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By Q. Mojok. Jarvis Christian College.

Acceptance tests are normally done between a person of the institution (preferably a medical physicist) and an engineer or technical representative of the manufacturer 20 mg nexium sale. For second hand equipment buy nexium 40mg mastercard, compliance with the original manufacturer’s specifications can be tricky, unless it has been specified in the acquisition agreement. Previous service records should be examined in detail, and repaired or replaced components should be tested very carefully to assess whether they may compromise safety. Adjustment costs may have to be borne by the user, unless clearly indicated in the acquisition agreement that the responsibility is the institution’s or the company’s providing the equipment. Consumables, such as X ray film or printing paper, should be available at acceptance testing, to ensure that the tests can be performed and documented. Commissioning Commissioning is the process in which the necessary clinical data are acquired so that the unit can be used clinically. If so, these data should be consulted and verified before allowing patient examinations or treatments. Verification should be performed by a knowledgeable and competent medical physicist and should be more or less extensive depending on the complexity of the equipment. Establishment of quality control/quality assurance programmes Based on the acceptance testing and on the acquired data during commissioning, it is important to develop a set of tests and establish compliance criteria to check that the unit continues to perform adequately. The institution’s medical physicist should assume responsibility that the unit always functions within the established tolerances. Specific attention was given to: (i) the situation in developing countries, where access to proper imaging must be improved; (ii) the fact that training in diagnostic imaging and radiation protection is part of the safety culture; and (iii) the need to normalize education requirements for radiation, which is a high priority. The areas covered were the need for dose reduction as a result of standardized quality assurance procedures, education and training, and the development and implementation of a sustainable safety culture, research needs to improve the knowledge in individual radiosensitivity of patients, as well as the access to proper imaging techniques and training in diagnostic imaging and radiation protection in developing countries. Integration of radiation protection and safety It is important to include radiation protection and safety plans in management control systems in hospitals. This can best be achieved by involvement of key managers, authority given to radiation protection experts and transparent internal audits. Key challenges within such a process include effective communication within the organization and adoption of a graded approach towards radiation and safety. Dose assessment and national registries It is important to assess effective collective doses from diagnostic X ray and nuclear medicine examinations. This can be best achieved by establishing national registration systems to monitor frequency and doses, with the aim of identifying long term trends. The results can be used to select priorities for clinical audit and optimization actions. Experience shows that it is beneficial to engage stakeholders (professionals, institutional representatives, users) in developing methodology for clinical audits focusing on processes and outcomes. Of equal importance is the cooperation between authorities and professionals when establishing clinical audits. Quality assurance, education and training, and the development of a radiation safety culture Radiation protection is embedded in everyday clinical practice and is part of overall standard procedures. Radiographers have an important role in medical radiation protection; it is important that their education and training meets high standards. There is a strong need for increased cooperation between education and training organizations and employers. Adherence to dose reduction should be rewarded through accreditation and communication. Education to achieve a culture of radiation protection should go hand in hand with promoting justified use of radiation based examination. Risk management measures reduce the potential or even prevent unintended exposures and they are, therefore, a critical component of radiation protection culture. There is a need to demonstrate, through standard health technology assessment, that radiation protection measures, such as technological development, meet clinical cost– benefit requirements. The establishment of a safety culture is a focus area within the efforts of the International Radiation Protection Association to develop and enhance a strong radiation protection culture. The implementation of the Basic Safety Standards in health care at the global level Access to high quality and safe radiotherapy is particularly essential for developing countries. Specific attention should be given to developing countries, where access to proper imaging should be improved and training in diagnostic imaging and radiation protection should be a high priority. Individual sensitivity One of the key future impacts on medical radiation protection from advances in radiobiology is the specific consideration of the individual sensitivity of patients to ionizing radiation. There is an increasing opportunity to take into account the variability of the individual sensitivity of patients in diagnostic applications of ionizing radiation. Specific emphasis is on the most sensitive patients, the most sensitive tissues, the examinations with the highest dose and the most frequent examinations. Repeated medical exposures of young patients that are hypersensitive to ionizing radiation are a major concern for radiation protection. If fully established, the system of radiation protection may need to be revised to take into account individual sensitivity to ionizing radiation.

Causes include the following: r Benign follicular adenoma: Single lesions with well- Macroscopy/microscopy developed fibrous capsules discount nexium 40mg with visa. Nodules may be cystic nexium 40 mg visa, haemorrhagic and fi- hormones, which may result in hyperthyroidism. Enlargement of the gland can cause tracheal compres- r Thyroid cyst (15–25%): These may be simple cysts sion leading to shortness of breath and choking. About more common with retrosternal goitre, when the nod- 15% are necrotic papillary tumours. Toxic multinodular goitre has a particularly high incidence of cardiac arrhythmias and other cardiac complications. Clinical features Patients may present with a palpable lump or may be diagnosed on incidental imaging. Ultrasound scanning of the thyroid may be useful r History of neck irradiation exposure. Cystsand r Malignancy is more common in children and patients nodules may be aspirated by fine needle aspiration for over 60 years. Investigations Management r Thyroid function tests are used to determine thyroid Subtotal thyroidectomy may be required for cosmetic status. Isotope scans may also be used to demon- reasons or due to compression symptoms or thyrotoxi- strate either a cold nodule, a hyperactive gland (toxic cosis. Patients must be medically treated and euthyroid multinodular goitre) or a ‘cold’ gland containing a before surgery. A solitary mass within the thyroid gland that may be r Fine needle aspiration for cytology is used to differen- solid or cystic. Incidence Management 5% of population have a palpable solitary thyroid nod- Benign lesions only require treatment if they cause hy- ule. Up to 50% of population have a solitary nodule at perthyroidism or for cosmetic reasons. Chapter 11: Thyroid axis 431 If suspicious cells are identified on cytology a thyroid r The autoantibody can cross the placenta, causing lobectomy should be performed. Clinical features Graves’ disease (primary thyrotoxicosis) Hyperthyroidism produces palpitations, nervousness, fatigue, diarrhoea, sweatiness, tremor and intolerance Definition of heat. Weight loss with increased or normal appetite Graves’ disease is an autoimmune thyroid disease. Proptosis (exophthalmos) with lid retraction, stare and Sex lid lag are prominent features, and in its most severe F > M form it may cause sight loss due to damage to the optic nerve. Thyroid dermopathy (also called pretibial myxoedema) r Fifteen per cent of patients have a close relative with is a thickening or ‘orange-peel appearance’ of the skin, Graves’, and 50% of relatives have circulating thyroid most often affecting the lower leg. Microscopy The thyroid epithelial cells are increased in number and size with large nuclei. This causes a generalised, uncontrolled stimulation lymphocyte infiltration may also be seen. After many years the gland becomes non-functional and Investigations the patient becomes hypothyroid. Other complica- is made by a combination of clinical features and detec- tions of Graves’ disease may also be due to similar tion of thyroid autoantibodies. Thesecomplicationsdonotresolveontreat- Management ment to reduce the overactivity of the thyroid. Antithyroid drugs (usually carbimazole) are given to r Some symptoms of Graves’ disease relate to apparent suppress the gland. Graves’ disease commonly enters catecholamine (noradrenaline and adrenaline) excess, remission after 12–18 months, so a trial of withdrawal for example tachycardia, tremor and sweating. Patients who are severely symptomatic roid hormones induce cardiac catecholamine recep- with hyperthyroidism also benefit from β-blockers. Subtotal thyroidectomy results in normali- Primary Idiopathic/autoimmune thyroid atrophy sation of thyroid function in 70%. The patient must be made Iatrogenic: radioactive iodine, surgery, drugs euthyroid before surgery with antithyroid drugs and β- Iodine deficiency (common in Nepal, Bangladesh) blockers (see page 436). Inborn errors of hormone synthesis Secondary Panhypopituitarism due to pituitary adenoma Iatrogenic: pituitary ablative therapy/surgery Prognosis Tertiary Hypothalamic dysfunction (rare) Thirty to fifty per cent of patients used to undergo spon- Peripheral resistance to thyroid hormone (rare) taneous remission without treatment. Hypothyroidism (myxoedema) Thyrotoxic crisis (storm) Definition Definition Hypothyroidism is a clinical syndrome resulting from a Arare syndrome of severe acute thyrotoxicosis, which deficiency of thyroid hormones. Pathophysiology Congenital hypothyroidism causes permanent develop- Pathophysiology mental retardation. In children it causes reversible de- Levels of thyroid-binding protein in the serum fall and layedgrowthandpuberty,anddevelopmentaldelay.

The Image Wisely campaign is modelled cheap nexium 20mg, in part purchase 40 mg nexium with mastercard, on the Image Gently campaign and is focused on appropriate and safe use of medical imaging for adult patients [6]. This initiative is a cooperative effort of the American College of Radiology, American Association of Physicists in Medicine, American Society of Radiologic Technologists, and the Radiological Society of North America. The Choosing Wisely programme is an effort by the American Board of Internal Medicine Foundation to encourage physicians to be better stewards of finite health care resources, including the use of imaging procedures [7]. Instilling a culture of safety in an organization encompasses several processes and steps, many of which are outlined in this paper. Foremost, it requires leadership from the top of the organization, and recognition by all employees that safety is everyone’s responsibility. The radiation dose to the population of the United States of America from medical radiation is now almost equal to that of background radiation, and increased more than seven times in the 25 years from the early 1980s to 2006. There has been an inexorable rise in the range and numbers of minimally invasive interventional techniques being performed using fluoroscopy, and these techniques have offered enormous benefits to many patients who otherwise may not be candidates for more invasive surgery. The range of radionuclides that can be used in medicine has also increased and the types of specific radiotherapy have become more complex. Despite these huge benefits, health professionals have to accept that some procedures deliver high radiation doses to patients. Radiation injuries, in interventional radiology and cardiology, and accidental exposures in radiotherapy are fortunately not common compared to the number of procedures or treatments performed, but were increasingly reported in the 1990s and 2000s. It is now 11 years since the International Conference on the Radiological Protection of Patients in Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy was held in March 2001, in Malaga, Spain. This landmark conference is now often referred to simply as the ‘Malaga conference’ among radiological protection professionals, which is a reflection of the significance of the event. These included optimization with an emphasis on reducing doses and risks without compromising image quality or treatment effectiveness, recognition of high dose procedures, monitoring doses from multiple examinations, and the development of adequate infrastructures to support the safe use of ionizing radiation in medicine. The subsequent Action Plan addressed issues of education and training of health professionals; appropriate exchange of information, with wider dissemination of that related to protection of patients; and the provision of practice specific guidance documents in collaboration with professional bodies and international organizations. Many national and international organizations have worked on initiatives to improve patient safety. Guidance on the use of appropriate imaging investigations for a wide range of clinical problems have been produced to aid clinicians and to reduce the unnecessary irradiation of patients. A learning, no blame culture has been encouraged by the establishment of databases, e. Two campaigns in the United States of America have been established to raise awareness of radiation and to lower doses where possible. The Image 2 Gently campaign is an initiative of the Alliance for Radiation Safety in Pediatric Imaging aimed at lowering radiation dose in the imaging of children. Several subsequent publications have focused on providing guidance on specific topics, for example, Preventing Accidental Exposures from New External Beam Radiation Therapy Technologies [7], while others have been more general, for example, Radiological Protection in Medicine [8]. This training now needs to extend beyond those traditionally working in radiology departments as the number of non-radiological specialists using ionizing radiation is increasing, and this was addressed in Radiological Protection in Fluoroscopically Guided Procedures Performed outside the Imaging Department [10]. Working parties are reviewing areas of justification and reference levels for both diagnostic and interventional imaging. Technological developments in medicine continue at a great pace and it is a challenge to produce timely recommendations that deal with the associated radiological protection issues. In addition, there is an ongoing need to raise the awareness of radiological protection among the many health professionals who either use or request procedures involving ionizing radiation, often with little or no knowledge. Significant progress has been made in the radiological protection of patients since the Malaga conference. This has been due to the considerable efforts of individuals and many organizations. Despite the achievements, there is no place for complacency and it is the responsibility of all radiological protection and health care professionals to continue to make improvements that enhance patient safety. This forms part of a larger move to improve the system of benefit–risk assessment, which takes in three key steps: awareness, appropriateness and audit (the ‘three As’). Justification of medical exposures at three levels as identified by the International Commission on Radiological Protection (from Ref. Awareness of this assessment is frequently portrayed in the media as a cost issue but health professionals correctly see the bigger picture of good medical practice and radiation safety as the two main criteria for selection of the best test first, before cost effectiveness. The balance of health benefit against radiation risk in a justified medical procedure is almost invariably in favour of the benefit. Imaging referral guidelines have been available for over 20 years in Europe and have been advocated through a European Commission Directive [6]. Rapid developments in imaging technology and new advances in medical imaging required an update of the guidelines by the European Commission in 2003. The American College of Radiology’s Appropriateness Criteria [10] and Western Australia’s Diagnostic Imaging Pathways [11] provide evidence based guidance considering global evidence. Such guidance is also helpful to promote good medical practice and may improve cost effectiveness by facilitating the best and possibly only test first.