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In September 2001 generic tofranil 75mg without a prescription, the Board requested the Secretariat to convene a group of experts to formulate — on the basis of the conference’s findings purchase 25mg tofranil otc, conclusions and recommendations — an Action Plan for future international work related to radiological protection of patients cheap tofranil on line, and to submit the Action Plan for approval discount 75mg tofranil amex. The objective of the International Action Plan was to improve patient safety as a whole. The involvement of international organizations and professional bodies was considered crucial to performing the actions and achieving the goals outlined in the Action Plan. In addition, external experts are invited to participate as members of the task groups or working parties that produce the documents on radiological protection recommendations. Technology in medicine is evolving very rapidly and the use of ionizing radiation is likely to increase in the coming years. Not only medical and paramedical personnel but also industry engineers and maintenance professionals are to be considered in this issue. Strategies for optimization in reducing organ doses in the cardiovascular and cerebrovascular systems need to be implemented. Since X rays and radium started to be used in medicine, there has been a gigantic development in diagnosis and therapy practices making use of ionizing radiation. There have also been growing international efforts to improve radiological protection in medicine. Thus, the Bonn conference completed a cycle of unprecedented international cooperation for protecting patients and medical staff against the detrimental effects of radiation exposure. The time seems to be ripe for this paper summing up the achievements and the remaining challenges of radiological protection in medicine, the main purpose being to pursue a future strategy for dealing with these issues. The paper is organized under the old Roman motto veni, vidi, vici in three parts, namely: veni — coming from a successful history; vidi — examining new challenges; and vici — successfully moving towards an international regime for radiation safety in medicine. It is noted, however, that his opinions in this paper do not necessarily reflect those of these bodies. An international radiological protection regime would eventually evolve under the aegis of several prestigious international organizations, becoming a network of science, paradigm and regulatory standards. What follows is a summary account of this successful history, with a focus on protection in medicine, particularly of patients. The early stages At the beginning of the twentieth century, the knowledge of radiation and its effects was limited and the main concern was protecting the staff practising the medical use of the sole radiations being employed at that early time, namely X rays and radium emissions. Those early recommendations state that: “the dangers of over-exposure to X rays and radium can be avoided by the provision of adequate protection and suitable working conditions. It is the duty of those in charge of X ray and radium departments to ensure such conditions for their personnel” (para. That early recommendation states that “screening stands and couches should provide adequate arrangements for protecting the operator against scattered radiation from the patient” (para. The early advice included some curious counsel on ergonomics, such as that X ray departments should not be situated below groundfloor level and that all rooms (including dark rooms) should be provided with windows affording good natural lighting and ready facilities for admitting sunshine and fresh air whenever possible, and with adequate exhaust ventilation capable of renewing the air of the room not less than 10 times an hour, and with air inlets and outlets arranged to afford cross-wise ventilation of the room, and, surprisingly, they should preferably be decorated in light colours (paras 3–6 of Ref. The Commission recognizes “that in medical procedures, exposure of the patient to primary radiation is generally limited to parts of the body, but the whole body is exposed to some extent to stray radiation. Accordingly, it recommended that “the medical profession exercise great care in the use of ionizing radiation in order that the gonad dose received by individuals before the end of their reproductive periods be kept at the minimum value consistent with medical requirements”. Moreover, concerning the exposure of patients for medical reasons, the Commission believed that “it would not be possible to make specific recommendations on dose limitation that would be appropriate for all examinations on individual patients”. The Commission also emphasized that the term ‘medical exposure’ referred “to the exposure of patients in the course of medical procedures and not to the exposure of the personnel conducting or incidentally associated with such procedures” (para. On the other hand, already at that time, the Commission started to show growing concern for the exposure of patients. It emphasized “the need for limiting the doses from radiological procedures to the minimum amount consistent with the medical benefit to the patient” (para. The Commission noted that medical exposures constituted already at that time and for the foreseeable future “the main source of population exposure”. Since it was considered likely that in most countries the number of persons medically exposed would increase, owing to the development of new procedures as well as to improved conditions for medical care, the Commission judged “increasingly important that these technological improvements should be matched by appropriate consideration of the radiation protection of the patient” (para. The Commission also re-emphasized that “careful attention to techniques would, in many cases, result in a considerable reduction of the dose due to medical procedures, without impairment of their value”. To achieve this reduction, the Commission pointed out “the value of adequate training in radiological protection for all persons who administer radiation exposures to patients” (para. These recommendations provide primary general recommendations on medical uses of radiation. For diagnostics, the recommendations covered X ray diagnostic installations, fluoroscopy, radiography, photofluorography, dental radiography and diagnostic uses of radioactive substances. For therapy, it covered beam therapy, conventional X ray therapy, superficial X ray therapy, ‘megavolt’ X ray and particle beam therapy, sealed source beam therapy, non-collimated sealed source therapy, and therapy with unsealed sources. It also generally addressed, perhaps for the first time, the issue of protection of patients. The report collated information necessary “for an adequate understanding of the principles and practice of protection of the patient in the widest sense”. It was recognized that the achievement of this purpose “was not within the scope of a single discipline, but requires a multidisciplinary effort by all who instigate X ray investigations, by those in any way concerned with the use of X ray diagnostic equipment and techniques, and by those responsible for the relevant educational programmes”. They re-emphasized protection against medical exposures, which were redefined as “the intentional exposure of patients for diagnostic and therapeutic purposes, and to the exposures resulting from the artificial replacement of body organs or functions (e. It is equally important that this assessment be made against a background of adequate knowledge of the physical properties and the biological effects of ionizing radiation. It is also necessary to consider alternative therapeutic procedures and to compare their effectiveness and their dangers with those associated with radiological treatment. It intended to guide radiologists and others concerned with diagnostic radiology with regard to the factors that influence radiation doses and, hence, radiation risks from different types of X ray examination. Recognizing that the protection of the patient in radiotherapy requires, uniquely, not the avoidance of radiation exposure or even the avoidance of risk of severe damage to some tissues, but rather achieving the optimal balance between the efficacy of sterilizing the malignant growth and minimizing treatment related complications by keeping radiation doses as low as reasonably achievable, the recommendations presented a broad overview useful to all involved in the proper therapeutic application of radiation. The new recommendations were very detailed and comprehensive and are still widely used today. Exposure of an individual to other sources, such as stray radiation from the diagnosis or treatment of other persons, is not included in medical exposure. Exposures incurred by volunteers as part of a programme of biomedical research are also dealt with in this document on the same basis as medical exposure” (para. They address the issue of dose limits in medical exposure indicating that: “they are usually intended to provide a direct benefit to the exposed individual. If the practice is justified and the protection optimised, the dose in the patient will be as low as is compatible with the medical purposes. Any further application of limits might be to the patient’s detriment” and, therefore, recommending that “dose limits should not be applied to medical exposures”, but introducing the concept of dose constraints (para. Furthermore, each increment of dose resulting from occupational or public exposure results in an increment of detriment that is, to a large extent, unaffected by the medical doses” (para. The recommendations also assessed, perhaps for the first time, the issue of medical exposure of pregnant women. It further considered that: “a pregnant patient is likely to know, or at least suspect, that she is pregnant after one missed menstruation, so the necessary information on possible pregnancy can, and should, be obtained from the patient herself. If the most recent expected menstruation has been missed, and there is no other relevant information, the woman should be assumed to be pregnant. The question of dosimetry in medical exposure is also addressed indicating that: “the assessment of doses in medical exposure, i. In diagnostic radiology, there is rarely a need for routine assessment of doses, but periodic measurements should be made to check the performance of equipment and to encourage the optimisation of protection. In nuclear medicine, the administered activity should always be recorded and the doses, based on standard models, will then be readily available” (para. However, each procedure, either diagnostic or therapeutic, is subject to a separate decision, so that there is an opportunity to apply a further, case-by-case, justification for each procedure. This will not be necessary for simple diagnostic procedures based on common indications, but may be important for complex investigations and for therapy” (para. They also recognize that: “there is considerable scope for dose reductions in diagnostic radiology using the techniques of optimisation of protection. Consideration should be given to the use of dose constraints, or investigation levels, selected by the appropriate professional or regulatory agency, for application in some common diagnostic procedures. They should be applied with flexibility to allow higher doses where indicated by sound clinical judgement” (para. They recalled again that “medical exposures are usually intended to provide a direct benefit to the exposed individual.

As well as improving clinical outcomes buy generic tofranil 25mg, they simplify distribution of multiple medications purchase cheapest tofranil, which can be an important advantage in a resource-limited health-care setting discount tofranil 75 mg without prescription. The major challenge remains one of implementation – new strategies are required for the many millions of under-treated individuals with established cardiovascular disease in low and middle income countries cheap tofranil. For people with cardiovascular disease in low and middle income countries, access to preventive care is usually dependent upon their ability to pay, and hence it is this large, underserved group that stands to gain most from a polypill (32, 33). Yet in many places, effec- tive interventions for chronic diseases are poorly delivered or are not available at all. In some settings, lack of human, physical and financial resources are the major constraining factors. In other settings, resources are available but are used in a fragmented In a rural South African setting, a nurse-led chronic and inefficient manner. Factors to take into account disease management programme for high blood include the following: pressure, diabetes, asthma, and epilepsy was » evidence-based decision support tools can improve established as part of primary health care for a the delivery of effective care for chronic diseases; population of around 200 000 people. The pro- » effective clinical information systems, including gramme included the introduction of: clinic-held patient registries, are an essential tool for provi- treatment cards and registries; diagnostic and ing the continuity of care necessary for chronic management protocols; self-management sup- diseases; port services; and regular, planned follow-up with a clinic nurse. Nurses were able to improve disease control among most of the patients: 68% of patients with high blood pressure, 82% of those with diabetes,109 and 84% of those with asthma (34). Five greater efficiency from their health systems health-care facilities, each with a multidisciplinary team of by combining disease management for all staff, were involved in the decision-making and planning of chronic conditions. They enable the » reallocation of financial and human resources to facilitate organization of patient information, tracking implementation of these services. Multidisciplinary health-care teams, centred on primary The Secretariat of Health of Mexico health care, are an effective means in all settings of achieving this has launched a “crusade for the goal and of improving health-care outcomes (37 ). It is possible, however, to provide some the implementation of a structured of the core skills from these disciplines in other ways (by training diabetes education programme. It may be possible to provide core trained to adopt a quality improve- aspects of effective health care that in more resourced settings ment methodology. Among the inno- would be provided by health professionals from several different vations in primary health centres disciplines. The while among those receiving usual production of an evidence-based guideline is a resource-intensive care the proportion only increased and time consuming process. Documented foot lines are available for many chronic diseases (see, for example, care education increased to 76% of http://www. For example, simply providing information about the guideline is likely to have little impact, but linking the guideline to workshops or outreach training sessions and providing prompts within medical records are much more likely to change practice (41). Inter- A chronic disease self-management programme was developed in Shanghai from 1999 to 2001. The ventions that aim to improve the ability of patients and their programme was conducted by trained volunteer lay carers to manage conditions can be highly effective and leaders and included exercise, the use of cognitive are an essential component of chronic disease care (46). In some conditions, communities and six districts of Shanghai, and is being notably after myocardial infarction, rehabilitation reduces replicated in other cities (43). Multidisciplinary and intensive rehabilitation programmes, common in high income countries, are typically not feasible in low and middle income countries. This included mobil- » Multidisciplinary rehabilitation services in patients with chronic ity training and training to perform normal low back pain can reduce pain and improve function (48). Quality of life improved for » Cardiac rehabilitation (following myocardial infarction), with a some 95% of participants (44). In many from targeted communities (villages and low and middle income countries, this rehabilitation approach is not slum areas) were taught to identify and feasible owing to shortages of health workers and other resource train people with disabilities. Review of effective interventions In these situations, community-based rehabilitation is a viable alter- native, using and building on the community’s resources as well as those offered at district, provincial and central levels. Community-based rehabilitation is implemented through the combined efforts of people with disabilities, their families, organizations and communities, as well as the relevant governmental and nongovernmental health, education, vocational, social and other services. Such efforts are being made in more than 90 (mostly low and middle income) countries. There have been As an overall approach, some important successes that might be applied nationally. For example, the Pain it has not been rigorously and Palliative Care Society in Kerala has developed a network of 33 palliative care evaluated but site-spe- clinics providing free care to those who need it, with an emphasis on home care. Palliative care ranges from which five countries – Botswana, Ethiopia, Uganda, United personal care and assistance in daily living to Republic of Tanzania and Zimbabwe – and the World counselling and pain management. The current evidence provides little guid- local nongovernmental organizations, particularly Hospice ance on whether one approach is superior to Africa Uganda, the Ministry of Health has included pain another and suggests that further studies would relief and palliative care in the home care package, based be useful (52–54). Services include essential drugs for pain and other symp- tom relief, food and family support. I was also having trou- ble remembering things and had to urinate a lot,” she recalls. After that, Zahida ignored her symptoms for eight long years before seeking medical care again, this time in Islamabad, 70 km from her home town. A second blood test finally established the nature of the problem and she started feeling much better almost immedi- ately after taking her first shot of insulin. One of her legs was amputated below the knee, as a result of an ulcer on her foot going untreated. Zahida holds her local hospital responsible for not having detected raised blood glucose in the first place, but admits that she should have reported the ulcer on her foot to her doctor much sooner. Now 65 years old, she is slowly recovering at home from the physical and emotional effects of surgery with the help of her son and daughter- in-law. Many of the complications of diabetes, such as leg 115 amputation, can be prevented with good health care. Chronic diseases are already the major cause of death in almost all countries, and the threat to people’s lives, their health and the economic development of their countries is growing fast. Yet, as this part of the report has shown, the knowledge exists to deal with this threat and to save millions of lives. Effective and cost-effective interventions, and the knowledge to implement them, have been shown to work in many countries. If existing interventions are used together as part of a comprehensive, integrated approach, the global goal for preventing chronic diseases can be achieved. The only question is how governments, the private sector and civil society can work together to put such approaches into practice. If they do so in the ways outlined in the next part of the report, the global goal for chronic disease prevention and control will be achieved and millions of lives will be saved. Reduction in the incidence of noncommunicable disease interventions: lessons from type 2 diabetes with lifestyle intervention or metformin. Changes in sodium intake and blood pressure in a mellitus by changes in lifestyle among subjects with impaired community-based intervention project in China. School-based health education quickly does reduction in serum cholesterol concentration lower programs can be maintained over time: results from the risk of ischaemic heart disease? Vartiainen E, Jousilahti P, Alfthan G, Sundvall J, Pietinen P, London, Food Standards Agency, Dairy Council, Health Puska P. Cardiovascular risk factor changes in Finland, 1972– Education Trust, 2004 (http://www. International workplace health promotion program conducted in Japan for Journal of Tuberculosis and Lung Disease, 2000, 4:1002–1008. Paper prepared for the Transportation Research screening for noncommunicable disease: World Health Board and the Institute of Medicine Committee on Physical Organization Consultation Group Report on methodology of Activity, Health, Transportation, and Land Use. The long-term impact of Johnson & Johnson’s Health los Andes, Corporation de Universidades Centro de Bogota, & Wellness Program on employee health risks. Journal of Occupational and Environmental and evaluation of the Agita Sao Paolo Program using the Medicine, 2002, 44:21–29. Implementing clinical for cervical cancer in low- and middle-income developing guidelines: current evidence and future implications. Bulletin of the World Health Organization, 2002, of Continuing Education in the Health Professions, 2004, 79:954–962. Effectiveness and costs of interventions Implementation and quantitative evaluation of chronic disease to lower systolic blood pressure and cholesterol: a global and self-management programme in Shanghai, China: randomized regional analysis on reduction of cardiovascular-disease risk. Hypertension management in a community-based rehabilitation in Punjab, Pakistan: I: Russian polyclinic. Therapy-based rehabilitation services for stroke patients at chronically ill seniors. Review: exercise-based cardiac rehabilitation reduces all- cause and cardiac mortality in coronary heart disease. The impact of different models of specialist palliative care on patients’ quality of life: a systematic literature review.

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