By D. Hurit. Chatham College. 2018.

Symptoms from mild degenerative • allodynia: sensation of pain in response to a nor- conditions may be amplified proven 12.5mg hydrochlorothiazide. The questioning of the sever- stances in the tissues (inflammation) generic hydrochlorothiazide 12.5 mg fast delivery, but also by ity of pain exacerbates depression in patients with changes in the spinal cord processing of neuronal chronic pain. These pro- • Acute pain: the normal body responds to nox- tective and incapacitating functions are an acute ious stimuli with the experience of pain. Chronic pain The remainder of this chapter considers the under- This suggests persistence of the pain for a long standing, mechanisms and management of the time. Pain usually restricts Mechanisms of pain generation movement and is useful in preventing further damage to the joint. In contrast, neuropathic The following account separates pain mechanisms joints that have lost sensation, for example in dia- into distinct entities, but it must be remembered betes, degenerate rapidly. Sensation can be attributed to an area of the body that does not exist because the brain still has a rep- resentation of the absent part (e. As with many chronic stimulation of tissues can lead to pain; for example pains, the problem is within the central nervous the sensation of pressure when maintaining an system and it rarely responds to conventional uncomfortable posture is relieved on shifting analgesia. It is often subconscious and protects us • Higher pains We have probably all suffered grief, from damage when attention may be focused perhaps the death of a loved relative or failure in elsewhere. We describe this as • Tissue injury This results in structural elements painful and although the pain cannot be localized being damaged and an inflammatory response to a particular body part, it is nevertheless very real. Both noxious stimulation and disorders of transmission •Transmission is modified by inhibitory interneu- or perception have identical results—the experience of rones which are switched on by large-fibre input pain. This explains the effect of stimulation-induced analgesia: large-fibre input activating the inhibi- tory neurones reduces the input from smaller The variability of pain fibres. We are all familiar with this effect: when we It can be seen that pain experience and expression suffer a minor injury, our instinct is to ‘rub it bet- can be triggered and conditioned by many factors ter’. The and vibration and thereby reduces the transmis- body is subjected to millions of stimuli each day; sion of nociceptive information from the small most are of no significance or threat and need to be fibres activated in the injury. The fact that responses to stimulation how the nervous system can modify in response to can vary in intensity according to factors both electrical and chemical activity in nerves. The within and outside the body led Melzack and Wall brain also contributes by exerting ‘central control’ to propose the Gate Control Theory of Pain (Fig. It notes that: thereby helping to explain how mood and behav- • Sensory information from the periphery is car- iour affect processing within the spinal cord. The ried to the spinal cord in large-diameter (pressure, whole state is referred to as one of neuroplasticity touch and vibration) or small-diameter (pain and that occurs in a changing matrix of electrical and temperature) nerve fibres. A dull, aching Clinical assessment of chronic pain ‘second pain’ transmitted by the smaller fibres fol- lows after a fraction of a second and this is more The correct management of the patient with prolonged. Chronic pain is a specific neuralgia may be described as shooting, fibromyal- condition that must be recognized and treated, gia as exhausting, burning and nauseating. Patients’ tions are often long and complex, and involve dif- symptoms may previously have been dismissed— ferent hospitals and specialists. Diffuse or non-dermatomal pat- • medications; terns of pain distribution are related to central • type and effects of physiotherapy; sensitization and do not imply that the symptoms • aids and appliances; are not genuine. Some patients have no physical signs despite se- vere symptoms—again this does not imply that the Psychological assessment pain is not genuine. This may Measurement of pain be related to the pain itself, but is also associated with frustration or anger at many previous at- It is impossible to measure an experience directly tempts at treatment or the failure of treatment, so we rely on written or verbal self-report, as well as lack of a clear diagnosis or disease, and loss of social facial expression, body language and behaviour to and financial status. The assistance of a psychologist is in- of breakthrough analgesia tablets taken may be valuable to explore emotional issues associated useful as a measure of pain or of the effectiveness of with, or caused by, the pain. Psychological measures of coping, dis- patients should be seen with a partner in order to tress and depression are all valuable tools in assess independently the degree of physical and exploring the pain; however, they should be emotional disturbance at home and with the interpreted carefully in conjunction with a clinical family. Investigations Physical examination Patients with chronic pain have usually had many It is unusual for patients to present with ‘put on’ investigations and may be frustrated that nothing symptoms of pain. They may not understand that symptoms and the reaction to examination are ex- pain cannot be seen on their scans and X-rays. Care aggerated, but this is not surprising considering must be taken to explain that the absence of posi- that most patients with years of suffering are likely tive findings does not mean that the pain is in any to be distressed and anxious. Exaggeration may be way ‘imaginary’, ‘all in the mind’ or ‘psychologi- to convince rather than to deceive. Using terms such as ‘crumbling spine’ or movement; ‘degenerative changes’ in chronic low back pain • nerves: function, swelling or tenderness over the may invoke fear for the future and a life of increas- course of a peripheral nerve; ing disability, whereas in fact both back pain and • muscles: power and tone, localized or general- the preferable term ‘age-related change’ are com- ized tenderness; mon and are not well correlated. The patient on the left had been confined to bed for 2 years with back pain; the pa- tient on the right had never had a day’s back pain in her life. Intervention is only appropriate if there Respiratory depression (often a feared compli- is a realistic chance of success—an honest opinion cation) is not seen, even with very high doses, is appreciated. For some conditions associated with provided that doses are increased in a stepwise ongoing tissue damage, such as rheumatoid arthri- fashion—for example by 30% increments accord- tis, it is possible to suppress the inflammation and ing to effect. This may not be completely patients but with careful titration it can be mini- successful, so the treatment of pain may have to mized.

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As more information was generated buy generic hydrochlorothiazide 12.5mg, databases grew bigger discount 12.5 mg hydrochlorothiazide, more experimental information became available, and better and more accurate algorithms for gene identification and prediction were released. The letter C was not included since it usually stands for “comple- mentary”, which means that the gene is located in the complementary strand. As expected, the classes that exhibited the greatest numbers of changes were the un- known category and the conserved hypothetical category (Table 4-1). The re- annotation of the genome sequence allowed the identification of four sequencing errors making the current sequence size change from 4,411,529 to 4,411,532 bp (Camus 2002). Comparative genomics In recent times, new technologies have been developed at an overwhelming pace, in particular those related to sequencing and tools for genome sequence data man- agement, storage and analysis. As of April 2007, 484 microbial genomes have been finished and projects are underway aimed at the sequencing of other 1,155 micro- organisms (http://www. Mycobacteria are not an exception in this titanic genome-sequencing race; since 1998, when the first myco- bacterial genome sequence was published (Cole 1998a); many genome projects have been initiated. Until April 2007, 34 projects on the genome sequencing of different mycobacterial species are finished or in-process. For this reason, these are the strains that have been used as reference strains for comparative genomics both in vitro and in silico. The next step in comparative genomics was the use of genomic subtractive hybridi- zation or bacteria artificial chromosome hybridization for the identification of re- gions of difference among the strains under analysis (Mahairas 1996, Gordon 1999). As a result, they identified 10 regions of difference, including the three previously described (Mahairas 1996). Until 2002, most studies concerning comparative genomics were based on differ- ences among the strain type M. Some excellent reviews are available on comparative genomics, made before the publication of the second M. This strain was considered to be highly transmissible and virulent for human beings (Fleischmann 2002). With the sequence of this second strain, a first approach to the bioinformatic analysis of intraspecies variability became possible. Dark gray filled cells indicate the presence in all strains tested, light gray indicate the presence in some strains, white is absence from all strains tested. These studies have been complemented with data obtained from the genome sequence of a third organism of the M. Sequencing con- firmed the absence of 11 regions of difference, and the presence of only one inser- tion in comparison to the sequenced M. The comparison of the three genomes reflects the high degree of conservation among the members of the M. However, it is important to mention that the greatest degree of variation among these bacilli is found in genes encoding cell wall components and secreted proteins. Some other changes are registered in genes coding for lipid synthesis and secretion as the mmpL and mmpS family of genes. The sequencing of whole genomes of Mycobacterium leprae (Cole 2001), Mycobacterium avium subspecies paratuberculosis (Li 2005) and of other mem- bers of the genus, such as Mycobacterium smegmatis and M. Recently, a report compared the metabolic pathways shared among five of the mycobacterial genomes that have been sequenced (the genome sequence of M. The characteristics of the sequenced ge- 124 Genomics and Proteomics nomes of organisms in the genus Mycobacterium are presented in Table 4-2. The microarray approach allows the comparison of a large number of genomes, providing information on the diversity, frequency, and phenotypic effects of poly- morphisms in the population (Tsolaki 2004). Unfortunately, the microarray technique cannot detect genes present in a clinical isolate that are absent in the reference strain. These changes can originate from small deletions, deletions in homologous repetitive elements, point mutations, genome rearrangements, frame-shift mutations, and multi-copy genes (Ochman 2001, Schoolnik 2002). Although associations be- tween host and pathogen populations seems to be highly stable, the evolutionary, epidemiological, and clinical relevance of genomic deletions and genetic variation regions remain ill-defined, as do the molecular bases of virulence and transmissi- bility (Hirsh 2004). Evidently, these differences cannot include sequences present in clinical isolates that are absent from M. That number accounts for near half of all 126 Genomics and Proteomics the mycobacterial strains that are currently undergoing complete genome sequenc- ing. The rate of deletion in genes involved in intermediary metabolism and respiration, and in cell wall synthe- sis is surprisingly high. The use of microarray-based comparative genomics for the study of the genetic variability of pathogens provides interesting information. Not only the identifica- tion of the deleted or absent genes is important, but also the differential hybridiza- tion signal between samples is of interest. These differential signals can indicate sequence divergence or a difference in the copy number, which may provide an insight into strain evolution and pathogenesis (Taboada 2005). Functional genomics Functional genomics is the analysis of the biological function of the genes and their products within a cell or organism. Unlike genomics and proteomics, functional genomics focus on gene transcription, translation, and protein-protein interactions.

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Day after the night before: infuence of evening alcohol on risk of hypoglycemia in patients with Type 1 diabetes purchase 25 mg hydrochlorothiazide visa. Comparison of abdominal adiposity and overall obesity in predicting risk of Type 2 diabetes among men (1–3) order 12.5 mg hydrochlorothiazide with mastercard. Comparison of Body Mass Index, waist circumference, and waist/hip ration in predicting incident Diabetes: A Meta-Analysis. Systematic review: comparative effectiveness and safety of oral medications for Type 2 diabetes mellitus. Effects of aerobic exercise on lipids and lipoproteins in adults with Type 2 diabetes; a meta-analysis of randomized-controlled trials. Safety and magnitude of changes in blood glucose levels following exercise performed in the fasted and the postprandial state in men with Type 2 diabetes. Impact of high-fat/low-carbohydrate, high/low-glycaemic index or low-caloric meals on glucose regulation during aerobic exercise in Type 2 diabetes. Effects of a protein preload on gastric emptying, glycemia, and gut hormones after a carbohydrate meal in diet-controlled Type 2 diabetes. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with Type 2 diabetes. Infuence of fat and carbohydrate proportions on the metabolic profle in patients with Type 2 diabetes: a meta- analysis. One-year comparison of a high-monounsaturated fat diet with a high-carbohydrate diet in Type 2 diabetes. Comparative study of the effects of a one-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in Type 2 diabetes. Comparison of a simple algorithm with carbohydrate counting for adjustment of mealtime insulin glulisine. Effect of wheat bran on glycemic control and risk factors for cardiovascular disease in Type 2 diabetes. Carbohydrate and fbre recommendations for individuals with diabetes: a quantitative assessment and meta- analysis of the evidence. Weight loss in obese diabetic and non-diabetic individuals and long-term diabetes outcomes – a systematic review. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Effects of exercise on glycemic control and body mass in Type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. Effect of omega-3 fatty acids on cardiovascular risk factors in patients with Type 2 diabetes and hypertriglyceridemia: an open study. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. Effects of lifestyle modifcation on central artery stiffness in metabolic syndrome subjects with pre-hypertension and/ or pre-diabetes. Effects of a Mediterranean-style Diet on the Need for Antihyperglycaemic Drug Therapy in Patients with Newly Diagnosed Type 2 Diabetes. Effects of comprehensive lifestyle modifcation on diet, weight, physical ftness, and blood pressure control: 18-month results of a randomised controlled trial. Third Report of the expert panel on the detection, evaluation and treatment of high blood cholesterol in adults. The effect of plant sterols or stanols on lipid parameters in patients with Type 2 diabetes: A meta-analysis. Effects of long-term plant sterol or stanol ester consumption on lipid and lipoprotein metabolism in subjects on statin treatment. Enteral nutritional support and use of diabetes-specifc formulas for patients with diabetes a systematic review and meta-analysis. The high prevalence of malnutrition in elderly diabetic patients: implications for anti-diabetic drug treatments. Evidence-based nutrition guidelines for the prevention and management of diabetes 53 Chapter X: Chapter title head here References 202. Disturbed eating behaviours and eating disorders in Type 1 diabetes: clinical signifcance and treatment recommendations. Brief screening tool for disordered eating; internal consistency and external validity in contemporary sample of pediatric patients with Type 1 diabetes. Caring for people with Type 1 diabetes mellitus engaging in disturbed eating or weight control; a qualitative study of practitioners’ attitudes and practice. Report from the Commission to the European Parliament and the Council on foods for persons suffering from carbohydrate metabolism disorders (diabetes). Welcome to Embryology in 2009 and thank you for choosing your next stage in your own development with me! In the past 20 years as a researcher I have seen enormous changes in our understanding of this topic and the methods we employ to further our knowledge. This topic and its associated methodologies are now found at the core of scientific investigations and current medical research. Dr Mark Hill, course coordinator This current page will introduce the current course and link to related online course resources (bookmark this as your start page).

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Loss of 10% of total body water usually produce lethargy cheap hydrochlorothiazide 12.5mg with amex, fever and dryness on mucous membrane and a 20% loss is fatal generic hydrochlorothiazide 25mg visa. Extra cellular fluids found as interstitial fluid (the immediate environment of body cells), blood plasma and lymph, cerebrospinal, synovial, fluids of the eye & ear, pleural, pericardial, peritoneal, gastrointestinal and glomerular filtrate of the kidney. The concentration of water in the interstitial fluid is slightly higher than the concentration of water in plasma. The plasma proteins are responsible for this difference 354 Human Anatomy and Physiology A B Figure: 13. Hydrostatic pressure: it is the force exerted by a fluid against the surface of the compartment containing fluid. Osmotic pressure: Is the pressure that must be applied to a solution on one side of a selectively permeable membrane to prevent the Osmotic flow of water across the membrane from a compartment of pure water. When there is shift in the pressure of water to wards the interstitial space, accumulation of fluid in the space occur. Such accumulation of water produces distention of the tissue which appears as puffiness on the surface of the body. Causes of edema may be plasma protean leakage decreased protein synthesis, increased capillary or venous hydrostatic pressure, obstructed lymphatic vessels and inflammatory reaction. Under normal condition water is taken in to and excreted from the body, so it matches to maintain homeostasis. Drinking of water is regulated by nervous mechanism (thirst center in the brain) together with hormonal mechanism (Antidiuretic hormone). Kidneys are the organs regulated by homeostatic feed back response they are responsible for excreting most of the water from the body. These three electrolytes are particularly important in maintaining body function and normal water distribution among the fluid compartment. Enzymes, hormones and the distribution 360 Human Anatomy and Physiology of ions can all be affected by the concentration of hydrogen H ion. H Homeostatic maintenance of an acceptable P range in the extra cellular fluid is accomplished by three mechanisms: 1. This task is accomplished in renal tubules, where + hydrogen & ammonium ions are secreted in to urine, when H is excreted sodium is exchanged. Movement of water from one body compartment to another is controlled by a) Atmospheric pressure b) Hydrostatic pressure c) Osmotic pressure d) a & c only e) b & c only 364 Human Anatomy and Physiology 4. The function of electrolytes in the body include a) Contributing to body structure b) Facilitating the movement of water between body compartments c) Maintaining acid – base balance d) a and b only e) a, b, & c 5. Reproduction by means of sexual intercourse produces new human beings and hereditary traits to be passed from both parents to their children’s. The sex hormones play an important role both in the development and function of the reproductive organ and in sexual behavior & drives. By third fetal month it stats is to descend and by the seventh month of fetal life it passes through the inguinal canal. Because the tests hang in scrotum out side the body their temperature is of cooler than the body temperature by 3 Degree Fahrenheit. Next to tunica albuginea is Tunica Vaginals, which is a continuation of membrane of abdomino-pelvic cavity. Each test contain 800 lightly coiled Semniferous Tubules which produce thousands of sperm each second. The germinal tissue contains two types of cells: spermatogenetic cell producing or developing the sperm cell and the sustentacular cell, which provide nourishment for the germinal sperm. Between the semniferous tubules clusters of endocrine cells called interstitial endocrinocytes (Leydig cell) secret male sex hormone (Androgens) where testosterone is the most important. Epididymis: - The semniferous tubules merge in the central posterior portion of the testes as epydidimis. It is located easily over the spermatic cord; hence male permanent (surgical) contraceptive method (vasectomy) is usually performed over it. As it passes from tail of epididymis it is covered by spermatic cord containing testicular artery, vein, autonomic nerves, lymphatic and connective tissue. After the ducts deferens pass through the inguinal canal it free from spermatic cord and pass behind the urinary bladder, where it 372 Human Anatomy and Physiology travels along side an accessory gland, the seminal vesicle and becomes ejaculatory duct. They receive secretion from the seminal vesicles and pass through the prostate where they receive additional secretion. Seminal vesicles Seminal vesicles are paired; secretary sacs lie next to the Ampulla of the ducts deference. Bulbo urethral glands secrets clearly alkaline 374 Human Anatomy and Physiology fluid to neutralize the acidity of urine during the onset of sexual excitement and it also act as a lubricant. Has two main function, It caries urine through urethra to the out side during urination and it transports semen through the urethra during ejaculation. The loosely fitting skin of the penis is folded forward over the glans to form the prepuce or foreskin, which usually excised during circumcision.

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Many addiction treatment pharmaceutical industry has not made providers are unable to prescribe pharmaceutical substantial investments in the development of therapies and medical professionals who could new and effective addiction treatment 231 prescribe such therapies fail to address medications discount 12.5mg hydrochlorothiazide free shipping. A related problem is that some contributing factors to the increased medical medical professionals appear to have a treatment of mental health disorders order hydrochlorothiazide 25 mg with amex, such as disproportionate concern about the safety risks depression and anxiety, in the past two decades of addiction medications relative to medications has been the development and marketing of aimed at treating other medical conditions. However in recent years, the addiction medications have been noted and pharmaceutical industry has cut back safety concerns raised--particularly with regard dramatically on investments in the development 223 of new pharmaceutical therapies for these and to smoking cessation treatments, side effects 233 exist for many medications aimed at treating other mental health conditions. The large other health conditions and typically are profits that pharmaceutical companies were able acknowledged as an acceptable risk of treatment. Addiction treatment providers do not speak with Coupled with the rising cost of research and clarity or consistency about what the goals of development, the fact that pharmaceutical treatment are, what counts as quality treatment, companies face dramatic losses once the patents how performance and outcomes should be on many of their largest money-making drugs measured and what practices should be expire makes the current climate for the implemented to improve treatment and achieve development of new innovative medications * 239 measurable outcomes. For example, transporters that underlie addiction and that are organizations like the Council on Graduate promising targets for the development of Medical Education and the National Advisory 235 medications to prevent and treat addiction. Council on Nurse Education and Practice are public-private partnerships with Congressional Aside from economic concerns, other factors mandates to provide sustained assessment of the inhibiting investments in new pharmaceutical 241 needs of the medical and nursing fields. Even for which states that every physician must assume smoking cessation, which offers a huge clinical responsibility for the diagnosis and potential market, investments are negligible referral of patients with addiction and explicates compared with the costs associated with the particular competencies needed to fulfill that developing medications to treat the responsibility. Despite these and other efforts by government and professional Translating the rapidly-evolving science of organizations to put forth guidelines and addiction into science-based treatments will principles aimed at ensuring proper training in require dramatic changes in incentives for the risky substance use and addiction, physicians pharmaceutical industry to invest in innovative continue to be insufficiently equipped to address medications, increased public understanding that 242 the needs of their substance-involved patients. Such inconsistency in goals makes and outcome measurement, including limited measuring and assessing the effectiveness of consensus regarding core quality standards and treatment very difficult. The primary goals of medical care are the prevention, diagnosis and treatment of illness, injury and disease, and the consequent 246 relief of pain and suffering. The picture is not as clear in addiction treatment: there is little agreement among addiction treatment providers about what the goals of treatment are or should be and whether successful treatment is defined by abstinence, a reduction in clinical symptoms or a reduction in negative health and social 247 * consequences. Program Staff Further complicating the measurement of Directors Providers outcomes is the failure to understand that Tobacco addiction in many cases is a chronic disease that Complete abstinence 49. Government and private funders Inadequate Insurance Coverage and insurance companies increasingly are pressing addiction treatment programs to In spite of recent expansions in coverage for demonstrate the effectiveness of their programs intervention and addiction treatment through 250 health care parity laws and the Affordable Care and services. However, most programs do not measure performance or treatment outcomes or Act, insurance coverage for addiction and have reliable evaluation data to demonstrate the related services remains severely limited 251 compared with coverage for other health efficacy of their services. This lack of insurance coverage 252 for effective--and cost-effective--intervention addiction treatment. The asked about the three main ways that their end result is that millions of Americans are program evaluates how well it is doing, the most denied treatment, health care costs continue to common response offered was “program rise as do social consequences and costs, and 257 completion rates” (68. Its strength is a clear and long- to conduct and support “research, training, overdue recognition of the nature of the disease health information dissemination and other of addiction and the importance of addressing it programs with respect to the cause, diagnosis, in a unified way. The result is a disjointed array of programs and  Shifting evaluation efforts from a focus on efforts that often have quite different performance-based measures that document perspectives and approaches to addressing the the process of service delivery to a focus on issues surrounding substance use and addiction, patient outcomes, and rewarding those which further contributes to the segmented view programs that demonstrate positive patient 265 of addiction as multiple substance- and outcomes; and behavior-specific problems, rather than a single disease with different manifestations. Although these supporting research and prevention are steps in the right direction, the research efforts; advocating for state and federal documented in this report demonstrates clearly policies that would expand access to that the current treatment infrastructure is treatment; and working to establish riddled with barriers to closing the vast gap addiction medicine as a recognized 267 271 between research evidence and practice. Such brief trainings use, including tobacco, alcohol and have proven effective in improving health other drugs. Recent research within the alcohol and other drugs, and to promote Medicaid and Veterans Health more broadly the adoption of these Administration systems demonstrates the 277 286 practices in the medical field. For example, in 2012, the Joint Commission announced new, * voluntary measures for hospitals that choose Screening, Brief Intervention, Referral and to provide screening, brief intervention and Treatment. The performance Our perspective is that, although tactically measurement sets related to alcohol and impressive, the [Joint Commission’s] other drugs include screening, brief measure set [regarding tobacco screening and interventions, treatment, discharge planning cessation services] is strategically flawed 287 291 and follow up. Hospitals are with risky substance use than all the urging required to choose four out of 14 possible and pleading we’ve undertaken for the past core performance measurement sets, with no 292 25 to 30 years. However, other sets of measures that hospitals may choose to be held accountable for include those that they already perform routinely, limiting the reach of this promising development which would require more effort and resources than most other 290 measurement sets. Effective, evidence-based interventions and treatment options exist that can and should be delivered through the health care system. A substantial body of research demonstrates that providing effective prevention, intervention, treatment and disease management services yields improvements in health and considerable reductions in costs to government and taxpayers; research also suggests that providing these services does not result in significant increases in insurance costs. In the face of these facts, it is unethical, inhumane and cost prohibitive to continue to deny effective care and treatment for the 40. No one group or sector alone can realize the changes required in health care practice, government regulation and spending, insurance coverage, and public understanding to bring addiction prevention and treatment and reductions in risky substance use in line with the standard of care for other public health and medical conditions. Concerted action is required on the part of physicians and other medical and health professionals, policy makers, insurers and the general public. Likewise, addiction has been seen for too long -227- as a character flaw and a moral failing rather  Connection to support and auxiliary than a preventable and treatable disease. Efforts already underway to counseling, and mutual support close this gap must be expanded and accelerated. Evidence-based screening can be conducted by a Incorporate Screening and Intervention for broad-range of licensed providers with general Risky Substance Use, and Diagnosis, training in addiction and specific training in how Treatment and Disease Management for to conduct such screens and what to do with Addiction into Routine Medical Practice patients who screen positive. Brief interventions can be provided by health professionals-- As essential components of routine medical care licensed graduate-level medical or mental health practice, all physicians and other medical clinicians--trained in addiction care.

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