Repeat Image Evaluation Paper

Repeat Image Evaluation Paper Daniele Balsamo The image repeat is a lateral lumbar spine. The lumbar spine protocol is usually part of a three view, anterior posterior (AP) a lateral and a C5 S1 spot image. For trauma, often is requested one lateral to assure that there is no risk to move the head of the patient. A complete sequence includes also to two obliques (LAO and RAO) to visualize the zygapophyseal joint space. . For a proper lateral spine positioning, the radiographer places the patient either standing or recumbent left lateral. Shoulder and ASIS should be aligned vertically through the midcoronal plane, to assure there is no tilt or rotation, the thoracic and lumbar spine should be aligned parallel to the table, to assure no rotation. A contact shield should be placed on the table lateral to the spine to reduce back scattering. A contact shield should be placed on the gonad area if does not interfere with area of interest. The spine should be aligned parallel to the longitudinal line of the collimation light. Ask the patient to suspend their breathing on expiration. The essential anatomy is, longitudinally T-12 to sacrum, laterally including the soft tissue posteriorly to the spine and all the body of the vertebrae anteriorly. Anatomy best demonstrated is the spinous process, the intervertebral disk space and the vertebral body (McQuillen Martensen, 2015, p. 431). Because different body habitus can affect the position of the lumbar spine, depending of the body fat or muscle in the hip area, a special attention is required in positioning the spine laterally. The leg had to be flexed to reduce the natural curvature of the hip, a sponge or a towel is placed superiorly to the iliac crest to the sagging of the spine due the position on a flat table. The sponge allows to keep the natural curvature and the spine parallel to the image receptor (IR.) Different pathology can affect the lumbar spine imaging. Scoliosis is a curvature of the spine to the left or the right side. Lordosis is an accentuated curvature of the spine toward the anterior aspect. Can be reduced flexing the knee and bringing L5 and sacrum more parallel. Will be visualized in AP projection with the intervertebral disc space look closed. If the patient has a lateral curvature (scoliosis) of the spine, should be placed in a lateral position with the curvature toward the IR to keep the intervertebral disk space as open as possible, the center ray should be going through in the maximum curvature point referencing the AP projection. Spondylolysis is a fracture of the pars interarticularis in the vertebral arch, visualized in the oblique projection and appear as a Scotty dog collar. Spondylolisthesis is the slide forward and down of one vertebral body to another inferiorly. These pathologies could limit the motion range of the patient, but they dont affect the positioning technique. Central ray should be on L3, positioning one inch a half superior to the iliac crest. The area of interest is from the first lumbar spine to the intravertebral space between the fifth lumbar spine and the sacrum. The beam is perpendicular to the IR and the distance from the tube is 43 inch. The system is a DR Siemens system, with a fluoroscopy table, and a wall bucket that uses a rail moved x- ray tube. The exposure indicator is express in EXI, the range is 150 under exposed, 250 optimal exposure, 500 overexposed. The system use two method to evaluate the exposure, the first is the setting of the proper anatomic part and body habitus of the patient. The radiographer sets the anatomic part and the body habitus on the display, the machine uses an automatic programmed technique (APT), that follows predefined anatomic chart sets by the manufacturer. Next the machine then uses the automatic exposure control(AEC) to determine the proper exposure. When a certain amount of remnant x-rays are hitting the ionic chamber in the IR, the exposure is terminated. The AEC gives consistency between exposures if the positioning of the anatomy on the right photo cell is correct. For the AP projection of lumbar spine, the EI is 367, the exposure factors are 75 KVp, 189 mAs, For the left anterior oblique is Exposure Index (EXI) is 290, 77Kvp and 200 mAs. The EXI for the right anterior oblique is 205, with 65 Kvp 98 mAs. The left lateral EXI is 258,near to the optimal 250, the 90Kvp and 75 mAs . The left lateral repeat has an EXI of 260 with a 90 Kvp and 83 mAs . The radiographer can evaluate the image visually using the magnify lens in the image Pac viewer. When the quantum noise, is visible in the image and the anatomic edge are blurry this indicates an underexpose image. For an overexpose image the contrast is high and the image has very minimal shades of gray In the DR Siemens system used for this procedure the image receptor size is a 17 by 17. The collimation is done by using the beam limitation device in the machine. The aperture diaphragm in the tube housing can be manipulated by the radiographer with two controls and the light will resize proportionally to the exposure field. In a standard lateral spine, the collimation should be height wise 17 and lengthwise 8. Appropriate shielding in lateral spine should be considered when is possible use a contact shield over the gonads, without superimposing essential anatomy. There is no requirement of patient preparation for the L-spine x-ray, except for the appropriate clothes, or hospital gown to avoid artifacts. Other patient artifact could be jewelry, belly piercing, or underwear with sparkle or other metallic materials. Other artifact can be generated by patient movement. System artifact can be grid related and software related. Grid related are: grid cut off, when the center ray is not centered on the image receptor and not parallel to the grid, the result is line artifact visualized through all the image. Software related are the use of wrong algorithm and wrong anatomic chart, this create a wrong image compensation and can enhance details in the wrong anatomic part (tissue instead of bones). Sometimes is use intentionally reapply the algorithm on a chest x-ray to better visualize the pic line. Factors that defines the quality of the image are: brightness, contrast, spatial resolution and distortion. Image brightness, in digital radiography (DR), is the amount of exposure of the image receptor that affect the value of light or dark value of the image. This value can be adjusted in digital radiography with window level in the image viewer. Although is limited to the latitude of the image, in DR can be adjusted 50% up for underexposed image and 200% down for overexposed. The display brightness is a hardware quality factor and need to be calibrated to give a consistent image quality output. Contrast in an image is defined by the visual recognition of a change of density in adjacent part in a tissue, defines the edges of the anatomy improving details visibility. Subject contrast is generated by the differential absorption in the body. Is determined by the patient physical properties, such as weight, muscle mass and body habitus. As the contrast goes up the latitudes and the shades of gray are getting lesser. Two adjacent tissue with same density will have poor if none contrast. In the PACS image viewer the contrast is controlled by window width. Spatial resolution (306-309) is a quality of the image receptor and display, is determined by the matrix of pixels, bigger is the matrix better is the resolution. Does affect the image quality because define how small of an anatomic detail can be visualized. Can be affected by motion, patient(voluntary) and organs(involuntary) such as heart beat or peristalsis of GI tract. Focal spot blur is an effect of the shape of the focal spot on the anode. As the OID of the object increase so will the focal spot blur on the cathode side. Distortion shape size, spatial Is affected by OID and SID and positioning of body part, image receptor and tube angle. When the tube, the anatomy and the IR are not aligned properly elongation and distortion can occur. If the anatomic part is not enough near to the IR magnification will occur. There are two main errors that lead to a repeat of the image all related to positioning. First, the center ray should be centered in L3 instead is centered on L2 -L1 , and consequently the inferior side of the sacrum is cut off the field of view. Second, the lumbar spine between L4 and L1 is not parallel to the image receptor and shows the inferior base of the vertebral body, in this case the leg were not flexed enough. Collimation should be more tight 8 longitudinal. That will also decrease backscattering and will give more contrast to the image. Another visible error is the rotation of the spine References Bontrager, K. L., Lampignano, J. P. (2014). Textbook of Radiographic Positioning and Related Anatomy. (8th ed.) St. Louis, Mo.: Elsevier/Mosby. McQuillen Martensen. (2015). Radiographic Image Analysis. (4th ed.) St. Louis, MO.: Elsevier. [DB1] [DB2]

Book Report On The Outsiders Essay -- Essays Papers

Book Report On The Outsiders Character Analysis: Ponyboy Curtis - Ponyboy is a fourteen-year-old member of a gang called the Greasers. His parents died in a car accident, so he lives alone with his two older brothers, Darry and Soda. He is a good student and athlete, but most people at school consider him a vagrant like his Greaser friends. Sodapop Curtis - Soda is Pony's handsome, charming older brother. He dropped out of school to work at a gas station, and does not share his brothers' interest in studying and sports. Darrel Curtis - The oldest of the Curtis boys, Darry is also the acknowledged leader of the Greasers. Johnny Cade - Johnny is Pony's closest friend and the gang's pet. They are especially protective of him since he is smaller than the rest, his father beats him, and he is afraid to walk the streets alone after being attacked by a group of Socs. Cherry Valance - Cherry is from the richer part of town and associates mainly with the Socs, but she befriends Pony and the other Greasers and gives them information about the Socs. Bob Gardner - Bob is Cherry's boyfriend. Johnny murders Bob to stop him from killing Pony. Dallas Winston - A member of the Greasers, Dally has spent time in prison. He helps Johnny and Pony by telling them to go to Jay Mountain to hide out and by giving them money. Two-Bit Mathews - The Greasers' oldest member. He acts like a mentor or mascot to the Greasers. Steve Randle - Soda's best friend and anoth...

Sexuality, Corruption, and Power Dynamics in the Bloody Chamber

Sexuality, corruption and power dynamics in The Bloody Chamber Sexuality is a prevalent theme in Angela Carter’s story The Bloody Chamber. Sexual violence within a relationship often reveals aspects of each party’s identity and character as well as affects its power dynamics. Carter depicts sex both explicitly and implicitly in the story through the heroine’s own thoughts of her newfound sexuality and her sexual experiences with the Marquis.Carter’s implicit and explicit portrayals of sex and sexuality in The Bloody Chamber reflect changes in the power dynamic between the heroine and the Marquis throughout the text, develop the identity of the heroine and reveal aspects of the Marquis’ character, and challenge notions of gender. The first incident of an implicit portrayal of sexuality occurs during the narrator’s train ride away from her childhood home towards her new life with her future husband, the Marquis.No physical act of sex is describ ed, but it is the first time that the reader sees the heroine’s sensual side and departure from innocence through Carter’s use of sexual language. It is as if the train ride away from home symbolizes her departure from innocence and into womanhood. Carter uses words such as â€Å"ecstasy†, â€Å"burning†, â€Å"pistons thrusting†, shuddered†, and â€Å"throb† to convey the heroine’s newfound sexual arousal and her thoughts about sex.Carter’s description of the heroine’s â€Å"young girl’s pointed breasts and shoulders† depicts her innocence and virginity (Carter, 8), yet she is consumed with thoughts of sex. This contrast symbolizes the development of the heroine’s identity from childhood to womanhood. Implicit sexuality is also seen on the train ride when the heroine expresses her anticipation of sex. She says: â€Å"for the first time in my innocent and confined life, I sensed in myself a po tentiality for corruption that took my breath away. (Carter, 11). The heroine feels this way because of the way the Marquis watches her with an â€Å"assessing eye of a connoisseur inspecting horseflesh†, and sees for the first time the â€Å"carnal avarice† of the way he looks at her. The Marquis views her as a piece of meat; similar to the way a predator would eye his prey. From this scene, it is evident to the reader that the Marquis treats his women as possessions, and has a primal instinct regarding sexuality.The heroine has lived a sheltered, pure life and is completely new to such concepts as lust and sexual passion, but it is at this moment that she realizes the potential of becoming a woman susceptible to sexual domination and corruption. This scene reflects the power dynamic in the relationship stemming from the Marquis’ obvious desire for sexual possession, corruption, and control, and the heroine’s recognition of her impending sexual exploitat ion. The scene further develops the heroine’s identity towards becoming a woman.Despite the Marquis’ obvious misogyny, his actions excite the heroine because they make her feel as if she is a sexual and desirable being. She recounts his marriage proposal, and says: â€Å"When I said that I would marry him, not one muscle in his face stirred, but he let out a long, extinguished sigh. I thought: Oh! how he must want me! And it was as though the imponderable weight of his desire was a force I might not withstand, not by virtue of its violence but because of its very gravity. (Carter, 9) This quote shows how the heroine perceives the Marquis’ sigh as a sign that he is in love with her, when the more likely reality is that it is a sigh of victory, as if he has just conquered his latest possession. Regardless of these opposing interpretations, it is evident in the last line of this quote that the heroine senses the combination of sexual desire and violence inherent i n the Marquis’ character, and the harm it poses to her. Little does the heroine know how real the Marquis’ penchant for sex and violence is, and how he channels that desire towards the murder of women.The heroine seems accepting of the submissive role in her relationship with the Marquis, and the thought excites her. This assumption further reflects the power dynamic between the Marquis and his wife, as well as the gender roles that both characters embody. The Marquis fits the description of a power-hungry, domineering male, and the heroine that of a naive, innocent girl who obeys her husband. The heroine’s naivety is reflected when she says she is â€Å"bemused that, after those others, he should now have chosen me. She obviously does not understand that the reason he is not still in mourning for his last wife is because he murdered her. Carter’s explicit portrayal of sex occurs when the Marquis first shows the heroine the mirrored room and disrobes her . The heroine narrates the scene as if she is describing a rape, similar to the ones in the Marquis’ collection of pornographic paintings: â€Å"And when nothing but my scarlet, palpitating core remained, I saw, in the mirror, the living image of an etching by Rops from the collection he had shown me when our engagement permitted us to be alone together. (Carter, 15). When the Marquis later takes the heroine’s virginity, it is a form of punishment for the heroine’s disobedience in perusing his collection of books. This reveals the power dynamic that will present itself again in the story, of the Marquis setting the heroine up to disobey him, then punishing her. He makes her wear the choker of rubies as if it is a collar, kisses it before he kisses her, and â€Å"twines her hair into a rope† as if it is a weapon he could use to hurt her. These actions further exemplify the Marquis’ desire for violence and corruption enveloped in sex.Once the heroin e is no longer a virgin and the Marquis leaves the castle, the heroine takes on the role of woman of the house. The reader sees the development of the heroine’s identity, as her independence is revealed through solitary actions such as playing the piano, her true passion, and directing the staff. The heroine is portrayed as a woman who is in control of her domain, rather than a girl under the control of her husband, even though she is still very much trapped in the castle. Power dynamics shift once the heroine loses her virginity, because that was what defined her corruptibility, innocence and youth.The heroine and the reader also witness for the first time a Marquis who has had all the force and power knocked out of him. The narrator says â€Å"He lay beside me, felled like an oak, breathing stertorously, as if he had been fighting with me. In the course of that one-sided struggle, I had seen his deathly composure shatter like a porcelain vase flung against a wall; I had he ard him shriek and blaspheme at the orgasm. † (Carter, 18). Prior to this sexual experience, the heroine had never seen the Marquis be emptied of his composure or expose his vulnerability.She believes that she may have discovered the man underneath the powerful facade when she says â€Å"And perhaps I had seen his face without its mask; and perhaps I had not. † The Marquis is always so in control and holds power over the heroine, but she realizes that if his exterior is removed for a moment, he is not as powerful as he seems. This scene influences the power dynamic within the relationship, since the heroine is no longer convinced that the Marquis holds so much unquestionable authority over her.This transition in the power dynamic aids the heroine’s decision to disobey the Marquis’ instructions when he leaves. The heroine’s identity is further developed after the she discovers the bloody chamber and the Marquis returns to the castle. Now that she has discovered the truth about her husband and the fate of his previous wives, the narrator admits to herself that she is in true danger. â€Å"How could I know, indeed? Except that, in my heart, I’d always known its lord would be the death of me. † (Carter, 33).She is no longer an unknowing, innocent, uncorrupted girl, as she now knows who the Marquis truly is and what he plans to do to her, and she realizes there is nothing desirable about him or their relationship. The narrator realizes that she has played directly into the Marquis’ hands, and has â€Å"lost at that charade of innocence and vice in which he had engaged me. Lost, as the victim loses to the executioner. † (Carter, 34). The heroine has fallen for every trap that the Marquis has set for her, right up until her impending death.The power dynamics of the relationship shift at this moment in the story. The heroine has discovered the Marquis true intentions, so he no longer holds any secrets that she is unaware of. She sees him as the monster he is, and not as the powerful man he pretends to be. The narrator observes as the Marquis â€Å"raised his head and stared at me with his blind, shuttered eyes as though he did not recognize me, I felt a terrified pity for him, for this man who lived in such strange, secret places that, if I loved him enough to follow him, I should have to die† (Carter, 35).The heroine begins to pity the Marquis rather than fear him, and sees his loneliness underneath his powerful disguise. One could argue that the power dynamics truly shift in the heroine’s favor once her mother kills the Marquis, as he is destroyed, but the true shift takes place once the heroine discovers who the Marquis really is, because she no longer has any reason to obey him as a husband. Once the narrator realizes that she is not in a legitimate husband-wife relationship and her husband intends to murder her, there is no reason for her to act like a loving, faith ful wife or submit to this man.The end of the text shows how Carter challenges gender roles throughout the story. At the beginning, the heroine is portrayed as a naive girl who marries a man not because she’s sure she loves him, but because she’s sure she wants to marry him (Carter 8). The reader sees how she fits the notion of the inexperienced, submissive gender willing to obey a man and accept all the riches he offers her. The Marquis fits the notion of a masochistic, domineering male who sees women as objects and seeks to control them and entice them with wealth.However, by the end of the novel, the heroine outlives the Marquis and is no longer the object of a man’s desire for violence and sexual corruption. She marries a man who is blind and poor, so that he can neither objectify her for her beauty nor buy her love with money and gifts, and she no longer has any desire for these things. This change is seen when the narrator says: â€Å"We lead a quiet life , the three of us. I inherited, of course, enormous wealth but we have given most of it away to various charities. (Carter, 40). The Marquis has fallen from his position as a powerful, wealthy, controlling man, and in true feminist fashion, the heroine emerges the victor. Carter’s descriptions of implicit and explicit scenes of sex and sexuality involving the heroine and the Marquis illustrate the development of the two characters’ relationship with each other and the power dynamics involved, as well as their own identity transitions throughout the story.The reader witnesses the narrator’s journey from girlhood and her desire for sexual corruption, through her torture, submissiveness and sexual self-discovery, all the way until her assumption of power over the Marquis. The heroine defeats the preconceived notions of gender roles as her values and character are completely altered by the end of the story. The Bloody Chamber depicts the lethal combination of sexual ity and violence and the desire to be sexually corrupted without comprehending the implications and true nature of the relationship.

The Integration Of Law And Ethics - 945 Words

As the subject title indicates, Substantive ethics is about the integration of law and ethics in corporate ethics programs. The author of this article gives numerous examples of why integration of law and ethics is needed. There are numerous areas of concern, such as dishonest corporate dealings, global human rights, tort lawsuits, and questionable executive salaries (Blodgett, 2012). There is a view that laws are rules meant to be followed and not necessarily understood for its ethical value. This in turn is a major factor as to why ethical violations exist. New regulations are created often times in the corporate environment or society in response to ethical petitions for change (Blodgett, 2012). In order to have â€Å"ethical sustainability† (Blodgett, 2012, p. 39), the ethical component of laws must be incorporated with new regulations (Blodgett, 2012) The article examines the correlation of law and ethics as it focuses on managerial decision making and corporate governance. It is approached in three ways via the applied approach, change of corporate ethics codes, and restructuring the current view of law and ethics (Blodgett, 2012). The three main applied approach are the â€Å"separate realm view† (Paine, 1994a. b., p. 154). This view interprets a law as a minimum or base level standard that must be followed. In contrast, the ethical principles of morals and behavior are viewed as grander and distinguished from the law (Jennings, 2006). 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My Personal Philosophy Of Nursing - 1160 Words

Personal Philosophy of Nursing Introduction The development of a philosophy related to the profession of nursing is important in that it provides a framework for the nurse to base his/her work on. Philosophy is defined by Merriam-Webster as â€Å"a search for a general understanding of values and reality by chiefly speculative rather than observational means†. In other words, philosophies are based on beliefs and assumptions with an overall goal of obtaining an objective which states the nurse’s purpose in the profession. In my undergraduate nursing program I was exposed to multiple nursing concepts that guided my practice. Coupled with my ten years of experience in the nursing field, I was enabled to formulate my own framework or guide to nursing. The paradigm which resonates with me the most is the interactive-integrative perspective as it views practice â€Å"as having multiple, interrelated parts in relation to a specific context.† (Newman, Sime, Corcoran-Perry, 1991, p.38). 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My Strengths And Weaknesses As A Social Worker Helps Me

Self-Evaluation Assessment Social work exists to provide effective social services to individuals, families, groups, communities and society so that social functioning may be enhanced and the quality of life improved. (Zastrow, 2013) Assessing my strengths and weaknesses as a social worker helps me see what I must maintain, and what I must improve on to become the kind of social worker that educates and inspires. The skills I identify with in my practice are; empathy, identifying strengths, and respect. These skill sets are vitally important to ensure clients receive the best possible outcome. When assessing clients a specific skill that I identify with is empathy. Empathy is the ability to understand and share feelings of others. To effectively display empathy requires certain characteristics. Some of the characteristics of empathy that I employ are; having the innate ability to put myself in the other people’s shoes. This allows for a better understand toward the experience s the family has gone through. For empathy to be displayed accurately, effective communication is essential. Effective communication is asking the right questions and providing reflective listening so the family knows the professional truly understands their circumstances. Effective communication allows for an accurate assessment of the family. Effective communication is a vitally important component of empathy. Empathy can be displayed though effective communication, such as, effectivelyShow MoreRelatedAdvantages I Can Get from My Strengths and Weaknesses1078 Words   |  4 PagesA persons strengths and weaknesses are vital in whom a person is. Most people have no idea if they are weak and some do. 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Public Health Problem Of Vitamin D Deficiency In Australia - Sample

Question: Discuss about the Public Health Problem Of Vitamin D Deficiency In Australia. Answer: Introduction: Vitamin D is an essential component for the regulation of calcium and phosphorus in human body. It supports bone mineralization and strengthens bone. Appropriate level of Vitamin D in human body has been found to decrease the likelihood of bone disorders like rickets and osteoporosis in children. However, the Vitamin D deficiency has become a major public health issue globally due to limited exposure to sunlight. Vitamin D deficiency has been found to contribute to adverse health consequences such as cardiovascular disease, obesity and complication in pregnancy (1). This report particularly examines the public health problem of Vitamin D deficiency in Australia and examines the actions taken in the country to address the issue at population level. Is Vitamin deficiency a public health problem in Australia Vitamin D is an essential fat soluble vitamin for bone health because it helps in the regulation and absorption of calcium level in blood. It is also regarded as important to maintain bone health and prevent fractures. The review of the prevalence of Vitamin D deficiency has shown that it is prevalent in many countries worldwide particularly those falling in low latitudes. About 1 billion people have been found to have low vitamin D levels and the disease is common mostly in all age groups (2). It is also linked to other diseases like hypertension, diabetes, cancer and autoimmune disease because Vitamin D is needed for healthy cardiovascular system, hormones and immunity. The human body get most the Vitamin D from regular exposure to sunlight as the skin produces the vitamin when exposed to ultraviolet B (UVB) light from the sun. However, Vitamin D deficiency is also public health burden in Australia despite receiving plenty of sunlight. The most common cause for this is that people are not adequately exposed to enough sunlight on a daily basis. People with naturally very dark skin are at high risk of Vitamin D deficiency because dark skin pigment has lesser ability to produce Vitamin D. Secondly, exposure time decreases in people due to location, season and amount of skin exposed to sunlight. For example, people working indoor environment, older and weak adults, and those who avoid the due to health issues get little or no sun exposure at all and become prone to Vitamin D deficiency risk. A mother who is low in Vitamin D also increases the risk in breastfed babies. In addition, certain health conditions and medication also cause low Vitamin D in an individual (3). National study has confirmed that Vitamin D deficiency has become an emerging heath issue in Australia. In a study done with 11000 adults in Australia, one-third of them were found to be deficient in Vitamin D. It highlighted the Vitamin D status of Australia by stating that women, elderly, obese, non-European background people and people with less amount of physical activity are at greater risk of deficiency (4). The negative point for public health system of Australia is that they have abundance of rich sunlight, still Vitamin D deficiency is turning out to be a major health issue in the country. The proportion of risk differs on the basis of level of deficiency. For instance, low level of deficiency leads to soft bones and frequent fractures and high level of deficiency leads to life threatening diseases like osteoporosis, cancer, diabetes and cardiovascular disease. According to the Australian Bureau of Statistics National Health Measures Survey (NHMS), the level of deficiency is determined based on the following cut off: Mild deficiency for Vitamin D level of 30-49 nmol/L Moderate deficiency for 13-29 nmol/L vitamin D Severe deficiency for less than 12nmol/L Total deficiency for less than 50 nmol/L Sufficient level at greater than 50nmol/L On the basis of above definition for severity, the survey done in 2010-2012 showed that majority of Australian adults had good levels of Vitamin D. 23% had mild deficiency to moderate deficiency and only 1% has severe deficiency. Hence, 23% or one in every four adults in Australia were found to suffer from Vitamin D deficiency. The deficiency was found more in older adults than younger people. The rate of deficiency varied with season too with low rate in winter and high rate in summer. The survey also revealed that risk of Vitamin D deficiency was higher for people born in Southern and Central Asia compared to those born in Australia. People who were physically inactive and obese were also found to have low levels of the vitamin. (5). A study also points out to Vitamin D deficiency in South Australian population and high burden of dealing with the condition (6). There is a need to take future actions to reduce the risk factor for the disease and improve Vitamin D level. Action being taken in Australia to address Vitamin D deficiency: The publication of the ABS report for Vitamin D deficiency in Australia was associated with many issues and controversies, which finally led to health service or policy related changes. Firstly, a new indication for Vitamin D supplementation was identified after a study showed that vitamin D supplementation reduces the risk of respiratory tract infection. The impact of Vitamin D supplementation on reducing Vitamin D deficiency was also studied by various researchers and many health professional were confused about the health benefits of supplementation. However, tone study showed that sun exposure and Vitamin D have independent effects on disease risk and more research is needed to identify the true benefits of supplementation of reducing the risk of immune function impairment and cardiovascular disease (8). In response to the ABS report for 2011-12, many public health actions has been taken to address the prevalence of Vitamin D deficiency in Australia. Firstly, changes in many policies were also done to maintain Vitamin D levels in different food items because many foods were found to have less amount of Vitamin D. As indicated by the Australian Standard, it mandated the food manufacturing company to maintain the limit of 55mm/kg of Vitamin D in butter and fortified food products. In response to the low level of vitamin D in children and adults, dietary Vitamin D consumption per day for children were also provided. Hence, public health agency took the initiative of supplementing the food supply with vitamin D to maintain the level of deficiency in Australian people. Focusing on the dietary source of Vitamin D was also considered important because of the lifestyle choices of the Australian population. Many people remain indoor or use sunscreen while going to prevent risk of skin cancer and so the Vitamin D limits supplementation from food items is considered a good step by the government. Mandatory fortification of milk and yoghurt was also proposed to reduce the risk of Vitamin D deficiency in the population (7). However, there is no clarity regarding whether food products fortification should be made voluntary or mandatory. Taking strong decision and policy reform in this area may help to reduce the public health burden associated with the disease. Public health action was also taken to support screening of all women with Vitamin D deficiency during pregnancy. Observational studies in Australia had showed that among women attending antenatal care in Sydney, 15% had serum HD lower than 25nmol/L. Taking action for pregnant women was particularly considered important due to the high associated with the deficiency for them. Vitamin D deficiency in newborn has been found to led to low serum calcium level, rickets and defective tooth enamel in newborn baby. Impact on fetal growth is also seen as children with vitamin D deficient mothers has been found to have lower birth weight and low mineral density. It also increases the likelihood of diseases like cancer, multiple sclerosis and schizophrenia because of the affect on the functioning of different body tissues (9). In response to address this issue in pregnant women, Vitamin D supplementation was considered important to improve maternal vitamin D status during pregnancy. The clinica l practice guideline showed that screening for the deficiency in women was important if they has dark skin, limited exposure to sunlight and pre pregnancy BMI of greater than 402.. Dosage and forms of supplementation was decided and calcium intake level was fixed. For women below 18 years, it was 1300 mg calcium and for women above 18 years, it was 1000 mg. The recommendation for health staff was to maintain the dose of Vitamin D in women and dietary source of calcium and Vitamin D was planned which included milk, bony fish, nuts, margarine, eggs and soy beverages (10). Hence, this step was found to be effective in reducing the risk and identifying at risk person effectively. A peer-reviewed research article also examined the implications of vitamin D supplementation in Australia. After the report on high rates of Vitamin D deficiency, very few studies evaluated the impact of Vitamin D supplements on health outcome. Although between the year 2000-2011, about $94 million supplement were sold in Australia, however there was lack of study regarding analyzing the way supplementation is used. The research study investigated about the effects of vitamin D supplementation to improve and further develop the supplementation process. Vitamin D requirement was not met from diet because very few food items in Australia has adequate vitamin D levels. Despite the fortification of edible oil and spreads, the vitamin D level was not met by many food producing agencies. However, those who took supplements led a healthier lifestyle and their quality of diet was also good. They were also found to be aware about the need for sun exposure and eating foods containing Vitamin D . Such people were healthier compared to those who did not used supplements. The implication from the study is that after the first decade of vitamin D supplementation, awareness about risk and testing has increased among public. However, one negative result seen from the study is that Australia is spending too much on supplementation in other areas too where it is not necessary (11). Hence, to reduce unnecessary spending, development of appropriate vitamin D supplementation guideline is necessary. This will help to correct the dose required and prevent unnecessary use too. Taking action regarding preventing vitamin D deficiency was also found to improve the cancer incidence in Australia. Cancer has been a common public threat in Australia and WHO recommendation was that this can be prevented by addressing the risk factors such as tobacco smoking, diet, physical inactivity, sun exposure and alcohol consumption. Although this study considered many other elements apart from sun exposure and Vitamin D intake, the information related to Vitamin was only analyzed for this study. The strength of this study was that it pointed out to the recent rise in vitamin D deficiency due to the influence of the sun protection programs. Adequate level of Vitamin D can be maintained only when skin is exposed to the sun followed by receiving small proportion of vitamin D through diet (12). Hence, the public health action of increasing the awareness about risk and benefits of sun exposure became important to reduce the deficiency and public health burden related to Vitamin D deficiency. Currently, people still has doubts regarding the role of sun protection and effective public health action in this area is considered important. Strategies or recommendation for future focus to reduce burden from Vitamin D deficiency: The review of the Australian Governments action to reduce vitamin D deficiency pointed out to many strength and weakness of the Public Health Agency. For instance, the fortification of the food items and the policy development regarding it was a beneficial step for the country considering the lack of vitamin D level in different food items. Secondly, the guideline regarding Vitamin D supplementation and Vitamin D supplementation was considered as an important step to reduce the risk in pregnant women and new born babies too. However, the analysis of the public level action also pointed out to certain areas of improvement. For instance, lot of unnecessary investment in Vitamin D supplementation was also seen because of poor knowledge regarding Vitamin D supplementation and its daily intake among public. The sun protection program and the tendency to remain indoors was also regarded as a factor leading to high rate of vitamin D deficiency. Over-screening and over-diagnosis was also con sidered as an issue in preventing the health issue. Hence, in future more action is required regarding educating the public about importance of sun exposure, improving the screening process and maintaining a health life style along with good diet to reduce the health burden associated with Vitamin D deficiency. The future recommendation to improve Vitamin D testing in Australia is that unnecessary labeling and overtreatment in healthy individual needs to be reduced. The rate of increase in testing has increased the cost for 25-hydroxyvotamin D deficiency in the country (24(OH)D). Variation in frequency of testing and adapting international testing guideline was found. Hence, the recommendation is to separate individuals who are at high risk of deficiency such as elderly people or people with dark skins. It is necessary to follow the Australian Bone and Mineral Society recommendation of testing every three months after a loading dose 25(OH)D has been given to affected people (13). In addition, to track the benefits of the supplementation, it is necessary to monitor the performance of the replacement therapy on health outcome of people. Adoption of specific guideline for 25(OH)D testing may also improve the efficiency of testing. Conclusion: The report summarized the prevalence of the Vitamin D deficiency in Australia and pointed out to public health burden by means of present risk and inefficiency in the public health system of the country. In response to the data or report presented on the rise in rate of Vitamin D deficiency, the public health action implemented in Australia to reduce the health risk was discussed. It gave the idea about the benefits of supplemented program and also pointed out to future action due to the identification of improvement in testing and screening process for Vitamin D deficiency. References WHO | Vitamin D nutrition with a focus on the prevention of rickets and vitamin D deficiency in pregnant women [Internet]. Who.int. 2017 [cited 1 September 2017]. Available from: https://www.who.int/nutrition/events/2015_vit_d_workshop_pregnantwomen_21to24Apr15/en/ Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem?. The Journal of steroid biochemistry and molecular biology. 2014 Oct 31;144:138-45. Vitamin D | Osteoporosis Australia [Internet]. Osteoporosis.org.au. 2017 [cited 1 September 2017]. Available from: https://www.osteoporosis.org.au/vitamin-d Vitamin D deficiency strikes one-third of Australians [Internet]. Deakin.edu.au. 2017 [cited 1 September 2017]. Available from: https://www.deakin.edu.au/research/research-news/articles/vitamin-d-deficiency-strikes-one-third-of-australians 0.55.006 - Australian Health Survey: Biomedical Results for Nutrients, 2011-12 [Internet]. Abs.gov.au. 2017 [cited 1 September 2017]. Available from: https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.006Chapter2002011-12 Gill TK, Hill CL, Shanahan EM, Taylor AW, Appleton SL, Grant JF, Shi Z, Dal Grande E, Price K, Adams RJ. Vitamin D levels in an Australian population. BMC public health. 2014 Sep 26;14(1):1001. Nutrition D. Food fortification with vitamin D: a public health issue for Australians [Internet]. Deakin Nutrition. 2017 [cited 1 September 2017]. Available from: https://deakinnutrition.wordpress.com/2013/07/04/food-fortification-with-vitamin-d-a-public-health-issue-for-australians/ Hartley M, Hoare S, Lithander FE, Neale RE, Hart PH, Gorman S, Gies P, Sherriff J, Swaminathan A, Beilin LJ, Mori TA. Comparing the effects of sun exposure and vitamin D supplementation on vitamin D insufficiency, and immune and cardio-metabolic function: the Sun Exposure and Vitamin D Supplementation (SEDS) Study. BMC public health. 2015 Feb 10;15(1):115. Department of Health | 8.9 Vitamin D deficiency [Internet]. Health.gov.au. 2017 [cited 4 September 2017]. Available from: https://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-b~maternal-health-screening~vitamin-d-deficiency Vitamin D Deficiency in Pregnancy [Internet]. 2017 [cited 4 September 2017]. Available from: https://www.kemh.health.wa.gov.au/development/manuals/OG_guidelines/sectionb/1/b1.1.9.pdf Bilinski K, Talbot P. Vitamin D supplementation in Australia: implications for the development of supplementation guidelines. Journal of nutrition and metabolism. 2014 Aug 19;2014. Youl P, Baade P, Meng X. Impact of prevention on future cancer incidence in Australia. InCancer Forum 2012 Mar (Vol. 36, No. 1, p. 37). The Cancer Council Australia. Bilinski K, Boyages S. Evidence of overtesting for vitamin D in Australia: an analysis of 4.5 years of Medicare Benefits Schedule (MBS) data. BMJ open. 2013 Jan 1;3(6):e002955.