Olanzapine for schizophrenia refractory to typical and atypical antipsychotics: an open-label, prospective trial

The role of olanzapine in treatment-resistant schizophrenia is still unresolved. This article presents an open-label, prospective, 14-week trial with olanzapine in patients with schizophrenia and schizoaffective disorder selected for unambiguous resistance to either clozapine or risperidone and to typical antipsychotics. Forty-three inpatients (mean age, 41.6 years; mean duration of illness, 21.7 years) were enrolled and treated after cross-titration from their previous antipsychotic treatment with olanzapine 10 to 40 mg daily without any concomitant antipsychotic medication. Patients were evaluated with the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impressions Scale, and the Extrapyramidal Symptom Rating Scale. The change with olanzapine treatment was associated with a PANSS total score improvement of 3.7 (SD = 15.6; not significant). There was a significant improvement for the PANSS cognitive and depression/anxiety factors, whereas the PANSS excitement factor worsened. The improvement rate was superior in patients receiving olanzapine doses higher than 20 mg. A total of 16.7% of patients reached response criteria set forth by a previous study. There was a significant decrease in extrapyramidal side effects (t = 2.04; p < 0.05) and statistically significant, yet modest, weight gain. These results indicate that olanzapine is only modestly effective in these severely treatment-resistant patients with schizophrenia. However, a trial with olanzapine can be recommended in these patients before moving to augmentation strategies, given the lack of proven alternatives and the observation that 16.7% of patients reached the response criteria.

Continuing Education in Nursing: A 10-Year Retrospective Study of CE Offerings Presented by the Kentucky Nurses Association

BACKGROUND

The purpose of this retrospective study was to evaluate continuing education (CE) offerings presented by the Kentucky Nurses Association during a 10-year period.

METHOD

Data were collected and analyzed from 37 CE offerings (N = 474 respondents).

RESULTS

Findings revealed that the majority of the respondents reported that the CE offerings were useful, stimulated them to seek further information, and resulted in acquisition of significant knowledge or skills for nursing education or practice. However, fewer than half of the respondents reported they were able to implement changes in nursing education or practice as a result of the CE offerings.

CONCLUSION

Findings supported the usefulness of CE in nursing education and practice and the need for further research evaluating CE and the correlation between CE and nursing education and practice.

Reproductive health consequences of intimate partner violence. A nursing research review

Intimate partner violence is widespread and results in significant negative mental and physical health outcomes for women. This article is a review of nursing research on intimate partner violence and women's reproductive health and focuses on studies published since 1995, building on prior reviews. We begin with research on forced sex and the resulting physical and emotional trauma as well as implications for contraception, STD/HIV prevention, and condom use negotiation. We then discuss several approaches to the study of abuse during pregnancy, including several studies of nursing interventions. We conclude with the clinical implications of these studies.

Ethical ramifications of alternative means of recruiting research participants from cancer registries

BACKGROUND

The protection of confidentiality and the extent to which voluntary and meaningful informed consent can be obtained from potential participants are critical when recruiting patients for clinical research from cancer registries. In the current study the authors describe the influence of two methods of recruitment from a cancer registry (direct contact by research staff and contact by research staff after physicians alert potential participants) on these issues.

METHODS

Enrollment rates were tabulated using each recruitment method and complaints received from potential participants regarding recruitment were reviewed.

RESULTS

Of 416 women approached to participate, the first 351 women were recruited by way of direct contact by research staff and the remaining 65 women were recruited by research staff after their physician had sent them an alert letter. There was no difference in the enrollment rate using the two methods. One potential participant believed that her confidentiality had been violated and another hung up the telephone when contacted directly; two potential subjects reported feeling pressure to participate because their physician sent them a letter.

CONCLUSIONS

Although concerns regarding violating confidentiality clearly are justified when recruiting research participants from cancer registries, patients also may feel pressure to participate if physician notification is part of the process. It is incumbent on investigators and institutional review boards charged with overseeing this research that they respect confidentiality and avoid pressuring persons to participate in research. It also is critical that persons whose medical information will be entered into cancer registries be informed about this process as well as how the registry will be used for research.

Severity of abuse before and during pregnancy for African American, Hispanic, and Anglo women

OBJECTIVE

To describe timing and severity of abuse before and during pregnancy for African American, Hispanic, and white Anglo American women.

FINDINGS

Among 199 abused women, 18.1% of the women were abused during pregnancy but not the year before, 30.2% were abused the year before but not during pregnancy, and 51.8% were abused both the year before and during pregnancy. The timing of abuse did not vary by ethnicity. The three (ethnicity) by three (timing) factorial analysis of variance showed severity of abuse to vary by timing of abuse. Women reporting abuse both before and during pregnancy reported greater severity of abuse on each of the five measures than did women abused only before pregnancy or only during pregnancy.

CONCLUSIONS

Over half (51.8%) of the women reported abuse before and during pregnancy with these women reporting greater severity of abuse on all five severity scores. Timing and severity of abuse did not vary by ethnic group. The majority of women abused during pregnancy were also abused prior to pregnancy, indicating the need for universal screening of all women during each health encounter.

Testing an intervention to prevent further abuse to pregnant women

Although violence against women is recognized as a major public health problem, few interventions have been developed to reduce abuse. In this study, 132 pregnant women received three counseling sessions that were designed to reduce further abuse. A comparison group of 67 abused women were offered wallet-sized cards listing community resources for abuse. Women in both groups were followed at 6 months and 12 months post-delivery. Using repeated measures MANCOVA with entry scores as a covariate, we found significantly less violence reported by women in the intervention group than by women in the comparison group.

Safer-Sex Education for Persons With Mental Illness

1. Safer-sex education is crucial for controlling the spread of HIV and this education is within the realm of nursing practice. 2. Safer-sex education for persons with mental illness must include repetitive, interactive education capitalizing on verbal, visual, written, tactile, and motor skill teaching methods to compensate for learning disabilities that have been identified in this population. 3. In this study, individual rather than a group teaching approach to the sensitive subject of safer-sex provided the most learning. The study subjects did not exhibit overt sexual behavior, increased sexual acting out, regression, or overstimulation when safer-sex education was presented.

Evaluation of commercial PC-based DICOM image viewer

While each software product incorporated some excellent features, none included the full repertoire of needed functions. Depending on the specific clinical practice setting, absence of a function could constitute an inconvenience or preclude use of the software. For a referring physician inside the hospital, another software application affords access to the radiologist report, but remote access may not be available. When the primary practice involves plain radiography, the lack of sophisticated tools for managing complex cross-sectional images is a minor inconvenience, but for a neuroradiologist it is a major inconvenience. Comparisons with prior exams and measurement tools are often used to assess changes in patient status, but these tools are primitive stage of development. Although we concluded that our staff could use these products to evaluate patient exams, we will continue to search for a product that provides full support for clinical operations.

There is apparently no technological limitation precluding inclusion of these tools of PC viewer software, rather it seems to be the result of incomplete requirement definition, inadequate software development, or deliberate decisions to limit product development. Development activity seems to have shifted from PC-based viewers to Web-based products.

Severity of abuse to pregnant women and associated gun access of the perpetrator

To investigate the relationship between abuse to pregnant women and gun access by the abuser, an ethnically stratified cohort of 199 pregnant abused women (70 African-Americans, 63 non-Hispanic Anglo-American, and 66 Hispanic women were interviewed using: (1) The Index of Spouse Abuse, a measure of the severity of physical and nonphysical abuse; (2) The Danger Assessment Scale, a measure of potential danger of homicide; and (3) The Severity of Violence Against Women Scale, a measure of threats of violence and actual violence. There were no significant differences by ethnicity among the 41.2% of the abused women who reported that their male partner had access to a gun. Among these same women reporting gun access, 17% reported the abuser kept the gun on his body. Women reporting gun access by the abuser reported higher level of abuse on all scaled instruments (P = < 0.01). To protect women's safety and prevent further trauma and potential homicide, routine assessment for abuse and gun access is recommended. Additionally, policy initiatives to remove firearms from abuse perpetrators may reduce the severity of violence experienced by abused women.

Comparison of two rapid latex agglutination tests for detection of cryptococcal capsular polysaccharide

The Murex Cryptococcus Test was compared with the Cryptococcal Antigen Latex Agglutination System (CALAS) for detecting cryptococcal polysaccharide in 173 cerebrospinal fluid (CSF) specimens and 117 serum samples with 99% and 97% concordance, respectively. Eighteen CSF samples and 17 serum samples were positive in both assays, and 249 were negative. The sensitivity and specificity of the Murex relative to the CALAS were 90% and 100%, respectively, for CSF, and 81% and 100%, respectively, for serum. Six discrepancies were arbitrated by retesting, using a third analytic method, review of other laboratory and clinical data, or both. The reaction in 1 CSF specimen was considered false positive by the CALAS, and the reactions in 2 serum samples were false negatives by the Murex. For 3 patients with previous cryptococcal meningitis but no active disease, only the CALAS detected antigen, suggesting that the Murex has less analytic sensitivity in this context. Titer differences dictate that direct comparisons between the 2 tests are not feasible. There were no false-positive reactions in limited testing with either method using specimens from patients with concurrent noncryptococcal infections or in rheumatoid factor-positive serum samples. Infections caused by Cryptococcus neoformans serotypes A or AD were detected equally by both assays. Based on our study, we have elected to continue to use the CALAS for routine testing for cryptococcal antigen.

Violent pornography and abuse of women: theory to practice

To examine violent pornography use and associated violence against women, an ethnically stratified sample of 198 abused women were asked about their partners' use of pornographic materials, and if they had been asked or forced to look at, act out, or pose for pornographic scenes or pictures. Overall, 40.9% of the women reported the abuser used pornographic material, with the proportion significantly higher for Whites (58.7%), compared to Blacks (27.1%) or Hispanics (38.5%). When groups were formed according to the abuser's use of pornography and associated involvement of the woman, violence scores as measured on the Index of Spouse Abuse, Danger Assessment, and Severity of Violence Against Women scales were significantly higher (p = <.001) for women reporting the abuser requested or forced her to look at, act out, or pose for pornographic scenes. Severity of violence was not related simply to whether or not the abused used pornography. This analysis is a beginning step toward understanding how pornography influences woman abuse.

Safety behaviors of abused women after an intervention during pregnancy

OBJECTIVE

To evaluate an intervention protocol, administered during pregnancy, for increasing safety-seeking behaviors of abused women.

DESIGN

Prospective, ethnically stratified cohort analysis.

SETTING

Public prenatal clinics.

PARTICIPANTS

Pregnant women reporting physical or sexual abuse in the year before or during the present pregnancy. One hundred thirty-two women met study criteria, received the intervention, and were followed for 1 year after the completion of the pregnancy.

INTERVENTION

Three education, advocacy, and community referral sessions that included information on safety behaviors.

MAIN OUTCOME MEASURE

Adoption of safety behaviors by abused women. Safety behaviors were measured before the intervention, twice during pregnancy, and at 2, 6, and 12 months after completion of the pregnancy.

RESULTS

Repeated measures analysis of variance showed a significant increase in adoption of each safety behavior (p < .0001), with most behaviors showing a significant increase after the first intervention session.

CONCLUSIONS

Pregnant women who were abused and were offered an intervention protocol report a significant increase in safety behavior adoption during and after pregnancy. Abuse during pregnancy is common. Identification of abuse and immediate clinical intervention that includes information about safety behaviors can result in safety behavior adoption that may prevent future abuse and increase the safety and well-being of women and infants.

Factors related to research utilization by registered nurses in Kentucky

The current health care environment mandates an outcomes-driven approach to care. Outcomes-based, and practice-driven, nursing research can be an essential organizational investment to maintain viability. Registered nurses in Kentucky appear motivated and ready to participate in and use relevant nursing research in their practice environment. Administrative support for those endeavors can be a key component in the successful conduct of clinical research and translation into clinical practice. Participation in research endeavors by both nursing staff and management can support the value of nursing in the current health care delivery system. This study adds to the literature in the area of research utilization in that random selection, a relatively large sample size, and all RNs in the state (not just members of the professional nursing organization) were used. Hopefully, the results of this study can be used to bring together all important parties in the research utilization process--experts, quality assurance nurses, managers in control of resources, risk managers, and those providing patient care.

Symptoms of post-traumatic stress disorder in abused women in a primary care setting

Abuse is a major source of trauma to women, and post-traumatic stress disorder (PTSD) results from exposure to extreme trauma. To describe the relationship between symptoms of PTSD and severity of abuse, an ethnically stratified cohort of 131 abused women in a primary care setting was interviewed. Symptoms of PTSD, both intrusion (i.e., trouble falling asleep, strong waves of feelings about the abuse) and avoidance (i.e., trying not to think or talk about the abuse, staying away from reminders of the abuse), were significantly (p < 0.01) correlated to severity of abuse, regardless of ethnicity. When asked about childhood physical or sexual abuse, women reporting physical abuse had significantly (p < 0.05) higher intrusion scores, whereas those reporting sexual abuse had significantly (p < 0.004) higher avoidance scores. Sixty-five percent of the women reported dreams, flashbacks, or terror attacks and had significantly (p < 0.001) higher mean results on both intrusion and avoidance. The need to offer abused women information about the connection between severity of abuse and symptoms of PTSD is discussed. We recommend that clinicians ask all abused women about dreams, flashbacks, or terror attacks to assess for further symptoms of PTSD.

Resource use by abused women following an intervention program: associated severity of abuse and reports of abuse ending

Although violence against women is recognized as major public health problem, little is known about the effectiveness of interventions. To evaluate severity of abuse and use of community resources following an intervention program, 132 pregnant abused women received three counseling sessions in a prenatal setting. A comparison group of 67 abused women were offered a wallet-sized card listing community resources for violence. Resource use, severity of abuse, and reports of the abuse ending were measured for both groups at 6 and 12 months after delivery. Resource use was significantly (p < .001) related to severity of abuse, irrespective of whether the woman had received the intervention. Women using resources at 6 months were also users at 12 months. These findings indicate a "survivorship model" whereby abused women assertively and persistently seek a variety of community resources to end the abuse. The recommendation that primary care providers go beyond traditional identification and referral for abuse to coordination and evaluation of service delivery is discussed.

Physical abuse, smoking, and substance use during pregnancy: prevalence, interrelationships, and effects on birth weight

OBJECTIVE

To establish the singular and combined occurrence of physical abuse, smoking, and substance use (i.e., alcohol and illicit drugs) during pregnancy and its effect on birth weight.

DESIGN

Prospective cohort analysis.

SETTING

Urban public prenatal clinics.

PARTICIPANTS

414 African American, 412 Hispanic, and 377 white pregnant women.

MAIN OUTCOME MEASURE(S)

Occurrence of physical abuse was 16%; smoking, 29.5%; and alcohol/illicit drug use, 11.9%. Significant relationships existed between physical abuse and smoking for African American and white women. For African American women, 33.7% of women who were not abused smoked, versus 49.5% of women who were abused (chi 2 = 8.21; df = 1; p < 0.005). Alcohol/illicit drug use was 20.8% for nonabused women compared with 42.1% for abused women (chi 2 = 18.18; df = 1; p < 0.001). For white women, 46.6% of women who were not abused smoked, versus 59.6% of those who were abused (chi 2 = 5.22; df = 1; p < 0.005). As a triad, physical abuse, smoking, and alcohol/ illicit drug use were significantly related to birth weight (F[3, 1040] = 30.19, p < 0.001).

CONCLUSIONS

Physical abuse during pregnancy is common, readily detected with a five-question screen, and associated with significantly higher use of tobacco, alcohol, and illicit drugs. Clinical protocols that integrate assessment and intervention for physical abuse, smoking, and substance use are essential for preventing further abuse and improving smoking and substance cessation rates.

Abuse during pregnancy: associations with maternal health and infant birth weight

A stratified, prospective cohort analysis was completed on 1,203 African American, Hispanic, and white women. All women were assessed for abuse at the first prenatal visit and twice more during pregnancy. They were also assessed for risk factors of low birth weight using Institute of Medicine correlates. Prevalence of physical or sexual abuse during pregnancy was 16% (1 of 6). Abused women were twice as likely to begin prenatal care during the third trimester, with abuse preceding late entry. Abuse was recurrent, with 60% of the women reporting repeated episodes. More severe abuse was significantly correlated with lower infant birth weights for all three ethnic groups. Abuse during pregnancy was a significant risk for low birth weight as well as maternal low weight gain, infections, anemia, smoking, and use of alcohol and drugs. When compared to women who were not abused, women abused during pregnancy delivered infants averaging 133 g less. Abused white women delivered infants with the greatest reduction in birth weight.