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As we will see gluten causes erectile dysfunction trusted cialis extra dosage 200mg, there are some elements of the skeleton that must be present for some diseases to doctor who treats erectile dysfunction purchase cialis extra dosage 60mg without prescription be diagnosed erectile dysfunction treatment in singapore effective cialis extra dosage 100 mg, irrespective of how suggestive signs elsewhere may appear hypogonadism erectile dysfunction and type 2 diabetes mellitus buy 50mg cialis extra dosage mastercard. A small amount of periosteal new bone may be normal, especially on children’s bones, and 35 Those who wish to learn more about general pathology, and about the way in which modern pathologists look at diseases of the bones and joints should consult Ed Friedlander’s web site, This familiarity is achieved by examining dozens, preferably hundreds, of skeletons. The carpals and tarsals, and the occipito-axial and lumbro-sacral junctions of the spine are notable examples. There are also a number of other variants to be aware of, the so-called non-metric traits, including the septal aperture in the distal humerus or the sternal aperture36 which may be confused with pathological holes; the bipartite patella that may be confused with a patellar fracture; or the supra-condylar process on the medial side of the distal humerus, which might imply soft tissue trauma. Another trap into which the tyro may readily fall is to mis-identify those holes that normally appear in bone as manifestations of joint disease, or occasionally, malignant disease. There are many foramina in the base of the skull though which blood vessels and nerves pass, and the ends of the long bones may be perforated by dozens of holes allowing the access of blood vessels to the metabolically active trabeculae and bone marrow beneath the cortex. There may also be small cortical defects, especially on the concave aspects of joints. The proximal surface of the rst phalanx of the foot is a common site and is sometimes referred to as pseudo-erosions because they can be confused with true erosions that accompany some forms of joint disease (see Chapter 4). Pseudo-pathology: Calvin Wells (1908–1978) was active in palaeopathology during the 1950s, 1960sandearly1970s and for much of this period – certainly during the 1950sand1960s – he was one of only a handful of people working in the eld in the United Kingdom. Thus, he accounted for the greater number of cita tions in the palaeopathological literature. His over-interpretive style has now largely fallen out of fashion, especially among those palaeopathologists who require some 36 the sternal aperture presents a hazard for acupuncturists as an acupuncture point used for treating lung disease lies over the place where the aperture is usually found (in up to 10% of individuals). Inserting a needle through the aperture may well pierce the underlying right ventricle and blood pulsing up around the needle will not be a welcome sight to either patient or operator; deaths have been noted. I am grateful to Mrs Ann Beavis, herself an acupuncturist, for bringing this hazard to my attention. All must be recognised for what they are and not confused with true pathological changes. The synovial joints are the most numerous and the only ones commonly affected by disease. Some joints change their appearance with age and these changes are often used by phys ical anthropologists to help age a skeleton. The pubic symphysis and the auricular surface of the ilium are particularly useful in this regard. Inthistypeof joint the articulating ends of the bone are held in place by a capsule which is com posed externally of a layer of brous tissue that varies in thickness partly due to the attachment of ligaments of tendons. The capsule is well supplied with blood vessels, lymphatics and nerve endings which may extend down to the synovial membrane. The articulating ends of the bone are covered with cartilage which varies in thickness from 1–7 mm; it is thicker in larger than in small joints and in joints under considerable stress, such as those of the leg. The cartilage-forming cells (the chondrocytes) obtain their nutrients by diffusion from uid within the joint. Articular cartilage provides a moveable surface with an extremely low coefcient of friction, much less than that of two opposing Teon-coated surfaces. The bone immediately beneath the articular cartilage is referred to as the subchon dral bone plate and is usually made up of trabeculae that curve around the inferior surface of the cartilage. Immediately above subchondral plate there is a calcied zone of cartilage that is known as the tide mark. Forcomparison, the coefcient of friction of Teon, both static and kinetic, is 0. Types of joints Type of joint Properties Examples Suture Bone joined by connective tissue. Skull Immobile Syndesmosis Fibrous joint where articulating bones Distal tibiobular joint are joined by ligaments. Minor degrees of movement permitted by stretching of ligaments Gomphosis Special type of brous articulation xing Teeth teeth in the jaws Symphysis Bones joined by brocartilaginous or Symphysis pubis; brous connective tissue. Very small intervertebral disc; degree of movement permitted sternomanubrial joint Synchondrosis Temporary joints composed of hyaline Growth plates; cartilage existing only during growth neurocentral joint; phase of the skeleton. Eventually spheno-occipital joint obliterated by bony union Synovial Joints containing a synovial membrane. Large and small joints of the Fully mobile extremities; facet joints of spine; costovertebral and costotransverse joints; sternoclavicular joint All bone contained within a joint is covered with periosteum except for that covered by articular cartilage. The joint capsule is rmly attached to the periosteum and variable lengths of non-articular bone may be present within the capsule. The synovial membrane covers all structures within the joint except for the cartilage and the non-articular bone. It attaches around the rim of the cartilage, at the so called joint margin; the region of non-articular bone within a joint is called the bare area. The intima contains two types of cell, type A, which are like macrophages and probably have a phagocytic function, and type B that secrete hyaluronic acid which helps lubricate the joint. The function of the synovial membrane is to secrete synovial uid which provides nutrition to 2 Further details of the structure of joints can be found in any standard text book of anatomy. The knee joint contains the best known of these intra articular structures in the form of the menisci and cruciate ligaments whose injury is dreaded by all athletes. Three stages in this process can be recognised beginning with an enzymatic breakdown of the cartilage matrix. During this stage, the metabolism of the chondrocytes is affected, leading to the release of enzymes, including metalloenzymes, that further break down the matrix. The chondrocytes also release enzyme inhibitors but in insufcient quantities to counteract the prote olytic effect. During the second stage, the cartilage starts to brillate both horizontally and vertically. The surface of the cartilage becomes eroded, leading to the release of frag ments of collagen and proteoglycan (one of the constituents of the matrix) into the joint cavity. It develops in areas of the joint where the articular cartilage has been completely lost and bare bone rubs on bare bone to produce a surface as shiny as a billiard ball. These factors include age, genetics, sex, race, obesity and trauma and, most importantly, movement. Ageisimportant,and both incidence and prevalence increase with increasing age, such that, in extreme old age, there is scarcely anyone left with a completely normal set of joints. Various precipitating factors are shown, any number of which may interact to produce joint failure, the end result of which is the combination of pathological signs that is referred to as osteoarthritis. There is no means of knowing from the appearance of the joint which of the precipitants was the proximate cause. The heads of both femurs have been displaced from the acetabulum and false joints (pseudoarthroses) have formed on the iliac crest with the production of new bone and eburnation. The fact that eburnation is present shows that there was movement at the false joint and the individual was probably able to get around reasonably well. This may occur in the context of other joint diseases such as rheumatoid arthritis, or following trauma. Osteoarthritis does not necessarily produce signicant symptoms and there may be little correlation between the morphological appearances of a joint and the symptoms experienced by a particular patient. Osteoarthritis is uncommon under the age of about forty17 but the incidence and prevalence increases considerably thereafter. Osteoarthritis should never be used as an ageing criterion for the skeleton, however, as there are no other means to calculate age-specic prevalences which are necessary when comparing frequency between studies (see Chapter 13). There is also a form that particularly affects older women known as generalised osteoarthritis. Likewise, there is often little or no relationship between radiographic appearances and the signs or symptoms in a particular patient (I Watt, Bone disorders: a radiological approach, Balliere’s Clinical Rheumatology, 2000, 14, 173–199). Osteoarthritis of the patello-femoral compartment of the knee showing marginal osteophyte, eburnation and pitting on the joint surface. Scoring in the direc tion of movement of the joint is clearly seen on the eburnated area. The femoral head shows relatively little change, but the acetabulum is widened with a large collar of marginal osteophyte and new bone on the joint surface.

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The distinction between nucleus and anulus is clear impotence at 30 years old buy cialis extra dosage 50 mg with amex, and the disc height is normal young healthy erectile dysfunction cialis extra dosage 60mg free shipping, with or without horizontal b gray bands erectile dysfunction ka desi ilaj purchase 40 mg cialis extra dosage amex. The distinction between nucleus and anulus is unclear erectile dysfunction at the age of 24 buy generic cialis extra dosage 200mg, and the disc height is c normal or slightly decreased. The distinction between nucleus and anulus is lost, and the disc d height is normal or moderately decreased. Grading of disc degeneration Grade V: the structure of the disc is inhomo the grading is performed geneous, with a hypointense black signal on T2 W midsagittal fast intensity. The distinction between nucleus spin-echo images accord and anulus is lost, and the disc space is col e ing to Pfirrmann et al. Sagit tal T2 W and axial T2 W images in a different pa tient show disc extrusion (arrows)with compression oftheL5nerveroot(arrow heads) between the L4/5 disc and the ligamentum c flavum. Intraspinal tumor a Sagittal T1 W, b T2Wandc axial T1 W, d T2 W, and e contrast enhanced T1 W fat suppressed images. There is a contrast enhancing epidural mass (arrowheads) arising from the subperiosteal bone of the lamina of L2 with impression of the dural sac. T1 W image shows fatty degeneration (straight black arrows) of the adjacent multifidus and longissimus mus cles. There is a bone marrow signal change in the joint facet with hyperintensity in T2 and contrast enhancement in T1 (curved arrow). Epidural lipomatosis a Sagittal T1-weighted, b sagittal T2 W, and c axial T2 W images (at the L4/5 level) demonstrate an increased amount of epidural fat (curved arrows)ashyperintensetissueinallthreesequences. Theduralsac(asterisk)isnarrowedwithdefor mation and flattening in the axial image. Acute postoperative epidural bleeding a Sagittal T1 W and b T2 W, as well as c axial T2 W images at the L2 and d L4 levels, show postoperative epidural bleeding after decompression surgery. In the T1 W image, the bleeding (white arrowheads) is slightly hyperintense compared to the cerebrospinal fluid. T2 W images show different stages of bleeding with in part T2-hyperintense hyperacute bleeding (curved arrows) and T2-hypointense acute bleeding (black arrowheads). Contrast agents shorten Such agents are virtually always gadolinium chelates, which predominantly T1 relaxation times shorten T1 relaxation times. This means that there is increased signal on T1 W sequences wherever the contrast agent is accumulated (typically within vessels, hyperemic tissue, and joint spaces). Enhanced, fat-suppressed T1 W images are most useful [17, pathology 25, 31] in suspected cases of: spondylodiscitis epidural abscess or soft tissue infection neoplasm ankylosing spondylitis or other inflammatory rheumatologic disorders 238 Section Patient Assessment a c d Figure 9. Spinal infection a Sagittal T1 W, b T2W andc contrast enhanced T1 W fat suppressed images as well as d axial T1 W fat suppressed and e T2 W images in spondylodiscitis of the thoracic spine. There is collapse of one vertebral body and of the intervertebral disc (white curved arrow) and contrast enhancement within both vertebral bodies and within an epidural mass (arrows) with slight deformation of the dural sac. Inflammatory changes with abscess formation (arrowheads)canbeseeninthe paravertebral space. Additional Sequences Gradient-echo and fat-suppressed T2 W sequences are the two most commonly employed additional sequences. The “*”inT2*Wisemployedbecause pulsation artifacts the signal on these sequences is not only determined by T2 relaxation times but also by additional factors. The main reason to use such sequences is the reduc tion of pulsation artifacts within cerebrospinal fluid commonly present on T2 W images. These artifacts consist of hypointense regions which may obscure or imi Imaging Studies Chapter 9 239 tate abnormalities. They may for instance interfere with the diagnosis of vascular malformations and other filling defects within the subarachnoidal space. Gradi ent-echo images tend to provide excellent contrast between the cerebrospinal Gradient-echo sequences fluid on one hand and the spinal cord or discs on the other hand. Gradient-echo sequences additionally have disadvan and spinal cord tages such as marked susceptibility artifacts in the presence of metallic implants and fragments [33]. There are many different types of gradient echo sequences, depending on the manufacturer. These sequences are commonly used for screening in suspected abnor malities not seen on the standard sequences. Such motion is most pronounced in fluid (cerebrospinal and spectroscopy fluid, seroma). In normal cellular tissue such as the spinal cord or bone marrow are still evolving motion is restricted. Under pathologic conditions, different types of diffusion pattern can be observed. Diffusion imaging is most commonly applied to the brain for the assessment of ischemia. In the early phase, motion may be more restricted than in the surrounding tissue but increases with development of necrosis. In the spine, diffusion imaging has mainly been applied to bone, such as the differentiation of traumatic and pathologic (mainly tumor-related) fractures [52]. Proton (1H)-spectroscopy provides spectra of the many different compounds of the examined volume including the protons contained in water and body fat. In 1H-spectroscopy, ment of spinal disorders proton-containing compounds such as N-acetyl aspartate, creatine, and choline can be identified [8]. Spectroscopy is not limited to 1Hbutmayalsobeperformedwith other types of nuclei including phosphorus, sodium and others. The list of such devices typically cated in the presence of car includes: diac pacemakers and neuro cardiac pacemakers stimulators neurostimulators insulin pumps inner ear implants metallic fragments Metallic spinal implants the metallic implants used in spine surgery including pedicular screws are not are not a contraindication contraindications for imaging from the point of view of patient safety. These artifacts are caused by local distortion of the magnetic field by the metallic objects and appear as hypointense regions surrounding the implant. Pure titanium implants are less prone to susceptibility artifacts than steel alloy implants. Gener than stainless steel ally, spin-echo sequences cause fewer artifacts than gradient-echo sequences [26]. One possibility is the use of prism glasses, which allow the patient to observe the magnet opening. Susceptibility artifact and artifact reduction a Conventional anteroposterior and b lateral radiographs of a 43-year-old female patient several years after scoliosis sur gery in Th9 to L3 with implant rupture (bold arrow) in the level Th9/10. Imaging Studies Chapter 9 241 are often unable to stay motionless for the 20 min required for a standard exami nation. Hip flexion, which might relieve the patient’s pain, is only possible to a limited degree in most magnet designs. Initially, four detector rows were employed which were quickly followed by 16, 40 and 64 detector rows. If necessary, the patient can be moved in the crani ocaudal axis using a joystick, placed within the reach of the radiologist’s elbow or hand. In order to protect the patient and the radiologist from high radiation doses, low-dose imaging (lower mAs) is usually performed. In addition, a reduced number of pixels (reduced spatial resolution) and near-real-time image reconstruction algorithms are commonly used in order to reduce acquisition time [42]. This mineral density method is not commonly employed, however, for a number of reasons. Onthe other hand, this method is a projectional method and may overestimate bone density in the presence of spondylophytes. Typical imaging protocols in the cervical, thoracic, and lumbar, spine, as well as for the sacroiliac joints, are shown in Table 2. Such indications include: acute spinal trauma evaluation of spinal fusion planning of complex surgical procedures. These artifacts depend on the volume, orientation and atomic number of the implant. The 99mTc distribution at that time shows the activity of the osteoblasts and thus demonstrates bony turn over activity. Images acquired within a few minutes after the injection demon Imaging Studies Chapter 9 245 strate the vascularity of the tissue. Bone scintigraphy is mainly used as a screen Bone scan remains a skeletal ing tool because it demonstrates the entire skeleton in a single examination.

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Pediatrics Vertebral subluxations and other malpositioned articulations and structures have many possible causes impotence 40 years buy cialis extra dosage 50 mg with visa, one of which can often be the birth process erectile dysfunction treatment homeveda 200mg cialis extra dosage amex. According to erectile dysfunction after prostate surgery generic 60mg cialis extra dosage with mastercard Towbin erectile dysfunction treatment spray buy cialis extra dosage 100 mg, "The birth process, even under optimal controlled conditions, is potentially a traumatic, crippling event for the fetus. Mechanical stress imposed by obstetrical manipulation even the application of standard orthodox procedures may prove intolerable to the fetus. The view has been expressed clinically that most neonatal injuries observed in the delivery room are neurological. Gutmann found that 80% of the children he examined shortly after birth, or as infants, were suffering from "subluxation" of C1, causing all manner of conditions. Suh and others note that chiropractic care should begin at birth, when subluxation is likely to occur. Ressel advises that early chiropractic care is essential, as abnormal spine and nerve system habits (vertebral subluxation) are caused very early in life. Janse proposes that proper spinal health in the children of today will insure a better next generation. Geriatrics the care of elderly patients is a special responsibility of the doctor of chiropractic and requires appropriate additional attention to age-related factors and possible complications. Chiropractic care is a strongly indicated element in maintaining mobility in elderly patients and thus fostering a healthier physical profile as well as a more positive mental attitude. Furthermore, the drugless nature of chiropractic care assist senior citizens in avoiding the otherwise widespread drug-related complications of other forms of care related to the spine and nervous system -228 11. Care of the chronic pain dysfunction patient must be balanced between the extremes of reducing patient dependency on the chiropractor and providing maximum relief or reduction in symptoms whereby the patient will approach pre-injury productivity and self-worth. The rationale for chiropractic management in chronic pain dysfunction syndromes of articular origin is well established in the scientific literature. Chronic musculoskeletal conditions are frequently progressive and degenerative if inappropriately managed. A current search of the literature has not substantiated the scientific efficacy of the long term use of specific pharmaceuticals in chronic pain syndromes. Additionally, commonly used pharmacological agents may hasten the deterioration process if used inappropriately for prolonged periods. The doctor of chiropractic is uniquely suited to care for and rehabilitate the chronic pain patient without the use of drugs or surgery. Long term chiropractic management, when appropriately delivered, based on a case by case evaluation, provides benefits to the patient which are not addressed by any other health care discipline. The following neurophysiological and biomechanical principles support the rational for long term chiropractic management of the biomechanically compromised patient suffering from a chronic pain syndrome. Prevention of joint adhesions and subsequent proteoglycan degradation in the hyaline cartilage and intrinsic spinal ligaments. Multiple research universities have demonstrated that immobilized joints rapidly undergo cartilaginous degradation with deterioration of the hyaline cartilage surface, producing additional degenerative change and increased pathology. The neuroreceptive field is described as all the receptors which supply sensory input to the spinal cord and brain, from the skin, ligaments, muscles, and intrinsic joint structures in a given spinal segment level. Loss of normal function in a given spinal joint produces alteration of the receptive field with a loss of neural network connections, producing a deafferentation state and loss of central sensory integration, at the thalamocortical level. Appropriate chiropractic care provides neural input for the receptive fields and inhibits further loss due to deafferentation. When this nocifensive spasm is left unaddressed, metabolic depletion occurs producing an alteration of the muscle and ligament cytoarchitecture with infiltration of fibrotic tissue. Prolongation of the chronic pain stimulus produces nociceptive pools within the spinal cord which are easily recruited through seemingly insignificant exacerbations. Long term chiropractic management inhibits and frequently prevents excessive nociceptor pool facilitation in all but the most severely injured. Insuring proper articular coupled biomechanics in functional rehabilitation programs. Management of the patient in chronic pain may include chiropractic supervision of rehabilitation programs. Failure to recognize pathomechanical dysfunction within spinal articulations increases likelihood of exacerbation and progression of degenerative effects seen in the chronic pain patient. Biomechanical integrity of the spine and extremity articulations is essential to produce optimum rehabilitation success in these patients. The doctor of chiropractic must be acutely aware of the psychosocial motivation of the patient in chronic pain. A care regime which allows the patient to become excessively dependent on the doctor for psychosocial support, beyond the requirements of his or her impairment, is unacceptable. The need for long term care should be based on the presence of a condition/injury or illness which has been documented by peer acceptable criteria and has been determined to be permanent and/or progressive. The necessity of long term palliative or supportive care should accomplish one or more of the following goals in order to be considered necessary and appropriate: 1. The current body of research in this area supports the observation that initial degenerative changes are measurable within one week of the occurrence of vertebral subluxation and other malpositioned articulations and structures. Vertebral subluxations and other malpositioned articulations and structures, regardless of their origin, will initiate negative physiological changes. A chiropractor views the detection, location, control, reduction and correction of vertebral subluxations and other malpositioned articulations and structures during all levels of care to be vital toward the optimum expression of health. In order to ascertain the optimal elapsed time period between chiropractic office visits, the practitioner would then begin the process of decreasing or increasing visit frequency. Should the indicators for the presence of a vertebral subluxation and other malpositioned articulations and structures be imperceptible or absent, in the clinical opinion of the practitioner, office visit frequency would be decreased. At some point in this process, however, the indicators for the presence of a vertebral subluxation and other malpositioned articulations and structures may again be manifested, necessitating a chiropractic adjustment and a reassessment of visit frequency. Visit frequency, duration, and level of considerations may also be influenced by a number of factors in addition to clinical indicators. These include, but are not limited to: age, occupation, lifestyle, past history, genetic predisposition, spinal structure, number of subluxations present, chronicity, compromise of bony integrity and degree of patient compliance. The concerns of the public regarding health care have shifted to an active responsibility for their physical well-being. Scientific evidence identifies components of the vertebral subluxation and other malpositioned articulations and structures and may reveal physiologic changes that occur after the correction of the vertebral subluxation and other malpositioned articulations and structures. Moreover, it is observed clinically that dramatic changes may occur after the correction of a vertebral subluxation and other malpositioned articulations and structures. Vertebral subluxations and other malpositioned articulations and structures may occur during the birth process, therefore, it is imperative that chiropractic care should begin as soon as possible. Anrig-Howe C: Scientific ramifications for providing pre-natal and neonatal chiropractic care. Baiduc, H: How Chiropractic Care Can Promote Wellness, Northwestern College of Chiropractic. Banks B, Beck R, Columbus M, et al: Sudden Infant Death Syndrome: A Literature Review with Chiropractic Implications. Bonci A, Wynne C: the Interface between Sudden Infant Death Syndrome and Chiropractic. Cassidy & Wedge: the Epidemiology and Natural History of Low Back Pain and Spinal Degeneration, Kirkaidy-Willis W. Al: Chiropractic patients in comprehensive home-based geriatric assessment, follow-up and health protion program. Dishman R: Review of the Literature Supporting a Scientific Basis for the Chiropractic Subluxation Complex. Eriksen K: Correction of juvenile idiopathic scoliosis after primary upper cervical chiropractic care: a case report. Froehle R: Ear infection: a retrospective study examining improvement from chiropractic care and anlyzing for influencing factors. Haldeman S: the Neurophysiology of Spinal Pain Syndromes, inModern Developments in the Principals and Practice of Chiropractic, New York: Appleton-Century-Crofts, pp. Hildebrandt R: Chiropractic Physicians as Members of the Health Care Delivery System: the Case for Increased Utilization. Jamison J: Preventive Chiropractic and the Chiropractic Management of Visceral Conditions: Is the Cost to Chiropractic Acceptance Justified by the Benefits to Health Care

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Syndromes

  • If the medication was prescribed for the patient
  • Idiopathic thrombocytopenic purpura (ITP)
  • Improper use of crutches
  • Excessive bleeding
  • Do not eat or drink anything after midnight the night before surgery.
  • Severe abdominal pain
  • Speech difficulties
  • If you smoke, try to stop. Ask your doctor or nurse for help quitting.
  • Fecal incontinence
  • Fever

A multidisciplinary court of reviewers was also established erectile dysfunction drugs new 200mg cialis extra dosage mastercard, comprising ninety one nationally recognised oncology experts from the fields of medical impotence your 20s generic cialis extra dosage 200mg otc, surgical and radiation oncology impotence in diabetics buy cheap cialis extra dosage 100 mg, palliative care and oncology nursing impotence from stress cheap 40 mg cialis extra dosage amex. Reviewers who specialised in one or two particular tumour sites were sent only the relevant chapters. General radiation oncology, medical oncology, surgery and palliative care reviewers received all the chapters for review. Forty-two of the reviewers provided comments, with 43% of these reviewers being from a non-radiation oncology specialty. This resulted in 139 changes to the text, radiotherapy utilisation trees, epidemiological data or evidence cited including a number of offers of additional epidemiological data. The review also resulted in two major reconstructions of the radiotherapy utilisation trees for two tumour sites. The radiotherapy utilisation trees for breast and lung cancer have recently been published in international general oncology journals. Results the recommended overall optimal radiotherapy utilisation rate based upon the best available evidence was estimated to be 52. Tumour type Proportion of all Patients receiving Patients receiving cancers radiotherapy (%) radiotherapy (% of all cancers) Breast 0. Multivariate sensitivity analysis using Monte Carlo analysis indicates that the 95% confidence limits were 51. The tightness of the confidence interval suggests that the overall estimate is robust. This final estimate is remarkably precise despite uncertainty existing in relation to data for some indications for radiotherapy and occasional uncertainty between treatment options of approximately equal efficacy (such as radiotherapy, surgery or watchful waiting for early prostate cancer). The tight confidence interval may be explained by the fact that good quality data existed for the initial branches of the tree (for example, data such as tumour type and stage at presentation). Most of the uncertainty existed in the distal or near-terminal branches of the tree, and therefore affected only very small proportions of the cancer population and had little effect on the overall estimate. In addition, the effect of these variations was such that some would increase the overall utilisation rate while others would reduce it, so that to a large extent they cancelled each other. Applications of the Model the estimated overall optimal radiotherapy utilisation rate is 52. The model of radiotherapy utilisation developed in this project has many current and future benefits. In addition, the study has highlighted a number of controversies within cancer management that may have a moderate impact on this estimate and therefore may provide some priority to future research. The following recommendations are made regarding the potential applications of the model and the final estimate of optimal radiotherapy utilisation derived from it. Planning radiotherapy services on a population basis the radiotherapy utilisation rate can be used as a benchmark in planning future radiotherapy services. A readily adaptable model of the type described in this study will allow easy recalculation should cancer incidence or treatment recommendations change in the future. The model can be adapted for use in other populations that have differing distributions of cancers and stages at diagnosis, for example, in countries such as India where cervical cancer is much more common than in Australia. However, there are other uses for radiotherapy that are not included in this estimate and that will need consideration when planning radiotherapy resources. Radiotherapy has an established role in the management of non malignant conditions (benign tumours and non-cancerous conditions) as well as a role in the management of non-registered cancers such as non melanomatous skin cancers. The overall need for radiotherapy resources is difficult to estimate as the overall incidence for these conditions is unknown. However, it remains important to consider this additional workload in resource planning. In the absence of a reasonable estimate, it was considered appropriate to consider the actual workload of radiation oncology departments with respect to the above conditions. We therefore examined actual radiotherapy activity rates for non-malignant and non-registered cases. The William Buckland Cancer Centre in Victoria, reported on the case mix and outcomes of 9838 patients treated at the centre between 1992 and 2002. The treatment of non melanomatous skin cancers, heterotopic bone, benign neoplasms and other non-malignant conditions accounted for 12% of radiotherapy activity. It should be noted that some cases of skin cancer may be treated by kilovoltage radiotherapy, but in many centres electrons produced by linear accelerators are the only modality available to treat skin cancers. Taking a middle figure of 11% of cases treated by linear accelerators as an estimate of the proportion of non-notifiable conditions receiving radiotherapy, this can then assist in the planning of appropriate resources using the following calculations. For every 1000 cancer cases in a population: • 523 patients would need radiation as an optimal part of their management based upon the results of this project (calculated optimal radiotherapy utilisation rate of 52. This means that an estimated 654 courses of treatment will be required for every 1000 cancer patients diagnosed with a registered cancer. Table 2: Estimated optimal number of courses of treatment per 1000 registered cancers. Proportion Total Number of new registered cancers 1000 Number of patients requiring radiation 52. For a linear accelerator with an overall capacity of 450 courses per year, this non-registered cancer load would represent 50 courses. Estimating shortfalls between optimal and actual rates of radiotherapy utilisation and providing a benchmark for service delivery the radiotherapy utilisation trees that have been developed for each of the tumour sites are a diagrammatic representation of optimal evidence-based cancer care from a radiotherapy perspective. Epidemiological data from patterns of care studies will allow comparisons to be made between the actual rates of radiotherapy delivery and the evidence-based ideal rate. Further details can be determined by analysing the distributions of tumour stage, histology, age, performance status and other factors, in order to better define areas of discrepancy between the actual and ideal utilisation rates. Modelling the effects on the overall recommended radiotherapy utilisation rate of changes to a particular cancer incidence or changes in staging the TreeAge Data software used to construct the radiotherapy utilisation trees can readily modify the overall model should there be changes in the incidence of certain cancers, a change in the stage distribution or a change in therapy recommendations based on clinical trials. For example, if another country with a very different cancer incidence profile were to use the model then the only requirement to recalculate the optimal radiotherapy utilisation rate would be to alter the incidence of each of the cancers. Similarly, a change in stage distribution of cancer due to the development of superior staging investigations (such as the impact of Positron Emission Tomography on staging non-small cell lung cancer), or following the introduction of a screening programme could easily be incorporated into the model. Determining optimal rates and resources for other treatment modalities Throughout the course of this project, the methodology has been refined and improved upon. It could also be used to plan other services if criteria were known for the use of a particular service. For instance, if we knew the factors that predict the need for palliative care referral or genetics review, then resource planning could be assisted by calculating the optimal utilisation rate in a similar fashion to that described here for radiotherapy. Identifying areas of research that would have the greatest impact on radiotherapy service delivery As well as the research opportunities discussed above, this project has identified several potential future research activities that would directly impact on the accuracy of this model. A few of these general areas are discussed below: (a) Epidemiological studies – the construction of the radiotherapy utilisation tree has identified a number of areas where there is uncertainty about the proportion of patients with certain conditions and has highlighted the need for better data. The main areas identified as being sub-optimal are those near terminal branches of the utilisation tree and those identified as showing variation requiring sensitivity analysis. More meaningful data, particularly longitudinal population-based data, would be valuable in the following areas: the incidence of metastasis over time and by stage, and treatment for the more common cancers the proportion of patients who develop metastases to organs other than bone and brain, and the need for symptomatic control patterns of metastatic spread with time and the proportion of patients who develop metastases of differing types the proportion of patients who develop symptoms as an indication for palliative radiation treatment over time performance status and how this changes with relapse, and the effect of patient choice when two treatment modalities are considered similar in efficacy and are equally available. The main controversies identified in terms of their impact on the optimal radiotherapy utilisation rate are: • the role of radiotherapy (as opposed to observation or surgery) for localised prostate cancer • the role of radiotherapy for T4 colon cancer • the criteria for adjuvant radiotherapy for node-positive melanoma (need to be better defined) • the role of radiotherapy for positive margins post-prostatectomy (should be clearly determined) • the role of lymph node dissection for endometrial cancer • the role of surgery (versus radiotherapy) for localised bladder cancer. However, the utilisation tree does not assess whether the treatment intent would be palliative or radical, and does not predict the number of fractions of treatment that would be evidence-based, nor the complexity of the patient’s care. Various models of complexity have been reported in the literature that might be used in future studies so that even more accurate predictions of radiotherapy workload could be determined. Although the scope of this study is confined to exploring the optimal utilisation of radiotherapy (limited to external beam megavoltage radiotherapy) for notifiable cancers only, the overall estimate provides a useful tool for assisting in the planning of adequate radiotherapy resources. Based upon actual re-treatment rates of 25% and actual radiotherapy treatment rates for non-registered conditions of 11% of total linear accelerator capacity, we estimate that at least 1. Introduction Background Radiotherapy is an essential mode of cancer treatment and contributes to the cure or palliation of many cancer patients. Radiotherapy facilities have high capital costs and their operation is staff intensive. The planning of efficient, equitable radiotherapy services for a population requires a rational estimate of need. In this project we have undertaken to calculate such an estimate, based on the occurrence of each type of cancer, the evidence-based indication for radiotherapy in the treatment of each type of cancer, and the probability that radiotherapy will be chosen as a form of treatment. Previous reports from Commonwealth and State agencies have proposed that 50 percent of all new cases of registered cancer in Australia should be treated with external beam radiotherapy (1) (2-5). Although this figure is based almost entirely on expert opinion, it is currently accepted as the guide for estimating utilisation and is used to plan for the distribution and number of linear accelerators. However, its validity is questionable, it is not responsive to changing clinical indications, and it does not include an assessment of the rate of re-treatment (about 25% of radiotherapy cases are currently re-treated with radiotherapy) (5).

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