Caduet
David A. Bedell, MD
- Associate Professor of Family Medicine
- Roy J. and Lucille A. Carver College of Medicine
- University of Iowa
- Iowa City, Iowa
Recognize the clinical features of osteogenesis imperfecta and the clinical spectrum of the disease 3 cholesterol kid definition caduet 5 mg visa. Know that "malignant" osteopetrosis is a recessively inherited disorder of osteoclasts 2 grams of cholesterol in eggs generic caduet 5mg mastercard. Know that rickets and osteopenia may occur in premature infants as a result of dietary phosphate and/or calcium deficiency 5 cholesterol levels charts caduet 5 mg amex. Know the principal clinical and biochemical manifestations of hypophosphatasia cholesterol levels g l caduet 5mg generic, an inherited deficiency of alkaline phosphatase leading to ricketslike bone disease and craniosynostosis 2. Know that distal type renal tubular acidosis may lead to rickets in childhood and eventually to dense nephrocalcinosis 4. Be able to distinguish between benign and clinically significant forms of hyperphosphatasemia 2. Know the embryology of the formation and migration of the thyroid gland and the developmental genes involved b. Know the pattern and timing of hypothalamicpituitary thyroidal function in the fetus 2. Understand the synthesis of thyroid hormones, including iodide metabolism, uptake, organification, incorporation into thyroglobulin, coupling, and proteolytic secretion 3. Be aware of the changes in thyroid hormone concentrations in the immediate neonatal period and the first weeks after birth b. Understand the metabolism of thyroid hormone, its regulation, and its physiologic significance 6. Know that thyroid hormone receptors belong to the nuclear (steroid) hormone receptor superfamily, and that multiple isoforms exist c. Understand the role of the surge of thyroid hormone in thermal homeostasis, especially in the newborn period B. Be aware that transplacental passage of certain substances including radioiodine, iodides, propylthiouracil and methimazole administered to the mother may affect fetal thyroid development and/or function 2. Know the value of ultrasonography in detecting thyroidal enlargement in the fetus c. Know the efficiency of fetal brain deiodination in the face of fetal hypothyroidism d. Know that when there is hypothyroidism in the mother and the fetus, severe mental retardation is likely in the fetus b. Be aware of potential effects on the breastfed infant of antithyroidal agents ingested by the mother b. Know the approximate incidence of the various causes of congenital hypothyroidism g. Recognize that congenital central hypothyroidism is often associated with other pituitary hormone deficiencies 2. Be aware that congenital hypothyroidism is the most common disease screened for in newborns 4. Know the clinical findings of congenital hypothyroidism and when they become manifest 7. Know the clinical findings of Pendred syndrome and recognize that mutations in the affected gene are an important cause of sensorineural deafness b. Be aware that the recommended dosage of thyroxine per kg of body weight for congenital hypothyroidism changes with the age of the child 4. Know potential side effects of overtreatment of congenital hypo thyroidism (premature craniosynostosis and advanced bone age) 8. Know that mild hypothyroidism frequently normalizes and that treatment may not be necessary d. Recognize that congenital hypothyroidism may not be detected in a small number of infants by neonatal screening c. Be aware that thyroid hormone deficiency may develop during treatment of growth hormone deficiency c. Know which drugs may interfere with thyroid function (eg, iodides, lithium, and amiodarone) and the clinical correlates of these drugs in thyroid physiology d. Know that some chromosomal disorders (Down syndrome, Turner syndrome) predispose a patient to the development of autoimmune endocrine diseases f. Recognize the importance of iodide deficiency as a cause of hypothyroidism in some parts of the world g. Be aware of the clinical findings of acquired hypothyroidism including typical impact on growth patterns 2. Recognize the characteristics of the thyroid gland on physical examination or imaging studies in autoimmune acquired hypothyroidism 4. Be aware of association of the autoimmune acquired hypothyroidism with other autoimmune endocrine diseases, including the autoimmune polyglandular syndromes 5. Know that clinical features of secondary or tertiary hypothyroidism are milder than primary hypothyroidism b. Know the techniques for monitoring the adequacy of thyroid hormone replacement in primary hypothyroidism and in central hypothyroidism, including the need to delay thyroxine monitoring for at least five half lives (5 weeks) after dose adjustment 3. Know the effects of age and size on thyroid hormone replacement dosage in patients with secondary or tertiary hypothyroidism 4. Be aware of the effects on thyroid function tests of treatment with large doses of thyroxine 5. Recognize the occurrence of pseudotumor cerebri in some hypothyroid children treated with thyroxine d. Be aware that mutations in the thyroid hormone receptor beta are associated with thyroid hormone resistance b. Be aware of the clinical findings in thyroid hormone resistance, including attention deficit hyperactivity disorder b. Differentiate between Graves disease and other conditions involving hyperthyroidism 2. Know the usefulness of the measurement of T4, free T4, and T3 concentrations in hyperthyroidism 3. Understand that the reference ranges for thyroid function tests provided by many laboratories are often specific to adults, and not children 7. Know how to use betablocking agents for immediate control of the symptoms of Graves disease 5. Know the intra and postoperative complications of surgical treatment of Graves disease 8. Know the indications and use of radioiodine in the treatment of Graves disease 10. Know the clinical significance of dysalbuminemia and the characteristic laboratory findings b. Be aware of the clinical and laboratory findings in acute suppurative thyroiditis b. Be aware that subacute (lymphocytic) thyroiditis may be a cause of transient hyperthyroidism followed by transient hypothyroidism and then by euthyroidism b. Be aware of the propensity for transient abnormalities caused by subacute (lymphocytic) thyroiditis to recur in affected individuals 4. Know the predisposing factors to the development of thyroid carcinoma such as irradiation and the increased risk in children less than 10 years of age b. Recognize that natural history of medullary carcinoma of the thyroid varies, depending on the specific mutation 6. Know the indications for biopsy, including fine needle aspiration biopsy, of a single thyroid nodule 4. Understand that metastases of follicular and papillary thyroid cancer may be curable with radioiodine 3. Understand that distant metastases of medullary thyroid carcinoma are not currently curable but that longterm survival is still possible f. Understand the importance of genetic testing at an early age and prophylactic thyroidectomy in individuals with a family history of medullary carcinoma d. Know that diffuse enlargement of the thyroid is most commonly due to chronic lymphocytic thyroiditis b. Be aware of causes of diffuse thyroid enlargement other than chronic lymphocytic thyroiditis d. Know that Hodgkin disease and other infiltrative hematologic diseases (eg, histiocytosis) and their treatment may involve the thyroid gland 2.
In the context of a rapidly Although it is important to properly characterize the eti growingneckmassthatmaycompromisetheairwayandcause ology of metastatic tumor sites cholesterol test kit price purchase caduet 5mg on-line, it would be unusual for this thoracic outlet syndrome cholesterol zelf meten safe caduet 5mg, there are very few findings from knowledge to have a significant effect upon the planning or staging that could delay planned local therapies cholesterol levels change with age buy caduet 5 mg with visa. For this reason cholesterol natural remedies trusted caduet 5 mg, impending neurological crisis, either from a growing brain in most circumstances primary surgery should not be delayed metastasis or vertebral metastases that compromise the spinal to biopsy distant metastases. Such biopsies may be pursued cord, would constitute sufficient cause for delaying primary after primary surgery is completed in the rare circumstances thyroid site surgery until after emergent surgical or radio when such questions arise. The timely, decisive surgical risk, particularly in the context of severe ischemic input of all specialties is critical in defining the initial man cardiac or cerebrovascular disease. Early interactions with pain and Only imminently threatening disease elsewhere. Furthermore, it is important to also have readily available Strength of Recommendation: Strong gastroenterological expertise (evaluation of nutritional status Quality of Evidence: Low and potential need for enteral or parenteral nutritional sup port) and radiological expertise (timely interpretation of im Indications for neoadjuvant therapy. Careful radiological assessment of tumor in Because formulation of the initial management plan re volvement in the visceral compartment, nearby vascular quires rapid, complex, and integrated decision making, these structures, and posterior paraspinous structures may reveal patients should ideally be evaluated and cared for at medical significant obstacles to successful primary surgery. This is centers that have in place highly functional multidisciplinary because a 69% rate of tracheal invasion, 55% rate of esopha management teams. The rarity of the disease, coupled with geal invasion, and 39% rate of carotid artery involvement the breadth of knowledge required to arrive at initial treat have been reported (102). Endoscopic evaluation of hypo ment recommendations, makes it quite challenging for even pharynx, esophagus, larynx, and trachea may be needed to the most experienced thyroid cancer specialist to care for these supplement radiographic studies. Strength of Recommendation: Strong If a primary tumor is deemed unresectable, then there are Quality of Evidence: Low alternative approaches. Likewise, neoadjuvant chemotherapy (104) may prove 1year survival is *20% (1, 106). Women under age 60 Strength of Recommendation: Strong years had a better prognosis when they had surgical excision Quality of Evidence: Low and/or external beam radiotherapy. Patients without adequate deci ease confined to the thyroid gland, absence of distant meta sionmaking capacity cannot provide genuine consent to stases, and complete resection of the primary tumor are treatment. The following questions administered to 78 subjects; 15 patients were able to receive can help to assess decisionmaking capacity. The goal of this discussion is to reach consensus over the realistic treatment *The Patient SelfDetermination Act (127, 128) requires hospitals, options that can be offered to the patient to improve conti nursing homes, and other health care facilities to ask about Advance nuity of care and reduce internal disagreement over goals of Directives or to record patient preferences regarding certain treat care. Ad ditionally, all states have specific health care laws that include pessimistic messages, can dramatically affect advanced care proxy/surrogate decision making. Although treating physicians should consult with their hospital ethics advance directive forms in the United States vary from state to committee or hospital attorney about appointing a proxy de state, these documents can also specify patient preferences cision maker. In this discussion, all relevant potential risks and by a values history (151, 152). Patients who have indicated benefits of available therapies must be disclosed (139). In patients with locoregional disease, the determination of whether the tumor is resectable should be based on what structures are involved, whether a satisfactory resection can be achieved (R0/R1), and whether resection of the involved structure results in significant morbidity or mortality. Patients with anaplastic thyroid carcinoma who agus, trachea, and/or superior vena cava is not uncommon present with locoregionally confined but unresectable dis and needs to be evaluated to determine resectability. Some patients may subsequently be deemed to have performed to evaluate the extent of disease locally and to resectable tumor. A highresolution ultrasound of the neck should be obtained to evaluate the possible. There are insufficient data to deter nerve invasion, tracheal and/or esophageal invasion, a direct mine if there is a difference in diseasefree survival rates be laryngoscopy, bronchoscopy, and esophagoscopy, respec tween patients who have grossly negative margins (R1 tively, should be performed. Strength of Recommendation: Strong Quality of Evidence: Moderate Optimal extent of surgery and control/survival. Patients with anaplastic thyroid carcinoma, resect of patients presenting with widely metastatic disease (58, 163). Likewise, the role for completion consider this procedure when there is concern for or docu thyroidectomy (if only an initial lobectomy was performed) is mented injury to the ipsilateral recurrent laryngeal nerve, or based more upon the characteristics of the nonanaplastic removal of or no identification of the ipsilateral parathyroid malignancy than on the incidental finding of anaplastic mi glands. If there is extrathyroidal invasion, an en bloc resection crocarcinoma, including the findings of preoperative imaging (but not total laryngectomy) with the goal of achieving gross studies evaluating the contralateral lobe for the initial lobec negative margins should be considered. There are insufficient data to demonstrate a difference the operative resection should be considered in the context of in diseasefree survival or causespecific mortality based on morbidities that may occur from resecting adjacent involved the extent of thyroidectomy for an incidental (microscopic) structures. Similarly, incomplete re complete/near complete resections or in patients with un section or tumor debulking (R2) should also not be performed resected disease, as discussed in the later sections on radio because it is unlikely to be beneficial for local control and/or therapy. In patients with extrathyroidal invasion, an en bloc resec Strength of Recommendation: Strong tion should be considered if grossly negative margins (R1 Quality of Evidence: Low resection) can be achieved. In such cases, the tumor may become Strength of Recommendation: Weak resectable even if initially unresectable. Although external Quality of Evidence: Low beam radiation may result in significant fibrosis and scarring making surgical resection difficult, patients who have a du Surgical risk to recurrent laryngeal nerve. If a patient rable response and who have residual disease may be con presents with ipsilateral recurrent laryngeal nerve palsy, one sidered operative candidates if there is no other disease needs to be extremely careful in the operating room to avoid outside the neck. There are, however, limited data in the lit injury to the opposite recurrent laryngeal nerve. Tracheostomy does lead to secretions, Every attempt should be made to identify the contralateral need for frequent suctioning, and overall discomfort that the recurrent laryngeal nerve, especially if the ipsilateral nerve patient may experience. However, it does overcome acute is paralyzed, to protect the nerve from injury, which may airway distress with some prolongation of life. Strength of Recommendation: Strong Tracheostomy may be temporarily beneficial in patients Quality of Evidence: Low with impending airway loss. Critical in defining approaches to be used are (i) the procedure, the patient should remain intubated for a short wishes or directives of the patient, (ii) the fitnessof the patient to period of time and extubated either in the operating room undergo candidate therapeutic approaches, (iii) the availability itself or in the recovery room with close observation. Typically, the tracheostomy, which should be performed in the operating mainstays of therapy in addition to surgery can involve loco room (172, 173). The best results in terms of both local control and Strength of Recommendation: Strong survival from numerous studies appear to result from surgical Quality of Evidence: Low resection followed by radiation therapy, usually in combina tion with chemotherapy. Timing and sequencing of perioperative radiation and/or Similarly, in another smaller populationbased study from systemic chemotherapy. There are no definitive data that British Columbia analyzing 75 patients, survival was better in indicate when radiation and systemic therapy should start or patients who had more extensive surgery and had highdose how they should be sequenced. In the Mayo Clinic series, postoperative radiation operative healing has transpired and when the patient has re was associated with an improvement in median survival from covered sufficiently to lie supine and enable immobilization. In 3 to 5 months, but this was not statistically significant particular, radiation treatment planning should begin expedi (p = 0. However, systemic chemotherapy series after maximum surgical debulking and postoperative can often be initiated more quickly after surgery than can ra chemoradiation therapy.
The neonatal clinical ventilator allocation protocol applies to all patients 28 days old and younger in all acute care facilities Statewide cholesterol ratio nice purchase caduet 5 mg with mastercard. As with the other protocols cholesterol test margin of error purchase generic caduet online, all neonatal acute care patients in need of a ventilator myth of cholesterol in eggs cheap caduet 5mg free shipping, whether due to influenza or other conditions cholesterol average daily intake caduet 5mg online, are subject to the clinical protocol. Ventilatordependent chronic care patients are only subject to the clinical 159 Chapter 3: Neonatal Guidelines Abstract ventilator allocation protocol if they arrive at an acute care facility. The purpose of applying exclusion criteria is to identify patients with the highest probability of mortality, even with ventilator therapy, in order to prioritize patients most likely to survive with ventilator therapy. While most of the exclusion criteria from the Pediatric Guidelines were adopted for the Neonatal Guidelines, the Neonatal Clinical Workgroup decided to include additional conditions, such as gestational age and birth weight, which are specific to the population. If a patient has a medical condition on the exclusion criteria list, s/he is not eligible for ventilator therapy. In order for a patient to 160 Chapter 3: Neonatal Guidelines Abstract continue with ventilator therapy, s/he must demonstrate an improvement in overall health status at each official clinical assessment. These results reveal the presence (or likelihood), severity, and number of acute organ failure(s), which indicate mortality risk. The second part is the magnitude of improvement or deterioration of overall health based on these parameters, which provides additional information about the likelihood of survival with ventilator therapy. Together, these clinical variables provide an overall health assessment of a patient. The other clinical factor reveals whether a patient is experiencing kidney failure, and while useful, it should never be the sole reason to justify a triage decision involving extubation. At 48 hours, because a patient has only had two days to benefit from ventilator therapy, the progress required to justify continued ventilator use is not expected to be dramatic. However, after 120 hours, a patient must demonstrate a pattern of further significant improvement in health to continue. After the 120 hour clinical assessment, a patient who is eligible to continue with ventilator therapy is reassessed every 48 hours with the same three clinical parameters listed above. A patient who no longer meets the criteria for continued use receives alternative forms of medical intervention and/or palliative care. Ideally, a triage officer/committee has experience working with neonatal patients. The color (blue, red, yellow, or green) determines the level of access to a ventilator (blue = lowest access/palliate/discharge, red = highest access, yellow = intermediate access, and green = defer/discharge). If the eligible patient pool consists of only neonates, a randomization process, such as a lottery, is used each time a ventilator becomes available because there are no other evidencebased clinical factors available to consider. DecisionMaking Process for Removing a Patient from a Ventilator: There may be a scenario where there is an incoming red code patient(s) eligible for ventilator therapy and a triage officer/committee must remove a ventilator from a patient whose health is not improving. In this situation, first, patients in the blue category (or the yellow category if there are no blue code patients receiving ventilator therapy) are vulnerable for removal from ventilator therapy if they fail to meet criteria for continued ventilator use. If the pool of ventilated patients vulnerable for removal consists of only neonates, a randomization process, such as a lottery, is used each time to select the (blue or yellow) patient who will no longer receive ventilator therapy. While the framework of the neonatal and pediatric clinical ventilator allocation protocols is the same, a triage officer/committee may need to evaluate the mortality risks of children and neonates using different clinical assessment tools. Although a patient with the greatest chance of survival with ventilator therapy should receive (or continue with) this treatment, it is not obvious how this determination should be made when the mechanisms used to predict mortality risk are not the same. The use of different clinical tools to assess mortality is acceptable, primarily because no other appropriate alternative exists. Ideally, experienced clinicians with appropriate training in both neonatal and pediatric mass casualty scenarios will be able to provide an overall assessment of survivability for both populations. The Task Force determined that it would not be appropriate to use young age as a tiebreaker criterion when a patient pool consists only of children. It would be nearly impossible to have consensus on which age range(s) would have priority access to ventilators over another age group because the reasoning behind such thresholds is subjective. Alternative Forms of Medical Intervention and Palliative Care: Alternative forms of medical intervention, such as other methods of oxygen delivery and pharmacological antivirals, should be provided to those who are not eligible or waiting for a ventilator. Patients who have a medical condition on the exclusion criteria list or who no longer meet the clinical criteria for continued ventilator use receive alternative forms of medical intervention and/or palliative care. Logistics Regarding Implementation of the Guidelines: Once the Guidelines are implemented, there must be communication about triage, and realtime data collection and analysis to modify the Guidelines based on new information. In addition, there must be realtime data collection and analysis on the pandemic viral strain, such as symptoms, disease course, treatments, and survival, so that the clinical ventilator allocation protocol may be modified accordingly to ensure that patients receive the best care possible. Knowing the exact availability of ventilators also assists a triage officer/ committee in providing the most appropriate treatment options for patients. Neonatal Triage Although much has been written on the clinical and ethical issues regarding ventilator allocation for adults during an influenza pandemic, most emergency preparedness plans do not address how to treat children. While some policymakers are starting to develop pediatric specific guidance, none have any detailed information or instruction on neonatal triage. Because neonates have different physiological processes and levels of maturation and development, applying a pediatric plan to neonates is not appropriate. The Task Force considered the practical and ethical issues involved in allocating scarce ventilators to neonates. The Task Force also 4 convened a Neonatal Clinical Workgroup, consisting of specialists in neonatal, maternalfetal, obstetrics, pediatric, ethics, palliative care, and critical care fields to develop the neonatal clinical ventilator allocation protocol. Premature infants often need ventilators because their lungs are not fully developed or functional. Unlike pediatric patients, whose overall mortality rates are low, neonates, depending on their weight and gestational age, generally have higher mortality rates. Meetings were held via teleconference and were held in February, March, April, October, and November 2013. However, while the ethical framework is the same for all populations, there are special considerations when triaging children (see Chapter 2, Pediatric Guidelines) and additional concerns when neonates are involved. There is broad societal consensus that children are vulnerable and should be protected, however, it is not clear whether the public would be more or less sensitive to the loss of neonates compared with toddlers and other children. Young babies may be perceived as the most vulnerable of all populations, and there may be a strong preference in devoting resources for their survival. Conversely, older children may have had time to build relationships with more individuals who have formed deeper emotional attachments to these children. While the loss of a neonate is tragic, the general public may have a preference for saving older children because of 8 the bonds that people have already developed with these children.
Do women have lower relationships in treatment are less likely retention rates than menfi This is a diffcult to successfully complete treatment if their question to answer because treatment retention new partner discontinues treatment cholesterol in eggs yolk generic 5mg caduet mastercard. In one often involves the contribution and interaction qualitative study cholesterol levels history discount caduet 5mg with mastercard, all of the women who did not of numerous variables cholesterol lowering foods images cheap 5mg caduet overnight delivery. Studies have begun to successfully complete treatment established a identify these variables and how they relate sexual relationship during the early phase of to each other to infuence treatment retention outpatient treatment (Ravndal and Vaglum rates among women (see Ashley et al cholesterol ratio percentage purchase cheap caduet line. In and patterns of use are common factors that a study examining variables associated with typically infuence or predict retention among retention in outpatient services, women younger clients in general (see Simpson 1997). Among than 21 were not as likely to successfully women, several factors have been identifed that complete outpatient treatment (ScottLennox infuence or predict retention. Nonetheless, this found that women who are older at their frst is not an exhaustive list of retention conditions arrest were more likely to complete treatment or issues, but one that is limited to factors (Pelissier 2004). Sociodemographics While education level is infuential, it may be Relationships: Support from a partner a refection of other client characteristics or during treatment and recovery can contribute socioeconomic conditions. According for women in alcohol and drug abuse treatment to Jacobson, Robinson, and Bluthenthal contributed to favorable outcomes in one study (2007), limited economic resources may play a (Trepper et al. Zlotnick 138 Substance Abuse Treatment for Women Criminal justice and child defcits were more likely to complete treatment. In a similar study conducted by Haller and Miles protective services referral and (2004), women with more severe pathology were involvement twice as likely to leave treatment against medical It appears that either referral or involvement advice. While these studies have limitations, with the criminal justice system or child they do shed light on the role of psychiatric protective services is associated with longer issues in retention among women, particularly lengths of treatment (Brady and Ashley 2005; pregnant women, and the need to provide Chen et al. Specifcally, appropriate intervention earlier in the treatment Nishimoto and Roberts (2001) concluded that process. The fndings of a study examining the women who were mandated by the criminal effects of traumaintegrated services suggest that justice system to enter treatment and who also women who receive these mental health services had custody of their children were more likely may engage in treatment longer (Amaro et al. Review of the literature indicates that positive treatment outcomes for women are associated with variables related to the Pregnancy characteristics of the therapist. Grella treatment crises, and the ability to manage (1999) concluded that pregnant women were countertransference during therapy; Beutler et more likely to spend less time in treatment, and al. Women need a treatment environment length of stay may be more related to the stage that is supportive, safe, and nurturing of pregnancy. In another retention study among (Cohen 2000; Grosenick and Hatmaker 2000; women, women who entered treatment late in Finkelstein et al. The type of confrontation used in traditional programs tends to be ineffective for women Pregnancy and cooccurring disorders: unless a trusting, therapeutic relationship has Pregnancy often adds to the challenge of been developed (Drabble 1996). Early research retaining clients who have severe psychiatric on women in treatment demonstrated that disorders in treatment. Approaches based on awareness, understanding, and trust are less aggressive and more likely to Type of treatment services effect change (Miller and Rollnick 2002). An Samesex versus mixgender groups: While atmosphere of acceptance, hope, and support literature (Grella 1999; Gutierres and Todd creates the foundation women need to work 1997; Niv and Hser 2007; Roberts and through challenges productively. Inconsistent results are focus on treatment goals that are important to evident when comparing retention and outcome the client. A groups provide more genderresponsive services collaborative, supportive approach builds on than mixgender groups. The treatment services is not effective in improving client and counselor agree to work together to retention or outcome (Bride 2001). Several qualitative studies (Grosenick mechanisms prevent her from reaching her and Hatmaker 2000; NelsonZlupko et al. Women are as likely to impose the same societal gender stereotypes that they experience onto other women in the group (Cowan and Ullman 2006). Some women may see other women as a threat to their relationships and engage in competitive behavior in the group process, and other women may impose and project their internalized negative stereotypes onto other group members;. In addition, studies, women have identifed several counselor studies support that women who are involved characteristics they believe contribute to in or initially receive greater intensive care, treatment success: nonauthoritarian attitudes specifcally residential treatment, are more and approach, confdence and faith in their likely to remain in treatment and in continuing abilities, and projection of acceptance and care care (Coughey et al. Retention is also heightened when appears to play a paramount role in predicting treatment services also include individual posttreatment outcome (Gehart and Lyle 2001; counseling for women (NelsonZlupko et al. Although women show greater preference them versus women whose children did not stay for female staff in addiction treatment, with them, women whose children stayed with further research is needed in examining the them had a longer length of stay (retention). The issues of anger, autonomy, power, and stereotypical roles have great impact on women clients and are extremely important issues for women in therapy. For some women, because of previous dependence on men, their emotional responses to anger are more likely to be repressed and viewed as unacceptable. For other women, autonomy and power are often seen as masculine traits and inappropriate for women. Substance Abuse Treatment for Women 141 Improving Transitions and Retention Rates for Women Programs that maintain relationships or connections with women throughout their treatment and during stepdown transitions from more intensive to less intensive treatment appear paramount in maintaining high levels of retention. Using supportive telephone calls between residential and outpatient addiction treatment is an effective strategy for women. Women are more likely than men to attend continuing care if a telephone intervention is implemented (Carter et al. In addition, women are more likely to stay in treatment during transitions to less intensive levels of care if it is the same treatment agency (ScottLennox et al. They found that with children believed it was important to have women who had prior successes were more apt female staff, while 38 percent of the clients and to complete treatment. While selfeffcacy may 46 percent of the staff sample asserted that male play an important role, methodological issues staff were important. In provide a male perspective on various clinical addition, other general retention studies have issues, such as relationships. Nonetheless, several trends were confdence and confdence in the treatment evident. These family relationships form a basic model for the relationships women later and Needs develop with others. Women with a substanceusing family Relationships and the Need for background may develop adult relationships Connection that mimic these broken family dynamics. Relationships and as support for daytoday living and growth that center on substance use, or include (Covington and Surrey 1997; Finkelstein emotionally or physically negative, harmful 1993, 1996; Miller 1984).
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