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Each anxiety and depression (Field et al 1992 purchase cefdinir 300mg antibiotics to treat acne, Fraser & Kerr intervention is considered against this background purchase cefdinir 300mg with mastercard antibiotic 54 312, 1993 cefdinir 300 mg sale antibiotic you cant drink alcohol, McKechnie et al 1983, Meek 1993). Hay puts forward a self-healing framework one of the significant risks in medicine is that of for exploring the emotional states associated with the omission – not doing enough, or not having enough specific ailment, and then suggests affirmations to knowledge to act on the patient’s condition. As • Acupuncture discussed in this chapter, therapeutic choices should • Gentle passive exercise (see Chapter 9) reflect the individual’s current levels of vitality or • Functional/indirect manual methods (e. The more robust the person, the greater release methods, see Chapter 7) the therapeutic load that can be safely managed without negative consequences. Conversely, the more frail, and • General non-specific mobilization (see Chapter 8) the greater the current adaptive burden, the lighter and • Soft tissue/myofascial release/muscle energy/ less invasive should be any therapeutic input. Carlos Cesarman, Santa Cruz, Mexico It should be recalled that all therapeutic interven- Aust G, Fischer K 1997 Changes in body equilibrium tions, however minimal, represent an adaptational response caused by breathing. A posturographic study load for the individual’s system to respond to (this is with visual feedback. Balaban C, Thayer J 2001 Neurological bases for This makes therapeutic choices critical: matching balance–anxiety links. Annual Review of involved – a key element in decision-making (see Nutrition 22:309–323 Box 4. Mediation of anorexia by human recombinant tumor Placing these concepts in context for students and necrosis factor through a peripheral action in the rat. Journal of Pain and Symptom of Osteopathy Journal 7(4):25–29 Management 17:65–69 Chaitow L 2004 Breathing pattern disorders, motor Ernst E 2001 Life-threatening complications after spinal control, and low back pain. Rheumatology Effects of dominant somatotype on aerobic capacity International 22(2):56–59 trainability. Elsevier, London, p 243–258 Drug therapies and lifestyle modification that Cochrane Database of Systematic Reviews 2006 Issue 4. Wiley, Chichester 114(3):22–28, 32 Conner M, Norman P 1995 Predicting health behaviour: Field T, Morrow C, Valdeon C et al 1992 Massage research and practice with social cognition models. Journal of Chronic Fatigue Syndrome Ettlingen, Germany 3:43–51 Defeo G, Hicks L 1993 A description of the common Field T, Cullen C, Diego M et al 2001 Leukemia compensatory pattern in relationship to the osteopathic immune changes following massage therapy. Lancet 359(9322):2018–2026 Field T, Hernandez-Reif M, Diego M et al 2005 Cortisol Dempsey J, Sheel A, St Croix C 2002 Respiratory decreases and serotonin and dopamine increase influences on sympathetic vasomotor outflow in following massage therapy. Respiratory Physiology and Neurobiology Neuroscience 115:1397–1413 130(1):3–20 Foldi M, Strossenreuther R 2003 Foundations of manual Dhabhar F, Viswanathan K 2005 Stress-induced lymph drainage, 3rd edn. Mosby, St Louis enhancement of leukocyte trafficking to sites of surgery Ford M, Camilleri M, Hanson R 1995 Hyperventilation, or immune activation. Brain, Behavior and Immunity central autonomic control, and colonic tone in humans. Journal of Psychosomatic Research 35(8):564–577 41(5):481–493 Ironson G, Field T, Scafidi F et al 1996 Massage therapy Hauser H, Karl J, Stolz R 2000 Information from is associated with enhancement of the immune systems structure and colour. Journal of Bodywork and Movement Neurobiologic mechanisms in manipulative therapy. Therapies 4:31–38 Plenum Press, New York Hernandez-Reif M, Field T, Largie S et al 2002 Jefferey E 2006 Detoxification basics. Managing Parkinson’s disease symptoms reduced by massage biotransformation: metabolic, genomic, and therapy. Journal of Psychosomatic Kai M, Anderson M, Lau E 2003 Exercise intervention: Research 57(1):45–52 defusing the world’s osteoporosis time bomb. Bulletin Hernandez-Reif M, Field T, Ironson G et al 2005 of the World Health Organization 81(11):827–830 Natural killer cells and lymphocytes are increased in Kalitchman L, Livshits G, Kobyliansky E 2004 women with breast cancer following massage therapy. Association between somatotypes and blood pressure International Journal of Neuroscience 115(3):495–510 Annals of Human Biology 31(4):466–476 Hodges P, Gandevia S 2000a Activation of the human Kasseroller R 1998 Compendium of Dr Vodder’s diaphragm during a repetitive postural task. Haug, Heidelberg, p 190 Physiology 522:165–175 Kirchfeld F, Boyle W 2000 Nature doctors: pioneers in Hodges P, Gandevia S 2000b Changes in intra- naturopathic medicine. Lancet Contraction of the human diaphragm during postural 338(8772):899–902 adjustments. News in Hodges P, Heijnen I, Gandevia S 2001 Postural activity Physiological Sciences 1:25–27 of the diaphragm is reduced in humans when Kollath W 1950 Uber die Mesotrophie, ihre Ursachen respiratory demand increases. Schriftenreihe fur Huey S, West S 1983 Hyperventilation: its relation to Ganzheitsmedizin Band 3. Journal of Abnormal Stuttgart Psychology 92:422–432 Kretchmer E 1921 Physique and character. Manual London (from Körperbau und Charakter, Springer, Therapy 3(1):2–11 Berlin) 98 Naturopathic Physical Medicine Kriege T 1969 Fundamental basis of iris diagnosis. Advanced Nutrition Fowler, London Publications Inc Kuchera M 1997 Treatment of gravitational strain Lowen A 1975 Bioenergetics. In: Vleeming A, Mooney V, Dorman Geoghegan, New York T, Snijders C, Stoeckart R (eds) Movement, stability and Lum L 1987 Hyperventilation syndromes in medicine low back pain. Journal of the Royal Society of Kuhne L 1902 Handbook of the science of facial Medicine 80:229–231 expression. Plenum Press, New York, backrub on the physiological components of relaxation: p 113–123 a meta-analysis. Nursing Research 46(1):59–62 Lutgendorf S, Costanzo E 2003 Langevin H, Yandow J 2002 Relationship of Psychoneuroimmunology and health psychology: an acupuncture points and meridians to connective tissue integrative model. Lederman E 2005 Science and practice of manual Rohrmoser, Bonn Am Rhein therapy, 2nd edn. Baillière’s Best initiated by free radicals, oxidant chemicals, and Practice and Research in Clinical Rheumatology therapeutic drugs in the aetiology of chemical 17(4):629–647 hypersensitivity disease. Journal of Orthomolecular Psychiatry 12:166–183 Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C 2000 Lewit K 1999 Manipulative therapy in rehabilitation of Pool exercise combined with an education program for the locomotor system, 3rd edn. Journal of Rheumatology 10:2473–2481 Liem T 2004 Cranial osteopathy: principles and practice. Naturopath and Herald of Health 41(3):72 Lindlahr H 1918a Natural therapeutics, vol 2: practice. Journal of Nursing Lindlahr H 1918c Acute diseases: their uniform Scholarship 25(1):17–21 treatment by natural methods. Lindlahr Publishing, Chicago Mehling W, Hamel K 2005 Randomized, controlled trial of breath therapy for patients with chronic low-back Lindlahr H 1918d Natural therapeutics, vol 2: practice. Alternative Therapies in Health and Medicine Lindlahr Publishing, Chicago, p 16 11(4):44–52 Lindlahr H 1924 Iridiagnosis and other diagnostic Mesina J, Hampton D, Evans R et al 1998 Transient methods, 6th edn. Homotoxin-Journal Medicine 4:43–47 10:345–359 Newman Turner R 2000 Naturopathic medicine. Farrar, Letchworth Garden City Straus & Cudahy, New York Ng J, Richardson C, Kippers V, Parnianpour M 1998 Rhudy J, Meagher M 2000 Fear and anxiety: divergent Relationship between muscle fiber composition and effects on human pain thresholds.

Cholecystokinin cholescintig- raphy: detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease proven cefdinir 300 mg infection under crown tooth. Gallbladder contraction inducted by cholescystokinin: bolus injection or infusion? Calculation of a gallbladder ejection fraction: advantage of continuous sincalide infusion over the three-minute infusion method cefdinir 300mg cheap 6 bacteria. Use of c-terminal octapeptide of cholecystokinin for gallbladder evacuation in cholescintigraphy discount cefdinir 300mg on line antibiotics for acne yes or no. Acalculous biliary pain: cho- lecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Its 16,000 members are physicians, tech- nologists, and scientists specializing in the research and practice of nuclear medicine. Existing Practice Guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. The Practice Guidelines recognize that the safe and effective use of diagnostic nuclear medicine imaging requires specific training, skills, and techniques, as described in each document. For correspondence or reprints contact: Dominique Delbeke, Vanderbilt University Medical Center, 21st Ave. These Practice Guidelines are an educational tool designed to assist practitioners in providing appropriate care for patients. They are not inflexible rules or require- ments of practice and are not intended, nor should they be used, to establish a legal standard of care. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circum- stances presented. Thus, an approach that differs from the Practice Guidelines, standing alone, is not necessarily below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the Practice Guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowl- edge or technology subsequent to publication of the Prac- tice Guidelines. The practice of medicine involves not only the science, but also the art, of preventing, diagnosing, alleviating, and treating disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diag- nosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these Practice Guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these Practice Guidelines is to assist practitioners in achieving this objective. Optimally performed hepatobiliary scintigraphy is a sensitive method for detecting numerous disorders involv- ing the liver and biliary system. Therefore, it is crucial to correlate findings on hepatobiliary scintigraphy with clinical information and findings on other relevant modalities in order to arrive at a correct diagnosis. Ad- junctive pharmacologic maneuvers may enhance the diag- nostic utility of hepatobiliary scintigraphy and provide the quantitative assessment necessary for certain specific ap- plications. The goal of hepatobiliary scintigraphy is to provide diagnostic and management assistance to physicians who are involved in the care of patients with liver and biliary system ailments. Computer acquisition and analysis, including pharmacologic interventions, are used according to varying indications and an individual patient’s needs. Right-upper-quadrant pain variants, as defined by the American College of Radiology Appropriateness Criteria (31) 5. A theoretic possibility of allergic reactions should be considered in patients who receive multiple doses of hepatobiliary compound (78). Request The nuclear medicine physician should review all avail- able pertinent clinical, laboratory, and radiologic informa- tion before the study. Additional information specifically related to hepatobiliary scintigraphy includes: 1. Current medications, including the time of their most recent administration (with particular attention to opioid compounds) 4. Patient preparation and precautions To permit timely gallbladder visualization, the adult patient must have fasted for a minimum of 2 and preferably 6 h before administration of the radiopharmaceutical. Children should be instructed to fast for 2–4 h, whereas infants need to fast for only 2 h before radiotracer injection. However, fasting for longer than 24 h (including those on total parenteral nutrition), can cause the gallbladder not to fill with radiotracer within the normally expected time frame. Disregard of the above guidelines may result in a false-positive nonvisuali- zation of the gallbladder. Mebrofenin may be selected instead of disofenin in mod- erate to severe hepatic dysfunction because of its higher hepatic extraction. Image acquisition A large-field-of-view g-camera equipped with a low- energy all-purpose or high-resolution collimator is rec- ommended. Whenever possible, continuous (dynamic) computer acquisition (usually in the anterior or left ante- rior oblique view) should be performed (1 frame/min). The image matrix of 128 by 128 is optimal on a standard large-field-of-view camera. In pediatric patients an appro- priate electronic acquisition zoom should be used. Initial images are usually acquired dynamically, starting at injection and continuing for 60 min. When visualization of the gallbladder is the endpoint of the study, it can be stopped earlier when activity is seen in the gallbladder. To resolve concern about common bile duct obstruction (highly unlikely in the presence of gallbladder visualiza- tion), demonstration of tracer activity in the small bowel may need to be pursued. The digital data can be reformatted to 4- to 6-min images for filming or digital display. Cinematic display of the data may reveal additional information not readily apparent on reformatted display. Image intensity scaling should be study-relative rather than individual frame–rela- tive. The former allows for appreciation of activity changes over the duration of the study. If the patient is being studied for a biliary leak, 2- to 4-h delayed imaging (or longer delays in some cases) and patient-positioning maneuvers (e. Any drainage bags should by included in the field of view if the biliary origin of a leak or fistula is in question.

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Even in the ment forces act continually above the diastolic blood pressure controlled conditions of the operating theatre buy discount cefdinir 300 mg online antibiotics quick guide, acute hypotension resulting in compression and ultimately death of nerves order cefdinir 300 mg amex antibiotics libido, blood after tourniquet deflation is commonly observed buy cefdinir 300 mg free shipping antibiotic resistance executive order. An external entrapping force will nearly always compress hyperaemia in the released limbs. Taking the With so many uncontrollable variables in the prehospital envi- weight off a harness or releasing two limbs trapped by a dashboard ronment, it is impossible to accurately predict muscle viability may result in both limbs being suddenly released, and as such the against Ischaemia time. Lengthy entrapments will obviously have a reduction in cardiac output can in itself be fatal, particularly in detrimental effect, but it important to appreciate that there is abso- the presence of a relatively fixed cardiac output from heart disease, lutely no ‘minimum’ universally agreed time for ‘safe’ suspension drugs or pre-existing valvular heart defects. Cardiac electrical activity functions in both a very narrow pH When the integrity of muscle cell walls are breeched by an rangeand concentrationsofintra- and extracellularions, inparticu- external force, intracellular components leak extracellularly while lar calcium and potassium. There are a number of mechanisms that water and extracellular ions will flow into the damaged tissue, so called third space fluid loss. Vasodilates Heart block Arrythmogenic Worsens shock Triggers apoptosis Acute kidney injury: an indirect effect of muscle damage K+ Direct renal damage result from the nephrotoxic properties of a Lactic acid Reperfusion Injury −ve inotropic effect Arrythmogenic variety of leaked intracellular substances such as proteases and purines. However, damage principally occurs indirectly as the kidneys attempt to filter acidotic plasma and the muscle protein, Phosphate Microvascular impairment myoglobin (Figure 19. Thromboembolic Material 3rd space fluid shift Micro & macro vascular impairment It is very important, from a therapeutic perspective, to appreciate Pulmonary embolism that myoglobin itself causes no renal damage. It is a small protein Fat embolism Disseminated intravascular coagulation that is freely filtered and eliminated by the kidneys with no nephro- toxic properties. This by-product of anaerobic metabolism, together Where tourniquets have been applied, they should remain in with other organic acids being released from cells, lowers the pH of place until the patient is fully resuscitated, potential haemorrhage urine. As the filtered myoglobin combines with urine below a pH of points addressed and in a safe environment. Ferrihaemate in the hospital resuscitation room or operating theatre, with full is both directly nephrotoxic to renal tubules and causes mechanical cardiovascular monitoring and support. There may be cases where obstruction by precipitating within the lumen of nephrons. Inad- there is a long delay to definitive care and in these cases ‘staged equate circulating volume due to hypovolaemia and third space release’ should be employed. Amputation prior to release will also prevent the sequelae of urine and wash away rapidly accumulating ferrihaemate and other the reperfusion syndrome by removing the source of the problem. Resuscitate the system Management A haemodynamically stable system will handle a reperfusion injury Isolate and move to a place of safety better than a collapsed, shocked system. A great deal of thought By applying arterial tourniquets just proximal to a harness or needs to be applied to preparing the circulation prior to entrapment entrapping force, one can prevent the massive haemorrhage or release. There is a wealth of data from disaster medicine literature to rescue cardioplegia frequently encountered with sudden release support early circulatory resuscitation prior to reperfusion. Spend- of an entrapment on scene; transferring the problem to a safer, ing time optimizing an entrapped person poses significant health controlled environment (Box 19. This ethos fits well within the and safety risks, the obvious being the stability of the entrapping establishedphilosophyof‘scoopandrun’. Medical staff casualty, they should be rescued as soon as is safely possible must work in close collaboration with rescue personnel, ideally as and placed in the horizontal recovery position if consciousness an integrated team, to understand differing roles and needs. There is no evidence to support rescue in the semi- Systemic resuscitation prior to extrication in earthquake entrap- recumbent position. An initial Tourniquets must be purposefully designed for prehospital use, 20 mL/kg bolus (10 mL/kg in elderly people) of 0. Ongoing fluid administration should continue at a rate of degree of ischaemic reperfusion injury themselves, but the benefits 5 ml/kg/hour with additional fluid boluses titrated against clin- greatly outweigh this risk, especially where ambulance transit times ical response. Hartmann’s) must be strictly avoided in the field to avoid tourniquet and the patient remains stable then delayed application hyperkalaemia. When the patient is collapsed in a confined space, of a tourniquet is not required as ‘washout’ will have already intravenous access maybe challenging and intraosseous infusion occurred. Trauma: Suspension and Crush 101 Forprolongedtransfersthepatientshouldhaveaurinarycatheter gluconate and an enema of sodium or calcium resonium if available. Improving urine output is a good Calcium should only be given under these circumstances, as you indication of end organ perfusion and that preventative manage- run the risk of precipitating metastatic calcification and further mentisstartingtobecomeeffective. Standard medical management strategies for hyperkalaemia tend to be ineffective, as hyperkalaemia in a crush injury results from muscle wall damage, and not ionic or osmotic shifts. Patients Analgesia must therefore be immediately transferred to an intensive care Pain is often minimal in the early post-crush phase because of environment capable of haemofiltration. As limbs become In the event that prehospital anaesthesia is required as part progressively more swollen and the intrinsic analgesic effects of of the resuscitative process, non-depolarizing muscle relaxants endorphins wear off, pain will become more problematic. Regional local anaesthetic blocks may also be useful in providing additional analgesia for the trapped limb, but avoid long acting agents which may mask the onset of compartment Alkaline diuresis syndrome. When evacuation times are prolonged (>4 hours) the use of alkaline diuresis may be considered. Alkaline diuresis will prevent the precipitation of toxic myoglobin metabolites in nephrons and Staged tourniquet release strategy help ameliorate acidosis and hyperkalaemia. This allows for controlled washout and sys- oedema (particularly in the presence of pre-existing renal or heart temic redistribution of ischaemic metabolites during reperfusion. The risk of iatrogenic metabolic alkalosis and sodium It should be employed on one limb at a time and the patient overload is greater in the unmonitored prehospital environment must be monitored closely. If at any point the patient becomes and where possible alkaline diuresis should be left for the hospital unstable, then the tourniquet should be immediately reapplied environment where it can be titrated to urine output, urine pH and and the patient’s cardiovascular state managed prior reinstituting serum pH. Once optimal volume resuscitation has been achievedfurtherhypotensiveepisodesmaybetreatedwithinotropic or vasopressive agent. Tourniquet Released + Re-inflated 30 sec later Tips from the field 3 Min • Resuscitate the system prior to release • Consider use of tourniquets to prevent rescue cardioplegia Tourniquet Released • Limb amputation may be considered in the non-viable limb • Prepare for clinical deterioration after release. Introduction Permanent Cavity The term ballistic trauma encompasses any physical trauma sus- tained from the discharge of arms or munitions. The two main types of ballistic trauma likely to be experienced by prehospital practi- Figure 20. The rise in terrorist activity over the last decade and the increased use of firearms during criminal passage of the projectile the temporary cavity collapses down to acts means such injuries are becoming increasingly common. Cavitation within solid organs such as the liver, kidney and brain leads to massive tissue disruption.

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The second course could include lectures on standards and standardization order cefdinir 300mg without prescription antibiotic 300mg, assay design and optimization cefdinir 300mg overnight delivery horse antibiotics for dogs, the evaluation of antisera including Scatchard analysis purchase cefdinir 300mg virus contagious, iodination techniques, stability and storage of reagents, and techniques for the local preparation of simple reagents, such as standards and quality control material for selected analytes. This could also be demonstrated in practical classes and experiments carried out to validate locally produced reagents. Other practical classes could be designed to demonstrate and compare different separation methods. During the first week, participants carry out standard statistical exercises and proceed to the construction of various types of calibration curves, Scatchard plots, response–error relationships and precision profiles, with no computational assistance beyond a hand-held calculator, to ensure that all underlying concepts are well understood. The second week sees a repetition of the first week, with the difference that the work is not done manually, but using a computer and a data processing software package or packages. Advanced reagent production A further group training activity may now be organized on advanced reagent production methods, confined to participants from centres equipped, or likely to become equipped, to undertake this activity to a significant extent. Not many laboratories, especially in developing countries, have the equipment and other facilities required for the production of monoclonal antibodies. If training in this area is required, it would be better provided on an individual basis at a suitable advanced centre. Participants in an external quality assurance scheme organized at the national or regional level 64 2. A training course devoted to tumour marker assays would focus on the special problems involved (high dose hook, etc. Such missions are both popular and effective because the same expert can train many persons and training is in a local context, taking into account circumstances in the host laboratory. An expert mission also has the advantage of establishing a relationship between a centre in a developing country, which may be working in relative isolation, and the more advanced home laboratory of the expert. Participants have an opportunity to update their knowledge and acquaint themselves with recent advances. The most appropriate and cost effective option for the training of technicians in developing countries is a suitable training centre within the region. In special fields, such as steroid receptor assays for example, an expert mission followed by a short period at an advanced centre outside the region may be necessary. Academics who need to be trained for longer periods and to a higher level may need to be accommo- dated at advanced centres in developed countries. Specially identified labora- tories may be developed to become a centre of excellence for training purposes within a given country or region. Ideally, nurses should serve in diagnostic nuclear medicine sections and be present during nuclear cardiology stress testing. A nurse is the first interface with the ward nursing of inpatients and should be able to inject ward patients with radiopharmaceuticals (e. Nurses in nuclear medicine are required to perform the following duties: —General physical and mental care of patients under examination or treatment; —Examination of vital signs; —Administration of drugs and injections on the instruction of doctors; —Explanation to patients of procedures and provision of support to the receptionist; —Handling of radiopharmaceuticals and radioactive waste in cooperation with pharmacists and technologists; —Taking appropriate radiation protection measures for patients and families, especially those comforting children and elderly people. In order to carry out these functions correctly, nurses need a basic knowledge of radiation, radionuclides and the biological effects of radiation, and should receive training on the safe handling of radioactive materials as well as radiation protection. Education and training should be offered both in undergraduate courses in a school of nursing and in postgraduate training courses in hospitals. Nurses should receive a final briefing before they start working in a department of nuclear medicine. In developing countries, nuclear medicine has historically often been an offshoot of pathology, radiology or radiotherapy services. The level of nuclear medicine services is categorized according to three levels of need: Level 1: This level is appropriate where only one gamma camera is needed for imaging purposes. The radiopharmaceutical supply, physics and radiation protection services are contracted outside the centre. A single imaging room connected to a shared reporting room should be sufficient, with a staff of one nuclear medicine physician and one technologist, with backup. Level 2: This level is appropriate for a general hospital where there are multiple imaging rooms in which in vitro and other non-imaging studies would generally be performed as well as radionuclide therapy. Level 3: This level is appropriate for an academic institution where there is a need for a comprehensive clinical nuclear medicine service, human resource development and research programmes. Introduction This section deals with the establishment of a nuclear medicine service for performing diagnostic and therapeutic procedures. Recommendations related to human resources development and the procurement of equipment, specifi- cations of imaging devices and clinical protocols are expanded on in other sections. The first step in establishing a nuclear medicine service is to consider the space, equipment and staffing requirements. Space requirements will vary according to the level of the service, depending on whether a simple in vitro or in vivo imaging laboratory is envisaged or whether there are plans for a full in vitro laboratory and for in vivo imaging therapeutic procedures. Space should also be allocated for an in- house radiopharmacy if unit doses are being prepared on-site from ‘cold’ kits and 99mTc generators. The initial design and planning should take into account a number of factors in addition to the space needed for routine imaging and staffing needs. Radiation protection is an important issue and the following measures should be taken: —Walls and doors of laboratories should be painted with good quality washable paint; —Work-table tops should have a smooth laminated finish; —Floors should be impervious to liquids; —There should be an adequate supply of lead containers and shielding lead bricks; —Remote handling devices are desirable; —Ventilated fume cupboards are similarly desirable. Radioactive waste disposal must follow local radiation protection guidelines and space must be available for waste storage. Nuclear medicine is an advanced but cost effective specialty which can solve specific clinical problems. Since it changes rapidly with the development of new technologies for imaging devices and new radiopharmaceuticals, it calls for specialized training together with specific site preparation. Nuclear medicine staff need to have sufficient administrative skills to interact with referring physicians, hospital administrators and financial supporting bodies such as 68 3. The general public needs to be both reassured and informed (about treatment), as proper interaction with patients requires their full cooperation. The level of services, information and patient interaction varies according to region, general standard of educational and socioeconomic conditions, and the standard of health care. Nuclear medicine services vary from one country to another, although cardiology and nuclear oncology are generally the most commonly performed studies. In certain regions, renal studies, infection localization and even liver– spleen scans are still very important. The planning of a nuclear medicine department should be preceded by a study of population demographics and the prevalence of diseases in the respective country. This groundwork allows for prioritization and planning of an appropriate nuclear medicine service.