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The Examiner should defer issuance and may advise the applicant to diabetic bags 1mg glimepiride with mastercard request a Medical Flight Test. Examination Techniques A careful examination for surgical and other scars should be made, and those that are significant (the result of surgery or that could be useful as identifying marks) should be described. Medical documentation must be submitted for any condition in order to support an issuance of a medical certificate. Disqualifying Condition: Scar tissue that involves the loss of function, which may interfere with the safe performance of airman duties. Examination Techniques A careful examination of the Iymphatic system may reveal underlying systemic disorders of clinical importance. The Examiner should specifically inquire concerning a history of weakness or paralysis, disturbance of sensation, loss of coordination, or loss of bowel or bladder control. Certain laboratory studies, such as scans and imaging procedures of the head or spine, electroencephalograms, or spinal paracentesis may suggest significant medical history. The Examiner should note conditions identified in Item 60 on the application with facts, such as dates, frequency, and severity of occurrence. Some require only temporary disqualification during periods when the headaches are likely to occur or require treatment. Other types of headaches may preclude certification by the Examiner and require special evaluation and consideration. Likewise, the orthostatic faint associated with moderate anemia is no threat to aviation safety as long as the individual is temporarily disqualified until the anemia is corrected. An unexplained disturbance of consciousness is disqualifying under the medical standards. Because a disturbance of consciousness may be expected to be totally incapacitating, individuals with such histories pose a high risk to safety and must be denied or deferred by the Examiner. If the cause of the disturbance is explained and a loss of consciousness is not likely to recur, then medical certification may be possible. The basic neurological examination consists of an examination of the 12 cranial nerves, motor strength, superficial reflexes, deep tendon reflexes, sensation, coordination, mental status, and includes the Babinski reflex and Romberg sign. The Examiner should be aware of any asymmetry in responses because this may be evidence of mild or early abnormalities. The Examiner should evaluate the visual field by direct confrontation or, preferably, by one of the perimetry procedures, especially if there is a suggestion of neurological deficiency. Aerospace Medical Disposition A history or the presence of any neurological condition or disease that potentially may incapacitate an individual should be regarded as initially disqualifying.


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When we evaluate a test that is more than 12 months old managing diabetes during intercurrent illness in the community cheap 1mg glimepiride overnight delivery, we must consider the results in the context of all the relevant evidence, including why the test was performed and whether there has been an intervening event or improvement or worsening of your impairment. We will purchase a new exercise test only if we cannot make a determination or decision based on the evidence we have. It must be performed using a generally accepted protocol consistent with the prevailing state of medical knowledge and clinical practice. A description of the protocol that was followed must be provided, and the test must meet the requirements of 4. The exercise test must be paced to your capabilities and be performed following the generally accepted standards for adult exercise test laboratories. With a treadmill test, the speed, grade (incline), and duration of exercise must be recorded for each exercise test stage performed. The exercise protocol may need to be modified in individual cases to allow for a lower initial workload with more slowly graded increments than the standard Bruce protocol. Levels of exercise must be described in terms of workload and duration of each stage; for example, treadmill speed and grade, or bicycle ergometer work rate in kpm/min or watts. These tests are designed primarily to provide evidence about myocardial ischemia or prior myocardial infarction, but do not require you to exercise. These tests are used when you cannot exercise or cannot exercise enough to achieve the desired cardiac stress. Drug-induced stress tests can also provide evidence about heart chamber dimensions and function; however, these tests do not provide information about your aerobic capacity and cannot be used to help us assess your ability to function. Some of these tests use agents, such as Persantine or adenosine, that dilate the coronary arteries and are used in combination with nuclear agents, such as thallium or technetium (for example, Cardiolyte or Myoview), and a myocardial scan. Other tests use agents, such as dobutamine, that stimulate the heart to contract more forcefully and faster to simulate exercise and are used in combination with a 2-dimensional echocardiogram. We will not purchase cardiac catheterization; however, if you have had catheterization, we will make every reasonable effort to obtain the report and any ancillary studies. We will consider the quality and type of data provided and its relevance to the evaluation of your impairment. For adults, we generally see two types of catheterization reports: Coronary arteriography and left ventriculography. For coronary arteriography, the report should provide information citing the method of assessing coronary arterial lumen diameter and the nature and location of obstructive lesions. Some individuals with significant coronary atherosclerotic obstruction have collateral vessels that supply the myocardium distal to the arterial obstruction so that there is no evidence of myocardial damage or ischemia, even with exercise. When the results of quantitative computer measurements and analyses are included in your case record, we will consider them in interpreting the severity of stenotic lesions. For left ventriculography, the report should describe the wall motion of the myocardium with regard to any areas of hypokinesis (abnormally decreased motion), akinesis (lack of motion), or dyskinesis (distortion of motion), and the overall contraction of the ventricle as measured by the ejection fraction. Quantitative computer analysis provides precise measurement of segmental left ventricular wall thickness and motion.

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The syndrome most usually results from bilateral posterior cerebral artery territory lesions causing occipital or occipitoparietal infarctions but has occasionally been described with anterior visual pathway lesions associated with frontal lobe lesions blood glucose 76 buy glimepiride amex. The completion phenomenon: insight and attitude to the defect: and visual function ef? Cross References Agnosia, Anosognosia, Confabulation, Cortical blindness Anwesenheit A vivid sensation of the presence of somebody either somewhere in the room or behind the patient has been labelled as anwesenheit (German: presence), pres ence hallucination, minor hallucination, or extracampine hallucination. Hence, listlessness, paucity of spontaneous movement (akinesia) or speech (mutism), and lack of initiative, spontaneity, and drive may be features of apa thy these are also all features of the abulic state, and it has been suggested that apathy and abulia represent different points on a continuum of motivational and emotional de? Apathy may be observed in diseases affecting frontal?subcortical struc tures, for example, in the frontal lobe syndrome affecting the frontal convexity, or following multiple vascular insults to paramedian diencephalic structures (thalamus, subthalamus, posterior lateral hypothalamus, mesencephalon) or the posterior limb of the internal capsule; there may be associated cognitive impair ment of the so-called subcortical type in these situations. Apathy is also described following amphetamine or cocaine with drawal, in neuroleptic-induced akinesia and in psychotic depression. Selective serotonin-reuptake inhibitors may sometimes be helpful in the treatment of apathy. Cross References Abulia; Akinetic mutism; Dementia; Frontal lobe syndromes Aphasia Aphasia, or dysphasia, is an acquired loss or impairment of language func tion. Language is dis tinguished from speech (oral communication), disorders of which are termed dysarthria or anarthria. Conduction aphasia is marked by relatively normal spontaneous speech (perhaps with some paraphasic errors), but a profound de? In transcortical motor aphasia spontaneous output is impaired but repetition is intact. Transcortical: Broca Wernicke Conduction motor/sensory Fluency vv N N v/N Comprehension N vv N N v Repetition N/N Naming N? N = normal; v=impaired Aphasias most commonly follow a cerebrovascular event: the speci? Aphasia may also occur with space-occupying lesions and in neurodegenerative disorders, often with other cognitive impairments. The term is now used to describe a motor disorder of speech production with preserved comprehension of spoken and writ ten language. Aphemia probably encompasses at least some cases of the ?foreign accent syndrome, in which altered speech production and/or prosody makes speech output sound foreign. Cross References Anarthria; Aphasia; Aprosodia, Aprosody; Dysarthria; Phonemic disintegra tion; Speech apraxia Aphonia Aphonia is loss of the sound of the voice, necessitating mouthing or whispering of words. Dystonia of the abductor muscles of the larynx can result in aphonic segments of speech (spasmodic aphonia or abductor laryngeal dystonia); this may be diagnosed by -37 A Applause Sign hearing the voice fade away to nothing when asking the patient to keep talk ing; patients may comment that they cannot hold any prolonged conversation. Aphonia should be differentiated from mutism, in which patients make no effort to speak, and anarthria in which there is a failure of articulation. Cross References Anarthria; Dysphonia; Mutism Applause Sign To elicit the applause sign, also known as the clapping test or three clap test, the patient is asked to clap the hands three times. The tendency to clap more than three times, even when demonstrated by the examiner, is said to be speci?

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Ondansetron (Zofran) Class: Antiemetic Action: First selective serotonin blocking agent to signs diabetes 3 year olds discount 2mg glimepiride with mastercard be marketed. Oxygen enters the body through the respiratory system and is transported to the body tissues for energy. Emergency use to reverse hypoxemia and, in doing so, helps oxidize glucose to produce adenosine triphosphate (aerobic metabolism). Indications: Hypoxia, hypoperfusion, ischemic chest pain, respiratory insufficiency, suspected stroke, confirmed/suspected carbon monoxide poisoning, cardiac insufficiency or arrest Contraindications: None in the prehospital emergency setting Onset/Duration: Onset: Immediate and Duration: Less than 2 min Dose/Route: Adult: 1-4 lpm via nasal cannula and 10-15 lpm via nonrebreather mask Peds: Same as adult but using age appropriate sized devices Side Effects: nausea/vomit, irritation to respiratory tract Note: Administer and titrate to maintain a minimum SpO2 of 94% Oxytocin (Pitocin) Class: Hormone Action: Oxytocin is a natural hormone secreted by the posterior pituitary gland. Indications: Post-partum hemorrhage Contraindications: Hypersensitivity, baby hasn?t delivered Onset/Duration: Onset immediate; Duration 1 hour Dose/Route: Adult: 40 units diluted in 1000 mL Normal Saline titrated to control bleeding Peds: Not recommended Side Effects: Hypotension, tachycardia, chest pain/coronary artery spasm, cardiac dysrhythmias, hypertension Pralidoxime (2-Pam) Class: Cholinesterase reactivator and antidote Action: Pralidoxime reactivates the enzyme acetylcholinesterase which allows acetylcholinesterase to be degraded, thus relieving the parasympathetic overstimulation caused by excess acetylcholine as seen in organophosphate poisoning. Commonly seen in the prehospital setting packaged with atropine in DuoDote or Mark 1 autoinjector kits. Procainamide Class: Antidysrhythmic (Class 1A) Action: Suppresses phase 4 depolarization in normal ventricular muscle and Purkinje fibers, reducing the automaticity of ectopic pacemakers. Promethazine also acts as an antiemetic and sedative agent with some anticholinergic properties. This produces complete muscle paralysis but since it is a depolarizing agent it causes fasciculations and muscular contractions making it the drug of choice for rapid sequence induction aka chemically assisted endotracheal intubation. Onset/Duration: Onset: less than 1min and Duration: 5-10 min Dose/Route: Adult: 1-1. Thiamine (Betaxin) Class: Vitamin (B1) Action: Thiamine is also known as vitamin B1. Thiamine combines with adenosine triphosphate to form thiamine pyrophosphate, a coenzyme necessary for carbohydrate metabolism. With adequate dioxide pneumoperitoneum, and the necessary adjustments to adjustments and pharmacologic therapy, many of these alterations can minimize and manage them. Data sources: Data were obtained from searches in PubMed years Conclusion: A thorough understanding of the pathophysiology which 1997 to 2009, using key words: laparoscopy and anesthesia, effects of occurs during carbon dioxide intra-abdominal insuffation is mandatory pneumoperitoneum on cardiovascular system, pneumoperitoneum and to manage promptly any complications that arise. The First Affliated Hospital, Chongqing Medical University, Chongqing 400016, China. The First Affliated Hospital of Chongqing Medical University, Chongqing 400016, China. Corresponding author: Associate Prof Liu Xin Wei Department of anesthesiology, the First Affliated hospital, Chongqing University of Medical Science, Chongqing 400016, China. A euvolemic status is of great importance a highly soluble gas, it is readily absorbed into the circulation through prior to surgery to reduce any cardiac depression via reduced 41 preload caused by the pneumoperitoneum. Dexter et al [19] studied 2 groups of glutamic oxaloacetic transaminase and glutamic pyruvic transaminase.

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Shield design should provide 12 A device designed to diabetes prevention rfp purchase glimepiride 4mg online be worn by a person to monitor any radiation dose received by the person. Where possible, shielding of Radiation the fingers and hands from beta rays should also be provided. Sources should be Protection manipulated with long forceps, special remote handling devices or other suitable Series instruments. Where the results of the check measurement vary by more than 5% from the certified activity or kerma rate, the source should not be used until further independent verification of the source activity has been conducted. Contamination checks should be carried out by a Qualified Expert who is competent in operating the brachytherapy equipment or manipulating the source (as relevant) and in interpreting the contamination test results. Where the results of the contamination testing of afterloading brachytherapy equipment remote control equipment indicate the presence of significant contamination from the source, persons using the equipment will need to: If the results of the contamination testing of manual afterloading tubes or of plaques indicate the presence of significant contamination, the affected tubes or plaques will need to be withdrawn from use. When a wipe test is not possible, tests should be made to detect radiation emitted by any radioactive contamination inside or on the outer surface of the source transfer system or applicator. Significant contamination of remote afterloading brachytherapy equipment is unlikely but is confirmed if the results of the contamination check indicate an activity of more than 200 Bq from the wipe test, or radiation greater than twice normal background from the check with a sensitive radiation detector. Reporting to the relevant regulatory authority of significant contamination of remote afterloading brachytherapy equipment and sources is necessary so that relevant information can be disseminated to other sites using similar equipment. The surface of the plaque or mould containing the radioactivity should always be pointed, and held at as great a distance as possible, away from treatment personnel. The following applies to the use of radioactive plaques in the treatment of ophthalmological or dermatological conditions: The plaque is typically a circular or elliptical curved disc of up to about 20 mm diameter. A stem handle is attached to the shielded back of the plaque mounting (in some cases the handle is screwed into the mounting and detachable). The Series ancillary equipment required for these treatments includes an accurate stopwatch No. The dose rate used for calculation of treatment time is generally adjusted annually for radioactive decay. When unshielded, these plaques are capable of delivering biologically significant doses within minutes. The handling techniques during use should therefore include ensuring the active side of the plaque is always directed away from the operator and other people (including the patient except for the actual period of treatment). The life of the strontium-90 plaque is considered by the manufacturers to be limited to 15 years, but may be longer subject to regulatory requirements and assuming it has been treated with care. Sterilisation of the plaque should be by isolated chemical means, and not by autoclaving or boiling. If the plaque is not handled with care, the active surface may become scratched or damaged in some way that will disrupt the integrity of the activity across the plate. This may result in shedding of the silver metal containing the strontium-90 and may compromise the even dose rate across the plate which is necessary for optimal patient treatment.

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Physiologic and functional outcome correlates of brain tissue hypoxia in traumatic brain injury diabetes yellow toenails cheap 2 mg glimepiride with visa. Cerebral perfusion pressure between 50 and 60 mm Hg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Favorable outcome in traumatic brain injury patients with impaired cerebral pressure autoregulation when treated at low cerebral perfusion pressure levels. Intraoperative applications of intracranial pressure monitoring in patients with severe head injury. Evaluation of optimal cerebral perfusion pressure in severe traumatic brain injury. Continuous monitoring of cerebrovascular pressure reactivity in patients with head injury. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head 189 injury. A cerebral profusion pressure greater than 80 mm Hg is more beneficial In: Hoff J, Betz A, eds. The only way to be assured that this is being achieved to the greatest extent possible is to measure brain metabolites which provide reassurance that the needs of oxidative metabolism are being met. Both provide information about large brain regions, as does jugular venous O2 monitoring (S Oj 2). In recent decades, invasive monitors have been developed that monitor brain pressure, oxygenation (PbrO2), and blood flow on a 3 continuous or nearly continuous basis. Intracranial pressure is a clinically important surrogate measure of brain health discussed elsewhere in these guidelines. Substantial gaps in our knowledge currently exist regarding how the data provided by advanced cerebral monitors should be used. Studies published to date have attempted to explore putative thresholds of prognostic significance; however, uncertainty remains as to the precise thresholds that should be employed, and if the notion of a threshold best characterizes the relationship with outcome. For regional monitors, there is insufficient understanding of how specific brain regions and 4 distance from focal lesions affect measurements. Moreover, placement of these monitors with stereotactic precision is not currently feasible for these devices. It is critical to consider these limitations and knowledge gaps when examining the literature supporting use of these technologies for patient care. Applicability 5,6 the included Class 2 studies were conducted at single sites and have small sample sizes, which could limit their applicability.

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However diabetes definition pdf purchase glimepiride 4 mg with mastercard, adjuvant radiotherapy ?should be considered in the presence of ?adverse pathology (defined as margins <8mm, capillary lymphatic space invasion, thickness>5mm, positive nodes) (80) (81). This differs from the radiotherapy recommendations of Berek and Hacker, who suggest post operative radiotherapy in patients with > 2 micro-metastases, one macrometastasis, extra-capsular spread or surgical margins <5mm clear. Vulvar carcinoma incidence Vulvar carcinoma represents 5% of all gynaecological malignancy in Australia (9). Most of the radiotherapy utilisation trees use stage as a major branch point in determining the need for radiotherapy. This is because most of the reported epidemiological data were not supported with additional data regarding prognostic factors that help determine the risk of locoregional recurrence and hence the need for radiotherapy. Surgical series provided good data on locoregional recurrence risk but not by surgical stage. The approach taken was therefore to use the locoregional recurrence risk factor analyses rather than stage to help determine the proportions of vulvar carcinoma patients in whom radiotherapy would be recommended. Performance status No data exists on performance status by stage for vulvar cancer. However, several gynaecological oncology reviewers commented that even frail and elderly patients can tolerate surgical excision. Therefore, it was recommended that almost all patients should receive surgery as primary treatment. The decision as to whether to give post-operative radiotherapy should be made based upon the presence or absence of adverse pathological features. However, for early vulvar disease a sub group has been identified in whom radiotherapy is recommended. However, according to some gynaecological oncologists, there is no evidence to support the pathological parameters quoted in the guidelines. These experts state that evidence for post-operative radiotherapy exists only in patients with > 1 macro-metastasis, > 2 micro metastases, extranodal spread or margins < 5mm. These patients are considered to be at intermediate or high risk for recurrence and significant failure rates occur in the absence of radiotherapy (75) (85) (86) (87). They published incidence proportions for ?low, ?intermediate and ?high risk as 67%, 18% and 15% respectively. Intermediate and high risk patients are defined as patients with 2 unilateral lymph nodes, tumours of > 2 cm with 1 positive node and lesions > 8 cm with no positive nodes. Incidence of post-surgical recurrence the treatment of recurrent vulvar cancer has not been standardized due to the various ways in which recurrence may present. Two expert reviewers in this report both suggested that surgery is almost always the treatment of choice for local recurrence but nodal recurrences will almost always require radiation (either alone or in combination with surgery). Three patients developed local recurrence and all were successfully salvaged with further radical surgery. The development of distant metastases is rare without local recurrence and therefore a branch on the decision tree has been omitted. The omission of a branch on the decision tree corresponding to those who did not receive radiotherapy at initial treatment or at recurrence, and who subsequently developed isolated distant recurrence amenable to palliation with radiotherapy (such as brain or bone metastases) is unlikely to alter the overall estimate for optimal radiotherapy utilisation.

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Clinicians should consider changing the treatment plan by increasing the level of care offered to diabetes type 2 carb counting buy line glimepiride patients. Patients who fail to progress in outpatient treatment may benefit from a temporary transition to a higher level of care, followed by a return to outpatient management after greater stabilization of symptoms has been achieved. Referral to ancillary clinical services should be considered for patients for whom these problems emerge during the course of treatment, as identified upon re-assessment. Patient Demonstrates Improved Symptoms and Functioning but Requires Maintenance Treatment: Treatment may also lead to slight or moderate improvement that nonetheless leaves the patient with significant distress and impairment in functioning. If the patient demonstrates partial (insufficient) remission, consider one of the following treatment modification options: Continue the present treatment approach to allow sufficient time for full response. This option might be worth considering when a treatment involves acquisition of skills. Or, treatment may not have yet yielded its maximum potential effect because of limited patient compliance; steps taken to increase adherence to treatment prescriptions may accelerate responsivity to the intervention. For example, if current functioning remains poor despite some symptom improvement or the patient stands to experience major consequences for failure to improve more rapidly. When Symptoms and Other Trauma-Related Problems Show Significant Improvement, the Options Include the Following: Clinician judgment, based on discussion with the patient, will be the basis of such a decision. When therapy has resulted in clinically significant improvement but the improvement in functioning is recent and of limited duration, a continuation of the existing type and intensity of treatment may be indicated if the clinician judges that time is required for the patient to continue practicing new skills or to otherwise consolidate treatment gains. This will be especially true if the clinician judges that a reduction in level of therapeutic support would threaten treatment gains. If treatment has produced clear benefit but the patient is continuing to show treatment gains week-by-week, it may also be helpful to maintain the treatment as is, in hopes of continued improvement. For many patients, some level of continuing care may be indicated after more intensive help has produced improvements. A step down to less resource-intensive help can often be accomplished by changing treatment type. Patient Demonstrates Remission from Symptoms: When the patient demonstrates remission from symptoms and there are no indications for further therapy, it is time to discontinue treatment. Discontinuation of treatment may be anxiety-provoking for some patients who have come to depend on the therapist. If this is the case, it may be helpful to discontinue treatment by using the step-down approach noted above and gradually moving toward termination.


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Any evidence of any other personality disorder diabetes cure 2014 purchase 2 mg glimepiride visa, neurosis, or mental refer to their letter health condition to determine what f. Results of clinical interview: Detailed history regarding psychosocial, or developmental problems; academic and employment performance; family or legal issues; substance use/abuse (including treatment and quality of recovery); aviation background and experience; medical conditions and all medication use; and behavioral observations during the interview and testing. Any other history pertinent to the context of the neuropsychological testing and interpretation. Discuss any weaknesses or concerning deficiencies that may potentially affect safe performance of pilot or aviation-related duties (if any). Discuss rationale and interpretation of any additional testing that was performed. Submit your report along with the CogScreen computerized summary report (approximately 13 pages) and summary score sheet for all additional testing performed. Additional reports If the airman has other conditions that require a special issuance, those reports should also be submitted according to the Authorization Letter. Drug and/or alcohol testing results summarized, how often tested, how many tests performed to date. Continued use despite damage to physical health or impairment of social, personal, or occupational functioning. Department of Transportation; or 3) Misuse of a substance that the Federal Air Surgeon, based on case history and appropriate, qualified medical judgment relating to the substance involved, finds: (i) Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or (ii) May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges. Convictions; or 403 Guide for Aviation Medical Examiners C. The 8500-8 specifically asks the airman to report if they ?ever in their life have been diagnosed with, had, or presently have. In some cases, additional information will be required before a medical certificate may be issued. If none have occurred, that should be noted in Block 60 per the disposition table. If the airman is on a Special Issuance for drug or alcohol condition(s) and they have a new event, they should not fly under 61. The airman must take a separate action to report a conviction or administrative action to security. Upon receipt and review of all of the above information, additional information or action may be requested. Include any other alcohol or drug offenses, (arrests, convictions, or administrative actions) even if they were later reduced to a lower sentence. It should describe the circumstances surrounding the offense and any field sobriety tests that were performed.

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Unknown primary cancer tree Executive Summary the planning of efficient diabetic diet free foods purchase glimepiride 4mg mastercard, equitable radiotherapy services for a population requires a rational estimate of demand. In this project we have calculated an estimate of ideal radiotherapy utilisation based on the incidence of each type of cancer, the evidence-based indication for radiotherapy in the treatment of that cancer, and the proportion of cancer patients included in that indication for radiotherapy. Background the radiotherapy utilisation rate is defined as the proportion of a defined population of patients with a notifiable cancer that receives radiotherapy during their lifetime. Variations have also been reported in other countries such as Canada and the Nordic countries, where utilisation ranges from 20? These variations stress the importance of using rigorous evidence-based methods to estimate an optimal radiotherapy utilisation rate that can act as a benchmark against which actual utilisation rates can be compared. It has been widely stated by Commonwealth and State agencies that 50% of all new cases of cancer in Australia will require radiotherapy at some stage of their illness. This 50% treatment rate is based almost entirely on expert opinion, and it is not responsive to changing clinical indications. To estimate, using the best available evidence, the ideal proportion of new cases of registered cancer that should receive megavoltage external-beam radiotherapy at some time during the course of their illness. Methodology In this study, an indication for radiotherapy is defined as a clinical situation in which radiotherapy is recommended as the treatment of choice on the basis of evidence that radiotherapy has a superior clinical outcome compared to alternative treatment modalities (including no treatment) and where the patient is suitable to undergo radiotherapy based on an assessment of performance status indicators and the presence or absence of co-morbidities. If guidelines did not exist for particular cancer types and tumour sites, or where the guidelines did not adequately address radiotherapy use, other sources of evidence were identified. These included treatment reviews, randomised controlled trials, population-based studies of care, and single institution studies. This software has been used for decision analyses in health and economic assessments of the cost-effectiveness of various treatments. We used the software to illustrate the indications for radiotherapy in a diagrammatic form (as a tree), to perform basic calculations such as multiplication of factors and summation of the results, and to perform statistical analyses such as sensitivity analyses of variability. Parameters can be readily adjusted in the tree if indications for radiotherapy or epidemiological data distributions change in the future and the software can then rapidly estimate the adjusted utilisation rates. The utilisation trees depict the clinical conditions for which radiotherapy is indicated. Each terminal branch of the tree shows whether or not radiotherapy is recommended for a particular type of cancer in individuals with specific clinical attributes. In some circumstances, the indication for radiotherapy occurred in the initial stages of management. In other circumstances, radiotherapy was given later in the disease course (for instance, in patients who developed a local recurrence and who had not previously had an indication for treatment with radiotherapy). The purpose of our project was to determine the proportion of all cancer patients who have at least one indication for radiotherapy at some time in the course of their illness. Patients requiring radiotherapy were counted only once, even if they had multiple indications at different stages in their illness. The radiotherapy utilisation trees also depict the proportion of patients in each branch of the tree.


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