How: or, Behind the Curtain.
|
|
- Julius Nelson
- 5 years ago
- Views:
Transcription
1 How: or, Behind the Curtain.
2 A peek into laboratory testing
3 Collection is Key! No coats, purses, etc in bathroom Turn off water at sink Use colored (blue, green) disinfectants in toilets Use collection containers with temperature indicators (AND READ THEM) Observed collection NOT foolproof FOLLOW PROTOCOLS for hair and oral fluid NEVER, NEVER EVER encourage fluid intake!!!!!!!!!!!!!!!!
4 Moving from Collection To Testing. SCREENING Report Toxicology Urine toxicology screen Opiates: <300 ng/ml Opiate Confirmation Oxycodone: 425 ng/ml C O N F I R M A T I O N DEFINITIVE
5 Analysis SCREENING Most are immunoassaybased Movement to mass spectrometry Targets range from specific compounds to broad classes Selected to give good window of detection DEFINITIVE METHODS Currently, mass spectrometry Gas chromatography/mass spectrometry (GC/MS) Liquid chromatography/tandem mass spectrometry (LCMSMS, UPLCMS) Very specific Greater sensitivity hours p ingestion
6 What do we mean by specificity? CH 3 N CH 3 N HO O OH CH 3 O O OH MORPHINE CODEINE CH 3 N HO CH 3 O O OXYCODONE O Cocaine assays Opiate assays
7 Comparison of Several IAs Amount of drug needed to trigger a positive response LAB IA 1 LAB IA2 POCT 1 POCT 2 Calibrator lormetazepam oxazepam glucuronide Cut off 300 ng/ml oxazepam oxazepam CLONAZEPAM NORDIAZEPAM OXAZEPAM LORAZEPAM
8 Cut-offs The lowest concentration of a drug considered to be positive. Example: THC immunoassay 20 ng/ml; mass spec 3 ng/ml Concentration depends on method and setting. Clinical: Manufacturer or lab determined based on analytical ability. Work place drug testing, etc: Defined by federal or state statutes, or agency (DOT, DOD, IOC, NFL, etc).
9 Examples of Cut-offs Class target C/O (IA) C/O (GC/MS) Amphetamines d-amphetamine/ d- methamphetamine /50/200/ 500 Barbiturates secobarbital Benzodiazepines diazapam/ lormetazepam /100 Cannabinoids 9 COOH-THC 20 3/15 Cocaine benzoylecgonine /100 Methadone methadone Opiates morphine 2000/ Phencyclidine PCP 25 25
10 Time to result IA vs MS In-lab IA POCT IA MS Minutes to hours Minutes Complexity Moderate Waived to moderate (to high) Specificity (what is detected) Sensitivity (how much) Low to moderate ng/ml (qualitative) Low ng/ml (qualitative) When to use Screening Screening Time sensitive Appropriate staff and CLIA Hours to days High High pg/ml (quantitative) Screening and confirming Disputed screen Screening results unexpected Known inability of screen to detect drug NOTE: NO test or method is error free. Most errors occur before analysis (at time of collection!)
11 Comprehensive Testing Reserve for very, selected patients $$$$, 1-2 week tat May need both blood and urine Usually multiple screens followed by definitive Examples: Hallucinogen panel: hallucinogens, amphetamines, LSD, MDMD, methedrone, mescaline, PCP, belladonna alkaloids, tryptamines, salvinorins, phenethylamines Profiles to detect OTCs and prescriptives (>200 drugs)
12 Validity Testing ph Creatinine Specific gravity Common added adulterants (same old list): H2O; detergents, bleach, salt, ammonia, acids Glutaraldehyde Nitrites Chromates Peroxide and peroxidase
13 Interpretations Result below c/o Drug absent Drug present, but below designated cut-off Assay does not detect drug Result at or above c/o Screen: detected drugs belonging to the indicated class or another similar substance that cross-reacts with antibody in assay Confirmation or definitive: drug is present The result does not tell you the route, time of, or amount of ingestion.
14 Oh, NO! Unexpected Results... What does the metabolic profile look like? pharmacokinetics Was drug administered correctly, etc? Ex: frequency of fentanyl patch replacement What other drugs are used/prescribed, including CAMs? Use of grapefruit, etc? Pharmacogenetics Cross-reactivity with similar compounds (or contamination) Have any issues been reported with generics? Where is the prescription being filled?
15 Oh, NO! Unexpected Results... Were there any issues during collection? Human error? Office or Laboratory? re-test if there is any doubt and talk to the laboratory!
16 Talk to YOUR LAB An expert is often available to help with interpretations Some can be tricky even we scratch our heads Many manufacturers of screening assays Many versions of confirmation methods No two are the same DON T use web based info We are part of the health care team and here to work with you!
17 Drug testing results Should always be used in context with other patient data eg, medical record, med lists (inc old), assessment and monitoring data, behavioral observation, anecdotal remarks from family Are NOT indicative of every therapeutic compliance scenario. Expert knowledge of drug metabolism and sometimes collaboration with laboratory is essential to an accurate interpretation
18 Guidelines In current review National Academy of Clinical Biochemistry with American Academy of Pain Management, evidenced based Clinical Laboratory Standards Institute consensus based Let me know if you are interested in reviewing
19 Outline History and use of drug testing in the clinical setting Who, what, when, where, how, and why Behind the curtain testing What s in this urine? Your conundrums: audience submits cases
20 What s in This Urine?
21 Case 1 A 32 yo female with past medical history of ADHD, anxiety, and hypothyroidism is seen for follow-up treatment of chronic back pain of 3 years duration. Medication list includes Adderall XL 30 mg po, daily Xanax 0.5 mg po, bid Levothyroxine 100 mcg po, daily Percocet 5/325 mg po, 1-2 q 6 h What do you expect to find in her urine?
22 Case 1 What do you expect to find in her urine? Adderall amphetamine Xanax alprazolam (extensive metabolism) Percocet oxycodone (oxymorphone) with acetaminophen Levothyroxine thyroxine, not monitored in urine Urine Drug Screens: Amphetamines c/o 500 ng/ml; broad specificity w amphetamine/methamphetamine + many sympathomimetic amines Benzodiazepines c/o 200 ng/ml; moderate specificity across class, but excellent w alprazolam and metabolites Opiate c/o 300 ng/ml; poor specificity to oxycodone (<1%)
23 Case 1 What do you expect to find in her urine? Urine Drug Screen: Amphetamines 500 ng/ml Benzodiazepines 200 ng/ml Opiate 300 ng/ml Do these results make sense analytically? Are these results appropriate to prescribed medications?
24 Amphetamine and Methamphetamine Methamphetamine amphetamine norephedrine Optical isomers (d- and l-) Illicit methamphetamine is either d- or a racemic mixture Drugs containing amphetamine or methamphetamine Amfetamine, Adderal, benzedrine, Dexedrine, Desoxyn, Methedrine, Vick s inhaler Compounds metabolized to amphetamine or methamphetamine Amphetaminil, benzphetamine, clobenzorex, dimethylamphetamine, ethylamphetamine, famprofazone, fencamine, fenethylline, fenproporex, furfenorex, mefenorex, prenylamine, selegiline Methylphenidate (Ritalin) differs and often NOT detected by amphetamine immunoassays. Isomers not distinguished by most routine methods! Special chromatography needed Look at prescribed amph/methamph (what is isomer composition?) > 20% d-methamphetamine is suspicious
25 Metabolic Profile of Opiates OXYMORPHONE OXYCODONE HEROIN HYDROMORPHONE 6-ACETYLMORPHINE HYDROCODONE MORPHINE CODEINE NORMORPHINE MORPHINE 3-GLUCURONIDE NORCODEINE CODEINE GLUCURONIDE NORMORPHINE GLUCURONIDE NORCODEINE GLUCURONIDE
26 Metabolic Profile of Opiates OXYMORPHONE OXYCODONE HEROIN HYDROMORPHONE 6-ACETYLMORPHINE HYDROCODONE MORPHINE CODEINE MORPHINE NORMORPHINE 3-GLUCURONIDE NORCODEINE CODEINE GLUCURONIDE NORMORPHINE GLUCURONIDE NORCODEINE GLUCURONIDE
27 Metabolic Profiles of Benzodiazepines Alprazolam -OH alprazolam + 4-OH alprazolam Chlordiazepoxide nordiazepam + oxazepam Clonazepam 7-aminoclonazepam Diazepam temazepam + nordiazepam + oxazepam Flurazepam N-OH ethyl glucuronide Flunitrazepam 7-aminoflunitrazepam Lorazepam lorazepam glucuronide Oxazepam oxazepam glucuronide Temazepam oxazepam
28 Case 1 What do you expect to find in her urine? Urine Drug Screen: Amphetamines 500 ng/ml Benzodiazepines 200 ng/ml Opiate 300 ng/ml Amph screen appropriate w analytical expectations and prescribed medications. Results may be appropriate. Benzo screen has excellent cross-reactivity with aprazolam and its primary metabolites. Results may be appropriate. Opiate screen used has poor cross-reactivity with oxycodone. Results suspect.
29 Case 1 Confirmations ordered Amphetamines Amphetamine 3900 ng/ml Others < c/o Benzodiazepines OH-alprazolam 1429 ng/ml Others < c/o Are these appropriate? Opiates Morphine 1152 ng/ml Others < c/o
30 Case 1 Amphetamine results are consistent with prescription Benzodiazepine results are consistent with prescription Opiate results are inconsistent with prescription She subsequently admits to selling her prescription and using heroin (last use was several days earlier).
31 Case 2 42 yo female Fentanyl Reports lack of pain control by day 3 UDS ordered All below cut-off Concerned provider calls to ask about fentanyl detection using screen, should confirmation be done? Resident explains fentanyl not detected by opiate screen and approves fentanyl confirmation Confirmation is also bdl Now what?
32 Case 2 Investigation Review of medications shows order for generic fentanyl patch with reapplication every 5 days. Fentanyl patch was prescribed to be changed every 5 d timing was too long. And at time of case, FDA recall for generic brand used. Recommended serum drug concentrations Serum fentanyl pre-application of patch shows no detectable fentanyl. Serum fentanyl 24 h later within therapeutic range.
33 Case 3 53 yo male, chronic back pain Prescription: MS Contin 30 mg 2/d What do you expect in the urine? UDS Amphetamines <500 ng/ml Barbiturates <200 ng/ml Benzodiazepines <200 ng/ml Cannabinoids 20 ng/ml Cocaine 150 ng/ml Opiates 300 ng/ml Methadone <300 ng/ml
34 Case 3 Prescription: MS Contin 30 mg 2/d What do you expect in the urine? UDS Amphetamines <500 ng/ml Barbiturates < 200 ng/ml Benzodiazepines < 200 ng/ml Cannabinoids 20 ng/ml Cocaine 150 ng/ml Opiates 300 ng/ml Methadone < 300 ng/ml Propoxyphene < 300 ng/ml Confirmation Opiates Morphine ng/ml Codeine <50 ng/ml Hydromorphone 237 ng/ml Hydrocodone <50 ng/ml Oxycodone <50 ng/ml Oxymorphone <50 ng/ml 6AM <15 ng/ml Cocaine Cocaine <50 ng/ml Benzoylecgonine 120 ng/ml Cannabinoids THC carb acid 72 ng/ml
35 Case 3 Prescription: morphine Confirmation Morphine ng/ml Hydromorphone 237 ng/ml Is this appropriate?
36 Case 3 Where s the cocaine? Cocaine Cocaine <50 ng/ml Benzoylecgonine 120 ng/ml ng/ml Excretion Pattern of Cocaine and metabolites time (h) BZE EME COC
37 Case 3 Is this passive inhalation? Cannabinoids THC carb acid 72 ng/ml
38 Case 4 39 yo male with chronic low back pain following a MVA in 2003 who returns to clinic for follow-up. Meds: Lioresal (baclofen) 10 mg/po tid Voltaren (diclofenac sodium) 1% gel topical 2-4 g 5x/d Docusate sodium 100 mg po prn Neurontin (gabapentin) 800 mg/po tid Dolophine (methadone) 10 mg/po 2 morning, 1 afternoon, 1 evening, 2 bedtime Roxicodone (oxycodone) 15 mg/po qid prn pain Tylenol (acetaminophen) 325 mg/po 2 tab q 8 h prn pain What do you expect to find in his urine?
39 Case 4 Screen Results Methadone 300 ng/ml Opiates < 300 ng/ml* Benzodiazepines < 200 ng/ml THC < 20 ng/ml * Remember most opiate screens do not cross-react well with oxycodone Confirmation Results Oxycodone < 50 ng/ml Oxymorphone < 50 ng/ml Are these results consistent or inconsistent with prescribed medications?
40 Case 4 Review past results Screening Opiates < 300 <300 <300 <300 Methadone Confirmation Oxycodone < 50 < 50 < 50 < 50 Now what? Oxymorphone < 50 < 50 < Methadone EDDP Adulterants unremarkable unremarkable unremarkable unremarkable
41 Could this patient have an altered metabolic profile? CYP P450s, esterases, others Ultra-rapid metabolizers metabolize drugs faster than normal Extensive metabolizers normal Intermediate metabolizers metabolize slower than normal Poor metabolizers metabolize much slower than normal Excretion patterns comparing Rapid v Poor metabolizer hours p ingestion
42 Case 4 CYP450 2D6 Two copies of CYP 2D6*4, poor metabolizer CYP2D6*4 has no activity CYP2D6: codeine (morphine*), hydrocodone (hydromorphone*), tramadol (o-desmethyl-tramadol), oxycodone (oxymorphone*) CYP3A4: codeine (norcodeine), hydrocodone (norhydrocodone), tramadol (N-desmethyl-tramadol), fentanyl (norfentanyl)*, methadone (EDDP), buprenorphine (norbuprenorphine) * fentanyl, oxymorphone, morphine, hydromorphone undergo significant 1 st pass metabolism Now, what do you think of his urine drug testing results?
43 Case 5 54 yo, male 4 d Hx: nausea, vomiting, dyspnea, mental status change Agitated, hallucinating PMH: cirrhosis, anemia, ETOH abuse, hepatitis C Medications: amitriptyline, promethazine, tramadol, hydrocodone /acetaminophen
44 Case 5 Resident calls laboratory: Can we send out a comprehensive tox screen to look for peyote, LDS, etc? She notes that the patient has a Combined respiratory alkalosis and metabolic acidosis with a prolonged PTT What additional test results would you want to see (first)?
45 Case 5 CHEM: Na 146 ( ) BUN 11 (7-21) PO ( ) K 3.5 ( ) CR 1 ( ) Mg 2.0 ( ) Cl 116 (98-107) glu 87 (65-110) AST 26 ( 19-55) HCO 3 9 (22-30) OSMO 309 ALT 22 (19-72) alk phos 107 (38-126) Ca 8.2 ( ) GGT 27 (13-126) bili 0.3 (0-1.2) NH 4 27 (15-45) UA: SG 1.005; ph 5.5 HEME: HCT 35.3 (37-51); PT 15 ( ); PTT 38.3 ( ); INR 1.65 ABG: ph 7.39 ( ); pco 2 17 (35-45); po (80-110) Tox: UDS neg, ETOH neg Referral Testing: Heavy Metals: As 20 g/d, Pb 12 g/d ANYTHING ELSE?
46 Case 5 How about a simple salicylate level?
47 Case 6 Interpret these results: Opiate Confirmation BUPRENORPHINE > ng/ml Norbuprenorphine < 5 ng/ml
48 Additional Resources Baselt. Disposition of Toxic Drugs and Chemicals in Man American Academy of Pain Medicine Relieving Pain in America Reisfield, Bertholf, et al. J Opioid Manag. 2007;3:80-6.; J Opioid Manag. 2007;3:333-7 Yang JM. Clin Lab Med. 2001;21: Hammett-Stabler C, et al. Clinica Chimica Acta. 2002;315: Cook JH, et al. J Anal Toxicol. 2000;24: Casavant MJ. Pediatr Clin N Am. 2002;49: Moeller K, et al. Mayo Clin Proc. 2008;83:66-76 Cone et al. J. Anal Toxicol 2006;30:1-5 Wasan et al Pain Medicine 2008; 9: Starrels, etc al. J Gen Intern Med 27: Radnovich, et al. Postgrad Med. 2014;126(4): McCarberg, et al. Curr Med Res Opin. 2013;29(5): Jannetto, et al. Expert Opin Drug Metab Toxicol. 2011;7(6): Sehgal, et al. Pain Physician. 2012;15(3 Suppl):ES67-92 Meldrum. JAMA. 2003; 12;290(18): Bonezzi, et al. Minerva Anestesiol. 2012;78(6): Kwon, et al. Pain Pract Nov 20. doi: /papr Hurley, et al. Curr Opin Anaesthesiol Aug 29. Mantyh. Curr Opin Support Palliat Care. 2014;8(2):
49 Outline History and use of drug testing in the clinical setting Who, what, when, where, how, and why Behind the curtain testing What s in this urine? Your conundrums: audience submits cases
50 Now for your questions
51 Drug Testing Case Studies <11% <2.5%
52 Drug Testing Case Studies
53 Adulterants, Substituted Specimen Your chronic pain patient, who is on methadone and Provigil, hands you a urine specimen that is less than 90 o F and has a specific gravity of <1.001 and a creatinine less than 2. What do you think about this specimen? What do you tell the patient?
54 Validity Testing Specific Gravity >1.001 and <1.030 Creatinine >2 mg/dl Temperature ph > 4.5 < 9 normal range ph absolute invalid <3 >11
55 Adulterants, Substituted Specimen Your chronic pain patient, who is on methadone and Provigil, hands you a urine specimen that is less than 90 o F and has a specific gravity of <1.001 and a creatinine less than 2. What do you think about this specimen? What do you tell the patient?
56 Drug Testing Case Studies Patient on Adderall for ADHD and temazepam (Restoril) tests positive for: Amphetamine and oxazepam (Serax) Are the results compatible with the legitimate prescriptions?
57
58 Office Based Urine Drug Screening J. Paul Martin, MD, FASAM Medical Review Officer
Laboratory Testing to Support Pain Management: Methods, Concepts and Case Studies
Laboratory Testing to Support Pain Management: Methods, Concepts and Case Studies Frederick G. Strathmann, PhD, DABCC, (CC,TC) Medical Director, Toxicology Associate Scientific Director of MS ARUP Laboratories
More informationSeptember HCMC Toxicology Transition: Additional information and Frequently Asked Questions
September 2016 HCMC Toxicology Transition: Additional information and Frequently Asked Questions Many clinicians have asked for more information about the Urine Drug Compliance Analysis (LAB8742) switch
More information1/27/ New Release, Quest Diagnostics Nichols Institute, Valencia
NEW TESTS Please Note: Not all test codes assigned to each assay are listed in the table of contents. Please refer to the complete listing on the page numbers indicated. Test Code Test Name Effective Date
More informationUrine Drug Screening: The Essentials of Interpretation
Urine Drug Screening: The Essentials of Interpretation Loralie J Langman, PhD DABCC (CC, MD, TC), F-ABFT Director Clinical and Forensic Toxicology Laboratory, Mayo Clinic Professor, Mayo Clinic College
More informationUsing Liquid Chromatography Tandem Mass Spectrometry Urine Drug Testing to Identify Licit and Illicit Drug-Use in a Community-based Patient Population
Using Liquid Chromatography Tandem Mass Spectrometry Urine Drug Testing to Identify Licit and Illicit Drug-Use in a Community-based Patient Population Adam S. Ptolemy 1, Colleen Murray 2, Edward Dunn 3,
More informationThe Drug Testing Process. Employer or Practice
Disclosures Clinical Professor, Jefferson Medical College BOD MROCC [Medical Review Officer Certification Council] BOD National Sleep Foundation BOD POEMS [Pennsylvania Occupational & Environmental Medicine
More informationLaboratory Service Report
4 05/25/19 Client C702884-DLP ROCHESTER Amphetamines, Confirmation Positive Confirmed POSITIVE by LC-S/S for the following: Amphetamine = 52 ethamphetamine = 124 ethamphetamine exists in the d- and l-isomeric
More informationUrine Opioid Dependency Panel (UODP) 1
Drug Testing Panels Urine Opioid Dependency Panel (UODP) 1 Amphetamines Amphetamine Methamphetamine Methylenedioxyamphetamine Adderall, Dexedrine, Vyvanse, Lisdexamfetamine (Speed, Bennies, Crystal Meth,
More information3703 Camino del Rio South 100-A San Diego, CA, Phone Fax CLIA# 05D years
Drug Adherence Assessment Report CleanAssure TM (DRIED BLOOD SPOT): Detection Range see NOTES. Prescribed Medications: NO MEDICATION LIST PROVIDED CONSISTENT RESULTS - MEDICATION DETECTED (PARENT DRUG
More informationFrequently Asked Questions: Opiate Dependency and Methadone Maintenance Treatment program follow-up
Frequently Asked Questions: Opiate Dependency and Methadone Maintenance Treatment program follow-up Dr. Bhushan M. Kapur Associate Professor Department of Laboratory Medicine and Pathobiology, Faculty
More informationUrine Drug Testing Methods 3-5
Urine Drug Testing Methods 3-5 Type of Test Logistics Pearls Initial Screening Test: Immunoassay Confirmatory Test: Gas chromatography-mass spectrometry (GCMS) + or Liquid chromatography-mass spectrometry
More informationPhysician s Reference for Urine and Blood Drug Testing and Interpretation
Physician s Reference for Urine and Blood Drug Testing and Interpretation DETECTIMED PANEL Urine (test code 70195) Screen Confirmation Screen Confirmation Alcohol Ethanol Amphetamines Amphetamine Methamphetamine
More informationPharmacokinetics and Disposition of UDM Comparison of Various Sources for Drug Testing: Urine, Blood, Hair, Saliva. Edward J. Cone, Ph.D.
Pharmacokinetics and Disposition of UDM Comparison of Various Sources for Drug Testing: Urine, Blood, Hair, Saliva Edward J. Cone, Ph.D. Johns Hopkins School of Medicine, Baltimore, MD & ConeChem Research,
More informationUrine drug testing it s not always crystal clear
Urine drug testing it s not always crystal clear Kirk Moberg, MD, PhD, FASAM Executive Medical Director, UnityPoint Health Illinois Institute for Addiction Recovery Clinical Professor of Internal Medicine
More informationTesting for Controlled Substances
Testing for illicit drugs Testing for Controlled Substances 1 Purposes: Employment Sports Screening medical eval. Legal Monitoring Treatment Probation Prescribing controlled substances Forensics 2 Drug
More information3703 Camino del Rio South 100-A San Diego, CA, Phone Fax CLIA# 05D Director: David J.
Drug Adherence Assessment Report Prescribed Medications: NO MEDICATION LIST PROVIDED CONSISTENT RESULTS - REPORTED MEDICATION DETECTED (PARENT DRUG AND/OR METABOLITE) REPORTED PRESCRIPTION FLAG ANTICIPATED
More informationDrug Adherence Assessment Report
Prescribed Medications: Drug Adherence Assessment Report FENTANYL, OXYCODONE CONSISTENT RESULTS - REPORTED MEDICATION DETECTED (PARENT DRUG AND/OR METABOLITE) REPORTED ANTICIPATED TEST PRESCRIPTION (S)
More information3/8/2018. Reasons for Doing UDT. UDT: A Tool in Risk Assessment. Faculty/Presenter Disclosure. Urine Drug Testing in Chronic Pain Management
Urine Drug Testing in Chronic Pain Management March 8, 2018 Faculty/Presenter Disclosure Faculty: Andrew J Smith, MDCM Relationships with commercial interests: None to report Andrew J Smith, MDCM Staff
More informationPatient-Centered Urine Drug Testing. Douglas Gourlay, MD, MSc, FRCPC, FASAM
Patient-Centered Urine Drug Testing Douglas Gourlay, MD, MSc, FRCPC, FASAM Declaration of Potential Conflict of Interest The content of this presentation is non- commercial and does not represent any conflict
More informationEDUCATIONAL COMMENTARY rd TEST EVENT Chemistry Urine Drug Testing
EDUCATIONAL COMMENTARY 2003 3 rd TEST EVENT Chemistry Urine Drug Testing Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE
More informationTest Definition: PDSOX Pain Clinic Drug Screen, Chain of Custody, Urine
Reporting Title: Pain Clinic Drug Screen, CoC, U Performing Location: Rochester Specimen Requirements: Container/Tube: Chain-of-Custody Kit (Supply T282) containing the specimen containers, seals, and
More informationPain Medication Management Program Monitors Patient Compliance
PeaceHealth Laboratories UPDATE 2014/15 Edition Pain Medication Management Program Monitors Patient Compliance BENEFITS Monitors analgesic medication adherence to ensure patient safety and protect your
More informationEffective Date: Approved by: Laboratory Executive Director, Ed Hughes (electronic signature)
1 Policy #: 803 (PLH-803-02) Effective Date: NA Reviewed Date: 4/11/2008 Subject: URINE DRUG SCREENS Approved by: Laboratory Executive Director, Ed Hughes (electronic signature) Approved by: Laboratory
More informationWhat Your Drug Test Really Means. Krista Beiermann, RN, OHS Occupational Health Services, Columbus Hospital
What Your Drug Test Really Means Krista Beiermann, RN, OHS Occupational Health Services, Columbus Hospital Disclosure There are no relevant financial relationships with commercial interests associated.
More informationWelcome - SAMHSA s Role. Welcome SAMHSA Key Messages 4. Welcome SAMHSA s Direction
Welcome - SAMHSA s Role 2 Welcome and Opening Remarks The National Conference on Substance Abuse, Child Welfare and the Courts Division of Workplace Programs Ron R. Flegel, BSMT, M.S. and Charles Lodico,
More informationUrine Drug Testing to Monitor Opioid Use In Managing Chronic Pain
Faculty Disclosure Henry C. Nipper, PhD, DABCC Dr. Nipper has listed no financial interest/arrangement that would be considered a conflict of interest. Urine Drug Testing to Monitor Opioid Use In Managing
More informationLCMS-8050 Drugs of Abuse: 113 Analytes with Polarity Switching
Liquid Chromatography Mass Spectrometry SSI-LCMS-8 LCMS-8 Drugs of Abuse: Analytes with Polarity Switching LCMS-8 Summary Seventy six analytes and their internal standards are described below. Multiple
More informationPain Management and Compliance Toxicology. Greg Jellick, MSFS, D-ABFT-FT Technical Director Quality Toxicology San Antonio, TX
Pain Management and Compliance Toxicology Greg Jellick, MSFS, D-ABFT-FT Technical Director Quality Toxicology San Antonio, TX Prescription Drug Abuse: A National Problem Prescription drug abuse is a growing
More informationUrine Drug Testing. Methadone/Buprenorphine 101 Workshop. Ron Joe, MD, DABAM December 10, 2016
Urine Drug Testing Methadone/Buprenorphine 101 Workshop Ron Joe, MD, DABAM December 10, 2016 Learning objectives Clarify the purpose of urine drug testing (UDT) Distinguish between UDT for detection of
More informationTest Definition: PCDSO Pain Clinic Drug Screen, Urine
Reporting Title: Pain Clinic Drug Screen, U Performing Location: Rochester Specimen Requirements: Collection Container/Tube: Plastic urine container Submission Container/Tube: Plastic, 60-mL urine bottle
More informationThe Utility of Urine Drug Screening
The Utility of Urine Drug Screening Treating Addiction, Saving Lives Sea Cruises Bye Tazmania, still far from New Zealand February 8 th, 2018 Mandy Manak, MD FASAM, ISAM, CSAM, MRO Medical Director, ICDO
More informationPain Medication Management Program Supports Patient Outcomes and Adherence
PeaceHealth Laboratories UPDATE 2015 Revised Edition Pain Medication Management Program Supports Patient Outcomes and Adherence BENEFITS Monitors analgesic medication adherence to ensure patient safety
More informationAlcohol. Ethanol Highlands Parkway, Suite 100 Smyrna, GA 30082
Alcohol The alcohol of interest is ethanol. Ethanol has a sedative effect in the brain. Ethanol intoxication symptoms include blurred vision, slurred speech, poor coordination and difficulty thinking depending
More informationCaring for ME Webinar: Urine Drug Screening Speaker: Dr. Jonathan Fellers Tuesday, November 20, PM
Caring for ME Webinar: Urine Drug Screening Speaker: Dr. Jonathan Fellers Tuesday, November 20, 2018 12 1 PM Audio is available through your computer speakers. Mission Maine Quality Counts is a nonprofit
More informationWelcome! Supreme Court of Ohio Specialized Dockets Conference. October 23-24, 2017
Welcome! Supreme Court of Ohio Specialized Dockets Conference October 23-24, 2017 Drug Testing: Do you know enough to be dangerous? Presented by William L. Parker President & CEO American Court & Drug
More informationConflict of Interest Disclosure
Patient Rx Drug Misuse and Abuse: Compliance Toxicology Monitoring in Clinical Practice Toxicology Staff Andrea Terrell, Ph.D., DABCC Chief Scientific Officer George Behonick, Ph.D., DABFT, Manager, FBU
More informationToxicology Testing Is it a Good Fit for Your Laboratory? Rebecca Kenner, BA, MT, DLM(ASCP) Leigh Ann Smith, BS, MLS(ASCP), CLS
Thursday April 6, 2017 B16 Toxicology Testing Is it a Good Fit for Your Laboratory? Rebecca Kenner, BA, MT, DLM(ASCP) Leigh Ann Smith, BS, MLS(ASCP), CLS Global Analytical Development DESCRIPTION: Are
More informationDrug Screening: Things You Need to Know
Drug Screening: Things You Need to Know (a view inside the clinical laboratory) Gary L. Horowitz, MD Director, Clinical Chemistry, Beth Israel Deaconess Medical Center Associate Professor of Pathology,
More informationLearning Objectives. Drug Testing 10/17/2012. Utilization of the urine drug screen: The good, the bad, and the ugly
Utilization of the urine drug screen: The good, the bad, and the ugly Jennifer A. Lowry, MD Chief, Section of Medical Toxicology Children s Mercy Hospital Kansas City, MO Learning Objectives Describe the
More informationToxicology 101. Arizona Problem Solving Courts April 25, 2016
Toxicology 101 Arizona Problem Solving Courts April 25, 2016 Aaron Brown, Ph.D. Technical Group Lead Norchem Drug Testing Laboratory Cordant Health Solutions Flagstaff, Arizona Toxicology Toxicology is
More information10/16/2017. Objectives. Drug Testing Interpretation in Addiction Care. Background. Which is Nonadherent?
Objectives Drug Testing Interpretation in Addiction Care Brandi Puet, Pharm.D. Describe the difference between immunoassay and confirmatory testing. List explanations for unexpected negative or positive
More informationControlled Substance Monitoring in the Age of the Opioid Epidemic
Controlled Substance Monitoring in the Age of the Opioid Epidemic Paul E. Hilliard, MS, MD Hospital Pain Committee Chair Department of Anesthesiology CME housekeeping I have no financial disclosures AKA,
More informationDisclosures. You're in Control or Urine Control Clinical Pearls of Drug Testing Case Studies. 9/20/17
You're in Control or Urine Control Clinical Pearls of Drug Testing Case Studies Jeffrey Fudin, BS, PharmD, FCCP, FASHP www.paindr.com Disclosures Astra Zeneca (Speakers Bureau) Collegium (Consultant) Daiichi
More informationDrugs of Abuse I Serum
Drugs of Abuse I Serum 2017-11 1.10 For quality monitoring of quantitative measurements by chromatographic methods These reference materials are produced on the basis of human matrices. The highly accurate
More informationURINE DRUG TOXICOLOGY
Psychiatry and Addictions Case Conference UW Medicine Psychiatry and Behavioral Sciences URINE DRUG TOXICOLOGY Suzanne E. Rapp, MD GENERAL DISCLOSURES The University of Washington School of Medicine also
More informationA Simple and Accurate Method for the Rapid Quantitation of Drugs of Abuse in Urine Using Liquid Chromatography
Application Note LCMS-109 A Simple and Accurate Method for the Rapid Quantitation of Drugs of Abuse in Urine Using Liquid Chromatography Time of Flight (LC-TOF) Mass Spectrometry Introduction Many clinical
More information3703 Camino del Rio South 100-A San Diego, CA, Phone Fax CLIA# 05D years
Drug Adherence Assessment Report CleanAssure TM (DRIED BLOOD SPOT): Detection Range see NOTES. Prescribed Medications: HYDROMORPHONE (DILAUDID, EXALGO), CYCLOBENZAPRINE (FLEXERIL), METHADONE (METHADOSE),
More informationA Comprehensive Screening of Illicit and Pain Management Drugs from Whole Blood Using SPE and LC/MS/MS
A Comprehensive Screening of Illicit and Pain Management Drugs from Whole Blood Using SPE and LC/MS/MS Introduction Drug analysis from whole blood is gaining popularity due to a more complete measurement
More informationLinking Opioid Treatment in Primary Care. Roxanne Lewin M.D.
Roxanne Lewin M.D. The Facts Fewer than 10 percent of individuals with an alcohol use disorder and only about 20 percent of individuals with an opioid use disorder receive specialty treatment. Many individuals
More informationForensic Toxicology Scope of Testing and Detection Limits
Forensic Toxicology Scope of Testing and Detection Limits Table of Contents QUALITATIVE ANALYSES... 2 Volatile Screen by GC/FID... 2 Carbon Monoxide by Microdiffusion... 2 Ethylene Glycol by GC/MS... 2
More informationDrugConfirm Advanced Urine Dip Cards.
DrugConfirm Advanced Urine Dip Cards The information in this presentation is a general overview on using the Confirm BioSciences DrugConfirm Advanced drug test cup but can be applied to many similarly
More informationOne of These Tests is Not Like the Other: Comparative effectiveness, cost-effectiveness and utilization guidance in pain management testing
& One of These Tests is Not Like the Other: Comparative effectiveness, cost-effectiveness and utilization guidance in pain management testing Speaker Frederick G. Strathmann Learning Objectives Discuss
More informationLC Application Note. Dangerous driver?
LC Application Note Dangerous driver? www.palsystem.com Dangerous driver? Robert M. Sears 1 ; Kenneth C. Lewis 2 ; and Kim Gamble 3 1 SC Law Enforcement Division, Columbia, SC 29221; 2 OpAns LLC, Durham
More informationPrescription Drug Monitoring Reference Guide: 2017
Prescription Drug Monitoring Reference Guide: 2017 Prescription Drug Monitoring Test Codes Test Codes Drug/Drug Class P P,D,M P,D D,M D Alcohol Metabolites 90079 16910 92142 16217 Amphetamines 92222 70245
More informationValidation Report for the Neogen Fentanyl Kit for ELISA Screening of Whole Blood and Urine Specimens
Validation Report for the Neogen Fentanyl Kit for ELISA Screening of Whole Blood and Urine Specimens This document describes the validation of a Neogen Fentanyl kit for the semi-quantitative analysis of
More informationEvaluation of the Integrated E-Z Split Key Cup II for Rapid Detection of Twelve Drug Classes in Urine
Technical Note Evaluation of the Integrated E-Z Split Key Cup II for Rapid Detection of Twelve Drug Classes in Urine Dina N. Greene, Christopher M. Lehman, and Gwendolyn A. McMillin* University of Utah
More informationProof of Concept for Automated SPE/HPLC/MS/MS Methods to Replace Traditional Immunoassay with MS Confirmation of Driving Under the Influence Samples
Proof of Concept for Automated SPE/HPLC/MS/MS Methods to Replace Traditional Immunoassay with MS Confirmation of Driving Under the Influence Samples Robert M. Sears, Toxicology Technical Leader 1, Kenneth
More informationnextgen precision Test Report
nextgen precision TM Test Report SUMMARY OF PRECISION S NEXTGEN TEST REPORT In an effort to provide as much clinical insight as possible to our providers, we created our comprehensive NextGen Precision
More informationPrepared by Date Adopted Supersedes Procedure # Review Date Revision Date Signature. Distributed to # of Copies Distributed to # of Copies
Procedure: Status DS Prepared by Date Adopted Supersedes Procedure # Review Date Revision Date Signature Distributed to # of Copies Distributed to # of Copies PRINCIPLE: The Status DS 10 Panel (MET/OPI/COC/THC/PCP/BZO/BAR/MTD/TCA/AMP)
More informationUrine Drug Screening (UDS) Dr. Erica L. Weinberg December 2017
Urine Drug Screening (UDS) Dr. Erica L. Weinberg December 2017 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any
More informationSchedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines-upon-Thames, TW18 3HR, UK
Schedule of ccreditation United Kingdom ccreditation Service 2 Pine Trees, Chertsey Lane, Staines-upon-Thames, TW18 3HR, UK ccredited to Laboratory locations: Gavenny Court Brecon Road bergavenny Monmouthshire
More informationCDIA TM Marijuana Colloidal Gold Test Cassette (Saliva)
CDIA TM Marijuana Colloidal Gold Test Cassette (Saliva) Cat. No.: DTSJZ023 Pkg. Size: Intended Use The CDIA TM Marijuana Colloidal Gold Test Cassette (Saliva) is an immunochromatography based one step
More information2013 Clinical drug and alcohol testing solutions. Product Catalog. CLIA-waived point of care test devices
2013 Clinical drug and alcohol testing solutions Product Catalog CLIA-waived point of care test devices HELPING YOU MAKE INFORMED DECISIONS ABOUT ABUSE. Substance abuse testing with more substance. 2 of
More informationPROFESSIONALISM AND COMMENTARY. Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management
bs_bs_banner Pain Medicine 2013; 14: 1813 1820 Wiley Periodicals, Inc. PROFESSIONALISM AND COMMENTARY Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management Disclosure: The
More informationUrine Testing for Opioids
Urine Testing for Opioids J. David Haddox, DDS, MD Vice President Risk Management & Health Policy Purdue Pharma L.P. Tufts Health Care Institute Program on Opioid Risk Management The Role of Urine Drug
More informationEuropean Guidelines for Workplace Drug Testing in UrineandOral fluid
EWDTS European Workplace Drug Testing Society European Guidelines for Workplace Drug Testing in UrineandOral fluid 9th EWDTS Symposium in Lisbon Sanna Taskinen Michaela Neuhofer Updating project # 2 Current
More information[ APPLICATION NOTE ] APPLICATION BENEFITS INTRODUCTION WATERS SOLUTIONS KEYWORDS
A Comprehensive Method for the Analysis of Pain Management Drugs and Drugs of Abuse Incorporating Simplified, Rapid Mixed-Mode SPE with UPLC-MS/MS for Clinical Research Jonathan P. Danaceau, Scott Freeto,
More informationChemaTox Blood Drug Testing Matrix (Updated May 24th, 2016)
ChemaTox Blood Drug Testing Matrix (Updated May 24th, 2016) Email: DREtox@chematox.com; Phone: (303)440-4500 Always identify any medications/drugs the suspect states they have taken, or that you suspect
More information1. Amphetamine (Adderall, desoxyn, Dexedrine,dextrostat, spancap, oxydess II)
Cross reactivity of various pharmaceuticals against the Drugs of Abuse Screening Panel (posted 2/3/09) The following tables are only applicable to the specific analyzer and reagents used at HRHS main lab.
More informationDrugConfirm Advanced Instant Urine Drug Test Cups Training Guide.
DrugConfirm Advanced Instant Urine Drug Test Cups Training Guide The information in this presentation is a general overview on using Confirm BioSciences DrugConfirm Advanced urine drug test cup; however,
More informationINTERPATH LABORATORY, INC. TEST UPDATES
EFFECTIVE DATE: February 16, 2016 INTERPATH LABORATORY, INC. TEST UPDATES Please take note of the following test updates and make the appropriate changes in your Interpath Service Manual. Feel free to
More informationORAL FLUID AS A CHEMICAL TEST FOR THE DRE PROGRAM : HISTORY, THE FUTURE, AND PRACTICAL CONSIDERATIONS
ORAL FLUID AS A CHEMICAL TEST FOR THE DRE PROGRAM : HISTORY, THE FUTURE, AND PRACTICAL CONSIDERATIONS Barry K Logan PhD, DABFT National Director of Forensic Services, NMS Labs Willow Grove PA Disclaimer
More informationQuickTox Drug Screen Dipcard (with and without Adulteration Tests)
QuickTox Drug Screen Dipcard (with and without Adulteration Tests) Training and Certification Program Presented by Branan Medical Corporation Branan Medical Corporation 10015 Muirlands Road Irvine, California
More informationDRUGS OF ABUSE
DRUGS OF ABUSE www.btnx.com 1-888-339-9964 Rapid Response Drugs of Abuse and Alcohol Screening Devices BTNX Inc. prides itself in offering quality drug detection tests for accurate, safe and rapid testing.
More informationGold Standard for Urine Drug Testin Urine Drug Testing Why U rine? Urine?
Gold Standard for Urine Drug Testing Developed by TRMC Pain Management Center Jill Duffy, RN,BC Pam Kennell, RN, BC Heidi Beisch, RN Urine Drug Testing A DIAGNOSTIC tool For an OBJECTIVE test Based on
More informationRapid Alcohol Screening Devices. p19
CLIA-WAIVED Product Catalog RAPID DRUG SCREENING DEVICES Rapid Urine Drug Screening Devices. p5 Rapid Alcohol Screening Devices. p19 Complementary Products. p23 HELPING YOU MAKE INFORMED DECISIONS ABOUT
More informationApplications of High Resolution Mass Spectrometry in Forensic Toxicology. Patrick Kyle, PhD.
Applications of High Resolution Mass Spectrometry in Forensic Toxicology Patrick Kyle, PhD pkyle@umc.edu Financial Disclosures Grant/Research Support: None Salary/Consultant Fees: None Board/Committee/Advisory
More informationFully Automated Online Sample Preparation and LC-MS/MS Analysis of Drugs of Abuse in Oral Fluids
PO-CON1753E Fully Automated Online Sample Preparation and LC-MS/MS Analysis of Drugs of Abuse in Oral Fluids ASMS 2017 TP-442 Joshua F. Emory 1, Nathan DeFreitas 2, Michael Roberts 1, Manoj Tyagi 2, M.
More informationRapid LC/TOF MS for Analytical Screening of Drugs in the Clinical Research Lab
Application Note Clinical Research Rapid LC/TOF MS for Analytical Screening of Drugs in the Clinical Research Lab Authors Adam Barker 1,2, Frederick G. Strathmann 3, Natalie N. Rasmussen 4, and Carrie
More informationQuickTox Drug Screen Dipcard (with and without Adulteration Tests)
QuickTox Drug Screen Dipcard (with and without Adulteration Tests) Training and Certification Program Presented by CLIAwaived.com, San Diego, CA Distributed by CLIAwaived.com www.cliawaived.com 1-858-481-5031
More informationInterpretation of Pain Management Testing Results Using Case Examples
Interpretation of Pain Management Testing Results Using Case Examples Philip M. Sobolesky, 1 * Breland E. Smith, 1 Amadeo J. Pesce, 2 and Robert L. Fitzgerald 1 Background: Because of the increasing volume
More informationAnalysis and interpretation of drug testing results from patients on chronic pain therapy: a clinical laboratory perspective
Article in press - uncorrected proof Clin Chem Lab Med 2009;47(8):971 976 2009 by Walter de Gruyter Berlin New York. DOI 10.1515/CCLM.2009.220 2009/180 Analysis and interpretation of drug testing results
More informationEvaluation of the Impact of Expanding ELISA Screening in DUID Investigations. Aileen Lu*, Karen S. Scott, Aya Chan-Hosokawa, and Barry K.
Evaluation of the Impact of Expanding ELISA Screening in DUID Investigations Aileen Lu*, Karen S. Scott, Aya Chan-Hosokawa, and Barry K. Logan FSF Emerging Forensic Scientist Award Oral Presentation Disclosure
More informationDAU. Scheme Description. Drugs of Abuse in Urine Proficiency Testing Scheme
DAU Drugs of Abuse in Urine Proficiency Testing Scheme Scheme Description LGC Standards Proficiency Testing 1 Chamberhall Business Park Chamberhall Green Bury Lancashire BL9 0AP United Kingdom Telephone:
More informationCutoff levels for hydrocodone in a blood test
Cutoff levels for hydrocodone in a blood test The premier DNA and drug testing company in the North Texas area. Specializing in legal cases but also provide testing for employers and private individuals.
More informationTITLE: Guidelines for Treatment of Chronic Pain EFFECTIVE DATE: LAST REVISED DATE: LAST REVIEWED DATE:
TITLE: Guidelines for Treatment of Chronic Pain EFFECTIVE DATE: 4.19.16 LAST REVISED DATE: 4.19.16 LAST REVIEWED DATE: 4.19.16 Table of Contents 1. How do I conduct my first few visits with a patient who
More informationDisclosures. Get Your Specimens in Order:
Get Your Specimens in Order: The Importance of Individualized Test Orders and Timely Test Utilization Jennifer Bolen, JD Disclosures Jennifer Bolen, JD Consultant to Generation Partners Consultant to Abbott
More informationYou Can t Fool the Bladder Police. Effective Use of Urine Drug Screening
You Can t Fool the Bladder Police Effective Use of Urine Drug Screening Why Test? Accountability Create and maintain safe treatment environment Compliance with licensing or policy Collection Supervised
More information80305, 80306, 80307,G0480, G0481, G0482, G0483, G0659
80305, 80306, 80307,G0480, G0481, G0482, G0483, G0659 CMS Policy for Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont Local policies are determined by the performing
More informationE XCEL LENCE JUST GOT BETTER UCT FORENSICS CLEAN SCREEN XCEL SPE COLUMNS
FORENSICS UCT E XCEL LENCE JUST GOT BETTER CLEAN SCREEN XCEL SPE COLUMNS CLEAN SCREEN XCEL COLUMNS EXTRACTION OF BASIC DRUGS AND METABOLITES FROM URINE/ BLOOD USING SPE CARTRIDGES 130mg Clean Screen Xcel
More informationMulti-Drug Screen Test
Multi-Drug Screen Test Package Insert for OTC/CLIA-Waived- and Professional Use For in vitro diagnostic use only The Multi-Drug Screen Test offers a variety of solutions for fast and reliable drug testing
More informationValidation of a Benzodiazepine and Z-Drug Method Using an Agilent 6430 LC/MS/MS
Validation of a Benzodiazepine and Z-Drug Method Using an Agilent 6430 LC/MS/MS Application Note Forensics Authors Jason Hudson, Ph.D., James Hutchings, Ph.D., and Rebecca Wagner, Ph.D. Virginia Department
More informationUrine Drug Testing - What Do the Results Mean and What Do I Tell the Patient? Andrea Trescot, MD, FIPP
Urine Drug Testing - What Do the Results Mean and What Do I Tell the Patient? Andrea Trescot, MD, FIPP Disclosure Andrea Trescot, MD, FIPP Pain and Headache Center Eagle River, AK President, Alaska Society
More informationAgilent Clinical LC/MS: Review of Established LC-MS QQQ Clinical Research Applications. dr. Jan Srbek, HPST. Page 1
Agilent Clinical LC/MS: Review of Established LC-MS QQQ Clinical Research Applications dr. Jan Srbek, HPST Page 1 Major LC-MS Clinical Applications Steroids/Endocrinology Vitamin D Testosterone, Estradiol
More informationCross-reactivity reactivity in EMIT
Blood Drug Analysis at the State Bureau of Investigation Crime Laboratory Richard W. Waggoner, Jr. Sample Requirements 2-10 ml gray top vacutainers At least 10 ml of urine sample for drug facilitated sexual
More informationDOF. Scheme Description. Drugs in Oral Fluid Scheme
DOF Drugs in Oral Fluid Scheme Scheme Description LGC Standards Proficiency Testing 1 Chamberhall Business Park Chamberhall Green Bury Lancashire BL9 0AP United Kingdom Telephone: +44 (0) 161 762 2500
More informationTests recently added to the NMS Labs test menu. New Tests are effective immediately.
Modified Date: 01/12/2012 In our continuing effort to provide you with the highest quality toxicology laboratory services available, we have compiled important changes regarding a number of tests we perform.
More informationRapid and Sensitive Analysis of a 93-Compound Forensic Panel in Urine using the QTRAP /Triple Quad 4500 LC- MS/MS System
Rapid and Sensitive Analysis of a 93-Compound Forensic Panel in Urine using the QTRAP /Triple Quad 4500 LC- MS/MS System Xiang He, 1 Casey Burrows 1, Matthew Noestheden 2, Michael Jarvis, 2 Adrian Taylor,
More informationSmartNotes. Understanding the SAMHSA Guidelines for Drugs of Abuse Testing
DIAGNOSTICS SAMHSA Guidelines SmartNotes Understanding the SAMHSA Guidelines for Drugs of Abuse Testing The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency within the US
More informationValidation of an Automated Method to Remove
Shahana Wahab Huq 1, Richard Thomas 2, Agnes Cua 2, Seyed Sadjadi 1 1 Phenomenex, 411 Madrid Avenue, Torrance, CA 951 2 Precision Toxicology, 33 Bunker Hill Street, San Diego, CA 9219 Validation of an
More information