Examination of a New Brief Screener to Measure Trauma Symptoms and Violence Exposure Among Young Children.

The purpose of this study was to create a reliable, quick and easy to administer screening measure of violence exposure and trauma for children from infancy through age 7. In a sample of 6,676 children, caregivers completing a 22-item screener reported nearly one out of five youth had been exposed as witness or victim to at least one kind of violence. For trauma, caregivers reported that their children had trouble going to sleep at least sometimes (15.83%), had cried or had a tantrum to exhaustion (15.61%) and had difficulty concentrating or focusing (15.55%). Analyses showed reliable internal consistency for violence exposure (.74) and trauma (.85) scales. Factor analyses revealed a single trauma factor and two violence exposure factors, witnessing and victimization. These data provide support for a brief screening measure for trauma and violence exposure in children from birth through age seven that can be administered by minimally trained staff in public systems and community-based agencies who can then refer children and families to necessary assessment and treatment services.

Violence Exposure and Early Substance Use in High-Risk Adolescents.

This study examines the relationship between violence exposure and early substance use as mediated by trauma symptoms. The Assessment of Liability and Exposure to Substance Use and Antisocial Behavior Scale was used to assess violence exposure at age 10 and substance use by age 12. Mediation analysis indicated direct relationships between violence exposure and tobacco/illegal drug use and indirect relationships between violence exposure and girls' substance use through trauma symptoms. Practitioners should consider violence exposure as a risk factor for early substance use in high-risk youths and potential gender differences in trauma symptom pathways to early substance use.

The safety of and indications for immediate reconstruction of head and neck melanoma defects: our early experience.

Melanoma excision requires wide margins, leaving large defects. Surgical dogma has taught that definitive reconstruction of melanoma defects be performed after permanent pathology results, with skin grafts favored. However, this results in an open wound and the need for a second operation. The advantages of immediate reconstruction with flaps are single-stage surgery, high patient satisfaction, no period of disfigurement, and cost savings. Our purpose was to evaluate rate of positive margins and local recurrence after immediate reconstruction of head and neck melanoma (HNM) defects with flaps to determine safety of this approach. We prospectively followed all patients with HNM treated at a single center from January 2010 to June 2012 and collected patient and tumor data and reconstruction type. Outcomes assessed were permanent pathology margins and local recurrence rate. Risk factors for positive margins were assessed. Seventy-six patients with HNM were treated with wide excision and immediate flap reconstruction with a mean age of 59 years. Five patients had melanoma in situ and 71 had invasive melanoma. There was a 15.4% ulceration rate. Median thickness for invasive melanoma was 2.2 mm. Mean excision margin was 1.4 cm. Median follow-up was 2 years; 5.3% of patients had positive margins on permanent pathology after reconstruction and 3 were reexcised with negative margins. Local recurrence rate was 2.6% with no recurrence in patients with previous reexcised positive margins. Significant risk factors for positive margins were melanoma in situ excised with 5-mm margins (P=0.012) and desmoplastic melanoma (P<0.02). Immediate flap reconstruction after excision of HNM can be safely performed with low positive margin and local recurrence rates. This should be offered to patients, especially those with primary melanomas with distinct borders and excision margins greater than or equal to 1 cm.

Contributing factors to aggressive behaviors in high school students in Turkey.

Violence among young people is an important public health topic as a universal problem. One of the recent issues concerning both the media and parents is the aggressive behavior among the high school students in Istanbul and the worldwide. The aim of this study was to investigate the types and rates of aggressive behavior and the contributing factors to this behavior among high school students. Sample was composed of 805 students of 14-18 ages attending five high schools in Istanbul. The most common aggressive behavior among the students was found to be "beating others," 34.5% (n = 278). Past experiences of violence of high school students (direct exposure to violence/witnessing violence/exposure to/witnessing attack with knife/gun) were determined as the most contributing factor to aggressive behavior. The present study investigated the nature of violent behaviors and associations between violent behaviors and contributing factors among high school students from Turkey.

Prevalence of Homologous Recombination Pathway Gene Mutations in Melanoma: Rationale for a New Targeted Therapeutic Approach.

Homologous recombination DNA damage repair (HR-DDR) deficient patients with various solid tumors have been treated with PARP inhibitors. However, the clinical characteristics of patients with melanoma who have HR-DDR gene mutations and the consequences of PARP inhibition are poorly understood. We compared the commercially available next-generation sequencing data from 84 patients with melanomas from our institution with a dataset of 1,986 patients as well as 1,088 patients profiled in cBioportal. In total, 21.4% of patients had ≥1 functional HR-DDR mutation, most commonly involving BRCA1, ARID1A, ATM, ATR, and FANCA. Concurrent NF1, BRAF, and NRAS mutations were found in 39%, 39%, and 22% of cases, respectively. HR-DDR gene mutation was associated with high tumor mutational burden and clinical response to checkpoint blockade. A higher prevalence of HR-DDR mutations was observed in the datasets from Foundation Medicine (Cambridge, CA) and those from the Cancer Genome Atlas. Treatment of HR-DDR‒mutated patient-derived xenograft models of melanoma with PARP inhibitor produced significant antitumor activity in vivo and was associated with increased apoptotic activity. RNA sequencing analysis of PARP inhibitor-treated tumors indicated alterations in the pathways involving extracellular matrix remodeling, cell adhesion, and cell-cycle progression. Melanomas with HR-DDR mutations represent a unique subset, which is more likely to benefit from checkpoint blockade and may be targeted with PARP inhibitor.

Evaluation of Treatment and Other Factors That Lead to Drug Court Success, Substance Use Reduction, and Mental Health Symptomatology Reduction Over Time.

Adults presenting with substance use and mental health disorders in the criminal justice system is well documented. While studies have examined drug courts and medication-assisted treatment (MAT), few have examined social and behavioral health indicators, and even fewer have multiple study periods. This study employed a comprehensive approach to studying the MAT contribution to drug court success; reduce substance use, mental health symptoms, and risky behaviors; and the role that violence or trauma plays in mental health symptomatology. Using three time points, our findings indicated that MAT did not play a significant role in the reduction of substance use, risky behaviors, or mental health symptoms or increasing the odds of successful court graduation. However, there was an overall improvement from intake to termination in reduction of substance use, risky behaviors, and mental health symptomatology. Other factors, including social support, may play a role in drug court graduation. Policy implications are discussed.

Intraoperative radiation therapy for recurrent head-and-neck cancer: the UCSF experience.

PURPOSE: To review a single-institutional experience with the use of intraoperative radiation therapy (IORT) for recurrent head-and-neck cancer. METHODS AND MATERIALS: Between 1991 and 2004, 137 patients were treated with gross total resection and IORT for recurrence or persistence of locoregional cancer of the head and neck. One hundred and thirteen patients (83%) had previously received external beam radiation as a component of definitive therapy. Ninety-four patients (69%) had squamous cell histology. Final surgical margins were microscopically positive in 56 patients (41%). IORT was delivered using either a modified linear accelerator or a mobile electron unit and was administered as a single fraction to a median dose of 15 Gy (range, 10-18 Gy). Median follow-up among surviving patients was 41 months (range, 3-122 months). RESULTS: The 1-year, 2-year, and 3-year estimates of in-field control after salvage surgery and IORT were 70%, 64%, and 61%, respectively. Positive margins at the time of IORT predicted for in-field failure (p = 0.001). The 3-year rates of locoregional control, distant metastasis-free survival, and overall survival were 51%, 46%, and 36%, respectively. There were no perioperative fatalities. Complications included wound infection (4 patients), orocutaneous fistula (2 patients), flap necrosis (1 patient), trismus (1 patient), and neuropathy (1 patient). CONCLUSIONS: Intraoperative RT results in effective disease control with acceptable toxicity and should be considered for selected patients with recurrent or persistent cancers of the head and neck.

Using Claims Data to Examine Hospital Readmission Risk in Patients With Schizophrenia and Comorbid Marijuana Use Disorders.

OBJECTIVE: Few epidemiologic studies have examined marijuana use disorder and repeated hospitalizations related to schizophrenia. To address this gap, this study examines time to readmission by indicators for recent marijuana use disorder in the presence of alcohol use disorder (AUD) and other drug use disorder. METHOD: Our sample consisted of 4,349 patients with a primary diagnosis of schizophrenia spectrum disorder (SSD) in 2005 in individually linked California Health Care Cost and Utilization Project (CA HCUP) data. Readmissions were assessed from 2005 to 2011. Predictors for readmission were examined using a stratified, recurrent-event, Cox proportional hazards model. Sensitivity analyses were conducted on patients readmitted in 2010 or 2011. RESULTS: We found that having marijuana use disorder or AUD alone within 90 days of initial hospitalization was associated with longer times until first readmission. A lower risk of readmission for those with recent marijuana use disorder persisted through the fifth readmission (hazard ratio [HR] = 0.92, 95% CI [0.85, 0.99]) but was not significant in the sixth or greater readmission nor in sensitivity analyses. SSD patients with recent other drug use disorder had an increased risk for a second to fifth readmission (HR = 1.13, 95% CI [1.06, 1.20]). Those with recent AUD had an increased risk for a sixth or greater readmission (HR = 1.15, 95% CI [1.07, 1.23]). Both of these results remained significant in the sensitivity analysis. CONCLUSIONS: We found that AUD and other drug use disorder increase readmission risk in patients with SSD after a first hospitalization, whereas marijuana use disorder does not appear to be associated with an increased risk for readmission.

Neurotropic melanoma invading the inferior alveolar nerve.

BACKGROUND: Desmoplastic neurotropic melanoma (DNM) and neurotropic melanoma (NM), rare lesions of the head and neck, often present as a benign-appearing nodule which later progresses to cranial nerve involvement. OBJECTIVE: To discuss treatment and outcome of 3 cases of DNM/NM of the lower lip. METHODS: Three case reports with 12- to 54-month follow-up and literature review. RESULTS: The first case had an initial excision of melanoma of his lower lip and presented 16 years later with severe bilateral atrophy of his muscles of mastication with NM and underwent intensity modulated radiation therapy but no further resection. We also report two other cases of DNM of the lip, one of which received gamma knife radiosurgery for intracranial extension. LIMITATIONS: Small retrospective case series. CONCLUSIONS: Locoregional recurrences from DNM are more common than distant metastasis warranting vigilant surveillance following resection of the initial lesion. Radiation therapy and gamma knife radiosurgery may be used for cases of unresectable recurrences.

Role of the head and neck surgeon in sentinel lymph node biopsy for cutaneous head and neck melanoma.

OBJECTIVE: To determine the reliability of sentinel lymph node biopsy (SLNB) in head and neck cutaneous melanomas to accurately stage nodal basins, describe techniques for safe SLNB in the neck and parotid regions, and discuss treatments. STUDY DESIGN: Retrospective chart review with follow-up mean of 11 months. METHODS: The charts of 80 patients treated for head and neck cutaneous malignancies from January 2001 through June 2003 were reviewed for presentation, treatment, and outcome. RESULTS: All patients received lymphoscintigraphy and SLNB for melanoma with Breslow thickness greater than 1 mm. Accurate preoperative lymphoscintigraphy and blue dye injection along with facial nerve monitoring when indicated correlated with safe SLNB. Eleven (14%) patients required completion surgery after positive SLNB and underwent evaluation for adjuvant therapies. There were three cases with complications: two postoperative hematomas and one seroma. CONCLUSIONS: Safe and reliable SLNB depends on the knowledge of the anatomy in the head and neck region, reliability of preoperative lymph node mapping with lymphoscintigraphy, and possible additions of blue dye injection and facial nerve monitoring. Complete surgical treatment of positive SLNB cases along with adjuvant therapies potentially improves control of these cutaneous malignancies with manageable morbidity.

Sentinel lymph node biopsy in head and neck cancer.

Sentinel lymph node biopsy (SLNB) offers a minimally invasive technique to examine the proximal lymph node basin for micrometastases in clinically N0 necks in patients head and neck cancer. This technique has been validated in the management of breast cancer and cutaneous malignant melanoma (CMM) and is under active investigation in the management of multiple other solid tumors.SLNB is used routinely in the management of head and neck melanoma and is investigational for other cancers of the head and neck. SLNB provides prognostic information for patients with CMM and identifies those patients that may benefit from additional treatment. This article examines the history, rationale,science, and current status of SLNB in head and neck with emphasis on melanoma.

Management of cervical metastases in advanced squamous cell carcinoma of the base of tongue.

OBJECTIVE: To clarify the role of neck dissection following primary radiotherapy for treatment of squamous cell carcinoma of the base of tongue. DESIGN: Case series. SETTING: Academic, tertiary care medical center. PATIENTS OR OTHER PARTICIPANTS: A consecutive series of 45 patients with biopsy-proven squamous cell carcinoma of the base of tongue and cervical metastases treated with primary radiotherapy at The University of California, San Francisco, was examined. Patients with a prior history of neck irradiation, neck dissection, or head and neck cancer within 5 years were excluded. MAIN OUTCOME MEASURES: Overall survival and regional control. RESULTS: Of the 45 patients treated with definitive radiotherapy, 25 (56%) achieved a complete response, 13 (29%) achieved a partial response, 4 (9%) were nonresponders, and 3 (7%) did not complete radiotherapy. Two thirds of the complete responders had N2 or N3 disease; 3 had recurrences in the neck, 1 of which was an isolated neck recurrence. Of the 13 partial responders, 5 had isolated persistence of disease, with 4 undergoing neck dissections. The only long-term survivors among the partial responders were those 4 who underwent a neck dissection. Overall survival was 50% at 3 years and 32% at 5 years. Regional control for complete responders was 84% at 5 years. CONCLUSIONS: The low rate of isolated regional recurrence in patients with a complete response to radiotherapy supports the practice of surveillance alone in such patients. Patients with less than a complete response appear to benefit from prompt surgical salvage.

The development of successful tracheoesophageal voice restoration.

Effective treatment for laryngeal cancer concerns the preservation of voice. Progress has been made in treatment, rehabilitation,restoration of the airway, and nonsurgical treatments. With the introduction of tracheoesophageal speech and the voice prosthesis,many treated patients acquire socially acceptable speech after total laryngectomy and maintain satisfactory quality of life.

Violence, coping, and mental health in a community sample of adolescents.

The current study examined the coping strategies, exposure to violence and psychological trauma symptoms of violent adolescents compared to less violent and nonviolent adolescents in a community sample. An anonymous self-report questionnaire was administered to students in six public high schools (grades 9-12). The 10% most violent adolescents were identified and compared to their less violent and nonviolent peers. A total of 3724 students represented 68% of adolescents in all targeted schools. Ages ranged from 14 to 19 years; 52% were female; and 35% were African-American, 34% Caucasian and 23% Hispanic. Analyses revealed that violent adolescents compared to their less violent and nonviolent peers employed more maladaptive coping strategies, were exposed to higher levels of violence and reported higher clinical levels of psychological trauma symptoms. Maladaptive coping was also significantly associated with psychological trauma symptoms and violent behavior, even after controlling for the influence of demographic factors. The findings support the importance of appropriate identification, assessment and referral services for adolescents in nonclinical settings, and the role that coping strategies play in contributing to adolescent mental health and well-being.

Long-term prognosis and significance of the sentinel lymph node in head and neck melanoma.

OBJECTIVE: To report the long-term significance of sentinel lymph node (SLN) biopsy on prognosis, determine false-negative SLN occurrences, and determine risk factors for death and recurrence in a large series of patients with head and neck melanoma. STUDY DESIGN: Case series with tumor registry review. SETTING: Academic tertiary care medical center. SUBJECTS AND METHODS: A database review was performed of all patients who underwent SLN biopsy for head and neck melanoma from 1994 to 2009. End points assessed were SLN status, recurrence, false-negative SLN results, and survival comparing SLN-positive and SLN-negative patients and different locations. Survival curves and multivariate analyses were performed. RESULTS: SLN biopsy was performed in 365 patients. SLNs were identified in 98.6% of patients with a mean of 3.7 nodes removed from 1.6 nodal basins per patient. Median follow-up was 8 years. The SLN was positive in 40 (11%) patients. SLN-positive patients had significantly thicker melanomas, higher recurrence (P < .0001), and a significant decrease in overall survival compared with SLN-negative patients (P < .002). Scalp melanoma patients had significantly thicker melanomas and an elevated risk of SLN positivity, recurrence, and death compared with other sites. Seventeen of 365 SLN-negative patients developed regional nodal disease for a false-omission rate of 5.2% and a negative predictive value of a negative SLN to be 94.8%. Risks for false negative-SLN occurrences included thick melanomas and scalp melanomas. CONCLUSION: SLN biopsy is accurate in head and neck melanoma and provides significant prognostic data. Scalp melanoma patients present with thicker tumors with an increase in SLN positivity and false-negative SLN occurrences.

Recurrent salivary gland carcinomas treated by surgery with or without intraoperative radiation therapy.

BACKGROUND: The optimal treatment for patients with locally recurrent carcinomas of the salivary glands is unclear. METHODS: Ninety-nine patients underwent salvage surgery for locally recurrent salivary gland carcinomas. Eighty-one (82%) had previously received radiation. Thirty-seven patients (37%) received intraoperative radiation therapy (IORT) to a median dose of 15 Gy (range, 12-18 Gy) at the time of salvage. RESULTS: The 1-, 3-, and 5-year estimates of local control after salvage surgery were 88%, 75%, and 69%, respectively. A Cox proportional hazard model identified positive margins (0.01) and the omission of IORT (p = .001) as independent predictors of local failure. The 5-year overall survival was 34%. Distant metastasis was the most common site of subsequent failure, occurring in 42% of patients. CONCLUSIONS: IORT significantly improves disease control for patients with locally recurrent carcinomas of the salivary glands. The high rate of distant metastasis emphasizes the need for effective systemic therapies.

Lymphatic drainage patterns of head and neck cutaneous melanoma observed on lymphoscintigraphy and sentinel lymph node biopsy.

BACKGROUND: The purpose of this study was to evaluate lymphatic drainage patterns of head and neck cutaneous melanoma observed on preoperative lymphoscintigraphy and sentinel lymph node biopsy (SLNB) and determine discordancy from clinically predicted lymphatic drainage patterns. METHODS: We conducted a retrospective chart review of 114 patients with head and neck cutaneous melanomas evaluated with preoperative lymphoscintigraphy and SLNB from January 2001 through July 2004. RESULTS: At least one sentinel lymph node (SLN) was identified in 97% of cases. On preoperative lymphoscintigraphy, an SLN was identified in an area not clinically predicted in 49 cases (43%). The most common sites of discordancy were in areas not typically dissected in standard neck dissections, such as the postauricular region, or in areas of more distant drainage than described previously, such as the inferior or posterior neck. Their percentages of discordant cases were 51%, 27%, and 22%, respectively. The sites of regional recurrence occurred in two cases not predicted on preoperative lymphoscintigraphy and in two cases of failed SLNB. CONCLUSIONS: On the basis of preoperative lymphoscintigraphy and the results of SLNB, head and neck cutaneous melanomas do have expected lymphatic drainage patterns despite perceived discordancy with previously clinically predicted drainage patterns that are based on standard neck dissection specimens. These "discordant" sites can still harbor melanoma, and all sites predicted on preoperative lymphoscintigraphy still need to be explored. The four cases of recurrences underscore the importance of close follow-up for all patients regardless of the SLNB result.

The gene expression signatures of melanoma progression.

Because of the paucity of available tissue, little information has previously been available regarding the gene expression profiles of primary melanomas. To understand the molecular basis of melanoma progression, we compared the gene expression profiles of a series of nevi, primary melanomas, and melanoma metastases. We found that metastatic melanomas exhibit two dichotomous patterns of gene expression, which unexpectedly reflect gene expression differences already apparent in comparing laser-capture microdissected radial and vertical phases of a large primary melanoma. Unsupervised hierarchical clustering accurately separated nevi and primary melanomas. Multiclass significance analysis of microarrays comparing normal skin, nevi, primary melanomas, and the two types of metastatic melanoma identified 2,602 transcripts that significantly correlated with sample class. These results suggest that melanoma pathogenesis can be understood as a series of distinct molecular events. The gene expression signatures identified here provide the basis for developing new diagnostics and targeting therapies for patients with malignant melanoma.