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INTRODUCTION A retired dean and academic vice president of 15 years, who had previously taught graduate students, decided to return to academia in 2006. Kenneth Stewart began teaching undergraduate psychology courses and rapidly realized that the students he was teaching were very different from the students he had taught 20 years ago. The current students seemed less prepared and less motivated, frequently challenged instructor decisions about deadlines, and seemed to hold the instructor more accountable for their learning than themselves. In the classroom, the students displayed a short attention span, decreased mental endurance, and less of an ability to understand the feelings of others.1 Interested in what was causing the change in the students, the professor administered the California Psychological Inventory, Revised, to his students. This is a self-reported personality inventory of 434 true/false questions used to self-describe the behavior of individuals. He then compared the results of the students from 1987 to those of his current class of 20 students, ranging in age from 21–24 years old.1 In the inventory, the current students described themselves as possessing lower levels of perseverance, self-sufficiency, selfcontrol, personal awareness of others, and ambition than the previous generations of students. In addition, the students admitted to possessing weak study habits, were insistent in having things go their way, were easily irritable, and were more disrespectful of rules.1 Stewart later realized that his students were irritated because he did not provide the amount of feedback and approval that the students felt they were entitled to receive.1 (However, he also discovered that many students would return and thank him for challenging them and having expectations that other instructors did not have.) Two thoughts come to mind when reading the above paragraphs and relating them to current physician assistant (PA) education. One is that the scenario generally describes many current first-year PA students nationally. Two, how can these students — who possess few qualities of a practicing PA (perseverance, self-sufficiency, and personal awareness of others) — be transformed into good practicing PAs? This generation — variously known as Generation Y, Millennial Generation, Net Generation, Echo-Boomers, Google Generation, or the Nexters — encompasses approximately 90 million individuals born approximately between 1980–2001.2,3 This generation has been defined by shifts in parenting styles as well as by such issues as globalization, 9/11, and governmental mistruths.4

Using methods of community-based participatory research, a prospective randomized controlled trial of a violence prevention program based on Latino cultural values was implemented with elementary school children in a Mexican American community. Community members participated in intervention program selection, implementation, and data collection. High-risk students who participated in the program had greater nonviolent self-efficacy and demonstrated greater endorsement of program values than did high-risk students in the control group. This collaborative partnership was able to combine community-based participatory research with a rigorous study design and provide sustained benefit to community partners.

Measurement of the effectiveness of violence prevention interventions is in a developmental phase. Social capital provides a framework within which to examine this topic from a community perspective. The purpose of this study was to examine the relationships among three measures of social capital and attitudes about violence among Mexican-Americans. A cross-sectional survey was conducted of households randomly selected by block in two adjacent Mexican-American communities. Demographics, attitudes about and experiences with violence, and three measures of social capital (collective efficacy, neighborhood block conditions, community integration) were assessed. Descriptive, bivariate, and logistic regression analyses were used to examine indicators of violence attitudes and experiences. Of the 473 respondents who completed the survey, 323 (68%) were female, 393 (83%) were Mexican-American, 395 (84%) were born in the US, and 346 (72%) owned their own homes. Participants with high measures of collective efficacy were 1.68 times more likely to have negative attitudes about violence (CI 1.06-2.65) and 15.25 times more likely to have negative attitudes about couple violence (CI 9.05-25.74). Participants with high scores on neighborhood block conditions were 2.33 times more likely to have negative attitudes about couple violence (CI 1.40-3.87). Scores on community integration were not significant indicators of participants' tolerance and experiences with violence. Two measures of social capital were positively associated with and predictive of negative attitudes toward violence. The results suggest that primary violence prevention programs in Mexican-American communities should focus on strengthening a sense of collective efficacy and improving neighborhood conditions.

Fibrinogen is a positive acute-phase protein and its hepatic synthesis is enhanced following inflammation and injury. However, it is not clear whether fibrinogen synthesis is also responsive to oral nutrients and whether the response to a meal may be affected by age. Our aim in this study was to investigate the acute effect of oral feeding on fibrinogen synthesis in both young and elderly men and women. Fibrinogen synthesis was determined in 3 separate occasions from the incorporation of l[(2)H(5)]phenylalanine (43 mg/kg body weight) in 8 young (21-35 y) and 8 elderly (60 y) participants following the ingestion of water (control), a complete liquid meal (15% protein, 30% fat, and 55% carbohydrate), or only the protein component of the meal. The ingestion of the complete meal enhanced fibrinogen fractional synthesis rates (FSR) by 17 +/- 6% in the young and by 38 +/- 10% in the elderly participants compared with the water meal (P0.02). A comparable stimulation of FSR occurred with only the protein component of the meal in both young (29 +/- 7%) and elderly participants (41 +/- 9%) compared with the water meal (P0.005). Similar results were obtained when fibrinogen synthesis was expressed as absolute synthesis rates (i.e. mg.kg(-1).d(-1)). The results demonstrate that fibrinogen synthesis is acutely stimulated after ingestion of a meal and that this effect can be reproduced by the protein component of the meal alone, both in young and elderly adults.

The literature about women in prison says little about characteristics of women in local jails. The goal of this study was to better understand the demographics and characteristics of these women to develop responsive programming. A cross-sectional survey of 346 women in an urban jail was conducted. Descriptive statistics were generated, and a logistic regression analysis was performed to examine contributors to multiple arrests. Of the 346 women surveyed, 65.3% were incarcerated for minor charges and 58.9% had been incarcerated four or more times. Of those with children, the majority had children younger than 18, and nearly 30% had children younger than 5. Partner abuse and involvement in the juvenile justice system were significantly related to multiple arrests. These findings indicated that many women in jail are caught in a cycle of multiple arrests and violence, with many of their children likewise involved.

Forging new frontiers is one description for the completion of the Human Genome Project (HGP) in 2003. This project produced a human DNA blueprint that is revolutionalizing society, changing healthcare, and producing new practice standards. With the genome map, scientists are identifying DNA variations that transform traditional models of health promotion, disease prevention, disease classification, treatment, and symptom management. The HGP is shifting emphasis from traditional genetics to an expanded genomic message. Nursing has responded to the HGP completion by establishing genomic nursing competencies. In 2005, the American Nurses Association (ANA), along with 48 nursing organizations, including the National Association of Clinical Nurse Specialists (NACNS), endorsed minimum essential genetic/genomic nursing competencies for all registered nurses, regardless of education or specialty area. How does the clinical nurse specialist (CNS) explore the HGP frontier and integrate essential genomic nursing competencies into practice? This article discusses the HGP, the development of essential genetic/genomic nursing competencies, and the genomic role of the advanced practice CNS. A 1-day genomics program is described as a pilot project for integrating competencies in practice and education.

Objective:General practitioners (GPs) play an integral role in addressing the psychological needs of palliative care patients and their families. This qualitative study investigated psychosocial issues faced by GPs in the management of patients receiving palliative care and investigated the themes relevant to the psychosocial care of dying patients.Method:Fifteen general practitioners whose patient had been recently referred to the Mt. Olivet Palliative Home Care Services in Brisbane participated in an individual case review discussions guided by key questions within a semistructured format. These interviews focused on the psychosocial aspects of care and management of the referred patient, including aspects of the doctor/patient relationship, experience of delivering diagnosis and prognosis, addressing the psychological concerns of the patients' family, and the doctors' personal experiences, reactions, and responses. Qualitative analysis was conducted on the transcripts of these interviews.Results:The significant themes that emerged related to perceived barriers to exploration of emotional concerns, including spiritual issues, and the discussion of prognosis and dying, the perception of patients' responses/coping styles, and the GP's personal experience of the care (usually expressed in terms of identification with patient).Significance of results:The findings indicate the significant challenges facing clinicians in discussions with patients and families about death, to exploring the patient's emotional responses to terminal illness and spiritual concerns for the patient and family. These qualitative date indicate important tasks in the training and clinical support for doctors providing palliative care.

“Here we go again. We've been through this before. Some pushy crazy white person comes in and wants to tell us what to do … but then she started talking to us about us having control and us making ...

While the decisions and policies of individual countries have an impact on womens health locally those of the US government have a profound global effect. While US agencies both federal and nongovernmental have expended millions of dollars in an effort to improve reproductive health their efforts are often hampered by US policies that interfere with the best interests of the women they are trying to help. Although the United States has historically provided leadership and funding in international reproductive health agencies the current situation is one of reduced or canceled funding to agencies and an insistence on linking funding with adherence to religious faith-based values. Over the past 8 years three US policies in particular have greatly limited the work of government and international agencies to improve womens health: the international gag rule cessation of funding to the United Nations Population Fund (UNFPA) and abstinence focus for HIV/AIDS prevention. (excerpt)

Our objective was to examine the intention of academic primary care physicians to educate women about emergency contraception (EC) and whether differences in their intention varies with patient situation, knowledge and attitudes about EC, gender, or specialty.As part of a larger cross-sectional survey about intention to prescribe EC with 96 faculty physicians from one Southern and three Midwestern universities, we analyzed factors associated with intention to educate patients about EC. Physicians were from departments of family medicine, obstetrics-gynecology, and pediatrics.The main outcome variable was intention to educate about EC. Attitudes and perceived peer expectations on educating about EC predicted physicians' intentions to provide EC education to their patients. Neither knowledge about EC nor physician demographics predicted intention to educate. Almost one in five respondents were reluctant to provide education to sexually active adolescents. Physicians who had high intention to educate were more likely than others to believe that educating about EC enhances a woman's reproductive options and that EC education reduces unintended pregnancy and abortion. Providers with low intention to educate were more likely to consider EC education to be inconvenient and to take too much clinic time.To maximize training programs, physicians' attitudes, beliefs, and professional expectations should be examined when designing and initiating educational interventions.

BACKGROUND:: Little information is available to guide researchers who must estimate the costs associated with obtaining postintervention survey data from research cohorts. OBJECTIVE:: To estimate the costs of following girls involved in the juvenile justice system who were part of a reproductive health promotion intervention for 6 months; to determine the costs of collecting follow-up data; and to determine how participant characteristics, recruitment sites, and follow-up methods affect costs. METHOD:: Direct and indirect costs associated with program staff and various support services' time and the costs of incentives for participation were used to calculate the total cost of follow-up for each participant. Associations between the participant and program characteristics and total costs were assessed using bivariate and multivariate tests. RESULTS:: Of the 449 participants, 402 (89.5%) completed 6-month follow-up. Participants who had been or were pregnant, were runaways, had a history of partner violence, or did not use birth control at baseline were less likely to complete follow-up data. An average of 5.8 attempts was made over an average of 2.97 hr to locate each participant. The average cost of follow-up was $101.82 per participant. Locating participants using family members had the smallest impact on cost, whereas working with parole officers had the largest impact on cost. DISCUSSION:: These findings have implications for researchers preparing budgets for interventions that include a follow-up data collection. Greater resources should be allocated and specific strategies should be implemented when research cohorts have large numbers of participants with specific risk behaviors. Language: en

Introduction The purpose of this study was to examine attitudes and behaviors associated with parenthood and pregnancy among adolescents in the juvenile justice system. Method A cross-sectional survey of attitudes and behaviors about parenthood was conducted with 300 adolescents residing in three juvenile detention centers. Results Data revealed high rates of risky behaviors that resulted in parenthood/pregnancy and generally positive attitudes about being an adolescent parent. Positive attitudes about parenthood (P = .000) and lower self-efficacy to not have sex (P = .021) were significantly correlated with having been pregnant or having fathered a child. Logistic regression showed positive attitudes about parenthood and the combination of drinking and driving together were significant predictors of pregnancy (P ≤ .05). Discussion Pediatric nurse practitioners working with adolescents in the juvenile justice system who routinely provide prevention counseling and implement health promotion programs must take into account the reality that many adolescents in this population are or will become parents and do not consider pregnancy as an outcome to be necessarily avoided. Moving beyond primary and secondary prevention strategies to implement programs to prevent second pregnancies and enhance parenting skills will provide needed health benefits to these adolescent parents.

EXCERPTIntimate partner violence (IPV) results in both short-term and long-term physical and emotional problems for the women involved. Exposure to IPV has a continuing cyclical effect on children who are witnesses (McNutt, Carlson, Persaud, & Postmus, 2002). Millions of health care dollars are spent every year addressing the effects of such violence. Public health principles of secondary and primary prevention provide a way for nurses to implement a clinical approach to IPV.ABOUT THE AUTHORPatricia J. Kelly, PhD, MPH, RN, FNP is an Associate Professor at University of Missouri-Kansas City Kansas City, Missouri.

Purpose Girls today make up 25% of youth in the juvenile justice system (JJS). To address the interrelated sexual and dating violence risk behaviors of this population, we compared the relative impact of a 6-hour, peer-led group intervention, Girl Talk-2, whose goal was to decrease sexual and dating violence risk behaviors, with the impact of a comparison group in which the same information was presented in a standard lecture and video format. Methods A cyclic cohort study with alternating intervention and comparison programs were implemented with 539 girls at 6 sites of a county JJS. Data were collected on relevant knowledge, attitudes and practices pre-intervention, immediately postintervention, and 6 months postintervention. Results Although all participants had high rates of risky behaviors, knowledge and attitudes about sexual protective behaviors were worse as girls’ level of involvement in the JJS increased. At 6 month follow-up, the Girl Talk-2 intervention group had significantly higher use of condoms and communication skills to defuse potentially violent situations than girls in the comparison group. Both groups had improvement in knowledge and attitudes over time, and the intervention group reported higher use of newly acquired communication skills. Conclusions The Girl Talk-2 intervention showed significant changes in 2 out of 3 key protective behaviors for participants when compared with a comparison group. Effective behavioral interventions are essential to assist girls in the JJS safeguard their future health.

Theories about women's health have not traditionally been extended to include the healthy development of young women. This article applies a women's health perspective to the implementation and evaluation processes of a gender-specific primary prevention program that worked with 9-to 14-year-old Hispanic girls in a low-income community. Although community-based after-school programs can be an important venue for education and girls’ development, long-term effects are elusive to evaluate. The authors used ethnographic techniques to learn more about girls and their interactions with the program and to assess short-term program impact. Three themes were found: Program environment can contribute to girls’ expression and behavior, issues of struggling families can slide girls into early adulthood, and mentoring can benefit both girls and adult women. Community-based primary prevention programs, although an essential part of a social safety net available to low-income girls, provide researchers with a unique set of evaluation challenges.

Although research has examined providers' knowledge, attitudes and prescribing behaviors with regard to emergency contraception, none has used a theory-based approach to understanding the interplay of these factors.A cross-sectional survey of 96 faculty physicians from one Southern and three Midwestern universities was conducted in 2004 to assess factors associated with intention to prescribe emergency contraception. The theory of reasoned action guided the study hypotheses and survey design. Correlation and regression analyses were used to examine the data.Only 42% of respondents strongly intended to prescribe emergency contraception for teenagers, but 65-77% intended to do so for all other specified groups (women who ask for the method, who have had a method problem, who have experienced rape or incest, and who have had unprotected sex). Consistent with the theory of reasoned action, high intention to prescribe emergency contraception was associated with positive attitudes toward doing so and with the perception that specific colleagues or professional groups support prescribing it; however, the perception of support by colleagues or professional groups in general did not predict intention. Also consistent with the theory, physicians' knowledge about emergency contraception and their demographic characteristics were not significant.Interventions to encourage physicians to provide emergency contraception should take into account their attitudes toward the method and the components of those attitudes.

A significant portion of the US population has serious problems with both literacy and understanding how to effectively use and understand health-related information. An understanding of the breadth and significance of this problem and its impact on health outcomes is now clear. Interventions and strategies for effectively working with patients with limited literacy must be developed and evaluated. An agenda for medical and public health workers, health educators, and researchers is suggested.

Advanced practice nurses and nurse researchers with experience in clinical settings may encounter challenges in the initial development and implementation of community-based projects. Participatory action research methodology, a user-friendly framework for community-based research activities, provides a way for researchers and community members to work together to define a problem, take action, and evaluate their work. This article attempts to bridge the theory-implementation gap by describing background steps that researchers can use when conceptualizing and initiating a research project with community partners. Suggestions for initial steps and the planning and review cycles are presented, along with examples from the literature.

Adolescents in the juvenile justice system have many risk behaviors that endanger their immediate and future health. They are a vulnerable and often overlooked population for whom pediatric nurses working in community settings can provide important prevention services. To develop an intervention targeted to the specific sexual risk behaviors of young women in a juvenile detention center, this study was designed to assess baseline levels of knowledge, values, and behaviors. The study used a cross-sectional survey design. A convenience sample of 100 adolescent girls (ages 13-17 years, mean 14.8) largely from Hispanic backgrounds (74%) who were detained in the juvenile justice system completed a simplified version of the Mathtech sexuality questionnaire. Correct answers and a brief educational program were provided at the completion of the questionnaire. Results suggest that the overwhelming majority of this population is sexually active (94%) and has inadequate knowledge of basic information on sexuality (mean knowledge score, 10.9 out of possible 18 points). While many young women indicated a belief in the importance of contraception (91%), fewer were comfortable going to a clinic for birth control (46%) or had used a reliable method in the past month (37%). Work that will help to increase knowledge, clarify values, and shape healthy behaviors is essential for this high-risk, vulnerable population.

This study looked at an emergency department based intervention to reduce sexual risk behaviors.

Objective To describe social influences on girls' sexual behaviors. Design Descriptive, exploratory study using interviews with five focus groups. Setting/Participants 48 adolescent girls, ages 12 to 16 years, who were confined in a juvenile detention center for a variety of charges. Interventions None. Main Outcome Measures Girls' perceptions of influences on their sexual behaviors. Results The analysis revealed three themes: the influence of traditional gender roles, a lack of power in heterosexual relationships, and an ongoing search for romance. Conclusions The social context of adolescent girls' lives can promote sexual activity and unprotected sex. Effective prevention efforts must acknowledge the context within which sexual risk occurs and address motivations and barriers in the target population.

The prevalence of Chlamydia trachomatis, a sexually transmitted disease, and the association of selected behavioral risk factors were assessed in a population of adolescents in two juvenile detention facilities. Urine was collected for Chlamydia testing and a brief interview conducted for risk and demographic information. Almost all of the 200 participants were sexually active, many before the age of 13 years. The prevalence of Chlamydia infection was 22.2% among female and 8.7% among male participants. Injection drug use was the only statistically significant variable associated with infection. Education and community services are necessary to break the cycle of infection for this high-risk population.

Tuberculosis treatment is an important component of community health programs. Understanding how different groups of patients experience tuberculosis can influence the completion of drug therapy. This study explored how a sample of patients with active tuberculosis experienced their illness. Guided by questions from Kleinman's (1980) explanatory model, 28 semistructured interviews were conducted in public health clinics. The analysis suggested that patients understood tuberculosis through the medical model and perceived themselves as disease vectors. After their diagnosis became known, almost all patients felt that their family and friends avoided or shunned them. Patients responded to these attitudes by isolating themselves and becoming secretive about their illness. An awareness of patients' experiences can help nurses to understand behaviors that may be labeled as noncompliant and design interventions that address these behaviors. Modifying community attitudes and behaviors poses a longer term challenge to the elimination of tuberculosis.

Lesbians have complained about the lack of awareness and sensitivity of their health care providers, resulting in unnecessary examinations and inappropriate focus on reproductive issues. This study attempted to identify psychosocial and health care needs of lesbians, to assess relationships with primary care providers and disclosure of sexual orientation, and to describe the chronologic features of a sexual identity and lifestyle. An anonymous, self-administered written questionnaire was distributed through a campus lesbian organization. Fifty-three women (median age 23 years) completed the questionnaire. Whereas 60% had disclosed their sexual orientation to their parents, only 31% had "come out" to their health care provider. Of participants who had disclosed their sexual preference to a provider, 27% reported a negative effect on their health care, 57% of participants who never had penile intercourse had annual Papanicolaou smears, and 16% felt pressured in the past to accept birth control from a physician. Lesbian sexuality was associated with several risk factors, such as childhood abuse (20%), alcohol or drug problems (39%), suicide attempts (27%), depression (49%), and physical or verbal abuse at school (34%). Average age of awareness of sexual orientation was 15 years, and average age of first homosexual activity was 17 years. Lesbians are at risk for depression, substance abuse, and suicide attempts. Although most would like to confide in their physician, few do because of fears of negative reactions. Communication must be improved to better address their specific health care needs.

Purpose: To review adolescents' utilization of a hospital emergency department (ED) in a rural area, to identify their characteristics, and to explore their motivation to seek health care in this setting. Methods: A retrospective chart survey of all 4932 adolescent visits (ages 12–18 years, 55.5% females) to the ED in a small town with a population of 55,000 serving a rural area was conducted for the calendar year 1989. Chief complaints and diagnoses were retrospectively categorized according to six groups: injury, pulmonary problems, Ob/Gyn, infection, nonspecific pain (complaint/no diagnosis (diagnoses), and "other". Results: There was an increasing number of visits with increasing age. Adolescents with private insurance, who accounted for 50% of patients, were more likely than self-paying adolescents (14%) and adolescents on Medicaid (36%) to have a primary care source and to have access to a telephone. Injury was the most common diagnosis with motor vehicle accidents (MVA) accounting for 15% of all injuries. Self-paying adolescents and those on Medicaid were more likely to be diagnosed with an infection or an Ob/Gyn problem than adolescents with health insurance. Only 5.9% of adolescents were admitted to the hospital service. 8.5% of adolescents were discharged from the ED without a diagnosis. 78% of these had complained about nonspecific pain. Conclusions: Many adolescents in this rural area were found not to have an identified primary care source and to seek health care in EDs. Illnesses that could have been prevented or treated in a more cost-effective setting thus become "emergencies." Primary care sources are needed that are accessible and acceptable to adolescents.

Objective To assess the prevalence and correlates of hepatitis C virus infection in a sample of detained adolescents. Design/Setting/Participants Cross-sectional prevalence study with 10- to 18-year-old adolescents who were consecutively admitted to a juvenile detention center in San Antonio, Tex. Main Outcome Measures The prevalence of hepatitis C virus infection and associated risk factors. Results Of the 1002 participants, 75% were Hispanic and the mean age was 15 years. Twenty adolescents had laboratory data consistent with hepatitis C virus infection, giving an overall prevalence of 2.0% (95% confidence interval, 1.2-3.1). All adolescents infected with hepatitis C virus were Hispanic (13 boys and 7 girls). Although a high proportion of the participants reported having had intranasal drug use (55.6%), tattooing (50.5%), or body piercing (25.3%), the only factor significantly associated with hepatitis C virus infection was having a history of injection drug use. Injection drug use was reported by 5.3% of the participants but by 95% (19/20) of those infected with the hepatitis C virus. Conclusions This study indicates that injection drug use was linked with the majority of hepatitis C virus infections in this population of detained adolescents, similar to findings in adults. These adolescents reported a high frequency of other behaviors that could potentially pose a risk for contracting bloodborne infections. Effective prevention and awareness programs in a detention setting need to be comprehensive and include screening, hepatitis A and B immunizations, and risk-reduction counseling.

Purpose The purpose of this study is to investigate the effect of chromium picolinate supplementation on insulin sensitivity in HIV disease. Methods The study consisted of six HIV-positive patients (3 female; 3 male) with insulin resistance (IR) determined by a hyperinsulinemic-euglycemic clamp. Insulin sensitivity was determined as the rate of infused glucose necessary to maintain euglycemia during an infusion of insulin (Rd). Subjects were infused with 1.2 mU insulin/kg body weight per minute to elevate plasma insulin levels to ˜ 40 microU/mL, sufficient to suppress hepatic glucose production in other insulin-resistant states. Dextrose was administered intravenously at variable rates to maintain plasma glucose at 90 mg/dL. Plasma glucose was assessed from arterialized blood, obtained by the heated hand technique. Insulin resistance was determined between the second and third hour of insulin infusion. Plasma glucose was determined by the glucose oxidase method. To normalize for differences in body composition, insulin sensitivity is expressed as mg glucose/kg lean body mass (LBM) per minute. Lean body mass was determined by dual-energy x-ray absorptiometry (DEXA) performed with a total body scanner. Patients with an Rd Results Insulin sensitivity significantly increased after 8 weeks of chromium picolinate (p 40% improvement in Rd. One subject9s insulin sensitivity was unchanged post-chromium. Conclusion Supplementation with chromium picolinate may improve insulin sensitivity in HIV disease. Further study is required. (Table)

Background Myopathic pain is a feared complication of HMG CoA reductase inhibitor (statin) therapy, due to associated rhabdomyolysis. The incidence of rhabdomyolysis is low, but myalgias, fatigue and weakness are frequent in statin treated patients and often play a decisive role in patient adherence to the prescribed treatment. Preliminary evidence has implicated mitochondrial defects in ATP production as responsible for these symptoms in patients on chronic statin therapy. Methods Prospectively studied patients on chronic statin therapy (with simvastatin or atorvastatin) with complaints of muscle pain, weakness, fatigue had their myalgias graded on a validated pain scale (range 0-10). Creatine phosphokinase (CPK) values were obtained and correlated with the patients9 self-rated discomfort, statin choice and dosage. The patients participated in a randomized blinded trial of coenzyme Q10 or vitamin E supplementation with the statin choice and dosage held constant. Pain scale and CPK were repeated at the end of 1 month. Statistical testing included measurement of correlation coefficients, Fisher exact test with significance at p Results A total of 41 patients (16 atorvastatin 10-80 mg/day; 25 simvastatin 10-80 mg/day) were enrolled. On entry the average pain score was 4.7 (range 0-8) and the average CPK was 138.8 (range 34-573 mg/dL). There was no significant baseline correlation between pain score and CPK (lowest versus highest CPK quartile 5.4 versus 4.2 mean pain score; p = NS). There was no significant difference in baseline pain score between atorvastatin versus simvastatin (5 versus 4.5 respectively; p = NS) treated patients and no significant correlation in either group of pain severity with statin choice (correlation coefficients -0.13 atorvastatin, -0.47 simvastatin) or dose. After one month pain scores improved (-3 mean) in 20 patients and remained the same or worsened (+0.7 mean) in 21 patients. There was no relation between the magnitude or direction of change in pain score and the change in the repeat CPK. The mean CPK increased by 15.3 mg/dL in the improved pain group and decreased by 14.7 mg/dL in the group with the same or worsened pain; p = NS. Conclusions Myalgias, fatigue and weakness not associated with marked increases in CPK are frequent in patients treated with statins. Traditional CPK testing is unreliable for confirming the presence and severity of the patient9s symptoms and assessing changes in severity. Further work is necessary to develop an objective marker to detect, confirm and quantitate myalgias, fatigue, and weakness associated with statin therapy.

In Reply .—We concur with Dr Smith. This was our first encounter with this child, who had never received regular medical care. Her mother had died, and she was living with her sister. There were no available medical records. Unfortunately, this is not uncommon. Many children with Down's syndrome in rural West Virginia receive only episodic, acute care. However, we obtain yearly thyroid function tests as a part of our routine examination of patients with Down's syndrome.

Background Perception of neighborhood social environment can influence an individual’s susceptibility to drug dependence. However, this has never been examined with a jailed sample, where frequent transitions between local jails and disadvantaged neighborhoods are common. Understanding these associations could aid in the design of targeted programs to decrease drug dependence and recidivism among the incarcerated. Methods For this study, 596 women and men from three Kansas City jails were surveyed over the course of six months in 2010. Drug dependence was assessed with DSM-IV criteria. Independent variables included fear of one’s neighborhood, perceived level of neighborhood violence, and social capital. All data were self-reported and were analyzed using logistic regression. Results Controlling for gender and age, fear of neighborhood violence was associated with increased odds of having drug dependence (OR = 1.27, CI 1.02, 1.58) and a higher level of social capital prior to incarceration was associated with lower odds of drug dependence (OR = 0.65, CI 0.44, 0.96). Mental health problem diagnosis and past year intimate partner violence were significant mediating factors. Gender and race/ethnicity were significant moderating factors between neighborhood disadvantage and drug dependence. Conclusions Our study suggests that drug dependence programs for women and men who cycle between jails and communities require both individual- and community-level interventions. To be most effective, programs at the community-level should focus on helping specific groups navigate their communities, as well as address individual health needs associated with drug dependence.