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One observation made at the conference was that as the complexity of diagnostic and therapeutic devices increases purchase benicar 40mg line, quality assurance measures must be simplified 1 www buy generic benicar 20mg on-line. The challenge of improving the care of patients in countries with greatly limited resources was raised several times during the conference buy benicar 40mg amex, and was recognized as a great and unfulfilled need across the globe. It was widely recognized that health care is a collaborative partnership between those who provide care and those who receive it, and that true collaboration requires: (i) truthfulness and directness; (ii) partnership and collaboration; (iii) openness and transparency; (iv) understanding of benefits, risks and options; and (v) engagement and involvement of all parties. It was recognized that all medical procedures employing ionizing radiation should be provided within a culture of safety. Such a culture requires active leadership from the top, but is everyone’s responsibility if it is to be fulfilled. This process commenced for the 1996 edition with a review in 2006, followed by the decision to revise, commencing in 2007. It is crucial that only persons who meet particular requirements are allowed to act in these roles. Appropriately trained personnel will continue to underpin radiation protection in medicine in the next decade. It could be argued that, in the past, the level of implementation of the radiation protection principle of justification in medical exposure was not as good as it should have been, partly due to lack of clarity about who is responsible. Imaging is the area of medical uses of radiation where this is particularly a problem. On the one hand, the referring medical practitioner knows the patient, the medical history and the clinical context, while, on the other, the radiological medical practitioner has specialist knowledge about the proposed procedure — its benefits, risks and limitations. However, the practice of defensive medicine may lead to the referring medical practitioner requesting more procedures than necessary. In some countries, there may be a financial conflict of interest for the radiological medical practitioner — the more procedures performed, the greater the income. Fortunately there is a growing body of knowledge about the appropriateness of given examinations or procedures for given conditions — the so-called referral guidelines [3] or criteria of appropriateness [4] — and these act as a bridge between the referring and the radiological medical practitioner. The next decade will see the increasing role of software for referrals, with the incorporation of appropriateness criteria into such systems. This is not a new requirement, but rather one that is becoming increasingly realizable as information technology continues to advance. Such imaging is effectively occurring in the area of medicine between biomedical research programmes and established medical practice. It is complicated by the presence of entrepreneurial medicine and by self-presenting patients who have been reached by the media. The quality and robustness of such software is crucial to radiation safety and, clearly, software must meet acceptable standards. The review is to be performed by the radiological medical practitioners, the medical radiation technologists and the medical physicists, and they would essentially ask themselves the questions: ‘How are we really doing? While requirements for individual monitoring are well established for medical uses of radiation, there is an almost inverse relationship between compliance in being monitored and the likelihood of occupational exposure. Those persons unlikely to receive much dose wear their dosimeters as required, while those with a high likelihood of significant occupational exposure seem to not regularly wear their dosimeters. For example, there is strong evidence that personnel performing interventional cardiology procedures are not being effectively monitored [8]. This situation will only improve, using current types of dosimetry, if monitoring is clearly seen as adding value. One way that this can occur is to use the monitoring results to improve occupational radiation protection in the facility. Without good radiation protection practice, some health professionals could easily exceed the new dose limit. There is a clear need for education and training, provision of appropriate protective tools and, again, monitoring to ensure acceptable occupational radiation protection for the more at risk occupationally exposed personnel for the next decade. It not only sets the basic requirements, it also provides the foundation for enabling further actions. In the coming years, specific guidance on radiation could be provided on the following topics: optimization of radiological protection for new technology in medicine; management of patient and staff protection as a global approach; occupational lens doses and extremity doses; radiation risk communication to patients; justification of some medical procedures including the impact of external factors; tissue reactions during complex interventional procedures; patient dose recording and tracking in imaging; expanding the use of diagnostic reference levels; radiation risk assessment in radiotherapy; requirement for sufficient trained staff to support radiological protection in medical installations.

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Syncope is a sign of critical stenosis order 20mg benicar free shipping, which requires plasia of the tricuspid valve with abnormal valve urgent treatment buy benicar 20mg cheap. Auscultation reveals a click and harsh Pathophysiology mid-systolic ejection murmur heard best on inspiration Regurgitation of blood into the right atrium during sys- in the left second intercostal space often associated with tole results in high right atrial pressures and hence right a thrill order benicar 40mg with amex. A left parasternal heave may also be felt due to atrial hypertrophy and dilatation. In the chronic un- cases intervention is required before decompensation of treated patient there can be hepatic cirrhosis from the the right ventricle occurs. Echocardiography is diagnostic and is also essential to assess right ventricular function. Tricuspid regurgitation Definition Management Retrograde blood flow from the right ventricle to the Functional tricuspid regurgitation usually resolves with rightatrium during systole. Severe organic tricuspid 48 Chapter 2: Cardiovascular system regurgitation or refractory functional regurgitation may Sinus nodal arrhythmias require operative repair (or rarely replacement). Cardiac arrhythmias A cardiac arrhythmia is a disturbance of the nor- Aetiology mal rhythm of the heart. Tachycardias are also subdivided according to their Clinical features origin: Most patients are asymptomatic but occasionally post- r Sinustachycardia. If bradycardia is episodic and severe, syncope r Ventricular tachyarrhythmias such as ventricular may occur. However, in patients with bundle branch block Most cases do not require treatment other than with- and in cases where the rapid rate of supraventricu- drawal of drugs or treatment of any underlying cause. Chapter 2: Cardiac arrhythmias 49 Sinus tachycardia rate may be regular, bradycardic, tachycardic or variable with pauses. Carotid sinus massage typically leads to a Definition sudden and sometimes prolonged sinus pause. Aetiology/pathophysiology Sinustachycardia is a physiological response to main- tain tissue perfusion and oxygenation. Causes include Complications exercise, fever, anaemia, hypovolaemia, hypoxia, heart The most important complication is cardiac syncope, as failure, hyperthyroidism, pulmonary embolism, drugs in other forms of bradycardia. Clinical features Investigations Palpitations with an associated rapid, regular pulse rate. In addition anti-arrhythmic drugs may be required to Management controlanytachycardia. Atrial arrhythmias Sinus node disease Atrial ectopic beats Definition Sinusnode disease or sick sinus syndrome is a tachy- Definition cardia/bradycardia resulting from damage to the sinus Atrial ectopic beats include extrasystoles and premature node. Aetiology/pathophysiology Aetiology Sinusnode disease is relatively common in the elderly Atrial ectopics are common in normal individuals. All dueto ischaemia, infarction or degeneration of the sinus cardiac cells have intrinsic pacemaker ability. The condition is characterised by prolonged in- ually depolarise until a threshold is reached at which tervals between consecutive P waves (sinus arrest) and point rapid depolarisation occurs and a cardiac action periods of sinus bradycardia. This is most rapid in the sinoatrial may allow tachycardias (typically atrial fibrillation) from node, the normal pacemaker of the heart. This combination of fast and slow or group of cells the gradual depolarisation is more rapid supraventricular rhythms is known as tachy-brady syn- than usual, or if the voltage threshold for rapid depolar- drome. Common causes are electrolyte Tachycardiamaycausepalpitations,andlongpausesmay abnormalities, alcohol or nicotine excess, anaemia, med- cause dizziness and syncope. Clinical features Atrial flutter presents with palpitations, dizziness, syn- Investigations cope or cardiac failure. Massage of the Management carotid sinus causes a transient increase in block with Atrial ectopic beats do not require treatment, although consequent slowing of the ventricular rate. If atrial ectopic beats are fre- Investigations quent they may progress to other atrial arrhythmias. Atrial flutter produces a characteristic regular sawtooth ‘flutter’ waves at a rate of 300 bpm seen best in lead V1. Atrial flutter is a rapid atrial rate between 280 and 350 bpm, most commonly 300 bpm.

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The available data on doses received by people approaching patients after implantation show that buy benicar 20mg on line, in the vast majority of cases cheap 20mg benicar free shipping, the dose to comforters and carers remains well below 1 mSv/a order 20mg benicar with amex. Moreover, due to the low activity of an isolated seed and its low photon energy, no incident/accident linked to seed loss has ever been recorded. A review of available data shows that cremation can be allowed if 12 months have elapsed since 125 103 implantation with I (3 months for Pd). If the patient dies before this time has elapsed, specific measures must be undertaken. However, although the therapy related modifications of the semen reduce fertility, patients must be aware of the possibility of fathering children after such a permanent implantation, with a limited risk of genetic effects for the child. Patients with permanent implants must be aware of the possibility of triggering certain types of security radiation monitor. Considering the available experience after brachytherapy and external irradiation of prostate cancer, the risk of radio-induced secondary tumours appears to be extremely low, but further investigation might be helpful. Only the (rare) case where the patient’s partner is pregnant at the time of implantation may need specific precautions. Specific recommendations should be given to patients to allow them to deal adequately with this event. As far as cremation of bodies is concerned, consideration should be given to the activity that remains in the patient’s ashes and the airborne dose, potentially inhaled by crematorium staff or members of the public. Specific recommendations have to be given to the patient to warn the surgeon in case of subsequent pelvic or abdominal surgery. The wallet card including the main information about the implant (see above) may prove to be helpful in such a case of triggering certain types of security radiation monitor. The risk of radio-induced secondary tumours following brachytherapy should be further investigated. Avoidance of radiation injuries from medical interventional procedures Interventional radiology (fluoroscopically guided) techniques are being used by an increasing number of clinicians not adequately trained in radiation safety or radiobiology. Many of these interventionists are not aware of the potential for injury from these procedures or the simple methods for decreasing their incidence. Many patients are not being counselled on the radiation risks, nor followed up when radiation doses from difficult procedures may lead to injury. Some patients are suffering radiation induced skin injuries and younger patients may face an increased risk of future cancer. Interventionists are having their practice limited or suffering injury, and are exposing their staff to high doses. In some interventional procedures, skin doses to patients approach those experienced in some cancer radiotherapy fractions. Injuries to physicians and staff performing interventional procedures have also been observed. Acute radiation doses (to patients) may cause erythema, cataract, permanent epilation and delayed skin necrosis. Protracted (occupational) exposures to the eye may cause opacities in the crystalline lens. The absorbed dose to the patient in the area of skin that receives the maximum dose is of priority concern. Each local clinical protocol should include, for each type of interventional procedure, a statement on the cumulative skin doses and skin sites associated with the various parts of the procedure. Interventionists should be trained to use information on skin dose and on practical techniques to control dose. Maximum cumulative absorbed doses should be recorded in the patient record, and there should be a patient follow-up procedure for such cases. Patients should be counselled if there is a significant risk of radiation induced injury, and the patient’s personal physician should be informed of the possibility of radiation effects. Training in radiological protection for patients and staff should be an integral part of the education of those using interventional techniques.

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