I. Hogar. Cleveland State University.
Four blood cultures were taken over a 24-hour Microbiology/Evaluate laboratory data to make period from a 20-year-old woman with severe identiﬁcations/Gram-negative bacilli/3 diarrhea order generic glucotrol xl pills. A urine Answers to Questions 41–44 specimen obtained by catheterization also showed gram-negative rods purchase 10mg glucotrol xl free shipping, 100 purchase genuine glucotrol xl line,000 col/mL generic 10 mg glucotrol xl free shipping. The antibiotic pattern of Urease = Neg Lysine decarboxylase = + resistance to carbenicillin and ampicillin is Phenylalanine deaminase = Neg characteristic for Klebsiella. A stool culture from a 30-year-old man suﬀering from bloody mucoid diarrhea gave the following 43. The biochemical tests Hektoen agar = green colonies; listed are necessary to diﬀerentiate Shigella from E. Tree blood cultures taken from a 30-year-old Answers to Questions 45–47 cancer patient receiving chemotherapy and admitted with a urinary tract infection grew 45. Given the following is commonly recovered from immunosuppressed biochemical reactions, which is the most likely patients. Yersinia enterocolita produces Ornithine decarboxylase = Neg non–lactose-fermenting colonies on MacConkey agar, salmon-colored colonies on Hektoen agar, and A. Klebsiella pneumoniae with a translucent border, can be confused with Microbiology/Evaluate laboratory data to make Aeromonas spp. To identiﬁcations/Gram-negative bacilli/3 diﬀerentiate, an oxidase test must be performed, 46. What is the most likely undercooked ground beef contaminated with fecal identiﬁcation of this gram-negative rod? Klebsiella pneumoniae Microbiology/Evaluate laboratory data to make identiﬁcations/Gram-negative bacilli/3 47. A 6-year-old female patient was admitted to the hospital following 2 days of severe diarrhea. Patient history revealed a hamburger lunch at a fast-food restaurant 3 days earlier. Yersinia enterocolitica Microbiology/Evaluate laboratory data to make identiﬁcations/Gram-negative bacilli/3 7. A Yersinia pestis is the cause of bubonic and pneumonic the axilla and groin lymph nodes. Bubonic plague causes swelling of the groin cultures were obtained, resulting in growth of lymph nodes (bubos), whereas pneumonic plague gram-negative rods resembling “closed safety involves the lungs. The transmission is from rodents (rats, Testing demonstrated a nonmotile rod that was ground squirrels, or prairie dogs) to humans by the biochemically inert. What is the most likely bite of ﬂeas (vectors) or by ingestion of contaminated identiﬁcation? Te majority of clinical laboratories with a available antisera for somatic “O” antigen 157 and microbiology department should have the ﬂagellar “H” antigen 7. However, Yersinia pestis isolates capability of serotyping which pathogenic should be sent to a public health laboratory for Enterobacteriaceae? Ingestion of contaminated tissue of a β-lactamase that hydrolyzes broad-spectrum D. Inhalation of contaminated airborne droplets antibiotics such as the cephalosporins as well as penicillin and monobactam antibiotics. Which isolates of the Enterobacteriaceae family strains are detected by demonstrating their resistance most commonly produce extended-spectrum to β-lactam antibiotics. Salmonella typhi and Shigella sonnei Microbiology/Apply knowledge of fundamental biological characteristics/Antibiotic susceptibility/2 7. Presumptive tests used for identiﬁcation of the Acinetobacter baumannii Pseudomonas spp. D Both organisms are oxidase positive, motile, and between Pseudomonas aeruginosa and produce pyoverdin. In addition to motility, which test best diﬀerentiates Answers to Questions 5–9 Acinetobacter spp. Alcaligenes is motile by peritrichous Identiﬁcation/2 ﬂagella and oxidase positive. C The two genera, Pseudomonas and Stenotrophomonas, and Stenotrophomonas maltophilia are: are motile and grow well on MacConkey agar. Which Pseudomonas is usually associated with a chronically infected with the mucoid strain of lung infection related to cystic ﬁbrosis? A nonfermenter recovered from an eye wound is types but is distinguished by biochemical tests and oxidase positive, motile with polar monotrichous susceptibility to the polymyxins. Pseudomonas diminuta personnel were infected with these bacteria during Microbiology/Apply knowledge of fundamental the 1960s and 1970s. Which biochemical tests are needed to diﬀerentiate Answers to Questions 10–13 Burkholderia cepacia from S. D The oxidase test and red pigment (pyorubin), as well Which is the most likely organism? The two organisms are Microbiology/Evaluate laboratory data to make very similar biochemically, but B. Both organisms are oxidase positive, grow on MacConkey agar, and are motile by 12. A specimen from a 15-year-old female burn other pseudomonads are inhibited along with related patient was cultured after débridement, and the nonfermentative bacteria. D All species of Acinetobacter are oxidase negative and Susceptible grow on MacConkey agar. Colistin (Polymixin B) = Susceptible produce yellow pigment (like Acinetobacter) but are oxidase positive and do not grow on MacConkey Tese results indicate which of the following agar. Acinetobacter lwoﬃi compound complexes with α-naphthylamine, forming a red product. Media containing nitrates are used for Microbiology/Evaluate laboratory data to make the identiﬁcation of nonfermenters. The diazonium compound detects oxidase positive, nonmotile, and does not grow on nitrite only, and the organism may have reduced the MacConkey agar is: nitrates to nitrogen, ammonia, nitrous oxide, or A. A 20-year-old horse groomer exhibited a produced orange-tan colonies on blood agar that “glanders-like” infection. Most of the biochemical tests Growth at 42°C = Neg were negative, including the cytochrome oxidase test. Te culture was plated on blood Mueller–Hinton agar (pyocyanin pigment) produced agar and MacConkey agar. This virulence factor allows highly resistant to most of the antibiotics tested for many nosocomial infections such as those of the except amikacin, tobramycin, and ciproﬂoxacin. Stenotrophomonas maltophilia is the causative agent of glanders in mules, donkeys, D. It is not part of the human skin ﬂora and the most likely transmission to humans is through Microbiology/Apply knowledge of laboratory data to broken skin. A Vietnam War veteran presented with a Answers to Questions 24–25 “glanders-like” infection (melioidosis). B Burkholderia pseudomallei infections often produce were positive for cytochrome oxidase, oxidized abscesses in organs (liver, spleen, lungs) as well as glucose and xylose, and grew at 42°C. The surfaces of rice paddies in Northern Thailand have a Microbiology/Apply knowledge for identiﬁcation/ high prevalence of this organism. Which atmospheric condition is needed to recover with diarrhea is suspected of being infected with Campylobacter spp. Select the best medium for recovery onto a Campy-selective agar at 35°C–37°C and identiﬁcation of this organism. A curved gram-negative rod producing Answers to Questions 1–4 oxidase-positive colonies on blood agar was recovered from a stool culture. In the test, a Microbiology/Evaluate laboratory data to make loopful of bacterial colonies is suspended in sodium identiﬁcations/Bacteria/3 deoxycholate, 0. Pseudomonas putida any but the most aerotolerant Campylobacter to Microbiology/Evaluate laboratory data to make survive. Cultures for Campylobacter should be identiﬁcations/Bacteria/3 incubated for 48–72 hours before reporting no growth. Which group of tests best diﬀerentiates Answers to Questions 5–8 Helicobacter pylori from C. Catalase, oxidase, and nalidixic acid sensitivity secretions and biopsies and has been implicated C.
Drug Enhancer Results Insulin Sodium glycocholate Absorption only in presence of enhancer (F 0 buy glucotrol xl 10 mg on line. An important consideration here is that osmotic-controlled devices require only an osmotic pressure to be effective purchase genuine glucotrol xl on line, thus such devices operate essentially independently of the drug formulation and also the surrounding environment buy generic glucotrol xl. Hence order glucotrol xl 10mg without a prescription, for oral delivery, changes in pH or ionic strength in the gastrointestinal tract will not affect the drug release rate. Thus, far less variability in drug release is achieved with this system, in comparison to traditional coating strategies. Relatively constant plamsa drug concentrations were achieved within 6 h and maintained for at least 24 hours (Figure 6. A two-fold improvement in cholesterol lowering efficacy was realized by using osmotic pump technology for the oral delivery of simvastatin. The colon can also be used as an absorption site for the delivery of drugs to the systemic circulation. Although absorption from the colon is generally considerably lower than from the small intestine, systemic drug delivery via the colon is associated with a number of advantages, including: • prolonged residence time, thus the drug is allowed prolonged contact with the absorbing surface; • relatively low enzyme secretion and low brush border enzyme activity, which makes it a particularly attractive site for the absorption of enzymatically labile drugs such as therapeutic peptides and proteins; • drugs absorbed from the proximal colon are delivered directly into the systemic circulation, avoiding hepatic first-pass effect. Some approaches, such as the use of sustained release formulations, enteric-coated dosage forms and osmotic pumps, were not 162 originally designed for colon-specific drug delivery. However, it is possible to increase the proportion of the drug delivered to the colon by modifying the original formulations. A further colonic drug delivery strategy involves the use of a prodrug which is metabolized by enzymes found only in the colon. An example is menthol-β-D-glucuronide, which is stable at various pHs and in the luminal contents of the rat stomach, proximal small intestine, and distal small intestine, but which undergoes accelerated hydrolysis in the rat cecum and colon. These prodrugs are relatively poorly absorbed in the upper gastrointestinal tract but are rapidly hydrolyzed into dexamethasone and glucuronic acid once in the colon. Specificity of colonic delivery in humans should be even greater due to lower levels of β-D-glucuronidase activity in the small intestine. Azoreduction is another important approach that has been used for targeted drug delivery to the colon. Classical examples include prontosil and sulphasalazine; on reaching the colon anaerobic bacteria reductively cleave the azo bond and release the active agent (sulphanilamide and 5-aminosalicylic acid, respectively) and a carrier moiety. Newer approaches include the development of an azo polymeric system, consisting of poly(2-hydroxyethylmethacrylate), poly(styrene) and the azoaromatic compound 4,4- divinylazobenzene, which is claimed to act as a cross-linker between the polymer chains. Azo polymer coated pellets and capsules have been shown to promote the oral administration of insulin and desmopressin in rats. Other azo polymer systems have demonstrated potential for the systemic delivery of vitamin B12 and ibuprofen. Hydrogels are aqueous gels, usually made of hydrophilic polymers, which are cross-linked either by chemical bonds or other cohesive forces such as hydrogen bonding, or ionic or hydrophobic interactions (see Chapter 16). Although insoluble in water, they are able to swell rapidly in water and retain large volumes of water in their swollen structures. Different hydrogels can afford different drug release patterns and the use of hydrogels to facilitate colonic delivery have been investigated. For example, hydrogels and xerogels have been prepared using a high-viscosity acrylic resin gel, Eudispert hv, which have excellent staying properties in the lower part of the rectum, over a fairly long period. These gels have demonstrated potential in potentiating the absorption of salicylamide and propentofylline, a new cerebral microcirculation- improving agent. The device comprises an impermeable capsule body fitted with a hydrogel plug (Figure 6. In aqueous media, the plug hydrates, swells and after a time period defined by the plug’s dimensions, is ejected from the device, thereby allowing a bolus drug release from the capsule. The device may be configured to target drug release to the colon by application of an enteric coat, which prevents hydration of the plug while it is in the stomach. Once in the small intestine, the enteric coating dissolves, thereby allowing plug hydration to take place. Plug ejection and therefore release from the capsule can be controlled to take place after transit through the small intestine and entry into the colon. First, the colonic epithelia are practically impermeable to all but low molecular weight lipophilic drugs; second, the transit time to the colon is long. A pharmaceutical preparation taken on an empty stomach is likely to arrive in the ascending colon about 5 hours after dosing, with the actual arrival dependent largely on the rate of gastric emptying. Drug delivery within the colon is greatly influenced by the rate of transit through this region. In healthy men, capsules and tablets pass through the colon in 20–30 hours on average. Solutions and particles usually spread extensively within the proximal colon and often disperse throughout the entire large intestine. In order to avoid the build- up of drugs from successive doses in patients with relatively slow colonic transit, the duration of drug release should be limited to about 15 hours. This will allow 5 hours for the formulation to reach the colon and 10 hours for the delivery in this region. Specialized antigen-presenting epithelial cells cover the patches, called M-cells (modified epithelial cells). Unlike the intestinal enterocytes, the M cells of the Peyer’s patches are capable of extensive endocytic uptake of macromolecules and microparticles (Figure 6. The efficiency of uptake is dependent on many factors, including: • Particle size: it would appear that particles of certain compositions in the size range 50–3,000 nm are capable of uptake by the Peyer’s patches and subsequent translocation through the lymphatics. Particles of 3–10 µm are often retained within the Peyer’s patches and do not subsequently move through the lymph. Microparticles taken up by the Peyer’s patches may migrate through the underlying lymphatics and ultimately reach the blood via the thoracic lymph duct. The mucosal surfaces of the intestinal, respiratory and urogenital tracts are the most common sites of pathogen entry, and over 90% of all infections are acquired by mucosal routes. However, effective vaccination at mucosal surfaces requires the localized production of secretory immunoglubulin A (sIgA). Parenteral vaccines, which induce predominantly immunoglobulin G and M responses in the blood (rather than sIgA 164 Figure 6. Attenuated M cells (M) extend as membranelike cytoplasmic bridges between the absorptive columnar epithelial cells present on either side (C). Beneath the M cell lies a small nest of intraepithelial lymphocytes (L) together with a central macrophage (Mac). The M cell provides a thin membrane-like barrier between the lumen above and the lymphocytes in the intercellular space below. This M cell has taken up the macromolecules and particulate matter that reach it and macrophages (Mac) may ingest them. In contrast, oral vaccines offer the ability to induce a local sIgA response and therefore offer greater efficiency than parenteral vaccines in the treatment of infectious diseases. Although the potential of microparticulates as drug/ vaccine delivery systems has thus far focused on the oral route of delivery, there is now increasing attention being paid to their potential for alternative mucosal routes, in particular, the nasal route and the vaginal route (see Section 11. The high prevalence of lymph node involvement in disease is due to the role of lymphatic tissue in the provision of the body’s immune response. However, the oral route may also prove to be important for the lymphatic uptake of lipophilic drugs and macromolecules. In addition to the treatment of diseases of the lymphatics, drug targeting to the lymphatics may be used to facilitate sustained release effects, as the drug must distribute from the lymphatics into the general circulation. Delivery into the systemic circulation following oral lymphatic delivery is also a means of avoiding first-pass liver metabolism. Strategies are being developed to selectively redirect drug absorption into the lymphatics. Formulation of drugs in lipid-based particles or oil increases lymphatic uptake, while macromolecules and colloidal particles may enter the lymphatic system through clefts in the terminal vessels or by pinocytosis. Oral delivery of lipophilic drugs to lymph nodes is associated with the transport of chylomicrons, which are formed following the absorption of lipid digestion products in enterocytes. The colloids accumulate in the mesentric lymph nodes after oral administration and the development of carriers with enhanced intestinal drug delivery may result in efficient drug transport to the abdominal lymph nodes. The oral bioavailability of propanolol was shown to increase when administered in oleic acid and other lipid media. It is thought that the oleic acid forms an ion-pair with the drug and the entire complex is incorporated into chylomicrons.
The study allows determination of vein compressibility as well as ﬂow characteristics discount glucotrol xl 10mg without a prescription. Veins that are incompressible with ﬁrm pressure applied by the ultrasound probe are considered thrombosed order discount glucotrol xl on line. Flow can be increased by distal compression and decreased by increasing intraabdominal pressure order glucotrol xl mastercard. There are no strict criteria to achieve the differentiation; however order 10 mg glucotrol xl mastercard, there are some “soft” signs that can be helpful. If the thrombus is acute, it generally is not echogenic on duplex and is relatively soft on compression. A randomized comparison of the clinical utility of real time compression ultra-sonography versus impedance plethysmography in the diagnosis of deep-vein thrombosis in symptomatic outpatiens. A new rapid assay currently is available to detect D-dimer, which is a speciﬁc derivative of cross-linked ﬁbrin that is released when ﬁbrin is lysed by plasmin. Its utility is questionable, however, if duplex ultrasonography is available readily. It is performed by placing a catheter into the pulmonary artery, usually via a femoral vein puncture, and injecting contrast into both lungs. Pulmonary embolism as a cause of death; the changing mortality in hospitalized patients. The study is invasive and has a signiﬁcant list of complications, includ- ing cardiac arrthymias, contrast reaction, and bleeding. Perfusion scans involve the injection of radiolabeled colloid into a peripheral vein, followed by scanning of the lung in several positions. This is followed by inhalation of a radiola- beled aerosol for the ventilation portion of the study. The scans are graded as normal, very low probability, low probability, intermediate probability, and high probability (Table 29. When the V/Q scan is intermediate probability, many physicians also obtain a lower extremity venous duplex scan. If that is positive, then the patient should be anticoagulated, if there are no contraindi- cations and no further testing is necessary. High probability ≥2 large (>75% of a segment) segmental perfusion defects without corresponding ventilation or roentgenographic abnormalities or substantially larger than either matching ventilation or chest roentgenogram abnormalities ≥2 moderate segmental (≥25% and £75% of a segment) perfusion defects without matching ventilation or chest roentgenogram abnormalities and 1 large mismatched segmental defect ≥4 moderate segmental perfusion defects without ventilation or chest roentgenogram abnormalities Intermediate probability (indeterminate) Not falling into normal, very low, low-, or high-probability categories Borderline high or borderline low Difﬁcult to categorize as high or low Low probability Nonsegmental perfusion defects (e. The Swollen Leg 519 Treatment Once the diagnosis of a venous thromboembolic event has been con- ﬁrmed and, occasionally, before it has been conﬁrmed and, if the index of suspicion is high, the patient should be anticoagulated. In addition to conventional anticoagulation, a small subset of patients may beneﬁt from thrombolytic therapy. Many patients have contraindications or relative contraindications to the use of thrombolysis that obviate their use. It is believed to be due to antibodies directed against platelet complexes with heparin. Response to warfarin is variable depending on the patient’s liver function, diet, age, and concomitant medications. Multiple studies have shown that starting warfarin therapy in addition to heparin is safe and effective. Warfarin has a long half-life, variable depending on the patient, and must be withheld for several days prior to any signiﬁcant intervention. The weight-based heparin dosing nomogram compared with a “standard care” nomogram: a randomized controlled trial. Comparison of subcutaneous low-molecular-weight heparin with intravenous standard heparin in proximal deep-vein thrombosis. Comparison of once-daily subcutaneous fragmin with continuous intra- venous unfractionated heparin in the treatment of deep vein thrombosis. Subcutaneous low-molecular-weight heparin compared with continuous intravenous unfractionated heparin in the treatment of proximal deep vein thrombosis. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. They have a predictable anticoagulant effect based on body weight, so that laboratory moni- toring is unnecessary. Acomparison of six weeks with six months of oral anticoagulant therapy after a ﬁrst episode of venous thromboembolism. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. Comparison of once-daily subcutaneous fragmin with continuous intravenous unfractionated heparin in the treatment of deep vein thrombosis. Subcutaneous low-molecular- weight heparin compared with continuous intravenous unfractionated heparin in the treatment of proximal deep vein thrombosis. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein throm- bosis. The most commonly performed surgical intervention is the placement of an inferior cava ﬁltration device. Most commonly, cava ﬁlters are placed for relative contraindications to anticoagulation or, increasingly, for pulmonary embolus prophylaxis for patients who cannot be anticoagulated safely. Simple procedures, such as high ligation of the greater saphenous vein at the saphenofemoral junc- tion, are reasonable for superﬁcial thrombosis of the greater saphenous vein. More signiﬁcant operations, such as iliofemoral venous thrombec- tomy or surgical pulmonary embolectomy, have a role, but fortunately they only rarely need to be employed. While the likelihood of this being the case is low in the absence of injury, stasis, or history of a hypercoagulable state, it would be reasonable to interrogate her venous anatomy with a venous duplex scan. Signs include venous telangiectasias, swelling, and varicose veins, as well as lipodermatosclerosis and venous ulceration. Lipoder- matosclerosis represents a constellation of skin changes, including thickening of the skin, hemosiderin deposition of the skin, and a dry scaly dermatitis of the skin. Treatment of venous thrombosis with intravenous unfractionated heparin in the hospital as compared with subcutaneous low- molecular-weight heparin administered at home. Risk factors associated with varicose veins may include prolonged stand- ing, heredity, female sex, parity, and history of phlebitis. The diagnosis of deep venous insufﬁciency generally is made clinically based on history and clinical exam. Various volumes of the leg are then calculated with the patient in several posi- tions (Fig. Particular attention currently is being paid to communicating veins, those that connect the deep and super- ﬁcial venous systems. Incompetence of the perforating veins has been implicated in the development of venous stasis ulcers. Typical recording of volume changes during a standard sequence of postural changes and exercise: patient in a supine position with the legs ele- vated 45° (a); patient standing with weight on the nonexamined leg (b); patient performing a single tiptoe movement (c); patient performing 10 tiptoe move- ments (d); patient again standing with weight on the nonexamined leg (e). Air- plethysmography and the effect of elastic compression on venous hemody- namics of the leg. Copyright © 1987 The Society for Vascular Surgery and The American Association for Vascular Surgery. With permission from The Society for Vascular Surgery and The American Associa- tion for Vascular Surgery. The Swollen Leg 523 Treatment Conservative, nonoperative, treatment for chronic venous insufﬁ- ciency has been and remains the primary therapy. This form of therapy generally focuses on decreasing lower extremity venous hypertension. Due to the limitation of bed rest and elevation, some form of com- pression is prescribed. The most common compression garment is a commercially made, graduated compression stocking that provides increased compression at the level of the ankle, but less compression as it ascends the leg. Patients with active venous ulceration can be treated with any of a number of layered compression dressings. The most common is the paste gauze dressing developed by the German dermatologist Paul Unna in 1896. The current Unna’s boot consists of dome paste dressing, containing calamine, zinc oxide, glycerin, sor- bitol, and magnesium aluminum silicate.
Associate Director Executive Director Hartford Dispensary Matrix Institute on Addictions Hartford purchase glucotrol xl without prescription, Connecticut Playa Vista discount 10 mg glucotrol xl visa, California Kimber P buy glucotrol xl with mastercard. Aaron Rolnick Redwood City purchase line glucotrol xl, California Executive Vice President Detroit Organizational Needs in Treatment Karl G. Detroit, Michigan Medical Director of Addiction Psychiatry Hampton Roads Clinic Andrew J. Hartford, Connecticut Professor Emeritus, Psychiatry University of Chicago Deborah Stephenson, M. Naperville, Illinois Central Valley Clinic San Jose, California 314 Appendix F Eric C. Professor Medical Director Department of Psychiatry and Behavioral San Joaquin County Sciences Office of Substance Abuse Johns Hopkins University School of Stockton, California Medicine Baltimore, Maryland W inifred Verse-Barry, Ph. Family Outpatient Services Director of Clinical Services Gateway Healthcare Habit Management Pawtucket, Rhode Island Boston, Massachusetts Charlotte L. See Health Insurance Portability and family involvement, benefits of, 133 Accountability Act Federal Regulation of Methadone Treatment, history Institute of Medicine study, 20 of co-occurring disorders, 55 financial issues, patient, 123ñ124, 139 criminal, 58 and principles of medical ethics, 301 drug and medication, 40 forms of dosage. See dosage forms employment, 59 funding issues, 7ñ8 medical, 50 military, 59 G of nonopioid substance use, 50 gateway drugs, 1, 14 of opioid addiction, 11 Gearing, Dr. See lesbian, gay, and bisexual patients diversion of, 159 liver over-the-counter, 48 effects on, 35ñ36 for patients with co-occurring disorders, 205 toxicity, 166 prescription, 48 liver disease take-home, 81ñ82 and hepatitis C, 168 medication-assisted treatment for opioid and liver transplant, 171 addiction. See naloxone challenge test mobile treatment units, 90 Narcotic Addict Treatment Act of 1974, 21, 25 models of care, 202 narcotics farms, 15 money management, 60 Narcotics Register, New York City, 16 monotherapy tablets, 69 Narcotic Treatment Programs: Best Practice morphine, 12ñ17 Guideline, 237 duration of action, 217 National Institutes of Health consensus panel and neonatal abstinence syndrome, 219 recommendations, 4, 20 and pain management, 174ñ175 necrotizing fasciitis, 163ñ164 motivational enhancement, 130 Neonatal Abstinence Score, 219 motivational interviewing, 53 neonatal abstinence syndrome, 216, 218ñ219 Motivational Interviewing: Preparing People and buprenorphine, 220ñ221 for Change, 130 and methadone, 219 motivation for seeking treatment, 54, 96, 107, nicotine, effects of, 185 191 and pregnancy, 212 multidisciplinary treatment team, 100 node-link mapping, 128 multiple substance use, 48, 106, 111 nonmalfeasance, principle of medical ethics, and co-occurring disorders, 181 298 and dosage adjustments, 187 nutrition, and pregnancy, 223ñ224 and increased drug testing, 188 Nyswander, Dr. See opioid treatment programs stages of, 65 outcome predictors, 3 phases of treatment, 101 overdose in pregnancy, 217 acute, 102ñ108 overdose risk, 65, 202 continuing-care, 119 oxycodone, 17, 83, 122, 151, 175 medical maintenance, 114ñ116 OxyContinÆ, 151, 217 rehabilitative, 108ñ113 supportive-care, 113ñ114 P tapering and readjustment, 116ñ119 transition between, 108, 119 pain management, 95, 112 physical examination, 50ñ51 for acute pain, 175 physicianís waiver. See waiver, physicanís, to and addiction, 7 dispense buprenorphine for chronic pain, 176ñ177 polysubstance abuse. See cocaine for suicidality, 203 Strategies for Developing Treatment Programs tools for, 194 for People W ith Co-Occurring Substance sedatives, nonbenzodiazepine, effects of, 184 Abuse and Mental Disorders, 189 selective serotonin reuptake inhibitors. See nicotine, effects of Improving Cultural Competence in tolerance to opioids, 12, 71 Substance Abuse Treatment (forthcoming), Tombs, the. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. The Keys allow you—the busy clinician or program administrator— to locate information easily and to use this information to enhance treatment services. It also exam ines related m edical, psychiatric, sociological, and substance use disorders and their treatm ent as part of a com prehensive m aintenance treatm ent program. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U. The information in this report is intended to help health care decision-makers; patients and clinicians, health system leaders, and policymakers, make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i. This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. We would like to offer special thanks to Mary Gauld, Maureen Rice, and Roxanne Cheeseman for assistance and guidance with project management and editorial help. The project would not be complete without their wisdom, experience, good will, and sense of humor. We acknowledge the hard work of Nicholas Hobson, our computer programmer, for creating our evolving systematic review management software. Our Technical Expert Panel provided valuable insights and challenges as well as ways to meet them. Our technical experts were David Bates, Doug Bell, Ken Boockvar, Chris Gibbons, Joy Grossman, Jerry Gurwitz, Joe Hanlon, Kevin Johnson, John Poikonen, Gordon Schiff, Bimla Schwarz, and Dennis Tribble. They represent a broad range of expertise and experience and the report is stronger because of them. Another group of experts who have been extremely helpful at improving the analyses of our data were our technical reviewers. Other expert reviewers were Anne Bobb, Elizabeth Chrischilles, Alan Flynn, and Kevin Marvin. We searched peer-reviewed electronic databases, grey literature, and performed ® ® ® hand-searches. Grey literature searching involved Internet searching, reviewing relevant Web sites, and searching electronic databases of grey literatures. Randomized controlled trials and cohort, case-control, and case series studies were independently assessed for quality. All data were abstracted by one reviewer and examined by one of two different reviewers with content and methods expertise. After duplicates were removed, 32,785 articles were screened at the title and abstract phase. Of these, 361 met only content criteria and were listed without further abstraction. Substantially more studies, and studies with stronger comparative methods, evaluated prescribing and monitoring. Other health care professionals, patients, and families are important but not studied as thoroughly as physicians. Hospitals and ambulatory clinics were well-represented in the literature with less emphasis placed on long-term care facilities, communities, homes, and nonhospital pharmacies. Most studies evaluated changes in process and outcomes of use, usability, and knowledge, skills, and attitudes. We found little data on the effects of forms of medications, conformity, standards, and open source status. Much descriptive literature discusses implementation issues but little strong evidence exists. Discuss Gaps in Research, Including Specific Areas That Should Be Addressed and Suggest Possible Public and Private Organizational Types To Perform the Research and/or Analysis........................ To What Extent Does the Evidence Demonstrate That Health Care Settings (Inpatient, Ambulatory, Long-Term Care, etc. Research Design for studies across the Phases of Medication Management and Education and Reconciliation................................................................................................... Settings for the Phases of Medication Management and Reconciliation and Education............................................................................................................................ Clinicians Evaluated in Outcomes Studies of Medication Management Phases, Education, and Reconciliation.................................................................................................. Research Design for Studies Across the Phases of Medication Management and Education and Reconciliation....................................................................................................... Settings for the Phases of Medication Management and Reconciliation and Education................................................................................................................................ Clinicians Evaluated in Outcomes Studies of Medication Management Phases, Education, and Reconciliation...................................................................................................... Patients and Caregivers Studied by Phase of Medication Management and Education and Reconciliation........................................................................................................................ Summary of the Number of Studies Reporting Statistically Significant Process Changes in Studies of Prescribing by Process for Hospital and Ambulatory Based Studies...................... Summary of the Number of Statistically Significant Process Changes in Studies of Order Communication by Process for Hospital and Ambulatory Based Studies......................... Study Designs Used in Studies Measuring Intermediate Outcomes Across the Phases for Medication Management.........................................................................................................