Benzylpenicillin versus flucloxacillin for penicillin-susceptible Staphylococcus aureus bloodstream infections from a large retrospective cohort study

In clinical practice, differing opinions exists regarding the optimal management of patients with penicillin-susceptible Staphylococcus aureus (PSSA) bloodstream infection (BSI). The aim of this study was to compare the 30-day mortality of patients treated with benzylpenicillin or flucloxacillin for PSSA BSI from a large prospectively collected data set from Australia and New Zealand. A logistic regression model and propensity score treatment analysis using inverse probability of treatment weighting were used. A total of 915 patients were included in the study, with an overall mortality rate of 12.9% (118/915) [benzylpenicillin 10.5% (33/315) and flucloxacillin 14.2% (85/600)]. Endocarditis was associated with benzylpenicillin treatment choice, whereas skin and soft-tissue infection was associated with flucloxacillin treatment choice. In the multivariate analysis, increased 30-day mortality was associated with flucloxacillin compared with benzylpenicillin [odds ratio (OR) = 1.6, 95% confidence interval (CI) 1.0-2.5; P = 0.05). When adjusted for treatment choice in the propensity score analysis, flucloxacillin was again associated with increased 30-day mortality (OR = 1.06, 95% CI 1.01-1.1; P = 0.03). An increase in 30-day mortality associated with flucloxacillin use suggests a potential benefit for benzylpenicillin therapy in patients with PSSA BSI.

Multiple traumatisation and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: a preliminary study

BACKGROUND

Individuals with intellectual disability (ID) are at greater risk of exposure to traumatic life events compared with the non-ID population. Yet no study to date has examined the role of multiple traumatisation and subsequent psychopathology in people with ID. The aim of this study was to explore the association between multiple traumatisation and subsequent mental health.

METHODS

A preliminary cross-sectional study involving 33 participants with DSM-5 post-traumatic stress disorder completed self-report questionnaires on exposure to traumatic life events and post-traumatic stress disorder symptoms, anxiety, depression and general distress.

RESULTS

A proportion of 42.4% of the sample reported multiple traumatisation, including exposure to life events in both childhood and adulthood. Those who reported exposure to life events in childhood and adulthood reported significantly higher risk of harm, depression and general psychological distress compared with those who reported exposure to life events only in adulthood.

CONCLUSIONS

Preliminary results indicate that more severe psychopathology is associated with multiple traumatisation in childhood and adulthood compared with trauma experienced solely in adulthood.

Targeting curcumin to specific tumour cell environments: the influence of ancillary ligands

Tumour-activation of prodrugs has the potential to improve the efficacy of anticancer agents while minimising systemic toxicity. Cobalt complexes are of interest in this respect as chaperones to deliver and release anticancer agents in the low oxygen, reducing environment of solid tumours. In addition to being able to release a cytotoxic ligand under the conditions of the tumour microenvironment, it is fundamental that the chaperone complex must also be able to penetrate through multiple cell layers to deliver the cytotoxin to all regions of the tumour. Herein, we report an investigation of the distribution and metabolism of two chaperone complexes of the anticancer agent curcumin within monolayer tumour cells and multicellular tumour spheroids. Using a combination of X-ray fluorescence microscopy, confocal fluorescence microscopy, and X-ray absorption spectroscopy, we demonstrate how the nature of the chaperone complex can profoundly influence the cellular uptake, distribution, and release mechanism of curcumin, providing key insights into the design of this class of prodrug.

Select critically ill patients at risk of augmented renal clearance: experience in a Malaysian intensive care unit

Augmented renal clearance (ARC) refers to increased solute elimination by the kidneys. ARC has considerable implications for altered drug concentrations. The aims of this study were to describe the prevalence of ARC in a select cohort of patients admitted to a Malaysian intensive care unit (ICU) and to compare measured and calculated creatinine clearances in this group. Patients with an expected ICU stay of <24 hours plus an admission serum creatinine concentration <120 µmol/l, were enrolled from May to July 2013. Twenty-four hour urinary collections and serum creatinine concentrations were used to measure creatinine clearance. A total of 49 patients were included, with a median age of 34 years. Most study participants were male and admitted after trauma. Thirty-nine percent were found to have ARC. These patients were more commonly admitted in emergency (P=0.03), although no other covariants were identified as predicting ARC, likely due to the inclusion criteria and the study being under-powered. Significant imprecision was demonstrated when comparing calculated Cockcroft-Gault creatinine clearance (Crcl) and measured Crcl. Bias was larger in ARC patients, with Cockcroft-Gault Crcl being significantly lower than measured Crcl (P <0.01) and demonstrating poor correlation (rs=-0.04). In conclusion, critically ill patients with 'normal' serum creatinine concentrations have varied Crcl. Many are at risk of ARC, which may necessitate individualised drug dosing. Furthermore, significant bias and imprecision between calculated and measured Crcl exists, suggesting clinicians should carefully consider which method they employ in assessing renal function.

A multi-technique investigation of copper and zinc distribution, speciation and potential bioavailability in biosolids

The use of biosolids in agriculture continues to be debated, largely in relation to their metal contents. Our knowledge regarding the speciation and bioavailability of biosolids metals is still far from complete. In this study, a multi-technique approach was used to investigate copper and zinc speciation and partitioning in one contemporary and two historical biosolids used extensively in previous research and field trials. Using wet chemistry and synchrotron spectroscopy techniques it was shown that copper/zinc speciation in the biosolids was largely equivalent despite the biosolids being derived from different countries over a 50 year period. Furthermore, copper speciation was consistently dominated by sorption to organic matter whereas Zn partitioned mainly to iron oxides. These data suggest that the results of historical field trials are still relevant for modern biosolids and that further risk assessment studies should concentrate particularly on Cu as this metal is associated with the mineralisable biosolids fraction.

Antimicrobial Utilisation in 37 Australian and New Zealand Intensive Care Units

This multi-centre point prevalence study reports on antimicrobial dosing patterns, including dose, mode of administration and type of infection, in 37 Australian and New Zealand intensive care units. Of 422 patients admitted to an intensive care unit on 8 May 2007, 195 patients (46%) received antimicrobial treatment, 123 patients (29%) received no antimicrobials and 104 patients (25%) received prophylactic antimicrobials only. Dosing data were available for 331 antimicrobials used to treat 225 infections in 193 patients. Respiratory (40%), abdominal (13%) and blood stream (12%) infections were most common. For adult patients, ticarcillin/clavulanate (23% or 40/177), meropenem (20% or 35/177) and vancomycin (18% or 32/177) were the most frequently used antibiotics; vancomycin was most commonly used in children (31% or 5/16). The majority of antimicrobials were administered as bolus doses or infusions of less than two hours (98% or 317/323); only six patients received extended or continuous infusions. The mode of administration was unknown in eight cases (4.1%). The total defined daily dose for adult patients receiving antimicrobial therapy was 2051 defined daily doses per 1000 patient days. Our results confirm that the use of continuous infusions remains rare, despite increased interest in continuous infusions for time-dependent antibiotics.

Differential phase contrast with a segmented detector in a scanning X-ray microprobe

Scanning X-ray microprobes are unique tools for the nanoscale investigation of specimens from the life, environmental, materials and other fields of sciences. Typically they utilize absorption and fluorescence as contrast mechanisms. Phase contrast is a complementary technique that can provide strong contrast with reduced radiation dose for weakly absorbing structures in the multi-keV range. In this paper the development of a segmented charge-integrating silicon detector which provides simultaneous absorption and differential phase contrast is reported. The detector can be used together with a fluorescence detector for the simultaneous acquisition of transmission and fluorescence data. It can be used over a wide range of photon energies, photon rates and exposure times at third-generation synchrotron radiation sources, and is currently operating at two beamlines at the Advanced Photon Source. Images obtained at around 2 keV and 10 keV demonstrate the superiority of phase contrast over absorption for specimens composed of light elements.

Out-of-area placements in Scotland and people with learning disabilities: a preliminary population study

People with learning disabilities have a different pattern of disease from the general population and high health needs that are frequently unidentified and unmet. Many require responses from general and specialist health services. A picture is emerging of some people with learning disabilities, often with complex care needs, moving from their home area on what is being termed, out-of-area placements, to receive specialist care. However, within the learning disability population, limited research has been undertaken and the impact on health services is unknown. Data were collected from health and social care providers to identify people with learning disabilities moving in and out of services across Scotland. Further data about the consequences and impact of out-of-area placements were gathered in one geographical area using focus group methodology. The results suggest that people with learning disabilities are moving in, out and across Scotland, often as a result of breakdown of local care arrangements or because of lack of specialist resources. Planning, service development and effective communication need to be in place to address the needs of this increasing and ageing population.

Quantitative phase imaging with a scanning transmission x-ray microscope

We obtain quantitative phase reconstructions from differential phase contrast images obtained with a scanning transmission x-ray microscope and 2.5 keV x rays. The theoretical basis of the technique is presented along with measurements and their interpretation.

Experimental measurement of the four-dimensional coherence function for an undulator x-ray source

A full measurement of the four-dimensional coherence function from an undulator beam line is reported. The analysis is based on the observation that the data are consistent with a coherence function that is mathematically separable. The effective source size can be altered by changing the width of the exit slit, and the complete coherence function is presented for two settings. We find, to within experimental error, that the four-dimensional complex degree of coherence can be described as a real Gaussian function that depends only on the difference of the spatial coordinates.

Fluctuation X-ray microscopy: a novel approach for the structural study of disordered materials

Measuring medium-range order is a challenging and important problem in the structural study of disordered materials. We have developed a new technique, fluctuation x-ray microscopy, that offers quantitative insight into medium-range correlations in disordered materials at nanometre and larger length scales. In this technique, which requires a spatially coherent x-ray beam, a series of speckle patterns are measured at a large number of locations in a sample using various illumination sizes. Examination of the speckle variance as a function of the illumination spot size allows the structural correlation length to be measured. To demonstrate this technique we have studied polystyrene latex spheres, which serve as a model for a dense random-packed glass, and for the first time have measured the correlation length in a disordered system by fluctuation X-ray microscopy. We discuss data analysis and procedures to correct for shot noise and detector noise. This approach could be used to explore medium-range order and subtle spatial structural changes in a wide range of disordered materials, from soft matter to nanowire arrays, semiconductor quantum dot arrays and magnetic materials.

Structure and dynamics of a nanocolloidal silica gel dispersion

We studied the structure and the dynamics of a nanocolloidal silica gel dispersed in an organic solvent [octylcyanobiphenyl (8CB)] as a function of the silica density by x-ray intensity fluctuation spectroscopy (XIFS). The silica density of the dispersed aerosil gel samples ranged from 0.03 to 0.20 g cm-3 and the autocorrelation of the silica scattering was probed over the q range from 0.03 to 0.15 nm-1 (corresponding to length scales from 42 to 209 nm) at a constant room temperature at which 8CB is in the smectic-A phase. The gel structure has a fractal dimension in this density range of df approximately 2.15. The time autocorrelation functions of the gels show clear density-dependent and complex dynamics. The gel relaxation times are very long and become bimodal with nonergodic character for densities from 0.10 to 0.16 g cm-3. In this same density range, the fluctuation contrast (strength) is a minimum while the relaxation time becomes independent of wave vector. Together, these results indicate that there is a narrow silica density range for these gels in which the dynamics changes dramatically. This suggests a complex phase diagram for the dynamics of aerosil gels as a function of densification.

Fresnel coherent diffractive imaging

We present an x-ray coherent diffractive imaging experiment utilizing a nonplanar incident wave and demonstrate success by reconstructing a nonperiodic gold sample at 24 nm resolution. Favorable effects of the curved beam illumination are identified.

Synchrotron beam coherence: a spatially resolved measurement

We report a precise and spatially resolved measurement of the complex degree of coherence of a one-dimensional 1.5-keV beam produced by a third-generation synchrotron source. The method of phase-space tomography is used, which requires only measurements of the x-ray intensity. We find that the field is statistically stationary to within experimental error, the correlations are very well approximated by a Gaussian distribution, and the measured coherence length is in excellent agreement with expectations.

X-ray phase imaging: Demonstration of extended conditions for homogeneous objects

We discuss contrast formation in a propagating x-ray beam. We consider the validity conditions for linear relations based on the transport-of-intensity equation (TIE) and on contrast transfer functions (CTFs). From a single diffracted image, we recover the thickness of a homogeneous object which has substantial absorption and a phase-shift of --0.37 radian.

The angiogenic receptor KDR is widely distributed in human tissues and tumours and relocates intracellularly on phosphorylation. An immunohistochemical study

AIMS

Angiogenesis is an important factor in tumour growth and metastasis. Vascular endothelial growth factor receptor 2 (VEGFR-2) or KDR plays a crucial role in angiogenesis. The aim of this study was to raise and characterize antibodies against phosphorylated KDR which could be used for studies on human tissues to assess KDR activation and novel inhibitors of KDR activation in clinical trials.

METHODS AND RESULTS

Three monoclonal antibodies and one rabbit polyclonal antiserum were produced. The specificity of the antibodies was confirmed by ELISA. One of the mouse antibodies and the rabbit polyclonal antiserum reacted with a 200-kDa band on a Western blot of human umbilical vein endothelial cell (HUVEC) lysates, the molecular weight of KDR. Immunohistochemical staining showed that phosphorylated KDR is present in a wide variety of normal tissues including liver, colon and placenta, and is not restricted to endothelium. It was also present in a number of human tumours including breast carcinomas, colonic carcinomas and non-Hodgkin's lymphomas. The pattern of staining was membranous, cytoplasmic and nuclear.

CONCLUSIONS

This study has shown that phosphorylated KDR is present in a wide variety of tumour and tissue types and is not confined to endothelium.

Measurement of the spatial coherence function of undulator radiation using a phase mask

A measurement of the horizontal coherence function of 7.9 keV radiation from an undulator beam line at the Advanced Photon Source is reported. X-ray diffraction from a phase-shifting mask was used, and the coherence function was measured as a function of the width of beam-conditioning slits in the beam line. The coherence distribution is found to be best described by a Lorentzian function.

Rapid on-site defibrillation versus community program

INTRODUCTION

For patients who suffer out-of-hospital cardiac arrest, the time from collapse to initial defibrillation is the single most important factor that affects survival to hospital discharge. The purpose of this study was to compare the survival rates of cardiac arrest victims within an institution that has a rapid defibrillation program with those of its own urban community, tiered EMS system.

METHODS

A logistic regression analysis of a retrospective data series (n = 23) and comparative analysis to a second retrospective data series (n = 724) were gathered for the study period September 1994 to September 1999. The first data series included all persons at Casino Windsor who suffered a cardiac arrest. Data collected included: age, gender, death/survival (neurologically intact discharge), presenting rhythm (ventricular fibrillation (VF), ventricular tachycardia (VT), or other), time of collapse, time to arrival of security personnel, time to initiation of cardiopulmonary resuscitation (CPR) prior to defibrillation (when applicable), time to arrival of staff nurse, time to initial defibrillation, and time to return of spontaneous circulation (if any). Significantly, all arrests within this series were witnessed by the surveillance camera systems, allowing time of collapse to be accurately determined rather than estimated. These data were compared to those of similar events, times, and intervals for all patients in the greater Windsor area who suffered cardiac arrest. This second series was based upon the Ontario Prehospital Advanced Life Support (OPALS) Study database, as coordinated by the Clinical Epidemiology Unit of the Ottawa Hospital, University of Ottawa.

RESULTS

The Casino Windsor had 23 cases of cardiac arrests. Of the cases, 13 (56.5%) were male and 10 (43.5%) were female. All cases (100%) were witnessed. The average of the ages was 61.1 years, of the time to initial defibrillation was 7.7 minutes, and of the time for EMS to reach the patient was 13.3 minutes. The presenting rhythm was VF/VT in 91% of the case. Fifteen patients were discharged alive from hospital for a 65% survival rate. The Greater Windsor Study area included 668 cases of out-of-hospital cardiac arrest: Of these, 410 (61.4%) were male and 258 (38.6%) were female, 365 (54.6%) were witnessed, and 303 (45.4%) were not witnessed. The initial rhythm was VF/VT was in 34.3%. Thirty-seven (5.5%) were discharged alive from the hospital.

CONCLUSION

This study provides further evidence that PAD Programs may enhance cardiac arrest survival rates and should be considered for any venue with large numbers of adults as well as areas with difficult medical access.

Pediatric visceral leishmaniasis in Western Sicily, Italy: a retrospective analysis of 111 cases

The clinical and epidemiological characteristics of 111 consecutive cases of visceral leishmaniasis identified from 1980 to 2000 in a Sicilian pediatric hospital were analyzed retrospectively. The mean age of the patients was 1.7 years. All children were HIV negative, but 15% were severely malnourished. Fever and splenomegaly were present in all cases and hepatomegaly in 101 (90.1%) cases. Thrombocytopenia and anemia were both observed in 78 (70.2%) cases and leukopenia in 47 (42.3%) cases. A bone marrow aspirate was obtained in all cases; Leishmania amastigotes were detected in 89 (80.2%) cases. Initial treatment consisted of meglumine antimoniate in 99 (89.2%) patients and amphotericin B in 12 (10.8%) patients. Only two children treated with meglumine antimoniate relapsed. The findings highlight the differences between the cases of visceral leishmaniasis observed in the Mediterranean basin and those observed in other regions. The use of the term "Mediterranean visceral leishmaniasis", rather than the term "kala-azar", is proposed for cases observed in the Mediterranean area.

Vagus nerve stimulation decreases left ventricular contractility in vivo in the human and pig heart

1. Studies of the effect of vagus nerve stimulation on ventricular myocardial function in mammals are limited, particularly in the human. 2. The present study was designed to determine the effect of direct electrical stimulation of the left vagus nerve on left ventricular contractile state in hearts paced at 10 % above the natural rate, in anaesthetised pigs and anaesthetised human subjects undergoing open chest surgery for coronary artery bypass grafting. 3. Contractility of the left ventricle was determined from a series of pressure-volume loops obtained from a combined pressure and conductance (volume) catheter placed in the left ventricle. From the measurements a regression slope of the end-systolic pressure-volume relationship was determined to give end-systolic elastance (Ees), a load-independent measure of contractility. 4. In six anaesthetised open chest pigs, stimulation of the peripheral cut end of the left cervical vagus nerve induced a significant decrease in Ees of 26 +/- 14 %. 5. In nine patients electrical stimulation of the left thoracic vagus nerve close to its cardiac branch resulted in a significant drop in Ees of 38 +/- 16 %. 6. The effects of vagal stimulation were blocked by the muscarinic antagonist glycopyrronium (5 mg kg(-1)). 7. Administration of the beta-adrenoreceptor antagonist esmolol (1 mg kg(-1)) also attenuated the effect of vagal stimulation, indicating a degree of interaction of vagal and sympathetic influences on contractility. 8. These studies show that in the human and pig heart the left vagus nerve can profoundly decrease the inotropic state of the left ventricular myocardium independent of its bradycardic effect.

Nitric oxide and the autonomic regulation of cardiac excitability. The G.L. Brown Prize Lecture

Cardiac sympathetic imbalance and arrhythmia; Nitric oxide-cGMP pathway and the cholinergic modulation of cardiac excitability; Nitric oxide-cGMP pathway and the sympathetic modulation of cardiac excitability; Functional significance of nitric oxide in the autonomic regulation of cardiac excitability; Summary; References. Experimental Physiology (2001) 86.1, 1-12.

Rats exhibiting acute behavioural tolerance to nicotine have more [125I]alpha-bungarotoxin binding sites in brain than rats not exhibiting tolerance

Adult male Sprague-Dawley rats trained to discriminate nicotine (0.4 mg/kg, s.c. vs vehicle) using a two-lever food-reinforced operant discriminative stimulus (DS) paradigm were tested as to the ability of each subject to develop acute tolerance to nicotine. Nicotine (0.8 mg/kg, s.c.) was administered to nicotine-trained rats in their home cage and each rat tested as to its ability to detect a 2nd dose of nicotine (0.4 mg/kg, s.c.) injected at 30 min intervals thereafter (90-180 min). Tolerance was determined by evaluating nicotine-correct responding during a 2 min test session. The results of this experiment indicated that 8 out of 31 rats (26%) displayed acute tolerance (desensitizers); 18 rats (58%) did not exhibit acute tolerance (non-desensitzers) and five rats (16%) fell into a middle group and were designated as neither desensitizers or non-desensitizers. The mode time for acute tolerance was 150 min, with each desensitizer rat displaying a unique temporal profile which was replicable 4-5 weeks later. Receptor autoradiographic analysis indicated no significant differences in [3H]epibatidine binding sites in the brains of desensitizers and non-desensitizers. In contrast, [125I]alpha-bungarotoxin binding was significantly higher in a number of brain regions in desensitizers. In situ hybridization analysis revealed no difference in alpha7 nAChR subunit mRNA levels between desensitizers and non-desensitizers. These observations can be interpreted to suggest that the ability to display acute tolerance to nicotine is contingent upon the ability to upregulate alpha7 nAChRs. These data may also be central to understanding the variability of tobacco use in humans, which may be contingent on the ability of the receptors binding to alpha-bungarotoxin to be responsive to nicotine-induced desensitization.

Neuronal nicotinic receptors in the human brain

Neuronal nicotinic acetylcholine receptors (nAChRs) are a family of ligand gated ion channels which are widely distributed in the human brain. Multiple subtypes of these receptors exist, each with individual pharmacological and functional profiles. They mediate the effects of nicotine, a widely used drug of abuse, are involved in a number of physiological and behavioural processes and are additionally implicated in a number of pathological conditions such as Alzheimer's disease, Parkinson's disease and schizophrenia. The nAChRs have a pentameric structure composed of five membrane spanning subunits, of which nine different types have thus far been identified and cloned. The multiple subunits identified provide the basis for the heterogeneity of structure and function observed in the nAChR subtypes and are responsible for the individual characteristics of each. A substantial amount of information on human nAChR structure and function has come from studies on neuroblastoma cell lines which naturally express nAChRs and from recombinant nAChRs expressed in Xenopus oocytes. In vitro brain nAChR distribution can be mapped with a number of appropriate agonist and antagonist radioligands and subunit distribution may be mapped by in situ hybridization using subunit specific mRNA probes. Receptor distribution in the living human brain can be studied with noninvasive imaging techniques such as PET and SPECT, with a significant reduction in nAChRs in the brains of Alzheimer's patients having been identified with [11C] nicotine in PET studies. Despite the significant body of knowledge now accumulated about nAChRs, much remains to be elucidated. This review will attempt to describe the current knowledge on the nAChR subtypes in the human brain, their functional roles and neuropathological involvement.

Front-line police officers' practices, perceptions and attitudes about the enforcement of impaired driving laws in Canada

A survey of front line police officers' practices, perceptions and attitudes regarding detection of impaired driving, processing of driving while impaired (DWI) charges, criminal court proceedings and DWI sanctions was conducted across Canada. A sample of 1545 officers of all jurisdictions across the country, representative of different types of police services (i.e. national, provincial, municipal) and types of policing (i.e. traffic, general duty) were surveyed by mail. The results, based on a 71% response rate, indicate that: an average of 7.5 charges/year are laid by officers resulting mainly from erratic driving; videotaping and mobile breath testing could improve efficiency of DWI enforcement; it takes an average of 2 h 48 min to process each DWI charge; about 2/3 of officers say plea bargaining occurs at least sometimes; the average length of DWI trial is over 4 h; less than half of officers think Crown Attorneys are adequately prepared for DWI cases; about 3/4 of officers think the accused escapes conviction on a legal technicality at least sometimes; about 30% of officers say short-term licence suspensions and other forms of discretion are used at least sometimes; DWI places fifth in priority among 15 offences, up from eighth in a 1981 survey; DWI is a priority for most police management but human resources are not adequate; and there is greater support for administrative than for Criminal Code changes. Multiple regressions indicated that the number of DWI charges laid by officers depended mainly on the officers' personal priority regarding DWI enforcement. The results suggest that many officers want to enforce DWI laws but that the numerous procedural and legal barriers that they confront often force them to exercise discretion in the laying of DWI charges.

Targeting male perpetrators of intimate partner violence: Western Australia's "Freedom from Fear" campaign

Violence against women by their partners is now recognized as a major international public health problem, in both developed and developing countries. For example, it is estimated that each year in the US, 4 million women experience a serious assault by their partner and that the victim-related economic cost of partner violence is about US$67 billion. Traditional domestic violence campaigns focus on legal threats and sanctions in an attempt to stop men from being violent. While incarcerating violent men and issuing protection orders are necessary components of domestic violence prevention interventions, they do not--and cannot--remove women's fear of the man reappearing at some future time or place, often with tragic consequences. Furthermore, many women do not want to leave the relationship, nor do they want the man incarcerated; they simply want the violence to stop. The Western Australian "Freedom From Fear" campaign is an innovative social marketing initiative that acknowledges these factors and aims to reduce the fears of women (and children) by motivating perpetrators and potential perpetrators to voluntarily attend counseling programs.