Medical Definitions and Techniques
You will find a number of articles appearing on this site in which we use terminology that may be unfamiliar to some of our readers. The definitions of terms cited below are our attempt to provide clear understanding of the meaning of these terms.
Definitions of terms used in clinical trials
(7/7/08)- Clinical trials are conducted in phases. Each phase of a trial has a different purpose and helps scientists to answer different questions.
PHASE I TRIALS- A study is done on a new drug or treatment in a small group of people for the first time to evaluate its safety, determine a safe dosage and identify side effects.
PHASE II TRIALS- The study drug or treatment is given to a larger group of people to see if it is effective and to further evaluate its safety.
PHASE III TRIALS- The study drug or treatment is given to large groups of people to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the drug or treatment to be used safely.
PHASE IV TRIALS- Post-marketing studies delineate additional information including the drugs risks, benefits and optimal use.
Within these phase trials, certain terms are used. Here are the definitions of common terms;
Basic research-done in laboratory, basic research involves studying how cells work, how they communicate, how they know what to do, and what conditions and drugs make their function more or less effective.
Clinical research- Treatments with the most promising laboratory results move from laboratory and animal studies into clinical trial stage. In clinical trials, scientists apply their discoveries to humans, testing new drugs, devices, or innovative therapies in selected patients. carefully conducted clinical trails are the safest way to evaluate potential medical treatments assessing their effectiveness and potential risks.
Cross-over trials-trials in which patients receive both the treatment and the placebo at different times, with careful monitoring of their responses to both approaches.
Double-blind trials- trials in which neither the patient nor the researcher knows if the patient is receiving the treatment or the placebo.
Exclusion criteria- factors that do not allow someone to participate in clinical trial
IDE- Investigational Device Exemption-permission granted by the FDA to use new medical device during a clinical trial
Inclusion trial- the factors that allow someone to participate in a clinical trial.
IRB-Institutional Review Board, an independent committee of physicians, statisticians, community advocates and others. The IRB is charged with ensuring that all clinical trials within a given medical institution are ethical and that the rights of the participants in those trials are protected.
Open label studies- studies in which both the patient and the researcher know that the patient is receiving the treatment and not the placebo.
Placebo- an inactive substance or dummy" treatment.
Prospective trials- trials in which patients are identified and then observed over time.
Randomized trials- trials in which patients are arbitrarily grouped into a treatment and a controlled group. The control group receives either the current standard treatment or no treatment at all. The results of the control group are then compared with those of the treatment group.
Translational research- the evolution of basic research into therapies for patients. Translational research involves identifying drugs, devices, or treatments that hold promise; funding
Terms Associated with Senior Living
An adult home (AH) is established and operated for the purpose of providing long-term residential care, room, board, housekeeping, personal care and supervision to five or more adults unrelated to the operator. Adult homes may be operated by a natural person, a partnership, a not-for-profit corporation, a public corporation, a non-publicly traded business corporation or a limited liability company.
An enriched housing program (EHP) is established and operated for the purpose of providing long-term residential care to five or more adults, primarily persons sixty-five years of age or older, in community-integrated settings resembling independent housing units. The program provides or arranges for the provision of room, board, housekeeping, personal care and supervision. Enriched housing programs may be operated by a natural person, a partnership, a not-for-profit corporation, a public corporation, a non-publicly traded business corporation or a limited liability company.
A residence for adults (RESIDENCE) is established and operated for the purpose of providing long-term residential care, room, board; housekeeping and supervision to five or more adults, unrelated to the operator.
An assisted living program, (ALP) which is available in some adult homes and enriched housing programs, combines residential and home care services. It is designed as an alternative to nursing home placement for individuals who historically have been admitted to nursing facilities for reasons that are primarily social, rather than medical in nature. The operator of the assisted living program is responsible for providing or arranging for resident services that must include room, board, housekeeping, supervision, personal care, case management and home health services.
Absorption: refers to intake of a drug or alcohol to the bloodstream; affected by the physiochemical properties of the drug, concentration and solubility of the drug, area and nature of absorbing surface and blood circulation to the site of absorption. Drug absorption varies between individuals and within individuals as we age.
Affective Disorder: Used in a general way to speak of any of the depressive illnesses. It is a taxonomic term that does not capture the sadness and dread that are at the core of depression.
Agonist: a drug that binds to a receptor and initiates a change in the function of the cell. A drug that is an agonist, has attraction to bind to a given receptor and will activate the receptor and subsequently lead to a change in the function of the cell.
Aneurysm: ballooning of a blood vessel to a size that is twice its normal diameter. Aneurysm develop when weaknesses is the aortic wall succumb to the constant pressure of rushing blood and begin to stretch outward.
Angiogenesis: the process involving the formation of new blood vessels from pre-existing vessels. Angiogenesis is a normal process in growth and in wound healing, but it is also involved in the transition of tumors from a dormant state to a malignant state.
Antagonist: Describes the function of the medication at its target site. Drugs function by effectively reducing the number of receptors available for the transmitter to activate, thus trying to reestablish normal physiological function or prevent a disease from occurring. An antagonist will bind to a receptor site but will not cause any change in the function of the receptor or the cell. They will prevent the agonist compound from having any effect on the cell.
Arterial occlusive diseases: diseases that involve blockages of the large arteries. Common causes include atherosclerosis (hardening of the arteries), inflammation and stenosis
Atypical Depression: Characterized by mood reactivity and reversal of typical endogenous features of depression. Symptoms include hyperphagia, hypersomnia and intense feelings of lethargy, pathological sensitivity to rejection. All of which are in the opposite direction to the symptoms of "typical" endogenous depression.
Balloon angioplasty: a procedure in which a catheter is inserted into a narrow artery. A tiny balloon at the tip of the catheter is inflated to clear the blockage and widen the artery
Basal Ganglia: involved primarily in the control of motor activity, and deficits in this area are significant in movement disorders such as parkinsonianism and Huntingtons chorea. Components of the basal ganglia include the caudate nucleus, putamen, globus pallidus, lentiform nucleus, substantia nigra and others.
Beta amyloid: protein that is the main component of amyloid plaques in various neurological disorders, most prominently Alzheimer?s disease.
Biomarker or Biological marker: a physical trait such as a body chemical or DNA, used to measure the course of a disease.
Blood Brain Barrier: refers to the function of central nervous system capillaries that prevent many substances from entering the brain and/or spinal cord, acting as a selective filter to limit harmful substances into the brain.
Cardiac output: the volume of blood that the heart pumps each minute.
Carotid endarterectomy: a surgical procedure to remove blockages from the inside of the carotid artery.
Carotid stenosis: narrowing of the carotid artery caused by fatty deposits. Carotid stenosis can lead to transient ischemic attacks (TIAs or ?mini strokes?) or strokes.
Cerebrum: the largest and most rostral aspect of the brain, consisting of bilateral hemispheres divided into several lobes (frontal, temporal, parietal and occipital). Outer cerebrum, or cerebral cortex, is concerned with the highest order of conscious function and integration of central nervous system. Different areas of the cerebral cortex are involved in sensory and motor function, intellectual and cognitive abilities, short-term memory, speech, and control of other activities such as the autonomic nervous system.
Clinical: relating to the treatment of a patient or to the symptoms or course of a disease.
Cognitive Therapy: designed to alleviate symptoms and to help patients learn effective ways of dealing with the difficulties contributing to their suffering. The techniques employed are directed at changing errors or biases in patients cognition.
Congenital: refers to disease that is present at birth (as opposed to acquired).
Diagnosis of a syndrome/disorder/disease: implies neither a specific etiology nor a common response to treatment. It is a hypothesis, the clinicians best judgment about the nature of an ailment. It is rendered with the knowledge that multiple causes are likely to be found for each syndrome. One purpose is to improve the match of available treatments with the problems presented by the patient. A second purpose is prognostication, to help patients with regard to likely outcomes. It also simplifies complex data, helps in communication between professionals and satisfies a need to refine clinical research.
Disease: a medically definable process, in terms of pathophysiology and pathology. Illness is what the patient experiences.
Dose-Response Curve: involves the relationship between the dosage of a drug and a specific response to the drug. At some threshold dosage, the response begins to occur and continues to increase in magnitude before reaching a plateau. This provides data about dosage range over which the drug is effective, as well as the peak response that can be expected from the drug.
Drug Affinity: describes the amount of attraction between a drug and a receptor. It is related to the amount of drug required to bind to the unoccupied receptors. A drug with high affinity binds readily to the open receptor, even if the concentration in the body before the receptors become occupied.
Drug Metabolism or biotransformation: refers to chemical changes that take place in the drug following administration. Enzymes located within specific tissues are responsible for changes in the drugs structure and subsequently altering the pharmacologic properties of the drug. Biotransformation of the drug usually occurs within a matter of minutes or hours, thus reducing chances for toxic effects due to drug accumulation or drug activity. Primary location for drug metabolism is the liver. Other locations include the lungs, kidneys, gastrointestinal epithelium and skin.
Dysphoria: unpleasant mood characterized by an exaggerated feeling of depression and unrest.
Effectiveness Trials: assess the effectiveness of new treatment in the less controlled setting of clinical practice. Patient selection is usually less restrictive. Such studies are undertaken once therapies are found to be efficacious.
Efficacy Trials: attempt to demonstrate significant benefit within the controlled setting of clinical trials
Electric Shock Therapy or Electric Convulsive Therapy (ECT): when delivered in the appropriate manner, it is a relatively non-invasive means to deal with severe depression with a minimal of adverse effects. It probably has received more of a bad reputation than it deserves. It involves either administering an electric current to one (unilateral) or both sides of the brain (bilateral).
Endothelial cells: the inside lining of the blood vessels throughout the circulatory system.
Endovascular: referring to a surgical treatment in which a catheter containing miniature instruments is inserted under the skin into a blood vessel.
Enteral: referring to the intestine. Enteral nutrition may be delivered to the intestine through a tube into the stomach.
Enteral administration of drugs: One of two primary ways drugs are administered. In fact, it is the most common way. It involves the alimentary canal with examples being oral, sublingual and rectal administration of drugs. (See parenteral administration for the other general method.) By far the easiest way of taking mediation and is relatively safe because it avoids the large, sudden increase in plasma levels when drugs are administered in other fashions. Most of the medications administered this way are absorbed through the small intestine and then transported to liver where a significant amount of the drug may be metabolized and destroyed prior to reaching its site of action. Many factors effect absorption rate through the small intestine: intestinal infection, presence of food, rate of gastric emptying, amount of visceral blood flow etc. Hence a lot of variability in drug response between individuals and also intra-individual variation.
Epidemiologic Catchment Area (ECA): a community based survey of psychiatric epidemiology providing data on the prevalence and incidence of 17 major disorders measured by the Diagnostic Interview Schedule (DIS) using DSM III criteria. Data was collected at 5 geographically distinct sites distributed throughout the continental US using a complex sampling scheme. Total sample size 19,182. Sites include New Haven, St. Louis, Baltimore, Durham, Los Angelos.
Epidemiology (epi means upon; demos denotes population; and -logy means study of) The study of diseases in population. Populations are groups defined by a common characteristic, and the common characteristics associated with diseases often give clues as to etiology. It is the concept of a target population; the population to which inference is to be made.
Etiological Factors for disease: Biological & behavioral factors; environmental factors; immunological factors; nutritional factors; genetic factors; services, social factors and spiritual factors; all of which can play a role in the development of a disorder.
Fluoxetine (Prozac): a SSRI that has the longest track record in widespread use among the SSRIs. Has a half-life of up to 6 weeks, thus making it difficult to switch medications.
Functional Impairment: Difficulty that substantially interferes with or limits role functioning in one or more major life activities, including basic living skills (e.g. eating, bathing, dressing); instrumental living skills (e.g. maintaining a household, managing money, getting around in the community, taking a prescribed medication); and functioning in social, family and vocational/educational contexts.
GABA (Gamma-Aminobutyric Acid): is a neurotransmitter implicated in depressive and other psychiatric disorders. GABA receptors contain five different protein subunits, which come in a variety of shapes. GABA is the predominant amino acid transmitter used to mediate presynaptic inhibition in the spinal cord as well as an inhibitory transmitter in areas of the brain such as the cortex and basal ganglia.
Glutamate: is an amino acid found in high quantities in the brain and spinal cord and usually cause excitation in CNS neurons.
Half-Life of a Drug: the amount of time required for 50% of the drug remaining in the body to be eliminated. This is dependent not only on the ability of the organs to remove the drug from the plasma, but also the distribution or presence of the drug in the plasma. It is desirable to bring plasma concentrations of the drug up to a certain level and maintain them at that level. A drug that undergoes extensive inactivation in the liver may have a long half-life if it is sequestered intracellularly in skeletal muscle.
Heart failure: inability of the heart to pump enough blood through the body. There are numerous causes and types of heart failures
Human (Clinical) Studies: testing of drugs on humans after obtaining favorable result from animal trials. Drug companies file an investigational new drug (IND) application with the FDA. When the FDA approves the application, the drug company can begin testing the drug in humans. See Phases of.
Impairment: refers to "loss" or abnormality of psychological or emotional structure or function. It can be defined objectively (medical procedures to evaluate impairment include clinical examination, lab tests, and patients medical history and symptom reports) and is unrelated to individuals social circumstances. It reflects limitations of capacity or functional ability, the degree of pathology.
Intestinal rehabilitation: multidisciplinary therapy including nutrition, medicines, surgery, and possibly transplantation, to treat short bowel syndrome.
Intravenous: through a vein. Intravenous nutrition is delivered through a central vein in the body.
Limbic System: composed of several structures that are dispersed throughout the brain but are often considered as a functional unit or system within the central nervous system. Components of this system are cortical structures such as amygdala, hippocampus and cingulate gyrus as well as the hypothalamus, certain thalamic nuclei, mammillary bodies, septum pellucidum etc. The common function of all these structures is that they are involved in the control of emotional and behavioral activity (motivation, aggression, sexual activity and instinctive responses).
Major Depressive Disorder: while objective criteria exist to define this disorder based on an attempt to standardize research in this area (this definition can be found in our articles), we are struck more by the descriptions from writers whose metaphors (e.g. "the draining out of vital forces") try to develop an existential meaning of the word depression. A. Alvarez, described it in his book, The Savage God, "My life felt so cluttered and obstructed that I could hardly breathe. I inhabited a closed, concentrated world, airless and without exits." This comes closer to the meaning of clinical depression we use in our articles. There is nothing romantic about this disorder especially when it enters a pathological stage. "The remove of personality. The hidden, shadowy terror of devouring misery. The hallow lifelessness of her pupils, cartoonishly exaggerated into large, black pools of medication. The listless physicality" (Nell Carey, Editor of Unholy Ghost: Writers on Depression, describing her sisters depression.)
Meta-analysis: using statistical methods to pool samples from different studies and then try to extract conclusions that each study individually fails to prove. It is a more precise estimate of the magnitude and significance of the variable being studied. It involves a systematic review of studies using a quantitative procedure to combine, synthesize and integrate information across them. It tries to tease out more precise information, by combining different studies.
Metastatic cancer: cancer that has spread from an original site to other sites in the body.
Mood Disorders: a general term that includes Depressive Disorders, Bipolar Disorders, Mood Disorders Due to a General Medical condition, Substance Induced Disorders. These are to be distinguished from mood episodes such as major depressive episode, manic episode, mixed episode and hypomanic episode. These episodes according to the DSM-IV diagnostic criteria "do not have their own diagnostic codes and cannot be diagnosed as separate entities: however they serve as the building blocks for the disorder."
MRI: Magnetic resonance imaging, also called magnetic resonance tomography (MRT), is a method of imaging the body using strong magnetic fields and non-ionizing radiation. MRI provides far better contrast resolution (the ability to distinguish the differences between similar tissues) than CT scan.
Neurotransmitter: a chemical substance that transmits nerve impulses, or messages, from one cell to another
Neurotransmitters: regulate different aspects of mood, cognition and behavior. Examples of neurotransmitters include dopamine, serotonin, histamine, acetylcholine, GABA, glycine, glutamate, substance P, enkephalins and norepinephrine. Abnormalities of neurotransmitter function are associated with different symptoms. Thus, for example, dopamine abnormalities are associated with decreased ability to experience pleasure, decreased motivation, decreased attention and cognitive slowing. Although neurotransmitters can be generally described as either excitatory or inhibitory within the CNS, some transmitters may have different effects depending on the nature of the postsynaptic receptors involved.
New Drug Application (NDA): following phase III of clinical testing, the drug sponsor applies for a new drug application, which is reviewed by the FDA. If the FDA finds the results favorable, the drug company can market the drug for conditions/ diseases, which are applicable to phase testing results.
Over-the-Counter Drugs: non-prescription drugs that usually contain low doses of their "active ingredients" so that the chances of toxic effect are relatively small. These drugs can be purchased directly by the consumer without consulting a physician.
Parenteral administration of drugs: One of two primary routes of drug administration. It involves nonalimentary routes such as inhalation, injection, topical and transdermal methods. (See enteral administration for other general method drugs can be administered.) This allows the drug to be delivered to the target site more directly, and the quantity of the drug that actually reaches the target site is often more predictable. They are usually not subject to first-pass inactivation in the liver.
PET/ positron emission tomography: a method of imaging that detects metabolic or chemical activity in the body. In contrast, CT scans( computed tomography or computed axial tomography ?CAT) show anatomical structures. For example, a PET scan would show a tumor?s increased sugar uptake, while a CT scan would reveal its size and density.
Pharmacodynamics: the effects the drug will have upon the bodys organs.
Pharmacokinetics: study of absorption, distribution within body, metabolism or excretion and action of drugs
Phases of Drug Testing: Divided into three primary phases; phase I involves testing the drug, usually less than a year, on a relatively small number of healthy volunteers to obtain information about the effects of the drug on humans; phase II, usually 2 years, the drug is tested in a small, select patient population to evaluate the effect of the drug in testing a specific disease or pathological condition; phase III, usually 2 years, the clinical evaluation is expanded to include more patients as well as more evaluators and goal is to obtain information regarding the drugs safety and effectiveness in a large patient population. A fourth phase, known as post-marketing surveillance, is instituted following the appearance of the drug in the market. Untoward incidences are reported to the FDA when the drug is used on the general population. This is done for an indefinite period of time.
Potency: is related to the dosage that produces a given response in specific amplitude. It does not mean overall therapeutic benefits, but just refers to the fact that less of the drug is required to produce a given response.
Preclinical Studies: Potentially new drugs are tested in animals, one to two years, to obtain pharmacokinetics and pharmacodynamic properties of the drug and also information on dosage and toxicity.
Pressure sores: Also called decubitus ulcer or bedsore, a chronic wound occurring in people confined o bed for long periods of time.
Prevalence: number of existing cases of a disorder or condition in a defined population over a given period of time. Studies of prevalence may permit predictions of future prevalence rates. Prevalence rate of depression is assumed to be as high as 17%.
Prodromal Symptoms: A mixed group of behaviors, related in temporal manner to the onset of a disorder
Psychopharmacologist: physicians trained in treating psychiatric illnesses with medications. They would appear to see the illness as a biological disease, implying it has an organic etiology the same as diabetes, epilepsy, heart attack etc. The logic psychopharmacologists appear use is that many people feel better when taking certain medication, ergo the disease is caused by a physical pathology or that the symptoms have a pathological base that can be adjusted with medication to reduce the symptoms, but maybe not cure the disease. Many also recognize the need to explore social circumstances, temperament and related issues as effective adjunctive treatment for dealing with the psychiatric illness.
Psychotherapy: a potpourri of treatment modalities involving in most cases an interaction between an individual and a therapist or analyst. While research results are mixed about its effectiveness, there is a large body of scientific literature that indicates positive correlation with behavioral changes and "feeling better".
Quality of Life: value assigned to duration of life as modified by the impairments, functional status and social opportunities that are influenced by disease, injury, treatment or social and political policy.
Receptor: the component of the cell to which the drug binds and through which a chain of biochemical events is initiated. Many receptors are proteins located on or within the cell. Membrane receptors act as an ion pore and thus change the membrane permeability or may affect cell function by being linked to some intracellular biochemical process and when activated, will stimulate or inhibit some type of intracellular effector such as an enzyme, which than leads to a change in cell function.
Refractory: resistant or unresponsive to treatment.
Remission: the marked decrease or abatement of symptoms of an illness
Resistance: ability of a disease to withstand attempted treatment by a therapy.
Restenosis: literally means the reoccurrence of stenosis (which is abnormal narrowing of an artery or other blood vessel)
Selective Serotonin Reuptake Inhibitors (SSRIs): the most widely prescribed medication for depression. Four most popular SSRIs are fluoxine (Prozac), sertraline (Zoloft), fluoxetine (Paxil), and citalopram (Celexa). Usually have a clinical effect in 2-3 weeks, although it may take longer to reach the maximum antidepressant effect.
Self-efficacy: an individuals estimate of his ability to cope with a situation, and outcome expectancy; an individuals estimate of the likelihood of certain consequences occurring. This combination of assessments of potential threat and coping resources determines how anxious an individual may become in a given situation.
Serotonin: a neurotransmitter that plays an important part in conditions including depression, bipolar disorder, anxiety, migraine headaches, and others.
Sertraline (Zoloft): a SSRI with a short half-life allowing easier switching of medications.
Short bowel syndrome: a serious illness in which the intestine is shortened, either by disease or necessary surgery. Patients with short bowel syndrome are unable to digest food properly
Social Network: refers to structural characteristics such as proximity to others, frequency of social contact and the type of relationship (e.g. spouse, confidant, relative, friend, group).
Social Support, Type & Amount: refers to three types: emotional support involves comforting by physical affection or expressing concern for well-being; guidance support involves giving knowledge of how to do something or suggesting some action; tangible support involves providing housing, money, transportation etc.
Synapse: Communicating cell-cell junction that allows signals to pass from a nerve cell to another cell. In a chemical synapse the signals carried by a diffusible neurotransmitter; in an electrical synapse a direct connection is made between the cytoplasms of the two cells via gap junctions.
Syndrome: refers to a constellation of signs (what the examiner sees) and symptoms (what the patient reports) that recur regularly in clinical populations
Temperament: a conceptual term that categorizes a functionally significant component of an individuals psychological structure. It is not immutable, but it shows consistency over time and also a degree of cross-situational consistency.
Temporary (Total or Partial) disability: any injury or illness other than death or permanent disability which results in a minimum of number of days (3 to 7), specified by each State, during which the person is unable to perform any work for pay and from which he or she can be expected to recover fully, or any injury or illness which results in a temporary loss of wages or impairment of wage earning capacity.
Therapeutic Index: Relationship between the median effective dose (the dosage at which 50% of the population respond to the drug in a specific manner) and the median toxic dose (the dosage at which 50% of the group exhibits the adverse effect of the drug). The higher the therapeutic index, the more safe the drug is considered to be. It simply indicates that it would take a much higher dose to invoke a toxic response that it does to cause a beneficial effect.
Thymosin: A hormone secreted by the thymus gland that stimulated parts of the immune system.
Vascular: related to the blood vessels.
A not infrequent question asked of us by senior citizens refers to many of the new medical techniques to help diagnose various conditions. Many of these techniques have abbreviations as names and are quite confusing. To help our readers, we are staring a series of articles in which we will try to explain the function of these machines.
Positive Emission Tomography (PET) is a technique that measures physiological function by looking at blood flow, metabolism, neurotransmitters and radio labelled drugs. PET offers quantitative analysis, allowing relative changes over time to be monitored as the disease process evolves or in response to a specific stimulus.
The technique is based on the detection of radioactivity emitted after a small amount of a radioactive tracer is injected into a peripheral vein. The tracer is administered as an intravenous injection usually labeled with oxygen-15, fluorine-18, carbon-11 or nitrogen-13. The total radioactive dose is similar to the dose used in computed tomography (CT). PET scans take 10-40 minutes to complete. They are painless, and, as for computed tomography, the patient is fully clothed.
A common use for PET is to measure the rate of consumption of glucose in different parts of the body. One clinical use of this is to distinguish between benign and malignant tumors. Malignant tumors metabolize glucose at a faster rate than benign tumors.
Other applications of PET include looking at blood flow and Oxygen consumption in different parts of the brain-for example, in understanding strokes and dementia. Tracking chemical neurotransmitters, such as dopamine in Parkinson's Disease can also be performed with this technique.
PET has further application in cardiology (in pretransplantation assessment of viable myocardium) in distinguishing recurrent tumors from radiation necrosis and surgical scarring, and in variety of cancers.
(Material for this summary came from Valk, Bailey, Townsend and Maisey (Eds.). Positron Emission Tomography. Principles and Practices. London:Springer-Verlag, 2002.)
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL
SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE
" How to Select a Nursing Home"
Compiled by Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated july 7, 2008
e-mail: firstname.lastname@example.org or email@example.com
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