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McLellan and coworkers (1999) described a Cognitive and Behavioral system with an active case management compo- Therapies nent to help patients access services for hous- Other interventions order cheap viagra super active line psychological reasons for erectile dysfunction causes, both in use and under ing quality 50mg viagra super active erectile dysfunction caused by anabolic steroids, medical care, and legal and parenting study, include cognitive-enhanced techniques to assistance. Six months after the systemís imple- increase treatment participation, modify mentation, patients receiving these services behavior, and address patientsí social, emo- showed greater reduction in alcohol use and tional, and behavioral problems, as well as any improvement in medical conditions, family co-occurring disorders. The consensus panel aspects of their lives that reinforce abstinence believes that substance abuse and addiction and to understand how these reinforcers can involve major learning elements and are influ- serve as alternatives to substance use. This approach is useful for thoughts, actions, and feelings and their sub- treatment planning because it sets concrete stance use and to increase patient participation goals and emphasizes positive behavioral in counseling (Czuchry and Dansereau 2003). Patients with poor attention more effective than negative, punishing contin- stamina were found to have greater success in gencies or threats (Gruber et al. In one study, a balance of posi- Less educated patients exposed to mapping- tive and negative reinforcements, as part of a enhanced counseling also had better 12-month well-constructed contingency management followups than those in standard counseling plan, helped patients reduce their drug use (Pitre et al. Tangible rewards, such as colleagues, ìThe use of node-link mapping take-home medication privileges, should be appears to reduce cultural, racial, and class paired with social reinforcements, such as barriers by providing a visual supplement and praise from the counselor or other patients, to a common language that enhances counselorñ optimize their value. For example, a nega- tive drug test result might earn one take-home medication dose (other treatment and program variables must be taken into account, including Federal and State regulations). Other incentives may include special gressive muscle relaxation and desensitization, scheduling for medication administration, meal contingency management had a demonstrated vouchers, gift certificates, entertainment tick- record of effectiveness, whereas systematic ets, or toys for patientsí children. Designing desensitization alone was less effective in such programs requires significant effort, yet eliminating opioid use but reduced fear of with- the rewards can add an important dimension to drawal and general anxiety (Piane 2000). They used gram of motivational stepped-care levels in take-home medication privileges to increase which clear contingencies were matched with the involvement of significant others and treatment responses. They also poorly were moved to a more intensive level of used behavior-contingent treatment availability care. Those who responded well received less to improve drug test results and counseling intensive care. In another study comparing should be defined clearly and implemented con- contingency vouchers (which had monetary sistently. Contingencies may be individualized value and were exchangeable for goods and ser- based on each patientís targeted areas of vices) with methadone dosage increases, both behavioral change or implemented on a uni- incentives increased negative drug test results, form, programwide basis. Tailoring behavioral but only contingency vouchers increased dura- contingencies to patientsí needs has been found tions of drug abstinence (Preston et al. Piane Dosage increases should be based on evidence (2000) effectively combined contingency incen- of withdrawal symptoms and other medical tives with systematic desensitization for patients assessments, not good behavior. Providing Com prehensive Care and M axim izing Patient Retention 129 The consensus panel emphasizes that, when to resolve chronic psychological and social contingency management is used to control use problems. Another should have more specialized training than valuable guide is Motivational Interviewing: those responsible for drug-focused counseling. Preparing People for Change (Miller and Psychotherapists should possess advanced Rollnick 2002). Both counseling and psy- tured and focus on interpersonal-relationship chotherapy can be short term and solution building, self-insight, reflection, and discussion directed, but psychotherapy more often is used (Vannicelli 1992). This might involve their acquiring job skills, developing hobbies, or rebuilding relationships. Group treatment can treatment of sexual abuse for patients during provide a sense that individuals are not alone substance abuse treatment. A helpful, straightforward handbook for seling, it should develop referral relationships patients is About Methadone (Lindesmith for outside diagnosis and treatment. Strategies to engage these patients in treatment ï Effects and side effects of addiction treatment are described in chapter 6. Both cravings types of education may involve presenting infor- ï Developing nonñdrug-related leisure activities mation about substance abuse and addiction to patients alone, in groups, or with their families. Question assumptions about alcohol and drug use, and clarify that such use undermines recovery. Involvem ent Holding sessions for several families can be cost The consensus panel believes that family effective, supportive, and mutually beneficial. The concept of ìfamilyî tion and allow participants to express their feel- should be expanded to include members of the ings and concerns. These continuing forums help secure family support for patient treatment and identify acute family problems needing focused therapy. Nunes and colleagues (1998b) staff and reserved for families with serious recommended that treatment providers ask problems with behaviors or attitudes that about the mental health and adjustment of contribute to patientsí addictions, which, if patientsí children and consider routine psychi- unchecked, might affect recovery. Dawe and referrals to community-based services often are colleagues (2000) reported improved needed, and the consensus panel urges that parentñchild relations and positive outcomes such connections be established. Family therapy for children with conduct problems after may be more effective for some patients than behavioral training that provided their parents individual counseling, group therapy, or family with improved parenting techniques. Child assessment stable, treatment focus on concerns about cus- requires trained personnel and may be unreal- tody, children, and parenting. A counselor who determines that Psychodynamic parenting groups take a more a patient is neglecting or abusing young children intensive approach, exploring topics such as is required to report the neglect or abuse. Counselors should incorporate appropriate assessment procedures, referrals, or treatment responses for violence. They might have to help Peer Support, or M utual-Help, patients remove themselves from dangerous situ- Program s ations. Counselors should have a broad view of domestic violence that includes female (to male) The most popular, widely used mutual-help aggression, same-sex physical and emotional models are 12-Step recovery programs, such abuse, and issues related to elder abuse. They are sources for social provide general didactic groups or seminars and support, peer identification, relapse preven- other resources addressing domestic violence. Members of sup- port groups gain strength and security from others who understand and share their con- Integrative cerns and who offer practical strategies for surviving ìone day at a time. Some patients, unable to handle rejection, have chosen not to return, others have chosen prematurely to taper from maintenance medication, and some have used this diffi- culty as justification to self-medicate. For information, contact the National Alliance of Methadone Advocates (212-595-6262 or www. Other Approaches Decreases in substance abuse among group participants have been associated with attend- In acupuncture, thin needles are inserted ing meetings frequently, obtaining a sponsor, subcutaneously at points on the body for thera- ìworkingî the 12 Steps, and leading meetings peutic purposes. Some believe that acupunc- (American Psychiatric Association 1995, 1996; ture can relieve pain, anxiety, and withdrawal Landry 1997). However, 12-Step groups are symptoms related to substance abuse, although not for everyone. Its use to treat opioid with- Patients should not be pressured to attend sup- drawal was first reported in 1973. Resistance to attendance should However, a National Institutes of Health be discussed and respected. Every effort consensus statement lists addiction as one con- should be made to help a patient find an dition for which acupuncture treatment might appropriate peer support program. Although the mechanism of acupunc- ative strategies have evolved to promote ture is not understood, some researchers have mutual-help programs, such as simulated meet- focused on the analgesic effects of opioid pep- ings to introduce patients to the language, cus- tides released during the procedure (National toms, and rules of groups. A useful manual is Relapse strategy to ensure that a severe relapse is Prevention W orkbook (Daley 2002). Relapse Prevention Strategies for M ultiple Substance Use Education about relapse is a key part of treat- Patients who abuse multiple substances may ment. Educational approaches should teach require modified relapse prevention strategies.

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In a patient with Factor deficiency/3 dysfibrinogenemia viagra super active 25mg lowest price erectile dysfunction doctors in pittsburgh, fibrinogen is not polymerized 3 buy genuine viagra super active on-line relative impotence judiciary. X Hemostasis/Evaluate laboratory data to recognize health and disease states/Factor deficiency/3 53 54 Chapter 2 | Hemostasis 7. Von Willebrand’s disease is a disorder disorders is most consistent with these results? Hypofibrinogenemia of the patient’s plasma to correct any specific Hemostasis/Correlate clinical and laboratory data/ factor-deficient plasma. Each laboratory patient’s plasma is mixed with: should calculate its own normal ranges based on A. Normal control plasma Hemostasis/Apply principles of basic laboratory procedures/Coagulation tests/2 2. Which of the following is associated with an Answers to Questions 13–19 abnormal platelet aggregation test? Therefore, Which of the following disorders may be in von Willebrand’s disease (deficiency or functional indicated? In primary fibrinolysis, the fibrinolytic Hemophilia/2 system is activated and fibrin monomers are normal. Fibrinogen deficiency against the phospholipid-dependent coagulation Hemostasis/Correlate clinical and laboratory data/2 factors. An inherited disorder of coagulation healing and may cause severe bleeding problems. Fletcher factor (prekallikrein) deficiency may be Answers to Questions 20–23 associated with: A. One of the complications associated with a severe such as hemarthrosis (bleeding into the joints). Immune-mediated thrombocytopenia subtype 1, and 70%–80% of these cases are Hemostasis/Apply knowledge of fundamental biological associated with mild bleeding. Subtype 3 involves characteristics/Hemophilia/1 the total absence of the von Willebrand’s molecule and is associated with severe bleeding. Te most common subtype of classic von and 2B result in deficiency of intermediate and/or Willebrand’s disease is: high molecular weight portions of the von Willebrand A. It is a cofactor of heparin important naturally occurring physiological inhibitor D. They are either directed circulating anticoagulant is: against a specific clotting factor or against a group of A. D The lupus anticoagulant interferes with phospholipid-dependent coagulation assays 4. Phospholipid-dependent assays present in human milk; it is not recommended for pregnant and lactating women. Which statement about Coumadin (warfarin) is Antithrombin is a heparin (not warfarin) cofactor. D Heparin is a therapeutic anticoagulant with an Hemostasis/Correlate clinical and laboratory data/ antithrombin activity. Which combination of the tests is Quantitative fibrinogen assay, however, is not expected to be abnormal? Hemostasis/Correlate clinical and laboratory data/ Aspirin is another antiplatelet drug that inhibits Heparin therapy/3 platelet aggregation by blocking the action of the 10. Prasugrel protein that accelerates protein C activation Hemostasis/Correlate clinical and laboratory data/ 1,000-fold by forming a complex with thrombin. What test is commonly used to monitor warfarin Heparin inhibits thrombin, and therefore, causes a therapy? Ecarin time other vitamin K–dependent proteins such as proteins Hemostasis/Correlate clinical and laboratory data/ C and S. What clotting factors (cofactors) are inhibited by warfarin therapy for prophylaxis and treatment of protein S? C Urokinase is a thrombolytic drug commonly used to Clotting factors/2 treat acute arterial thrombosis. C The International Society of Hemostasis and Terapies/2 Thrombosis has recommended four criteria for the 16. Diagnosis of lupus anticoagulant is confirmed by diagnosis of lupus anticoagulant: (1) a prolongation which of the following criteria? Neutralization of the antibody by high corrected); (3) evidence that the inhibitor is directed concentration of platelets against phospholipids by neutralizing the antibodies D. B Lupus anticoagulant interferes with phospholipids in with the presence of lupus anticoagulant? Trombocytosis/thrombosis in a bleeding tendency unless there is a coexisting Hemostasis/Correlate clinical and laboratory data/ thrombocytopenia or other coagulation abnormality. Can be used as a fibrinolytic agent young age Hemostasis/Apply knowledge of fundamental biological D. Which of the following tests is most likely to be abnormal in patients taking aspirin? It prevents platelet Hemostasis/Correlate clinical and laboratory data/ aggregation by inhibition of cyclo-oxygenase. Inhibitors/2 Aspirin has no effect on the platelet count, platelet morphology, or prothrombin time. C Up to 22% of patients taking aspirin become resistant Aspirin resistance/2 to aspirin’s antiplatelet effect. C Laboratory tests for evaluation of thrombophilia are Antithrombotic therapy/2 justified in young patients with thrombotic events, in patients with a positive family history after a single thrombotic event, in those with recurrent spontaneous thrombosis, and in pregnancies associated with thrombosis. Decreased levels of prothrombin in plasma/ Hemostasis/Apply knowledge of fundamental biological thrombosis characteristics/Inhibitors/1 D. Increased levels of prothrombin in plasma/ bleeding Answers to Questions 25–30 Hemostasis/Correlate clinical and laboratory data/ Prothrombin/3 25. B Prothrombin G20210A is defined as a single-point mutation of the prothrombin gene, resulting in 26. Factor V Leiden promotes thrombosis by increased concentration of plasma prothrombin preventing: and thereby a risk factor for thrombosis. The thrombotic episodes generally occur Hemostasis/Correlate clinical and laboratory data/ before age 40. What is the approximate incidence of factor V gene that inhibits factor Va inactivation by antiphospholipid antibodies in the general protein C. D Currently, the platelet aggregation test is considered Hemostasis/Apply knowledge of fundamental biological the gold standard for evaluation of aspirin resistance. Which of the following laboratory tests is helpful no effect on platelet count and morphology.

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Peripheral vein nutrition is a less optimal form of feeding in that adequate caloric support cannot be achieved except in unusual circumstances order viagra super active toronto sleeping pills erectile dysfunction. Consequently purchase viagra super active 25mg on line treatment of erectile dysfunction in unani medicine, it is seldom used except where there are no other options or during the transition phase to full enteral feeding status. Complications of Parenteral Feeding: Tolerance to parenteral feedings should be evaluated throughout the course. In that acute parenteral nutrition is most common in patients who are critically ill, considera- tion always must be given to fluid status as well as glucose intolerance and electrolyte abnormalities. An acute shift toward anabolism may unmask preexisting body electrolyte deficiencies (see Monitoring Progress and Complications, below. Abnormalities of acid–base balance also occur more frequently in such patients, and alterations in electrolyte compo- sition (such as acetate salts) of solutions may be indicated. As always, patients with indwelling catheters must be monitored carefully for 58 S. An abrupt change in glucose tolerance may indicate infection related to the catheter or another source. Problems Related to Access These problems can be life-threatening and include misadventures related to placement of enteral or parenteral feeding portals. Acute pneumothorax, inadvertent arterial puncture, air embolism, and per- foration of the vena cava or heart can accompany attempts at central venous access. Insertion of catheters by experienced personnel serves to minimize these complications. More frequently, however, it is the initial misplacement of the catheter or latent events such as insertion-site infection or vessel thrombosis that provide troubling morbidities to patients. These complications are monitored by a rigorous adherence to sterility guidelines and protocols and by regular physical examination of the patient. A constant awareness of the potential for these events promotes early intervention and treatment. Problems related to placement of enteral feeding portals arise with similar, if not greater, frequency. Although it is increasingly popular to return to intragastric feeding, proper tube placement and function also must be assured. Problems of aspiration, especially in patients prone to reflux, may preclude this route of enteral nutrient provision. Under such circumstances, the placement of small-bore feeding catheters either transgastrically or transcutaneously requires experienced per- sonnel. As noted above, enteral feeding tubes may cause abdominal distention or symptoms that must be investigated. Careful, daily physical examination is an essential component of the monitoring regimen. Problems related to access portals as well as organ dys- function and fluid imbalance may be detected initially, or solely, on this basis. A determination of red blood cell indices may help to define iron deficiency (not routinely provided in intravenous nutrition). Eval- uation of basic bleeding parameters is undertaken to detect the pres- ence of vitamin K deficiency, which also may develop in parenterally fed patients. Trace mineral deficiencies may be a latent problem, especially in patients with preexisting malnutrition and prolonged inflammatory conditions. Attention should be given to patients with previous compromise of intestinal absorption. Problems of Excess Significant changes in overall clinical status as well as specific organs may provoke a state of excess provision. At least daily evalua- tion of glucose tolerance, by blood or urine sampling, is indicated in all patients. An abrupt increase in glucose levels in an otherwise stable patient must suggest infection until proven otherwise. Glucose excess also may precipitate or aggravate pulmonary prob- lems in some patients. If the rate of endogenous glucose oxidation is exceeded, carbon dioxide retention may result in respiratory distress or weaning problems in ventilated patients. Other evidence of nutrient excess occurs during conditions of evolv- ing organ dysfunction. A reduction in volume and nitrogen load as well as evaluation of electrolyte tolerance may be indicated. Under such circumstances, a reduction in nitrogen load or alteration in amino acid formulation may be indicated. Some patients may require liquid diets as a transition to solid food, but this does not necessitate an interruption of the tapering schedule. In patients who have been receiving supplemental insulin, peripheral low-dose dex- trose infusions minimize the chances of hypoglycemia. This decision requires input from several sources, including family and home healthcare agencies as well as social work and nursing professionals. Nutrition Support in the Surgery Patient 61 juncture, particularly if the patient does not steadily recover from her injuries. A prospective, randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma. A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Immediate postoperative enteral feeding results in impared respiratory mechanics and decreased mobility. To understand the normal electrolyte composition of body fluids and how they are modified by injury and surgical disease. To recognize the clinical manifestation of common electrolyte abnormalities and methods for their correction. Case 2 A 40-year-old woman presents with a 1 week history of persistent upper abdominal pain in association with nausea and vomiting. Physical examination is unrevealing except for loss of skin turgor and reduced breath sounds over the right chest. Case 3 A 58-year-old woman presents with a 1-week history of confusion, lethargy, and persistent nausea. Introduction An understanding of changes in fluid, electrolyte, and acid–base con- cepts is fundamental to the care of surgical patients. These changes can range from mild, readily correctable deviations to life-threatening abnormalities that demand immediate attention.

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Exclude - Not a Primary Study National/international technology guide white paper buy 100mg viagra super active with visa best erectile dysfunction doctor in india. Exclude - Not a Primary Study Percentage of alerts or reminders that resulted in desired action proven viagra super active 50 mg erectile dysfunction treatment natural remedies. Exclude - Not a Primary Study E-26 Prescribing patterns of preferred or formulary medications. Exclude - Not a Primary Study Public governance models for a sustainable health information exchange industry. Exclude - Not a Primary Study Reduction in hospital-acquired complications and infections. Exclude - Not a Primary Study E-27 Standards on verbal orders rank high among common compliance problems. Exclude - Not a Primary Study Study finds benefits in ‘paperless’ hospitals: ‘patients appear safer and hospital bottom lines may imrpove’. Exclude - Not a Primary Study Technological advances in adherence interventions are not expected panacea. Exclude - Not a Primary Study Technology, government incentives drive electronic prescribing. Exclude - Not a Primary Study E-28 Universal patient floor increases patient flow, decreases handoff, improves patient safety. Exclude - Not a Primary Study Consider human factors engineering when designing your patient safety projects. Exclude - Not a Primary Study Federal government’s paperless requirements come with many Practical benefits. Exclude - Not a Primary Study E-30 Follow-up calls help patients adhere to treatment plan, avoid readmissions. Exclude - Not a Primary Study Health system sets ‘zero errors’ as its goal for patient safety, quality. Exclude - Not a Primary Study State e-health activities in 2007: Findings from a state survey. Patient’s medication information and e-Health development in Finland: A case study of a Finnish primary care organization. Understanding implementation: The case of a computerized physician order entry system in a large Dutch university medical center. Same systems, different outcomes: Comparing the implementation of computerized physician order entry in two dutch hospitals. Evaluation of the performance of drug-drug interaction screening software in community and hospital pharmacies. Evaluation of a computer-assisted method for individualized anticoagulation: Retrospective and prospective studies with a pharmacodynamic model. Designing a patient care medication and recording system that uses bar code technology. Feasibility and acceptability to patients of a longitudinal system for evaluating cancer-related symptoms and quality of life: pilot study of an e/Tablet data-collection system in academic oncology. Safe medication practices compared at a teaching hospital and a community hospital. Using the electronic medical record to predict the pharmacological management of acute myocardial infarction The University of UtahEditor. Problems and some solutions in adapting clinical practice guidelines for asthma patient management into a computerised management system. Medical informatics in the intensive care unit: overview of technology assessment. Implementation of computerized chemotherapy provider order entry in veterans affairs medical center and its role in a three tier check system. Implementation of computerized chemotherapy provider order in veterans affairs medical center and its role in the three tier check system. Personal health information management and the design of consumer health information technology: Background report. A randomized comparison of a computer-based dosing program with a manual system to monitor oral anticoagulant therapy. A computer generated induction system for hospitalized patients starting on oral anticoagulant therapy. Cost effectiveness of telemedicine for the delivery of outpatient pulmonary care to a rural population. Experiences from the use of data-driven decision support in different environments. International Journal of Advanced Pervasive and Ubiquitous Computing 2009;1(3):42-60. Monatsschrift Kinderheilkunde 1993;Organ der Deutschen Gesellschaft fur Kinderheilkunde. Six generations of the insulin dosage computer: a new clinical device for diabetes self-management through specialized centres. The impact of initiatives in education, self- management training, and computer-assisted self-care on outcomes in diabetes disease management. Averting iatrogenic hypoglycemia through glucose prediction in clinical practice: Progress towards a new procedure in diabetes. Integration of a pharmacy based anticoagulation parameter into a medical group quality scorecard. Acceptability of computerized physician’s drug prescription in Grenoble Teaching Hospital, France: Survey of 44 prescribers. Electronic transmission of drug-ordering from wards to clinical pharmacies by intra­ or internet. Improving medication safety in a community hospital: Identifying medication errors/near misses and developing policies for high-risk medications. The effect of the controlled entry of electronic prescribing and medicines administration on the quality of prescribing, safety and success of administration on an acute medical ward. Clinical information technologies and inpatient outcomes a multiple hospital study. Electronic prescribing systems in pediatrics: the rationale and functionality requirements. Exclude - Not a Primary Study American Hospital Association, American Society of Health-System Pharmacists, Hospitals & Health Networks. Exclude - Not a Primary Study American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Optimizing the prevention of venous thromboembolism: recent quality initiatives and strategies to drive improvement. The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review. Measuring nurses’ time in medication related tasks prior to the implementation of an electronic medication management system.