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Education to achieve a culture of radiation protection should go hand in hand with promoting justified use of radiation based examination buy 800 mg viagra vigour overnight delivery erectile dysfunction drugs levitra. Risk management measures reduce the potential or even prevent unintended exposures and they are 800 mg viagra vigour free shipping erectile dysfunction doctors rochester ny, 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. In order to improve our knowledge of this important question, individual sensitivity and hypersensitivity to low doses of medical imaging and consequences for radiation protection systems and practices have to be explored further by targeted research activities. Moreover, the technical development in diagnosis and therapy has increased the capabilities for more targeted and individual approaches. Radiation protection and safety issues are closely linked to patient safety issues, and management control systems must include radiation protection and safety. Consideration should be give to make maximum dose reduction techniques mandatory in new acquisition techniques. It is recommended to replicate the best practices that have been applied to the nuclear industry and adjust them to the medical sector. As the ultimate goal is to arrive at a situation where medical radiation protection is evidence based, there is a need to narrow the gap between evidence and practice. For this purpose, more emphasis has to be devoted to risk assessment, long term follow-up and risk management.

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It is important to establish exactly whether it includes parts (X ray tubes are very costly viagra vigour 800 mg for sale erectile dysfunction drugs in ghana, for example) and when the warranty actually starts purchase viagra vigour 800 mg otc erectile dysfunction shake recipe. 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. Examples of potential problems are wedges for cobalt therapy machines, image receptors for mammography units and collimators for gamma cameras. It is essential that replacement parts be available from the original manufacturer or a reputable distributor for the length of the intended use of the equipment. The recipient institution should investigate from the original manufacturer the length of time they can support the equipment and whether local distributors and/or third party maintenance organizations have spare parts and accessories in stock, for how long and at what cost. Equipment which uses some kind of software, especially if it is no longer manufactured, may have old software versions that may be out of date, or if nothing else, awkward to use. Before acquiring any equipment, the availability of software upgrades should be explored from the original manufacturer and budgeted for. Environmental (facility) conditions There are several types of environmental concerns that need to be addressed when installing a piece of equipment in a new facility built to house it. First, the facility needs to comply with local building codes regarding space, accessibility, floor loading capacity, electrical power (voltage, frequency, phase and heat dissipation), water volume, pressure and drainage, etc. If the equipment emits radiation, the structural shielding needs to be calculated and its adequacy tested — preferably before the unit is installed, but certainly before it is put into clinical use — taking into account patient, staff and public dose constraints [3]. If the second hand equipment to be acquired is to be placed in an already existing building, to comply with local regulations may be more difficult, as there may be structural limitations. Furthermore, if open radioactive sources, such as those used in nuclear medicine, are included, there should be a plan for disposal of the radioactive waste that will be generated. Most types of radiological equipment can only function well with a stable power supply. This is particularly true for old computed tomography scanners, which cannot function unless the room temperature is very low. The requirements for both temperature and humidity should be known before the equipment is acquired.

However buy viagra vigour 800 mg line erectile dysfunction solutions pump, the lack of progress in ap- Most of the research performed regarding diagnosis in plying research findings to the messy world of clinical medical contexts has concerned static decision problems: practice suggests that we might benefit from examination only 1 decision needs to be made generic viagra vigour 800 mg with visa erectile dysfunction 43, the situation does not of an expanded set of questions. However, much of the work of medicine concerns dy- namic decision problems: (1) a series of interdependent Diagnostic Models decisions and/or actions is required to reach the goal; (2) A great deal of the work to date has assumed that diag- the situation changes over time, sometimes very rapidly; nostic thinking is best described by highly rationalized (3) goals shift or are redefined. In contrast to static problems, in dynamic little or no consideration of alternative approaches. There problems there is no theory or process element even close are some exceptions, including criticisms of this view 4,5 6 to being considered normative, either for approaching the (see Berg and colleagues and Toulmin ), Norman’s 7,8 problem or for establishing a particular sequence of de- research on clinical reasoning, and Patel and col- 9 cisions and/or actions as correct. Neverthe- Statement of Author Disclosures: Please see the Author Disclosures Problem Detection and Recognition section at the end of this article. One of the greatest holes in our current knowledge base Requests for reprints should be addressed to Beth Crandall, Klein is the failure to address issues of problem detection and Associates Division, Applied Research Associates, 1750 Commerce Center Boulevard North, Fairborn, Ohio 45324-6362. Diagnostic problems do not present them- E-mail address: bcrandall@decisionmaking. In may be the complexity of the systems and work processes order to discern the problem contained within a particular that surround diagnosis. We know that differences in set of circumstances, practitioners must make sense of an diagnostic performances exist, but we do not understand uncertain and disorganized set of conditions that initially diagnostic failure in any deep or detailed way. In the 15,16 emergency department, for example, the physician’s di- make little sense. Here, much of the work of diag- 10,17–19 agnostic process is carried out within the context of large nosis consists of preconscious acts of perception and sense making by clinicians who use a variety of numbers of patients, many of whom have multiple prob- 13 lems; there is little time, resources are constrained, and strategies to discern the real-world context. Given a stream of passing phenomena, distinguishing between conditions are chaotic. Some possibilities worth consid- items that are relevant or irrelevant, and those that must ering include: be accounted for compared with those that can be dis- ● Context: In what situations, and under what conditions, counted, creates a preconscious framing that bounds the are diagnostic failures most and least prevalent? We need problem of diagnosis before it is ever consciously con- to understand the real-world contexts in which medical sidered. If we are going to understand how prob- ● Team influences: The individual physician is surrounded lems are missed or misunderstood, we need to understand by other healthcare providers, including other clinicians, the processes involved in their detection and recognition. How does the distributed nature of patient care foster or prevent diagnostic failure? Having a concern to the captain and take assertive action if those solid diagnosis often makes much of clinical work easier. Is aviation’s example a useful ana- However, the lack of a firm diagnosis does not relieve the logue? Thus, one might argue that the central such as medication errors and nosocomial infections. This another way, the central question of clinical work might leads to the question, What system-level practices fos- not be, “What is the diagnosis? We know Individual Versus Distributed Cognition that with experience, diagnostic performance improves Most research on diagnostic decision making has concen- but that such progress is not invariant.

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Markell and Voge’sMedical Parasitology buy viagra vigour 800mg mastercard erectile dysfunction after drug use, 9 edition (2009) discount viagra vigour 800mg mastercard erectile dysfunction psychological treatment, Saunder’s Elsevier Publishing Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of gastrointestinal system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing 36 Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of genitourinary system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 37 th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of nervous system and psychology will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25th edition (2010): McGraw-Hill Medical Publishing Division 2. Markell and Voge’s Medical Parasitology, 9th edition (2009), Saunder’s Elsevier Publishing Immunology 1.

It is important to note that models like this are not predictors of individual drug use viagra vigour 800mg mastercard erectile dysfunction pills uk. Just because a young person is surrounded by risk factors quality viagra vigour 800 mg erectile dysfunction treatment guidelines, it does not automatically follow that he or she will engage in any of the problem behaviours identified – rather it postulates that there is a higher risk of such behaviours. Web of Influence Domains Individual Risk and Protective Factors y Biological and Psychological Dispositions y Attitudes and Values y Knowledge and Skills y Problem Behaviours † Refers to the total complex of external social, cultural and economic conditions affecting a community or an individual. School/Work Risk and Protective Factors y Bonding y Climate y Policy y Performance 4. Community Risk and Protective Factors y Bonding y Norms y Resources y Awareness/Mobilisation 5. Society/Environment Related Risk and Protective Factors y External social, economic and cultural conditions y Norms y Policy/Sanctions For a more detailed discussion of risk and protective factors recommended reading would be Dr. Mark Morgan’s ‘Drug Use Prevention – An Overview of Research’ published by the National Advisory Committee on Drugs in 2001. As with the previous section, it is important to note that the following information is aimed at an adult audience in order to build their capacity to engage with young people in drugs education and prevention work in the school setting and, as such, is not a resource to be given out to students in an unmediated fashion. Engaging young people in discussion around drug facts should always be done in a way which is (i) developmentally appropriate (ii) in accordance with the curriculum being used (iii) in accordance with the school’s substance policy The information is organised around the following headings: y Name y Physical Description(s) y Administration y Desired Effects y Duration of Effects y Signs and Symptoms of Use y Short Term Risks y Long Terms Risks y Legal Status 25 Drug Facts All drugs are viewed in terms of both their desired effects and their associated short and long-term risks. This emphasis on risk, as opposed to distinctions between so called ‘soft’ and ‘hard’ drugs is because the risks involved in drug use are not located purely within the drug itself but rather, how the drug is used, how much is used, who uses it and where – as discussed earlier in the section on the epidemiological triangle. Equally, the soft/hard distinction can also be used to build an argument as to which drugs (i. Drugs and the Law Drug laws in Ireland are complex and subject to change and schools are advised to be proactive in developing a good working relationship with local Gardaí as they will be able to clarify issues relating to drug laws. The laws that are the most relevant to the school setting include the Misuse of Drugs Acts 1977 and 1984. Offences under the Misuse of Drugs Act include: y Possession of any small amount for personal use y Possession with intent to supply to another person y Production y Supplying or intent to supply to another person y Importation or Exportation y Allowing premises you occupy to be used for the supply or production of drugs or permitting the use of drugs on premises y Growing of opium poppies, cannabis and coca plants y The printing or sale of books or magazines that encourage the use of controlled drugs or which contain advertisements for drug equipment There are other laws controlling tobacco, alcohol, solvents and medicines. Equally, drugs, their various uses and our understanding of them change over tim e. W ith this in m ind, there is a list of organisations and websites at the end of this handbook which you can consult if you encounter substances or related behaviours not included in the following section. Tobacco use also figures in cannabis smoking, where cannabis users may use tobacco along with the crumbled cannabis resin in the production of a joint or spliff (hand-rolled cannabis cigarette). Tobacco can also be administered via smokeless products such as snuff, which is sniffed, or ‘dipped’ that is, held between the lip and the gum of the mouth. Under Section 6 of the Tobacco (Health Promotion and Protection) Act 1988 the importation and distribution of these smokeless products are banned due to concerns around their adverse effects on health. However, the acute effects of nicotine dissipate within a few minutes and nicotine disappears from the body in a few hours, as it is metabolised fairly rapidly.

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There was a 23% reduction in myocardial infarction and coronary death discount viagra vigour 800mg free shipping erectile dysfunction pills cialis, a 24% reduction in the need for coronary revasculariza- tion buy viagra vigour 800 mg lowest price impotence clinics, and a 17% reduction in fatal and non-fatal strokes, giving a 21% reduction overall in major cardiovascular events. In some trials, participants had high blood pressure, diabetes or ischaemic heart disease. Statins reduced ischaemic heart disease events at age 60 by an estimated 61% in the long term; there was little reduction in the first year but a 51% reduction by the third year. They also reduced the overall risk of stroke by 17%, preventing thromboembolic stroke but not haemorrhagic stroke. Any possible excess of haemorrhagic stroke was greatly outweighed by the protective effect against ischaemic heart disease events and thromboembolic stroke. Twelve randomized placebo-controlled double-blind trials, with a follow-up of at least 3 years, were included. The analysis confirmed that patients, whether diabetic or not, benefit from lipid-lowering in accordance with their absolute cardiovascular risk. The evidence for efficacy of other lipid-lowering agents in primary prevention is weak. This was a mixed primary and secondary prevention study, which randomly assigned 2131 patients with previ- 48 Prevention of cardiovascular disease ous cardiovascular disease and 7664 without to receive either fenofibrate or a placebo. At 5 years follow-up, fenofibrate did not significantly reduce the risk of coronary events. While statins and resins had a significant lipid-lowering effect, n-3 fatty acids did not significantly affect cholesterol levels. Although there is little reason to believe that the effects would be different in non-Europeans with similar baseline risks of cardiovascular disease and similar lipid profiles, research is needed to examine the effects of lipid-lowering treatment in other racial groups. Risks There is no evidence from the large studies that cholesterol-lowering therapy increases the risk of death from other causes (333, 337, 338). Meta-analysis of data from statin trials has not shown an excess of adverse symptoms, including muscle pain and various gastrointestinal symptoms, in the treated group. Rhabdomyolysis (indicated by serum creatine kinase ≥10 times the upper limit of normal) was reported in 55 treated patients (0. The incidence of rhabdomyolysis is estimated to be about one per million person–years of use. Hepatitis (indicated by alanine aminotransferase ≥3 times the upper limit of normal) was reported in 449 treated patients (1. Data from randomized trials of cholesterol reduction and disease events have not provided evi- dence that a low serum cholesterol concentration increases mortality from any cause, other than possibly haemorrhagic stroke. Too few haemorrhagic strokes were observed in the randomized trials to resolve the uncertainty related to this condition. Further, the risk of haemorrhagic stroke affected only people with a very low cholesterol concentration and, even in this group, the risk was outweighed by the benefits from the reduced risk of coronary heart disease. In the Cholesterol Treatment Trialists Collaboration meta-analysis, there was no evidence of an effect on cancer deaths.