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Several subsequent publications have focused on providing guidance on specific topics order kamagra effervescent 100mg online, for example discount 100 mg kamagra effervescent with visa, Preventing Accidental Exposures from New External Beam Radiation Therapy Technologies [7], while others have been more general, for example, Radiological Protection in Medicine [8]. This training now needs to extend beyond those traditionally working in radiology departments as the number of non-radiological specialists using ionizing radiation is increasing, and this was addressed in Radiological Protection in Fluoroscopically Guided Procedures Performed outside the Imaging Department [10]. Working parties are reviewing areas of justification and reference levels for both diagnostic and interventional imaging. Technological developments in medicine continue at a great pace and it is a challenge to produce timely recommendations that deal with the associated radiological protection issues. In addition, there is an ongoing need to raise the awareness of radiological protection among the many health professionals who either use or request procedures involving ionizing radiation, often with little or no knowledge. Significant progress has been made in the radiological protection of patients since the Malaga conference. This has been due to the considerable efforts of individuals and many organizations. Despite the achievements, there is no place for complacency and it is the responsibility of all radiological protection and health care professionals to continue to make improvements that enhance patient safety. This forms part of a larger move to improve the system of benefit–risk assessment, which takes in three key steps: awareness, appropriateness and audit (the ‘three As’). Justification of medical exposures at three levels as identified by the International Commission on Radiological Protection (from Ref. Awareness of this assessment is frequently portrayed in the media as a cost issue but health professionals correctly see the bigger picture of good medical practice and radiation safety as the two main criteria for selection of the best test first, before cost effectiveness. The balance of health benefit against radiation risk in a justified medical procedure is almost invariably in favour of the benefit. Imaging referral guidelines have been available for over 20 years in Europe and have been advocated through a European Commission Directive [6]. Rapid developments in imaging technology and new advances in medical imaging required an update of the guidelines by the European Commission in 2003. The American College of Radiology’s Appropriateness Criteria [10] and Western Australia’s Diagnostic Imaging Pathways [11] provide evidence based guidance considering global evidence. Such guidance is also helpful to promote good medical practice and may improve cost effectiveness by facilitating the best and possibly only test first. Guidelines are aimed to be used by: — Referring practitioners: general practitioners, doctors-in-training and non-medically qualified health professionals. Barriers to the use of guidelines are common globally and include: — Overloaded knowledge base: ● Medical and technical advances often take priority for medical education; ● Competition for inclusion in curricula/continuing professional development; — Time challenged agenda: ● Erroneous belief that the fastest test with shortest waiting time is best. The role of clinical audit for monitoring guideline availability and use is promoted with advice on external audit [15] and suggestions of local internal audit [16]. Although there is potential for considerable quality improvement through clinical audit, this tool is still not uniformly used in all regions. Regional and national efforts include a European Commission sponsored guidelines project, and valuable collaborative campaigns in North America such as Image Gently [19] and Image Wisely [20], which have become global in interest and distribution. Undoubtedly, the success of future initiatives lies in collaborative global efforts such as the Global Summit for Radiological Quality and Safety in 2013 where the barriers, needs and solutions of the radiological community in both developed and under-resourced countries will be considered. In conclusion, justification is facilitated through imaging referral guidelines, implementation and uptake which may be enhanced with further tools such as clinical decision support systems. Future efforts for improved radiation safety through justification are aided by principles such as the three As: awareness, appropriateness and audit, with collaborative efforts for future success focused firmly on the ‘three Rs’: referrers, radiologists and regulators. Doctors/health professionals generally have poor awareness of the risks involved and consistently underestimate them. Knowledge of, and compliance with, guidelines for referral for common examinations is poor. The ethical background considerations to this situation are briefly reviewed and a strategy for improvement is proposed, i. It is easy to overlook justification and risk–benefit analysis in busy, technically excellent departments, in which the scale of practice verges on the industrial. The approach is fundamentally based on ethical considerations although financial and health technology assessment issues are also important [2–4]. The Nordic countries have endorsed the three As approach and the heads of the European Regulatory Competent Authorities have also expressed support for the approach. Thus, the role of ethics has been critically important in revisiting and rethinking the concept of justification in radiology [3]. It allows us to subject our assumptions to critical evaluation, and can provide an early warning system in respect of problems that might otherwise go undetected [3, 5, 6]. General considerations and core principles in medical ethics The thinking behind the current framework for radiation protection in medicine is to be found in core publications of the International Commission on Radiological Protection from some decades ago.

Some types of drugs specific to cultural groups cheap 100 mg kamagra effervescent with amex, such as kava and khat discount kamagra effervescent 100mg online, can also contribute to problems in the Australian setting and some individuals may have experienced torture, trauma, grief and loss, making them vulnerable to harmful use of drugs. In 2013, use of licit and illicit drugs was more common in people who identified as homosexual or bisexual in Australia than for those 68 identifying as heterosexual. However, priority drug types change over time and differ due to local circumstances. In addition to these priority drug types, jurisdictions should be aware of emerging trends or drugs with concentrated use in specific communities. These include image enhancing drugs (steroids) and volatiles (fuel, paint and aerosols). Poly-drug use is also a significant concern and strategies that address this can be very effective at reducing harm. Tobacco smoking also carries the highest burden of drug-related costs on the Australian 73 community. Australia’s implementation of a range of multifaceted tobacco control measures has been effective in reducing smoking rates over recent decades, with daily smoking for those aged 14 years or older declining in Australia from 24. Smokers are also having fewer cigarettes 74 per week (96 in 2013 compared to 111 in 2010). Challenges remain for tobacco, including addressing the inequality in smoking rates between some disadvantaged populations and the broader community. In addition, it is important to maintain low smoking rates and expand smoke-free areas to protect people from second hand smoke. Responding to the introduction of e-cigarettes is also a matter currently faced by Australian jurisdictions. In 2010, the cost of alcohol-related harm (including harm to others) was reported to be $36 billion. Alcohol is also 77 associated with 3,000 deaths and 65,000 hospitalisations every year. The costs of tobacco, alcohol and illicit drug abuse to Australian society in 2004/05. National Drug Strategy 2016-2025 31 While the burden of alcohol harms in the community remains high, some gains have been made. The proportion of people aged 14 or older who consumed alcohol daily declined between 2004 (8. The proportion of people exceeding the lifetime risk guidelines has reduced from 20. In the 2013 National Drug Strategy Household Survey, respondents were asked if anyone under the influence of or affected by alcohol had perpetrated verbal abuse, physical abuse or put them in fear in the preceding 12 months. Research suggests that there were 90 ‘one-punch’ deaths in Australia between the years 80 2000 to 2012. Stimulants can be taken orally, smoked, snorted/inhaled and dissolved in water and injected. Some of the harms that can arise from the use of methamphetamines and other stimulants include mental illness, cognitive impairment, cardiovascular problems and 81 overdose. This figure has remained stable since 2007, but is lower 83 than the prevalence recorded between 1998 and 2004. However, among those who use amphetamine, the use of the powder form of the drug decreased significantly from 51% in 2010 to 29% in 2013, while the use of crystal-methamphetamine more than doubled since 2010 (from 22% to 50% in 2013) amongst methamphetamine users. There was also a significant increase in the proportion of users consuming methamphetamine daily or weekly (from 9% in 2010 to 16% in 2013). In addition, 16% of Australians identified methamphetamine as the illicit drug of most concern to the community (an increase from 10% in 2012). Violent behaviour is also more than six times as likely to occur among methamphetamine dependent people when they are using the drug, compared to 84 when they are not using the drug. As the most widely used of the illicit drugs in Australia, cannabis carries a significant burden of 87 disease. In particular, cannabis dependence among young adults is correlated with, and probably 88 contributes to, mental disorders such as psychosis. The harms that can arise as a result of the use of pharmaceutical drugs 90 depend on the drug used, but can include fatal and non-fatal overdose. Harms also include infection and blood vessel occlusion from problematic routes of administration, memory lapses, coordination impairments and aggression. There has been a significant increase in the misuse of pharmaceutical drugs in Australia. However, Australia has seen an increase in the prescription and use of licit opioids. In particular, the supply of 85 Ministerial Council on Drug Strategy (2006) National Cannabis Strategy 2006-2009, Commonwealth of Australia, Publications Approval No.

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This illustrates how a classification system for disease that is divorced from the biological basis of disease can mislead and impede efforts to develop better treatments buy 100mg kamagra effervescent mastercard. Similarly buy kamagra effervescent 100 mg with mastercard, the health care industry in the United States depends on an accurate disease classification system to track the delivery of medical care and to determine reimbursement rates. Both of these communities rely on highly robust data collection practices to make decisions that can impact millions of individuals. In this context, a formalized nomenclature is essential for clear communication and understanding. Thus, two extensive stakeholder groups, represented on one hand by biomedical researchers and biotech and pharma, and on the other by clinicians, health agencies and payers, are widely perceived to be largely unrelated, and to have distinct interests and goals, and therefore taxonomic needs. This is unfortunate because new insights into human disease emerging from basic research and the explosion of information both in basic biology and medicine have the potential to revolutionize disease taxonomy, diagnosis, therapeutic development, and clinical decisions. However, more integration of the informational resources available to these diverse communities will be required before this potential can be fully realized with the attendant benefits of more individualized treatments and improved outcomes for patients. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 11 Figure 1-1: A) Different stakeholder communities are perceived to have distinct taxonomic and informational needs. B) Integration of information and a consolidation of needs could better serve all stakeholders. In 1910 educator Abraham Flexner released a report that revolutionized American medical education by advocating a commitment to professionalization, high academic standards, and close integration with basic science (Flexner 1910). The vast expansion of molecular knowledge currently under way could have benefits comparable to those that accompanied the professionalization of medicine and biomedical research in the early part of the 20th century. Creation of a Knowledge Network of Disease that consolidates and integrates basic, clinical, social and behavioral information, and that helps to inform a New Taxonomy that enables the delivery of improved, more individualized healthcare, will be a crucial element of this revolutionary change. The ability of current taxonomic systems to incorporate fundamental knowledge is also limited by their basic structure. Taxonomies historically have relied on a hierarchical structure in which individual diseases are successively subdivided into types and sub-types. This rigid organizational structure precludes description of the complex interrelationships that link diseases to each other, and to the vast array of causative factors. It also can lead to the artificial separation of diseases based on distinct symptoms that have related underlying molecular mechanisms. However, despite their remarkable genetic, molecular, and cellular similarities, these diseases are currently classified as distantly related. While this approach may have been adequate in an era when treatments were largely directed toward symptoms rather than underlying causes, there is a clear risk that continued reliance on hierarchical taxonomies will inhibit efforts—already successful in the case of some diseases—to exploit rapidly expanding mechanistic insights therapeutically. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 13 A further limitation of taxonomic systems is the intrinsically static nature of their information content. Moreover, the static structure of current taxonomies does not lend itself to the continuous integration of new disease parameters as they become available. This is particularly troublesome given that new data regarding the molecular nature of disease are becoming available at an ever-increasing rate. While the linearizations will be relatively static and hierarchical, the foundational layer is being designed to support multi-parent hierarchies and connections, and to be updated continuously. Importantly, the new classification will combine phenomenological characterization 45 of phenotype with genomic factors that might explain or at least distinguish phenotypes. Different lung cancers, for example, could be explicitly differentiated by genomic characterization. This is important because knowledge about the specific molecular pathways contributing to the biology of particular types of lung cancer can be used to guide selection of the most appropriate treatment for such patients. As discussed in detail in following sections of this report, the first stage in developing this Knowledge Network would involve creating an Information Commons containing a combination of molecular data, medical histories (including information about social and physical environments), and health outcomes for large numbers of individual patients. The Committee envisions this stage occurring in conjunction with the ongoing delivery of clinical care to these patients, rather than in specialized settings specifically crafted for research purposes. The second stage, the construction of the Knowledge Network itself, would involve data mining of the Information Commons and integration of these data with the scientific literature—specifically with evolving knowledge of the fundamental biological mechanisms underlying disease. Such a Knowledge Network of Disease would enable development of a more molecularly-based taxonomy. This “New Taxonomy” could, for example, lead to more specific diagnosis and targeted therapies for muscular dystrophy patients based on the specific mutations in their genes. In other cases, it could suggest targeted therapies for patients with the same genetic mechanism of disease despite very different clinical presentations. Most users would interact with these resources at the higher-value-added levels, the Knowledge Network and the New Taxonomy, rather than at the level of the underlying Information Commons. Investigators using the Knowledge Network of Disease could propose hypotheses about the importance of various inter-and intra-layer connections that contribute to disease origin, severity, or progression, or that support the sub-classification of particular diseases into those with different molecular mechanisms, prognoses, and/or treatments, and these ideas then could be tested in an attempt to establish their validity, reproducibility, and robustness. Validated findings that emerge from the Knowledge Network of Disease and are shown to be useful for defining new diseases or subtypes of diseases that are clinically relevant (e. However, in either case, the goal of basing the New Taxonomy on the Knowledge Network of Disease will be to improve markedly the quantity and quality of information that can be used in biomedicine for the basic discovery of disease mechanisms, improved disease classification, and better medical care.

To view disease management as separate to other forms of land and wildlife management ensures that opportunities for good disease prevention will be missed discount kamagra effervescent 100 mg on line. Wetland managers are the key stakeholders in delivering healthy wetlands and purchase 100mg kamagra effervescent with visa, as such, all efforts should be made to integrate disease management thoroughly within wetland site management plans and other stakeholder activities at wetlands. Invasive alien species of flora and fauna are considered the second biggest threat after habitat loss and destruction to biodiversity worldwide, the greatest threat to fragile ecosystems such as islands, and are a major cause of species extinction in freshwater systems. Climate change may also exacerbate the spread of non-native species as warmer temperatures may allow currently ‘benign’ non-native species to potentially extend their ranges and become invasive. Invasive species impact native species in a wide range of ways, including competition, predation, hybridisation, poisoning, habitat alteration and disease. With respect to the latter, invasive alien species can carry novel pathogens non-symptomatically, to which native species may have no natural immunity. Crayfish plague], and amphibian chytridiomycosis carried non-symptomatically by introduced species such as American Bullfrogs Lithobates catesbeianus causes population declines and plays a role in amphibian extinctions [►Section 4. There are many parallels between prevention and control of invasive alien species, and of infectious diseases, such as the proactive measures of: Risk analysis and assessment ►Section 3. Communication, education, participation and awareness Training regarding management of those species ►Section 3. In general, to apply the concept of wise use and maintain biodiversity and ecological function i. Although a good understanding of disease dynamics is needed for the most effective proactive disease control strategies, there are some basic generic principles which, if implemented, are likely to reduce risks of disease emergence. For example, strategies for biosecurity (including prevention of introduction of invasive alien species), reduction of stresses on hosts and environment, and prevention of pollution, will bring obvious health benefits. Table 2-1 provides a list of proactive practices for disease prevention and control and the locations of further information in Chapter 3. Practice Section of Manual for further information Healthy wetland management Wise use of wetlands Site-specific risk assessments ►Section 3. Reactive strategies may include determining an evidence base, conducting surveillance, animal movement restrictions and instigating various other control measures. Reactive strategies for complete disease eradication may involve substantial intervention. With such a wide variety of wetland stakeholders, it is important to appreciate that there is the potential for differences in opinions over reactive disease control strategies and thus cross-cutting education, awareness raising and communication about these activities is advisable, particularly where rapid responses to disease emergence are required. Practice Section of Manual for further information Utilisation of multidisciplinary advisory groups in response to ►Section 3. Their application is illustrated in the case studies throughout the Manual and in the ‘Prevention and Control in Wetlands’ sections of the disease factsheets in Chapter 4. Wetland users do not need to become disease experts but communication and awareness raising programmes should aim to increase motivation to become engaged and ‘do the right thing’, with respect to disease management. This will likely only come from becoming informed about the problem, understanding the issues and implications, and participating in the solutions. Developing capacity to undertake disease management may involve formal education and training of key personnel e. Communication networks of key wetland stakeholders, including disease control authorities, should be established in ‘peacetime’ to facilitate rapid disease control responses should the need arise. This Manual aims to provide some of the information as a foundation for communication and public awareness programmes. The concept of ‘One World One Health’ has arisen due to the appreciation of the fundamental connectivity in health of humans, domestic livestock and wildlife. Embracing an ecosystem approach to health in wetlands involves recognising the dependence of health and well-being on ‘healthy wetlands’ which can only be achieved through wise use, most often at a landscape and/or catchment scale. If wetland stakeholders understand both the impacts of diseases and how to prevent and control them, they will feel motivated and empowered to take action. Stakeholder understanding must be built through effective communications or training but action will also be influenced by capacity to respond. To view disease management as separate to other forms of land and wildlife management ensures that opportunities for good disease prevention will be missed. Therefore, integrating disease management into wetland management means putting disease consideration at the heart of the wetland management planning process. Effective management of any disease is dependent on a good understanding of its epidemiology and the ecology of host populations. The dynamics of disease in wildlife populations can be highly complex, and disease management interventions can have unpredictable outcomes. Invasive alien species and novel pathogens and parasites have many parallels in their biology, the risks they pose, and in the measures required to prevent their establishment and control. Prevention of their introduction is preferable to subsequent control, and wetland management practices aimed at prevention of any of these can provide additional benefits and protection from all. In: Global biodiversity mechanisms: a thematic review of recent developments and future evidence needs. Rinderpest and peste des petits ruminants: Virus plagues of large and small ruminants (Biology of Animal Infections). Healthy wetlands, healthy people: a review of wetlands and human health interactions.

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