Inherited haemolytic anaemia Complications Achronically high serum bilirubin predisposes to the Hereditary spherocytosis formation of pigment gallstones order 5 mg propecia mastercard hair loss 40 year old man. Chronic haemolysis predisposes to folate deﬁciency and thus levels should Deﬁnition be monitored and replacement given as required buy 5mg propecia free shipping hair loss 6 months after birth. Par- An autosomal dominant condition in which the red cells vovirus infections that cause a temporary bone marrow are spherical. Hereditary elliptocytosis is an autosomal failure may result in an aplastic crisis. Investigations r Haemolysis is suggested by a rise in bilirubin, high Incidence urinary urobilinogen (due to bilirubin breakdown Commonest inherited haemolytic anaemia; 1 in 5000. In intravascular haemolysis, red cell fragments are Aetiology/pathophysiology seen in the blood ﬁlm, whereas spherocytes may be There is a high new mutation rate with 25% of patients present in extravascular haemolysis. The underlying cause is cell life span can be demonstrated using labelled red aweakness in the link between the cytoskeleton and cells. This may be a quantitative or 474 Chapter 12: Haematology and clinical immunology functional abnormality of any of the membrane proteins Incidence (spectrin, ankyrin, protein 4. These cells are more rigid than normal and As HbF synthesis is normal, it presents at 6 months. Sex Clinical features M = F Spherocytosis may present as neonatal jaundice or anaemia with chronic malaise and splenomegaly. Nor- Geography mal infections cause a relative increase in haemolysis and Occurs most frequently in Africa, Middle East, India and may result in jaundice. Aetiology Investigations Apoint mutation on chromosome 11 results in a sub- Anaemia is usually mild. A blood ﬁlm will demonstrate stitution valine for glutamine at the sixth codon on the the spherocytes, but this cell morphology is not diagnos- β globin chain to form haemoglobin (Hb)S. Thediagnosiscanbeconﬁrmedbydemonstratingthe dehydration, hypoxia and cold may precipitate a sickle osmotic fragility of the red blood cells. Patients are given Pathophysiology pneumococcal vaccinations and prophylactic antibiotics HbS molecules, when deoxygenated tend to aggregate post splenectomy. The red blood cells become inﬂex- ible and sickle shaped and become trapped in the mi- Haemoglobinopathies crocirculation, especially within bones, resulting in mi- Haemoglobinopathies are abnormalities in the nor- crovessel occlusion. Normal haemoglobin is made up of four polypeptide chains Clinical features each containing a haem group. HbA is the main adult Sickle cell trait (the carrier state) is asymptomatic, but form comprising two α chains and two β chains. Sickle cell also have a minor haemoglobin HbA2,which makes up anaemia is a clinical spectrum ranging from asymp- around 2% of the circulating haemoglobin and con- tomatic to severe haemolytic anaemia and recurrent sists of two α chains and two δ chains. Painful vascular occlusive crises typically haemoglobins result from: produce symptoms of bone pain and pleuritic chest pain r Abnormal globin chain production such as thalas- with a low-grade fever. Other patterns of crisis: r Acute sequestration (pooling of blood in liver and Sickle cell anaemia spleen) requires transfusion for apparent hypo- Deﬁnition volaemia. Autosomal recessive condition in which there is abnor- r Pulmonary infarction may occur in association with mal structure of the globin chain. Chapter 12: Haemoglobin disorders and anaemia 475 Complications syndrome or cerebral infarction require exchange blood Patients have a susceptibility to infections including transfusionstoremovesicklecells. Transfusionsmayalso streptococcal infections and osteomyelitis often due be indicated in patients with regular severe crises and to salmonella. Prognosis Retinal detachment and proliferative retinopathy may Thereismarkedvariationintheseverityofthecondition, result in blindness. See also complications of haemolytic some patients have a relatively normal life span with few anaemia (page 473). Blood ﬁlm shows a α-Thalassaemia high reticulocyte count and sickle shaped red blood cells. Deﬁnition r Sickle screening tests use a reducing solution, which Inherited haemoglobinopathy with defective synthesis causes HbS to precipitate. Aetiology r X-ray of the tubular bones may show destruction and α-Thalassaemia is caused by gene deletions. There are medullary sclerosis together with periosteal bone for- four copies of the α gene, two on each chromosome 16. Management Clinical features Treatment is largely symptomatic with prophylactic an- r Deletion of all four copies of the α gene (–/–) prevents tibiotics,folicacidandpneumococcalvaccination. This disorder agement of a painful crisis includes oxygenation, ade- is also termed haemoglobin Bart’s (γ4)hydrops syn- quate hydration and analgesia. Acute se- r Deletion of three genes (–/α-) causes HbH disease (a questration requires blood transfusion, as patients be- moderate anaemia with splenomegaly and the pro- comeshocked. Normal Investigations Full blood count shows microcytosis with or without Sickle Trait anaemia. These mutations may result in no β chain production Investigations (β0)orveryreducedproduction (β+). The reticulocyte count is noproductionofβ globinandhavetheclinicalpicture raised and there are nucleated red cells. Management Excess α chains precipitate in the red blood cells r Thalassaemiaminordoesnotrequiretreatment;how- or combine with δ resulting in increased HbA2, and ever, iron supplements should be avoided unless γ resulting in increased levels of fetal haemoglobin co-existent iron deﬁciency has been demonstrated. The partners of women with thalassaemia minor r If there are defects in both β and δ genes, patients shouldbescreenedtoallowappropriategeneticcoun- have thalassaemia intermedia (homozygous) or tha- selling. Homozygous combined β, γ and δ are in- r Thalassaemia major and symptomatic thalassaemia compatible with life. This Clinical features aims to suppress ineffective erythropoesis and pre- r Thalassaemia minor/trait is asymptomatic with a vent bony deformity, while allowing normal growth mild hypochromic microcytic anaemia. Iron overload is prevented by the r Thalassaemia intermedia causes symptomatic mod- use of the chelating agent desferrioxamine, which is erate anaemia with splenomegaly. Splenectomy should be considered in patients ure to thrive and recurrent infections. Bone the production of fetal haemoglobin ceases and the marrow transplantation has been used successfully patient becomes symptomatic with a severe anae- in young patients with severe β-thalassaemia major. Extramedullary haemopoesis causes hepato- Other treatments under investigation include gene splenomegaly, maxillary overgrowth and trabecula- therapy and drugs to maintain the production of fetal tion on bone X-rays. Random X inacti- vation (Lyonisation) means that some heterozygous fe- Glucose-6-phosphate dehydrogenase males may also have symptoms. Clinical features With such a wide variety of genes and enzymatic activity, Aetiology aspectrum of clinical conditions occur. Investigations Pathophysiology During an attack the blood ﬁlm may show irregularly IgMorIgG antibodies are produced, which bind to red contracted cells, bite cells (indented membrane), blister cells. Autoimmune haemolytic anaemia Deﬁnition Clinical features Acquired disorders resulting in haemolysis due to red The clinical features, speciﬁc investigations and manage- cell autoantibodies. IgM anti human globulin Red cells coated in antibodies Agglutination (visible) Figure 12. Splenectomy may be indicated if lymphatic leukaemia, haemolysis is severe and carcinoma and drugs such refractory. Cold haemagglutinin May be primary or secondary IgM antibodies agglutinate best Treat any underlying cause and disease to Mycoplasma at 4◦C, often against minor avoid extremes of temperature.
High sodium intake reduces effectiveness of antihypertensive therapies and is determined best by a 24-h urine sodium collection cheap propecia 5 mg on line hair loss cure october 2014. The prevalence of proteinuria is 4–8% worldwide and 10–20% in hypertensive propecia 1 mg sale hair loss cure 2014, obese, and/or diabetic populations. The presence of even small amounts of albuminuria (>10 mg/g) is associated with adverse cardiovascular outcomes. Types of Proteinuria Traditionally, normal urinary protein excretion is considered to be <150 mg/24-h; total urinary proteins measured are comprised of immunoglobulins, assorted globulins, and Tamm-Horsfall mucoprotein. Persistently elevated total urinary protein signifies: a) defect(s) in the glomerular basement membrane b) impaired tubular protein reabsorption, eg, tubulointerstitial nephritis c) increased filtration of low molecular weight protein(s), ie, “overflow proteinuria” as may occur with light chains. Persistent proteinuria is defined as two or more positive quantitative tests of protein excretion, separated by at least 2 weeks. Common, benign sources of albuminuria/proteinuria include orthostatic proteinuria, intense activity/exercise, and fever. The urinalysis dipstick may not register proteinuria when the urine is highly dilute, (ie, specific gravity 1. Notably, a new classification system that eschews the terms micro- and macroalbuminuria may be established in the near future. The urine dipstick favors albumin detection and is relatively insensitive for tubular proteinuria, eg, immunoglobulin light chains. If tubular proteinuria is suspected, specific qualitative and quantitative examinations may be required, eg, serum free light chain analysis (Freelite™) and serum and urine immunofixation. For screening purposes, a 24-h urine is unnecessary, but if a serum monoclonal protein is detected, a 24-h urine collection for immunofixation is indicated. Consultation with a clinical laboratory expert is advised to optimize diagnostic yield in such cases. Patients with stable, persistent proteinuria of <1 g/24-h have a very small risk of progression to kidney failure compared to individuals with greater proteinuria. Inflammation upregulates hepcidin, a liver-synthesized protein that reduces gut iron absorption and impedes iron release from the reticuloendothelial system to the developing erythron. To correct iron deficiency, oral iron should always be tried initially, and multiple iron salt preparations are available. Darbepoetin alfa (Aranesp )® : 40–300 mcg, subcutaneously, q2–4 wk or q1 mo; begin therapy at Hb <10 g/dL at starting dose, 0. Calcification occurs most frequently in coronary arteries, aorta, and cardiac valvular leaflets. However, therapeutic interventions have increased the prevalence of adynamic bone disease. Currently, P binders remain a mainstay of therapy in patients with elevated levels. Vitamin D includes vitamins D2 and D3 and three active D sterols, calcitriol, and two synthetic vitamin D2 compounds. Paricalcitol, a calcitriol analog, is active upon administration and does not require in vivo activation. Doxercalciferol and paricalcitol exert vitamin D-like actions and are less prone to induce hypercalcemia than calcitriol. During Ca-based P-binder therapy, the total daily elemental Ca intake (dietary + prescribed) should not exceed 2000 mg daily. Sevelamer hydrochloride, a non-metal anion exchange resin, and lanthanum carbonate are non-Ca-based P-binders. These agents may be used as initial P-binder therapy, if arterial/cardiac vascular calcification is present or, if the corrected Ca is >10. Trend analysis of each parameter is preferred over treatment(s) directed at absolute parameter levels. Only rarely should a single abnormal value of Ca or P warrant discontinuation of active vitamin D sterols. Lipid evaluation should be conducted at initial evaluation, 2–3 months after treatment changes, and at least, annually afterward. Hypoalbuminemia and related nutritional disorders, including vitamin and mineral deficiencies are common. Preventing malnutrition through periodic visits to a trained renal nutritionist for nutrition surveillance is recommended and may avert complications. Protein Intake High biological value protein intake should be maintained, while sodium, potassium, and phosphorus intake are restricted. A controlled protein diet slows the decline of kidney function more than one with more liberal protein intake. Monitoring A 24-h urine collection for sodium (goal <100 mEq Na per 24-h), urea nitrogen and creatinine is highly informative regarding the level of compliance with a dietary prescription. To preserve lean body mass, a supervised exercise regimen should be considered in conjunction with dietary recommendations. Lastly, booster vaccinations with tetanus toxoid, diphtheria, and acellular pertussis vaccines (Tdap) may be administered alone or co-administered with any of the vaccines listed below. Revaccination with a single dose may be considered 5 years after the last dose in persons 65 y. Tetanus, diphtheria (Td); Tetanus, diphtheria and pertussis (Tdap) Td Dose 1 of initial series: 0. Therefore, conservative management, when chosen, focuses the shift from simply attempting to prolong life to providing quality of life and alleviation of symptoms. Physical conditions such as vision and manual dexterity, motivational level to actively participate in care, and family/social circumstances all play roles in the decision-making process. Peritoneal dialysis as a modality option was discussed with 61% of patients before initiation of dialysis. Peritonitis can be treated with intra-peritoneal or iv antibiotics and may require catheter exchange. Notably, the failure of access function limits the delivered dose of dialysis, a major survival determinant. Vascular Access Planning and Construction Key issues include timely nephrology referral; vein preservation; vascular access creation planning; timely referral to a surgeon specialized in access construction; post-construction follow- up; and appropriate intervention(s). The patient should be evaluated by venous mapping, preferably by ultrasound duplex scanning of the non-dominant arm (non-hand writing); if unsuitable, the dominant arm may be used for access creation. Therefore, vein preservation during hospitalizations and outpatient care must occur. Educational programs reinforcing the above should be provided to patients, their families and healthcare providers. Alternative therapies should be explored in each clinical circumstance and the risk-to-benefit ratio of any agent must be determined by the prescribing individual. Pharmacy consultation is advised to optimize drug dosing, particularly in cases of acute kidney injury.
Above all buy propecia 5mg visa hair loss women vitamin deficiency, let her be- ware of the cold purchase propecia mastercard hair loss cure jo, and let there not be any aromatic fumigation to the nose. But this can be applied more safely to the oriﬁce of the womb, because the womb follows sweet-smelling substances and ﬂees foul-smelling ones. For this, odor- iferous spices are good, such as musk, ambergris, aloewood, and similar things, and also odoriferous herbs, such as mint, fennel, oregano, and similar things. Et ut cicius loquatur, unge palatum cum melle et naresc cum aqua calida, et unctionibus semper mun- diﬁcetur,d et muscillagines semper emunganture et emundentur. Puer itaque semper est fricandus et quelibet eius membra in unaquaquef parteg fascia sunt retinenda et iungenda,h et rectiﬁcanda sunt eius membra, scilicet caput, frons, ¶a. On the Mode of Generation of the Embryo * In the ﬁrst month, there is purgation of the blood. In the eighth month, Nature moves and the infant is made complete in the blessing of [all] its parts. Then, attention needs to be paid that the milk does not enter the ears and the nose when [the child] is nursing. And let the umbilical cord be tied at a distance of three ﬁngers from the belly, because ac- cording to the retention of the umbilical cord the male member will be greater or smaller. And so that it might talk all the more quickly, anoint the palate with honey and the nose with warm water, and let it always be cleaned with unc- tions, and let the mucous secretions always be wiped oﬀ and cleaned. And so the child ought always to be massaged and every part of its limbs ought to be restrained and joined by bandages, and its features ought to be straightened, that is, its head, forehead, nose. Cutis eius equaliter est mouenda, quodm etiam consueuitn ﬁeri post mamillarum susceptionem. In principio natiuitatis oculi cooperiendi sunt, et summopereo cauendum est nep in loco lucido. Ante ipsum sint diuerse pic- ture, panni diuersi coloris, margarite, cantilenis et facilibusq uocibus utatur; ante eumr non est asperis uocibus cantandums neque raucis, sicut lumbardis. Cum uero tempusv natiuitatis [va] dentium uenerit,w gingiue singulis diebus cum butyro et auxungia galline semper sunt fricande, et aqua ordeix liniende. Quod si uenter eius laxabitur, superponatur em- plaustrum quod ﬁtz exaa cimino et aceto et admisceatur zuccara; gumi arabici, bolus armenicus, et similia sunt admiscenda et ei danda. Si uero uenter con- stringitur,ab ﬁat ei suppositorium de melle et bombace et stercore muris, quod est supponendum. Caro que est inai pectore gallinarum et fasianorum et perdicum estaj tribuenda, quodak postquam bene capere ceperit, mamillarum substan- tiam mutare incipiesal et eas in nocte suggere non permittas, sicut superius dictum est. Ita in die etam ordina[vb]te ducendusan est, et obseruandusao ne inap tempore calido a lacte remoueatur. Primo fomentetur cum decoctione her- barum istarum, scilicetf branceg ursine cum radice altee, et foliis apii, et petro- selini, et maratri, et omnes herbe diuretice, bulliant in aqua et ponaturh super uas membrum patientis, et cooperiatur panno lineo ut sudet. If either of these appears, for a time try to abstain from the accustomed bandaging and let it sleep for a while. Then let it be bathed in warm water and let it be restored to the accustomed practice [of binding]. Its skin ought equally to be massaged, which also is customary to be done after taking the breast. Right after birth its eyes ought to be covered, and especially it ought to be protected from strong light. There should be diﬀerent kinds of pictures, cloths of diverse colors, and pearls placed in front of the child, and one should use nursery songs and simple words; neither rough nor harsh words (such as those of Lombards) should be used in singing in front of the child. After the hour of speech has approached, let the child’s nurse anoint its tongue frequently with honey and butter, and this ought to be done especially when speech is delayed. One ought to talk in the child’s presence frequently and easy words ought to be said. When the time for the extrusion of its teeth comes, the gums ought always to be rubbed each day with butter and goose grease, and they ought to be smeared with barley water. If its belly becomes lax, let a plaster which is made from cumin and vinegar and mixed with sugar be placed over it; gum arabic, Ar- menian bole, and similar things ought to be mixed together and given to the child. But if its belly is constricted, let a suppository be made for it from honey and cotton and mouse dung, which should then be inserted. When the time comes when it begins to eat [solid foods], let lozenges be made from sugar and similar things and milk in the amount of an acorn and let them be given to the infant so that it can hold them in its hand and play with them and suck on them and swallow a little bit of them. The meat of the breast of hens and pheasants and partridges ought to be given because after it begins to take these things well, you will begin to change reliance upon the breasts and you should not permit the child to suck them at night, as was said above. First, let the limb be fomented with a decoction of these herbs, that is, bear’s breech with root of marsh mallow and with leaves of wild celery, parsley, and fennel, and all di- uretic herbs. And let the limb of the patient be placed above the vessel, and let it be covered with a linen cloth so that it sweats. Then let chamomile and marsh mallow be cooked in water, and in this thick mixture let wax be melted, and let the whole limb then be covered with this. Afterward, Liber de Sinthomatibus Mulierum milla et altea in aqua coquantur, et in illa uiscositate mallaxeturi cera, et totum membrum inde cooperiatur. Postea fascea linea ligetur stricte, et ita mem- brum patientis sudet per noctem unam,j manek fricetur ut spiritus excitenturl et ﬂuantm ad locum dolorosum. Quo facto friceturn statimo cum dyaltea, ita composita due partes dyalteap et tertiaq de oleo laurisr commisceantur et un- gaturs membrum predicto modo ter uel quater in die. Tunc accipe dyaceraseos, [ra] ceroneum, oxicroceum,t et ad inuicem puluerizentur. Hiis factis iniungatur requiesab et occium, utaturcalida et humida dieta,optimo uino et mediocriter rubeo, quod bibat quousque curetur. Et si lac minuatur, pultes de farina fabarum et similiter rizi, et de pane simulei et dej lacte et zuccara facte denturk ei ad sorbendum, quibusl lac augmentetur,m et parum seminis feniculi sit admixtum. Si uero lac eius fuerit grossum, nutrimentum eius est subtiliandum et ita cogatur laborare. Book on the Conditions of Women let it be tied tightly with linen bandages, and thus let the limb of the patient sweat through one night; in the morning, let it be rubbed so that the spirits are aroused and ﬂow to the painful part. This having been done, let the limb be rubbed with dialtea, thus composed: two parts dialtea and a third of lau- rel oil mixed together; and let the limb be anointed in the above-mentioned manner three or four times a day. These things having been done, let rest and leisure be ordered; let the patient have a warm and moist diet, with good quality, moderately red wine, which s/he should drink until s/he is cured. On Choosing a Wet Nurse * A wet nurse ought to be young, having a clear color, a woman who has redness mixed with white, who is not too close to her last birth nor too far removed from it either, who is not blemished, nor who has breasts that are ﬂabby or too large, a woman who has a large and ample chest, and who is a little bit fat. She should not eat salty or spicy or pungent things, nor those things in which heat is strong, nor styptic things, nor leeks or onions, nor the rest of those spices which are added to foods for ﬂavoring, such as pep- per, garlic, garden rocket, but above all garlic. And if her milk is diminished, let porridges made of bean ﬂour and likewise of rice, and wheat bread and milk and sugar be given to her to drink, by which things the milk is augmented, and let a little fennel seed be mixed in. If, on the other hand, her milk be- comes thick, let her nutriment be made subtle, and so let her be compelled to work. If the milk becomes thin, let her nutriments be thick and strong, and let her get more sleep. If the bowel of the child is loose, let constipating things be given to the nurse. Si uerod in corpore pueri antrax apparuerit, detur nutrici aqua ordei, et quan- doque scariﬁcetur.
Responsibility for other public health functions may be found within the branch known as public health or within other organisations buy discount propecia 5 mg hair loss blog. In other words buy 5mg propecia with visa hair loss treatment dubai, public health expertise is generally diffused through various organisations in a society. While the overall aims of the two are thus similar, the ways of achieving them are different. Furthermore, each is likely to be more effective if the two work in synergy rather than against each other (3). In view of the variability of the provision of public health services, the diversity of functions and the range of sciences that contribute to it, however, it is unsurprising that few medical practitioners have a clear idea of what public health is and what it does. Canada has produced an online textbook on public health (4) - probably the only comprehensive public health text book aimed at medical students and the clinical professions – and a recent issue of the American Journal of Preventive Medicine (5) was devoted to reports from the conference ‘Patients and Populations: Public Health in Medical Education’ organised to showcase best practices in North America. Teaching in public health is often the responsibility of non-physicians , or1 physicians not involved in individual patient care, so that many public health teachers are not in a position to make links between public health and clinical subject matter. By absorbing the ‘hidden curriculum’ common in large hospital centres, students can come to view public health as an unimportant subject that reduces the time available for learning exciting high-tech medicine. As a result, it is not surprising that many students find public health uninteresting and irrelevant to the practice of clinical medicine (6). These attitudes are likely to persist as students progress to become practising physicians. Jacobsohn et al look specifically at hospital policies based on in-patient scenarios (3) - while Stone proposes a framework that links the main themes of public health with clinical actions of prevention, diagnosis, treatment and follow-up (7). Gillam and Maudsley list the ‘Liverpool Seven Pointers toward a population perspective on health’ (8) - and Harper proposes a series of questions linked to seven contexts of the clinical encounter (9). Finally, Trevena et al link the ‘Sydney 8 questions’ to population health learning objectives (10). Although these proposals are all written in the context of undergraduate education, they are also relevant to postgraduate and continuing medical education and the questions and themes would be very useful for initiating discussion around the concepts of public health. Integrating clinical practice and public health knowledge Although public health and medicine each have a different focus, when integrated into clinical practice, public health knowledge, attitudes and skills can improve the quality of care provided and is essential to practice in a number of ways. Most physicians use public health concepts in practice, although they may not be aware of it. Being able to define the public health knowledge, skills and attitudes they apply may assist physicians in improving the quality of their care and their contribution to the health patients and the community. Individual patient-physician encounter At the core of medicine is the encounter between physician and patient. During these encounters, the concept of the determinants of health and of the socio- ecological model of health provides an understanding of why the patient became ill and his chances of regaining health. The determinants of health may also determine the patient’s capacity to deal with disease and to follow the physician’s advice. Familiarity with models of health behaviours provides the physician with pointers on how to counsel on lifestyles and treatment. Epidemiology and evidence-based medicine are essential to efficient investigation, accurate diagnosis, and effective decision-making with regard to the management and interpretation of new information generated by research. As results of general epidemiological enquiry often underlie health information on the frequency of disease in populations, being able to interpret this information allows physicians to prioritise differential diagnoses according to the lifestyles and the determinants of the health of their patients. Explaining the impact of avoidable risk factors, the meanings of test results and the risks and benefits of different ways of managing disease requires knowledge of a number of epidemiological concepts. Accurate diagnosis and management of environmental disease requires the physician to take an environmental history (11) and have knowledge of how to control environmental disease or knowledge of local public health services which may be required to solve the problem. Preventive intervention Preventive intervention is perhaps the most obvious way in which physicians put public health knowledge, skills and attitudes into practice. Physicians may intervene as part of a public health programme, for instance by participating in vaccination programmes, by setting up in-practice prevention programmes or by using opportunities for clinical prevention. To do so, physicians need to be up to date with public health programmes and clinical prevention guidelines. For areas where there are no national or regional evidence-based preventive care guidelines, there are a number of reliable sources that provide guidelines as well as discussions of the evidence and rationale for the guidelines. This gives physicians information on the risks and benefits of the interventions which they can discuss with their patients. The approach to disease management is not very different from the approach to prevention, both are based on assessment of the risks and benefits of interventions, which may include watchful waiting. As prevention differs from treatment in that it does not tackle an existing problem, differences in ethical values may come into play. Practice population To maintain the health of the people in their area, physicians assess the needs of their practice population and community, orient their practice to meet those needs and advocate for the health of the local community. Here again the physicians are using epidemiology and applying the principles of health promotion; community development and empowerment. Physicians also play a role in protecting populations from environmental and transmissible disease. As diagnosticians in direct contact with patients, they are in a unique position to identify and report unusual occurrences of disease. They are also well placed to assess possible disease sources and advise on how to reduce the spread of disease. In doing so, they are familiar with the basics of outbreak prevention and control as well as with local public health services. They borrow from management science to prioritise and implement change and to develop practice systems that improve the delivery of care. The Australian ‘Green book’ gives practical advice on how to improve delivery of preventive care, some of which can be adapted to improving patient management and follow-up (14). As part of the health system, physicians collaborate with other professionals to provide a comprehensive service. They know the resources in their area and they know how to advocate for their improvement. In so doing, they apply notions of health service organisation as well as leadership and communication skills. They also balance the needs of individuals against the needs of their practice population, employing concepts from health economics as well as applying the ethics of population medicine. Finally, physicians use the principles of infection control to prevent iatrogenic infections and cross infections between patients attending their practice. Issues specific to rural areas All these roles and responsibilities apply as much to general practice as to other branches of medicine - and as much to rural as to urban practice. However, the type, place and context of practice influence the depth of competence required in different aspects of public health. The physician in a rural general practice is likely to be one of the few health professionals in the area.