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Aminophylline has been reported to be an efity and leakage of irritative chemical products; no fective treatment for methotrexate-induced subacute connection has been made with prior external beam neurotoxicity (Bernini et al antibiotic drops for conjunctivitis purchase stromectol 12mg on line. Transient lesions in the occipital poles, cerebellum, and centrum semiovale have been de5-Fluorouracil. Ifosphamide, commonly used to treat sarcomas, medulloblastoma, and other Narcotics. Cancer patients often require narcotics pediatric and adult tumors, can cause severe neurofor control of pain. Narcotics occasionally cause toxicity manifested by coma and seizures (Bhardwaj neurotoxicity and seizures. It dine, the metabolite normeperidine has been imis a mitotic spindle inhibitor, and it exerts its major plicated. Recent reis not the determining factor for, the accumulation ports link paclitaxel-induced encephalopathy with and neuroexcitatory effect of normeperidine (Goetseizures, particularly in those patients treated with ting and Thirman, 1985; Kaiko et al. Reversible encephalopathy and seizures have who have been treated with an intravenous moralso been reported with vincristine. A brain biopsy phine solution containing sodium bisulfate as a specimen in one reported case revealed neurotubupreservative (Meisel and Welford, 1992). Immunosuppressant drugs such as cyPropoxyphene has been reported to cause status closporin are given to bone marrow transplant reepilepticus. These agents have been reported to induce seizures in patients pretreated with Antiemetics. Some neuroleptics used as antiemetics busulfan or platinum compounds (Ghany et al. The newer antiemetics, such as ondansetron, seizures have been reported after the administration cause less neurotoxicity. Conand chemotherapy receive broad-spectrum antibiottrast-induced seizures are caused by an increased ics or multiple antibiotics. Some of these have been susceptibility to seizures and increased permeability associated with encephalopathy and seizures. Renal failure and the presence or history of altered levels of consciousness in cancer patients. The accompanying cerebral dysicity seems to be due to an increased concentration function is diffuse, even in the rare case of a focal or of the drug in brain tissue when it is given in high complex partial seizure (Cascino, 1993; Stein and doses or given to patients with impaired renal funcChamberlain, 1991). An impaired mechanism for clearance of the can be caused by volume depletion or volume overdrug from brain tissue may be involved, but this has load, by drugs, or by a malignancy, such as occurs not yet been documented (Schliamser et al. Intravascular volume depletion occurs as a result of poor fluid intake, fluid Methylphenidate (Ritalin). Patients with brain tuloss with emesis, or retention of fluid in the abdommors or systemic cancer often experience fatigue, inal cavity (ascites), either neoplastic or due to conlethargy, depressed mood, and overall neurobehavgestive heart failure. As in paraneoplastic quency of seizures in patients who have a history of syndrome, it occurs most commonly in patients with epilepsy or seizures due to the presence of brain tusmall cell lung carcinoma and also in those with mor. For other types of cancer, the production of methylphenidate therapy for cancer patients with neuectopic hormones is less well documented. Diagnosis is made on the basis of lablung tumors, or metastatic lymphangitic spread. Paoratory findings of hyponatremia, hypo-osmolality of tients with pulmonary fibrosis secondary to chemothe serum, and increased urine osmolality. It is important to correctly diagnose the cause of hyponatremia to treat it appropriately. Hydration with Seizures with Infectious Causes normal saline solution corrects the problem of fluid depletion. Fluid restriction, sodium supplementation, Cancer patients are very susceptible to infections, and and sometimes diuretics are indicated to treat fluid seizures occur in those patients who have systemic overload. Patients stricting fluids, administering demeclocycline, and undergoing high-dose chemotherapy with bone maridentifying and, if possible, removing the cause. The syndrome may recur, indicating tumor tomegalovirus, herpes zoster virus); bacteria, includrecurrence (McDonald and Dubose, 1993; Richarding common pathogens and opportunistic agents son 1995; Ritch, 1988). Clinically, patients with tients who receive total parenteral nutrition and reseizures caused by infections present with confusion, sults from either the insulin in the solution or withaltered level of consciousness (encephalitis), menindrawal of total parenteral nutrition. Seizures with Vascular Causes Seizures can occur with blood glucose levels below 40 mg/dL; they are usually preceded by diaphoresis, Cancer patients have both embolic and thrombotic tremor, a sensation of hunger, and nervousness. The pathogenesis of cerebrovascular events in these patients includes cancerand treatmentHypocalcemia and Hypomagnesemia. Embolic events can occur in the Hypocalcemia and hypomagnesemia occur in patients presence of cardiac arrhythmia, which occurs in pawho receive intensive chemotherapy, especially cistients treated with paclitaxel, in those with cardiomyplatin, with overhydration (Bachmeyer et al. Hypocalcemia has also associated marantic endocarditis (Rosen and Armbeen reported in patients treated with amphotericin strong, 1973). It occurs less commonly with malnutrition or in patients with secondary hypoparathyroidism followThrombotic Stroke. Seizures are a comserved in patients who have hypercoagulability synmon manifestation of hypocalcemia because of the indromes, paraneoplastic phenomena associated with creased excitability of the cerebral cortex. Other pancreatic cancer, breast carcinoma, and other maclinical manifestations of hypocalcemia and hypolignancies (Collins et al. Hypoxia is another potential, although less apy to the brain can induce vasculopathy, another pocommon, cause of seizures in cancer patients. It is important to elicit the past medical history, focusing on prior history of seizures, Venous Sinus Thromboses. Venous sinus thromcardiac disease, pulmonary disease, diabetes, and boses can occur with the secondary venous infarchead trauma. Common symptoms associated with tions that can be caused by tumor invasion or metaseizures are headache, paresthesias, diaphoresis, difstatic or infectious meningitis. Venous infarctions are ficulty breathing, gastric discomfort, and occasionally most often hemorrhagic. The physical and neurologic examinations will Parenchymal and Intratumoral Hemorrhage. The presonset seizure or an increase in seizure frequency ocence of focal neurologic deficits suggests that the pacurs in those patients with hemorrhage into a primary tient has a focal intracranial lesion (parenchymal or or metastatic brain tumor. Of the metastatic tumors, dural/meningeal), either neoplastic, infectious (abmelanoma, renal cell carcinoma, and choriocarciscess, empyema), hemorrhagic, or vascular. Altered level of consciousness, myoclonus, and asterixis sugSpontaneous Subarachnoid Hemorrhage. It is tures; and blood levels for drugs such as cyclosporin, important to appreciate that subarachnoid hemormethotrexate, aminophylline, ethanol, and, if approrhages can recur along with seizures as part of their priate, street drugs. The extent of edema and tients who are thrombocytopenic or who develop a mass effect can also be evaluated. In such cases, even minor trauma may of meningitis, leptomeningeal metastases, and subcause hemorrhage. It must be performed with great caution in patients who have an intracerebral mass or thrombocytopenia. The diagnosis of seizures in cancer patients is made Electroencephalography helps to identify the seion the basis of a detailed history, physical and neuzure focus and differentiate between disease prorologic examinations, laboratory tests, neuroimaging cesses. Specific findings on electroencephalograms results, and electroencephalographic findings. The use of prophylactic antiepileptic attacks, and panic attacks, which can all mimic drugs in patients with brain tumors who do not have seizures. Airway patency must For treatment of generalized seizures, phenytoin is be established, and intravenous therapy with benzousually the first drug administered. For complex pardiazepines (lorazepam, diazepam) and antiepileptic tial seizures, carbamazepine may be the first-line drugs (phenytoin, phenobarbital) must be initiated.

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The demonstration that ribosomal P proteins and other autoantigens are found on the surface of some normal and apoptotic cells may provide an important clue to their potential pathogenic role antibiotic resistance who report 2014 cheap stromectol 3 mg with amex. The notion that some autoantibodies may be fingerprints incriminating a causeoretiologyofthediseasearealsobeingclarified. First, the rapid advancement of new technologies (autoantigen arrays,microfiuidics and nanotechnology) will change the complexion of the autoantibody testing by providing a wealth of serological information that will almost certainly challenge current paradigms and clinical associations. It is now possible to use a drop of blood to analyze serum for the presence of over 100 difierent autoantibodies in a single test that can be completed and reported within minutes. Second, it is anticipated that autoantibody testing will be a critical part of monitoring and evaluating patients placed on a variety of the newer biological therapeutics. For example, it is increasingly clear that interferon and tumor necrosis factor blockade therapies are associated with the induction of autoantibodies and, in some cases, full blown disease. Interestingly,these observations fall on the historical evidence that drugs such as procainamide and hydralazine can induce autoantibodies and lupus syndromes. However, the implications of longer term health care costs of missing an early diagnosis in a patient with forme fruste disease must also be carefully considered. A cost-efiective and rational approach to autoantibody testing algorithms and clinical practice guidelines are overdue. Clinical studies to address these issues will prove worthwhile and save patients from needless,expensive and invasive tests,and missed diagnosis that can lead to significant morbidity and mortality. This book and reference guide is intended to assist the physician understand and interpret the variety of autoantibodies that are being used as diagnostic and prognostic tools for patients with systemic rheumatic diseases. Although the landscape of autoantibody testing continues to change,this information will be a useful and valuable reference for many years to come. Fritzler Notes for the Use of this Book this reference book on the serological diagnosis of systemic autoimmune diseases is divided into two main sections. The autoantibodies observed in autoimmune diseases are described in alphabetical order in Part 1, and autoimmune disorders as well as symptoms that indicate the possible presence of an autoimmune disease are listed in Part 2. Bibliographic references were omitted due to the broad scope of the subject matter. Only the first authors of historical or some important recent publications have been named. In as far as they were known to the authors, synonyms or alternative names for the antibodies were also listed. Obsolete terminology is indicated as such, and the names preferred by the authors are used in the alphabetical index. The autoantibody description section begins, in some cases, with a brief introduction or historical account. This is followed by information on the target structures (autoantigens), detection methods, clinical relevance, and indications for testing of the autoantibody. White Letters on Green Background these are autoantibodies of high diagnostic relevance (markers for diagnosis, prognosis or monitoring) that can usually be determined in all laboratories. Black Letters on Light Green Background the clinical relevance of these antibodies is (still) unclear due to their very low frequency of detection, discrepancies between the findings of difierent studies (lack of comparability due to difierences in study design, methodology, ethnic differences, etc. Black Letters on White Background these autoantibodies are currently not clinically relevant, are no longer clinically relevant, or are clinically relevant only in isolated cases. This can also include disease-specific autoantibodies if their testing does not provide any added diagnostic advantages over other parameters. Thus, analyses of autoantibodies with multiplexed array technologies are preferred once the distinctive staining pattern is identified. Autoantigens Various heat shock proteins (heat-stress-induced proteins) like Hsp60, Hsp70 and Hsp90. Clinical Relevance Hsp antibodies occur in a number of autoimmune and non-autoimmune diseases (especially infections) as well as in healthy individuals. The use of Hsp antibodies for diagnosis of arteriosclerosis and autoimmune diseases of the inner ear is being evaluated. Suspicion of drug-induced lupus (especially after procainamide, hydralazine, isoniazid, chlorpromazine, methyldopa, beta blockers, anticonvulsant, sulfasalazine or captopril use). Antihistone antibodies tend to disappear within one year of discontinuing the causative drug. Difierential recognition of antinuclear antibodies in sera presenting a typical chromatin fiuorescence pattern. Part 2 System ic Autoim une Diseases Syndrom es, Diagnostic Criteria, Sym ptom s 192 Sfififififififi Afififififififififi Dfififififififi fi Sfifififififififi,Dfififififififififi,Sfififififififi Abortion, spontaneous Recurrent spontaneous abortions that generally occur after the 10th week of gestation (caused by thrombotic events in the placenta) are a characteristic sign of antiphospholipid syndrome. Acro-Osteolysis Occurs as a typical feature of systemic sclerosis and is a refiection of a severe acral microcirculatory disorder. Amaurosis fugax Reversible, mostly unilateral blindness due to retinal circulatory disorder. Coombs-positive autoimmune hemolytic anemia may occur in systemic lupus erythematosus and rarely in other connective tissue diseases. Coombs-positive hemolytic anemia occurs in about 9 % of patients with antiphospholipid syndrome. Its clinical picture is extremely variable, and the complications arising from the disease may be minimal to life-threatening. For histopathologic confirmation, thrombosis should be present without significant evidence of infiammation in the vessel wall. Pregnancy morbidity a) One or more unexplained deaths of a morphologically normal fetusatorbeyondthe10th week of gestation, with normal fetal morphologydocumentedbyultrasoundorbydirectexaminationofthe fetus, or b) One or more premature births of a morphologically normal neonate before the 34th week of gestation because of (i) eclampsia or severe preeclampsia defined according to standard definitions, or (ii) recognized features of placental insuficiency, or c) Three or more unexplained consecutive spontaneous abortions before the 10th week of gestation, with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded. In studies of populations of patients who have more than one type of pregnancy morbidity, investigators are strongly encouraged to stratify groups of subjects according to a, b, or c above. Thus, patients who fulfil criteria should be stratified according to contributing causes of thrombosis. Ro52 antibodies can be found but did not have any diagnostic or prognostic relevance. Polysynovitis (arthralgia, arthritis, tenosynovitis) 198 Sfififififififi Afififififififififi Dfififififififi fi Sfifififififififi,Dfififififififififi,Sfififififififi 3. Ro52 antibodies are found at high frequencies but without aid in diagnosing this type of autoimmune myositis. Arthralgia Common feature of all degenerative and infiammatory rheumatic diseases; frequently occurs as a manifestation of systemic and organ-specificautoimmune diseases. Common symptom of systemic autoimmune diseases: Connective tissue diseases, systemic vasculitides, relapsing polychondritis, hypocomplementemic urticarial vasculitis syndrome. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The system is generally user friendly as peutic apheresis is in the best interest of the patient. Furthermore, the gory P has been eliminated in the current Special Issue American College of Chest Physicians uses this and all previous diseases with category P in the Fourth approach to evaluate therapeutic recommendations, most Special Issue, namely dilated cardiomyopathy, inflammarecently recommendations for the use of antithrombotic tory bowel disease, and age-related macular degeneration agents [12,13]. We adopted the evidence quality criteunderstand that the grade can be used in support and ria defined by the University HealthSystem Consortium against the use of any particular therapeutic modality. This challenge has been an issue of bias; inconsistency of results; indirectness of evidence; for many groups working on clinical recommendations and/or sparse evidence. Over last several years there has been a based on observational studies can be increased by large concerted effort to generate a system, which better magnitude of effect; all plausible confounding would translates the existing evidence to treatment of the reduce a demonstrated effect; and/or dose-response gradiindividual patient. The members of the subcommittee were encouraged the Grading of Recommendations Assessment, Develto take these variables into consideration.

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Transsexual antibiotics cause yeast infection buy generic stromectol 3mg on-line, transgender, and gender nonconforming people might seek the assistance of a voice and communication specialist to develop vocal characteristics. Competency of Voice and Communication Specialists Working with Transsexual, Transgender, and Gender Nonconforming Clients Specialists may include speech-language pathologists, speech therapists, and speech-voice clinicians. In most countries the professional association for speech-language pathologists requires specifc qualifcations and credentials for membership. In some countries the government regulates practice through licensing, certifcation, or registration processes (American SpeechLanguage-Hearing Association, 2011; Canadian Association of Speech-Language Pathologists and Audiologists; Royal College of Speech Therapists, United Kingdom; Speech Pathology Australia; Vancouver Coastal Health, Vancouver, British Columbia, Canada). The following are recommended minimum credentials for voice and communication specialists working with transsexual, transgender, and gender nonconforming clients: 1. Specialized training and competence in the assessment and development of communication skills in transsexual, transgender, and gender nonconforming clients. Continuing education in the assessment and development of communication skills in transsexual, transgender, and gender nonconforming clients. This may include attendance at professional meetings, workshops, or seminars; participation in research related to gender identity issues; independent study; or mentoring from an experienced, certifed clinician. Other professionals such as vocal coaches, theatre professionals, singing teachers, and movement experts may play a valuable adjunct role. Such professionals will ideally have experience working with, or be actively collaborating with, speech-language pathologists. Assessment and Treatment Considerations the overall purpose of voice and communication therapy is to help clients adapt their voice and communication in a way that is both safe and authentic, resulting in communication patterns that clients feel are congruent with their gender identity and that refect their sense of self (Adler, Hirsch, & Mordaunt, 2006). It is essential that voice and communication specialists be sensitive to individual communication preferences. Individuals should not be counseled to adopt behaviors with which they are not comfortable or which do not feel authentic. Individuals may choose the communication behaviors that they wish to acquire in accordance with their gender identity. These decisions are also informed and supported by the knowledge of the voice and communication specialist and by the assessment data for a specifc client (Hancock, Krissinger, & Owen, 2010). Targets of treatment typically include pitch, intonation, loudness and stress patterns, voice quality, resonance, articulation, speech rate and phrasing, language, and non-verbal communication (Adler et al. Existing protocols for voice and World Professional Association for Transgender Health 53 the Standards of Care 7th Version communication treatment can be considered in developing an individualized therapy plan (Carew, Dacakis, & Oates, 2007; Dacakis, 2000; Davies & Goldberg, 2006; Gelfer, 1999; McNeill, Wilson, Clark, & Deakin, 2008; Mount & Salmon, 1988). Feminizing or masculinizing the voice involves non-habitual use of the voice production mechanism. Prevention measures are necessary to avoid the possibility of vocal misuse and long-term vocal damage. All voice and communication therapy services should therefore include a vocal health component (Adler et al. It is recommended that individuals undergoing voice feminization surgery also consult a voice and communication specialist to maximize the surgical outcome, help protect vocal health, and learn non-pitch related aspects of communication. Voice surgery procedures should include follow-up sessions with a voice and communication specialist who is licensed and/ or credentialed by the board responsible for speech therapists/speech-language pathologists in that country (Kanagalingam et al. While many transsexual, transgender, and gender nonconforming individuals fnd comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage 54 World Professional Association for Transgender Health the Standards of Care 7th Version & Karim, 2000). For the latter group, relief from gender dysphoria cannot be achieved without modifcation of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity. In some settings, surgery might reduce risk of harm in the event of arrest or search by police or other authorities. Follow-up studies have shown an undeniable benefcial effect of sex reassignment surgery on postoperative outcomes such as subjective well being, cosmesis, and sexual function (De Cuypere et al. Additional information on the outcomes of surgical treatments are summarized in Appendix D. Some people, including some health professionals, object on ethical grounds to surgery as a treatment for gender dysphoria, because these conditions are thought not to apply. It is important that health professionals caring for patients with gender dysphoria feel comfortable about altering anatomically normal structures. In order to understand how surgery can alleviate the psychological discomfort and distress of individuals with gender dysphoria, professionals need to listen to these patients discuss their symptoms, dilemmas, and life histories. Genital and breast/chest surgical treatments for gender dysphoria are not merely another set of elective procedures. Typical elective procedures involve only a private mutually consenting contract between a patient and a surgeon. These surgeries may be performed once there is written documentation that this assessment has occurred and that the person has met the criteria for a specifc surgical treatment. By following this procedure, mental health professionals, surgeons, and of course patients, share responsibility for the decision to make irreversible changes to the body. Relationship of Surgeons with Mental Health Professionals, Hormone-Prescribing Physicians (if Applicable), and Patients (Informed Consent) the role of a surgeon in the treatment of gender dysphoria is not that of a mere technician. To that end, surgeons must talk at length with their patients and have close working relationships with other health professionals who have been actively involved in their clinical care. Consultation is readily accomplished when a surgeon practices as part of an interdisciplinary health care team. In the absence of this, a surgeon must be confdent that the referring mental health professional(s), and if applicable the physician who prescribes hormones, are competent in the assessment and treatment of gender dysphoria, because the surgeon is relying heavily on their expertise. Once a surgeon is satisfed that the criteria for specifc surgeries have been met (as outlined below), surgical treatment should be considered and a preoperative surgical consultation should take place. During this consultation, the procedure and postoperative course should be extensively discussed with the patient. Ensuring that patients have a realistic expectation of outcomes is important in achieving a result that will alleviate their gender dysphoria. All of this information should be provided to patients in writing, in a language in which they are fuent, and in graphic illustrations. Patients should receive the information in advance (possibly via the internet) and given ample time to review it carefully. The elements of informed consent should always be discussed face-to-face prior to the surgical intervention. Questions can then be answered and written informed consent can be provided by the patient. Because these surgeries are irreversibile, care should be taken to ensure that patients have suffcient time to absorb information fully before they are asked to provide informed consent. Surgeons should provide immediate aftercare and consultation with other physicians serving the patient in the future. Patients should work with their surgeon to develop an adequate aftercare plan for the surgery. Overview of Surgical Procedures for the Treatment of Patients with Gender Dysphoria For the male-to-female (MtF) patient, surgical procedures may include the following: 1. Genital surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty; 3. Non-genital, non-breast surgical interventions: facial feminization surgery, liposuction, lipoflling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipoflling), hair reconstruction, and various aesthetic procedures. For the female-to-male (FtM) patient, surgical procedures may include the following: 1. Genital surgery: hysterectomy/ovariectomy, reconstruction of the fxed part of the urethra, which can be combined with a metoidioplasty or with a phalloplasty (employing a pedicled or free vascularized fap), vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses; World Professional Association for Transgender Health 57 the Standards of Care 7th Version 3.

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Part A helps to pay for care in hospitals antibiotics for pet birds order stromectol 3 mg on-line, skilled nursing facilities, and hospice care. Eligible New Jersey Residents must (800) 869-4499 be 65 years of age or older and have an income of no Waivers have clinical and financial eligibility criteria choice of standardized health plans. Enrollment periods are limited; however, special enrollment opportunities for those who County Boards of Social Services, See Page 17 need it are available throughout the year. Center for Ethics and Advocacy in Healthcare Division of Aging Services Call Center (800) 792-9745 (609) 588-7048 The child must have been 21 years old or younger when the medical bills were incurred. In general, if you participate in any of the following Renters who have their heating costs included in their programs you also may qualify for telephone assisrent may also qualify. The benefit ing providers participate in Lifeline Assistance and Link is also available to customers who have electric and gas Up programs in New Jersey: costs included in their rent. It also provides a ers from having their gas or electric shut off between death benefit of $10,000. The ultimate goal is for children to maximize their potential to lead full, productive lives with their families and within their own communities. A State Interagency Coordinating Council, appointed by the governor, advises and assists the Department of Health as the lead agency in the development and implementation of early intervention for infants and toddlers with developmental delays or disabilities, and their families. With family agreeSouthern Regional Early Intervention Collaborative ment, anyone may call to make a referral. A service Winslow Professional Building coordinator will be assigned to work with the family. The collaboratives are responsible for child Toll Free Number for the find, public awareness, initial referral, service coordination, training and technical assistance and family Early Intervention System support. The New Jersey Department of Education administers state and federally funded aid programs for more than 1. For children age three to five, the Project Head Start is a federally funded pre-school child study team includes a speech correctionist or program for children. Upon completion of the evaluation and prior to For Local Head Start Programs, call: placement in special education, an Individualized (609) 376-9077 Education Program, with stated goals and objececlkc. Services for people with disabilities include vocational evaluation and assessment, training, counseling, education, job placement assistance, supported employment and support for entrepreneurs with disabilities. The goals Last names A-M x23648, N-Z x23645 of the program are to offer beneficiaries with disabilities Beneficiaries also can use a combination of work incenNew Jersey Economic Development Authority tives to maximize their income until they begin earning Telephone: (866) 534-7789 enough to support themselves. Individuals with an interest in becoming self-employed should present this option to their vocational rehabilitation counselor. If a solid business plan is put together, there may be capital investment Receiving Social Security Disability available for a variety of start-up needs. Support primarily consists of training in business management and assistance in establishing vending locations. People with disabilities who are employed and are between the ages of 16 to 64 can qualify for the program with an annual gross earned income of up to approximately $61,500. Its Community Development Division adminmay assist qualified renters facing eviction, finanisters several programs targeted to people with cial assistance to communities, local government, special needs. Alliance members who care for loved ones with chronic conditions, disinclude grassroots organizations, professional associaabilities, disease, or the frailties of old age. Instruction is available in English and Spanish for services, consumer representation on advisory For more information visit the website at: committees, etc. The telephone numbers of the four Kinship agencies the child must be less than 30 days old and must not and the counties they serve are listed below: have been abused or neglected. Caregivers can also learn how to become 1-877-569-0350 (Atlantic, Burlington, a registered family day care provider. Child Care Health leadership and technical assistance to non-profit orgaConsultant Coordinators provide consultation, edunizations and local educational agencies to help those cation and training about the health and safety needs organizations put successful parental involvement proof children in child care. Signs of possible abuse include: Physical Abuse n Unexplained or repeated injuries, such as welts, bruises, or burns n Injuries that are in the shape of an object (belt buckle, electric cord, etc. A concerned caller does not need proof to report an allegation of child abuse and can make the report anonymously. Therefore, here are possible; if addressing an adult, say Bill instead of a few tips for improving your language related to Billy. The business may not, however, insist on proof of certification before permitting admittance of a service dog accompanying a person with a disability. However, the owner of the animal has sole responsibility for its behavior and may be charged for any damages the animal causes as long as the business has a policy of charging non-disabled customers for damages that they cause. Medical Equipment and Supplies Evaluate equipment for repairs and obtain and keep spare parts. It should include: sterile adhesive bandages in assorted sizes, assorted sizes of safety pins, cleansing agents/soaps, latex gloves (2 pairs), 4-6 sterile gauze pads (2-inch and 4-inch), three triangular bandages, non-prescription drugs, three rolls each of 2 and 3 inch sterile roller bandages, scissors, tweezers, needle, moistened towelettes, antiseptic, thermometer, two tongue depressors, and a tube of petroleum jelly or other lubricant. Medications and Medical Needs Create a list of current prescriptions, names and dosages. Telecommunications Make sure your cell phone battery and any extra batteries are kept fully charged. Personal Assistant Care Consider checking into a nursing home or hospital if a disaster is anticipated. Also, back up generators will be operating to assist people who use power wheelchairs and/or ventilators. Service Dog The animal always should wear an identification tag with all necessary contact information. Miscellaneous Keep battery-operated flashlights and/or lanterns with lots of extra batteries. For additional information, contact the Division of Fire Safety: (609) 633-6106 It is unlawful to evict an oxygen-user from a rental property, solely on the basis of oxygen use, as long as the oxygen is stored and used appropriately. While airlines may not require passengers with disabilities to provide advance notice of their disability or intent to travel (except in some very specific circumstances), doing so may in some cases help to avoid inconvenience. The screener will perform a hand inspection of your equipment if it cannot fit through the X-ray machine. You can ask for a private screening for the inspection of your prosthetic device or body brace. Identification may include: cards or documentation, presence of a harness or markings on the tags.

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World Professional Association for Transgender Health 103 the Standards of Care 7th Version Acne antibiotics for acne bacteria cheap stromectol 12mg overnight delivery, androgenic alopecia Acne and varying degrees of male pattern hair loss (androgenic alopecia) are common side effects of masculinizing hormone therapy. Criteria for Feminizing/Masculinizing Hormone Therapy (one referral or chart documentation of psychosocial assessment) 1. If signifcant medical or mental concerns are present, they must be reasonably well-controlled. If signifcant medical or mental health concerns are present, they must be reasonably well controlled. Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. Criteria for genital surgery (two referrals) Hysterectomy and ovariectomy in FtM patients and orchiectomy in MtF patients: 1. Persistent, well documented gender dysphoria; World Professional Association for Transgender Health 105 the Standards of Care 7th Version 2. The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before a patient undergoes irreversible surgical intervention. These criteria do not apply to patients who are having these surgical procedures for medical indications other than gender dysphoria. Metoidioplasty or phalloplasty in FtM patients and vaginoplasty in MtF patients: 1. If signifcant medical or mental health concerns are present, they must be well controlled; 5. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional. Because of the controversial nature of sex reassignment surgery, this type of analysis has been very important. These changes were not seen as positive; rather, they showed that many individuals who had entered the treatment program were no better off or were worse off in many measures after participation in the program. These fndings resulted in closure of the treatment program at that hospital/medical school (Abramowitz, 1986). Subsequently, a signifcant number of health professionals called for a standard for eligibility for sex reassignment surgery. In 1981, Pauly published results from a large retrospective study of people who underwent sex reassignment surgery. This study included patients who were treated before the publication and use of the Standards of Care. Since the Standards of Care have been in place, there has been a steady increase in patient satisfaction and decrease in dissatisfaction with the outcome of sex reassignment surgery. Studies conducted after 1996 focused on patients who were treated according to the Standards of Care. The fndings of Rehman and colleagues (1999) and Krege and colleagues (2001) are typical of this body of work; none of the patients in these studies regretted having had surgery, and most reported being satisfed with the cosmetic and functional results of the surgery. Even patients who develop severe surgical complications seldom regret having undergone surgery. Quality of surgical results is one of the best predictors of the overall outcome of sex reassignment (Lawrence, 2003). The vast majority of follow-up studies have shown an undeniable benefcial effect of sex reassignment surgery on postoperative outcomes such as subjective well being, cosmesis, and sexual function (De Cuypere et al. A weakness of that study is that it recruited its 384 participants by a general email rather than a systematic approach, and the degree and type of treatment was not recorded. Study participants who were taking testosterone had typically being doing so for less than 5 years. Reported quality of life was higher for patients who had undergone breast/chest surgery than for those who had not (p<. Scores were compared to those of 20 healthy female control patients who had undergone abdominal/pelvic surgery in the past. Quality of life scores for transsexual patients were the same or better than those of control patients for some subscales (emotions, sleep, incontinence, symptom severity, and role limitation), but worse in other domains (general health, physical limitation, and personal limitation). It is diffcult to determine the effectiveness of hormones alone in the relief of gender dysphoria. Most studies evaluating the effectiveness of masculinizing/feminizing hormone therapy on gender dysphoria have been conducted with patients who have also undergone sex reassignment surgery. Favorable effects of therapies that included both hormones and surgery were reported in a comprehensive review of over 2000 patients in 79 studies (mostly observational) conducted between 1961 and 1991 (Eldh, Berg, & Gustafsson, 1997; Gijs & Brewaeys, 2007; Murad et al. Patients operated on after 1986 did better than those before 1986; this refects signifcant improvement in surgical complications (Eldh et al. Most patients have reported improved psychosocial outcomes, ranging between 87% for MtF patients and 97% for FtM patients (Green & Fleming, 1990). Weaknesses of these earlier studies are their retrospective design and use of different criteria to evaluate outcomes. A prospective study conducted in the Netherlands evaluated 325 consecutive adult and adolescent subjects seeking sex reassignment (Smith, Van Goozen, Kuiper, & Cohen-Kettenis, 2005). Patients who underwent sex reassignment therapy (both hormonal and surgical intervention) showed improvements in their mean gender dysphoria scores, measured by the Utrecht Gender Dysphoria Scale. Scores for body dissatisfaction and psychological function also improved in most categories. This is the largest prospective study to affrm the results from retrospective studies that a combination of hormone therapy and surgery improves gender dysphoria and other areas of psychosocial functioning. There is a need for further research on the effects of hormone therapy without surgery, and without the goal of maximum physical feminization or masculinization. In current practice there is a range of identity, role, and physical adaptations that could use additional follow-up or outcome research (Institute of Medicine, 2011). Invited papers were submitted by the following authors: Aaron Devor, Walter Bockting, George Brown, Michael Brownstein, Peggy Cohen-Kettenis, Griet DeCuypere, Petra DeSutter, Jamie Feldman, Lin Fraser, Arlene Istar Lev, Stephen Levine, Walter Meyer, Heino Meyer-Bahlburg, Stan Monstrey, Loren Schechter, Mick van Trotsenburg, Sam Winter, and Ken Zucker. Most were completed by September 2007, with the rest completed by the end of 2007. The fnal papers were published in Volume 11 (1-4) in 2009, making them available for discussion and debate. A subgroup of the Revision Committee was appointed by the Board of Directors to serve as the Writing Group. The Board also appointed an International Advisory Group of transsexual, transgender, and gender nonconforming individuals to give input on the revision. From the survey results, the Writing Group was able to discern where these experts stood in terms of areas of agreement and areas in need of more discussion and debate. World Professional Association for Transgender Health 109 the Standards of Care 7th Version the Writing Group met on March 4 and 5, 2011 in a face-to-face expert consultation meeting. They reviewed all recommended changes and debated and came to consensus on various controversial areas. These decisions were incorporated into the draft, and additional sections were written by the Writing Group with the assistance of the technical writer. The draft that emerged from the consultation meeting was then circulated among the Writing Group and fnalized with the help of the technical writer. Discussion was opened up on the Google website and a conference call was held to resolve issues. Feedback from these groups was considered by the Writing Group, who then made further revision. Funding the Standards of Care revision process was made possible through a generous grant from the Tawani Foundation and a gift from an anonymous donor. Process of soliciting international input on proposed changes from gender identity professionals and the transgender community; 3. Transgender people have a gender identity that differs from the sex which they were assigned at birth, and are estimated to represent 0.

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Id (hypersensitivity response) reactions are treated by wet compresses antimicrobial lock therapy order cheapest stromectol, topical corticosteroids, occasionally systemic corticosteroids, and eradication of the primary source of infection. Recurrence is prevented by proper foot hygiene, which includes keeping the feet dry and cool, gentle cleaning, drying between the toes, use of absorbent antifungal foot powder, frequent airing of affected areas, and avoidance of occlusive footwear and nylon socks or other fabrics that interfere with dissipation of moisture. In people with onychomycosis (tinea unguium), topical therapy should be used only when the infection is confned to the distal ends of the nail; however, even topical therapy for 48 weeks typically has a cure rate less than 50%. Studies in adults have demonstrated the best cure rates after therapy with oral itraconazole or terbinafne; however, safety and effectiveness in children has not been established. However, preferred treatment in adults is pulse therapy with terbinafne, 500 mg, daily, for 1 week each month for 2 months (fngernails) to 4 months (toenails). Guidelines for dosing of terbinafne for children are based on studies for tinea capitis and are weight based: children weighing 12 to 20 kg, 62. Removal of the nail plate followed by use of oral therapy during the period of regrowth can help to affect a cure in resistant cases. Public areas conducive to transmission (eg, swimming pools) should not be used by people with active infection. Because recurrence after treatment is common, proper foot hygiene is important (as described in Treatment). People should be advised to dry the groin area before drying their feet to avoid inoculating tinea pedis dermatophytes into the groin area. Toxocariasis may manifest only as asymptomatic eosinophilia or pulmonary wheezing. Characteristic manifestations of visceral toxocariasis include fever, leukocytosis, eosinophilia, hypergammaglobulinemia, and hepatomegaly. Other manifestations include malaise, anemia, cough, and in rare instances, pneumonia, myocarditis, and encephalitis. When ocular invasion (resulting in endophthalmitis or retinal granulomas) occurs, other evidence of infection usually is lacking, suggesting that the visceral and ocular manifestations are distinct syndromes. Visceral toxocariasis typically occurs in children 2 to 7 years of age often with a history of pica but can occur in older children and adults. Humans are infected by ingestion of soil containing infective eggs of the parasite. Eggs may be found wherever dogs and cats defecate, often in sandboxes and playgrounds. Direct contact with dogs is of secondary importance, because eggs are not infective immediately when shed in the feces. Microscopic identifcation of larvae in a liver biopsy specimen is diagnostic, but this fnding is rare. An enzyme immunoassay for Toxocara antibodies in serum, available at the Centers for Disease Control and Prevention and some commercial laboratories, can provide confrmatory evidence of toxocariasis but does not distinguish between past and current, active infection. This assay is specifc and sensitive for diagnosis of visceral larva migrans but is less sensitive for diagnosis of ocular larva migrans. In severe cases with myocardithis or involvement of the central nervous system, corticosteroid therapy is indicated. Infammation may be decreased by topical or systemic corticosteroids, and secondary damage decreased with surgery. Signs of congenital toxoplasmosis at birth can include a maculopapular rash, generalized lymphadenopathy, hepatomegaly, splenomegaly, jaundice, pneumonitis, diarrhea, hypothermia, petechiae, and thrombocytopenia. Some severely affected fetuses/infants die in utero or within a few days of birth. The classical triad of cerebral calcifcations, chorioretinitis, and hydrocephalus is rare but it is highly suggestive of congenital toxoplasmosis, and it is seen primarily in babies whose mothers were not treated for toxoplasmosis during gestation. Toxoplasma gondii infection acquired after birth may be asymptomatic, except in immunocompromised people. When symptoms develop, they are nonspecifc and include malaise, fever, headache, sore throat, arthralgia, and myalgia. Occasionally, patients may have a mononucleosis-like illness associated with a macular rash and hepatosplenomegaly. Myocarditis, myositis, hepatitis, pericarditis, pneumonia, and skin lesions are rare complications in the United States and Europe. However, these manifestations and more aggressive disease, including brain abscesses, life-threatening syndromes, and death, have been observed in immunocompetent people infected in certain tropical countries in South America, such as French Guiana, Brazil, and Colombia. Isolated ocular toxoplasmosis commonly results from reactivation of congenital infection but also occurs in people with acquired infection. Characteristic retinal lesions (chorioretinitis) develop in up to 85% of young adults after untreated congenital infection. Acute ocular involvement manifests as blurred vision, eye pain, decreased visual acuity, foaters, scotoma, photo phobia, or epiphora. The most common late fnding is chorioretinitis, which can result in unilateral vision loss. Ocular disease can become reactivated years after the initial infection in healthy and immunocompromised people. In this latter group of patients, the differential diagnosis should be widened to other pathogens, such as molds and nocardia. Seropositive hematopoietic stem cell and solid organ transplant patients are at risk of their latent T gondii infection being reactivated. In these patients, toxoplasmosis may manifest as pneumonia, unexplained fever, myocarditis, hepatosplenomegaly, lymphadenopathy, or skin lesions in addition to brain abscesses and diffuse encephalitis. T gondii-seropositive solid organ donors (D+) can transmit the parasite via the allograft to seronegative recipients (R-). Thirty percent of D+/Rheart transplant recipients develop toxoplasmosis in the absence of anti-T gondii prophylaxis. The term T gondii infection is reserved for the asymptomatic presence of the parasite in the setting of an acute or chronic infection. In contrast, the term toxoplasmosis should be used when the parasite causes symptoms and/or signs during the acute infection or reactivation of chronic infection in immunosuppressed patients. The tachyzoite and the host immune response are responsible for symptoms observed during the acute infection in humans or during the reactivation of a latent infection in immunocompromised patients. The tissue cyst is responsible for latent infection and usually is present in skeletal muscle, cardiac tissue, brain, and eyes of humans and other vertebrate animals. The oocyst is present in the small intestine of cats and other members of the feline family; it is responsible for transmission through soil, water, or food contaminated with infected cat feces. The seroprevalence of T gondii infection (a refection of the chronic infection and measured by the presence of T gondii-specifc IgG antibodies) varies by geographic locale and the socioeconomic strata of the population. The age-adjusted seroprevalence of the parasite in the United States has been estimated at 11%. Cats generally acquire the infection by feeding on infected animals (eg, mice), uncooked household meats, or water or food contaminated with their own oocysts. Cats may begin to excrete millions of oocysts in their stools 3 to 30 days after primary infection and may shed oocysts for 7 to 14 days. After excretion, oocysts require a maturation phase (sporulation) of 24 to 48 hours in temperate climates before they are infective by the oral route. Sporulated oocysts survive for long periods under most ordinary environmental conditions and can survive in moist soil, for example, for months and even years. Intermediate hosts (including sheep, pigs, and cattle) can have tissue cysts in the brain, myocardium, skeletal muscle, and other organs. Humans usually become infected by consumption of raw or undercooked meat that contains cysts or by accidental ingestion of sporulated oocysts from soil or in contaminated food or water. A large outbreak linked epidemiologically to contamination of a municipal water supply also has been reported. A recent epidemiologic study revealed the following risk factors associated with acute infection in the United States: eating raw ground beef; eating rare lamb; eating locally produced cured, dried, or smoked meat; working with meat; drinking unpasteurized goat milk; and having 3 or more kittens. In this study, eating raw oysters, clams, or mussels also was identifed as novel risk factor. Untreated water also was found to have a trend towards increased risk for acute infection in the United States.

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The thyroid gland is a butterfy-shaped endocrine gland When someone is frst started on thyroid hormone the that is normally located in the lower front of the neck antimicrobial effects of spices 12 mg stromectol otc. The physician will make stay warm and keep the brain, heart, muscles, and other sure the thyroid hormone dose is correct by performing a organs working as they should. Although these all contain the same synthetic T4, there are different inactive ingredients in each of 1. Suppression therapy is used primarily in of the change, so that your thyroid function can be repatients with thyroid cancer to prevent recurrence or checked. When thyroid hormone is used to treat Indeed, it is very important for pregnant women, or women hypothyroidism, the goal of treatment is to keep thyroid who are planning to become pregnant, to have normal function within the same range as people without thyroid thyroid function to provide the optimum environment for problems. The best time to take thyroid hormone is probably need an increased dose of thyroid hormone during their frst thing in the morning on an empty stomach. You should discuss the timing of thyroid blood is to be consistent, and take your thyroid hormone at the tests with your physician, but often thyroid function is same time, and in the same way, every day. Desiccated (dried and powdered) animal thyroid Sometimes taking your thyroid hormone at night can make (Armour), now mainly obtained from pigs, was the most it simpler to prevent your thyroid hormone from interacting common form of thyroid therapy before the individual with food or other medications. It is and therefore most patients require thyroid hormone for also available still as a prescription. If you miss a dose of thyroid hormone, it is usually best animal thyroid are not purifed, they contain hormones and to take the missed dose as soon as you remember. It is proteins that never exist in the body outside of the thyroid also safe to take two pills the next day; one in the morning gland. Yet other products can prevent the absorption of the full dose of thyroid hormone. These include iron, calcium, soy, certain antacids and some cholesterollowering medications. For all these reasons, it is important for people taking thyroid hormone to keep their physician up to date with any changes in the medications or supplements they are taking. T3 has a very short life span in the body, while Some people with normal thyroid blood tests have the life span of T4 is much longer, ensuring a steady symptoms that are similar to symptoms of hypothyroidism. A preparation of synthetic T3 (Cytomel) is Several scientifc studies have looked at whether T4 available. After taking a tablet of Cytomel there are very therapy would be of beneft to patients with symptoms that high levels of T3 for a short time, and then the levels fall off overlap with hypothyroid symptoms and normal thyroid very rapidly. In all cases, there was no difference between times each day, and even doing this does not smooth out T4 and a placebo (sugar pill) in improving symptoms or the T3 levels properly. Moreover, excess thyroid hormone can increase the risk of Some hormone preparations containing both T4 and T3 heart rhythm problems and bone loss making the use of are available in the United States (Thyrolar). Combination thyroxine for suppressing benign thyroid tissue more risky T4/T3 preparations contain much more T3 than is usually than benefcial in iodine suffcient populations. There has been interest in whether a needed both to replace the function of the removed combination of T4 and T3, with a lower amount of T3 given thyroid gland and to keep any small or residual more than once a day, might result in better treatment amounts of thyroid cancer cells from growing of hypothyroidism, especially in those patients that do (see Thyroid Cancer brochure). In these cases, suppression therapy is also an important part of the Cytomel (T3) is taken in addition to T4. In this case, the benefit of preventing the growth of residual thyroid cancer cells outweighs the risks of a mild increase in the risk of fast, irregular heart rhythms, exacerbation of chest pain and decreased bone density. The duration of suppression therapy in cancer patients is currently being debated. As an organization that strongly understand what the disease is about and what their specifc believes in providing prostate cancer patients, caregivers treatment options are. This includes a network of more than 200 support groups across National Alliance of State Prostate Cancer the country and abroad to help patients and caregivers make informed decisions on health care. It is a reliable wealth of important information about options and management of side efects at all phases of the prostate cancer, in a readable and understandable format. Success is achieved when men speak up, are engaged in their personal health and are not afraid to take action. By advancing research, encouraging action, and philanthropic organization dedicated to funding life-saving providing educational support, we can create Generation cancer research. It serves as a foundation of knowledge as patients and families begin to discuss options with their health care provider. The prostate is found below the bladder near this will help you prepare and plan for the base of the penis and in front of the rectum. The urethra is a tube that carries urine from the bladder and the prostate is a walnut-sized gland. Above the prostate and behind is an organ that makes fuids or chemicals the the bladder are two seminal vesicles. The prostate gland produces a vesicles are also glands that make a fuid that is white-colored fuid that is part of semen. Semen leaves the body through is made up of sperm from the testicles and fuid the urethra. As a result, Cancer is a disease that starts in the cells of treatment will often focus on reducing the your body. Prostate cancer starts in the cells of amount of testosterone in the body or blocking the prostate gland. Facts about prostate cancer Unlike normal cells, cancer cells can grow or A risk factor is anything that increases your spread to form tumors in other parts of the chance of cancer. The older a man is, the greater the chance of Cancer can spread to distant sites through getting prostate cancer. Prostate cancer can metastasize in the bones, lymph nodes, liver, lungs, and other African-American men organs. All men are at risk for prostate cancer, but African-American men are more likely to get Cancer can also spread through lymph. Lymph travels throughout the body in a diagnosed, African-Americans have similar network of small tubes called lymph vessels. Family history Usually, prostate cancer grows slowly and Men who have a family member with prostate stays in the prostate. However, some prostate cancer have a greater chance of getting cancers grow and spread quickly. Physical exam Testing is used to fnd and treat prostate A physical exam is a study of your body. A overview of tests you might receive and doctor will check your body for signs of disease. A health care provider will: fi Check your temperature, blood pressure, pulse, and breathing rate General health tests fi Weigh you Medical history fi Listen to your lungs and heart Before and after cancer treatment, your fi Look in your eyes, ears, nose, and throat doctor will look at your medical history. A medical history is a record of all health issues fi Feel and apply pressure to parts of your and treatments you have had in your life. Your doctor will ask about the Imaging tests health history of family members who are blood relatives. This information is called a Imaging tests take pictures of the inside of your family history. Doctors can see the primary the family about all cancers, not just prostate tumor, or where the cancer started, and look for cancer. The radiologist will send this report to your doctor who will discuss the results with you. All of the images are x-rays to take pictures from many angles combined to make one detailed picture.

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This mindset began to change when boards of nursing petitioned state legislatures to approve diversion legislation virus of the heart stromectol 3 mg online. The new legislation made it possible to offer treatment to addicted nurses without having a negative impact on their licenses as long as they continued to meet certain requirements. Forty-one states, the District of Columbia, and the Virgin Islands have since developed programs to channel nurses with a substance use disorder into treatment and recovery programs, monitor their return to work and prevent their licenses from being revoked or suspended. Purpose of the Manual the purpose of the Substance Use Disorder in Nursing manual is to provide practical and evidence-based guidelines (Appendix A) for evaluating, treating and managing nurses with a substance use disorder. The authors developed the guidelines by conducting an exhaustive review of the research literature on alcohol and drug abuse and surveying alternative to discipline programs to assess their current practices. The result is a comprehensive resource of the most current research and knowledge synthesized from both the literature and the feld. While the manual was developed for alternative to discipline programs and boards of nursing in an effort to enhance program content and its delivery, it also provides essential theoretical and practical guidelines for clinicians, educators, policymakers and public health professionals. Information on prevention, detection and intervention of substance use disorder cases is presented. The manual also contains key research fndings, guidelines and program recommendations and provides examples of model contracts, forms and reports. An extensive body of scientifc evidence shows that approaching addictions as a treatable illness is extremely effective fnancially and across the broader societal impacts. When treatments for nurses are individually tailored to meet their needs and an appropriate supportive monitoring system is in place, then recovering nurses are not impaired and can practice safely. It is the hope of the National Council of State Boards of Nursing that this manual will be a helpful tool that can be used to implement better practices in helping the healers to heal themselves and at the same time helping to protect the public. Introduction and Purpose 3 Use of Terms Throughout this manual the term substance use disorder is used more often instead of terms such as chemical dependency or addiction. The labels given to people with alcohol and drug problems can contribute to the stigmatization, de-medicalization and criminalization of those problems (White, 2007). For example, recent research found that when an individual was referred to as a substance abuser versus having a substance use disorder they were more likely to be thought of as personally culpable and therefore punitive rather than therapeutic measures could be taken (Kelly, Dow, & Westerhoff, 2009). On the contrary, a nurse with a substance use disorder can be high-functioning and high-achieving. A confdential program means that all records regarding an individual participating in the alternative program are not shared with the board of nursing, employers, treatment providers, boards of nursing in other states or the public unless agreed to by the participant through the contract or signed consent to release information. Non-public is used in this manual to mean that all information including but not limited to reports, memoranda, statements, interviews or other documents either received or generated by the program shall remain privileged and confdential and participation in the alternative program is not disclosed to the public but is known by the board of nursing and can be required to be shared with employers, treatment providers and other state boards of nursing. Interventions in response to chemically dependent nurses: Effect of context and interpretation. The word addiction is often Iused as an umbrella term to describe a group of problems that can be broken out into drug addiction, alcoholism, substance use disorder and chemical dependence. Increasingly, addiction is also used to describe many pleasure-producing and compulsive behaviors. As the dependence or addiction progresses the benefts of using substances diminish and more drugs or alcohol are needed to feel the same level of pleasure. Both are believed to have a genetic component that is infuenced by environmental and social factors. The more risk factors a person has, the greater the chance that the use of alcohol and drugs will result in addiction. A human brain is more vulnerable during the developmental stages, which continues into adulthood. Therefore, using mind-altering substances in childhood or adolescence interferes with the normal development of brain function as well as other delicate systems. Using mind-altering substances through injection or inhalation has an even stronger and more immediate effect. The brain receives a signifcant and often deadly jolt of stimulation which alters the brain neurochemistry. However, ingestion will at least give the body time to metabolize the substance and lead to a somewhat mitigated infuence on the central nervous system. For nurses, the long hours, extra shifts, staffng shortages and shift rotations pose a unique challenge. The ready availability of medications and issues with the administration of narcotics can be liabilities for some nurses as well. Overall risk factors, especially those that tend to make all individuals more susceptible to developing a substance use disorder have been divided into general categories. Later, as the disease of addiction progresses they may use these substances again to feel normal or to attenuate negative symptoms of withdrawal and cravings. However, the desire to recreate the positive feelings is the primary factor behind drug dependence even though research has demonstrated that tolerance to a particular substance can develop, which requires a higher dose to achieve the same desired effect. Impulses move from the middle of the brain (limbic system) to the forebrain (the thinking center of the brain) and back again, releasing neurochemicals that infuence and modulate brain activity. Dopamine is a naturally occurring, mind-altering substance and one of the essential neurotransmitters in the brain whose higher levels produce the feeling of euphoria associated with other imbibed mind-altering substances. The short term use of mind-altering chemicals can cause temporary deregulation of the neurotransmitters in the brain and are expressed by some unique and usually temporary behaviors. Long term use can often cause permanent changes in the neuroregulatory system in the brain with resultant negative behaviors. The neuroregulatory changes that occur in drug addicts and alcoholics serve to reset their brain reward systems outside of normal societal limits. This leads to a loss of control over the use of mind-altering substances and the development of the compulsive use of such substances despite negative consequences (Koob & LeMoal, 2008). General symptoms of substance use problems include defensiveness, isolation, irritability and diffculty following through on work assignments. Signs and symptoms of a prescription-type substance use disorder can include coming to work on days off and volunteering for overtime. Coming to work while on vacation can suggest the need to divert prescription drugs from clinical supplies. Unfortunately, others can misinterpret these behaviors as dedication to duty by the employee which leaves the substance use disorder unrecognized. Nurses with a substance use disorder can also display suspicious behaviors surrounding incorrect narcotic counts, may consistently volunteer to administer medications, wait to be alone to open a narcotic cabinet and may lack witnesses to verify the wasting of unused medications. Nurses with an untreated addiction can jeopardize patient safety because of impaired judgment, slower reaction time, diverting prescribed drugs from patients for their own use, neglect of patients and making a variety of other errors (Dunn, 2005). Nurses who suspect a substance use disorder in co-workers need to be provided with guidelines and a clear process for reporting their concerns in a discreet and non-threatening manner (Tirrell, 1994). This will increase the likelihood that substance use problems are detected earlier and dealt with appropriately. If nurses do not have a clear process for acting on concerns about a colleague they may attempt to cover up for the person instead, which can contribute to the danger for the affected nurse as well as for patients (Serghis, 1999). Data also indicate that the likelihood of successful treatment outcomes is higher when treatment is implemented earlier in the addiction process (Martin, Schaffer, & Campbell, 1999). Giving a staff the proper information for reporting and rehabilitation can also lead to other benefts. Torkelson, Anderson & McDaniel, (1996) found that organizations where the problem of nurses with a substance use disorder were not perceived as threatening promoted a culture of openness, participation and professionalism. In addition, such organizations were more likely to refer, reintegrate and hire recovering nurses with a substance use disorder. This was still true after controlling for hospital vacancy rate as a variable in the study.