Integrated health care and the advanced practice nurse.

As state-designed Medicaid reforms are enacted and commercial insurance carriers begin to manage care, advanced practice nurses (APNs) must be ready to aggressively pursue opportunities for clinical participation. Understanding the contractual obligations of becoming a provider, as well as adopting strategies for successful participation in these emerging integrated networks, will be critical for APNs. Successful contracting requires a carefully defined set of practice activities and a willingness to become a team player in a complex organization.

Incest revisited: delayed post-traumatic stress disorder in mothers following the sexual abuse of their children.

The case histories of four women who developed symptoms of post-traumatic stress disorder following the disclosure of the sexual abuse of their daughters are presented. These individuals also exhibited comorbid symptoms of depression and personality disorders. Awareness of the sexual abuse of their daughters catalyzed a reliving of their own childhood victimization. The psychodynamics operating in these cases, as well as treatment strategies are also presented. A brief follow-up of three of the four cases is included.

Negotiating capitated rates for nurse-managed clinics.

Successful negotiation of capitated rates will dictate whether nurse-managed clinics will survive the financial restructuring of the health care industry. It requires a clear understanding of what the clinic is contracted to do and an ability to teach a managed-care company what the services are worth.

Comparing child victims and adult survivors: clues to the pathogenesis of child sexual abuse.

Sexual abuse consists of two discrete traumatic elements; the repeated infliction of sexual assault that is superimposed on a chronic background of pathological family interaction, including betrayal, stigmatization, role reversal, and violation of personal boundaries. The acute episodes of sexual assault may be overwhelming to the child and result in anxiety-related symptoms, including PTSD. The long-standing family dysfunction leads to a pathological defensive organization that becomes woven into the victim's personality structure, resulting in long-term characterological changes. As the sexually abused child progresses through adolescence into adulthood, and the immediacy of his or her victimization recedes to the background, the acute posttraumatic anxiety symptoms are gradually replaced by more enduring symptoms and characterological defenses. Traumatic memories of the abuse become repressed or dissociated from consciousness. Identifications, attitudes, and affects derived from the abusive environment are usually organized around victimization experiences, leading to identifications with the aggressor or victim, which contribute to sadomasochistic object relationships and problems with the regulation of sexual behavior. The repressed or dissociated traumatic memories of sexual abuse carry the potential for producing future psychopathology through displacement in the form of conversion symptoms or somatization, and by generating delayed PTSD when these memories are elicited by current experiences. Anxiety and depression triggered by the emergence of these traumatic memories often lead to alcohol and drug abuse. These substances may be used for their anxiolytic and antidepressant effects.

Psychiatric impairment and childhood victimization experiences in female child molesters.

OBJECTIVE: To assess psychiatric impairment and childhood victimization experiences in female child molesters. METHOD: Eleven incarcerated female child molesters were compared to 11 women imprisoned for nonsexual offenses as to their psychiatric diagnoses based on interviews with the Structured Clinical Interview for DSM-III-R, Outpatient Version (SCID-OP), the SCID II for Personality Disorders, and the Harvard-Upjohn Post-Traumatic Stress Disorder (PTSD) Interview. A family and sexual history with a description of childhood victimization experiences was also obtained by using the Wyatt Sexual History Questionnaire. RESULTS: The majority of the subjects in each group exhibited major depression, alcohol/substance abuse, and PTSD, but the sexual offenders demonstrated more psychiatric impairment on the Global Assessment of Functioning Scale on the SCID-OP. The sexual offenders demonstrated a higher incidence of childhood physical and sexual abuse within the family than the comparison group, and these victimization experiences were more severe and more frequently associated with PTSD. The sexual offenders and the comparison women described negative relationships with parents and caretakers, and with spouses or boyfriends. However, the sexual offenders perceived their parents as more abusive, while the comparison women regarded their parents as more neglecting. CONCLUSIONS: Incarcerated female child molesters exhibited greater psychiatric impairment and more intrafamilial physical and sexual abuse than a comparison group of women imprisoned for nonsexual offenses.

Child sexual abuse: immediate and long-term effects and intervention.

OBJECTIVE: The primary purpose of this review is to highlight the progress made in the area of child sexual abuse during the recent decade and to identify the gaps in our current knowledge about this syndrome. METHOD: More than 100 articles on child sexual abuse were reviewed, the majority written from 1980 to the present concerning the demographics of child sexual abuse, the psychological effects of child sexual victimization, the psychopathology encountered in adult survivors of child sexual abuse, hypotheses regarding the nature of the trauma, a critique of the research, and approaches to intervention. RESULTS: Although a wide variety of psychological sequelae have been documented in sexually abused children referred for evaluation or treatment, there appears to be considerable variability in the severity of the symptoms, and we remain ignorant of sequelae in abused children who never enter the mental health system. However, some of these children may become symptomatic in adult life. Validation of sexual abuse is hampered by the lack of specific behavioral markers. Methodological difficulties in child sexual abuse research include problems with definition, failure to measure severity of the abuse, sampling problems, failure to use standardized or appropriate instruments, problems with validation, and failure to use control groups. CONCLUSIONS: Despite an increased focus on child sexual abuse in the recent decade, many gaps remain in our knowledge. Prospective longitudinal follow-up studies of sexually abused children and treatment outcome studies are urgently needed.

Calcaneal osteotomy for retrocalcaneal exostosis.

In cases in which radiographic and clinical criteria warrant surgical management of Haglund's deformity, calcaneal osteotomy should be considered. Although postoperative recuperation is extended with this procedure as compared with simple exostectomy, the long-term results have proved more successful. Because of the relative technical difficulty in performing the procedure, perioperative planning and anatomic considerations are essential.

Child maltreatment and its victims. A comparison of physical and sexual abuse.

Although physical and sexual abuse are separate and distinct types of victimization, their impact on children is quite similar. Both of these forms of maltreatment involve the exploitation or misuse of a child by a parent or caretaker in the context of a pathologic family system. Physical and sexual abuse constitute an acute traumatic event for the child, generating phobic responses and anxiety-related symptoms including post-traumatic stress disorder. The long-term traumatic elements stemming from the chronic stigmatization and scapegoating contribute to problems of depression and low self-esteem and distortions in character formation. Betrayal by a primary caretaker leads to mistrust of others and difficulties with object relationships. Perhaps the most striking similarity between physical and sexual abuse of children is the tendency of the children to re-enact and recreate their victimization with others, leading to a transmission of violence in the next generation. Like their parents who were frequently victimized during childhood, they repeat and perpetuate an "aggressor-victim" interaction in their subsequent relationships. Both physical and sexual abuse are embedded in a deviant family structure, which adds to the psychopathology of the children. The contrast between physical and sexual abuse can be demonstrated by their specific impact on aggression and sexuality, respectively. The physically abused child has difficulty in experiencing and modulating aggressive impulses, whereas the victim of incest is often impaired in his ability to experience and integrate sexual feelings. The physically abused child is also at greater risk for cognitive and CNS impairment. Intervention with the abusing parents is the first step in protecting the children from further damage, but treatment of the child victims is necessary not only to diminish their psychopathology and emotional distress, but to prevent the cycle of violence in the next generation.

Identifying correlates of reabuse in maltreating parents.

Forty-five abusive parents (40 mothers, 5 fathers) in treatment at a large, urban medical center's child abuse program were compared on 22 parent, child, and treatment variables posited to bear on reabuse. While no one variable by itself was strongly associated with reabuse, the data indicated that interactions involving several variables (e.g., income source, marital status, and the abuser's personal abuse history) significantly differentiated between reabusers and nonreabusers. Implications of the findings for research and clinical intervention are discussed.

Biochemistry of protein-isocyanate interactions: a comparison of the effects of aryl vs. alkyl isocyanates.

In addition to their use in the polyurethane and pesticide industries, isocyanates have proven to be useful probes for the exploration of protein structure. This paper focuses on three aspects of isocyanates: their broad reactivity, their reversible interaction with cholinesterases, and the relative hydrolysis rates of alkyl and aryl isocyanates. The broad reactivity of isocyanates as well as the demonstrated affinity labeling of serine and sulfhydryl esterases are discussed. Extension of the affinity labeling studies to include the analysis of the inhibition of cholinesterases by methyl isocyanate shows that methyl isocyanate is not an effective inhibitor of any of the cholinesterases. The inhibition of cholinesterases by alkyl isocyanates shows a pattern of decreased specificity with decreased alkyl chain length. The inhibition of cholinesterases by isocyanates is shown to be reversible, with a maximum rate of reversal seen at physiological pH. This reversal is characteristic of the reaction of an isocyanate with a sulfhydryl group. Finally, the affinity labeling of proteins must compete successfully with the hydrolysis of isocyanates in aqueous solution. The hydrolysis of alkyl isocyanates is shown to be significantly slower than that of the aryl isocyanates.

Akin osteotomy of the hallux proximal phalanx utilizing Richards mini staple fixation.

The purpose of this manuscript is to describe an effective alternative form of internal fixation after Akin-type osteotomies of the first proximal phalanx, when surgically correcting hallux valgus in patients who exhibit a structural deformity. Intraoperative technique, postoperative management, potential complications, and a review of alternative fixation modalities are described.

Child abuse by siblings.

The case histories of five children who inflicted serious injuries on their younger siblings are described in detail. The children shared several experiences in common: They had been physically abused themselves; their families were undergoing crises, which accentuated their maternal deprivation and rejection; they were burdened with excessive caretaking for the target sibling, who was perceived as the favorite; they had also experienced the recent loss of their father or paternal caretaker. The psychodynamics associated with sibling abuse represented an intensification of "normal" sibling rivalry due to the abuser's own maltreatment and deprivation. Pent-up rage towards the mother was displaced onto the sibling rival. The abusers made use of identification with the aggressor as a prominent mechanism of defense. The sibling attacks were adaptive for the abusers in the following ways: (a) They afforded them a measure of revenge against the more highly regarded sibling rival; (b) they served as an outlet for rage directed towards the mother; (c) they were used as an attention getting device; (d) they provided a sense of mastery over the trauma of their own abuse; and (e) were used to "educate" the abusing parent.