Analysis of possible sexual assault or abuse in a 67-year-old female with early dementia post-brain attack.

The case analysis explores an emergency department visit by a 67-year-old female with early dementia post-brain attack, with complaints of possible sexual assault or abuse. This patient resides in a long-term skilled nursing facility. The case outlines the forensic care provided by the Advanced Practice Forensic Nurse (APFN) once medically cleared by the emergency department Advanced Practice Nurse (APN). The case discussion includes issues related to sexuality in aging populations, consent, sexual abuse or assault in institutions, and forensic care of older persons. Expected genital injuries in older women that result from sexual assault and abuse are also explored. The case discussion will analyze the key elements for critical thinking and clinical reasoning and demonstrate standards of care for the APFN and APN practice.

Correlates of hepatitis B virus and HIV knowledge among gay and bisexual homeless young adults in Hollywood.

Homeless gay and bisexual (G/B) young men have multiple risk factors that increase their risk of contracting hepatitis B virus (HBV) and human immunodeficiency virus (HIV). This study used baseline information from structured instruments to assess correlates of knowledge to HIV and HBV infection from 267 young (18-39 year old) G/B active methamphetamine, cocaine, and crack-using homeless men enrolled in a longitudinal trial. The study is designed to reduce drug use and improve knowledge of hepatitis and HIV/AIDS in a community center in Hollywood, California. Regression modeling revealed that previous hepatitis education delivered to G/B men was associated with higher levels of HIV/AIDS and hepatitis knowledge. Moreover, higher HIV/AIDS knowledge was associated with combining sex and drinking alcohol. Associations with hepatitis B knowledge was found among G/B men who were engaging in sex while under the influence of marijuana, who were receiving support from non-drug users, and who had been homeless in the last 4 months. Although being informed about HIV/AIDS and hepatitis did not preclude risky sexual and drug use behavior, knowledge about the dangers of concurrent sex with substance use is important. As higher levels of knowledge of hepatitis was associated with more moderate drug use, early access to testing and teaching harm reduction strategies remain critical to reduce exposure and infection of HBV and HIV in this population.

Impact of nursing intervention on improving HIV, hepatitis knowledge and mental health among homeless young adults.

In a prospective two-group pilot study of a convenient sample of 156 young adults, we assessed improvement in HIV cognitive and transmission knowledge, hepatitis knowledge, and mental health at six-month follow-up. Multiple linear regression analysis revealed higher six-month scores in total HIV/AIDS knowledge, HIV/AIDS cognitive knowledge, HIV transmission knowledge and HBV and HCV knowledge at 6 months in the Hepatitis Health Promotion (HHP) group compared to the Art Messaging (AM) group. Moreover, homeless young participants who reported having significant others in their lives, and excellent or very good health did better than their counterparts. Youth who were attempting to get their lives together had higher scores for all types of knowledge except HBV. Hallucinogen users had significantly worse scores on all knowledge measures than non-users. Lastly, the HHP group revealed an improvement in psychological well-being compared to the AM group.

Impact of nursing intervention on decreasing substances among homeless youth.

BACKGROUND: Alcohol use, and in particular, binge drinking, and methamphetamine use is pervasive among homeless youth and remains a social pressure among this vulnerable population. However, there is no compelling evidence that specific interventions for reducing drug and alcohol use are effective for homeless youth. OBJECTIVES: This community-based participatory action pilot study assessed the impact of an intervention study focused on decreasing use of drugs and alcohol among a sample of homeless young adults (N= 154) visiting a drop-in site in Santa Monica, California. The two programs consisted of an HIV/AIDS and Hepatitis Health Promotion (HHP) program led by nurses and an Art Messaging (AM) program led by artists. Six-month follow-up data were obtained from 100 of these individuals. RESULTS: Findings revealed significant reductions in alcohol and marijuana use and binge drinking in both the HHP and AM programs. However, homeless youth in the HHP program reported additional reductions in methamphetamine, cocaine, and hallucinogen use at 6-month follow-up. CONCLUSIONS: Reductions in drugs and alcohol are important as these substances are linked to HIV/AIDS, hepatitis, and other health risks in homeless youth. SCIENTIFIC SIGNIFICANCE: The successful outcomes of the study intervention validate the utility of nurse-led and artistic health promotion strategies to decrease drug and alcohol use and other risky behaviors in homeless youth populations.

Recognizing and treating Adult ADHD.

Many adults with attention deficit/hyperactivity disorder are undiagnosed. Nurse practitioners should understand the etiology, screening, assessment, diagnosis, and treatment of ADHD in adults.

Study protocol: Phase III single-blinded fast-track pragmatic randomised controlled trial of a complex intervention for breathlessness in advanced disease.

BACKGROUND: Breathlessness in advanced disease causes significant distress to patients and carers and presents management challenges to health care professionals. The Breathlessness Intervention Service (BIS) seeks to improve the care of breathless patients with advanced disease (regardless of cause) through the use of evidence-based practice and working with other healthcare providers. BIS delivers a complex intervention (of non-pharmacological and pharmacological treatments) via a multi-professional team. BIS is being continuously developed and its impact evaluated using the MRC's framework for complex interventions (PreClinical, Phase I and Phase II completed). This paper presents the protocol for Phase III. METHODS/DESIGN: Phase III comprises a pragmatic, fast-track, single-blind randomised controlled trial of BIS versus standard care. Due to differing disease trajectories, the service uses two broad service models: one for patients with malignant disease (intervention delivered over two weeks) and one for patients with non-malignant disease (intervention delivered over four weeks). The Phase III trial therefore consists of two sub-protocols: one for patients with malignant conditions (four week protocol) and one for patients with non-malignant conditions (eight week protocol). Mixed method interviews are conducted with patients and their lay carers at three to five measurement points depending on randomisation and sub-protocol. Qualitative interviews are conducted with referring and non-referring health care professionals (malignant disease protocol only). The primary outcome measure is 'patient distress due to breathlessness' measured on a numerical rating scale (0-10). The trial includes economic evaluation. Analysis will be on an intention to treat basis. DISCUSSION: This is the first evaluation of a breathlessness intervention for advanced disease to have followed the MRC framework and one of the first palliative care trials to use fast track methodology and single-blinding. The results will provide evidence of the clinical and cost-effectiveness of the service, informing its longer term development and implementation of the model in other centres nationally and internationally. It adds to methodological developments in palliative care research where complex interventions are common but evidence sparse. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00678405ISRCTN: ISRCTN04119516.

Truths and myths that influence the sexual decision-making process among young multiethnic college women.

In the United States, half of all new human immunodeficiency virus (HIV) cases are among 13- to 24-year-old women. Heterosexual contact is the primary route of transmission (73%). Young African Americans account for 56% of reported HIV cases. In an earlier study, S. T. Roberts and B. L. Kennedy (2006) studied sexual decision making among 100 young multiethnic college women (YMCW). Participants reported high condom use intention (84%) but inconsistent condom use (64%). Participants perceived their risk of acquiring HIV and sexually transmitted diseases (STDs) as low; however, their actual risk was assessed as high. YMCW reported that alcohol and drugs impaired their judgment to practice safer sex. The YMCW concurrently reported that alcohol and drugs were a routine part of their sexual experiences. The current study examined a group of YMCW to elucidate the reasons that the knowledge of safer-sex practices was not put into practice. The authors sought insight into the lived experiences of YMCW's sexual behavioral choices. The qualitative study recruited 15 participants. Focus groups were conducted, and quantitative HIV and STD knowledge questionnaires were administered. The YMCW verbalized high knowledge of HIV, STDs, and safer-sex practices. The questionnaire scores evidenced significant knowledge deficit in these same categories. Themes emerged from the narrative date. Two beliefs or myths explained why women engaged in sex without a condom. The first belief was that YMCW were not in control of their sexual behavior when "being in the moment." The second belief was "not remembering what happened" secondary to alcohol use. The women reported that the myths were culturally accepted in their peer group; however, the YMCW knew that the myths were untrue. The YMCW expressed a strong desire for someone to teach them "real information" on sexuality as this information was missing in their health education courses.

Medical school selection: impact of dysfunctional tendencies on academic performance.

PURPOSE: Dysfunctional personality characteristics have a negative impact on the learning process, academic motivation, academic grades and course attendance. They are associated with higher levels of anxiety and negative mood before examinations, a lack of self-confidence and fear of failure, social skills deficits, and personal and social relationship problems. Dysfunctional personality characteristics inhibit interpersonal working relationships and are detrimental to team effectiveness. Previous research revealed that the majority of students selected into an Australian undergraduate medical programme via the process of academic merit, application and interview reported elevated levels of dysfunctional personality characteristics. Our research now identifies those patterns of dysfunctional behaviour that impacted on academic grades over the first 3 years of the medical programme. METHODS: Dysfunctional personality characteristics in a sample of Australian undergraduate medical students were assessed with the Hogan Development Survey (HDS). The scores of 139 students were then correlated with their end-of-year examination marks for each of the first 3 years of medical training, and their average grade. RESULTS: Pearson's bivariate correlation analysis revealed that there were a number of significant negative relationships between academic grades and the HDS syndromes of Away and Against. There were significant positive relationships between academic grades and the HDS syndrome of Diligent. CONCLUSIONS: To enrol and teach students who fail to graduate, need to repeat, choose not to pursue a career in medicine upon graduation, or become inefficient practitioners is costly. A measure of dysfunctional behaviour has the potential to predict academic performance and improve the cost-effectiveness of medical education.

Medical school selection: Screening for dysfunctional tendencies.

AIM: One of the aims of medical selection is to deselect students who have personal characteristics that would impact negatively on their ability to interact with patients, supervisors and peers and impede their ability to cope with the stress of medical training. The arduous requirements of the formal curriculum, the customs and rituals of the socialisation process and the mistreatment and abuse reportedly experienced by students all contribute to stress, mental illness, suicide, lowered self-confidence in clinical ability, decreased ability to learn and alcohol and substance abuse. There has been little research on the effectiveness of the selection interview in deselecting students with negative personal characteristics. Our research profiles the dysfunctional interpersonal tendencies of students already selected into a medical programme through the process of academic merit, application and interview. METHODS: During 2001 and 2002, 159 students enrolled in an Australian undergraduate medical programme completed the Hogan Development Survey (HDS), which is a self-report measure of dysfunctional personality characteristics that inhibit the development of working relationships with others. RESULTS: The HDS identified negative personality characteristics in medical students that were not detected in the selection interview. CONCLUSIONS: The presence of patterns of dysfunctional behaviour in medical training has implications for the selection, teaching and pastoral care of medical students. The HDS has the potential to identify negative personal characteristics that are hard to detect during a selection interview, and may be a valuable adjunct to the interview.

Why are young college women not using condoms? Their perceived risk, drug use, and developmental vulnerability may provide important clues to sexual risk.

BACKGROUND: Young multiethnic college women (YMCW) are at risk for STDs and HIV secondary to high-risk sexual behaviors that are related to developmental issues such as invincibility, low perceived risk, and substance use. METHOD: One hundred YMCW on a southern California university campus completed surveys that examined variables that impacted their sexual risk. RESULTS: The study yielded many significantly correlated variables. Women with low perceived risk, lower use of drugs and alcohol, and who had parental involvement had lower sexual behavior risk. Women that were sexually assertive, had intentions to use condoms, and did not use substances used condoms more often. Older students in advanced grades who had steady partners used substances less and had decreased sexual risk, however, they experienced partner resistance to condoms, which canceled out any reduced risk. In a multiple regression analysis, condom use intention and substance use predicted condom use, perceived risk and substance use predicted sexual behavior risk. White women had significantly higher substance use, perceived sexual risk, and sexual behavior risk than did Latinas and African Americans. CONCLUSIONS: Despite their assertiveness and intentions, many participants had multiple sexual partners, and 64% of the YMCW were inconsistent condom users. Despite knowing the elevated risks, 52% used drugs and alcohol during sex. Negative attitudes (61%) about condoms were also demonstrated as a key factor in the lack of condom use.

Changes in neural circuitry of language before and after treatment of major depression.

Language tasks requiring semantic analysis of word meaning activate distinct brain areas including the anterior cingulate gyrus at about 200 msec after the stimulus onset, the left lateral prefrontal cortex at about 250 msec, and the left temporo-parietal (Wernicke's) area at 500-600 msec. Reading the same words activate the insula around 800 msec and left occipital cortex around 200 msec stronger than the semantic analysis in normal subjects. Many of these brain areas also show abnormal activity in resting state in patients with major unipolar depression. We measured 128-channel event-related brain potentials (ERPs) and statistical probability mapping in the use generation task carried out with single visual nouns to explore the topography and time course of these cortical activations related to semantic processing in 11 patients with major unipolar depression before and 8 weeks after treatment with the selective serotonin reuptake inhibitor (SSRI) citalopram. Before treatment in depressed state, the time course for the left prefrontal cortex activation did not show slowing, but was accompanied by the right prefrontal activation with a similar time course. The left posterior temporo-parietal activation appeared later than in normals. Treatment was accompanied by the complete elimination of the right prefrontal activation in the same use generation task. Time course of the posterior left temporo-parietal area showed a trend toward normalization. Insula-related activation in reading task was not seen in depressed state, but was evident in the same patient group after the depression has lifted, presumably as a result of treatment with citalopram.

Post-Traumatic Stress Disorder in subjects with schizophrenia and bipolar disorder.

The purpose of this study was to identify subjects with Post-traumatic Stress Disorder (PTSD) consequent to hallucinations and delusions and the experiences related to psychosis in schizophrenic and bipolar subjects. Schizophrenic and bipolar subjects were given questionnaires in order to evaluate PTSD incidence and symptoms. Subjects with classical types of trauma were excluded. Depression and stress scales were also answered. About one-third of schizophrenic subjects and one-half of bipolar subjects met PTSD criteria on the Penn PTSD Inventory. Hallucinations and delusions were identified as traumatic events in 60% of subjects with schizophrenia, but in only 15% of the subjects with bipolar disorder. Also, childhood abuse and various present stressors may contribute to the current PTSD symptomatology. Increases in PTSD scale scores were paralleled by increases in Beck depression scale scores. This study underscores the need for mental health clinicians to be sensitive to patients' illness experiences and to be aware of the therapeutic implications in treating PTSD in subjects with schizophrenia and bipolar illnesses.

Allergy in panic disorder patients: a preliminary report(1).

In this study of panic disorder patients, 71.8% were found to have allergies. Compared to the nonallergic subjects, the allergic subjects had more full-blown situational panic attacks and significantly higher scores on 7 of the 14 symptoms in the Hamilton Anxiety Scale. More subjects in the allergic group had comorbid anxiety disorders, but only the number with specific phobias was significantly higher than for the nonallergic. These results are discussed in terms of our present theories of panic disorder.

Work, social, and family disabilities of subjects with anxiety and depression.

BACKGROUND: Functional impairment scales are increasingly used to evaluate subjects with a variety of mental disorders. METHODS: We evaluated the work, social, and family disabilities of 228 subjects with 6 common anxiety and depressive disorders, as assessed by the Sheehan Disability Scale (major depression, panic disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, and mixed anxiety and depression). RESULTS: Subjects in the 6 diagnostic groups had significantly higher work, social, and family disability scores than control subjects, with the exception of the social phobia and panic disorder subjects' scores for family disability. Those with depressive disorders tended to have significantly higher family disability scores than the anxiety disorder subjects. CONCLUSION: Subjects with both anxiety and depressive disorders from primary care clinics and from chronic psychiatric and medical populations need further evaluation and treatment of the disabilities to decrease the personal, family, and economic burdens of these disorders.