Depression, suicidal ideation and STD-related risk in homeless older adolescents.

Goals of this study were to examine the frequency of depression and related constructs of suicidal ideation and hopelessness in a sample of homeless older adolescents and their associations with behaviors that may increase the risk of sexually transmitted disease (STD). Diagnostic interviews and blood/urine samples were obtained from 523 homeless adolescents (mean age=17.8). Overall, 12.2 per cent had a current DSM-IV diagnosis of major depression and 6.5 per cent had dysthymia, with higher rates for female and older participants. Depression appeared to precede rather than follow homelessness and was associated with biologically verified STDs (in older participants), infrequent condom use, a non-heterosexual orientation (in older participants), and lifetime homosexual experience. Unlike depression, suicidal ideation and hopelessness were associated with higher rates of intravenous drug use but lower rates of multiple sex partners and, in young homeless women, less sexual coercion. Depression is frequent in homeless older adolescents and has a complex association with STD-related behaviors.

Relationship of sexual orientation to substance use, suicidal ideation, suicide attempts, and other factors in a population of homeless adolescents.

PURPOSE: To explore the relationship of sexual orientation and gender to four sets of factors: (a) family history, (b) incarceration, (c) substance use, and (d) depression and suicide, in a population of homeless adolescents. METHODS: A sample of homeless adolescents was recruited in Portland, Oregon and assessed using semi-structured interviews at baseline, three months and six months. A total of 532 youths (216 females and 316 males) provided data on sexual orientation and other variables. Heterosexual (n = 391) and non-heterosexual youths (n = 141) were compared on all sets of factors, primarily using logistic regressions. RESULTS: 44.9% of females identified as lesbian or bisexual, while only 13.9% of males identified as gay or bisexual. Gay, lesbian, bisexual, and "unsure" (GLBU) youths were less likely to have been in foster care or arrested, but were more likely to have spent time in a locked mental health treatment facility. More than one-third of all participants reported use of injection drugs. GLBU youths were more likely to have recently used amphetamines and to have injected drugs, however, gay-bisexual males were less likely to have recently used marijuana. GLBU status was associated with recent measures of depression and suicidal ideation, but not with lifetime measures. Associations of sexual orientation with several lifetime measures were different than with prospective measures, demonstrating the limitations of using lifetime measures rather than recent or prospective measures. CONCLUSIONS: This population of homeless adolescents appears to be higher in its high rate of injection drug use and the large proportion of females who identify as lesbian or bisexual than found in other studies. The high rates of depression and suicidal ideation, especially among GLBU youth, are of great concern.

Flexyx Neurotherapy System in the treatment of traumatic brain injury: an initial evaluation.

OBJECTIVE: To conduct a preliminary experimental evaluation of the potential efficacy of Flexyx Neurotherapy System (FNS), an innovative electroencephalography (EEG)-based therapy used clinically in the treatment of traumatic brain injury (TBI). PARTICIPANTS: Twelve people aged 21 to 53 who had experienced mild to moderately severe closed head injury at least 12 months previously and who reported substantial cognitive difficulties after injury, which interfered with their functioning. DESIGN: Participants were randomly assigned to an immediate treatment group or a wait-list control group and received 25 sessions of FNS treatment. They were assessed at pretreatment, posttreatment, and follow-up with standardized neuropsychological and mood measures. RESULTS: Comparison of the two groups on outcome measures indicated improvement after treatment for participants' reports of depression, fatigue, and other problematic symptoms, as well as for some measures of cognitive functioning. Most participants experienced meaningful improvement in occupational and social functioning. CONCLUSION: On the basis of these results, FNS appears to be a promising new therapy for TBI and merits more extensive evaluation.

Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population.

BACKGROUND: High rates of unprotected intercourse and illegal drug use have been reported among homeless adolescents. As a transient population with the potential to act as disease vectors from one location to another, incidence and prevalence of sexually transmitted infections in this population are of particular concern. GOAL: To assess a homeless adolescent population for incidence and prevalence of Chlamydia trachomatis, herpes simplex virus type 2, hepatitis B virus, hepatitis C virus, HIV, and psychosocial correlates of the acquisition of sexually transmitted infections. STUDY DESIGN: Longitudinal with assessments at baseline, 3 months, and 6 months (n = 536; 319 males and 217 females). RESULTS: Baseline prevalence of C trachomatis was 4.17% for males and 6.30% for females. Prevalence of herpes simplex virus type 2 was 5.73% for males and 12.50% for females. Hepatitis B virus and hepatitis C virus prevalences were 3.60% and 5.0%, respectively. HIV seroprevalence was 0.3%. The incidence of sexually transmitted infections was significantly higher among females than among males (16.7% versus 9.8%) and was associated with inconsistent condom use and, for females, number of partners and sex with older partners. Incident hepatitis B virus and hepatitis C virus infection rates were 3.44% and 6.61%, respectively; both were associated with injection drug use. CONCLUSIONS: Among females, the incidence of herpes simplex virus type 2 (> 25%) and C trachomatis (12%) was relatively high. Inconsistent condom use was the primary factor associated with a significantly greater risk of incident sexually transmitted infections. This was especially true for females with multiple partners. Homeless adolescents also are at high risk for hepatitis B virus and hepatitis C virus infection, primarily associated with self-reported injection drug use.

Childhood sexual abuse, adolescent sexual coercion and sexually transmitted infection acquisition among homeless female adolescents.

OBJECTIVE: To examine the relationship between childhood experiences of sexual abuse, sexual coercion during adolescence, and the acquisition of sexually transmitted infections (STIs) in a population of homeless adolescents. METHOD: Homeless adolescent females (N = 216) from a northwestern United States city were recruited by street outreach workers for a longitudinal study of STI epidemiology. Baseline data on childhood abuse and recent history of sexual coercion were used to predict physiologically confirmed STI acquisition over the subsequent 6 months. RESULTS: About 38% of all girls reported a history of childhood sexual abuse (CSA). Girls with a history of CSA were more likely to report recent sexual coercion. In turn, sexual coercion in the last three months was significantly associated with a higher number of sexual partners (but not with a greater frequency of intercourse or with lower rates of condom use). Number of sexual partners significantly predicted the future acquisition of an STI within 6 months. CONCLUSIONS: Interventions to reduce risky sexual behaviors in homeless adolescent females may need to consider the impact of CSA, particularly on the number of sexual partners during adolescence. However, it also should be noted that engagement in intercourse often results from coercion and is not voluntary in this population.

IQ scores among homeless older adolescents: characteristics of intellectual performance and associations with psychosocial functioning.

Intellectual performance and the associations of IQ with the quality of psychosocial functioning were studied in a sample of homeless older adolescents. Fifty homeless older adolescents (ages 16-21) completed the Wechsler Adult Intelligence Scale-Revised (WAIS-R) and a questionnaire assessing psychosocial functioning and sexual risk factors. The WAIS-R scores were comparable to population means, with performance IQ scores tending to be higher than verbal IQ scores. The IQ was unrelated to the duration of homelessness. Higher IQ scores were significantly correlated with only a minority of the measures of psychosocial functioning, including less self-reported depression and lower reported delinquency, but also less self-control in high-risk sexual situations, less perceived peer support for safer sex, and a higher perceived likelihood of acquiring HIV.

Late infections following allogeneic bone marrow transplantation: suggested strategies for prophylaxis.

Bone marrow transplant recipients remain at risk for infections for a variable period of time even after adequate hematologic reconstitution. Late infections are a significant cause of morbidity and can be fatal in 4-15% of these patients. Patients with chronic graft versus host disease (GVHD) and unrelated-donor transplant recipients, even without GVHD, are at particular risk. Most late infections occur in the first post-transplant year, the majority are caused by bacteria, particularly encapsulated organisms, or herpes group viruses (CMV and VZV) and present with cutaneous, sino-pulmonary or systemic involvement. Effective chemoprophylaxis is available only for the encapsulated bacteria (penicillin or erythromycin) and Pneumocystis carinii (trimethoprimsulfamethoxazole). Routine use of long-term I.V. immunoglobulin supplementation has not been shown to be effective and may be harmful as it may delay reconstitution of humoral immunity. Active immunization (pneumococcal vaccine, influenza vaccine and HiB) can be effective in patients more than 6-12 months from transplant who do not have GVHD. In this review we present our experience, a summary of published literature on the subject of late infections in bone marrow transplant patients and offer guidelines for preventative strategies.

Characteristics of a 20-minute whole blood rapid assay for cardiac troponin T.

OBJECTIVES: A qualitative whole blood rapid assay for cardiac troponin T (cTnT) was examined. The assay uses the same antibodies as for a benchmark ELISA, but the capture and detection roles were switched to enhance specificity. DESIGN AND METHODS: The cTnT Rapid Assay and ELISA were compared in 643 samples from patients having myocardial infarction, coronary artery bypass surgery, ischemic heart disease, musculoskeletal disease, renal failure, or other noncardiac conditions. Concordance between the methods was compared using the McNemar Test and cTnT cutoff of 0.2 micrograms/L. RESULTS: For the "cutoff" of 0.2 micrograms/L, concordance between the cTnT Rapid Assay and ELISA was in the range of 90-95% for each group except the renal failure patients, where concordance was 77.9%. There was no significant difference between the cTnT Rapid Assay and ELISA, except in the renal failure and ischemic heart disease patients, where there was a greater number (p < 0.05) of cTnT Rapid Assay negative results when the ELISA was > 0.2 micrograms/L. Overall concordance between the cTnT Rapid Assay and CK-MBmass was 78%. CONCLUSION: The McNemar test indicated that the cutoff for the cTnT Rapid Assay was 0.2 micrograms/L. Evidently the lower concordance among renal failure and ischemic heart disease patients reflects higher cTnT specificity for the Rapid Assay that was conferred by switching the capture and detection antibodies.

Sexually transmitted disease prevention: adolescents' perceptions of possible side effects.

Forty-eight sexually active adolescents participated in an open-ended interview about the possible secondary consequences (side effects) of implementing measures to reduce the risk of contracting a sexually transmitted disease (STD). These adolescents noted 134 different consequences, which were grouped into 15 substantive categories. When four prevention measures (using condoms, being selective about sex partner(s), being monogamous, and abstaining from sexual activity) were analyzed, different patterns of consequences that were salient to these adolescents emerged. The results are discussed in terms of their implications for understanding and improving adolescent decision making about STD prevention.

Cytokine expression in human cutaneous chronic graft-versus-host disease.

Although chronic graft-versus-host disease (GVHD) remains a frequent complication of bone marrow transplantation (BMT), the pathogenesis remains unclear. We examined the potential role of cytokines in mediating chronic GVHD. Skin samples from seven patients with cutaneous chronic GVHD, six post-BMT controls and six normal controls were evaluated by reverse transcription polymerase chain reaction for the proinflammatory cytokines interleukin-1 alpha (IL-1 alpha) and tumor necrosis factor-alpha (TNF-alpha), Th1-associated cytokines IL-2 and interferon-gamma (IFN-gamma), Th2-associated cytokines IL-4, IL-5 and IL-10, and fibrosis-associated cytokines platelet derived growth factor (PDGF) and transforming growth factor-beta (TGF-beta). IFN-gamma transcription was significantly more frequent in cutaneous chronic GVHD (86%) vs post-BMT and normal controls (17% (P = 0.03) and 0 (P = 0.005), respectively). IL-2 transcription was more frequent in chronic GVHD (28%) and post-BMT controls (50%) vs normal controls (17%). TNF-alpha mRNA was frequent in chronic GVHD (71%) and post-BMT controls (83%), but not significantly more than in normal controls (50%). Transcription of IL-1alpha, IL-4, IL-5 and IL-10 was infrequent in all three groups. PDGF and TGF-beta mRNA were detected in the majority of all samples. The frequent transcription of IFN-gamma in cutaneous chronic GVHD supports its potential role in mediating the associated tissue injury. While the cellular sources of these cytokines are uncertain, their expression and secretion in situ may propagate the cytotoxic cascade and perpetuate the tissue injury. Better understanding of the contribution of FN-gamma and other cytokines to the pathogenesis of chronic GVHD may allow the design of more specific and more effective therapy.

Toward a social ecology of community coalitions.

This article is guided by several premises. First, community coalitions fit with a social ecology perspective of health promotion because they work with multiple domains and promote community change. Second, the community context affects the functioning of coalitions. Third, key leaders are an important part of the social fabric of a community and influence the social ecology of a community; therefore a coalition should include key leaders and influence them and their organizations. The purpose of this article is to advance an understanding of the social ecology of coalitions by describing concepts, variables and results from two national studies and by providing anecdotal evidence and a measure of key leaders from our own work. After briefly defining and describing community coalitions, we: (1) review literature on contextual variables and community coalitions, (2) provide examples of contextual variables influencing community coalition development, and (3) discuss the relationship of key leaders in multiple domains and community coalitions. The article concludes with a discussion of the need for a framework of contextual variables and a promising next step.

Does sexual coercion play a role in the high-risk sexual behavior of adolescent and young adult women?

Sexual coercion and its relationship to high-risk sexual behavior were examined in five samples of young women. Sample 1 (N = 22) consisted of sexually active adolescents aged 15 to 19. Samples 2 (N = 206) and 3 (N = 70) were recruited from among patients at three sexually transmitted disease clinics. Sample 4 (N = 51) consisted of young homeless women living on the street in a large city. Sample 5 (N = 51) was recruited from among young women on a college campus. Across all samples, 44.4% of women indicated that they had been forced into some form of sexual activity against their will. Self-reports of sexually coercive experiences were consistently related to risky sexual behavior. It appears that many young women are coerced into engaging in high-risk sexual behavior. This implies the need for greater attention to male coercive sexual behavior and women's skills for coping with such behavior.

Late infections after allogeneic bone marrow transplantations: comparison of incidence in related and unrelated donor transplant recipients.

Infectious complications are a major cause of morbidity and mortality after allogeneic bone marrow transplantation (BMT). We have evaluated the incidence of late infections (beyond day +50) in recipients of related (RD) and unrelated donor (URD) allogeneic BMT, factors associated with increased risks of infection, and the impact of the late infections on survival. Between 1989 and 1991, 249 patients received an RD (n = 151) or URD (n = 98) allogeneic BMT at the University of Minnesota and all late infections were investigated. Three hundred sixty-seven late infectious events developed in 162 patients between 50 days and 2 years after BMT. The incidence of any late infection was greater in URD versus RD recipients (84.7% v 68.2%, respectively; P = .009). In multivariate analysis, advanced graft-versus-host disease (GVHD) was significantly associated with late infections. The effect of GVHD was apparent only in RD recipients (relative risk [RR], 2.29; P = .003), whereas URD recipients, with or without GVHD, had more late infections compared with RD recipients without GVHD. Multivariate analysis showed that late posttransplantation infections were the dominant independent factor associated with increased nonrelapse mortality (RR, 5.5; P = .0001), resulting in improved 3-year survival for RD versus URD recipients (49.9% +/- 8% v 34.4% +/- 10%; P = .004). In this study, we observed that late infections are more frequent in URD recipients, resulting in substantially higher nonrelapse mortality. This prolonged period of increased infectious risk in URD recipients suggests the need for aggressive surveillance and therapy of late infections and perhaps prolonged antibiotic prophylaxis for all URD BMT recipients.

The tissue expression of cytokines in human acute cutaneous graft-versus-host disease.

Although acute graft-versus-host disease (GVHD) is a common complication after allogeneic bone marrow transplantation (BMT), the specific pathophysiology of tissue damage has not been elucidated. We have previously described an infiltrate of CD2+, CD8+, alpha/beta receptor+ T lymphocytes, and the upregulation of ICAM-1 in tissues with acute GVHD. We hypothesized that these infiltrating lymphocytes may secrete cytokines that could contribute to tissue damage. In the current study, we used reverse transcription (RT) polymerase chain reaction (PCR) to explore the mRNA expression of candidate inflammatory cytokines IL-1 alpha, IL-2, IL-4, IL-6, TNF-alpha, and interferon-gamma (IFN-gamma) in peripheral blood mononuclear cells (PBMC) and skin biopsies of allogeneic BMT patients with GVHD and controls. In post-BMT control PBMC (n = 10); IL-2 RNA was infrequent (20% of samples) but was significantly more frequently detectable (71%; P < 0.05) after development of acute GVHD (n = 7). IL-4 expression was also more common in PBMC from patients with acute GVHD (57% vs. 30%; P < 0.05). Consistent with the PBMC data, IL-2 and IL-4 RNA were also more frequently detectable in skin biopsies with GVHD (n = 10): 70% of samples expressed IL-2 vs. 25% of normal controls (n = 8; P < 0.05); 60% had detectable IL-4 RNA vs. 0% of controls (P < 0.05). IFN-gamma detectability (40% vs. 12%; P < 0.05) was also more frequent in GVH skin. For both PBMC and skin, IL-1 alpha expression was infrequent in GVHD and controls, whereas TNF-alpha and IL-6 were expressed in nearly all samples. These data suggest that upregulated expression of IL-2, IL-4, and IFN-gamma may be part of the inflammatory cascade of human acute GVHD, while IL-1 alpha, TNF-alpha, and IL-6 are not discriminatory for the inflammation observed at the time of initial GVHD diagnosis.

Predictive factors for chronic graft-versus-host disease after histocompatible sibling donor bone marrow transplantation.

We analyzed factors associated with the development of chronic graft-versus-host disease (GVHD) in 469 consecutive patients receiving matched sibling allogeneic bone marrow transplantation (BMT). Overall, 41 +/- 6% (95% confidence interval) developed chronic GVHD between 2 and 50 months after BMT. Multivariate analysis showed that previous acute GVHD was the dominant independent risk factor predisposing to chronic GVHD (Relative Risk 4.82, p < 0.0001). In addition, recipient age of > or = 18 years and male recipient with female donor were also independent predictive factors for development of chronic GVHD. When acute GVHD and recipient age were considered, groups with distinctive risks of chronic GVHD were identified. Patients under 18 without previous grade II-IV acute GVHD had only a 10 +/- 5% risk of chronic GVHD. Patients over 18 with no prior grade II-IV acute GVHD had a 31 +/- 12% risk while patients with advanced acute GVHD, regardless of age, had the highest risk and 70 +/- 8% developed chronic GVHD. It is important to consider these factors when designing and assessing clinical trials of chronic GVHD prophylaxis and treatment.

Subject attrition in prevention research.

Subject attrition threatens the internal validity of substance abuse prevention studies because differences in the rate of attrition and the substance use behavior of remaining subjects in the different conditions could account for any differences found in substance use rates. Attrition threatens the external validity of prevention studies because, to the extent that study dropouts are different from remaining subjects, the results of the study may not be generalizable to study dropouts. Analysis of these threats to the validity of prevention studies should be routinely conducted. However, studies of alcohol and drug abuse prevention have generally failed to report or analyze subject attrition. Smoking prevention studies have more frequently reported attrition, and they have recently begun to analyze the degree to which attrition may affect the internal and external validity of the study. Evidence thus far suggests that differences in attrition across conditions do occur occasionally. The evidence is substantial that study dropouts are systematically more likely to smoke, to use other substances, and to score highly on other risk-taking measures.

Social and behavioral factors associated with high-risk sexual behavior among adolescents.

Relationships among risky sexual behaviors, other problem behaviors, and the family and peer context were examined for two samples of adolescents. Many adolescents reported behaviors (e.g., promiscuity or nonuse of condoms) which risked HIV or other sexually transmitted disease infection. Such risky behaviors were significantly intercorrelated. Consistent condom use was rare among those whose behavior otherwise entailed the greatest risk of infection. In both samples, an index of high-risk sexual behavior was significantly related to antisocial behavior, cigarette smoking, and illicit drug or alcohol use. Social context variables, including family structure, parenting practices, and friends' engagement in problem behaviors, were associated with high-risk sexual behavior. Finally, for sexually active adolescents, problem behaviors and social context variables were predictive of nonuse of condoms. Results were consistent across the two studies and regression weights held up well under cross-validation.

The efficacy of social-influence prevention programs versus "standard care": are new initiatives needed?

This study evaluates the effects of a school-based smoking prevention program after 1 year, using school (22 middle/elementary schools, 15 high schools) as both the unit of randomization and the unit of analysis. The multigrade level (grades 6 through 9) intervention was designed to address comprehensively the social influence factors that encourage smoking. Teacher survey data indicated that treatment schools had a median of 10 classroom sessions devoted to tobacco/drug use education, 5 of which were the sessions designed for this evaluation, and control schools had also dedicated a median of 10 classroom sessions to tobacco/drug education. Thus, the study evaluated the incremental effects of the social influence intervention compared to "standard-care" curricula. Among those who reported smoking one or more cigarettes in the month prior to the intervention, there was a significant treatment effect on rate of smoking at one year, but no grade level, gender, or interaction effects. The 1-year covariate-adjusted smoking rate among pretest smokers in the treatment schools was 76.6 cigarettes per month, compared to 111.6 cigarettes per month in control schools, a 31.4% difference. These effects were not accounted for by differential subject attrition. The analyses for nonsmokers, however, showed no significant effects, and the program did not affect self-reported alcohol or marijuana use. Taken together with the results of other prevention studies, these results point to the need for the development and evaluation of new initiatives to prevent substance use.