Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know

This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.

The Effect of Corticosteroid Injections on Postoperative Infections in Trigger Finger Release

BACKGROUND

Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release.

METHODS

A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement.

RESULTS

Of 3234 patients who underwent trigger finger release, 58 (1.8%) were identified with postoperative infections, 6 (0.2%) of which were deep infections. History of corticosteroid injection was significantly more common in patients with postoperative infection. Compared with an age-matched, gender-matched, and body mass index-matched cohort, patients with postoperative infection had significantly increased rate of diabetes mellitus at 34.5% to 19% (P = .04).

CONCLUSIONS

While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.

Influence of Corticosteroid Injections on Postoperative Infections in Carpal Tunnel Release

PURPOSE

Corticosteroid injections (CSIs) are commonly used in carpal tunnel syndrome; however, recent literature has demonstrated risk of postoperative infection associated with preoperative CSIs in other orthopedic fields. The aim of this study was to assess the relationship of CSIs and postoperative infection following carpal tunnel release (CTR).

METHODS

A single-center retrospective review was conducted from 2010 to 2019 to identify patients who underwent CTR with subsequent antibiotic prescription for chart-documented wound infection. A demographically-matched cohort of 100 patients was identified for comparison. Information on patient demographics, comorbidities, injection history, and presence of postoperative infection was collected.

RESULTS

Thirty-nine patients (0.67% of all CTR patients) were identified with postoperative infections, 3 of which (0.05% of all CTR patients) were deep infections. In the infection cohort, 16 of 39 (41%) patients received an injection prior to surgery, whereas 16 of 100 (16%) patients in the control cohort received an injection. History of CSI was significantly more common in patients with postoperative infection, and patients in the infection cohort had a significantly shorter average time from injection to surgery by approximately 55 days.

CONCLUSIONS

Corticosteroid injections in the preoperative period are associated with postoperative infection after CTR. Proximity of injection to time of surgery plays a role, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

P063 SystmOne clinical reporting to identify high-risk rheumatology patients for shielding

Background/Aims 

At the start of the COVID-19 pandemic, shielding guidance was issued by Public Health England with a risk stratification guide developed by the BSR to assist with patient identification. At BTHFT we benefited with all GP practices in the region using TPP SystmOne (S1) for medical records. We describe how we used S1 to help identify high risk patients under our care.

Methods 

We did not appreciate the full extent we could use S1 to identify patients in our initial shielding identification process. As such, we reviewed notes of patients on biologic prescriptions and SC MTX from Homecare prescription lists. To capture patients on high dose prednisolone, we identified patients with a recent diagnosis of GCA and patients with recent prescriptions of > 20mg prednisolone through pharmacy records. On recognising the ability of S1 to identify patients that had glucocorticoid exposure through primary care and/or on cDMARDS we used S1 reporting mechanisms to identify these patients. Clinical record sharing enabled BTHFT’s rheumatology department to access S1 for all patients under their care. S1’s clinical reporting function was used to search for patients within at least one of the following cohorts before being combined in a single cohort of ‘at risk’ patients (heart, lung or kidney disease, ≥70 years, diabetes or hypertension [including pulmonary artery hypertension]). Reports were created for patients on any DMARD issued within primary care within the previous 12 weeks. High dose steroid use was more challenging to demonstrate, but a report was devised to include all patients with an issued prescription for prednisolone 5mg tablets within the preceding 8 weeks (for any reason). An additional report was created for patients with a rheumatological diagnosis co-existing with an interstitial lung disease. Using S1's report joining function, the different drugs and ‘at risk’ cohorts were combined to provide an accurate list of patients with features increasing their vulnerability to COVID-19. This list was easily modifiable and searches were re-run to update lists once inclusion on the shielding list was updated.

Results 

Patients meeting the criteria for shielding were then advised in writing including signposting to BTHFT’s rheumatology website and helpline for further information if required. By searching for all prednisolone prescriptions, this would have included patients given prednisolone for other reasons. 5mg tablet strength ensured patients on low dose were excluded, but we recognise some patients were likely over-recruited into this cohort.

Conclusion 

We can update our searching methods to easily include patients on biologics and SC MTX by some additional bulk coding in preparation for future shielding specifications thereby bypassing the need to review individual notes for patients. We were able to achieve an accurate shielding list in a relatively short space of time to reduce patient risk.

Disclosure 

D. Kirby: None. K. Nadesalingam: None.

The Leicestershire fracture index

The aim of the Leicestershire Fracture Index is to bring together data from routine sources: inpatient, outpatient and A&E, into a single patient-centred database and in so doing promote the use of outpatient systems. The index should then be able to provide accurate information on incidence and outcomes and hence be a reliable foundation for audit, a basis for estimating needs and activities and a sampling frame for research. The development is particularly timely in view of the increased sophistication of contract specification with a move from simple speciality totals to detailed service provision and the introduction of effectiveness and outcome measures for outpatient services.

Defining the proteome of human iris, ciliary body, retinal pigment epithelium, and choroid

The iris is a fine structure that controls the amount of light that enters the eye. The ciliary body controls the shape of the lens and produces aqueous humor. The retinal pigment epithelium and choroid (RPE/choroid) are essential in supporting the retina and absorbing light energy that enters the eye. Proteins were extracted from iris, ciliary body, and RPE/choroid tissues of eyes from five individuals and fractionated using SDS-PAGE. After in-gel digestion, peptides were analyzed using LC-MS/MS on an Orbitrap Elite mass spectrometer. In iris, ciliary body, and RPE/choroid, we identified 2959, 2867, and 2755 nonredundant proteins with peptide and protein false-positive rates of <0.1% and <1%, respectively. Forty-three unambiguous protein isoforms were identified in iris, ciliary body, and RPE/choroid. Four "missing proteins" were identified in ciliary body based on ≥2 proteotypic peptides. The mass spectrometric proteome database of the human iris, ciliary body, and RPE/choroid may serve as a valuable resource for future investigations of the eye in health and disease. The MS proteomics data have been deposited to the ProteomeXchange Consortium via the PRIDE partner repository with the dataset identifiers PXD001424 and PXD002194.

Is the Glasgow Coma Scale Score in Children in the Emergency Department Lower During the Night?

The body clock may, through stimulation of melatonin secretion, influence the Glasgow Coma Scale (GCS) score. The aim of this study was to investigate whether the time of presentation of children in the emergency department is associated with GCS scores.

METHODS

We performed a retrospective review of 6,649 records of children presenting to an emergency department, with comparison of patients with GCS scores lower than 15 seen during the daytime and night time regarding diagnosis, disease severity, GCS score, age, sex, and ethnic group.

RESULTS

Of 4,034 children seen during the daytime, 25 had GCS scores lower than 15, whereas 34 of 2,592 children seen during the night had GCS scores lower than 15 (P = .005). There were no differences in age, sex, ethnicity, or disease severity between the group of patients seen during the daytime and those seen during the night. Conditions presenting with reduced GCS scores were seizures (32%), respiratory tract infection (17%), other infections (20%), trauma (13%), and other conditions (18%). Significantly more children with respiratory tract infections and low GCS scores presented during the night (P = .029).

DISCUSSION

The presentation of children with low GCS scores was more common during the night. Children with reduced GCS scores and viral respiratory tract infections presented more frequently during the night. Assessment of patients' level of consciousness during the night needs to discriminate difficulties in eliciting a response due to fatigue from features of cerebral dysfunction.

Gas Diffusivity Through EPS Foams

A simple multiscale model was developed and used to predict gas diffusivities through expanded polystyrene foam at near standard temperature and pressure conditions. The technique involves measuring gas diffusivities at various length scales then combining them using an electrical analogy for parallel resistances to construct an effective property. A commonly used experimental technique, the continuous flow method, was used to obtain diffusivity data for argon through polystyrene films and foams. Although a simple Fickian mathematical model was able to predict diffusivities through films, a simple ‘coarse’ multiscale model that accounts for the morphological features was developed for the foam.

Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence

OBJECTIVES

To identify the changes in sexual behaviour that led to the dramatic reduction in the prevalence of HIV in Uganda in the early 1990s.

METHODS

Seven different types of evidence were examined: (1) models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; (2) reports of behaviour change in the primary newspaper in Uganda; (3) surveys with questions about perceptions of personal behaviour change; (4) large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour; (5) smaller less representative surveys of reported sexual behaviour collected in other years; (6) reports of numbers of condoms shipped to Uganda; and (7) historical documents describing the implementation of HIV prevention programmes in Uganda.

RESULTS

All seven types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners.

CONCLUSIONS

Consistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and breaking up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalised epidemics.

An implantable ligation device that achieves male sterilization without cutting the vas deferens

OBJECTIVES

To determine whether the Vasclip implant procedure would (a) be equivalent to vasectomy in producing azoospermia, (b) produce greater patient satisfaction postoperatively, and (c) result in lower complication rates, postoperative pain, hematoma formation, spermatic granuloma, and surgical site infection when compared with historical controls.

METHODS

Sterilization and complications were studied in 124 consecutive patients.

RESULTS

Successful sterilization, defined by azoospermia at 10 to 14 months, was observed in 116 of 119 subjects. The effectiveness seemed to be equivalent to that of vasectomy. The incidence of postoperative pain and hematoma formation was similar to that with standard methods. The Vasclip procedure had similar infection rates and seemed to have lower rates of sperm granuloma when compared with vasectomy. In 3 subjects with persistent presence of sperm, histologic examination after traditional vasectomy indicated that misalignment of the device led to partial vas incision with recanalization. Patient acceptability was high: of the clinical study patients, 99% of survey respondents would recommend that other men considering a vasectomy have the Vasclip procedure.

CONCLUSIONS

The Vasclip implant procedure represents a new, effective, office-based alternative to vasectomy. Physicians' benefits can include reduced procedural time and reduction of postprocedural complications. Potential patients' benefits include reduced risk of postoperative infection and sperm granuloma formation.

Measurement of cardiac output before and after cardiopulmonary bypass: Comparison among aortic transit-time ultrasound, thermodilution, and noninvasive partial CO2 rebreathing

OBJECTIVES

A noninvasive continuous cardiac output system (NICO) has been developed recently. NICO uses a ratio of the change in the end-tidal carbon dioxide partial pressure and carbon dioxide elimination in response to a brief period of partial rebreathing to measure CO. The aim of this study was to compare the agreement among NICO, bolus (TDCO), and continuous thermodilution (CCO), with transit-time flowmetry of the ascending aorta using an ultrasonic flow probe (UFP) before and after cardiopulmonary bypass (CPB).

DESIGN

Prospective, observational human study.

SETTING

Veterans Affairs Medical Center Hospital.

PARTICIPANTS

Sixty-eight patients.

METHODS

Matched sets of CO measurements between NICO, TDCO, CCO, and UFP were collected in 68 patients undergoing elective CABG at specific time periods before and after separation from CPB. After anesthetic induction, all patients had an NICO sensor attached between the endotracheal tube and the breathing circuit, a PAC floated into the pulmonary artery for TDCO and CCO monitoring, and a UFP positioned on the ascending aorta and used for the reference CO. Bland-Altman analysis was used to compare the agreement among the different methods.

MEASUREMENTS AND MAIN RESULTS

Bland-Altman analysis of CO measurements before CPB yielded a bias, precision, and percent error of 0.04 L/min +/- 1.07 L/min (44.8%) for NICO, 0.18 L/min +/- 1.01 L/min (41.7%) for TDCO, and 0.29 L/min +/- 1.40 L/min (57.5%) for CCO compared with simultaneous UFP CO measurements, respectively. After separation from CPB (average 29 mins), bias, precision, and percent error were -0.46 L/min +/- 1.06 L/min (37.3%) for NICO, 0.35 L/min +/- 1.39 L/min (46.1%) for TDCO, and 0.36 L/min +/- 1.96 L/min (64.7%) for CCO compared with UFP CO measurements, respectively.

CONCLUSIONS

Before initiation of CPB, the accuracy for all 3 techniques was similar. After separation from CPB, the tendency was for NICO to underestimate CO and for TDCO and CCO to overestimate it. NICO offers an alternative to invasive CO measurement.

Vero cytotoxin-producing Escherichia coli O157 gastroenteritis in farm visitors, North Wales

An outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) gastroenteritis in visitors to an open farm in North Wales resulted in 17 primary and 7 secondary cases of illness. E. coli O157 Vero cytotoxin type 2, phage type 2 was isolated from 23 human cases and environmental animal fecal samples. A case-control study of 16 primary case-patients and 36 controls (all children) showed a significant association with attendance on the 2nd day of a festival, eating ice cream or cotton candy (candy floss), and contact with cows or goats. On multivariable analysis, only the association between illness and ice cream (odds ratio [OR]=11.99, 95% confidence interval [CI] 1.04 to 137.76) and cotton candy (OR=51.90, 95% CI 2.77 to 970.67) remained significant. In addition to supervised handwashing, we recommend that foods on open farms only be eaten in dedicated clean areas and that sticky foods be discouraged.

Potent and long-acting corticotropin releasing factor (CRF) receptor 2 selective peptide competitive antagonists

We present evidence that members of the corticotropin releasing factor (CRF) family assume distinct structures when interacting with the CRF(1) and CRF(2) receptors. Predictive methods, physicochemical measurements, and structure-activity relationship studies have suggested that CRF, its family members, and competitive antagonists such as astressin [cyclo(30-33)[DPhe(12),Nle(21),Glu(30),Lys(33),Nle(38)]hCRF((12-41))] assume an alpha-helical conformation when interacting with their receptors. We had shown that alpha-helical CRF((9-41)) and sauvagine showed some selectivity for CRF receptors other than that responsible for ACTH secretion(1) and later for CRF2.(2) More recently, we suggested the possibility of a helix-turn-helix motif around a turn encompassing residues 30-33(3) that would confer high affinity for both CRF(1) and CRF(2)(2,4) in agonists and antagonists of all members of the CRF family.(3) On the other hand, the substitutions that conferred ca. 100-fold CRF(2) selectivity to the antagonist antisauvagine-30 [[DPhe(11),His(12)]sauvagine((11-40))] did not confer such property to the corresponding N-terminally extended agonists. We find here that a Glu(32)-Lys(35) side chain to side chain covalent lactam constraint in hCRF and the corresponding Glu(31)-Lys(34) side chain to side chain covalent lactam constraint in sauvagine yield potent ligands that are selective for CRF(2). Additionally, we introduced deletions and substitutions known to increase duration of action to yield antagonists such as cyclo(31-34)[DPhe(11),His(12),C(alpha)MeLeu(13,39),Nle(17),Glu(31),Lys(34)]Ac-sauvagine((8-40)) (astressin(2)-B) with CRF(2) selectivities greater than 100-fold. CRF receptor autoradiography was performed in rat tissue known to express CRF(2) and CRF(1) in order to confirm that astressin(2)-B could indeed bind to established CRF(2) but not CRF(1) receptor-expressing tissues. Extended duration of action of astressin(2)-B vs that of antisauvagine-30 is demonstrated in the CRF(2)-mediated animal model whereby the inhibition of gastric emptying of a solid meal in mice by urocortin administered intraperitoneally at time zero is antagonized by the administration of astressin(2)-B but not by antisauvagine-30 at times -3 and -6 h while both peptides are effective when given 10 min before urocortin.

Identification of potent and selective neuropeptide Y Y(1) receptor agonists with orexigenic activity in vivo

Neuropeptide Y (NPY) binds to a family of G-protein coupled receptors termed Y(1), Y(2), Y(3), Y(4), Y(5), and y(6). The use of various receptor subtype-selective agonists and antagonists has facilitated identification of the receptor subtypes responsible for mediating many of the biological effects of NPY. For example, the potent orexigenic activity of NPY is believed to be mediated by both the Y(1) and Y(5) receptor subtypes. Several selective Y(5) receptor agonists that stimulate food intake in rodents are available, but no selective Y(1) receptor agonist has been reported. We have identified several NPY analogs that bind the NPY Y(1) receptor with high affinity and exhibit full agonist activity, measured as inhibition of forskolin-stimulated cAMP production in cells expressing the cloned NPY Y(1) receptor. [D-Arg(25)]-NPY, [D-His(26)]-NPY, Des-AA(10--17)[Cys(7,21),Pro(34)]-NPY, Des-AA(11--18)[Cys(7,21),D-Lys(9)(Ac)]-NPY, Des-AA(11--18)[Cys(7,21),D-Lys(9)(Ac),Pro(34)]-NPY, Des-AA(11--18)[Cys(7,21),D-Lys(9)(Ac),D-His(26)]-NPY and Des-AA(11--18)[Cys(7,21),D-Lys(9)(Ac),D-His(26), Pro(34)]-NPY bind the NPY Y(1) receptor with K(i) values of 0.9 +/- 0.2, 2.0 +/- 0.3, 0.2 +/- 0.05, 0.7 +/- 0.1, 0.2 +/- 0.01, 2.2 +/- 0.3, and 1.2 +/- 0.3 nM, respectively, and inhibit forskolin-stimulated cAMP production with EC(50) values of 0.2 +/- 0.02, 0.5 +/- 0.04, 0.3 +/- 0.03, 0.5 +/- 0.05, 0.4 +/- 0.16, 5.3 +/- 0.32, and 5.1 +/- 0.97 nM, respectively. These peptides are highly selective for the NPY Y(1) receptor relative to the NPY Y(2), Y(4), and Y(5) receptors. [D-Arg(25)]-NPY, [D-His(26)]-NPY and Des-AA(11--18)[Cys(7,21), D-Lys(9)(Ac),D-His(26),Pro(34)]-NPY stimulate food intake dose-responsively in Long-Evans rats for at least 4 h after intracerebroventricular administration. Although the involvement of Y(1) receptors in several physiological activities, such as vasoconstriction and anxiolysis, remains to be investigated, adequate tools are now available.

Hyponatraemia and selective serotonin re-uptake inhibitors in elderly patients

Hyponatraemia (serum sodium arbitrarily defined as less than 135 mmol/L) is an increasingly recognised adverse effect of selective serotonin re-uptake inhibitors (SSRIs). Its precise prevalence and incidence in the elderly are hard to determine because of confounding factors including other prescribed medications and medical conditions. Although hyponatraemia has been reported with all SSRIs and venlafaxine, most studies are small, retrospective, limited by confounding variables or are individual case reports. The risk of developing hyponatraemia while on an SSRI seems to increase with age, female, sex, previous history of hyponatraemia and the concomitant use of other medications known to include hyponatraemia. The sodium concentrations of most patients with SSRI associated hyponatraemia return to normal within days to weeks of SSRI withdrawal. A few cases of SSRI rechallenge indicate that hyponatraemia may sometimes be a transient effect with tolerance developing over time. There is an urgent need for controlled, rigorous studies to confirm the extent of the association between SSRIs and hyponatraemia. Older drugs such as tricyclic antidepressants also need systematic study. It remains quite unclear whether any specific SSRI or venlafaxine has a stronger association with hyponatraemia than any other antidepressant drug.

Schoolwide effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students

Few studies have tested schoolwide interventions to reduce sexual risk behavior, and none have demonstrated significant schoolwide effects. This study evaluates the schoolwide effects of Safer Choices, a multicomponent, behavioral theory-based HIV, STD, and pregnancy prevention program, on risk behavior, school climate, and psychosocial variables. Twenty urban high schools were randomized, and cross-sectional samples of classes were surveyed at baseline, the end of intervention (19 months after baseline), and 31 months afterbaseline. At 19 months, the program had a positive effect on the frequency of sex without a condom. At 31 months, students in Safer Choices schools reported having sexual intercourse without a condom with fewer partners. The program positively affected psychosocial variables and school climate for HIV/STD and pregnancy prevention. The program did not influence the prevalence of recent sexual intercourse. Schoolwide changes in condomuse demonstrated that aschool-based program can reduce the sexual risk behavior of adolescents.

Manifestations of poverty and birthrates among young teenagers in California zip code areas

CONTEXT

Given that many communities are implementing community-wide initiatives to reduce teenage pregnancy or childbearing, it is important to understand the effects of a community's characteristics on adolescent birthrates.

METHODOLOGY

Data from the 1990 census and from California birth certificates were obtained for zip codes in California. Regression analyses were conducted on data from zip code areas with at least 200 females aged 15-17 between 1991 and 1996, to predict the effects of race and ethnicity marital status, education, employment, income and poverty, and housing on birthrates among young teenagers.

RESULTS

In bivariate analyses, the proportion of families living below poverty level within a zip code was highly related to the birthrate among young teenagers in that zip code (r=.80, p<.001). In multivariate analyses, which controlled for some of the correlates of family poverty level, the proportion of families living below poverty level remained by far the most important predictor of the birthrate among young teenagers (b=1.54), followed by the proportion of adults aged 25 or older who have a college education (b=-0.80). Race and ethnicity were only weakly related to birthrate. In all three racial and ethnic groups, poverty and education were significantly related to birthrate, but the effect of college education was greater among Hispanics (b=-2.98) than among either non-Hispanic whites (b=-0.53) or blacks (b=-1.12). Male employment and unemployment and female unemployment were highly related to the birthrate among young teenagers in some racial or ethnic groups, but not in others.

CONCLUSIONS

Multiple manifestations of poverty, including poverty itself, low levels of education and employment, and high levels of unemployment, may have a large impact upon birthrates among young teenagers. Addressing some of these issues could substantially reduce childbearing among young adolescents.

Safer choices: reducing teen pregnancy, HIV, and STDs

OBJECTIVES

This study evaluated the long-term effectiveness of Safer Choices, a theory-based, multi-component educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high school students.

METHODS

The study used a randomized controlled trial involving 20 high schools in California and Texas. A cohort of 3869 ninth-grade students was tracked for 31 months from fall semester 1993 (baseline) to spring semester 1996 (31-month follow-up). Data were collected using self-report surveys administered by trained data collectors. Response rate at 31-month follow-up was 79%.

RESULTS

Safer Choices had its greatest effect on measures involving condom use. The program reduced the frequency of intercourse without a condom during the three months prior to the survey, reduced the number of sexual partners with whom students had intercourse without a condom, and increased use of condoms and other protection against pregnancy at last intercourse. Safer Choices also improved 7 of 13 psychosocial variables, many related to condom use, but did not have a significant effect upon rates of sexual initiation.

CONCLUSIONS

The Safer Choices program was effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants of such behavior.

Psychosocial predictors of delay of first sexual intercourse by adolescents

This investigation predicted adolescents' delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the 3 psychosocial determinants and onset. The participants (N = 827), part of a cohort initially surveyed in the 9th grade, reported at baseline that they had never engaged in intercourse. The multivariable proportional hazards regression model suggested that adolescents with more positive attitudinal and normative beliefs, as well as those with a parent who graduated from college, were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse.

Psychosocial predictors of delay of first sexual intercourse by adolescents

This investigation predicted adolescents' delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the 3 psychosocial determinants and onset. The participants (N = 827), part of a cohort initially surveyed in the 9th grade, reported at baseline that they had never engaged in intercourse. The multivariable proportional hazards regression model suggested that adolescents with more positive attitudinal and normative beliefs, as well as those with a parent who graduated from college, were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse.

Sexuality and sex education at home and school

This article reviews numerous studies of parent-adolescent communication about sexuality and 30 studies of sexuality and HIV education programs. Although parent-adolescent communication about sexuality has increased during the last few decades, both the occurrence and the quality of this communication could still be greatly improved. There does not exist a clear simple relationship between greater parent-adolescent communication and less adolescent risk-taking behavior, but both adults and youth believe it is important anyway. Sexuality and HIV education programs do not increase any measure of sexual activity, but some of them with ten common characteristics do reduce sexual risk-taking, either by delaying or reducing sexual behavior or increasing condom use. Thus, these programs can be an effective component in a larger initiative to reduce HIV, other STDs, and unplanned pregnancy in adolescence.

Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program

This study evaluated the effectiveness of the first year of Safer Choices, a theoretically based, multicomponent HIV, STD, and pregnancy prevention program for high school youth. The study featured a randomized trial involving 20 schools in California and Texas, with a cohort of 3,869 ninth-grade students. Students who completed both the baseline and the first follow-up survey approximately seven months later were included in the analysis (n = 3,677). Safer Choices enhanced 9 of 13 psychosocial variables including knowledge, self efficacy for condom use, normative beliefs and attitudes regarding condom use, perceived barriers to condom use, risk perceptions, and parent-child communication. Safer Choices also reduced selected risk behaviors. Specifically, Safer Choices reduced the frequency of intercourse without a condom in the three months prior to the survey, increased use of condoms at last intercourse, and increased use of selected contraceptives at last intercourse.

Reflections on two decades of research on teen sexual behavior and pregnancy

During the past 20 years, both researchers and program developers made great progress in their efforts to reduce adolescent unprotected sex and prevent teen pregnancy. Research studies are now more likely to employ experimental designs with random assignments, to have large sample sizes with adequate statistical power, to measure actual sexual and contraceptive behaviors, to measure longer term effects, to employ proper statistical methods, and to report results in an unbiased manner. As a result of this body of research, large advances have occurred in our understanding of: 1) the incidence of teen pregnancy, and its consequences; 2) the effects of improving adolescent knowledge, increasing access to contraception, and improving parent/child communication; and 3) the characteristics of effective programs. The on-going evaluation of sex and HIV education programs coupled with creativity and perseverance on the part of program developers led to two groups of effective programs--sex and HIV education programs that reduce sexual risk-taking behavior, and youth development programs that reduce teen-age pregnancy and childbearing.

The impact of condom availability [correction of distribution] in Seattle schools on sexual behavior and condom use

OBJECTIVES

Ten Seattle high schools made condoms available through vending machines, baskets in school clinics, or both. This study measured the number of condoms that students obtained and subsequent changes in sexual behavior and condom use.

METHODS

Schoolwide surveys were administered in spring 1993 and in spring 1995, before and during the condom availability program. These data were compared with data from nationally representative surveys administered at the same time.

RESULTS

Seattle students obtained an average of 4.6 condoms per year, the vast majority from baskets and very few from vending machines. Relative to the national samples, the percentage of Seattle students who had ever had sex remained stable after the program began; current sexual activity decreased significantly; and the percentage of sexually experienced students who used a condom the last time they had sex decreased significantly, particularly in the 5 schools with baskets of condoms in clinics.

CONCLUSIONS

Making condoms available in Seattle schools enabled students to obtain relatively large numbers of condoms but did not lead to increases in either sexual activity or condom use.

Sexually transmitted diseases, unintended pregnancy, and adolescent health promotion

Adolescence is a critical period in the development of sexual behaviors that may lead to acquiring sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and to unintended pregnancy. Understanding adolescent sexual behavior is essential for understanding adolescents' risk of pregnancy and STD/HIV infection and for planning and evaluating health promotion activities. This chapter reviews the sexual behaviors and psychosocial factors associated with STDs and unintended pregnancy among adolescents as well as school-, community-, and clinic-based interventions designed to reduce risk behaviors and promote adolescent sexual health.

Validity of scales measuring the psychosocial determinants of HIV/STD-related risk behavior in adolescents

We examined the content, construct and concurrent validity of scales to assess beliefs and self-efficacy related to adolescents' sexual risk behavior. We addressed content validity in the scale development process by drawing on literature and theory, and by pre-testing items with focus groups. We used confirmatory factor analysis of two models, an intercourse involvement model and a condom use model, to assess construct validity. The final intercourse involvement model included three scales: norms about sexual intercourse, attitudes about sexual intercourse and self-efficacy in refusing sex. The final condom use model included five scales: norms about condoms, attitudes about condom use, self-efficacy in communicating about condoms, self-efficacy in buying/using condoms and barriers to condom use. After two alterations to the models, the chi 2 and other indices indicated that the data fit the models well. Supporting the concurrent validity of the scales, high school students who had never had sexual intercourse had more negative attitudes toward sexual intercourse among teenagers, perceived norms toward sexual intercourse among teenagers to be more negative and expressed greater self-efficacy in refusing sex than did those who had experienced sexual intercourse. Consistent condom users had more positive attitudes and norms about condoms, had higher self-efficacy in communicating about and buying/using condoms, and perceived fewer barriers to condom purchase and use than did inconsistent condom users.

A new barrier-free burn center

This article describes a barrier-free burn center that is accessible to persons with disabilities and that complies with Title III of the Americans with Disabilities Act. The burn center has 3 separate components: patient rooms, patient support facilities, and staff support facilities. Thirteen rooms are used to care for 16 patients. Two of the 13 rooms are accessible to people with disabilities. These 2 rooms have wide doors that permit a wheelchair to pass through, and they have enough clear floor space for a wheelchair to make a 180 degrees turn. The rooms have a sink that is accessible from a wheelchair. The bathrooms have large, clear floor spaces that allow for the turning of a wheelchair, elevated toilets, grab bars, and showers that permit wheelchair access. Special wheelchairs that provide easier shower and commode access are available. The patient support services feature a large hydrotherapy room that contains a table-shower system that allows a person in a wheelchair to gain access to both sides of the shower table. A tub room has been constructed to provide compact patient bathing and hydromassage, and it is also accessible to people in wheelchairs. The staff support services include a locker room that has a shower accessible to people with disabilities so that staff members with mobility disorders can work in the burn center. Grade II braille writing marks all of the signs that designate the permanent rooms and spacing in the burn center and in the contiguous common use areas. The common use area has a restroom accessible to people with disabilities and a waiting room with a telephone communications system for people with mobility disorders or mobility impairment.

The safer choices project: methodological issues in school-based health promotion intervention research

Randomized trials of school-based health promotion programs present unique design and analytical issues not widely discussed in the research literature. This article describes the Safer Choices study--a school-based program for prevention of HIV, other sexually transmitted diseases, and pregnancy--to illustrate critical methodological issues involved in large-scale, school-based intervention trials, particularly those evaluating interventions with a school-wide focus. The issues presented are: 1) comparability of the intervention and control groups even when few units are randomized; 2) factors that affect the decision to use a cohort or cross-sectional design; and 3) appropriate analysis strategy when the unit of randomization and intervention is at the school level, but observations are at the student level.

Electrophysiological actions of neuropeptide Y and its analogs: new measures for anxiolytic therapy?

Neuropeptide Y (NPY) has neuromodulatory actions on multiple brain functions including endocrine, behavioral, and circadian processes. Behavioral studies suggest that NPY is a potent anxiolytic; however, little is known about how NPY affects general arousal and/or attention states. The present study evaluated the effects of NPY on spontaneous brain activity as well as auditory processing by using electrophysiological measures. Electroencephalographic (EEG) and event-related potentials (ERPs) were obtained in awake animals after intracerebroventricular administration of NPY (1.0, 3.0 nmol) and two of its analogs, active at Y1 (1.0, 3.0 nmol) and Y2 (1.0, 3.0 nmol) receptor sites. NPY was found to produce dose-related effects on electrophysiological measures. Spectral analyses of the EEG revealed that NPY produced slowing of delta activity (1-2 Hz) in the frontal cortex and high frequency theta activities (6-8 Hz) concomitant with a speeding up of low frequency theta (4-6 Hz) in cortex, hippocampus, and amygdala. At higher doses (3.0 nmols) in addition to shifts in frequency, EEG power was also significantly reduced in all frequencies (0.5-50 Hz) in cortex, and in the higher frequencies (8-32 Hz) in the amygdala. The Y1 and Y2 agonists had a somewhat different profile of EEG effects than the parent compound. At the 1 nmol dose both agonists were found to produce selective depressions in power in the hippocampus. The 3.0 nmols dose of the Y1 agonist produced decreases in EEG stability, an effect commonly produced by anxiolytic drugs, whereas the Y2 agonist produced increases in EEG stability in cortex and amygdala. Auditory processing, as assessed by ERPs, was affected most significantly in the frontal cortex where dose-dependent decreases in the N1 component of the ERP, a finding also commonly seen after anxiolytics, was found. Y1 and Y2 agonists were also found to significantly reduce the amplitude of the N1 component of the ERP but less so than the parent compound. The electrophysiological and behavioral profiles of NPY and the Y1 agonist resembles those of anxiolytics such as ethanol and benzodiazepines. Taken together these data suggest that electrophysiological measures of the actions of this peptide system may represent a new potentially useful assay for the development of anxiolytic drugs.

Anxiolytic activity of NPY receptor agonists in the conflict test

This investigation examined receptor subtype specificity and possible modulation by GABAa receptor ligands of NPY-induced behavioral responses to stressful stimuli. First, a series of NPY receptor agonists were examined for their potential effects on punished responding in a conflict test modified for incremental shock. NPY, peptide YY (PYY) and NPY Y1 receptor agonists [Leu31,Pro34]-NPY and [Gly6, Glu26,Lys26,Pro34]-NPY produced increases in punished responding in the conflict test. No significant effects on unpunished responding were noted. The pattern of responding was similar to that observed with the benzodiazepine agonist chlordiazepoxide. Neither pancreatic peptide (PP) nor the Y2 agonists NPY13-36 or [Glu2,32,Ala6,Dpr27,Lys28]-NPY significantly altered punished or unpunished responding. Of significance, the atypical Y1 agonist [Cys7,21,Pro34]-NPY produced negligible effects on punished responding, consistent with the presence of a subclass of Y1 receptors. Second, the anxiolytic effects of NPY were subjected to treatments that block actions at the GABAa receptor complex. The increase in punished responding produced by NPY was not altered by administration of the benzodiazepine antagonist flumazenil and only partially blocked by the picrotoxinin receptor ligand isopropylbicyclophosphate (10 and 15 microg/kg). These findings further support the hypothesis that the pharmacologic substrates for the anxiolytic-like actions of NPY may be mediated by the Y1 receptor subtype and suggest that these actions are independent of either the benzodiazepine or picrotoxinin binding sites of the GABA/benzodiazepine receptor complex.

The impact of the Postponing Sexual Involvement curriculum among youths in California

Postponing Sexual Involvement (PSI) is a widely implemented middle school curriculum designed to delay the onset of sexual intercourse. In an evaluation of its effectiveness among seventh and eighth graders in California, 10,600 youths from schools and community-based organizations statewide were recruited and participated in randomly assigned intervention or control groups; the curriculum was implemented by either adult or youth leaders. Survey data were collected before the program was implemented, and at three months and 17 months afterward. At three months, small but statistically significant changes were found in fewer than half of the measured attitudes, behaviors and intentions related to sexual activity; at 17 months, none of these significant positive effects of the PSI program had been sustained. At neither follow-up were there significant positive changes in sexual behavior; Youths in treatment and control groups were equally likely to have become sexually active, and youths in treatment groups were not less likely than youths in control groups to report a pregnancy or a sexually transmitted infection. The evaluation suggests that PSI may be too modest in length and scope to have an impact on youths' sexual behavior.