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By: K. Carlos, M.A., M.D., M.P.H.

Professor, Perelman School of Medicine at the University of Pennsylvania

Waste materials from the drawing up of patient injections can be divided into two groups asthma treatment inhaler order fluticasone 100mcg with amex, those with long and those with short half-lives asthma symptoms 97 purchase fluticasone 100mcg free shipping. Technetium99m waste normally requires storage for only 48 hours asthma definition by who buy fluticasone visa, in a plastic bag inside a shielded container. Gallium-67, 131I and other longer half-life materials should be placed in a separate labelled and dated plastic bag and stored safely. Sharp items, such as needles, should be separated and placed in a shielded plastic container for safety. When disposing of waste, attention should be paid to the following points: - Normally once the surface dose rate in any individual bag of waste is below 5 mGy/h it can be disposed of (check with the local regulatory authority). It may be advisable to document the date of the last menstrual period on the nuclear medicine request form. A sign warning patients to tell staff if they are pregnant should be displayed in the waiting room. Pregnancy is not an absolute contraindication to radionuclide studies and in many situations, such as confirmation or exclusion of pulmonary embolus, may provide essential diagnostic information. If a patient is pregnant it is imperative to discuss the indications for the study with a departmental medical officer, and the fact that the patient is pregnant must be clearly marked on the consultation form. A smaller than normal activity of radiopharmaceutical may be administered, thereby minimizing radiation to the foetus. There is little risk involved with the use of 99mTc radiopharmaceuticals, but studies with other radionuclides should be avoided unless clinically justified. If a pregnant patient does have a nuclear medicine procedure, there are ways of calculating the radiation dose to the foetus, and tables of radiation doses. The foetal dose arises from the mother (usually from bladder activity) and from radionuclides that have crossed the placenta to the foetal circulation. Personnel monitoring All nuclear medicine staff must be routinely monitored for occupational radiation exposure. This includes nursing staff but may not need to include clerical staff, unless they are involved with patients. Monitors should be worn between waist and chest, and underneath any protective clothing (lead gowns) which might be used. The monitor should be changed regularly and, in any case, at intervals of no longer than 12 weeks. Each batch of monitors will come with a control monitor (to correct for natural background radiation and other factors), which must be kept in a place where there is no chance of radiation exposure from radionuclides or X rays. Records must be kept for their working lifetime, including the cumulative (running total) dose. Depending on the local regulatory requirements, it may be convenient to maintain detailed records only for the current year, and to keep yearly totals otherwise. Under the laws of many countries, the head of nuclear medicine will be held responsible for this, as well as for staff safety. The basic principle of radiation safety is to aim for the lowest feasible dose, not to allow staff to receive any regulatory dose limit. Staff who exceed this limit, on a pro rata basis (dose multipied by monitoring period in weeks/52), should be checked to ensure that their work practices are safe and that they have not been accidentally or unnecessarily exposed. If nurses are regularly involved, then they should be regularly monitored, otherwise monitoring need only be carried out for each case. Here, electronic direct reading dosimeters are advisable to allow continuous knowledge of the total dose. Routine and area monitoring Routine and area monitoring covers regular surveys of the radiation background in critical areas such as the radiopharmacy. These allow practices and safety measures to be modified before staff doses increase, particularly when new radiopharmaceuticals, radionuclides or increased activities are involved. The radiopharmacy should have a permanent area monitor (scintillation counter or ionization chamber), with an audible signal for dose rate, to allow staff to know when radioactive sources are exposed. Typically this would be a radiation safety committee with the responsibility for overseeing radiation safety practices in the hospital, and advising the administration on radiation safety issues. Representation from the nuclear medicine section is very important and should be mandatory.

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The capillary filtration pressure pushes fluid out of the capillaries and colloidal osmotic pressure exerted by the plasma proteins and pulls fluid back into the capillaries asthma treatment journal articles purchase genuine fluticasone line. Albumin which is the smallest and most abundant of plasma proteins asthmatic bronchitis in infants purchase fluticasone with a visa, provide the major osmotic force for the return of fluid to asthma treatment plan student buy cheap fluticasone line vascular compartments. Edema o o Refers to excess interstitial fluid in the tissues It is not a disease but rather the manifestation of altered physiological function. Mechanisms of Edema formation 124 Pathophysiology There are four major mechanisms of edema formation. The common causes of increased capillary hydrostatic pressures are: Congestive heart failure o Right side heart failure: - increased capillary hydrostatic pressure due to increased systemic venous pressure with increased blood volume. Decreased colloidal osmotic Pathophysiology o Renal failure results in edema by increasing capillary pressure due to salt and water retention which results in vascular congestion. Liver cirrhosis with portal hypertension:o Portal veins hypertension can occur when there is venous obstruction like in the case of cirrhosis, per portal fibrosis, etc. Venous obstruction o Localized edema occurs when there is venous obstruction like in the case of phlebothrombosis (thrombus formation in the vein). Increased gravitational forces: - Increased gravitational force occurs in long standing Leg Edema. Edema develops when plasma protein level become inadequate because of abnormal loss or inadequate productions. When fluid moves to the interstitial space vascular volume decrease, as a result, the kidney responds by secreting renninangiotensin aldosterone hormones that cause salt and water retention to worsen the edema. Hypoproteinemia:-causes decreased colloid osmotic pressure and results from:Malnutrition: - example ­ Edema in kwashiorkor. Protein loss:-in burn excess loss of protein occurs when large area of skin is injured or destroyed. Protein loosing enteropathy:-is a protein malabsorption syndrome, which results in protein loss with stool. Nephrotic syndrome: loss of large amount of protein through urine, when the glomerular capillaries become permeable to plasma proteins. Increased capillary permeability Direct damage to blood vessels, such as with trauma and burns, may cause increased permeability of the endothelial junctions. Inflammation causes vasodilatation, which leads to accumulation of fluids in the affected area. Obstruction of the Lymphatics Osmotically active plasma proteins and other large particles rely on the lymphatic for movements back into the circulatory system from interstitial space. Common causes of lymphatic obstruction are:· · · · Surgical removal of lymph nodes for cancer Radiation therapy Malignant metastasis Inflammations 128 lymph Pathophysiology · Filiariasis (parasitic infection of the lymph vessels) 4. Classification of Edema There are three types of fluid collection in the tissues a. Pitting edema o When accumulation of interstitial fluid exceeds the capacities of tissue gel, the tissue water is mobile; I. Non pitting Edema 129 Pathophysiology o Is a condition in which severeal proteins have accumulated in the tissue space and coagulated. Is usually seen in lymphatic obstruction, venous thrombosis, or following local trauma. Accumulation of fluid in the serous cavities o o o the potential spaces are closely linked with lymphatic drainage system. Examples Pleural effusion:- accumulation of fluid in pleural cavity Ascites: - accumulation of fluid in the peritoneal cavity. Definition: 130 Pathophysiology Nephrotic syndrome is not a specific glomerular disease, but a constellation of clinical finding that result from increased glomerular permeability to protein. It results from a decreased colloidal osmotic pressure that accompanies the loss of plasma protein. Other factors like increased salt and water retention may also play a role in edema formation. Hyperlipidemia - It is characterized by elevated serum level of both triglycerides and cholesterol - It is due to compensatory increase in albumin synthesis by the liver; which serves as stimulant for synthesis of lowdensity lipoproteins. Massive proteinuria:It is the core phathophysiologic problem in nephrotic syndrome.

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These responses can be compared to asthma symptoms score purchase fluticasone 250mcg overnight delivery interview responses of people without cancer to asthmatic bronchitis diagnosis cheap fluticasone 100 mcg with visa determine whether they had different exposures juice asthma treatment buy fluticasone mastercard. One study of this kind, conducted with Registry data, found a possible association between alcohol consumption and breast cancer. Researchers can also use Registry data to determine whether groups of people with specific exposures, for example, those working in certain occupations, are more likely to develop cancer than people who do not have these exposures. This includes all: · Hospitals · Diagnostic and Treatment Centers; · Radiation Treatment Centers; · Ambulatory Surgery Centers; · Nursing Homes; · Clinics; · Laboratories; and · Managed Care Organizations. Over time, the volume of cancer reports has increased, along with the amount of data collected for each report. Essentially, data collected by the Registry can be divided into two major categories: information pertaining to the disease process and information about the patient. Regarding the disease process, the Registry collects data on the: · anatomic site of the tumor; · cell type/histology of the cancer · stage at diagnosis; and · type of treatment rendered. If a patient is diagnosed with more than one type of cancer, this same information is collected for each unique tumor. The Registry also collects specific socio-demographic information on every patient diagnosed with cancer, consisting of, but not limited to: · age; · sex; · ethnicity; · race; · residence; and · place of birth. The Registry includes reports of all malignant cancers, except selected skin cancers. In situ cancers are very early cancers, while invasive cancers have more potential to spread or metastasize to other parts of the body. The Registry also collects data on brain and nervous system tumors classified as benign or which have an uncertain behavior. Benign tumors are growths that do not have the potential to metastasize beyond the tissue where they originated. If the facility has nothing to report for a particular month, the person(s) responsible for submitting cancer data must contact his/her Field Representative and inform them of that fact in writing. Once received at the Registry, cancer reports are processed utilizing a combination of automated and manual protocols before they can be used for data analysis. All incoming reports are electronically matched against records on file for patients diagnosed during the past 30+ years in New York State. About six percent of all cancers are second primaries (new cancers occurring among those patients who have been previously diagnosed with cancer). For some sites, such as oral cavity and pharynx, the number of multiple primaries in an individual may be quite high. Registry staff must review all tumor reports that match to reports already on the database to determine whether the new report represents a new primary cancer, or one that was previously reported. These include addresses with incomplete information on the record, mailing addresses not identified by street name. Boxes, rural routes, apartment buildings) and addresses located on newly created streets or those that run between several towns or counties. The field services staff monitor the number of cases submitted by each facility and the total number of cancer cases for a given diagnosis year. Although facilities are required to submit cases within six months of diagnosis or first contact with the patient, some case reports are not received until after a year or more has passed. When most of the data for a given year are received and processed, then death information processing begins. Any mention of cancer on the death certificate is also recorded regardless of whether the person died as a direct result of the cancer. This is an important process, as year of diagnosis, stage at diagnosis, histology and many other important pieces of information are not included on a death certificate. Of all tumors recorded at the Registry, approximately 3 percent are reported from death certificates for which no additional information is available. This is typically attributed to deaths which in a nonhospital setting or out of state. In some cases, the deceased had been diagnosed and treated for cancer at a facility other than the one in which he or she passed away and further information cannot be found. Further information is provided in Part 6: Death Certificate Only and Death Clearance Lists. The number of microscopically confirmed cases and the number with non-specific diagnoses indicate the accuracy of diagnostic information.

Consequently asthma treatment article buy 100 mcg fluticasone with mastercard, increased macrophage infiltration into maternal adipose tissue in combination with increased insulin resistance may contribute to asthma symptoms in children age 5 order fluticasone visa the regulation of adipose mass during pregnancy (Xu et al asthmatic bronchitis with exacerbation cheap 250 mcg fluticasone otc. Taken together there is little direct evidence that placental hormonal factors directly regulate maternal homeostasis and particularly quantitative changes in adipose tissue mass. Given the obligatory weight gain in the maternal tissues (uterus, breast, blood), and the fetal-placental unit, a weight gain less than ~7. Metabolic profile, dietary patterns, and eating behaviors of pregnant women undergoing weight loss or no weight gain have not been studied, but expected changes in fuel homeostasis can be deduced from studies conducted in pregnant women subjected to fasting. Glucose and insulin were lower, and acetoacetate and -hydroxybutyrate were two to three times higher, in pregnant than non-pregnant women at 12-60 hours but not 84 hours (Felig and Lynch, 1970). Ketonuria and Ketonemia in Pregnancy As first described by Freinkel (1980), pregnancy can be considered a condition of "accelerated starvation" because of the changes in maternal metabolism. The accelerated starvation occurs because of the increase in insulin resistance, particularly related to lipid metabolism, as discussed previously. As a result, there is an increased risk of developing ketonuria and ketonemia in pregnancy even among women with normal glucose tolerance. Chez and Curcio (1987) reported that eight of nine women with clinically normal pregnancies developed ketonuria at various times during their pregnancy. Pregnant women develop ketonemia much earlier than non-pregnant women during prolonged fasting because of the accelerated starvation. The ketone concentrations in maternal blood were equivalent to those in amniotic fluid and were fortyfold above levels in fed subjects. The assumption is that amniotic fluid levels represent maternal-to-fetal transport. Felig (1973) also hypothesized that ketones become an important metabolic fuel for the fetal brain once glucose concentrations decrease, because the human fetal brain has the enzymes necessary for ketone oxidation. In contrast, in diabetic women eating higherenergy diets, only 14 percent had ketonuria, and in pregnant non-diabetic women, only 7 percent developed ketonuria. Measurement of blood ketones was never positive if the urine measure was 2 plus and acetoacetate levels were always less than 1 mmol/L. Pregnant women with diabetes are more likely to develop elevated blood ketones than women with normal glucose tolerance. Nevertheless, a substantial proportion of pregnant women with normal glucose tolerance have elevated blood ketone levels some time during gestation. The extent to which fat mass accretion is critical rather than incidental to pregnancy is not clear, but unrestrained weight gain leads to postpartum weight retention. Placental size is strongly correlated with fetal growth, averaging approximately 500 g in singleton pregnancies. Amniotic fluid weight may affect maternal gestational weight gain by as much as 1 kg at term. Poor plasma volume expansion is associated with a poorly growing fetus and poor reproductive performance. Pregnancy is a condition of systemic inflammation that also influences maternal and fetal nutrient utilization. Therefore, caution is warranted regarding periods of prolonged fasting and weight loss during pregnancy and the development of ketonuria. Research Recommendation 3-2: the committee recommends that the National Institutes of Health and other relevant agencies should provide support to researchers to conduct studies on the eating behaviors, patterns of dietary intake and physical activity, and metabolic profiles of pregnant women, especially obese women, who experience low gain or weight loss during pregnancy. Areas for Additional Investigation the committee identified the following areas for further investigation to support its research recommendation. The research community should conduct studies on: · · Potential effects of maternal weight loss on components of maternal body composition for both the mother and the fetus, particularly in obese women; and Mechanisms by which placental hormonal factors and systemic inflammation impact the regulation of maternal metabolism during pregnancy. Standards of birth weight in twin gestations stratified by placental chorionicity. Trends in fetal growth among singleton gestations in the United States and Canada, 1985 through 1998. Short review: ultrasound in the estimation of human intrauterine placental growth. Prepregnancy weight status, prenatal weight gain, and the outcome of term twin gestations. Insulin sensitivity and B-cell responsiveness to glucose during late pregnancy in lean and moderately obese women with normal glucose tolerance or mild gestational diabetes.

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