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Any sensory stimulation such asnoiseresultsingeneralisedmusclespasmsincluding Poliomyelitis arching of the back (opisthotonos) buy genuine cialis soft erectile dysfunction 2. Spasms of the lar- ynx can impede respiration discount cialis soft 20mg on-line erectile dysfunction before 30, and autonomic dysfunc- Denition tion causes arrhythmias discount cialis soft 20 mg with amex erectile dysfunction treatment hong kong, sweating and a labile blood Infection of a susceptible individual with poliovirus type pressure. Geography Acute poliomyelitis has been eradicated in developed Complications countries, apart from rare cases due to the live, atten- Muscle spasms may lead to injury, in severe cases res- uated oral polio vaccine. Thevirusisneurotropic,withpropensityfortheanterior r A booster dose with tetanus toxoid (which is an in- horn cells of the spinal cord and cranial nerve motor activated toxin which induces active immunisation), neurones. The virus enters via the gastrointestinal tract, or course of three injections, should additionally be then migrates up peripheral nerves. Theincubationperiodis7 14days,anumberofpatterns Active tetanus:Patients should be nursed in a quiet, occur: dark area to reduce spasms. Surgical wound debride- r Subclinical infection occurs in 95% of infected indi- ment should be performed where indicated and intra- viduals. However, the immunoglobulin can only neu- r Paralytic poliomyelitis occurs in about 0. Dys- phagia and dysarthria result, with the risk of aspi- Cerebritis and cerebral abscess ration pneumonia. Denition iv Respiratory involvement may lead to the need for Afocal infection within the parenchyma of the brain ventilatory support. Complications Post-polio syndrome this is progressive, often painful Aetiology weakness in the territories originally affected by the Often the causative organism cannot be identied, or acute illness which can occur many years later (usually a mixed growth of bacteria is found. More suffer cause cerebral abscesses include various Streptococci, from pain, but without progressive weakness. Immuno- to be a failure of the compensatory mechanisms which suppressed patients are predisposed to fungal abscesses occur to bring about the original recovery those with such as Candida, Aspergillus and Toxoplasma. The organism may enter the brain by direct exten- sion from meningitis, otitis media or sinusitis, or Investigations by haematogenous spread, e. Management Clinical features r Acute treatment is supportive with bed rest, respira- The onset of symptoms is usually insidious, with tory support where indicated. In the rst 1 2 weeks, there is inammation and oedema iii Shortening: Leg length inequality of up to 3 cm (cerebritis). Later, necrosis and liquefaction lead to for- may be treated by built up shoes, larger differences mation of a cavity lled with pus. There are acute in- may require leg lengthening (or shortening of the ammatory cells (neutrophils), surrounded by gliosis opposite leg) procedures. Frequently treatment is by a combination of antimicro- bial therapy and surgical drainage. Incidence Approximately 2% have two or more seizures during Prognosis their lives. Age Any Sex Tuberculoma M = F Denition Atuberculoma is a localised caseous abscess within Aetiology the brain caused by M. West, but the commonest single intracranial lesion in Most of the others are thought to be genetically deter- India. Rupture into the subarachnoid space may cause r Cerebral infarction particularly in the elderly. There may be a Jacksonian March, with the epilepsy progressively involving more of a limb, e. Complex partial (impaired conciousness) May begin as a simple partial then become complex, or be complex from the start. Secondary generalised Partial seizures (simple or complex) can progress to secondary generalised seizures. Generalised seizures Nonconvulsive (absence) Impaired conciousness but without falling, although there may be involuntary movements. Atonic (drop attacks) Loss of muscle tone causing patient to fall to ground The main terms used to describe seizures are: gitis, stroke etc which may need urgent treatment. It is Partial (focal, localised seizure) also important to decide if the patient is likely to have r A partial seizure may be simple (no loss of con- further seizures. Status epilepticus Management This is dened as a prolonged single attack or continuing With a rst seizure, it is important to exclude any under- attacks of epilepsy without intervals of consciousness. Sodium valproate Gabapentin r Lorazepam or diazepam are rst-line treatment Lamotrigine Topiramate r If no response, intravenous phenytoin loading dose Tiagabine Levetiracetam of 15 mg/kg is given. The management of epilepsy should include the discussion of social is- Acute confusional state (delirium) suessuchassupportathome,relationships,employment andpsychologicalissuessuchasdepression. Womenwho Denition wish to become pregnant need special advice, but there Rapid onset of global but uctuating confusion with an is no reason why they should not have children. There underlying toxic, vascular, ictal (seizure) or metabolic are support groups available. Consider saving r Disorientation and impaired conscious level urine for toxicology screen. Management r Motoractivity may be increased but is often purpose- r Detection of the underlying cause of the confusional less. Severe cases may require benzodiazepines, Toxic Alcohol intoxication, withdrawal haloperidol or one of the newer anti-psychotics such Drugs Prescribed/illicit drugs, including as risperidone or olanzapine. The prognosis is dependent Hepatic failure on the underlying cause and co-morbid features. Hypoxia Hypoxia and/or hypotension Vitamin deciency Vitamin B12 Thiamine (Wernicke Korsakoff) Coma Intracrania Denition Trauma Head injury Coma is a state of unrousable unconsciousness. Vascular Transient ischaemic attack, stroke, any intracranial bleed or space- occupying lesion Aetiology Epilepsy May be post-ictal (after a seizure) or The causes are mainly those of acute confusional state nonconvulsive status (see Table above), although there are other causes as well. No response 1 Best verbal response Management Orientated 5 Following resuscitation treatment of the underlying Disorientated 4 Inappropriate words 3 cause is the main priority. In at-risk patients such as alco- Best motor response holics and in pregnancy, intravenous thiamine should Obeys verbal commands 6 be given prior to any intravenous glucose as there Localizes painful stimuli 5 Withdrawal to pain 4 is a small risk of precipitating irreversible Wernicke Flexion to pain 3 Korsakoff s syndrome. No response 1 r Empirical use of naloxone (reverses opiates), umaze- nil (reverses benzodiazepines) should be considered. Head Injury Denition Head injury is one of the most common causes of death Clinical features and disability in young men, mainly due to road trafc It is important to establish the level of consciousness. Incidence 1 The rst priority is resuscitation stabilise airway, Common;basedonhospitalattendancesandadmissions breathing and circulation and check the glucose level the incidence is 250 per 100,000 population. Hypoxia, hypoglycaemia or hypotension are reversible causes of coma and will exacerbate any Age other cause. Pathophysiology The pathology of head injury can be divided into two groups: Complications r Primary brain damage: Short term: Vascular, e. Subarachnoid and intracerebral ticularly on the side of the trauma (coup lesion) and haemorrhage may also occur. Long term: ii Diffuse axonal injury due to shearing forces caus- r Posttraumatic epilepsy.

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One can direct statements back to patients about their illness and how they are taking care of themselves cheap cialis soft on line erectile dysfunction journal. It removes the physician from the destructive interpersonal drama with these patients buy generic cialis soft canada erectile dysfunction medications over the counter, and allows the physician to be an advisor safe 20mg cialis soft erectile dysfunction causes in young males. The handling of a referral of a patient to a psychiatrist requires a high degree of sensitivity. Patients may feel that they are being told they are crazy or their problems are all in their head. Patients who have borderline or narcissistic disorders are especially prone to these reactions due to their issues around dependency, abandonment, and personal slights. For these reasons the best model is when the psychiatrist is an ongoing part of the treatment team. The doctor can say to the patient that the referral will help the doctor and patient to work even better as the allergic disease is treated. The doctor can make sure to set an appointment with the patient after his or her scheduled time to see the psychiatrist. The role of the psychiatrist to treat any underlying psychiatric disorders such as depression or anxiety can help the patient focus with the allergist on what needs to happen to help the allergic disease. This is inherent in being a physician, where the challenge is to aid individuals with their problems. It is important to maintain a sense of respect and understanding for our patients. By training the ability to truly listen and understand what the patient is experiencing, the physician can wisely and firmly respond. A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. Management of this disorder, which accounts for approximately 16 million patient visits per year, has changed dramatically in the past 50 years. This is due to new insights into the pathophysiology of sinusitis, advances in rhinoscopy (nasal endoscopy), improved radiographic imaging, and availability of antibiotics ( 1). Technical advances in endoscopic instrumentation have defined a new era in the office diagnosis and surgical management of sinusitis, permitting an unprecedented level of precision. Understanding the indications as well as the technical limitations of diagnostic and therapeutic rhinoscopy is now essential for practitioners who manage chronic sinusitis. Hirschman performed the first fiberoptic nasal examination using a modified cystoscope ( 2). Messerklinger of Graz began to use this technology for systematic nasal airway evaluation. He reported that primary inflammatory processes in the lateral nasal wall, particularly in the middle meatus, result in secondary disease in the maxillary and frontal sinuses ( 2). Messerklinger found that small anatomic variations or even minimal inflammatory activity in this area could result in significant disease of the adjacent sinuses as a result of impaired ventilation and drainage. With this observation, he used endoscopes to develop a surgical approach to relieve the obstruction in such a way that normal sinus physiology was preserved. Specifically, he demonstrated that even limited surgical procedures directed toward the osteomeatal complex and the anterior ethmoid air cells could relieve obstruction of drainage from the frontal and maxillary sinuses. This philosophy was markedly different from the ablative sinus procedures advocated in the past, such as Caldwell-Luc, in that cilia and sinus mucosal function were preserved. The ethmoid sinus develops into a labyrinth of 3 to 15 small air cells; however, the other sinuses exist as a single bony cavity on each side of the facial skeleton. The ethmoid and maxillary sinuses are present at birth and can be imaged in infancy. The frontal sinuses develop anatomically by 12 months and can be evaluated radiographically at 4 to 6 years. Sphenoid sinuses develop by the age of 3 but cannot be imaged until a child is 9 or 10 years of age. The point at which mucosal outpouching occurs persists as the sinus ostium, through which the sinus drains ( 3). Diagnostic rhinoscopy offers a wealth of information regarding the distribution of inflammatory foci within the sinonasal labyrinth and the associated anatomic variations that may impair physiologic sinus drainage. It is usually performed in an office setting with the aid of topical decongestants and topical anesthesia. It is essentially an extension of the physical examination that helps confirm the diagnosis, gain insight into the pathophysiologic factors at work, and guide medical or surgical therapy. The principles of diagnostic and therapeutic rhinoscopy are based on a firm understanding of the anatomy and physiology of the nose and sinuses (Fig. The lateral nasal walls are each flanked by three turbinate bones, designated the superior, middle, and inferior turbinates. The region under each turbinate is known respectively as the superior, middle, and inferior meatus. The frontal, maxillary, and anterior ethmoid sinuses drain on the lateral nasal wall in a region within the middle meatus, known as the osteomeatal complex. This is an anatomically narrow space where even minimal mucosal disease can result in impairment of drainage from any of these sinuses. The sphenoid sinus drains into a region known as the sphenoethmoidal recess, which lies at the junction of the sphenoid and ethmoid bones in the posterior superior nasal cavity. The nasolacrimal duct courses anteriorly to the maxillary sinus ostium and drains into the inferior meatus. The ethmoid bone is the most important component of the osteomeatal complex and lateral nasal wall. It is a T-shaped structure, of which the horizontal portion forms the cribriform plate of the skull base. The vertical part forms most of the lateral nasal wall and consists of the superior and middle turbinates, as well as the ethmoid sinus labyrinth. A collection of anterior ethmoid air cells forms a bulla, which is suspended from the remainder of the ethmoid bone, and hangs just superiorly to the opening of the infundibulum into the meatus. The drainage duct for the frontal sinus courses inferiorly such that its ostium lies anterior and medial to the anteriormost ethmoid air cell. Therefore, the main components of the osteomeatal complex are the maxillary sinus ostium/infundibulum, the anterior ethmoid cells/bulla, and the frontal recess. The infundibulum and frontal recess exist as narrow clefts; thus, it is possible that minimal inflammation of the adjacent ethmoidal mucosa can result in secondary obstruction of the maxillary and frontal sinuses. The paranasal sinuses are lined by pseudostratified-ciliated columnar epithelium, over which lays a thin blanket of mucus. The cilia beat in a predetermined direction such that the mucous layer is directed toward the natural ostium and into the appropriate meatus of the nasal airway. This is the process by which microbial organisms and debris are cleared from the sinuses ( 4). This principle of mucociliary flow is analogous to the mucociliary elevator described for the tracheobronchial tree. The maxillary ostium and infundibulum are located superior and medial to the sinus cavity itself. Therefore, mucociliary in the maxillary sinus must overcome the tendency for mucus to pool in dependent areas of the sinus.

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Studies performed in humans have demonstrated that regular use of racemic albuterol is associated with increases in airway responsiveness to allergen ( 18 buy cialis soft visa erectile dysfunction doctors in sri lanka,51) buy 20mg cialis soft with amex erectile dysfunction treatment uk. Since then purchase cialis soft 20 mg otc erectile dysfunction gene therapy, evidence points to the stereoselectivity of b 2-adrenergic mediated bronchodilation and in the development of airway hyperresponsiveness. In vitro, (R)-albuterol induces bronchodilation in isolated human trachea ( 52), whereas (S)-albuterol augments contractile responses to histamine and leukotriene C4 in bronchial tissue ( 53). In isolated smooth muscle cells, (S)-albuterol has been shown to increase calcium influx (54,55). In vivo, the differences between (R)-albuterol and (S)-albuterol continue to exist. In 1999, a preservative-free formulation of (R)-albuterol, called levalbuterol, became commercially available for nebulized administration. Clinical studies have evaluated the safety and efficacy of levalbuterol in adults and children. A multicenter randomized study in 362 teenagers and adults with moderate to severe asthma reported that 0. Because of the flat dose-response curve, this study failed to show a significant difference with regard to efficacy between levalbuterol and racemic albuterol. In this study, levalbuterol use was associated with dose-dependent side effects similar to those seen for racemic albuterol. In a smaller study of levalbuterol and racemic albuterol in children, lower doses of levalbuterol were as effective as 2. Other investigations have not confirmed this finding (65,66), yet regular treatment with (R)-albuterol and racemic albuterol results in partial loss of bronchoprotection after methacholine challenge ( 66). Despite the use of controller therapy, some individuals may develop breakthrough symptoms or acute exacerbations of their disease. Rapid-acting b agonists are recommended for the relief of mild or severe symptoms. These guidelines also suggest that the frequency with which b agonists are needed for symptom relief serves as a useful marker of asthma control and of the need for adjusting antiinflammatory therapy. Rapid-acting b agonists may also be used to confirm the diagnosis of asthma by establishing whether reversible bronchospasm exists ( 67). These agents are also effective therapy for the prevention of symptoms, such as exercise-induced bronchospasm, when used 5 to 15 minutes before exercise ( 69,70 and 71). Given their short duration of action, rapid-acting agents are not well suited for the prevention of nocturnal symptoms. The regular daily use of these agents is generally not recommended, but this has been a source of controversy for many years. Although some reports maintain that routine use of b2 agonists is safe and effective (72), other studies have reported detrimental effects. Although some prospective studies of regular inhaled b-agonist use failed to demonstrate deterioration in asthma ( 82,83,84 and 85), other studies have shown deleterious effects in as little as 3 weeks (86). Because there has been no evidence that regular use of rapid-acting b agonists improves long-term asthma control, their regular use is not advised. Consensus panel reports clearly state that antiinflammatory treatment should be considered when b agonists are needed on a frequent, regular basis ( 67,68,71). In light of their slower onset of action, long-acting b agonists are not recommended for relief of acute symptoms (87). These agents block exercise-induced bronchoconstriction ( 88,89) as well as cold air induced responses ( 90) for up to 12 hours. Given their onset of action, they should be administered 30 to 60 minutes before exercise ( 91). Despite the ability to prevent such symptoms, long-acting b agonists should be used as adjunctive therapy to inhaled corticosteroids and should not be used as monotherapy (67,87,91). Moreover, these results are superior to those seen after increasing the dose of inhaled corticosteroids. Although all groups improved, a similar study in children failed to demonstrate an additional benefit for salmeterol after 1 year of treatment (99). Based on the benefits demonstrated in these studies, long-acting b agonists should be used in conjunction with inhaled corticosteroids for the management of asthma that is inadequately controlled (100). Levalbuterol has been approved for use by nebulization in patients aged 12 years or older for treatment of asthma. It may be administered every 6 to 8 hours, but, similar to the other rapid-acting agents, levalbuterol should not be used for maintenance therapy. Levalbuterol may be a suitable alternative for patients who experience unacceptable side effects from racemic b agonists, but further studies are needed to clarify the position of levalbuterol in the management of asthma. It is important to note that most of the adverse effects associated with b agonists are reduced when these drugs are administered through inhalation. Given the widespread distribution of b2 receptors, many organ systems may be affected. The most common complaint is tremor, which is due to stimulation of b2 receptors in skeletal muscle (103). Often associated with oral or intravenous administration, tachycardia and palpitations are much less frequent when usual doses are administered through inhalation. Mediated by b vascular relaxation in skeletal muscle, cardiac stimulation occurs as a result of decreased peripheral resistance with resultant sympathetic output. Isoproterenol use is associated with alterations in coronary blood flow that may lead to subendocardial ischemia ( 105). Transient decreases in PaO2 may occur when vascular dilation and increased cardiac output enhance perfusion to underventilated areas of lung ( 106). Abdominal complaints are sometimes seen in children receiving aggressive therapy for management of severe, acute asthma. Metabolic effects include hyperglycemia (due to glycogenolysis) and reductions in + + serum potassium and magnesium. Intracellular potassium shifts occur as a result of direct stimulation of the Na -K pump. Magnesium also moves in this fashion, but increased urinary excretion further contributes to the reduction in this cation. A review noted that despite the low frequency with which this occurs, these reactions may be quite severe, even life-threatening (107). It has been suggested that a lack of efficacy to b agonists may also be attributed to this phenomenon. Contamination of nebulized solutions, particularly from multidose bottles may also contribute to this problem. Finally, recent investigations suggest that the detrimental effects of (S)-albuterol may account for paradoxical bronchospasm ( 109). Short-term loss of effectiveness, or tachyphylaxis, occurs for b agonists as it commonly does with agonist cell surface receptor interactions. Whether clinically relevant tachyphylaxis to bronchodilatory effect exists remains controversial ( 1). Tolerance occurs after as little as 3 weeks of repeated use and appears to affect the duration rather than peak response ( 110,111,112 and 113).

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It will be capable of delivering up to 5 mA deuteron beams at 40 MeV as well as light and heavy ion beams with up to 1 mA current at up to 14 cheap cialis soft 20mg without a prescription erectile dysfunction most effective treatment. Tere is potential for radioisotope gamma-rays and energetic electrons cialis soft 20 mg overnight delivery erectile dysfunction doctors austin texas, the latter production by fast neutron irradiation ports in the causing important energy deposition purchase cialis soft amex erectile dysfunction protocol scam. Consequently that of the highest fux research reactors, it can the specifc activity of radioisotopes produced in be further boosted by combination with a fssile (,n) reactions is inherently limited. Provided suitable resonant transitions are found, such a production will not compete in Gamma induced nuclear reactions quantity with conventional radioisotope produc- Electron beam generated Gamma rays via tion but can give access to specifc cases providing Bremsstrahlung can also be used directly for isotope higher specifc activity (e. Gamma the promising 225Ac generator for targeted alpha rays can also be used to induce photo-fssion, e. Targets may be irradiated in all three phases Enrichment of target isotope and use of pure ele- solid, liquid and gas. The majority of accelerator-produced radionuclides is Enrichment applies to all polyisotopic elements and obtained in non-carrier-added quality. This param- is directly related to economic aspects and techni- eter is undoubtedly very favourable for production cal feasibility. In many to: cases, it is the only way to accomplish radionuclidic physico-chemical form of the irradiated mate- purity that meets criteria for application in humans rial (co-determines maximum applicable beam (e. In design and automation (facilitates target han- contrast, recycling of solid targets is usually based dling and minimises personnel s radiation burden, on wet chemistry that results in losses of at least a allows for optimal recycling of enriched material, few percent of the original amount. Another issue that must be solved is forms a glassy material with much better thermal the optimal chemical form of a radionuclide result- resistance than elemental 124The used for production ing from its separation from the target matrix: it of 124I; enriched 76SeO is also more suitable for pro- 2 must be compatible with further production of a duction of 76Br than elemental 76Se and Cu As for 3 radiopharmaceutical. Finally, presence of chemi- the production of the same 76Br via 3He activation cal impurities in the target matrix and chemicals of monoisotopic arsenic). A higher validated and each batch of target material tested beam energy loss requires a thicker target layer, i. Due to the routine more material, ofen expensive, and more efcient character of radionuclide production for nuclear cooling due to higher heat dissipation in the tar- medicine, economic aspects play an important role get layer. Finally use of a wider energy range may in the choice for a complex solution of a target sys- increase the production of radionuclidic impurities. The time of bombardment (irradiation time) For a given radionuclide and given production is also strongly related to production costs, since route there are four parameters available to increase cyclotron operation is rather expensive. Example of a multipurpose internal slanted solid target with extremely low angle suitable for production of e. For radionuclides with a half-life signifcantly longer than the irradiation time, the produced activity is almost directly proportional to the irradiation time. Maximisation of the fnal variable, the beam current, is limited by the accelerator performance and by the targetry. The most widespread are: are directly cooled from the back during process- According to their location with respect to the ing, only the activated layer is etched and used for cyclotron (external or internal). Linear accelera- separation of a radionuclide, and the target can then tors always use external targets. Recently, an interesting varia- examples of internal slanted targets are production tion on liquid targets have attracted the attention systems for 67Ga, 111In, 201Tl or 211At. Tese were success- Modern compact cyclotrons accelerate protons fully used for the pilot production of e. The shape of the target modify the beam parameters), or located at the end body is very ofen conic in order to compensate for of a beam line whose elements allow for shaping the the gradual increase of the beam diameter due to beam. The external location enables installation of beam straggling in the gas flling, while minimis- all kinds of target systems, i. The phase of the target matrix strongly infu- Operation and processing of both liquid and gas ences the target s characteristics. Solid targets are targets can be easily automated, including recycling preferably metallic layers with the best possible of enriched flling. Disassembled external gas target system flled with highly enriched 82Kr for production of 81Rb (top) and its position on an external beam line of the cyclotron U-120M (bottom); a similar target flled with 124Xe is used for production of 123I (Nuclear Physics impurities are opened. This cooling efciency and the necessary amount of tar- allows the system to range further from the valley get matrix. Slanted targets (also called tangential of beta-stability thereby forming more exotic radi- or grazing angle targets) are a good choice for solid onuclides. Small angles and higher product yield is accompanied by a reduc- project the beam diameter on a larger target sur- tion in selectivity. In the extreme case of very high face, thereby reducing the heat power per unit of projectile energy (GeV protons) very thick targets area and the target thickness required for optimal (tens of g/cm2) can be irradiated and via fragmen- beam energy loss. Both factors improve cooling tation, spallation and fssion reactions virtually all and increase the maximum applicable beam cur- isotopes from hydrogen up to the target element are rent, especially for target matrices of low thermal produced simultaneously. Cyclotron production of 99mTc wou ld to combine mass separation with chemical separa- require external slanted, high-current targetry that tion to be able to extract single radionuclides. This means that only a few reaction channels that potentially contribute to formation of signifcant radionuclidic 3. The clinical restrictions requiring longer hospitalisation and isola- value and cost-efectiveness of myocardial perfusion tion afer 131I treatment. Deaths from Side efects are mild and reversible and quality-of-life prostate cancer are ofen due to bone disease and of the patients is improved [Kha11]. The defnition of symptomatic Lymphoma is a blood cancer afecting the white skeletal event covers very serious events such as blood cells. Tese patients with advanced follicular lymphoma that were events are decisive for the quality of life of a cancer either treated by an induction treatment (chemother- patient. The time to the a comprehensive comparison provided some caution frst symptomatic skeletal event was 15. It is expected that these sumption may difer signifcantly before, during and modifcations could further improve the outcome. Making an assessment of since data from the previous Dose Datamed 1 project possible future trends in radionuclide needs requires (1998-2002) show that Belgium had similar or higher frst of all a comprehensive view of the past and pre- per capita use of nuclear medicine procedures than sent use. Technetium-99m itself issue: if more generators become available more 82Rb is used in more than 80% of diagnostic nuclear will be used (see section 3. Tese applications represent Terapy procedures are still largely dominated approximately 30 million examinations worldwide by 131I for thyroid treatment. Terefore, a weekly 99Mo production of temporal evolution of the use of therapy isotope, about 10. Zevalin hours) and its daughter 99mTc (6 hours), a continu- (90Y-ibritumomab) and 177Lu-rituximab are used for ous supply of 99Mo/99mTc generators to hospitals or treatment of lymphomas. Worldwide radiopharmaceuticals they can be applied in more 99Mo production is presently being converted from hospitals and more countries. Teir priority is to achieve optimal coordi- reactor vs accelerator nation of their operating periods to ensure a secure supply of 99Mo worldwide. However, the current Today the worldwide supply of 99Mo relies on a limited number of research reactors and processing * It has to be stressed that it is indeed a pure policy issue and not a real proliferation risk since one 99Mo production target contains facilities. Its production is essential for provid- just 4 grams of 235U while many thousands of such targets would ing nuclear medicine with 99mTc in the form of be needed to make a nuclear bomb. The pathway of the produced 99Mo/99mTc from the irradiation facilities to the users.