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By Q. Angar. State University of New York College at Farmingdale. 2019.

This autonomy is not transferred to a surrogate decision maker discount celecoxib 200 mg online, even one who is very credible buy celecoxib 100mg with visa. A 246 Medicine family conference in this case would not change the overriding issue—that a valid living will is in effect. Antihistamines and cortico- steroids are frequently given as well, although they have little immediate effect. The patient should be offered venom immunotherapy after recovery from the systemic reaction. Removal without compression of an insect stinger is worthwhile, but not the primary concern. However, the cost of lifelong prophylaxis in this patient would be high, and the preva- lence of adverse drug reaction would be between 10 and 25%. This expense is generally considered high compared to a more conservative approach of treating an attack when it does occur. Prophylactic therapy would be reserved for patients who already had one or more acute attacks. Although hyperuricemia is associated with arteriosclerotic disease, the association is not felt to be causal, and there is no proven cardiovascular benefit to reducing the uric acid level. In patients with lymphoproliferative disease, prophylaxis for the prevention of renal impairment is recom- mended. The risk of urolithiasis is sufficiently low that prophylaxis is not necessary until the development of a stone. The 50- year-old Hodgkin’s disease patient has active tuberculosis and must be treated with a three- or four-drug regimen. A 20-year-old female develops urticaria that lasts for 6 weeks and then resolves spontaneously. A 20-year-old male is found to have weight loss and generalized lymph- adenopathy. He has hypogammaglobulinemia with a normal distribution of immunoglobulin isotypes. The patient should receive the standard vaccine protocol 249 Copyright © 2004 by The McGraw-Hill Companies, Inc. A 25-year-old female complains of watery rhinorrhea and pruritus of the eyes and nose that occurs around the same season each year. In this patient, symptoms are being produced by an IgE antibody against a spe- cific allergen b. The patient should be evaluated for latex allergy by skin testing or demonstra- tion of specific IgE antibody c. A 30-year-old male develops skin rash, pruritus, and mild wheezing about 20 min after an intravenous pyelogram performed for the evaluation of renal stone symptoms. For each numbered item, select the one lettered option with which it is most closely associated. Items 458–460 For each clinical description, select the one most likely immunologic defi- ciency. A 40-year-old white woman with a history of chronic otitis and sinusi- tis is found to have a serum IgA level of 1 mg/dL. She may suffer an anaphylactic reaction following the administration of serum products b. A 55-year-old farmer develops recurrent cough, dyspnea, fever, and myalgia several hours after entering his barn. Testing of pulmonary function several hours after an exposure will most likely reveal an obstructive pattern b. Immediate-type IgE hypersensitivity is involved in the pathogenesis of his ill- ness c. Demonstrating precipitable antibodies to the offending antigen confirms the diagnosis of hypersensitivity pneumonitis 463. She believes that she gets a rash several hours after eating small amounts of peanuts. The foods most likely to cause allergic reactions include egg, milk, seafood, nuts, and soybeans d. The organ systems most frequently involved in allergic reactions to foods in adults are the respiratory and cardiovascular systems e. A 32-year-old woman experiences a severe anaphylactic reaction fol- lowing a sting from a hornet. Adults are unlikely to die as a result of an insect sting compared to children with the same history d. She should be skin-tested with venom antigens and, if positive, immunother- apy should be started Allergy and Immunology 253 Items 465–468 For each immunologic deficiency, select the most likely infectious process that might result. Some do have underlying illnesses such as chronic infection, myeloproliferative disease, collagen vascular disease, or hyperthyroidism. Patients have hypo- gammaglobulinemia, often with associated T cell abnormalities. Diarrhea can be idiopathic, with malabsorption, or secondary to chronic infection such as giardiasis.

Outre la documentation prévue à l’article 15 generic celecoxib 200mg overnight delivery, l’Organe publiera 200 mg celecoxib fast delivery, aux dates qu’il aura fixées, mais au moins une fois par an, les renseignements relatifs aux évaluations qui lui paraîtront devoir faciliter l’application de la présente Convention. Les données techniques sont publiées à des fins de contrôle et pour répondre aux besoins des chercheurs, 7. Les observations suivantes s’appliquent aux tableaux des entreprises et du public en général. Elles s’appuient statistiques figurant dans les deuxième, troisième, qua- sur les renseignements que les gouvernements fournissent trième et cinquième parties de la présente publication: à l’Organe en application des dispositions pertinentes de la Convention de 1961. Les informations relatives à l’état a) Les données figurant dans les tableaux sont celles dont l’Organe disposait au 1er novembre 2008; d’adhésion des pays et territoires à la Convention de 1961 et à la réception par l’Organe des renseignements b) Les fractions d’unité de mesure n’apparaissent pas dans les relevés des quantités figurant pour chaque pays. La fabrication peut avoir lieu au début ou supérieures à 500 milligrammes ont été arrondies au d’une année à partir de matières premières qui étaient gramme supérieur; les fractions de gramme inférieures à en cours d’utilisation à la fin de l’année précédente. Certains rendements nécessitent toutefois une intervention représentent seulement la somme des chiffres fournis à de l’Organe en vue de les élucider; l’Organe et ne constituent pas nécessairement les totaux mondiaux complets. Les noms des tenu du fait que le processus de fabrication s’étale d’une territoires non métropolitains apparaissent en italique. Estupefacientes: Previsiones de las necesidades mun- a la Convención y de la recepción de información diales para 2009; Estadísticas de 2007 es uno de los (estadísticas y previsiones) de los Gobiernos por parte tres informes técnicos que la Junta Internacional de de la Junta. El informe técnico sobre estupefacientes se publica presente informe técnico) es necesaria, entre otras cosas, en cumplimiento de las disposiciones del artículo 15 para informar a los Gobiernos de los límites aplicables (Informes de la Junta) de la Convención Única de 1961 a la fabricación y el comercio internacional de estupefa- sobre Estupefacientes, que estipula lo siguiente: cientes durante un año derminado. La Junta redactará un informe anual sobre nico) tiene por objeto suministrar información, a efectos su labor y los informes complementarios que consi- del análisis, entre otras cosas, sobre la disponibilidad y dere necesarios. Dichos informes contendrán, además, utilización de estupefacientes en diversos países y terri- un análisis de las previsiones y de las informaciones torios. La publicación de las previsiones y estadísticas estadísticas de que disponga la Junta y, cuando pro- relativas a la producción, fabricación, existencias y uti- ceda, una indicación de las aclaraciones hechas por lización de estupefacientes cumple también la función de los gobiernos o que se les hayan pedido, si las proporcionar a los países fabricantes y productores hubiere, junto con las observaciones y recomenda- información sobre las tendencias previsibles, a fin de ciones que la Junta desee hacer. Estos informes serán alentarlos a adaptar sus planes de manera que les permita sometidos al Consejo [Económico y Social] por mantener el equilibrio entre la oferta y la demanda. Estos informes serán comunicados a las que se han de presentar a la Junta intervienen diversos Partes y publicados posteriormente por el Secretario organismos de la administración nacional (de las ramas General. Las Partes permitirán que se distribuyan sin de salud, policía, aduanas y justicia, entre otras), y el limitación. El análisis de la información que las adminis- cionamiento del sistema de previsiones) de la Convención traciones nacionales suministran a la Junta permite apre- de 1961 se estipula que: ciar el grado de eficacia con que funciona cada adminis- tración, por ejemplo, mediante la comparación de las Además de los informes mencionados en el artí- previsiones y las estadísticas que presentan en relación culo 15, la Junta publicará, en las épocas que deter- con un año determinado, como se hace respecto de todos mine, pero por lo menos una vez al año, la infor- los países y territorios en la quinta parte del presente mación sobre las previsiones que pueda, a su parecer, informe técnico. Los datos técnicos sobre los estupefacientes se publi- can con fines de fiscalización y para atender las necesi- dades de los investigadores, las empresas y el público en general. Los datos se basan en la información suminis- Observaciones sobre los trada a la Junta por los Gobiernos de conformidad con las disposiciones pertinentes de la Convención de 1961. La fabricación puede tener lugar a comienzos de gramo superior; cuando las fracciones de kilogramo son un año utilizando materias primas que se estaban de menos de 500 gramos, se redondean al kilogramo empleando ya a finales del año anterior. Sin embargo, ciertas deadas al gramo superior; cuando las fracciones de tasas de rendimiento requieren investigación por parte gramo son de menos de 500 miligramos, se redondean de la Junta; al gramo inferior. El guión largo (—) significa que la cantidad es a la Junta y no necesariamente los totales mundiales nula. Por las razones indicadas en los apartados b) signo “=” significa una cantidad (nula) o inferior a la y c) supra, los totales son a veces mayores o menores unidad de medida considerada. Los nombres de tasas de rendimiento de la fabricación varían de un año los territorios no metropolitanos aparecen en bastardilla. Le signe “"” signifie que le and provides a record of the receipt of reports required by the Board. Le signe “=” signifie que Those reports include the quarterly statistics of imports and exports la Convention de 1961 et le Protocole de 1972 s’appliquent au of narcotic drugs (form A), the annual estimates of requirements of territoire respectif. Le signe “"” signifie également que le pays ou narcotic drugs, manufacture of synthetic drugs, opium production territoire concerné a présenté le rapport prévu. Par “1961”, on and cultivation of opium poppy for purposes other than opium entend la Convention de 1961 sous sa forme originale et l’abréviation production (form B) and the annual statistics of production, “1961/72” indique qu’il s’agit de la Convention de 1961 telle que manufacture, consumption, stocks and seizures of narcotic drugs modifiée par le Protocole de 1972. The table permits an assessment of the rate of accession to the 1961 Convention and of the way in which the parties are fulfilling their obligations by furnishing to the Board the required information. Failure by a country or territory to provide mandatory reports to the Board may indicate problems in the implementation of the provisions of the 1961 Convention in that country or territory. Notas: Countries (and territories to which the 1961 Convention could apply) are divided into three groups: parties to the 1961 Convention En el cuadro de la segunda parte se indica, respecto de cada país as amended by the 1972 Protocol; parties to the 1961 Convention y territorio no metropolitano, el estado de la adhesión a la Conven- in its original form only; and non-parties to the 1961 Convention. The sign “=” indicates that the 1961 Convention and requeridos por la Junta que se han recibido de cada uno de ellos. The sign “"” is Esos informes incluyen las estadísticas trimestrales de importaciones also used to indicate that the respective country or territory furnished y exportaciones de estupefacientes (formulario A), las previsiones the relevant report. The 1961 Convention in its original form is indi- anuales relativas a las necesidades de estupefacientes, la fabricación cated as “1961”; and “1961/72” is used to indicate the 1961 Con- de estupefacientes sintéticos, la producción de opio y el cultivo de vention as amended by the 1972 Protocol. Countries and territories la adormidera con fines distintos de la producción de opio (formu- that provided all the required reports (i. El cuadro permite hacer una apreciación del índice de adhe- Notes: siones a la Convención de 1961 y de la forma en que las partes están cumpliendo sus obligaciones suministrando a la Junta la Le tableau de la deuxième partie indique, pour chaque pays et información requerida. El hecho de que un país o territorio no pre- territoire non métropolitain, l’état d’adhésion à la Convention unique sente a la Junta los informes que está obligado a enviar puede ser sur les stupéfiants de 1961 et à cette convention telle que modifiée indicio de problemas en la aplicación de las disposiciones de la par le Protocole de 1972 et rend compte de la réception des rapports Convención de 1961 en ese país o territorio.

Potential problems associated with medical management of ectopic pregnancy include drug side effects and treatment failure 200 mg celecoxib overnight delivery. Some patients treated with meth- otrexate will develop acute abdominal pain due to the process of “tubal abor- tion celecoxib 100mg amex. A few common surgical tech- niques used for treatment of ectopic pregnancy include salpingotomy, salpingos- tomy, and partial salpingectomy. These techniques can be used to treat the majority of unruptured ectopic pregnancy, whereas exploratory laparotomy may be used in cases of ruptured ectopic pregnancy. On examination, her blood pressure is 120/80 mm Hg and her heart rate is 80 beats per minute. She states that she underwent in vitro fertilization and is currently 8 weeks pregnant. Transvaginal sonography reveals a singleton intrauterine gestation with cardiac activity, and a moderate amount of free fluid in the cul de sac. In general, any woman in the childbearing age group with abdominal pain or abnormal vaginal bleeding should have a pregnancy test. A large number of women who undergo methotrexate treatment of ectopic pregnancy will have some abdominal discomfort. As long as there are no signs of rupture such as hypotension, severe pain, or free fluid on ultrasound, expect- ant management may be practiced. In vitro fertilization with embryo transfer produces a rate of coexisting intrauterine pregnancy and ectopic pregnancy of up to 3% (markedly higher than the spontaneous rate of 1:10,000). Thus, a woman who has undergone in vitro fertilization who presents with abdominal fluid and hypotension must be suspected as having an ectopic pregnancy, even when an intrauterine preg- nancy has been visualized on sonography. The presence of uterine cramping, vaginal bleeding, passage of tissue, and an open cervical os in a pregnant woman is consistent with an incomplete abortion. This patient likely has a completed abortion with the resolution of symp- toms following passage of tissue and now with a small uterus and closed cervi- cal os. Nevertheless, there is still a possibility of ectopic pregnancy and perhaps the “tissue” passed was only blood clot. Dilation and curettage would generally be performed, and if chorionic villi found the diagnosis is miscarriage; absence of chorionic villi establishes the diagnosis of ectopic pregnancy which may be treated by surgery or methotrexate. Consider pregnancy even when a woman has had a tubal ligation or is using contraception. Surgery, not methotrexate, is the best treatment for the patient who is hemodynamically unstable or with significant abdominal pain. The patient was noted to have numerous episodes of nausea and vomit- ing over the past 1 1/2 months, which has persisted despite antiemetic therapy and adjustments in her diet. On examination, the patient is lethargic but will respond to painful stimuli and open her eyes. She is found to be lethargic and noted to be hypovolemic with blood pressure of 92/44 mm Hg and heart rate of 130 beats per minute. Know the physiologic changes in pregnancy and their impact on common dis- eases in pregnancy. Considerations This patient described in the scenario above is significantly ill and needs aggres- sive fluid replacement, electrolyte replacement, and correction of metabolic abnor- malities. She has complicated hyperemesis gravidarum, and needs a diagnostic workup such as pelvic ultrasound if not previously performed, right upper quadrant ultrasound, and thyroid function tests. Antiemetic therapy, and fluid replacement and nothing by mouth should be initiated. The patient should be followed carefully once discharged to ensure that she doesn’t become so volume depleted. For this chapter, the discussion will be focused on: hyper- emesis gravidarum, spontaneous abortion, asthma exacerbation, hyperthyroidism/ thyroid storm, preterm premature rupture of membranes, and pyelonephritis. Hyperemesis Gravidarum Nausea and vomiting in pregnancy is very common, affecting up to 75% of pregnant women. However, hyperemesis gravidarum, which is defined as intractable emesis with volume depletion and metabolic/electrolyte alterations is less common, with prevalence of about 2% of pregnancies. Typically it occurs in women in the first tri- mester, and is diagnosis of exclusion. The emergency physician should not be lulled into complacency because nausea and vomiting is so common in pregnant women. The evaluation should include addressing the degree of volume depletion and exploring the possibility of metabolic issues such as electrolyte abnormalities, renal or liver function abnormalities, and the possibility of other etiologies. Pregnant women are typically young and healthy, and significant hypovolemia with compensation without appearing ill. A careful history should be taken regard- ing the amount of oral intake, medications taken if any, and the presence of other possible causes of emesis.

The Act of Higher Education (1993) has restored the rights of the medical universities to award postgraduate degrees and residency buy celecoxib 100mg without a prescription, and permission was also given to license Physicians’ procedures 200 mg celecoxib with visa. This kind of training required a new structure, a new administrative apparatus, and a suitable training center. The introduction of the credit system, starting in September 2003, has been mandatory in every Hungarian university, helping the quantitative and qualitative evaluation of the students’ achievements. Admission requirements for Hungarian students are defined at national level, and they are applicable for every student wishing to be enrolled into the Medicine or Dentistry programs. International students must pass an entrance exam in biology and (depending on their preference) in physics or chemistry. In some special cases it may be possible for the candidates to apply for transfer to higher years on the basis of their previous studies and achievements. Entrance for certain courses of the Health College is also possible on the basis of a special evaluation (scoring) and an entrance interview. The total number of contact hours in medical education is over 5,500, which can be divided into three main parts: basic theoretical training (1st and 2nd year), pre-clinical subjects (3rd year) and clinical subjects (4th and 5th year) followed by the internship (6th year). The proportion of the theoretical and practical classes is 30% to 70%; whereas the students/instructors ratio is about 8/1. The first two years of dentistry education are similar to the medicine program, but the former contains a basic dental training that is followed by a three-year-long pre-clinical and clinical training. Besides the medicine and dentistry programs, there are several other courses also available, including molecular biology. The Medicine program delivered in English and intended for international students was commenced in 1987; whereas the Dentistry and Pharmacy programs for international students started in 2000 and 2004, respectively. Compared to the Hungarian program, the most important differences are: -Hungarian language is taught, -More emphasis is laid upon the tropical infectious diseases (as parts of the “Internal Medicine” and “Hygiene and Epidemiology” courses). The 6th year of the curriculum is the internship that includes Internal Medicine, Pediatrics, Surgery, Obstetrics and Gynecology, Neurology, and Psychiatry. The completion of these subjects takes at least 47 weeks, although students are allowed to finish them within a 24-month-long period. The successfully completed internship is followed by the Hungarian National Board Examination. Just like the rest of the courses, the internship is also identical in the Hungarian and English programs. A one-year-long premedical (Basic Medicine) course, which serves as a foundation year, is recommended for those applicants who do not possess sufficient knowledge in Biology, Physics and Chemistry after finishing high school. After graduation, several interesting topics are offered for PhD training, which lasts for three years. If interested, outstanding graduates of the English General Medicine and Dentistry programs may join these PhD courses (“English PhD-program”). Special education for general practitioners has been recently started and a new system is in preparation now for the training of licensed physicians in Debrecen. The accredited PhD programs include the following topics: -Molecular and Cell Biology; Mechanisms of Signal Transduction -Microbiology and Pharmacology -Biophysics -Physiology-Neurobiology -Experimental and Clinical Investigations in Hematology and Hemostasis -Epidemiological and Clinical Epidemiological Studies -Cellular- and Molecular Biology: Study of the Activity of Cells and Tissues under Healthy and Pathological Conditions -Immunology -Experimental and Clinical Oncology -Public Health -Preventive Medicine -Dental Research The PhD-programs are led by more than 100 accredited, highly qualified coordinators and tutors. Medical Activity at the Faculty of Medicine The Faculty of Medicine is not only the second largest medical school in Hungary, but it is also one of the largest Hungarian hospitals, consisting of 49 departments; including 18 different clinical departments with more than 1,800 beds. It is not only the best-equipped institution in the area but it also represents the most important health care facility for the day-to-day medical care in its region. The Kenézy Gyula County Hospital (with some 1,400 beds) is strongly affiliated with the University of Debrecen and plays an important role in teaching the practical aspects of medicine. There are also close contacts between the University and other health care institutions, mainly (but not exclusively) in its closer region. The University of Debrecen has a Teaching Hospital Network consisting of 24 hospitals in Israel, Japan and South Korea. Scientific Research at the Faculty of Medicine Scientific research is performed both at the departments for basic sciences and at the laboratories of clinical departments. The faculty members publish about 600 scientific papers every year in international scientific journals. According to the scientometric data, the Faculty is among the 4 best of the more than 80 Hungarian research institutions and universities. Lots of scientists reach international recognition, exploiting the possibilities provided by local, national and international collaborations. Internationally acknowledged research areas are Biophysics, Biochemistry, Cell Biology, Immunology, Experimental and Clinical Oncology, Hematology, Neurobiology, Molecular Biology, Neurology, and Physiology. Dermatological Allergology Full Professor, Head of Division of Human István Juhász M. Clinical And Health Psychology Associate Professor, Head of Division of Attila Bánfalvi M. The requirements in these premedical science subjects are rigorous, thus it is recommended that students who need a period of preparation prior to beginning the General Medicine, Dentistry or Pharmacy Program join the Basic Medicine Course.

Therefore after suspicion of growth restriction it is fundamental to identify his etiology in order to optimize the clinical management buy cheap celecoxib 200mg on line. A complete careful examination of the fetal anatomy must be performed for excluding or detecting malformations best celecoxib 100mg. In the same way in case of suspected infections the fetal involvement can be better assessed. In order to assess placental function Doppler Blood Flow on the umbilical arteries must be carried out.. In this way it is possible to detect possible reduction of blood supply to the fetus. Haemodynamic changes occur, heart rate can be altered, amniotic fluid production is reduced (inducing olygohydramnios) and fetal movements are also reduced. Therefore the clinical management is mainly based on the monitoring of these changes, especially haemodynamic and heart activity. By studying these changes it is possible to evaluate the fetal response and adaptation. In very severe cases the blood flow can be absent or reversed in the diastolic phase. In this particular haemodynamic condition perinatal mortality and morbidity are very high. Short term and long term variability values and their trend along time are usually the basis for choosing the timing of the delivery. The management anyway must be different in case of End Diastolic Flow Absent or Reverse Flow9. The timing of the delivery should not be based only on the amniotic fluid assessment. Whenever possible the fetal management and the delivery should take place in tertiary level Center. Perinatal mortality and morbidity are significantly increased as compared to normally growing fetuses. The etiology is multifactorial and must be carefully assessed as the outcome is strongly dependent on it. After that by using second level tests like Doppler flowmetry it is possible to identify the fetuses that are affected by chronic hyopoxaemia. The clinical management is based on the monitoring of hypoxaemia and cardiotochography, when available computer assisted, is usually the principal guide for choosing the time of the delivery when necessary. Doppler flowmetry on umbilical arteries should be performed for assessing placental function. Stray-Pedersen B Restricted fetal growth in sudden intra- uterine unexplained death. Screening for fetal growth restriction: a mathematical model of the effect of time interval and ultrasound error. A randomized trial using ultrasound to identify the high risk fetus in a low risk population. The clinical significance of absent or reverse end-diastolic flow in the fetal aorta and umbilical artery. Pre-gestational and gestational diabetes remain an important medical complication, with consequences for the mother and the child in the short and long term. The care of the pre-gestational diabetes has improved, but major complications, such as congenital malformations, sudden fetal death and the association with pre-eclampsia, need better understanding. Obesity is becoming a major problem not only in relation to the increased incidence of type 2 pre-existing diabetes, but also as a risk factor in preg- nancy. It is a heterogeneous disorder and affects at least 3 percent of pregnancies in the Western World2, 3. The metabolic adaptation that oc- curs during normal pregnancy involves apparent deterioration of glucose tolerance and hyperinsulinism, but only in a minority of women the diagnostic criteria for gestational diabetes are present4. Insulin secretion is increased during pregnancy and there is evi- dence that insulin resistance exists5, 6. The morphological basis for this hyperinsulinism is marked B cell hypertrophy and hyperplasia, and hyperactivity of the individual B cell7. In the past, gestational diabetes was reported to be associated with increased perinatal mortality8-10. Perinatal morbidity, in particular fetal macrosomia is increased in gestational diabetes. Fetal macrosomia is associated with an increased num- ber of operative deliveries and with shoulder dystocia12, 13. This clearly means that women with risk factors (obesity, a history of fa- milial diabetes, a personal birth weight of more than 4. There is growing evidence that tight control of diabetes before pregnancy improves fetal and maternal outcome. Education and management may prevent congenital malforma- tions and early pregnancy loss, and can improve the maternal condition14. Many studies have shown that congenital malformations are more numerous in infants of type 1 diabe- tes.

Other signs include required celecoxib 200mg with visa, preferably before patients are completely ex- the use of accessory muscles of respiration order celecoxib 200 mg with amex, tachypnoea, hausted (see Table 3. With time the arteries undergo a and <8kPa when stable with polycythaemia, nocturnal proliferative change leading to irreversible pulmonary hypoxaemia, peripheral oedema or pulmonary hyper- circulationchanges. Patients increase in blood viscosity and predisposes to must have stopped smoking (for safety reasons), and an thrombosis. Investigations Prognosis Blood gas monitoring is the most important initial in- Fifty per cent of patients with severe chronic breathless- vestigation to establish the type of failure and will dictate ness die within 5 years, but in all stopping smoking is the the mode of oxygen therapy. Pulmonary embolism Pathophysiology Following a pulmonary embolus there is a reduction in Definition the perfusion of the lung supplied by the blocked vessel. Thrombus within the pulmonary arteries causing lack Ventilation perfusion mismatch occurs, leading to hy- of lung perfusion. Production of surfactant also stops if perfu- or uncommonly from the heart embolises to the lungs. Infarct is rare (only occurring in around Prevalence 10% of cases) as the lung is also supplied by the bronchial Common. Aetiology The causes of thrombosis can be considered according Clinical features to Virkhow’s triad: The result of a pulmonary embolism depends on the size r Disruptioninbloodflowparticularlystasis:Prolonged and number of the emboli. Signs include hypoten- Factor V gene, which causes resistance to activated sion, a loud pulmonary component of the second protein C), oral contraceptives, malignant disease and heart sound, tachycardia with third and fourth heart smoking. Pleural inflam- 1 In massive pulmonary embolism, there is haemody- mationresultsinapleuralfrictionrubandalow-grade namic compromise which may require resuscitative pyrexia. With large emboli, thrombolysis or surgical Clinical signs of a deep vein thrombosis may also be thrombectomy with cardiac bypass may be life-saving. For small or moderate Blood enters the pulmonary vasculature and thus there emboli subcutaneous low molecular weight heparin is is congestion proximal to the blockage. Therapy is converted to warfarin after 48 hours (for 3 Repair results in the formation of a white scar. Lifelong war- farin may be indicated depending on the underlying Microscopy cause, or in recurrent embolism. Typical features include haemorrhage (due to extravasa- 3 If anti-coagulants are unsuccessful or contraindicated tion of blood), loss of cell architecture, cellular infiltra- a filter may be inserted into the inferior vena cava to tion and occasionally necrosis. Atelectasis and areas of hypoperfusion may be seen, and large emboli may cause Pulmonary hypertension an elevated hemidiaphragm and enlarged proximal pul- Definition monary arteries. A ventilation perfusion (V/Q) scan is Aetiology usually diagnostic, but is less helpful if the chest X-ray Pulmonary hypertension may be secondary to a variety is abnormal. This in turn raises r Right ventricular ‘strain’ pattern – T wave inversion the pulmonary capillary and arterial pressures (left in leads V1–V4. A similar syndrome is associated with Management sytemic lupus erythematosus, scleroderma and Ray- Treatment is aimed at the underlying cause. The result is a de- disease may benefit from oxygen therapy to reduce crease in the lumen of the vessels and hence an increased the vasoconstrictor effect of hypoxia. Progressive fail- r Long-term intravenous infusion of epoprostenol ure of the right side of the heart occurs which is called (prostacyclin) improves the outcome of patients with ‘cor pulmonale’. The administra- tion of bosentan (a nonselective endothelin receptor Clinical features antagonist) may also be beneficial in patients with Dyspnoea, syncope and fatigue are common. Symptoms primarypulmonaryhypertensionalthoughlong-term of the underlying cause and of right ventricular failure follow-up data are not yet available. Occupational lung disease Right heart failure leads to peripheral oedema and hep- atomegaly. A pulmonary mid systolic ejection murmur and an Introduction to occupational early diastolic murmur of pulmonary regurgitation may lung disease be heard (Graham–Steel murmur). Mostpatientswithoccupationallungdisease are entitled to compensation according to their degree Microscopy of disability. If pulmonary hypertension is long-standing, micro- scopy reveals hypertrophy of the media of the vessels with an increase in the amount of smooth muscle. Investigations Incidence r Achest X-ray may show right ventricular and right The incidence of asbestos related disease increased dra- atrialenlargement. Thecentralpulmonaryarteriesare matically in recent decades but appears to have peaked usually prominent and may be ‘pruned’ peripherally. Itisdebatablewhethertheyarecarcinogenic, Pattern of disease Causative agents but their use has now been banned in new buildings Pulmonary fibrosis Mineral dusts such as coal, silicon in the United Kingdom. They persist in the lung for alveolitis allergic response many years and are very fibrogenic and carcinogenic. Acute bronchitis, Irritant gases such as sulphur pulmonary dioxide, chlorine, ammonia, oedema oxides of nitrogen Bronchial carcinoma Asbestos, polycyclic hydrocarbons, Macroscopy/microscopy radon in mines r Asbestos bodies: These are long thin asbestos fibres in the lung parenchyma coated with haemosiderin and Aetiology/pathophysiology protein to form brown filaments with a beaded or Asbestos is made up of various silicates. Theyaretheresultofmacrophages, rally as a fibre, and has been widely used for its insulative which surround and attempt to engulf the fibres, but properties. It was used in sheets in buildings, sprayed on fail to clear them leading to fibroblast proliferation pipes as lagging, in shipbuilding and for boiler insula- and fibrosis. However, it is easily inhaled and the fibres induce r Pleural plaques are well-circumscribed elevated afibrogenic reaction in the lung.

This requires the ability to assess buy celecoxib 200mg cheap, adapt quality 200 mg celecoxib, modify, analyse and evaluate in a variety of situations and environments in the practice of radiation therapy. Critical decision-making is, therefore, inherent to the practice of radiation therapy and is demonstrated in the competencies required of entry-to-practice therapists. The competency profile defines the standard for certification and registration of entry-level radiation therapists in Canada. Accredited programs must ensure that their certification candidates possess all the competencies listed in the profile. Education programs are encouraged to include additional skills at their discretion. That the Radiation Therapist: - has completed an accredited Canadian educational program, or is eligible for certification by another recognized process; - has acquired the theoretical knowledge required to achieve a wide range of competencies; - has developed a broad knowledge base that has been assessed prior to the certification examination; - commits to the principle that their primary role and function is to serve the public interest; - is a member of the inter-professional health care team, collaborating with other health care professionals to provide appropriate patient care in the planning and delivery of radiation therapy treatments; - is responsible for the safe and effective application of ionizing radiation; - is responsible for the production, assessment, optimization and archiving of images; - is responsible for the performance of therapeutic planning and treatment procedures; - participates in interventional procedures; - is responsible for the education of patients, public and other health care providers regarding ionizing radiation for medical use; - performs effectively encompassing physical, psychological, social, economic and cultural factors that interact in predictable and unpredictable ways; - recognizes patients as unique individuals, treating them with dignity and respect; Nov 06 Revised Feb 2008 1 Page 3 - practices in accordance with legislation, regulatory and professional bodies’ standards of practice, scope of practice, codes of ethics and other relative documents; - performs in a manner consistent with public interest, employment philosophies and practices, current research and advancing technology; - seeks guidance from experienced practitioners, colleagues and employers to enhance the therapist’s individual experience and knowledge; - promotes and participates in the advancement of this dynamic profession through active involvement, continuous learning, professional development and research; - adheres to and promotes professional standards. It is realized that due to regional and institutional differences level of achievement for some competencies may vary based on evolving changes in technology, practice and facility policies. The survey requested a rating of the examinable competencies for frequency of application, importance and future significance in the healthcare work environment. The results of the survey were analyzed and the examinable competencies rated either H, M, L based on the response to frequency, importance and significance for the future. The competency levels provide a guide (blue print) for certification exam development. Validation of all competencies, including identification of examinable competencies and their associated competency levels will be conducted at least every five years. Due to rapid changes in technology and practice certain portions of the profile may be validated more frequently to ensure the profiles are reflective of practice and workplace needs. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without the prior written permission of the Canadian Association of Medical Radiation Technologists. The profile defines competencies reflecting the integration of knowledge, skills, attitudes and judgment necessary to practice in an environment that requires the technologist to use effective organizational skills and critical thinking. This requires the ability to assess, adapt, modify, analyse and evaluate in a variety of situations and environments in the practice of nuclear medicine technology. Critical decision-making is, therefore, inherent to the practice of nuclear medicine technology and is demonstrated in the competencies required of entry-to-practice technologists. The competency profile defines the standard for certification and registration of entry-level nuclear medicine technologists in Canada. Education programs are encouraged to include additional skills at their discretion. That the nuclear medicine technologist - has completed an accredited Canadian program, or other recognized program - has acquired the theoretical knowledge required to achieve a wide range of competencies - has developed a broad knowledge base that has been assessed prior to the certification examination - commits to the principle that their primary role and function is to serve the public interest - is a member of the inter-professional health care team collaborating with other health care professionals to provide appropriate patient care in the delivery of diagnostic and therapeutic imaging services is responsible for the safe and effective application of ionizing radiation - is responsible for the production, assessment, optimization and archiving of images - is responsible for the performance of diagnostic and therapeutic nuclear medicine procedures - is responsible for the education of patients, public and other health care providers regarding ionizing radiation for medical use - performs effectively encompassing physical, psychological, social, economic and cultural factors that interact in predictable and unpredictable ways Nov 06 Revised Feb. It is realized that due to regional and institutional differences level of achievement for some competencies may vary based on evolving changes in technology, practice and facility policies. The survey requested a rating of the examinable competencies for frequency of application, importance and future significance in the healthcare work environment. The results of the survey were analyzed and the examinable competencies rated either H, M, L based on the response to frequency, importance and significance for the future. The competency levels provide a guide (blue print) for certification exam development. Validation of all competencies, including identification of examinable competencies and their associated competency levels will be conducted at least every five years. Due to rapid changes in technology and practice certain portions of the profile may be validated more frequently to ensure the profiles are reflective of practice and workplace needs. Due to regional differences in the practice of nuclear medicine technology it is recognized that candidates may not be clinically competent in 100% of nuclear medicine clinical procedures. G 2 Recognize patterns consistent with pathology and anomalies related to the H cardiovascular system in relation to a nuclear medicine procedure. G 3 Understand the anatomy and physiology of the cardiovascular system G 4 Understand the effects including contraindications, risks and interactions of H agents (i. I 2 Recognize patterns consistent with pathology and anomalies related to H genitourinary system in relation to a nuclear medicine procedure. I 3 Understand the anatomy and physiology of the genitourinary system I 4 Understand the effects including contraindications, risks and interactions of H agents (i. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without the prior written permission of the Canadian Association of Medical Radiation Technologists. The profile defines competencies reflecting the integration of knowledge, skills, attitudes and judgment necessary to practice in an environment that requires the technologist to use effective organizational skills and critical thinking. This requires the ability to assess, adapt, modify, analyse and evaluate in a variety of situations and environments in the practice of radiological technology. Critical decision-making is, therefore, inherent to the practice of radiological technology and is demonstrated in the competencies required of entry-to-practice technologists. The competency profile defines the standard for certification and registration of entry-level radiological technologists in Canada. Education programs are encouraged to include additional skills at their discretion. That the Radiological Technologist: - has completed an accredited Canadian program, or other recognized program; - has acquired the theoretical knowledge required to achieve a wide range of competencies; - has developed a broad knowledge base that has been assessed prior to the certification examination; - commits to the principle that their primary role and function is to serve the public interest; - is a member of the inter-professional health care team, collaborating with other health care professionals to provide appropriate patient care in the delivery of diagnostic imaging services; - is responsible for the safe and effective application of ionizing radiation; - is responsible for the production, assessment, optimization and archiving of images; - is responsible for the performance of diagnostic radiographic/fluoroscopic procedures; - participates in interventional procedures; - is responsible for the education of patients, public and other health care providers regarding ionizing radiation for medical use; Dec 06 Revised Feb 2008 1 Page 127 - performs effectively in all environments taking into consideration physical, psychological, social, economic and cultural factors that can occur in predictable and unpredictable ways ; - recognizes patients as unique individuals, treating them with dignity and respect; - practices in accordance with legislation, regulatory and professional bodies’ standards of practice, scope of practice, codes of ethics and other relative documents; - performs in a manner consistent with public interest, employment philosophies and practices, current research and advancing technology; - seeks guidance from experienced practitioners, colleagues and employers to enhance the technologist’s individual experience and knowledge; - promotes and participates in the advancement of this dynamic profession through active involvement, continuous learning, professional development and research; - adheres to and promotes professional standards.