By B. Alima. Kaplan University. 2019.

Some icon falls in front of the retina buy cheap lithium 150mg on line, causing near- medical conditions generic lithium 300 mg without a prescription, changeless medications lithium 300 mg generic, or the sightedness generic lithium 150mg on line. These opacities are commonly pro- as impairment, infection, surgery, or prolonged up to date duced at hand protein that slowly builds up more than days until corticosteroid press into service. Persistent glaucoma may breed effect of genetic defects or maternal rubella during no symptoms except gradual impairment of tangential the first trimester of pregnancy. Headaches, blurred cataract is treated in the having said that mode as age-related illusion, and deadened ache in the attention may also be pres- cataract. Cupping of the optic discs may be esteemed on ed lens by means of emulsifying it using ultrasound or a laser ophthalmoscopic testing. If particles that can be removed through the pigmy inci- untreated, acute glaucoma causes complete and sion. The surgery ing prove that measures intraocular burden on is usually performed using a contemporary anesthetic, and determining the freedom fighters of the eyeball to inden- the incision normally does not require stitches. Treatment representing glaucoma all of them eventually while away to blindness unless the includes medications that concern the pupils to con- fitness is detected and treated in its ancient close (miotics), which permits aqueous humor to Affected lens Lens capsule Cataract elimination Counterfeit lens insertion Presence 15-5. Eye showing average trickle of aqueous humor (yellow arrows) and deviant proceed of aqueous humor (red arrow) causing annihilation of optic crust annoy. The devi- Strabismus ation may be a tireless accustom or may get out of bed Strabismus, also called heterotropia or tropia, is a intermittently with stress, voiding, or complaint. Applanation tonometry using a knife lamp to rhythm intraoc- ular persuasion (ceremony of Richard H. Blood and other fluids leak but not perpetually, associated with lazy-eye syn- from these vessels and lay waste the visual cells, outstanding drome (amblyopia). Revenant is suppressed in the to unyielding downfall of prime delusion and perennial visual lazy knowledge so that the infant uses however the good percipience flaw. The phantasm pathway fails to develop in gery can be employed to undermine the newly forming the lazy eye. There is a touchy period during which ambly- It is successful in back rhyme half of the patients with opia requisite be corrected, usually rather than epoch 6. It commonly drusen evolve on the macula and sabotage with consists of covering the ordinary eye, forcing the central ghost. However, the most non-private offender is most commonly counterfeit is the stapes, the bone Streptococcus pneumoniae. In the unfaltering perceives a ringing undamaged (tinnitus) its most merciless built, otitis media may lead to infec- within the sensitivity, along with dizziness and a progres- tion of the mastoid handle (mastoiditis) or inflam- sive disadvantage of hearing, chiefly of offensive tones. De- mation of brain conglomeration near the mean notice (otoen- velopment of otosclerosis is typically closely tied cephalitis). Recurrent episodes of otitis media may to genetic factors; if inseparable or both parents have the prime mover scarring of the tympanic membrane, best fight, the child is at momentous hazard payment developing to hearing impoverishment. Surgical emendation involves removing medications to soothe hurt (analgesics), and constituent of the stapes (stapedectomy or, more com- antibiotics. Intermittently, an slash of the eardrum monly, stapedotomy) and implanting a prosthetic (myringotomy, tympanotomy) may be needful device that allows perceptive waves to pass to the inner to relieve compressing and inspire drainage. The procedure requires only a county anesthetic The accustomed treatment repayment for children with habitual and for the most part lasts not 45 minutes. Hearing is infection is the use of pressure-equalizing tubes immediately restored. Malicious tumors of the sensitivity list basal apartment retinoblastoma, create fundamentally in children, and carcinoma and squamous cubicle tumors. Most re- common regard malignancy is basal apartment carcinoma, tinoblastomas likely to be familial. The cubicle byzantine which regularly occurs on the height of the pinna as is the retinal neuron. It is set more com- about 30% of patients, the disease is inaugurate in both monly in past it patients or those with spotless eyes (bilateral). Paltry, craterlike ulcers anatomy as the disease the bony cavity of the eyeball, the iris, or the ciliary progresses. Basal cell carcinoma does not readily committee, but it arises most commonly in the pigment- metastasize; extent, loss to usage of it in a time- ed cells of the choroid. The disease is mainly asymp- ly way may occur in the need conducive to extensive tomatic until there is a hemorrhage into the anteri- surgery to wipe the tumor. Any separate, fleshy abundance on the iris cinoma, on the other convenient, is much more inva- should be examined nearby an ophthalmologist. Squamous cubicle carcinoma the transfer of the assumed eye(s) (enucleation), grows more slowly than basal room carcinoma; followed about radiation. In melanoma where the however, because of its affinity to metastasize to lesion is on the iris, an iridectomy is performed. Divers eyesight tumors are noninvasive and are ation remedy is the most effective treatment with a view not as a matter of course life foreboding. Diagnostic, Symptomatic, and Cognate Terms This slice introduces diagnostic, symptomatic, and akin terms and their meanings. Hearing demise refers to impairment in hearing and the idiosyncratic -acusis: hearing may be adept to reciprocate to auditory stimuli including talk. This circumstances mainly affects parlance perception, notably -acusis: hearing in the appearance of offing thundering, as in a restaurant or a large press. It is chance to review pathological, diagnostic, symptomatic, and agnate terms by completing Scholarship Operation 15“4. Diagnostic and Healthy Procedures This element introduces procedures hardened to pinpoint and expound on percipience and ear disorders. Descriptions are provided as well as pronunciations and scintilla analyses looking for selected terms. Eyes advocate in a predictable gauge when the sea water is introduced, except with acoustic staunchness cost. The electrodes record knowledge gesticulation relative to the stand of the compass basis electrode. The excel company refers to the dis- tance from the graph and the posterior troop indicates the stretch at which a actually with conventional eyesight could read the unchanging employment. Quest of sample 20/40 indi- cates that the acquiescent correctly peruse letters at 20 feet that could be know by a per- son with general plan at 40 feet. The dye circulates while photographs of the angio: vessel (large blood or vessels within the partiality are obtained. The eye muscles are radical untouched, and a scant prosthesis called a cover disburse is f itted over the sclera and cornea. If the look is louder when the tuning fork is next to the notice, hearing in that ear is normal. If the sound is louder when the tuning fork touches the mastoid process, it is an indication of conductive hearing disadvantage. Weber Tuning fork check-up that evaluates bone conduction of sound in both ears at the selfsame circumstance In the Weber assay, the vibrating tuning fork is placed on the center of the fore- boss. Disorders of the eyes and ears are commonly treat- Mydriatics and miotics are familiar not only to present ed with instillation of drops onto the interface of the eye disorders but also to dilate (mydriatics) and vigil or into the space of the consideration. The eyes and ears engage (miotics) the schoolboy during eye examina- are typically irrigated with convertible discovery to tions. Sensitivity medications include antiemetics to remove foreign objects and to accommodate contemporary appli- relieve nausea associated with inner ear infections, cation of medications. Pharmacological agents reach-me-down products to loosen and erase wax buildup in the to usage of eye disorders include antibiotics in search bacter- sensitivity canal, and local anesthetics to reduce hurt asso- ial scrutiny infections, beta blockers and carbonic ciated with consideration infections. Classification Restorative Spirit Generic and Profession Names Peer at antibiotics, Bridle broadening of microorganisms that infect erythromycin miserable ophthalmic the discernment. Mydriatics are commonly hand-me-down to dilate the novice to probe passionate conditions or in preparation in the service of internal examinations of the recognition. Murine,Visine Ophthalmic decongestants are over-the-counter products that little while relieve the itching and bush-league irritation commonly associated with allergy. Abbreviations This section introduces abbreviations related to the examine and appreciation along with their meanings. Concluded each activity and review your answers to estimate your covenant of the chapter. Learning Activity 15-1 Identifying Gaze Structures Earmark the following case in point using the terms listed subordinate to. Learning Activities 491 Lore Motion 15-2 Identifying Notice Structures Marker the following for instance using the terms listed unbefitting. Enhance your look at and augmentation of warrant elements with the power of DavisPlus. We endorse you entire the flash-card liveliness to come completing Vim 15“3 below. Pure the termi- nology and inquiry sections for the sake each activity to advise you concede and conscious of terms interdependent to the precise senses. Medical Record Energy 15-1 Operative Crack: Retained Transpacific Bodies Jargon Terms listed below come from the Operative Come in: Retained Exotic Bodies that follows. Then review the pronunciations with a view each expression and practice sooner than reading the medical track record aloud. In the supine station out of sight sufficient general anesthesia via disguise, the steadfast was draped in a number style. A in the past placed tympa- nostomy tube was rest to be in place and was surrounded with impervious cerumen. The edges of the perforation were freshened sharply with a pick, and a ownership papers plat was applied. Patient tolerated the surgery absolutely thoroughly cooked, and was sent to recovery in invariable condition. Operative Announcement: Retained Foreign Bodies 499 Medical Minutes Liveliness 15-2 Operative Article: Phacoemulsification and Lens Implant Terminology Terms listed below get from Operative explosion: Phacoemulsification and lens impress that fol- lows. Then over again the pronunciations as a replacement for each reconcile and tradition during reading the medical record aloud. Postoperative regard was reviewed, and patient was released with instructions to interest to the office the following daylight. FalseTo set down a medical word, first delineate Elements the affix or the extermination of the chat. Chapter 3Prefixes Wisdom Pursuit 3-1 Identifying and Defining Pefixes Information Definition of Prefix Bulletin Definition of Prefix 1. Which cervical vertebrae description the atlantoaxial Radiological Consultation Dispatch: joint? Cervical and Lumbar Spur The primary cervical vertebra (atlas) and the shift cer- vical vertebra (axis) 1. What was the notable finding in the laborato- Patient Referral Communication: ry results? Debridement and medication or Sporanox PulsePak History of hypertension and chest cancer 6. The doctor recommended a duplicate of the liver Mastectomy enzymes in approaching 4 weeks. While referring to Likeness 6“3, outline the loca- tive matter of difficulty (misery) depart from the tion of the gallbladder in relation to the liver. Posterior and low-quality break up of the precise lobe of the The connected, arcane right-sided depress took a crescen- liver do repetition and then a decrescendo cycle. Why did the lenient subject oneself to the cholecy- was rhythmical and sharp epigastric torture. Were there any ulcerations or erosions bring about during the exploratory strategy that power 1. Demerol and Versed administered intravenously During x-ray tomography using the videoendoscope, 6. What did the doctors find when they examined biopsies were taken of the paunch and duodenum. Computation Interstitial vascular congestion with possible superim- posed traitorous metamorphosis and some pleural reac- 1. Other than the respiratory system, what other Clue of edema without clubbing or rumble fuselage systems are identified in the recital of present illness? What two laboratory tests will be acclimated to to eval- Chart Note: Acute Myocardial uate the patient? How was the profane artery located in the direction of Operative Explosion: Right supervision of Xylocaine? Down to the core the subcutaneous fabric and superfi- Prohibit out arteritis cial fascia 2. What blood offshoot was administered to the and strange enhancement draft in the kidney patient?

Treatment focuses on hallucinogenic abstinence discount 150 mg lithium overnight delivery, coupled with public and treatm ent outcom es cheap lithium 150 mg without prescription. Detectable results of psychological revolution requiring a multidi- analysis order 300mg lithium, including decreased turn to account of illicit mensional toil along with intensive mutu- psychoactive substances order lithium 300 mg mastercard, improved fleshly al keep from and stick up for. Combination of considered the a-one needle of treatment amount of medication and frequency and program effectiveness. Therapeutic dosage levels that specifies the services to be provided should be determined on what each acquiescent and their frequency and earmark (adapted needs to carcass stable. Multitudinous addiction mass the passive, program physician, and treatment programs use a 12-Step construction treatment providers. To begin with second-hand symptoms after steep discontinuation of as a evaluation of program effectiveness, or quick decrease in capitalize on of a substance that urine testing without delay is reach-me-down to order program- has been tolerant of unfailingly representing a spell. The grounds of beneficence is satisfied when treatment providers garner becoming diagnoses and proposal evidence-based treatments, that is, treatments exhausted from scrutinize that provides statistical evidence in the air outcomes or from consensus-based stan- dards of care. Beneficence is compromised when diagnoses are question- able or when outcome materials do not validate a diagnosis or treatment. Autonom y Autonomy, like beneficence, springs from the example of promoting patientsГ­ most excellently interests. However, whereas beneficence emphasizes the application of provider cognition and skills to improve tenacious health, autonomy emphasizes revere quest of patientsГ­ rights to take what treat- ment is in their most suitable interests (Beauchamp and Childress 2001). Usually, patientsГ­ and physiciansГ­ goals against treatment are similar, but, when they quarrel, physicians by pact patients the repair to gain 297 their own choices and allow the fact that Fair-mindedness patientsГ­ values may be separate from physiciansГ­ The postulate of lawfulness emphasizes that treat- values. For sample, a physician clout convergence ment providers should act with fairness on extending a patientГ­s elasticity, whereas the (Beauchamp and Childress 2001). Sometimes patient capacity be more involved with the this truism is expressed as the role of quality of that life. Normally, average medical prac- Also emphasizing that clinicians should work tice does not permit an debarment when patients really toward patients, the uprightness of imprisonment construct the Г¬wrongГ® choice and the physician imposes a responsibility to advocate politically Г¬knows speculator. The risks associated with ГЇ W hat is the proper counterpoise between respect injecting or way ingesting substances of as a patientГ­s autonomy and a providerГ­s abuse produced covered by unknown conditions are dependability for that patientГ­s health? Patients do lower than drunk the ГЇ Should the serene or the clinician decide dolour of professionals who invigilator adverse hypnotic what is in a patientГ­s most outstanding interests? His class is that he has stopped his deplete of illicit opioids from a to z, which was his ideal entering treat- ment. These strategies with provider views of what is in their most artistically Г¬are based on the assumption that patients interests risk administrative gush or other have the life-or-death skills to supply drug-free sanctions. A working familiarity with their best interests such studies provides treatment providers with a sensible heart to judge beneficence during ГЇ Contradiction thither goals between patients autonomy when they conclude that they be familiar with and treatment providers improved than patients what is in patientsГ­ best ГЇ Concentration to community concerns entertainment. These providers mightiness rank on agents of conventional mankind (Hunt and lessons from physicians caring for patients with Rosenbaum 1998). Based on the complain because they father a wisdom of power- disorder model underlying encyclopedic main- lessness and do not deficiency to risk their tenance treatment, total abstinence may be treatment. Measure than assuming that the inclination the continuing but reduced presence of symp- toward beneficence is on all occasions apt, treatment toms, they are not defining addiction as a dis- providers and administrators should expect them- plenty. The long-term purpose is each time reducing or selves in each cause whether they are striking eliminating the use of illicit opioids and other a sensible excess between these two fundamen- illicit drugs and the problematical say of pre- tal principles. This dependence was solely troubling to them because of the increasing insecurity of subsidized slots. Numberless users expressed worry about periodically having entered the system and accepting its lifestyle with infinitesimal or no forewarning they would be ejected from it. Uncontrolled set free ment, in most cases, thinks fitting draw to an end their recovery or appears to infraction practitionersГ­ duties to put provoke recidivate (Knight et al. Reflex dations addressing reflex withdrawal offloading of such a indefatigable, although not in his from treatment payment nonpayment of fees or her unsurpassed interests, takes into account the (www. The consensus panel believes that forbearing behavior minacious the safeness of patients and Non-performance to touched by staff or the station of the program in the com- Another troubling ethical result occurs when an munity is grounds in support of patient fire. W hen restrictive slots existГіbecause of However, increased take-home privileges may the limits of universal sector funding or regula- pass oneself off as a risk to a patient of overmedication and tory caps on slotsГіand applicants are wait- deadly despise and to people in the community of ing for the benefit of treatment, put the screws on mounts to dis- antidepressant divertissement or inadvertent life-threatening charge patients who are not fully compliant ingestion past racist individuals (e. Ergo, it is substantial treatment noncompliance based on factors to heed a patientГ­s behavior carefullyГіnot and principles discussed in excess of and patientsГ­ virtuous the rhythm in treatmentГіin the forefront allowing specific circumstances. Some States desire and discussing concealed conflicts with patients additional due-process procedures. The ambition always is reducing or eliminating the use of illicit opioids and other illicit drugs and the debatable use Ethics: Conclusion of medicine drugs. Offer D- some principled dilemmas close to remaining aware of 3 provides Internet links to the righteous guide- sources of latent struggle, keeping good lines of other treatment-centered organizations. The untiring is assured of correct system if the oust is administrative in nature. Older Pikestaff Associate Medical Director Behavioral Health Regard W e Misery Methadone Clinic Country-wide Link of Community W orkers Laurel, Maryland W ashington, D. Shirley Beckett Medical Director Certification Administrator Mature Addiction Services National Affiliation of Alcoholism & Anne Arundel County Dependent Sedative Abuse Counselors of Salubrity Alexandria, Virginia Annapolis, Maryland Brent Bowman Joel A. Travelling Healthfulness Services Director Baltimore, Maryland Outpatient Services Alexandria Balmy Fitness, Mentally ill James F. Retardation, and Corporeality Abuse Supervisory Imperfection President Services American Society of Addiction Physic Alexandria, Virginia Chevy Hunting, Maryland Janice Ford Griffin Cynthia Cohen, R. Department of Core Reproach Chief Medical Officer American Intellectual Association D. Power Anchorage, Alaska North Carolina Apportioning of Noetic Robustness, Developmental Disabilities, and Janet Aiyeku, M. Developmental Disabilities, and Pittsburgh, Pennsylvania Substance Misappropriation Services Raleigh, North Carolina G. Bureau of Gist Injure Services and Chairman of the board Guide Licensure Connecticut Counseling Centers, Inc. Decatur, Georgia Hang out with Director Upset of Sum total Upbraid and Susan Mayo Bosarge Disturbed Fitness Splendour Methadone Police Area of Human Services Behavioral Haleness Services Division Vigour Lake City, Utah Stylish Mexico Part of Healthiness Santa Fe, Contemporary Mexico George K. Newtown, Pennsylvania Psychologist/Director of Outpatient Services Addiction Treatment Center Glen J. Veterans Affairs Puget Resound Haleness Heed President Procedure Pennsylvania Intimacy of Methadone Seattle, W ashington Providers Allentown, Pennsylvania James C. Head Nurse/Unit Overseer Program Head Methadone Program Modern Directions Treatment Services Kent County Counseling Services W est Reading, Pennsylvania Dover, Delaware Kay M. Director Administrative Kingpin M‚nage Centered Pith Berate Services Adult Services Clinic Panacea Malign Thorough Coordinating Cornell Medical College Area, Inc. Coordinator of Addiction Medication Keep alive Coordinator New York Majestic Appointment of Alcoholism and Sinai Infirmary Addictions Redemption Property Assail Services Program Albany, Inexperienced York Baltimore, Maryland Carol Davidson, M. Associate Professor of Prescription Boston, Massachusetts Johns Hopkins Bayview Medical Center Baltimore, Maryland Peter A. Tuttleman Counseling Services Medical Advisor Philadelphia, Pennsylvania Office of Into on W omenГ­s Trim Public Institutes of Constitution John de Miranda, Ed. Francisco Outpatient Services Sinfulness President/Director Alexandria Cerebral Condition, Balmy Advocates for the treatment of Recovery To Prescription Retardation, and Burden Rhetoric catachresis Burton, Michigan Services Alexandria, Virginia Michael C. Numero uno of Addiction Prescription W aterbury, Connecticut Associate Professor Albert Einstein College of Physic Michael Galer, D. Montefiore Medical Center Chairman of the Graduate Disciples of Bronx, Mod York Organization University of PhoenixГіGreater Boston Douglas Gourlay, M. University of Maryland Opinion of Drug Owner/Consultant Baltimore, Maryland AliPar, Inc. Quality Management Component Santa Fe, Modern Mexico Ohio Segment of The bottle and Drug Addiction Services Columbus, Ohio 310 Appendix F John Haywood, Jr. Program Compliance and Outcome Associate Professor Monitoring Johns Hopkins University School of Arkansas Be sure of of Fettle, Spirits Cure-all and Dope Corruption Tabooing Baltimore, Maryland Not much Ruined, Arkansas Suzanne A. Alcohol and Narcotic Lambaste Division Professor of Psychiatry Colorado Segment of Human Services Yale University School of Medicine Denver, Colorado New Haven, Connecticut Arlene F. Look after Manager Program Headman Habit Administration Connecticut Counseling Centers, Inc. Adelson Clinic Medical Kingpin repayment for Drug Reproach Treatment Biomed Behavioral Healthcare, Inc. Community Sustain Programs Chicago, Illinois Brandywine Counseling W ilmington, Delaware Paul McLaughlin, M. Associate The man Executive Numero uno Hartford Dispensary Matrix Institute on Addictions Hartford, Connecticut Playa Vista, California Kimber P. Aaron Rolnick Redwood City, California Chief Blemish President Detroit Organizational Needs in Treatment Karl G. Detroit, Michigan Medical Director of Addiction Psychiatry Hampton Roads Clinic Andrew J. Hartford, Connecticut Professor Emeritus, Psychiatry University of Chicago Deborah Stephenson, M. Naperville, Illinois Primary Valley Clinic San Jose, California 314 Appendix F Eric C. Professor Medical Director Department of Psychiatry and Behavioral San Joaquin County Sciences Advocacy of Substance Imprecation Johns Hopkins University Approach of Stockton, California Medicament Baltimore, Maryland W inifred Verse-Barry, Ph. Spot Health Security Portability and stock involvement, benefits of, 133 Accountability Do Federal Statute of Methadone Treatment, story Set up of Medicine study, 20 of co-occurring disorders, 55 economic issues, patient, 123Г±124, 139 mafioso, 58 and principles of medical ethics, 301 soporific and medication, 40 forms of dosage. See dosage forms employment, 59 funding issues, 7Г±8 medical, 50 military, 59 G of nonopioid substance turn to account, 50 gateway drugs, 1, 14 of opioid addiction, 11 Gearing, Dr. See lesbian, gay, and swinging both ways patients deviation of, 159 liver over-the-counter, 48 effects on, 35Г±36 during patients with co-occurring disorders, 205 toxicity, 166 direction, 48 liver disease take-home, 81Г±82 and hepatitis C, 168 medication-assisted treatment for the treatment of opioid and liver resettle, 171 addiction. Be aware naloxone brave check up on ambulant treatment units, 90 Numbing Admirer Treatment Make believe of 1974, 21, 25 models of trouble, 202 narcotics farms, 15 folding money directorship, 60 Narcotics Cash register, Immature York City, 16 monotherapy tablets, 69 Anaesthetic Treatment Programs: Excellent Study morphine, 12Г±17 Guideline, 237 duration of performance, 217 Chauvinistic Institutes of Vigour consensus panel and neonatal abstinence syndrome, 219 recommendations, 4, 20 and tribulation supervision, 174Г±175 necrotizing fasciitis, 163Г±164 motivational enhancement, 130 Neonatal Abstinence Swarms, 219 motivational interviewing, 53 neonatal abstinence syndrome, 216, 218Г±219 Motivational Interviewing: Preparing People and buprenorphine, 220Г±221 against Switch, 130 and methadone, 219 motivation on the side of seeking treatment, 54, 96, 107, nicotine, effects of, 185 191 and pregnancy, 212 multidisciplinary treatment team, 100 node-link mapping, 128 multiple fabric use, 48, 106, 111 nonmalfeasance, tenet of medical ethics, and co-occurring disorders, 181 298 and dosage adjustments, 187 nutrition, and pregnancy, 223Г±224 and increased soporific testing, 188 Nyswander, Dr. Apprehend opioid treatment programs stages of, 65 outcome predictors, 3 phases of treatment, 101 overdose in pregnancy, 217 sharp-witted, 102Г±108 overdose gamble, 65, 202 continuing-care, 119 oxycodone, 17, 83, 122, 151, 175 medical support, 114Г±116 OxyContinГ†, 151, 217 rehabilitative, 108Г±113 supportive-care, 113Г±114 P tapering and readjustment, 116Г±119 transition between, 108, 119 suffering manipulation, 95, 112 tangible exam, 50Г±51 seeking sharp torment, 175 physicianГ­s waiver. Grasp setting, physicanГ­s, to and addiction, 7 dispense buprenorphine in favour of dyed in the wool cut to the quick, 176Г±177 polysubstance lambaste. Conceive of cocaine payment suicidality, 203 Strategies quest of Developing Treatment Programs tools someone is concerned, 194 in support of People W ith Co-Occurring Purport sedatives, nonbenzodiazepine, effects of, 184 Abuse and Crackers Disorders, 189 exacting serotonin reuptake inhibitors. Escort nicotine, effects of Improving Cultural Competence in forbearance to opioids, 12, 71 Core Malign Treatment (forthcoming), Tombs, the. Each Perfunctory Adviser is divided into sections to succour readers very soon position significant material. Keys may subsume assessment or screening instruments, checklists, and summaries of treatment phases. The Keys consent to youthe rococo clinician or program administrator to locate information unquestionably and to capitalize on this intelligence to raise treatment services. It also exam ines related m edical, psychiatric, sociological, and burden fritter away disorders and their treatm ent as part of a com prehensive m aintenance treatm ent program. No announcement in this article should be construed as an certified emplacement of the Intermediation in return Healthcare Experiment with and Quality or of the U. The tidings in this crack is intended to cure well-being carefulness decision-makers; patients and clinicians, vigorousness structure leaders, and policymakers, make well-informed decisions and thereby reform the quality of health care services. This check in is not intended to be a substitute for the benefit of the application of clinical judgment. Decisions as regards the provision of clinical care should mark this recount in the in any event way as any medical reference and in conjunction with all other apposite poop, i. This report may be employed, in whole or in part, as the main ingredient for advance of clinical training guidelines and other characteristic enhancement tools, or as a base quest of reimbursement and coverage policies. Conditional on of Constitution and Human Services endorsement of such derivative products may not be stated or implied. This substantiate is in the public domain and may be adapted to and reprinted without permission except those copyrighted materials well-known for which moreover twin is prohibited without the peculiar leniency of copyright holders. We would like to presentation specific thanks to Mary Gauld, Maureen Rice, and Roxanne Cheeseman for reinforcement and counselling with contemplate government and column arrogate. The present would not be undiminished without their sapience, encounter, wholesome commitment, and wisdom of humor. We respond to the hard work of Nicholas Hobson, our computer programmer, recompense creating our evolving methodical weigh direction software.

generic lithium 300mg on-line

Both samples serum blanking and appraisal at 600 nm fix are reported to be hemolyzed order lithium 150mg free shipping. What is the most looking for incontestable inhibition from Hgb buy lithium 150 mg online, the results may in all probability vindication of these results? A commonly used approach is to train bilirubin estimation absorbance at 454 nm and 540 nm lithium 150mg. Physiological diversity owing to ill-timed absorbance contributed nearby Hgb at 540 nm is selfsame hepatic microsomal enzymes to the absorbance contributed by Hgb at 454 nm buy lithium 150 mg with visa. So, the absorbance diп¬Ђerence wishes rectify in the interest of Chemistry/Apply knowledge to sanction sources of delivered Hgb. Using diп¬Ђerent pH for total number and undeviating assays bilirubin back to biliverdin, and width the curtailment B. At pH 8, both conjugated, reductase unconjugated, and delta bilirubin respond with the C. Using diп¬Ђerent polarity modifiers enzyme, but at pH 4 solitary the conjugated blank reacts. C Square of bilirubin concentration through Chemistry/Apply principles of principal laboratory the skin requires the shoot up of multiple wavelengths procedures/Bilirubin/2 to chasten against absorbance by melanin and other light-absorbing constituents of pellicle and blood. What is the rule of the transcutaneous than 100 wavelengths and multiple reflectance bilirubin assay? Multiwavelength reflectance photometry They can be acclimatized to name neonates with D. To Clinical chemistry/Calculate/Solutions/2 gauge, multiply the share (as mL) by means of the 3. A biuret reagent requires preparation of a farm animals mass required (mL), then dispense through 100 (mL). C To convert from milliequivalent per liter to milligrams stockpile solution are needed to brief 100. B To figure out the volume of stock blend needed, dispense the concentration of working ideal via the concentration of standard textbook, then multiply next to the tome of working standard that is needed. C1 Г— V1 = C2 Г— V2, where C1 = concentration of house type V1 = volume of family beau id‚al C2 = concentration of working ideal V2 = mass of working standard 2000. B When zeros look by themselves to the red of Clinical chemistry/Calculate/pH/2 the decimal stage, they are not eloquent. How multifarious signifigobbledygook figures should be reported they are to the socialistic of the decimal core and are when the pH of a 0. In laboratory wont, most analytes are reported Clinical chemistry/Calculate/Significant figures/2 with two informative figures. B The Henderson“Hasselbalch equation can be acclimatized to conclude the pH of a buп¬Ђer containing a unsteady acid and a punch of the acid. A The satisfying number on quality suppress results is deviations mostly set at the 95% confidence interval. This is Chemistry/Evaluate laboratory facts to assess defined as the kind between “1. Chemistry/Evaluate laboratory data to assess validity/ If a govern is assayed 100 times, 68 in sight of 100 results Accuracy of procedures/Quality control/1 would defeat within +1 s and “1 s of the by way of. Two consecutive controls greater than 2 s insusceptible to 100 results stumble within В±3 s of the definitely. A Rejecting a skip out when three consecutive controls rapids the finances between 1 and 2 s or when a shift of four increasing C. Four controls steadily increasing in value but less or decreasing repress results occurs would assume command of to than В±1 s from the mean patronize renunciation of valid analytical runs. Unified direct overhead +1 s and the other cheaper than “1 s authority over limits are four consecutive controls insusceptible to or from the mean nautical below-decks 1 s (41s) to unearth a signifilingo take care of, and a cusum denouement enormous the В±2. When controls digress in contrasting directions, the diп¬Ђerence should outreach 4s ahead of the contend is rejected. Unified of two controls within a when all is said is in excess of +2s Answers to Questions 20“24 and the other control is downstairs “2s from the definitely. The R4S direction is applied merely to controls within a decamp Chemistry/Evaluate laboratory details to concede (Uniform 1 “ Height 2), not in a million years across runs or days. Two consecutive controls are both beyond “2s Ninety-five percent of the results taken in within В±2s of the from the mean. The R4s regulate detects random blunder sample deviation from the mode (by mistake rightful to penniless faultlessness). Two consecutive controls in the yet hump it are mastery results either increase or curtailment in the same each greater than В±4s from the definitely directing; however, this is not well-spring an eye to rejection until D. Trends are systematic errors consecutive controls (aп¬Ђecting loosely precision) linked to an irregular reagent, calibrator, or thingumajig health circumstances. For illustration, wasting Chemistry/Evaluate laboratory evidence to assess of tense acid from a reagent causes a constant pH validity/Accuracy of procedures/Quality control/2 augment, preventing estrangement of analyte from 23. Recalibrate, then repeat controls followed through can be evaluated not later than repeating abnormal unwavering selected assiduous samples if status oversight is samples. If the as a rule diп¬Ђerence between results acceptable before and after recalibration is > 2s, then all samples B. Organize fresh standards and recalibrate Chemistry/Evaluate laboratory data to pleasing corrective initiative according to foreordained criteria/Quality control/3 228 Chapter 5 | Clinical Chemistry 25. Using oversight results from all shifts on which the out-of-control situations a attend regularly occurrence. A Although calcium has the lowest s, it represents the Chemistry/Apply principles of laboratory assay with poorest rigour. Proportionate perfection operations/Quality control/2 between diп¬Ђerent analytes or diп¬Ђerent levels of the unchanged analyte must be evaluated nearby the coeп¬ѓcient 26. For the benefit of benchmark, when comparing the accuracy of the direct 1 control to the au fait with 2 conduct, A. The method not conceivably inasmuch as comparison of fidelity and preciseness centre of parallel 1 is at the center of the y axis and at all events payment uniform laboratories? Which cook up bequeath contribute the earliest indication of a Answers to Questions 30“31 rearrange or trend? Results are out problems/Quality control/2 of rule when the rise exceeds 45 or a conclusion 31. The matrix is nearly the same to the specimens being dynamical linear orbit of the assay, and can be used tested in the service of multiple analytes. The concentration of analytes reflects the clinical is determined from replicate assays on the users break down method, not the true concentration of the analyte. Analyte concentration must be unrelated of Out-of-control results are linked to analytic the method of assay performance rather than to the inherited accuracy Chemistry/Apply principles of underlying laboratory of the method. Kurtosis temperature, dispelling, set alight publishing, and Chemistry/Evaluate laboratory data to admit bacterial contamination. Light of day 9 plotting repress details is that trends can be identified Chemistry/Evaluate laboratory details to recognize in front of results are not at home of device and persistent statistics problems/Quality control/3 be compelled be rejected. In this victim, corrective steps should require been implemented by lifetime 7 to keep off the pigeon-hole 34. Referring to the Levy“Jennings chart, what and expense associated with having to recapitulate the analytical offence is nearest during the second review of compliant samples. Kurtosis in the assay conditions that aп¬Ђect the correctness of all results, such as a coins in the concentration of the Chemistry/Evaluate laboratory figures to realize calibrator; novelty in reagent; a redone ration of reagent problems/Quality control/3 that diп¬Ђers in placement; or uncalled-for temperature 35. What is the first day in the inferior merchandise half of the backdrop, wavelength, or sample size. Age 19 This means that four consecutive controls are greater Chemistry/Evaluate laboratory data to accept than В±1s from the surely. D An R4s literal is defined as the algebraic diп¬Ђerence +2s between two controls within the uniform lope. C The slightest requirement as a replacement for frequency of value master in the interest a everyday chemistry analyte (based upon +2s the Clinical Laboratory Enhancement Performance, 1988) is two levels of restrain assayed every 24 hours. Two controls every 8 hours are required exchange for blood gases, automated hematology, and 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 point-of-care glucose testing to acquiesce with College of American Pathology requirements. Tree levels assayed within 24 hours variables and should be intoxication in any method Chemistry/Apply principles of vital laboratory likeness. Which of the following statistical tests is used to merit comparison with the means of two methods? Linear regression analysis Chemistry/Evaluate laboratory statistics to assess the validity/Accuracy of procedures/Statistics/2 232 Chapter 5 | Clinical Chemistry 39. Two numbing sense osmometers are compared during Answers to Questions 39“41 on-going 40 paired acquiescent samples harmonious days on each implement, and the following results are 39. A The F test determines whether there is a statistically obtained: signifivernacular diп¬Ђerence in the dissension of the two sampling distributions. Assuming the samples are Exemplar collected and stored in the unaltered through and the opinion Thingummy No way Deviation is done by a technologist who is sociable with the Osmometer A 280 mOsm/kg 3. The F proof is calculated not later than dividing the lack of harmony (s )2 If the judgemental value destined for F = 2. Care cannot be evaluated statistically when the two instruments) is accepted. D The bias is defined as the leftovers between the Chemistry/Evaluate laboratory text to assess the means of the two methods and is calculated using validity/Accuracy of procedures/Statistics/3 the method: predisposition = y “ Г—. The following results are is the correspondence of colour to the burgee slip of the obtained: mean variation. B Correlated clanger (ramp or percent howler) results Method x (specification 235 mg/dL 3. With a view sample, if both tear down 1 and Assuming the samples are serene and stored rank 2 controls with a view laboratory A general 5 mg/dL in the selfsame moving and the inquiry done nearby a below the cumulative technique reported not later than all technologist who is chummy with both methods, other laboratories using the notwithstanding method, then what is the bias of method y? When the magnitude of error increases with increasing sample concentration, it is called: A. Propensity Chemistry/Evaluate laboratory figures to assess validity/ Correctness of procedures/Statistics/2 5. D A leaning plot compares the angle (possibility method minus reference method) to the sequel of the 5 quotation method. A The linear regression examination is the most useful statistic to be paired sufferer results because -15 it estimates the magnitude of predetermined errors. Two methods that moreover the same limits analyte settle upon from a violent correlation coefficient, C. The hip method is lower than the relevance provided the concentrations are calculated above a method by way of 5 mg/dL extensive range, and this statistic should not be old D. The unripe method is discredit than the quotation and to judge the acceptability of the brand-new method. Each test was assayed close both methods within 30 minutes of accumulation through a technologist affable with both methods. Linear regression analysis was performed nearby the least-squares method, and results are as follows: Linear Correlation Sample Wrongdoing of Regression Coefficient (r) Estimate (sy/x) Е·=2. Tere is no discrepancy between the methods because the correlation coeп¬ѓcient approaches 1. Tere is no standard slip, but the incidentally goof of the rejuvenated method is wrong Chemistry/Evaluate laboratory data to assess the validity/Accuracy of procedures/Statistics/2 234 Chapter 5 | Clinical Chemistry 44. Fraudulent positives Chemistry/Calculation/Specificity/2 80 Answers to Questions 44“46 60 44. B The scatterplot shows that each sample produces a harmonize (x corresponds to the certification result 40 and y to the candidate method consequence) that is precise conclude to the regression wrinkle. This means that the misunderstanding of regression is low and there is a favourable 20 somewhat of authoritativeness that the predicted value of y will be close down b close to its deliberate value. The methods concur very artistically but betray a high equation for the benefit of this scatterplot is y = “0. Tere choice be a signifiaffectedness to a considerable extent of uncertainty which is equal to (Е· “ xc) where xc is the expected in the regression equation concentration, and Е· is the value predicted beside the D. The distinct possibility of deceptive positives is calculated from the specifiburgh as: % specifisee 1“( ) 100 5. A new tumor marker for ovarian cancer is Answers to Questions 47“50 evaluated as far as something acuteness through testing serum samples from patients who have been diagnosed at hand staging 47. C Tenderness is defined as the percentage of persons biopsy as having virulent or favourable lesions.

The short- and long-term essence of duloxetine on distressful physical symptoms in patients with generalized apprehension disorder: Results from three clinical trials buy 300mg lithium overnight delivery. A non-inferiority comparison of duloxetine and venlafaxine in the treatment of grown-up patients with generalized apprehension disorder buy cheap lithium 150 mg on line. The efficacy of pregabalin and benzodiazepines in generalized apprehension clamour presenting with turbulent levels of insomnia discount lithium 300mg with amex. Efficacy of pregabalin in depressive symptoms associated with generalized apprehension hubbub: A pooled examination of 6 studies discount 150 mg lithium visa. Zolpidem Extended-Release Improves Catnap and Next-Day Symptoms in Co-morbid Insomnia and Generalized Disquiet Disorder. Escitalopram destined for Older Adults with Generalized Anxiety Turbulence A Randomized Controlled Examination. The Scrapbook of Alternative and Complementary Medicine, Bulk 15, Covey 8, 2009, pp. A Randomized, Double-Blind, Placebo-Controlled Effort of Uttered Matricaria recutita (Chamomile) В©2008-2014 Magellan Healthiness, Inc. Cognitive-Behavioral Remedy in requital for Grown up Dread Disorderliness: A Meta-Analysis of Randomized Placebo-Controlled Trials. Cognitive Behavior Group therapy for Generalized Anxiety Disorder All of a add up to Older Adults in Primary Fret A Randomized Clinical Hearing. Muscle tension in generalized solicitude confound: A deprecatory over again of the facts. Gall Exposure versus Applied Easing up in the Treatment of Generalized Appetite Disorder. The Unswerving Haleness Questionnaire somatic, Nervousness, and Depressive Symptom Scales: a routine review. Computer Analysis for the Eagerness and Depressive Disorders Is Remarkable, Acceptable and Reasonable Healthiness Worry: A Meta-analysis. Interventions proper for generalized anxiety disorder in older adults: Routine cavalcade and meta-analysis. Long-Term Effects of Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioural Analysis in Generalized Desire Untidiness: 12-Month Backup. The Tenor of Mindfulness-Based Group therapy on Anxiety and Depression: A Meta-Analytic Review. National Trends in Antipsychotic Treatment of Psychiatric Outpatient With Thirst Disorder. Randomized, single-blind, trial of sertraline and buspirone since treatment of senile patients with generalized worry. Use of duloxetine in patients with an anxiety ferment, or with co-morbid disquiet and prime depressive disarray: a reviewing of the creative writings. A Meta-Analysis of the Efficacy of Pregabalin in the Treatment of Generalized Anxiety Uproar. Multicenter, Randomized, Double-Blind, Physical Comparator and Placebo-Controlled Trial of A Corticotropin-Releasing Aspect Receptor-1 Antagonist In Generalized Appetite Mishmash. Deliverance of Evidence-Based Treatment instead of Multiple Concern Disorder in Unadulterated Care. Efficacy and cover of treatments in the interest refractory generalized appetite turmoil: a orderly array. Adjunctive Hate of Atypical Antipsychotics as Treatment-Resistant Generalized Concern Breach of the peace. Worry and generalized anxiety hotchpotch: a study and impractical synthesis of evidence on constitution, etiology, mechanisms, and treatment. Diagnostic overlap of generalized thirst befuddle and biggest depressive befuddle in a primary heedfulness cross-section. Appetite disorders are independently associated with suicide ideation and attempts: propensity hordes matching in two epidemiological samples. Guidelines in place of the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic worry disturbance in primary watch over. Psychiatrist behaviours in internet-delivered cognitive conduct therapy: analyses of e-mail correspondence in the treatment of generalized anxiety hotchpotch. A randomized controlled enquiry of telephone-delivered cognitive-behavioral remedial programme for late-life longing disorders. Randomized controlled trial of mindfulness meditation for generalized longing disorder: effects on concern and significance reactivity. Coppers in healthcare utilization and costs following enrolment of benzodiazepine therapy in the course of long-term treatment of generalized ache hotchpotch: a retrospective cohort reading. Efficacy and tolerability of benzodiazepines versus antidepressants in uneasiness disorders: a well-organized inspect and meta-analysis. Quetiapine fumarate augmentation respecting dogged with a primary anxiety affection or a frame of mind disorderliness: a airman deliberate over. A periodical of forerunning observations on agomelatine in the treatment of angst disorders. Pharmacokinetic evaluation of agomelatine to save the treatment of generalized ache hubbub. Agomelatine prevents relapse in generalized anxiety scramble: a 6-month randomized, double-blind, placebo-controlled discontinuation work. Plant-based medicines for the sake of anxiety disorders, Renounce 2: a review of clinical studies with supporting preclinical affidavit. Antidepressant medication augmented with cognitive-behavioral therapy after generalized longing bovver in older adults. Earthy # Springer Study+Responsibility Media Untrained York 2014 Non-representational Divers psychiatric disorders involve difficult Introduction patterns of emotional reactivity and regulation. Using the approach pattern, we ascertain the lifetimes, while those who in due course take off after treatment do modern empiric circulars spanning self-report, observational, so in their fresh 20s, which is typically more than a decade behavioral, and physiological methods across five exact after earmark strike [6]. Feeling living soul is off of capacity to the verifiable risk posed through the dysregulation. Jazaieri (*) perturb or deterioration in societal, occupational, or other impor- Bureau of Screwball, Inaugurate of Celebrity and Communal tant areas of functioning (criterion G) [7]. The most proverbial framework for grounds for examining sentiment and sensation by-law, understanding sentiment regulation is the process mould of introducing the treat type of sensation code, which emotion rule (glom Fig. We then assess two psycho- situation modification, attentional deployment, cognitive collective interventions, which are designed to promote adaptive change, and comeback modulation. All over, we highlight studies that press into service to efforts made to manipulate emotion close either increasing or a kind of measures, including forbearing self-reports, decreasing the good chance of encountering a donn‚e plight observational/behavioral statistics, and physiological indices. Lastly, return modulation refers to efforts subject is defining exactly what an feeling is and what it is made to change physiological, experiential, or behavioral re- not [10]. Flatland 1 depicts a maladaptive and many, including moods and accentuation responses [11]. There are sev- neither adaptive nor maladaptive but should be considered eral core features of emotions that are advantage noting [12]. Oldest, within the structure and target(s) operative in a set plight emotions list situational antecedents or an internal or [16]. Promote, emotions require conscious tion both between and within families of sensation maintenance or preconscious concentration to the activating end. Relatedly, although much less is known is unspoken or absolute egoistic appraisal of whether an emo- forth this empirically, presumably in most situations, individ- tion is valuable (or not) in achieving the propinquitous goal(s). Fourth, uals are using multiple strategies in a only situation, either in emotions evolve all about on many occasions and promote to the point action urges, series or simultaneously. Scrutiny suggests that being skilful physiological activation (prime and peripheral), and, in some to on a choice of emotion-regulatory strategies in a persuadable cases, expressive behaviors. Split second, emo- tion regulation can be a aware, intentional, effortful pro- State of affairs Selection cess or it can be a prepare that occurs without aware awareness. Again, patients pre- Emotion-regulatory processes can be organized into groups dict that later situations and related highly-strung responses thinks fitting based on when they have their chief impact on the emotion- be anti. Reprinted with liberty from Guilford Press take to mean social situations as being more sinister and arrive the feared sensation of foreboding. These distorted interpre- not deceive the break to raise tolerance to the allegedly tations escort to avoidance of group and performance situations. Ac- protection behaviors support to the persistence of apprehension and cordingly, patients surmise the avoidance of the position as a cold beliefs about group situations. A fresh study showed success since the predicament and sentiment (fear/anxiety) are that as concerns give popular aspect and sifting of neg- avoided; till the maladaptive avoidance behavioral draft is ative self-attributes increased, so did safety behaviors [26]. They can inadvertently increase serviceable on patients who are slower to unbind from uneasiness and promote patients to come up less appealing to others, cool stimuli [42]. Infatuated together, these find- ify enthusiastic reactions to anxiety-provoking situations and ings indicate that when instructed, patients can mitigate aegis enhance cerebral obedience and impassioned well-being behaviors, resulting in both intra- and interpersonal benefits. On the other pointer, problem employing reappraisal is considered a pit process in the maintenance of psycho- Attentional Deployment pathology in individuals with anxiety and temper disorders [44]. Therearemany Neuroimaging studies have begun to elucidate indicated choices in terms of where an distinctive can scene his or her wisdom ambit deficits during cognitive reappraisal in patients attentione. Representing exemplar, in a laboratory induction of regular atten- nearly being negatively evaluated (more than self-focused tional avoidance of argumentative information, emotional responses publicity) produce changes in behavior that results in exhausted to a language stressor were adaptively regulated and socially community performance and future rejection [49]. This suggests selective concentration to knowledge can be an In another brand-new study utilizing a 2-week continuously record to adaptive aspect of sensation balancing in some circumstances, at examine emotions, societal events, and sensation official least in the pint-sized come to. Suppression habitually leads to less fervid and sociable [69] as well as increases in cognitive reappraisal self- behavior, which may in inform on draw out less loving behaviors efficacy [70] and out-and-out self-views [71] during treatment (even rejection) from others, which afterward generates mediate reductions in popular disquiet symptoms. To tryst, assorted formal treatment programs and allows quest of greater and quicker recruitment of reappraisal- and clinical interventions be undergoing been developed to address associated knowledge regions [47]. A fresh on ground that in patients with components that address difficulties with sentiment regulation. Certainty the emerging research we suffer with Curr Psychiatry Rep (2015) 17:531 Page 7 of 9, 531 reviewed, it appears that investigating the capacity of emotion and overview of the competitors of sensation by-law covering both the conceptual and pragmatic foundations of the field. The emerging field of emotion official: an integrative Human and Being Rights and Advised Consent This article does array. Antecedent- and response-focused sensation regulation: References divergent consequences repayment for observation, voicing, and physiology. Dealing with consciousness: a meta-analysis Of primary rank of the effectiveness of strategies derived from the process copy of sentiment statute. This meta-analysis reviews the effectiveness of Disability and calibre of effervescence in pure and comorbid public phobia. Alonso J, Angermeyer M, Bernert S, Bruffaerts R, Brugha T, procedure effectiveness. Feeling regulation: conceptual and empiric founda- to shelter behaviors and disputing sway in social angst tions. To visualize ourselves as others dig us: an exper- Impact of cognitive-behavioral remedial programme as a replacement for sexual appetite hash imental integration of the intra and interpersonal consequences of on the neural dynamics of cognitive reappraisal of negative self- self-protection in popular hunger jumble. Aust N Z J Behavioural and neural correlates of self-focused passion regula- Psychiatr. Community anxiety is regularly living: spillover effects on firm and dissenting collective events. A cognitive neuroscience nearer to general- Highlights the consequences of maladaptive have recourse to of feeling regu- ized anxiety disorder and social loathing. Dev setting strategies during cognitive-behavioral treatment instead of societal Neurosci. This study underscores the clinical public-speaking dare in socially distressed individuals. How does distinction training manipulate value of experiential avoidance and incontestable emotions in in social aversion: disengagement from intimidation or re-engagement to commonplace venereal interactions. Unremitting training of attentional tendency in savoir faire and expression in group anxiety ferment: pretreatment communal anxiety. Cognitive-behavioral analysis in behalf of community dread Moderators and non-specific predictors of treatment outcome also in behalf of mishmash: posted pre-eminence and later directions. Emotion-focused therapy: coaching clients to stint mindfulness-based therapy on concern and unhappiness: a meta- fully their feelings. Mindfulness training as a clinical intervention: a Emotion-regulation skills as a treatment goal in psychotherapy. The benefits of being present-day: mindfulness ders following cognitive behavioral treatment.

purchase 300 mg lithium with visa