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Urine screening practices in methadone main- Staff attitudes and retention of patients in tenance clinics: A survey of how results are methadone maintenance programs 500mcg advair diskus with mastercard. Sexual activity under the influence of treatment outcome in pregnant purchase advair diskus 500 mcg amex, methadone- drugs is common among methadone clients. American Journal on Dependence: Proceedings of the 61st Annual Addictions 4(1):56ñ59, 1995. Methadone disease prevention and health promotion dosage and retention of patients in mainte- update: Universal precautions for prevention nance treatment. Medical Journal of of transmission of human immunodeficiency Australia 154(3):195ñ199, 1991. Published virus, hepatitis B virus, and other blood- erratum in Medical Journal of Australia borne pathogens in health-care settings. Bibliography 245 Morbidity and Mortality W eekly Report Centers for Disease Control and Prevention 37(24):377ñ388, 1988a. Department of Health and Human Services, Centers for Disease Control and Prevention. Morbidity and Polydrug and methadone addicted newborns: Mortality W eekly Report 51(46):1051ñ1052, A continuum of impairment? Suicidality in a sample of Sexually transmitted diseases treatment methadone maintenance clients. Heavy for a changing epidemicóUnited States, drinking in a population of methadone- 2003. Eleven years of community- of nevirapine and methadone and guidelines based directly observed therapy for tubercu- for use of nevirapine to treat injection drug losis. Preventing adverse drug interac- lance program to monitor UltramÆ (tramadol tions before they occur. Enzyme immunoassay validation for the Clinics of North America 38(3):525ñ537, detection of buprenorphine in urine. Dear Colleague (Letter to opioid Pain intolerance in opioid-maintained former treatment professionals). American toxicology as an outcome measure in drug Journal on Addictions 10(2):159ñ166, 2001. Cytochrome P450 System: Drug Interaction Psychiatric disorders among drug dependent Principles for Medical Practice. Research on contingency man- American Journal of Drug and Alcohol Abuse agement of drug dependence: Clinical impli- 19(1):65ñ78, 1993. Toxicologic Substance Abuse and Mental Health Services aspects of heroin substitution treatment. American Journal of Demystifying Evaluation: A Manual for Obstetrics and Gynecology 129(6):679ñ686, Evaluating Your Substance Abuse Treatment 1977. People W ith Physical and Cognitive Integrating Substance Abuse Treatment and Disabilities. Enhancing Motivation for Change in Substance Abuse Treatment for Persons W ith Substance Abuse Treatment. Abuse and Mental Health Services Clinical Guidelines for the Use of Administration, 1999d, reprinted 2001. Recovering Alcoholics and Drug-Dependent Journal of Maintenance in the Addictions Persons, 3d ed. Motivational response to methadone maintenance treat- Interviewing: Preparing People To Change ment. Antisocial personality disorder, psychopathy Current W omenís Health Reports 1(1):27ñ30, and injecting heroin use. The relationship Disorders: Assessment and Treatment between suicide and heroin overdose among (Practical Resources for the Mental Health methadone maintenance patients in Sydney, Professional). Scientific tion in a sample of patients in treatment for American 243(6):138ñ154, 1980. Methadone plasma methadone maintenance: Clinical opportuni- level: Sustained by a reservoir of drug in tis- ties and challenges. Archives of ing: Urinalysis results in the first year of Internal Medicine 120(1):19ñ24, 1967. Methadone maintenance in preg- Complications of severe mental illness related nancy: Consequences to care and outcome. Is it justifiable to withhold treatment Drug Enforcement Administration, Office of for hepatitis C from illicit-drug users? Diagnostic testingóLaboratory ence partner violence: Isolation and male and psychological. Alcohol Clinical not interact in the same way with the Experimental Research 17(3):681ñ686, 1993. Drug and Alcohol Dependence Interindividual variability of the clinical 54(3):259ñ265, 1999.

Educate the patient about surgical site infections buy advair diskus 250mcg without a prescription, relevant symptoms and signs advair diskus 500mcg without prescription, and the need to report them if noted. Additional studies that are frequently ordered include a urinalysis, urine pregnancy test, and, when indicated, liver function studies. While the list of additional studies could go on and on, the important principle to understand is that few of these studies are helpful when routinely ordered. Selective laboratory evaluation, coupled with a thorough history and physical exam, will prove to be both safer and more cost-effective. Imaging Studies The disease process being treated should dictate the imaging studies ordered. Most patients can be brought to the operating room safely based on the performance of good history and physical exam. Diagnostic imaging studies should be ordered to fine-tune the history and physical and so that appropriate surgical planning decisions can be made. This routine order is somewhat historical, carrying over from the days of prevalent tuber- culosis. Healthy young patients with no evidence of pulmonary disease benefit little from a chest x-ray. It is rare in a patient who has a normal pulmonary exam that the chest x-ray significantly alters the operation for which it was ordered. It is more reasonable to obtain a chest x-ray in an elderly patient, and, at times, this results in interesting findings, such as a lesion requiring further workup. Perioperative Care of the Surgery Patient 17 Informed Consent Informed consent should be viewed as an opportunity for the surgeon to take some time to explain to the patient why an operation is necessary, what the operation entails, what sort of recovery to expect, and what complications might be incurred. The discussion should be frank and honest while sensitive to obvious anxieties of the preoperative patient. It is also helpful, when possible, to have this discussion in the presence of a concerned spouse or family member. With this in mind, the discussion may best be done sometime well in advance of the operation. The discus- sion, when possible, also should include nonoperative therapies for the given disease process. Case Evaluation When considering the approach to the surgical patient as it applies to the case cited at the beginning of this chapter, there are several impor- tant considerations. First, the patient most likely does have a surgical problem and most likely requires an operation. He most likely does not require an emergency operation, and therefore the physicians attend- ing to the patient have some time to fully evaluate the problem with an appropriate series of laboratory tests and diagnostic studies. A thorough and honest assessment of the patient’s comorbid conditions and risks for major surgery is necessary prior to proceeding with a significant operation. Summary The successful approach to the surgical patient requires the physician to understand the anatomic and physiologic problems with which the patient presents, listen to the patient, collect a detailed history, and then perform a complete physical exam. Based on the history and physical, a diagnosis, or at least a working differential diagnosis, is derived. Although the aforementioned steps are not unique to surgery, the dif- ference lies in the fact that a surgeon undertakes the aforementioned steps en route to an intervention. The intervention may be minor and expose the patient to minimal risk or it may be very significant and may permanently alter the patient’s life. To earn that trust, surgeons must be well trained, exhibit good judgment, understand the limitations of their patients based on their comorbidities, and understand the limitations of their own ability. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). History of present illness: Three days ago, when lifting a very large pine tree that blew over in a recent windstorm, the patient felt a sudden pain in his left groin. The acute pain resolved, but he continues to feel a “dragging” sensation in same area. Review of systems: Noncontributory: • Gastrointestinal: Denies change in bowel habits; no history of con- stipation; no hematochezia; no nausea and vomiting. Nackman Pertinent social/family history: Non–union worker who loads and unloads delivery trucks. Upon standing, a bulge observed in left inguinal region: no erythema, nontender, easily reduced. The Relevance of Evidence-Based Medicine Many of the issues involved in the care of patients include “age-old” traditions that may be based on empiricism. Until several decades ago, drainage of the gall- bladder bed following cholecystectomy was the standard of care and was based on the belief that drainage of the affected area would promote healing and reduce postoperative complications. Through the 1970s, students and residents heard from their instructors and super- visors: “This is how my mentor taught me to drain the gallbladder bed, so you should do it this way, too. Even though the traditional dogma had been rebuked by demonstrating no need for routine drainage, the clinical practice took decades to change.

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Which method is most sensitive for detection of Answers to Questions 3–6 viral meningitis? Te test is positive only in cases of smear-positive codes for vancomycin resistance but is not found in and culture-positive infections S quality 250mcg advair diskus. Te test can detect 85%–90% of smear-negative 250 mcg advair diskus visa, minimal number of organisms present in the culture-positive infections specimen, and sensitivity is 90% or lower when the D. B Cancers are caused by genetic damage to cells that procedures/Tuberculosis testing/2 disrupt the cell cycle. Which statement accurately describes the clinical Answers to Questions 7–9 utility of translocation testing in leukemia? D Some translocations occurring after treatment are occurring after treatment predictive of relapse. However, other subtype are always the same translocations, such as the 15:22 translocation D. Which is the most sensitive method of minimal Translocations associated with a type of leukemia are residual disease testing in chronic myelogenous not identical in all cases. How can cell proliferation be explained by the using primers to the p210 and p230 transcripts. A hybrid protein is made that up-regulates the cytometry can detect 1 malignant cell per 10,000 cell cycle nonmalignant cells, but a panel of antibodies is C. Activation of an oncogene causes loss of a protein that inhibits mitosis and is D. Te majority of cases of Duchenne’s muscular dystrophy are caused by which type of genetic 11. Molecular/Apply knowledge of fundamental biological The c-myc protein is an activator of genes involved in characteristics/Muscular dystrophy/2 mitosis. Molecular/Apply knowledge of special procedures/ The remaining 40% can be caused by microdeletions, Muscular dystrophy/2 point mutations, or insertions that are not usually detected by available primer sets. This process follows other genetic markers located near the disease gene so that crossing over is improbable. Transcription signaling by the mutant protein down-regulate cell signaling events that lead to C. A Pharmacogenetics (sometimes called are important in identifying which condition? Risk for primary biliary cirrhosis Individual differences in drug metabolism can be C. Progression of hepatitis C to hepatic cirrhosis attributed in part to polymorphisms in the genes D. Approximately how may mutations have been polymorphic genes that account for metabolism of identified in the gene coding for the cystic fibrosis approximately 40% of drugs. Phenotypical expression trans membrane conductor regulator protein varies with the locus involved. The most common mutation is a deletion of three base pairs that code for phenylalanine at position 508 of the protein, ΔF508. Some with no other symptoms infants may be too young for accurate sweat testing, D. Which of the following alleles has the highest always associated with pancreatic disease). Other than infertility, they are asymptomatic thrombophilia) and may or may not have a sweat chloride level D. This results in a codon that substitutes valine for alanine and results in an enzyme that is more heat sensitive. The enzyme converts 5,10 methylenetetrahydrofolate to 5-methyltetrahydrofolate (folate). The methyl group from the latter is transferred to homocysteine, forming methionine. Such persons have an approximately threefold increased risk of coronary artery disease. All of the alleles listed are of sufficiently high frequency to warrant screening of at-risk populations. The prothrombin G20210A allele has a frequency of approximately 2%, factor V-Leiden 5%, and ΔF508 approximately 3% (in Whites). Both factor V-Leiden and the prothrombin G20210A mutation result in proteins that increase the risk of thrombosis. The point mutation in factor V-Leiden results in a protein that is resistant to inactivation by protein C. The base substitution in G20210A (guanine to adenine at position 20210) results in increased transcription of the gene and overproduction of prothrombin.

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