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Activation of memory circuits during cue-elicited human cocaine addicts buy simvastatin online now cholesterol test starvation. PET study of competition between intrave- cal specificity for drug-users and drug stimuli buy simvastatin 20 mg fast delivery low cholesterol foods for breakfast. Am J Psychiatry nous cocaine and C-11 raclopride at dopamine receptors in human subjects buy simvastatin 10 mg with mastercard cholesterol per day. Regional brain metabolic activation during tion in human brain. Functional MRI of human brain activation JAMA 1998;279:376–380. Acute effects of cocaine on human brain on Problems of Drug Dependence, Nashville, TN, 1996. A neural substrate of pre- in cocaine abusers: implications in addiction. Addiction, a disease of compulsion Y Acad Sci 1992;654:171–191. Activation of the hippocampus in normal hu- duced high and dopamine transporter occupancy. Proc Natl mans: a functional anatomical study of memory. Selective inhibition of cocaine-seeking behaviour dysfunction in drug abuse: implications for the control of behav- by a partial D3 dopamine receptor agonist. Emotion, decision-making the reinforcing effects of cocaine in rats. Dissociable cognitive deficits in the decision- self-administration: demonstration using a discrete trials proce- making cognition of chronic amphetamine abusers, opiate dure. Baclofen as a cocaine-anti- tryptophan-depleted normal volunteers: evidence for monoami- craving medication: a preliminary clinical study. Choosing between small, likely rewards and during cue-induced cocaine craving. Soc Neurosci Abstr 1999; large, unlikely rewards activates inferior and orbital prefrontal 25:815(abst No. Activation of reward circuitry in human opiate 1994;15:374–379. FOWLER Brain imaging can be used to assess the following in the ters. Both types of isotopes can be used to label ligands for human brain: (a) morphology [computed tomography (CT) specific receptor, transporter, or enzymatic systems to be and magnetic resonance imaging (MRI)];(b) electrical and used with PET or SPECT to quantify these parameters in living human brains. In addition, PET tracers such as [18F] magnetic signals [electroencephalography (EEG) and mag- or [11C]-labeled deoxyglucose (FDG, CDG) and [15O]-la- netoencephalography (MEG)];(c) neurotransmission [posi- tron emission tomography (PET) and single photon emis- beled water can be used to measure regional brain glucose sion computed tomography (SPECT)];(d) tissue metabolism and cerebral blood flow (CBF), and SPECT tracers such as 99mTc hexamethylpropyleneamineoxime composition [magnetic resonance spectroscopy (MRS)]; and (e) blood flow and metabolism [functional MRI (HMPAO) can be used to measure CBF. This information can be used to obtain images that reflect This chapter focuses mainly on the application of PET, brain structure, brain function, or chemical composition. SPECT, and MRI for the investigation of the effects of Information on structure in the brain can be obtained on drugs of abuse in the human brain and their relationship the basis of differences in chemical composition between with their reinforcing, addictive, and toxic effects. For structural brain imaging, this is description of these imaging techniques follows. Information on detect and measure the spatial distribution and movement brain function is derived from the differences in magnetic of radioisotopes in tissues of living subjects. PET measures properties of oxygenated versus deoxygenated hemoglobin compounds labeled with positron emitting radioisotopes (blood oxygenation-dependent or BOLD contrast). During and SPECT with single photon emitting radioisotopes. An activation of a brain region, an excess of arterial blood is advantage of the positron emitters is that some of these are delivered into the area, with concomitant changes in the isotopes for the natural elements of life (11C, 15O, 13N), and ratio of deoxyhemoglobin to oxyhemoglobin. Concentra- this feature enables labeling of compounds without affecting tion on a wide variety of compounds that reflect metabolic their pharmacologic properties. Although labeling an or- state of the tissue and cell integrity can be obtained with ganic compound with a single photon emitter such as 123I MRS. MRS can also be used to measure the concentration and metabolism of compounds such as 13C-glucose. The positron emitters used for which can be done using imaging modalities that measure imaging have shorter half-lives than the single photon emit- electrical activity, CBF, or brain metabolism. Of the modali- ties used for functional imaging, fMRI has the highest spa- tial resolution. Conversely, MEG and EEG are the imaging technologies with the highest temporal resolution, which Nora D. Volkow: Medical Department, Brookhaven National Labora- enables the examiner to assess the temporal displacement tory, Upton, New York. Fowler: Chemistry Department, Brookhaven National Labora- of activation signals as they propagate in brain on the order tory, Upton, New York. IMAGING MODALITIES USED TO INVESTIGATE THE LIVING HUMAN BRAINa Parameter Temporal Spatial Measured Resolution Resolution Sensitivity MEG Function 1 ms 5 mm EEG 1 ms 10–15 mm CT Structure ms MRI Structure ms 1. Research instruments have been developed that have better performance. CT, computed axial tomography; EEG, electoencephalography; MEG, magnetoencephalography; MRI, magnetic resonance imaging; PET, positron emission tomography; SPECT, single photon emission computed tomography. The effect of drugs of abuse on neurotransmission has thus can provide information on potential organ toxicity. PET and SPECT have the highest sensi- has been evaluated with PET. Co- PHARMACOLOGIC PROPERTIES OF DRUGS caine and MP were found to have a large brain uptake (7% OF ABUSE IN THE HUMAN BRAIN to 10% injected dose) and to have an almost identical pat- tern of distribution in the human brain, where they bound The investigation of the pharmacologic properties of drugs entails studies of their pharmacokinetics (primarily using PET and the [11C]-labeled drug) as well as their pharmaco- TABLE 103. DRUGS WITH ABUSE LIABILITY THAT dynamics (using PET or SPECT and a radiotracer with HAVE BEEN LABELED WITH A POSITRON EMITTER specificity for a particular molecular or biochemical target (CARBON-11) or using PET, SPECT, and fMRI to assess brain function). Drug Class Specific Drug Reference or Review Because these studies are done in awake human subjects, one can investigate the relationship between the behavioral Psychostimulants Cocaine 5,6 effects of drugs and their effects on brain function and neu- Methylphenidate 113 Metamphetamine 114 rochemistry. Opiates Morphine 115 Heroin 115 Codeine 115 Pharmacokinetics Buprenorphine 116 Methadone 117 PET can be used to measure the absolute uptake, their re- Cannabinoids THC 118 11 Nicotine Nicotine 119–120 gional distribution, and the kinetics of [ C]-labeled drugs Caffeine Caffeine 112 in the human brain. Moreover, the labeled drug can also LSD LSD 121 be used to determine the target organs for the drug and Chapter 103: Application of Imaging Technologies in Drug Addiction 1477 rate of drug clearance is relevant in their reinforcing effects. In the case of cocaine, the fast rate of clearance enables repeated, frequent administration that is characteristic of cocaine bingeing (cocaine is taken every 15 to 30 minutes), whereas for MP, its relatively slow clearance from brain is likely to produce accumulation and toxicity that thus pre- vents frequent repeated administration. Pharmacodynamics Multiple parameters pertaining to the mechanisms of action of the drug of abuse can be investigated with imaging. These include measurement of the efficacy of the drug of abuse at the molecular target that is associated with the reinforcing effects of the drug of abuse (i. These parameters can be assessed both in nonaddicted control subjects and in ad- FIGURE 103. Left: Images at the level of the striatum obtained dicted patients to determine whether there are differences with [11C]cocaine and with [11C]methylphenidate at different in the responses between them. Right: Time activity curves for radiotracer concentration in striatum and temporal course for the 'high' expressed as a percentage from peak after pharmacologic doses of intravenous cocaine (upper panel) and of intravenous methylphenidate (lower panel). Studies on theirpharmacokinetics anddistribution inhuman brain.
B: Newer studies suggest an alternative model buy genuine simvastatin online cholesterol lowering diet and exercise plan, in which several limbic sites initially interact with one another independently discount simvastatin 20 mg mastercard cholesterol lowering foods in ayurveda. Because of their reciprocal connections to all these regions order simvastatin 20 mg visa cholesterol test diet, the midline thalamic nuclei constitute part of the initiating circuit, acting as a subcortical synchronizing site. Generalization can occur through gradual recruitment of adjacent neocortex or through the thalamus, which secondarily recruits the neocortex. Amyg, amygdala; DG, dentate gyrus; EC, entorhinal cortex; HC, hippocampus. Second, endogenous neuromodulators that can alter neuronal excita- it raises the possibility that hippocampal or extrahippocam- bility. To optimize the development of novel strategies for pal interventions during the 'silent' period may prevent the treatment of MTLE, these molecular studies should be the evolution of spontaneously recurring seizures. Third, it performed in parallel in extrahippocampal areas and in the indicates that any of a number of limbic brain areas, or even hippocampal region whenever possible. This approach certain neuronal populations within a given region, could should eventually provide significant advances in the ther- conceivably be targeted for surgical or pharmacologic inter- apy of this debilitating disorder. Although the pathophysiologically important role of ex- trahippocampal brain regions in MTLE is supported by ACKNOWLEDGMENTS the successful outcome of various surgical interventions in patients with medically intractable epilepsy (5,9,10,14–16), Work described in this article was in part supported by several critical questions need to be resolved before the ther- United States Public Health Service grants NS 16102, NS apeutic approaches listed earlier can be adequately evaluated 25605, and NS 37562. Chugani (Wayne State University, Detroit, MI) for neuronal death, gliosis, and synaptic reorganizations pro- providing the micrographs shown in Fig. Phila- widespread throughout the limbic system, we need to elabo- delphia: Lea & Febiger, 1993. New York: Raven, in controlling seizure spread and generalization. Anatomic dent changes in the composition of neurotransmitter recep- organization and physiology of the limbic cortex. Depth electrode studies in mesial temporal epilepsy. New York: Raven, 1991: complemented by examining shifts in the concentration of 371–384. Hippocampal resections and the use ronal loss in layer III of the entorhinal cortex in patients with of human tissue in defining temporal lobe epilepsy syndromes. Glucose and [´ 14C]flumazenil projections to the hippocampal CA1region in the rat: an under- positron emission tomography abnormalities of thalamic nuclei estimated pathway. Subcortical metabolic in synaptic responses of entorhinal and hippocampal neurons alterations in partial epilepsy. Positron emission amino-oxyacetic acid (AOAA) injection: an in vitro and in vivo tomography in generalized seizures. Relationships sclerosis associated with temporal lobe epilepsy. BMJ 1956;2: between MR-imaged total amount of tissue removed, resection 1403–1407. Amgdaloid sclerosis cal outcome following selective amygdalohippocampectomy. Stereotactic amygdalohippocampo- in experimental and human temporal lobe epilepsy. Epilepsy Res tomy for the treatment of medial temporal lobe epilepsy. Erkrankung des Ammonshorns als aetiologisches correlated with long-term, free recall of emotional information. Arch Psychiatr Nervenkrankh 1880;10: Proc Natl Acad Sci USA 1996;93:8016–8021. The histopathology of convulsive disorders patients with complex partial seizures of left temporal origin. Interictal cerebral glucose of subtotal temporal lobectomy. Quantitative magnetic of the brain in epilepsy, with particular reference to the temporal resonance imaging in temporal lobe epilepsy: relationship to lobes. Altered patterns of dynorphin immunoreactivity suggest mossy fiber reorganiza- 1876. Rapid kindling with recurrent in rats: visualization after retrograde transport of biocytin. J hipocampal seizures: effect of stimulus frequency and train dura- Comparative Neurology 1995;352:515–534. Neurosurgery 1978;3: rent excitatory circuits in the dentate gyrus of hippocampal 234–252. Subcortical structures and pathways involved in convul- campal kainate in the rat. Possible functional consequences of synaptic reor- 46. FAST and SLOW amyg- ganization in the dentate gyrus of kainate-treated rats. Neurosci dala kindling rat strains: comparison of amygdala, hippocampal, Lett 1992;137:91–96. Limbic seizure and brain damage produced by kainic 1854 Neuropsychopharmacology: The Fifth Generation of Progress acid: mechanisms and relevance to human temporal lobe epi- epileptogenesis: does disinhibition play a role? Permanently altered hippocampal structure, excita- of pilocarpine in rats: structural damage of the brain triggers bility, and inhibition after experimental status epilepticus in kindling and spontaneous recurrent seizures. Epilepsia 1991;32: the rat: the 'dormant basket cell' hypothesis and its possible 778–782. Hip- campus versus a chronic, kainate rat model of hippocampal pocampus 1996;6:347–470. Recurrent sponta- aminobutyric acid type A receptor function in CA1pyramidal neous hippocampal seizures in the rat as a chronic sequela to neurons. A new model of chronic GABA A receptor subunits in the hippocampus of the rat after temporal lobe epilepsy induced by electrical stimulation of the kainic acid-induced seizures. Self-sustaining induced by lowering extracellular [Mg2 ] in combined hippo- status epilepticus after brief electrical stimulation of the perfor- campal-entorhinal cortex slices: modulation by receptors for ant path. The TINS/TIPS lecture The molecular biology lepsy Res 1995;20:93–104. Model of chronic spontaneous limbic 1993;16:359–365. J entorhinal cortex are epileptiform in an electrogenic rat model Pharmacol Exp Ther 1995;274:1113–1121. Hyperexcitability of entorhinal cortex and hip- sion in young and adult rats. Expression of the medial entorhinal cortex in combined entorhinal and hippo- glutamate transporters in human temporal lobe epilepsy. Shortened duration GABA A receptor Neuroscience 1996;72:399–408.
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Phasic versus tonic dopamine release and the modula- with risperidone cheap simvastatin 40 mg fast delivery cholesterol medication that is not a statin. Elevated dopa decarboxyl- 5-HT2A receptor occupancy in schizophrenic patients discount simvastatin 20 mg without prescription fat and cholesterol in shrimp. Am J ase activity in living brain of patients with psychosis safe simvastatin 10 mg cholesterol foods avoid. Single pho- receptor density and affinity: a PET study with [11C]raclopride ton emission computerized tomography imaging of amphet- in man. Increased striatal dopa- tron emission tomographic study. J Clin Psychopharmacol 1998; mine transmission in schizophrenia: confirmation in a second 18:82–83. Schizophrenia is associated receptor occupancy of olanzapine in schizophrenia: a PET inves- with elevated amphetamine-induced synaptic dopamine con- tigation. D2 dopamine receptor blockade and clinical response: a 123I 126. Increased base- IBZM SPET (single photon emission tomography) study. Psy- line occupancy of D2 receptors by dopamine in schizophrenia. Quantification of neuro- pancy in clozapine treated patients demonstrated by PET. Irreversible binding of chopharmacology (Berl) 1993;110:365–367. Psychotic propensity associated with four- pancy profile of loxapine determined using PET. Neuropsycho- fold elevated dopamine binding to D2-like receptors in caudate pharmacology 1996;15:562–566. Cerebral metabolite abnor- D2 receptor occupancy and plasma levels on low dose oral halo- malities correlate with clinical severity of HIV-1 cognitive motor peridol: a PET study. Brain elimination half-life levels and clinical effects in schizophrenia and schizoaffective of fluvoxamine measured by 19F magnetic resonance spectros- disorder. Brain pharmacokinetics D2 receptor occupancy with low-dose haloperidol treatment: a and tissue distribution in vivo of fluvoxamine and fluoxetine PET study [see comments]. Life Sci 1995;57: tion of the cerebral distribution of general anesthetics in vivo L103–L107. Neurol- optical imaging of protease activity for tumor detection. Neurology 2000;54: of gene expression using magnetic resonance imaging. Fluorescently detect- techniques in multiple sclerosis: clinical applications and clues able magnetic resonance imaging agents. A 'smart' magnetic resonance MR histograms differ between MS subtypes. Neurology 2000; imaging agent that reports on specific enzymatic activity. Imaging brain structure and function, resonance imaging in multiple sclerosis: correlation with attacks, infection and gene expression in the body using light. Nat Med 2000;6: disease in late onset families [see comments]. Magn Reson Med 2000;43: changes in MRI brain volumes in older adults. Free radical generation in human endothelial cells 137. Acute effects of cocaine exposed to anoxia and reoxygenation. Transplant Proc 1998;30: on human brain activity and emotion. Visualizing gene oxide synthesis in biological systems. Biochim Biophys Acta 1999; expression in living mammals using a bioluminescent reporter. Use of reporter genes lial nitric oxide synthase in nitric oxide generation in the brain for optical measurements of neoplastic disease in vivo. The appearance of psychotic symptoms in childhood, albeit symptoms, it is now certain that children, like adults, can rare, is an important clinical entity. This importance extends and do experience psychoses (i. Children and adolescents experience the same our understanding of the principal psychotic conditions. They The term psychosis is generally categoric and includes can lose the connections between their thoughts (formal subgroups within it. It is clear that the peak onset of the thought disorder) and have perceptions without external most common psychotic disorders, schizophrenia and bipo- stimuli (hallucinations). The term psychosis as described by lar disorder, is in adolescence (1,2). This points directly McHugh and Slavney (3) is intended simply to indicate toward developmental events in biological, social, and psy- that mental life has been disrupted in its capacities or forms, chological domains of late childhood and adolescence that as a result of a process that generates new forms of psycho- set the stage for activating psychotic disorders. Modern psychiatry eschews the mis- chotic disorders. Delusions and interplay between environmental and biological forces is at hallucinations are considered to be positive psychotic symp- work across the spectrum of these conditions. Delusions are fixed, false, idiosyncratic beliefs that the trist who must determine whether a young patient suffers child cannot be deterred from, with logical reasoning, from a psychotic disorder faces a challenging array of possi- whereas hallucinations are percepts that arise in the absence bilities, more extensive than when the patient is an adult. Psychotic symptoms always The influences of development, environment, and cogni- encompass a broad range of conditions, but it is particularly tion are greater for young or developmentally immature so when they appear in children and adolescents. Nonbiological events are clearly symptoms in children present distinctive diagnostic and more influential because, in most respects, children are more clinical challenges because of the powerful influences of im- vulnerable to their surroundings. Immaturity makes chil- maturity and the moving target produced by development. Children routinely have intrusions of fan- about whether children are capable of having psychotic tasy into ordinary mental life; determining when this becomes pathologic can be a matter of degree. Children learn and experiment with imitation, and they can acquire habits and strategies used by those around them. Towbin: Complex Developmental Disorders Clinic, De- ner. When one examines a 5-year old child who claims hood psychoses. Nevertheless, there came an acknowledg- that he is 'superman and can fly,' the challenge is to deter- ment and new awareness of major developmental differences mine whether the child has a delusion.
However quality simvastatin 10 mg cholesterol in eggs nutrition facts, photocopies for commercial gain are not permitted best 10 mg simvastatin cholesterol ratio target. It will be continuously updated and improved order generic simvastatin pills quick cholesterol lowering foods, in both content and useability. Readers are encouraged to contact the author regarding typographical or factual errors, issues of disagreement, further suggested topics, or other matters. I am greatly indebted to Désirée Fritsch for translating two chapters into French, Dr Ilaria for translating a chapter into Italian and Assoc Prof Petar Marinov for translating two chapters into Bulgarian. Saxby Pridmore MD, AM Discipline of Psychiatry University of Tasmania S. RR-12 Sexually Transmitted Diseases Treatment Guidelines, 2010 department of health and human services Centers for Disease Control and Prevention MMWR ConTEnTS Te MMWR series of publications is published by the Ofce of Surveillance, Epidemiology, and Laboratory Services, Centers for Introduction.............................................................................. Casey, MD Management of Persons Who Have a History of Penicillin Allergy. King Cervical Cancer Screening for Women Who Attend STD Clinics Information Technology Specialists or Have a History of STDs....................................................... Roper, MD, MPH, Chapel Hill, NC, Chairman Hepatitis B........................................................................... Caine, MD, Indianapolis, IN Proctitis, Proctocolitis, and Enteritis........................................... Fielding, MD, MPH, MBA, Los Angeles, CA Ectoparasitic Infections............................................................. Holmes, MD, PhD, Seattle, WA Sexual Assault and STDs.......................................................... Iglehart, Bethesda, MD Terms and Abbreviations Used in This Report.......................... Maki, MD, Madison, WI Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Rullan, MD, MPH, San Juan, PR William Schafner, MD, Nashville, TN Anne Schuchat, MD, Atlanta, GA Dixie E. Workowski, MD1,2 Stuart Berman, MD1 1Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 2Emory University, Atlanta, Georgia Summary Tese guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the feld of STDs who met in Atlanta on April 18–30, 2009. Te information in this report updates the 2006 Guidelines for Treatment of Sexually Transmitted Diseases (MMWR 2006;55[No. Included in these updated guidelines is new information regarding 1) the expanded diagnostic evaluation for cervicitis and trichomoniasis; 2) new treatment recommendations for bacterial vaginosis and genital warts; 3) the clinical efcacy of azithromycin for chlamydial infections in pregnancy; 4) the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; 5) lymphogranuloma venereum proctocolitis among men who have sex with men; 6) the criteria for spinal fuid examination to evaluate for neurosyphilis; 7) the emergence of azithromycin-resistant Treponema pallidum; 8) the increasing prevalence of antimicrobial-resistant Neisseria gonorrhoeae; 9) the sexual transmission of hepatitis C; 10) diagnostic evaluation after sexual assault; and 11) STD prevention approaches. Introduction Methods Te term sexually transmitted diseases (STDs) is used to These guidelines were developed using a multistage refer to a variety of clinical syndromes caused by pathogens process. Beginning in 2008, CDC staf members and public that can be acquired and transmitted through sexual activity. Although articles), focusing on the common STDs and information that these guidelines emphasize treatment, prevention strategies and had become available since publication of the 2006 Guidelines diagnostic recommendations also are discussed. CDC staf Tese recommendations should be regarded as a source of members and STD experts developed background papers and clinical guidance and not prescriptive standards; health-care tables of evidence that summarized the type of study (e. CDC staf then developed a draft nizations, and other primary-care facilities. Tese guidelines document on the basis of this evidence-based review. In April focus on the treatment and counseling of individual patients 2009, this information was presented at a meeting of invited and do not address other community services and interven- consultants (including public- and private-sector professionals tions that are essential to STD/human immunodefciency virus knowledgeable in the treatment of patients with STDs), where (HIV) prevention eforts. Specifcally, participants identifed key questions regarding STD treatment that emerged from the literature reviews and Corresponding Author: Kimberly Workowski, MD, Division of discussed the information available to answer those ques- STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, tions. Discussion focused on four principal outcomes of STD STD, and TB Prevention, 10 Corporate Square, Corporate Square Blvd, MS E02, Atlanta, GA 30333. Telephone: 404-639-1898; therapy for each individual disease: 1) treatment of infection Fax: 404-639-8610; kgw2@cdc. Health-care of specifc regimens also were discussed. Te consultants then providers have a unique opportunity to provide education and assessed whether the questions identifed were relevant, ranked counseling to their patients (5,6). As part of the clinical inter- them in order of priority, and answered the questions using view, health-care providers should routinely and regularly obtain the available evidence. In addition, the consultants evaluated sexual histories from their patients and address management of the quality of evidence supporting the answers on the basis of risk reduction as indicated in this report. Guidance in obtain- the number, type, and quality of the studies. Efective interviewing and counseling skills, Practices (ACIP) (2–4). The recommendations for STD characterized by respect, compassion, and a nonjudgmental screening during pregnancy and cervical cancer screening attitude toward all patients, are essential to obtaining a thorough were developed after CDC staff reviewed the published sexual history and to delivering prevention messages efectively. How in background papers that will be published in a supplement is it for you? When more history is an example of an efective strategy for eliciting infor- than one therapeutic regimen is recommended, the sequence is mation concerning fve key areas of interest (Box 1). For those infections with regardless of individual circumstances (e. Patients seeking treatment or screening for a particular unless otherwise specifed. Recommended regimens should STD should be evaluated for all common STDs. All patients be used primarily; alternative regimens can be considered in should be informed about all the STDs for which they are being instances of signifcant drug allergy or other contraindications tested and notifed about tests for common STDs (e. STD/HIV Prevention Counseling Clinical Prevention Guidance USPSTF recommends high-intensity behavioral counseling Te prevention and control of STDs are based on the for all sexually active adolescents and for adults at increased following fve major strategies: risk for STDs and HIV (5,6). All providers should routinely • education and counseling of persons at risk on ways to obtain a sexual history from their patients and encourage risk- avoid STDs through changes in sexual behaviors and use reduction using various strategies; efective delivery of prevention of recommended prevention services; messages requires that providers communicate general risk- • identifcation of asymptomatically infected persons and reduction messages relevant to the client and that providers of symptomatic persons unlikely to seek diagnostic and educate the client about specifc actions that can reduce the treatment services; risk for STD/HIV transmission (e. One such approach, known as client- • “Do you have sex with men, women, or both? One such approach, • “Is it possible that any of your sex partners in the known as Project RESPECT, demonstrated that a brief counsel- past 12 months had sex with someone else while ing intervention led to a reduced frequency of STD/HIV risk- they were still in a sexual relationship with you? Prevention of pregnancy curable STDs, including trichomoniasis, chlamydia, gonorrhea, • “What are you doing to prevent pregnancy? Protection from STDs have been successfully implemented in clinic-based settings. Practices information on these and other efective behavioral interventions • “To understand your risks for STDs, I need at http://efectiveinterventions. Training in client-centered counseling • If “sometimes:” “In what situations (or with whom) is available through the CDC STD/HIV Prevention Training do you not use condoms?