By S. Zarkos. Saint Rose College. 2018.

The training part includes a specified period of didactic classroom and laboratory training in the areas of (a) radiation physics and instrumenta- 288 16 discount 20 mg pantoprazole with amex. Radiation Regulations and Protection tion buy 40 mg pantoprazole fast delivery, (b) radiation protection order 20mg pantoprazole otc, (c) mathematics pertinent to radioactivity, (d) chemistry of by-product material, and (e) radiation biology and radiation dosimetry (for radiation safety officer). The work experience must be under an authorized user, radiation safety officer, or nuclear pharmacist depending on the specific authorization of by- product material requested and must include (a) ordering, receiving, and unpacking radioactive materials, and surveying; (b) calibration of dose calibrators and survey meters; (c) calculating, measuring, and preparing dosages for patients; (d) procedures for spill management; (e) safely admin- istering dosages to patients (for authorized users only); and (f) elution of radioactive generators (for localization and imaging studies). In addition, approval by the training and experience method requires a written certification by a preceptor that the individual has acquired com- petence in the techniques to function independently for a specified use of by-product material. The required hours of training and experience vary for different types of uses of radioactive material and are listed below. A medical event Medical Uses of Radioactive Materials 289 occurs when a dose exceeds 5rem (0. The report must include the licensee’s name, prescribing physician’s name, brief description of the event, cause of the event, effect of the event, if any, on the individual, corrective action taken, if any, and whether the affected individual or his or her relative or guardian has been notified. The individual’s name or identification number shall not be included in the report. The licensee shall notify the individual and the referring physician of the event no later than 24 hours after the discovery, unless the referring physi- cian personally takes the responsibility of informing or not informing the individual based on medical judgment. If a verbal notification is made, the licensee shall inform the individual of the availability of a written descrip- tion of the event, which the licensee will provide upon request. Radiation Regulations and Protection 5rem (50mSv) total effective dose equivalent, or has resulted in unintended permanent functional damage to an organ or biological system of the child. The conditions, timing, and descriptions of the report are identical to those of the medical events described above. Practically in nuclear medicine, patients treated with 131I-NaI are commonly considered under these regulations. The patient-specific calculations depend on the choice of the occupancy factor and the physical or effective half-life. These instructions must be given in writing to the patients to follow after release. If the dose to a breast-fed infant or child could exceed 100mrem (1mSv) assuming continuous breast- feeding by a patient administered with a radiopharmaceutical, then instruc- tions on discontinuation of breast-feeding and consequences of failure to follow the guidance must also be given. Limits of activities that require instructions to breast-feeding patients and recordkeeping. Recordkeeping Records must be maintained for the receipt, storage, and disposal of radioactive materials, and also for various activities performed in the radi- ation laboratories. There are two types of packaging: Type A: This type of packaging is used primarily for most radiopharma- ceuticals. Such packaging is sufficient to prevent loss of radioactive mate- rial with proper shielding to maintain the prescribed exposure during normal transportation. Type B: When the radioactivity exceeds the limits specified in Type A, Type B packaging must be used. Such packaging is considerably more accident resistant and is required for very large quantities of radioactive material. The packages must pass certain tests such as the drop test, corner drop test, compression test, and 30-min water spray test. Each package must be labeled on opposite sides with the appropriate warning label (one of the labels in Table 16. The label must identify the content and amount of radionuclide in curies or becquerels. Department of Transportation labels required for transportation of radioactive materials. The outside of the inner packaging or, if there is no inner packaging, the outside of the packaging itself bears the marking, “Radioactive”. No shipping paper is required for both limited quantity or empty packages, if the material is not hazardous. European Regulations Governing Radiopharmaceuticals 295 Employees who ship hazardous material including radioactive material must have hazmat training to be able to recognize and identify hazardous material, to conduct their specific function, and to enforce safety procedures to protect the public. The training must be given to a new employee within 90 days of employment and then repeated every three years. The training is provided by the hazmat employer or other public or private sources, and a record of training must be made. Directives are manda- tory to be translated into national legislation and implemented in each member country. Guidelines are recommendations (not mandatory) for implementation of the directives by each member country. Regulations are mandatory for all member countries without adoption into individual national legislation. This directive facilitates the free movement of medicinal drugs among the member states, and sets guidelines for production of quality medicinal products using good manufacturing methods supervised by qualified per- sonnel. This directive also controls the importation of medicinal products from a third country, particularly regarding the quality and integrity of the products. Radiation Regulations and Protection A drug can be approved for marketing in either a centralized or decentralized way.

Spironolactone is used as a diuretic and to treat hirsutism in women (usually in combina- tion with estrogen) generic pantoprazole 20 mg without prescription. The adrenals also synthesize various androgens cheap pantoprazole 20mg visa, predominantly dehydroepiandrosterone and androstenedione generic pantoprazole 40mg. A wide array of steroid compounds with various ratios of mineralocorticoid to glucocorti- coid properties has been synthesized. Chapter 10 Drugs Acting on the Endocrine System 233 table 10-2 Properties of Adrenocortical Steroids Equivalent Metabolic Anti-Inflammatory Sodium-retaining Agent Dose (mg) Potency Potency Potency Oral Glucocorticoids Cortisol 20 20 1 1 Cortisone 25 20 1 1 Prednisone 5 5 4 0. Cortisone acetate and prednisone are 11-keto steroids that are converted to 11-hydroxyl groups by the liver to give cortisol and prednisolone, respectively. Methylation or hydroxylation at the 16a position abolishes mineralocorticoid activity with little effect on glucocorticoid potency. Natural and synthetic steroids enter cells rapidly and interact with these intracellular receptors. The resulting complexes modulate the transcription rate of specific genes and lead to an increase or decrease in the levels of specific proteins. Both natural and synthetic steroids are excreted by the kidney following reduction and for- mation of glucuronides or sulfates. All of the steroids listed in Table 10-2 (except aldosterone) may be administered orally. Various glucocorticoid preparations are available for otic, rectal, or topi- cal administration. As discussed in Chapter 9, glucocorticoids administered as inhalants are used to treat asthma. Drug administration attempts to pattern the circadian rhythm: A double dose is given in the morning, and a single dose is given in the afternoon. Alternate-day therapy relieves clinical manifestations of the disease state while causing less severe suppression of the adrenal–hypothalamic–pituitary axis. In this therapy, large doses of short-acting or intermediate-acting glucocorticoids are administered every other day. Patients removed from long-term glucocorticoid therapy must be weaned off the drug over several days, using progressively lower doses to allow recovery of adrenal responsiveness. Therapeutic actions and adverse effects are extensions of these physiologic effects. The anti-inflammatory effects of glucocorticoids are pro- duced by the inhibition of all of the classic signs of inflammation (erythema, swelling, soreness, and heat). Therapeutic uses (1) Glucocorticoids are used in replacement therapy for primary or secondary insufficiency (Addison disease); this therapy usually requires the use of both a mineralocorticoid and a glucocorticoid. Chapter 10 Drugs Acting on the Endocrine System 235 (b) These agents are also used in hypersensitivity and allergic reactions. Adverse effects and contraindications (1) Most of the adverse effects of glucocorticoids are exaggerated physiologic effects leading to a state of iatrogenic Cushing disease. Actions (1) Mineralocorticoids primarily affect the kidney, regulating salt and water balance and increasing sodium retention and potassium loss. Mineralocorticoids are used in replacement therapy to maintain electro- lyte and fluid balance in hypoadrenalism. Mitotane causes selective atrophy of the zona fasciculata and zona reticularis and can reduce plasma cortisol level in Cushing syndrome produced by adrenal carcinoma. Mitotane use is limited to adrenal carcinomas when other therapies are not feasible. Aminoglutethimide blocks the conversion of cholesterol to pregnenolone and reduces adre- nal production of aldosterone, cortisol, and androgens. Aminoglutethimide is useful in treating hyperadrenalism due to adrenal carcinoma or con- genital adrenal hyperplasia. Metyrapone blocks the activity of 11-hydroxylase, thereby reducing cortisol production. Ketoconazole is an antifungal agent that, at high doses, is a potent inhibitor of several of the P-450 enzymes involved in steroidogenesis in the adrenals and gonads. Natural thyroid hormones are formed by the iodination of tyrosine residues on the glyco- protein thyroglobulin. More than 99% of circulating T4 is bound to plasma proteins; only 5%–10% of T3 is protein bound. Levothyroxine sodium is preferred to liothyronine because it has better oral absorption, has a longer t1/2, and produces a favorable T4:T3 ratio. Thyroid hormones are essential for normal physical and mental development of the fetus. Linear growth of the long bones, growth of the brain, and normal myelination depend on thyroid hormone. Hypothyroidism in infants leads to cretinism (myxedema with physical and mental retardation). They also increase the synthesis of fatty acids and decrease plasma cholesterol and triglyceride levels. Primary, secondary, or tertiary hypothyroidism caused by (1) Hashimoto disease (2) Myxedema (3) Simple goiter (thyroid gland enlargement without hyperthyroidism) (4) Following surgical ablation of the thyroid gland b.

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This category therefore preferred to stay as close as possible to the original includes “rapid progression to residual hearing purchase 20mg pantoprazole fast delivery. Progression is called significant when the doubt that fluctuations in inner-ear function of this kind that threshold at the appropriate frequencies increases significantly not only include hearing ability but also vestibular function are with increasing age purchase pantoprazole 40mg with visa. Another report generic 20 mg pantoprazole free shipping, however, indicates a lack of significant 0 progression in longitudinal analyses of such cases (36). Such widening of the bony contours of the endolym- with a relatively flat audiometric configuration at mild-to-severe phatic duct was identified as a key feature in Pendred syndrome threshold levels if X and/or Y are some type of nontruncating (31) as well as an associated feature in some other syndromal mutation (Fig. The most important truncating muta- hearing disorders, such as branchio-oto-renal syndrome. Further research into such a pos- High-frequency downsloping audiometric sibility certainly requires additional large-scale efforts. However, threshold data collected by F Häfner conduction threshold may show a low-frequency audiometric (personal communication to P. The symbol # followed by a number labels mean age-related typical audiograms covering the specified number of different traits or families. Stability is the rule for ( 1 kHz) were increased, which produced a much steeper autosomal-recessive traits. The last two conditions were of The age-related typical audiograms shown in Figure 13. The age of onset was esti- high-frequency configuration with stable thresholds at moder- mated at 15 to 25 years using fitting methods in cross-sectional ate-to-severe levels. In the following, the majority Although one of the patients described by McGuirt et al. Speech recognition was relatively good in the pure tone audiogram averaged over all frequencies was 71 dB. American family according to the phoneme scores analysed by The precise audiometric configuration was not clearly described. Given the natural history of otosclerosis, the threshold at an advanced age and therefore should be regarded with clinical picture must include progression over at least a few reservation. In some of the autosomal-dominant traits, progression impairment, especially at the high frequencies (Fig. Almost all of the other autosomal dominant traits with the mid-frequency configuration show This category includes stable and progressive low-frequency, progression. Minor differences between these (5– 40 years) and progression beyond “presbyacusis. Rapid initial deterioration with a gradually decreas- this category because of its low-frequency–like features. Congenital residual hearing on a possibly auto- seemed to do reasonably well at first sight. For other traits, especially the less typical tion is also found in high-frequency downsloping configurations or prevalent traits, probably the best strategy for guided pheno- (Fig. Sometimes, however, careful phenotyping does con- Despite this type of detailed observations that can be made tribute to the guidance of genotyping to the effect that the regarding possibly distinctive features, the differential diagnosis latter can be limited and considerable time, efforts, and costs of phenotypes is often quite problematic. It appeared It is important to realise in which types of genetic hearing that regrouping of phenotypes within and between the four impairment disorder the affected subjects are likely to have main classes pertaining to Figures 13. An important item for coun- similar or dissimilar to previously reported ones (7,70). Although in such cases, the degree of performed as previously outlined using the chi-square test. We have outlined the purpose of S 1 indicates complete similarity ( identity), whereas S 0 a b Table 13. It should be noted that a conventional chi-square test can be used for testing across separate arrays (single trait or average), but that a chi-square test for goodness of fit should be used if (average) norm values are applied as representing the expected values for comparison with a single trait. Prior to performing a conventional chi-square test on a given contingency table that can be constructed by combining any arrays, cells should be combined where necessary according to general rules described for chi-square tests in most textbooks on statistics. Audiometric profiles associated with genetic nonsyndromal hearing impairment 197 198 Current management indicates no similarity at all. In order to attempt forming tentative whose audiometric profiles are shown in Figures 13. If the threshold audiograms of different loci, we performed such a tentative cluster had S 0. Starting from the highest S value involv- whether the cluster could be extended with additional loci while ing a given locus, we looked at the successive other loci. If newly derived age-related thresh- fused with the age-related threshold audiograms of three loci old audiograms look most similar to those of the incomplete each. This kind of observation demonstrates that our assignment of loci to the main tentative phenotypes for which Figures 13. It is indeed possible to group fairly similar age-related threshold audiograms in a We wish to thank Dr. Kremer for commenting on the number of different clusters that might represent separate manuscript. Audiometric profiles associated with genetic nonsyndromal hearing impairment 199 References 17.

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The primary function of a collimator is to direct the gamma rays emitted from a selected source to a scintillation detector in a specifically desired manner buy generic pantoprazole 20 mg line. They are parallel hole discount pantoprazole 20 mg line, converging and diverging multihole collimators and the pinhole collimator order pantoprazole 40 mg amex. By using these collimators, images can be scanned either in 1:1, magnified or reduced scale. Magnification can be achieved by means of computer zooming (blowup), converging collimator magnifi­ cation and pinhole magnification. It is, however, to be emphasized that technically computer zooming and geometrical magnification by converging collimator do not truly or efficiently enhance spatial resolution, whereas pinhole magnification does! The pinhole collimator is a simple, lead shielded, cone shaped device which tapers into a small aperture perforated in the tip adapter made of tungsten steel. The geometry of the pinhole is such that it creates an inverted image of the object. Its design is based on aperture size, acceptance angle, collimator length and material. Aperture size is the most important and direct determinant of the system’s resolution and sensitivity. A collimator with a smaller aperture can produce an image with higher resolution, but at the expense of system sensitivity, which means longer acquisition time. It is to be noted that the magnification, resolu­ tion and sensitivity of a pinhole collimator acutely change with the aperture-to-target distance; thus, all three parameters rapidly and simultaneously improve as the aperture-to-target distance is reduced and vice versa. It is similarly important to know that image magnification can be achieved by placing the collimator tip to target as closely as possible. However, the close approximation of a pinhole collimator inevitably results in a degraded image in the peripheries of the field of view due to rapid fall-off, an important pitfall. In general, the indication of pinhole scanning is decided by the size of the target to be scanned. In general, pinhole scanning may be satisfactorily carried out at a 0-10 cm aperture-to-skin distance. In paediatric subjects, the scan time can be as short as 10 min, since immature bones tend to accumulate tracer more avidly. Using a dual pinhole camera system, two pinhole scans can be obtained simultaneously in different projections. The time required by pinhole scanning has been a source of worry, but it is unfounded. The anterior and posterior scans may be supplemented by lateral, oblique or any specially angled views to disclose findings that are not visualized in other views. Some of the commonly used special views include the open mouth view of the upper cervical spine, Water’s view of the paranasal sinuses, the seated view of the sacrum and coccyx, the butterfly view of the sacroiliac joint and the tunnel view of the distal femur. It is also widely used in bone and joint study and oncol­ ogy, but still suffers from the drawbacks of low specificity, low yield and relatively high machine cost. The data set is reconstructed into multiple sectioned slices by the filtered back projection method and displayed in the transverse, coronal, sagittal or oblique dimension. In addition, the elimination of out-of-plane activity can enhance the con­ trast up to sixfold [15]. The first limiting factor is related to the characteristics of the multihole parallel collimator, the general design of which is focused on high sensitivity rather than high resolution because of acquisition time. Thirdly, the miniature image format contributes to a lowering of resolution with resultant concealment of scan information. Acute osteomyelitis Bone scans are sensitive and specific in detecting early osteomyelitis, particu­ larly in the long bone. This is the earliest sign that reflects the ischaemia produced in the infec­ tive focus both by bacterial embolization in the arterial arcade and elevated intra- medullary pressure. Once active lysis sets forth, tracer uptake becomes extremely intense in the lesional bone, typically localizing in the metaphysis (Fig. Close observation may reveal the epiphyseal border of the tracer uptake to be well demar­ cated by ‘hot’ physeal plate, but with the diaphyseal border blurred. As the disease progresses, however, the area of abnormal uptake spreads toward the diaphysis, presenting a fade-out front. Acute infective osteitis Acute infective osteitis is a suppurative infection of the cortical bone. Anterior pinhole scan of the left hip with acute osteomyelitis shows typical intramedullary location of intense tracer uptake (arrow). It is not similar to Brodie’s abscess, which is a chronic suppurative lesion of cancellous bone. Pinhole scans may show an ill-defined area of intense tracer uptake longitudinally in the cortex. Typically, it is eccentric unless the infection spreads to the entire circumference (Fig. Acute infective periostitis Acute infective periostitis refers to a primary infection of the periosteal cloak that covers the cortex. Infective products tend to accumulate beneath the periosteum, eventually spreading to the cortex.

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Cardiomyopathy is a feature of many mitochondrial from high school and has no learning difficulties buy 40 mg pantoprazole with mastercard. Acquired somatic mitochondrial mutations may is of short stature with a height of 56 in proven 40 mg pantoprazole. A deletion on the paternal manual vaginal examination reveals an anteverted order pantoprazole 20 mg with visa, ante- copy of chromosome 15 is the cause. What is the same site on chromosome 15, but on the maternal copy, re- most likely diagnosis? All the following are inherited disorders of connec- corrected when the patient was a teenager and a recent tive tissue except shoulder dislocation. A 30-year-old male comes to your office for genetic recommendations for follow-up should include which of counseling. The disease is caused by mutations in the gene for bacteria, chest radiograph, and purified protein derivative acid β-glucosidase. The following pedigree is an example of what pat- ilar to this one with fever of unknown origin, which of the tern of inheritance? Chronic hypoxia causes biochemical changes whereby oxygen delivery to tissues is not impaired. In comparison to someone living at sea level, which of the following changes would be expected in a healthy person acclimated Solid figure Affected individual to living at high altitude? Independent of insurance status, income, age, and comorbid conditions, African-American patients are less I-106. Diseases that are inherited in a multifactorial genetic likely to receive equivalent levels of care when compared fashion (i. Prescription of analgesic for pain control bearing certain histocompatibility antigens include B. A 32-year-old man seeks evaluation for ongoing fevers vidual who has lost nondeclarative memory? Inability to recall a spouse’s birthday 3 months ago, and for the past 6 weeks, he has been experi- B. Inability to recognize a photo that was taken at one’s ens with night sweats once weekly and has lost 4. Inability to recognize a watch as an instrument for no rashes and reports no ill contacts. He has seen his pri- keeping time mary care physician on three separate occasions during E. Inability to remember the events of one’s high this time and has had documented temperatures of 38. A complete blood count showed a white and complains only of small masses in her groin. She states blood cell count of 15,700/µL with 80% polymorphonu- that they have been present for at least 3 years. His past medical history is significant for coronary guinal lymph nodes that are mobile, nontender, and dis- artery bypass grafting many years ago, status post-carotid crete. His medications include aspirin, carvedilol, simvastatin, lisinopril and furosemide. Fine-needle aspiration for culture and cytopathology most likely cause of this patient’s erectile dysfunction? All of the following diseases are associated with mas- sive splenomegaly (spleen extends 8 cm below the costal I-118. The wife of the patient in the preceding scenario also margin or weighs >1000 g) except reports to you that she has experienced a low sexual de- A. Her medications include an aspirin, meto- prolol, simvastatin, verapamil, and a multivitamin. The presence of Howell-Jolly bodies, Heinz bodies, asks whether an oral agent will assist with her sexual de- basophilic stippling, and nucleated red blood cells in a sire. Which of the following is true regarding infection sexual arousal disorder risk after elective splenectomy? Splenectomy patients over the age of 50 are at great- body weight in the past year. Staphylococcus aureus is the most commonly impli- recently being widowed, he has no pertinent social his- cated organism in postsplenectomy sepsis. He is not able to generate an erec- complete blood count; electrolytes, renal function, liver 16 I. Maculopapular rash that begins on the face and trunk chest x-ray, which are unrevealing. He is up to date on his and spreads to the extremities (centrifugal spread) routine cancer screening.

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