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Communication barriers may signiﬁcantly decrease effective access to health services and inhibit the degree to which a patient can beneﬁt from such services buy cheap atrovent 20mcg online. Migrants buy atrovent 20mcg low cost, for In 1994 generic atrovent 20mcg otc, the main obstacle to obtain- example, often face language and other cultural barriers. Almost Social inequality, poverty and inequitable access to resources, including 75% of people who could not obtain health care, result in a high burden of chronic diseases among women medicines reported unavailability as worldwide, particularly very poor women. However, In general, women tend to live longer with chronic disease than men, since then the situation has changed though they are often in poor health. The costs associated with health dramatically: availability of medi- care, including user fees, are a barrier to women’s use of services. By 2000, 65–70% of people who unless there is agreement from senior members (whether male or female) could not obtain medicines reported of the household. Women’s workload in the home and their caregiving unaffordability as the main reason, roles when other family members are ill are also signiﬁcant factors in while unavailability accounted for delaying decisions to seek treatment. Population-based surveys of blindness in Africa, Asia and many high income countries suggest that women account for 65% of all blind people world- wide. Cataract blindness could be reduced by about 13% if women received cataract surgery at the same rate as men. The decision to delay treat- ment is often inﬂuenced by the cost of the surgery, inability to travel to a surgical facility, differences in the perceived value of surgery (cataract is often viewed as an inevitable consequence of ageing and women are less likely to experience support within the family to seek care), and lack of access to health information (28). This section describes how chronic diseases cause poverty and draw individuals and their families into a downward spiral of worsening disease and impoverishment. In Bangladesh, for example, of those households that moved into the status “always poor”, all reported death or severe disabling diseases as one of the In Jamaica 59% of people with main causes. Existing knowledge underestimates the implications of chronic avoided some medical treatment as diseases for poverty and the potential that chronic disease prevention a result (30). Ongoing health care-related expenses for chronic diseases are a major problem for many poor people. Acute chronic disease-related events – such as a heart attack or stroke – can People in India with diabetes spend be disastrously expensive, and are so for millions of people. The poorest die without treatment, or to seek treatment and push their family into people – those who can least afford poverty. Those who suffer from long-standing chronic diseases are in the cost – spend the greatest pro- the worst situation, because the costs of medical care are incurred over portion of their income on medical a long period of time (34). On average, they spend 25% of their annual income on private care, compared with 4% in high income groups (31). Spending money on tobacco deprives people of education opportunities that could help lift them out of poverty and also leads to greater health-care costs. Indirect costs on food instead, saving the lives of 350 include: children under the age of ﬁve years each day. The poorest households in Bangla- » reduction in income owing to lost productivity from illness or death; desh spend almost 10 times as much on » the cost of adult household members caring for those who are ill; tobacco as on education (37). However, in low and middle users but belong to households that use income countries disability insurance systems are either underdeveloped tobacco (38). In the United Kingdom, the average cost of monthly health insurance pre- The illness of a main income earner in low and middle income countries miums for a 35-year-old female smoker signiﬁcantly reduces overall household income. People who have chronic is 65% higher than the cost for a non- diseases are not fully able to compensate for income lost during periods smoker. Male smokers pay 70% higher of illness when they are in relatively good health (36). Households often sell their possessions to cover lost income and health-care costs. In the short term, this might help poor households to cope with urgent medical costs, but in the long term it has a nega- tive effect: the selling of productive assets – property that produces income – increases the vulnerability of households and drives them into poverty. Such changes in the investment pattern of households are more likely to occur when chronic diseases require long-term, costly treatment (36). But one thing she clearly remembers is that each time she returned home without receiving adequate treatment and care. Name Maria Saloniki Today, this livestock keeper and mother of 10 children is Age 60 Country United Republic ﬁghting for her life at the Ocean Road Cancer Institute in Dar of Tanzania es Salaam. It took Maria more than three years to discover the Diagnosis Breast cancer words to describe her pain – breast cancer – and to receive the treatment she desperately needs. In fact, between these ﬁrst symptoms and chemotherapy treatment, Maria was prescribed herb ointments on several occasions, has been on antibiotics twice and heard from more than one health professional that they couldn’t do anything for her. The 60-year-old even travelled to Nairobi, Kenya to seek treatment, but it wasn’t until later, in Dar es Salaam, that a biopsy revealed her disease. Maria’s story is sadly common in the understaffed and poorly equipped hospital ward she shares with 30 other cancer patients. Her husband, who now works day and night to pay for her medicine and feed their children, can’t afford both the treatment costs and the bus fare to come and visit her. To compensate for the lost productivity of a sick or disabled adult, children are often removed from school; this deprives them of the opportunity to study and gain qualiﬁcations.
Mairal Failure on the steps of simulation generic atrovent 20 mcg fast delivery, planning and delivery of radiation dose in radiotherapy — A reality in clinical practice L atrovent 20 mcg without a prescription. Radiation dose to paediatrics during chest and abdomen X ray examinations at Muhimbili National Hospital (Tanzania): Initial results W buy atrovent 20 mcg cheap. Muhogora Safety education and training in radiation protection for medical workers — A developing country’s experience M. Paci Awareness and attitude of radiographers towards radiation protection in Bangladesh S. Rao Argentina’s situation in tomography and the use of reference levels as a tool to optimize dose in procedures R. Sapiin Adherence to radiation protection rules and procedures in developing countries — A case for Uganda M. Seguya Overview of occupational radiation protection of medical workers in Estonia 2001-2011 J. Shubina Evolution of regulations to ensure radiological safety in diagnostic radiology — Practice in India A. Sonawane Strategy of Indonesia’s nuclear energy regulatory agency to control patient dose in the utilization of radiology diagnostic equipment A. Sutrisno Results of a national program of radiation protection of patients conducted by the relevant medical societies (8 years’ experience) R. Akahane Managing radiation protection and safety in the hospital — Success factors and challenges A. Almén Estimation of population doses from diagnostic radiological and nuclear medicine procedures: A tool for authorities to promote justification and optimization R. Bly Individual radiosensitivity and increasing medical doses: Two serious risk factors for patients M. Bourguignon First results of population dose assessment from X ray and nuclear medicine examinations in Serbia O. Guibelalde Education and training in radiation protection for health care professionals — A survey in Finland R. Pesznyák Methodology and inaccuracies in the estimation of collective effective dose from diagnostic and interventional procedures in a university hospital E. Setting the Scene for the The conference was held in Bonn, 3–7 December 2012, and aimed, in particular, to: Next Decade • Indicate gaps in current approaches to radiation protection in medicine; • Identify tools for improving radiation protection in medicine; • Review advances, challenges and opportunities in the ﬁeld of radiation protection in medicine; Proceedings of an • Assess the impact of the International Action Plan for the International Conference Radiation Protection of Patients, in order to prepare new international recommendations, taking into account newer 3–7 December 2012 developments. It resulted in the Bonn Call for Action, which will focus efforts Bonn, Germany in radiation protection in medicine in the next decade, and maximize the positive impact of such efforts. Key: b Ref: Myocardial Infarction (591) Davidson’s Principles and Practice of Medicine. A thirty five year old man presents in a clinic with history of chronic productive cough that is worse in the morning and brought on by changes in posture. Key: b Ref: Bronchiectasis (Page 684) Davidson’s Principles and Practice of Medicine. Key: c Ref: Adverse Reaction of First Line Anti Tuberculosis Drugs (Page 702) Davidson’s Principles and Practice of Medicine. A fifteen year old boy who is diabetic presents with pain abdomen, vomiting and shortness of breath. Key: a Ref: Diabetic Ketoacidosis (Page 820) Davidson’s Principles and Practice of Medicine. A ten year old boy gives history of swelling of body starting from face and more on getting up in the morning. On examination his blood pressure is normal, pallor is absent and jugular venous pressure is not raised. Key: e Ref: Nephrotic Syndrome (Page 480) Davidson’s Principles and Practice of Medicine. A young girl comes in the cardiology ward with history of breathlessness and palpitations for last one year. After auscultation of precordium cardiology registrar makes diagnosis of mitral stenosis. The most important sign on which this diagnosis is based is: a) Ejection systolic murmur. Key: b Ref: Mitral Stenosis (Page 619) Davidson’s Principles and Practice of Medicine. Key: a Ref: Rheumatic Fever (Page 618) Davidson’s Principles and Practice of Medicine. An old lady presents with history of fever and left sided chest pain for one month. Examination of respiratory system shows decreased chest movements, stony dull percussion note and absent breath sounds on left side. Key: d Ref: Clinical Exam of Respiratory System (Page 649) Davidson’s Principles and Practice of Medicine.
Translating information about genetic risk of disease into focused prevention 20 mcg atrovent for sale, such as gene therapy discount atrovent 20mcg online, that extinguishes disease risk at the molecular level effective atrovent 20mcg, remains a daunting scientiﬁc and technical challenge. However, one hundred years will not have to pass before genetic information reshapes healthcare. This signature is then 16 Digital Medicine compared to computer libraries of known strains of the virus that are susceptible or resistant to various drugs in the therapeutic cocktail. By tailoring the elements and dosages in the cocktail to the genetic signature of the virus, far more rapid and efﬁcient clearing of the virus has been achieved. Giving the drug to patients whose cells do not display this receptor means wasting $20,000 on a drug with no clinical effect. Many new drugs will be approved in the next few years conditional upon a genetic test to determine if the therapy is likely to be effective. These uses represent only the beginning of a new era of personal- ized, genetically customized medicine (Figure 2. Within a decade, the genetic signature of a pathogen such as a virus or a cancer cell may form the basis for fabrication of customized therapies, such as vaccines, speciﬁcally targeted at that pathogen. Clinical laboratories will use genetic information to identify targets on the cell surface or in the nucleus of the pathogen that can be blocked by antibodies or by agents that retard or prevent dangerous genes from expressing in the ﬁrst place. Progress in gene therapy has been ham- pered, however, by the vigor of the immune response to new genetic material introduced into the body, as well as by an inability to target new genetic information to the right places in the genome. Control over expression of disease-causing pathogens or genes may be a more achievable goal than inserting the “correct” genetic information. This curative role will be the result of molecular infor- mation technologies—microarrays and computerized cell sorting, principally—focused on acquiring genetic information about the patient and the pathogen. Pathologists will also ﬁnd themselves competing in genetic diagnosis with the radiologists as they develop molecular imaging technology. Impact on Health Systems The ability to use genetic information to guide and craft therapy will become a key differentiator of hospitals and health centers within the next decade, much as open-heart surgery was during the 1970s. Personalized medicine based on genetic testing represents the leading edge of a huge new service opportunity for our nation’s health system, as well as a powerful tool set for making drug therapy safer and more effective. Previously, the output of these analyses was paper notes with line drawings, x-ray ﬁlm, and pathology slides. Today, the analyses are in digital form, and the results can be stored, retrieved, and sent electronically. Diagnostic results will ﬂow seamlessly through the so-called “electronic medical record” into structured and timely recommendations to the care team. Clarke once said that at some level of sophistica- tion, technology is indistinguishable from magic. Flow Cytometry Flow cytometry enables a laboratory technician to count and sort individual cells ﬂowing through a highly pressurized thread of water up to a rate of up to 70,000 cells per second, plucking single cells of interest (each less than one-twentieth of the width of a human hair) out of the stream with magnetic pulses and dropping them into wells in a laboratory tray. This remarkable speciﬁcity is made possible by computerized interpretation of the diffraction patterns of a laser beam passing through the thread and bouncing off individual cells. The scat- tered light reaches electronic plates positioned around the stream, which record the pattern of light as digital information. Using a computer-controlled magnetic pulse, the operator can pluck speciﬁc cells from the stream for further analysis. Flow cy- tometry is powerful enough to detect, for example, fetal cells in a 20 Digital Medicine sample of the mother’s blood and extract them without the need for invasive and sometimes dangerous amniocentesis. It can also count and categorize cancer cells by their shape or the constellation of receptors on their surface. If this becomes possible, ﬂow cytometry will be the tool hospitals use to ﬁnd stem cells in the blood. These cells will be cultured and redirected to therapeutic levels for treating diseases like Parkinson’s, diabetes, or spinal cord injury. Because they are cultured from an individual’s own cells, the recipient will not require a lifetime of immune suppressants to enable them to do their work. In all cases, the signals are detected by digital arrays and converted to digital information structured and stored by computers. These technologies, revolutionary when they were developed, made noninvasive evaluation of tissues and internal organs possi- ble, tilting diagnosis decisively away from exploratory surgery (and tilting power and clinical inﬂuence toward radiology). These images can reveal the extent of damage to the heart or brain from a heart attack or stroke and help determine if a tumor has been destroyed by radiation or chemotherapy. In addition, the capability of diag- nosing the type of lesion has increased by 40 percent. With molec- ular imaging, these technologies will actually be able to identify real-time cellular changes or gene expression patterns that preﬁgure disease. In the 30 years since they were invented, there has been a logarithmic growth in the computing power of a microchip. This growth in computing power was predicted by Gordon Moore, one of the founders of Intel, in 1967. In one of the most extraordinary (self-fulﬁlling) predictions in the history of technology, Moore said that the power of a microchip would double every 18 months with cost remaining constant (Figure 2. More powerful computing engines mean more rapid acquisition of images and more options for manipulating and reconstructing these images.