Reducing risk and building agency for vulnerable asylum seekers.

Asylum seekers are inherently vulnerable. Certain populations who were vulnerable before becoming asylum seekers, such as females, lesbian, gay, bisexual, transgender, queer, and other sexual identities (LGBTQ+) persons, and unaccompanied minors (UAMs) become increasingly vulnerable when seeking asylum. This study conducted a focused literature review of these three groups that led to a series of recommendations. Findings reveal that female, LGBTQ+, and UAM asylum seekers are three of the most underserved groups in the humanitarian social vulnerability context. Ongoing barriers to supporting programs include bureaucratic shortfalls, lack of funding, turnover of support staff, and lack of national or local support. This research produced three main recommendation categories. The first, overarching, recommendation is the building of agency within these populations through dialogue. This recommendation is explored in the most detail. The final two recommendations include enforcing protection of these groups and providing access to physical and mental healthcare. Female, LGBTQ+, and UAM asylum seekers struggle to survive the prevalent violence, sexual assault, and health issues associated with their circumstance. Related programing can more effectively address all these threats if they are tailored to the specific needs of these groups.

Randomized trial of care management to improve Parkinson disease care quality.

OBJECTIVE: To test effects on care quality of Chronic Care Model-based Parkinson disease (PD) management. METHODS: This 2-group stratified randomized trial involved 328 veterans with PD in southwestern United States. Guided care management, led by PD nurses, was compared to usual care. Primary outcomes were adherence to 18 PD care quality indicators. Secondary outcomes were patient-centered outcome measures. Data sources were telephone survey and electronic medical record (EMR). Outcomes were analyzed as intent-to-treat comparing initial and final survey and repeated-measures mixed-effects models. RESULTS: Average age was 71 years; 97% of participants were male. Mean proportion of participants receiving recommended PD care indicators was significantly higher for the intervention than for usual care (0.77 vs 0.58) (mean difference 0.19, 95% confidence interval [CI] 0.16, 0.22). Of 8 secondary outcomes, the only significant difference of the changes over time was in the positive Patient Health Questionnaire-2 depression screen for intervention minus usual care (-11.52 [95% CI -20.42, -2.62]). CONCLUSION: A nurse-led chronic care management intervention, Care Coordination for Health Promotion and Activities in Parkinson's Disease (CHAPS), substantially increased adherence to PD quality of care indicators among veterans with PD, as documented in the EMR. Of 8 secondary outcomes assessed, a screening measure for depressive symptomatology was the only measure that was better in the intervention compared to usual care. More telephone calls in CHAPS were the only utilization difference over usual care. While CHAPS appears promising for improving PD care, additional iterative research is needed to refine the CHAPS model in routine clinical care so that it measurably improves patient-centered outcomes (NCT01532986). CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that for patients with PD, CHAPS increased adherence to PD quality of care indicators.

Telemedicine and the evaluation of cognitive impairment: the additive value of neuropsychological assessment.

INTRODUCTION: The number of people in the United States living with dementia is projected to rise to over 7.1 million in the next 12 years, representing a 40% increase from current levels. This anticipated "dementia tsunami" has led to a recent state and national policy emphasis on early detection, improved care quality, reduced caregiver burden, and increased access to care. The ability to achieve these objectives is limited by few dementia specialists in rural and small communities and the challenges of travel to and within congested urban regions for dementia patients and their caregivers. Telemedicine is one such means for responding to this lack of access to subspecialty assessment and care. We describe our early experiences with this technology applied to neuropsychological assessments, with data from 31 patients. METHODS: As part of an interdisciplinary dementia care demonstration project, clinical video teleconferencing provides real-time high resolution video interactions between dementia subspecialists in a major metropolitan medical center and patients in 3 outlying clinics located 180, 150, and 100 miles away. Comprehensive neuropsychological assessments, designed to address referral questions related to neurocognitive disorders via clinical video teleconferencing, are conducted as one component of interdisciplinary care. OUTCOMES: Eighty-seven percent of patients referred for neuropsychological assessment had an inaccurate neurocognitive diagnosis at the time of referral. Unmet and unrecognized mental health treatment needs were identified in over 77% of patients. In addition, acceptance was good for patients, caregivers, and clinicians. DISCUSSION: Teleneuropsychology is proving to be an excellent resource for clarifying cognitive and psychiatric diagnoses, and integrating individual strengths, weaknesses, and preferences into treatment and care plans used by other health care providers, patients, and caregivers.

Depression in premenopausal women with HSDD: baseline findings from the HSDD Registry for Women.

OBJECTIVE: Hypoactive sexual desire disorder (HSDD) is a multifactorial disorder that is affected by, and may affect, mental health. Data are from the HSDD Registry for Women, a large multicenter observational study of US women with clinically diagnosed generalized, acquired HSDD. We analyzed complete baseline data from 1088 premenopausal women. METHODS: Validated measures of sexual function and distress, physical and mental health, and depression symptoms were obtained from participant and clinician questionnaires. Depression was defined as having a current diagnosis, symptoms (by Patient Health Questionnaire), or use of antidepressant (AD) medication. RESULTS: Thirty-four percent met criteria for current depression, of whom 56% took AD medication. Depressed women were less happy with their relationship, had greater difficulty forming or maintaining relationships, and decreased partnered sex compared with nondepressed HSDD patients. Sexual function was significantly lower in women with current depression (p < .001) versus nondepressed women. Among AD users, those with inadequately treated depression had increased severity of HSDD (p = .02) and reduced sexual desire (p = .04) compared with women in remission. Otherwise, AD use was not associated with sexual function differences among women with HSDD and diagnosed depression. CONCLUSIONS: About one third of premenopausal women with HSDD presented with current symptoms or a diagnosis of depression. Women with HSDD and depression reported poorer relationships and sexual function compared with women with HSDD and no depression. AD use was associated with sexual dysfunction only among women with unresolved symptoms of depression, and conversely, current symptoms of depression were associated with more severe HSDD among AD users.

Sexual desire problems in women seeking healthcare: a novel study design for ascertaining prevalence of hypoactive sexual desire disorder in clinic-based samples of U.S. women.

BACKGROUND: Hypoactive sexual desire disorder (HSDD) has been estimated to occur in 10%-15% of adult women in large population-representative and community-based studies. However, none of these studies have used in-person diagnostic interview assessment to rule out alternative diagnoses, nor has the impact of other health conditions or help-seeking experiences been investigated. The current study aimed to determine the prevalence of generalized acquired HSDD in women aged ≥18 who attended primary care or obstetrics and gynecology clinics for nonurgent clinic visits in the United States. METHODS: A total of 701 women were enrolled at 20 clinical sites across the United States between June 11, 2010, and October 15, 2010. Participants completed a two-part self-administered questionnaire, and a validated, structured, in-person diagnostic interview, conducted by a trained health professional was used for diagnosing HSDD according to DSM-IV-TR criteria. RESULTS: Fifty-two women (7.4%) were assigned a diagnosis of generalized acquired HSDD. Prevalence was lower in minority and postmenopausal women. Level of education and other sociodemographic factors did not appear to differentiate between women with and without HSDD. A marked increase in HSDD prevalence was noted in the perimenopausal (i.e., 40-49 years) and immediate postmenopausal (i.e., 50-59) age groups. Of the women diagnosed with HSDD, 53% had sought care from a health professional for HSDD. CONCLUSIONS: In this sample of women recruited in the clinical care setting, we observed an overall prevalence rate of 7.4% of acquired, generalized HSDD, with markedly increased prevalence in midlife women.

Characteristics of premenopausal and postmenopausal women with acquired, generalized hypoactive sexual desire disorder: the Hypoactive Sexual Desire Disorder Registry for women.

OBJECTIVE: Little is known about the natural history of hypoactive sexual desire disorder (HSDD). We examined the sociodemographic, relationship, help seeking, sexual function, and medical characteristics of women with a clinical diagnosis of generalized, acquired HSDD by menopause status. METHODS: This study was a cross-sectional baseline data analysis from the HSDD Registry for Women (N = 1,574, from 33 US clinical sites). HSDD was clinically diagnosed and confirmed. Validated measures of sexual function, relationship factors, and health, as well as newly developed questions on help seeking were assessed using the questionnaire. RESULTS: Participants were predominantly married or living with a partner (81.7%) and represented a range of race/ethnic backgrounds and ages (mean ± SD, 42.9 ± 11.9 y). Most (56.8%) described their HSDD severity as "moderate to severe," with 26.5% rating the problem severe. Nonetheless, most women (69.8%) reported being happy in their relationship, and 61.8% were satisfied with their partner communication. Postmenopausal women had lower Female Sexual Function Index total scores, indicating worse sexual function (14.0 ± 7.5) than premenopausal women (16.7 ± 6.8, P < 0.001), although both groups had similarly low scores on the sexual desire domain (3.4 ± 1.3 vs 3.3 ± 1.4). Less than half of the overall sample had sought professional help, among whom hormonal treatments had been used by 23.7% of postmenopausal women and by 7.6% of premenopausal women. CONCLUSIONS: Most women with HSDD were in long-term partner relationships with high levels of overall relationship satisfaction. Postmenopausal women were more likely to seek help for their disorder, despite similarly high levels of distress associated with HSDD. Further research is needed to examine treatment outcomes.

Sexual desire, distress, and associated factors in premenopausal women: preliminary findings from the hypoactive sexual desire disorder registry for women.

This article presents data from a validation sample of 390 premenopausal women clinically diagnosed with hypoactive sexual desire disorder (HSDD) enrolled in the HSDD Registry for Women. Participants completed validated measures of sexual distress (e.g., Female Sexual Distress Scale Revised, Question 13) and sexual function including desire (e.g., Female Sexual Function Index). Results showed that lower levels of desire in these women were associated with diminished sexual satisfaction, increased sexually related distress, and fatigue or stress in the women's lives. In addition, the level of distress related to sexual desire decreased with age. The authors conclude that even among women with clinically diagnosed HSDD, the level of sexually related distress varies with situational factors, such as stress and fatigue.

The NERI Hypogonadism Screener: psychometric validation in male patients and controls.

OBJECTIVE: Hypogonadism (HG) is a clinical disorder consisting of reduced testosterone (T) levels and characteristic signs and symptoms of low T. Current instruments used to assess hypogonadal symptoms in men lack adequate measurement properties. To present data on the quantitative validation of a new self-report instrument (HG Screener) developed to identify men with symptoms of HG. DESIGN: This is a psychometric validation study conducted at 16 clinical sites across the Unites States. Subjects completed two visits separated by 2-4 weeks. PATIENTS: One hundred and thirty-one men (82 hypogonadal patients with total T≤10·4 nmol/l and 49 controls with total T>10·4 nmol/l) aged 21-75 years were enrolled. MEASUREMENTS: Self-reported assessments including the HG Screener (at both visits) along with seven validated questionnaires. RESULTS: The results of a factor analysis identified five functional factors or domains. The resulting instrument contains 25 items consisting of 18 functional items in five core domains (sexual function, mood, memory, sleep function and fatigue) and seven physical symptom items. Overall, the new instrument was found to have strong psychometric properties, including acceptable discriminant, construct and content validity, as well as good internal consistency and test-retest reliability. CONCLUSIONS: A new screening tool (HG Screener) for identifying men with HG has been developed and validated according to FDA standards. This new instrument possesses acceptable psychometrics and is available for clinical or research use.

The HSDD registry for women: a novel patient registry for women with generalized acquired hypoactive sexual desire disorder.

INTRODUCTION: Hypoactive sexual desire disorder (HSDD) is a clinically challenging disorder in women. Little is known about the natural history of the disorder and long-term consequences. A longitudinal registry can address these needs. AIM: To design and implement a registry study of HSDD in women to characterize the natural history of HSDD and current treatment practices. METHODS: A longitudinal multicenter registry study has been initiated at clinical sites across the United States. A total of 1,500 women (approximately 1,000 premenopausal, 500 postmenopausal) with clinically-diagnosed HSDD, confirmed by the Decreased Sexual Desire Screener, will be recruited over 24 months at up to 40 clinical sites. Participants will be followed with in-clinic or remote, computer-assisted follow-up. Data from the initial implementation phase was analyzed to assess feasibility of the protocol. A qualitative substudy (N = 40) was conducted to assess content validity of the participant questionnaire. MAIN OUTCOME MEASURES: The primary outcome measure for the Registry study is a patient-based global impression of change in HSDD. Secondary outcome measures are derived from two sources: (i) self-administered questionnaire completed by the participant, and (ii) medical history review completed by the clinician. The questionnaire includes validated measures of sexual function, quality of life, relationship factors, and physical and mental health, as well as newly developed questions on treatments and medications. RESULTS: As of February 12, 2009, 290 women (209 premenopausal, 81 postmenopausal) had been recruited from 15 clinical sites. Results of the initial implementation phase and qualitative substudy on the participant questionnaire show that the Registry protocol is highly feasible and the questionnaire consisting of previously validated scales and selected new items has high content validity. CONCLUSIONS: As the first longitudinal registry study in female sexual dysfunction, the HSDD Registry will contribute to a broader understanding of the impact and treatment needs of women with clinically diagnosed HSDD.

Assessing symptoms of hypogonadism by self-administered questionnaire: qualitative findings in patients and controls.

BACKGROUND: Current screening instruments for hypogonadism lack adequate specificity and diagnostic accuracy. A new self-administered questionnaire of hypogonadism symptoms is being developed to address this need. The process for questionnaire development and results from the first (qualitative) phase are presented. METHODS: Qualitative interviews were conducted based on a new conceptual model of hypogonadism and according to standards for questionnaire development. An item pool was generated from focus groups and in-depth interviews with two groups of hypogonadal patients, treated (N = 26) and untreated (N = 26), and age-equivalent controls (N = 28). Standardized scoring of the qualitative interviews was used to confirm conceptual domains in the model and to generate questionnaire items for further validation. RESULTS: Key domains identified in both patients and controls included: (a) physical function; (b) bodily signs and symptoms; (c) sexual function and libido; (d) sleep function; (e) mood and affective function; (f) memory and cognitive function. The final domain is distress or bother associated with hypogonadism symptoms. This domain was only relevant to the patient groups. CONCLUSIONS: The first stage in the design of a new hypogonadism screener has been completed. Seven domains were identified and draft items were developed in each domain according to current standards of patient-reported outcomes.