but have good penetration, whereas lower energy particles (other than neutrons) cannot make materials radioactive, but have poorer penetration.


title: Sterilization (microbiology)

text: Irradiation is used by the United States Postal Service to sterilize mail in the Washington, D.C. area. Some foods (e.g. spices and ground meats) are sterilized by irradiation.


title: Sterilization (microbiology)

text: Subatomic particles may be more or less penetrating and may be generated by a radioisotope or a device, depending upon the type of particle.


title: Sterilization (microbiology)

text: Fluids that would be damaged by heat, irradiation or chemical sterilization, such as drug solution, can be sterilized by microfiltration using membrane filters. This method is commonly used for heat labile pharmaceuticals and protein solutions in medicinal drug processing. A microfilter with pore size of usually 0.22 µm will effectively remove microorganisms. Some staphylococcal species have, however, been shown to be flexible enough to pass through 0.22 µm filters. In the processing of biologics, viruses must be removed or inactivated, requiring the use of nanofilters with a smaller pore size (20–50 nm). Smaller pore sizes lower the flow rate, so in order to achieve higher total throughput or to avoid premature blockage, pre-filters might be used to protect small pore membrane filters. Tangential flow filtration (TFF) and alternating tangential flow (ATF) systems also reduce particulate accumulation and blockage.


title: Sterilization (microbiology)

text: Membrane filters used in production processes are commonly made from materials such as mixed cellulose ester or polyethersulfone (PES). The filtration equipment and the filters themselves may be purchased as pre-sterilized disposable units in sealed packaging or must be sterilized by the user, generally by autoclaving at a temperature that does not damage the fragile filter membranes. To ensure proper functioning of the filter, the membrane filters are integrity tested post-use and sometimes before use. The nondestructive integrity test assures the filter is undamaged and is a regulatory requirement. Typically, terminal pharmaceutical sterile filtration is performed inside of a cleanroom to prevent contamination.


title: Sterilization (microbiology)

text: Instruments that have undergone sterilization can be maintained in such condition by containment in sealed packaging until use.


title: Rook (chess)

text: The rook (; ♖, ♜) is a piece in the game of chess. It may move any number of squares horizontally or vertically without jumping, and it may an enemy piece on its path; additionally, it may participate in castling. Each player starts the game with two rooks, one in each corner on their own side of the board.


title: Rook (chess)

text: Formerly, the rook (from Persian رخ "rokh"/"rukh", meaning "chariot") was alternatively called the tower, marquess, rector, and comes (count or earl). The term "castle" is considered to be informal, incorrect, or old-fashioned.


title: Rook (chess)

text: The white rooks start on squares a1 and h1, while the black rooks start on a8 and h8. The rook moves horizontally or vertically, through any number of unoccupied squares (see diagram). The rook cannot jump over pieces. The rook may capture an enemy piece by moving to the square on which the enemy piece stands, removing it from play. The rook also participates with the king in a special move called castling, wherein it is transferred to the square crossed by the king after the king is transferred two squares toward the rook.


title: Rook (chess)

text: The rook is worth about five pawns. In general, rooks are stronger than bishops or knights (which are called minor pieces) and are considered greater in value than either of those pieces by nearly two pawns, but less valuable than two minor pieces by approximately a pawn. Two rooks are generally considered to be worth slightly more than a queen (see chess piece relative value). Winning a rook for a bishop or knight is referred to as winning the exchange. Rooks and queens are called major pieces or heavy pieces, as opposed to bishops and knights, the minor pieces.


title: Rook (chess)

text: In the opening, the rooks are blocked in by other pieces and cannot immediately participate in the game, so it is usually desirable to connect one's rooks on the by castling and then clearing all pieces except the king and rooks from the first rank. In that position, the rooks support each other and can more easily move to occupy and control the most favorable .


title: Rook (chess)

text: A common strategic goal is to a rook on the first rank of an open file (i.e., one unobstructed by pawns of either player) or a half-open file (i.e., one unobstructed by friendly pawns). From this position, the rook is relatively unexposed to risk but can exert control on every square on the file. If one file is particularly important, a player might advance one rook on it, then position the other rook behind—doubling the rooks.


title: Rook (chess)

text: A rook on the seventh rank (the opponent's second rank) is typically very powerful, as it threatens the opponent's unadvanced pawns and hems in the enemy king. A rook on the seventh rank is often considered sufficient compensation for a pawn. In the diagrammed position from a game between Lev Polugaevsky and Larry Evans, the rook on the seventh rank enables White to draw, despite being a pawn down.


title: Rook (chess)

text: Two rooks on the seventh rank are often enough to force victory by the blind swine mate, or at least a draw by perpetual check.


title: Rook (chess)

text: Rooks are most powerful towards the end of a game (i.e., the endgame), when they can move unobstructed by pawns and control large numbers of squares. They are somewhat clumsy at restraining enemy pawns from advancing towards promotion, unless they can occupy the file behind the advancing pawn. As well, a rook best supports a friendly pawn towards promotion from behind it on the same file (see Tarrasch rule).


title: Rook (chess)

text: In a position with a rook and one or two versus two rooks, generally in addition to pawns, and possibly other pieces, Lev Alburt advises that the player with the single rook should avoid exchanging the rook for one of his opponent's rooks.


title: Rook (chess)

text: The rook is adept at delivering checkmate. Below are a few examples of rook checkmates that are easy to force.


title: Rook (chess)

text: In the medieval shatranj, the rook symbolized a chariot. The Persian word "rukh" means "chariot", and the corresponding piece in the original Indian version, chaturanga, has the name "ratha" (meaning "chariot"). In modern times it is mostly known as हाथी (elephant) to Hindi-speaking players, while east-Asian chess games such as xiangqi and shogi have names also meaning chariot (車) for the same piece.


title: Rook (chess)

text: Persian war-chariots were heavily armored, carrying a driver and at least one ranged-weapon bearer, such as an archer. The sides of the chariot were built to resemble fortified stone work, giving the impression of small, mobile buildings, causing terror on the battlefield.


title: Rook (chess)

text: In Europe the castle or tower appears for the first time in the 16th century in Vida's 1550 "Ludus Scacchia", and then as a tower on the back of an elephant. In time, the elephant disappeared and only the tower was used as the piece.


title: Rook (chess)

text: In the West, the rook is almost universally represented as a crenellated turret. The piece is called "torre" ("tower") in Italian, Portuguese, Catalan and Spanish; "tour" in French; "toren" in Dutch; "Turm" in German; "torn" in Swedish; and "torni" in Finnish. In Hungarian it is "bástya" ("bastion") and in Hebrew it is called "צריח" (, meaning "turret"). In the British Museum's collection of the medieval Lewis chess pieces the rooks appear as stern warders, or wild-eyed berserker warriors.


title: Rook (chess)

text: Rooks usually are similar in appearance to small castles; thus, a rook is sometimes called a "castle", though modern chess literature rarely, if ever, uses this term.


title: Rook (chess)

text: In some languages the rook is called a ship: Thai เรือ (), Armenian Նավակ (), Russian ладья (), Javanese ꦥꦿꦲꦸ (). This may be because of the use of an Arabic style V-shaped rook piece, which some may have mistaken for a ship. It is possible that the rendition comes from Sanskrit (ship); however, no chaturanga pieces were ever called a . Murray argued that the Javanese could not visualize a chariot moving through the jungles in sweeping fashion as the rook. The only vehicle that moved in straight fashion was ship, thus they replaced it with prahu. Murray, however, did not give an explanation of why the Russians call the piece a "ship".


title: Rook (chess)

text: Peter Tyson suggests that there's a correlation between the name of the piece and the word "rukh", a mythical giant bird of prey from Persian mythology.


title: Rook (chess)

text: In Kannada, it is known as ಆನೆ ("āāne"), meaning "elephant". This is unusual, as the term for elephant is in many other languages applied to the bishop.


title: Rook (chess)

text: Chess rooks frequently occur as heraldic charges. Heraldic rooks are usually shown as they looked in medieval chess sets, with the usual battlements replaced by two outward-curving horns. They occur in arms from around the 13th century onwards.


title: Arvind Swamy

text: Arvind Swamy (born 18 June 1970) is an Indian actor, model, entrepreneur and television presenter known for his work in Tamil cinema and a few Hindi, Telugu and Malayalam films. He was introduced as an actor by Mani Ratnam with the blockbuster film "Thalapathi" (1991) and subsequently starred in successful films such as "Roja" (1992), "Bombay" (1995), "Minsara Kanavu" (1997), "Thani Oruvan" (2015), and "Chekka Chivantha Vaanam" (2018). He made his debut as a director in the Netflix anthology series "Navarasa" (2021) in which his segment named "Project Agni (Adbhutha – Wonder)".


title: Arvind Swamy

text: Swamy also starred in other regional film industries, including Telugu and Malayalam films where he has done films such as "Mounam" (1995), "Daddy" (1992) and "Devaraagam" (1996). He has also appeared in Bollywood, making his appearance in "Saat Rang Ke Sapne" (1998). He briefly worked as a television presenter as the host of the third season of "Neengalum Vellalam Oru Kodi" (2012–2016) on Star Vijay.


title: Arvind Swamy

text: Swamy's parents are industrialist V. D. Swamy and Bharatanatyam dancer Vasantha. Swamy studied at the Sishya School and later in Don Bosco Matriculation Higher Secondary School, P. S. Senior Secondary School and completed his schooling in 1987. He then graduated from Loyola College, Madras in 1990 with a Bachelor of Commerce degree. He then went to the United States to do his master's degree in international business from Wake Forest University in North Carolina.


title: Arvind Swamy

text: Arvind Swamy wished to be a doctor. In college, he used to be a model for pocket money. In his Loyola Theatre Society, he wasn't well received and was asked to get off stage. Later on Mani Ratnam saw him in an advertisement and called for a meeting. Then he and Santosh Sivan introduced him to the basics of film-making.


title: Arvind Swamy

text: Arvind Swamy made his debut in Mani Ratnam's action drama film, "Thalapathi" (1991), where he played a young district collector pitted against a don and his own biological brother. Subsequently, Mani Ratnam signed him on to play the lead role in the 1992 political drama film "Roja" (1992). "Roja" and "Bombay" (1995) won awards at the State and National Film Award functions. His performance in "Bombay" was called "soulful" by "Time" magazine. Swamy has won several awards, popular and critical, for his films. He has been described as one of the first few actors in India who is able to achieve pan-Indian appeal. He lends his voice for the Tamil dubbing version for the adult Simba of Disney's "The Lion King" (1994). His next project was "Indira" (1995), followed by Telugu "Mounam" (1995) and Malayalam movie "Devaraagam" (1996).


title: Arvind Swamy

text: He starred in Rajiv Menon's "Minsara Kanavu" alongside Kajol and Prabhu Deva, which won four National Film Awards and high box office numbers. The film eventually performed well at the box office after a slow start, with Arvind Swamy eventually stating he was happy to be a part of the film. His next film was "Pudhayal" (1997). He appeared in his first straight Hindi film through Priyadarshan's "Saat Rang Ke Sapne" (1998) produced by Amitabh Bachchan. Co-starring alongside Juhi Chawla, Arvind portrayed the role of a village do-gooder. His final two releases before his sabbatical, "En Swasa Kaatre" (1999) and "Raja Ko Rani Se Pyar Ho Gaya" (2000).


title: Arvind Swamy

text: Swamy eventually stopped acting in films post-2000, after playing a guest role in Mani Ratnam's "Alaipayuthey", and opted to concentrate on his business interests. In 2000, he became the president of InterPro Global, and the chairman and managing director of Prolease India, engaged in transaction processing. He was in charge of operations and technology for the delivery of many processes across different verticals globally. He then founded Talent Maximus in 2005, a company engaged in payroll processing and temporary staffing in India.


title: Arvind Swamy

text: In 2005, he had an accident and injured his spine. He experienced partial paralysis of his leg and suffered in pain for many years. The treatment took another 4–5 years.


title: Arvind Swamy

text: After his successful treatment, Mani Ratnam called him once more to play a role in one of his films, "Kadal" (2013) for which Swamy dropped 15 kilograms. In 2013, he provided the voice-over for Santhosh Sivan's film "Ceylon".


title: Arvind Swamy

text: In 2015, he plays an iconic negative role of Sidharth Abhimanyu in "Thani Oruvan", for which he was highly praised and received positive reviews and many awards for his acting.


title: Arvind Swamy

text: In 2016, he reprised the same role in Telugu in the film "Dhruva" with Ram Charan, a remake of "Thani Oruvan", for which he got a lot of appreciation from the Telugu audience. Later the same year, he appeared in a Hindi movie, "Dear Dad". The game show "Neengalum Vellalam Oru Kodi" recruited Swamy for its third season, which started airing on 30 May 2016.


title: Arvind Swamy

text: In 2017, he did the title role of "Bogan", co starring Jayam Ravi, for which he again got an outstanding response from the critics and the audience.


title: Arvind Swamy

text: In 2018, he acted in "Bhaskar Oru Rascal". Arvind Swamy does a neat job without imitating what Mammootty did in the original. The film is followed by "Chekka Chivantha Vaanam" (2018). The film was released to positive reviews which also got him the Filmfare Award.


title: Arvind Swamy

text: In 2021, he acted in A. L. Vijay's directorial biographical-political drama "Thalaivii" opposite Kangana Ranaut. He portrayed the character of actor-politician M. G. Ramachandran in the film. Arvind Swami returns to Malayalam cinema after 25 years with "Ottu" (2022).


title: Arvind Swamy

text: Swamy married Gayathri Ramamurthy in June 1994 and has one daughter Adhira, born in 1996, and a son Rudra, born in 2000. The couple lived separately for seven years until 2010, when they filed for divorce. He was granted the custody of his children. He married Aparna Mukerjee in 2012.


title: Kozhikode

text: Kozhikode (), also known in English as Calicut, is a city along the Malabar Coast in the state of Kerala in India. It has a corporation limit population of 609,224 and a metropolitan population of more than 2 million, making it the second largest metropolitan area in Kerala and the 19th largest in India. Kozhikode is classified as a Tier 2 city by the Government of India.


title: Kozhikode

text: It is the largest city in the region known as the Malabar and was the capital of the British-era Malabar district. In antiquity and the medieval period, Kozhikode was dubbed the "City of Spices" for its role as the major trading point for Indian spices. It was the capital of an independent kingdom ruled by the Samoothiris (Zamorins). The port at Kozhikode acted as the gateway to medieval South Indian coast for the Chinese, the Persians, the Arabs and finally the Europeans. According to data compiled by economics research firm Indicus Analytics in 2009 on residences, earnings and investments, Kozhikode was ranked the second best city in India to live in.


title: Kozhikode

text: The exact origin of the name Kozhikode is uncertain. According to many sources, the name Kozhikode is derived from "Koyil-kota" (fort), meaning "fortified palace". The name also got corrupted into "Kolikod", or its Arab version "Qāliqūṭ" and later its anglicized version Calicut.


title: Kozhikode

text: Although the city's official name is Kozhikode, in English it is sometimes known by its anglicised version, "Calicut".


title: Kozhikode

text: The word "calico", a fine variety of hand-woven cotton cloth that was exported from the port of Kozhikode, is thought to have been derived from "Calicut". It is the historical capital of Kerala as the history dates back to 1498 AD when Vasco da Gama landed in Kappad, near Calicut.


title: Kozhikode

text: The ancient port of Tyndis which was located on the northern side of Muziris, as mentioned in the "Periplus of the Erythraean Sea", was somewhere around Kozhikode. Its exact location is a matter of dispute. The suggested locations are Ponnani, Tanur, Beypore-Chaliyam-Kadalundi-Vallikkunnu, and Koyilandy. Tyndis was a major center of trade, second only to Muziris, between the Cheras and the Roman Empire. Pliny the Elder (1st century CE) states that the port of "Tyndis" was located at the northwestern border of "Keprobotos" (Chera dynasty). The North Malabar region, which lies north of the port at "Tyndis", was ruled by the kingdom of Ezhimala during Sangam period. According to the "Periplus of the Erythraean Sea", a region known as "Limyrike" began at "Naura" and "Tyndis". However Ptolemy mentions only "Tyndis" as "Limyrike"'s starting point. The region probably ended at Kanyakumari; it thus roughly corresponds to the present-day Malabar Coast. The value of Rome's annual trade with the region was estimated at around 50,000,000 sesterces. Pliny the Elder mentioned that "Limyrike" was prone by pirates. The Cosmas Indicopleustes mentioned that the "Limyrike" was a source of peppers.


title: Kozhikode

text: In the 14th century, Kozhikode conquered larger parts of central Kerala after the seize of Tirunavaya region from Valluvanad, which were under the control of the king of "Perumbadappu Swaroopam" (Cochin). The ruler of Perumpadappu was forced to shift his capital (c. CE 1405) further south from Kodungallur to Kochi. In the 15th century, the status of Cochin was reduced to a vassal state of Kozhikode, thus leading to the emergence of Kozhikode as the most powerful kingdom in medieval Malabar Coast.During the 15th century Kalaripayat was important in the history of Malabar, some warriors lived, most notably "puthooram veettil" Aromal Chekavar and his sister Unniyarcha who were chieftains of martial arts.


title: Kozhikode

text: The port at Kozhikode held the superior economic and political position in medieval Kerala coast, while Kannur, Kollam, and Kochi, were commercially important secondary ports, where the traders from various parts of the world would gather. Kozhikode was the capital of an independent kingdom ruled by the samoothiris (Zamorins) in the Middle Ages and later of the erstwhile Malabar District under British rule. Arab merchants traded with the region as early as 7th century, and Portuguese explorer Vasco da Gama landed at Kozhikode on 20 May 1498, thus opening a trade route between Europe and India. A Portuguese factory and the fort was intact in Kozhikode for short period (1511–1525, until the Fall of Calicut). The English landed in 1615 (constructing a trading post in 1665), followed by the French (1698) and the Dutch (1752). In 1765, Mysore captured Kozhikode as part of its occupation of the Malabar Coast. Kozhikode, once a famous cotton-weaving centre, gave its name to the Calico cloth.


title: Kozhikode

text: It was ranked eleventh among Tier-II Indian cities in job creation by a study conducted by ASSOCHAM in 2007.


title: Kozhikode

text: Accounts of the city and the conditions prevailing then can be gleaned from the chronicles of travellers who visited the port city.


title: Kozhikode

text: Ibn Battuta (1342–1347), who visited six times, gives the earliest glimpses of life in the city. He describes Kozhikode as "one of the great ports of the district of Malabar" where "merchants of all parts of the world are found here". The king of this place, he says, "shaves his chin just as the Haidari Fakeers of Rome do... The greater part of the Muslim merchants of this place are so wealthy that one of them can purchase the whole freightage of such vessels put here and fit out others like them".


title: Kozhikode

text: Ma Huan (1403 AD), the Chinese sailor part of the Imperial Chinese fleet under Cheng Ho (Zheng He) lauds the city as a great emporium of trade frequented by merchants from around the world. He makes note of the 20 or 30 mosques built to cater to the religious needs of the Muslims, the unique system of calculation by the merchants using their fingers and toes (followed to this day) and the matrilineal system of succession.


title: Kozhikode

text: Abdur Razzak (1442–43) the ambassador of Persian Emperor Sha-Rohk finds the city harbour perfectly secured and notices precious articles from several maritime countries especially from Abyssinia, Zirbad and Zanzibar.


title: Kozhikode

text: The Italian Niccolò de' Conti (1445), perhaps the first Christian traveller who noticed Kozhikode, describes the city as abounding in pepper, lac, ginger, a larger kind of cinnamon, myrobalans and zedoary. He calls it a noble emporium for all India, with a circumference of .


title: Kozhikode

text: The Russian traveller Athanasius Nikitin or Afanasy Nikitin (1468–74) calls 'Calecut' a port for the whole Indian sea and describes it as having a "big bazaar."


title: Kozhikode

text: Other travellers who visited Kozhikode include the Italian Ludovico di Varthema (1503–1508) and Duarte Barbosa.


title: Kozhikode

text: Kozhikode and its suburbs formed part of the "Polanad" kingdom, which was a vassal state to the "Kolathunadu" of North Malabar, ruled by the "Porlatiri". The Eradis of Nediyiruppu at Kondotty in Eranad (Malappuram district) wanted an outlet to the sea, to initiate trade and commerce with the distant lands. and after fighting with the king Polatthiri for 48 years conquered the area around Panniankara. After this, Menokki became the ruler of "Polanad" and came to terms with the troops and people. After this, the town of Kozhikode was founded close to the palace at Tali. Then, the Eradis shifted their headquarters from Nediyiruppu to Kozhikode. The Governor of Ernad built a fort at a place called Velapuram to safeguard his new interests. The fort most likely lent its name to "Koyil Kotta" the precursor to Kozhikode. Thus the city came into existence sometime in the 13th century CE. The status of Udaiyavar increased and he became known as Swami Nambiyathiri Thirumulpad, and eventually Samuri or Samoothiri. Europeans called him in a corrupt form as Zamorin.


title: Kozhikode

text: At the peak of their reign, the Zamorins ruled over a region from Kollam (Quilon) to Panthalayini Kollam (Koyilandy). Following the discovery of sea route from Europe to Kozhikode in 1498, the Portuguese began to expand their territories and ruled the seas between Ormus and the Malabar Coast and south to Ceylon. Kallingal Madathil Rarichan Moopan and Pullambil Moopan and Vamala Moopan families were very prominent among those who said that two centuries ago, some Jenmis in Kozhikode were engaged in sea trade and shipping.


title: Kozhikode

text: According to K.V. Krishna Iyer, the rise of Kozhikode is at once a cause and a consequence of Samoothiri's ascendancy in Kerala. By the end of the century, Samoothiri was at the zenith of his powers with all princes and chieftains of Kerala north of Kochi acknowledging his suzerainty. The Sweetmeat Street ("Mittayi Theruvu") was an important trading street under Zamorin's rule.


title: Kozhikode

text: The First Battle of Cannanore that occurred in January 1502 between the Third Portuguese Armada and Kingdom of Cochin under João da Nova and Zamorin of Calicut's navy marks the beginning of Portuguese conflicts in the Indian Ocean. The defeat of joint fleet of the Sultan of Gujarat, the Mamlûk Burji Sultanate of Egypt, and the Zamorin of Calicut with support of the Republic of Venice and the Ottoman Empire in Battle of Diu in February 1509 marks the beginning of Portuguese dominance of the Spice trade and the Indian Ocean. The continuous wars between Zamorin navy under Kunjali Marakkars and Portuguese in the 16th century CE reduced the importance of Kozhikode as a centre of trade. The Kunjali Marakkars are credited with organizing the first naval defense of the Indian coast.


title: Kozhikode

text: The Zamorin in the beginning of next century expelled Portuguese with the help of Dutch East India Company. and In 1602, the Zamorin sent messages to Aceh promising the Dutch a fort at Kozhikode if they would come and trade there. Two factors, Hans de Wolff and Lafer, were sent on an Asian ship from Aceh, but the two were captured by the chief of Tanur, and handed over to the Portuguese. A Dutch fleet under Admiral Steven van der Hagen arrived at Kozhikode in November 1604. It marked the beginning of the Dutch presence in Kerala and they concluded a treaty with Kozhikode on 11 November 1604, which was also the first treaty that the Dutch East India Company made with an Indian ruler. By this time the kingdom and the port of Kozhikode was much reduced in importance. The treaty provided for a mutual alliance between the two to expel the Portuguese from Malabar. In return the Dutch East India Company was given facilities for trade at Kozhikode and Ponnani, including spacious storehouses.


title: Kozhikode

text: The arrival of British in Kerala can be traced back to the year 1615, when a group under the leadership of Captain William Keeling arrived at Kozhikode, using three ships. It was in these ships that Sir Thomas Roe went to visit Jahangir, the fourth Mughal emperor, as British envoy. Travancore became the most dominant state in Kerala by defeating the Zamorin of Kozhikode in the battle of Purakkad in 1755. Kozhikode came under British Rule after the Mysorean conquest of Malabar in the late 18th century CE.The British later also formed a regiment called the Thiyyar Regiment to meet their military operations in Malabar.


title: Kozhikode

text: Kozhikode was the capital city of Malabar District, one of the two districts in the western coast (Malabar Coast) of Madras presidency. During the British rule, Malabar's chief importance lay in producing pepper, coconut, tiles, and teak. Kozhikode municipality was formed on 1 November 1866 according to the Madras Act 10 of 1865 (Amendment of the Improvements in Towns act 1850) of the British Indian Empire, making it the first modern municipality in the state.


title: Kozhikode

text: Kozhikode Municipality was upgraded into Kozhikode Municipal Corporation in the year 1962, making it the second-oldest Municipal Corporation in the state.


title: Kozhikode

text: Kozhikode has a tropical monsoon climate (Köppen climate classification "Am"). A brief spell of pre-monsoon Mango showers hits the city sometime during April. However, the primary source of rain is the South-west monsoon that sets in the first week of June and continues until September. The city receives significant precipitation from the North-East Monsoon that sets in from the second half of October through November.


title: Kozhikode

text: Kozhikode has been a multi-ethnic and multi-religious town since the early medieval period. The Hindus form the largest religious group, followed by Muslims and Christians. Hindus form the majority at 57.37% of the population with 315807 members. Muslims form 37.6% of the population with 207298 members.


title: Kozhikode

text: The corporation of Kozhikode has an average literacy rate of 96.8% (national average is 74.85%). The male literacy rate is 97.93% and female literacy rate is 95.78%.


title: Kozhikode

text: Pre-modern Kozhikode was already teeming with people of several communities and regional groups. Most of these communities continued to follow their traditional occupations and customs till the 20th century. Brahmins, too, lived in the city mostly around the Hindu temples. Regional groups like the Tamil Brahmins, Gujaratis and Marwari Jains became part of the city and lived around their shrines.


title: Kozhikode

text: The Nairs formed the rulers, warriors and landed gentry of Kozhikode.The Thiyyas formed the "vaidyars" (Ayurveda Physicians), local militia and traders of Kozhikode. The Thiyyas were also heavily recruited into the Zamorin's army.Samoothiri army was called as Lokar,which constituted of warriors of Thiyyar and Nair caste soldiers.Zamorin also had an army called the 'Thiyyarpada' (Thiyya Army),which is formed by Thiyyar warriors. The Samoothiri had a ten thousand strong Nair bodyguard called the Kozhikkottu pathinaayiram (The 10,000 of Kozhikode) who defended the capital and supported the administration within the city. He had a larger force of 30,000 Nairs in his capacity as the Prince of Eranadu, called the Kozhikkottu Muppatinaayiram (The 30,000 of Kozhikode). The Nairs also formed the members of the suicide squad (chaver).


title: Kozhikode

text: The Muslims of Kozhikode are known as Mappilas, and according to the official Kozhikode website "the great majority of them are Sunnis following the Shafi school of thought. There are some smaller communities among the Muslims such as Dawoodi Bohras of Gujarati origin. Many of the Muslims living in the historic part of the city follow matrilineality and are noted for their piety. Though Christianity is believed to have been introduced in Kerala in the 1st century CE, the size of community in Malabar (northern Kerala) began to rise only after the arrival of the Portuguese missionaries towards the close of the 15th century. A few Christians of Thiruvitankoor and Kochi have lately migrated to the hilly regions of the district and are settled there.


title: Kozhikode

text: The Tamil Brahmins are primarily settled around the Tali Siva temple. They arrived in Kozhikode as dependants of chieftains, working as cooks, cloth merchants and moneylenders. They have retained their Tamil language and dialects as well as caste rituals. The Gujarati community is settled mostly around the Jain temple in and around the Valliyangadi. They owned many establishments, especially textile and sweet shops. They must have arrived in Kozhikode at least from the beginning of the 14th century. They belong to either the Hindu or the Jain community. A few Marwari families are also found in Kozhikode who was basically moneylenders.


title: Kozhikode

text: The city is administered by the Kozhikode Corporation, headed by a mayor. For administrative purposes, the city is divided into 75 wards, from which the members of the corporation council are elected for five years. Recently neighbouring suburbs Beypore, Elathur, Cheruvannur and Nallalam were merged within the municipal corporation.


title: Kozhikode

text: Kozhikode Corporation is the first City Corporation in Kerala after the creation of the state. Established in 1962, Kozhikode Corporation's first mayor was H Manjunatha Rao. Kozhikode corporation has four assembly constituencies – Kozhikode North, Kozhikode South, Beypore and Elathur – all of which are part of Kozhikode.


title: Kozhikode

text: The Kozhikode City Police is headed by a commissioner, an Indian Police Service (IPS) officer. The city is divided into six zones each under a circle officer. Apart from regular law and order, the city police comprise the traffic police, bomb squad, dog squad, fingerprint bureau, women's cell, juvenile wing, narcotics cell, riot force, armed reserve camps, district crime records bureau and a women's station. It operates 16 police stations functioning under the Home Ministry of Government of Kerala.


title: Kozhikode

text: National Highway 66 connects Kozhikode to Mumbai via Mangaluru, Udupi and Goa to the north and Kochi and Kanyakumari near Thiruvananthapuram to the south along the west coast of India. This highway connects the city with the other important towns like, Kasaragod, Kanhangad, Kannur, Thalassery, Mahe, Vadakara, Koyilandy


title: Kozhikode

text: Ramanattukara, Kottakkal, Kuttippuram, Ponnani, Kodungallur, North Paravur, Ernakulam, Edapally and proceeds to Alappuzha, Thiruvananthapuram and terminates at the southern tip of India, Kanyakumari.


title: Kozhikode

text: National Highway 766 connects Kozhikode to Bangalore through Kollegal in Karnataka via Tirumakudal Narsipur, Mysore, Nanjangud, Gundlupet, Sulthan Bathery, Kalpetta and Thamarassery.


title: Kozhikode

text: National Highway 966 connects Kozhikode to Palakkad through Malappuram,Perinthalmanna. It covers a distance of . At Ramanattukara, a suburb of Kozhikode, it joins NH 66. It passes through major towns like Kondotty, Perinthalmanna, and Mannarkkad and Malappuram. This stretch connects the city and Calicut International Airport.


title: Kozhikode

text: SH 29 passes through the city. It connects NH 212, Malabar Christian College, civil station, Kunnamangalam, Thamarassery, Chellot, Chitragiri and Road to Gudallor from Kerala border.


title: Kozhikode

text: State highway 38 starts from Pavangad near passes through Ulliyeri, Perambra, Kuttiady, Nadapuram, Panoor & Koothuparamba and ends at Chovva in Kannur. The highway is107;km long. It is one of the busiest route in the district.


title: Kozhikode

text: SH 54 connects the city to Kalpetta. The highway is long. The highway passes through Pavangad, Kozhikode, Ulliyeri, Perambra, Poozhithodu, Peruvannamuzhi and Padinjarethara.


title: Kozhikode

text: SH 34 starts from Koyilandy and ends in Edavanna which is 44.0 km long. This highway passes through Koyilandi, Ulliyeri, Balussery, Thamarassery, Omassery, Mukkam.


title: Kozhikode

text: Buses, predominantly run by individual owners, ply on the routes within the city and to nearby locations. City buses are painted green. Kerala State Road Transport Corporation (KSRTC) runs regular services to many destinations in the state and to the neighboring states. The city has three bus stands. All private buses to the suburban and nearby towns ply from the Palayam Bus Stand. Private buses to adjoining districts start from the Mofussil Bus Stand on Indira Gandhi Road (Mavoor Road). Buses operated by the KSRTC drive from the KSRTC bus stand on Indira Gandhi Road. KSRTC Bus Stand Kozhikode is the largest bus stand in Kerala having a size of 36,036.47 meter square. There are also KSRTC depots in Thamarassery, Thottilpalam, Thiruvambady and Vatakara.


title: Kozhikode

text: There are three routes available to Bangalore. Kozhikode–Sulthan Bathery-Gundlupet–Mysore–Bangalore is the preferred one and is very busy. Another route, is Kozhikode-Manathavady-Kutta-Mysore-Bangalore. The third one, less used, is Kozhikode–Gundlupet–Chamarajanagar–Kollegal–Bangalore.


title: Kozhikode

text: Private tour operators maintain regular luxury bus services to Mumbai, Bangalore, Coimbatore, Chennai, Vellore, Ernakulam, Trivandrum, Ooty, Mysore. etc. and mainly operate from the Palayam area. These are usually night services.


title: Kozhikode

text: The history of railways in Kerala dates to 1861 when the first tracks were laid between Tirur and Beypore.


title: Kozhikode

text: Calicut International Airport is from the city at Karipur in Kondotty, which is in the Malappuram district. It began operations in 1988. Domestic services are operated to major Indian cities. It received the status of an international airport in 2006.


title: Kozhikode

text: Calicut is one of the biggest economic hubs in Kerala. Service sector dominates the economy followed by industries. Nedungadi Bank, the first and oldest bank in the modern state of Kerala, was established by Appu Nedungadi at Kozhikode in the year 1899. Cyberpark, a Government of Kerala organisation, plans to build, operate and manage IT parks for the promotion and development of investment in IT and ITES industries in the Malabar region of Kerala. It would be the third IT hub in the state of Kerala. The two IT parks might create a total 100,000 direct job opportunities. The first project is the development of Cyberpark hub in Kozhikode with its spokes at Kannur and Kazargode IT parks. Other planned projects include the Birla IT park (at Mavoor) and Malaysian satellite city (at Kinaloor) where KINFRA has plans to set up a industrial park. In 2012, Kozhikode was given the tag of "City of Sculptures" (Shilpa Nagaram) because of the architectural sculptures around the city. Currently there are many IT companies running in UL Cyberpark, Government Cyberpark and Hilite Business Park.


title: Kozhikode

text: The city has a strong mercantile aspect. The main area of business was once "Valiyangadi" (Big Bazaar) near the railway station. As time progressed, it shifted to other parts of the city. The commercial heart has moved to "Mittai Theruvu" (Sweetmeat Street or S. M. Street), a long street crammed with shops that sell everything from saris to cosmetics. It also houses restaurants and sweetmeat shops. Today, the city has multiple shopping malls. Focus Mall (First mall of Kerala ), HiLITE Mall, Gokulam Mall, Address Mall and RP Mall are a few among them. LuLu Group International's Lulu Mall is under construction in the areas of Mankavu.


title: Kozhikode

text: In addition to the Malabar Mahotsavam, the annual cultural fest of Kozhikode, every year since 1981 the Tyagaraja Aradhana Trust has been conducting a five-day music festival in honour of Tyagaraja. The festival is complete with the Uncchavritti, rendering of Divyanama kritis, Pancharatna Kritis, concerts by professional artistes and students of music from morning to late in the evening.


title: Kozhikode

text: Kozhikode has a tradition of Ghazal and Hindustani music appreciation. There are many Malayalam Ghazals. The late film director and play back singer M. S. Baburaj, from Kozhikode was influenced by Ghazal and Hindustani.


title: Kozhikode

text: The Kozhikode radio station of All India Radio has two transmitters: Kozhikode AM (100 kilowatts) and Kozhikode FM [Vividh Bharathi] (10 kilowatts). Private FM radio stations are Radio Mango 91.9 operated by Malayala Manorama Co. Ltd. Radio Mirchi operated by Entertainment Network India Ltd. and Club FM 104.8 operated by Mathrubhumi group and Red FM 93.5 of the SUN Network. AIR FM radio stations are Kozhikode – 103.6 MHz; AIR MW radio station is Kozhikode – 684 kHz.


title: Kozhikode

text: A television transmitter has been functioning in Kozhikode since 3 July 1984, relaying programmes from Delhi and Thiruvananthapuram Doordarshan. Doordarshan has its broadcasting centre in Kozhikode at Medical College. The Malayalam channels based on Kozhikode are the Shalom Television, Darshana TV and Media One TV. All major channels in Malayalam viz. Manorama News, Asianet, Surya TV, Kairali TV, Amrita TV, Jeevan TV, and Jaihind have their studios and news bureaus in the city.


title: Kozhikode

text: Satellite television services are available through DD Direct+, Dish TV, Sun Direct DTH and Tata Sky. Asianet Digital TV is popularly known as ACV telecasts daily city news. Spidernet is another local channel. Other local operators include KCL and Citinet.


title: Kozhikode

text: The Calicut Press Club came into existence in 1970. It is the nerve centre of all media activities, both print and electronic. Begun with around 70 members in the roll, this Press Club, became a prestigious and alert media centre in the state with a present membership of over 280.


title: Kozhikode

text: Kozhikode is home to two premier educational institutions of national importance: the Indian Institute of Management Kozhikode (IIMK), and the National Institute of Technology Calicut (NITC). Other institutions include National Institute for Research and Development in Defence Shipbuilding (NIRDESH), Indian Institute of Spices Research (IISR), and National Institute of Electronics and Information Technology (NIELIT) are also based in Calicut.


title: Kozhikode

text: The University of Calicut is the largest university in Kerala and is located in Thenjipalam, about south of Calicut. This university was established in 1968 and was the second university set up in Kerala. Most of the colleges offering tertiary education in the region are affiliated to this university. The Calicut Medical College was established in 1957 as the second medical college in Kerala. Since then, the institution has grown into a premier centre of medical education in the state. Presently it is the largest medical institute in the state with a yearly intake of 250 candidates for the undergraduate programme.


title: Kozhikode

text: The Government Law College, Kozhikode situated in Vellimadukunnu on the out skirts of kozhikode town, is owned by the Government of Kerala and affiliated to the University of Calicut. The college caters to the needs of the north Malabar region of Kerala it is the third law college in kerala state founded in 1970.


title: Kozhikode

text: Zamurians Guruvayoorappan College, Malabar Christian college, Farook College, Devagiri College, Providence college for women, Govt. Arts & science college, Meenchantha, West Hill Government Engineering College, Kozhikode, Kerala Government Polytechnic College, Kozhikode.


title: Kozhikode

text: In 1876, a school for young Rajas was started in Kozhikode. This was later thrown open to all caste Hindu boys. In 1879, it was affiliated to the University of Madras as a second-grade college and with this, collegiate education in the district received a fillip. Secondary education recorded appreciable progress since 1915. The erstwhile Malabar district, of which the present Kozhikode district formed a part, holds a high rank among the districts of Madras Presidency in secondary education.


title: Do not resuscitate

text: A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on country, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary from country to country. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.


title: Do not resuscitate

text: Interviews with 26 DNR patients and 16 full code patients in Toronto in 2006-9 suggest that the decision to choose do-not-resuscitate status was based on personal factors including health and lifestyle; relational factors (to family or to society as a whole); and philosophical factors.


title: Do not resuscitate

text: Audio recordings of 19 discussions about DNR status between doctors and patients in 2 US hospitals (San Francisco and Durham) in 2008-9 found that patients "mentioned risks, benefits, and outcomes of CPR," and doctors "explored preferences for short- versus long-term use of life-sustaining therapy." A Canadian article (Diana Ginn and David Zitner, Canadian Family Physician, 1995 CPR Not for All Terminally Ill Patients) suggests that it is inappropriate to offer CPR when the clinician knows the patient has a terminal illness and that CPR will be futile.


title: Do not resuscitate

text: When medical institutions explain DNR, they describe survival from CPR, in order to address patients' concerns about outcomes. After CPR in hospitals in 2017, 7,000 patients survived to leave the hospital alive, out of 26,000 CPR attempts, or 26%. After CPR outside hospitals in 2018, 8,000 patients survived to leave the hospital alive, out of 80,000 CPR attempts, or 10%. Success was 21% in a public setting, where someone was more likely to see the person collapse and give help than in a home. Success was 35% when bystanders used an Automated external defibrillator (AED), outside health facilities and nursing homes.


title: Do not resuscitate

text: In information on DNR, medical institutions compare survival for patients with multiple chronic illnesses;


title: Do not resuscitate

text: Research shows that CPR survival is the same as the average CPR survival rate, or nearly so, for patients with multiple chronic illnesses,


title: Do not resuscitate

text: Survival is about half as good as the average rate, for patients with kidney or liver disease, or widespread cancer


title: Do not resuscitate

text: For people who live in nursing homes, survival after CPR is about half to three quarters of the average rate.


title: Do not resuscitate

text: In health facilities and nursing homes where AEDs are available and used, survival rates are twice as high as the average survival found in nursing homes overall. Few nursing homes have AEDs.


title: Do not resuscitate

text: Research on 26,000 patients found similarities in the health situations of patients with and without DNRs. For each of 10 levels of illness, from healthiest to sickest, 7% to 36% of patients had DNR orders; the rest had full code.


title: Do not resuscitate

text: As noted above, patients considering DNR mention the risks of CPR. Physical injuries, such as broken bones, affect 13% of CPR patients, and an unknown additional number have broken cartilage which can sound like breaking bones.


title: Do not resuscitate

text: Mental problems affect some patients, both before and after CPR. After CPR, up to 1 more person, among each 100 survivors, is in a coma than before CPR (and most people come out of comas).


title: Do not resuscitate

text: Organ donation is possible after CPR, but not usually after a death with a DNR. If CPR does not revive the patient, and continues until an operating room is available, kidneys and liver can be considered for donation. US Guidelines endorse organ donation, "Patients who do not have ROSC [return of spontaneous circulation] after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist." European guidelines encourage donation, "After stopping CPR, the possibility of ongoing support of the circulation and transport to a dedicated centre in perspective of organ donation should be considered." CPR revives 64% of patients in hospitals and 43% outside (ROSC), which gives families a chance to say goodbye, and all organs can be considered for donation, "We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation."


title: Do not resuscitate

text: 1,000 organs per year in the US are transplanted from patients who had CPR. Donations can be taken from 40% of patients who have ROSC and later become brain dead, and an average of 3 organs are taken from each patient who donates organs. DNR does not usually allow organ donation.


title: Do not resuscitate

text: Reductions in other care are not supposed to result from a DNAPR decision being in place. Some patients choose DNR because they prefer less care: Half of Oregon patients with DNR orders who filled out a POLST {known as a POST (Physician Orders and Scope of Treatment) in Tennessee} wanted only comfort care, and 7% wanted full care. The rest wanted various limits on care, so blanket assumptions are not reliable. There are many doctors "misinterpreting DNR preferences and thus not providing other appropriate therapeutic interventions."


title: Do not resuscitate

text: Patients with DNR are less likely to get medically appropriate care for a wide range of issues such as blood transfusions, cardiac catheterizations, cardiac bypass, operations for surgical complication, blood cultures, central line placement, antibiotics and diagnostic tests. "[P]roviders intentionally apply DNR orders broadly because they either assume that patients with DNR orders would also prefer to abstain from other life-sustaining treatments or believe that other treatments would not be medically beneficial." 60% of surgeons do not offer operations with over 1% mortality to patients with DNRs. The failure to offer appropriate care to patients with DNR led to the development of emergency care and treatment plans (ECTPs), such as the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which aim to record recommendations concerning DNR alongside recommendations for other treatments in an emergency situation. ECTPs have prompted doctors to contextualise CPR within a broader consideration of treatment options, however ECTPs are most frequently completed for patients at risk of sudden deterioration and the focus tends to be on DNR.


title: Do not resuscitate

text: Patients with DNR therefore die sooner, even from causes unrelated to CPR. A study grouped 26,300 very sick hospital patients in 2006-10 from the sickest to the healthiest, using a detailed scale from 0 to 44. They compared survival for patients at the same level, with and without DNR orders. In the healthiest group, 69% of those without DNR survived to leave the hospital, while only 7% of equally healthy patients with DNR survived. In the next-healthiest group, 53% of those without DNR survived, and 6% of those with DNR. Among the sickest patients, 6% of those without DNR survived, and none with DNR.


title: Do not resuscitate

text: Two Dartmouth doctors note that "In the 1990s...'resuscitation' increasingly began to appear in the medical literature to describe strategies to treat people with reversible conditions, such as IV fluids for shock from bleeding or infection... the meaning of DNR became ever more confusing to health-care providers." Other researchers confirm this pattern, using "resuscitative efforts" to cover a range of care, from treatment of allergic reaction to surgery for a broken hip. Hospital doctors do not agree which treatments to withhold from DNR patients, and document decisions in the chart only half the time. A survey with several scenarios found doctors "agreed or strongly agreed to initiate fewer interventions when a DNR order was present.


title: Do not resuscitate

text: After successful CPR, hospitals often discuss putting the patient on DNR, to avoid another resuscitation. Guidelines generally call for a 72-hour wait to see what the prognosis is, but within 12 hours US hospitals put up to 58% of survivors on DNR, and at the median hospital 23% received DNR orders at this early stage, much earlier than the guideline. The hospitals putting fewest patients on DNR had more successful survival rates, which the researchers suggest shows their better care in general. When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. The patients who received DNR orders had less treatment, and almost all died in the hospital. The researchers say families need to expect death if they agree to DNR in the hospital.


title: Do not resuscitate

text: In 2017, Critical Care Medicine (Ethics) and the American Society of Anesthesiologists (ASA) Committees on Transplant Anesthesia issued a statement regarding organ donation after circulatory death (DCD). The purpose of the statement is to provide an educational tool for institutions choosing to use DCD. In 2015, nearly 9% of organ transplantations in the United States resulted from DCD, indicating it is a widely-held practice. According to the President's Commission on Death Determination, there are two sets of criteria used to define circulatory death: irreversible absence of circulation and respiration, and irreversible absence of whole brain function. Only one criteria needs to be met for the determination of death before organ donation and both have legal standing, according to the 1980 Uniform Determination of Death Act (UDDA); a determination of death must be according to accepted medical standards. All states within the United States adhere to the original or modified UDDA. The dead donor role states that a patient should not be killed for or by the donation of their organs and that organs can only be procured from dead people (lungs, kidneys, and lobes of a liver may be donated by living donors in certain highly regulated situations). The definition of irreversibility centers around an obligatory period of observation to determine that respiration and circulation have ceased and will not resume spontaneously. Clinical examination alone may be sufficient to determine irreversibility, but the urgent time constraints of CDC may require more definitive proof of cessation with confirmatory tests, such as intra-arterial monitoring or Doppler studies. In accordance with the Institute of Medicine, the obligatory period for DCD is longer than 2 minutes but no more than 5 minutes of absent circulatory function before pronouncing the patient dead, which is supported by a lack of literature indicating that spontaneous resuscitation occurs after two minutes of arrest and that ischemic damage to perfusable organs occurs within 5 minutes.


title: Do not resuscitate

text: Most patients considered for DCD will have been in the intensive care unit (ICU) and are dependent on ventilatory and circulatory support. Potential DCD donors are still completing the dying process but have not yet been declared dead, so quality end-of-life care should remain the absolute top priority and must not be compromised by the DCD process. The decision to allow death to occur by withdrawing life-sustaining therapies needs to have been made in accordance to the wishes of the patient and/or their legal agent; this must happen prior to any discussions about DCD, which should ideally occur between the patient's primary care giver and the patient's agent after rapport has been established.


title: Do not resuscitate

text: The philosophical factors and preferences mentioned by patients and doctors are treated in the medical literature as strong guidelines for care, including DNR or CPR. "Complex medical aspects of a patient with a critical illness must be integrated with considerations of the patient's values and preferences" and "the preeminent place of patient values in determining the benefit or burden imposed by medical interventions." Patients' most common goals include talking, touch, prayer, helping others, addressing fears, laughing. Being mentally aware was as important to patients as avoiding pain, and doctors underestimated its importance and overestimated the importance of pain. Dying at home was less important to most patients. Three quarters of patients prefer longer survival over better health.


title: Do not resuscitate

text: Advance directives and living wills are documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. In contrast, it is a physician or hospital staff member who writes a DNR "physician's order," based upon the wishes previously expressed by the individual in their advance directive or living will. Similarly, at a time when the individual is unable to express their wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent. These various situations are clearly enumerated in the "sample" DNR order presented on this page.


title: Do not resuscitate

text: It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is their wish, as neither an advance directive nor a living will legally binds doctors. They can be legally binding in appointing a medical representative, but not in treatment decisions.


title: Do not resuscitate

text: Physician Orders for Life-Sustaining Treatment (POLST) documents are the usual place where a DNR is recorded outside hospitals. A disability rights group criticizes the process, saying doctors are trained to offer very limited scenarios with no alternative treatments, and steer patients toward DNR. They also criticize that DNR orders are absolute, without variations for context. The Mayo Clinic found in 2013 that "Most patients with DNR/DNI [do not intubate] orders want CPR and/or intubation in hypothetical clinical scenarios," so the patients had not had enough explanation of the DNR/DNI or did not understand the explanation.


title: Do not resuscitate

text: In the UK, emergency care and treatment plans (e.g. ReSPECT) are clinical recommendations written by healthcare professionals after discussion with patients or their relatives about their priorities of care. Research has found that the involvement of patients or their family in forming ECTP recommendations is variable. In some situations (where there are limited treatment options available, or where the patient is likely to deteriorate quickly) healthcare professionals will not explore the patient's preferences, but will instead ensure that patients or their relatives understand what treatment will or will not be offered.


title: Do not resuscitate

text: Medical bracelets, medallions, and wallet cards from approved providers allow for identification of DNR patients outside in home or non-hospital settings. Each state has its own DNR policies, procedures, and accompanying paperwork for emergency medical service personnel to comply with such forms of DNR.


title: Do not resuscitate

text: There is a growing trend of using DNR tattoos, commonly placed on the chest, to replace other forms of DNR, but these often cause confusion and ethical dilemmas among healthcare providers. Laws vary from state to state regarding what constitutes a valid DNR and currently do not include tattoos. End of life (EOL) care preferences are dynamic and depend on factors such as health status, age, prognosis, healthcare access, and medical advancements. DNR orders can be rescinded while tattoos are far more difficult to remove. At least one person decided to get a DNR tattoo based on a dare while under the influence of alcohol.


title: Do not resuscitate

text: DNR orders in certain situations have been subject to ethical debate. In many institutions it is customary for a patient going to surgery to have their DNR automatically rescinded. Though the rationale for this may be valid, as outcomes from CPR in the operating room are substantially better than general survival outcomes after CPR, the impact on patient autonomy has been debated. It is suggested that facilities engage patients or their decision makers in a 'reconsideration of DNR orders' instead of automatically making a forced decision.


title: Do not resuscitate

text: When a patient or family and doctors do not agree on a DNR status, it is common to ask the hospital ethics committee for help, but authors have pointed out that many members have little or no ethics training, some have little medical training, and they do have conflicts of interest by having the same employer and budget as the doctors.


title: Do not resuscitate

text: In the United States there is accumulating evidence of racial differences in rates of DNR adoption. A 2014 study of end stage cancer patients found that non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.


title: Do not resuscitate

text: There are also ethical concerns around how patients reach the decision to agree to a DNR order. One study found that patients wanted "intubation" in several scenarios, even when they had a Do Not Intubate (DNI) order, which raises a question whether patients with DNR orders may want CPR in some scenarios too. It is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing DNR.


title: Do not resuscitate

text: One study reported that while 88% of young doctor trainees at two hospitals in California in 2013 believed they themselves would ask for a DNR order if they were terminally ill, they are flexible enough to give high intensity care to patients who have not chosen DNR.


title: Do not resuscitate

text: There is also the ethical issue of discontinuation of an implantable cardioverter defibrillator (ICD) in DNR patients in cases of medical futility. A large survey of Electrophysiology practitioners, the heart specialists who implant pacemakers and ICDs, noted that the practitioners felt that deactivating an ICD was not ethically distinct from withholding CPR thus consistent with DNR. Most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. Pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like dialysis.


title: Do not resuscitate

text: A self-report study from 1999 conducted in Germany and Sweden found that the frequency of resuscitations performed against patients' wishes (per DNR status) was as high as 32.5% among German doctors polled.


title: Do not resuscitate

text: Medical professionals can be subjected to ramifications if they are aware of a DNR. Each state has established laws and rules that medical providers must follow. For example, in some states within the US, DNRs only apply within a hospital, and can be disregarded in other settings. In these states, EMTs can therefore administer CPR until reaching the hospital where such laws exist.


title: Do not resuscitate

text: If a medical professional knows of a DNR and continues with resuscitation efforts, then they can be sued by the family of the patient. This happens often, with a recent jury awarding $400,000 to the family of a patient for "Wrongful Prolongation of Life" in June 2021. Physicians and their attorneys have argued in some cases that when in doubt, they often err on the side of life-saving measures because they can be potentially be reversed later by disconnecting the ventilator. This was the case in 2013 when Beatrice Weisman was wrongfully resuscitated, leading to the family filing a lawsuit.


title: Do not resuscitate

text: Bystanders who are not healthcare professionals working in a professional setting are protected under the Good Samaritan Law in most cases. Bystanders are also protected if they begin CPR and use a AED even if there is a DNR tattoo or other evident indicator.


title: Do not resuscitate

text: Instead of violating a DNR, anesthesiologist often require suspension of a DNR during palliative care surgeries, such as when a large tumor needs to be removed or a chronic pain issue is being solved. Anesthesiologists argue that the patient is in an unnatural state during surgery with medications, and anesthesiologists should be allowed to reverse this state. This suspension can occur from during the pre-op, peri-op, and post-operative period. These suspensions used to be automatic and routine, but this is now viewed as unethical. The "Patient Self-Determination Act" also prohibits this, as automatic suspension would be a violation of this federal order. However, it is still a common practice for patients to opt for a suspension of their DNR depending on the circumstances of the surgery.


title: Do not resuscitate

text: Ethical dilemmas on suspending a DNR occur when a patient with a DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases, it has been argued that the principle of beneficence takes precedence over patient autonomy and the DNR can be revoked by the physician. Another dilemma occurs when a medical error happens to a patient with a DNR. If the error is reversible only with CPR or ventilation there is no consensus if resuscitation should take place or not.


title: Do not resuscitate

text: "DNR" and "Do Not Resuscitate" are common terms in the United States, Canada, and New Zealand. This may be expanded in some regions with the addition of "DNI" (Do Not Intubate). DNI is specific for not allowing the placement of breathing tubes. In some hospitals "DNR" alone will imply no intubation, though 98% of intubations are unrelated to cardiac arrest; most intubations are for pneumonia or surgery. Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic. Hospitals sometimes use the expression "no code", which refers to the jargon term "code", short for "Code Blue", an alert to a hospital's resuscitation team. If a patient does want to be resuscitated, their code status may be listed as "full code" (the opposite of DNR). If the patient only wants to be resuscitated under certain conditions, this is termed "partial code."


title: Do not resuscitate

text: Some areas of the United States and the United Kingdom include the letter A, as in "DNAR", to clarify "Do Not "Attempt" Resuscitation". This alteration is so that it is not presumed by the patient or family that an attempt at resuscitation will be successful.


title: Do not resuscitate

text: As noted above in Less care for DNR patients, the word "resuscitation" has grown to include many treatments other than CPR, so DNR has become ambiguous, and authors recommend "No CPR" instead. In the United Kingdom the preferred term is now "DNACPR", reflecting that "resuscitation" is a general term which includes "cardiopulmonary resuscitation" as well as, for example, the administration of intravenous fluid.


title: Do not resuscitate

text: Since the term DNR implies the omission of action, and therefore "giving up", a few authors have advocated for these orders to be retermed "Allow Natural Death".


title: Do not resuscitate

text: Others say AND is ambiguous whether it would allow morphine, antibiotics, hydration or other treatments as part of a natural death.


title: Do not resuscitate

text: New Zealand and Australia, and some hospitals in the UK, use the term "NFR" or "Not For Resuscitation". Typically these abbreviations are not punctuated, e.g., "DNR" rather than "D.N.R."


title: Do not resuscitate

text: Resuscitation orders, or lack thereof, can also be referred to in the United States as a part of Physician Orders for Life-Sustaining Treatment (POLST), Medical Orders for Life-Sustaining Treatment (MOLST), Physician's Orders on Scope of Treatment (POST) or Transportable Physician Orders for Patient Preferences (TPOPP) orders, typically created with input from next of kin when the patient or client is not able to communicate their wishes.


title: Do not resuscitate

text: Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos". This was implicitly a hospital DNR order, where 222 (or similar) is the hospital telephone number for the emergency resuscitation or crash team (NB: in 2004 the internal telephone number for cardiac arrests in all UK hospitals was standardised to "2222," and the same standardisation occurred across the whole EU in 2015). Current UK practice is for resuscitation recommendations to be standalone orders (such as DNACPR) or embedded within broader emergency care and treatment plans (ECTPs), such as the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT).


title: Do not resuscitate

text: DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable the decision to end resuscitation is made solely by physicians.


title: Do not resuscitate

text: A 2016 paper reports a survey of small numbers of doctors in numerous countries, asking "how often do you discuss decisions about resuscitation with patients and/or their family?" and "How do you communicate these decisions to other doctors in your institution?" Some countries had multiple respondents, who did not always act the same, as shown below. There was also a question "Does national guidance exist for making resuscitation decisions in your country?" but the concept of "guidance" had no consistent definition, For example, in the US, four respondents said yes, and two said no.


title: Do not resuscitate

text: In Victoria, a Refusal of Medical Treatment certificate is a legal means to refuse medical treatments of current medical conditions. It does not apply to palliative care (reasonable pain relief; food and drink). An Advanced Care Directive legally defines the medical treatments that a person may choose to receive (or not to receive) in various defined circumstances. It can be used to refuse resuscitation, so as avoid needless suffering.


title: Do not resuscitate

text: In NSW, a Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures, and which documents other aspects of treatment relevant at end of life. Such plans are only valid for patients of a doctor who is a NSW Health staff member. The plan allows for the refusal of any and all life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move to purely palliative care.


title: Do not resuscitate

text: There is no formally recognized protocol for creating and respecting DNR orders in Brazil's healthcare delivery system. The legality of not administering resuscitation procedures for terminally ill patients has not been clearly defined, leading many providers to practice caution around withholding CPR.


title: Do not resuscitate

text: Although DNR orders have not been institutionalized in Brazil there has been a significant amount of dialogue around the ethical question of whether or not to withhold resuscitation interventions. In the past two decades the Federal Medical Board of Brazil published two resolutions, CFM 1.805/2006 and CFM 1.995/2012, which address therapeutic limitations in terminally ill patients as well as advanced directives. A recent study also showed that in Brazil's healthcare system CPR is being withheld in scenarios of terminal illness or multiple comorbidities at rates similar to those in North America.


title: Do not resuscitate

text: Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada worked with the Canadian Bar Association to clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine when and how DNR orders are assigned. DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medical professionals can only be used if the patient is in a vegetative state.


title: Do not resuscitate

text: In 2005, France implemented its "Patients' Rights and End of Life Care" act. This act allows the withholding/withdrawal of life support treatment and as well as the intensified usage of certain medications that can quicken the action of death. This act also specifies the requirements of the act.


title: Do not resuscitate

text: The "Patients' Rights and End of Life Care" Act includes three main measures. First, it prohibits the continuation of futile medical treatments. Secondly, it empowers the right to palliative care that may also include the intensification of the doses of certain medications that can result in the shortening the patient's life span. Lastly, it strengthens the principle of patient autonomy. If the patient is unable to make a decision, the discussion, thus, goes to a trusted third party.


title: Do not resuscitate

text: In Israel, it is possible to sign a DNR form as long as the patient is at least 17 years of age, dying, and aware of their actions.


title: Do not resuscitate

text: In Italy DNR is included in the Italian law no. 219 of December 22, 2017 "Disposizioni Anticipate di Trattamento" or DAT, also called "biotestamento". The law no.219 "Rules on informed consent and advance treatment provisions", reaffirm the freedom of choice of the individual and make concrete the right to health protection, respecting the dignity of the person and the quality of life. The DAT are the provisions that every person of age and capable of understanding and wanting can express regarding the acceptance or rejection of certain diagnostic tests or therapeutic choices and individual health treatments, in anticipation of a possible future inability to self-determine. To be valid, the DATs must have been drawn up only after the person has acquired adequate medical information on the consequences of the choices he intends to make through the DAT. With the entry into force of law 219/2017, every person of age and capable of understanding and willing can draw up his DAT. Furthermore, the DATs must be drawn up with: public act authenticated private writing simple private deed delivered personally to the registry office of the municipality of residence or to the health structures of the regions that have regulated the DAT Due to particular physical conditions of disability, the DAT can be expressed through video recording or with devices that allow the person with disabilities to communicate. The DATs do not expire. They can be renewed, modified or revoked at any time, with the same forms in which they can be drawn up. With the DAT it is also possible to appoint a trustee, as long as he is of age and capable of understanding and willing, who is called to represent the signatory of the DAT who has become incapable in relations with the doctor and health facilities. With the Decree of 22 March 2018, the Ministry of Health established a national database for the registration of advance treatment provisions. Without the expression of any preference by the patient, Physicians must attempt to resuscitate all patients regardless of familial wishes.