By E. Vandorn. High Point University. 2018.
The results can be used to select priorities for clinical audit and optimization actions generic 160mg super avana fast delivery. Experience shows that it is beneficial to engage stakeholders (professionals super avana 160 mg low price, institutional representatives, users) in developing methodology for clinical audits focusing on processes and outcomes. Of equal importance is the cooperation between authorities and professionals when establishing clinical audits. Quality assurance, education and training, and the development of a radiation safety culture Radiation protection is embedded in everyday clinical practice and is part of overall standard procedures. Radiographers have an important role in medical radiation protection; it is important that their education and training meets high standards. There is a strong need for increased cooperation between education and training organizations and employers. Adherence to dose reduction should be rewarded through accreditation and communication. Education to achieve a culture of radiation protection should go hand in hand with promoting justified use of radiation based examination. Risk management measures reduce the potential or even prevent unintended exposures and they are, 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. Concern has been raised about the fact that there is little to no access to imaging techniques in developing countries. Access to high quality and safe radiotherapy is particularly essential for countries with low and medium income. Low and medium income countries represent 85% of the world’s population but only one third of radiotherapy treatment facilities are operated in these countries. Owing to improvements in hygiene and life expectancy, it is assumed that over the next decade the increase in cancer incidence in low and medium income countries will be about twice as high as in high income countries. There is an urgent need to develop and provide these countries with equipment for basic imaging and treatment. Training must go hand in hand with improvements in access to proper/ basic medical imaging. James’s Hospital, Dublin, Ireland f Expert Pro-Rad srl, Bucharest, Romania g French Nuclear Safety Authority, Paris, France Abstract The recently proposed revised Euratom Basic Safety Standards, while based on existing legislation in Europe, provide several important amendments in the area of radiation protection in medicine. These include, among others, strengthening the implementation of the justification principle and expanding it to medically exposed asymptomatic individuals, more attention to interventional radiology, new requirements for dose recording and reporting, an increased role of the medical physics expert in imaging and a whole new set of requirements for preventing and following up on accidents. The changes will bring further advances in radiation protection of patients across Europe but may pose some challenges to Member States, regulators and clinical professionals, who have to transpose them into national law and everyday practice. Those challenges are discussed in this paper and some suggestions for dealing with them are made, wherever allowed by the format of the relevant meeting. The need for further developments going beyond the revision of the Euratom (European Atomic Energy Community) legislation and requiring cooperation on national and European level has been clearly identified.
These are presented in the first section of Table 1 and are discussed more fully elsewhere [2 super avana 160mg with mastercard, 3 160mg super avana with amex, 9]. The three principles/values are found to be universally accepted and relatively culture independent. It is reasonable to assume that this can be transferred to radiology, which also requires a globally acceptable high recognition value system [2, 3]. There are additional problems in radiology, particularly those arising from communicating and managing the incomplete knowledge and uncertainty about risk we have in respect of both patients and the public. These also need to be addressed in the context of clear values with an ethical content. This gives rise to two additional values which are widely, but possibly not universally, subscribed to [3, 4]: — The precautionary principle, often referred to as Pascal’s wager; — Openness, transparency and accountability. The precautionary principle requires that we act prudently when we have to act out of incomplete knowledge, an approach that appears to be consistent with the wisdom literature of all cultures but at variance with medical radiation damage skeptics [3, 10]. Utilitarian principle See text There is a significant demand for radiological screening of asymptomatic patients for latent disease. Generally, when such programmes are formally approved by governments or by professional bodies, it is on the basis that more good than harm for the greatest number of people will result. This is most easily justified on the basis of the utilitarian principle, which seeks the greatest good for the greatest number of people [2, 3, 9]. Values 4–6, and particularly 5, are not as culture free as the three basic principles. They are the means of ensuring that those referred for radiological examinations really need them, i. These are briefly introduced here and the effectiveness of these interventions is discussed elsewhere [1, 6]. The three As: Appropriateness and referral guidelines Referral guidelines for diagnostic and interventional radiology have been in existence for 20 years and have been published by the European Commission and in Australia; Canada; Hong Kong, China; New Zealand; the United Kingdom; the United States of America and elsewhere. Today’s guidelines are increasingly evidence based, are intended to support decision making and are not prescriptive. Guidelines will assist in avoiding: repeat investigations; investigations when results are unlikely to affect patient management; investigating too early; the wrong investigation; and over-investigation. The effectiveness of guidelines can be greatly enhanced by involving the relevant stakeholders at all stages. It is essential to develop and disseminate guidelines suitable for global application, and regional/local adaptation; and to ensure resource or intellectual property issues do not unduly inhibit this. Including guidelines in information technology embedded order entry/decision support algorithms can be advantageous. The three As: Audit (clinical) Most countries seek to establish transparent, tangible procedures for managing quality in health care. A key element of this is clinical audit, which has been applied to many health care practices but has been slow to find its place in imaging. To assist States with implementation of these requirements, the European Commission prepared guidance on clinical audit in radiology . The approach is flexible and will enable the Member States to adopt a form of clinical audit consistent with their national arrangements. Justification is a cornerstone of radiation protection and should be among the top priorities in the audit programme. The audit of the compliance with guidelines can be a simple and effective tool for improving justification, appropriateness and referral patterns. The three As: Awareness and improved communication It is obvious that awareness about radiation dose and risk is poor among physicians in all parts of the world, irrespective of specialty. Simple, effective and scientifically more acceptable approaches have been proposed. These initiatives produce clear information on risk that acknowledges uncertainty and is readily accessible. For day-to-day use in clinical environments, a scale based on the equivalent number of chest X rays, or that state risk without citing dose, is likely to be adequate. Picano’s graphical approach to dose and risk for different patient groups (including children, adult males, adult females and the elderly) has much to recommend it . Finally, clear transparent public education programmes are essential, where imaging services are marketed directly to the public and to the worried well. This conference devoted a full session to it and recognized it as a major area for attention during the coming decade. The approach derives from an analysis of justification based on ethical considerations. However, the justification may also benefit from approaches that seek to reduce overutilization based on health economic or health technology assessment grounds. There are several compelling reasons: first, it is universally accepted that a significant percentage of imaging worldwide is inappropriate, with both over- and underutilization.
While becoming blind or deaf at the age of 65 was dealt with by summary fine buy super avana 160 mg free shipping, serious disease in a younger person earned a stiff prison sentence discount super avana 160 mg on line. On the other hand, arsonists or cheque forgers were sent to hospital and treated at public expense. It is not uncommon to see paedophiles labelled as diseased and getting more medical attention than their victims. A perusal of medieval penitentiaries would help to disabuse anyone of such a naive notion. As the rules of the power game strongly favour authority against individuals, constant vigilance against renewed threats to freedom (often deceptively described as the enhancement of freedom) is required. In the theocratic state, God was the highest authority, with absolute power vested by proxy in priests. And what escaped the surveillance of the priests was recorded by the celestial police in the Book of Life, or so the believers were told: The Judge Himself holds the book, in which every deed and desire, nay every word and thought of the dead has been written down. Without having touched a pen or held a book, without every having dictated a line or sealed a charter, every time he enters the church door, the faithful is reminded that, even with his most secret thought, he writes the text of his life, by which he will he judged on 75 that ominous day. Every person, without realising it, writes his or her own dos- sier, where every deviation from the norm is recorded at regular screenings. The doctor, the employer, the insurance company and the police hold (or soon will hold) in their interlinked computers all the information required, according to which the person will be judged when applying for a job, 166 Coercive medicine seeking medical care, applying for medical insurance, intending to travel abroad or wishing to procreate. With healthism as a state ideology, the blueprint for the iatrocratic state exists. Stakhanov was hailed as a national hero and held up as a glorious example to all Soviet workers. The search for the perfect Stakhanovite worker, abandoned in communist countries, has now been adopted by employers in Western democracies. By 1988, some two million lie-detector tests had been administered to job applicants, but Labour Department regulations subsequently restricted the prac- 77 tice. The detection of nicotine metab- olites in urine, even if the person does not smoke on the job, 79 may preclude promotion or a permanent employment. Thus for example, British Rail announced that from October 1993, 90,000 workers could be ordered to have a breath test for the presence of alcohol, even in jobs where safety was not an issue. A reading between 30 and 80 milli- grams (the driving limit is 80 milligrams) would result in 81 disciplinary action. On a minor scale, bureaucrats are given a free hand to exercise their power in persecuting smokers. On the univer- sity campus in Belfield, Dublin, heads of departments were circulated on October 28, 1991 with a memo issued by the college safety officer, who had seven degrees behind his name. Taxpayers provide remuneration and travelling expenses for these Nosey Parkers sneaking around the corridors of the University, sniffing out incrimin- ating evidence. In Britain, the 67-year-old landlord of an award-winning pub received a final written warning from the local Environmental Health Officer to stop smoking his pipe when pulling pints or to face a £5,000 fine and/or three 82 months in jail. The resulting report by the Office of Technology Assessment, revealed that a large number of major companies were planning to use it or had already done so. According to a report in Science, the advocates of genetic screening pointed out that the principle 83 of pre-employment screening was not new. In 1938, in Baltimore, for example, workers were tested for syphilis (by a grossly unreliable test) 84 and refused employment or sacked. With the breakdown of traditional con- fidence and professional secrecy, it is relatively easy for insurance companies to obtain relevant information on potential clients. And he expressed concern that many scientists now accept as ethical the cost-benefit calculations by employers or the insurance industry, which justify their exclusionary practices. A scandal erupted in England a few years ago when Asian immigrants had to prove their virginity. In Germany, women returning from abroad were interrogated when under suspicion that they had obtained an abortion. The first compulsory mass medical screening was, in fact, carried out by immigration authorities. As one inspector recalled, diag- noses were made rather casually, 170 Coercive medicine Deep lines about the mouth seemed to go with hernia, drooping lids pointed to trachoma or something like it, a certain pallor called for a careful examination of the heart, and the glint of eyes suggested tuberculosis. It is easy to imagine that genetic tests, identifying individuals prone to violence, mental disease and other socially unacceptable characteristics, will, in the future be required before being allowed to cross the border. Medicine, competing with theology, offers apparently scientific, and thus more credible, answers to the vagaries of human fate. Timeless philosophical debates about free-will versus determinism and heredity have been taken over by lifestylism and gen- etics. The political manipulation of these two, mutually exclusive, positions allows preventionists to claim in one breath that people have control over their health and mental equilibrium by adopting a healthy lifestyle, and that the risk of most diseases can be detected by genetic screening. In 1882 at the International Medical Congress in Vienna, Dr Benedict exhibited 50 brains of executed criminals on which he demon- 90 strated typical features of criminality. At a congress of criminal anthropologists in Paris, the discussion centred on the question of whether the criminal is a helpless victim to anatomical character and should therefore be exonerated from responsibility for his acts on the grounds of brain dis- ease, and offered treatment in a hospital for mending morals, rather than being punished.