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It is important to remember that veins have valves and that these must be accounted for when a vein is going to be used as an arterial conduit buy kamagra polo 100 mg overnight delivery. Endovascular procedures have been around since the early 1960s proven 100mg kamagra polo, but they have been reﬁned over the past decade proven kamagra polo 100mg. Most of these proce- dures can be performed percutaneously and therefore obviate the need for an incision and the associated pain cheap 100 mg kamagra polo with visa, healing, and recovery. Many endovascular procedures, therefore, readily can be done using only local anesthesia or in combination with mild sedation. Most of the techniques are preformed with a guidewire technique devised originally by Seldinger. These are all in a state of evolution, but there is growing evidence to support their use in properly selected patients (Table 28. Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibialperoneal revascularization. Durability of the in situ saphenous vein arterial bypass: a com- parison of primary and secondary patency. Randomization of autogenous vein and polytetraﬂuoroethylene grafts in femoral-distal reconstruction. Improved patency in reversed femoral-infrapopliteal autogenous vein grafts by early detection and treatment of the failing graft. Successful vein bypass in patients with an ischemic limb and a palpable popliteal pulse. Results of revascularization and amputation in severe lower extremity ischemia: a ﬁve-year clinical experience. Short-term and midterm results of an all-autogenous tissue policy for infrainguinal reconstruction. Infrapopliteal arterial bypass for limb salvage: increased patency and uti- lization of the saphenous vein used “in situ. Long-term results of infragenicular bypasses with autogenous vein originating from the distal superﬁcial femoral and popliteal arteries. Autogenous reversed vein bypass for lower extrem- ity ischemia in patients with absent or inadequate greater saphenous vein. Present status of reversed vein bypass grafting: ﬁve-year results of a modern series. Inﬂuence of Losartan, an angiotensin receptor antag- onist, on neointimal proliferation in cultured human saphenous vein. Six-year prospective multicenter randomized comparison of autologous saphe- nous vein and expanded polytetraﬂuoroethylene grafts in infrainguinal arterial reconstructions. Percutaneous transluminal angioplasty of the arteries of the lower limbs: a 5-year follow-up. Percu- taneous transluminal angioplasty of the femoropopliteal artery: initial and long-term results. Results of percutaneous transluminal angioplasty for peripheral vascular occlusive disease. Case Discussion The most appropriate ﬁrst step in dealing with the presented patient would be to anticoagulate her with systemic heparin. If she is a rea- sonable operative candidate, then one could go to the operating room and, under local anesthesia, perform a diagnostic angiogram. Depend- ing on the ﬁndings, a decision could be made as to whether the ischemia could be resolved with either endovascular techniques (e. Caution should be taken, however, to avoid lengthy emergent surgical procedures on these very elderly patients with signiﬁcant comorbidities. Summary Lower leg ischemia as a manifestation of peripheral arterial disease is common. Patients, like the patient in our case, may present with acute ischemia and warrant more aggressive management. The level of intervention, however, always must be tailored to the overall condition of the patient. Given the presences of signiﬁcant comorbidities in our patient, signiﬁcant caution is warranted before 510 R. Fortunately, with the advent of less invasive endovascular techniques, vascular interven- tionalists have more and potentially safer options. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. To describe the diagnosis, workup, and manage- ment options for symptomatic varicose veins and venous ulcers. The left leg is somewhat larger on exam than the right leg, but, other than a sensation of “fullness,” the patient denies any discomfort. History and Physical Examination As in all things that pertain to patient care, the history and the phys- ical exam are the cornerstones to getting at the etiology of the swollen leg. Giving the patient adequate time to explain the problem is critical and frequently can save valuable time and useless diagnostic studies. Of critical importance, however, is obtaining a sense of the immediacy of the problem. Once the timing of the swelling is ascertained, then a relatively simple thought process can be followed. The physical exam is critically important in the evaluation of the swollen leg, and, while not 100% accurate, it helps narrow the differ- ential diagnosis of the problem. The chronic nature of the situa- tion may alter somewhat the aggressiveness of the workup. Things to focus on include any obvious trauma, evidence of infection, or bony abnormality. Ultimately, one must decide if the swelling is systemic in nature, due to a vascular (venous) abnormality, or secondary to lymphedema. The unilateral nature of the swelling described by the patient in the case presented leads one to think that the etiology of the swelling is not systemic in nature. Systemic conditions like obesity or congestive heart failure generally lead to bilateral lower extremity swelling. Head and neck evaluation, with particular attention to the presence or absence of jugular venous distention, is important. Documentation of any masses may be telling when considering the etiology of venous or thromboembolic disease. The chest exam is important with regard to the presence or absence of rales or rhonchi. The presence of abdominal masses, which may be a source of venous or lymphatic obstruction, must be noted. Abdominal masses also may be indicative of an intraabdominal tumor and therefore a nidus for a hypercoaguable state. Checking the patient’s stool for occult blood also is important as an indicator of a possible neoplasm but also in planning therapy, particularly if anticoagulation is indicated. Obesity, a frequent cause of a “swollen” extremity, frequently is overlooked or disregarded as an etiology. Unilateral swelling, as in the case patient, certainly could be due to an intrabdominal mass or deep venous thrombosis. This implies that the swelling is bilateral in nature or that the “swelling” may be due to some other process. The nature of the swelling, the presence or absence of edema, the nature of the edema, the evidence of trauma, cellulitis, the nature and texture of the skin, the presence of ulcerations, and the locations and nature of the ulcerations all are important to document. The presence of pain, the location of pain, and the presence or absence of varicosi- 514 R. Incidence rate of clinically recognized deep vein thrombosis and/or pulmonary embolism per 100,000 population. The increase in rates for both male and female patients is well approximated by an exponential func- tion of age. A population-based perspective of the hospital incidence and case- fatality rates of deep venous thrombosis and pulmonary embolus. While arterial insufﬁciency rarely presents as swelling, the presence of peripheral pulses is important to document. Acute versus Chronic When the history obtained from the patient indicates that the swelling has occurred acutely, the differential veers toward disease processes that need to be diagnosed quickly and treated aggressively. Rudolf Virchow, a 19th century pathologist, surmised that three conditions tended toward thrombosis: intimal injury, stasis of blood ﬂow, and a hypercoaguable state. These observations have stood the test of time and are as true today as they were in Virchow’s time.
Investigation of Minor Bleeding Passage of small amounts of bright red blood per rectum cheap kamagra polo 100mg without a prescription, either mixed with or on the surface of the stool generic kamagra polo 100 mg line, can occur discount 100mg kamagra polo. When the bleeding is obvious and bright red best 100mg kamagra polo, it can be assumed that the blood loss is within or distal to the left colon. If there is obviously an anorectal cause in a young healthy patient, no further workup is necessary. In patients older than 40 years, in patients with a family history of colon cancer, and in patients in whom there is no obvious bleeding source by anoscopy or sigmoidoscopy, an elective colonoscopy fol- lowing a complete bowel prep is warranted. This is the best test because it is the most sensitive and speciﬁc for the detection of mucosal abnormalities or neoplasms. Alternately, a barium enema and sigmoi- doscopy could be performed if a colonoscopy cannot be performed. Bleeding is considered massive if transfusions of three to ﬁve units of blood are required to maintain hemodynamic stability within the ﬁrst 24 hours. The most likely source of bleeding in this instance is from diverticular disease (30–50%), with the remainder being from angiodysplasia (20–30%). An attempt always should be made to iden- tify the bleeding source prior to surgical intervention. If the bleeding is brisk, angiography is more likely to be positive, allowing embolic or vasoconstrictive therapy for deﬁnitive manage- ment. The mortality in the group of patients who require emergency surgery without diagnostic information is extremely high, often approaching 30% to 50% because of the require- ment for total colectomy. Hemorrhoids causing massive bleeding can be managed by banding or suture ligation. Surgical Management: The indications for surgery and the choice of operation remain controversial and require good clinical judgment. Efforts to localize the bleeding source are maximized to allow ther- apeutic intervention as mentioned and to direct a segmental resec- tion if a colectomy is necessary. Gastrointestinal Bleeding 371 hemorrhage controlled, then elective segmental resection may be carried out based on an assessment of the patient’s risks and the risks of rebleeding. An aggressive surgical approach often is advocated by those that argue that these patients often are elderly and tolerate rapid blood loss poorly because of medical comorbidities. However, the natural history of a bleeding source that has been controlled by pitressin or embolization is undeﬁned. Urgent segmental colectomy is indicated after localization if the bleeding cannot be controlled with the nonoperative measures, if the patient rebleeds during the same hospitalization, if blood products are limited or unavailable while awaiting spontaneous cessation, or if the patient refuses a transfu- sion (e. Blind total colectomy may be necessary when there is massive hemorrhage and when the lesion cannot be localized preoperatively or with intra- operative techniques. Recurrent bleeding after total colectomy approaches zero, but the morbidity of frequent loose bowel move- ments, in the elderly in particular, is not insigniﬁcant. Diverticular Bleeding: Bleeding can be expected to occur in 15% to 20% of patients with diverticulosis. The source of the bleeding generally is right sided (60%), even though diverticula generally are present on the left, and the source typically is a single diverticulum. The majority of patients (70–82%) stop bleeding, but 12% to 30% continue to bleed and require interven- tion. The cause of the hemorrhage appears to be erosion into the vasa recta that courses along the diverticula. Patients with diverticular hemorrhage frequently present with self- limited, minor episodes of bleeding. Patients often describe intermit- tent passage of bright red or maroon blood per rectum. Physical exami- nation usually is unremarkable, and evidence of abdominal tenderness is absent. Treatment for persistent or recurrent bleeding from a known diverticular source traditionally is to remove the affected segment of colon. Although bleeding generally is considered to be from a single vessel, endoscopic electrocoagulation has been consid- ered to carry a high risk of perforation of the adjacent diverticulum. Most of these lesions remain asymptomatic and typically occur in the elderly population, with the average age being 70. There- fore, the best diagnostic tool remains visceral angiography, which reveals a tortuous knot of blood vessels, sometimes with early ﬁlling of a large vein. Corbett rebleeding from these lesions is high, with patients often experiencing three to ﬁve bleeding episodes before a diagnosis is made. Angiodys- plasias can be managed successfully by colonoscopy and treated by endoscopic electrocoagulation. Neoplasms: In recent series, the incidence of massive colonic bleeding from ulcerated carcinomas or polyps ranged from 6% to 32%. Polyps may be amenable to endoscopic removal, but most carcinomas require resection. Inﬂammatory Bowel Disease: Although ulcerative colitis and Crohn’s disease both are characterized by bleeding and diarrhea, massive bleeding is quite uncommmon, representing only about 3% to 5% of those presenting with massive hematochezia. Ischemic Colitis: Ischemic colitis is the most common form of intestinal ischemia. It is thought to affect “watershed” areas of the colon where two blood supplies may incompletely overlap: the splenic ﬂexure sup- plied by the left branch of the middle colic artery and the ascending left colon. The severity of injury appears to be related to multiple factors includ- ing duration of ischemia, vessel caliber, acuity of ischemia onset, col- lateral circulation, and virulence of intestinal bacteria. The onset may be insidi- ous, not recognized, or attributed to the medical comorbidities. Onset of acute colonic ischemis is heralded by the sudden onset of crampy abdominal pain. This may be associated with bloody diarrhea, fever, abdominal distention, anorexia, nausea, or vomiting. Physical exam may reveal abdominal distention and tenderness over the involved segment. With transient intestinal ischemia, superﬁcial sloughing of the mucosa, submucosal hemorrhage, and edema generally resolve within 1 to 2 weeks without permanent sequelae. The bleeding scan is performed and within 15 minutes suggests an area of active hemor- rhage in the right colon. Arteriography conﬁrms the location of the bleeding site in the ascending colon, originating from a single vessel. The following day, after receiving a gentle bowel prep, a colonoscopy is performed. The procedure demonstrates numerous diverticuli in the descending and sigmoid colon. Patients who have evidence of massive blood loss should be resuscitated immediately. A careful history and a physical exam may provide clues to the etiology of the hemorrhage. If the patient is stabilized in the emergency room and hematemesis or bloody nasogastric aspirate has been documented, upper endoscopy is the standard of care for diagnosis and for segregating patients into low- and high-risk groups. Endoscopic treatment of those with major stigmata of ulcer hemorrhage is recommended. Surgical consultation should be obtained and the likelihood for surgical intervention will depend on the etiology of the bleed. The ﬁrst step in management of patients who present with rectal bleeding, stable or unstable, is a rigid sigmoidoscopy to exclude rectal lesions as a cause. If the patient is stable but has evidence of ongoing bleeding and the sigmoidoscopy is unrevealing, angiography and radionuclide scanning can be consid- ered, with radionuclide scanning being the preferred ﬁrst test. The major- ity of patients with bleeding diverticula (70–82%) stop bleeding, but 12% to 30% continue to bleed and require intervention. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. To recognize surgical conditions that require further evaluation and eventual operation. Cases Case 1 A 78-year-old man with a history of myocardial infarction and coro- nary artery bypass surgery is brought to the hospital by ambulance because of severe abdominal pain that suddenly began 6 hours ago. The patient is confused and disoriented, but he indicates that the pain is excruciating. The patient’s wife reports that he had an urgent desire to defecate when the pain began, but no further stool or ﬂatus has been noted. She provides a list of current medications that includes digoxin, pindolol (a beta-blocker), a baby aspirin, and a nitrate patch.
The cause may be neurologic (head injury quality kamagra polo 100mg, stroke) order 100mg kamagra polo overnight delivery, toxicologic (drug overdose discount 100mg kamagra polo with mastercard, alcohol intoxication) 100 mg kamagra polo otc, or metabolic (hepatic or renal failure, diabetic ketoacidosis). Nursing Process: The Care of the Patient with Altered Level of Consciousness— Assessment • Assess verbal response and orientation • Alertness • Motor responses • Respiratory status • Eye signs • Reflexes 343 • Postures • Glasgow Coma Scale Decorticate and Decerebrate Posturing Abnormal posture response to stimuli. Maintaining fluid status –Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O. Promoting Bowel and Bladder Function • Assess for urinary retention and urinary incontinence • May require indwelling or intermittent catherization • Bladder-training program • Assess for abdominal distention, potential constipation, and bowel incontinence • Monitor bowel movements • Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated • Diarrhea may result from infection, medications, or hyperosmolar fluids 346 6. Monitor I&O, weight, blood glucose, serum and urine electrolyte levels, and osmolality and urine specific gravity. The patient is asked to identify the day, date, or season of the year and to identify where he or she is or to identify the clinicians, family members, or visitors present. The nurse assesses for periorbital edema (swelling around the eyes) or trauma, which may prevent the patient from opening the eyes, and documents any such condition that interferes with eye opening. Motor response includes spontaneous, purposeful movement (eg, the awake patient can move all four extremities with equal strength on command), movement only in response to painful stimuli, or abnormal posturing (Hickey, 2003; Seidel, Ball, Dains, et al. If the patient is not responding to commands, the motor response is tested by applying a painful stimulus (firm but gentle pressure) to the nailbed or by squeezing a muscle. If the patient attempts to push away or withdraw, the response is recorded as purposeful or appropriate (―patient withdraws to painful stimuli‖). This response is considered purposeful if the patient can cross the midline from one side of the body to the other in response to painful stimuli. The motor response cannot be elicited if the patient has been administered pharmacologic paralyzing agents. Table 61-1 summarizes the assessment and the clinical significance of the findings. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and ongoing manner. Additional goals include bowel continence, accurate perception of environmental stimuli, maintenance of intact family or support system, and absence of complications (Rice et al. The nurse must assume responsibility for the patient until the basic reflexes (coughing, blinking, and swallowing) return and the patient becomes conscious and oriented. Therefore, the major nursing goal is to compensate for the absence of these protective reflexes. Obstruction of the airway is a risk because the epiglottis and tongue may relax, occluding the oropharynx, or the patient may aspirate vomitus or nasopharyngeal secretions. Because the patient cannot swallow and lacks pharyngeal reflexes, these secretions must be removed to eliminate the danger of aspiration. Positioning the patient in a lateral or semiprone position also helps, because it permits the jaw and tongue to fall forward, thus promoting drainage of secretions. Suctioning is performed to remove secretions from the posterior pharynx and upper trachea. Before and after suctioning, the patient is hyperoxygenated and adequately ventilated to prevent hypoxia (Hickey, 2003). The chest should be auscultated at least every 8 hours to detect adventitious breath sounds or absence of breath sounds. Nursing actions for the mechanically ventilated patient include maintaining the patency of the endotracheal tube or tracheostomy, providing frequent oral care, monitoring arterial blood gas measurements, and maintaining ventilator settings (see Chapter 25). Two rails are kept in the raised position during the day and three at night; however, raising all four side rails is considered a restraint by the Joint Commission on Accreditation of Healthcare Organizations. Care should be taken to prevent injury from invasive lines and equipment, and other potential sources of injury should be identified, such as restraints, tight dressings, environmental irritants, damp bedding or dressings, and tubes and drains. The comatose patient has an increased need for advocacy, and the nurse is responsible for seeing that these advocacy needs are met (Hickey, 2003). The quantity of fluids administered may be restricted to minimize the possibility of cerebral edema. If the patient does not recover quickly and sufficiently enough to take adequate fluids and calories by mouth, a feeding or gastrostomy tube will be inserted for the administration of fluids and enteral feedings (Dudek, 2006; Worthington, 2004). Providing Mouth Care The mouth is inspected for dryness, inflammation, and crusting. The unconscious patient requires conscientious oral care, because there is a risk of parotitis if the mouth is not kept scrupulously clean. The mouth is cleansed and rinsed carefully to remove secretions and crusts and to keep the mucous membranes moist. A thin coating of petrolatum on the lips prevents drying, cracking, and encrustations. If the patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips. Maintaining Skin and Joint Integrity Preventing skin breakdown requires continuing nursing assessment and intervention. Special attention is given to unconscious patients, because they cannot respond to external stimuli. Assessment includes a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin. Turning also provides kinesthetic (sensation of movement), proprioceptive (awareness of position), and vestibular (equilibrium) stimulation. After turning, the patient is carefully repositioned to prevent ischemic necrosis over pressure areas. Dragging or pulling the patient up in bed must be avoided, because this creates a shearing force and friction on the skin surface (see Chapter 11). Maintaining correct body position is important; equally important is passive exercise of the extremities to prevent contractures. The use of splints or foam boots aids in the prevention of foot drop and eliminates the pressure of bedding on the toes. The use of trochanter rolls to support the hip joints keeps the legs in proper alignment. The arms are in abduction, the fingers lightly flexed, and the hands in slight supination. Specialty beds, such as fluidized or low-air- loss beds, may be used to decrease pressure on bony prominences (Hickey, 2003). Preserving Corneal Integrity Some unconscious patients have their eyes open and have inadequate or absent corneal reflexes. The eyes may be cleansed with cotton balls moistened with sterile normal saline to remove debris and discharge (Hickey, 2003). Cold compresses may be prescribed, and care must be exerted to avoid contact with the cornea. Eye patches should be used cautiously because of the potential for corneal abrasion from contact with the patch. If body temperature is elevated, a minimum amount of bedding—a sheet, small drape, or towel—is used. However, if the patient is elderly and does not have an elevated temperature, a warmer environment is needed. Because of damage to the temperature center in the brain or severe intracranial infection, unconscious patients often develop very high temperatures. Such temperature elevations must be controlled, because the increased metabolic demands of the brain can exceed cerebral circulation and oxygenation, resulting in cerebral deterioration (Diringer, 2004; Hickey, 2003). Persistent hyperthermia with no identified clinical source of infection indicates brain stem damage and a poor prognosis. The bladder is palpated or scanned at intervals to determine whether urinary retention is present, because a full bladder may be an overlooked cause of overflow incontinence. If the patient is not voiding, an indwelling urinary catheter is inserted and connected to a closed drainage system. A catheter may also be inserted during the acute phase of illness to monitor urinary output. Because catheters are a major factor in causing urinary tract infection, the patient is observed for fever and cloudy urine. The urinary catheter is usually removed if the patient has a stable cardiovascular system and if no diuresis, sepsis, or voiding dysfunction existed before the onset of coma.
W hen a lack of cohesion exists kamagra polo 100mg sale, staff members Training should be offered for all staff mem- risk burnout generic 100mg kamagra polo with visa, disillusionment generic 100mg kamagra polo, or cynicism buy kamagra polo 100mg low cost. 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. One way to address negative staff Federal and State attitudes is to include successful patients in agencies and profes- training (Bell 2000). Training should ensure that staff events and resource dards require members are knowledgeable about drug materials abuse trends in the community. Staff members should have allow staff from access to generic skills training such as crisis smaller programs to attend their sessions. The importance ing organizations, such as the Association for of emphasizing sensitivity to patient needs Addiction Professionals, and professional should be reviewed periodically. A program physician might members, often the first to speak with patients, educate staff members about the etiology play an important role. A random-callback policy Control Plans avoids patient complaints of being unfairly Federal opioid treatment standards state that ìpicked onî by staff members. All scheduled that patients can substances should be accounted for rigorously the possibility of store medications and inventoried continuously. All from receipt through dispensing and measured take-home medica- at the beginning and end of each workday. W ithin the dispensary, remains misunderstood even among some employees should open the safe or work with health care professionals. Some treatment Transition in Federal oversight of substance providers have overcome community opposi- abuse treatment from the U. Having ade- Children and Family Services, Joint quate onsite staff is equally important in avoid- Commission on Accreditation of Healthcare ing and resolving community problems. Glezen Organizations, National Commission for and Lowery (1999) provide other practical Correctional Health Care, State of Missouri guidelines for addressing community concerns Department of Mental Health Division of about substance abuse treatment facilities. Alcohol and Drug Abuse, and W ashington Community opposition can be triggered when State Department of Social and Health Services community groups believe that they have been Division of Alcohol and Substance Abuseó informed or consulted insufficiently. The relations with the payer community (Edmunds availability of public transportation is impor- et al. Adding designed, and operated in accordance with alternative care models and longer acting accreditation standards, Federal guidelines, pharmacotherapies to the services continuum and State and local licensing, approval, and can decrease loitering, illicit transactions, ille- operating requirements. Staff and patients from the parent organizationís community should be part of a multifaceted, proactive effort relations department. Although program contacts w ith com m unity activities differ in specificity and scope, a Personal contact with community leaders per- community relations plan should address the mits open dialog, information sharing, and dis- following: cussion of community developments, needs, and problems. Occasional becoming increasingly instrumental in empow- press releases can ering patients as active participants in public community notify the public relations, community outreach, and program about specific support initiatives and in local, State, and services demon- services, activities, national community education efforts. Staff members with community improvement and and the general development expertise can support other public. A program organizations in advocacy, promotional, and counter negative support efforts. Consenting patients and staff can professional journals, sponsoring or research organize projects such as community cleanups institutions, provider coalitions, advocacy and neighborhood patrols. Such affilia- Improvement Exchange tions augment community relations efforts ï W hite House Office of National Drug Control through increased professional education and Policy (www. These forums also may present patient advisory committees, patient family 234 Chapter 14 community relations models that can be adapt- an outgrowth of providing service to the public. These patrols should features have been produced, providing impor- emphasize observation, not intervention. Logs tant, accurate information to the public about summarizing observations should be main- the science and policy of opioid addiction and tained. Media outreach can demystify treat- ment programs to provide increased treatment ment, counteract stigma, and improve fairness intensity. Communications should be logged, and staff participation in community events should be Decisions to discharge patients for loitering summarized. Letters and communications should balance consequences for the individual substantiating community complaints and the patient and public health against the need to programís followup should be on file. Confidentiality Medicine hold national and regional confer- remains paramount, so this relationship should ences that bring together treatment providers, be delineated carefully. A database explain how to improve their current treatment should be developed and updated (e. Other number and nature of community complaints sessions may focus on improving staff attitudes 236 Chapter 14 and the treatment system regarding implemen- opportunities of those stigmatized. For example, one application of commercial marketing conference, Blending Clinical Practice and technologies to programs to change social atti- ResearchóForging Partnerships To Enhance tudes. This publication proposed a unique Drug Addiction Treatment, held in April 2002 national approach to reducing stigma that (National Institute on Drug Abuse 2002), incorporates science-based marketing research, incorporated a special forum focused on the a social marketing plan, facilitation and sup- mediaís role in presenting addiction treatment port of grassroots efforts by the recovery and research issues in the context of science community, and promotion of the dignity of reporting. Performance outcome evaluation atic use of prescription drugs focuses on results, for example, patient ï reducing or eliminating associated criminal progress. Process evaluation focuses on how activities results were achievedóthe active ingredients ï reducing behaviors contributing to the spread of treatment. This improvements as guideposts and avoid terms simple evaluation would require only atten- such as ìsuccessî and ìfailure. Such a study can set a baseline and provide a bench- Process evaluation mark to evaluate the effects of changes in pro- gram practices, for example, prescribing indi- Process evaluation describes what is happening vidually appropriate dosages for patients. A process evaluation documents skills, employment, family relationships, and what actually happens during an intervention, social activities. For they take, specific problems and barriers example, evaluation of a treatment initiative encountered, strategies used to overcome these designed to reduce substance use, decrease problems and barriers, and necessary modifi- criminal involvement, and increase job skills cations to the original plan. Black patientsí use of emergency rooms for medical box, a commonly used term in this context (Ball care) to assess whether it has had other effects and Ross 1991, p. Clearinghouse for Alcohol and Drug Abuse Information at 800-729-6686 or A process evaluation can serve as a manage- www. For Substance Abuse Treatment ProgramsóA example, if a goal is to facilitate patientsí use of Manual is available at www. The process evaluation also can Outcome Measurement Resource Network that measure the intensity and duration of services is available through national. Community reinforcement approach and relapse prevention: 12 and 18 month follow-up. Long-term therapy with benzodiazepines despite alcohol dependence disorder: Seven cases reported. Psychiatric disorders in first- degree relatives of patients with opiate dependence. Prediction of 7-months methadone maintenance response by four measures of antisociality. Efficacy of daily and alternate-day dosing regimens with the combination buprenorphine- naloxone tablet. Thrice-weekly supervised dosing with the combination buprenorphine-naloxone tablet is pre- ferred to daily supervised dosing by opioid-dependent humans. Suicide: Understanding and Helping the Causes and rates of death among methadone Suicidal Person. W ound botulism associated with black patients with hepatitis B or hepatitis C virus tar heroin. International Journal of the Treatment of Drug Abuse: Research and Addictions 30(9):1177ñ1185, 1995. A risk-benefit analysis Journal of Health and Social Behavior of methadone maintenance treatment.