Mark Corson

By Z. Sinikar. University of Dallas.

These data are inconsis- Services should be woman centered and tent with product labeling imuran 50mg overnight delivery, which advises directly address traumatic events 50mg imuran fast delivery. The array of against breast-feeding in mothers treated with services may include buprenorphine or the buprenorphine-naloxone ï Special groups to address problems of preg- combination generic imuran 50mg overnight delivery. Based on research data, particu- nant women who are opioid addicted larly findings that buprenorphine is likely to be poorly absorbed by infants via the oral route, ï Available treatments for women addicted to the consensus panel recommends that women opioids, including pharmacotherapies maintained on buprenorphine be encouraged to ï Education and discussion groups on parent- breast-feed because of the benefits to infants ing and childcare and motherñchild interaction. The panel rec- ï Special groups and services for children and ommends more research, particularly to con- other family members firm that infants absorb little buprenorphine ï Couples counseling during breast-feeding. Pregnant women who are opioid addicted need comprehensive treatment services, including Psychosocial Barriers individual, group, and family therapy to address both the physiological and psychologi- W omen addicted to opioids typically face finan- cal effects of substance use and psychosocial cial, social, and psychological difficulties that factors. Guilt and associated with domestic violence, financial shame coupled with low self-esteem and self- support, food, housing, and childcare issues efficacy can produce behaviors difficult for can be overwhelming to women in recovery and some staff members to tolerate, such as late- should be addressed. Services should be aimed at eliminating should be provided in a gender-specific, non- substance use, developing personal resources, punitive, nonjudgmental, nurturing manner, improving family and interpersonal relation- with attention to each patientís fears and cul- ships, eliminating socially destructive behavior, tural beliefs (Kaltenbach et al. A related ment strategies offering positive reinforcement series of controlled, randomized studies (Jones for behavioral change have been effective in et al. In pregnant abstinence from substances and strengthening women maintained on methadone, low-value behaviors such as compliance with treatment incentives did not influence substance use plans and participation in vocational training (Jones et al. It is notewor- Carroll and colleagues (1995) compared the thy that interventions treatment. The group receiving enhanced treatment had better neonatal outcomes, but the two groups did not differ in percentages of Nutrition Assessm ent, positive drug tests. The authors attributed these results primarily to more frequent prena- Counseling, and tal care in the contingency management group. Assistance However, results of the study were limited by the small sample size (seven women in each People with substance use disorders often are group), the inability to discern which compo- poorly nourished. Substances themselves may nents contributed to improved outcomes, and impair usersí metabolism, interfere with nutri- use of a demanding contingency procedure that ent availability, and affect appetite. Their school-age have wholesome, well-balanced diets consistent children also might qualify for school breakfast with their ethnic or cultural backgrounds and and lunch programs, as well as summer food financial situations. Information about the members who facilitate a nutrition education Federal W omen, Infants, and Children pro- program. Managers are responsible for keeping staff members focused Medication on patient care and improved treatment outcomes. Managers should set clear staff guidelines, supply the needed resources, and create a culture that nurtures professional growth The Community and staff retention. In ment should recruit employees who reflect [A]dministrators addition, staff mem- patient demographics and should consider bers should main- hiring people who are recovering from addic- should recruit tain appropriate tion (see below). People working with diverse groups should remember that diversity also exists within cul- Transference and tures. It is important to be sensitive to cultural ally competent countertransfer- differences but to avoid acting on cultural ence. Understanding both a patientís people; offer with addictions cultural influences and his or her individuality project feelings or requires taking time to know the patient. Correctly identifying such factors Countertransference requires an effort to see the world through each supervision and occurs when treat- patientís eyes. Information on cultural compe- ment providers pro- tence and diversity is available at W eb sites of ongoing training. Sterling and col- urineî to describe an unsatisfactory urine drug leagues (2001) noted the existence of ìequivocal test (ìpositive testî is less judgmental). Staff findings of the effect that therapist and patient should avoid terms suggesting the criminal similarity plays in treatment outcomeî (p. The consen- Federal and State resources are available for sus panel believes that employing treatment programs seeking literature in languages other professionals and support staff who are in than English. Community colleges, universities, recovery also adds valuable perspectives to and other institutions or agencies might assist treatment and provides role models for in translating forms and pamphlets. State regulations may estab- lish a minimum abstinence period before an Flexibility in thinking, behavior, and attitudes. Staff biases, are not judgmental, and do not have members who are in recovery and their col- punitive attitudes toward patients (Bell 2000). At least Staff Retention one study has associated such attitudes with Retaining staff is important for several reasons: lower rates of patient retention and poorer patient outcomes (Caplehorn et al. Staff members can experience permitting staff members to attend offsite burnout when they work in isolation with training during work hours. Managers should take concrete steps ï Encourage professional development by to retain staff, including the following: supporting staff certifications. Even the most ï Offer routine praise and recognition for staff professional, committed counselor struggles contributions and achievements. Staff members usually feel less isolated and overwhelmed Training when a team makes treatment decisions. W hen a lack of cohesion exists, staff members Training should be offered for all staff mem- risk burnout, disillusionment, or cynicism. A bers, including secretaries, nurses, counselors, well-coordinated team also reduces the level supervisors, and managers, to ensure a strong of intrastaff disagreements about patient care knowledge base so that staff members do their and decreases the likelihood of ìstaff split- best and to affirm that all staff members are ting,î when patients pit staff members against valued members of the treatment team. Managers should sional staff members acquire education credits hold regular staff meetings. Staff cooperation to maintain their licensure by offering onsite also can be fostered through training and training, collaborating with other agencies for retreats. The program director or manager reciprocal training, or paying for educational should mediate disputes among staff members.

Realization of an assisted system for medical decision and follow-up in hematologic diseases treated with sequential chemotherapy imuran 50mg lowest price. Work activities before and after implementation of an automated dispensing system buy discount imuran 50mg. Pharmaceutical care implementation with computerized interventions in a tertiary care teaching facility: Canadian approach discount imuran 50mg otc. Exclude - Not a Primary Study E-143 Gugerty B, Wooldridge P, Coleman S and others. Computerized physician order entry: Paradigm shift in pharmacy practice in a tertiary care teaching hospital. Using telemedicine technology for pharmaceutical services to ambulatory care patients. Drug effectiveness reporting and monitoring systems: Discussion and prototype development. Computerized decision support in drug prescribing I: Better survey of patients’ medications yields better quality of care. Designing a medication-administration system for the smallest patients was a huge challenge. Focusing on food and fitness: State strategies for healthy communities and economic development. A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting. Depression affects adherence measurement but not the effectiveness of an adherence intervention in heart failure patients. Impact of barcode medication administration on medication safety: Importance of adherence and ongoing monitoring to sustain improvements. A proposed model for an internet-based computerised anticoagulant monitoring system. Unintended consequences of information technologies in health care: An interactive sociotechnical analysis. Impact of an electronic medication administration record and bar code scanning system on the accuracy of medication administration in hospitalized patients. Decision support systems and communication in medicine at the University of Limburg. Computerized physician order entry: Veterans Affairs Health Care System experience. An intravenous medication safety system: preventing high-risk medication errors at the point of care. Development of a patient medication instruction provision system which reflects the doctor’s prescribing intentions. Electronic prescription for controlled substances - New prescribing option to benefit prescriber, pharmacist and patient. Using health information technology to improve drug monitoring: a systematic review. Using intranet-based order sets to standardize clinical care and prepare for computerized physician order entry. Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of beta- blockers: A randomized trial. Development and implementation of the medication module of a hospital ward information system using a pen- based computer. Implementation of an interactive computer- assisted infection monitoring program at the bedside. Using a clinical decision support system to determine the quality of antimicrobial dosing in intensive care patients with renal insufficiency. Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. Effect of computerisation on Australian general practice: does it improve the quality of care? Information system issues facing clinical laboratories serving complex integrated delivery systems. Utilizing a point of care documentation system for increased medication administration accuracy. Evaluation of pharmaceutical interventions due to drug-related problems in hospitalized patients. Influence of simple computerized feedback on prescription charges in an ambulatory care: A randomized clinical trial. The effect of computerized feedback coupled with a newsletter upon outpatient prescribing charges: A randomized controlled trial. Online--an Internet-based decision tool for adjuvant chemotherapy in early breast cancer. A prospective randomised trial comparing individualised pharmacokinetic dosage prediction for aminoglycosides with prediction based on estimated cratinine clearance in critically ill patients. Implementing technology to improve medication safety in healthcare facilities: a literature review. Estimation of the supporting functions for prescription making in an order entry system. Contribution to medical risk management of computerized prescription order entry systems - Improvement of master maintenance system using a commercially available order entry program. Electronic prescribing influence on calcium supplementation: a randomized controlled trial. Implementation and evaluation of a comprehensive system to deliver pediatric continuous infusion medications with standardized concentrations. Electronic medical record use by office-based physicians and their practices: United States, 2006.

De gerapporteerde procedure in combinatie met de gestelde wettelijke criteria voor relatieve ion-intensiteiten resulteert in een krachtige techniek om de onzekerheid van de bevestigingsanalyse te bepalen generic imuran 50mg free shipping, zodat het risico op een vals-positief resultaat beperkt wordt discount 50mg imuran. Om het belang van selectiviteit te illustreren generic imuran 50 mg overnight delivery, zijn in dit proefschrift twee uitdagingen gepresenteerd waarin selectiviteit een belangrijke rol speelt. Ten eerste een methode waarin de selectiviteit extreem hoog moet zijn om verschil te kunnen maken tussen een verboden antibioticum en haar antimicrobiologisch inactieve isomeren. Ten tweede een methode waarbij de selectiviteit bewust wordt gecompromitteerd zodat een effectieve monitoringsstrategie wordt verkregen waarbij niet alleen het antibioticum zelf wordt gedetecteerd, maar ook eiwitgebonden metabolieten daarvan. Doordat dit antibioticum verdacht carcinogeen is en geassocieerd wordt met aplastische anemie bij de mens, is het verboden voor gebruik bij voedselproducerende dieren. Als dat zo is, 333 heeft dit mogelijk invloed op de bestaande wetgeving en de interpretatie van analytische resultaten. De isomeerscheiding op de analytische kolom, de selectiviteit van de gemonitorde product-ionen en de monstervoorbewerking zijn kritische parameters. Om reproduceerbare retentietijden te verkrijgen wordt isocratische elutie toegepast op een α-zuurglycoproteïnekolom. In het geval van urinemonsters zijn matrixcomponenten in het eindextract aanwezig die ervoor zorgen dat de retentietijden van alle isomeren afnemen, waardoor onvoldoende chromatografische resolutie wordt verkregen. Om dit te voorkomen is een intensieve opschoning van de monsterextracten ontwikkeld, bestaande uit een vaste fase extractie met daarna een vloeistof-vloeistofextractie. De ontwikkelde methode is volledig gevalideerd en voldoet aan de gestelde criteria voor alle -1 isomeren. Met name penicillines worden veelvuldig gebruikt in de veehouderij en als humaan medicijn. Resistentie voor cefalosporines en in minder mate carbapenems komt tevens voor, wat een gevaar vormt voor de volksgezondheid. De uitdagingen voor de analyse van ß-lactams zijn (1) de instabiliteit van enkele componenten behorende tot deze groep en (2) het metabolisme van ceftiofur en cefapirine, en eiwitbinding van ceftiofurresiduen. Een beperkte instabiliteit van cefapirine en desfuroylceftiofur is waargenomen bij verhoogde temperatuur. Ceftiofur en cefapirine degraderen meteen en volledig in basisch milieu, resulterend in antimicrobieel inactieve producten. Ceftiofur en cefapirine degraderen tevens in de aanwezigheid van nierextract resulterend in eerder gerapporteerde en nog niet eerder gerapporteerde producten. Condities die vaak voorkomen bij de analyse van ceftiofur en cefapirine kunnen leiden tot snelle afbraak van deze componenten. Daarom wordt op theoretische gronden geconcludeerd dat het waarschijnlijk is dat een onderschatting van het ceftiofur- en cefapirinegehalte plaatsvindt bij toepassing van de conventionele methoden voor de analyse van deze componenten en dat een nieuwe methode, die rekening houdt met het metabolisme en deze degradatie noodzakelijk is. Om effectief off-label gebruik van ceftiofur aan te kunnen tonen dient een analysemethode naast ceftiofur zelf ook de actieve metabolieten daarvan te kunnen detecteren. Er is vastgesteld dat methode A niet geschikt is voor de kwantitatieve analyse van de totale hoeveelheid ceftiofurmetabolieten, noch voor de effectieve detectie van off-label gebruik van ceftiofur. Methode B resulteert in goede kwantitatieve resultaten, echter deze methode is uitsluitend geschikt voor de analyse van ceftiofur, niet voor andere cefalosporines. Methode C geeft tevens goede kwantitatieve resultaten en deze methode lijkt geschikt voor toepassing van de analyse van diverse cefalosporines in kippenvlees. De methode is volledig gevalideerd en de bepaalde methodekarakteristieken zijn acceptabel bevonden voor de kwantitatieve analyse van 21 van de 22 ß-lactams. Daarnaast is aangetoond dat de ontwikkelde methode effectief is voor het opsporen van off-label gebruik van ceftiofur, omdat met deze methode ook eiwitgebonden residuen worden gedetecteerd. In hoofdstuk 6 zijn toekomstperspectieven betreffende antibioticumanalyse besproken. Er is onderzoek nodig om de optimale condities voor beide dimensies te bepalen en om een goede koppeling te maken tussen beide dimensies. Door de hoge diffusiesnelheid en de lage tegendruk kunnen zeer snelle scheidingen met hoge resolutie verkregen worden. In hoofdstuk 6 worden ook de verwachte ontwikkelingen in de monitoring van residuen besproken. Het nationaal monitoringsplan zal meer risicogebaseerd worden en daardoor is een flexibelere aanpak vereist. Het meest efficiënt is het gebruik van generieke, veel componenten omvattende, screeningsmethoden in combinatie met enkele zeer selectieve bevestigingsmethodes. Daarnaast zal, door de verregaande ontwikkeling van bacteriële resistentie, monitoring steeds meer gericht worden op het testen van antibioticumgebruik in het algemeen naast de monitoring van antibiotica in voedselproducten. Hierbij moeten detectiegrenzen zo laag mogelijk zijn en is het gebruik van andere matrices mogelijk relevant, zoals mest, haar, veren, veegmonsters (alle niet-invasief) en botten. Op basis van het onderzoek gepresenteerd in dit proefschrift, kunnen we de volgende vraag beantwoorden: “Hoeveel selectiviteit is vereist? Normaal gesproken bestaat er een wisselwerking tussen 337 selectiviteit en het aantal componenten dat met één methode geanalyseerd kan worden. Voor screeningsmethoden zou derhalve een lagere selectiviteit volstaan, terwijl de selectiviteit van bevestigingsmethoden hoog moet zijn. Hieruit wordt geconcludeerd dat bij methodeontwikkeling en –validatie, het van groot belang is de parameter selectiviteit in detail te bestuderen. Deadlines, mislukte experimenten, lastige reviewers… Gelukkig heb ik de afgelopen jaren de druk die ik voelde enigszins weten te beperken. Echter, zodra de promotiedatum bekend werd, ontstond toch een licht gevoel van spanning in mijn onderbuik. Het gaat nu echt gebeuren… Zoals zo vaak de laatste maanden, zit ik weer eens in de voorkamer achter de laptop aan tafel. De hond ligt snurkend op de bank en op de achtergrond hoor ik zacht het geluid van de televisie. Een documentaire of zoiets… Het grootste deel van het proefschrift ligt gelukkig al lang klaar, de opmaak is gedaan.