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why restate thesis in conclusion 3. The physician serves as a fiduciary who acts in the best interest of the patient, using the most current evidence-based medical information. In this role as infant advocate, the physician oversees the responses (decisions) of his or her patient's parents. It is the responsibility of the physician to involve the court system when he or she perceives that the infant's interests are inappropriately threatened by the parents' decision. B. There is considerable debate on how to define the "best interests" of the infant. The most controversial issue is whether the primary focus should be the preservation of life (the vitalist approach) or to maintaining a particular quality of life (the nonvitalist approach). This debate enters into difficult decisions more frequendy as it becomes technically possible to sustain smaller and sicker infants.

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http://projects.csail.mit.edu/courseware/?term=college-essay-opening-lines college essay opening lines Data are limited for use of igras in children younger than 5 years of age, persons recently exposed to tb, health care workers, and immunodeficient patients. 20 the cdc has endorsed the use of igra tests in all circumstances where the ppd is used. Igras are approved for the diagnosis of ltbi in hiv-infected patients, but sensitivity is diminished. 20 igras are preferred for testing patients who have received bcg and in patients who have poor rates of return for ppd skin test reading. Testing with both ppd and igra generally is not recommended, but may be useful in certain situations (eg, if the initial ppd test is negative and the risk for infection, clinical suspicion, or the 1126  section 15  |  diseases of infectious origin table 75–1  criteria for tuberculin positivity, by risk group reaction ≥ 5 mm of induration reaction ≥ 10 mm of induration hiv-infected persons recent immigrants (ie, within the last 5 years) from highprevalence countries injection drug users residents and employeesa of the following high-risk congregate settings. Prisons and jails, nursing homes and other long-term facilities for the elderly, hospitals and other health care facilities, residential facilities for patients with aids, and homeless shelters mycobacteriology laboratory personnel, persons with the following clinical conditions that place them at high risk. Silicosis, diabetes mellitus, chronic renal failure, some hematologic disorders, other specific malignancies, gastrectomy, and jejunoileal bypass children younger than 4 years of age or infants, children, and adolescents exposed to adults at high risk a recent contact of a person with tb disease fibrotic changes on chest radiograph consistent with prior tb patients with organ transplants and other immunosuppressed patients (receiving the equivalent of 15 mg/day or more of prednisone for 1 month or longer, taking tnf-α antagonists)b reaction ≥ 15 mm of induration persons with no risk factors for tb       for persons who are otherwise at low risk and are tested at the start of employment, a reaction of 15 mm or more of induration is considered positive. B risk of tb in patients treated with corticosteroids increases with higher dose and longer duration. A risk for poor outcome is high. Or if the initial ppd test is positive and additional evidence of infection is required. Or the patient has a low risk of infection or progression). 20,21 igras, and for that matter the ppd, should not be used to rule in or rule out the diagnosis of active tb disease. 21 treatment general approaches to treatment the primary treatment approach is the use of antimicrobials active against m. Tuberculosis. Monotherapy can be used only for patients with ltbi, as evidenced by a positive skin test or positive igra in the absence of signs or symptoms of disease. Once active disease is present, typically three or four drugs must be used simultaneously from the outset of treatment. 4,13,20,16 the shortest duration of treatment is 4 months in the unusual case of smear and culture negative clinical cases of pulmonary tb, and up to 2 years of treatment may be necessary for advanced cases of multidrug-resistant tuberculosis (mdr-tb). 20,22 directly observed treatment (dot) is a method used to ensure adherence in which patients are directly observed by a health care worker while taking their antituberculosis medication. 23 this also is a cost-effective way to ensure completion of treatment. Desired outcomes steps should be taken to (a) prevent the spread of tb (respiratory isolation). (b) find where tb has already spread (contact investigation). And (c) return the patient to a state of normal weight and well-being. Items (a) and (b) are performed by public health departments. Clinicians involved in the treatment of tb should verify that the local health department has been notified of all new cases of tb. In rare instances, surgery may be needed. 16 pharmacologic therapy »» treating ltbi isoniazid is used for treating ltbi. Typically, isoniazid 300 mg daily (5–10 mg/kg of body weight) is given alone for 9 months. Lower doses usually are less effective. 16 in some instances, a 6 month duration of treatment with isoniazid alone is an acceptable alternative. Pyridoxine (25–50 mg/day in adults) can reduce the risk of peripheral neuropathy. 16,24 treatment of ltbi reduces a person’s lifetime risk of active tb from about 10% to about 1%.

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