By Z. Brenton. University of South Alabama.

The economies of scale provided by industrial-scale sequencing have hastened progress to the point where at least two companies now have the majority of expressed human genes in their freezers cheap advair diskus online amex asthmatic bronchitis 1. This has certainly had the effect of restricting access to key therapeutic genes buy cheap advair diskus online asthmatic bronchitis vs pneumonia, but on the other hand subscribers to these proprietary databases have early access to information which would not otherwise be available purchase advair diskus with a visa asthma treatment rajiv dixit. At the moment, the main beneficiaries of this commercial effort are pharmaceutical and biotech companies who see such access as conferring a significant competitive advantage on their research and development activities. Although there are as yet no methodologies for real-time gene expression observations, the attempt by companies such as Incyte and Affymetrix to place whole genomes on silicon chips, together with the advent of continuous flow hybridization approaches, promises a much greater depth to temporal analysis of complex biological processes than hitherto possible, bringing with it new opportunities for defining appropriate therapeutic intervention points in complex biological cascades. This information can now be complemented by hybridization array approaches, in which the expression of defined subsets of genes (or indeed the expression of entire genomes) can be carefully monitored at high volume across specific time courses and dose regimens, providing a degree of accuracy and reproducibility in determining the level of gene expression which sequencing alone cannot achieve. Together, sequencing and arraying techniques can be used to provide information on both the biology of disease and the behavior of compounds as they impact a biological system. The scientific basis of hybridization arraying as a technique for the determination of gene expression levels is shown in Figures 15. A full description of these hybridization arraying approaches has been published and is also available on the Web (see Table 15. Access to comprehensive sequence databases and the bioinformatics tools to analyze them plays a central role in these gene expression monitoring approaches, illustrating their “reach-through” impact in genomics in general. A further technique which holds considerable promise for evaluating individual gene expression at the histological or cellular level is in situ hybridization. This provides a cellular level of resolution to gene expression analysis which complements that of microarray analyses. All the above techniques have major potential applications in drug delivery, from defining new members of key transporter and receptor gene families and their expression, to providing experimental systems for evaluating the efficacy of new delivery systems. Similar databases will undoubtedly emerge from mammalian systems as mammalian cell genome closure and proteomics advance. Systematic approaches to biological function are encompassed within the broad area of “functional genomics”. For most of this century, our knowledge of cell biology has been primarily descriptive, reproducible in vitro work dating only from the 1960s. From the ability to induce neuronal cell differentiation to the observation of cellular apoptosis, cell culture is now offering radically new insights into the way in which genetic programs are executed at a functional level. The advent of genomic biology places cell structure and structural biology in a new context. Processes fundamental to cell biology, such as protein translocation and apoptosis, can now be seen as variations on an evolutionarily conserved theme. For drug discovery and delivery, this growing knowledge of cell biology is extremely useful. Not only has an intimate appreciation of cellular processes behind disease revealed new therapeutic targets, the inner workings of the cell have now become accessible to exploitation. The development of cell-based screening technologies, ranging from yeast-based screening to reporter gene assays, underlies the increasing trend towards directly harnessing cell biology to drug discovery. Cell-based systems are biology’s way of dividing the expressed genome into functional units. In drug discovery, a focus on specific cell systems, such as T-cells and fibroblasts for assembly of human immunodeficiency virus or herpes simplex virus particles and endothelial cells for demonstrating adhesion- dependent processes, often provides convenient primary drug screening systems. Other single cell systems, such as yeast, and even entire organisms, such as Caenorhabditis elegans, have themselves been positioned as cell-based screening systems, capable of relatively high-throughput screening using appropriate reporters, or even visual analysis. The value of such systems for functional genomics and genetic engineering has been greatly enhanced by access to genome sequences of both organisms, and they may provide new and sensitive ways of examining the potential of new delivery mechanisms. Proteomics may therefore be more useful than genomics for identifying therapeutic targets within the cell. Until recently the development of proteomics was limited by the availability of technology to reproducibly separate protein components from the cellular pool and to specifically identify the protein sequence of small amounts of protein products. The development of 2 D polyacrylamide gels which separate proteins according to molecular weight in one dimension and charge in the other direction has provided a high- resolution quantitative method for separation of low levels of expressed proteins. Tissue extracts are pooled and initial protein purification undertaken using ion-exchange and affinity chromatography. The resultant protein fractions are further separated by reverse-phase high performance liquid chromatography. The bands are identified using standard techniques such as silver or fluorescent dyes and the expression profile may be used to compare expression of proteins in normal and diseased tissue or to examine changes in expression under stress conditions or following drug administration. In this way proteins associated with different diseased or stress conditions can be identified and the changes in protein expressions, for example, due to drug metabolism may be identified. The specific proteins may be identified by in situ digestion and analysis by mass spectrometry. Recent developments in this technology have resulted in the technique being accepted as the primary tool for high- throughput, high-sensitivity protein analysis. The identification of the mass of individual peptide fragments allows the analyst to search genomic and protein sequence databases in order to find genes and/or proteins which would be expected to give the same fragmentation patterns. A highly matched database sequence will provide the full sequence and identify the protein. Although reliable, this technique may lead to false positive results in some cases. To overcome this problem many proteomic companies are now adopting the technique of tandem mass spectrometry to unambiguously identify protein sequences. This technique subjects proteins to successive routines of fragmentation and mass analysis in order to provide the actual amino acid sequence. Mode of drug action 372 By probing drug treated cells for expression of genes and proteins it may be possible to more precisely identify the specific mode of action of a drug of known therapeutic value, for example natural herbal remedies, thereby offering opportunities to develop new drugs for such therapeutic conditions. Toxicology The monitoring of expression of certain genes and proteins in, for example, hepatic cells offers a means of detecting upregulation of metabolic enzymes such as P450 isoenzymes. Similarly, such profiling may also provide opportunities to identify the mechanisms of drug toxicity of therapeutic agents in order to design new drugs to overcome these problems. Clinical applications These technologies will also allow the screening of patients for particular diseases or metabolic polymorphisms, which may dictate whether a patient is a rapid or slow metabolizer of certain drugs. Such response markers will allow more stringent selection criteria to be applied to clinical trials selection and could also be used to more specifically adjust a drug dosing regimen to a particular patient’s metabolic profile. Such diagnostic screens allow more effective patient treatment and the development of therapeutic agents specifically designed for the treatment of specific patient subpopulations. In the future these screening techniques will allow us to more readily identify upregulated enzymes in diseased tissues which will facilitate the development of prodrug-based technologies for the site-specific chemical delivery of drugs to these diseased cells. The identification of surface-expressed disease-specific ligands will allow targeting of polymeric and microparticulate drug delivery systems to these particular diseased cells through the use of molecular entities specifically targeted against these ligands. It is clear that genomics and proteomics are complementary in that genomics has an important role in providing data for elucidating amino acid sequences identified through proteomics, and proteomics provides a means of identifying those genes which have functional importance. The identification of future therapeutic targets will be driven by cross-fertilization between these two disciplines through bioinformatics. A perfect prodrug is a molecule which has no intrinsic pharmacological activity until it is converted enzymatically to a new molecular form which displays pharmacological activity.

Oval fat bodies are derived from: the dry reagent strip test for bilirubin is positive and A purchase advair diskus with mastercard asthma 4 by 4 by 4. A The term lipoid nephrosis is a synonym for idiopathic Urine sediment/2 (primary) nephrotic syndrome safe 500 mcg advair diskus asthma doctor. Both Body fluids/Correlate clinical and laboratory data/ acute and chronic glomerulonephritis cause low urine Renal disease/2 osmolality purchase advair diskus once a day asthma definition 34, azotemia, acidosis, hypertension, proteinuria, and hematuria. Which of the following conditions is seen in acute Answers to Questions 35–39 renal failure and helps to differentiate it from prerenal failure? Abnormal urinary sediment uremia, and hyperkalemia in both prerenal and acute renal failure. The kidneys are not damaged in prerenal Body fluids/Correlate clinical and laboratory data/ failure and, therefore, the microscopic examination is Renal disease/2 usually normal. A In acute renal failure, reduced glomerular filtration acute renal failure and helps to differentiate it from coupled with decreased tubular secretion results chronic renal failure? Proteinuria sediment in chronic renal failure is characterized by Body fluids/Correlate clinical and laboratory data/ intermittent heavy hematuria and proteinuria. Failure to be decreased in untreated cases of acute renal of the tubules results in retention of hydrogen ions failure? Uric acid increased, while hyperkalemia is a constant finding Body fluids/Correlate clinical and laboratory data/ in acute renal failure. Which of the following conditions is associated proteinuria, it is greatest in the nephrotic syndrome. Acute pyelonephritis sediment in nephrotic syndrome in adults is not Body fluids/Correlate clinical and laboratory data/ usually characterized by either hematuria or pyuria. Renal disease/2 Various casts, lipid laden renal epithelial cells, and oval fat bodies are usually found. Heavy metal poisoning and complement-mediated damage such as occurs in poststreptococcal glomerulonephritis, or from the Body fluids/Apply knowledge of fundamental biological production of autoantibodies that attack the basement characteristics/Renal disease/2 membrane as in Goodpasture’s syndrome. Acute glomerulonephritis is often classified by the pattern of injury rather than the cause. For example, insulin deficiency produces sclerotic vascular damage to the glomeruli, often resulting in crescentic glomerulonephritis. Cytomegalovirus infections and heavy metal poisoning cause damage to the tubules, resulting in nephrosis. Since it is Body fluids/Apply knowledge of fundamental biological focused in the medulla, the disease involves mainly characteristics/Renal disease/2 the tubules. All of the following are common characteristics pyelonephritis is not associated with reduced of the nephrotic syndrome except: creatinine clearance, azotemia, or oliguria. Which of the following conditions is a syndrome), the creatinine clearance and serum characteristic finding in patients with potassium are usually normal. B Obstructive renal disease may result from renal or physiological processes/Renal disease/2 urinary tract calculi, benign prostatic hypertrophy, chronic urinary tract infection, or urogenital 43. Obstruction causes the hydrostatic composed of: pressure in Bowman’s space to increase. Postrenal Body fluids/Apply knowledge of fundamental biological failure produces many of the same serum characteristics/Renal calculi/1 abnormalities as acute renal failure, including hyperkalemia, acidosis, edema, and azotemia. Bacteriuria and pyuria are common, and hematuria may result from rupture of the vasa recta or other blood vessels. B Over three-fourths of urinary tract stones are composed of calcium salts, and hyperparathyroidism is commonly associated with calcium stones. Stones composed of magnesium ammonium phosphate are called struvite and lodge in the renal pelvis, causing a characteristic “staghorn” appearance on radiographic examination. Stones mainly composed of calcium phosphate are called hydroxyapatite or bushite, depending upon the calcium composition. Which of the following abnormal crystals is often Answers to Questions 44–45 associated with formation of renal calculi? Tyrosine crystals form fine dark sheaves or needles and may Body fluids/Correlate clinical and laboratory data/ result from liver disease or tyrosinosis, an overflow Renal calculi/2 aminoaciduria. Ampicillin (rarely) forms long colorless prisms for about three-fourths of all stones in sheaves in some patients being treated with high B. A Three-fourths of all stones contain calcium and in the ureters three-fourths of these contain calcium oxalate. Stones are usually comprised of single salts are usually composed of several inorganic salts, but Body fluids/Apply knowledge of fundamental biological calcium oxalate is the most common component of characteristics/Renal calculi/2 urinary stones. Stones made of primarily calcium phosphate (as hydroxyapatite) are light and crumble easily. Stones made of struvite (ammonium magnesium phosphate) are radiodense and lodge in the renal pelvis, forming an outline of the structures resembling the antlers of a deer (staghorn calculi). Arachnoid membrane Endothelia of the choroid plexus vessels and Body fluids/Apply knowledge of fundamental biological ependymal cells lining the ventricles act as a barrier characteristics/Cerebrospinal fluid/1 to the passage of proteins, drugs, and metabolites. Normal values for mononuclear cells are higher chloride levels are 10%–15% higher than plasma. When Body fluids/Correlate laboratory data with volume is low, an abnormally high difference is physiological processes/Cerebrospinal fluid/2 observed between the opening and closing pressure. Low opening pressure is caused by reduced volume or block above the puncture site. Which of the following findings is consistent Answers to Questions 4–5 with a subarachnoid hemorrhage rather than a traumatic tap? Bacterial meningitis causes a neutrophilic pleocytosis, viral meningitis a lymphocytic pleocytosis, and tuberculous and fungal meningitis a mixed-cell pleocytosis. Other causes of pleocytosis include multiple sclerosis, cerebral hemorrhage or infarction, and leukemia. Viral meningitis malignancy, subarachnoid hemorrhage, and some persons with multiple sclerosis. Low glucose in Body fluids/Correlate clinical and laboratory data/ malignancy and multiple sclerosis results from Cerebrospinal fluid/2 increased utilization. Te diagnosis of multiple sclerosis is often based Answers to Questions 10–13 upon which finding? While the IgG index is sensitive, it is electrophoresis increased in many other disorders. Pleocytosis of mixed cellularity least some of the oligoclonal bands must not be C. B In fungal meningitis, the glucose will be low and using a warm slide be examined? Mycobacterium tuberculosis infection of mixed cellularity consisting of lymphocytes, D. The total protein and myelin basic protein are often increased and the glucose is decreased. Cytocentrifugation should be used to rather than a chamber differential concentrate the cells followed by staining with Wright’s stain.

Other incentives may include special gressive muscle relaxation and desensitization buy advair diskus 100mcg without a prescription asthmatic bronchitis how long does it last, scheduling for medication administration cheap advair diskus line asthmatic bronchitis hospitalization, meal contingency management had a demonstrated vouchers purchase advair diskus 100 mcg otc asthma case definition, gift certificates, entertainment tick- record of effectiveness, whereas systematic ets, or toys for patientsí children. Designing desensitization alone was less effective in such programs requires significant effort, yet eliminating opioid use but reduced fear of with- the rewards can add an important dimension to drawal and general anxiety (Piane 2000). They used gram of motivational stepped-care levels in take-home medication privileges to increase which clear contingencies were matched with the involvement of significant others and treatment responses. They also poorly were moved to a more intensive level of used behavior-contingent treatment availability care. Those who responded well received less to improve drug test results and counseling intensive care. In another study comparing should be defined clearly and implemented con- contingency vouchers (which had monetary sistently. Contingencies may be individualized value and were exchangeable for goods and ser- based on each patientís targeted areas of vices) with methadone dosage increases, both behavioral change or implemented on a uni- incentives increased negative drug test results, form, programwide basis. Tailoring behavioral but only contingency vouchers increased dura- contingencies to patientsí needs has been found tions of drug abstinence (Preston et al. Piane Dosage increases should be based on evidence (2000) effectively combined contingency incen- of withdrawal symptoms and other medical tives with systematic desensitization for patients assessments, not good behavior. Providing Com prehensive Care and M axim izing Patient Retention 129 The consensus panel emphasizes that, when to resolve chronic psychological and social contingency management is used to control use problems. Another should have more specialized training than valuable guide is Motivational Interviewing: those responsible for drug-focused counseling. Preparing People for Change (Miller and Psychotherapists should possess advanced Rollnick 2002). Both counseling and psy- tured and focus on interpersonal-relationship chotherapy can be short term and solution building, self-insight, reflection, and discussion directed, but psychotherapy more often is used (Vannicelli 1992). This might involve their acquiring job skills, developing hobbies, or rebuilding relationships. Group treatment can treatment of sexual abuse for patients during provide a sense that individuals are not alone substance abuse treatment. A helpful, straightforward handbook for seling, it should develop referral relationships patients is About Methadone (Lindesmith for outside diagnosis and treatment. Strategies to engage these patients in treatment ï Effects and side effects of addiction treatment are described in chapter 6. Both cravings types of education may involve presenting infor- ï Developing nonñdrug-related leisure activities mation about substance abuse and addiction to patients alone, in groups, or with their families. Question assumptions about alcohol and drug use, and clarify that such use undermines recovery. Involvem ent Holding sessions for several families can be cost The consensus panel believes that family effective, supportive, and mutually beneficial. The concept of ìfamilyî tion and allow participants to express their feel- should be expanded to include members of the ings and concerns. These continuing forums help secure family support for patient treatment and identify acute family problems needing focused therapy. Nunes and colleagues (1998b) staff and reserved for families with serious recommended that treatment providers ask problems with behaviors or attitudes that about the mental health and adjustment of contribute to patientsí addictions, which, if patientsí children and consider routine psychi- unchecked, might affect recovery. Dawe and referrals to community-based services often are colleagues (2000) reported improved needed, and the consensus panel urges that parentñchild relations and positive outcomes such connections be established. Family therapy for children with conduct problems after may be more effective for some patients than behavioral training that provided their parents individual counseling, group therapy, or family with improved parenting techniques. Child assessment stable, treatment focus on concerns about cus- requires trained personnel and may be unreal- tody, children, and parenting. A counselor who determines that Psychodynamic parenting groups take a more a patient is neglecting or abusing young children intensive approach, exploring topics such as is required to report the neglect or abuse. Counselors should incorporate appropriate assessment procedures, referrals, or treatment responses for violence. They might have to help Peer Support, or M utual-Help, patients remove themselves from dangerous situ- Program s ations. Counselors should have a broad view of domestic violence that includes female (to male) The most popular, widely used mutual-help aggression, same-sex physical and emotional models are 12-Step recovery programs, such abuse, and issues related to elder abuse. They are sources for social provide general didactic groups or seminars and support, peer identification, relapse preven- other resources addressing domestic violence. Members of sup- port groups gain strength and security from others who understand and share their con- Integrative cerns and who offer practical strategies for surviving ìone day at a time. Some patients, unable to handle rejection, have chosen not to return, others have chosen prematurely to taper from maintenance medication, and some have used this diffi- culty as justification to self-medicate. For information, contact the National Alliance of Methadone Advocates (212-595-6262 or www. Other Approaches Decreases in substance abuse among group participants have been associated with attend- In acupuncture, thin needles are inserted ing meetings frequently, obtaining a sponsor, subcutaneously at points on the body for thera- ìworkingî the 12 Steps, and leading meetings peutic purposes. Some believe that acupunc- (American Psychiatric Association 1995, 1996; ture can relieve pain, anxiety, and withdrawal Landry 1997). However, 12-Step groups are symptoms related to substance abuse, although not for everyone. Its use to treat opioid with- Patients should not be pressured to attend sup- drawal was first reported in 1973. Resistance to attendance should However, a National Institutes of Health be discussed and respected. Every effort consensus statement lists addiction as one con- should be made to help a patient find an dition for which acupuncture treatment might appropriate peer support program. Although the mechanism of acupunc- ative strategies have evolved to promote ture is not understood, some researchers have mutual-help programs, such as simulated meet- focused on the analgesic effects of opioid pep- ings to introduce patients to the language, cus- tides released during the procedure (National toms, and rules of groups. A useful manual is Relapse strategy to ensure that a severe relapse is Prevention W orkbook (Daley 2002). Relapse Prevention Strategies for M ultiple Substance Use Education about relapse is a key part of treat- Patients who abuse multiple substances may ment. Educational approaches should teach require modified relapse prevention strategies. Separate interventions drug cravings and slips to prevent full-blown may be necessary for each substance because relapses. Relapse prevention strategies often the associated risks of relapse are different for distinguish between slips and relapses, with each. For course, no level of opioid use should be con- example, a patient may associate heroin use doned, but when a relatively mild and isolated with socializing and cocaine use with alleviating episode occurs, the consensus panel recom- depression. Providing Com prehensive Care and M axim izing Patient Retention 137 Some researchers have noted that an absti- treatment for relapse prevention concluded nence violation effect may occur when a patient that these treatments, although studied for abstains from a substance but then relapses years, were ineffective (Conklin and Tiffany and possibly overuses it. W hen a slip or lapse occurs, the patientís self- Patient Follow up Strategies esteem can be lowered, which he or she may Patient followup and continuing care have been attempt to repair by continuing or increasing found to be critical to preventing relapse and substance use.

C This type of test compares the students to each requirement encompasses which educational other rather than grading the students on a set of objective? All of these options of analysis to plot the standards cheap 250 mcg advair diskus free shipping asthma spacer, construct a best-fit calibration line 250 mcg advair diskus fast delivery asthmatic bronchitis turn into pneumonia, and determine the Education and management/Apply knowledge of concentration of the controls buy 100mcg advair diskus amex asthma symptoms in 12 year old. The affective educational methodology/3 domain describes the student’s ability to value 6. A chemistry test result from a chemotherapy the results as acceptable or to repeat the patient was within normal limits on Tuesday. B The technologist chose to investigate the situation Monday (“flagged” high and approaching a in order to resolve a discrepancy. Te technologist performing the valuing, and characterization refer to the affective test noted a delta-check error and remembered domain in dealing with the problem presented here. C When a demonstration of a complex instrument is educational methodology/3 necessary, a small group of students should be 7. In general, academic evaluation of students assembled around the instrument to permit clear depends on the ability of the instructor to create a visibility. A diagram with the major functioning test that reflects the stated objectives of the course parts should be provided, along with an assignment material as well as making the test: of a written summary or questions about the A. Written and oral Education and management/Apply knowledge of educational testing/1 Chapter 9 | Education and Management 525 9. Herzberg’s theory relies on motivators that are of students a topic to discuss or a problem to solve part of the job design in order to instill job rather than a formal lecture by the instructor. Tese same motivators can become Each participant is given a portion of the topic dissatisfiers if they are lacking in a job. Tis method of learning is motivators are: popular and used easily with which of the A. Histogram evaluation diminishes Education and management/Apply knowledge of Education and management/Apply knowledge of educational methodology/2 management theory/1 10. An instructor of medical laboratory science was Answers to Questions 9–13 given the task of expanding the curriculum for the senior (baccalaureate degree) medical laboratory 9. Which of the following subjects in problem solving and to utilize the input of all should be included in the curriculum? C The ever-changing role of the medical laboratory scientist in a clinical laboratory prompts the Education and management/Education/Apply curriculum committee to re-evaluate the courses knowledge of entry level skills/1 required by the students on a yearly basis. Respect for the worker and acknowledgment of management in which the employee is his/her ability to perform a task considered a valuable asset. Maslow’s theory of management is based upon: ascending order, are physiological, safety, security, A. Te premise that all workers are unmotivated social, esteem, and self-actualization. A According to Frederick Herzberg, achievement, happy opportunity for advancement, recognition, D. Te professional development of the employee challenging work, responsibility, and a chance for advancement and personal growth are motivators Education and management/Apply knowledge of and should be included as part of a job design. Te laboratory is undergoing a renovation listed, the four core processes for all managers are D. Employees jointly agree to institutional goals planning, organizing, directing, and controlling. Education and management/Apply knowledge of Planning includes formulating of goals and management theory/2 objectives, organizing the tasks, and establishing schedules. Te four essential functions of a manager are: communication, relationships, job descriptions, and A. Directing, leading, forecasting, implementing steps and stages of the plan, including coordination C. Innovating, designing, coordinating, problem resource utilization and outcomes, managing costs, solving and modifying the process to improve quality. Which of the following questions is allowable are related to legitimate occupational qualifications. Overtime pay cost of a test in order to obtain the desired profit Education and management/Laboratory economics/1 margin. Tests sent to reference laboratories or done in-house have the added cost that is referred to as 18. Which of the following accounts for the largest the surcharge/cost-plus method of determining test portion of the direct cost of a laboratory test? Using the surcharge/cost-plus method for determining test charges, determine the charge for an ova and parasite examination on fecal specimens, given the following information: Collection, handling, clerical, and so forth = $2. In deciding whether to adopt a new test on the Answers to Questions 20–24 laboratory’s automated chemistry analyzer, which parameters are needed to determine the number of 20. D The formula for calculating the break-even point tests that must be performed to break even? Number of other tests performed per month The total fixed costs are the expenses that are not D. The average between test volume and revenue or costs for reimbursement represents the expected revenue batch-run tests? Revenue is approximately equal for both as instrumentation, labor, and management do not high- and low-volume tests change with the size of the batch. In most laboratories, about 80% of the revenue is generated by the laboratory tests that 22. Te specific laboratory procedures are procedures, which are grouped according to billed according to which system of coding? A hospital has a contract with a major medical (known) revenue based upon a negotiated per-capita insurer that reimburses the laboratory at a rate fee for the members of the group. Tis type of the laboratory must manage its resources to provide reimbursement is called: covered laboratory tests to the group at a cost that A. A preferred provider discount prospective payment system is used by Medicare and C. Diagnosis-related group and is based upon projecting the cost of a Education and management/Laboratory economics/2 laboratory test in a specific region. According to federal and state regulations, a the fees for laboratory tests are incorporated hospital’s capital budget should include which into the reimbursement covering the specific of the following before projects that cost $150,000 diagnosis-related group rather than the type can be submitted for approval? Salaries and wages for new employees obstetrics department or new wing to the laboratory. A certificate of need There are specific federal guidelines (most states Education and management/Laboratory economics/1 also require them) to follow and the limit is set at $150,000. This is done to control duplication of services as well as oversupply of hospital beds. In order to budget for next year’s salaries for these employees, the laboratory 25. A The total (paid) hours are the total number of hours manager needs to submit which figures for the for which employees are paid. Total hours of part-time employees the total (paid) hours in order to give a clear picture of what is needed for the next year of wages and Education and management/Laboratory economics/1 salaries. Submit as four individual tests Education and management/Laboratory regulation 27.

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