Jeffrey Dahmer

Jeffrey Dahmer When I was a little kid I was just like anybody else. I was born in Milwaukee in May 21, 1960, the son of Lionel and Joyce Dahmer. At the age of six after some minor surgery, which coincided with the birth of my brother, there seemed to be a change in me. At the time a career opportunity for my father resulted in my family moving from Iowa to Ohio. I don’t know why it started. I don’t have any definite answers on that myself. If I knew the true, real reasons why all this started, before it ever did, I wouldn’t probably have done any of it.Though the thoughts were like arrows, shooting through my mind from out of the blue. By the time I was fourteen the compulsions to murder and necrophilia began to occur. I’d rather be talking about anything else in the world right now, but just after I graduated from high school, in June 1978, I picked up a hitchhiker named Steven Hicks, I took him home to my parents' house, where we drank beer and had sex. When he tried to leave, I killed him with a barbell by hitting his head. That night in Ohio, that was one impulsive night. Nothing’s been normal since then. It tainted my whole life.After it happened I thought I’d just try to live as normally as possible and bury it, but things like that don’t stay buried. I didn’t think it would, but it does, it tainted my whole life. I wish I hadn’t done it. At the same time of my first killing, my alcohol consumption became uncontrollable and in January 1979, I dropped out of Ohio State University after only one term due to my drunkenness. Thus, my recently remarried father insisted that I enlist in the Army, and I was sent to Germany. Though my drinking problem persisted and two years later the Army discharged me for alcoholism.Following my discharge I returned home to Ohio where I went through Hicks' decomposing remains, pulverized them with a hammer, and scattered the pieces even more widely in the woods. La ter in October 1981 I was arrested for disorderly conduct and my father sent me to live with my grandmother in Wisconsin, but my alcohol problems persisted. My next arrest occurred some years later, in September 1986, for masturbating in front of two young boys, for which I received a one-year probationary sentence. In September 1987 I took my second victim, Steven Toumi, whom I met in a gay bar.We checked into a hotel room and drank a lot. I had no intention of doing it. However, the next morning, I found Toumi dead beside me. I was in complete shock. I just couldn’t believe I had done it again after those years when I’d done nothing like that. I don’t know what was going through my mind. I have no memory of it. I tried to dredge it up but I have no memory whatsoever. I bought a large suitcase to transport Toumi's corpse to my grandmother's basement, where I had sex with, and masturbated on it, before dismembering it and disposing of the remains in the rubbish. I developed a pattern of murder that persisted for the duration of my thirteen year killing spree: I sought out mostly African-American men at gay meeting places, lured them home to his grandmother's basement with promises of money or sex, where I would ply them with alcohol laced with drugs, strangle them, have sex with the corpse or masturbate on it, then dismember the corpses and dispose of them, usually keeping their genitals or skulls as souvenirs.I often took photos of each victim at various stages of my murder process, so I could recollect each act afterwards and relive the experience. This re-enactment included assembling the skulls and masturbating in front of them, to achieve gratification. My grandmother eventually tired of the late nights and drunkenness, although she had no knowledge of the other activities, forced me to move out in September 1988, but before that I killed another two people at her house.At this point I had an extreme close call with authorities: I had an encounter with a thirteen-year-old Laotian boy which resulted in charges of sexual exploitation, and second-degree sexual assault, being laid against me. I pleaded guilty, claiming that the boy had appeared much older and, while I awaited sentencing, I moved back in temporarily with my grandmother, where I once again put her basement to gruesome use; in February 1989 I lured an aspiring African-American model, named Anthony Sears, and I drugged, strangled, sodomized, photographed, dismembered and disposed of his body.In May 1989, at my trial for child molestation, to my defense the counsel argued that I needed treatment, not incarceration and the judge agreed, handing down a five year probationary sentence, with one year prison sentence on â€Å"day release†, under which I continued to work at my job, but returned to the prison at night. I was released after ten months, despite my father writing to the judge urging him that I be held until I had received appropriate treatm ent. Then I spent three months with my grandmother on my release before moving into my own partment in May 1990. During the next fifteen months before the time of my capture, my victim count accelerated; and I killed 12 more young men. I developed rituals as I progressed, experimenting with chemical means of disposal, and I also consumed the flesh of my victims. I drilled into my victim's skulls while they were still alive, injecting them with Muriatic acid to see whether I could extend my control to the living. Most of my victims died instantly, but one man survived for a number of days in a zombie-like state, with limited motor function.I was always careful to select my victims on the fringes of society, so that it was less likely for the police to search for them. In the case of my thirteenth victim I had yet another close call; it was a 14-year-old Laotian boy who was, coincidentally, the younger brother of the boy I had been convicted of molesting three years earlier. To my dis may on May 26, 1991, my neighbor, Sandra Smith, called the police to report that a young Asian boy was running naked in the street. When the police arrived, he was incoherent, and the police believed me when I told them that the boy was my 19-year-old lover who had just had too much to drink.The police escorted me and my victim home at which point I strangled the boy and continued with my usual rituals. My luck finally ran out on July 22, 1991, when two Milwaukee police officers picked up Tracy Edwards, a young African-American, who was wandering in the streets with a handcuff dangling from one of his wrists. They decided to follow up his claims that a â€Å"weird dude† had drugged and restrained him, and they coincidently arrived at my apartment, where I calmly offered to get the keys for the handcuffs.Edwards claimed that the knife I had threatened him with was in the bedroom and when the officer went in to corroborate the story he noticed photographs of dismembered bodies lying around. He shouted to his colleague to restrain me so I fought back but I was eventually subdued. A subsequent search revealed the head in the fridge, as well as three more in the freezer, and preserved skulls, jars containing genitalia, and an extensive gallery of macabre photographs. I think in some way I wanted it to end, even if it meant my own destruction. Yes, I do have remorse, but I’m not even sure myself whether it is as profound as it should be.I’ve always wondered myself why I don’t feel more remorse. I was completely swept away with my own compulsion. I don’t know how else to put it. It didn’t satisfy me completely so I was thinking another one will. Maybe this one will, and the numbers started growing and just got out of control, as you can see. When you’ve done the type of things I’ve done, it’s easier not to reflect on yourself. When I start thinking about how it’s affecting the families of people, a nd my family and everything, it doesn’t do me any good. It just gets me very upset.Despite having confessed to the killings during police interrogation, I initially pleaded not guilty to all charges. However, against the advice of my legal counsel, I changed my plea to guilty by virtue of insanity. My defense then offered every gruesome detail of my behavior, as proof that only someone insane could commit such terrible acts, but the jury chose to believe the prosecutor's assertion that I was fully aware that my acts were evil, but that I chose to commit them anyway, which resulted after only five hours deliberation in the finding of me being guilty, but sane, on all counts, on February 17, 1992.I was sentenced to fifteen consecutive life terms, a total of 957 years in prison. I adjusted well to prison life, although I was initially kept apart from the general population. I convinced authorities to allow me to incorporate more with other inmate. On November 28, 1994, in accord ance with my inclusion in regular work details, I was assigned to work with two other prisoners, one of whom was a white supremacist murderer, Jesse Anderson, and the other a delusional, schizophrenic African-American murderer, Christopher Scarver.Twenty minutes after we had been left alone to complete their tasks the guards returned to find that Scarver had crushed my skull, and fatally beaten Anderson with an object. Following my death, the city of Milwaukee was keen to distance itself from the horrors of my actions, and the ensuing media circus surrounding my trial.In 1996, fearing that someone else might purchase my fridge, photographs and killing tools collection and start a museum, they raised more than $400,000 to buy his effects, which they promptly incinerated. This is the grand finale of a life poorly spent and the end result is just overwhelmingly depressing, it’s just a sick, pathetic, wretched, miserable life story, that’s all it is. I should have gone to college and gone into real estate and got myself an aquarium, that’s what I should have done.

Gladiator Powerplay Essay

Gladiator is a film about Maximus, a roman general who was to be the next emperor, succeeding Aurelius. Aurelius’ son Commodus gets angry and jealous at the fact that he was not chosen by his father to be next in line. He then proceeds to kill his father and orders Maximus to be killed. Maximus flees but finds out that his family has been murdered. He later gets enslaved and becomes a gladiator, where he trains under Proximo who also was a former gladiator. He then starts a journey to get the peoples power and to gain revenge over the person who killed his own family (Commodus). Imperial or political power play * Maximus has to gain the trust and power from the general public * Commodus is jealous that he did not get picked as the next emperor * Maximus is shown as being fearless which makes the crowd like him even more * Maximus has nothing to lose, so Commodus can’t do any more damage to his public image * Maximus was shown to be a noble and powerful Roman general Power play in relationships * Maximus and Commodus has a strong tension to show each other who has more power * Commodus and Aurelius had a bitter relationship and ended in Commodus murdering Aurelius * Maximus and Proximo where Maximus had learnt to become a fearless gladiator * Commodus’s guards and Proximo, where Proximo gets murdered * The People and Commodus

Text - In - Context Paper Essay Example | Topics and Well Written Essays - 1250 words

Text - In - Context Paper - Essay Example The protagonist lives an extremely squalid life upon arrival in England. This feature is revealed at the sharing of tiny rooms amongst numerous men. Feeding standards were entirely low. However, the men moved gradually from the room to get married. The story quotes, â€Å"Every now and then someone in the house moved out, to live with a woman whom his family back in Calcutta had determined he was to wed† (Lahiri 174). Iyer, Zare, Shankar and Cheung are major critics in literature. In their publications, they affirm the influence of Lahiri’s life experiences to her writing. The critics also qualify Lahiri’s work as a short story. â€Å"The Third and Final Continent† takes the form of a short story in prose fiction. This story features majorly immigrant families and individuals from India (Iyer and Zare, 42). Iyer and Zare reinforce this fact in his analysis and criticism of the story. Indian immigrants shared a uniform culture. As denoted previously, the me n moved out of the room to get married to women chosen by their families (Iyer and Zare, 42). They usually traveled back to their native home Calcutta to get married (Lahiri 174). This story is narrated in the first person voice. The protagonist expresses his journey and adversities from the onset of his journey from India to England and Britain. He suffers poverty in England after serving in a library. Subsequently, he travels back to India for his marriage processes. He obtains a wife and travels to America where he still lives under squalid conditions in Mrs. Croft’s room. As he lived in this place, he was waiting for his wife in India to obtain a green card. His wife eventually obtains a green card and joins him in America. The protagonist gets a better house to accommodate his wife. Throughout his stay in America, he was serving in a library at M.I.T (Lahiri 176). The protagonist nurtures his family in this foreign land. His son pursues higher education in Harvard Univer sity. At the culmination of the narration, the protagonist encourages his son by narrating his past encounters. He asserts that nothing should be impossible if he survived on three continents. This short story drives much influence from the lives of immigrants in foreign lands (Iyer and Zare, 44). Lahiri is a major voice in modern literature. However, a majority of her literary works may constitute ancient ideologies. She focuses on harmonizing the antique ideologies and thoughts with the recent happenings (Iyer and Zare 40). This author has a rich history and background. She was a daughter of Indian immigrants. Her father and mother upheld Indian principles and perspectives even after their settlement in America. Lahiri’s father served at a library in the University of Rhode Island. Her father oversaw her academic achievements from kindergarten to the tertiary level. She went to South Kingstown High School with the support of her parents. After graduating from Barnard Colleg e, she joined Boston University to further her course in Literature (Shankar and Cheung x). Shankar and Cheung are major literary critics that also reinforce the influence of Lahiri’s life experiences to her writing of the story. This history had a definite impact on the composition of â€Å"The Third and Final Continent.† Characterization borrows much from her background (Iyer and Zare, 40). There is an evident link of the protagonist and Lahiri’

Baroque Style Research Paper Example | Topics and Well Written Essays - 750 words

Baroque Style - Research Paper Example The Taking of Christ, painting by Caravaggio, represents Baroque style as well. The story of the painting is interesting, because for a long time it was attributed to another artist. It was painted at the beginning of the 17th century for Mattei family. It was known that the painting existed but its location was not known. When it was found and examined in Dublin, it became apparent that it truly belongs to Caravaggio’s hand, because it was characterized by the features that typically belonged to the painter’s style: â€Å"bright highlights, dark sharp shadows, and a black background† (Caravaggio Gallery, 2013) One technique that Caravaggio often used in his paintings is the use of the back of his brush to highlight or outline parts. It is also present at the painting. The sharp contrast between light and dark characteristic for Caravaggio, is outstanding here. The artist took Biblical story as the base for The Taking of Christ – betrayal of Christ by Juda s and his taking by the Roman soldiers. There are seven figures at the painting. It is interesting to see how the expressions of their faces are different. Jesus is calm and peaceful, He knows about what He needs to go through, and He is ready for that. In contrast to Jesus, the face of St. John shows pain and distress. The disciple is shocked by what is going on. The face of Judas is seemingly calm as he is kissing the cheek of Christ and thus betrays him. Therhe man with the lantern, is believed to be the self-portrait of Caravaggio himself.

Ch8 - reflectional journal Essay Example | Topics and Well Written Essays - 250 words

Ch8 - reflectional journal - Essay Example These tools can highly transform teaching skills and education. The â€Å"high tech† tools offer various advantages that range from lesson planning, lesson presentation, record keeping, and classroom management. Therefore, a teacher can be able to accomplish many tasks within a short period than when using the traditional method. Additionally, the tools can help to show subject-related documents like science and can also enlarge or rather zoom-in images presented in these subjects. Technology also presents internet-based sites that provide helpful information that students can use in their researches (Bates & Poole, 2003). This makes teaching easy and less boring than when using the traditional methods. My personal view is that technology should be utilized in almost all teaching practices. The reading presents social media as a platform that can be used to form one’s own Professional Learning Community (PLC). In my view, I feel that social media acts as a communication and collaboration tool between me as a teacher and the students. Some of the social media platforms such as Twitter, Facebook, and student blogs support this kind of interaction thus allowing effective learning environment. The social media can remain safe for student to use by ensuring personal and professional barriers are in place and also ensuring the language used is on task being learnt and is respectful (Bates & Poole, 2003). This way social media use will more effective and education level will

The role of salt marshes in the coastal system Essay

The role of salt marshes in the coastal system - Essay Example Since salt marshes are shallow areas, the plants that exist in salt marshes are those that can adapt to the tidal changes in the volume of water. The water waves that make it to the salt marshes carry with them tons of organic material which accumulate overtime to form peat. There are many varieties of salt marshes namely: low marsh, high marsh, panes and pools and upland border. Apart from providing thick vegetation, salt marshes are also amongst the most productive ecosystems in the world (New Hampshire Department of Environmental Services, 2004). Role of Salt Marshes in the Coastal System: Salt marshes are sometimes referred to as tidal marshes, the reason being that salt marshes are found in zones between high and low tide. Salt marshes thrive well along the coastal areas because the vegetation is not sturdy enough to withstand strong waves, therefore towards the coastal areas, where the intensity of the waves is reduced to quite an extent, salt marshes thrive (Casagrande, 1997). Salt marshes serve many purposes, namely; they cleanse pollutants from marine water, provide a habitat to many marine species, provide a barrier against soil erosion, provide a source of refuge for the vulnerable marine species, salt marshes are rich in organic matter therefore they form a food chain for the marine life and also provide good nutrient value for the vegetation in the salt marshes (Department of Environmental Protection: Florida Marine Reseach Institute, 2010). Let us throw some light on the varied roles of salt marshes: Remove Pollutants from the Water Since the speed of the waves reduces considerably by the time they reach salt marshes, many suspended particles that are otherwise carried away by the waves throughout the sea, tend to settle. These suspended particles sometimes comprise of toxic nutrients from human activities, thus by allowing them to settle the salt marshes play a key role in cleansing the water of toxic sediments. The thick vegetation helps in slow ing down the waves which in turn causes the particles to settle. Furthermore, during the months of summer and spring the salt marshes’ plants take up the nutrients which if left in the water, would turn into algae, further polluting the water by causing â€Å"Eutrophication† and thus depleting the oxygen supply of the water (Cloern, 2007). The toxic contaminants which are settled by the salt marshes form peat which results in the removal of these toxic substances from the marine food web. Moreover, the microbes present in the salt marshes tend to remove nitrogen from the ecosystem (Edwards, 2010). This is beneficial even to the surrounding eelgrass. The reason behind this is that the existence of high levels of nitrogen encourages the growth of phytoplankton. Phytoplankton refers to microscopic organisms that live in water (Lindsey, 2010). This phytoplankton, when in excess blocks the sunlight which is needed for eelgrass to thrive. Therefore, the presence of salt mars hes also benefits eelgrass. Harbour Marine Food Chains The excessive nutrients found in the salt marshes form food chains for marine species. Primarily, the plant matter that partially decays in the salt marshes forms a good source of food for marine species in the deeper waters. This decayed vegetation is taken away by the tidal waves into the ocean where it becomes the food of many marine animals. A two way process runs between aquatic

Technology Fundamentals Essay Example | Topics and Well Written Essays - 1250 words

Technology Fundamentals - Essay Example The literature, art and history on the matter should be explored to reduce the doubts and blanks about the objective kept. Comparison between those should be done to dig most appropriate ideas and facts. Lakota Sioux culture poses an interesting and profound one which creates a domain of better analytical and reading opportunities. The areas of their prevalence, linguistic values, beliefs, tradition, dressing styles etc. all are equally important for the study. The culture of Lakota Sioux is being identified from various sources giving rigid support for out studies. Students should understand the distinct facts and values of Lakota Sioux culture through the completion of the set learning objective. â€Å"Rosebud Traditional Lakota Radio Station† is good source for Lakota Sioux cultural appreciation which helps in â€Å"building an independent traditional radio station on rosebud† (Rosebud traditional Lakota radio station and drive, n.d., para.1). The radio broadcast helps to revitalizes the courage, strength and quintessence of self-important Lakota Sioux culture. The broadcast is carried out as KINI FM 96.1 with much support given to spreading the virtues and traits of Lakota Sioux through various music programs which are connected to classic as well as modern touches of their culture. The other perspectives to be observed are the history, art and performance of Lakota Sioux. The films are very good sources of these factors explicitly. Two films named "Lakota Quillwork: Art and Legend-A Story of Sioux Porcupine Quilling: Past and Present. 1990" and "TAHTONKA: The Plains Indians and Their Buffalo Culture. 1973† can be utilized for achieving our learning objective. (Maldonado & Winick, 2004, para.3). It is a tradition among Lakota females to conduct ‘porcupine quilling’ which is being covered completely in the film Lakota Quillwork: Art and Legend-A Story of Sioux Porcupine Quilling: Past and Present. The audience get ideas on

A Scientific Model for Grassroots O.D Assignment

A Scientific Model for Grassroots O.D - Assignment Example Instead, their efforts in O.D. lead to disappointing results. Regarding the need for grassroots O.D., no one can change an organization. Each individual within an organization needs to contribute to cultural change in order to achieve positive results in O.D. Besides, mentorship programs could be very effective. A grassroots O.D. model is again useful as it involves setting the bar, motivating change, sustaining the change, and scaling the change to enterprise. Essentially, drive to change is achieved through passionate commitment, which is characterized by good roles and actins, supporting organizational resources, and managing risks. To bring out all the points about O.D. effectively, the article is divided into various sections. An abstract is written to introduce the article and all it entails. The introduction section defined the problem and its background, including the models used. Each model is discussed in depth with respect to the topic, but the main model addressed is the grassroots O.D. model. The article is written in a scholarly manner with all sections being addressed including the methodology, achievement of the model, and conclusion/ summary. To show that the intensive study and research has been conducted from other sources, the resources used are indicated. The article is well presented, but it lacks a clear distinction in the three key sections of a scholarly article, especially the methodology, and

English 2 Investor Relations Officer Essay Example | Topics and Well Written Essays - 1250 words

English 2 Investor Relations Officer - Essay Example The officers work in fast-paced environment and must have excellent communication, interpersonal and decision-making skills in order to adequately perform their duties. Self-confidence and emotional maturity enables the officer to maintain trust and build relationships with other stakeholders in the commercial real estate development industry (Marcus 145). The investor relation officer will interact with the senior management and his or her responsibilities include talking to analysts, planning presentations, designing corporate messages and establishing policies that will guide the corporate disclosures (Fitch 6). Investor relations officer is a challenging and competitive career that entails handling of a wide variety of corporate matters and communicating with various stakeholders in the industry. Thesis statement: Investor relations officer is a rewarding career that offers high personal growth and professional development opportunities for the job holder. Investor relation officer in commercial real estate development is tasked with providing information and managing communications with all stakeholders (Fitch 6). He or she maintains existing client relationships and identifies opportunities for the existing clients to use the commercial real estate development products. Investor relations offers accurate information on the earnings forecasts, annual and quarterly reports and strategy decisions of the company (Fitch 6). He or she is expected to prepare real estate development research reports on the emerging trends and distribute them through newsletters to the stakeholders. The investor relations officer deals with pension funds, insurance companies, lending financial institutions, and investors who own the company stocks (Fitch 6). Another critical task is managing press releases, investor materials and conferences. The investor relations officer is expected to enhance the corporate reputation and image through participating in cor porate events and

Sherlock Holmes Essay Example for Free

Sherlock Holmes Essay How does Arthur Conan Doyle create an atmosphere of mystery and build suspense in The Speckled Band? To what extent are his methods typical of all the other stories in The Adventures of Sherlock Holmes?  The story The speckled band was written by Arthur Conan Doyle in 1982 and is one of the many stories in the large Sherlock Holmes series of stories. As known the stories are based on inquiries and investigations, because of course Sherlock Holmes is an investigator, this in itself gives a sense of excitement to the story because you know that there will e a constant thrill throughout the story, especially seems as it is likely that it will be based on something like a murder, or an affair, etc. As soon as the story starts, Holmes gets straight into the action, as a poor victim comes round to his home and asks him for help. She is portrayed to the reader as being in a very poor and vulnerable position by her face (being) all drawn and grey, with restless, frightened eyes, like those of some hunted animal, she is also shivering from fear and so now the reader knows that there is a vulnerable victim, that something is wrong, and that something unjust will be done against her, and so it builds the excitement and suspense in the readers mind. This same scenario is presented in A case of Identity when Miss Sutherland comes to Sherlock Holmes in a similar vulnerable state, frightened. As usual straight away Holmes picks up on all the little details, such as the mud stains on the victims clothes, and manages to create a clear picture in his mind of the situation. The victim is called Miss Helen Stoner. When she first came into the story she was wearing black, veiled and grey haired. She was shivering and terrified, which creates a scary if not intriguing scene leaving the reader asking why is she in this state?!, the lady also gave a violent start, by saying It is fear Mr Holmes, It is terror.  The story then goes on and Holmes is told about the ladys step father, who instantly Holmes recognizes as the murderer.  We can make out from the story, that her step father Doctor Grimesby Roylott was a violent man who had a bad and short temper, and after his wife dies he shut himself up at home and became very violent, and we are told that he is a man of immense strength, and absolutely uncontrollable in his anger. The suspected murderer is described as being a very strong and powerful person, and extremely dangerous, this adds suspense and excitement to the story because from this description you can instantly tell that something out of the ordinary has got to happen with this man.  The killing motive is also freaky in a way, because what he was trying to kill Miss Helen Stoner for was money. His wife left money for her daughters, but if they die he would receive the money.  Personally I dont feel sympathy for Doctor Roylott because hes sick and twisted, hes also very selfish, but a very dangerous man. The scene of the murder adds a considerable amount of suspense to the story, this is because as it is first described, the building is made out to be a scary if not haunted freaky place.  The house is described as The building was of grey, lichen-blotched stone, with a high central portion and two curving wings, like the claws of a crab, thrown out on each side. In one of these wings the windows were broken and blocked with wooden boards, while the roof was partly caved in basically making it look like a picture of ruin. This creates a spooky and scary atmosphere, which makes the reader feel very cautious because its a typical description of a haunted house where anything could suddenly happen. This atmosphere can be easily related to a typical atmosphere of a murder mystery. To add to the atmosphere or fear and horror, the reader is told about the Doctors hobby of keeping wild dangerous animals, and that there is a Wild baboon and a cheetah in the grounds of the house. In the story Holmes suspects Grimesby Roylott as the murder suspect, and he treats the case as urgent, and helps Helen Stoner straight away. This gives the reader the impression that it is important, and so it adds to the feeling that something big is going to happen, and that the case is dangerous. The addition of creepy objects in the house also helps relate an atmosphere, such as the useless ventilator, and the ropes which hung down to the ladys bed.  Holmes also suspects the animal as a dangerous exotic one, in this case it being a snake, and this is not obvious to the reader, and so they will be kept waiting to see what these strange object, and weird animals are all there for. In the end, the murderer who correctly turns out to be Doctor Roylott, gets killed by his own weapon the deadly snake.  This makes the story come to an exciting end, and it in many ways sums up the complete suspense and mystery that has been throughout the book, and makes it all clear to the reader at the end.  The readers will also think about if they think he deserved to get killed because he is sick and twisted, and because he does not care for any one apart from himself. I like my murder mysteries to have a twist at the end and that good always wins.

Practice Nurses Role in Treating Chlamydia

Practice Nurses Role in Treating Chlamydia The practice nurses role in treating chlamydia and improving the sexual health of the nation Introduction Chlamydia treatment has been the focus of considerable research interest in the past few years. A huge proportion of what used to be called NSU, or was even undiagnosed non-specific pathology, is now recognised as being due to the chlamydia pathogen. It has now achieved the unenviable status of being considered responsible (numerically) for the greatest amount of sexually transmitted disease in the UK today (Duncan 1998) Given the fact that it is now therefore recognised as being a major contributing factor in the overall picture of sexual health, we must examine ways in which the NHS is set up to tackle the problem. (HPA 2003) As with many health related issues such as this there are a number of subsidiary issues that must be considered in relation to the main theme. These include the role of the screening process in trying to contain the prevalence of chlamydial infection, the practice nurse’s role in that screening process, the current thoughts on the treatment of chlamydia and the practice nurse’s role in not only the treatment, but also the partner tracing activity that is vital to try to stop the spread of the disease. (Fenton et al 2001) The practice nurse is generally ideally placed within the primary healthcare team to act as a central liaison point for many of these activities If we start by considering the whole issue of screening. On one level, one could be forgiven for thinking that the issues relating to screening are actually rather simple. We know that many cases of chlamydia are actually asymptomatic (see on). Given the fact that it can cause considerable damage and is eminently treatable, why not screen for it and get rid of it? Sadly, it is not as simple as that. (Simms et al 1996) The National Institute for Clinical Excellence (NICE) has set up the National Chlamydia Screening Programme (NCSP). It quotes its rationale for doing so as: Genital Chlamydia trachomatis is the commonest Sexually Transmitted Infection (STI) in England Genital chlamydial infection is an important reproductive health problem ~ 10-30% of infected women develop pelvic inflammatory disease (PID). A significant proportion of cases, particularly amongst women, are asymptomatic and so, are liable to remain undetected, putting women at risk of developing PID. Screening for genital chlamydia infection may reduce PID and ectopic pregnancy. The study itself was exemplary in design with an entry cohort of nearly 8,000 patients. The authors considered the efficacy of several different methods of screening and then compared the results of the programmes against the costs of allowing the disease to continue untreated in the community and these include all the sequelae of infertility, pelvic inflammatory disease and ectopic pregnancy in women together with the complications that can occur in the male partners (infertility again) and prostatitis. (Berry et al 1995) The paper even covered the incidence of both pneumonia and eye infections in their children. The structure of the study was quite comprehensive insofar as it compared the results of four separate groups One group received no screening at all, a second group were screened if they exhibited mucopurulent cervicitis, the third group included all women who were less than 30 yrs. old and the last group was all women irrespective of symptoms. The actual screening tool was the Polymerase chain reaction (PCR) which is a very specific and sensitive antibody based test. It was performed on either urine or direct cervical samples. (Barlow et al 2001) The study protocol then called for all positive testing patients to receive treatment with doxycycline for seven days. The analysis section of the paper is both long and complex. We shall therefore condense our examination of this part of the study into an examination of the results. The overall treatment costs of treating all of the medical complications of chlamydial infection was calculated as $676,000. Each of the positive screening strategies produced a significant reduction in the expected cost of complications that was greater than the cost of the actual screening exercise. A condensation of the tabulated results is shown here: Screening method Screening costs ($) Medical costs ($) Total cost ($) Number of PID cases PID cases prevented No screening 676,000 676,000 152 CDC criteria 55,000 390,000 446,000 88 64 Women 75,000 297,000 372,000 67 85 Universal screening 120,000 270,000 391,000 61 91 The results need little explanation, as it can be clearly seen that both the costings and the number of cases prevented argue strongly for a case for screening. The only point of contention is the decision on the population that the health care system will fund for screening. Overall, the authors state that their regime reduced the incidence and prevalence of pelvic inflammatory disease by 60% when compared to the unscreened group. The other significant factor was that, taking all groups as an average, they noted a total healthcare saving of about $50 per woman screened, and this clearly does not take any account of any associated comorbidity, pain and suffering that is caused by the chlamydia infection A further corollary can be drawn from the results. The authors went on to provide an impressive statistical analysis of the comparative costs of different community groups with different rates of prevalence. Of great importance to our considerations here was the fact that the authors concluded that the cost of screening was cost effective when the incidence of infection in a population of asymptomatic women was above 1.1%. when the incidence rose above 11% then they found that the screening of all women and their partners became the most effective strategy. To some extent, this study can be considered the â€Å"gold standard† for most of the studies in this area. It is well conceived, meticulously executed and well and thoughtfully analysed to give meaningful results which are of great practical importance. Despite such comments it should be noted that there are a number of negative points to be considered in this particular study. The universal treatment constant was the seven day doxocycline treatment. We should note (as the authors did) that there is therefore a potential for non-compliance with the whole seven day regime, and this may introduce a potential source of bias in the figures(Haddix et al.1995). We can also point to other studies that have addressed this particular problem with a one dose treatment regime (azithromycin). It is fair to note that despite the potential for bias, extrapolation to these other studies does not appear to show significant differences in the overall results (Lea et al 1997) The issue of screening, although covered reasonably comprehensively in the last paper, certainly as far as matters of cost are concerned, is examined further in the paper by (Duncan et al. 2001). This paper approaches the issues from a different perspective. It includes the issues of male screening And takes an overview of the Public Health issues from a sociological viewpoint, which makes it, (in our examination of the current literature), almost unique. We should note that we have already addressed the issues faced by the NCSP, but the other major public document in this area is the report commissioned by the Chief Medical Officer (CMO 1998). It is instructional to discuss the recommendations of this group as they differ significantly from the screening criteria used in the previous paper. The recommended groups for screening here are the following: Everyone with symptoms of chlamydia infection, All those attending genitourinary medicine clinics, Women seeking termination of pregnancy.1 Opportunistic screening of young sexually active women under 25 years Women over 25 with a new sexual partner or two or more sexual partners in the past year. In the context of our considerations here, we should note that the advisory group identified the optimum sites for screening as the primary healthcare team (family planning clinic) as well as the usual GUM clinics. (Stokes 1997) The Duncan paper is particularly well written and a major point that comes from it is in sharp contrast to that found in the Howell study. One of the criteria that they suggest for screening males in the population is that women may find that being screened has connotations of being dirty and unattractive A positive result is said to be associated with promiscuity. The authors suggest that not screening men not only fosters gender inequalities but it reduces the Public Health impact on the Man’s responsibilities for sexual health. (Pierpoint et al 2000) There is no argument that this is a valid point, but the paper does not produce any evidence to show that male screening has a positive impact on the cost-effectiveness of the screening procedure. (Stephenson et al 2000) The paper does however, contrast these statements with the accepted fact that women are actually easier to target than men, as they are generally heavier health care users than men in the major at risk age range. (Oakeshott et al 1998) The paper points to the need to tackle the issues of sexual inequality, as it could be considered that the screening programmes may have less than the desired effect if they are perceived by women to be little more than surveillance of their particular sexual habits. It draws a clear analogy between a women only screening programme for chlamydia and the well established women only cervical cytology screening clinics. The paper quotes (Holgate et al 1998) in the comment: The potentially adverse consequences of sexual intercourse a private event can be surveyed and treated through screening services a publicly based and funded system . It is women who transcend this private, public dichotomy and find their lives scrutinised in a manner alien to men . The focus is commonly upon women both as transmitters and contractors of relevant viruses as both those whose cervixes are surveyed and whose sexual activity comes under surveillance. The paper then has a long middle section which, as a critical analysis, is little more than a diatribe against women being singled out for screening. It is fair to say that all of the arguments put forward are valid, to a degree, but are presented with a strongly feminist viewpoint, which is both understandable and worthy of merit form a sociological standpoint. The arguments are not however, convincing from a scientific, financial or practical perspective. The conclusions of the paper are entirely justified in calling for a greater understanding of the woman’s point of view when organising and running screening clinics, in order to broaden their appeal to the target groups. (Santer et al 2000) With specific reference to the role of the nurse in the primary healthcare team screening for chlamydia we can now turn and examine an excellent paper by Grun (et al 1997) which looked at two different methods of screening for chlamydia in a nurse run primary healthcare setting. The study set out to try to accurately determine the prevalence of chlamydia in the North London area using the ligase chain reaction (LCR) technique which is similar to the PCR mentioned earlier. (Butt et al 2001) This particular study used the rather labour intensive cervical scrape method for sampling, which had the added benefit that cervical cytology could be assessed at the same time. The paper is quite detailed in its description of its method and appears to be rigorous in its execution. It is worthy of our consideration here because of it’s direct relevance to our prime consideration. The results and conclusions of the paper make for interesting reading One of the more significant conclusions was that, on the basis of their findings, if there was a policy of simply screening all women aged 25 and all women who had had two or more partners in the past year, they would have detected 20 out of a possible 23 positive chlamydia infections in their cohort. The authors make a salient comment that including other screening criteria such as marital status (which has been suggested by other authors [Lossick JG, et al 1996]), would have made no statistically significant impact on their detection rate. They also make the comment, in line with the other authors we have examined, that selective screening appears to be more cost effective than universal screening, although the actual cost implications were not specifically considered in this paper. In contrast to the Howell paper, it suggests that screening become a viable tool when the community prevalence rate approaches 5% The fourth paper to be reviewed is the more recent paper by Adams (et al 2004). This paper takes a more general overview of the whole issue of chlamydia in the UK. This is effectively a meta analysis of nineteen different papers (selected from 357 studies) which report the incidence of chlamydia as tested by the PCT method on urine samples. This is significant as it is the first meta analysis to be carried out on UK data. (Armitage et al 2001) The results are extremely detailed and many are only of marginal relevance to our considerations here. We shall restrict our comments to those aspects that are specifically relevant. Firstly, the authors comment on the current prevalence of 8.1% of the population testing positive in the under 20 age group, progressively diminishing to 1.4% in the over 30 group. The significance of this is that it is very much lower than other studies. For example studies set in GUM clinics put the prevalence in the under 20 age group in the region of 17% and antenatal clinics at about 12%. (Piementa et al 2003) This may therefore have relevance in targeting of specific at risk groups. It should be noted that this study gave no data with regard to the incidence of chlamydia in the male population. (Dixon et al 2002) Our comments made earlier about the asymptomatic nature of the bulk of the infections, is borne out in the fact that only 8% of those tested and found to be positive, actually volunteered that they had any genital symptoms (of any sort). Another important consequence of this study is the fact that it highlights the comparatively high detection rate to be found in attenders at primary healthcare team premises. This shows a gap in the reasoning and recommendations of the National Sexual Health and HIV Strategy for England (D of H 2002) which currently suggests targeting GUM clinics and family planning centres as prime sites for screening centres. Following on from the reasoning expounded in the last paper, we can look at a provocatively entitled article by Kufeji (et al 2003)† Who is being tested for genital chlamydia in primary care?† The paper makes the point that we already have enough evidence to clearly identify the target populations that are the most likely to give a good yield as far as screening is concerned (viz. the most â€Å"at risk† groups). The raison d’à ªtre of this paper was to compare the characteristics of the actual groups screened with the characteristics which we know to be representative of the groups most likely to be at risk. The corollary of this reasoning being that if the two groups do not match then all the calculations made about the cost effectiveness of a selective screening process do not hold water. (Kinn et al 2000) The most striking feature of this paper is the fact that we know (Adams et al 2004) that the maximum age incidence for chlamydia is in the sexually active under 20 age group and the incidence rapidly decreases with age to the over 30 age group. Kufeji and his co-workers found that the majority of the tests done (63%) were done on the over 25 yr. age group where we would expect the results to be positive only in about 1.5% of the population. Adams’ findings were confirmed with a positive rate of 13.3% found in the under 20 yr. olds tested. The paper also point to the fact that the practices studied had a comparatively high healthcare staff to patient ratio. In the practices where the ratio was lower, even less opportunistic testing was done. (Shefras et al 2002) This correlates to the finding that the Townsend score ( of social deprivation) correlated highly with both a reduction in the amount of testing and an increase in the prevalence of chlamydia. In the words of the authors the study points to the fact that screening programmes for chlamydia in primary healthcare settings suffer from â€Å"a selection bias and social desirability bias, and they do not aim to provide complete descriptive information on testing patterns across a population.† It should be noted that this particular study was not just on a small sample. The authors took as their entry cohort all of the 119 General Practices in Nottingham which collected a total of over 7,000 samples. The authors note that the number of tests done in General Practice is increasing at about 35% per year. It follows that if a significant number of these are inappropriately targeted, this has profound implications for the related costings of the exercise. One other salient point in this study was the fact that only 1 in 40 tests were done on men. (Chernesky et al 1999) The last major paper that we shall review in this section is the paper by Cassell (et al 2003) this deals with the thorny issue of partner notification when screening turns up a positive result. Hitherto contact tracing had largely been in the realms of the GUM contact tracing nurse. With the expansion of the screening role into the realms of General Practice and other clinics, the contact tracing role has also expanded and may well have lost some of it’s efficiency due to both a lack of skill, time and resources. (D of H 2002). Cassell and her colleagues have tried to investigate the extent to which this perceived reduction in contact tracing may be responsible for the relentless increase in the overall incidence of chlamydia. (Radia et al 2001). The study was done by postal questionnaire to all GPs in Nottinghamshire. They got a 56% response rate. Arguably the most significant finding of the study was the fact that 86% of respondents considered that chlamydia testing was part of the remit of the primary healthcare team, while only 40% considered that partner notification was a primary healthcare team role. The rationale for this was, that most of the non-contact tracing respondents felt that it was their role to inform the patient that they should inform their partners. Given the fact that we have evidence from the Duncan paper that women tend to equate a positive test with promiscuity and being â€Å"dirty†, it is perhaps not surprising that a substantial number of partners do not get told. If you add to this number the unknown number of chlamydia infections that may have come from clandestine or extramarital liaisons, then this number may be higher still. This is clearly both hypothesis and conjecture but it would seem to be dictated by common sense. The paper goes into considerable detail about the reasons why different primary healthcare teams have different practices, but rather worryingly a surprising 20% treat chlamydia with a dose of antibiotic which is less than the currently recommended therapeutic level recommended by the Central Audit Group for Genitourinary Medicine, (Stokes et al 1997) The difficulty of a postal questionnaire study is that there is an intrinsic bias in the study design. It is quite conceivable that the 56% of primary healthcare teams who responded were the ones who may have been sufficiently motivated to be positive about matters to do with chlamydia and may therefore have been better informed that those who did not respond. In the words of the authors â€Å"our study probably over-represents primary healthcare teams already testing for chlamydia and may exaggerate the extent of good practice.† The paradox outlined by this study is that while the majority of GPs and their teams are already willing to assume the mantle of diagnosing and managing chlamydial infection, the same majority agree that contact tracing is the main difficulty in managing these patients. The study made enquiries relating to the presence of follow up strategies which were designed to minimise the risk of further infection and found that there was â€Å"very little evidence to be found† other than by putting the onus on the patient to tell their partners. It follows from this observation, and the authors put it quite succinctly: If testing in primary care continues to increase without adequate support for partner notification, much of the resource used in testing women will be wasted. (Griffiths et al 2002) If we accept the premise that an increasing amount of chlamydia screening will be done in General Practice in the future, it is likely that an increasing proportion will fall to the practice nurse or the family planning nurse specialist. (Stokes et al 2000). If this is the case, then it is common sense to maximise the benefit of chlamydia screening by supporting the healthcare professionals with time and resources to perform proper contact tracing to minimise the risk of re-infection. (EHC 1999) Conclusions In this review we have selected six primary papers which each represent a significant contribution to the evidence base in our knowledge of the rationale for screening and treatment of chlamydia infection. (Sackett 1996) From our examinations it is clear that there is a considerable disparity in the figures pertaining to the prevalence of chlamydia infection in the community. The paper by Adams (Adams et al 2004) gives us a partial rationale for this and that is that studies done in different areas of health care practice will yield different results because they have a different clientele. It is not, perhaps, surprising that a study done in a GUM clinic will report different prevalences than a study done in a General Practice setting. The common factor that runs through all of the papers examined is the fact that it is rare to find that men are screened. Generally the figures suggest about 2-5% of men are screened when compared to the number of women. There is no evidence to suggest that they have lower infection rates than women and, according to Duncan (et al 2001), there are a number of very good sociological reasons why men should be screened as frequently as women. The fact of the matter is that women are subject to screening with much greater frequency than men and therefore bear the brunt of both the indignity and the responsibility. 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