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From national perspective antibiotic resistance due to overuse of antibiotics in agriculture 100mg cefixime with mastercard, mental disturbances (including depression) constitute 15% of reasons for disability status issued by Disability Assessment Board regarding people between 15 and 59 years old (Central Statistical Office bacteria images cheap 200 mg cefixime, 2009) antibiotics zithromax generic cefixime 200 mg free shipping. Considering the fact that the rate of psychiatric diseases tend to bacterial diseases discount 200 mg cefixime overnight delivery increase, it is assumed that recently the number of people disabled by mental conditions is even higher. Study conducted by the European Depression Association (2012) revealed that even 10% of European employees stay on a sick leave due to depression, and the average length of the absences stands at 36 days. This tendency is also confirmed by the result of German studies, in according to which people affected by depressive symptoms tend to leave work due to sick leave and disability status (Thielen et al. There are various factors related with occupational obstacles affecting people suffering from depression. Furthermore, there are various symptoms of depression that affect worker’s cognitive functioning, such as attention, memory and decision making deficits (Hammar, Ardal, 2009). The situation is being made more complex as a result of the frequent need to undergo pharmacological and psychotherapeutic treatment. A report from studies governed by Lazarski University in Warsaw (2014) suggests that so-called ‘depression epidemy’ leads to significant public costs as a result of work-related difficulties experienced by people at productive ages when depression is most often diagnosed. A large number of people suffering from affective disorders’ symptoms hesitate to search for professional help. It is due to the fact that they do not recognize their own health status thinking that those symptoms are rather a result of specific, short-term problems that they can deal with. Considering high costs generated by work absences and decreased efficiency of people with affective disorders, there is a highlighted need to increase social knowledge about mental health as well as its disturbances. Such educational interventions would be aimed not only at early diagnosis and treatment but also at prevention that would increase people’s quality of life and protect against the disease. Preventing depression – introducing Depression Prevention Programme in Malopolska region 2. Aims of the programme the Depression Prevention Programme was aimed at educating inhabitants of Malopolska region about depression – its causes, symptoms and treatment. It was supposed to broaden social knowledge regarding depression and to change social perception of professional psychiatric and psychological help. The second aim of the programme was to conduct educational and preventive counsels for people who experienced various difficulties in order to implement specific health-improving habits and increase their depression resilience. During the promotion actions, including television and radio programmes, people were being educated about symptoms, treatment and causes of depressive symptoms, as well as encouraged to take part in the programme in order to take a look at one’s life difficulties and strengths and benefit from practice counsels that may decrease depression risk. It should be highlighted that the chosen form of intervention was psychoeducation. This form is characterized by accessible and not invasive communication about important issues. Educational counsels were conducted in nine places in Malopolska region (Lesser Poland Voivodeship). More than 50 consultants were engaged in the project, all of them being psychiatrist, psychologists and/or psychotherapists with work experience. In case of some participants the questionnaires were incomplete or incorrectly filled. Furthermore, only less than a half of the participants decided to benefit from the second counsel. As a result, selected objects’ results were included in basic statistical analysis, depending on the questionnaires available. The greater results, the higher resiliency level, both global and domain-specific. The total score ranges from 0 to 20, and the level of hopelessness increases with increasing scores. The symptoms included feeling of despondence, hopelessness and lack of interest in everyday 54 International Psychological Applications Conference and Trends 2015 activities. This assessment tool has been developed on the base of language adaptation of similar, simple English-language questionnaires Type of assessment scale was modified for 110. The main characteristic of the measure is the ability to capture patient’s functioning through positively formulated questions that were not focused on deficit approach. The questions referred to participants feelings of consultants’ expertise and the quality of interpersonal contact. After that, with consultant’s assistance, they assessed their global and domain-related satisfaction using Two Question Test and Appraisal of Life Areas Questionnaire. It took a form of a dialogue about life areas in which participants reported difficulties and lack of satisfaction. Depending on the character and level of participant’s symptoms the information covered possible factors determining perceived deficits, instructions of possible positive life changes, as well as methods of treatment. Participants were motivated to implement changes in their daily routines and enhanced to share their experiences during second, control meeting. The second stage of the project took place after two months from the first meeting. The efficacy of the firs counsel was discussed with the participant and new aims to increase well-being were jointly formulated. It should be emphasize that one of the most important principle of the programme was to enhance participants’ active attitude and to encourage them to introduce their own opinions and ideas. At both stages, after the consultation had been finished, both participants and consultants filled in Assessment of Preventive Counsel Questionnaires. In order to ensure anonymity of respondents and make results more objective participants did not fill in the questionnaire in consultant’s presence. Results Because when the conference proceeding book was composed participants’ numeric results had just been obtained, only basic statistics will be introduced in the article. It can suggest that in numerous cases they experienced various negative feelings, including lack of energy and interest in work and everyday activities. It is in accordance to consultants’ experiences that will be presented during the presentation. Although the significance of differences had not been yet calculated, main results in this matter including the first edition of the programme, conducted in 2013, can be described. As far as areas of functioning assessed by Appraisal of Life Areas are concerned, statistically significant results were obtained in two of them: Coping in difficult situations (3,15-3,64, p=0,015), feeling of control on own’s life (3,47-3,82, p=0,45), Psychical well-being (2,99-3,68, p=0,001) and Action will (3,47-3,87, p=0,37). There is a need to emphasise that there were no areas where decreases in subjective well-being were observed. On the base of presented descriptive results it can be seen that differences between two measurements are also observed in most of measured areas. Although the main aim of the programme was educational one and no control group was included, participants’ experiences suggest that at least in certain cases, experienced change was conditioned by modifications implemented in the wake of the first counsel. Summary and discussion Results obtained during the Depression Prevention Programme indicate a need to arrange further prevention programmes that would help people suffering from various symptoms of mental disturbances. Such interventions would be especially helpful for those who are not aware about diagnostic and treatment possibilities or who experience different difficulties in finding appropriate help. Experiences derived from Depression Prevention Programme revealed that during educational counsels, people have the possibility to analyse their own strengths and weaknesses, as well as to benefit from professional help in primary diagnose and deciding about future actions decreasing depression risk. It is important to analyse the reasons of why numerous participants did not decide to continue the programme by taking part in the second, control counsel. Obviously, objective factors such as random life events and lack of time probably played an important role. However, it should be noticed that, although the programme was developed for healthy population, there were numerous participants suffering from various severe symptoms that had a corrosive effect on their functioning. Such observation highlights the problem that majority of people still decide to search for professional help when the symptoms are severe and lead to difficulties in everyday functioning. As such people received practical information about mental health service, they could consider the second counsel redundant. Described programme’s results enhance further development of similar initiatives that would be more concentrated on their role in promoting healthy behaviors and preventing mental diseases. Future educational and prevention programmes should also include the third, postponed measurement that would allow to observe possible stability of obtained effects. Although presented programme was mostly aimed at education, future directions in the field should be more methodologically improved, including control group that would be needed to further estimate the real effect of implemented preventive interventions. Furthermore, measures used in evaluation of participants’ should be verified and extended with validated and sensitive instruments that would assess depressive symptoms (such as Beck Depression Inventory). Last but not least, it would be significant to implement such educational and preventing strategies in relation to other mental disorders and attempt to assess the specificity of the interventions.

However antibiotics that treat strep throat order cefixime 100 mg mastercard, in Barclay’s Bank v O’Brien (1993) antibiotic knee spacer cefixime 200mg sale, also heard by the House of Lords length of antibiotics for sinus infection buy generic cefixime 200mg on-line, the facts were different and resulted in a different outcome antimicrobial dressings cefixime 100mg line. In this case the husband and wife jointly owned the matrimonial home, subject to a mortgage of fi25,000. The husband wished to increase the overdraft of a company of which he was a shareholder. It was agreed that the overdraft would be increased to fi135,000 (reducing to fi120,000 after three weeks), with the matrimonial home being used as security. The bank manager instructed that the husband and wife were to be given an explanation of the nature of the transaction and that, if there appeared to be any doubts surrounding the transaction, the bank staff should suggest that independent legal advice should be obtained. This was not done and the wife signed the appropriate documents, having been told by her husband that the amount being secured was fi60,000 and for three weeks only. She signed without having been given any advice as to the nature and possible consequences of the transaction. However, the bank was fixed with constructive notice of the husband’s misrepresentation regarding the loan. A significant difference between this case and Pitt was that in Pitt, the loan was apparently for the benefit of both parties offering the security whereas, in the present case, it was for the advantage of only one of the parties. The House of Lords summarised the position as follows: Where one cohabitee has entered into an obligation to stand surety for the debts of the other cohabitee and the creditor is aware that they are cohabitees: (a) the suretyship will be valid and enforceable by the creditor unless the suretyship was procured by undue influence, misrepresentation or other legal wrong of the principal debtor; (b) if there has been misrepresentation, undue influence, or other legal wrong by the principal debtor, unless the creditor has taken reasonable steps to satisfy himself that the surety entered into the obligation freely and in knowledge of the true facts, the creditor will be unable to enforce the surety obligation because he will be fixed with constructive notice of the surety’s right to set aside the transaction; and (c) unless there are special circumstances, a creditor will have taken reasonable steps to avoid being fixed with constructive notice if the creditor warns the surety (at a meeting not attended by the principal debtor) of the amount of her potential liability and of the risks involved, and advises the surety to take independent legal advice. Mrs D was not a customer of the bank and before the bank would accept her guarantee it referred her to an independent solicitor who advised her as to the nature and legal effect of the guarantee. The court found that there was no reason to doubt that she understood the advice given. However, the title deeds to the property were lodged with Mr Frere-Smith, a solicitor who had acted for Mr and Mrs D in the past. Mrs D visited Mr Frere-Smith, who advised her in the strongest terms that her arrangement with M was ill-advised. She nevertheless proceeded to sign the guarantee and the charge on 12 February 1985. When M’s overdraft exceeded the amount of the guarantee, the bank sought to enforce their security. Before the action came to trial, Mrs Dempsey died and her executors were defending the claim. Their defence was as follows: (i) Mrs D was induced by M’s undue influence to provide security for M’s overdraft; (ii) the bank was on notice of the undue influence; (iii) the bank was not entitled to enforce its security. The trial judge found that although the bank did not have actual or constructive notice of undue influence, it was put on notice by a telephone call made by Mr Frere-Smith to the bank on 5– 6 March informing them of the circumstances under which Mrs D had signed the guarantee and the legal charge. M’s overdraft already exceeded fi30,000 before the events of March had put the bank on notice. Held by the Court of Appeal: the trial judge was wrong to hold that the guarantee and charge were affected by undue influence. Even if there were a presumption of undue influence, it had been rebutted by the fact that Mrs D had had independent legal advice from two solicitors but nevertheless decided to proceed with the transaction. Classification of undue influence In Barclays’ Bank v O’Brien (1993), the House of Lords adopted the classification of undue influence suggested by the Court of Appeal in Bank of Credit and Commerce International v Aboody (1992). It must be proved by the weaker party that the contract was entered into as a result of the undue influence of the stronger party. In Williams v Bayley (1866), the son gave the bank several promissory notes upon which he had forged the endorsements of his father. At a meeting between the three parties, the banker made it clear that unless the father undertook responsibility the son would be prosecuted. The father agreed to make a mortgage to the bank in return for the promissory notes. It would seem that once undue pressure has been proved, the contract may still be held to be valid if the stronger party can show that the weaker party nevertheless exercised free and independent judgment: Barton v Armstrong (1975). Class 2 Presumed undue influence In this situation, there is a relationship of trust and confidence between the parties of such a nature that it is fair to presume that the dominant party abused that relationship in procuring the weaker party to enter into the transaction. In such a case, undue influence is presumed to have been exerted without the need for the weaker party to prove that it has. If the dominant party wishes to enforce the transaction, the burden of proof falls on the dominant party to show that the weaker party entered into the transaction in consequence of having exercised independent judgment. As we have seen, many of these cases involve wives guaranteeing their husband’s borrowings by agreeing to put up the matrimonial home as security. The wife can raise a presumption of undue influence in such cases by showing that the transaction was to her manifest disadvantage. The bank can avoid this result by showing that the wife entered into the transaction of her own free will, with full realisation of the possible consequences. The case law shows that the best way for the bank to do this is to insist that the documentation be completed in the presence of a qualified legal practitioner. Note: although we have been speaking in terms of wives claiming undue influence, similar principles will apply to any case of presumed undue influence. In a recent case involving no less than eight appeals by wives, the Court of Appeal laid down useful guidance as to what level of legal advice is necessary in such cases. This does not ensure that the wife will not go ahead in defiance of legal advice, but it does mean that the bank’s security will almost certainly be protected. It has been made clear (see Inche Noriah v Bin Omar (1929)) that legal advice is not an absolute prerequisite for a bank to be able to enforce its security, but cases where it will be able to do so in the absence of legal advice must be very rare. In Royal Bank of Scotland v Etridge (No 2) (1998), eight appeals by wives claiming to have been induced to charge the matrimonial home, either by the husband’s undue influence or his misrepresentation, were considered. The Court of Appeal laid down the following guidelines: (a) if a wife deals with a bank through a solicitor, whether it is her own solicitor or a solicitor who is acting for both herself and her husband, the bank was entitled to assume that the solicitor had given proper professional advice and had considered and advised upon any potential conflicts of interest; (b) if the wife did not approach the bank through a solicitor, it would be sufficient to protect the bank if the bank urges her to obtain independent legal advice. This is especially so if the solicitor confirms that he has explained the transaction and the wife appeared to understand it; (c) there is not always a conflict of interest between husband and wife. The fact that the solicitor was prepared to advise the wife indicates that he considered himself to be independent; (d) the bank is not required to enquire as to what advice the solicitor has given to the wife. Nor is it obliged to enquire whether the advice was adequate; (e) if the bank introduces the solicitor to the wife, the solicitor is acting as the wife’s solicitor and owes a duty to the wife. Therefore, the bank could enforce the agreement); and 171 Law for Non-Law Students (f) if the solicitor advises the wife negligently, she will still be bound by her agreement with the bank, but she will have an action against the solicitor in respect of any loss she suffers. In Barclay’s Bank v Coleman (2000), the meanings of ‘manifest disadvantage’ and ‘independent legal advice’ were considered by the Court of Appeal. The case was yet another where a wife had signed documents granting a second charge over the matrimonial home in favour of a bank in order to secure her husband’s borrowings in respect of a property he was purchasing in New York. The crucial point was that the certificate of independent legal advice was signed by a legal executive employed in a solicitor’s practice. The trial judge held that although the bank was not entitled to rely on the certificate in order to show that the wife had had independent legal advice, nevertheless a presumption of undue influence could not arise because the wife had not shown that the transaction was to her manifest disadvantage: the transaction was to the future benefit of the family. The court held: (a) that the manifest disadvantage should not be looked at in a narrow way. The charge upon the matrimonial home covered all moneys owed to the bank for the time being, so that although the wife had charged the home for the purpose of buying a property in New York, the charge did not simply cover debts in respect of that property. On balance, this was a manifest disadvantage; and (b) the fact that the certificate of independent legal advice was signed by a legal executive did not invalidate it. The certificate confirmed that the full effect of the contents of the legal charge had been explained to the wife, that it was understood by her and that she had signed the charge of her own free will. It had been given by the legal executive acting within the authority given to him by his principal. Thus, although there was presumed undue influence because of the manifest disadvantage of the transaction to the wife, the bank had taken reasonable steps, in relying on the legal executive’s certificate, to avoid being fixed with notice of the wife’s right to set the transaction aside. One element of presumed undue influence which does not apply in the case of actual undue influence is that the party seeking to set the contract (or gift) aside must show that the transaction is to his manifest disadvantage. Presumed undue influence is of two types: Class 2A Certain relationships give rise to a presumption of undue influence as a matter of law. Established categories of special relationship include solicitor and client, doctor and patient, parent and child. Note that the child is 172 Chapter 8: Unfair Contracts regarded as being ‘emancipated’ only when the child may be taken to have broken free of the parent’s influence, so that, in one case, it was held that the presumption of undue influence existed in the case of a married woman who was, nevertheless, still greatly influenced by her mother: Lancashire Loans v Black (1934).

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People use defense mechanisms like minimization and denial to antibiotic essential oils purchase cefixime 200mg fast delivery sustain their idealized conception of their corrupt leaders virus transmission 100mg cefixime amex, whom they depict as the victims of excessive or unprincipled attacks (Burston antibiotics for acne worth it 200 mg cefixime for sale, 2014) can you take antibiotics for sinus infection when pregnant 100mg cefixime with mastercard. The fight against corruption in Russia is a strategic task of the state, whose solution is aimed at ensuring the security of individuals, society and the state. Since corruption in Russia has become systematic, fighting it requires systemic measures, including the educational measures. Prevention and the fight against corruption are important at any stage of its development, it is important to remove the feeling of hopelessness of such a struggle and belief in the irreversibility of corruption. Corruption in the Mental Health Professions –Psychology, Psychiatry and the “New Normal”. Economic Psychology: Current theoretical and applied problems: Proceedings 12th International Scientific and Practical Conference. The image of the Belarusian State in students’ consciousness during the recent financial crisis. The pathology of politics: violence, betrayal, corruption, secrecy, and propaganda. Methodological study design anticorruption behavior in activity of employees of state organizations. Moreover, teaching staff play a predominant role and are the best point of reference for any changes to be introduced in teaching, in the way to manage classes, in the use of tools, changes in methodology or teaching strategies, and also in the ways students learn, etc. The teacher ceases to be a figure who only transmits knowledge and becomes a guide or facilitator of learning. The teacher, therefore, takes on a different commitment with the ways of learning, of approaching students, guiding tutorials, assessing student learning, etc. It would be expected that a demotivated staff with few incentives and a low opinion of their worth as teachers would be less committed to their teaching, research and management work, and as a result would achieve less success in their work with students. But could it be that their vocation as teachers and the professionalism of university staff are sufficient motivating factors in themselvesfi It is for these reasons that we have wished to analyse the situation of teaching staff in universities in Madrid. In university organisations the teaching staff is one of the key elements that leads to work being done more or less effectively. Human Resources are beginning to consider the staff as the major asset in Organisations. Therefore, in this study, we have attempted to show what issues have the greatest impact. This research aims to study the level of motivation of teaching staff in the Universities in Madrid and analyse the different factors that affect performance at work in the roles of teacher, researcher and manager. It also aims to discover whether or not motivation influences a teacher’s everyday work and which variables affect the university work “climate” and other issues involved. For this study, 7696 questionnaires were sent to teachers at the 13 Universities in the Madrid Region. The article is based on the personal study of criminal cases files and also on the survey of law enforcement officers. We provide authors’ classification of motives of the given crimes caused by such social-psychological factors as destructive family relationships and personal desadaptation. Introduction Lately crimes of violence have started to occupy one of the leading positions among important social problems. Domestic criminal behaviour due to its considerable spread causes noticeable damage to the society. Like in many other countries women are subjects to psychological, sexual and physical violence on the side of their husbands. Study of the family crimes is one of the relevant problems of forensics and psychology. Evidence Study of the criminal-justice struggle with domestic crimes of violence as a separate division is connected with the separation of these crimes from all other crimes, envisaged by the criminal law. Deeper analysis of 365 case files conducted by us allowed us to point out some similar features of domestic crimes of violence and essential relations between them that stipulates their unity and integrity of the whole problem. Our assumptions of similarities of domestic violent crimes were discussed with detectives and judges. As a result we came to a conclusion that the common signs of all the domestic crimes of violence are: 1) act of crime on the whole; 2) locality of the territory of the conflict development (family); 3) situations of committing of domestic crimes of violence; 4) the similar in its essence way of crime, characterizing the objective side of a crime (alternatively: physical violence or threat of it); 5) intentional (conscious) character of use of violence (threat of violence); 6) specificity of relationships between a criminal and his/her victim. In the given article we will consider only the last two features of a family crime of violence that allow uniting them into one group. The results of analysis of the other indications were published in the earlier works. The foundation for the analysis of the aims of the physical violence is the type of intention. The closest purpose of such physical violence is its result in the form of socially dangerous physical consequences the final aim of such an action can be different. Depending on the relation to the ultimate purpose and physical consequence of the violence the latter may be classified into “physical violence – end in itself” (infliction of a physical consequence is the end in itself for a criminal) and “physical violence – means of achieving another goal” (physical consequence doesn’t coincide with the final aim that is either directly indicated in the elements of crime or follow it, or is indifferent to the qualification) 162 International Psychological Applications Conference and Trends 2015 Needs are the foundation for motivation. Antonyan rightly supposes that “a motive is a subjective sense that includes psychological gain from certain actions” (Antonyan Y. Motives become apparent in different psychological spheres (conscious, subconscious). You cannot define motives only on the basis of actions without careful consideration of their structure, without understanding person’s background, without considering the crime committed outside of other actions and events. It’s necessary to know what function the motives fulfill towards the personal needs and what the psychological “gain” is from a committed crime. Frequently when a person explains his/her behaviour he/she substitutes motive for reasoning in order to hide, ennoble real motives. The real motives and motivational processes slip away not only from law enforcement agents, but from a criminal as well. In a survey (63 respondents) it was found out that in 73% defendants in crimes of violence see blows as a punishment for victim’s offence, and in 46% cases believe that tortures are a necessary form of compulsion and obedience (Beltsov N. Among the main motives of crimes of violence towards underage and ageing members of a family in our opinion can be pointed out the following ones: parents’, relatives’ lack of desire to bring a child up; parents’, relatives’ lack of desire to provide material or other kind of assistance to an underage or elderly member of a family; unwillingness to have a child because of child’s psychological or physical disadvantages; sexual; lucrative; hooligan. Miller, 2003) among the motives for violent crimes towards the other members of the family the following ones were pointed out: subconscious need to transfer onto a different person humiliation that earlier was posed on a criminal; subconscious need to let out suppressed feelings; need to have at one’s disposal a living object for manipulating; to transfer of personal childhood experience, determined by the need to idealize own childhood and parents by dogmatic transference of parents’ ways of upbringing to his/her own child; desire to take revenge for the pain a parent has once experienced. Having summarized the results provided by other authors’ and our personal research plus the materials of the legal precedents we came to a conclusion that domestic crimes of violence depending on the motives can be divided into 5 groups. The first group unites crimes of violence based on the motives of assertion and self-assertion and a criminal’s desire to affirm his/her authority in the family. The second group is represented by crimes of violence committed with lucrative impulses such as: gain (intention to gain property or the right to property of an under-age victim, desire to get rid of alimony etc. To such “defensive motives” are ascribed: suppression of offences, humiliation from a victim; suppression of violence, attacks from a victim on a criminal; protection from violence, attacks from a victim on other members of a family. The most wide-spread cases are when the main motive of violence is a criminal’s desire for selfaffirmation. Violence acquires independent meaning as a means of establishing of criminal’s power. Discharge of frustration tension is reflected on the so-called “surrogating actions” that can be transferred to people who have nothing to do with the conflict situation. In this case the assault victim turns out to be defenseless, and the attacker is sure of his/her impunity. In this case the reason of criminal’s aggression can be work and home problems, personal failures, and crimes of violence are directed towards people who happened to be nearby. To our mind in this situation the reason of a destructive behaviour are inferiority complexes. The protest feeling, aspiration to get rid of one’s inferiority, dependent position from: parents, bosses, spouses and the like – all this pushes a personality to asocial behaviour and crimes. The mechanism of the criminal behaviour is such that social maladjustment, diffidence is replaced by a perverted aspiration to become strong, to excel over others. Paradoxically this phenomenon leads to “inferiority complex transformations into superiority complex” (Adler, 2011). The defendant never says that he/she wants to deliver a blow, injure, impose a certain lifestyle and the like. Not a subject of a conflict is important but victim’s incitement to a certain state, damaging.

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The right ovary is not identified trans-abdominally and therefore a vaginal scan was undertaken” antibiotic susceptibility testing trusted 100mg cefixime. The gallbladder is contracted as the patient is not fasted therefore the presence of small gallstones cannot be confirmed or excluded with confidence” antibiotics for dogs bad breath cefixime 100 mg amex. Where no conclusion is possible 3m antimicrobial oral rinse generic cefixime 100mg without a prescription, alternative explanations for the ultrasound appearances may be offered infection limited mobile al proven 200 mg cefixime. For example: “I have informed the patient that she has an ovarian cyst which requires follow up. Good reporting avoids confusion, clearly identifies the appropriate findings and gives a correct interpretation in a clear and unambiguous format. Ultimately, good reporting equates to good communication skills and, in the clinical context, will avoid error and potential harm to the patient. In addition, a clinical history should be taken to include: o Reason for referral, age, menstrual history, symptoms, relevant medication, previous gynaecological surgery / treatment. Details of type of examination and patient consent should be documented in the report. Colour Doppler and/or power Doppler may be relevant in appropriate clinical presentations. Structures to examine/evaluate the pelvic scan should demonstrate: o normal anatomy/variants including age and menstrual status-related appearances of the whole organ in at least two planes o assessment of size, outline, echotexture and echogenicity o pathological findings the following structures should be examined: o Bladder – size, shape, contents o Cervix internal os, external os, cervical canal, continuity with uterus, assessment of size, outline, echotexture o Vagina assessment of outline, echotexture o Rectouterine pouch (pouch of Douglas) -fi For example examining the kidneys in the presence of a large fibroid (to exclude hydronephrosis) or to confirm/exclude abdominal ascites where a complex ovarian mass has been seen. Pelvic ultrasound reporting the report should contain the following information: • Summary of clinical details; • Type of examination performed i. It may be useful to have a standardised reporting format for normal gynaecological scans which includes the organs routinely examined and which is acceptable to the imaging department and referring clinicians. The uterus is normal in size but there is a 6mm x 4mm polyp within the endometrium. Anteverted uterus containing several submucosal fibroids on the anterior wall, the largest of which is Xmm in diameter. Ultrasound appearances of both ovaries are normal with a corpus luteum in the left ovary. Adjacent to the right ovary is a complex tubular structure measuring YxYxYmm containing low level echoes. These ultrasound appearances are consistent with pyosalpinx or tubo-ovarian abscess. Portal venous, hepatic venous and arterial systems Diaphragm Contour, movement, presence of adjacent fluid, masses, lobulations Ligaments Appearance of falciform ligament, ligamentum teres and venosum Gallbladder Size, shape, contour and surrounding area. Ultrasound characteristics of the wall and the nature of any contents Common Maximum diameter and contents; optimally it should be visualised to the head of pancreas duct Pancreas Size, shape, contour and ultrasound characteristics of head, body, tail and uncinate process; diameter of main duct Spleen Size, shape, contour and ultrasound characteristics including the hilum. Assessment of volume preand post-micturition 49 bladder Prostate Size and shape GastroWall thickness, contents, diameter of lumen, motility, presence/absence of masses intestinal tract Other Where relevant include: omentum, muscles, abdominal wall, possible hernias, lymph nodes sites structures for potential fluid collection (including upper/ lower abdomen and the thorax) Proceed to examination of the pelvis where necessary (Refer to gynaecology section) During the examination the ultrasound practitioner should demonstrate: • normal anatomy/variants of abdominal organs and structures including age-related appearances of each organ in at least two planes. The ultrasound practitioner should be able to tailor the examination according to the clinical presentation, and the emphasis of the examination of the abdominal structures may be altered according to the clinical scenario and patient history. Sufficient clinical information should be supplied with the request, together with either a working diagnosis or a specific clinical question to be answered. The purpose of the scan is to survey the entire organ if possible with representative images of normality and any pathology being taken. Left side down decubitus, left posterior oblique and intercostal surveys of the liver and biliary tree are essential if the entire organ is to be evaluated, as these positions allows access to areas of the liver not seen in the supine position. Exclude the presence of free fluid in the upper abdomen before turning the patient. The intestines are part of the abdominal cavity and gassy bowel has typical patterns which should be recognised by experienced operators. The abdominal ultrasound examination is inevitably a clinical examination and any tenderness during a scan should be noted and stated in the report, indicating where possible whether it is organ-specific or diffuse. Reporting of abdominal examinations 50 General principles of reporting apply and reference is made to the reporting section of this document, section 2. Sample abdominal ultrasound reports Outlined below are sample reports for various common clinical scenarios. These are provided as guidance with an aim of standardising and improving reporting skills in this important field of practice. The gallbladder is tender, has a thickened, oedematous wall and contains several stones. Bilirubin 400 µmol/L Abdominal ultrasound: There is intrahepatic duct dilatation around the porta hepatis and into the left lobe of liver. Although no liver lesions are seen on this baseline scan, a non-contrast scan does not exclude the presence of metastases. Chronic liver disease Clinical details: Known chronic alcoholic with liver cirrhosis. The portal and splenic veins remain patent with hepatopetal flow and there are varices around the splenic hilum which have increased since the previous examination. The gallbladder has a thickened oedematous wall, is tender and contains several stones. The common bile duct is normal in calibre 6mm but contains at least two small stones at the lower end. The head and body of the pancreas are normal, but there are limited views of the tail due to body habitus. The lesion demonstrates peripheral nodular arterial enhancement with rapid centripetal filling and good contrast take-up in the sinusoidal phase. There are no focal lesions but the liver texture is diffusely nodular and the liver capsule is irregular. Size Liver measurements have been controversial as alterations in liver volume may not be reflected in isolated measurements. However, the recommended measurement is from apex of the liver under the right hemidiaphragm down to the tip of the right lobe (from an approximately mid clavicular probe position). The normal range varies with patient size (especially height) and in congenital variations of liver segments. Rule of thumb < 15cm = normal > 16cm = enlarged 15 -16cm = borderline (unless previous imaging available for comparison) Early enlargement may more sensitively identified by the blunting of the free inferior edge of the right liver which in health is a sharp point. Echotexture the liver is minimally hyperechoic or isoechoic compared to the normal renal cortex. Where abnormality is suspected, or diffuse liver disease is the clinical indication for the scan, then a split screen comparison image of Liver/Kidney and Spleen/ Kidney should be taken. Where the liver texture suggests steatosis (fatty change) then the following assessments should be specifically made: • loss of signal in deep liver due to increased attenuation • loss of prominence of intrahepatic portal vein branch walls • altered liver surface (steatosis and fibrotic change often coexist) • Colour and Pulse Wave Doppler analysis of portal and hepatic veins Liver surface Subtle alterations in liver texture may be confirmed if the liver capsule can be demonstrated to be irregular rather than smooth. Images of the anterior aspect of the right lobe should be acquired intercostally with a high frequency linear probe. A left side down decubitus position and/or left posterior oblique position may be helpful. If the liver texture is diffusely abnormal, including diffuse fatty infiltration, or if portal hypertension /or chronic hepatitis is mentioned on the request, then Doppler studies of the portal vein and hepatic venous waveform should be obtained. This can be significantly raised in some patients but this is of no significance except in liver transplants where it may indicate vessel stenosis and needs reporting if above 40cm/s (mean flow velocity). The gallbladder neck usually sits in the gallbladder fossa and the fundus is frequently mobile, dependent upon patient position. The gallbladder should be scanned following a period of fasting (drinking clear fluids only) in order to distend it. It should be examined in at least two patient positions for example supine, left side down decubitus, left posterior oblique and/or erect in order to establish movement of any contents and to unfold the organ. It is good practice to examine the gallbladder both along its long and transverse axes. The gallbladder is normally pear-shaped when optimally dilated, with a narrow neck, widening towards the fundus. These shapes can conceal small stones if care is not taken to ‘unfold’ the organ and examine it comprehensively. The wall of the neck of the gallbladder is slightly thicker than the wall of the body and fundus in a normal organ. Frequently the neck describes a ‘J’ or reversed J shape, and particular attention should be paid to this area to exclude pathology such as trapped stones.

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