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Some beliefs and culture can affect radiation medicine’s acceptability and accessibility generic reminyl 4mg with mastercard. Human resources Most low income countries face challenges in radiation medicine services because of the lack of skilled human resources buy generic reminyl 4mg on line. As a consequence, general practitioners often have to interpret the radiological images; nurses or technical personnel, without adequate education and training, carry out the diagnostic examinations or the treatment delivery; and inappropriately trained physicists or engineers assume quality aspects, safety and maintenance responsibilities [10]. On the other hand, there is a lack of mechanisms for the necessary certification or recognition of these professionals [11]. In some countries, these human resources are so scarce that it is not possible to include formal education programmes at the national level; and in those that do have these programmes, they are not of sufficient quality. The possibilities for continuing education for professionals are also very limited in developing countries. Many professionals choose to migrate due to a lack of opportunities for education and training; underfunding of health services; lack of established posts and career opportunities; health service management shortcomings; civil unrest or personal security. Radiation protection and quality assurance Although radiation doses to patients in radiographic examinations are generally considered to be small in comparison with the immense benefits derived from these examinations, it is necessary to optimize the dose to the amount that is necessary to produce the image quality required for a diagnosis. There is also a tremendous amount of waste of resources with regard to the image quality produced in radiographic examinations. On the other hand, an examination that does not help medical management is unjustified, no matter how small the dose is. Many factors influence the effectiveness and safety of radiotherapy treatments, such as accurate diagnosis and the stage of the disease, good therapeutic decisions, the precise location of the tumour, and the planning and delivery of treatment. These procedures should be performed according to previously accepted clinical protocols by adequately trained personnel, with properly selected and functioning equipment, to the satisfaction of patients and referring physicians, in safe conditions and at minimum cost. Many low income countries face an increase in incidence and mortality of many diseases, which are potentially curable if early diagnosis and appropriate treatment are available. Diagnostic imaging and radiotherapy can provide public health programmes with tools to screen, diagnose, treat and palliate many diseases. The incorporation of such technology in developing countries requires a careful study of feasibility that ensures its appropriateness and sustainability. Additionally, it is essential for the human resources working in these services to be trained in the use of the respective technologies. Relevant authorities should be committed to incorporating and maintaining the technology, as well as to ensuring the quality of care and safety. A more widespread and proper use of radiation medicine will lead to a reduction in mortality and help to combat many diseases and conditions of public health concern, as well as to improved quality of life for people in developing countries. Emphasis is placed on the needs of the recipient facility; the provision of tools, accessories, spare parts and manuals; the arrangements for acceptance testing, commissioning and maintenance of the equipment; and the training of staff and service technicians regarding equipment operation and maintenance. Ideally, equipment should be bought new, but to minimize capital costs, developing countries may consider acquiring pre-owned machines, either directly from donors or refurbished from manufacturers. Other costs in addition to capital costs need to be taken into account: installation and siting costs, which involve potential room modifications, equipment transport and custom fees when applicable; operational costs, which include registration and licence fees, utility consumption such as electricity and water, supplies and consumables; and human resources costs that encompass salaries and training of operators, maintenance staff and consultants — if needed. There are also indirect costs, such as facility and equipment depreciation, as well as unexpected fees arising from legal, accounting, clinical, architectural, engineering and medical physics consultations. The procurement issues involved in equipment acquisition should be carefully analysed. The type of radiological equipment that facilities need should depend on the types of services that the facility offers or plans to offer and the staff available or budgeted for to operate and maintain the equipment. The number, characteristics and technical specifications should depend on the population to be served, the availability of resources in the respective health care system, and the volume of procedures to be carried out in a given unit of time [2]. The very first issue the facility should consider is whether the type of equipment to be acquired is really needed and whether it will require additional staff to operate it. Radiation safety requirements The design of radiation emitting equipment and equipment to be used with radioactive materials, such as a gamma camera, should comply with national or international radiation protection and safety standards [3]. Compliance with manufacturer’s specifications Second hand equipment should maintain the original manufacturer’s specifications. If an original feature is no longer functional, but the equipment could still be used, this should be clearly indicated in the documentation provided by the donor/seller. Warranties Refurbished equipment should be sold with warranties, at least for one year of operation. It is important to establish exactly whether it includes parts (X ray tubes are very costly, for example) and when the warranty actually starts. Obsolescence Even in good operating conditions and meeting the manufacturer’s specifications, equipment should not be acquired if deemed to be obsolete; i. For example, a cobalt therapy unit with an adequate radioactive source is not obsolete, but a mammography unit with a tungsten target and an aluminum filter is, because the image quality that is produced is substandard. Acquiring obsolete equipment may have detrimental effects on the health care system. Availability of operation and service manuals No piece of equipment should be acquired without operation and service manuals. This may be difficult if the language of the original equipment owner was different from that of the intended recipient and the equipment is no longer being manufactured. Availability of accessories and replacement parts When acquiring second hand equipment, it is important to assess whether the original accessories come with the main unit.

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Remove vegetation/silt in channels to avoid a drop in velocity which may lead to further vegetation growth and good habitat for snails generic 4mg reminyl with visa. Note that personnel involved in the manual removal of vegetation are increasing their exposure to snails reminyl 4mg sale. Flow rate should only be addressed with knowledge of the ecology of the snail in question e. Expose snail habitat: Remove littoral vegetation from the sides of canals feeding irrigation projects to expose snail habitat. Thought should be given to downstream conditions and the potential for the liberated snails to recolonise new habitat. Where possible dry out littoral zones to strand snail populations, however take into account the specific ecology and the resilience of the target species. Chemical control: Use of molluscicides may cause environmental damage and should be avoided. Applications are usually restricted to places frequently used by people for swimming, bathing etc. Biological control of intermediate snail hosts using larger, more voracious aquatic snails which do not harbour schistosome infection and out-compete local snails, has also been successful but should only be used after expert consultation due to their effects on local biodiversity. Livestock Prevention of contamination of wetland habitat with livestock excreta should be the main priority. To reduce the risk of infection, susceptible livestock should be removed from wetlands and replaced with non-susceptible species (or by farm machinery if the purpose of livestock is mechanical management). Infected and susceptible livestock should be treated with flukicides such as praziquantel. However, re-infection may occur quickly if the source of contamination is left uncontrolled. Wildlife High density populations of susceptible wildlife increase the potential for disease transmission. Interaction between livestock and wildlife should be prevented wherever possible and supplementary feeding of wild animals close to water sources should also be avoided. Humans The following practices may help reduce the likelihood of infection in humans: Avoiding contact with snail-infested waters and using water supplied from covered pipes or pit-wells. It is safest to consider all freshwater bodies in endemic areas as potential transmission sites if sites are otherwise unidentified. For agricultural workers at constant risk of infection, periodic examination and treatment may be the most feasible approach to disease control. A clean water supply and improved sanitation (including for people onboard boats) must be provided to stop human excrement entering wetlands. Treat infected individuals Anthelmintics such as praziquantel and oxamniquine (for S. If the local economic situation allows, consider mass treatment programmes for non-infected individuals following episodes of flooding. It is important that anthelmintic treatment be applied in conjunction with sanitation improvements to prevent widespread re-infection and subsequent cycles of treatment/re-infection thus increasing the potential for drug resistance to develop. Schistosomes contain cross- reacting antigens and vaccine development programmes are currently in progress. Frequent exposure of humans to schistosomes of domesticated animals can impart a degree of immunity to disease-causing species. Public health education Many countries and regions may lack funds for public education especially to isolated human settlements. However, an informed public are able to make personal decisions over their contact and use of standing water and thus reduce the risk of infection to themselves and their livestock. Problems may arise in areas where wildlife mixes with high density livestock and/or human populations. Effect on livestock An estimated 165 million animals are infected in Africa and Asia. In these regions most infections are subclinical but, depending on the schistosome species, can still cause serious morbidity and mortality (e. Worldwide, 207 million people are infected with schistosomiasis and it is especially important because of its prevalence in children and capacity to hinder growth and learning. Similarly, schistosomiasis impacts on economic development in developing countries by reducing the productivity of human workforces. Eradication programmes including widespread administration of praziquantel and implementation of improved sanitation are costly and beyond the means of many developing nations. These blood-feeding ectoparasites are found in almost every region of the world, typically in grassy, wooded habitat.

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If we wait even 10 years discount 4 mg reminyl with visa, we will find that the problem is even larger and more expensive to address generic 8mg reminyl otc. Prosperity is bringing to our nation many benefits, but there are some changes that are not positive. As our diets and hab- its are changing, so are our waist- viii Supporting statements lines. Already, more than 35% of women in Nigeria are overweight; by 2010 this number will rise to 44%. We do not need to say, “we are a poor nation, we cannot afford to deal with chronic diseases”. As this report points out, there are low-cost, effective measures that any country can take. Governments have a responsibility to support their citizens in their pursuit of a healthy, long life. It is not enough to say, “we have told them not to smoke, we have told them to eat fruit and vegetables, we have told them to take regular exercise”. We must create com- munities, schools, workplaces and markets that make these healthy choices possible. I believe, and the evidence supports me, that there are clear links between health, economic development and poverty alleviation. If my government and I are to build a strong Nigeria, and if my brothers and sisters throughout Africa are to create a strong continent, then we must include chronic diseases in our thinking. If we take action now, it could be that the predictions outlined in these analyses never come true. I will join with the World Health Organization to implement the changes necessary in Nigeria, in the hope that we, too, can contribute towards achieving the global goal of reducing chronic disease death rates by 2% per year over the next 10 years, saving 36 million lives by 2015. However, we now have major public health issues due to chronic diseases that need to be addressed with equal energy and focus. This World Health Organization report, Preventing chronic diseases: a vital investment, is of relevance to me, as Indian Minister for Health, as my country tackles the increasing number of issues relating to chronic disease. The scale of the problem we face is clear with the projected number of deaths attributable to x Supporting statements chronic diseases rising from 3. A number of my fellow citizens are featured within this report, as Faces of Chronic Disease. Sridhar Reddy, who, like a huge proportion of Indians, consumed tobacco and bat- tled both serious cancer and associated financial debts. His story is all too familiar in a country which is the world’s second largest producer, as well as consumer, of tobacco, where we consequently experience huge rates of cancer, including the largest numbers of oral cancer in the world. Stories of hope include Menaka Seni, who faced potential tragedy when she suffered a heart attack. However, this proved to be the wake-up call she needed and she is now changing her health behaviour to tackle the weight and high blood pressure that have contributed to her heart disease and diabetes. Her diabetes prob- lem is all too common in India, where we are at the top of the global league table for the number of people with the disease – an estimated 19. Some of the strategies for battling chronic disease have already been put in place. A National Cancer Control Programme, initiated in 1975, has established 13 cancer registries and increased the capacity for therapy. An integrated national programme for the prevention and control of cardiovascular diseases and diabetes is under development. Additionally, we need to initiate comprehensive action to promote healthy diet and physical activity; and health services need to be reoriented to accommodate the needs of chronic disease prevention and control. I believe that, if existing interventions are used together as a part of a comprehensive integrated approach, the global goal for preventing chronic disease can indeed be achieved and millions of lives saved. All segments of the society must unite across the world to provide a global thrust to counter this global threat. Governments must work together with the private sector and civil society to make this happen. Like so many developing and developed countries around the world, China is facing significant health challenges, not just with infectious diseases but now with the double burden of chronic disease. Chronic disease death rates in our middle-aged population are higher than in some high income coun- tries. We have an obesity epidemic, with more than 20% of our 7–17 year old children in urban centres tipping the scales as either overweight or obese. This situation is especially tragic considering that at least 80% of all heart disease, stroke and diabetes are preventable. And our global economies will also suffer severe consequences from societies battling chronic diseases. Currently a national chronic disease control network is being built to comprehensively survey our population. This is the type of comprehensive and integrated action that will achieve success in combating chronic diseases.

Protein excretion in- creases in the upright position discount reminyl 8mg with visa, and proteinuria buy cheap reminyl 8mg on line, which disappears on early morning collection before ambula- Imaging of the urinary tract tion is called orthostatic proteinuria, a benign condi- tion affecting 2–5% of adolescents, but uncommon over Plain X-ray of the kidneys, ureters and the age of 30 years. The outlines of the kidneys are unreliably seen because of overlying bowel Investigations gas. All positive urine dipstick measurement of protein should be confirmed by laboratory testing. It avoids caused by alkaline urine, antibiotics and X-ray contrast the use of contrast dyes, which have to be given intra- media. False negatives occur when there is proteinuria venously, are nephrotoxic, and to which patients occa- without much albuminuria, e. In renal failure, small Urinalysis and microscopy to look for haematuria and kidneys mean chronic renal failure, normal size kid- evidence of urinary tract infection. The exceptions are diabetes mellitus, munoglobulins and plasma protein electrophoresis. Urine electrophoresis for Bence Jones protein or dif- r In refractory pyelonephritis to look for a renal abscess, ferentiating glomerular (mainly albumin) from tubu- obstruction or an underlying anatomical abnormality lar loss (lighter chain proteins). Serial X-rays are r In polycystic kidney disease it can be useful if one cyst then taken, which show the passage of the dye through is thought to be infected or malignant. If there Nuclear medicine scans is obstruction, dye will be ‘held-up’ on one or both sides. Anon-nephrotoxic radioisotope is given intravenously, The exact site of obstruction can often be seen with di- which is taken up and excreted by the kidneys. Afillingdefectwithintheuretersuggestsa may be ‘static’ (for anatomical detail), or ‘dynamic’ (for radiolucent stone or tumour. All patients struction, furosemide is given – the radioisotope will should be well hydrated. Gadolinium is stents may be placed as part of the procedure to relieve non-nephrotoxic. Each renal artery the catheter, to demonstrate the cause and site of is selectively catheterised and contrast injected. The amount produced is lower in those with through the urethra in order to visualise the interior low muscle bulk, in women, children and the elderly. Flexible cystoscopy can be done under It is freely filtered, a small amount is also secreted at local anaesthetic, as a daycase procedure, but rigid cys- the tubules. Plasma creatinine is increased by strenu- toscopyisperformedunderanepiduralorgeneralanaes- ous exercise, ingestion of meat, certain drugs (trimetho- thetic. The bladder is distended with distilled water or prim and cimetidine) impair tubular secretion. It is de- saline, and forceps or diathermy loops can be inserted creased in malnutrition, wasting diseases, immediately through the instrument to take biopsies, and treat su- after surgery and by corticosteroids. In most patients, serial or previous spected, and fibreoptic ureteroscopes can be passed up, measurements of creatinine are useful to monitor the to look for ureteric lesions such as stones or carcinoma. Clearance is defined as the ‘virtual’ volume of blood cleared (by the kidney) of solute per unit time. When nephrons are lost or are not func- where U = urinary concentration, V = urine flow rate tioning properly, there is compensation by the remain- and P = plasma creatinine. It is 24-hour urinary collections are inconvenient and in- higher following protein intake, in a catabolic state, af- accurate. The best known of these is the creatinine because it is avidly reabsorbed at the proximal Cockcroft and Gault formula: tubules in a fluid-depleted state. If the creatinine is also proportionally raised (creatinine is normally Forwomen multiply by 1. This is indicated in severe Chapter 6: Clinical 231 be performed in cases of deterioration of renal function in patients with known kidney disease, to help guide treatment, for example in systemic lupus erythemato- sus, and relatively frequently in renal transplant patients particularly to look for rejection. The biopsy can be performed percutaneously, or at open surgery (unusual unless the other method is not possible, or contraindicated, e. Ultrasound guidance is used, and usually two cores are obtained using a spring-loaded biopsy needle. These are examined under light microscopy, electron microscopy andimmunofluoresenceorimmunoperoxidasestaining. Serum creatinine Complications include haematuria, bleeding under the renal capsule and bleeding out into the retroperi- Figure 6. In up to 3% renal failure (creatinine clearance becomes inaccurate), of individuals, blood transfusion is required for bleed- for kidney donors and patients receiving chemotherapy. Contraindications to percutaneous renal biopsy: Anion gap calculation is useful in metabolic acidosis, to r Clotting abnormality or low platelets (unless cor- differentiate causes. The r Small kidneys (<9 cm), as this indicates chronic irre- formula used to calculate the anion gap varies from versible kidney damage. In metabolic acidosis, an increased anion gap occurs due Relative contraindications include obesity (technically to raised acid levels: r difficult), single kidney (except of a transplanted kidney) Lactic acidosis (exercise, shock, hypoxia, liver failure).

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