Cambridge Catalogue  
  • Help
Home > Catalogue > Obstetric Anesthesia
Obstetric Anesthesia

Details

  • Page extent: 992 pages
  • Size: 228 x 152 mm
  • Weight: 0.8 kg

Library of Congress

  • Dewey number: 617.9/682
  • Dewey version: 22
  • LC Classification: RG732 .O2634 2007
  • LC Subject headings:
    • Anesthesia in obstetrics--Handbooks, manuals, etc
    • Anesthesia, Obstetrical--methods--Handbooks
    • Pharmaceutical Preparations--Handbooks

Library of Congress Record

Paperback

 (ISBN-13: 9780521709392)




Obstetric Anesthesia

Edited by

MAY C. M. PIAN-SMITH, MD, MS
Co-Chief, Division of Obstetric Anesthesia
Department of Anesthesia and Critical Care
Massachusetts General Hospital;
Assistant Professor
Department of Anesthesia
Harvard Medical School
Boston, MA

LISA LEFFERT, MD
Co-Chief, Division of Obstetric Anesthesia
Department of Anesthesia and Critical Care
Massachusetts General Hospital;
Instructor
Department of Anesthesia
Harvard Medical School
Boston, MA





CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi

Cambridge University Press
32 Avenue of the Americas, New York, NY 10013–2473, USA

www.cambridge.org
Information on this title: www.cambridge.org/9780521709392

© 2007, 2006, Obstetric Anesthesia, by PocketMedicine.com, Inc.

This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without
the written permission of Cambridge University Press.

First published 2007

Printed in the United States of America

A catalog record for this publication is available from the British Library.

Library of Congress Cataloging in Publication Data

Obstetric anesthesia / [edited by] May C.M. Pian-Smith, Lisa Leffert.
   p. ; cm.
ISBN-13: 978-0-521-70939-2 (pbk.)
ISBN-10: 0-521-70939-3 (pbk.)
1. Anesthesia in obstetrics – Handbooks, manuals, etc. I. Pian-Smith,
May C. M., 1959– II. Leffert, Lisa, 1962–
[DNLM: 1. Anesthesia, Obstetrical – methods – Handbooks.
2. Pharmaceutical Preparations – Handbooks. WO 231 O14 2007]
RG732.O2634  2007
617.9′682–dc22      2007016913

ISBN 978-0-521-70939-2 paperback

Cambridge University Press has no responsibility for
the persistence or accuracy of URLs for external or
third-party Internet Web sites referred to in this publication
and does not guarantee that any content on such
Web sites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate and/break up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.





NOTICE

Because of the dynamic nature of medical practice and drug selection and dosage, users are advised that decisions regarding drug therapy must be based on the independent judgment of the clinician, changing information about a drug (e.g., as reflected in the literature and manufacturer’s most current product information), and changing medical practices.

While great care has been taken to ensure the accuracy of the information presented, users are advised that the authors, editors, contributors, and publisher make no warranty, express or implied, with respect to, and are not responsible for, the currency, completeness, or accuracy of the information contained in this publication, nor for any errors, omissions, or the application of this information, nor for any consequences arising therefrom. Users are encouraged to confirm the information contained herein with other sources deemed authoritative. Ultimately, it is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for the patient. Therefore, the author(s), editors, contributors, and the publisher make no warranty, express or implied, and shall have no liability to any person or entity with regard to claims, loss, or damage caused, or alleged to be caused, directly or indirectly, by the use of information contained in this publication.

Further, the author(s), editors, contributors, and the publisher are not responsible for misuse of any of the information provided in this publication, for negligence by the user, or for any typographical errors.





CONTENTS



Preface page xxi
PART ONE. OBSTETRIC ANESTHESIA
Achondroplasia 2
Acromegaly 3
Acute Fatty Liver of Pregnancy (AFLP) 6
Acute Glomerulonephritis 9
Acute Interstitial Nephritis 12
Acute Tubular Necrosis 14
Adrenal Insufficiency 16
Alcoholic Hepatitis 19
Amniotic Fluid Embolus (AFE) 21
Amyotrophic Lateral Sclerosis (ALS) 24
Anemia 26
Anesthesia for Cesarean Delivery 28
Anesthesia for Non-Obstetric Surgery in the Pregnant Patient 45
Ankylosing Spondylitis 51
Ankylosing Spondylitis, Back Problems 53
Antepartum Assessment 56
Antiphospholipid Syndrome 62
Aortic Regurgitation 65
Aortic Stenosis 74
ARDS 83
Arnold-Chiari Malformation 85
Arrhythmias 88
Arterial Lines 96
Ascites 98
Aspiration 100
Assisted Reproductive Technologies (ART) 102
Asthma 109
Autoimmune Hepatitis 111
Basics of Regional Anesthesia 113
Bell’s Palsy 117
Benign Intracranial Hypertension (BIH) 119
Bilateral Renal Cortical Necrosis 122
Bone Marrow Malignancies and Bone Marrow Transplant Patients 125
Brain T umor 128
Breech in Labor 139
Cardiac Arrest 142
Cardiomyopathy 146
Carpal Tunnel Syndrome 153
Causes of Acute Renal Failure in Pregnancy 155
Central Venous Lines 156
Cerebral Venous Sinus Thrombosis 158
Cervical Cerclage 163
Chest Compressions 164
Chronic Low Back Pain/History of Previous Spine Surgery 166
Chronic Pain 168
Cirrhosis 180
CNS Infection (Bacterial Meningitis & Viral Encephalitis) 182
Combined Spinal/Epidural Anesthesia-Analgesia 184
Congenital Fibrinogen Disorders 187
Cystic Fibrosis 188
Depression 189
Diabetes Insipidus 192
Diabetes Mellitus 194
Dilation & Curettage/Evacuation (D&C, D&E) 205
Disseminated Intravascular Coagulation (DIC) 207
Eating Disorders 210
ECT During Pregnancy 214
Epidural Abscess 218
Epidural Analgesia 220
Epilepsy 228
Factor Deficiencies 232
Familial Dysautonomia (Riley-Day Syndrome) 234
Fetal Circulation and Placental T ransfer of Drugs 238
Fever During Pregnancy 240
Gallstones 245
General Anesthesia and the Diff icult Airway 247
General Concepts: Liver Disease 253
Gestational Back Pain 264
Gestational Thrombocytopenia 266
Glomerulonephropathies 267
HELLP Syndrome 270
Hemoglobinopathies 271
Hemolytic Anemias 273
Hepatic Encephalopathy 274
Hepatitis A 277
Hepatitis B 278
Hepatitis C 280
Hepatitis D 282
Hepatitis E 283
Hereditary Motor & Sensory Neuropathy 284
Herpes Simplex Virus 286
HIV and AIDS 290
Hypercoaguable States & Patients on Anticoagulation Therapy 303
Hypercortisolism (Cushing’s Syndrome) 310
Hyperparathyroidism 314
Hyperthyroidism 319
Hypoparathyroidism 325
Hypothyroidism 328
ICU Care 333
Idiopathic Postpartum Renal Failure 334
Idiopathic Thrombocytopenic Purpura 336
Implantable Cardioverter Defibrillators (ICDs) 337
Influenza 343
Informed Consent 344
Intra-Amniotic Infection 346
Intracranial Aneurysm 350
Intracranial Arteriovenous Malformations 359
Intrahepatic Cholestasis of Pregnancy 365
Intrapartum Assessment 369
Ischemia & MI in Pregnancy 374
Landry-Guillain-Barré Syndrome (GB) or Acute Inflammatory Demyelinating Polyradiculopathy 387
Local Anesthetic Pharmacology 389
Massive Blood Transfusion 398
Maternal Hydrocephalus 398
Maternal Hydrops 403
Maternal Resuscitation 404
Mechanical Ventilation 419
Meconium 424
Meralgia Paresthetica 426
Mitral Regurgitation 427
Mitral Stenosis 436
Mitral Valve Prolapse Syndrome 447
Multiple Gestations 452
Multiple Sclerosis (MS) 464
Muscular Dystrophy 468
Myasthenia Gravis: Management of the Parturient with Autoimmune Disease 471
Myasthenia Gravis: Management of the Parturient with Neurologic Disease 476
Myotonia & Myotonic Dystrophy (Steinert’s, Batten-Curschmann’s & Hoffman’s Disease) 481
Neonatal Airway Management 485
Neonatal Ⅳ Access 492
Neonatal Status at Birth 495
Neurofibromatosis 499
Noninfectious Fever w/ Epidurals 502
Non-Initiation of Neonatal Resuscitation 504
Nonreassuring Fetal Heart Rate Tracing 505
Normal Hematologic Changes of Pregnancy 513
Normal Renal Changes in Pregnancy 514
Obese Parturient 515
Obsessive-Compulsive disorder 527
Osteogenesis Imperfecta 530
Other Causes of Thrombocytopenia 532
Pacemakers 534
Panic Disorder 538
Parturients After Renal Transplantation 541
Parturients on Dialysis 544
Pelvic Trauma 546
Pheochromocytoma 547
Placenta Accreta 552
Placenta Previa 553
Placental Abruption 555
Poliomyelitis 556
Polymyositis/Dermatomyositis 559
Portal Hypertension 562
Postoperative Pain After Cesarean Section 564
Postpartum Assessment 568
Postpartum Evaluation & Management of Neurologic Complications of Regional Anesthesia 569
Postpartum Hemorrhage 578
Postpartum Infection 579
Postpartum Tubal Ligation 582
Postpoliomyelitis Muscular Atrophy (Postpolio Syndrome) 584
Post-resuscitation Care 586
Pre-Eclampsia and HELLP Syndrome 588
Prenatal Diagnosis 591
Preparation for Newborn Resuscitation 594
Psychotic Disorders & Bipolar Disorder 597
Pulmonary Artery (PA) Catheter 604
Pulmonary Edema 607
Pulmonary Embolus (PE) 609
Pulmonary Hypertension 612
Pulmonary Physiologic Changes of Pregnancy 614
Relief of Labor Pain With Systemic Medication 616
Renal Replacement Therapy 626
Restrictive Lung Disease 630
Resuscitation of the Neonate 632
Retained Placenta 637
Rheumatoid Arthritis, Autoimmune Disease 638
Rheumatoid Arthritis, Back Problems 642
Risk Management 644
Routine Newborn Care 655
Scleroderma 657
Scoliosis 663
Severe Pre-eclampsia 665
Spina Bifida 671
Spinal Analgesia 673
Spinal Cord Injury 679
Stroke 685
Sturge-Weber Syndrome 692
Substance Abuse 694
Suicide/Homicide/Domestic Violence 704
Systemic Lupus Erythematosus 707
Thalassemia 712
Thrombotic Microangiopathy 713
Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome 716
Thyroid Nodular Disease 718
TOLAC and VBAC 720
Troubleshooting/Managing Inadequate Regional Anesthesia 724
T ubulointerstitial Disease 727
Umbilical Cord Prolapse 730
Urolithiasis 732
Uterine Atony 735
Uterine Inversion 736
Uterine Rupture 737
UTI/Acute Pyelonephritis 739
Varicella Zoster 741
Viral Hepatitis, General 744
Volume Expansion for the Neonate 745
Von Hippel-Lindau Disease (VHL) 747
Von Willebrand Disease 748
PART TWO. OBSTETRIC ANESTHESIA FORMULARY
Acetaminophen (T ylenol) 752
Actiq (Fentanyl) 752
Acyclovir (Zovirax) 753
Adenocard (Adenosine) 753
Adenosine (Adenocard) 754
Advil (Ibuprofen) 755
Albuterol Oral Inhaled Aerosol (Proventil, Ventolin) 756
Aluminum Hydroxide (Maalox) 756
Amidate (Etomidate) 757
Amiodarone (Cordarone, Pacerone) 758
Amitriptyline (Elavil) 758
Amlodipine (Norvasc) 759
Ampicillin 759
Ancef (Cefazolin) 760
Anectine (Succinylcholine) 761
Apresoline (Hydralazine) 761
Aspirin 762
Astramorph (Morphine) 763
Atenolol (T enormin) 764
Ativan (Lorazepam) 764
Atorvastatin (Lipitor) 765
Atropine 766
Atrovent (Ipratropium) 766
Azithromycin (Zithromax) 767
AZT (zidovudine) 768
Bactrim (Co-Trimoxazole/Sulfamethoxazole) 768
Benadryl (Diphenhydramine) Oral/Injectable 769
Benzocaine 20% (Cetacaine, Hurricaine) 770
Betamethasone 771
Bicitra (Sodium Citrate) 771
Bupivacaine (Marcaine, Sensorcaine) 772
Butorphanol (Stadol) 773
Caffeine (No-Doz, Vivarin) 774
Calcium Chloride/Calcium Gluconate 774
Carbamazepine (T egretol) 775
Carbocaine (Mepivacaine) 776
Carboprost Tromethamine (Prostaglandin F2ɑ; Hemabate) 776
Cardizem (Diltiazem) 777
Catapres (Clonidine) 778
Cefazolin (Ancef) 779
Cef triaxone (Rocephin) 779
Cetacaine (Benzocaine 20%) 780
Chirocaine (Levo-bupivacaine) 780
Chloroprocaine, 3% (Nesacaine) 781
Cipro (Ciprofloxacin) 782
Ciprofloxacin (Cipro) 782
Cis-atracurium (Nimbex) 783
Cleocin (Clindamycin) 783
Clindamycin (Cleocin) 784
Clonidine (Catapres) 784
Compazine (Prochlorperazine) 785
Cordarone (Amiodarone) 786
Co-Trimoxazole/Sulfamethoxazole (Bactrim) 786
Coumadin (Warfarin) 787
Cytotec (Misoprostol) 788
Dalteparin (Fragmin) 789
Dantrium (Dantrolene) 789
Dantrolene (Dantrium) 790
DDAVP (Desmopressin) 791
Demerol (Meperidine) 792
Depakene (Valproic Acid) 793
Depakote (Valproic Acid) 794
Desflurane (Suprane) 795
Desipramine (Norpramin) 795
Desmopressin (DDAVP, Stimate) 796
DiaBeta (Glyburide) 797
Diazepam (Valium) 797
Digitek (Digoxin) 798
Digoxin (Lanoxin, Digitek) 799
Dilacor (Diltiazem) 800
Dilantin (Phenytoin) 800
Dilaudid (Hydromorphone) 801
Diltiazem (Cardizem, Dilacor, Tiazac) 802
Diphenhydramine (Benadryl) Oral/Injectable 802
Diprivan (Propofol) 803
Duragesic (Fentanyl) 804
Duramorph (Morphine) 805
Duranest (Etidocaine) 806
Effexor (Venlafaxine) 806
Elavil (Amitriptyline) 807
Endocet (Oxycodone/Acetaminophen) 808
Enoxaparin (Lovenox) 808
Ephedrine 809
Epinephrine 810
Ergotamine 811
Eskalith (Lithium Carbonate) 812
Etidocaine (Duranest) 812
Etomidate (Amidate) 813
Famotidine (Pepcid) 814
Fentanyl (Sublimaze, Actiq, Duragesic) 814
Ferrous Sulfate 815
Fioricet (Acetaminophen/Butalbital/Caffeine) 816
Fiorinal (Aspirin/Butalbital/Caffeine) 816
Flagyl (Metronidazole) 817
Fluoxetine (Prozac) 817
Forane (Isoflurane) 818
Fragmin (Dalteparin) 819
Furosemide (Lasix) 820
Gabapentin (Neurontin) 820
Garamycin (Gentamicin) 821
Gentamicin (Garamycin) 821
Glucophage (Metformin) 822
Glyburide (Micronase, DiaBeta, Glynase) 823
Glycopyrrolate 823
Glynase (Glyburide) 824
Haldol (Haloperidol) 825
Haloperidol (Haldol) 825
Hemabate (Prostaglandin F2ɑ, Carboprost Tromethamine) 826
Heparin Sodium 827
Humalog (Insulin) 828
Humulin (Insulin) 828
Hurricaine (Benzocaine 20%) 829
Hydralazine (Apresoline) 830
Hydrochlorothiazide 831
Hydrocortisone 831
Hydromorphone (Dilaudid) 832
Ibuprofen (Motrin, Advil) 833
Iletin (Insulin) 833
Imipramine (Tofranil) 834
Imitrex (Sumatriptan) 835
Indocin (Indomethacin) 835
Indomethacin (Indocin) 836
Insulin (Novolin, Humulin, Humalog, Lente, Iletin, NPH) 837
Ipratropium (Atrovent) 838
Isoflurane (Forane) 838
Ketalar (Ketamine) 839
Ketamine (Ketalar) 840
Ketorolac (Toradol) 841
Labetalol (Normodyne, Trandate) 841
Lanoxin (Digoxin) 842
Lasix (Furosemide) 843
Lente (Insulin) 843
Levo-bupivacaine (Chirocaine) 844
Levophed (Norepinephrine) 845
Levothroid (Levothyroxine) 845
Levothyroxine (Synthroid, Levoxyl, Levothroid) 846
Levoxyl (Levothyroxine) 847
Lidocaine (Xylocaine) 848
Lipitor (Atorvastatin) 848
Lithium Carbonate (Eskalith, Lithobid) 849
Lithobid (Lithium Carbonate) 850
Lopressor (Metoprolol) 851
Lorazepam (Ativan) 851
Lovenox (Enoxaparin) 852
Lyphocin (Vancomycin) 853
Maalox (Aluminum Hydroxide) 853
Magnesium Hydroxide (Milk of Magnesia, Rolaids) 854
Magnesium Sulfate 855
Marcaine (Bupivacaine) 855
Meperidine (Demerol) 856
Mepivacaine (Carbocaine, Polocaine) 857
Metformin (Glucophage) 858
Methergine (Methylergonovine; Ergotamine) 859
Methylergonovine (Methergine; Ergotamine) 859
Metoclopramide (Reglan) 860
Metoprolol (Lopressor, Toprol XL) 861
Metronidazole (Flagyl, Metro) 861
Miconazole 862
Micronase (Glyburide) 862
Midazolam (Versed) 863
Milk of Magnesia (Magnesium Hydroxide) 864
Misoprostol (Cytotec) 864
Morphine (Astramorph, Duramorph) 865
Motrin (Ibuprofen) 866
Nalbuphine (Nubain) 866
Naloxone (Narcan) 867
Narcan (Naloxone) 868
Naropin (Ropivacaine) 869
Neostigmine 869
Neo-Synephrine (Phenylephrine) 870
Nesacaine (3% 2-Chloroprocaine) 871
Neurontin (Gabapentin) 871
Nimbex (Cis-Atracurium) 872
Nitro-Bid (Nitroglycerin) 872
Nitroglycerin Ⅳ (Tridil, Nitro-Bid) 873
Nitropress (Sodium Nitroprusside) 874
Nitrous Oxide 874
No-Doz (Caffeine) 875
Norcuron (Vecuronium) 876
Norepinephrine (Levophed) 876
Normodyne (Labetalol) 877
Norpramin (Desipramine) 878
Norvasc (Amlodipine) 878
Novocaine (Procaine) 879
Novolin (Insulin) 879
NPH (Insulin) 880
Nubain (Nalbuphine) 881
Nystatin 882
Omeprazole (Prilosec) 882
Ondansetron (Zofran) 883
Oxycodone/Acetaminophen (Percocet, Roxicet, Endocet, Tylox) 883
Oxytocin (Pitocin, Syntocinon) 884
Pacerone (Amiodarone) 885
Paroxetine (Paxil) 886
Paxil (Paroxetine) 886
Penicillin G 887
Pentothal (Thiopental Sodium) 888
Pepcid (Famotidine) 889
Percocet (Oxycodone/Acetaminophen) 889
Phenergan (Promethazine) 890
Phenobarbital Sodium 891
Phenylephrine (Neo-Synephrine) 891
Phenytoin (Dilantin) 892
Pitocin (Oxytocin) 893
Polocaine (Mepivacaine) 894
Pontocaine (Tetracaine) 894
Prednisone 895
Pregnancy Categories 896
Prilosec (Omeprazole) 897
Procaine (Novocaine) 897
Prochlorperazine (Compazine) 898
Promethazine (Phenergan) 899
Propofol (Diprivan) 900
Propylthiouracil (PTU) 900
Prostaglandin F2ɑ (Carboprost Tromethamine; Hemabate) 901
Protamine 902
Proventil (Albuterol Oral Inhaled Aerosol) 902
Prozac (Fluoxetine) 903
PTU (Propylthiouracil) 904
Ranitidine (Zantac) 905
Reglan (Metoclopramide) 905
Remifentanil (Ultiva) 906
Retrovir (Zidovudine) 907
Rocephin (Ceftriaxone) 907
Rocuronium (Zemuron) 908
Rolaids (Magnesium Hydroxide) 908
Ropivacaine (Naropin) 909
Roxicet (Oxycodone/Acetaminophen) 910
Sensorcaine (Bupivacaine) 910
Sertraline (Zoloft) 911
Sevoflurane (Ultane) 912
Sodium Citrate (Bicitra) 913
Sodium Nitroprusside (Nitropress) 913
Stadol (Butorphanol) 914
Stimate (Desmopressin) 915
Sublimaze (Fentanyl) 916
Succinylcholine (Anectine) 916
Sufenta (Sufentanil) 917
Sufentanil (Sufenta) 918
Sumatriptan (Imitrex) 918
Suprane (Desflurane) 919
Synthroid (Levothyroxine) 920
Syntocinon (Oxytocin) 920
Tegretol (Carbamazepine) 921
Tenormin (Atenolol) 922
Terbutaline 923
Tetracaine (Pontocaine) 923
Thiopental Sodium (Pentothal) 924
Tiazac (Diltiazem) 925
Tofranil (Imipramine) 926
Toprol XL (Metoprolol) 926
Toradol (Ketorolac) 927
Trandate (Labetalol) 928
Tridil (Nitroglycerin) 928
T ylenol (Acetaminophen) 929
T ylox (Oxycodone/Acetaminophen) 929
Ultane (Sevoflurane) 930
Ultiva (Remifentanil) 930
Valacyclovir (Valtrex) 931
Valium (Diazepam) 932
Valproic Acid (Depakote, Depakene) 932
Valtrex (Valacyclovir) 933
Vancocin (Vancomycin) 934
Vancomycin (Lyphocin, Vancocin) 934
Vasopressin 935
Vecuronium (Norcuron) 936
Venlafaxine (Effexor) 936
Ventolin (Albuterol Oral Inhaled Aerosol) 937
Versed (Midazolam) 938
Vivarin (Caffeine) 938
Warfarin (Coumadin) 939
Xylocaine (Lidocaine) 940
Zantac (Ranitidine) 940
Zemuron (Rocuronium) 941
Zidovudine (AZT, Retrovir) 941
Zithromax (Azithromycin) 942
Zofran (Ondansetron) 943
Zoloft (Sertraline) 943
Zovirax (Acyclovir) 944




Preface



Obstetric Anesthesia is a definitive, comprehensive and yet easily navigated reference for all anesthesia practitioners caring for parturients. With chapters written by Harvard anesthesia residents and fellows, it has been carefully edited and updated by faculty mentors and reflects the practice at our affiliated institutions.

   The formatting was designed to offer rapid access to information, and thus is suited as a convenient reference on the labor floor. The first section focuses on the pharmacology, physiology and delivery of anesthesia as they relate to pregnancy. The second section offers both medical theory, as well as practical steps for the management of patients with co-existing disease (relevant physiology, pathology, obstetric management and anesthetic management). The third section focuses on the management of obstetric emergencies (physiology, pathology, step-by-step management and potential complications). We also include sections on anesthesia for non-delivery surgery and strategies for managing adverse outcomes such as neurologic complications and risk management. Finally, the book includes a detailed formulary of common medications, emphasizing indications, contraindications, and maternal and fetal effects of the drugs.

   Obstetric Anesthesia is the result of a huge collaborative effort involving our trainees and our faculty colleagues. We thank the authors for their hard work and the contagious enthusiasm that they brought to the task. Indeed, it is working in this wonderful community that makes our clinical and teaching jobs so rewarding; thus it was not surprising that this writing project, too, was stimulating and enjoyable. This book is a reflection of the intellectual curiosity, high standards and dedication to patient care that characterize this amazing team.

   We also acknowledge gratefully the important administrative assistance of Linda Patten.

May C. M. Pian-Smith, and Lisa Leffert


printer iconPrinter friendly version AddThis