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Nothing in this section may be construed so as to prohibit the licensed person rendering that treatment from informing that parent or guardian discount 10 mg nolvadex otc. For the purposes of this section “abuse of drugs” means the use of drugs solely for their stimulant nolvadex 20 mg lowest price, depressant or hallucinogenic effect upon the higher functions of the central nervous system and not as a therapeutic agent recommended by a practitioner in the course of medical treatment generic nolvadex 10 mg overnight delivery. Nothing in this section may be construed so as to prohibit the licensed person rendering this treatment from informing that parent or guardian. For purposes of this section, “abuse of drugs” means the use of drugs solely for their stimulant, depressant or hallucinogenic effect upon the higher functions of the central nervous system and not as a therapeutic agent recommended by a practitioner in the course of medical treatment. Urgency of treatment (b) A minor has the same capacity as an adult to consent to medical treatment if, in the judgment of the attending physician, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual. Substance abuse, sexual health treatment (c) A minor has the same capacity as an adult to consent to: (1) Treatment for or advice about drug abuse; (2) Treatment for or advice about alcoholism; (3) Treatment for or advice about venereal disease; (4) Treatment for or advice about pregnancy; (5) Treatment for or advice about contraception other than sterilization; (6) Physical examination and treatment of injuries from an alleged rape or sexual offense; (7) Physical examination to obtain evidence of an alleged rape or sexual offense; and (8) Initial medical screening and physical examination on and after admission of the minor into a detention center. Refusal of treatment (c-1) The capacity of a minor to consent to treatment for drug abuse or alcoholism under subsection (c)(1) or (2) of this section does not include the capacity to refuse treatment for drug abuse or alcoholism in an inpatient alcohol or drug abuse treatment program certified under Title 8 of this article for which a parent or guardian has given consent. Psychological treatment (d) A minor has the same capacity as an adult to consent to psychological treatment as specified under subsection (c)(1) and (2) of this section if, in the judgment of the 64 attending physician or a psychologist, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual. Civil liability (e) A licensed health care practitioner who treats a minor is not liable for civil damages or subject to any criminal or disciplinary penalty solely because the minor did not have capacity to consent under this section. Parental notification (f) Without the consent of or over the express objection of a minor, a licensed health care practitioner may, but need not, give a parent, guardian, or custodian of the minor or the spouse of the parent information about treatment needed by the minor or provided to the minor under this section, except information about an abortion. The consent of the parent or legal guardian of such minor shall not be necessary to authorize hospital and medical care related to such drug dependency and, notwithstanding any provision of section fifty-four of chapter one hundred and twenty-three to the contrary, such parent or legal guardian shall not be liable for the payment of any care rendered pursuant to this section. Consent shall not be granted under subparagraphs (ii) through (vi), inclusive, for abortion or sterilization. Consent given under this section shall not be subject to later disaffirmance because of minority. The consent of the parent or legal guardian shall not be required to authorize such care and, notwithstanding any other provisions of law, such parent or legal guardian shall not be liable for the payment for any care rendered pursuant to this section unless such parent or legal guardian has expressly agreed to pay for such care. No physician or dentist, nor any hospital, clinic or infirmary shall be liable, civilly and criminally, for not obtaining the consent of the parent or legal guardian to render medical or dental care to a minor, if, at the time such care was rendered, such person or facility: (i) relied in good faith upon the representations of such minor that he is legally able to consent to such treatment under this section; or (ii) relied in good faith upon the representations of such minor that he is over eighteen years of age. All information and records kept in connection with the medical or dental care of a minor who consents thereto in accordance with this section shall be confidential between the minor and the physician or dentist, and shall not be released except upon the written consent of the minor or a proper judicial order. When the physician or dentist attending a minor reasonably believes the condition of said minor to be so serious that his life or limb is endangered, the physician or dentist shall notify the parents, legal guardian or foster parents of said condition and shall inform the minor of said notification. The commissioner of public health shall prescribe a form for physicians to use in obtaining such consent. A pregnant woman seeking an abortion shall sign the consent form described above at least twenty-four hours in advance of the time for which the abortion is scheduled, except in an emergency requiring immediate action. She shall then return it to the physician performing the abortion who shall maintain it in his files and destroy it seven years after the date upon which the abortion is performed. If a pregnant woman is less than eighteen years of age and has not married, a physician shall not perform an abortion upon her unless he first obtains both the consent of the pregnant woman and that of her parents, except as hereinafter provided. If a pregnant woman less than eighteen years of age has not married and if one or both of her parents or guardians refuse to consent to the performance of an abortion, or if she elects not to seek the consent of one or both of her parents or guardians, a judge of the superior court department of the trial court shall, upon petition, or motion, and after an appropriate hearing, authorize a physician to perform the abortion if said judge determines that the pregnant woman is mature and capable of giving informed consent to the proposed abortion or, if said judge determines that she is not mature, that the performance of an abortion upon her would be in her best interests. A pregnant woman less than eighteen years of age may participate in proceedings in the superior court department of the trial court on her own behalf, and the court may appoint a guardian ad litem for her. Proceedings in the superior court department of the trial court under this section shall be confidential and shall be given such precedence over other pending matters that the court may reach a decision promptly and without delay so as to serve the best interests of the pregnant woman. A judge of the superior court department of the trial court who conducts proceedings under this section shall make in writing specific factual findings and legal conclusions supporting his decision and shall order a record of the evidence to be maintained including his own findings and conclusions. Nothing in this section is intended to abolish or limit any common law rights of persons other than those whose rights it governs for the purpose of any civil action or any action for injunctive relief under section twelve U. The consent of any other person, including a spouse, parent, guardian, or person in loco parentis, is not necessary to authorize these services to be provided to a minor.

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Overall opioid use is far more Most cannabis seizures are related to cannabis resin in prevalent (some 0 discount nolvadex 20 mg free shipping. The most prevalent prescriptions drugs in the region Cannabis resin found on the European market origi- seem to be prescription opioids nolvadex 10 mg online. While cannabis resin sei- non-medical use of prescription opioids has been reported zures declined over the 2005-2009 period buy nolvadex 10mg with mastercard, those of by Costa Rica, Brazil and Chile. High levels of con- Despite the increasing importance of cannabis herb, sumption have been reported for 2009, in particular overall cannabis seizures declined by 19% between 2005 from Argentina, Brazil and, to a lesser extent, Chile. Cocaine is trafficked to Europe mainly by sea, though in Drug-related deaths terms of reported seizure cases, deliveries by air are Countries in South America, including the Caribbean higher. Countries consistently strong increases in trafficking over the 1998-2006 period rank cocaine first as the primary cause of death, which – cocaine seizures declined massively over this period is in accordance with high prevalence of cocaine use and (-53%). This partially reflects improved cooperation the dominance of cocaine in treatment demand. The countries of West Illicit drug production in Europe is mainly linked to and Central Europe accounted for 97% of all European cannabis, amphetamines and ecstasy. In addition to direct shipments from South America, shipments via Africa, notably West • Cannabis production in Europe is believed to be increasing, mostly in indoor settings. Twenty-nine Africa, gained strongly in importance over the 2004- European countries reported domestic cultivation of 2007 period, before decreasing over the 2007-2009 cannabis herb in 2008. Though the Iberian peninsula, followed by the Netherlands and Belgium, continue to be main entry • In the past, ecstasy-group substances used to be points for cocaine shipments into Europe, there have manufactured predominantly in West Europe. Te also been reports of shipping cocaine to the Balkan Netherlands and Belgium are still the main sources for ecstasy in Europe. However, manufacture has shifted region (by container or air freight) for final destinations away from the region and only a few laboratories were in the European Union. Heroin seizures made in Europe accounted for 38% of • Most amphetamine seized in Europe is manufactured, the world total in 2009. Heroin seizures are mostly con- in order of importance, in the Netherlands, Poland centrated in South-East Europe (63% of all heroin sei- and Belgium. While Methamphetamine production and consumption are, heroin seizures in West and Central Europe remained however, still the exception in Europe. Europe’s share in global ecstasy seizures Cocaine use is still concentrated in West and Central declined from 90% in 1996 to 18% in 2009. Cocaine prevalence rates in West and Central Europe accounted for 24% of global amphetamine sei- Europe doubled between 1998 and 2006 but remained zures in 2009. More than 80% of all European amphetamine seizures in 2009 took place in The next most prevalent substance is ecstasy (0. Methamphetamine use is ecstasy’ and as a ‘date rape drug,’ increased four-fold in mainly limited to the Czech Republic, though some Europe over the 2005-2009 period. European seizures consumption also occurs in neighbouring Slovakia, some accounted for almost 80% of the world total. Illicit drug use In contrast to other regions, non-medical use of pre- scription drugs has not been regarded as a major prob- The most prevalent drug in Europe is cannabis, showing 32 lem in Europe so far. Around 18% of the total canna- non-medical use of prescription opioids than heroin. Following years of The highest levels of non-medical use of prescription significant increases, cannabis use appears to have stabi- opioids so far have been reported from Northern Ireland lized in Europe. Other countries in Europe reporting a substantial Cocaine is the second most prevalent drug (0. In % of global 2005 2006 2007 2008 2009 total in 2009 Cannabis resin 907,423 618,448 853,654 937,027 623,369 49% Cannabis herb 105,577 132,558 144,310 178,345 198,841 3% Cocaine 106,587 121,065 79,864 62,737 56,736 8% Amphetamines-group 9,906 11,434 11,216 9,771 9,077 14% of which amphetamine 8,039 6,019 8,791 9,438 8,117 24% Ecstasy 4,709 5,649 5,839 1,763 995 18% Heroin 22,165 22,171 26,394 29,206 28,762 38% Opium 2,059 1,292 1,445 1,324 1,379 0. Khat is not under international control, though a drug users all across Europe, including substitution number of countries – including countries in Africa – treatment clients. Studies show that between 11% and 33 have introduced national legislation to prohibit its cul- 70% of clients report current use of benzodiazepines. Drug-related deaths Trafficking For Europe, the best estimates suggest that there are Most of the cannabis trafficking is for shipments across between 25,000 and 27,000 drug-related deaths annu- African countries. Only smaller amounts are destined ally, with a rate between 46 and 48 deaths per one mil- for overseas markets, mainly in Europe.

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Diagnosis is made by culture of the specific patho- and are generally found only in cold-water systems nolvadex 20 mg overnight delivery. Tissue biopsy is the Biofilms effective 10 mg nolvadex, which are the filmy layer at the solid (pipe) and most sensitive means of obtaining a specimen for culture generic 10 mg nolvadex with mastercard. The mycobacterial fatty acid– and velop in tendon sheaths, bursae, joints, and bones after direct wax-rich impermeable cell wall results in a hydrophobic cell inoculation of the organisms through accidental traumas, surgical surface that permits adherence to solid substrates (e. These mycobacterial species as well as others without apparent trauma, presumably due to hematogenous in- are incredibly hardy, and resist the activity of organomercurials, fection. After open heart surgery, osteomyelitis of the sternum chlorine, 2% concentrations of formaldehyde and alkaline glutaral- caused by M. An expansive or all-encompassing discussion of Recently, mycobacterial outbreaks of M. The whirlpool isolates were subsequently molecularly American Thoracic Society Documents 385 identified as the same strains as those recovered from patients. However, they have also been reported after insertions of prosthetic devices such as (but not e. Sputum collection: Do not allow a patient to drink or washers that used a terminal tap water rinse cycle (246–249). Recognition of outbreaks: Be familiar with the settings water is not acceptable, especially for a terminal rinse. Thirty-one environmental and human strain diversity will make identification of specific sources of outbreak–related M. A similar outbreak has been raises the question, Can environmental shielding protect patients described in San Antonio, Texas (108). Should Health care–associated mycobacterial pseudo-outbreaks are patients with known or previous mycobacterial lung disease or problematic for a number of reasons. A consensus among experts has not been reached events, unnecessary expense incurred by the hospital and pa- on these important questions. This issue is yet to be assessed or addressed by public Recommendations: health personnel. The instruments should The first clue to the identity of a nontuberculous mycobacte- have a terminal alcohol rinse. Less as a result of specimen contamination than as a result of than 15% of cases, however, can be traced to this source, sug- disease. However, even these species can, under some gesting that other environmental reservoirs are also important. The clinician should use sion than cavitary disease, such that long-term follow-up (months in vitro susceptibility data with an appreciation for its to years) may be necessary to demonstrate clinical or radio- limitations. The major limitations for effective therapy were the sputum conversion rates at 6 months were comparable between absence of antimicrobial agents with low toxicity and good azithromycin- and clarithromycin-containing regimens (67 vs. Patients received rifampin and ethambu- and azithromycin, and presumably all other macrolides. Another similar study, however, failed to show clarithromycin and azithromycin, which have substantial in vitro a similar benefit of clarithromycin-containing regimens (277). In a second trial, azithromycin and all compan- able and inconsistent drug combinations, this study demon- ion medications were given on a three-times-weekly basis. The choice of therapeutic regimen for a specific patient de- Some of the important unresolved controversies in the management pends to some degree on the goals of therapy for that patient. The choice of therapeutic regimen, therefore, may be tion, and has less severe drug–drug interactions than rifampin, different for different patient populations. These guidelines offer which is critically important with complicated antiretroviral regi- a choice of several treatment options that can be selected based mens (286–289). Rifabutin also affects clarithromycin metabo- on the clinical presentation and needs of an individual patient. Some beneficial effect of macrolide-containing treatment regimens for patients with bronchiectasis could be due to immune-modulating effects of the macrolide (296). American Thoracic Society Documents 389 the tolerance of the patient to specific drugs and drug combina- attenuated doses, then gradually increasing the desired therapeu- tions. Recommended intermittent drug dosages include (1) Intermittent amikacin or streptomycin for the first 2 to 3 clarithromycin 1,000 mg or azithromycin 500–600 mg, (2)ethambu- months of therapy should be considered for extensive, especially tol 25 mg/kg, and (3) rifampin 600 mg given three times weekly.

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Barley and colleagues (152) compared dialectical behavior therapy received by patients with borderline personality disorder on a specialized personality disorder inpatient unit with treat- ment as usual on a similar-sized inpatient unit discount nolvadex 20 mg on-line. They found that the use of dialectical behavior therapy was associated with reduced parasuicidal behavior nolvadex 20 mg low cost. It is unclear whether improvement was due to dialectical behavior therapy per se or to other elements of the specialized unit nolvadex 10 mg cheap. Perris (153) reported preliminary findings from a small uncontrolled, naturalistic follow-up study of 13 patients with borderline personality disorder who received cognitive behavior ther- apy similar to dialectical behavior therapy. Twelve patients were evaluated at a 2-year follow-up point, and all patients maintained the normalization of functioning that had been evident at the end of the study treatment. Other controlled studies reported in the literature of cognitive behavior approaches are dif- ficult to interpret because of small patient group sizes or because the studies focused on mixed types of personality disorders without specifying borderline cohorts (154–156). Treatment of Patients With Borderline Personality Disorder 51 Copyright 2010, American Psychiatric Association. In summary, there are a number of studies in the literature suggesting that cognitive behavior therapy approaches may be effective for patients with borderline personality disorder. Most of these studies involved dialectical behavior therapy and were carried out by Linehan and her group. Replication studies by other groups in other centers are needed to confirm the validity and generalizability of these findings. Instead, longer forms of treatment, such as “schema-focused cognitive therapy” (147), “complex cognitive therapy” (144), or dialectical behavior therapy (17), are usually recommended. The standard length of dialectical behavior therapy is approximately 1 year for the most commonly administered phase of the treatment. It involves 1 hour of individual therapy per week, more than 2 hours of group skills training per week (for either 6 or 12 months), and 1 hour of group process for the therapists per week. Other versions of dialectical behavior therapy, such as that administered in a brief inpatient setting (151), may be useful but are not necessarily more effective than other forms of inpatient treatment. For example, as Linehan (17) pointed out, focusing on “therapy-interfering behavior” is similar to the psychodynamic emphasis on trans- ference behaviors. Beck and Freeman (19) noted that cognitive therapists and psychoanalysts have the common goal of identifying and modifying “core” personality disorder problems. However, psychodynamic therapists view these core problems as having important unconscious roots that are not available to the patient, whereas cognitive therapists view them as largely in the realm of awareness. It is not clear how successfully psychiatrists who have not been trained in cognitive behavior therapy can imple- ment manual-based cognitive behavior approaches. Although dialectical behavior therapy has been well described in the literature for many years, it is not clear how difficult it is to teach to new therapists in settings other than that where it was developed. Variable results in other settings could be due to a number of factors, such as less enthusiasm for the method among therapists, differences in therapist training in dialectical behavior therapy, and different patient populations. Although the Linehan group has developed training programs for therapists, certain characteristics recommended in dialectical behavior therapy (e. Group therapy a) Goals The goals of group therapy are consistent with those of individual psychotherapy and include stabilization of the patient, management of impulsiveness and other symptoms, and examina- tion and management of transference and countertransference reactions. Groups provide special opportunities for provision of additional social support, interpersonal learning, and diffusion of the intensity of transference issues through interaction with other group members and the ther- apists. In addition, the presence of other patients provides opportunities for patient-based lim- it-setting and for altruistic interactions in which patients can consolidate their gains in the process of helping others. However, these studies had no true control condition, and the efficacy of the group treatment is unclear, given the complexity of the treatment received. Another small chart review study of an “incest group” for patients with borderline personality disorder (159) suggested shorter subsequent inpatient stays and fewer outpatient visits for treated patients than for control subjects. A randomized trial (160) involving patients with borderline person- ality disorder showed equivalent results with group versus individual dynamically oriented psy- chotherapy, but the small sample size and high dropout rate make the results inconclusive.

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