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1/13. couples therapy for women survivors of child sexual abuse who are in addictions recovery: a comparative case study of treatment process and outcome.

    Treatment for women who are survivors of child sexual abuse and who have a history of substance abuse has largely involved gender-specific interventions. This study examines the use of conjoint couple therapy with a cohort of women who were survivors of child sexual abuse and who are in addiction recovery and with their partners. A comparative case study analysis incorporated standardized clinical measures with client and therapist interviews. Brief conjoint therapy was found to assist couples in the specific relationship skill areas of communication and mutual problem solving. Further, substantive gains were found in the realm of affective relations. The women reported an increase in support from their male partners, and the men reported a decrease in negative emotional atmosphere in the relationship.
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2/13. Psychiatric issues in the management of patients with hiv infection.

    Approximately 1 million persons are now infected with human immunodeficiency virus (hiv) in the united states. Evidence exists that psychiatric disorders are common in patients with hiv and that these patients may not receive optimal care because their psychiatric disorders are a barrier to medical care, communication with clinicians, and adherence to medical recommendations. We describe herein a complex case seen at The Johns Hopkins Hospital with several psychiatric conditions that are common in our hiv clinic population. We describe the collaborative treatment of the patient by a multidisciplinary team including both medical and mental health practitioners. We briefly describe a coherent diagnostic and treatment approach to patients in hiv clinics and the supporting rationale from the literature. We discuss the need for comprehensive evaluation, a multidisciplinary treatment team, and therapeutic optimism.
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3/13. Collaboration--together we can find the way in dual diagnosis.

    Service systems in health and community agencies are struggling to deliver mental health services to adults with an intellectual disability. Many professionals feel ill equipped to assess and treat mental health disorders in this population. This Australian case study describes the collaborative effort required to meet the complex health needs of a client with an intellectual disability and the needs of her family, and the role played by a specialist, Disability Health Service. The key elements of this successful interagency collaboration are outlined and include good communication, adequate resourcing, and a willingness to resolve dynamic tensions and learn from each other.
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4/13. Just a click away: recreational drug Web sites on the internet.

    The explosive growth of the internet in recent years has provided a revolutionary new means of interpersonal communication and connectivity. Information on recreational drugs-once limited to bookstores, libraries, mass media, and personal contacts-is now readily available to just about anyone with internet access. Not surprising, internet access greatly facilitates the free and easy exchange of ideas, opinions, and unedited and nonrefereed information about recreational drugs. This article presents a patient who came to medical attention as the result of recreational drug-taking behavior directly influenced by her internet browsing. A second case is presented in which the only information available about the medical effects of a new "designer" drug was found on a recreational drug internet Web site. Several such Web sites are described in detail. Despite the presence of Web sites that convey antidrug messages, the drug sites that espouse "risk reduction" and "safe" and "responsible" drug use are easily accessible and potentially alluring to children and adults. Health care providers who care for adolescents should be particularly aware of the content of these drug sites.
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5/13. The multi-service network: reaching the unserved multi-problem individual.

    A small number of multi-problem, service-resistant individuals in every metropolitan community consume extraordinary amounts of human service at great cost to publicly-funded agencies with less than satisfactory benefit to the individual. This paper describes an innovative collaboration among mental health, alcohol/drug treatment, corrections, forensic, and social and housing agencies to provide more effective services at less cost. The theory of action was that (1) inter-agency communication and (2) external controls developed by core service agencies increase the efficacy of treatment and reduce the cost of caring for multi-problem clients. Agencies refer clients to the Multi-Service Network who are then screened for problematic multi-agency involvement. Case conferences result in individual service plans. Three illustrative cases are described and the results of two evaluative studies summarized. Cost of care for clients appears to have been reduced. Agencies appear to have benefited from improved information and communication. Clients' behavior was stabilized by external controls and more adequate attention to their needs.
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6/13. Psychiatric barriers to readiness for treatment for hepatitis c Virus (HCV) infection among injection drug users: clinical experience of an addiction psychiatrist in the hiv-HCV coinfection clinic of a public health hospital.

    Among injection drug users, psychological and psychiatric barriers to readiness for treatment for hepatitis c virus (HCV) infection include mood and anxiety disorders, cognitive deficits, temperament disorders, and personality vulnerabilities, as well as ongoing drug use. Many aspects of these barriers can be overcome with direct treatment or social support. To establish effective treatment for HCV infection in this population of patients, it is essential that the patient and providers develop a rapport that allows for active communication. It is also important that the patient make an effort to adhere to the treatment requirements and that the patient receive the appropriate evaluation and management of treatable barriers.
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7/13. Use of milieu as a problem-solving strategy in addiction treatment.

    Addicted clients begin their recovery through detoxification and treatment in a structured inpatient unit. The focus of treatment is most appropriately on learning new, more constructive ways for solving problems. Everyday living skills can best be learned in a therapeutic milieu where interactions in the here-and-now are examined and opportunities are present for practicing problem-solving skills. A therapeutic milieu can be designed and initiated through efforts of the nursing staff and members of other disciplines. It is a group treatment approach emphasizing active participation in structured activities, decision-making by consensus involving all members of the community, and a reward and restriction system based on the appropriateness of client behaviors. Certain problem behaviors of addicted clients can be addressed through confrontation and group pressure; to be expected are problems with manipulation, avoidance, aggression, impulsiveness, and grandiose denial. Staff members who work in a therapeutic milieu approach to treatment of addicted clients share certain concerns. Strategies need to be developed for dealing with manipulative attempts at splitting the staff into opposing forces, clarifying roles, enforcing unit policies, and lessening feelings of hopelessness when clients fail to achieve sobriety. A cohesive staff who work at trusting each other in an atmosphere of open communication and equitable conflict resolution are best able to support each other while addressing common concerns. While treatment in a therapeutic milieu is an effective beginning in the process of recovery, it must be remembered that it is only a beginning in the long, slow process of rehabilitation. And during that process, there are likely to be relapses, which can be used as learning tools in the development of improved problem-solving skills.
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8/13. Gastro-colic fistula complicating benign gastric ulcer in analgesic abusers.

    Two cases of gastro-colic fistula occurring in analgesic abusers are described. In both patients, the fistulous communication was diagnosed at endoscopy and subsequently verified by upper gastrointestinal tract barium studies. Gastro-colic fistula is a rare complication of benign peptic ulcer disease. Whilst salcylates and cortico-steroids have been implicated as aetiological agents, abuse of compound analgesics has not previously been reported. Since the first description of gastro-colic fistula in 1755, thirty documented cases associated with benign gastric ulcer have been reported. Most often, gastro-colic fistula occurs secondary to gastric or colonic malignancy. barium enema examination is the most accurate diagnostic study. endoscopy has been confined to the visual inspection of the ulcer and establishing the benign nature of these lesions.
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9/13. Influence of deaf-mute parents on the character of their offspring.

    hearing children raised by deaf-mute parents suffer severe communication problems with their environment from the very moment of their birth. Later on feelings of alienation may ensue. Such conditions may influence the personality of offspring of deaf-mute people. A detailed representative case report of a patient with borderline personality is reported. The patient was a daughter of a quite typical deaf-mute couple. An attempt to relate some of her main characteristics and mechanisms of adaptation to factors in her early childhood is described.
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10/13. corynebacterium diphtheriae endocarditis: sustained potential of a classical pathogen.

    This communication concerns a case of endocarditis caused by corynebacterium diphtheriae. The patient was a 35-year-old male drug addict who was brought to the hospital with fever, chills, and abdominal pain. Two days after admission, blood cultures were found to be growing gram-positive rods suggestive of diphtheroids. Repeated blood cultures grew the same organism, which was identified as a nontoxigenic strain of C. diphtheriae. The patient subsequently was identified as having acquired immune deficiency syndrome. Although isolates are divided into toxigenic and nontoxigenic strains, all isolates of C. diphtheriae should be considered potentially toxigenic. Because diphtheria generally is considered only of historic interest, few laboratories perform tests to identify it and instead report all isolates as "diphtheroids" or Corynebacterium. Because all isolates are potentially toxigenic, and because there is a large reservoir of nonimmunized people, laboratories must be alert to possible serious epidemiologic situations.
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