Risk and protective factors for sexual risk taking among adolescents involved in Prime Time

This article describes a preliminary qualitative evaluation of risk and protective factors associated with consistent contraceptive use and healthy sexual decision-making among ten of the first participants in the Prime Time intervention study. Prime Time is an 18-month intervention including one-on-one case management and peer educator training targeting sexually active 13-17-year-old girls who are recruited from health care clinics. Using an approach grounded in findings from previous research, social cognitive theory, and the social development model, Prime Time aims to improve participants' contraceptive use consistency, reduce number of sexual partners, and reduce unwanted sexual activity. Findings from this preliminary evaluation alert health care providers to the complex and dynamic nature of adolescent girls' sexual behaviors and to a broad range of risk and protective factors within individuals and their environments that may influence adolescent girls' sexual behaviors and contraceptive use. Findings suggest that an ongoing, supportive relationship with a case manager who is able to pace and tailor an intervention to the individual young person can have positive effects on adolescent girls' sexual behaviors and contraceptive use.     

Dynamic Three-Dimensional Ultrasound to Evaluate Scapular Movement Among Manual Wheelchair Users and Healthy Controls

Background:

A large percentage of individuals with spinal cord injury (SCI) report shoulder pain that can limit independence and quality of life. The pain is likely related to the demands placed on the shoulder by transfers and propulsion. Shoulder pathology has been linked to altered scapular mechanics; however, current methods to evaluate scapular movement are invasive, require ionizing radiation, are subject to skin-based motion artifacts, or require static postures.

Objective:

To investigate the feasibility of applying 3-dimensional ultrasound methods, previously used to look at scapular position in static postures, to evaluate dynamic scapular movement.

Method:

This study evaluated the feasibility of the novel application of a method combining 2-dimensional ultrasound and a motion capture system to determine 3-dimensional scapular position during dynamic arm elevation in the scapular plane with and without loading.

Results:

Incremental increases in scapular rotations were noted for extracted angles of 30°, 45°, 60°, and 75° of humeral elevation. Group differences were evaluated between a group of 16 manual wheelchair users (MWUs) and a group of age- and gender-matched able-bodied controls. MWUs had greater scapular external rotation and baseline pathology on clinical exam. MWUs also had greater anterior tilting, with this difference further accentuated during loading. The relationship between demographics and scapular positioning was also investigated, revealing that increased age, pathology on clinical exam, years since injury, and body mass index were correlated with scapular rotations associated with impingement (internal rotation, downward rotation, and anterior tilting).

Conclusion:

Individuals with SCI, as well as other populations who are susceptible to shoulder pathology, may benefit from the application of this imaging modality to quantitatively evaluate scapular positioning and effectively target therapeutic interventions.Key words: kinematics, scapula, ultrasound, wheelchair userThe shoulder is a common site of injury across many populations. Because it is the most mobile joint in the body, the high prevalence of disorders is not surprising. Individuals are at increased risk for shoulder pathology when exposed to high forces, sustained postures, and repetitive movements.¹ Wheelchair users are exposed to all of these factors in activities of daily living. Among manual wheelchair users (MWUs), 35% to 67% report shoulder pain.^2–7 In this population, the presence of shoulder dysfunction significantly affects function and decreases quality of life.^8,9 With altered scapular kinematics being linked to a multitude of shoulder problems, the identification of changes in kinematics may allow for earlier detection of pathology and targeting of appropriate interventions.^10–25 However, evaluation of dynamic scapular movement is a challenging task, as the scapula rotates about 3 axes while also gliding underneath overlying tissue. Direct visualization of the bone is ideal but is often limited by cost, availability, and exposure to radiation, and skin-based systems are prone to error.^26–33The overall goal of this study was to investigate the feasibility of applying 3-dimensional ultrasound methods, previously used to look at scapular position in static postures, to evaluate dynamic scapular movement.³⁴ The specific goals were as follows:

1. Evaluate intermediate angles of functional elevation during dynamic movement (30°, 45°, 60°, and 75°). We hypothesize that we will see incremental increases in external rotation, upward rotation, and posterior tipping throughout the movement to maintain the distance between the acromion and humerus.
2. Compare dynamic scapular movement between MWUs and able-bodied controls (ABs). We anticipate that the nature of wheelchair propulsion and demands of activities of daily living will elucidate differences between this population and ABs with comparably lower daily demands on the shoulder.
3. Evaluate the effect of loading on scapular movement, as other studies have suggested that differences in kinematics are clearer in the presence of loading.^10,35,36
4. Investigate the relationship between shoulder pathology, age, years since injury, and body mass index (BMI) and scapular positioning.

     

Prioritizing core components of successful transitions from child to adult mental health care: a national Delphi survey with youth,caregivers, and health professionals

Youth accessing mental health care often experience a disruption in care as they attempt to transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Few studies have evaluated interventions seeking to improve the experience and outcomes of CAMHS–AMHS transitions, in part due to lack of consensus on what constitutes best practices in intervention success. As such, the aim of this study was to engage patients, caregivers, and clinicians to prioritize core components of successful CAMHS–AMHS transitions which can be used in the design or evaluation of transition interventions. As such, a Delphi study was conducted to determine core components of successful CAMHS–AMHS transitions. Guided by the principles of patient-oriented research, three balanced expert panels consisting of youth, caregivers, and clinicians ranked and provided feedback on the importance and feasibility of core components of CAMHS-AMHS transitions. Components endorsed as feasible or important with ≥ 70% agreement from any panel moved to the next round. As a result, a list of 26 core components of CAMHS–AMHS transitions has been refined which can be used in the design, implementation, or evaluation of interventions intended to improve transition experiences and outcomes for youth in mental health care. Youth and families were engaged in an expert advisory role throughout the research process, contributing their important perspectives to the design and implementation of this study, as well as interpretation of the findings.

     

Late animation deformity in the denervated pedicled latissimus dorsi flap

Optimal management of the thoracodorsal nerve in pedicled latissimus dorsi flaps for mastectomy reconstruction is controversial. The incidence and etiology of animation deformity despite muscle denervation remain poorly‐ understood. This study examines the incidence, etiology, and risk factors of late animation. A retrospective review identified breasts reconstructed with a denervated pedicled latissimus dorsi flap. The incidence and severity of postoperative animation were examined with investigation of potential patient, oncologic, and reconstructive causative factors. Patients completed a survey to assess lifestyle implications. A cadaveric dissection identified anatomical causes of persistent muscle innervation. Forty‐one reconstructions with a minimum follow‐up of 2 years (average 6.25 years) identified no significant relationship between animation and patient or treatment factors. While absent in the first postoperative year, animation was identified in 90% of patients on long‐term follow‐up, with 32% reporting pain, and 25% indicating lifestyle interferences. This high frequency of animation correlated with cadaveric results that identified multiple extramuscular nerve branches innervating the latissimus in 9 of 10 specimens. The distance between nerve branches was 5.4 ± 0.7 mm, and the distance between the superior muscle margin and the branching point was 22.7 ± 2.3 mm. Persistent animation deformity, despite nerve transection, is attributable to anatomical differences in the thoracodorsal branching patterns, rather than patient or therapeutic factors. While early follow‐up may suggest transection of a single nerve branch is adequate to prevent animation, our study demonstrates that long term, it is insufficient in most cases. Exploration for additional nerve branches or high division proximal to the branching site is suggested, and preoperative patient counseling is recommended.     

Brain death

To establish the diagnosis of brain death, the physician must document the irreversible loss of all brain function while excluding conditions that can mimic brain death. Confirmation of irreversibility requires continued observation for variable periods, depending on individual circumstances and the use of confirmatory tests. In some cases, consultation with an expert who is experienced in the diagnosis of brain death may be necessary. Several scientific and social issues relating to brain death remain unresolved.     

Isolated metastatic myocardial carcinoid tumor in a 48-year-old man

This brief report describes an asymptomatic patient with a myocardial mass. Two-dimensional echocardiography, technetium Tc 99m cardiac nuclear scan, and transesophageal echocardiography were performed to define the mass. The mass, which involved the subvalvar right ventricular free wall, was resected and determined to be a metastatic carcinoid tumor by histologic and immunohistochemical analysis. Further investigation revealed the presence of a midgut carcinoid tumor located within the terminal ileum, which was also resected surgically. The patient recovered well after surgery and adjunctive chemotherapy. To our knowledge, this is the first report of comprehensive nuclear and echocardiographic imaging, supplemented by surgical and pathologic findings, in an asymptomatic patient with isolated myocardial metastasis of an ileal carcinoid tumor.