An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study

INTRODUCTION

The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair.

METHODS

A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC).

RESULTS

A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia.

CONCLUSION

This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.

Adapting Surgical Clerkship Curricula in Response to the COVID-19 Pandemic

BACKGROUND

Coronavirus disease-19 (COVID-19) impacted medical education and led to the significant modification or suspension of clinical clerkships and rotations.

OBJECTIVES

To describe a revised surgery clerkship curriculum, in which we divided in-person clinical teaching into smaller groups of students and adopted online-based learning to foster student and patient safety while upholding program standards.

METHODS

The third-year surgery core clerkship of a 4-year international English-language program at the Medical School for International Health at Ben Gurion University of the Negev, Beer Sheva, Israel, was adapted by dividing students into smaller capsules for in-person learning and incorporating online learning tools. Specifically, students were divided evenly throughout three surgical departments, each of which followed a different clinical schedule.

RESULTS

National Board of Medical Examiners clerkship scores of third-year medical students who were returning to in-person clinical clerkships after transitioning from 8 weeks of online-based learning showed no significant difference from the previous 2 years.

CONCLUSIONS

To manage with the restrictions caused by COVID-19 pandemic, we designed an alternative approach to a traditional surgical clerkship that minimized the risk of exposure and used online learning tools to navigate scheduling challenges. This curriculum enabled students to complete their clinical rotation objectives and outcomes while maintaining program standards. Furthermore, this approach provided a number of benefits, which medical schools should consider adopting the model into practice even in a post-pandemic setting.

Associations between asthma trigger reports, mental health conditions, and asthma morbidity among world trade center rescue and recovery workers

Aim: There is limited information regarding asthma triggers in World Trade Center (WTC) rescue and recovery workers (RRW) or how mental health conditions affect the perception of triggers. Methods: We included 372 WTC workers with asthma. The Asthma Trigger Inventory (ATI) assessed triggers along five domains: psychological, allergens, physical activity, infection, and pollution. We administered the Structured Clinical Interview to diagnose post-traumatic stress disorder (PTSD), major depression and panic disorder (PD). The Asthma Control Questionnaire (ACQ) and Mini Asthma Quality of Life Questionnaire (AQLQ) measured asthma control and quality of life, respectively. Linear regression models were fitted to examine the association of ATI total and subdomain scores with mental health conditions as well as the percent of ACQ and AQLQ variance explained by ATI subscales. Results: The most common triggers were air pollution (75%) and general allergens (68%). PTSD was significantly associated with psychological triggers (partial r²=0.05, p < 0.01), physical activity (partial r²=0.03, p < 0.01) and air pollution (partial r²=0.02, p = 0.04) subscales while PD was significantly associated with air pollution (partial r²=0.03, p = 0.03) and general allergens (partial r²=0.02, p = 0.03). ATI subscales explained a large percentage of variance in asthma control (r²=0.37, p < 0.01) and quality of life scores (r²=0.40, p < 0.01). Psychological subscale scores explained the largest portion of the total variability in ACQ (partial r²= 0.11, p = 0.72) and AQLQ (partial r²=0.14, p = 0.64) scores. Conclusion: RRW with mental health conditions reported more asthma triggers and these triggers were associated with asthma morbidity. These data can help support interventions in RRW with asthma.

Post-traumatic stress disorder dimensions and asthma morbidity in World Trade Center rescue and recovery workers

OBJECTIVE

Using data from a cohort of World Trade Center (WTC) rescue and recovery workers with asthma, we assessed whether meeting criteria for post-traumatic stress disorder (PTSD), sub-threshold PTSD, and for specific PTSD symptom dimensions are associated with increased asthma morbidity.

METHODS

Participants underwent a Structured Clinical Interview for Diagnostic and Statistical Manual to assess the presence of PTSD following DSM-IV criteria during in-person interviews between December 2013 and April 2015. We defined sub-threshold PTSD as meeting criteria for two of three symptom dimensions: re-experiencing, avoidance, or hyper-arousal. Asthma control, acute asthma-related healthcare utilization, and asthma-related quality of life data were collected using validated scales. Unadjusted and multiple regression analyses were performed to assess the relationship between sub-threshold PTSD and PTSD symptom domains with asthma morbidity measures.

RESULTS

Of the 181 WTC workers with asthma recruited into the study, 28% had PTSD and 25% had sub-threshold PTSD. Patients with PTSD showed worse asthma control, higher rates of inpatient healthcare utilization, and poorer asthma quality of life than those with sub-threshold or no PTSD. After adjusting for potential confounders, among patients not meeting the criteria for full PTSD, those presenting symptoms of re-experiencing exhibited poorer quality of life (p = 0.003). Avoidance was associated with increased acute healthcare use (p = 0.05). Sub-threshold PTSD was not associated with asthma morbidity (p > 0.05 for all comparisons).

CONCLUSIONS

There may be benefit in assessing asthma control in patients with sub-threshold PTSD symptoms as well as those with full PTSD to more effectively identify ongoing asthma symptoms and target management strategies.

Challenges in modelling the random structure correctly in growth mixture models and the impact this has on model mixtures

Lifecourse trajectories of clinical or anthropological attributes are useful for identifying how our early-life experiences influence later-life morbidity and mortality. Researchers often use growth mixture models (GMMs) to estimate such phenomena. It is common to place constrains on the random part of the GMM to improve parsimony or to aid convergence, but this can lead to an autoregressive structure that distorts the nature of the mixtures and subsequent model interpretation. This is especially true if changes in the outcome within individuals are gradual compared with the magnitude of differences between individuals. This is not widely appreciated, nor is its impact well understood. Using repeat measures of body mass index (BMI) for 1528 US adolescents, we estimated GMMs that required variance-covariance constraints to attain convergence. We contrasted constrained models with and without an autocorrelation structure to assess the impact this had on the ideal number of latent classes, their size and composition. We also contrasted model options using simulations. When the GMM variance-covariance structure was constrained, a within-class autocorrelation structure emerged. When not modelled explicitly, this led to poorer model fit and models that differed substantially in the ideal number of latent classes, as well as class size and composition. Failure to carefully consider the random structure of data within a GMM framework may lead to erroneous model inferences, especially for outcomes with greater within-person than between-person homogeneity, such as BMI. It is crucial to reflect on the underlying data generation processes when building such models.

Transoral incision free fundoplication (TIF) - A new paradigm in the surgical treatment of GERD

An estimated 10 billion dollars is spent treating gastro-oesophageal reflux disease (GERD) in the USA every year. The present article reports a case of the safe and successful use of transoral incisionless fundoplication (TIF) using the EsophyX90™ device in the surgical treatment of GERD.

Function of beta1 integrin in oral epithelia and tooth bud morphogenesis

Integrin beta1 is critical for basement membrane organization and hair follicle morphogenesis in the skin epidermis; however, less is known about its function in the developing oral epithelium. Since the skin and oral epithelia share structural similarity, we hypothesized that beta1 integrin function would be critical for the normal development of oral epithelium and tooth buds. The conditional (oral mucosa-specific) beta1 integrin knockout (KO) mice displayed severe disruption of the basement membrane of the tongue epithelium and developing tooth buds. Interestingly, unlike the developing hair follicles, early morphological development of the KO molar tooth buds was normal. However, subsequent morphogenetic events, such as cusp formation, cervical loop down-growth, and ameloblast polarization, did not occur normally. Primary KO oral keratinocytes showed defective cell spreading and robust focal adhesions. Our studies indicate that beta1 integrin plays an essential role in the normal development of the oral epithelium and its appendages.

Rain, temperature, and child-adolescent height among Native Amazonians in Bolivia

BACKGROUND

Global climate change and recent studies on early-life origins of well-being suggest that climate events early in life might affect health later in life.

AIM

The study tested hypotheses about the association between the level and variability of rain and temperature early in life on the height of children and adolescents in a foraging-farming society of native Amazonians in Bolivia (Tsimane').

SUBJECT AND METHODS

Measurements were taken for 525 children aged 2-12 and 218 adolescents aged 13-23 in 13 villages in 2005. Log of standing height was regressed on mean annual level and mean intra-annual monthly coefficient of variation (CV) of rain and mean annual level of temperature during gestation, birth year, and ages 2-4. Controls include age, quinquennium and season of birth, parent's attributes, and dummy variables for surveyors and villages.

RESULTS

Climate variables were only related with the height of boys age 2-12. The level and CV of rain during birth year and the CV of rain and level of temperature during ages 2-4 were associated with taller stature. There were no secular changes in temperature (1973-2005) or rain (1943-2005).

CONCLUSION

The height of young females and males is well protected from climate events, but protection works less well for boys ages 2-12.

The incidence of pulmonary embolism in open versus laparoscopic gastric bypass

Obesity independently increases the risk of pulmonary embolism (PE). We compare a superobese population (body mass index [BMI] > 55 kg/m(2)) undergoing open gastric bypasses (OGBs) with a similarly matched group of laparoscopic gastric bypasses (LGB) to see if the incidence of PE differs. We included all patients undergoing OGB (n = 193, average BMI = 51 kg/m(2)) at our institution by a single surgeon between July 1999 and April 2001. Thirty-one patients were superobese (BMI > 55 kg/m(2)). LGB was started at our institution in April 2001. Since that time 213 patients (average BMI = 52 kg/m(2)) have undergone the procedure. One hundred and nine patients were superobese. Pre- and postoperative prophylaxis included sequential compression stockings and subcutaneous heparin. Postoperatively, patients who developed signs of hypoxia, tachypnea, or tachycardia underwent a chest X-ray and spiral computed tomography. In addition, all patients who expired in the 30-day postoperative period underwent postmortem examination. Data were analyzed using the chi-squared test. In the OGB group, four patients (2.1%) developed PE. All occurred in superobese patients with a BMI > 55 kg/m(2). Three were fatal PEs and one was nonfatal. None of these patients had a prior history of deep vein thrombosis, PE, venous stasis disease, or pulmonary hypertension. In the LGB group, one patient (0.9%) had a nonfatal PE. This patient had a history of deep vein thrombosis. The incidence of PE was statistically higher in the superobese OGB group (P < 0.01). Despite the theoretical hindrance to venous return and vena caval compression observed with pneumoperitoneum, fewer PEs occurred in the laparoscopic group. Our data, however, suggest that patients with a BMI > 55 kg/m(2) might be at an increased risk for PE independent of operative approach.

Insulin-sensitizing effects of thiazolidinediones are not linked to adiponectin receptor expression in human fat or muscle

Circulating adiponectin levels are increased by the thiazolidinedione (TZD) class of PPARgamma agonists in concert with their insulin-sensitizing effects. Two receptors for adiponectin (AdipoR1 and AdipoR2) are widely expressed in many tissues, but their physiological significance to human insulin resistance remains to be fully elucidated. We examined the expression patterns of AdipoR1 and AdipoR2 in fat and skeletal muscle of human subjects, their relationship to insulin action, and whether they are regulated by TZDs. Expression patterns of both AdipoRs were similar in subcutaneous and omental fat depots, with higher expression in adipocytes than in stromal cells and macrophages. To determine the effects of TZDs on AdipoR expression, subcutaneous fat and quadriceps muscle were biopsied in 14 insulin-resistant subjects with type 2 diabetes mellitus after 45 mg pioglitazone or placebo for 21 days. This duration of pioglitazone improved insulin's suppression of glucose production by 41% and enhanced stimulation of glucose uptake by 27% in concert with increased gene expression and plasma levels of adiponectin. Pioglitazone did not affect AdipoR expression in muscle, whole fat, or cellular adipose fractions, and receptor expression did not correlate with baseline or TZD-enhanced insulin action. In summary, both adiponectin receptors are expressed in cellular fractions of human fat, particularly adipocytes. TZD administration for sufficient duration to improve insulin action and increase adiponectin levels did not affect expression of AdipoR1 or AdipoR2. Although TZDs probably exert many of their effects via adiponectin, changes in these receptors do not appear to be necessary for their insulin-sensitizing effects.

Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference?

Intestinal obstruction and other complications have been reported following Roux-en-Y gastric bypass (RYGB) surgery. There is controversy of whether the alimentary limb should be placed in the retrocolic or antecolic position. A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75-cm alimentary limb based upon technical consideration (the presence of adhesions from prior surgical procedures, thickness of the transverse mesocolon and mobility of the small bowel mesentery). Group A (216) patients had placement of the Roux limb anterior to the transverse colon, and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19-64) and the body mass index ranged from 40 to 75 kg/m2. Patients were followed for 24-86 months (mean 36 months). Any patients lost to follow-up were excluded. The average age of patients in the study was 40 years (range 19-64 years). Patients in both groups were similar in their body mass index and demographic characteristics. Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, P>0.05). Thirteen patients required reoperation for intestinal obstruction (seven patients in group A and six patients in group B (P>0.05). Development of anastomotic stricture occurred in one patient (0.5%) in group A and three patients (1%, P>0.05) in group B. There were no differences in mean operating room times, hospital length of stay, and excess weight lost. No other complications during the follow-up period were attributed to the position of the alimentary limb. Placement of the Roux limb in the antecolic position is may be technically more feasible in some patients and does not appear to be associated with more complications. It avoids the risk of an internal hernia through the transverse and does not appear to be associated with feeding difficulties in the early or late postoperative period.

Experience with inferior vena cava filter placement in patients undergoing open gastric bypass procedures

OBJECTIVE

Patients undergoing open gastric bypass (OGB) for morbid obesity are at significant risk for pulmonary embolism (PE) despite the use of subcutaneous heparin injections and sequential compression devices. Prophylactic preoperative inferior vena cava (IVC) filter placement may reduce this risk. We report our experience with simultaneous IVC filter placement and OGB in an operating room setting.

METHODS

From July 1999 to April 2001, 193 patients (group 1) underwent OGB. Eight patients had prophylactic intraoperative IVC filters placed for deep vein thrombosis, PE, or pulmonary hypertension. From May 2001 to January 2003, 181 patients (group 2) underwent OGB. There were 33 IVC filters placed for body mass index (BMI) greater than 55 kg/m2 in addition to the above-mentioned criteria. To confirm observations made in group 1 and 2 patients, from July 2003 to May 2005, 197 patients (group 3) underwent OGB, and patients with a BMI greater than 55 kg/m2 (n = 35) were offered IVC filter placement. Group 3A (n = 17) consented to IVC filter placement, and group 3B (n = 18) did not.

RESULTS

Fifty-eight IVC filters were placed (100% technical success rate) with an increase in operating room time of 20 +/- 5 minutes. In group 1, the eight patients with IVC filters had a BMI greater than 55 kg/m2. There were four PEs (3 fatal and 1 nonfatal) in the other 185 patients, all which occurred in patients with BMIs greater than 55 kg/m2. In group 2, there were no PEs. The perioperative PE rate in these patients was reduced from 13% (4/31; 95% confidence interval [CI], 1.1%-25.7%) to 0% (0/33; 95% CI, 0%-8.7%). Perioperative mortality was reduced from 10% (3/31; 95% CI, 0%-20.0%) to 0% (0/33; 95% CI, 0%-8.7%). There were no pulmonary emboli or deaths related to PE in group 3A patients. Group 3B patients had a 28% PE rate (two fatal and three nonfatal) and an 11% PE-related death rate. None of the remaining patients in group 3 had a PE.

CONCLUSIONS

Intraoperative IVC filter placement for the prevention of PE in morbidly obese patients undergoing OGB is feasible. We observed a significant reduction in the perioperative PE rate when a BMI greater than 55 kg/m2 was used as an indication for IVC filter placement despite the use of subcutaneous heparin injections and sequential compression devices.

Anthropometric variability in the USA: 1971-2002

AIM

The study analysed variability in physical stature, weight, and body mass index (BMI) in the USA during 1971-2002.

SUBJECTS

Subjects were non-Hispanic Blacks and Whites, 2-74 years of age from the National Health and Nutrition Examination Surveys (NHANES I-III and 1999-2002).

METHODS

The coefficient of variation and the standard deviation of the logarithm of stature, weight, and BMI were used to assess anthropometric variability for groups defined by age, race, sex, income, and survey year. Weighted ordinary least squares regressions were used to estimate the effect of socio-economic variables on anthropometric variability.

RESULTS

(a) The relation between age and variability in weight or BMI resembles an inverted U, (b) men have lower variability in BMI than women, (c) Blacks and the poor have greater variability in weight and BMI than Whites or than the non-poor, and (d) variability in anthropometric indices increased during 1971-2002. Results were robust to the measure of variability used and to the use of the mean and mean square of the anthropometric indicators as explanatory variables.

CONCLUSION

Since anthropometric indices correlate reliably with canonical indicators of well-being (e.g. income), growing variability in anthropometric indices, particularly among the Blacks and the poor, signals growing inequality in quality of life--a worrisome trend.

Intussusception: An Uncommon Cause of Postoperative Small Bowel Obstruction after Gastric Bypass

Intussusception of the jejuno-jejunal anastomosis is a rare complication of the Roux-en-Y gastric bypass (RYGBP). There are only 3 previous cases reported in the surgical literature. We describe 2 adults who developed jejuno-jejunal intussusception requiring emergent laparotomy several months after RYGBP. Both patients underwent exploratory laparotomy after the diagnosis was made with abdominal CT scan. Each patient had an uneventful postoperative course after bowel resection and revision of the enteroenterostomy. Small bowel obstruction due to intussusception may occur many months after RYGBP and may present with non-specific symptoms such as crampy abdominal pain, nausea, and vomiting. The diagnosis of this rare entity is typically made via abdominal CT scan. Treatment mandates urgent abdominal exploration with reduction.

Measurement of young women's attitudes about communication with providers regarding Papanicolaou smears

PURPOSE

To describe the psychometric properties of a scale created to measure communication with the provider regarding Papanicolaou (Pap) smears.

METHODS

A scale based on expectancy-value theory was developed and administered to 490 young women aged 12 to 24 years in an urban adolescent clinic. Psychometric properties were assessed using factor analysis to evaluate latent variables, intraclass correlation coefficient to evaluate test-retest reliability, and Cronbach coefficient alpha to evaluate internal consistency reliability. Content validity was assessed by qualitative interviews, feedback on a pilot survey, and expert review. Construct validity was evaluated by examining whether relevant health care characteristics, knowledge, and attitudes were significantly associated with perceived communication.

RESULTS

Mean respondent age was 18.2 +/- 2.1 years; 50% were black and 22% Hispanic. The scale items loaded on one factor. The intraclass correlation coefficient was 0.83 and Cronbach alpha 0.95. Report of a consistent provider, report that a provider recommended a Pap smear, knowledge of Pap smears and Human Papillomavirus (HPV), intention to return for follow-up Pap smears, and positive attitudes about Pap follow-up were significantly associated with good communication.

CONCLUSIONS

The scale appears to be reliable and valid as a measure of young women's communication with providers regarding Pap smears. Future research should focus on whether this newly developed scale is useful in the design and evaluation of cervical cancer prevention programs for young women.

The psychology of gastric bypass surgery

BACKGROUND

This article discusses the importance of psychological evaluation of gastric bypass (GBP) surgery candidates and post-surgical psychological support services, using the Center for Weight Reduction Surgery at Montefiore Medical Center as a model. The study of psychological predictors of post-operative outcome is in its beginning stages, and the small body of literature on this topic is reviewed.

METHODS

115 GBP surgery candidates completed a clinical interview and a self-report measure, the MMPI-2.

RESULTS AND CONCLUSIONS

A high prevalence of psychopathology and personality disturbance was found in this population. The impact that psychological disturbance may have on post-operative outcome is discussed. The authors also provide a qualitative analysis of the psychological themes commonly found among this population, as well as psychosocial interventions that have been found helpful.

Socioeconomic status, depression, and health service utilization among adolescent women

This article examines relationships among socioeconomic status (SES), depression, and health services utilization among 5,735 adolescent women. In cross-sectional analyses, effects of SES on having obtained a routine physical examination and use of psychological/emotional counseling in the past year are examined. Then, longitudinal analyses determine the effects of health service utilization on depression at 1 year follow-up (T2) controlling for baseline depression and SES. SES was associated with medical but not mental health service use. SES and health service use independently predicted T2 depression and an income x baseline depression interaction was noted. The findings and their implications are discussed.

Adolescents' perceptions of social status: development and evaluation of a new indicator

OBJECTIVE

Eliminating health disparities, including those that are a result of socioeconomic status (SES), is one of the overarching goals of Healthy People 2010. This article reports on the development of a new, adolescent-specific measure of subjective social status (SSS) and on initial exploratory analyses of the relationship of SSS to adolescents' physical and psychological health.

METHODS

A cross-sectional study of 10 843 adolescents and a subsample of 166 paired adolescent/mother dyads who participated in the Growing Up Today Study was conducted. The newly developed MacArthur Scale of Subjective Social Status (10-point scale) was used to measure SSS. Paternal education was the measure of SES. Indicators of psychological and physical health included depressive symptoms and obesity, respectively. Linear regression analyses determined the association of SSS to depressive symptoms, and logistic regression determined the association of SSS to overweight and obesity, controlling for sociodemographic factors and SES.

RESULTS

Mean society ladder ranking, a subjective measure of SES, was 7.2 +/- 1.3. Mean community ladder ranking, a measure of perceived placement in the school community, was 7.6 +/- 1.7. Reliability of the instrument was excellent: the intraclass correlation coefficient was 0.73 for the society ladder and 0.79 for the community ladder. Adolescents had higher society ladder rankings than their mothers (micro(teen) = 7.2 +/- 1.3 vs micro(mom) = 6.8 +/- 1.2; P =.002). Older adolescents' perceptions of familial placement in society were more closely correlated with maternal subjective perceptions of placement than those of younger adolescents (Spearman's rho(teens <15 years) = 0.31 vs Spearman's rho(teens 15 years) = 0.45; P <.001 for both). SSS explained 9.9% of the variance in depressive symptoms and was independently associated with obesity (odds ratio(society) = 0.89, 95% confidence interval = 0.83, 0.95; odds ratio(community) = 0.91, 95% confidence interval = 0.87, 0.97). For both depressive symptoms and obesity, community ladder rankings were more strongly associated with health than were society ladder rankings in models that controlled for both domains of SSS.

CONCLUSIONS

This new instrument can reliably measure SSS among adolescents. Social stratification as reflected by SSS is associated with adolescents' health. The findings suggest that as adolescents mature, SSS may undergo a developmental shift. Determining how these changes in SSS relate to health and how SSS functions prospectively with regard to health outcomes requires additional research.

Reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) in adolescent medical practice

PURPOSE

To determine the internal consistency and 1-week test-retest reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) among adolescent medical patients.

METHODS

A research assistant administered the POSIT to a consecutive sample of 15- to 18-year-old patients arriving for routine medical care at a hospital-based adolescent medical practice. Each subject returned for a retest 1 week later. Internal consistency for each scale on test and retest was calculated using Cronbach alpha, and 1-week test-retest reliability by the intraclass correlation coefficient (r) and the kappa coefficient (kappa).

RESULTS

The Substance Use/Abuse, Mental Health Status, Educational Status, and Aggressive Behavior/Delinquency scales had favorable alpha scores (>.70). Others, including Physical Health Status, had lower alpha scores. High intraclass correlation coefficients were found for all 10 POSIT scales (r =.72 to.88), although (r) was lower for males on two of the scales. Kappa coefficients for all scales indicated good reproducibility beyond chance (kappa =.42 to.73).

CONCLUSIONS

This study provided supportive evidence for the reliability of the POSIT in primary care medical settings, although some POSIT scales could likely be improved. The 20- to 30-min administration time is most practical in settings that are dedicated to adolescent medicine, and computerized administration and scoring are needed.

Adoption as a risk factor for attempted suicide during adolescence

OBJECTIVE

Depression, impulsivity, and aggression during adolescence have been associated with both adoption and suicidal behavior. Studies of adopted adults suggest that impulsivity, even more than depression, may be an inherited factor that mediates suicidal behavior. However, the association between adoption and adolescent suicide attempts and the mechanisms that might explain it remain unknown. The objective of this study was to determine the following: 1) whether suicide attempts are more common among adolescents who live with adoptive parents rather than biological parents; 2) whether the association is mediated by impulsivity, and 3) whether family connectedness decreases the risk of suicide attempt regardless of adoptive or biological status.

METHODS

A secondary analysis of Wave I data from the National Longitudinal Study of Adolescent Health was conducted, which used a school-based, clustered sampling design to identify a nationally representative sample of 7th- to 12th-grade students, with oversampling of underrepresented groups. Of the 90 118 adolescents who completed the National Longitudinal Study of Adolescent Health in-school survey, 17 125 completed the in-home interview and had parents of identified gender who completed separate in-home questionnaire. The subset of adolescents for this study was drawn from the in-home sampling according to the following criteria: 1) adolescent living with adoptive or biological mother at the time of the interview, 2) adolescent had never been separated from mother for more than 6 months, 3) mother was in first marriage at the time of the interview, and 4) the adoptive mother had never been married to the adolescent's biological father. Of the 6577 adolescents in the final study sample, 214 (3.3%) were living with adoptive mothers and 6363 (96.7%) were living with biological mothers. Variables. The primary outcome measured was adolescent report of suicide attempt(s) in the past year. Other variables included in the analyses were sociodemographics characteristics (gender, age, race/ethnicity, family income, parental education), general health (self-rated health, routine examination in the past year, need for medical care in the past year that was not obtained), mental health (depressive symptoms, self-image, trouble relaxing in the past year, bad temper, psychological or emotional counseling in the past year), risk behaviors (cigarettes, alcohol, marijuana, sexual intercourse ever, delinquency, physical fighting in the past year, impulsive decision making), school-related characteristics (grade point average, school connectedness), and family interaction (family connectedness, parental presence, maternal satisfaction with parent-adolescent relationship). Data Analysis. Univariate analyses were used to compare adoptees versus nonadoptees, suicide attempters versus nonsuicide attempters, and adopted suicide attempters versus nonadopted suicide attempters on all variables. Variables that were associated with attempted suicide were entered into a forward stepwise logistic regression procedure, and variables that were associated with the log odds of attempt were retained in the model. The area under the model's receiver operating characteristic curve was calculated as a measure of its overall performance. After the association of adoption with attempted suicide was demonstrated, the potential mediating effect of impulsivity was explored by adding it to the model. The same procedure was followed for any variable that was associated with adoption in the full sample or the subsample of suicide attempters. To determine whether any variable in the model moderated the association between adoption and suicide attempt, the interaction term for that variable x adoption was forced into the model.

RESULTS

Adoptees differed significantly from nonadoptees on 4 of 26 variables. They were more likely to have attempted suicide (7.6% vs 3.1%) and to have received psychological or emotional counseling in the past year (16.9% vs 8.2%), and their mothers reported higher parental education and family income. Attempters differed significantly from nonattempters on all variables except for age, race/ethnicity, parental education, family income, and routine examination in the past year. On logistic regression, 9 variables were independently associated with attempted suicide: depression (adjusted odds ratio [AOR]: 3.41), counseling (AOR: 2.83), female gender (AOR: 2.31), cigarette use (AOR: 2.31), delinquency (AOR: 2.17), adoption (AOR: 1.98), low self-image (AOR: 1.78), aggression (AOR: 1.48), and high family connectedness (AOR: 0.60). The receiver operating characteristic curve for the model had an area of 0.834, indicating performance significantly better than chance. The AOR for adoption did not change when parental education, family income, and impulsivity were forced into the model. (ABSTRACT TRUNCATED)

Intention to return for papanicolaou smears in adolescent girls and young women

OBJECTIVE

Sexually active adolescent girls have high rates of abnormal cervical cytology. However, little is known about factors that influence intention to return for Papanicolaou screening or follow-up. The aim of this study was to determine whether a theory-based model that assessed knowledge, attitudes, and behaviors predicted intention to return.

METHODS

The study design consisted of a self-administered, cross-sectional survey that assessed knowledge, beliefs, perceived control over follow-up, perceived risk, cues for Papanicolaou smears, impulsivity, risk behaviors, and past compliance with Papanicolaou smear follow-up. Participants were recruited from a hospital-based adolescent clinic that provides primary and subspecialty care, and the study sample consisted of all sexually active girls and young women who were aged 12 to 24 years and had had previous Papanicolaou smears. The main outcome measure was intention to return for Papanicolaou smear screening or follow-up.

RESULTS

The enrollment rate was 92% (N = 490), mean age was 18.2 years, 50% were black, and 22% were Hispanic. Eighty-two percent of participants intended to return. Variables that were independently associated with intention to return included positive beliefs about follow-up (odds ratio [OR]: 1.07; 95% confidence interval [CI]: 1.02-1.11), perception that important others believe that the participant should obtain a Papanicolaou smear (OR: 1.93; 95% CI: 1.38-2.74), perceived control over returning (OR: 1.24; 95% CI: 1.06-1.46), and having received cues to obtain a Papanicolaou smear (OR: 1.31; 95% CI: 1.08-1.60).

CONCLUSIONS

Analysis of this novel theoretical framework demonstrated that knowledge and previous behaviors were not associated with intention to return for Papanicolaou smear screening and follow-up in this population of young women. However, modifiable attitudinal components, including personal beliefs, perception of others' beliefs, and cues to obtaining Papanicolaou smears, were associated with intention to return.

Development of a Bright Futures curriculum for pediatric residents

OBJECTIVE

To develop a standardized case-based curriculum for pediatric residents on child growth, development, behavior, and adolescent medicine that incorporates the Bright Futures health supervision guidelines.

DESIGN

This project included a needs assessment, development of a list of important topics, writing and revising of standardized cases, formative evaluation of cases, and efficacy pilot testing of 2 cases.

SETTING

A large pediatric teaching hospital continuity clinic.

PARTICIPANTS

Pediatric residents, fellows, and faculty.

INTERVENTIONS

Preparation of standardized cases, facilitator training, and resident-led teaching conferences.

OUTCOME MEASURES

Learner and facilitator evaluation forms and two 10-item diagnostic skills assessments.

RESULTS

During the project, faculty-fellow teams wrote 29 case-teaching modules. All participants gave high ratings to cases, and resident facilitators reported increased comfort with the case discussion method. Resident learners' ability to accurately interpret developmental screening tests and growth charts improved following sessions on those topics.

CONCLUSIONS

Further evaluation is required, but these standardized cases appear promising for teaching pediatric residents. The curriculum is now freely available to faculty nationwide.

The "test-tube" generation: parent-child relationships and the psychological well-being of in vitro fertilization children at adolescence

The introduction of in vitro fertilization (IVF) at the end of the 20th century constituted a fundamental change in the way in which families could be created, and by the start of the new millennium an increasing number of children have been (and are being) born as a result of this procedure. This article presents findings of a longitudinal study of the first cohort of children conceived by IVF to reach adolescence. Thirty-four IVF families, 49 adoptive families, and 38 families with a naturally conceived child were compared on standardized interview and questionnaire measures of parent-child relationships and children's psychological well-being. The few differences in parent-child relationships that were identified appeared to be associated with the experience of infertility rather than with IVF per se. The IVF children were found to be functioning well and did not differ from the adoptive or naturally conceived children on any of the assessments of social or emotional adjustment.

Randomized controlled trial of a safer sex intervention for high-risk adolescent girls

OBJECTIVE

To determine the effect of an individualized safer sex intervention on condom use and recurrent sexually transmitted disease (STD) among female adolescents diagnosed as having an STD.

DESIGN

Randomized controlled trial.

SETTING

Urban children's hospital adolescent clinic and inpatient service.

PARTICIPANTS

One hundred twenty-three adolescents with cervicitis or pelvic inflammatory disease.

INTERVENTION

Participants completed a questionnaire and then were randomized to receive standard STD education or to watch a videotape and have an individualized intervention session. Follow-up questionnaires were completed at 1, 3, 6, and 12 months. Intervention participants met with an educator at 1, 3, and 6 months to discuss interim sexual history and review the intervention.

MAIN OUTCOME MEASURES

Change in self-reported condom use and recurrence of STD. Other self-reported behaviors, sexual risk knowledge, attitudes toward condoms, and condom use negotiation skills were also assessed.

RESULTS

At 1 month, compared with control participants, intervention participants had increased sexual risk knowledge and more positive attitudes toward condoms and tended to use condoms more with a nonmain partner. At 6 months, fewer intervention participants than controls had sex with a nonmain sexual partner in the previous 6 months. At 12 months, intervention participants were less likely to have a current main partner and had a lower rate of recurrent STD than controls, but these differences were not significant.

CONCLUSIONS

This individualized safer sex intervention may improve condom use and decrease the number of partners among adolescent girls who have had an STD. Studies with larger samples are needed to determine definitive intervention effects on recurrent STD in this high-risk population.

Risk factors and characteristics of youth living with, or at high risk for, HIV

Over 8,000 adolescents and young adults (4,111 males; 4,085 females) reported on several HIV-related risk behaviors during enrollment into 10 service demonstration projects targeted to youth living with, or at risk for, HIV. Distinct risk patterns emerged by gender when predicting HIV serostatus (versus unknown serostatus/negative serostatus). Males who had injection drug risk histories, had sex with an HIV positive partner, had sexually transmitted diseases, had sex with males, and/or were homeless had an inflated risk of being HIV positive. Females who engaged in sex with an HIV partner, had sex with an injection drug user, and/or had sexually transmitted diseases, were at the highest HIV risk. For both samples, engaging in sex with women reduced the likelihood of HIV positive status. Very basic information about risk factors obtained at service intake offers important information about HIV status of "high risk" youth presenting for care in community programs, as well as suggests clear risk factors for targeted preventive efforts.

Validity of adolescent and young adult self-report of Papanicolaou smear results

OBJECTIVE

To assess the validity of adolescent and young adult report of Papanicolaou smear results and to determine sociodemographic, cognitive, and behavioral factors associated with incorrect reporting.

METHODS

We conducted a cross-sectional study of 477 female subjects aged 12 to 24 years who attended an adolescent clinic and had a previous Papanicolaou smear. Subjects completed a self-administered survey assessing self-report of Papanicolaou smear results, knowledge about Papanicolaou smears and human papillomavirus (HPV), attitudes about Papanicolaou screening and follow-up, and risk behaviors. The sensitivity, specificity, positive predictive value, and negative predictive value of self-reported results were calculated using the cytology report as the standard. Variables significantly associated with incorrect reporting were entered into logistic regression models controlling for age and race to determine independent predictors for incorrect reporting.

RESULTS

Of the 477 participants, 128 (27%) had abnormal cytology reports and 66 (14%) had incorrect self-reports. Sensitivity of self-report was 0.79, specificity 0.89, positive predictive value 0.72, negative predictive value 0.92, and kappa (kappa) 0.66. The adjusted odds ratios (OR) and 95% confidence intervals (CI) of the variables comprising a logistic regression model predicting incorrect reporting were an HPV knowledge source of zero (OR 2.4, CI 1.0, 5.8), low perceived communication with the provider (OR 2.1, CI 1.1, 4.0), and no contraception at last intercourse (OR 5.5, CI 2.7, 11.0).

CONCLUSION

The validity of adolescent and young adult self-reported Papanicolaou smear result is high, except among those who lack knowledge of HPV, perceive poor communication with the provider, and use contraception inconsistently.

Depressive symptoms and cigarette smoking among teens

CONTEXT

Although several risk factors for tobacco use have been implicated in the development of depression, smoking progression has typically been viewed as a consequence of depression. The results of limited longitudinal studies are controversial.

OBJECTIVE

To assess the nature and direction of the relationship between cigarette smoking and depression among teens.

DESIGN

Prospective analysis of baseline and 1-year follow-up data from the National Longitudinal Study of Adolescent Health.

SETTING

In-home teen and parent interviews.

PARTICIPANTS

Two samples were identified. For the first sample, 8704 adolescents who were not depressed at baseline based on CES-D scores were identified for analyses of the effects of cigarette smoking on development of high depressive symptomatology. Baseline smoking status, which could vary in this group, was the predictor of interest in these analyses. For the second sample, 6947 teens who had not smoked cigarettes in the 30 days before the baseline survey (noncurrent smokers) were identified for analyses on the effect of high depressive symptoms on subsequent moderate to heavy cigarette use at 1 year of follow-up. Baseline high depressive symptomatology based on CES-D score was the predictor of interest in this sample.

MAIN OUTCOME MEASURES

Among the nondepressed, developing high depressive symptoms at 1 year of follow-up. Among noncurrent smokers, smoking at least 1 pack per week at 1 year of follow-up.

RESULTS

For the nondepressed, multivariate modeling revealed that current cigarette smoking was the strongest predictor of developing high depressive symptoms in all models (final model odds ratio [OR]: 3.90; 95% confidence interval [CI]: 1.85,8.20). For noncurrent smokers, although in bivariate analyses, baseline high depressive symptoms increased the risk of heavy smoking nearly threefold, multivariate modeling revealed that baseline high depressive symptoms were not predictive of heavy smoking when controlling for other determinants of smoking in teens. Previous experimentation with smoking was the strongest predictor of becoming a heavy smoker (OR: 3.04; 95% CI: 1.93,4.88).

CONCLUSIONS

In contrast to common dictum, depression does not seem to be an antecedent to heavy cigarette use among teens. However, current cigarette use is a powerful determinant of developing high depressive symptoms.

Adolescents' understanding of social class: a comparison of white upper middle class and working class youth

PURPOSE

Social class is increasingly being recognized as an important factor in the development of population-based variation in health among teens. However, little consensus exists regarding its measurement or conceptualization.

METHODS

This study examined beliefs about social class of 48 working class and 50 upper middle class 16-year-old, white teens.

RESULTS

Working class teens were more likely to misclassify themselves with regard to social class position. Significant class differences were present in beliefs regarding social mobility, parents' equity, equality of opportunity within society, and financial status as adults. How this conceptualization of social class translates into population-based variation in health remains an important area for further inquiry.

Accuracy of teen and parental reports of obesity and body mass index

OBJECTIVES

Adolescent obesity is becoming an increasing public health problem. This study determines: 1) differences in teen and parental report of obesity, 2) amount of misclassification using body mass index (BMI) from self-reported versus measured height and weight as an indicator of obesity, and 3) whether misclassification varies by gender and socioeconomic status.

DESIGN

Weighted data from 15 483 baseline (T1) youth and parental interviews from the National Longitudinal Study of Adolescent Health were used. Seventy-four percent of teens were reinterviewed 1 year later (T2). Parents reported socioeconomic status indicators and whether their teen was obese. Teens reported height, weight, and weight perception. BMI was calculated from both self-reported height and weight at T1 and T2 and from measured height and weight at T2. Those with a BMI > or =95% corrected for age and gender were considered obese.

RESULTS

At T1, nearly one half of teens (47%) reporting they were very overweight were not obese by BMI. For teens obese by BMI, 19.6% were reported to be obese by both parent and teen, 6.4% by teen only, 29. 9% by parent only, and 44.2% by neither teen nor parent. For those with persistent obesity, teen and/or parental report failed to identify more than one third (34%) as obese; 23.4% were identified by both teen and parent report, 5.4% by teen report only, and 37.2% by parent only. At T2, the correlation between BMI calculated from self-reported versus measured height and weight for the overall population was very strong (r = .92). Specificity of obesity status based on self-reported BMI, compared with obesity status based on measured BMI was .996; sensitivity, .722; positive predictive value, .860; and negative predictive value, .978. Overall, 3.8% of teens were misclassified using self-report measures. Girls were no more likely than boys to be misclassified as obese using BMI from self-reported height and weight.

CONCLUSIONS

Parental report is a better indicator of obesity than teen report of weight status, but parental and teen reports are both poor predictors of adolescent obesity. Using BMI based on self-reported height and weight correctly classified 96% as to obesity status. Thus, studies can use self-reported height and weight to understand teen obesity and its correlates/sequelae.

Service use patterns of youth with, and at high risk for, HIV: a care typology

This paper uses confirmatory structural equation models to develop and test a theoretical model for understanding the service utilization history of 4679 youth who received services from 10 national HIV/AIDS demonstration models of youth-appropriate and youth-attractive services funded by the Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration. Although the projects differ from one another in the areas of emphasis in their service models, each is targeted to youth at high risk for HIV, or those youth who have already contracted HIV. Collectively, the projects represent a comprehensive adolescent HIV service model. This paper examines the characteristics of the services provided to young people ranging from outreach to intensive participation in medical treatment. Major typologies of service utilization are derived empirically through exploratory factor and cluster analysis methods. Confirmatory structural equation modeling methods are used to refine the exploratory results using a derivation and replication strategy and methods of statistical estimation appropriate for non-normally distributed service utilization indicators. The model hypothesizes that youth enter the service system through a general construct of connectedness to a comprehensive service model and through service-specific methods, primarily of outreach or emergency services. Estimates are made of the degree to which a comprehensive service model drives the services as opposed to specific service entry points.

Protein kinase C activity following exposure to magnetic field and phorbol ester

We examined the separate and combined effects of 60 Hz sinusoidal magnetic fields (MFs) and a phorbol ester on protein kinase C (PKC) activity in HL60 cells. No enhancement in PKC activity was observed when a cell culture was exposed to a 1.1 mT (rms) MF alone or to a combination of MF and 2 microM phorbol 12-myristate 13-acetate (PMA) for 1 h. In a second set of experiments, cells were preexposed to a less than optimal concentration of PMA (50 nM) for 45 min, followed by a 15 min exposure to both PMA and MF. The data showed a greater decrease in cytosolic PKC activity and a larger increase in membrane activity than was induced by either 1 h PMA treatment alone or PMA and sham MF exposure. One logical conclusion from these data is that MFs may be acting in a synergistic manner on a pathway that has already been activated. Therefore, we suggest that MFs, rather than producing biological effects by a new pathway or mechanism of interaction, exert their effect(s) by interacting with already functioning reactions or pathways. If correct, the question of an MF's mechanism of interaction refocuses on how weak fields might enhance or depress a molecular reaction in progress, rather than on finding a new transduction pathway.

Reliabilities of short substance abuse screening tests among adolescent medical patients

OBJECTIVE

To determine the internal consistency and 1-week test-retest reliability of the Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD), the CAGE-AA (CAGE questions adapted for adolescents), and 4 modified items from the Drug and Alcohol Problem QuickScreen (DAP-4) among adolescents.

METHODS

Fifteen- to 18-year-old medical patients (n = 173) completed screening tests during a routine medical visit and then again 1 week later. Internal consistency for each test and retest was calculated using Cronbach's alpha, and 1-week test-retest reliability was calculated by using Winer's unbiased estimate of the intraclass correlation coefficient (r).

RESULTS

The SSI-AOD has good internal consistency (alpha =.83) and the CAGE-AA questions acceptable internal consistency (alpha =.60). Alpha varied with gender and race, and item analysis indicated the CAGE-AA test could be improved. As expected, the DAP-4 had a lower alpha score (.46). All screening instruments studied had high 1-week test-retest reliabilities (range r =.82-.90).

CONCLUSIONS

The SSI-AOD is a reliable substance abuse screening instrument among adolescent medical patients. The CAGE-AA questions must be further revised and tested before their use can be recommended. The DAP-4 questions are likely measuring different, but important, constructs.

The association between adolescent spirituality and voluntary sexual activity

PURPOSE

The purpose of this study was to describe the spectrum of adolescent spirituality and to determine the association between dimensions of spirituality and voluntary sexual activity (VSA) in adolescents.

DESIGN

A sample of 141 consecutive youth aged 11-25 years presenting to an urban, hospital-based adolescent medicine clinic completed a 153-item instrument assessing sociodemographics, psychosocial parameters, and eight specific aspects of spirituality including: (1) religious attendance, (2) religious importance, (3) intrinsic and (4) extrinsic religious motivation, (5) belief in God, (6) belief in divine support, (7) existential aspects of spirituality, and (8) spiritual interconnectedness. Adolescents were also asked about VSA.

RESULTS

Sixty-one percent of respondents were African-American and 67.4%, female; mean age was 16.0+/-2.4 years. Adolescent religious attendance was equally distributed across the categories from "none" to "weekly or greater" attendance. Over 90% felt religion was somewhat important in their lives. Over 85% reported belief in God. Fifty-six percent of respondents reported a history of VSA. Greater importance of religion (p = 0.035) and higher spiritual interconnectedness with friends (p = 0.033) were inversely associated with VSA. A multiple logistic regression model including age, gender, race, socioeconomic status, and specific denomination of religious faith, importance of religion, and spiritual interconnectedness found that spiritual interconnectedness with friends (OR = 0.92, 95% CI = 0.85, 0.99) and age (OR = 1.75, 95% CI = 1.34, 2.28) were independent predictors of VSA.

CONCLUSIONS

Spirituality is a common facet of adolescents' lives. Younger age and higher spiritual interconnectedness, particularly interconnectedness among spiritual friends, are independently associated with a lower likelihood of VSA.

Splitting fees or splitting hairs? Fee splitting and health care--the Florida experience

Attorneys Jacobs and Goodman review the prohibitions against fee-splitting under Florida law and argue that Florida and other states need a clear statutory definition of prohibited activities. In addition, the authors argue that the Florida Board of Medicine has applied the prohibition against fee-splitting arbitrarily and in contrast to legal precedent set by the Second District Court of Appeals. Finally, the authors suggest that Minnesota provides clear legislative guidance on the issue of fee-splitting and that the approach adopted by Minnesota is more practical in today's complex health care reimbursement environment.

Teaching residents about development and behavior: meeting the new challenge

OBJECTIVE

To determine the teaching methods, materials currently used, and unmet needs for teaching developmental-behavioral pediatrics (DBP) at pediatric training programs in the United States.

DESIGN

Cross-sectional survey of US pediatric residency training programs. The survey questionnaire consisted of 3 instruments: a program director survey, a developmental-behavioral pediatrics survey, and an adolescent medicine survey.

PARTICIPANTS

Survey packets were mailed in January 1997 to 211 programs identified by mailing labels from the Association of Pediatric Program Directors.

RESULTS

Data from 148 programs (70%) completing both the DBP survey and program director survey were analyzed. Ninety-five percent of programs reported a block rotation, and 95% of those stated that the rotation was mandatory. Eighty-seven percent had a formal curriculum. Most programs reported using articles, lecture outlines, and precepting for teaching DBP. Few programs used standardized case-based or computerized materials. Most programs, however, indicated a desire for these materials. Few programs felt that 4 topics were covered adequately: adoption (12%), violence (24%), substance use (28%), and conduct problems (41%). Programs that perceived that they covered these topics adequately were more likely to use written cases as part of their curriculum (Mann-Whitney test, 1373.5; P=.04). Barriers to teaching included lack of adequate faculty, time, money, and curricular resources.

CONCLUSIONS

Pediatric residency programs have made significant gains in mandatory DBP training. However, many programs report a lack of adequate faculty, teaching materials, and methods. Responding programs indicated an interest in case-based materials. This approach may represent an alternative and underutilized resource for teaching DBP.