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For eczema impotence 40 years order dapoxetine 90 mg with mastercard, nummular eczema erectile dysfunction high blood pressure order 90 mg dapoxetine with mastercard, neurodermatitis severe erectile dysfunction causes buy dapoxetine 90 mg overnight delivery, stasis example erectile dysfunction causes prescription drugs purchase 30 mg dapoxetine, an ectopic kidney is a kidney that is not in dermatitis, and dyshidrotic eczema. Usually, ectopic pregnancies contact with a substance that the immune system occur because a fertilized egg settles and grows in a recognizes as foreign, such as poison ivy or certain Fallopian tube. Also known as occur in other locations, such as the ovary, cervix, allergic contact dermatitis. An ectopic pregnancy is usually due to the inability of a fertilized egg to make its eczema, contact A localized reaction that way through a Fallopian tube into the uterus. A major concern with ectopic pregnancy characterized by clear, deep blisters that itch and is internal bleeding. The pain, which is usually sharp and stabbing, is often one-sided and may occur in the pelvis, eczema, nummular Coin-shaped patches of abdomen, or even the shoulder or neck (due to irritated skin that may be crusted, scaling, and blood from a ruptured ectopic pregnancy building extremely itchy. Nummular eczema appears most up under the diaphragm and the pain being commonly on the arms, back, buttocks, and lower “referred” up to the shoulder or neck). Ultrasound can also help edema the swelling of soft tissues as a result of determine whether a pregnancy is ectopic, as can excess fluid accumulation. Edema is often most culdocentesis, the insertion of a needle through the prominent in the lower legs and feet toward the end vagina into the space behind the uterus to see of the day because fluid pools while people maintain whether there is blood there from a ruptured an upright position. Treatment includes surgery, often by laparoscopy, to remove the ill-fated pregnancy. A edema, hereditary angioneurotic Localized ruptured Fallopian tube usually has to be removed. The outlook for future pregnancies normally prevents activation of a cascade of proteins depends on the extent of the surgery. Patients can develop recurrent attacks of swollen tissues, eczema An inflammatory reaction of the skin in pain in the abdomen, and swelling of the voice box which there are tiny blister-like raised areas in the (larynx) that can compromise breathing. The diagearly stage followed by reddening, swelling, bumps, nosis is confirmed when abnormally low levels of C1 crusting, and thickening and scaling. The most common sympTreatment options include antihistamines and male toms of pleural effusion are chest pain and painful steroids (androgens). Pleural effusion can be caused by heart and kidney failure, hypoalbuminemia (low levels of albumin in edentulous Being without teeth. Complete loss of the blood), infections, pulmonary embolism, and all natural teeth can substantially reduce quality of malignancies. Wounds must be efferent nerve A nerve that carries impulses tended to with great care, and infections must be away from the central nervous system. Joint efferent vessel A vessel that carries blood away injury must be avoided, and bracing may sometimes from the heart. For example, a pleural effusion is an abnormal accumulation of fluid in the pleural space between ehrlichiosis An acute tick-borne disease first the lungs and the chest wall, while a knee effusion is reported in humans in 1986. A infection by the rickettsia microbe, Ehrlichia canis, hemorrhagic effusion contains blood in the fluid. Erlichiosis is similar to Rocky Mountain spotted effusion, pericardial Too much fluid within the fibrous sac (pericardium) that surrounds the heart. A pericardial effusion involves the presence of an excessive amount of pericardial fluid, a pale yelejaculation Ejection of sperm and seminal fluid low serous fluid, within the pericardium. Only about two-thirds of the blood is spread thinly over the visceral and parietal pleurae normally pumped out with each beat, and that fracand acts as a lubricant between the two membranes. The ejecAny significant increase in the quantity of pleural tion fraction is an indicator of the heart’s health. If elbow bursitis is not caused by infection, treatment includes rest and the use of ice and medelbow the juncture of the long bones in the midications for inflammation and pain. The bone of the sitis is treated with antibiotics, aspiration, and arm (humerus) meets both the ulna (the inner bone surgery. The biceps muscle is the major crime that all health and social services professionmuscle that flexes the elbow hinge, and the triceps als are mandated to report. The primary stability of the elbow is provided by the ulnar elective mutism Complete lack of speech, collateral ligament, located on the medial (inner) believed to be chosen on the part of the patient. The outer bony prominence of the True elective mutism may be a reaction to a trauelbow is the lateral epicondyle, a part of the humerus matic event, the aftermath of damage to or pain in bone. Tendons attached to this area can be injured, the mouth or throat, or a symptom of extreme shycausing inflammation or tendonitis (lateral epiness. The inner portion of the found not to be chosen, but rather a symptom of elbow is a bony prominence called the medial epidamage or deformity of the speech apparatus or of condyle of the humerus. Electric elbow, arthritis of the Inflammation of the shock can cause burning at the site of entry of the elbow joint. If a person many systemic forms of arthritis, including rheumamay be in contact with high voltage, no one else toid arthritis, gouty arthritis, and psoriatic arthritis. Using a dry, nonconductive object such as a swelling, pain, tenderness, and decreased range of wooden stick, the switch should be switched off, to motion. Immediate emergency medical help is elbow, golfer’s Medial epicondylitis caused by required. Electrodes elbow, tip of the the bony tip of the elbow, are placed on the skin of the chest and connected in which is formed by the near end of the ulna, one of a specific order to a machine that, when turned on, the two long bones in the forearm (the other is the measures electrical activity all over the heart. Output usually appears on a long scroll of paper that displays a printed graph of activity on a comelbow bursitis A common form of bursitis that is puter screen. Electrolyte monitoring is important in before the patient starts taking the medicine, and treatment of anorexia and bulimia. Normal muscles produce a electroconvulsive therapy the use of contypical pattern of electrical current that is usually trolled, measured doses of electric shock to induce proportional to the level of muscle activity. Convulsions so induced can sometimes of muscle and/or nerves can produce abnormal treat clinical depression that is unresponsive to electromyogram patterns. An electron microscope permits greater magnification electrodiathermy See cauterization. The results are either printed electrophoresis A method used in clinical and out or displayed on a computer screen. Different research laboratories for separating molecules patterns of electrical impulses can denote various according to their size and electrical charge. Each kind of electrogastrogram A test in which the electrical molecule travels through the medium at a different current generated by the muscle of the stomach is rate, depending on its electrical charge and molecsensed and recorded in a manner very similar to ular size. Separation of the molecules occurs based that of an electrocardiogram of the heart. Recordings from the muscle are cal potentials generated by the retina of the eye are stored and analyzed by a computer. Although electrolysis is promoted as a permanent electroshock therapy See electroconvulsive process, many people find that hair does grow back therapy. Electrolysis may be done by a dermatologist, by an electrolysis technielephant nails See pachyonychia congenita. Electrolyte replacement is small molecules and ions, such as glucose and needed when a patient has prolonged vomiting or potassium. Some of these substances include hordiarrhea, and as a response to strenuous athletic mones, bacterial antigens, and antibodies. Examples of emboli are detached blood clots, clumps of bacteria, and clumps of other elliptocytosis A blood disorder characterized by foreign material, such as air. Inherited as a dominant trait, and differentiation, from fertilization to the beginelliptocytosis is due to the mutation of one of the ning of the third month of pregnancy (in humans). There are several forms of elliptocytosis caused by specific gene abnormalities. Foreign substances that can emergency contraceptive See contraceptive, cause embolisms include air bubbles, amniotic emergency. When clots in veins break off (embolize), they travel first to the emesis Vomiting. When a clot enters arterial emphysema 1 A lung condition characterized by circulation, it can travel to the brain, block a vessel an abnormal accumulation of air in the lung’s many there, and cause a stroke (cerebrovascular accitiny air sacs (alveoli). Because of the risk of stroke from paradoxithese sacs, they become enlarged and may break or cal embolism, it is usually recommended that even be damaged and form scar tissue.
A 60-year-old man erectile dysfunction treatment spray buy dapoxetine canada, a heavy smoker erectile dysfunction tips buy cheap dapoxetine line, presby chronic infection erectile dysfunction at age of 20 buy discount dapoxetine on line, with bronchi filled ents for advice to impotence at 70 cheap dapoxetine 90mg with visa stop smoking. On physiwith mucus and neutrophils cal examination, he is thin and has a ruddy complexion. He sits leaning smoking history presents with cough and forward with his lips pursed to facilitate shortness of breath. Histologic examination reveals (a) Bronchial smooth muscle hypertrophy small round blue cells, and a diagnosis of with proliferation of eosinophils small cell carcinoma is made. Which of the (B) Diffuse alveolar damage with leakage of following is a frequent characteristic of this protein-rich fluid into alveolar spaces form of lung cancerfi A 60-year-old woman with a heavy smok(e) Usually in a peripheral rather than in a ing history presents with chronic productive central location 219 220 Brs pathology 5. A 23-year-old man presents with radiographic evidence of bilateral hilar lymphadenopathy and interstitial lung disease. A major characteristic of this disorder is (Reprinted with permission from Rubin R, Strayer D, et al. A 50-year-old man dies of a respiratory home resident, has multiple bouts of pneuillness that had been characterized by dysmonia caused by Streptococcus pneumoniae. Initially episodic, his polyvalent vaccines directed at multiple “attacks” had increased in frequency and at serotypes of the organism have been adminthe time of death had become continuous istered but have not elicited long-acting and intractable. Which of the following is the lowing is the most likely histologic finding in probable explanation for this phenomenonfi A 25-year-old man presents with a pro(D) Primary tuberculosis, characterized by gressive illness of several days’ duration the Ghon complex characterized by nonproductive cough, (e) Secondary tuberculosis, resulting fever, and malaise. A lateral view chest from activation of a prior Ghon radiograph reveals platelike atelectasis. A 25-year-old African-American woman (a) Bacterial pneumonia, most likely presents with fatigue, dyspnea, nonprocaused by S. A 60-year-old man presents with fever (B) Adenocarcinoma of the lung and chills, productive cough with rusty spu(c) Eosinophilic granuloma tum, pleuritic pain, and shortness of breath (D) Idiopathic pulmonary fibrosis for the past several days. A complete blood (e) Sarcoidosis count reveals neutrophilia and an increase in band neutrophils. A 60-year-old man presents with dysreveals consolidation involving the entire left pnea on exertion and a nonproductive lower lobe. To which (B) Klebsiella pneumoniae of the following conditions is this patient (c) Staphylococcus aureus especially predisposedfi A 46-year-old woman presents with (D) Idiopathic pulmonary hemosiderosis fever, hemoptysis, weight loss, and night (e) Malignant mesothelioma of the pleura sweats. A female infant is born prematurely chest radiograph reveals apical lesions with at 28 weeks’ gestation. Sputum culfor assisted breathing, and a diagnosis of tures reveal numerous acid-fast organisms. Which of the following is the cause of this Which of the following disorders does this syndromefi A 50-year-old female presents with immobilized in bed for several days after restrictive lung disease. She had been aggressive clinical course with rapidly proimproving, but this morning she suffered gressive shortness of breath over the last the sudden onset of pleuritic chest pain, year. A lung biopsy reveals a patchy process hemoptysis, tachypnea, tachycardia, and characterized by temporally heterogeneous dyspnea. The chest radiograph of a 23-year-old cough, shortness of breath, and weight loss. The tuberculin test is mass with no evidence of primary tumor positive, but sputum smears and cultures elsewhere in the body. This is a classic case of acute laryngotracheobronchitis (croup), an acute inflammation of the larynx, trachea, and epiglottis. Due to the destruction of alveolar walls, a lack of elastic recoil causes air to become trapped in alveoli, and, thus, airflow obstruction occurs on expiration. The pathologic hallmark of chronic bronchitis is marked hyperplasia of bronchial submucosal glands and bronchial smooth muscle hypertrophy, which can be quantified by the Reid index, a ratio of glandular layer thickness to bronchial wall thickness. Small cell carcinoma of the lung is the most aggressive type of bronchogenic carcinoma. This is an undifferentiated tumor with small round blue cells and is least likely to be cured by surgery because it is usually already metastatic at diagnosis. Associated paraneoplastic syndromes include secretion of adrenocorticotropic hormone and antidiuretic hormone. The illustration shows noncaseating granulomas and giant cells, which, in the clinical setting described, are diagnostic of sarcoidosis. A frequent abnormal laboratory finding is polyclonal hypergammaglobulinemia along with hypercalcemia. Patients most often present with lung findings and hilar lymphadenopathy, but any organ system can be involved. Antibody responses to the more than 80 differing carbohydrate capsular antigens of the various strains of S. Because of this, memory cells are not formed, and long-lasting immunity is not achieved. Asthma manifests morphologically by bronchial smooth muscle hypertrophy, hyperplasia of bronchial submucosal glands and goblet cells, and airways plugged by mucus-containing Curschmann spirals (whorl-like accumulations of epithelial cells), eosinophils, and Charcot-Leyden crystals (crystalloids of eosinophil-derived proteins). Interstitial pneumonia is characterized by diffuse, patchy inflammation localized to the interstitial areas of alveolar walls, with no exudate in alveolar spaces, and intra-alveolar hyaline membranes. Viral pneumonias are the most common type of pneumonia in childhood, caused most commonly by the influenza virus. The organism is also known as the pneumococcus, and the disease entity is often referred to as pneumococcal pneumonia. Tuberculosis, at one time a frequent hazard in the United States, is now relatively uncommon except in immunocompromised individuals and persons returning 223 224 Brs pathology from parts of the world where the disease remains a common problem. Cavitation and selective localization to the pulmonary apices are characteristics of secondary tuberculosis. Secondary tuberculosis may spread through the lymphatics and blood to other organs, resulting in miliary tuberculosis. Sarcoidosis most often presents as a restrictive pulmonary disease that is characterized morphologically by noncaseating granulomas and can involve any organ system. Diagnostic features of note include highest incidence in persons of African lineage, somewhat higher incidence in women, bilateral interstitial pulmonary involvement, prominent hilar lymphadenopathy, polyclonal hypergammaglobulinemia, and hypercalcemia. Increased serum angiotensin-converting enzyme activity is a nonspecific indicator of granulomatous inflammation. Asbestosis is caused by inhalation of asbestos fibers, characterized by yellow-brown, rod-shaped ferruginous bodies with clubbed ends that stain positively with Prussian blue. Asbestosis results in a marked predisposition to malignant mesothelioma of the pleura or peritoneum. Exposure to asbestos is also a risk factor for primary lung carcinoma, as well as for carcinoma of the oropharynx, esophagus, and colon. The risk of primary lung carcinoma is greatly increased in cigarette smokers with exposure to asbestos. Neonatal respiratory distress syndrome (hyaline membrane disease) is the most common cause of respiratory failure in newborns and results from a deficiency of surfactant and immature development of the lungs. Surfactant reduces surface tension within the lung, facilitating expansion by inspiration and thus preventing atelectasis during expiration. The classically referenced indicator of fetal pulmonary maturity is a lecithin:sphingomyelin ratio of approximately 2:1 in the amniotic fluid, although techniques like lamellar body counts and the fluorescence polarization assay are now more commonly used to evaluate fetal lung maturity. Predisposing factors include prematurity, maternal diabetes mellitus, and birth by cesarean section. Known complications of this condition include bronchopulmonary dysplasia, patent ductus arteriosus, intraventricular brain hemorrhage, and necrotizing enterocolitis. Pulmonary embolism most often originates from venous thrombosis in the lower extremities or pelvis. An embolus migrates through the venous circulation to the right heart and gets trapped in branches of the pulmonary artery. Pulmonary embolism occurs in clinical settings of venous stasis, such as primary venous disease, congestive heart failure, prolonged bed rest or immobilization, or prolonged sitting while traveling. Both primary and secondary tuberculosis are characterized by caseating granulomas, often with Langhans giant cells, which heal by scarring and calcification. These are the most likely lung cancers to arise in never-smokers and are more common in women.
A qualitative study conducted in Tonga investigated the perceptions of 11 women who had developed gestational diabetes in the previous 12 months (Doran and Davis 2010) erectile dysfunction natural foods cheap dapoxetine uk. Women participating in the study were influenced by education and had an increased awareness of the need for behaviour change as a result of a diagnosis of gestational diabetes erectile dysfunction treatment options in india discount dapoxetine online amex. The difficulties involved in making the required behavioural changes were a common theme erectile dysfunction effects on relationship order dapoxetine 90 mg on line. Some women will experience significant anxiety when they learn that they have gestational diabetes erectile dysfunction diabetes cure buy cheap dapoxetine online, but most studies reported that this was not sustained in the antepartum or postpartum period. Women’s perception of having gestational diabetes was influenced by sociodemographic and cultural factors, the women’s experience during any prior pregnancies and interactions with their health-care provider. Maternal psychological outcomes included measures of anxiety, depression and health-related quality of life. All measures of the health state utility showed trends in favour of the intervention group, although not all were significant. At three months postpartum, fewer women in the intervention than in the routine care group had a score on the Edinburgh Postnatal Depression Scale suggestive of depression (8% versus 17%). One-third of the women feared their child could contract diabetes at delivery and/or have congenital malformations. Some women had trouble in following treatment regimens, with their main concerns being dietary advice and blood glucose testing. A study conducted in Italian diabetic clinics evaluated the quality of life of 245 pregnant women with diabetes (Dalfra et al 2012). A cross-sectional survey conducted in an Australian hospital examined the attitudes and beliefs towards gestational diabetes among a multiethnic sample (Carolan et al 2010). Indian and Vietnamese women indicated a lower valuing of patient autonomy and also reported fewer negative psychological effects than Caucasian and Filipino women (Carolan et al 2010). Another qualitative study, also from Australia, explored the experiences and understandings of South Asian women after diagnosis with gestational diabetes. Face-to-face interviews with 17 immigrant women found that before the diagnosis of gestational diabetes, women’s knowledge and awareness of any type of diabetes was low. Dietary advice received was seen to be challenging in the context of culturally different food habits and, consequently, managing diet after diagnosis proved difficult. Different attitudes to exercise in pregnancy also raised issues for women, such as the perception that too much physical activity might put a strain on the baby (Bandyopadhyay et al 2011). Practical support, through help with child care and undertaking other responsibilities, appeared to be particularly important (Smith et al 2005). The facilitators to physical activity included social support from family and friends, community safety, learning to drive and to speak English, exercise guidance and education, and child care. It includes: fi a dissemination plan for the full guideline and summary versions fi a PowerPoint presentation describing the key recommendations of the guideline, which can be downloaded fi recommendations for promoting the recommendations to key stakeholder groups including pregnant woman, Maori and Pacific communities, health care workers and maternity service providers fi an algorithm for health professionals, which can be downloaded fi suggestions for incorporating the guideline recommendations into a range of contexts such as conference programmes, journal articles, continuing education programmes and online quizzes fi an evaluation strategy to assess the extent to which the recommendations have been adopted into routine practice. When developing an evaluation strategy, the Guideline Development Team recommends, and emphasises the importance of, considering ways to identify those changes in practice that are likely to have the most significant impact on the health outcomes of women with gestational diabetes and their babies, and to identify what data are already being collected relating to these recommendations and how they can be used to monitor changes in practice. Studies that investigate whether early diagnosis and treatment lead to improved maternal and infant outcomes. A randomised controlled trial that compares current screening and diagnostic criteria with those proposed by the International Association of Diabetes and Pregnancy Study Groups in terms of their impact on maternal and infant outcomes is required. A randomised controlled trial to compare tight with less tight glycaemic control in women diagnosed with gestational diabetes in terms of their impact on maternal and infant outcomes. A randomised controlled trial of leisure activity interventions for the treatment of gestational diabetes. Randomised controlled trials that evaluate the outcomes of lifestyle versus pharmacological interventions to prevent type 2 diabetes in women with a previous history of gestational diabetes. Screening, diagnosis and management of gestational diabetes in New Zealand: 71 A clinical practice guideline References Afkhami-Ardekani M, Rashidi M. Gestational diabetes: dilemma caused by multiple international diagnostic criteria. Gestational diabetes mellitus: simplifying the international association of diabetes and pregnancy diagnostic algorithm using fasting plasma glucose. Evaluation of postpartum carbohydrate intolerance and cardiovascular risk factors in women with gestational diabetes. Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes. Lived experience of gestational diabetes mellitus among immigrant South Asian women in Australia. Exercise during pregnancy and gestational diabetesrelated adverse effects: a randomised controlled trial. Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: a qualitative study. Determinants of gestational diabetes mellitus: a case control study in a district tertiary care hospital in south India. A prospective study of prepregnancy dietary iron intake and risk for gestational diabetes mellitus. A prospective study of prepregnancy dietary fat intake and risk of gestational diabetes. Modestly elevated glucose levels during pregnancy are associated with a higher risk of future diabetes among women without gestational diabetes mellitus. Excessive early gestational weight gain and risk of gestational diabetes mellitus in nulliparous women. Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States: a systematic review of the evidence for screening in early pregnancy. Prospective study of pre-gravid sugar-sweetened beverage consumption and the risk of gestational diabetes mellitus. The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study. Prevalence of diagnosed and undiagnosed diabetes and prediabetes in New Zealand: findings from the 2008/09 Adult Nutrition Survey. Diagnostic and prognostic performances over nine years of a selective screening strategy for gestational diabetes mellitus in a cohort of 18,775 subjects. Long-term impact of neonatal breastfeeding on childhood adiposity and fat distribution among children exposed to diabetes in utero. Oral hypoglycaemic agents vs insulin in management of gestational diabetes: a systematic review and metaanalysis. Report of the Diabetes Care Workforce Service Review Team to Health Workforce New Zealand. Gestational diabetes mellitus in Tonga: insights from healthcare professionals and women who experienced gestational diabetes mellitus. Effectiveness of gestational diabetes treatment: a systematic review with quality of evidence assessment. A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors: a feasibility randomized control trial. International migration and gestational diabetes mellitus: a systematic review of the literature and meta-analysis. Antepartum glucose tolerance test results as predictors of type 2 diabetes mellitus in women with a history of gestational diabetes mellitus: a systematic review. Influence of breastfeeding during the postpartum oral glucose tolerance test on plasma glucose and insulin. Postpartum screening for diabetes among Medicaid-eligible South Carolina women with gestational diabetes. Maternal physical activity before and during early pregnancy as a risk factor for gestational diabetes mellitus. Body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus. Evaluating the extent of pregravid risk factors of gestational diabetes mellitus in women in Tehran. Prevalence of gestational diabetes mellitus and pregnancy outcomes in Iranian women.
Extremely hard X-rays are generated with betatrons sudden onset erectile dysfunction causes purchase online dapoxetine, synchrotrons and linear accelerators and are in the mega electron volt range how to fix erectile dysfunction causes buy dapoxetine from india. The most common are X-ray examinations of the human body and analysis of technical materials erectile dysfunction caused by stroke generic dapoxetine 30mg on-line. In X-ray therapy which antihypertensive causes erectile dysfunction buy discount dapoxetine online, the biological effect of X-rays is used to destroy malignant tissue. It is applied mainly to treat cancer patients, when high doses are delivered to a limited area of the body, with restricted irradiation of adjacent tissue. In 1914, he proved by interference experiments that fi-rays were electromagnetic waves. The corresponding photons, called fi-quants, have widely different energies, ranging from 0. The emission of fi-rays usually follows nuclear transformations, which place an atomic nucleus in a state of enhanced energy during processes of radioactivity and during capture of particles. Unlike fiand fi-radiation, fi-rays cannot be deflected by electric and magnetic fields. The fi-transition, also called fi-decay, is not radioactive decay in the usual sense, because neither the charge nor the mass number of the nucleus changes. Electromagnetic radiation in the same energy range can also be produced by the decay of elementary particles, annihilation of electron–positron pairs and acceleration and deceleration of high-energy electrons in cosmic magnetic fields or in elementary particle accelerators. Interaction of fi-rays with matter is described by the Compton scattering and photoelectric effect. At even higher energies, in the range of several mega electron volts, absorption of fi-quants results in neutron emission. External exposure occurs, for example, during X-ray examinations or during natural irradiation from building materials containing fi-ray emitters. Most of the dose from external irradiation is due to Xor fi-rays, because fiand fi-particles are readily absorbed by the clothes covering the body or by the superficial layer of skin, whereas Xand fi-rays can penetrate the body and even traverse it if their energy is sufficiently high (see Figure 1, Overall introduction). Internal irradiation occurs during the decay of radionuclides absorbed in the body, usually after ingestion or inhalation. In this case, fiand fi-particles are more important than Xor fi-rays, because fiand fi-emitters lose most or all of their energy in the tissues or organs in which they decay, while the energy of Xand fi-rays, which is usually lower than those of fiand fi-rays, is diffused throughout the body or even leaves the body without creating any damage. Doses of all types of radiation from external and internal exposure are summarized in the Overall introduction. Although it is difficult to evaluate the relative contribution of electromagnetic radiation in mixed radiation fields, it can be estimated to be about 50% (Figure 1). There are major natural and man-made sources of exposure, some of which are increasing. Medical exposure and natural terrestrial exposure are due mainly to Xand fi-rays. Other important components of these estimates are mixed radiation fields, such as internal fi-emitters with a considerable fi-ray component, whereas the important man-enhanced exposure from indoor radon and its short-lived daughter products is mainly internal exposure to fi-radiation. Cosmic radiation at ground level consists of particle radiation (mainly muons), with increasing contributions from neutrons at higher altitudes (see section 4. Exposure from terrestrial sources depends on the geological properties of the soil, which vary significantly. The average annual external exposure to fi-rays worldwide from terrestrial sources is 0. This value is derived from the average indoor (80 nGy h–1) and outdoor (57 nGy h–1) absorbed dose rates in air, assuming an indoor occupancy factor of 0. The lowest outdoor dose rates in air are reported for Canada (24 nGy h–1) and the lowest indoor rates for Iceland and New Zealand (20 nGy h–1). The maximum average values are found in Namibia (outdoors, 120 nGy h–1; indoors, 140 nGy h–1). The average exposures in eight countries of Europe ranged from 50 to 110 nGy h–1 in buildings and from 30 to 100 nGy h–1 in the open air (Green et al. Little exposure is derived from Xand fi-rays in extraterrestrial natural sources. The dose to individual patients undergoing radiotherapy is much higher than that experienced during diagnosis, although the number of patients is much smaller. As treatment with radiotherapy is intended to deliver high doses to target organs, mostly in elderly patients, attempts to transform collateral doses to non-target organs into effective doses are open to criticism. Although the dose per examination is generally low, the extent of the practice makes diagnostic radiography the main source of radiation from medical use. The use of X-rays and fi-rays for medical purposes is distributed very unevenly throughout the world, being closely associated with general health care level (see section 4. Seventy per cent of these services were available in countries with a welldeveloped health-care system. In highly developed countries, most plain-film examinations of the chest and extremities involve relatively low doses (effective doses of about 0. The approximate doses to the skin and the effective doses from a number of diagnostic procedures in developed countries are shown in Table 1. Computed tomography scanning has become widely available in many developed countries. The estimated annual effective dose from all diagnostic uses of radiation in those countries was estimated to be 1. A source of uncertainty in these estimates is the use of fluoroscopy, which results in much higher doses than radiography; furthermore, its prevalence is not fully known and is changing with time. The doses may vary widely: modern equipment with image amplifiers results in lower doses than older equipment with fluorescent screens, but high doses may still be received when fluoroscopy is used in interventional radiology as a means of guidance during surgical procedures, although this practice is infrequent. The collective dose is due mainly to the more frequent fluoroscopic examinations of the gastrointestinal tract. Approximate mean effective doses from diagnostic radiology procedures in highly developed countries Procedure Average effective Average number dose (mSv) per of examinations examination per 1000 population per year Chest radiograph 0. Doses may vary from these values by as much as an order of magnitude depending on the technique, equipment, film type and processing. Estimates of the doses are available for 86 572 persons in the Life Span Study out of about 120 000 persons who were in one of the cities at the time of the explosions. The collective dose to the colon for the 86 472 persons for whom dosimetry is available was 24 000 person–Sv (Burkart, 1996; see section 4. The doses decreased with distance from the epicentres, but the highest doses to the colon were > 2000 mSv. Atmospheric nuclear explosions were carried out at several locations, mostly in the Northern Hemisphere, between 1945 and 1980. Since 1963, nuclear tests have been conducted mainly underground, and the principal source of worldwide exposure due to weapons testing is the earlier atmospheric tests. The total collective effective dose of Xand fi-rays committed by weapons testing to date is about 2. With the exception of 137Cs and 125Sb, all of these radionuclides have radioactive half-lives of less than one year, and therefore delivered their doses soon after the explosions. Collective effective doses of the world population from external radiation committed by atmospheric nuclear testing Radionuclide Radioactive half-life Collective effective dose (1000 person–Sv) 137Cs 30 years 1210 95Zr 64 days 270 54Mn 310 days 180 106Ru 370 days 140 95Nb 35 days 130 125Sb 2. The collective dose to the local population of about 180 000 persons has been estimated to be approximately 500 person–Sv (Anspaugh et al. The collective dose from external irradiation was estimated to be 2600 person–Sv, corresponding to an average dose of 260 mSv (Tsyb et al. The doses of Xand fi-rays have not been estimated explicitly as most of the exposure is due to internal irradiation. The local collective effective dose from Xand fi-rays from external irradiation can be crudely estimated to be about 0. An additional component of the exposure is the long-lived radionuclides that are distributed worldwide; the only one that contributes significantly to external irradiation, however, is 85Kr, which has a radioactive half-life of about 10 years. A major accident in a nuclear power plant occurred in Chernobyl, Ukraine, in 1986 (see section 4. The Kyshtym accident was a chemical explosion that followed failure of the cooling system in a storage tank of highly radioactive fission wastes. The Windscale accident was caused by a fire in the uranium and graphite core of an air-cooled reactor primarily intended for the production of plutonium for military use. An important route of intake was through milk consumption, which was controlled near the accident, although it was a significant source of exposure further away.
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