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Emily Jaynes Winograd, PharmD

• Clinical Toxicology/Emergency Medicine Fellow
• Florida/USVI Poison Information Center-Jacksonville
• Jacksonville, Florida

Even when things were going bad with my guys in Boulder treatment carpal tunnel generic 75mg clopidogrel with visa, there was a crazy treatment 2nd degree heart block clopidogrel 75 mg with visa, joyful feeling about the book medications in carry on cheapest generic clopidogrel uk. Its writing came during a troubled period for the world in general and America in particular; we were suffering from our first gas pains in history medications quinapril cheap clopidogrel 75 mg with mastercard, we had just witnessed the sorry end of the Nixon administration and the first presidential resignation in history, we had been resoundingly defeated in Southeast Asia, and we were grappling with a host of domestic problems, from the troubling question of abortion-on-demand to an inflation rate that was beginning to spiral upward in a positively scary way. My daughter, who was then almost a year old, was dressed mostly in scrounged clothes. The year before that, I had married my wife Tabitha in a borrowed suit that was too big for me. Then Carrie sold to Doubleday, and Doubleday sold the reprint rights for a staggering sum of money which was, in those days, nearly a recordbreaker. People began to talk to me about investments, about tax shelters, about moving to California. These were changes enough to try and cope with, but on top of them, the America I had grown up in seemed to be crumbling beneath my feet. The first wave to touch that castle (or the first one that I perceived) was that long-ago announcement that the Russians had beaten us into space. On the surface, the Stand pretty much conforms to those conventions we have already discussed: an Apollonian society is disrupted by a Dionysian force (in this case a deadly strain of superflu that kills almost everybody-. Further, the survivors of this plague discover themselves in two camps: one, located in Boulder, Colorado, mimics the Apollonian society just destroyed (with a few significant changes) ; the other, located in Las Vegas, Nevada, is violently Dionysian. The first Dionysian incursion in the Exorcist comes when Chris MacNeil (Ellen Burstyn) hears that lionlike roar in the attic. In the Stand, Dionysus announces himself with the crash of an old Chevy into the pumps of an out-of-the-way gas station in Texas. But below all of this, hidden by the moral conventions of the horror tale (but perhaps not all that hidden), the face of the real Werewolf can be dimly seen. Much of the compulsion I felt while writing the Stand obviously came from envisioning an entire entrenched societal process destroyed at a stroke. I am suggesting that below the writer of the moral horror tale (whose feet, like those of Henry Jekyll, are "always treading the upward path") there lies another creature altogether. Yes, folks, in the Stand I got a chance to scrub the whole human race, and it was fun! I think it lies where it has always lain: in the hearts and minds of men and women of good will. In the case of the writer, this may mean beginning with a nihilistic premise and gradually relearning old lessons of human values and human conduct. Worse, all those deadly toys would be available to them, and things might well become a sprint to see which group of loonies could figure out how to launch them first. The book also tries to celebrate brighter aspects of our lives: simple human courage, friendship, and love in a world which so often seems mostly loveless. If such behavior is to be, it cannot be as a result of an intellectual moral stance; it is because there is such a thing as love, merely a practical fact, a practical force in human affairs. Morality is, after all, a codification of those things which the heart understands to be true and those things which the heart understands to be the demands of a life lived among others. And if we remove the label "horror story" or "fantasy genre" or whatever, and replace it with "literature" or more simply still, "fiction," we may realize more easily that no such blanket accusations of immorality can be made. Fiction is the truth inside the lie, and in the tale of horror as in any other tale, the same rule applies now as when Aristophanes told his horror tale of the frogs: morality is telling the truth as your heart knows it. When asked if he was not ashamed of the rawness and sordidness of his turnof-the-century novel McTeague, Frank Norris replied: "Why should I be But now the band has packed their melodies back inside their cases and has quitted the stage. Questions of morality in the pursuit of horror may be begging the actual question. Since no one cattle to claim her, and since her face was unmarred, a photograph was taken of her and distributed locally and then throughout the U. Days passed, weeks and months passed, but no relative, no playmate, no one in the nation came forward to identify her. Children see everything, consider everything; the typical expression of the baby which is full, dry, and awake is a vide-eyed goggle at everything. A child has not yet developed the obsessional behavior patterns which we approvingly call "good work habits. These are some of the popular myths; there are others which, while more specialized, seem just as outre. If you walk through holly bushes, your shadow can get caught and it will be left there forever, flapping on the sharp leaves. The child begins to wonder how Santa can be at the Value House, on a downtown corner ringing a bell over a Salvation Army pot, and up at the North Pole generaling his troop of elves all at the same time. Listen to me now: At eighteen or twenty or twenty-one, whatever the legal drinking age may be in your state, "getting carded" is something of an embarrassment. But you let ten years go past, get so you are looking the big three-o right in the eye, and there is something absurdly flattering about getting carded. It means you still look like you might not be old enough to buy a drink over the bar. The drinking age in Maine was then eighteen (booze-related accidents on the highways have since caused the lawmakers to move the age up to twenty), and all of those people had looked about eighteen to me. There seems to be some hidden yet overriding characteristic that makes what we all agree is the Adult Face. The boundaries of thought and vision begin to close down to a tunnel as we gear up to get along. At last, unable to grapple to any profit with Never-Never Land anymore, we may settle for the minor-league version available at the local disco. The job of the fantasy writer, or the horror writer, is to bust the walls of that tunnel vision wide for a little while; to provide a single powerful spectacle for that third eye. The job of the fantasy-horror writer is to make you, for a little while, a child again. But the fantasist begins to play with it as a child would, speculating about children from other dimensions, about dopplegangers, about God knows what. Let us pull a lever and see what it does, let us push it across the floor and see if it goes Rum-Rum-Rum or wacka-wacka-wacka. In short, let us have our Fortian rains of frogs and people who have mysteriously burned to death while sitting at home in their easy chairs; let us have our vampires and our werewolves. Let us have Little Nobody, who perhaps slipped sideways through a crack in reality, only to be trampled to death in the rush from a burning circus tent. Harlan Ellison, in spite of his rapid jive-talking shoot-from-the-hip Nervous-Norvus mode of conversation (talking with Harlan can sometimes be like talking with an apocalyptic Saladmaster salesman who has just taken three large bennies), has those eyes. Peter Straub, who dresses impeccably and who always seems to project the aura of some big company success, also has that look in his eyes. Here is a chance to bust that tunnel vision wide open, bricks flying everywhere so that, for a moment at least, a dreamscape of wonders and horrors stands forth as clearly and with all the magic reality of the first Ferris wheel you ever saw as a kid, turning and turning against the sky. Boys are thundering through autumn leaves on their way home past the library at four in the morning, and somewhere else, in some other world, even as I write this, Frodo and Sam are making their way toward Mordor, where the shadows lie. In his epic poem of a stewardess falling to her death from high above the fields of Kansas, James Dickey suggests a metaphor for the life of the rational being, who must grapple as best he/she can with the fact of his/her own mortality.

Hand contamination before and after different hand hygiene techniques: a randomized clinical trial medicine 6 year program cheap clopidogrel 75 mg otc. Prospective randomised trial of povidone-iodine medications derived from plants order clopidogrel, alcohol medications education plans buy clopidogrel with mastercard, and chlorhexidine for prevention of infection associated with central venous and arterial catheters medications given during dialysis discount 75 mg clopidogrel fast delivery. Feasibility of national surveillance of health-care-associated infections in home-care settings. Endogenous bacterial contamination of enteral tube feeding systems during administration of feeds to hospital patients. Device bulletin: Reporting adverse incidents and disseminating medical device alerts. Evaluation of a safety resheathable winged steel needle for prevention of percutaneous injuries associated with intravascular-access procedures among healthcare workers. Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care. Do catheter washouts extend patency time in long-term indwelling urethral catheters A randomized controlled trial of acidic washout solution, normal saline washout, or standard care. Bacteriuria in intermittent catheterization users: the effect of sterile versus clean reused catheters. What infection control measures will people carry out to reduce transmission of pandemic influenza An assessment of the incidence of punctures in latex and non latex dental examination gloves in routine clinical practice. Roundtable discussion with Department of Health, Muslim Chaplain and Islamic scholars to formulate advice on implementation of infection control guidelines. Urinary tract infection in children: diagnosis, treatment and long-term management. Promoting safer measurement and administration of liquid medicines via oral and other enteral routes. A comparison of prelubricated hydrophilic and non-hydrophilic polyvinyl chloride catheters for urethral catheterization. Alcoholic povidone iodine to prevent central venous catheter colonization: A randomized unit-crossover study. Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean university students during the peak pandemic period. Clean intermittent catheterisation from the acute period in spinal cord injury patients. Analysis of the research about heparinized versus nonheparinized intravascular lines. Involving the patient to ask about hospital hand hygiene: A National Patient Safety Agency feasibility study. The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. The national evidence-based guidelines for preventing healthcare associated infection. A cost-benefit analysis of gown use in controlling vancomycin-resistant enterococcus transmission: is it worth the price To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials. Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials. Impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures in health care workers. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey. Evaluation of bacterial contamination of a sterile, non air-dependent enteral feeding system in immunocompromised patients. Recommendations for selection of suitable hygiene procedures for use in the domestic environment. Systematic review of risk factors for urinary tract infection in adults with spinal cord dysfunction. A comparison of transparent adherent and dry sterile gauze dressings for long-term central catheters in patients undergoing bone marrow transplant. Efficacy of adding 2% (w/v) chlorhexidine gluconate to 70% (v/v) isopropyl alcohol for skin disinfection prior to peripheral venous cannulation. Clinical research: microbial contamination of low-profile balloon gastrostomy extension tubes and three cleaning methods. A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin resistant enterococci in an intensive care unit. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Colonization and infection with antibiotic-resistant bacteria in a long-term care facility. A comparison of transparent polyurethane and dry gauze dressings for peripheral i. Prospective randomized trial of 3 antiseptic solutions for prevention of catheter colonization in an intensive care unit for adult patients. A prospective randomized trial of the LoFric hydrophilic coated catheter versus conventional plastic catheter for clean intermittent catheterization. Cost-effectiveness of antiseptic-impregnated central venous catheters for the prevention of catheter-related bloodstream infection. Once versus twice-weekly changing of central venous catheter occlusive dressing in intensive chemotherapy patients: results of a randomized multicenter study. Evaluation of "closed" vs "open" systems for the delivery of peptide-based enteral diets. Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. Comparison of bacterial counts in glove juice of surgeons wearing smooth band rings versus those without rings. Risks of microbiological contamination of enteral feeds during the set up of enteral feeding systems. A prospective randomized study comparing a catheter-valve with a standard drainage system. Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use. In: Pope Cruickshank J, Woodward S (eds), Management of continence and urinary catheter care, London: Mark Allen Publishing Ltd. Cohen, General Counsel Chris Seefer, Director of Investigations Greg Feldberg, Director of Research Shaista I. Scott Tom Borgers Peter Adrian Kavounas Skipper Seabold Ron Borzekowski Michael Keegan Kim Leslie Shafer Mike Bryan Thomas J. More than two years after the worst of the fnancial crisis, our economy, as well as communities and families across the country, continues to experience the after shocks. This independent, -member panel was composed of private citizens with ex perience in areas such as housing, economics, fnance, market regulation, banking, and consumer protection. Six members of the Commission were appointed by the Democratic leadership of Congress and four members by the Republican leadership. The Commissions statutory instructions set out specifc topics for inquiry and called for the examination of the collapse of major fnancial institutions that failed or would have failed if not for exceptional assistance from the government. Where the Commission found such potential violations, it re ferred those matters to the appropriate authorities. The Commission also drew from a large body of ex isting work about the crisis developed by congressional committees, government agencies, academics, journalists, legal investigators, and many others.

The recognized alternative man or epicardium) actually drives the focus (hottest point) of agement has been atrioventricular nodal ablation and perma energy deeper into the tissue medicine logo buy 75 mg clopidogrel with visa, providing a faster and deeper nent pacemaker to control ventricular rate symptoms after hysterectomy cheap 75 mg clopidogrel with mastercard, but anticoagulation ablation medicine 44334 cheap clopidogrel 75 mg otc. Cryoablation: this has been used in cardiac surgery as a concomi the operative procedure is conducted with radiofrequency medicine man order clopidogrel with mastercard. Cryoablation with the extensive clinical use has now been cardial as well as an endocardial approach, either partially or used to complete an entire Maze procedure. Cryosurgery and radiofrequency are used for the excellent clinical safety record, though its use in atrial fibrillation epicardial approach. The epicardial approach may be advanced surgery has been reserved for creating spot lesions over the tricus with minimally invasive techniques either for management of pid and mitral valve annuli. The standard features of the procedure lone atrial fibrillation or chronic atrial fibrillation concomi are rapid freezing, and slow thawing with repeated freeze and thaw tant with moderate or severe mitral regurgitation. The newer technologies have been developed newer argon and helium-based systems allow for much colder tem to create transmural lesions during cardiac surgery; a potential peratures, which may limit the ablation time. The role of cryoabla limitation is the ability to perform and confirm that lesions are tion will continue to be endocardial even with new variable length transmural. Lesions are formed by local tissue technology for laser ablation is the fiberoptic delivery devices heating. They must be shown to ates a unidirectional linear ablation of 2 cm to 5 cm with a be safe, reliable and effective with no added morbidity and flexible configuration. The mechanism is wavelength depend mortality, and should be satisfactory for ablation of paroxys ent by creating harmonic oscillation in water molecules with mal, persistent or intermittent chronic atrial fibrillation. The wavelength technologies should be optimal for either nonbeating or beat chosen for good penetration is a 980 nm diode laser. Laser ablation can be applied to the epicardium, as well as endocardium Special surgical considerations because transmural lesions pass even through epicardial fat. Microwave ablation: this is considered to cause effective and Mitral regurgitation with posterior annular calcification is best controlled heating of large tissue volumes without causing char managed by excision of the bar of calcium and reconstruction ring of either the endocardial or epicardial surfaces (282-284. The valve is repaired or replaced depending on the frictional heating by induction of dielectric ionic movements. The same technique is used the method spares the endocardial surface, and local tissue for atrioventricular groove repair. The deeper penetration with microwave ment with preservation of the posterior leaflet. Ultrasound ablation: this technology uses an ultrasound the mechanism of mitral regurgitation in ischemic disease transducer to deliver mechanical pressure waves at high fre is often extremely difficult to precisely determine preopera quency. The tissue destruction is thermal and lesion depth cor tively and intraoperatively. Annuloplasty alone emitted from the transducer and resulting wave travels through may be adequate over time for control of ischemic mitral regur tissue causing compression, refraction and particle movement, gitation in some patients. There is the potential that ultrasound may both ischemic mitral regurgitation is best managed with techniques ablate and image, thus providing confirmation that the lesion for both abnormalities and recurrence may not be different is transmural. The course of mitral stenosis Percutaneous mitral commissurotomy with the Inoue balloon for severe mitral stenosis during pregnancy. Newer advances in the diagnosis and management of patients with valvular heart disease: Executive treatment of mitral stenosis. Percutaneous Heart Association Task Force on Practice Guidelines (Committee on mitral balloon valvotomy for recurrent mitral stenosis after surgical Management of Patients with Valvular Heart Disease. Predictors of long-term application of transvenous mitral commissurotomy by a new balloon outcome after percutaneous balloon mitral valvuloplasty. Percutaneous balloon assessment of commissural calcium: A simple predictor of outcome valvuloplasty compared with open surgical commissurotomy for after percutaneous mitral balloon valvotomy. Catheter balloon commissurotomy long-term results of mitral valve repair in 254 young patients with for mitral stenosis: Complications and results. Catheter balloon valvuloplasty for severe calcific of chordal preservation versus chordal resection in mitral valve aortic stenosis: A limited role. Comparison of open versus surgical closed and open mitral commissurotomy: Seven-year mitral commissurotomy with mitral valve replacement with or follow-up results of a randomized trial. Mid-term results of mitral valve from the National Heart, Lung, and Blood Institute Balloon replacement combined with chordae tendineae replacement in Valvuloplasty Registry. Prediction of outcome after percutaneous mitral commissurotomy: Six year results of the valve replacement for rheumatic mitral regurgitation in the era of N. Functional results 5 years valvotomy in reducing the severity of associated tricuspid valve after successful percutaneous mitral commissurotomy in a series of regurgitation. A predictive model on a regurgitant lesions of the aortic or mitral valve in advanced left series of 1514 patients. Mechanics of left ventricular contraction in chronic severe mitral Circulation 1992;85:448-61. Cathet Cardiovasc Diagn Determinants of pulmonary hypertension in left ventricular 1998;43:42. Echocardiographic results of balloon valvotomy in mitral stenosis with versus without prediction of left ventricular function after correction of mitral mitral regurgitation. J Am Coll Cardiol ejection fraction on postoperative left ventricular remodeling after 1996;27:1225-31. Am Heart J follow-up of patients undergoing percutaneous mitral balloon 1996;131:974-81. American Society and long-term outcome of percutaneous mitral valvotomy in of Echocardiography. J Thorac preoperative symptoms on survival after surgical correction of Cardiovasc Surg 1998;115:381-8. Cardiol Rev Echocardiographic predictors of survival after surgery for mitral 2001;9:137-43. Surgical treatment of angiographic predictors of operative mortality in patients undergoing asymptomatic and mildly symptomatic mitral regurgitation. Mitral regurgitation hemodynamic effects of the preserved papillary muscles during mitral due to ruptured chordae tendineae: Early and late results of valve valve replacement. Late outcomes of postoperative ventricular performance following valve replacement mitral valve repair for floppy valves: Implications for asymptomatic for chronic mitral regurgitation. Mitral valve replacement with and without chordal preservation in Current concepts of mitral valve reconstruction for mitral patients with chronic mitral regurgitation: Mechanisms for insufficiency. Valve repair improves the outcome of surgery for mitral invasive and conventional mitral valve surgery using premeasured regurgitation. Preoperative left mitral valve reconstruction with mitral valve replacement: ventricular peak systolic pressure/end-systolic volume ratio and Intermediate-term results. Lorusso R, Borghetti V, Totaro P, Parrinello G, Coletti G, mitral valve reconstruction with Carpentier techniques in 148 Minzioni G. Ann Thorac Surg Mechanism of outflow tract obstruction causing failed mitral valve 2001;71:1464-70. Curr Opin without chordal replacement with expanded polytetrafluoroethylene Cardiol 2002;17:179-82. New York: on the surgical treatment of ischemic mitral regurgitation: Operative McGraw Hill, 1997:991-1024. Mitral regurgitation: Basic pathophysiologic J Thorac Cardiovasc Surg 1996;112:287-92. Ischemic mitral regurgitation: Long-term outcome and prognostic Ann Thorac Surg 1999;68:820-4. Leaflet restriction versus coapting force: In vitro the posterior tricuspid leaflet and chordae: Technique and results. Mitral stenosis after mitral valve repair for strategy in mitral valve regurgitation based on echocardiography. Ann Thorac Surg mitral regurgitation due to severe myxomatous disease: Surgical 1998;66:1277-81. The edge-to-edge technique: Intraoperative transesophageal Doppler color flow imaging used to A simplified method to correct mitral insufficiency. Eur J guide patient selection and operative treatment of ischemic mitral Cardiothorac Surg 1998;13:240-6.

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Benzodiazepines are used for acute cocaine intoxication in patients who become extremely agitated and/or potentially dangerous (1203 treatment brachioradial pruritus order clopidogrel overnight. There is no evidence that anticonvulsants prevent stimulant-induced seizures treatment 5cm ovarian cyst clopidogrel 75 mg discount, and they are not recommended for this purpose medicine versed clopidogrel 75mg discount. Treating withdrawal the clinical features and duration of the cocaine abstinence syndrome are still somewhat con troversial treatment tennis elbow order clopidogrel 75 mg on-line. Although anhedonia and cocaine craving are common (1204), craving can be diffi cult to define (1204, 1209), and the cessation of cocaine use does not always cause specific withdrawal symptoms. However, many people do experience a characteristic withdrawal syn drome within a few hours to several days after the acute cessation of, or reduction in, heavy and prolonged cocaine use. Results from more recent inpa tient studies (1209, 1210) and one outpatient study (1211) have suggested that cessation of regular cocaine use is associated with relatively mild symptoms of depression, anxiety, anhedonia, sleep disturbance (insomnia or hypersomnia), increased appetite, and psychomotor retardation, which decrease steadily over several weeks. Similarly, initial stud ies of bromocriptine yielded promising results in the treatment of cocaine withdrawal (1216, 1217. A subsequent randomized, double-blind, controlled trial (1214) found a higher rate of cocaine-negative urine samples but a higher dropout rate among patients given bromocriptine than among patients given amantadine. An uncontrolled inpatient study (1218) found no re duction of cocaine craving with bromocriptine, and a randomized, double-blind, controlled trial (1219) found no significant difference between bromocriptine and placebo in reducing co caine use in outpatients. Finally, a large study of pergolide (1220) found no difference from placebo in either symptom reduction or continued cocaine use. Propranolol has recently been shown to have promise in reducing cocaine withdrawal symp toms, although its efficacy as a pharmacotherapy for cocaine dependence in general appears to be limited to those with relatively severe withdrawal symptoms (1221. There may be a sub group of patients who will respond to some form of pharmacotherapy with reduced craving and, subsequently, reduced use (see below); however, to date there are few research data to help the psychiatrist identify such patients. However, a number of studies have shown promising results with pharmacotherapeutic agents, and patients with more severe forms of cocaine dependence (e. An additional study that compared desipramine with placebo showed improvement with desipramine in the short term (6 weeks) but not at 12 weeks or 1 year (503. Interpreta tion of studies of desipramine may be confounded by differences in patient population, route of cocaine administration, and use of concomitant psychotherapies or other pharmacothera pies. The evidence for using dopamine agonists in treating cocaine dependence is also mixed. Of the dopamine agonist medications, amantadine is the best studied but has shown no overall benefit in most studies (1225, 1231, 1239. However, it may be useful for some patients, as it did demonstrate efficacy in one controlled trial (1240) and in another trial may have led sub jects with more severe withdrawal symptoms to have a better response (1226. Inconclusive or negative findings have been seen with other dopamine agonists, including selegiline (1241; F. Vocci, personal communication), L-dopa/carbidopa (1242), and pergolide (1220, 1243. Nal trexone has also been tested but has not been found to be useful for cocaine dependence (1255. More recent research, including one double-blind study (1262), has suggested some promise for another anticonvulsant, topiramate, for cocaine dependent patients. Modafinil (400 mg/day) has recently shown some efficacy for reducing cocaine abuse in an 8-week controlled study and merits further investigation (1265. Two pre vious cocaine interaction studies also support the potential efficacy and safety of modafinil (1266, 1267. Medications to change the subjective effects of cocaine Attempts to find a medication that blocks or attenuates the subjective (e. Other Treatment of Patients With Substance Use Disorders 107 Copyright 2010, American Psychiatric Association. Acupuncture Acupuncture is a somatic treatment that has been frequently used in the treatment of patients with a substance use disorder. Two recent large randomized, controlled trials (1279, 1280) of auricular acupuncture, a type of acupuncture that is supposed to be helpful specifically for pa tients with a substance use disorder, found the treatment to be no more effective than relaxation techniques or the needle insertion/sham acupuncture control condition. Moreover, cocaine craving and physiological arousal were not differentially affected by auricular acupuncture compared with sham acupuncture (1281. Thus, evidence for the benefits of acupuncture is weak, and if acupuncture is used, it should be part of a biopsychosocial treatment approach. It is at least as effective as manual-guided disease-model approaches (267, 1289) and can be associated with further decreases in cocaine use even after subjects leave treatment (1192, 1275, 1290, 1291. In addition to their work, the benefits of contingency management procedures have been replicated in other settings and samples, including cocaine-dependent individuals receiving methadone maintenance (195, 196, 1295, 1296), substance-abusing homeless individuals (1297), freebase cocaine users (1298), and pregnant substance users (1299. Psychodynamic and interpersonal therapies No randomized clinical trials have been conducted for psychodynamically oriented treatments for cocaine abuse or dependence, although a case series of individual psychodynamically ori ented psychotherapy (1300) and reports of psychodynamically oriented group psychotherapy (1301, 1302) have supported the efficacy of this approach. Furthermore, the attainment of significant periods of abstinence during treatment was associated with abstinence during follow-up, emphasizing that the inception of abstinence is an important goal of treatment (194, 1275. Cocaine use was signifi cantly reduced relative to baseline use after intensive treatment (36 individual and 24 group sessions over 24 weeks, for a total of 60 sessions) with group drug counseling alone; cognitive therapy (1306) plus group drug counseling; or supportive-expressive therapy, a psychodynam ically oriented approach (217), plus group drug counseling. However, the greatest reductions in cocaine use were noted with 12-step-based individual drug counseling plus group drug counseling (219); 12-step-oriented standard group counseling also appears to be comparable in efficacy with relapse prevention aftercare (229. In ad dition to these considerations, specific sequelae and patterns of co-occurring disorders need to be considered for patients with a cocaine use disorder. Specific co-occurring psychiatric disorders Co-occurring psychiatric and medical disorders are common among cocaine-dependent patients (1307. In addition, the results of a randomized, double-blind, placebo-controlled trial (445) suggest that de sipramine or amantadine treatment for depressed cocaine-abusing, methadone-maintained pa tients may reduce cocaine use. Given the evidence to date, however, these treatments alone cannot be expected to reduce cocaine use in these patients and must therefore be accompanied by appropriate psychosocial treatment for a cocaine use disorder (1309, 1310. Comorbid general medical disorders A range of general medical conditions are associated with cocaine use, depending on the route of administration of cocaine. Intranasal use may cause sinusitis, irritation and bleeding of the nasal mucosa, and nasal septum perforation. Smoking cocaine is associated with respiratory problems, such as coughing, bronchitis, bronchospasm, and pneumonitis, resulting from irrita tion and inflammation of the tissues lining the respiratory tract (1320, 1321. Barotrauma such as pneumothorax, pneumomediastinum, and pneumopericardium may occur as a result of coughing or a Valsalva-like maneuver that is performed to better absorb the drug (1322, 1323. Treatment of Patients With Substance Use Disorders 109 Copyright 2010, American Psychiatric Association.