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In discussing the etiology buy generic propecia 1mg hair loss in men going, treatment and sure generic 1mg propecia visa hair loss real cure, and become lodged in the sinuses or buy propecia 1 mg with mastercard hair loss extensions, more prevention of many diseases cheap propecia 1mg free shipping hair loss cure products, Ramazzini often goes alarmingly, in the throat. There is strong support for its use by those involved When you come to a patient’s house, you should ask in regular clinical usage; however, there are only him what sort of pains he has, what caused them, how anecdotal accounts and a few single case studies to many days he has been ill, whether the bowels are support application of this technique (Myers 2001). I may venture to Alternatives add one more question: what occupation does he follow? Manual cranial and facial manipulation (Chaitow 2005, Von Piekartz & Bryden 2001). He even had a word for those using word processors: Physiological effects The maladies that affect the clerks arise from three One explanation for the benefits noted may be the causes: first, constant sitting; secondly, incessant enhanced elimination of mucus from the nasal pas- movement of the hand and always in the same sages as a result of force from the inflated finger-cot, direction; and thirdly, the strain on the mind. The thus reducing pressure and pain and allowing incessant driving of the pen over paper causes intense increased sinus and nasal drainage. Tenderness following treatment, along the median pala- In essence, the model of care offered in occupational tine suture and other facial sutures, is common, persist- and ergonomic therapeutics is in precise alignment ing for several days. If that modality is • reduce pain and dysfunction accepted as being a reasonable use of force to achieve • identify barriers to recovery (ergonomic, a particular physiological benefit, then nasal specific psychosocial and personal) technique might be regarded in the same light. It is • assess people’s ability to function in their certainly probable – for example, if relief is obtainable environment from chronic sinus problems via nasal specific use – • improve people’s ability to meet the demands that this same result might be obtainable over time of their environment with gentler drainage methods, along with the stan- • reduce the demands of the environment to suit dard nutritional, hydrotherapeutic and botanical the individual and the population at risk strategies that are likely to be employed in naturo- • minimize the risk of developing symptoms. There is no attempt under this heading to provide Occupational and ergonomic therapies the range of information covered in other modality topics, as the range of methods, techniques, systems Indications/description and modalities employed in assessment and treat- In 1700 Ramazzini (1633–1714) wrote the first impor- ment within occupational and ergonomic therapy are tant book on occupational diseases and industrial as wide as the range of human activities. Trager hypothesized that, when muscles that normally produce a movement are receiving Further reading movement, something unusual is happening in the 1. The signals to the brain musculoskeletal injury: a clinical ergonomics would be primarily receptive and would not include approach to prevention, treatment and the usual impulses of muscle engagement and rehabilitation. Churchill Livingstone, proprioception for that particular movement (Juhan Edinburgh 1989). The passivity of the body can allow the client to feel movements that would normally be blocked by 2. This stillness Oscillatory/vibrational rhythmic methods also includes intervals when the practitioner removes Indications/description his/her hands and pauses. These pauses in movement Soft tissue and joint restrictions appear amenable to and hand contact allow the client to assimilate the new beneficial change in response to rhythmic oscillatory movement possibilities. A number of variations exist, variously dubbed Validation of efficacy = 4 (see Table 7. Proactive oscillatory methods are where the century with no reported negative effects should patient performs the movements while the provide adequate validation for the continued use of practitioner/therapist offers resistance – either such methods, until further research offers definitive partially (isotonic) or totally (isometric). Variables include the arc of motion, as well as the speed, ranging from several oscillations per Alternatives second to one oscillation every 3–4 seconds. Reactive oscillatory methods involve the passive, as well as imposed and ‘tuned into’ models practitioner/therapist performing the of oscillation/vibration, providing a range of alterna- movement, with the patient offering resistance. It is this format that is described edema fluid from the area, may directly stretch tissue, in the examples offered below. The client experiences rhythmical rocking trauma to reverse the deformation of fibrin through motions much of the time during the tablework. Chapter 7 • Modalities, Methods and Techniques 251 Pathway to organization Organization Possible outcome Figure 7. Reproduced with Psycho- General changes in motor permission from Lederman (2000) Sensory feedback response (proprioception) physiological General changes in pain perception General autonomic changes Sensory feedback Increased proprioception Harmonic (proprioception) Neurological technique Altered pain reflexes Effecting repair precesses Physical loading Local Mechanical changes tissue Fluid dynamic changes Lederman (2000) suggests that harmonic methods movement education. Trager Institute, Mill influence local tissue organization following trauma Valley, California (influencing mechanical in addition to fluid dynamic properties), as well as neurological (providing pro- Pilates methods prioceptive stimulation in addition to gating of pain) There is additional information in Chapter 9. Pilates-based exercises can be performed on the floor, termed ‘mat work’, or Cautions on equipment, termed ‘apparatus work’. A key piece None noted apart from caution regarding rate and of apparatus is the Reformer which comprises a single amplitude of rhythmic movements imposed on tissues bed frame equipped with a sliding carriage that uses under repair. Cables, bars, straps and pulleys are features of a variety of Naturopathic perspectives Pilates-based exercises, performed in multiple posi- There is something inherently naturopathic about tions. Strength, endurance and flexibility of the major bodily rhythms being employed to gently coax postural muscles involved in trunk (core) stability, enhanced circulatory and drainage efficiency as well particularly the abdominal group, receive focused as neurological coordination and integration in dis- attention (Mullhearn & George 1999). Comeaux Z 2002 Robert Fulford and the elderly (Hall et al 1999, Hutchinson et al 1998, Segal philosopher physician. Juhan D 1989 An introduction to Trager Pilates has also been described as a mind–body psychophysical integration and mentastics fitness program (Pilates 1934, 1945). The movements happen within the safe proceeds the practitioner adjusts the parameters of confines of conditioned reflexes, creating a playful movement in response to changes in resistance, sense of letting go and trust in the client. The rhythmical movement in Trager® creates a Comeaux (2004) suggests: lulling relaxation, like floating on the sea, or swaying The stretch, cyclic afferent input, and articulatory in a hammock. The practitioner can vary different movements associated with natural gait is a useful parameters: frequency, amplitude, direction, hand way of mobilizing restricted segments of the central contact, pattern, pause, position, stretch, or axis. The Facilitated Oscillatory Release approach to compression, while initiating movement from his/her the spine and sacrum attempts to replicate the gait feet, as the hands catch, nudge and anchor the cycle. Like a ballroom dancer, the practitioner can take advantage of gravity, momentum, tensegrity, and • Beginning with the patient in a prone position, tonus, while feeling for signs of impedance and flow. When resistance is felt, even a slight • This hand is then set into motion rhythmically 180 degrees out of phase with the motion of the pelvis, creating torsion of the torso. Reproduced with permission from by one of three strategies of application of rhythmic Blackburn J. Journal of Bodywork and Movement Therapies force: 2004;8(3):178–188 Chapter 7 • Modalities, Methods and Techniques 253 Box 7. In this application the intent would be to induce a relaxation pattern of baseline neuromuscular coordination and to entrain a more harmonic pattern. Comeaux (2004) makes clear: If a practitioner is applying these strategies to the spine, it is wise to begin with the patient in as gravity neutral a posture as possible, with access to the spine. Journal stimulation is reproduced that is equivalent to that of Bodywork and Movement Therapies 2004;9(2):88–98 during active walking, with its alternating pelvic rotation and counter torsion through the trunk. One strategy is to induce a stretch or articulation the strategies are assimilated, it is possible to mobilization with a rapid exaggeration of the transfer most of these strategies to the seated rotation of the segment in phase with the position. A second more forceful strategy is to add the trunk, with localization as is necessary. To diagnose exaggerated rotation out of phase with the in the pelvis and more particularly the sacrum, a developed rhythm. This applies a destructive reciprocal role of the two hands is used by rotating interference pattern to the established wave in the trunk to generate momentum, and letting the the tissue by introducing more energy. A third intervention strategy is to gently persist resonant tissue compliance, and to then making with the established wave pattern to soften tissue corrective suggestion. The tissues are then held in this of time (see below) offers restrictions a chance to position for variable periods (90 seconds is a ‘unlatch’, release, normalize.

Furthermore propecia 5 mg mastercard hair loss system, they allow detection of pathogens propecia 1 mg on line hair loss cure x sinusite, such as the human papilloma virus buy propecia 5mg without prescription hair loss in men ministry, that are refractory to in vitro propagation generic propecia 5 mg line hair loss cure at home. Antibodies used in a direct search for a given pathogen typically recognize antigens found in multiple copies on the microorganism and thus circumvent the need to replicate the agent. Unfortunately, the cross- reactivity of these antibodies with host antigens and other pathogens has compromised the convenient and broad use of these diagnostic reagents for some pathogens. In addition, some viruses establish latent infections in which active viral replication is substantially attenuated, thereby preventing detection by antigen based methods. For example, in visceral Leishmaniasis, the parasitological diagnosis can be performed using peripheral blood instead of bone marrow or spleen aspirates. Similarly, in chlamydia infections, urine can be used instead of urethral scrapings. This approach is in contrast to the traditional xenodiagnosis method, where 40 insects starving for 45 days are applied to the patient’s arms. In cutaneous Leishmaniasis, the invasiveness is reduced from regular biopsies to needle aspirates. Examples of pathogens that can be detected using these approaches are listed below. Pathogens with an asterisk represent those for which molecular based methods are the gold standard: Adenovirus Legionella pneumophila Bartonella henselae and Bartonella quintana * Leishmania sp. Borrelia burgdorferi Microsporidia * Chlamydia pneumoniae Mycobacterium avium * Chlamydia trachomatis Mycobacterium bovis Cytomegalovirus Mycobacterium leprae Epstein–Barr virus Mycobacterium tuberculosis Helicobacter pylori Mycobacterium ulcerans Hepatitis B virus Mycoplasma pneumoniae * Hepatitis C virus * Neisseria gonorrhoeae Hepatitis G virus Onchocerca volvulus Herpes viruses 6 and 8 Parvovirus B19 412 5. The virus site of latency is the epithelium, where most of the clinical presentations are encountered. The distinct virus genetic groups present different cellular tropisms and therefore present distinct clinical features (skin warts, benign head and neck tumours, genital warts and cervical carcinoma). Molecular methods have been developed in order to detect and type the virus in clinical specimens. This is achieved by molecular hybridization with radio- labelled probes in the Southern Blot procedures. Polymorphism in the host p53 gene has prognostic significance, defining groups that are more susceptible to cancer development and therefore requiring closer follow-up, leading to early detection and treatment of cervical cancer. These molecular methods are complementary to conventional investigations such as cervical smears and histopathological analyses (see the chronology of investigation in Fig. Trypanosoma cruzi and Chagas’ disease Chagas’ disease is caused by the protozoan T. The infective stages of the parasite are present in insect faeces and can penetrate through the epithelium into host cells. During the acute phase, which can last up to 60 days, a large number of circulating parasites are observed in the bloodstream. Patients may develop different clinical presentations, varying from oligosymptomatic to the development of myocarditis and meningoencephalitis. Following the acute phase, a chronic stage develops in which the level of circulating parasites is far below the threshold for microscopic detection. Approximately 10–20% of infected individuals will develop a symptomatic chronic disease hallmarked by cardiovascular–gastrointestinal involvement. Chagas’ disease due to blood transfusion is a problem in Latin America since in some endemic areas a significant percentage of potential blood donors (2–63%) may be infected. Etiological therapy for Chagas’ disease is indicated in either acute or recent chronic infections of less than ten years that seem to respond to treatment. Furthermore, patients with the chronic indeterminate form of the disease, the slight cardiac–digestive form, should also be treated. The diagnosis of Chagas’ disease can be made by different means depending on the phase of the disease. By contrast, in the chronic phase, circulating levels of parasites are low and therefore diagnosis depends on detection of the host serological response or on in vitro amplification of the parasites, such as xenodiagnosis or haemoculture. In the former, 40 uninfected triatomine bugs are allowed to feed on the patient and a month later the intestinal contents of the insects are examined for the presence of T. However, both parasito- logical methods lack sensitivity, and positive findings are achieved in less than 50% of seropositive chronically ill patients. In addition, these methods may select parasite subpopulations, distorting the typing of the involved parasite and epidemiological data. Although conventional serological assays can offer fast and fairly reliable diagnosis, they lack specificity, giving rise to false positive results that need confirmation by a parasitological test. Moreover, in congenital infection, serology is precluded by the circulation of maternal IgG antibodies during the first six months of life. The early diagnosis of congenital transmission is essential because treatment is more efficient when given closer to the time of delivery. Thus, a highly sensitive parasitological assay is needed for the diagnosis of an infected newborn of a Chagasic mother or for monitoring the presence of the parasites in the chronic phase of the disease. The amplified products are detected by gel electrophoresis and hybridized with a radiolabelled molecular probe. Details of the appropriate use of the molecular diagnosis of Chagas’ disease are given in Fig. Molecular diagnosis of genetic diseases using radioactive labelling It is known that several human diseases are caused by defective genes, but until very recently very few had been identified. The identification of such genes for a number of important diseases, such as cystic fibrosis, Huntington’s disease, Fragile X syndrome and haematological disorders, has led to the 416 5. However, for any particular ethnic group, about ten mutations will cover 90% of the genotype spectrum, simplifying screening strategies in genetic programmes. Molecular genetics laboratories now offer tests for a large number of diseases, such as: a- and b-Thalassaemia Huntington’s disease Alport’s syndrome Myotonic dystrophy Alzheimer’s disease Niemann–Pick’s disease Androgen’s insensitivity Ornithine transcarbamylase deficiency Angelman’s syndrome Prader–Willi’s disease Antitrypsin deficiency Retinitis pigmentosa Charcot–Marie–Tooth’s disease Sickle cell anaemia Choroideraemia Spinal muscular atrophy Cystic fibrosis Tay–Sach’s disease Fragile X syndrome Von Hippel–Lindau’s disease Haemophilia A Von Willebrand’s disease Hereditary neuropathies X-linked muscular dystrophy. In this section, a model of a genetic disease, Fragile X syndrome, in which the molecular diagnosis has had an impact in prevention, is given in more detail. Since the great majority of Fragile X patients share a mutation at precisely the same site in the gene, as opposed to a range of mutations scattered along the length of a gene, the genetic diagnosis (or exclusion) of Fragile X syndrome is remarkably reliable. Southern Blot analysis is the procedure of choice for medical diagnosis of Fragile X syndrome. The use of this methodology is essential to characterize the Fragile X mutation in males and females, to distinguish premutation from full mutation and to detect methylation. The double digest may also be used in distinguishing between an unmethylated large premutation and a small methylated full mutation. Southern Blot methods allow the molecular classification of alleles by estimation of the approximate size of the Fragile X expansion. Molecular diagnosis of cancer Cancer is due to genetic alterations that affect cell growth and differenti- ation. The most common molecular approach can be used for the following cancers: —Bladder cancer; —Breast cancer; —Colon cancer; —Leukaemia; —Liver cancer; —Lymphoma; —Melanoma; —Multiple endocrine neoplasia; —Neuroblastoma; —Ovarian cancer; —Prostate cancer; —Thyroid cancer. Mutations in this gene and loss of the normal allele is the most common alteration that leads to the progression of cancer.

Faced with awkward questions cheap propecia 1mg amex hair loss for men, and with no desire to be held responsible to Lorraine Hoskin generic 1mg propecia visa hair loss in men jogger, Wood quickly tired of the conversation cheap propecia 5mg mastercard hair loss medication causes. Lorraine Hoskin cheap 1 mg propecia otc hair loss on calves, however, is a fighter and she was determined to fight for the continued treatment of Samantha and for the Breakspear. Within a short time, this group gathered a large membership and Lorraine and others managed to mobilise hundreds of supporters. The group had seven voluntary committee members, and in its first weeks of existence it began a furious media blitz, getting stories on as many programmes and in as many newspapers as possible. Early in November, Lorraine managed to get an item on Thames Television local news. Unfortunately, Lorraine was relatively naive about the kind of battle she was plunging into. Nearly three years later, Lorraine was still dealing with the political fall-out of dirty tricks which followed her excursion into medical politics. Lorraine Hoskin is not given to paranoia but as the Support Group got off the ground, she began to notice the atmosphere of her life changing. The oppressive sense that someone was listening to or monitoring her telephone calls led her, four days after the interview, to ring a special British Telecom number, where she was given advice about possible phone taps. Lorraine would probably have thought little more about her phone, had it not been for an odd incident in January 1991. One morning she received a call from a man whom she did not know but who lived only a few streets away. Appended to the end of the list were a couple of phone calls actually made by the man who had received the bill. When 1 was shown the list in January 1991, I recalled that I had received a number of odd calls in the days following my conversation with Lorraine. The calls I received were all the same; when I picked up the phone, contrary to the normal procedure, it was I who was asked who I was. Involved in an investigation, as I was then, I am guarded about answering such calls and instead asked the caller who they were; on one occasion I was given the name of a London company which did not exist in the phone book. When she got hold of the itemised list, Lorraine Hoskin rang a number of the people on the list, only to find that, like me, they had all received similar information-gathering phone calls. There is nothing you can do in Britain if private parties, such as detective agencies, or government agencies, monitor your calls or even record your conversations. The police respond with quizzical indifference and suggestions of paranoia to such claims. Campaigns of intimidation and harassment against people who demonstrate opposition to the food and pharmaceutical industries as well as other big businesses follow conventional patterns. They can consist of minor aggravations, such as feeding bad credit-ratings into the system, through to death threats, and grossly intimidating physical attacks. None of these activities can be traced back to the vested interests which originate them. Work is passed from industry associations or company middle management to public relations firms and then on to discreet and unprincipled firms of private investigators. Beyond such firms the threads weave out into the criminal communities of large cities and to men who will do most things if the price is right. These men are not familiar with the issues: they are paid, given information about targets, and told how far they can go. The lexicon of industrial sabotage and dirty tricks is voluminous and, although most basic moves have a history in the work of the intelligence services and other secret organisations, they are often adapted and tailored to fit new circumstances. For nearly three years following her decision to fight back in defence of the Breakspear Hospital, Lorraine Hoskin found herself the subject of a sporadic but identifiable campaign of serious harassment. Lorraine Hoskin thought little about the letter; she knew that it did not involve her and thought that there must have been some kind of mix-up. As the months went by, with her own insurance company acting on her behalf, the case took on a bizarre dimension. Secondly, her van is a camper van and not a mini-van and, thirdly, Lorraine knows full well that she did not have any accidents during the stated period. Taken on their own, any of the bizarre and uncomfortable things which have happened to Lorraine could be accidents or coincidences. Placed in context, however, it seems more likely that they were steps in a planned campaign. She and her husband originally bought a house with a large garden at the back, so that Lorraine could build runs for puppies. She had kept two of the dogs which she bred, one, called Pru, she was particularly fond of. Early in November 1990, on a Sunday afternoon, Lorraine and her husband returned home from a family outing to find Pru dead. At the top of the gate the flat upright slats extended a couple of inches above a cross bar. The vet, who described the death as odd, suggested that the dog must have got her paws caught, then struggling to get out had a heart attack. Why, for instance, was there blood on the wall near the dog and yet no lacerations anywhere on the dog? Returning home in the early evening after a weekend day out, Lorraine found that, despite the fact that the gates were locked and the surrounding fence was secure, the dog had left the back garden. Although over the next few weeks the dog showed some improvement, this was quickly followed by lethargy and a refusal to eat. When it became evident that the dog was still seriously ill and in some pain, the vet recommended that it be put down. Within a week of appearing on the London Weekend Television programme, Lorraine Hoskin received her first threatening phone call. Over the following five months, she received three such phone calls, each of which suggested that she would be killed or injured. At home alone one evening, Lorraine received a call from a distraught woman, who accused her of having an affair with her husband. Phyllis Bass read to Lorraine over the phone other information which she said her husband had written down. Other information suggested that Lorraine had a six-year problem with alcoholism and that she had spent time hospitalised and on a life-support system as a consequence. In fact, Lorraine does not have an alcohol problem but a member of her extended family did have a six-year fight with alcoholism and did end up in hospital on a life-support system. Although Lorraine managed to persuade Phyllis Bass that she did not know her husband, the phone call distressed her. For the first time, Lorraine knew definitely that someone, whom she did not know and had no links with, had information about her: she could only think that the information had been gathered to do her harm. Lorraine rang to ask my advice; I told her that she must ring Phyllis Bass back and obtain as much information as possible about Geoffrey Bass before she reported the matter to the police. The police involvement in the case from that point onwards is a tale of scepticism and lack of commitment. Furious that she had phoned Lorraine Hoskin, he rang Lorraine to say that his wife had got it all wrong, he neither knew nor had any information about her. Lorraine, realising that good evidence was disappearing, rang Romford police station again and told them she wanted something done immediately about Phyllis and Geoffrey Bass, because in her opinion they might be linked to the threatening phone calls which she had been receiving.

Among the commonly used single photon emitting 201 99m perfusion tracers are Tl and the various Tc labelled perfusion tracers (e discount 5mg propecia fast delivery hair loss cure 4 children. While having different physical and pharmaco- kinetic properties propecia 1mg cheap hair loss nutrients, these tracers have considerably overlapping clinical uses and will therefore be considered in parallel in this section 1mg propecia hair loss treatment shampoo. Clinical indications The clinical indications for myocardial perfusion tomography are summarized in Table 5 purchase propecia 1mg visa hair loss forum. The presence of extensive ischaemia or myocardium at risk indicates the need for more invasive work-up, such as coronary angiography. Conversely, the absence of significant ischaemia or myocardium at risk generally rules out the need for intervention. Myocardial perfusion imaging can be performed in various settings: in patients with suspected coronary artery disease, after myocardial infarction or for the assessment of therapy. Myocardial perfusion imaging can also be used to evaluate the patho- logical significance of coronary lesions already detected by angiography. Angiographic coronary artery disease with a normal stress myocardial perfusion scan has little prognostic significance according to accumulated data. This helps clinicians to determine which patients to manage aggressively with invasive procedures and which ones to manage conservatively. As with detecting myocardium at risk, stratification using mycardial perfusion imaging can be done in various settings: in patients with suspected coronary artery disease, after myocardial infarction as well as before non- cardiac surgery (to determine the risk of perioperative cardiac events). The term ‘viable myocardium’, in its broadest sense, denotes any myocardium that is not infarcted. For the cardiologist, however, the search for myocardial viability is primarily a quest for myocardial hibernation. Myocardial hibernation is classically defined as chronic hypoperfusion and dysfunction that reverses after revascularization. It can be distinguished from myocardial stunning, which denotes acute but transient hypoperfusion and dysfunction, typically after a myocardial infarction in adjacent tissue that does not require intervention because it recovers spontaneously. It is now accepted, however, that the line separating hibernation from stunning is not as clear as was once thought. Various modifications to basic myocardial perfusion imaging protocols have been devised in order to distinguish hibernating, viable myocardium from non-viable, infarcted myocardium. These include late redistribution, re- injection imaging (both protocols using 201Tl) and nitrate augmented rest 201 99m imaging (using either Tl or Tc labelled agents). This may then be evaluated qualitatively by viewing the images in an endless loop cine-display, or quantitatively using commercially available software. The presence of global dilatation, thinned out walls, ventricular aneurysms and increased lung uptake are all suggestive of left ventricular failure. Radiopharmaceuticals A number of single photon emitting radiopharmaceuticals may be used for imaging myocardial perfusion. The three most commonly used at present are 201Tl and the 99mTc labelled tracers sestamibi and tetrofosmin. Thallium-201 also has gamma rays of 135 and 167 keV, which contribute little to the total image counts. The extraction fraction is linearly proportional to blood flow over a wide range of physiological flow levels, plateauing only at very high flow rates and logarithmically decreasing towards the very low flow range. Relative accumulation in the myocardium thus reflects relative regional perfusion. This radiotracer is characterized by redistribution in the myocardium, settling in equilibrium between the myocardial and blood pool concentrations. This makes 201Tl a marker of myocardial viability, which is perhaps its greatest advantage. Disadvantages Relatively long High hepatobiliary — half-life limits activity needs delay allowable dose. Protocols employing 99mTc-sestamibi involve post-injection waiting times of 45–90 min, to allow for adequate clearance of subdiaphragmatic activity. Technetium-99m-sestamibi is characterized by a minimal yet discernible amount of redistribution, which may sometimes be used as a marker of recoverable myocardium. Its main advantages are ease of preparation and faster hepatic clearance, allowing shorter post-injection waiting times of 20–30 min. Equipment (a) Cameras A single-crystal gamma camera is the basic piece of equipment required for myocardial perfusion imaging using both 201Tl and 99mTc agents. Planar imaging is not considered optimal for myocardial perfusion due to its lower sensitivity. Acquiring images in a single, symmetric energy window is adequate, although an asymmetric window as well as multiple window capability allow minimization and correction of scattered radiation. Many current gamma cameras provide an option for non-uniform attenuation correction using an attenuation map acquired with a transmission source. It is probable that transmission attenuation correction will become the standard technique in the future. With caution and experience, however, most attenuation artefacts can be identified even without special techniques or manoeuvres. For accuracy, there is still no substitute for a trained and experienced human operator. Nonetheless, automated drawings always require human verification, especially in cases of ventricles with extensive and severe perfusion defects. An effective quality control program should be strictly observed for myocardial perfusion imaging. Any error in the acquired image resulting from a failure of quality control will be magnified many times upon tomographic reconstruction. Pharmacological stress modalities should be selected for patients who are unable to perform upright leg exercise. A common protocol for treadmill exercise is the Bruce protocol with symptom limited stress. An infusion pump is essential with dobutamine, because of the tight control required of the infusion rate. Adenosine may be manually infused, but its extremely short duration of action requires special attention to be paid to the timing in order to maintain an adequate vasodilatory effect during tracer uptake, so an infusion pump is preferable. This is necessary because the peak effect of dipyridamole on coronary blood flow occurs 2–2. There is usually a mild reduction in systemic blood pressure, an increase in heart rate and cardiac output and a significant increase in coronary blood flow up to five times the resting values. Patient preparation In order to obtain optimal image quality and maximal diagnostic benefit from myocardial perfusion imaging, certain steps must be strictly observed for patient preparation. It is essential to obtain an adequate history and conduct a physical examination in order to interpret the images properly. Are there any predisposing conditions for small vessel disease, such as diabetes mellitus?