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New developments in detector technology are likely to result in a wider range of hybrid systems distal gastritis definition protonix 40mg sale. It should be noted that the technology used in dual photon imaging is changing rapidly gastritis symptoms patient uk safe protonix 20mg. The emphasis of this document is on instruments designed for whole body applications gastritis treatment diet buy protonix 20 mg with mastercard, although additional tests are included that provide comparative information related to other types of application gastritis diet meals purchase 20mg protonix. The major advance in this document is that no distinction is made between conventional and gamma camera based systems. A more direct comparison between the specifications should therefore be possible in the future. The parameters specifically defined in the new document include those listed below: 136 4. The additional tests suggested for applications other than whole body studies are: Scatter fraction Count loss and random event measurements (dead time and true event rates) should be made. Acceptance testing As in the case of single photon imaging, it is important that all aspects of system performance are tested immediately after installation, and the ability of the system to meet the functionality standards specified in the purchasing document must be confirmed. The daily quality control procedures include: - Checking detector performance with a standard source; - Updating detector normalization; - Monitoring and recording any shift in parameters and environment. The regular quality control procedures include: - Setting up and recalibrating the detector; - Checking the working parameter setting of the device; - Making a phantom study of transmission and emission. The less frequent quality control tests include: - After power shutdown: checking detector set-up and normalization; - After servicing: checking detector set-up, performance and normalization; - After change of source: checking normalization and making a phantom study; - When necessary: changing the transmission sources. Radiation protection and measurement equipment Any nuclear medicine facility involves the use of radiation in many different ways, including: - Handling, storage and disposal of small to large activities of radioactive material, potentially in gaseous, liquid and solid forms; - Storage and handling of sealed radiation sources; 138 4. As a result, different types of radiation measuring equipment are required as follows: - Passive personnel dosimeters; - Active (direct reading) personnel dosimeters; - Contamination monitoring instruments (photons and beta radiation at least); - Radiation field monitoring instruments (photons). Types of radiation detectors the various types of radiation detector are described briefly below, in particular their advantages, disadvantages and uses, all of which must be understood by the user. It operates by measuring individual radiation events, which can also be smoothed out into a continuous signal of radiation exposure rate. Geiger counters can be calibrated to read in units of absorbed dose or equivalent dose, with, however, limited accuracy. The detector itself is usually in the form of a cylinder of varying size, from 2 cm long by less than 1 cm diameter, to around 10 cm long by 3 cm diameter. The detector may have a thin entry window for more efficient detection of low energy photons and particles. The first two usually have a shield to filter out particles so that only photons are measured. Removing the shield also allows particles to be detected, for example in contamination measurements. End window type detectors can be made very thin to allow beta and even alpha particles with energies greater than about 50 keV to be detected, whereas side window types (with a larger surface area) are thicker and will only allow photons and more energetic beta particles to pass. Pancake type detectors also have a thin window but a larger area, and are designed for contamination measurements. In nuclear medicine, most of the photon and beta energies used are above 60 keV, so the energy limitation is not a major problem. The most versatile and useful Geiger counter for nuclear medicine use should have the following features: - Have a thin window (but with protection against accidental damage) for particle detection; - Have a window shield for discrimination against particles; - Produce an audible signal of radiation events (for contamination detection); - Be calibrated in dose rate units allowing a wide measurement range, say 10 Sv/h to 10 mSv/h; - Be energy compensated to give the lowest possible detectable energy; - Be powered by easily available batteries, or have an inbuilt battery charger. A detachable probe may be of use for contamination measurements, but inbuilt probes will suffice in most cases. Some models have an audible indication of dose rate and/or an alarm which sounds at predetermined steps of total dose. These devices are very useful where staff may be exposed to high levels of radiation, for example, when using 131I for therapy. They are, however, more bulky and expensive than Geiger counters and may not be as rugged. While they (like Geiger counters) measure exposure, they can be calibrated to measure absorbed dose or equivalent dose. They may operate at ambient pressure or be pressurized for higher sensitivity and stability.

Data on pesticide use by women and men in food production are incomplete and inconsistent gastritis diabetes diet discount protonix 20 mg visa. In a number of production systems in selected countries it is predominantly men who apply pesticides and are at great risk; in other countries gastritis diet ������� buy cheap protonix on-line, and on other crops gastritis symptoms child generic protonix 40 mg amex, mainly women apply them (Box 2 gastritis diet chart protonix 40 mg low cost. The reasons for these differences include cultural and social norms, educational levels and awareness (Gupta et al. In Indonesia women carry out the bulk of spraying on oil palm plantations in Kalimantan, using highly hazardous pesticides under unsafe conditions. These women became plantation labourers following the shifting of land ownership from the community to an oil palm company (White and White 2011). A study on pesticide use in smallholder rice production in northern Ghana found that male farmers were much more likely to use pesticides than were female farmers (82. Exposure occurs not only during spraying, but also during mixing and loading of sprayers, working in recently sprayed crops, and other activities such as weeding, thinning, harvesting, washing out of pesticide containers and, importantly, hand-washing of pesticide-contaminated clothes. Further, pesticides and sprayers may be present in domestic spaces where food is prepared. A study in South Africa found a higher frequency of pesticide poisoning symptoms among planters, weeders and harvesters (61. Gender differences in chronic effects from exposures to pesticides are also related to biological differences. Almost 100 pesticides have been identified as potentially contributing to increased risk of breast cancer, and of these at least 63 are known to have estrogenic effects in laboratory studies (Watts 2007). On the other hand, there are some pesticides to which males are more sensitive or that may have effects specific to their physiologies, such as those that increase risk of prostate cancer (Slotkin et al. These crops are increasingly embedded in industrialized and commercial food systems in several countries. Failed crops, the spiralling costs of inputs, financial hardship and loss of land are often behind farmer suicides. While global attention has been drawn to the male farmer pesticide-suicide epidemic, in rural areas of India and Sri Lanka, rates of suicide by pesticides are higher for young females aged 1524 (Gunnell and Eddleston 2003). In China, the only country with a higher overall rate of female than male suicides (mostly by young rural women), 62% of suicide deaths resulted from ingestion of pesticides, including rat poison (Yip and Liu 2006). In a few cases documented in India and Afghanistan (and widely suspected elsewhere) women have been murdered by being forced to drink pesticides in a form of chemical "honour killing" (The Economist 2010; Kumar et al. Women (and also children) saved significant time because less weeding (a traditional female responsibility) was required (Gouse et al. Women generally manage poultry, small dairy animals, and other livestock housed and fed within a homestead, while men are more prominent in the management of grazing and larger animals such as cattle, horses and camels. The gender balance of ownership, decision-making, livestock management and marketing of livestock products is highly variable. Sometimes women own (generally small) livestock, have control over the use and marketing of products such as eggs, milk and poultry meat, and make management decisions; in other cases men exercise these functions (Staal et al. When livestock-based production is scaled up, control over decision-making and income often shifts to men. In the Lake Faguibine area of northern Mali, for example, as the lake has dried up men have migrated as an adaptive strategy. Women who stay behind have perceived this change as increasing their vulnerability since livestock herding, which has become more risky due to climatic changes, has been added to their workloads (Djoudi and Brockhaus 2011). Animal rights in industrializing livestock production: In developed countries an increasing share of the food supply is produced in industrialized, highintensity agricultural operations. At the same time that animals are being treated as industrial commodities in large-scale food production systems, scientific research is increasingly establishing that non-human animals are sentient beings with complex emotional and cognitive lives (Berkoff 2013). Although animal rights movements are sometimes criticized as developed world liberalism (Donaldson and Kymlicka 2011), in developing countries animal welfare and Box 2. In many developing economies, conspicuous consumption of animal products, from leather to meats, by elite and upwardly mobile social groups has increased; such consumption can be interpreted as a symbol as well as a benefit of modernity and "development" (Dave 2014). Since the 1970s, notably in India, Oceania, the United States and Europe, women activists have constituted the primary driver of animal rights movements.

Lumbar puncture and systemic infectious workup should be considered given the recent fevers gastritis diet 2000 discount protonix generic, upper respiratory symptoms gastritis icd 9 buy protonix visa, and changes in cognition gastritis sintomas order protonix 40mg line. Infectious workup was notable for a rapid influenza swab that was positive for influenza A gastritis symptoms treatment order protonix on line amex. What is the differential diagnosis of subacute altered mental status and seizures in association with mesial temporal lobe changes Seizure activity itself can lead to transient T2 hyperintensities in the medial temporal lobes. Other considerations in this patient would be a paraneoplastic or autoimmune encephalitis, but the acute onset and rapid decompensation is atypical. Lumbar puncture showed total protein of 443 mg/dL, glucose of 98 mg/dL, with 4 leukocytes and 11 erythrocytes per mm3. The patient became progressively more somnolent, requiring transfer to an intensive care unit, and she was transferred to our hospital for further evaluation and management. Her cranial nerves were normal, and she was able to localize to noxious stimuli in all extremities. Reflexes were brisk, measuring 3/4 in all 4 extremities, and the patient had positive Hoffman signs, flexor plantar response on the right, and equivocal response with fanning of the toes on the left. Acyclovir was continued, and the patient was empirically treated for bacterial meningitis with vancomycin and ceftriaxone. Repeat lumbar puncture showed total protein of 794 mg/dL, glucose of 84 mg/dL, with 4 leukocytes and 19 erythrocytes per mm3. Chest X-ray demonstrated a left lower lobe opacity, and the patient was treated with a 7-day course of ceftriaxone and azithromycin for pneumonia. She was enrolled in a clinical trial comparing oseltamivir to zanamivir for treatment of influenza. However, her condition continued to deteriorate despite antiviral therapy, and she required intubation for airway protection. Over the next several days, her examination results worsened such that she no longer spontaneously moved her extremities and only demonstrated stereotyped movements in response to noxious stimuli. She demonstrated some purposeful movements on hospital day 9 and was extubated on hospital day 11. Her condition slowly improved over the next week, and she was discharged to a rehabilitation facility on hospital day 21. On discharge, she was alert, was able to speak in 2-word sentences, could follow simple commands, and was able to walk with assistance. On follow-up 8 months later, the patient was fully ambulatory without residual aphasia, but had significant persistent deficits in anterograde and retrograde memory. McCray cared for the patient presented, wrote the text, and helped to assemble the figures. Deborah Forst cared for the patient presented, helped edit the text, and helped to assemble the figures. Neurological complications of pandemic influenza A H1N1 2009 infection: European case series and review. H1N1 encephalitis with malignant edema and review of neurologic complications from influenza. Grinspan, Division of Pediatric Neurology, Harkness Pavilion, 5th Floor, 180 Fort Washington Ave. She presented to the obstetrical service fully dilated after 2 days of leaking vaginal fluid, and delivered a healthy baby girl. She had had a febrile seizure at age 4, and several brief convulsions as a teenager. She recalled 2 of 3 words at 5 minutes, but had no memory for recent events, including her delivery. She could not describe cocktail ingredients, despite working as a bartender, but correctly recited old addresses. Encephalopathy suggests a process affecting large areas of the brain bilaterally due to metabolic derangements or diffuse structural injury to gray and/or white matter.

The peripheral blood smear often but not invariably shows morphologic changes in the red blood cells compatible with hemolysis gastritis diet coconut water order protonix amex. For example gastritis diet 3-2-1 purchase protonix in united states online, many spherocytes suggest hereditary spherocytosis or immunohemolytic anemia and sickle cells suggest one of the sick cell syndromes gastritis diet 7 hari order 40mg protonix with amex. Examination of the peripheral blood smear shows large numbers of spherocytes gastritis diet bland purchase protonix on line amex, often accompanied by polychromatophils. In the majority of cases hematocrit levels are normal or near normal with minimal hemolysis; greater than 25 percent (often 75%) of red cells are elliptocytes. It should be noted that some elliptical cells also occur in thalassemia, iron deficiency, myelophthisic anemias, sickle cell disease, and megaloblastic anemia. Erythrocyte enzyme deficiencies Hereditary hemolytic anemia has been associated with 284 these disorders, however, are accompanied by other characteristic morphologic Hematology at least ten red cell enzyme deficiencies. The gene for G-6-P is sexBecause of the X-linkage, male patients are more severely affected than female patients. The deficiency is not limited to any particular racial or geographically defined population. Rather than producing acute hemolysis in association with drug ingestion, it causes a chronic congenital nonspherocytic hemolytic anemia. Generally the term hemoglobinopathy is used to signify a structurally abnormal hemoglobin with at least one amino acid substitution. Structural abnormalities may cause premature red cell destruction; easily denatured hemoglobins; hemoglobins with abnormal oxygen affinity; altered hemoglobin solubility; and, in a few instances, reduced globin synthesis. In this topic only the few clinically significant hemoglobinopathies are discussed. Hemoglobin S By far the most important hemoglobinopathies are those related to the presence of sickle hemoglobin (HbS). Sickle hemoglobin results form replacement 287 Hematology of the sixth amino acid form the N-terminal end of the chain, glutamic acid, by valine. Hemoglobin C syndromes Hemoglobin C (HbC) is probably the second most common hemoglobinopathy (2-3% gene frequency in black populations). HbC is caused by substitution of lysine for glutamic acid in the sixth position form the Nterminal end of the -hemoglobin chain (same location as the substitution in HbS). A variety of acquired clinical conditions result in shortened survival of previously normal red cells. These include immune-mediated destruction, red cell fragmentation disorders, acquired membrane defects, splenic effects, and the results of infections and environmental toxins. Immunohemolytic anemia 288 Invariably sickle cells are typically seen on Wright-stained peripheral blood Hematology Immunohemolytic anemias are the result of the binding of antibody, complement, or antibody plus complement to red cells. Antibodies formed against erythrocyte antigens may be either warm (active at 37oC) or cold (active at room temperature and below). In some cases, these antibodies activate a series of proteins, referred to collectively as complement; in others, the red cells are coated with antibody alone. As a result of complement activation by hemolytic antibodies, intravascular red cell lysis and release of hemoglobin may occur. The red cells are usually coated with IgG alone, IgG and complement or complement alone, but a minority of cases show IgA or IgM coating alone or combined with IgG antibody. Part of the coated membrane is lost so the cell becomes 290 Hematology progressively more spherical to maintain the same volume and is ultimately prematurely destroyed, usually predominantly in the spleen. The disease may occur at any age in either sex and presents as a hemolytic anemia of varying severity. Laboratory findings the hematological and biochemical finding are typical of a hemolytic anemia with spherocytosis prominent in the peripheral blood. The antibodies both on the cell surface and free in serum are best detected at 37oC. In these syndromes the autoantibody, whether monoclonal (as in the idiopathic cold hemeagglutinin syndrome or associated with 291 Hematology lymphoprolifertative disorders) or polyclonal (as following infection. Hemolytic syndromes of varying severity may occur depending on the titer of the antibody in the serum, its affinity for red cells, its ability to bind complement, and its thermal amplitude (whether or not it bids to red cells at 37oC). Agglutination of red cells by the antibody often causes peripheral circulation abnormalities.

General assessment findings and symptoms for patients with a drug resistant bacterial condition 3 gastritis diet kidney cheap 20 mg protonix overnight delivery. Pathophysiology gastritis diet pdf generic protonix 40mg online, incidence gastritis vs gerd symptoms cheap protonix 20 mg amex, causes gastritis sweating protonix 20 mg low cost, risk factors, methods of transmission, complications for a patient with a fungal infections 2. Progressive worsening of neurologic signs is characteristic of rabies and should be considered as a positive indicator for rabies Page 158 of 385 N. Antibiotic treatment during phase I prevents progression Antibiotic Resistant Infections 1. Consider age-related variations in pediatric and geriatric patients Communication and documentation for a patient with a communicable or infectious disease Transport decisions including special infection control procedures. Patient and family teaching regarding communicable or infectious diseases and their spread. Legal requirements regarding reporting communicable or infectious diseases/conditions A. Required reporting to the health department or other heath care agency Page 161 of 385 Medicine Endocrine Disorders Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Parathyroid hormone Pathophysiology, causes, Incidence, morbidity, and mortality, assessment findings, management for endocrine conditions A. Cushing syndrome Other endocrine disorders Consider age-related variations Pediatric A. Communication and documentation Transport decisions Patient education and prevention Page 164 of 385 Medicine Psychiatric Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Patterns of Violence, Abuse, and Neglect Assessment findings for behavioral/psychiatric patients A. Consider medical causes of acute crises Providing Empathetic and Respectful Management A. Pharmacodynamics of prescribed medications for behavioral/psychiatric disorders 1. Emergency use Consider age-related variations in pediatric and geriatric patients Communication to medical facility and documentation Transport decisions X. Page 167 of 385 Medicine Cardiovascular Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Ejection - Initial, shorter, rapid ejection followed by longer phase of reduced ejection i. Abnormal lipid metabolism or excessive intake or saturated fats and cholesterol b. Defined as a brief discomfort, has predictable characteristics and is relieved promptly - no change in this pattern b. Typical - sudden onset of discomfort, usually of brief duration, lasting three to five minutes, maybe 5 to 15 minutes; never 30 minutes to 2 hours b. Defined as impaired diastolic filling of the heart caused by increased intrapericardiac pressure B. Resuscitation - to provide efforts to return spontaneous pulse and breathing to the patient in full cardiac arrest b. Communications and transfer of data to the physician Termination of resuscitation efforts 1. Arrest is presumed cardiac in origin and not associated with a condition potentially responsive to hospital treatment (for example - hypothermia, drug overdose, toxicologic exposure, etc. Patient has a cardiac rhythm of asystole or agonal rhythm at the time the decision to terminate is made and this rhythm persists until the arrest is actually terminated g. Victims of blunt trauma in arrest whose presenting rhythm is asystole, or who develop asystole while on scene Page 194 of 385 2. Ventricular - Blood from left ventricle passes into right ventricle Patent Ductus Arteriosus 1. Malformations lead to altered cardiac function and hemodynamics Specific Diseases 1.

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