Nodular vasculitis (erythema induratum) associated with systemic minocycline.

A 29-year-old Caucasian woman presented with a 3-month history of bilateral lower limb swelling with painful erythematous nodules on shins without ulceration. She had been taking minocycline for acne vulgaris for 3 years. Biochemical investigations showed deranged liver function test with positive ANA and mixed antinuclear factor (ANF) pattern. A skin biopsy was in keeping with a diagnosis of nodular vasculitis. Her skin lesions and liver function test improved within 3 months of stopping the minocycline treatment. This case report raises the awareness that minocycline could be a potential cause of nodular vasculitis, patients on minocycline should be closely monitored and minocycline should ideally not be prescribed for more than 12 weeks, given the possible adverse effects.

Stigma, shame and family secrets as consequences of mental illness in previous generations: A micro-history approach.

In this article we evaluate micro-history as a method for investigating the meaning of stigma, shame and family secrets through generations. We present micro-histories of two Australian soldiers who developed mental illness years after serving in World War 1 and were committed to a psychiatric hospital where they died. Data were drawn from publicly available records and interviews with family members. The contrasting stories held by the families of each man illustrate the transmission of stigma and secrets through families. We explore possible reasons for the differences between the families related to the wider literature on stigma and mental health and show why the family stories people present should be considered social constructions rather than facts. We also address ethical issues that arose during the research, and which have relevance for researchers investigating sensitive or potentially stigmatising topics.

The Antibiotic Susceptibility Profile of Cutibacterium Acnes in Maltese Patients with Acne.

BACKGROUND: Antibiotics have been widely used for the management of acne vulgaris, which has led to increased resistance of Cutibacterium acnes (C. acnes). OBJECTIVES: We sought to determine the susceptibility profile of C. acnes, isolated from patients with acne, to different prescribed antibiotics and compare our findings with global data. The relationship between antibiotic resistance and sex, age, acne severity, presence of any affected siblings, disease duration, and previous antimicrobial treatment was also investigated. METHODS: Samples were collected from randomly selected pustular acne lesions of patients attending the Dermatology Outpatients Clinic at Sir Paul Boffa Hospital in Floriana, Malta. Samples were inoculated and incubated in anaerobic conditions until 100 cultured C. acnes samples were obtained. Antibiotic susceptibility testing was then performed using azithromycin, clindamycin, doxycycline, minocycline, tetracycline, and trimethoprim/sulfamethoxazole using the agar dilution method. RESULTS: The highest resistance was observed to azithromycin (18%) followed by clindamycin (16%). Resistance to doxycycline and tetracycline was only found in two percent of the isolates and there was no resistance to trimethoprim/sulfamethoxazole and minocycline. Resistance to azithromycin and clindamycin was associated with acne severity (p=0.01 and p=0.03). Resistance to clindamycin was also statistically significantly higher in patients with a history of antibiotic therapy or concurrent antibiotic therapy during the study (p=0.04). CONCLUSION: To our knowledge, this is the first study documenting the susceptibility of C. acnes isolates to different antibiotics in Malta. Future research is needed to determine the clinical significance of antibiotic resistance of C. acnes.

Gorlin-Goltz Syndrome: A Rare Syndrome Presenting as an Even Rarer de Novo Case with Numerous Features and Complications.

A 76-year-old woman with intellectual deficit presented with a small, pearly, telangiectatic raised lesion on the left cheek, together with an ulcerated lesion on the right side of the nose (Figure 1), which were clinically diagnosed as basal cell carcinomas (BCCs.) These were treated with cryotherapy. The patient had had a right hemimandibulectomy (Figure 1), and she showed frontal and temporal bossing and a wide nasal bridge.

Lessons from the past: Family involvement in patient admission and discharge, Beechworth Lunatic Asylum, 1900-1912.

In this study, document analysis is used to examine case books from the Beechworth Lunatic Asylum with the aim of determining the extent of family involvement in patients' admission and discharge. There were 420 male and 278 female patients admitted in the study period, with over half transferred from other Victorian asylums. Next of kin were identified for 64% of male and 84% of female patients. Families were involved in the admission of 52 (12%) male and 50 (18%) female patients, usually by bringing patients to the asylum or providing evidence of behavioural changes. Approximately 25% of patients were discharged (101 men and 62 women) and of these, families were involved in discharge for 26% of male and 71% of female patients, mainly by taking responsibility for them during trial discharge. Occasionally families refused to do this, or sought to have patients detained because of fears of violence. The relevance of the study to contemporary practice is explored, particularly the need for dialogue between clinicians and families who identify behavioural changes in family members, appropriate support for family carers, and timely provision of community care following discharge from inpatient facilities.

Chlorambucil-Induced Radiation Recall Dermatitis.

A 65-year-old woman was diagnosed with low-grade non-Hodgkin lymphoma (Figure 1). She was treated with six cycles of cyclophosphamide, hydroxydaunorubicin, oncovin (vincristine), and prednisolone (CHOP) and three cycles of fludarabine and mitoxantrone. Ten months later she received radiotherapy to the left groin (total dose of 50 Gy in 25 fractions over 5 weeks) without complications.

Views of young people with depression about family and significant other support: interpretative phenomenological analysis study.

Families and significant others have an important role in helping young people cope with depression, but lack of support undermines coping. In this paper, we present the views of young people with depression about the role of family and significant others in assisting them to cope with their illness. An interpretative phenomenological analysis study was undertaken using semistructured, audio-recorded interviews with 26 young people diagnosed with depression. The findings present two contrasting themes in the data, which reflect the young people's views about the influence of families and significant others in helping them cope with depression. The first, being supportive, highlighted how families and significant others helped through patience, tolerance, understanding, and encouragement; all of which strengthened young people's resilience as they attempted to cope with depression. The second theme, being unsupportive, showed how, in the young people's view, family conflict and change, and living in an unsupportive environment, compromised their ability to cope with depression. The findings suggest that mental health nurses, other clinicians, and primary care practitioners need to increase families' and significant others' understandings of depression and their capacity to support young people in these circumstances.

Primary caregivers' satisfaction with clinicians' response to them as informal carers of young people with first-episode psychosis: a qualitative study.

AIM: To explore first-time primary caregivers' experience of the way mental health nurses and other mental health clinicians respond to them as carers of young people with first-episode psychosis. BACKGROUND: Caregivers have a key role in supporting family members/relatives with mental illness, but their contribution is undervalued frequently by mental health nurses and other mental health clinicians. Design. Qualitative interpretative phenomenological analysis. METHOD: A qualitative interpretative design was undertaken, using semi-structured, audio-recorded interviews. Twenty primary caregivers were recruited through Orygen Youth Health, a first-episode psychosis centre in Melbourne. Interpretative phenomenological analysis was used to identify themes in the data. RESULTS: Two competing themes were identified in the data, highlighting caregivers' contrasting experience with mental health nurses and other mental health clinicians. First, most clinical staff were approachable and supportive. Second, several carers felt their contribution was undervalued by some clinical staff. This was as a consequence of being excluded from clinical deliberations because of clinical staffs' concerns and young people's requests about maintaining confidentiality regarding treatment, as well as carers feeling their role was not taken seriously by clinical staff. CONCLUSION: First-time primary carers have positive and negative experiences with first-episode psychosis mental health nurses and other clinicians, and these competing events are interrelated. Experiences are affected directly by the manner they are treated by clinical staff and this may, in turn, affect carers' commitment to caring, the way they engage with clinical staff on subsequent occasions and towards the first-episode psychosis service generally. RELEVANCE TO CLINICAL PRACTICE: Greater appreciation is needed of the contribution, experience and difficulties caregivers encounter in their role and in engaging with mental health nurses and other clinicians. Additional training is required for clinical staff in family interventions and to familiarise them with legislation and mental health policies relating to carers.

Mixed methods evaluation research for a mental health screening and referral clinical pathway.

RATIONALE: This study is an exemplar of mixed method evaluation research for development of a clinical pathway. AIM: To develop and evaluate an evidence-based, feasible mental health screening and referral clinical pathway for Department of Veterans' Affairs-funded community nursing care of war veterans and war widows in the Australian context. METHODS: Mixed methods were applied to formulate and clinically evaluate an appropriate pathway. The pathway was applied at urban and rural sites for the nursing care of 97 war veteran and war widow clients. Evaluative data were collected from clients, their informal carers, community nurses, and general practitioners. Chart auditing and pre-post measures were undertaken. Collaboration occurred with an interdisciplinary design team. RESULTS: The final modified six-page pathway includes use of validated screening tools (Kessler Psychological Distress Scale [K10]) and Alcohol Use Disorder Identification Test, appropriate referral information, directions for support and health-promoting education, and evidence-based guidelines. IMPLICATIONS FOR PRACTICE: The clinical pathway is a useful, tested, evidence-based guide for generalist community nurses to identify and suitably respond to common mental healthcare needs of war veterans and war widows. The pathway provides outcomes acceptable to clients and their carers, nurses and doctors. CONCLUSIONS: This study provides an evaluated clinical pathway for generalist community nurses to screen for mental health difficulties, make appropriate referrals as required and to support war veteran and war widow clients. However, the study also shows how research can be used to develop and evaluate practical, evidence-based clinical pathways.

Responding to stigma: first-time caregivers of young people with first-episode psychosis.

OBJECTIVE: This study explored how caregivers of young adults who had experienced a first episode of psychosis coped with stigma while maintaining their caregiving role. METHODS: Qualitative interviews were undertaken with 20 caregivers in Melbourne, Australia. RESULTS: Some caregivers adopted an open approach about disclosing their young person's illness. Alternatively, some were secretive about the illness, because of fears of and experiences with stigmatization if others found out. Caregivers also suggested ways to minimize the stigma that intensified their burden of care. CONCLUSIONS: The findings showed the kinds of roles that family members and others have in supporting caregivers. Caregivers who were secretive about their situation were particularly vulnerable to feeling burdened and needed additional support from clinicians. Caregivers need increased support to enable them to better cope with and respond to stigma.

First-time primary caregivers' experience of caring for young adults with first-episode psychosis.

Becoming a career is associated with physical, emotional, and financial hardship, with caregivers often experiencing a maelstrom of emotions as they struggle to understand what has happened to their loved one. While the burden of caring for young people with first-episode psychosis (FEP) has been well documented, much less is known about how carers develop the strength and resilience to continue caring. This qualitative study aimed to understand the experience of 20 first-time primary caregivers of young adults with FEP. Most caregivers were female (85%, n = 17) and parents (85%, n = 17). The average length of involvement as a caregiver at an FEP service was 14.5 months. Six main themes were identified in the data, highlighting the carers' experience in supporting young adults with FEP. Caregiving is a burdensome responsibility and is characterized as a roller coaster and unpredictable experience. Caregivers often feel responsible for the young person's illness; however, eventually most come to terms with the changes that have occurred in the young person with FEP. As a consequence of the illness, the relationship between caregiver and care recipient frequently becomes closer and deeper, although it is important that they both maintain hope for the future. These findings provide important insights into the experiences of first-time caregivers of young people with FEP, with direct implications for improving the information and support given to caregivers by FEP services, as well as the development of interventions that effectively address the unique challenges caregivers face following the onset of FEP.

An evaluation of a mental health screening and referral pathway for community nursing care: nurses' and general practitioners' perspectives.

AIMS AND OBJECTIVES: To evaluate a feasible, best practice mental health screening and referral clinical pathway for generalist community nursing care of war veterans and war widow(er)s in Australia. BACKGROUND: War veterans commonly experience mental health difficulties and do not always receive required treatment, as can also occur for war widow(er)s. Whenever opportunity arises, such as during community nursing care, it is vital to identify mental health problems in a health promotion framework. DESIGN: A clinical pathway was developed by literature review and consultation and then trialled and evaluated using mixed methods--quantitative and qualitative. METHODS: Community nurses who trialled the pathway completed an evaluation survey and attended focus groups. General practitioners responded to an evaluation survey. RESULTS: Most nurses found the pathway clear and easy to understand but not always easy to use. They emphasised the need to establish trust and rapport with clients prior to implementing the pathway. It was sometimes difficult to ensure effective referral to general practitioners for clients who screened positive for a mental health problem. When referral was accomplished, general practitioners reported adequate and useful information was provided. Some general practitioners also commented on the difficulty of achieving effective communication between general practitioners and nurses. CONCLUSIONS: Nurses and some general practitioners found the pathway useful for their practice. They offered several suggestions for improvement by simplifying the trialled pathway and accompanying guidelines and strategies to improve communication between nurses and general practitioners. This study adds understanding of how community nurses might productively screen for mental health difficulties. RELEVANCE TO CLINICAL PRACTICE: The trialled pathway, which was modified and refined following the study, is an evidence-based resource for community nurses in Australia and similar contexts to guide practise and maximise holistic care for war veterans and war widow(er)s and possibly other client groups.

Australian Bachelor of Midwifery students' mental health literacy: an exploratory study.

Many pregnant and post-partum women experience mental health problems, but midwives are frequently ill-equipped to provide support. The purpose of this study, conducted in Melbourne, Australia, was to examine first-year Bachelor of Midwifery students' mental health literacy about post-partum women with schizophrenia, using the vignette of "Mary". A non-probability sample of 38 commencing students was used. The results showed that the students had a mainly lay person-informed conceptualization of mental health interventions for post-partum women. They acknowledged that Mary had a mental health problem that might have a more favorable outcome with professional support, but this agreement did not extend to their understanding of the consequences of the failure to receive professional help. They believed that negative outcomes were less likely and positive outcomes were just as likely for Mary than for others in the community. The findings highlight the need for mental health theory and clinical subjects to be incorporated in midwifery curricula.

Bachelor of Nursing students career choices: a three-year longitudinal study.

This paper presents the findings of a survey which explored the career preferences of Australian Bachelor of Nursing students for certain clinical specialities. A convenience sample was recruited, with data collected three times between 2005 and 2007. With first-year students, acute care nursing of the adult and child and midwifery were the most popular career choices, whereas considerably less were interested in mental health or aged care nursing, and nearly two-fifths were undecided. By third-year, there was a shift in career preferences, with acute care of the adult and mental health being the most popular choices. In contrast, midwifery and aged care were the least preferred careers. The study provides some evidence students commence their course with a predominantly lay-informed image of nursing, but this may be tempered by favourable curricular influences towards the mental health field. However, the curriculum discourages students from pursuing a career in aged care and midwifery.

The PACT Project: improving communication at handover.

OBJECTIVE: To describe and evaluate the PACT (Patient assessment, Assertive communication, Continuum of care, Teamwork with trust) Project, aimed at improving communication between hospital staff at handover. DESIGN, SETTING AND PARTICIPANTS: The PACT Project was conducted between April and December 2008 at a medium-sized private hospital in Victoria. Action research was used to implement and monitor the project, with seven nurses acting as a critical reference group. Two communication tools were developed to standardise and facilitate shift-to-shift and nurse-to-doctor communication. Both tools used SBAR (situation, background, assessment, recommendation) principles. All nurses attended workshops on assertive communication strategies and focused clinical assessment of the deteriorating patient. Questionnaires were distributed to nurses and doctors at baseline, and post-implementation questionnaires and qualitative data were collected from nurses immediately after the project. MAIN OUTCOME MEASURES: Nurses' opinions of improvement in structure and content of handover; nurses' confidence in their communication skills. RESULTS: At baseline, 85% of nurses believed communication needed improvement. After implementation, 68% of nurses believed handover had improved and 80% felt more confident when communicating with doctors. CONCLUSION: Early evidence supports the use of standardised communication tools for handover, together with specific training in assertive communication and patient assessment. Long-term evaluation of patient outcomes is needed.

Subjective side effects of antipsychotics and medication adherence in people with schizophrenia.

AIM: This paper is a report of a study conducted to describe the prevalence of antipsychotic medication side effects in individuals with schizophrenia, and to assess if a relationship existed between side effects and medication-taking. BACKGROUND: Non-adherence to antipsychotics is common in people with schizophrenia. There is a direct relationship between non-adherence and relapse, but it is unclear if an association exists between side effects and non-adherence. METHOD: The Liverpool University Neuroleptic Side-effect Rating Scale was used with a convenience sample of 81 mental health service users with schizophrenia. Participants were recruited from one urban and one rural area in Australia in 2004. Data were analysed using Statistical Package for Social Science and nonparametric statistical methods based on the nature of data. FINDINGS: Around 20% of participants had missed taking their medication at least once in the week before data collection. About half experienced one or more side effects, but the level of accumulated side effects was not associated with medication omission. Older participants were more likely to experience anticholinergic and allergic side effects than their younger counterparts. Younger women were more likely to experience hormone-related side effects than older women. Overall, medication omission was not statistically significantly correlated with any of the seven Liverpool University Neuroleptic Side-effect Rating Scale subscales. CONCLUSION: Greater attention needs to be paid to age- and gender-specific side effects and to monitoring side effects in people prescribed atypical medication antipsychotics. Service users, case managers and prescribers may need additional training to assist them to identify side effects and to take steps to ameliorate or at least minimize their effects.

Acute (adult clinical inpatient) care nurses' attitudes towards and knowledge of nationally endorsed 5As smoking cessation guidelines.

Nurses are expected to be involved in health promotion, including smoking cessation. This study aimed to assess nurses' knowledge, sense of responsibility and willingness to provide smoking cessation interventions as described in the national 5As guideline. Data were collected by a survey distributed to a convenience sample of nursing staff (n=162) from thirteen different adult acute care wards at a major metropolitan Melbourne hospital. Nearly all respondents (87%) agreed that they had a responsibility to counsel patients, and 22% were already doing so, but only 22% (n=36) of respondents demonstrated an adequate level of knowledge of smoking cessation. Nurses were more likely to counsel patients on health conditions related to their area of practice than those that were not. The findings indicate that greater emphasis is needed in undergraduate courses and in-service programs to increase nurses' awareness, and implementation of the 5As guideline for smoking cessation.

Accessing health care professionals about antipsychotic medication related concerns.

The purpose of this research was to describe mental health service users' access to and satisfaction with health care professionals, including nurses, as related to users' antipsychotic medication concerns. Eighty-one service users were interviewed using a questionnaire. Participants stated that case managers were the most accessible, while psychiatrists were the least accessible. It was perceived that most professionals, apart from general practitioners, had adequate knowledge of medications. Most participants were satisfied with the way health care professionals dealt with the service users' concerns about medications, but almost 16% were dissatisfied with general practitioners. The findings emphasize that access to and satisfaction with health care professionals is an important factor in medication adherence.

Mental health clinicians' attitudes about consumer and consumer consultant participation in Australia: A cross-sectional survey design.

The purpose of this study was to assess mental health clinicians' attitudes about mental health consumer participation in inpatient psychiatric units. A cross-sectional survey design was used with a non-probability sample of 47 clinicians in the psychiatric units of a large Australian hospital. The results showed that gender, length of time as a clinician, and how long the staff worked in the units influenced their attitudes about consumer involvement. Females were more likely than males to support consumer participation in management and consumer consultants. Less experienced staff showed greater support than more experienced staff for mental health consumer involvement in treatment-related matters and consumer consultants in units. New staff members were more likely to register agreement-to-uncertainty regarding consumer involvement in treatment-related issues, whereas established staff members were more likely to record uncertainty about this issue. The findings showed that although reports and policies promoted participation, some clinicians were reluctant to accept consumer and consultant involvement.

The influence of friends on smoking commencement and cessation in undergraduate nursing students: a survey.

BACKGROUND: Smoking is one of the leading causes of morbidity and mortality in most countries. Despite the fact that nurses have an important role in health promotion, and are in a good position to see and reflect on the detrimental effects of tobacco smoking, research has shown that the rate of smoking among nurses is similar to the rest of the population. OBJECTIVE: The objective of this study was to examine the attitudes and experiences of undergraduate nursing students in relation to smoking commencement and cessation. It was part of a larger study that explored students smoking behaviours, knowledge and attitudes. METHOD: A non-probability sample of 366 undergraduate nursing students from a large Australian school of nursing and midwifery took part in the study. The participants completed the Smoking and Health Promotion instrument. Ethics approval was obtained prior to the commencement of the study. RESULTS: Peers and friends were an important influence on the decision to commence smoking. The wish to comply with peer norms was especially prominent in mid-adolescence. Most smokers wanted to cease smoking, and many had tried unsuccessfully to stop on one or more occasions. They conceded that the pleasure they obtained from smoking and the effects of stress acted as barriers to stopping. The participants acknowledged the adverse health effects of smoking and some had already experienced these effects, but neither of these was enough to prompt them to cease. CONCLUSIONS: Undergraduate nursing curricula need to place greater emphasis on examining smoking related illnesses, as well as health promotion and role modelling in particular. Health promotion strategies that target peers are needed as an alternative to programmes that use fear or appeals to moral authority to prevent individuals from commencing smoking or encouraging cessation.