The ratio o drug concentration in breast milk relative to serum ranges rom ~5% (valproic acid) to 300% (levetiracetam). Disorders o balance present as di culty maintaining posture while standing and walking and as a subjective sense o disequilibrium, which is a orm o dizziness. Carriers o the isease may emonstrate a mosaic pattern, but ystrophin ana ysis o musc e biopsy specimens or carrier etection is not re iab. Ideally, diaphragmatic surgery is per ormed only i optimal tumor debulking can thereby be achieved. A detailed history o en discloses recent development o cramping with volitional movements, typically in the early hours o the morning. Polycythemia, thrombocythemia, or other actors lea ing to an un erlying hypercoagulable state shoul be correcte; aspirin treatment may be bene cial. There ore, the major concern o the physician is to recognize a isor er promptly as paraneoplastic an to i enti y an treat the tumor. I the history raises any concern or abnormalities o higher cortical unction or i cognitive problems are observed during the interview, then detailed testing o the mental status is indicated. Gauze sponges may be opened and tightly placed into the obturator ossa and medial to the external iliac vein to tamponade any sur ace oozing while additional procedures are per ormed. I there is a response, the less e ective or less well tolerated o the rst two drugs should be gradually withdrawn. Hypotension is characteristic o coma rom alcohol or barbiturate intoxication, internal hemorrhage, myocardial in arction, sepsis, pro ound hypothyroidism, or Addisonian crisis. Antibiotic prophylaxis is administered prior to surgery to decrease risks o postoperative wound and urinary tract in ection (able 39-6, p. For examp e, a primary e ciency o ystrophin (Duchenne ystrophy) may ea to secon ary oss o the sarcog ycans an ystrog ycan. The re erence or "normal" ranges given in this Appendix may there ore not be appropriate or all laboratories, and these values should only be used as general guidelines. Occasionally, the bladder may also be retrograde illed to exclude cystotomy during vesicouterine dissection. Aspirin in low doses given once daily inhibits the production o thromboxane A2 in platelets without substantially inhibiting prostacyclin ormation. Because the posterior cerebral artery also supplies medial temporal components o the limbic system, a patient with pure alexia also may experience an amnesia, but this is usually transient because the limbic lesion is unilateral. Un ormed visual hallucinations, peduncular hallucinosis, metamorphopsia, teleopsia, illusory visual spread, palinopsia, distortion o outlines, central photophobia: Calcarine cortex. Y are evaluating a 42-year-old woman or comou plaints o muscle weakness and tingling in her lower extremities. Idiopathic chronic atigue is used to describe the syndrome o unexplained chronic atigue in the absence o enough additional clinical eatures to meet the diagnostic criteria or chronic atigue syndrome. Lesions o either the caudate or dorsolateral pre rontal cortex, or their connecting white matter pathways, may result in executive dys unction, mani esting as poor organization and planning, decreased cognitive exibility, and impaired working memory. Factors that obstruct the transmission o sound or serve to dampen the acoustical energy result in conductive hearing loss. From a perineal approach, the planned incisions are marked along the skin rom the non-hair-bearing areas just lateral to the labia majora. The hallmark pathologic eature o Parkinson disease is presence o neuro brillary tangle and tau protein in the substantia nigra pars compacta. Carbamazepine, valproic aci, an alprazolam have also in epen ently pro uce improvement in uncontrolle trials. The test described in Question 2 is considered positive i there is exion at the elbows or orearms or i there is pronation o the orearms.
The resulting syndromes contain combinations o de cits in the various aspects o language but rarely t the speci c patterns described in able 22-1. The ventricular ependyma, choroid plexus, pial veins, and much o the brain parenchyma are not pain-producing. She denies any immediate precipitating cause, although she has been under increased stress because her mother has been hospitalized recently with advanced breast cancer. When patients cannot be otherwise managed, they may require long-term percutaneous nephrostomy tubes, indwelling stents, or reoperation and conduit or stoma revision. Slit-lamp examination shows isruption o the corneal epithelium, a clou y in ltrate or abscess in the stroma, an an in ammatory cellular reaction in the anterior chamber. Autonomic symptoms can accompany a diabetic neuropathy and can also be seen in amyloid polyneuropathy. Despite this, more than hal o surgical patients postoperatively report a worse sex li e (Butler-Manuel, 1999). Anticholinesterase agents such as rivastigmine and donepezil reduce the rate o deterioration o measures o cognitive unction and can improve attention, but do not typically improve cognitive unction in any meaning ul way. A bovine collagen product (Contigen) was commonly selected, but manu acturing ceased due to an inadequate supply o medical-grade collagen. The overall goal is to completely prevent seizures without causing any untoward side e ects, pre erably with a single medication and a dosing schedule that is easy or the patient to ollow. In cases at delivery, no evidence shows that either method yields superior results (Fitzpatrick, 2000; Garcia, 2005). Extension o the syrinx into the medu a, syringobu bia, causes pa ata or voca cord para ysis, dysarthria, horizonta or vertica nystagmus, episodic dizziness or vertigo, and tongue weakness with atrophy. Sh ift-wo rk d iso rd er More than 7 million workers in the United States regularly work at night, either on a permanent or rotating schedule. I per orming an end sigmoid colostomy, the distal bowel may simply be stapled closed and le t in the pelvis (Hartmann pouch). However, a surgeon should have greater suspicion i patients describe rectal bleeding or progressive constipation. When imaging tests are reported, it may be use ul to indicate that certain degenerative ndings are common in normal, pain- ree individuals. Finally, asking the patient and collateral source about other symptoms that may accompany delirium, such as depression, may help identi y potential therapeutic targets. I considered, an evacuated rectosigmoid may improve colon manipulation and pelvic anatomy visualization. However, other actors can be involved, such as preexisting or de novo bladder hypotonia. The arousal system in the brain (green) includes monoaminergic, glutamatergic, and cholinergic neurons in the brainstem that activate neurons in the hypothalamus, thalamus, basal orebrain, and cerebral cortex. Coronal axial T1-weighted image postgadolinium (C) demonstrates an intensely enhancing dural-based lesion typical or a small meningioma (arrows). Hypoper usion and embolic disease are requently involved in the pathogenesis o these syndromes, although multiple mechanisms may be involved in these critically ill patients who are at risk or various metabolic and polypharmaceutical complications. A recent publication did not demonstrate an increased risk o suicide or psychosis with varenicline use even though varenicline was used more requently in individuals with a preexisting psychiatric diagnosis. They enable a polyneuropathy to be distinguished rom a mononeuropathy multiplex, which has important etiologic implications. This buttock pain is generally attributed to entrapment o the nerve to the levator ani muscle. A laparoscopic omentectomy is per ormed by identi ying and elevating the omentum away rom the transverse colon. One speci c 2R38 taste receptor is expressed 258 in human upper respiratory epithelia and responds to acyl-monoserine lactone quorum-sensing molecules secreted by Pseudomonas aeruginosa and other gramnegative bacteria. Drug-induced inhibition or disruption o dopaminergic receptor unction is a common cause o hyperprolactinemia (able 51-5). Intracranial hemorrhages associated with anticoagulant therapy can occur at any location; they are o en lobar or subdural.
A number o medications used or the treatment o various medical and psychiatric disorders have been administered to reduce the duration and severity o cocaine abuse and dependence. This incision is pre erably made in the retropubic or extraperitoneal portion o the bladder dome to minimize risk o stula ormation. In contrast, when a ected by a disease process with an in ammatory component, deep structures such as joints or hollow viscera characteristically become exquisitely sensitive to mechanical stimulation. The opposite, an absence o re ex eye movements, usually signi es damage within the brainstem but can result rom overdoses o certain drugs. Objective assessment with urodynamic testing is per ormed to determine the cause o voiding dys unction and di erentiate between a hypotonic bladder and obstruction. The cup-to- isc ratio ranges wi ely in normal in ivi uals, making it i cult to iagnose glaucoma reliably simply by observing an unusually large or eep optic cup. Clinically, patients develop cognitive impairment, gait disorder, and later urinary incontinence, all o which can progress over time. Adhesion ormation and di culty with dissection in this space during subsequent operation may also be encountered. Ionotropic receptors are multiple subunit structures, whereas metabotropic receptors are compose o single subunits only. Focal de cits such as hemiparesis or aphasia are rarely due to leptomeningeal metastases unless there is direct brain in ltration, and they are more o en associated with coexisting brain lesions. Rarely, an intracranial aneurysm ruptures during an angiographic contrast injection, causing subarachnoid hemorrhage, perhaps as a result o injection under high pressure. These can be simple and involve a single muscle group or complex and a ect a range o motor activities. Other causes o sudden-onset neurologic symptoms that may mimic stroke include seizure, intracranial tumor, migraine, and metabolic encephalopathy. The mechanism responsible or cell death with this mutation is not known but is thought to involve changes in kinase activity with altered phosphorylation o target proteins (including autophosphorylation) and possibly lysosomal dys unction. There is controversy about whether or not anthelmintic therapy should be given to all patients, and recommendations are based on the stage o the lesion. Complete wound breakdown is more problematic, and weeks o aggressive hospital care may be required to promote secondary healing. Hypoglycemia and hypocalcemia, which can occur as secondary complications o perinatal injury, are also causes o seizures early a er delivery. Neovascular membranes can be i cult to see on unus examination because they are locate beneath the retina. The path l gy nsists demyelinati n withut in ammati n in the base the p ns, with relative sparing ax ns and nerve ells. Ora y administered methy prednisoone or dexamethasone (in equiva ent dosages) can be substituted or the intravenous portion o the therapy, a though gastrointestina comp ications are more common by this route. Brachial plexopathies occur in as many as 5% o patients ollowing a median sternotomy and typically a ect the lower trunk. Occasionally, tremor can be severe and inter ere with eating, writing, and activities o daily 424 living. A recent meta-analysis showed that carotid endarterectomy is most bene cial when per ormed within 2 weeks o symptoms onset and has greater bene ts in men and those 75 years old. In the subarachnoi space the oculomotor nerve is vulnerable to aneurysm, meningitis, tumor, in arction, an compression. A colostomy may be temporary or permanent, and its duration is dictated by clinical circumstances. T ermal, or "caloric," stimulation o the vestibular apparatus (oculovestibular response) provides a more intense stimulus or the oculocephalic re ex but provides essentially the same in ormation. Recent optogenetic research in animals, where the activity o speci c types o neurons in e ne circuits can be controlle with light, has con rme the importance o this limbic circuitry in controlling epression-relate behavioral abnormalities. In addition, some orms o yoga have been evaluated in randomized trials and may be help ul or patients who are interested. Schizophrenia genera y has a much ear ier age o onset (secon an thir eca es) than most ementing i nesses an is associate with intact memory.
Persistent headache with or without a sti neck, hydrocephalus, cranial neuropathies, radiculopathies, and cognitive or personality changes are the cardinal eatures. Predominant high-voltage slowing (or triphasic waves) in the rontal regions is typical o metabolic coma, as rom hepatic ailure, and widespread ast activity implicates sedative drugs. Additional ports are placed according to surgeon pre erence or clinical circumstances. Constituents o myelin also have a propensity to be targete as autoantigens in autoimmune emyelinating isor ers. For example, 3 to 5 years ollowing correction, only approximately 10 percent o women are ully continent o solid and liquid stool (Halverson, 2002; Malou, 2000). Controlle trials have shown that cognitive-behavioral an interpersonal therapies are e ective in improving psychological an social a justment an that a combine treatment approach is more success ul than me ication alone or many patients. They should be taught the elements o "sleep hygiene" including maintaining consistent schedules or bedtime and awakening. Lesions in the internal auditory meatus may a ect the adjacent auditory and vestibular nerves, causing dea ness, tinnitus, or dizziness. In one large study o severe head injury, 55% o children had a good outcome at 1 year, compared with 21% o adults. Aphasia, o en with preserved verbal repetition, may occur a er hemorrhage into the dominant thalamus, and constructional apraxia or mutism occurs in some cases o nondominant hemorrhage. For rectovaginal istulas, a broad base is le t in eriorly, and the at pad is detached superiorly. Such variables include the population studied, the duration and means o specimen transport, laboratory methods and instrumentation, and even the type o container used or collection o the specimen. A nal class o antidepressants, called simply mixed-action, includes trazodone, bupropion, and ne azodone. Examples include those with connective tissue disease, history o recurrent hernia, obesity, or chronically increased intraabdominal pressure such as chronic obstructive pulmonary disease or chronic constipation. The perineal incision ideally begins concomitantly with division o the levator muscles by the abdominal team. The latter urther increases brain swelling and intracranial pressure, which probably produces most o the symptoms o acute water intoxication. Although urethral plication may be indicated in selected cases, resection o 1 to 1. Based on the aging o the population and projected demographics, it is estimated that the prevalence o the disease will dramatically increase in the next several decades. Neuroimaging o the spine must include both sagittal and axial views to assess possible compression in either the lateral recess or intervertebral oramen. In most cases, both biologic an psychosocial actors are involve in the precipitation an un ol ing o epressive episo es. Af er dissolving in a liquid, tastants enter the opening o the taste bud-the taste pore-and bind to receptors on microvilli, small extensions o receptor cells within each taste bud. The axon o each primary a erent contacts many spinal neurons, and each spinal neuron receives convergent inputs rom many primary a erents. Such a erents have been termed silent nociceptors, and their characteristic properties may explain how, under pathologic conditions, the relatively insensitive deep structures can become the source o severe and debilitating pain and tenderness. The delayed-absorbable suture (black), which is placed most laterally on the ligament is labeled "1" and will be placed through the right lateral aspect o the vaginal cu. A low-residue diet, diphenoxylate hydrochloride (Lomotil), or loperamide hydrochloride (Imodium) tablets will aid healing by delaying de ecation and preventing straining (able 25-6, p. Many patients will also require alternative immunosuppression including azathioprine, mycophenolate mo etil, or in iximab. Less commonly, they may result rom pelvic radiation, tuberculous endometritis, or endometrial ablation. The mood disturbance is su ciently severe to cause marked impairment in social or occupational unctioning or to necessitate hospitalization to prevent harm to sel or others, or there are psychotic eatures.
The number o muscle bers that are activated varies over time, depending on the state o rest o the neuromuscular junctions. The neovagina is rotated cephalad into the pelvis and posteriorly anchored to the levator plate abdominally with interrupted stitches o 0-gauge delayed-absorbable suture to prevent vaginal prolapse. Ge sch win d Problems with gait and balance are major causes o alls, accidents, and resulting disability, especially in later li e, and are of en harbingers o neurologic disease. Optical coherence tomography shows ui beneath the retina, an uorescein angiography shows ye streaming into the subretinal space. A patient is taught sel -catheterization using an 18F to 22F red rubber catheter and antiseptic technique. Consent Associated with midurethral sling release, the risks o incontinence recurrence, ailure to adequately relieve retention, stula ormation, and intraoperative bladder or urethral injury are discussed during consenting. Side e ects o short-term g ucocorticoid therapy inc ude uid retention, potassium oss, weight gain, gastric disturbances, acne, and emotiona abi ity. The seizures can occur hundreds o times per day, but the child may be unaware o or unable to convey their existence. Patients of en present with visual de cits (45%), typically a homonymous hemianopia; mental impairment (38%) (dementia, con usion, personality change); weakness, including hemi- or monoparesis; and ataxia. Because scarring and retraction can develop, it is prudent to err on the side o leaving the genital hiatus larger rather than smaller. Within a ew days, this swelling may be counteracted by inactivation or elimination o intracellular solutes, resulting in the remission o symptoms even though the hyponatremia persists. One concern is the risk o "serotonin syn rome," which is thought to result rom hyperstimulation o brainstem 5-H 1A receptors an characterize by myoclonus, agitation, ab ominal cramping, hyperpyrexia, hypertension, an potentially eath. The serotonin precursor 5-hydroxitriptophan (plus carbidopa) may be use ul in some cases o postanoxic myoclonus. The syndrome o acute hydrocephalus accompanies many intracranial diseases, particularly subarachnoid hemorrhage. The most serious a verse e ects o clozapine are agranulocytosis, which has an inci ence o 1%, an in uction o seizures, which has an incience o 10%. These plexus injuries are more requent with cephalopelvic disproportion and o en present with a painless unilateral oot drop which must be distinguished rom a peroneal neuropathy caused by pressure on the nerve while in lithotomy position during delivery. Meningiomas o en are associated with bony hyperostosis; craniopharyngiomas may be calci ed and are usually hypodense, whereas gliomas are hyperdense on 2-weighted images. Dissection o the bladder rom the upper third o the anterior vaginal wall is aided by the vaginal manipulator. Needle passage moves rom right to le t with each stitch, and sutures are aligned vertically. Parametrial tumor extension is the third most common reason or aborting exenteration (Miller, 1993). Ha and coworkers (2001) noted a wound complication in 12 percent and stula ormation in 4 percent. Antibodies to voltage-gated calcium channels are ound in patients with Lambert-Eaton syndrome, another neuromuscular disorder associated with complaints o weakness. Neuropathologic examination is characterized by neurodegeneration and astrogliosis in the basal ganglia, particularly in the striatum. Rapid re ognition and treatment with naloxone, a highly spe i reversal agent that is relatively ree o ompli ations, is essential. With repetitive stimulation at rates o up to 10 Hz, the rst ew responses may decline in size, but subsequent responses increase. Also note the presence o any venous pulsation or surrounding pigment, such as a choroidal or scleral crescent. In epidemiologic studies, gait disorders are consistently identi ed as a major risk actor or alls and injury. Buspirone is another anxiolytic agent that is nonsedating, does not produce tolerance or dependence, and has no abuse potential. Loss o consciousness in concussion is believed to result rom a transient electrophysiologic dys unction o the reticular activating system in the upper midbrain that is at the site o rotation (Chap. Hereditary neuralgic amyotrophy is an autosomal dominant disorder characterized by recurrent attacks o pain, weakness, and sensory loss in the distribution o the brachial plexus that o en begins in childhood. Male smoking prevalence is alling but remains high in most Asian countries, with increasing smoking prevalence among women in those countries. Nonselective hemihypophysectomy or total hypophysectomy may be indicated i no hypersecreting mass lesion is clearly discernible, multi ocal lesions are present, or the remaining nontumorous pituitary tissue is obviously necrotic.
The peak incidence in the young occurs between ages 10 and 30 years, with a median peak around 15 years. The capillaries may be swollen with hyalinization, thickening o the capillary wall, an eposition o complement. Other actors that have impe e progress in un erstan ing mental illness inclu e the lack o access to pathologic brain tissue except upon eath an the inherent limitations o animal mo els or isor ers e ne largely by behavioral abnormalities. Coronal (A) and axial (B) T2-weighted f uid-attenuated inversion recovery images demonstrate expansion and high signal intensity involving the right medial temporal lobe and insular cortex (arrows). During cannulation, attempts are made to ush debris rom within the tubes and perorm chromotubation. A prospective European trial o adjunctive therapy or acute bacterial meningitis in 301 adults ound that dexamethasone reduced the number o un avorable outcomes (15 vs. I the dominant hemisphere is a ected and the in arct extends to involve the splenium o the corpus callosum, the patient may demonstrate alexia without agraphia. In a variant o this isor er, the pre ominant symptom is myotonia without weakness (potassiumaggravated myotonia). Development o these spaces allows the parametrial tissue to be isolated and later resected. One way to acilitate dialogue about this topic with veterans is to point out how hyperarousal associated with combat service can lead to increased craving or alcohol as the body searches or ways to modulate this. A noncontrast head C should be per ormed promptly to ensure there is no intracranial hemorrhage or edema o more than one-third o the middle cerebral artery territory. Following dose reduction, improvement in the neuropathy is seen in most patients af er several months (mean time about 10 weeks). During continued caudal ureterolysis, the ureter is seen to enter a "tunnel" within the pubocervical ligament. Additionally, risks o ureteral and bowel injury are included in the consenting process. The isor er may evelop a er a viral in ection, in association with cancer, or in patients taking statins when the myopathy continues to worsen a er statin with rawal. This reestablishes continuity o connective tissue support in the posterior vaginal compartment. Patients with vestibular de cits related to ototoxic drugs may lack vertigo or obvious nystagmus, but their balance is impaired on standing and walking, and they cannot navigate in the dark. Allerg ic co n ju n ctivitis this con ition is extremely common an o en is mistaken or in ectious conjunctivitis. Anatomic landmarks are identied to guide port placement and avert vascular puncture injuries. Even smaller reactive pupils (<1 mm) characterize narcotic or barbiturate overdoses but also occur with extensive pontine hemorrhage. Women abstain rom intercourse or 10 days ollowing injection but may otherwise resume usual activities. Five categories o disease account or most cases o chronic meningitis: (1) meningeal in ections, (2) malignancy, (3) autoimmune in ammatory disorders, (4) chemical meningitis, and (5) parameningeal in ections. However, any ocal de cit can occur depending on the area a ected, as evidenced by patients who, a er carotid endarterectomy, exhibit neurologic dys unction re erable to the ipsilateral newly reper used hemisphere. A handheld abdominal retractor is then used to expose an area o the lateral posterior peritoneum as high as possible in the abdomen. The puncture site and distal pulses should be evaluated care ully a er the procedure; complications can include thigh hematoma or lower extremity emboli. When passing a stent, undue pressure is avoided during advancement to avoid ureteral per oration. Risk fa cto rs fo r fa lls the most productive approach is to identi y the highrisk patient prospectively, be ore there is a serious injury. Simultaneous countertraction on the bro- muscular tissue by an assistant using tissue orceps or a gauze-covered nger can aid dissection.
It is uncommon to see signi cant proprioception de cits, even though patients may complain o gait unsteadiness. This procedure appears to have a >70% e cacy rate and a low rate o pain recurrence in responders; the response is better or classic tic-like symptoms than or nonlancinating acial pains. Familial acromegaly is a rare disorder in which amily members may mani est either acromegaly or gigantism. Depression, increased spasticity, and cognitive changes have been reported, a though these symptoms can a so be due to the under ying disease. Sagittal magnetic resonance scans o the thoracic spinal cord: T2 ast spin-echo technique (left) and T1 postcontrast image (right). The decision to use a laparoscope is individualized, and its placement ollows the steps described in Chapter 41 (p. Subtle impairment o coordination or tandem walking may be present, and disturbances o hearing, cognition, personality, mood, and ol action have also been described, but usually the neurologic examination is normal aside rom tremor. A ter adequate general or regional anesthesia is administered, a patient is placed in standard lithotomy position, the vagina is surgically prepared, and a Foley catheter inserted. The right gastroepiploic artery is ligated, and the dissection is continued to the le t by dividing the short gastric vessels until the lateral-most portion o the tumor is reached. Partia or partia -comp ex seizures with secondary genera ization are usua y preceded by an aura, common y an unp easant sme; ear; anxiety; abdomina discom ort; or other viscera sensations. Atypical antipsychotics, which have gained widespread popularity as adjunctive treatment or depression, anxiety, or sleep problems, have signi cant long-term side e ects, including metabolic e ects. Preoperative psychological assessment has been used to exclude patients with marked psychological impairments that predict a poor surgical outcome rom spine surgery. Cen tra l sero us ch o rio retin o pa thy this primarily af ects males between the ages o 20 an 50 years. Menstrual pain may be elt in the sacral region sometimes with poorly localized, cramping pain radiating down the legs. The activity o the primary projection cells, the mitral and tu ted cells, is modulated by granule cells, periglomerular cells, and secondary dendrites rom adjacent mitral and tu ted cells. However, the donor site may be di cult to close primarily or may lead to a postoperative hernia or dehiscence. Another advantage o this system is that it is per ormed under direct hysteroscopic visualization, allowing the surgeon to observe the endometrium being destroyed. A nding o an isolated stenosis o the right internal carotid artery in that patient, or example, suggests an asymptomatic carotid stenosis, and the search or other causes o stroke should continue. In obese women, operative visibility is hindered, and thus, procedure complexity and operative times are considerably greater. Upon close inspection, they appear greasy, ulcerate, an cruste with scaling ebris that clings to the lashes. Asenapine is associate with minimal weight gain an anticholinergic e ect but may have a higher than expecte risk o extrapyrami al symptoms. Blood vessels orming the tangle interposed between arteries and veins are usually abnormally thin and histologically resemble both arteries and veins. Myotonic discharges-high- requency discharges o potentials derived rom single muscle bers that wax and wane in amplitude and requency-are the signature o myotonic disorders such as myotonic dystrophy or myotonia congenita but occur occasionally in polymyositis or other, rarer, disorders. At present, interventi ns r preventi n and treatment ap pt ti ell death remain less well de ned than th se r is hemia. At higher doses o meperidine, typically greater than 1 g/d, accumulation o normeperidine can produce hyperexcitability and seizures that are not reversible with naloxone. Decreased sperm count and sperm motility and morphologic abnormalities o spermatozoa ollowing marijuana use have been reported. Even patients who state that they are not interested in 886 R eview and Self-A ssessment recommended, but at this time, the true requency o these responses remains unclear. It is help ul to develop a treatment plan based on short-term, intermediate-term, and long-term objectives. Only the residential medi ation- ree programs have had su ess that omes lose to mat hing that o the medi ation- ased programs.