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By: Leonard S. Lilly, MD

  • Professor of Medicine, Harvard Medical School, Chief, Brigham and Women's/Faulkner Cardiology, Brigham and Women's Hospital, Boston, Massachusetts


Psychosocial treatments As noted previously allergy testing honolulu cheap cetirizine 10 mg overnight delivery, psychosocial treatments for opioid-related disorders have been studied only in programs that also provide maintenance treatment with either opioid agonists allergy wheat purchase cetirizine 5 mg. These findings were essentially replicated in three communitybased methadone maintenance clinics (218) allergy medicine behavior problems cetirizine 10mg cheap. Patients who received counseling and contingencies based on urine test results allergy medicine name brand buy 10 mg cetirizine, in addition to methadone, had better drug use outcomes than those who received methadone only. Patients who in addition received on-site general medical and psychiatric care, employment services, and family therapy had the best outcomes of all three conditions. In these studies, a reinforcer (reward) is provided to patients who demonstrate specified target behaviors such as providing drug-free urine specimens, accomplishing specific treatment goals, or attending treatment sessions. Stitzer and colleagues (197­199) have done extensive work in evaluating methadone take-home privileges as a reward for decreased illicit drug use. In a series of well-controlled trials, these researchers have demonstrated 1) the relative benefits of positive. Silverman and colleagues (195, 1295), drawing on the compelling work of Higgins and colleagues (described below), evaluated in a series of studies the efficacy of a voucher-based contingency management system to address concurrent illicit drug use (typically cocaine) among methadone-maintained opioid-dependent individuals. Abstinence, verified through urine screens, was reinforced through a voucher system in which patients received points redeemable for items consistent with a drug-free lifestyle that were intended to help the patient develop alternate reinforcers to drug use. Silverman and colleagues (195, 1295) demonstrated the efficacy of this approach in reducing illicit opioid and cocaine use. Opioid antagonist treatment (naltrexone) offers many advantages over methadone maintenance, including the fact that it is nonaddicting and can be prescribed without concerns about diversion, has a benign side effect profile, and can be less costly in terms of demands on professional time and patient time than the daily or near-daily clinic visits required for methadone maintenance (165). Most important are the behavioral aspects of treatment, as unreinforced opiate use allows the extinction of the association between cues and drug use. However, the interventions were not widely adopted, adherence remained a major problem, and naltrexone treatment and research dropped off considerably until the past few years, when the need for alternatives to methadone maintenance stimulated a modest revival of interest in naltrexone. Some of the most recent promising data about strategies to enhance retention and outcome in naltrexone treatment have come from investigations of contingency management approaches. Carroll and colleagues (167, 1407) found that reinforcement of naltrexone treatment adherence and drug-free urine specimens, alone or in combination with family involvement in treatment, improved retention rates and reduced drug use among recently detoxified opioid-dependent individuals. However, only 5% of the eligible patients agreed to participate (compared with 60% in the Woody et al. Psychodynamically oriented group therapy modified for substance-dependent patients appears to be effective in promoting abstinence when combined with behavioral monitoring and individual supportive psychotherapy (1301). Although some follow-up studies of naturalistic treatment have found equivalent efficacy for methadone maintenance and outpatient drug-free programs for heroin users (61, 1396­ 1398), early attempts at providing psychotherapy alone have yielded unacceptably high attrition rates (1399). Given the significant numbers of individuals with a cooccurring psychiatric and substance use disorder, improved methods for diagnosis are needed, including approaches for defining the precise temporal and etiological relation between substance use and other forms of psychopathology. Enhanced approaches for identifying prescription opioid dependence would also be beneficial, particularly in individuals with underlying physical disorders that are associated with significant pain. The time course of recovery from these effects once a patient is free of substances also needs delineating. More information is needed about the selection of treatment settings according to the unique needs of the individual patient. The utility of a particular treatment setting for specific disorders may also be worthy of further study. Treatment programs may exhibit differential efficacies or cost-effectiveness depending on the site of treatment, the mix of specific treatment modalities used, the organizational and managerial aspects of the treatment program, and the specific population of patients being served. In addition to learning about specific treatment settings, more information is needed on the specific treatments for intoxication and withdrawal. Additional studies may help guide the identification of patient populations that will benefit from specific treatments. Other therapeutic options could be developed depending on the gene or genes involved in the etiology or treatment responsiveness of substance use disorders. However, the study of a broad range of psychosocial therapies will enhance therapeutic options for each substance use disorder.

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The professional and the client discuss the implications allergy kvue purchase 5mg cetirizine with visa, both short- and long-term allergy washington dc buy cheap cetirizine 10 mg on-line, of any changes in gender role and use of medical interventions penicillin allergy symptoms joint pain generic 5 mg cetirizine with amex. These implications can be psychological allergy symptoms mouth generic cetirizine 10 mg with mastercard, social, physical, sexual, occupational, financial, and legal (Bockting et al. This task is also best conducted by a qualified mental health professional, but may be conducted by another health professional with appropriate training in behavioral health and with sufficient knowledge about gender nonconforming identities and expressions and about possible medical interventions for gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy. Assess, diagnose, and discuss treatment options for co-existing mental health concerns Clients presenting with gender dysphoria may struggle with a range of mental health concerns (Gуmez-Gil, Trilla, Salamero, Godбs, & Valdйs, 2009; Murad et al. Mental health professionals should screen for these and other mental health concerns and incorporate 24 World Professional Association for Transgender Health the Standards of Care 7th Version the identified concerns into the overall treatment plan. The presence of co-existing mental health concerns does not necessarily preclude possible changes in gender role or access to feminizing/masculinizing hormones or surgery; rather, these concerns need to be optimally managed prior to or concurrent with treatment of gender dysphoria. Qualified mental health professionals are specifically trained to assess, diagnose, and treat (or refer to treatment for) these co-existing mental health concerns. Mental health professionals can help clients who are considering hormone therapy to be both psychologically prepared (for example, has made a fully informed decision with clear and realistic expectations; is ready to receive the service in line with the overall treatment plan; has included family and community as appropriate) and practically prepared (for example, has been evaluated by a physician to rule out or address medical contraindications to hormone use; has considered the psychosocial implications). World Professional Association for Transgender Health 25 the Standards of Care 7th Version Referral for feminizing/masculinizing hormone therapy People may approach a specialized provider in any discipline to pursue feminizing/masculinizing hormone therapy. Hormone therapy can be initiated with a referral from a qualified mental health professional. Alternatively, a health professional who is appropriately trained in behavioral health and competent in the assessment of gender dysphoria may assess eligibility, prepare, and refer the patient for hormone therapy, particularly in the absence of significant co-existing mental health concerns and when working in the context of a multidisciplinary specialty team. Mental health professionals can help clients who are considering surgery to be both psychologically prepared (for example, has made a fully informed 26 World Professional Association for Transgender Health the Standards of Care 7th Version decision with clear and realistic expectations; is ready to receive the service in line with the overall treatment plan; has included family and community as appropriate) and practically prepared (for example, has made an informed choice about a surgeon to perform the procedure; has arranged aftercare). However, mental health professionals have a responsibility to encourage, guide, and assist clients with making fully informed decisions and becoming adequately prepared. Referral for surgery Surgical treatments for gender dysphoria can be initiated with a referral (one or two, depending on the type of surgery) from a qualified mental health professional. Each referral letter, however, is expected to cover the same topics in the areas outlined below. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this. Psychotherapy is not an absolute requirement for hormone therapy and surgery A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. First, a minimum number of sessions tends to be construed as a hurdle, which discourages the genuine opportunity for personal growth. Typically, the overarching treatment goal is to help transsexual, transgender, and gender nonconforming individuals achieve long-term comfort in their gender identity expression, with realistic chances for success in their relationships, education, and work. Psychotherapy for transsexual, transgender, and gender nonconforming clients, including counseling and support for changes in gender role Finding a comfortable gender role is, first and foremost, a psychosocial process. Psychotherapy can also aid in alleviating any co-existing mental health concerns. Because changing World Professional Association for Transgender Health 29 the Standards of Care 7th Version gender role can have profound personal and social consequences, the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Many transsexual, transgender, and gender nonconforming people will present for care without ever having been related to or accepted in the gender role that is most congruent with their gender identity. Calculated risks can be taken outside of therapy to gain experience and build confidence in the new role. Assistance with coming out to family and community (friends, school, workplace) can be provided. Mental health professionals can help these clients to identify and work through potential challenges and foster optimal adjustment as they continue to express changes in their gender role. Mental health professionals can assist clients with making thoughtful decisions about communicating with family members and others about their gender identity and treatment decisions. Psychotherapy may be helpful at different times and for various issues throughout the life cycle.

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In the days immediately following the World Trade Center collapse allergy x-ray purchase cetirizine 5mg, forensic scientists began the task of identifying the remains of those who perished in the disaster allergy forecast missouri buy 5mg cetirizine free shipping. The goal was to allergy medicine in 3rd trimester cheap cetirizine 5mg free shipping provide evidence for the ongoing criminal investigation of the attack and to allergy zyrtec doesn't work order 10mg cetirizine otc identify the remains at the site for families and friends of the victims. Used in combination, these techniques allowed the remains of many victims to be positively identified. Despite the heroic efforts of hundreds of molecular geneticists, forensic anthropologists, and medical examiners to identify the remains, no positively identified remains were recovered for almost half of the people who are thought to have died in the disaster. This approach, which begins with a phenotype (a mutant individual) and proceeds to a gene that encodes the phenotype, is called forward genetics. A geneticist might begin with a gene of unknown function, induce mutations in it, and then look to see what effect these mutations have on the phenotype of the organism. Today, both forward and reverse genetic approaches are widely used in analyses of gene function. This section introduces some of the molecular techniques that are used in forward and reverse genetics. Creating Random Mutations Forward genetics depends on the identification and isolation of random mutations that affect a phenotype of interest. Early in the study of genetics, geneticists were forced to rely on naturally occurring mutations, which are usually rare and can be detected only if large numbers of organisms are examined. The discovery of mutagenic agents-environmental factors that increase the rate of mutation (see Chapter 18)-provided a means increasing the number of mutants in experimental populations of organisms. Today, radiation, chemical mutagens, and transposable elements are all used to create mutations for genetic analysis. The choice of mutagen is an important consideration because different mutagens produce different types of mutations. For example, some mutagens predominately produce base-pair substitutions, whereas other mutagens produce insertions and deletions. The mutagen needs to increase the number of mutations so that enough mutants are obtained for analysis. However, too high a mutation rate may cause multiple mutations to appear in the same individual organism, making identification of the gene responsible for a mutant phenotype difficult, or may even kill the organism before the mutant phenotype can be observed. To determine all genes that might affect a phenotype, the creation of mutations in as many genes as possible is desirable-to saturate the genome with mutations. This procedure is done with a mutagenic screen, which will be described in Chapter 20. Although these techniques provide a great deal of information about the organization and nature of gene sequences, the ultimate goal of many molecular studies is to better understand the function of the sequences. In this section, we will explore some advanced molecular techniques that are frequently used to determine gene function and to better understand the genetic processes that these sequences undergo. Forward and Reverse Genetics the traditional approach to the study of gene function begins with the isolation of mutant organisms. For example, suppose a geneticist is interested in genes that affect cardiac function in mammals. A first step would be to find individuals-perhaps mice-that have hereditary defects in heart function. The mutations causing the cardiac problems in the mice could then be mapped, and the implicated genes could be isolated, cloned, and sequenced. The proteins produced by the genes could then be predicted from the gene sequences and isolated. Mutations are induced at specific locations through a process called site-directed mutagenesis. About half of the time the normal bases will be changed into mutant bases, and about half of the time the mutant bases will be changed into normal bases. Reverse genetics begins with a gene sequence and, through analysis, determines the phenotype that it encodes. Particular mutations can be introduced at specific sites within a gene by means of site-directed and oligonucleotide-directed mutagenesis.

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Many researchers have estimated the heritability of human traits by comparing the correlation coefficients of monozygotic and dizygotic twins (see p allergy symptoms to kerosene buy cetirizine 5 mg free shipping. One of the assumptions in using this method is that two monozygotic twins experience environments that are no more similar to allergy treatment worms buy cetirizine 5 mg without a prescription each other than those experienced by two dizygotic twins allergy symptoms 5 dpt order cetirizine 10mg on line. Give some specific examples of ways in which the environments of two monozygotic twins might be more similar than the environments of two dizyotic twins allergy forecast fairfield ct buy 10 mg cetirizine free shipping. A genetics researcher determines that the broad-sense heritability of height among Southwestern University undergraduate students is 0. Calculate the correlation coefficient for the heights of the mothers and daughters. Using regression, predict the expected height of a daughter whose mother is 67 inches tall. Assume that human ear length is influenced by multiple genetic and environmental factors. Suppose you measured ear length on three groups of people, in which group A consists of five unrelated persons, group B consists of five siblings, and group C consists of five first cousins. With the assumption that the environment for each group is similar, which group should have the highest phenotypic variance? Is it realistic to assume that the environmental variance for each group is similar? Because Sally is a Southwestern University undergraduate student, 10% of her height is determined by nongenetic factors. Ninety percent of variation in height among all undergraduate students in the United States is due to genetic differences. Ninety percent of the height of Southwestern University undergraduate students is determined by genes. Ten percent of the variation in height among Southwestern University undergraduate students is determined by variation in nongenetic factors. The length of the middle joint of the right index finger was measured on 10 sets of parents and their adult offspring. The mean parental lengths and the mean offspring lengths for each family are listed in the following table. Calculate the regression coefficient for regression of mean offspring length against mean parental length and estimate the narrow-sense heritability for this characteristic. For many years, he has fed his pigs the food left over from the local university cafeteria, which is known to be low in protein, deficient in vitamins, and downright untasty. The salesman claims that his company sells a new, high-protein, vitamin-enriched feed that enhances weight gain in pigs. Although the food is expensive, the salesman claims that the increased weight gain of the pigs will more than pay for the cost of the feed, increasing Mr. Jones responds that he took a genetics class when he went to the university and that he has conducted some genetic experiments on his pigs; specifically, he has calculated the narrow-sense heritability of weight gain for his pigs and found it to be 0. Jones says that this heritability value indicates that 98% of the variance in weight gain among his pigs is determined by genetic differences, and therefore the new pig feed can have little effect on the growth of his pigs. He chooses six cockroaches that have the largest wings; the average wing length among these selected cockroaches is 10 cm. From earlier studies, he knows that the narrow-sense heritability for wing length in his population of cockroaches is 0. Calculate the selection differential and expected response to selection for wing length in these cockroaches. What should be the average wing length of the progeny of the selected cockroaches? Drosophila buzzatii is a fruit fly that feeds on the rotting fruits of cacti in Australia. Timothy Prout and Stuart Barker calculated the heritabilities of body size, as measured by thorax length, for a natural population of D. A rancher determines that the average amount of wool produced by a sheep in her flock is 22 kg per year. In an attempt to increase the wool production of her flock, the rancher picks five male and five female sheep with the greatest wool production; the average amount of wool Quantitative Genetics 691 produced per sheep by those selected is 30 kg. She interbreeds these selected sheep and finds that the average wool production among the progeny of the selected sheep is 28 kg. A strawberry farmer determines that the average weight of individual strawberries produced by plants in his garden is 2 g.

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