Potential lethality of suicide attempts in youth.

Rates of suicide in youth have increased over the last 50 years, yet our ability to predict suicidal behaviours has not significantly improved during this time. Examining predictors of suicide attempt lethality can enhance our understanding of suicidality in youth, yet research has focused on actual medical lethality (the actual danger to life resulting from a suicide attempt) rather than potential lethality (the potential for death that is associated with a suicide attempt). Thus, the aim of the present study was twofold: first, we quantified the percentage of youth for whom the severity of suicide attempt was misclassified by considering only actual lethality; second, we tested whether key variables that predict the actual lethality of suicide attempts also predict the potential lethality of suicide attempts in youth. We examined these questions in a sample of children and adolescents admitted to a psychiatric inpatient unit following a suicide attempt. Over 70% of youth who made serious suicide attempts would have been misclassified by assessments relying on only actual lethality. Although several variables relevant to the construct of actual lethality significantly predicted potential lethality (e.g., male sex, substance use disorder), others did not. In addition, we found that the subset of youth who would have been misclassified as low risk based on actual lethality had a disproportionately high need for healthcare resources due to future hospital admissions. The present study provides evidence to suggest that considering potential lethality may lead to improved detection and prediction of suicide risk in youth, and in doing so supports recent calls to broaden considerations of the lethality associated with suicide attempts.

Does obesity modify the relationship between physical activity and breast cancer risk?

PURPOSE: With only 5-10% of breast cancer cases attributed to genetic inheritance, prevention efforts have focused on modifiable risk factors. Physical activity plays a role in reducing breast cancer risk; however, the interaction between physical activity and other modifiable risk factors, such as obesity, has received little attention. METHODS: A systematic review and meta-analysis was conducted of studies examining the relationship between physical activity and breast cancer and how it may be modified by body mass index (BMI). RESULTS: A total of 29 papers were included: 18 were cohort and 11 were case-control studies. Overall, a significant reduction in the relative risk of breast cancer was found in postmenopausal women with high versus low levels of physical activity for women with a BMI <25 kg/m2 (RR 0.85, 95% CI 0.79, 0.92) and ≥25 kg/m2 (RR 0.87, 95% CI 0.81, 0.93) but not ≥30 kg/m2 (RR: 0.93, 95% CI 0.76, 1.13). Physical activity was not associated with a significant reduction in risk of breast cancer in premenopausal women in any BMI group. CONCLUSION: The results of this meta-analysis suggest that physical activity is associated with a larger breast cancer risk reduction among women who are normal weight or overweight than among women who are obese. Since the included studies used diverse methods for assessment of physical activity and categories of BMI, results should be interpreted with caution and additional work is needed.

Relationship of metabolic and endocrine parameters to brain glucose metabolism in older adults: do cognitively-normal older adults have a particular metabolic phenotype?

Our primary objective in this study was to quantify whole brain and regional cerebral metabolic rates of glucose (CMRg) in young and older adults in order to determine age-normalized reference CMRg values for healthy older adults with normal cognition for age. Our secondary objectives were to--(i) report a broader range of metabolic and endocrine parameters including body fat composition that could form the basis for the concept of a 'metabolic phenotype' in cognitively normal, older adults, and (ii) to assess whether medications commonly used to control blood lipids, blood pressure or thyroxine affect CMRg values in older adults. Cognition assessed by a battery of tests was normal for age and education in both groups. Compared to the young group (25 years old; n = 34), the older group (72 years old; n = 41) had ~14% lower CMRg (µmol/100 g/min) specifically in the frontal cortex, and 18% lower CMRg in the caudate. Lower grey matter volume and cortical thickness was widespread in the older group. These differences in CMRg, grey matter volume and cortical thickness were present in the absence of any known evidence for prodromal Alzheimer's disease (AD). Percent total body fat was positively correlated with CMRg in many brain regions but only in the older group. Before and after controlling for body fat, HOMA2-IR was significantly positively correlated to CMRg in several brain regions in the older group. These data show that compared to a healthy younger adult, the metabolic phenotype of a cognitively-normal 72 year old person includes similar plasma glucose, insulin, cholesterol, triglycerides and TSH, higher hemoglobin A1c and percent body fat, lower CMRg in the superior frontal cortex and caudate, but the same CMRg in the hippocampus and white matter. Age-normalization of cognitive test results is standard practice and we would suggest that regional CMRg in cognitively healthy older adults should also be age-normalized.

Multicentre study of abdominal aortic aneurysm measurement and enlargement.

BACKGROUND: No effective treatment is currently available to prevent progression of small and medium-sized abdominal aortic aneurysms (AAAs). Identification of drugs with sufficient promise to justify large expensive randomized trials remains challenging. One potentially useful strategy is to look for associations between commonly used drugs and AAA enlargement in appropriately adjusted observational studies. METHODS: Potential AAA measurements were identified from abdominal imaging reports in the electronic data files of three medical centres from 1995 to 2010. AAA measurements were extracted manually and patients with an aneurysm of 3 cm or larger, who had at least two measurements over an interval of at least 6 months, were identified. Other data were obtained from the electronic data files (demographics, co-morbidities, smoking status, drug use) to conduct a propensity analysis of the associations of drugs and other factors with AAA enlargement. RESULTS: From 52,962 abdominal imaging studies, 5362 patients with an AAA of 3 cm or more were identified, of whom 2428 had at least two measurements over at least 6 months. Mean AAA follow-up was 3.4 years and the mean AAA enlargement rate was 2.0 mm per year. Propensity analysis demonstrated no significant association of AAA enlargement with statins, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Diabetes was associated with a reduction in AAA enlargement of 1.2 mm per year (P = 0.008), and chronic obstructive pulmonary disease was associated with increased enlargement (0.5 mm per year; P = 0.050). Moderate AAA measurement variation and substantial terminal digit preference were also observed, but the digit preference became less pronounced after 2000. CONCLUSION: This study confirms the negative association of diabetes with AAA progression. There was no evidence that commonly used cardiovascular drugs affect AAA enlargement.

Decision Regret among Patients with Early-stage Lung Cancer Undergoing Radiation Therapy or Surgical Resection.

AIMS: Clinical equipoise exists regarding early-stage lung cancer treatment among patients as trials comparing stereotactic body radiation therapy (SBRT) and surgical resection are unavailable. Given the potential differences in treatment effectiveness and side-effects, we sought to determine the associations between treatment type, decision regret and depression. MATERIALS AND METHODS: A multicentre, prospective study of patients with stage IA-IIA non-small cell lung cancer (NSCLC) with planned treatment with SBRT or surgical resection was conducted. Decision regret and depression were measured using the Decision Regret Scale (DRS) and Patient Health Questionnaire-4 (PHQ-4) at 3, 6 and 12 months post-treatment, respectively. Mixed linear regression modelling examined associations between treatment and decision regret adjusting for patient sociodemographics. RESULTS: Among 211 study participants with early-stage lung cancer, 128 (61%) patients received SBRT and 83 (39%) received surgical resection. The mean age was 73 years (standard deviation = 8); 57% were female; 79% were White non-Hispanic. In the entire cohort at 3 months post-treatment, 72 (34%) and 57 (27%) patients had mild and severe decision regret, respectively. Among patients who received SBRT or surgery, 71% and 46% of patients experienced at least mild decision regret at 3 months, respectively. DRS scores increased at 6 months and decreased slightly at 12 months of follow-up in both groups. Higher DRS scores were associated with SBRT treatment (adjusted mean difference = 4.18, 95% confidence interval 0.82 to 7.54) and depression (adjusted mean difference = 3.49, 95% confidence interval 0.52 to 6.47). Neither patient satisfaction with their provider nor decision-making role concordance was associated with DRS scores. CONCLUSIONS: Most early-stage lung cancer patients experienced at least mild decision regret, which was associated with SBRT treatment and depression symptoms. Findings suggest patients with early-stage lung cancer may not be receiving optimal treatment decision-making support. Therefore, opportunities for improved patient-clinician communication probably exist.

Tunneled island pedicle flap reconstruction for upper lateral cutaneous lip defects.

BACKGROUND: Esthetic upper lateral cutaneous lip reconstruction preserves the apical triangle, nasolabial fold symmetry, and free margin position. The tunneled island pedicle flap (IPF) is a novel single-stage reconstruction to achieve these goals. OBJECTIVES: Describe the technique and patient and surgeon-reported outcomes for the tunneled IPF reconstruction of upper lateral cutaneous lip defects. METHODS: Retrospective chart review of consecutive tunneled IPF reconstruction following Mohs micrographic surgery (MMS) at a tertiary care center between 2014 and 2020. Patients rated their scars using the validated Patient Scar Assessment Scale (PSAS), and independent surgeons rated scars using the validated Observer Scar Assessment Scale (OSAS). Descriptive statistics were generated for patient demographics and tumor defect characteristics. RESULTS: Twenty upper lateral cutaneous lip defects were repaired with the tunneled IPF. Surgeons rated scars with a composite OSAS score of 11.83 ± 4.29 (mean, SD) [scale of 5 (normal skin) to 50 (worst scar imaginable)] and an overall scar score of 2.81 ± 1.11 [scale of 1 (normal skin) to 10 (worst scar imaginable)]. Patients rated their scars with a composite PSAS score of 10 ± 5.39 [scale of 6 (best possible score) to 60 (worst)] and with an overall score of 2.2 ± 1.78 [scale of 1 (normal skin) and 10 (very different from normal skin)]. One flap was surgically revised for pincushioning, but none experienced necrosis, hematoma, or infection. CONCLUSIONS: The tunneled IPF is a single-stage reconstruction for upper lateral cutaneous lip defects with favorable scar ratings by patients and observers.

Oral Diseases and Oral Health-Related Quality of Life among Kenyan Children and Adolescents with HIV.

INTRODUCTION: Children and adolescents living with HIV (CALHIV) have a higher risk of hard and soft oral tissue diseases as compared with their healthy peers. It is important to increase awareness regarding the need to integrate oral health within medical care among pediatric HIV populations. Studies on associations of oral diseases with oral health-related quality of life (OHRQoL) in CALHIV are lacking. This study examined the association between oral diseases and OHRQoL in Kenyan CALHIV. METHODS: This cross-sectional analysis was nested in a longitudinal cohort study of CALHIV in Nairobi. CALHIV received oral examinations, and the World Health Organization's Oral Health Surveys and Record Form was administered. OHRQoL was measured with the Parental-Caregiver Perceptions Questionnaire, with the subdomains of global, oral symptoms, function limitations, and emotional and social well-being, with higher scores indicating poorer OHRQoL. Linear regression was used to model associations between OHRQoL and oral diseases, adjusting for age at the time of oral examination, CD4 counts, and caregiver's education. RESULTS: Among 71 CALHIV, the mean age was 12.6 y (SD, 2.9; range, 10 to <21), and the mean composite OHRQoL score was 12.6 (SD, 11.2). Ulcers (not herpes simplex virus or aphthous) were associated with the worst overall OHRQoL (mean, 21.8; SD, 11.1; P = 0.055) and oral symptoms subdomain (mean, 7.0, SD, 2.5; P = 0.003). Children with dry mouth and untreated caries had significantly higher mean global OHRQoL scores than those without disease (P < 0.0001). In the multivariate analysis, the OHRQoL composite score was 6.3 units (95% CI, -0.3 to 12.9) higher for those who had dry mouth and untreated dental caries; dry mouth accounted for the highest percentage of variability of OHRQoL (9.6%) and the global subdomain (31.9%). Ulcers accounted for the highest percentage of variability of the oral symptoms domain (15.4%). CONCLUSIONS: Oral ulcers, dry mouth, and untreated caries were associated with poorer OHRQoL in CALHIV. Integrating oral health into the primary care of CALHIV may improve their OHRQoL. KNOWLEDGE TRANSFER STATEMENT: This study aimed to determine the association of oral diseases with the oral health-related quality of life of children and adolescents living with HIV (CALHIV). The findings will form part of the evidence to incorporate oral health protocols into care programs for CALHIV. Oral health monitoring has the potential to increase the surveillance of HIV clinical status, monitor the effectiveness of antiretroviral therapy, and improve the oral health-related quality of life of CALHIV.

Comorbid dysthymia and substance disorder: treatment history and cost.

OBJECTIVE: The purpose of this study was to determine the treatment history and cost of previous treatment among patients with comorbid substance-related disorder and dysthymia, as compared to patients with substance-related disorder only. METHOD: Retrospective data were obtained regarding past treatment. Treatment cost was calculated on the basis of the 1996 cost of various treatment modalities. The setting was alcohol-drug programs located within departments of psychiatry in two centers. A total of 642 patients were assessed, of whom 39 had substance-related disorder and dysthymia and 308 had substance-related disorder only (the remaining patients had other comorbid conditions). Data collection instruments included an interview-based questionnaire regarding previous psychiatric and substance abuse treatment. Current cost of treatment in various settings was assessed on the basis of a survey of facilities used by patients in this area. RESULTS: Patients with substance-related disorder and dysthymia had received more substance-related disorder treatment in 18 of 20 measures. Patients with substance-related disorder and dysthymia used 4.7 times more substance-related disorder treatment dollars than patients with substance-related disorder only, although their demographic characteristics were similar. Past self-help activities and pharmacotherapy were remarkably similar for both groups. Although substance-related disorder treatment differed considerably between the two groups of patients, other types of psychiatric treatment (i.e., non-substance-related treatment) did not differ between the two groups. CONCLUSIONS: Patients with substance-related disorder and dysthymia are referred to (or seek) substance-related disorder treatment more often than patients with substance-related disorder only but are referred to (or seek) non-substance-related psychiatric treatment no more often than patients with substance-related disorder only. The cost of previous substance-related disorder treatment was several times higher for the patients with substance-related disorder and dysthymia.

Diagnosis of patients presenting to a Huntington disease (HD) clinic without a family history of HD.

About 9% of patients presenting to a Huntington disease (HD) clinic for evaluation of possible HD lacked a family history of the disorder. HD was the final diagnosis in 53 to 83% of these patients. As a group, HD-affected individuals without a family history of HD were older and had fewer CAG repeats than the average HD patient. Some patients presenting with chorea only had HD and others did not; patients developing a movement disorder after long-standing neuroleptic-treated psychiatric illness did not have HD.

Outbreak of pertussis in a fully immunized adolescent and adult population.

OBJECTIVE: To evaluate the spread of pertussis in a fully immunized eighth-grade class and the household contacts of two coindex cases of pertussis. DESIGN: Survey of infected subjects and their contacts was performed using culture, direct fluorescent antibody assay, and serological assays to establish the diagnosis of Bordetella pertussis. SETTING: Middle-class parochial school. PARTICIPANTS: A volunteer sample of 15 eighth-grade students and 13 household contacts of two identified cases of B pertussis infection. INTERVENTIONS: All participants had medical histories (including immunization status) and laboratory evaluation for B pertussis infection (including nasopharyngeal specimens and serum samples) obtained initially and 30 days later. After initial evaluation, all subjects received erythromycin ethyl succinate therapy. MAIN OUTCOME MEASURES: Assessment of B pertussis infection as defined by positive nasopharyngeal culture, direct fluorescent antibody, or serological tests. RESULTS: Laboratory evidence of B pertussis infection was found in eight (47%) of 17 immunized eighth-grade classmates and in three (23%) of 13 household contacts, all of whom were 12 years of age or older. CONCLUSIONS: Vaccine-induced immunity wanes by early adolescence. These older age groups may be infected with B pertussis and may serve as reservoirs of infection for other susceptible individuals.

Spectral analysis of the EMG and diaphragmatic muscle fatigue during periodic breathing in infants.

Periodic breathing occurs commonly in full-term and preterm infants. The mechanisms which switch breathing on and off within a cycle of periodic breathing are not certain. Since immature infants may experience diaphragmatic muscle fatigue, one potential switching mechanism is fatigue. Power spectra of the electromyogram, uncontaminated by the electrocardiograph artifact, were studied for evidence of diaphragmatic muscle fatigue during spontaneous periodic breathing in infants. A fall in the high-frequency (103-600 Hz) power and an increase in the low-frequency (23-47 Hz) power during periodic as compared with normal breathing would indicate fatigue. This effect was not observed in any of the infants studied. Hence, there is no evidence that periodic breathing is the result of diaphragmatic muscle fatigue. This finding suggests that the effect of drugs such as theophylline in eliminating periodic breathing may be unrelated to the fact that they also reduce fatigue.

Locomotor-respiratory coupling during wheelchair propulsion.

Visceral movement due to impact loading is believed to play a role in the locomotor-respiratory coupling (LRC) that has been detected in a number of mammalian species. In the bird and bat species in which LRC has been described, the effect of the wing muscles on the timing of respiration appears to be a dominant influence. To test the hypothesis that LRC occurs in humans propelling wheelchairs (where there is no impact loading and the arms are used for locomotion), we studied 10 wheelchair athletes on a motorized treadmill at three speeds. Each subject's data were analyzed by spectral analysis (based on the fast Fourier transform), which detected apparent LRC (rates within 1% of a single-digit integer ratio) in 12 (40%) of the 30 test settings. However, a control analysis, in which each subject's arm-thrust rates were compared with another subject's breathing rates, revealed apparent (but false) coupling in 8 (27%), not significantly less often (using the chi 2 test). These findings appear to refute the hypothesis that LRC occurs during wheelchair propulsion. These data are consistent with the theory that the visceral piston is important to LRC and suggest that rhythmic arm movements are insufficient to induce the phenomenon in this setting.

Coupling of cardiac and locomotor rhythms.

The pressure within exercising skeletal muscle rises and falls rhythmically during normal human locomotion, the peak pressure reaching levels that intermittently impede blood flow to the exercising muscle. Speculating that a reciprocal relationship between the timing of peak intramuscular and pulsatile arterial pressures should optimize blood flow through muscle and minimize cardiac load, we tested the hypothesis that heart rate becomes entrained with walking and running cadence at some locomotion speeds, by means of electrocardiography and an accelerometer to provide signals reflecting heart rate and cadence, respectively. In 18 of 25 subjects, 1:1 coupling of heart and step rates was present at one or more speeds on a motorized treadmill, generally at moderate to high exercise intensities. To determine how exercise specific this phenomenon is, and to refute the competing hypothesis that coupling is due to vertical accelerations of the heart during locomotion, we had 12 other subjects cycle on an electronically braked bicycle ergometer. Coupling was found between heart rate and pedaling frequency in 10 of them. Cardiac-locomotor coupling appears to be a normal physiological phenomenon, and its identification provides a fresh perspective from which to study endurance.

Memory performance on the intracarotid amobarbital procedure as a predicator of seizure focus.

The intracarotid amobarbital procedure (IAP) was performed on 56 patients with intractable complex-partial epilepsy who were candidates for temporal lobectomy. Seizure focus was lateralized to one hemisphere, as determined by surface EEG recordings and MRI evidence of temporal lobe disease. IAP memory items were presented following injection of 125 mg of sodium amytal into the internal carotid artery. Verbal, Nonverbal, Design, Pictorial, and Total memory scores were calculated based on recall/recognition of memory stimuli following drug recovery. Poorer memory was observed in the hemisphere ipsilateral to seizure focus on all memory scores. The Total Memory Score was the best memory measure, correctly classifying the largest number of patients. Using optimal cut-off scores on this measure, 75% of the patients with left hemisphere seizure focus and 79% of the patients with right seizure focus were correctly classified. There was a definite tendency for the dominant hemisphere to outperform the non-dominant. This must be taken into account in arriving at optimal cut-off points.

Two-dimensional Fourier spectrum of QRST integral maps in classification of patients prone to ventricular arrhythmia.

Two-dimensional Fourier spectra of QRST integral maps, obtained by body surface potential mapping, were analyzed to identify subjects prone to ventricular arrhythmia, when they have not been identified by the extrema count method. The diagnostic performance (84.38 percent) of the peak value of the Fourier spectrum as a classifier for subjects prone to ventricular arrhythmia showed an improvement of 3.65 percent over the use of the extrema count method as a classifier.

An adaptive "Wiener" filter for estimating the time-derivative of the left ventricular pressure signal.

This communication presents the development of an optimal digital differentiating filter based on the Wiener theory for estimating the peak derivative of the left ventricular pressure (LVP) signal. The magnitude coherence function is used to estimate the signal and noise spectra. The peak derivative obtained by this method is found to be within 2% of the results obtained by a seven-point second-order data fit and a DFT technique.

Smoking and breast cancer: a meta-analysis.

Epidemiological studies have implicated smoking as a possible risk factor in the etiology of breast cancer, yet the evidence is not conclusive. We conducted meta-analyses of peer-reviewed studies published between 1984 and 2001 to assess the relation between smoking and breast cancer. The studies were located by searching the MEDLINE (1966 to 2001) and Cancer Abstracts (1980 to 2001) databases. Combined estimators of relative risk (RR) were calculated using fixed and random effect models. The combined RR for ever smokers was 1.10 (95% CI = 1.02-1.18). The association was stronger in premenopausal cases (RR = 1.21, CI = 1.08-1.36). The dose-response trend was significant but weak for the number of cigarettes smoked per day and for the duration of smoking. Early age at the start of smoking was associated with elevated risk (RR = 1.14, CI = 1.06-1.23). Our results suggest that smoking is a weak risk factor for breast cancer and the risk is higher in the premenopausal period and in those who started smoking at an early age.

A clinical tool for rating response to civil commitment for substance abuse treatment.

OBJECTIVE: The objectives of this study were to develop a measure to assess patients' response to civil commitment, to test this measure on two groups of dually diagnosed patients (medically ill alcoholics and patients with dual mental and substance use disorders), and to identify patient characteristics associated with a positive response to commitment. METHODS: The outcome of 38 male veterans civilly committed to inpatient substance abuse treatment for an average of six months was rated by their treating clinicians. Raters used the Commitment Response Form (CRF), a scale anchored to behavioral descriptions that was developed for the study and that measures outcome in five areas: patients' attitude toward recovery, substance use, medical condition, engagement in substance abuse treatment, and independence of functioning. Each patient's medical records were reviewed by two clinical staff members who made independent retrospective ratings and a joint rating using the CRF. They also made independent and joint dichotomous ratings of whether the patient was a positive responder or a nonresponder to civil commitment. RESULTS: The CRF showed superior reliability when compared with the dichotomous rating of outcome. The scale demonstrated reasonable psychometric properties. Mean scale scores did not differ significantly by patient group; slightly more than half were rated as having a good to excellent overall response. Better outcome was associated with longer periods of previous abstinence from alcohol and a higher level of education. CONCLUSIONS: Use of a scale anchored to behavioral descriptions improved reliability of outcome determinations by clinical staff. Civil commitment resulted in good to excellent outcome in many but not all committed patients.

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior.

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.

Intracranial pressure monitoring in the management of the pediatric trauma patient.

Intracranial pressure (ICP) monitoring is an important adjunct in the management of the severely injured child with major head trauma. From a series of 18 patients with multiple trauma, smoke inhalation, and near-drowning, we report an illustrative case of head injury and pulmonary aspiration in which ICP monitoring was vital to appropriate therapy. The two most common techniques of ICP monitoring, the intraventricular catheter and the subarachnoid bolt, are described. Treatment of intracranial hypertension is discussed based on physiological principles. The continuous, objective recording of ICP assumes particular importance when therapy directed at other injured organ systems (ie, institution of positive end-expiratory pressure) could adversely affect the ICP. It is suggested that optimal care of children with multiple trauma and head injury include early ICP monitoring.