By W. Vasco. Ringling School of Art and Design. 2018.

Heavier particles have shorter ranges and therefore deposit more energy per unit path length in the absorber 60 caps brahmi with amex treatment kidney cancer symptoms, causing more damage brahmi 60caps line medications bad for your liver. On the other hand order brahmi 60caps with amex symptoms quitting smoking, g-rays and x-rays have no charge or mass and therefore have a longer range in matter and cause relatively less damage in tissue. Knowl- edge of the type and energy of radiations is essential in understanding the principles of radiation protection. The cardinal principles of radiation protection from external sources are based on four factors: time, distance, shielding, and activity. Time The total radiation exposure to an individual is directly proportional to the time of exposure to the radiation source. Therefore, it is wise to spend no more time than necessary near radiation sources. Distance The intensity of a radiation source, and hence the radiation exposure, varies inversely as the square of the distance from the source to the point of expo- sure. It is recommended that an individual should keep as far away as prac- tically possible from the radiation source. Procedures and radiation areas should be designed so that individuals conducting the procedures or staying in or near the radiation areas receive only minimum exposure. The G values are derived from the number of g-ray and x-ray emissions from the radionuclide, their energies, and their mass absorption coefficients in air. The exposure rate X from an n-mCi radionuclide source at a distance d cm is given by a The G value of photon-emitting radionuclides can be calculated from the expres- sion G = 199ΣN Ei imi, where Ni is the fractional abundance of photons of energy Ei in MeV, and m is the mass absorption coefficient (cm2/g) of photons of energy E in air. Shielding Various high atomic number (Z) materials that absorb radiations can be used to provide radiation protection. Because the ranges of a- and b- particles are short in matter, the containers themselves act as shields for these radiations. Therefore, highly absorbing material should be used for shielding of g-emitting sources, although for economic reasons, lead is most commonly used for this purpose. The radiopharmaceuti- cal dosages for patients should be carried in shielded syringes. Radionu- clides emitting b-particles should be stored in containers of low-Z material such as aluminum and plastic because in high-Z material, such as lead, they produce highly penetrating bremsstrahlung radiations. For example, 32P is a b− emitter and should be stored in plastic containers instead of lead containers. Activity It should be obvious that the radiation exposure increases with the inten- sity of the radioactive source. Therefore, one should not work unnecessarily with large quantities of radioactivity. Occupational workers including minors and pregnant women likely to receive in 1 year a dose in excess of 10% of the annual limit of exposure from the external radiation source 2. Three devices are used to measure the exposure of ionizing radiations received by an individual: the pocket dosimeter, the film badge, and the thermoluminescent dosimeter. Film Badge The film badge is most popular and cost-effective for personnel monitor- ing and gives reasonably accurate readings of exposures from b-, g- and x- radiations. The film badge consists of a radiation-sensitive film held in a plastic holder (Fig. Filters of different metals (aluminum, copper, and cadmium) are attached to the holder in front of the film to differentiate 278 16. Filters of metals of different densities stop different energy radiations, thus discriminating exposures from them. After exposure the optical density of the developed film is measured by a densitometer and compared with that of a calibrated film exposed to known radiation. Film badges are usually changed monthly for each radiation worker in most institutions. The main disadvantage of the film badge is the long waiting period (a month) before the exposed personnel know about their exposure.

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Clinically useful alkylating agents have a nitrosourea brahmi 60caps low cost symptoms diverticulitis, bis-(chloroethyl)amine brahmi 60caps mastercard treatment genital warts, or ethylenimine moiety brahmi 60caps free shipping treatment 24 seven. The electrophilic center of these agents becomes covalently linked to the nucleophilic centers of target molecules. These agents also target other critical biologic moieties—including carboxyl, imidazole, amino, sulfhydryl, and phosphate groups—which become alkylated. These agents can act at all stages of the cell cycle, but cells are most susceptible to alkylation in late G1 to S phases. With the exception of cyclophosphamide, parenterally administered alkylating agents are direct vesicants and can damage tissue at the injection site. Some degree of leucopenia occurs at adequate therapeutic doses with all oral alkylating agents. Leukopenia and thrombocytopenia are dose-limiting toxicities; repeat courses of treat- ment are given only after marrow function has recovered. It is metabolically activated to 4-hydroxycyclophosphamide, which in turn is nonenzymatically cleaved to aldophosphamide. In tumor cells aldophospamide is cleaved to phosphoramide mustard, which is toxic to tumor cells, and acrolein, the agent suspected to cause hemorrhagic cystitis. Cyclophosphamide is used to treat lymphomas, leukemias, mycosis fungoides, multiple myeloma, retinoblastoma, breast and ovarian carcinoma, and small cell lung cancer. It is a component of many combination treatments for a variety of cancers (Table 12-2). Cyclophosphamide has less incidence of thrombocytopenia than mechlorethamine, but immunosuppression is still the most important toxic effect. This agent is also usedin someautoimmune conditions,such aslupus nephritis, and arteritis. Ifosfamide (Ifex) is a cyclophosphamide analog with less potential to cause hemorrhagic cystitis. Melphalan and chlorambucil are derivatives of nitrogen mustard that contain phenylalanine and an aromatic ring, respectively. Chlorambucil is the slowest-acting nitrogen mustard and is the agent of choice in the treat- ment of chronic lymphocytic leukemia, some lymphomas, and Hodgkin disease. Busulfan is administered orally to treat chronic myelogenous leukemia and other myeloproli- ferative disorders. In high doses, it produces a rare but sometimes fatal pulmonary fibrosis, ‘‘busulfan lung. Carmustine, lomustine, and semustine are highly lipophilic; they cross the blood–brain barrier. Carmustine, lomustine, and semustine are useful in Hodgkin disease and other lympho- mas, as well as in tumors of the brain. These agents are markedly myelosuppressive, but with delayed effect, possibly up to 6 weeks. The use of these agents for various brain cancers has been declining since the introduction of temozolomide (see below). Streptozocin is a natural antibiotic that is composed of methylnitrosourea linked to the 2-carbon of glucose. It is administered orally and is primarily used to treat refractory anaplastic astrocytoma, such as glioblastoma multiforme; malignant mela- noma; and uterine leiomyosarcoma. This agent also inhibits enzymes involved in folate metabolism, including dihydrofolate reductase. Resistance results from transport defects and also amplification or alterations in the gene for dihydrofolate reductase. Methotrexate is transported into cells by folate carriers and activated to various forms of polyglutamate. Methotrexate is an important agent in childhood acute lymphoblastic leukemia, choriocar- cinoma, and other trophoblastic tumors in women. This agent is also useful in combination with other drugs in the treatment of Burkitt’s lym- phoma and other non-Hodgkin lymphomas, osteogenic sarcoma, lung carcinoma, and head and neck carcinomas.

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Requires a minimum of 40 patient samples representing wide range of concen- trations discount 60 caps brahmi overnight delivery treatment ind. Reference values (existing method) are plotted onxaxis brahmi 60 caps on line symptoms 6 week pregnancy, values from new method onyaxis discount brahmi 60 caps with visa treatment 100 blocked carotid artery. Preventive maintenance Schedule of maintenance to keep equipment in peak operating condition. Maintenance must be documented & must follow manufacturer’s specifications & frequencies. Function checks Procedures specified by manufacturer to evaluate critical operating characteristics of test system, e. Must be within manufacturer’s established limits before patient testing is conducted. When limit is exceeded, must determine if due to medical change in patient or lab error. Critical values Test results that indicate a potentially life-threatening situation. Person receiving critical values must record & read back patient’s name & critical values. Pertinent literature references collection, labeling, storage, preservation, transporta- 13. System for entering results in patient record & report- tion, processing, referral & criteria for specimen ac- ing (including protocol for critical values) ceptability & rejection 14. Procedures for microscopic examinations, including detection of inadequately prepared slides 3. Step-by-step performance of the procedure, including test calculations & interpretation of results 4. Preparation of slides, solutions, calibrators, controls, reagents, stains, & other materials used in testing 5. Corrective action when calibration or control results fail to meet lab’s criteria for acceptability 9. Limitations in methodology, including interfering substances Manufacturer’s instructions may be used for #1–12. Copies of procedures must be retained for 2 yr after discontinuance & must include dates of initial use & discontinuance. Restriction of access to information to those who have authorization and a need to know. Unauthorized disclosure of medical information could lead to charges of breach of confidentiality or invasion of privacy. Informed consent Consent for a medical procedure given by patient after procedure & possible risks have been explained. Drawing blood against a patient’s wishes could lead to charges of assault & battery. Each person handling specimen must sign chain-of-custody form that accompanies specimen & docu- ments custody of specimen at all times. Fluorometry Atoms absorb light of specific Light source (mercury or xenon arc Detector at 90ºto light source wavelength & emit light of lamp), primary monochromator, so that only light emitted by longer wavelength (lower sample holder (quartz cuvettes), sample is measured. Reagent probes, sample & reagent Doesn’t require excitation radia- Usually involves oxidation of cuvette, photomultiplier tube, tion or monochromators like luminol, acridinium readout device fluorometry. Nephelometry Similar to turbidity, but light is Light source, collimator, mono- Used to measure ag-ab rxn. Anions move to positively charged medium, buffer, stain, trophoresis, hemoglobin pole (anode); cations to negatively charged densitometer electrophoresis pole (cathode). Some analyzers have short sample & clot detection Reagent delivery Usually by syringes, pumps, or pressurized reagent bottles. Microalbumin 50–200 mg/24 hr ↑in diabetics at risk of Detects albumin in urine earlier than dipstick (on urine) predictive of diabetic nephropathy protein. Strict control of glucose & blood nephropathy pressure can prevent progression to end-stage renal disease. Primary Increases glucose levels Glucagon Stimulates glycogenolysis & gluconeogenesis.

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A limitation of the Kolmogorov–Smirnov test of normality without the Lilliefors correction is that it is very conservative and is sensitive to extreme values that cause tails in the distribu- tion effective brahmi 60caps treatment gastritis. The Shapiro–Wilk test has more statistical power to detect a non-normal distribution than the Kolmogorov–Smirnov test buy 60 caps brahmi overnight delivery symptoms viral meningitis. The Shapiro–Wilk test is based on the correlation between the data and the corresponding normal scores buy brahmi 60caps otc medicine qhs. The values of the Shapiro–Wilk statistic range between zero, which indicates non-normality of the data and a value of one which indicates normality. A distribution that passes these tests of normality provides extreme confidence that parametric tests can be used. However, variables that do not pass these tests may not be so non-normally distributed that parametric tests cannot be used, especially if the sample size is large. This is not to say that the results of these tests can be ignored but rather that a considered decision using the results of all the available checks of normality needs to be made. Birth weight marginally fails the Shapiro–Wilk test but the P values for gestational age Descriptive statistics 35 and length of stay show that they have potentially non-normal distributions. The Kolmogorov–Smirnov test shows that the distribution of birth weight is not signifi- cantly different from a normal distribution with a P value greater than 0. However, the Kolmogorov–Smirnov test indicates that the distributions of both gestational age and length of stay are significantly different from a normal distribution at P < 0. These tests of normality do not provide any information about why a variable is not normally distributed and therefore, it is always important to obtain skewness and kur- tosis values using Analyze → Descriptive Statistics → Explore and to request plots in order to visually inspect the distribution of data and identify any reasons for non-normality. Histograms also show whether there are any gaps in the data which is common in small data sets, whether there are any outlying values and how far any outlying values are from the remainder of the data. The normal Q–Q plot shows each data value plotted against the value that would be expected if the data came from a normal distribution. The values in the plot are the quantiles of the variable distribution plotted against the quantiles that would be expected if the distribution was normal. If the variable was normally distributed, the points would fall directly on the straight line. The detrended normal Q–Q plots show the deviations of the points from the straight line of the normal Q–Q plot. If the distribution is normal, the points will cluster ran- domly around the horizontal line at zero with an equal spread of points above and below the line. If the distribution is non-normal, the points will be in a pattern such as J or an inverted U distribution and the horizontal line may not be in the centre of the data. The box plot shows the median as the black horizontal line inside the box and the inter-quartile range as the length of the box. The inter-quartile range indicates the 25th to 75th percentiles, that is, the range in which the central 25–75% (50%) of the data points lie. If values are outside this range, they are plotted as outlying values (circles) or extreme values (asterisks). Extreme values that are more than three box lengths from the upper or lower edge of the box are shown as asterisks. Extreme and/or outlying values should be checked to see whether they are univariate outliers. If there are several extreme values at either end of the range of the data or the median is not in the centre of the box, the variable will not be normally distributed. If the median is closer to the bottom end of the box than to the top, the data are positively skewed. If the median is closer to the top end of the box, the data are negatively skewed. All of the plots should be inspected because each plot provides different 36 Chapter 2 information. These features indicate that the mean value will be an accurate estimate of the centre of the data and that the standard deviation will accurately describe the spread.

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Oral decontamination is cost-saving in the prevention of ventilator-associated pneumonia in intensive care units order brahmi 60caps with visa symptoms after hysterectomy. Prevention of ventilator-associated pneumonia by oral decontamination: a prospective safe brahmi 60 caps symptoms and diagnosis, randomized generic 60caps brahmi medicine journey, double-blind, placebo-controlled study. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. Relationship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients. Changing bacterial ecology during a five-year period of selective intestinal decontamination. Sedation, sucralfate, and antibiotic use are potential means for protection against early-onset ventilator-associated pneumonia. Gastro-oesophageal reflux in mechanically ventilated patients: effects of an oesophageal balloon. Closed suctioning system reduces cross-contamination between bronchial system and gastric juices. Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia. Care of the ventilator circuit and its relation to ventilator- associated pneumonia. Weekly versus daily changes of in-line suction catheters: impact on rates of ventilator-associated pneumonia and associated costs. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Subglottic secretion drainage for preventing ventilator- associated pneumonia: a meta-analysis. Influence of airway management on ventilator-associated pneumonia: evidence from randomized trials. Efficacy of heat and moisture exchangers in preventing ventilator-associated pneumonia: meta-analysis of randomized controlled trials. Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis. Antiseptic impregnated endotracheal tubes for the prevention of bacterial colonization. Endotracheal tubes coated with antiseptics decrease bacterial colonization of the ventilator circuits, lungs, and endotracheal tube. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. Exposure to allogeneic plasma and risk of postoperative pneumonia and/ or wound infection in coronary artery bypass graft surgery. Transfusion and postoperative pneumonia in coronary artery bypass graft surgery: effect of the length of storage of transfused red cells. Morbidity reduction in critically ill trauma patients through use of a computerized insulin infusion protocol: a preliminary study. Reducing ventilator-associated pneumonia rates through a staff education programme. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Strategy of antibiotic rotation: long-term effect on incidence and susceptibilities of Gram-negative bacilli responsible for ventilator-associated pneumonia. Impact on the incidence of ventilator-associated pneumonia caused by antibiotic-resistant gram-negative bacteria.

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