Current Events and U.S. Diplomacy Essay Example | Topics and Well Written Essays - 750 words - 3

Current Events and U.S. Diplomacy - Essay Example ion, in deed brought about transformation of the whole world’s politics resulting into a reformulation of economic, political, and military alliances in the entire world. This is evident from the current events and diplomatic relation that has improved between US and Russia since the end of the cold war. The objective of this paper is to explore the current relationship between US and Russia since the end of the cold war. The paper will also discuss the current US diplomatic approach to Lithuania, a former Soviet nation and provide a comparison of the relationships. Finally, the paper will summarize how the US has changed it relates to other countries over the past 20 years. The climax of Cold War gave Russia and United States a new chance to corporate. In fact, Russia took over the permanent seat which previously had been held by Soviet Union at the United Nations Security Council. It was also invited to join G-7, the world’s largest economic powers making it G-8. This has given Russia, and US and opportunity to cooperate in securing loose ties in the former Soviet Union. Trade has also improved between US and Russia. For instance, it is noted that Russia is the biggest producer of hydrocarbons, which US is the biggest consumer. The two nations have also developed a common bilateral corporation in missile defense as a way of ensuring security in the world (American Association for Advancement of Slavic Studies, American Council of Learned Societies and Ohio State University, 2009). However, U.S and Russia still lock horns in certain diplomatic matters. For instance, the United States has tried to push hard for further economic and political reforms in Russia, something that Russia sees as meddling in its internal affairs. The other area that has raised eye brows is the fact that US has invited other former Soviet Union countries to join NATO, an issue that Russia is opposed to. The two nations have also differed on the approach that should be used to

Text Analysis Essay Example | Topics and Well Written Essays - 1000 words

Text Analysis - Essay Example The main clause in this is 'iron man stood at the top of the cliff.' This clause is by itself a sentence. This means there is a complete meaning for it even if it is alone with no other phrase. (English grammar 2009). This structure of the sentence makes it ambiguous because since 'taller than a house' precedes 'iron man' and 'cliff', who or what is taller than a house might confuse the students. This affects the semantics of the sentence. This is due to improper phrase structure. It reads better as, 'The Iron Man, taller than a house, stood in the darkness, at the top, on the very brink of the cliff.' Thus, the sentence will be understood better. This creates a language cluster with 'at the top, on the very brink of the cliff.' Speaking about the pragmatics in it, the exact meaning of the sentence will be understood only if the students know who the iron man is or what the story is about. Else, they will be puzzled about how a man can be made of iron. The sentence alone will only give a sense of the real meaning; that the iron man, a very tall person, stood at the edge of the cliff in the darkness. As the students discuss among themselves, they might come up with negotiated meanings for the sent ence like the iron man wanted to jump off the cliff because he was standing at the edge of it. The denoted meaning is that the man was made of iron, that he was very tall, and that he stood at the edge of the cliff in the darkness. But, connotation might arise at the mention of iron and the edge of the cliff. It varies with each student, but it might be something like imagining themselves as the iron man or as standing at edge of a cliff. In this case, the first level of pragmatism is that the tall iron man stood at the edge of the cliff in the darkness. The second level of pragmatism gives the idea that it was night time. The third level of pragmatism will bring in thoughts like he will or will not die if he falls off the cliff because he's made of iron and there is a chance of falling since its dark. This sentence contains almost all the elements of English language, and can be used as a good example for teaching what phrases and clauses are. But considering the limitations of the students, this one is a bit confusing to start with. 2. The wind sang through his iron fingers: The nouns in the sentence are 'wind and 'iron fingers' where again, iron is a descriptive part. 'Sang' is the simple past tense verb in it. 'The' is the article and 'through' is the preposition. 'His' is the pronoun. The sentence is a very simple one with just a single clause. The sentence does not provide any ambiguity in its structure, and is right semantically. The meaning of the sentence is pretty easy for any child. Taking this particular sentence alone, its pragmatism is to be discussed. Since the iron man's name is not mentioned, the reference of 'his' will create a problem. The sense of meaning that this sentence gives is that the iron fingers had gaps in between through which the wind blew singing. The negotiated meaning can be that a giant had iron fingers with so much of gap in between them that even a child can pass through it. The denoted meanin

Case Study 2 -part 2 Essay Example | Topics and Well Written Essays - 750 words - 1

Case Study 2 -part 2 - Essay Example The average for the machine type one is the highest at 639.093 parts per minute with the highest standard deviation at 60.481, meaning that it also has the highest variability in machine production. Machine type two on the other hand has the lowest average rate at 120.765 ppm and the lowest standard deviation at 13.73011 attributing to its lower variability in machine production per minute. Machine type three has an average of 156.48 in the sample, a close rate in the production rate of 155 ppm as noted earlier. On the production per day sampling, machine type 2 had an average of 120.765 ppm, while its official rating is 200 ppm. Having the number of observation, the production levels, and the time period worked by each machine type as one block of independent variables, and the machine type as the dependent variable, the p-value of the summary table shown above, that t-statistic is negative for observation and time period worked by the machine, but 0.558 for observation. This indicates that the level of significance is favorable for obtaining the observed results when the null hypothesis is true. As shown by table 4 above, we shall reject the null hypothesis which states that machine type 1= 700, as accept the alternative hypothesis which states that machine type one is not equal to 700. This is because the calculated value of p= 0.0000002 is less than p value=0.05. For the machine type 2, the value of calculated p is close to zero which means that we reject the null hypothesis and accept the alternative hypothesis which states that Machine type 2 (rated 200 ppm) not equal to 200. While for the case of machine type 3 (rated 155 ppm) the value of calculated P=0.8258 which is greater than p=0.05 this prompt us not to reject null hypothesis and conclude that Machine type

SWOT Analysis for Isle of Wight Food Show Essay

SWOT Analysis for Isle of Wight Food Show - Essay Example The researcher states that the Isle of Wight (IOW) Food Show is jointly organized by Isle of Wight Tourism, Isle of White Chamber of Commerce, the Island Traders’ Association and Wiley Events. It is a two-day event taking place from 1 pm to 6 pm. Entry to the festival is free as per the Needles Park pays per attraction policy. Exhibitors are charged  £200 for the services rendered to them. Venue of the food show is Needles Park, Alum Bay in the North West of the island. Various stakeholders to the food show include accommodation providers, event organizers, transporters, visitor attractions, the local council, and DMO. Wiley Events has been the leader in the line of bespoke event management since 2001. Teddy Toddington and Pippa Powell, the partners of Wiley Events carry 20 years experience in event organizing. Both are experts in their own right and divide job functions as per their acumen into different event management functions. Wiley is also in an advisory role of offer ing consultancy services to other companies particularly in the areas of sales, operations, and administration. There are 21 specific touring sites, as identified by tourism data. Caravan sites also organize touring and camping, capturing 8% visitors of the event market. Summer is the peak season of tourism in the IOW when occupancy rate is 80%, which reduces to 37% in the spring and 19% in the autumn season. There are 60 worth-seeing sites, as per the Attractions, Mini-guide 2005 and places of interest could be 200, as taken from the Tourism Baseline Audit 2003. Measuring 23 miles by 13 miles, the Isle of Wight boasts of near about 2.6 million visitors each year with an approximate tourism spend of  £352 million a year, tourism being 24% of the Island’s GDP and the first tourism destination to encourage quality and supervised stay facility; Once reaching to the Isle of Wight, one finds the transport infrastructure fully customised for visitors’ comfort.

A New Realism-Crafting a US Foreign Policy for a New Century Essay Example for Free

A New Realism-Crafting a US Foreign Policy for a New Century Essay The political turmoil that the United States had yet to face in the 21st century was manifested in one brutal fell swoop on September 11, 2001, when thousands of innocent Americans were slaughtered on their native soil at the hands of vicious and brutal foreign operatives whose goal was to strike terror into the heart of the United States. Moreover, a clear message was sent- the rules of the international game of power were changed forever. Threats, it was clearly seen on that horrible day, could just as easily come from a group of motivated individuals as it could from an organized and recognized international government. With this in mind, foreign policy that heeds the changes in the international political landscape is a matter of life or death for not only the US, but every other nation on the face of the earth as well. In this research, a discussion of the construction of US foreign policy in the midst of sweeping changes in international affairs will be discussed from many points of view in an effort to ultimately better understand not only what has happened to effect change, but also what must occur for a brighter tomorrow to result. Jihad and International Politics As this research began, the point was made that 9/11 served as an abrupt wakeup call to not only America, but the entire world that there were forces afoot that could, seemingly at will, bring even the most powerful of nations to their collective knees through the use of terrorist actions that could be inflicted by a dozen people as bad as any army could possibly inflict. For all of this harsh reality, however, there is another stark reality in the years after 9/11- there has not been a sufficient level of improvement in the coordination of international intelligence levels and the law enforcement needed to effectively battle terrorism on a unified front (Richardson, 2007). Moreover, almost no effort has been made to understand why Jihadism exists, even though radical groups such as Al Qaeda have been shown to be making efforts to acquire nuclear weapons. With all of this happening, the obvious assumption would be that the US, as a superpower, would certainly lead the charge and do everything possible to understand the nature of the new enemy, what the enemy can inflict, and prevent access to nuclear materials that terrorist groups need in order to fabricate weapons of mass destruction. However, the reality is, from a President who has seemingly waged war against an innocent state in Iraq to intelligence organizations that have leaks of classified information on a regular basis, the US is setting a poor example in terms of antiterrorism. Illegal Weapons-Foreign and Domestic It has been said that guns do not kill people, but people do kill other people. In a world where thousands of people can be slaughtered without so much as a single shot fired, one still needs to realize that the traffic in illegal weapons- both in the US and globally, poses a national and international threat (Richardson, 2007). Weapons are readily available in towns large and small, for very little money. Legislation aimed at gun control does very little to prevent the problem to any measurable extent, and lawmakers are hard pressed for valid solutions to the dilemma in the US (Richardson, 2007). Of course, on an international scale, terrorists and other fringe groups are stockpiling huge amounts of weapons that are ready to be used at any time to inflict death without restriction. Beyond the issue of guns, the use of nuclear materials for the construction of weapons is a huge problem given the efforts of nations such as India, Pakistan and others now having the capability of manufacturing nuclear material and very little regulation in terms of how and where that material would in fact be distributed and used. The US has in fact been quite lacking in the securing of nuclear materials, and the required bans on the testing of nuclear weapons by other nations are either not in place or are not enforced adequately in the cases where they do exist (Richardson, 2007). This is yet another problem for the US to contend with- something bust be done to hold back the nuclear tidal wave before it is too late for everyone. Asia Rising Beginning with the recovery from the death and destruction of World War II, up to and through the Vietnam War and beyond, the nations of Asia have quite literally gone from hell and back many times. Rather than grinding those nations into a helpless submission, these challenges have seemingly motivated the billions of people of Asia to a new level of economic, military and educational ambition. In generations past, the goods of Asia were merely dismissed as useless and tawdry trinkets. However, with the increase in the level of education, implementation of technology, and old fashioned determination of Asians, the other nations of the world have been left with little choice but to take seriously the multi-faceted threats that Asia poses to the US and others (Richardson, 2007). To begin, one must come to terms with the highly dangerous economic threat of Asia; because of the huge influx of capital from American and European firms foremost, the business and industry of Asia has grown extremely strong. The resulting profits from these operations have given Asia the monetary muscle to conversely invest in businesses, real estate and industry, ironically enough, in the US and Europe. Therefore, what is seen in this instance is the full circle fulfillment of a sad destiny- Asia is slowly owning ever-increasing pieces of the rest of the world- a world that not too long ago dismissed Asia as a laughable excuse for a continent. Economic gains for Asia have likewise enabled the nations of Asia to be able to flex a bit of economic and military muscle. Take, for instance, China, a long-time Communist stronghold and now a stockpile for cash and weapons. In this case, the classic idea of â€Å"guns and butter† is seen in horrific reality. China not only holds a huge amount of the debt of the US and other nations, but also has been very likely putting together a massive army, complete with the latest weapons, including those of the nuclear variety. This, combined with the fact that China holds a radically different political mindset than many of the other nations of the world, makes for a potentially explosive situation. If, in fact, China chooses to recall the foreign debts that it holds, decides to invade other nations, or pose a more serious and tangible nuclear threat, there will be epic problems with which to contend, which brings back the recurrent theme of the US foreign policy in such situations. How can the US develop a realistic and effective foreign policy when dealing with a giant continent like Asia, populated with radical nations like China? Surely, a match of aggression with additional aggression is far from acceptable. Therefore, the challenge that lies ahead for the US is to maintain a strong position in the world and still avoid additional conflict. Russia Reborn A deadly myth exists in the world today- that which holds that Russia is all but dead and buried in the political landscape. In reality, Russia is coming back to life in a political and economic sense. While, admittedly, the economy of Russia has never been as economically viable as it could be in a freer economy, the military muscle which Russia is currently in the midst of rebuilding can once again pose a massive threat to the US. This, combined with the other enemies in the present day, can spell disaster. What Russia means for US foreign policy going forward is significant- if the US makes the fatal mistake of discounting the possibility of Russian aggression becoming a lethal situation, yet another bit of fuel will have been thrown on the political fire that has the potential to consume the US from abroad. Economic Imbalances Poverty is one of the evils which has been cited as a key culprit in the proliferation of global terror, bloodshed, and dispute (Richardson, 2007). Classically, the view of the human condition has always been that people who are hungry, sick, and lack the basic necessities of life are typically much more hostile and harder to negotiate with than one would find in the person of those who had a suitable standard of living. Another possibility is that nations which hate the US may hate in large part because of the resentment for the excesses which exist in the US and the apparent overindulgence of Americans in all forms of enjoyments and material goods. Meanwhile, religious extremists in the Middle East and elsewhere are watching the people of the US in the midst of excessive revelry and have come to the conclusion that people in America, who take so much for granted and do not seem to care very much about the plight of others in the world. As such, the prevailing viewpoint seems to be that Americans need to be shown that all is not well in all parts of the world and in a sense; the party is over in the US. Global Problems-American Solutions In the article which was utilized as the basis for this research, the author ultimately came to an interesting conclusion. Simply put, the author’s thesis is that the US first must stop using the granting of diplomatic relations with rogue nations as a reward for good behavior (Richardson, 2007). The reason for this is quite simple- these nations, which of course most likely have at their heart the goal of overcoming and defeating the US, will conduct themselves in an acceptable way only when they are being evaluated for the granting of diplomatic relations and once that is complete, and the US has let down its guard, the nations will once again resort to evil behavior, and the consequences could be drastic. The answer to this problem, as the author asserts, is the resurrection of a sort of Marshall Plan, especially in the case of Middle Eastern nation and North Africa as well. With this plan as the cornerstone, it is possible for the US to use its massive resources to provide educational, economic, and political aid to these hostile areas, with the hope of deflating the widespread efforts of Jihad and ultimately change the minds of those who hate the US- not with bullets, but with food and books and other help. Overall, the other enemy that the US should be seeking to eradicate, per the author, is poverty. The seemingly underlying cause of most of the violence that is taking place in the world is motivated by the lack of a suitable standard of living for some groups, and indeed, entire nations of people (Richardson, 2007). Therefore, if the element of deprivation were in fact taken away from the argument, what one would see would be a clearer way to look at the other fundamental differences between the West and other parts of the globe, and perhaps, some progress could be made to bring about a stronger, more reliable peace. Overall, what the US needs to do it would seem, is to look at problems on a global scale and consider the viewpoint of the enemy, and take steps in order to be able to be more of a friend and less of a foe. Conclusion In a world where the rules are constantly changing, the environment is becoming more deadly day by day, and the threat of terrorism and rogue nations spreads like a plague, the US stands as a stronghold of liberty and virtue in a sea of death and lawlessness. However, as has been seen, the US is seriously lacking in many areas where responsibility and action are desperately needed. Foreign policy is a key part of this action plan- without an aggressively enforced program of protecting American interests, maintaining a global peace, and fighting terrorism where it resides, it is very likely that chaos, evil and disaster will become the norm in the world instead of freedom, peace and safety. The writing is quite clearly on the wall- for America, action has to happen soon and continue to happen if the world is to be saved for those who wish to live in harmony and safety. The evil that turned the world upside down on a sunny morning in September, 2001 must not be allowed to prevail, and indeed, hollow policy without enforcement will be just as bad as no policy at all. Therefore, in closing, the issue is clear- foreign policy must change and grow with the times if the future is to exist at all. Bibliography Richardson, B. (2007). A New Realism: Crafting a US Foreign Policy for a New Century. Harvard International Review, Summer 2007, 26+.

Radiation Protection for Angiography Procedure.

Radiation Protection for Angiography Procedure. Fluoroscopic procedure produces the greatest patient radiation exposure rate in diagnostic radiology. Therefore the radiation protection in fluoroscopy is very important. Several feature and techniques in fluoroscopy are designed for protection to the patient during fluoroscopic procedure. a) Protection to Patient * A dead-man switch is a device (switch) constructed so that a circuit closing contact can only be maintained by continuous pressure on the switch by the operator. Therefore, when the machine is turned on by any means, whether by the push button at the control panel, or by the foot pedal, this switch must be held in for the machine to remain on. * The on-time of the fluoroscopic tube must be controlled by a timing device, and must end alarm when the exposure exceeds 5 minutes. An audible signal must alert the user to the completion of the preset on time. This signal will remain on until the timing device is reset. * The X-ray tube used for fluoroscopic must not produce X-rays unless a barrier is in position to intercept the entire cross-section of the useful beam. The fluoroscopic imaging assembly must be provided with shielding sufficient that the scatter radiation from the useful beam is minimized. * Protective barriers of at least 0.25 mm lead equivalency must be used to attenuate scatter radiation above the tabletop. This shielding does not replace the lead garments worn by personnel. Scattered radiation under the table must be attenuated by at least 0.25 mm lead equivalency shielding. * Additionally, most c-arm fluoroscopes have a warning beeper or light that activate when the beam is on, some have both. Never inactivate any warning devices, and keep ones foot off the foot pedal whenever possible. * Methods of limiting radiation exposure include: o making certain that the fluoroscopy unit is functioning properly through routine maintenance, o limiting fluoroscopic exposure time, o reducing fields of exposure through collimation, o keeping the X-ray source under the table by avoiding cross-table lateral visualization when possible, and o bringing the image intensifier down close to the patient b) Protection to personnel There are therefore three basic ways to minimize dose: * Reduce time of exposure * Use the inverse square law-doubling your distance away quarter your exposure * Use shielding by barrier These basics known as Cardinal Principle which is important to achieved ALARA. i) Time Radiation dose is directly proportional to the time, those by doubling the radiation time the dose is doubled and by having the radiation time the doses halved. Many factors impact the on time of a fluoroscopic procedure. The exposure time is related to radiation exposure and exposure rate (exposure per unit time) as follows: Exposure time = Exposure/Exposure rate Exposure = Exposure rate x time The algebraic expressions simply imply that if the exposure time is kept short, then the resulting dose to the individual is small. Method of reducing exposure time include meticulous advanced planning of the procedure, judicious use of contrast enhancement, appropriate positioning of the patient, orientation of the fluoroscope unit prior to beginning the procedure. ii) Distance The second radiation protection action relates to the distance between the source of radiation and the exposed individual. The exposure to the individual decreases inversely as the square of the distance. This is known as the inverse square law, which is stated mathematically as: where I is the intensity of radiation and d is the distance between the radiation source and the exposed individual. For example, when the distance is doubled the exposure is reduced by a factor of four. In mobile radiography, where there is no fixed protective control booth, the technologist should remain at least 2 m from the patient, the x-ray tube, and the primary beam during the exposure. In this respect, the ICRP (1982), as well as the NCRP (1989a), recommended that the length of the exposure cord on mobile radiographic units be at least 2 m long. Another important consideration with respect to distance relates to the source-to-image receptor distance (SID). The appropriate SIDs for various examinations must always be maintained because an incorrect SID could mean a second exposure to the patient. Long SID results in less divergent beam and thus decreases the concentration of photons in the patients. Short SID results in the reverse action and increases the patient dose. Hence the longest possible SID should be employed in examinations. However, if a greater than standard SID is used then greater intensity of radiation would be required to produce the same film density. Therefore it is recommended that only standard SIDs should be used. iii) Shielding Shielding procedure the most utilitarian results in the reduction of staff dose as there are times when the procedure list simply must function in close proximity, even directly cines fluoroscopy. In these circumstances there simply is no substitute for the best modern flexible lead gloves, lead glasses, lightweight lead apron and lead lined thyroid shield available. Appropriate shielding is mandatory for the safe use of ionizing radiation for medical imaging. Other method of shielding includes beam collimation, protective drapes and panels. Shielding of occupational workers can be achieved by following methods: * Personnel should remain in the radiation environment only when necessary (step behind the control booth, or leave the room when practical) * The distance between the personnel and the patient should be maximized when practical as the intensity of radiation decreases as the square of distance (inverse square law). * Shielding apparel should be used as and when necessary which comprise of lead aprons, eye glasses with side shields, hand gloves and thyroid shields. Lead aprons are shielding apparel recommended for use by radiation workers. These are classified as a secondary barrier to the effects of ionizing radiation. These aprons protect an individual only from secondary (scattered) radiation, not the primary beam. The thickness of lead in the protective apparel determines the protection it provides. It is known that 0.25 mm lead thickness attenuates 66% of the beam at 75kVp and 1mm attenuates 99% of the beam at same kVp. It is recommended that for general purpose radiography the minimum thickness of lead equivalent in the protective apparel should be 0.5mm. It is recommended that women radiation workers should wear a customized lead apron that reaches below mid thigh level and wraps completely around the pelvis. This would eliminate an accidental exposure to a concept us. Other protective apparel included eye glasses with side shields, thyroid shields and hand gloves. The minimum protective lead equivalents in hand gloves and thyroid shields should be 0.5mm. Lead lined glass and thyroid shield likewise reduce 90% of the exposure to the eyes and thyroid respectively. Lead lined gloves reduce radiation exposure to the hands; however they are no substitute for strict observation of appropriate fluoroscopic hygiene. Gloves should be considered as an effective means of reducing scatter radiation only. 2. State five clinical indications for the patient undergo the angiography procedure. 3. Explain the patient care management before, during and after the procedure Before a procedure: * Patients undergoing an angiogram are advised to stop eating and drinking eight hours prior to the procedure. * They must remove all jewelry before the procedure and change into a hospital gown. * If the arterial puncture is to be made in the armpit or groin area, shaving may be required. * A sedative may be administered to relax the patient for the procedure. * An IV line will also be inserted into a vein in the patients arm before the procedure begins in case medication or blood products are required during the angiogram. * Be aware of and follow all Local Rules and protocols * Prior to the angiography procedure, patients will be briefed on the details of the test, the benefits and risks, and the possible complications involved, and asked to sign an informed consent form. * Ensure that all exposures are justified and there is informed consent * Check patient identity * Position patient comfortably flat, with arm above head where possible * Ensure all members of staff in room are wearing suitable. For operations this should be lead glasses, thyroid collar and wrap-around lead apron * Check all staff are wearing radiation monitors correctly * Use all available lead shielding appropriately sited * Position table before screening * Keep tube current as low as possible and kVp as high as possible for cardiac studies, 60 – 90 kV is appropriate * Keep x ray tube at maximum and image intensifier / receptor at minimum distance from patient * Check all staff are as far away as possible in their role * Use dose reduction programmers when possible * Perform acquisitions on full inspiration where possible * Collimate closely to area of interest * Prolonged procedures: reduce dose to the irradiated skin eg. Change beam angulations * Minimize fluoroscopy time, high dose rate time and no of acquisitions * Remember software features, such as replay fluoro to minimize dose * Dont over use geometric magnification * Remove grid for small patients or when image intensifier / detector cannot be placed close to patient * Check and record screening time and DAP at the end of the case and review against the DRL. During the procedure: * The radiologic technologist will position you on the exam table. A radiologist a physician who specializes in the diagnostic interpretation of medical images will administer a local anesthetic and then make a small nick in your skin so that a thin catheter can be inserted into an artery or vein. The catheter is a flexible, hollow tube about the size of a strand of spaghetti. It usually is inserted into an artery in your groin, although in some cases your arm or another site will be selected for the catheter. * The radiologist will ease the catheter into the artery or vein and gently guide it to the area under investigation. The radiologist will be able to watch the movement of the catheter on a fluoroscope, which is an x-ray unit combined with a television monitor. * When the catheter reaches the area under study, the contrast agent will be injected through the catheter. By watching the fluoroscope screen, the radiologist will be able to see the outline of your blood vessels and identify any blockages or other irregularities. * Angiography procedures can range in time from less than an hour to three hours or more. It is important that you relax and remain as still as possible during the examination. The radiologic technologist and radiologist will stay in the room with you throughout the procedure. If you experience any difficulty, let them know. * Angiography also can be performed using magnetic resonance instead of x-rays to produce images of the blood vessels; this procedure is known as magnetic resonance angiography (MRA) or magnetic resonance venography (MRV). After the procedure: * Because life-threatening internal bleeding is a possible complication of an arterial puncture, an overnight stay in the hospital is sometimes recommended following an angiography procedure, particularly with cerebral and coronary angiograms. * If the procedure is performed on an outpatient basis, the patient is typically kept under close observation for a period of at six to 12 hours before being released. * If the arterial puncture was performed in the femoral artery, the patient will be instructed to keep his leg straight and relatively immobile during the observation period. * The patients blood pressure and vital signs will be monitored and the puncture site observed closely. Pain medication may be prescribed if the patient is experiencing discomfort from the puncture, and a cold pack is applied to the site to reduce swelling. It is normal for the puncture site to be sore and bruised for several weeks. * The patient may also develop a hematoma, a hard mass created by the blood vessels broken during the procedure. Hematomas should be watched carefully, as they may indicate continued bleeding of the arterial puncture site. * Angiography patients are also advised to enjoy two to three days of rest and relaxation after the procedure in order to avoid placing any undue stress on the arterial puncture. Patients who experience continued bleeding or abnormal swelling of the puncture site, sudden dizziness, or chest pains in the days following an angiography procedure should seek medical attention immediately. * Patients undergoing a fluorescein angiography should not drive or expose their eyes to direct sunlight for 12 hours following the procedure. 4. Identify the type of contrast medium, the dose and delivering technique in angiography procedure. * Reducing radiation doses to the patient also generally reduces doses to the medical personnel. Â · Angiography procedure is using fluoroscopy imaging technique which is a real-time imaging technique. 5. List down the catheters and guide wires inclusive of size, shape and the hole type that are used in angiography procedures. The use of lead gloves during procedures is unusual as they are cumbersome and difficult to work in. The automatic brightness control will increase the exposure to go through two layers and one only protects the hand, so if they are going to be used a programme that sets the radiation factors rather than allowing adjustment may be appropriate. In practice, with careful collimation and attenuation to detail it should not necessary for the operators hand to be in the primary beam and only close to it for short periods. While doing catheterization, radiologist should do it behind the lead glass viewer which consists of lead equivalent glass of 0.25mm thickness. Geometric consideration is one of the important things in angiography because source of exposure to personnel is mainly from scattered radiation from the patient. So, it is important to minimize the amount of scattered radiation to personnel. This can be achieved by geometric consideration involving the x-ray tube, patient and image intensifier. The image intensifier should be as close as possible to patient to minimize the amount of scattered radiation hitting personnel. Because in angiography room is sterile for all things, personnel such as radiologist, nurses, radiographer or student should wear shoes which are prepared only. Make sure that film badges always outside personnel body to measure the dose receive to the personnel. The most important thing to remember is that all individuals should be fully trained and learned to be responsible for radiation safety. Involvement of a radiation expert is essential and is particularly useful in equipment specification, assessment and quality assurance, but also in the formulation of Local Rules. Technique Reduces Physician Radiation Exposure During Angiography Current technique requires that physicians performing radiation procedures wear lead gowns. The new technique involves use of a body length floor mounted lead plastic panel to protect to physicians as they monitor patients angiograms and control exam table movement. An extension bar allows the physician to remain safely behind the shield and still retain table control for panning. In the study, researchers recorded radiation exposure to various parts of a physicians body during 25 coronary angiography procedures and compared those results with radiation exposure during angiography on 25 patients using conventional radiation protection. A lead apron, thyroid shield, eyeglasses and facemask were used in both techniques, but a ceiling mounted shield was used in the conventional technique. The researchers placed radiation badges outside and inside the facemask; outside and inside the thyroid shield; on the right and left arm; outside and inside the lead apron; and on the right and left leg. The new equipment resulted in a 90 percent reduction in radiation exposure to the physicians head, arms, and legs. Exposure of the thyroid and torso was minimal with both techniques. Enhanced physician radiation protection during coronary angiography is readily achievable with this new technique, said Martin Magram, M.D., of the University of Maryland Medical Center in Baltimore, Md. Dr. Magram presented the study results on May 3 at the American Roentgen Ray Society Annual Meeting in Vancouver, British Columbia. Dr. Magram pointed out that by freeing physicians from the need to wear lead gowns, the new technique could preserve their ability to benefit patients. It may extend by years their ability to apply the skills they have developed over long careers of serving patients, noted Dr. Magram. New methods of radiation protection must parallel the development of new radiation techniques, added Dr. Magram. The key is to limit medical workers radiation exposure with effective and easy-to-use techniques, and the use of this extension bar and lead plastic shield may be such a technique. Definition Angiography is the x-ray study of the blood vessels. An angiogram uses a radiopaque substance, or dye, to make the blood vessels visible under x ray. Arteriography is a type of angiography that involves the study of the arteries. Purpose Angiography is used to detect abnormalities or blockages in the blood vessels (called occlusions) throughout the circulatory system and in some organs. The procedure is commonly used to identify atherosclerosis; to diagnose heart disease; to evaluate kidney function and detect kidney cysts or tumors; to detect an aneurysm (an abnormal bulge of an artery that can rupture leading to hemorrhage), tumor, blood clot, or arteriovenous malformations (abnormals tangles of arteries and veins) in the brain; and to diagnose problems with the retina of the eye. It is also used to give surgeons an accurate map of the heart prior to open-heart surgery, or of the brain prior to neurosurgery. Precautions Patients with kidney disease or injury may suffer further kidney damage from the contrast mediums used for angiography. Patients who have blood clotting problems, have a known allergy to contrast mediums, or are allergic to iodine, a component of some contrast mediums, may also not be suitable candidates for an angiography procedure. Because x rays carry risks of ionizing radiation exposure to the fetus, pregnant women are also advised to avoid this procedure. Description Angiography is usually performed at a hospital by a trained radiologist and assisting technician or nurse. It takes place in an x-ray or fluoroscopy suite, and for most types of angiograms, the patients vital signs will be monitored throughout the procedure. Angiography requires the injection of a contrast dye that makes the blood vessels visible to x ray. The dye is injected through a procedure known as arterial puncture. The puncture is usually made in the groin area, armpit, inside elbow, or neck. The site is cleaned with an antiseptic agent and injected with a local anesthetic. First, a small incision is made in the skin to help the needle pass. A needle containing an inner wire called a stylet is inserted through the skin into the artery. When the radiologist has punctured the artery with the needle, the stylet is removed and replaced with another long wire called a guide wire. It is normal for blood to spout out of the needle before the guide wire is inserted. The guide wire is fed through the outer needle into the artery and to the area that requires angiographic study. A fluoroscopic screen that displays a view of the patients vascular system is used to pilot the wire to the correct location. Once it is in position, the needle is removed and a catheter is slid over the length of the guide wire until it to reaches the area of study. The guide wire is removed and the catheter is left in place in preparation for the injection of the contrast medium, or dye. Depending on the type of angiography procedure being performed, the contrast medium is either injected by hand with a syringe or is mechanically injected with an automatic injector connected to the catheter. An automatic injector is used frequently because it is able to propel a large volume of dye very quickly to the angiogram site. The patient is warned that the injection will start, and instructed to remain very still. The injection causes some mild to moderate discomfort. Possible side effects or reactions include headache, dizziness, irregular heartbeat, nausea, warmth, burning sensation, and chest pain, but they usually last only momentarily. To view the area of study from different angles or perspectives, the patient may be asked to change positions several times, and subsequent dye injections may be administered. During any injection, the patient or the camera may move. Throughout the dye injection procedure, x-ray pictures and/or fluoroscopic pictures (or moving x rays) will be taken. Because of the high pressure of arterial blood flow, the dye will dissipate through the patients system quickly, so pictures must be taken in rapid succession. An automatic film changer is used because the manual changing of x-ray plates can eat up valuable time. Once the x rays are complete, the catheter is slowly and carefully removed from the patient. Pressure is applied to the site with a sandbag or other weight for 10-20 minutes in order for clotting to take place and the arterial puncture to reseal itself. A pressure bandage is then applied. Most angiograms follow the general procedures outlined above, but vary slightly depending on the area of the vascular system being studied. A variety of common angiography procedures are outlined below: Cerebral angiography Cerebral angiography is used to detect aneurysms, blood clots, and other vascular irregularities in the brain. The catheter is inserted into the femoral or carotid artery and the injected contrast medium travels through the blood vessels on the brain. Patients frequently experience headache, warmth, or a burning sensation in the head or neck during the injection portion of the procedure. A cerebral angiogram takes two to four hours to complete. Coronary angiography Coronary angiography is administered by a cardiologist with training in radiology or, occasionally, by a radiologist. The arterial puncture is typically given in the femoral artery, and the cardiologist uses a guide wire and catheter to perform a contrast injection and x-ray series on the coronary arteries. The catheter may also be placed in the left ventricle to examine the mitral and aortic valves of the heart. If the cardiologist requires a view of the right ventricle of the heart or of the tricuspid or pulmonic valves, the catheter will be inserted through a large vein and guided into the right ventricle. The catheter also serves the purpose of monitoring blood pressures in these different locations inside the heart. The angiogram procedure takes several hours, depending on the complexity of the procedure. Pulmonary angiography Pulmonary, or lung, angiography is performed to evaluate blood circulation to the lungs. It is also considered the most accurate diagnostic test for detecting a pulmonary embolism. The procedure differs from cerebral and coronary angiograms in that the guide wire and catheter are inserted into a vein instead of an artery, and are guided up through the chambers of the heart and into the pulmonary artery. Throughout the procedure, the patients vital signs are monitored to ensure that the catheter doesnt cause arrhythmias, or irregular heartbeats. The contrast medium is then injected into the pulmonary artery where it circulates through the lung capillaries. The test typically takes up to 90 minutes. Kidney angiography Patients with chronic renal disease or injury can suffer further damage to their kidneys from the contrast medium used in a kidney angiogram, yet they often require the test to evaluate kidney function. These patients should be well-hydrated with a intravenous saline drip before the procedure, and may benefit from available medications (e.g., dopamine) that help to protect the kidney from further injury due to contrast agents. During a kidney angiogram, the guide wire and catheter are inserted into the femoral artery in the groin area and advanced through the abdominal aorta, the main artery in the abdomen, and into the renal arteries. The procedure will take approximately one hour. Fluorescein angiography Fluorescein angiography is used to diagnose retinal problems and circulatory disorders. It is typically conducted as an outpatient procedure. The patients pupils are dilated with eye drops and he rests his chin and forehead against a bracing apparatus to keep it still. Sodium fluorescein dye is then injected with a syringe into a vein in the patients arm. The dye will travel through the patients body and into the blood vessels of the eye. The procedure does not require x rays. Instead, a rapid series of close-up photographs of the patients eyes are taken, one set immediately after the dye is injected, and a second set approximately 20 minutes later once the dye has moved through the patients vascular system. The entire procedure takes up to one hour. Celiac and mesenteric angiography Celiac and mesenteric angiography involves x-ray exploration of the celiac and mesenteric arteries, arterial branches of the abdominal aorta that supply blood to the abdomen and digestive system. The test is commonly used to detect aneurysm, thrombosis, and signs of ischemia in the celiac and mesenteric arteries, and to locate the source of gastrointestinal bleeding. It is also used in the diagnosis of a number of conditions, including portal hypertension, and cirrhosis. The procedure can take up to three hours, depending on the number of blood vessels studied. Splenoportography A splenoportograph is a variation of an angiogram that involves the injection of contrast medium directly into the spleen to view the splenic and portal veins. It is used to diagnose blockages in the splenic vein and portal vein thrombosis and to assess the strength and location of the vascular system prior to liver transplantation. Most angiography procedures are typically paid for by major medical insurance. Patients should check with their individual insurance plans to determine their coverage. Aftercare Risks Because angiography involves puncturing an artery, internal bleeding or hemorrhage are possible complications of the test. As with any invasive procedure, infection of the puncture site or bloodstream is also a risk, but this is rare. A stroke or heart attack may be triggered by an angiogram if blood clots or plaque on the inside of the arterial wall are dislodged by the catheter and form a blockage in the blood vessels or artery. The heart may also become irritated by the movement of the catheter through its chambers during pulmonary and coronary angiography procedures, and arrhythmias may develop. Patients who develop an allergic reaction to the contrast medium used in angiography may experience a variety of symptoms, including swelling, difficulty breathing, heart failure, or a sudden drop in blood pressure. If the patient is aware of the allergy before the test is administered, certain medications can be administered at that time to counteract the reaction. Angiography involves minor exposure to radiation through the x rays and fluoroscopic guidance used in the procedure. Unless the patient is pregnant, or multiple radiological or fluoroscopic studies are required, the small dose of radiation incurred during a single procedure poses little risk. However, multiple studies requiring fluoroscopic exposure that are conducted in a short time period have been known to cause skin necrosis in some individuals. This risk can be minimized by careful monitoring and documentation of cumulative radiation doses administered to these patients. Normal results The results of an angiogram or arteriogram depend on the artery or organ system being examined. Generally, test results should display a normal and unimpeded flow of blood through the vascular system. Fluorescein angiography should result in no leakage of fluorescein dye through the retinal blood vessels. Abnormal results Abnormal results of an angiography may display a restricted blood vessel or arterial blood flow (ischemia) or an irregular placement or location of blood vessels. The results of an angiography vary widely by the type of procedure performed, and should be interpreted and explained to the patient by a trained radiologist. Arteriosclerosis A chronic condition characterized by thickening and hardening of the arteries and the build-up of plaque on the arterial walls. Arteriosclerosis can slow or impair blood circulation. Carotid artery An artery located in the neck. Catheter A long, thin, flexible tube used in angiography to inject contrast material into the arteries. Cirrhosis A condition characterized by the destruction of healthy liver tissue. A cirrhotic liver is scarred and cannot break down the proteins in the bloodstream. Cirrhosis is associated with portal hypertension. Embolism A blood clot, air bubble, or clot of foreign material that travels and blocks the flow of blood in an artery. When blood supply to a tissue or organ is blocked by an embolism, infarction, or death of the tissue the artery feeds, occurs. Without immediate and appropriate treatment, an embolism can be fatal. Femoral artery An artery located in the groin area that is the most frequently accessed site for arterial puncture in angiography. Fluorescein dye An orange dye used to illuminate the blood vessels of the retina in fluorescein angiography. Fluoroscopic screen A fluorescent screen which displays moving x-rays of the body. Fluoroscopy allows the radiologist to visualize the guide wire and catheter he is moving through the patients artery. Guide wire A wire that is inserted into an artery to guides a catheter to a certain location in the body. Iscehmia A lack of normal blood supply to a organ or body part because of blockages or constriction of the blood vessels. Necrosis Cellular or tissue death; skin necrosis may be caused by multiple, consecutive doses of radiation from fluoroscopic or x-ray procedures. Plaque Fatty material that is deposited on the inside of the arterial wall. Portal hypertension A condition caused by cirrhosis of the liver. It is characterized by impaired or reversed blood flow from the portal vein to the liver, an enlarged spleen, and dilated veins in the esophagus and stomach. Portal vein thrombosis The development of a blood clot in the vein that brings blood into the liver. Untreated portal vein thrombosis causes portal hypertension. For Your Information Books * Baum, Stanley, and Michael J. Pentecost, eds. Abrams Angiography. 4th ed. Radiation Protection for Angiography Procedure. Radiation Protection for Angiography Procedure. Fluoroscopic procedure produces the greatest patient radiation exposure rate in diagnostic radiology. Therefore the radiation protection in fluoroscopy is very important. Several feature and techniques in fluoroscopy are designed for protection to the patient during fluoroscopic procedure. a) Protection to Patient * A dead-man switch is a device (switch) constructed so that a circuit closing contact can only be maintained by continuous pressure on the switch by the operator. Therefore, when the machine is turned on by any means, whether by the push button at the control panel, or by the foot pedal, this switch must be held in for the machine to remain on. * The on-time of the fluoroscopic tube must be controlled by a timing device, and must end alarm when the exposure exceeds 5 minutes. An audible signal must alert the user to the completion of the preset on time. This signal will remain on until the timing device is reset. * The X-ray tube used for fluoroscopic must not produce X-rays unless a barrier is in position to intercept the entire cross-section of the useful beam. The fluoroscopic imaging assembly must be provided with shielding sufficient that the scatter radiation from the useful beam is minimized. * Protective barriers of at least 0.25 mm lead equivalency must be used to attenuate scatter radiation above the tabletop. This shielding does not replace the lead garments worn by personnel. Scattered radiation under the table must be attenuated by at least 0.25 mm lead equivalency shielding. * Additionally, most c-arm fluoroscopes have a warning beeper or light that activate when the beam is on, some have both. Never inactivate any warning devices, and keep ones foot off the foot pedal whenever possible. * Methods of limiting radiation exposure include: o making certain that the fluoroscopy unit is functioning properly through routine maintenance, o limiting fluoroscopic exposure time, o reducing fields of exposure through collimation, o keeping the X-ray source under the table by avoiding cross-table lateral visualization when possible, and o bringing the image intensifier down close to the patient b) Protection to personnel There are therefore three basic ways to minimize dose: * Reduce time of exposure * Use the inverse square law-doubling your distance away quarter your exposure * Use shielding by barrier These basics known as Cardinal Principle which is important to achieved ALARA. i) Time Radiation dose is directly proportional to the time, those by doubling the radiation time the dose is doubled and by having the radiation time the doses halved. Many factors impact the on time of a fluoroscopic procedure. The exposure time is related to radiation exposure and exposure rate (exposure per unit time) as follows: Exposure time = Exposure/Exposure rate Exposure = Exposure rate x time The algebraic expressions simply imply that if the exposure time is kept short, then the resulting dose to the individual is small. Method of reducing exposure time include meticulous advanced planning of the procedure, judicious use of contrast enhancement, appropriate positioning of the patient, orientation of the fluoroscope unit prior to beginning the procedure. ii) Distance The second radiation protection action relates to the distance between the source of radiation and the exposed individual. The exposure to the individual decreases inversely as the square of the distance. This is known as the inverse square law, which is stated mathematically as: where I is the intensity of radiation and d is the distance between the radiation source and the exposed individual. For example, when the distance is doubled the exposure is reduced by a factor of four. In mobile radiography, where there is no fixed protective control booth, the technologist should remain at least 2 m from the patient, the x-ray tube, and the primary beam during the exposure. In this respect, the ICRP (1982), as well as the NCRP (1989a), recommended that the length of the exposure cord on mobile radiographic units be at least 2 m long. Another important consideration with respect to distance relates to the source-to-image receptor distance (SID). The appropriate SIDs for various examinations must always be maintained because an incorrect SID could mean a second exposure to the patient. Long SID results in less divergent beam and thus decreases the concentration of photons in the patients. Short SID results in the reverse action and increases the patient dose. Hence the longest possible SID should be employed in examinations. However, if a greater than standard SID is used then greater intensity of radiation would be required to produce the same film density. Therefore it is recommended that only standard SIDs should be used. iii) Shielding Shielding procedure the most utilitarian results in the reduction of staff dose as there are times when the procedure list simply must function in close proximity, even directly cines fluoroscopy. In these circumstances there simply is no substitute for the best modern flexible lead gloves, lead glasses, lightweight lead apron and lead lined thyroid shield available. Appropriate shielding is mandatory for the safe use of ionizing radiation for medical imaging. Other method of shielding includes beam collimation, protective drapes and panels. Shielding of occupational workers can be achieved by following methods: * Personnel should remain in the radiation environment only when necessary (step behind the control booth, or leave the room when practical) * The distance between the personnel and the patient should be maximized when practical as the intensity of radiation decreases as the square of distance (inverse square law). * Shielding apparel should be used as and when necessary which comprise of lead aprons, eye glasses with side shields, hand gloves and thyroid shields. Lead aprons are shielding apparel recommended for use by radiation workers. These are classified as a secondary barrier to the effects of ionizing radiation. These aprons protect an individual only from secondary (scattered) radiation, not the primary beam. The thickness of lead in the protective apparel determines the protection it provides. It is known that 0.25 mm lead thickness attenuates 66% of the beam at 75kVp and 1mm attenuates 99% of the beam at same kVp. It is recommended that for general purpose radiography the minimum thickness of lead equivalent in the protective apparel should be 0.5mm. It is recommended that women radiation workers should wear a customized lead apron that reaches below mid thigh level and wraps completely around the pelvis. This would eliminate an accidental exposure to a concept us. Other protective apparel included eye glasses with side shields, thyroid shields and hand gloves. The minimum protective lead equivalents in hand gloves and thyroid shields should be 0.5mm. Lead lined glass and thyroid shield likewise reduce 90% of the exposure to the eyes and thyroid respectively. Lead lined gloves reduce radiation exposure to the hands; however they are no substitute for strict observation of appropriate fluoroscopic hygiene. Gloves should be considered as an effective means of reducing scatter radiation only. 2. State five clinical indications for the patient undergo the angiography procedure. 3. Explain the patient care management before, during and after the procedure Before a procedure: * Patients undergoing an angiogram are advised to stop eating and drinking eight hours prior to the procedure. * They must remove all jewelry before the procedure and change into a hospital gown. * If the arterial puncture is to be made in the armpit or groin area, shaving may be required. * A sedative may be administered to relax the patient for the procedure. * An IV line will also be inserted into a vein in the patients arm before the procedure begins in case medication or blood products are required during the angiogram. * Be aware of and follow all Local Rules and protocols * Prior to the angiography procedure, patients will be briefed on the details of the test, the benefits and risks, and the possible complications involved, and asked to sign an informed consent form. * Ensure that all exposures are justified and there is informed consent * Check patient identity * Position patient comfortably flat, with arm above head where possible * Ensure all members of staff in room are wearing suitable. For operations this should be lead glasses, thyroid collar and wrap-around lead apron * Check all staff are wearing radiation monitors correctly * Use all available lead shielding appropriately sited * Position table before screening * Keep tube current as low as possible and kVp as high as possible for cardiac studies, 60 – 90 kV is appropriate * Keep x ray tube at maximum and image intensifier / receptor at minimum distance from patient * Check all staff are as far away as possible in their role * Use dose reduction programmers when possible * Perform acquisitions on full inspiration where possible * Collimate closely to area of interest * Prolonged procedures: reduce dose to the irradiated skin eg. Change beam angulations * Minimize fluoroscopy time, high dose rate time and no of acquisitions * Remember software features, such as replay fluoro to minimize dose * Dont over use geometric magnification * Remove grid for small patients or when image intensifier / detector cannot be placed close to patient * Check and record screening time and DAP at the end of the case and review against the DRL. During the procedure: * The radiologic technologist will position you on the exam table. A radiologist a physician who specializes in the diagnostic interpretation of medical images will administer a local anesthetic and then make a small nick in your skin so that a thin catheter can be inserted into an artery or vein. The catheter is a flexible, hollow tube about the size of a strand of spaghetti. It usually is inserted into an artery in your groin, although in some cases your arm or another site will be selected for the catheter. * The radiologist will ease the catheter into the artery or vein and gently guide it to the area under investigation. The radiologist will be able to watch the movement of the catheter on a fluoroscope, which is an x-ray unit combined with a television monitor. * When the catheter reaches the area under study, the contrast agent will be injected through the catheter. By watching the fluoroscope screen, the radiologist will be able to see the outline of your blood vessels and identify any blockages or other irregularities. * Angiography procedures can range in time from less than an hour to three hours or more. It is important that you relax and remain as still as possible during the examination. The radiologic technologist and radiologist will stay in the room with you throughout the procedure. If you experience any difficulty, let them know. * Angiography also can be performed using magnetic resonance instead of x-rays to produce images of the blood vessels; this procedure is known as magnetic resonance angiography (MRA) or magnetic resonance venography (MRV). After the procedure: * Because life-threatening internal bleeding is a possible complication of an arterial puncture, an overnight stay in the hospital is sometimes recommended following an angiography procedure, particularly with cerebral and coronary angiograms. * If the procedure is performed on an outpatient basis, the patient is typically kept under close observation for a period of at six to 12 hours before being released. * If the arterial puncture was performed in the femoral artery, the patient will be instructed to keep his leg straight and relatively immobile during the observation period. * The patients blood pressure and vital signs will be monitored and the puncture site observed closely. Pain medication may be prescribed if the patient is experiencing discomfort from the puncture, and a cold pack is applied to the site to reduce swelling. It is normal for the puncture site to be sore and bruised for several weeks. * The patient may also develop a hematoma, a hard mass created by the blood vessels broken during the procedure. Hematomas should be watched carefully, as they may indicate continued bleeding of the arterial puncture site. * Angiography patients are also advised to enjoy two to three days of rest and relaxation after the procedure in order to avoid placing any undue stress on the arterial puncture. Patients who experience continued bleeding or abnormal swelling of the puncture site, sudden dizziness, or chest pains in the days following an angiography procedure should seek medical attention immediately. * Patients undergoing a fluorescein angiography should not drive or expose their eyes to direct sunlight for 12 hours following the procedure. 4. Identify the type of contrast medium, the dose and delivering technique in angiography procedure. * Reducing radiation doses to the patient also generally reduces doses to the medical personnel. Â · Angiography procedure is using fluoroscopy imaging technique which is a real-time imaging technique. 5. List down the catheters and guide wires inclusive of size, shape and the hole type that are used in angiography procedures. The use of lead gloves during procedures is unusual as they are cumbersome and difficult to work in. The automatic brightness control will increase the exposure to go through two layers and one only protects the hand, so if they are going to be used a programme that sets the radiation factors rather than allowing adjustment may be appropriate. In practice, with careful collimation and attenuation to detail it should not necessary for the operators hand to be in the primary beam and only close to it for short periods. While doing catheterization, radiologist should do it behind the lead glass viewer which consists of lead equivalent glass of 0.25mm thickness. Geometric consideration is one of the important things in angiography because source of exposure to personnel is mainly from scattered radiation from the patient. So, it is important to minimize the amount of scattered radiation to personnel. This can be achieved by geometric consideration involving the x-ray tube, patient and image intensifier. The image intensifier should be as close as possible to patient to minimize the amount of scattered radiation hitting personnel. Because in angiography room is sterile for all things, personnel such as radiologist, nurses, radiographer or student should wear shoes which are prepared only. Make sure that film badges always outside personnel body to measure the dose receive to the personnel. The most important thing to remember is that all individuals should be fully trained and learned to be responsible for radiation safety. Involvement of a radiation expert is essential and is particularly useful in equipment specification, assessment and quality assurance, but also in the formulation of Local Rules. Technique Reduces Physician Radiation Exposure During Angiography Current technique requires that physicians performing radiation procedures wear lead gowns. The new technique involves use of a body length floor mounted lead plastic panel to protect to physicians as they monitor patients angiograms and control exam table movement. An extension bar allows the physician to remain safely behind the shield and still retain table control for panning. In the study, researchers recorded radiation exposure to various parts of a physicians body during 25 coronary angiography procedures and compared those results with radiation exposure during angiography on 25 patients using conventional radiation protection. A lead apron, thyroid shield, eyeglasses and facemask were used in both techniques, but a ceiling mounted shield was used in the conventional technique. The researchers placed radiation badges outside and inside the facemask; outside and inside the thyroid shield; on the right and left arm; outside and inside the lead apron; and on the right and left leg. The new equipment resulted in a 90 percent reduction in radiation exposure to the physicians head, arms, and legs. Exposure of the thyroid and torso was minimal with both techniques. Enhanced physician radiation protection during coronary angiography is readily achievable with this new technique, said Martin Magram, M.D., of the University of Maryland Medical Center in Baltimore, Md. Dr. Magram presented the study results on May 3 at the American Roentgen Ray Society Annual Meeting in Vancouver, British Columbia. Dr. Magram pointed out that by freeing physicians from the need to wear lead gowns, the new technique could preserve their ability to benefit patients. It may extend by years their ability to apply the skills they have developed over long careers of serving patients, noted Dr. Magram. New methods of radiation protection must parallel the development of new radiation techniques, added Dr. Magram. The key is to limit medical workers radiation exposure with effective and easy-to-use techniques, and the use of this extension bar and lead plastic shield may be such a technique. Definition Angiography is the x-ray study of the blood vessels. An angiogram uses a radiopaque substance, or dye, to make the blood vessels visible under x ray. Arteriography is a type of angiography that involves the study of the arteries. Purpose Angiography is used to detect abnormalities or blockages in the blood vessels (called occlusions) throughout the circulatory system and in some organs. The procedure is commonly used to identify atherosclerosis; to diagnose heart disease; to evaluate kidney function and detect kidney cysts or tumors; to detect an aneurysm (an abnormal bulge of an artery that can rupture leading to hemorrhage), tumor, blood clot, or arteriovenous malformations (abnormals tangles of arteries and veins) in the brain; and to diagnose problems with the retina of the eye. It is also used to give surgeons an accurate map of the heart prior to open-heart surgery, or of the brain prior to neurosurgery. Precautions Patients with kidney disease or injury may suffer further kidney damage from the contrast mediums used for angiography. Patients who have blood clotting problems, have a known allergy to contrast mediums, or are allergic to iodine, a component of some contrast mediums, may also not be suitable candidates for an angiography procedure. Because x rays carry risks of ionizing radiation exposure to the fetus, pregnant women are also advised to avoid this procedure. Description Angiography is usually performed at a hospital by a trained radiologist and assisting technician or nurse. It takes place in an x-ray or fluoroscopy suite, and for most types of angiograms, the patients vital signs will be monitored throughout the procedure. Angiography requires the injection of a contrast dye that makes the blood vessels visible to x ray. The dye is injected through a procedure known as arterial puncture. The puncture is usually made in the groin area, armpit, inside elbow, or neck. The site is cleaned with an antiseptic agent and injected with a local anesthetic. First, a small incision is made in the skin to help the needle pass. A needle containing an inner wire called a stylet is inserted through the skin into the artery. When the radiologist has punctured the artery with the needle, the stylet is removed and replaced with another long wire called a guide wire. It is normal for blood to spout out of the needle before the guide wire is inserted. The guide wire is fed through the outer needle into the artery and to the area that requires angiographic study. A fluoroscopic screen that displays a view of the patients vascular system is used to pilot the wire to the correct location. Once it is in position, the needle is removed and a catheter is slid over the length of the guide wire until it to reaches the area of study. The guide wire is removed and the catheter is left in place in preparation for the injection of the contrast medium, or dye. Depending on the type of angiography procedure being performed, the contrast medium is either injected by hand with a syringe or is mechanically injected with an automatic injector connected to the catheter. An automatic injector is used frequently because it is able to propel a large volume of dye very quickly to the angiogram site. The patient is warned that the injection will start, and instructed to remain very still. The injection causes some mild to moderate discomfort. Possible side effects or reactions include headache, dizziness, irregular heartbeat, nausea, warmth, burning sensation, and chest pain, but they usually last only momentarily. To view the area of study from different angles or perspectives, the patient may be asked to change positions several times, and subsequent dye injections may be administered. During any injection, the patient or the camera may move. Throughout the dye injection procedure, x-ray pictures and/or fluoroscopic pictures (or moving x rays) will be taken. Because of the high pressure of arterial blood flow, the dye will dissipate through the patients system quickly, so pictures must be taken in rapid succession. An automatic film changer is used because the manual changing of x-ray plates can eat up valuable time. Once the x rays are complete, the catheter is slowly and carefully removed from the patient. Pressure is applied to the site with a sandbag or other weight for 10-20 minutes in order for clotting to take place and the arterial puncture to reseal itself. A pressure bandage is then applied. Most angiograms follow the general procedures outlined above, but vary slightly depending on the area of the vascular system being studied. A variety of common angiography procedures are outlined below: Cerebral angiography Cerebral angiography is used to detect aneurysms, blood clots, and other vascular irregularities in the brain. The catheter is inserted into the femoral or carotid artery and the injected contrast medium travels through the blood vessels on the brain. Patients frequently experience headache, warmth, or a burning sensation in the head or neck during the injection portion of the procedure. A cerebral angiogram takes two to four hours to complete. Coronary angiography Coronary angiography is administered by a cardiologist with training in radiology or, occasionally, by a radiologist. The arterial puncture is typically given in the femoral artery, and the cardiologist uses a guide wire and catheter to perform a contrast injection and x-ray series on the coronary arteries. The catheter may also be placed in the left ventricle to examine the mitral and aortic valves of the heart. If the cardiologist requires a view of the right ventricle of the heart or of the tricuspid or pulmonic valves, the catheter will be inserted through a large vein and guided into the right ventricle. The catheter also serves the purpose of monitoring blood pressures in these different locations inside the heart. The angiogram procedure takes several hours, depending on the complexity of the procedure. Pulmonary angiography Pulmonary, or lung, angiography is performed to evaluate blood circulation to the lungs. It is also considered the most accurate diagnostic test for detecting a pulmonary embolism. The procedure differs from cerebral and coronary angiograms in that the guide wire and catheter are inserted into a vein instead of an artery, and are guided up through the chambers of the heart and into the pulmonary artery. Throughout the procedure, the patients vital signs are monitored to ensure that the catheter doesnt cause arrhythmias, or irregular heartbeats. The contrast medium is then injected into the pulmonary artery where it circulates through the lung capillaries. The test typically takes up to 90 minutes. Kidney angiography Patients with chronic renal disease or injury can suffer further damage to their kidneys from the contrast medium used in a kidney angiogram, yet they often require the test to evaluate kidney function. These patients should be well-hydrated with a intravenous saline drip before the procedure, and may benefit from available medications (e.g., dopamine) that help to protect the kidney from further injury due to contrast agents. During a kidney angiogram, the guide wire and catheter are inserted into the femoral artery in the groin area and advanced through the abdominal aorta, the main artery in the abdomen, and into the renal arteries. The procedure will take approximately one hour. Fluorescein angiography Fluorescein angiography is used to diagnose retinal problems and circulatory disorders. It is typically conducted as an outpatient procedure. The patients pupils are dilated with eye drops and he rests his chin and forehead against a bracing apparatus to keep it still. Sodium fluorescein dye is then injected with a syringe into a vein in the patients arm. The dye will travel through the patients body and into the blood vessels of the eye. The procedure does not require x rays. Instead, a rapid series of close-up photographs of the patients eyes are taken, one set immediately after the dye is injected, and a second set approximately 20 minutes later once the dye has moved through the patients vascular system. The entire procedure takes up to one hour. Celiac and mesenteric angiography Celiac and mesenteric angiography involves x-ray exploration of the celiac and mesenteric arteries, arterial branches of the abdominal aorta that supply blood to the abdomen and digestive system. The test is commonly used to detect aneurysm, thrombosis, and signs of ischemia in the celiac and mesenteric arteries, and to locate the source of gastrointestinal bleeding. It is also used in the diagnosis of a number of conditions, including portal hypertension, and cirrhosis. The procedure can take up to three hours, depending on the number of blood vessels studied. Splenoportography A splenoportograph is a variation of an angiogram that involves the injection of contrast medium directly into the spleen to view the splenic and portal veins. It is used to diagnose blockages in the splenic vein and portal vein thrombosis and to assess the strength and location of the vascular system prior to liver transplantation. Most angiography procedures are typically paid for by major medical insurance. Patients should check with their individual insurance plans to determine their coverage. Aftercare Risks Because angiography involves puncturing an artery, internal bleeding or hemorrhage are possible complications of the test. As with any invasive procedure, infection of the puncture site or bloodstream is also a risk, but this is rare. A stroke or heart attack may be triggered by an angiogram if blood clots or plaque on the inside of the arterial wall are dislodged by the catheter and form a blockage in the blood vessels or artery. The heart may also become irritated by the movement of the catheter through its chambers during pulmonary and coronary angiography procedures, and arrhythmias may develop. Patients who develop an allergic reaction to the contrast medium used in angiography may experience a variety of symptoms, including swelling, difficulty breathing, heart failure, or a sudden drop in blood pressure. If the patient is aware of the allergy before the test is administered, certain medications can be administered at that time to counteract the reaction. Angiography involves minor exposure to radiation through the x rays and fluoroscopic guidance used in the procedure. Unless the patient is pregnant, or multiple radiological or fluoroscopic studies are required, the small dose of radiation incurred during a single procedure poses little risk. However, multiple studies requiring fluoroscopic exposure that are conducted in a short time period have been known to cause skin necrosis in some individuals. This risk can be minimized by careful monitoring and documentation of cumulative radiation doses administered to these patients. Normal results The results of an angiogram or arteriogram depend on the artery or organ system being examined. Generally, test results should display a normal and unimpeded flow of blood through the vascular system. Fluorescein angiography should result in no leakage of fluorescein dye through the retinal blood vessels. Abnormal results Abnormal results of an angiography may display a restricted blood vessel or arterial blood flow (ischemia) or an irregular placement or location of blood vessels. The results of an angiography vary widely by the type of procedure performed, and should be interpreted and explained to the patient by a trained radiologist. Arteriosclerosis A chronic condition characterized by thickening and hardening of the arteries and the build-up of plaque on the arterial walls. Arteriosclerosis can slow or impair blood circulation. Carotid artery An artery located in the neck. Catheter A long, thin, flexible tube used in angiography to inject contrast material into the arteries. Cirrhosis A condition characterized by the destruction of healthy liver tissue. A cirrhotic liver is scarred and cannot break down the proteins in the bloodstream. Cirrhosis is associated with portal hypertension. Embolism A blood clot, air bubble, or clot of foreign material that travels and blocks the flow of blood in an artery. When blood supply to a tissue or organ is blocked by an embolism, infarction, or death of the tissue the artery feeds, occurs. Without immediate and appropriate treatment, an embolism can be fatal. Femoral artery An artery located in the groin area that is the most frequently accessed site for arterial puncture in angiography. Fluorescein dye An orange dye used to illuminate the blood vessels of the retina in fluorescein angiography. Fluoroscopic screen A fluorescent screen which displays moving x-rays of the body. Fluoroscopy allows the radiologist to visualize the guide wire and catheter he is moving through the patients artery. Guide wire A wire that is inserted into an artery to guides a catheter to a certain location in the body. Iscehmia A lack of normal blood supply to a organ or body part because of blockages or constriction of the blood vessels. Necrosis Cellular or tissue death; skin necrosis may be caused by multiple, consecutive doses of radiation from fluoroscopic or x-ray procedures. Plaque Fatty material that is deposited on the inside of the arterial wall. Portal hypertension A condition caused by cirrhosis of the liver. It is characterized by impaired or reversed blood flow from the portal vein to the liver, an enlarged spleen, and dilated veins in the esophagus and stomach. Portal vein thrombosis The development of a blood clot in the vein that brings blood into the liver. Untreated portal vein thrombosis causes portal hypertension. For Your Information Books * Baum, Stanley, and Michael J. Pentecost, eds. Abrams Angiography. 4th ed.

The Crucible - Important Character Analysis :: Arthur Miller

In The Crucible, Arthur Miller establishes the universal theme that good does not always prevail over evil. It shows that fear and suspicion can produce a mass hysteria that destroys public order and rationality. This theme is clearly identified through the character's actions throughout the play. Three characters in the play demonstrate different types of human condition through the decisions they make. Reverend Hale and John Proctor represent the human condition to choose rationally while Danforth advocates a more traditional side. All but Danforth have a change of heart from the given situation. The Crucible argues that even when a society is corrupt, a person with high moral character can follow their conscience to make a good decision. Reverend Hale is called to Salem to help solve the witchcraft chaos. At first he is confident in doing his job as a reverend by following the church standards. He agrees with the court?s tactics, which involves searching for confessions to aid the trial in sentencing people to death. Over the course of the play he experiences a huge transformation. As he listens to both sides of the trial, he realizes that the church and court standards may be wrong, and he begins to question these standards within himself. He stops supporting the court because he can no longer accept the false prosecutions that Danforth continues to make. His final decision in going against the church and following his heart shows the true side of his character. He goes through the rest of the play trying to save people?s lives. When someone asks why he has come back he states, ?Why, it is all simple. I come to do the devil?s work? (986). This shows he feels that doing what may seem wrong to others is actually the right thing to do. His efforts are in vain, however, because in the end the Puritan Court overrules all other opinion. Danforth is the judge of the witch trials and is very stubborn in his ways. His handling of the trials is overbearing and intolerant. He is shocked when Francis Nurse dares to judge his authority and states, ?Peace, Judge Hawthorne, do you know who I am, Mr. Nurse (959). He thinks that he is superior to everyone else and he believes he has the best judgment of all. Because of his job he is feeling pressured to please the majority of the people.