Coat- bination therapies order zudena overnight erectile dysfunction doctors in colorado, these end-points have to be ings are often sugar- or cellulose-based and may be measured and fulfilled for all active components order zudena discount erectile dysfunction insurance coverage, employed when a drug tastes foul buy 100mg zudena otc erectile dysfunction pills that work, or to create a and they should not be administered separately. There are special physicochemical constraints, rate and extent of absorption, as determined by such as chelation, complex formation, or crys- comparison of measured parameters, e. For (iii), the data that has traditionally been most per- example, two oral formulations can be compared suasive has been a pharmacokinetic comparison of with an intravenous dose. The regulation also half-times of elimination, and at a frequency permits bioequivalence to be demonstrated using that captures distribution phase, Cmax and chronopharmacological effect, i. However, when single- exposure of the staff, carbon dioxide scrubbing, or multiple-dose studies do not exceed the approved and other pharmacokinetic features that are rarely clinical dose sizes, and when there will be retention encountered elsewhere. The usual protections for human and exhaled gas concentrations (including for subjects are required, and, of course, these include carbon dioxide) can now be measured real-time. Malignant hyperthermia is an adverse event that By definition, sustained release formulations is almost always associated with the inhalation of a differ pharmaceutically and pharmacokinetically halogenated hydrocarbon, and which can be from the innovator drug. Nitrous oxide and oxygen mixtures are Various tactics can be employed in the pursuit of sometimes used as analgesics during labour, or the sustained-release strategy, including mixtures when transferring patients in pain by road or heli- of granules with different thicknesses of polymer copter. In very cold weather, nitrous oxide can coating, all contained within a single capsule; os- liquify, reducing the delivered dose; shaking the motically driven tablets, which slowly release drug container helps. It is prophylaxis against nitrogen narcosis in the deep illogical to seek sustained-release formulations for sea, while minimizing fire hazard, is also well-de- drugs with relatively long half-times of elimination. Fire hazard from oxygen (arguably a gas- eous drug under some circumstances) is important; the disastrous fire inside the command capsule of Gases Apollo 3, during a lift-off rehearsal on the pad at Cape Kennedy, took place within a pure oxygen Gases are usually administered in the context of atmosphere. The British Association for Lung Research have recognized this complexity and issued a con- Metered Dose Inhalers and Nebulized Drugs sensus statement (Snell and Ganderton 1999) which recommends, at a minimum, a five-stage In general, and with a few rare exceptions (see collection apparatus, examination of a range of below), the inhaled route of administration is the particle sizes (0:05 À 5 mm), a range of flow rates most difficult that is commonly encountered. Particles The metered dose inhaler has been in use for > 10 mm are stated to be commonly impacted in about 50 years and doubtless forms the mainstay the pharynx; < 5 mm particles are assumed to be for the treatment of asthma, as well as for patients ideal for alveolar delivery, and < 0:05 mm particles with chronic bronchitis with a reversible compon- are said not to impact at all, being liable to be ent. Particle de- in the last few years, due to the need to change their position is dependent on a large number of other propellants into non-fluorohydrocarbon materials, factors, attested to by a vast literature that has as part of the global effort to protect the atmos- accumulated over at least the last 25 years, strad- pheric ozone layer. Other factors governing to vapour escaping from refrigerators and car air particle deposition (and example studies) include: conditioners, must have been negligible. Exercise and minute ventilation (Bennett et al cause of the inability to quantitate lung deposition 1985) and the general aim of avoiding systemic drug ab-. Breathing pattern, airway calibre, spacers and new drugs with specified nebulizers; labeling for a- reservoirs (Bennett 1991) dornase is the first to exhibit this change in policy. The physicochemical properties of the drug(s) This requires that the clinical development plan be (Zanen et al 1996) implemented, as early as possible, with the nebu-. This highly specialized field requires the The truth is that it is practically impossible to validation of the nebulizing system for each drug measure the lung deposition of inhaled drugs in and species separately. Formulations vary, but include sublin- gual pellets, chewable gums, and solid formulations The principal distinction between transdermal and that are held on a stick, somewhat like a lollipop. Both formulations are, how- are actually converted into a solution for swallow- ever, subject to the same skin irritancy testing prior ing and gastrointestinal absorption (e. As in oral transmucosal administration, potent drugs, with modest requirements for mass absorbed and rea- Intranasal sonable lipophilicity, are the best candidates for transdermal delivery. Even if unexploited by pharmaceutical scientists, the abuse of cocaine (in- cluding by primitive peoples), and nicotine (snuff ) Rectal has routinely used this route of administration for systemic delivery. Vast annual tonnages of anti- The use of suppositories is probably one of the allergy and decongestant drugs are now adminis- clearest examples of cross-cultural differences in tered to the noses of the developed world. A surgeon on a intended to treat local symptoms, and avoidance of famous ocean liner has commented that: `Part of systemic absorption is a favourable feature. This ric nocturnal asthma, and topical treatments for avoids repeated parenteral injections, and avoids proctitis and inflammatory bowel disease are the the digestive capacity of the gut. Organic solvents are often used to enhance the An intravaginal suppository is more accurately rate of absorption from the subcutaneous or intra- termed a pessary. For example, local use, including for Candida albicans and Tri- benzyl alcohol and sodium benzoate are used to chomonas infections, as well as for preparation of dissolve diazepam, and extravasation of this for- the cervix prior to induction of labour. Intravenous remifentanil is formu- lated with glycine, and hence it is not well-suited for The solubility of a drug, and the compatibility of a epidural administration. Stability The selection of an inert package is an essential part studies should include not only the range of tem- of the pharmaceutical development of a drug. Unfortunately, this occurs oc- are generally available for all tablets, although they casionally as an iatrogenic adverse event when the are inconvenient to arthritic hands; these are usu- injection (pH 9) extravasates; serious injury can ally the most impervious of all materials. Novel and temperature-controlled, but even so require pharmaceutical formulations seem to fall into two special arrangements for the conveyance of groups, those being used for gene therapy and livestock. However, such viruses have to be human, and their attenuation sometimes is Stability testing of drugs is an entire subspecialty lost after administration, leading to very serious within the pharmaceutical professions and cannot adverse events. Understanding the vocabulary will help was developed because that drug is almost insol- participation in team meetings, where pharmaceut- uble, but is also now being revived in the post- ical and clinical development must be coordinated. The intravenous emulsion A chapter on this scale will never equip a pharma- of propofol is also unique, again being invented out ceutical physician to conduct pharmaceutical de- of necessity. The volume edited by Williams vivo or in vitro studies have established the pharma- and Hottenderf (1997) provides more information cological profile of the new drug and a rationale for on the subjects that are discussed below. In many companies, drug metabolism is a The nature, timing, and extent of the initial non- separate entity from the toxicology function but, for clinical toxicology program depend on the clinical thesake of completeness of this chapter, adiscussion development plan that it must support. Al- though often quite detailed, these jurisdictions were Usually, the initial clinical goals are to study toler- rarely similar, and designing a non-clinical toxicol- ability and to provide initial pharmacokinetic as- ogy program that would be universally accepted sessments. Such a clinical study would require a re- group that consists of regulators and pharmaceut- stricted set of toxicity studies to support the safe ical company representatives from the three geo- use of the drug in this situation. On the other hand, graphical areas, has been meeting for several years some companies achieve economies by having the to address the harmonization of many aspects of the initial toxicology program be sufficient to support drug development process. Since exposure of patients in clinical trials Of equal importance to the successful initiation of a (in most cases) cannot last beyond the duration of non-clinical program are several factors that can the animal studies, careful consideration of the have a great impact on the rapidity with which a development schedule must be made, so that no program can be implemented. This requires that the appropriate pre- factors can result in unanticipated delays, costing clinical reports are available prior to the planned time and money. Since thalidomide, reproduction, approximates that anticipated for initial clinical and teratology studies have been required prior to usage, although, of course, this is unlikely to be enrollment of large numbers of women in clinical the formulation that is eventually marketed when studies. Factors such as method posed indication for the drug, postmenopausal or of synthesis, excipients and appropriate vehicles otherwise reproductively incapable women can be usually evolve from bench-scale drug supplies and used. However, the timing of the enrollment of simple vehicles, to more sophisticated galenicals as women needs to be understood well in advance so the program proceeds. Scale-up of manufacturing that the lack of appropriate non-clinical reports processes can result in bulk drug with different does not hinder clinical development. The type of formulation can affect the It is common, particularly for American com- pharmacokinetics of the drug, thus altering the panies, to carry out initial Phase I studies abroad. This has the effect of allowing Phase I studies to be initiated more rapidly and thus Early-stage small-scale synthesis methods will often obtaining information on preliminary safety and create a different profile of impurities or degra- pharmacokinetic data earlier. In these cases, whether the non-clinical formulations must be pre- since regulatory agencies require the use of both a pared daily or can be prepared weekly. If drugs are rodent and a non-rodent species, the typical ap- to be given orally, it is obvious that they must be proach would be to use the rat and the dog for the resistant to degradation of gastric acids and must toxicity studies, and mice or rabbits for other more be stable in the formulation itself (water, carbox- specialized studies.

Osmolarity is sensed in the hypothalamus by neurons known as osmoreceptors discount zudena 100 mg mastercard erectile dysfunction natural treatment reviews, which in turn stimulate secretion from those neurons that produce anti-diuretic hormone zudena 100 mg mastercard erectile dysfunction at 55. Secretion of anti- diuretic hormone is also simulated by decreases in blood pressure and volume discount 100mg zudena with mastercard impotence urologist, conditions sensed by stretch receptors in the heart and large arteries. Changes in blood pressure and volume are not nearly as sensitive a stimulator as increased osmolarity, but are nonetheless potent in severe conditions. For example, loss of 15–20% of blood volume by haemorrhage results in a massive secretion of anti-diuretic hormone. Another potent stimulus of anti-diuretic hormone is nausea and vomiting, both of which are controlled by regions in the brain with links to the hypothalamus. The most common disease state related to anti-diuretic hormone is diabetes insipidus. This condition can arise from either of two situations: • Hypothalamic (‘central’) diabetes insipidus. This results from a deficiency in secretion of antidiuretic hormone from the posterior pituitary. The major indication of either type of diabetes insipidus is excessive urine production; as much as 16 l of urine per day. If adequate water is available for consumption, the disease is rarely life-threatening. Hypothalamic diabetes insipidus can be treated with exogenous anti-diuretic hormone. Water pores are however completely impermeable to charged species, such as protons. Aquaporins comprise six transmembrane α-helices, and five interhelical loop regions (A–E) that form the extracellular and cytoplasmic vestibules. There are 13 known types of aquaporin in mammals; six of these are located in the kidney. Haemostasis provides several important functions: it maintains blood in a fluid state while circulating within the vascular system; it arrests bleeding at the site of injury by formation of a haemostatic plug (clot); and it ensures the removal of the haemostatic plug once healing is complete. In which the blood vessels contract as a result of neurological reflexes and local myogenic (muscle) spasm. In which a ‘platelet plug’, a loose collection of platelets, forms and acts as a base for the formation of a stable clot. Absent or defective platelets are noted in thrombocytopenic patients, who develop petechiae (small pinpoint haemorrhage). Platelets, derived from the fragmentation of megakaryocytes, are essential both in main- taining the integrity of the adherens junctions, which provide a tight seal between the endothelial cells that line the blood vessels, and in forming a clot where blood vessels have been damaged. The role of thromboxane A2 in platelet activation accounts for the beneficial effect of low doses of aspirin, a cyclooxygenase inhibitor, in preventing inappro- priate blood clotting (recovery after surgery, prevention of deep-vein thrombosis, avoiding heart attack). It inhibits platelet aggregation and appears to reduce the risk that ‘reamed out’ coronary arteries (after coronary angioplasty) will plug up again. Traumatised vessels and platelets liberate activating factors, which initiate the clotting process. Both pathways share a common pathway that converges at factor X with the production of thrombin (Figure 11. Fletcher factor and Fitzgerald factor were given to further coagulation-related proteins, namely prekallikrein and high-molecular weight kininogen respectively. Factor Xa and its co-factor Va form the prothrombinase complex, which activates prothrom- bin to thrombin. It forms on a phospholipid surface in the presence of calcium and is responsible for the activation of factor X. Its primary role is the conversion of fibrinogen to fibrin, the building block of a haemostatic plug. Thus what may have begun as a tiny, localised event rapidly expands into a coagulation cascade. In adding the γ -carboxyl group to glutamate residues on the immature clotting factors, vitamin K is itself oxidised. Another enzyme, vitamin K epoxide reductase, reduces vitamin K back to its active form. Vitamin K epoxide reductase is pharmacologically impor- tant as a target for the anticoagulant drugs warfarin and related coumarins (acenocoumarol, phenprocoumon and dicumarol). These drugs create a deficiency of reduced vitamin K by blocking the epoxide reductase, thereby inhibiting maturation of clotting factors. Warfarin is also used as a rat poison, causing death by lethal (internal) bleeding. A major physiological anticoagulant, this is a vitamin K-dependent serine pro- tease enzyme that is activated by thrombin. Protein C is activated in a sequence that begins with it binding, together with thrombin, to the cell-surface protein thrombomodulin. Quantitative or qualitative deficiency of either may lead to thrombophilia (a tendency to develop thrombosis). Recombinant protein C is now available to treat people threatened with inappropriate clotting, as a result of widespread infection (sepsis) for example. It is constantly active, but its adhesion to these factors is increased by the presence of heparin sulphate (a glycosaminoglycan) or the admin- istration of heparins (different heparinoids increase affinity to factor Xa, thrombin, or both). Some surgical patients, especially those receiving hip or heart valve replacements and those at risk of ischemic stroke (clots in the brain), are given heparin. Generated by proteolytic cleavage of plasminogen, a plasma protein synthesised in the liver. Plasmin proteolytically cleaves fibrin into fibrin degradation products, which inhibits excessive fibrin formation. This inhibits the release of granules that would lead to activation of additional platelets and the coagulation cascade. Although plas- minogen cannot cleave fibrin, it has an affinity for it and is incorporated into the clot when it is formed. Plasminogen contains secondary structure motifs (‘kringles’) which specifically bind lysine and arginine residues on fibrin. When converted from plasminogen into plasmin, it functions as a serine protease, cutting C-terminal to these lysine and arginine residues. Fib- rin monomers, when polymerised, form protofibrils, each consisting of two strands arranged anti-parallel. Thus, plasmin action on a clot initially creates nicks in the fibrin that lead to digestion and solubilisation. These convert plasminogen to the active plasmin, thus allowing fib- rinolysis to occur. Injected within the first hours after a heart attack, it dissolves the clot blocking the coronary artery, restoring blood flow before the heart muscle becomes irreversibly damaged. Decrease in platelet numbers may be due to various causes, including insufficient production (e. Most consumptive conditions lead to platelet activation, and some are associated with thrombosis. Haemophilia C is a much more rare autosomal recessive disorder, most commonly seen in Ashkenazi Jews (Ashkenazi Jews are those that are descended from the medieval Jewish communities of the Rhineland in the west of Germany).

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As governm ent assumes the responsibility for the fi­ nancing of medical care cheap 100mg zudena amex erectile dysfunction diabetes symptoms, it will necessarily install a large bureaucracy to police the flow of public funds into private hands buy zudena 100 mg visa erectile dysfunction treatment food. Concomitantly purchase zudena 100mg online erectile dysfunction treatment bangkok, it will expand its regulatory ap­ paratus to scrutinize the quality o f the product it is buying, the means by which it is provided, and the distribution o f the resources it is creating. If these bureaucracies behave as other service bureaucracies have—and there is no reason to assume otherwise—they will im pede rather than facilitate the flow of benefits from providers to consumers. But paradoxically, they will also seek to preserve the flow of benefits from providers to consumers. T he en­ trenchm ent o f a bureaucracy that feeds off a service by serving as an interm ediary between provider and consum er will then frustrate if not prevent change in the service sys­ tem of the future. As the governm ent assumes larger obligations for services and as the economy gradually shifts to a service economy, bureaucracies will swell in power as well as size. In the past, a key problem has been the rapacity of the private sector which controlled the resources necessary for a decent life. But in the future, control over the flow o f resources will rest m ore with 132 Medicine: a. Evidence is available that medical care has less impact on health than a variety of other factors. T he growth and strength of service bureaucracies will frustrate attem pts to reallocate resources—to shift re­ sources from services to other program s with a potentially greater impact on health. Today’s com puters are already deployed in medical care; scores o f software salesmen visit doctors’ offices and hospital corridors. T he com puter, one example of high medical technology, can improve medical care, but there are hazards as well. Decisions regarding the kind and the am ount of medical care are made by the physician, but also to an increasing extent by government. Currently, federal and state governments together purchase about 40 percent of the medical care provided in this country. However, it is equally possible that the com puter will facilitate despotic m anipulation o f consumers; it could dramatically lessen con­ sum ers’ opportunities to affect decisions about health care services. T he com puter might make possible instantaneous interaction between pa­ tient and provider without the necessity of an office or The Com puter Revolution: The High Technology of the Future 133 hospital visit. For example, a person experiencing certain symptoms may be able to take advantage o f a com puter link with a physician’s office. A com puter could be utilized for interrogation o f the patient and instantaneous coding of the patient responses. This is an example o f how medical care might be m ade m ore accessible to the consumer. G reater use of the com­ puter in the provision o f care will accelerate this trend. The use of the com puter in triage—situations in which decisions m ust be m ade as to who will receive life-saving medical care—has occurred. In a hospital in Salt Lake City, Utah, that is almost entirely com puterized, use of the com puter system presumably makes a physician’s diagnosis m ore accu­ rate. Reliance on the com puter will undoubtedly increase m arkedly in the next 20 to 30 years. A nother product of further developm ent of com puter technology is the patient com puter console. Patients could be provided with hom e consoles that would be program m ed with inform ation relating to their own condition and past treatm ent, and perhaps linked with the physician’s com puter system. T hrough use o f the console, patients would be able to retrieve inform ation relating to their conditions almost instantaneously. Since they pose an obvious threat to professional prerogatives, providers will probably resist the use of hom e consoles. One potentially adverse consequence o f increased use of the com puter in medical care derives from the fact that com puters cost money. W idespread deploym ent o f com put­ ers will drive up the costs of care and foster further speciali­ zation. T he recent history o f medical care reflects the unabating sophistication of medical care technology and the rapid specialization of practitioners. As m ore sophisticated technology is im plemented, substantial num bers of citizens will be deprived of care which only the rich will be able to 134 Medicine: a. T he alternative is the subsidy of costly procedures under a national health insurance program. But limits on the public purse will soon be reached, and a private m arket for the most costly procedures will undoubtedly develop. O ne of the dualities in medicine referred to in C hapter 3 is the schism between the an­ thropologic and technical approaches to care. If future use of the com puter is dictated by the proponents of technical care, an even greater erosion in the anthropologic approach can be expected. W hen intelli­ gently used by the physician and the patient, the com puter might lead to m ore accuracy in both diagnosis and treat­ ment. Further deemphasis in the hum an or an­ thropologic approach may have unforeseen costs that far outweigh the benefits of the use o f the com puter. T he com puter, as one o f the most powerful and allur­ ing tools for technicians, will contribute to its demise. T he alienation of individuals when grappling with large and complex organizations is conveyed in an extensive literature. T he scale and complex­ ity of the medical care system have im portant implications for health. T here is no definitive evidence correlating health with the scale of the treatm ent system, but the scale o f the delivery system is growing, irrespective of the means taken to finance care, or the nature of structural reform s within the system. Increasing sophistication o f the medical hard­ ware and superspecialization by practitioners has led to larger units for the delivery of care. Since the com puter increases the potential for control o f larger and m ore complex operations and feeds the specialization craze, m ore extensive use of the Work 135 com puter will facilitate the evolution o f larger and more complex units for care. Increases in the size o f institutions further attenuates the patient’s responsibility for health. Historically, with the rise of the professions of health, the individual has been relieved o f responsibility for health. T he advent o f larger systems of care will force already dependent patients to relate to bricks, m ortar, and bureaucrats. Something in the relationship between patient and physician may be essential to the pa­ tient’s well-being. W O R K In 1972, the D epartm ent of Health, Education and W elfare issued a report entitled Work in America.

Training requires the following components: (a) Trained teachers who are professional nuclear medicine practitioners; (b) Doctors hoping to pursue a career in nuclear medicine; (c) An established syllabus; (d) Mechanisms for the supervision of trainers; (e) Mechanisms for the supervision and assessment of trainees buy discount zudena 100 mg on-line erectile dysfunction after drug use. In addition buy zudena 100mg low cost impotence 10, while some countries may set entry requirements for training order cheap zudena online erectile dysfunction treatment milwaukee, others may adopt a system of continuous assessment throughout the training course and/or a final assessment. Successful trainees are awarded with a final certificate, degree or diploma that is recognized by the government, local health authority and hospital as an assurance of specialist competence in nuclear medicine. General professional training Nuclear medicine specialists must have a sound understanding of general and emergency medicine, including resuscitation, surgery, gynaecology, paediatrics and psychiatry. Nuclear medicine could be regarded as the last refuge of the physician in a hospital since all hospital departments seek nuclear medicine services to a greater or lesser extent. A general professional training in nuclear medicine is offered to doctors who have obtained their qualifications and completed a requisite period, usually of a year, as a medical or surgical house officer before obtaining registration as a medical practitioner. This requires a minimum of two years in clinical posts approved by the national training authority. During this time, the doctor should be directly involved in patient care and gain broad experience in a variety of clinical fields. Ideally, at least three quarters of the time spent in such clinical posts should include experience in the admission and follow-up of acute clinical emergencies. A minimum of six months of this time should include experience in ‘unselected emergency care’, i. A further six month assignment to a department of radiology is recommended for nuclear medicine trainees who are not following a career in radiology. Unfortunately, there is an increasing tendency among national authorities to set very specific, narrow and even discriminatory requirements for entry into particular specialties. It is recommended that there should be a final examination to ensure that candidates have adequate knowledge and skills to practice nuclear medicine. Training paths The training period for postgraduate nuclear medicine starts four years after the completion of general medical training, either from an internal medicine background or following training in diagnostic radiology. There should be a general training in radiology of at least eight weeks during the four year period. However, if a radiologist who has completed a four year general radiology training to certification level wishes to undertake further training in nuclear medicine to certification level, then a two year period of specialist nuclear medicine training that must include radionu- clide therapy is recommended. The responsible training body is required to set standards both for training and for the supervision of trainees. As a minimum requirement, officials from the training body should visit centres of specialist training in nuclear medicine to ensure the availability of trained professionals in nuclear medicine. These visits should also determine whether the resources and equipment satisfy the requirements of the training programme, and that trainees have sufficient space in which to work as well as access to information on web sites and in libraries. It is also important to ensure the availability of funding for accommodation, subsistence and the purchase of books, to be provided by the 12 2. Where the above conditions cannot be met by a national authority, consideration should be given to sending the trainees to a centre outside the country, for example by studying for an academic degree in nuclear medicine at a recognized institute abroad. Assessment of trainees Each training programme should contain a standard against which the progress of the trainee can be assessed for each element of the syllabus. The assessor should preferably be external to the department that is providing the training, such as a postgraduate dean, a consultant in nuclear medicine from another hospital or other senior person. The assessment may take the form of an interview, a written paper, an essay, a set of multiple choice questions, or an oral examination of displayed images of various nuclear medicine techniques in clinical practice. Each end of year assessment should carry a score that indicates how the candidate has progressed against the set target. Syllabus This section provides an indication of training for each of the four years: Year 1 (a) Scientific principles: —Basic physics and mathematics; —Instrumentation; —Principles of computing; —Basic radiation biology and radiation protection; —Basic radiopharmacy and radiochemistry; —Principles of tracer technology. Year 2 (a) Requirements of Year 1 in greater depth: —Tracer kinetics; —Computing and image processing; —Radiobiology including the biological effects of high and low levels of radiation; —Linear hypothesis and the threshold hypothesis of the biological response to low level radiation; —The effective dose equivalent and the calculation of radiation dose from radiopharmaceuticals. Year 4 Further practice and experience of techniques learned in years 1–3: —Legal and regulatory requirements; —Audit; —Departmental and hospital management; —Research techniques and evaluation; —Teaching and training. Practical training Postgraduate trainees are obliged to play an active in-service role in the practice of nuclear medicine in order to familiarize themselves with all the techniques required of a nuclear medicine practitioner, such as: (a) Protocols of in vivo and therapeutic procedures; (b) Data acquisition and processing with various types of equipment, quality control of instruments and labelled agents; (c) Interventional procedures, including physiological, pharmacological and mental stress related for diagnostic applications, and all therapeutic inter- ventions; (d) In vitro protocols and procedures, if appropriate. Arrangements The aim of postgraduate training is for trainees to attain a sufficiently high standard of theoretical and practical learning to qualify as a nuclear physician. A board or similar form of authority will award a certificate to successful trainees. Training in research and information retrieval The following specific elements should be emphasized in the training of research techniques: —Research project design; —Understanding the elements of research that can lead to bias; —Design of single centre and multicentre trials; —Analysis of results; —Statistics for analysing results; —Parametric and non-parametric methods; —Requirements for the publication of research; —Legal and ethical requirements: the local Research Ethics Committee; —Radioactive material licensing requirements for clinical practice and research; —Translation of laboratory work into clinical practice; —Obtaining information about, and contributing to, evidence based nuclear medicine; —The Cochrane library (Update Software, Oxford). Teacher training The following specific elements should be emphasized: —General teaching techniques; —Preparation of teaching materials; —Use of teaching aids; —Teaching by example; —Assessment of trainees; —Setting of exam questions, particularly of multiple choice questions. Undergraduate training Undergraduate training refers to teaching and training that is provided by, and takes place within, a medical college. The primary goal of training undergraduates is to introduce them to various radionuclide diagnostic and therapeutic methods and to give them an overview of the basic concepts, principles and major clinical applications of the specialty and its place in medical practice. Undergraduate training provides a basic understanding of nuclear medicine for all medical staff but is not sufficient for a qualified practitioner who is going to pursue a career in nuclear medicine. It is essential that all undergraduate medical students be taught about radiation. Unfortunately the potential of nuclear medicine in demonstrating physiology is usually not recognized in the teaching of physiology. Since physics has been dropped from the curriculum of pre-medical studies in many countries, an appreciation of the physical properties and biological effects of radiation is often lacking. Regulations concerning the protection of the patient from ionizing radiation means that qualified doctors must undergo some form of radiation protection instruction or course in order to practise in their particular field: cardiologists, in the screening of pacemaker wire; orthopaedic surgeons, in X raying the hip during the introduction of a prosthesis; ward medical staff, in injecting radiopharmaceuticals. Ideally, this certification of competence should be obtained during undergraduate training rather than during the period of clinical experience. In any event, the theoretical part should be made mandatory even if the practical instruction is at postgraduate level. All physical processes have advantages and disadvantages: in the case of electricity one can turn on a light or be 18 2. The goals and content of training determine the corresponding learning arrangements. Normally, theoretical teaching should be no less than 30–36 class hours, plus 10–14 hours of practical training (Table 2. Practical training In order to provide a good training, a medical teaching facility must fulfil certain basic requirements. For example, it should comprise a full scale nuclear medicine practice, with qualified, highly experienced medical personnel, including a medical doctor, radiochemist, medical physicist and a group of technologists or technicians. The department of nuclear medicine must have a sufficient variety and quantity of work and services to offer trainees meaningful work experience. The person(s) in charge of the training should have adequate academic knowledge as well as teaching experience in nuclear medicine.

By C. Faesul. Luther Seminary.