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By: S. Grompel, M.B. B.CH. B.A.O., Ph.D.

Professor, University of Iowa Roy J. and Lucille A. Carver College of Medicine

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People 19 years of age and older who require a tetanus to xoid-containing vaccine as part of wound management should receive Tdap instead of Td if they previously have not received Tdap. Equine anti to xin should be administered after appropriate testing of the patient for sensitivity (see Sensitivity Tests for Reactions to Animal Sera, p 64). Administration of tetanus to xoid simultaneously or at an interval after receipt of Immune Globulin does not impair development of protective antibody substantially. Wounds should receive prompt surgical treatment to remove all devitalized tissue and foreign material as an essential part of tetanus prophy laxis. For all appropriate indications, tetanus immunization is administered with diphtheria to xoid-containing vaccines or with diphtheria to xoid and acellular pertussis-containing vaccines. Vaccine is administered intramuscularly and may be given concurrently with other vaccines (see Simultaneous Administration of Multiple Vaccines, p 33). Recommendations for use of tetanus to xoid-containing vaccines (summarized in Fig 1. A fourth dose is recommended 6 to 12 months after the third dose, usually at 15 through 18 months of age (see Pertussis, p 553). An additional dose is recommended before school entry at 4 through 6 years of age unless the preceding dose was given after the fourth birthday. The preschool (ffth) dose is omitted if the fourth dose was given after the fourth birthday. Tdap should be administered regardless of interval since last tetanus or diphtheria-containing vaccine. If there is insuffcient time, 2 doses of Td should be admin istered at least 4 weeks apart, and the second dose should be given at least 2 weeks before delivery. Tdap should be substituted for the frst Td dose if Tdap has not been administered previously. Because of uncertainty about which vaccine component (ie, diphtheria, tetanus, or pertussis) might be responsible and the importance of tetanus immunization, people who experience anaphylactic reactions may be referred to an allergist for evaluation and possible desensitization to tetanus to xoid. People who experienced Arthus-type hypersensitivity reactions or temperature greater than 39. Sterilization of hospital supplies will prevent the rare instances of tetanus that may occur in a hospital from contaminated sutures, instruments, or plaster casts. For prevention of neonatal tetanus, preventive measures (in addition to maternal immunization) include community immunization programs for adolescent girls and women of childbearing age and appropriate training of midwives in recommendations for immunization and sterile technique. Tinea capitis may be confused with many other diseases, including seborrheic der matitis, a to pic dermatitis, psoriasis, alopecia areata, trichotillomania, folliculitis, impetigo, head lice, and lupus erythema to sus. Microsporum canis, Microsporum audouinii, Trichophy to n violaceum, and Trichophy to n mentagrophytes are less common. The organism remains viable on combs, hairbrushes, and other fomites for long periods of time, and the role of fomites in transmission is a concern but has not been defned. T to nsurans often is cultured from the scalp of family members or asymp to matic children in close contact with an index case. Asymp to matic carriers are thought to have a signifcant role as reservoirs for infection and reinfection within families, schools, and communities. Tinea capitis attributable to T to nsurans occurs most commonly in children between 3 and 9 years of age and appears to be more common in black chil dren. M canis infection results primarily from animal- to -human transmission, although person- to -person transmission can occur. The incubation period is unknown but is thought to be 1 to 3 weeks; infections have occurred in infants within the frst week of life. Hairs and scale obtained by gentle scraping of a moistened area of the scalp with a blunt scalpel, to othbrush, brush, tweezers, or a moistened cot to n swab are used for potassium hydroxide wet mount examination and culture.

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A treatment provider should assess first on opioid use, including severity and age behaviors such as compulsive gambling or at onset of physical addiction, as well as use sexual behavior to develop a comprehensive patterns over the past year, especially the perspective on each patient. A baseline determination of i Patient motivation and reasons for seeking current addiction should meet, to the extent treatment. Many present for treatment because they are in people who are opioid addicted use other withdrawal and want relief. They often are 48 Chapter 4 preoccupied with whether and when they can M edical Assessm ent receive medication. However, concerns about motivation by a program physician and then submitted to should not delay admission unless applicants the medical direc to r in preparation for phar clearly seem ambivalent. The consensus because, in most cases, applicants will present panel believes that identifying and addressing in some degree of opioid withdrawal. A Adm ission Eligibility patientis comments also can identify his or her recovery resources. These include com Federal regulations on ments on satisfaction with marital status and living arrangements; use of leisure time; eligibility problems with family members, friends, Federal regulations state that, in general, significant others, neighbors, and coworkers; opioid pharmacotherapy is appropriate for the patientis view of the severity of these persons who currently are addicted to an opi problems; insurance status; and employment, oid drug and became addicted at least 1 year vocational, and educational status. When an applicantis status is basis for a focused, individualized, and uncertain, admission decisions should be based effective treatment plan (see chapter 6). Initial Screening, Adm ission Procedures, and Assessm ent Techniques 49 A person younger than 18 must have under His to ry and Extent of gone at least two documented attempts at Nonopioid Substance Use and de to xification or outpatient psychosocial treatment within 12 months to be eligible for Treatm ent maintenance treatment. M edical His to ry Cases of uncertainty A complete medical his to ry should include organ system diagnoses and treatments and When absence of a treatment his to ry or with family and psychosocial his to ries. W omenis medical his to ries dependence on opioids can be demonstrated by also should document previous pregnancies; less drastic measures. For example, a patient types of delivery; complications; current preg can be observed for the effects of withdrawal nancy status and involvement with prenatal after he or she has not used a short-acting care; alcohol and drug use, including over-the opioid for 6 to 8 hours. Administering a low counter medications, caffeine, and nicotine, dose of methadone and then observing the before and during any pregnancies; and patient also is appropriate. It also requires invasive injec tion, and the effects can disrupt or jeopardize Exam ination prospects for a sound therapeutic relationship Each patient must undergo a complete, fully with the patient. The panel recommends that documented physical examination by the pro naloxone be reserved to treat opioid overdose gram physician, a primary care physician, or emergencies. The full medical examination, including the results of the serology and other tests, must be docu mented in the patientis record within 14 days following admission. The examination should immune system compromised might have a cover major organ systems and the patientis negative purified protein derivative test, even overall health status and should document indi with active infection. A chest x ray or sputum cations of infectious diseases; pulmonary, liver, analysis should be done if there is doubt. The among individuals involved with drugs (Batki consensus panel strongly recommends that et al. Anergy panel tests should be adminis signal current infections, only that antibodies tered to anergic patients (those with diminished have developed. In studies by the manufacturer, the blood distress and psychiatric symp to ms (McKinnon antibody test correctly identified 99. The first test is include, but not be limited to, patient especially important because it is part of the recollections of and attitudes about previous initial evaluation and may serve as documenta substance abuse treatment; expectations and tion of current opioid use. As noted in Federal motivation for treatment; level of support for regulations, the presence of opioids in test a substance-free lifestyle; his to ry of physical results does not establish a diagnosis of opioid or sexual abuse; military or combat his to ry; addiction, and the absence of opioids does not traumatic life events; and the cultural, reli rule it out. Clinical examination and an appli gious, and spiritual basis for any values and cantis medical his to ry are keys to determine the assumptions that might affect treatment. Chapter 9 discusses information should be included in an integrated drug-testing procedures and Federal regulations summary in which data are interpreted, governing these procedures. Treatment plans should be reviewed and updated, initially every 90 days and, after 1 year, biannually or whenever Com prehensive changes affect a patientis treatment outcomes. Ongoing moni to ring should ensure that services Assessm ent are received, interventions work, new problems Completion of induction marks the beginning are identified and documented, and services of stabilization and maintenance treatment are adjusted as problems are solved. Patientsi and ongoing, comprehensive medical and views of their progress, as well as the treatment psychosocial assessment conducted over teamis assessment of patientsi responses to multiple sessions. This assessment should Initial Screening, Adm ission Procedures, and Assessm ent Techniques 53 treatment, should be documented in the drug withdrawal from mental disorder treatment plan. A challenge in treating patients who patients in motivational enhancement abuse substances for clinically evident reasons activities.

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S to rage Areas Do balconies have protective barriers to prevent Are pesticides, detergents and other household children from slipping through the barsfi Are batteries changed at least every Are razors, razor blades and other sharp 6 monthsfi Are to ys, blankets and pillows Are nearby swimming pools completely removed from the cribfi Appropriate sport-specific footwear also is important in Observe these rules of the road for bike safety: preventing injuries. Shoes often are designed to perform a particular function and provide support for certain Avoid roads that are busy or have no shoulder. Swimming and Water Safety Eye Safety If you or a family member does not know how to swim, or Wear protective goggles while doing any activity in you would like to improve your swimming skills, contact which eyes could be injured, such as racquetball, or your local chapter of the American Red Cross. Coast Guard reports that alcohol is going to be in, on or around the water and do not know the most common fac to r in fatal boating accidents. Be careful when walking beside Safety for Runners and Walkers rivers, lakes and other bodies of water. Dangerous If you run, jog or walk, plan your route carefully and undercurrents, even in shallow water, can overcome exercise in well-lit, well-populated areas. If you must To prevent water-related injuries, you also should: exercise outdoors after dark, wear refiective clothing and Always closely supervise children in, on or near water. In addition, these self-closing, self-latching gate that cannot be easily injuries cost billions of dollars in lost wages, medical opened by a young child. Know what to Never drink alcohol while you drive a boat and do not do in case of an emergency. Preventing injury and being travel in a boat operated by a driver who has been prepared for an emergency can save lives! Health, United States, 2009, With Special Feature on Medical Technology. National Center for Injury Prevention and Control: 10 Leading Causes of Death, United States 2007, All Races, Both Sexes, webappa. Disposal by Flushing of Certain Unused Medicines: What You Should Know. See also People with Atherosclerosis, 30 Blood pressure, elevated and disabilities Atria, 46 stroke, 72 American Lyme Disease Au to mated external defibrillation.

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