The Present State of Housing and Treatment of Transgender Incarcerated Persons.

The care and housing of transgender (TGD) incarcerated persons is a complex concern that is growing because of the increased recognition and diagnosis of gender dysphoria in society. To remain current in this evolving landscape, there have been updates to federal manuals and state guidelines regarding the medical care and housing of the TGD population. Since the publication by Glezer and colleagues in 2013, there has not been a comprehensive overview of current federal and state guidelines, and legal and other considerations on this topic. We provide an update with special consideration given to housing practices, safety, and access to care. A review of the literature shows that the World Professional Association for Transgender Health (WPATH) standards and Prison Rape Elimination Act (PREA) requirements are not uniformly implemented and enforced on a state level. In fact, some states have policies that are in direct conflict with federal requirements. The safety and equitable treatment of both TGD and cisgender populations is an important topic that merits attention. As new challenges emerge, an increase in federal enforcement and consistency is needed to ensure the humane treatment and protection of TGD inmates.

Inferior Ophthalmic Vein-Dominant Dural Cavernous Fistula Embolization via Combined Orbitotomy and Direct Puncture of Inferior Ophthalmic Vein: A Case Report and Literature Review.

Dural carotid-cavernous fistulas (DCF) typically drain into the superior ophthalmic vein. Predominant involvement of the inferior ophthalmic vein (IOV) is rare, with only 4 documented cases in the literature. Here, the authors describe a case of a 51-year-old man who presented with acute left-sided proptosis, dysmotility, and vision loss and was found to have an IOV-dominant type D dural carotid-cavernous fistulas. The fistula could not be embolized by transfemoral endovascular access or orbitotomy alone and was ultimately managed with combined orbitotomy and direct IOV puncture. All previous reports of IOV-dominant dural carotid-cavernous fistulas in the literature were similarly inaccessible via the transfemoral approach. This case highlights the challenges of IOV cutdown and proposes an alternative management strategy. When IOV cutdown is precluded by the fragile, collapsed, or deep nature of the vessel, conversion to percutaneous IOV puncture may offer a safe and effective approach and mitigate the risks of direct puncture alone.

Complications and cosmetic outcomes of materials used in cranioplasty following decompressive craniectomy-a systematic review, pairwise meta-analysis, and network meta-analysis.

BACKGROUND: Optimal reconstruction materials for cranioplasty following decompressive craniectomy (DC) remain unclear. This systematic review, pairwise meta-analysis, and network meta-analysis compares cosmetic outcomes and complications of autologous bone grafts and alloplasts used for cranioplasty following DC. METHOD: PubMed, Embase, and Cochrane were searched from inception until April 2021. A random-effects pairwise meta-analysis was used to compare pooled outcomes and 95% confidence intervals (CIs) of autologous bone to combined alloplasts. A frequentist network meta-analysis was subsequently conducted to compare multiple individual materials. RESULTS: Of 2033 articles screened, 30 studies were included, consisting of 29 observational studies and one randomized control trial. Overall complications were statistically significantly higher for autologous bone compared to combined alloplasts (RR = 1.56, 95%CI = 1.14-2.13), hydroxyapatite (RR = 2.60, 95%CI = 1.17-5.78), polymethylmethacrylate (RR = 1.50 95%CI = 1.08-2.08), and titanium (Ti) (RR = 1.56 95%CI = 1.03-2.37). Resorption occurred only in autologous bone (15.1%) and not in alloplasts (0.0%). When resorption was not considered, there was no difference in overall complications between autologous bone and combined alloplasts (RR = 1.00, 95%CI = 0.75-1.34), nor between any individual materials. Dehiscence was lower for autologous bone compared to combined alloplasts (RR = 0.39, 95%CI = 0.19-0.79) and Ti (RR = 0.34, 95%CI = 0.15-0.76). There was no difference between autologous bone and combined alloplasts with respect to infection (RR = 0.85, 95%CI = 0.56-1.30), migration (RR = 1.36, 95%CI = 0.63-2.93), hematoma (RR = 0.98, 95%CI = 0.53-1.79), seizures (RR = 0.83, 95%CI = 0.29-2.35), satisfactory cosmesis (RR = 0.88, 95%CI = 0.71-1.08), and reoperation (RR = 1.66, 95%CI = 0.90-3.08). CONCLUSIONS: Bone resorption is only a consideration in autologous cranioplasty compared to bone substitutes explaining higher complications for autologous bone. Dehiscence is higher in alloplasts, particularly in Ti, compared to autologous bone.

Cauda Canis: Variation of a Tinel's Sign for a Sciatic Nerve Tumor.

A patient with a prior history of intradural schwannoma and disc herniation presented with radicular pain after being hit in the thigh by a dog's tail. She was worked up and found to have a tumor of her right sciatic nerve. The tumor was resected and histology was consistent with schwannoma. The dog's tail acted as a Tinel's sign maneuver and led to timely identification of her peripheral nerve tumor. Peripheral nerve schwannomas can present in unusual forms, and Tinel's maneuver may be a useful tool in diagnosis.

Presentation and management of IVC and iliac vein encroachment by lumbar pedicle screws: a case-report.

Pedicle screws are commonly used in spinal surgeries and are relatively safe, with venous complications occurring rarely. We report a patient with imaging following a L4-5 fusion that showed indentation of the inferior vena cava and right common iliac vein by the right L4 and L5 pedicle screws. She underwent revision surgery in which the hardware was removed and no bleeding was observed. Intraoperative venogram confirmed vascular integrity and absence of indentation on the venous structures following screw removal. The patient recovered without complications. Venous contact by pedicle screws should be treated on a case-by-case basis in a multidisciplinary approach with vascular surgery. We discuss a treatment algorithm for the operative management of this problem.

The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study.

OBJECTIVEUse of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.METHODSThis study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.RESULTSOf 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).CONCLUSIONSThis large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors' data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.

Mycobacterial Osteomyelitis of the Spine Following Intravesical BCG Therapy for Bladder Cancer.

Osteomyelitis is an infection of the bone that can involve the vertebral column. A rare cause of vertebral osteomyelitis is Mycobacterium bovis after intravesical Bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder. In this report, we describe the case of a 64-year-old male presenting with constitutional symptoms, progressive thoracic kyphosis, and intractable T11 and T12 radiculopathies over the proceeding six months. A CT scan revealed erosive, lytic changes of the T12 and L1 vertebrae with compression of the T12 vertebra. An MRI demonstrated T11-12 osteomyelitis with intervening discitis and extensive paraspinal enhancement with a corresponding hyperintensity on a short tau inversion recovery (STIR) sequence. A needle aspiration grew out Mycobacterial tuberculosis complex that was pansensitive to all antimicrobial agent therapies, except pyrazinamide on culture, a finding consistent with an M. bovis infection. The patient's infection and neurologic compromise resolved after transthoracic T11-12 vertebrectomies with decompression of the spinal cord and nerve roots as well as T10-L1 instrumented fusion and protracted antimicrobial therapy. The epidemiology and natural history of M. bovis osteomyelitis are reviewed and the authors emphasize a mechanism of vertebral inoculation to explain the predilection of M. bovis osteomyelitis in males after intravesical BCG therapy.

The Role of Liposomal Bupivacaine in Reduction of Postoperative Pain After Transforaminal Lumbar Interbody Fusion: A Clinical Study.

BACKGROUND: Postoperative pain after transforaminal lumbar interbody fusion (TLIF) is a barrier to early mobility. Intraoperative local infiltration of anesthetic agents is standard practice to alleviate postoperative pain. Liposomal formulations may prolong the action of these anesthetic agents. The purpose of this study was to investigate the role of liposomal bupivacaine in postoperative pain control in patients undergoing unilateral, single-level TLIF. METHODS: From a cohort of 74 patients, half received nonliposomal local anesthetic and half received liposomal bupivacaine (LB) (LB group) via local infiltration. Both groups received a standard postoperative analgesia regimen. Demographic information, postoperative pain scores (visual analog scale), analgesic consumption, length of stay, and complications were retrospectively collected. RESULTS: The area under the curve of cumulative pain scores was significantly lower in the LB group between 0 and 12 hours (15.0 ± 15.6 vs. 45.6 ± 21.1, P = 0.003) and between 12 and 24 hours (37.6 ± 20.6 vs. 48.4 ± 24.9, P = 0.05) after surgery. Significantly fewer narcotic equivalents were consumed in the LB group between 12 and 24 hours (16.0 ± 13.4 mg vs. 24.1 ± 19.7 mg intravenous morphine equivalents, P = 0.04). Length of stay was significantly shorter in the LB group than in the control group (3.1 ± 0.9 days vs. 4.3 ± 1.3 days, P < .001). CONCLUSIONS: LB may be a useful adjunct during unilateral TLIF for decreasing pain and narcotic consumption in the first 24 hours after surgery and may also decrease overall length of stay.

Reliability of the modified Tufts Lumbar Degenerative Disc Classification between neurosurgeons and neuroradiologists.

Cross-specialty inter-rater reliability has not been explicitly reported for imaging characteristics that are thought to be important in lumbar intervertebral disc degeneration. Sufficient cross-specialty reliability is an essential consideration if radiographic stratification of symptomatic patients to specific treatment modalities is to ever be realized. Therefore the purpose of this study was to directly compare the assessment of such characteristics between neurosurgeons and neuroradiologists. Sixty consecutive patients with a diagnosis of lumbago and appropriate imaging were selected for inclusion. Lumbar MRI were evaluated using the Tufts Degenerative Disc Classification by two neurosurgeons and two neuroradiologists. Inter-rater reliability was assessed using Cohen's κ values both within and between specialties. A sensitivity analysis was performed for a modified grading system, which excluded high intensity zones (HIZ), due to poor cross-specialty inter-rater reliability of HIZ between specialties. The reliability of HIZ between neurosurgeons and neuroradiologists was fair in two of the four cross-specialty comparisons in this study (neurosurgeon 1 versus both radiologists κ=0.364 and κ=0.290). Removing HIZ from the classification improved inter-rater reliability for all comparisons within and between specialties (0.465⩽κ⩽0.576). In addition, intra-rater reliability remained in the moderate to substantial range (0.523⩽κ⩽0.649). Given our findings and corroboration with previous studies, identification of HIZ seems to have a markedly variable reliability. Thus we recommend modification of the original Tufts Degenerative Disc Classification by removing HIZ in order to make the overall grade provided by this classification more reproducible when scored by practitioners of different training backgrounds.

Iatrogenic Spinal Cord Injury during Removal of the Inferior Articular Process in the Presence of Ossification of the Ligamentum Flavum.

Ossified ligamentum flavum (OLF) is a condition of heterotopic lamellar bone formation within the yellow ligament. Some patients with OLF can be asymptomatic. However, asymptomatic OLF may not be obvious on preoperative MRI and could increase the risk of iatrogenic injury during treatments for unrelated spinal conditions. This report describes a case of spinal cord injury caused by the indirect transmission of force from an osteotome to an asymptomatic OLF during the resection of a thoracic inferior articular process (IAP). To prevent this outcome, we urge careful review of CT imaging in the preoperative setting and advocate the use of a high-speed drill instead of an osteotome during bone removal in the setting of an adjacent area of OLF.

Application of Intrawound Vancomycin Powder during Spine Surgery in a Patient with Dialysis-Dependent Renal Failure.

Surgical site infections (SSIs) after spinal surgery are a serious complication that can be minimized with prophylaxis. Vancomycin is a common agent used in the prevention of SSI. Given that vancomycin is renally cleared, its use requires careful observation in dialysis-dependent patients due to toxicity at supratherapeutic levels. Since minimum inhibitory concentrations (MICs) for vancomycin have increased due to the emergence of resistant pathogens, the use of vancomycin in such patients is further complicated. Local instillation of vancomycin powder is thought to provide additional protection against SSI and have lower systemic absorption. We present a patient with end-stage renal disease that developed progressively debilitating cervical spondylotic myelopathy necessitating multilevel laminectomy and instrumented fusion. Prior to closure, 1 gram of vancomycin powder was sprinkled into the surgical incision. Postoperative serum vancomycin levels were well below those associated with nephrotoxicity and ototoxicity. Based on this experience, we reviewed the relevant guidelines that were designed to prevent postoperative infections in such dialysis-dependent patients. Intrawound application of vancomycin may be a legitimate and safe option for SSI prophylaxis in patients with renal failure on dialysis.

Granular cell tumor of the stellate ganglion presenting with Horner's syndrome.

We report a granular cell tumor (GCT) that occurred within the stellate ganglion of a 26-year-old woman who initially presented with a unilateral Horner's syndrome and progressive right upper extremity pain. We also review the literature related to the differential diagnoses of such a cervicothoracic tumor, with particular emphasis on the embryologic origin of these possibilities. GCT are rare tumors of Schwann cell origin which are more often found in subcutaneous locations than in relation to neural elements. In this woman, a mass identified on preoperative imaging was positioned anterolateral to the T1 vertebral body and displaced the vertebral artery anteriorly. During surgery, the lesion was observed within the sympathetic chain in the area of the stellate ganglion. The sympathetic chain was transected above and below the mass in order to achieve an adequate resection. The pathology demonstrated polygonal cells with diffuse eosinophilic granular cytoplasm positive for CD68 (a marker of lysosomes) and S-100 (a marker of neural crest derivatives) which established the diagnosis of GCT. This is the first patient, to our knowledge, with a granular cell tumor arising from the stellate ganglion.

Occipital condyle fracture in a patient with occipitalisation of the atlas.

Occipital condyle fractures and occipitalisation of the atlas are rare entities of the craniocervical junction. To the best of our knowledge, a patient presenting with a traumatic occipital condyle fracture and pre-existing occipitalisation of the atlas has not been previously reported. We report the case of a 79-year-old man presenting with an Anderson and Montesano type III fracture through a fused occipital condyle and lateral mass. This fracture was noted to extend into the transverse foramen and the C1-C2 joint space. The transverse ligament and ligamentum flavum were calcified but not disrupted and the atlantodental interval was within normal limits. The neurological examination was unremarkable with the exception of neck pain. The patient was treated conservatively and placed in a rigid cervical collar for 10 weeks with serial CT studies to monitor healing of the fracture. At 4 months of follow-up, the patient was pain free with nearly complete resolution of his occipital condyle fracture.

The effect of spinal osteotomies on spinal cord tension and dural buckling: a cadaveric study.

OBJECT: The standard surgical release of a tethered cord may result in recurrent scar formation and occasionally be associated with retethering. The application of spinal shortening procedures to this challenging problem potentially can reduce tension on the retethered spinal cord while minimizing the difficulties inherent in traditional lumbosacral detethering revision. Although spinal shortening procedures have proven clinical benefit in patients with a recurrent tethered cord, it is unclear how much shortening is required to achieve adequate reduction in spinal cord tension or what impact these osteotomies have on dural buckling. METHODS: The authors calculated mean values from 4 human cadavers to evaluate the effect of 3 different spinal shortening procedures--Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR)--on spinal cord tension and dural buckling. Three cadavers were dedicated to the measurement of spinal cord tension, and 3 other cadavers were devoted to myelography to measure dural buckling parameters. RESULTS: The SPO was associated with a maximal decrease in spinal cord tension of 16.1% from baseline and no dural buckling with any degree of closure. The PSO led to a mean maximal decrease in spinal cord tension of 63.1% from baseline at 12 mm of closure and demonstrated a direct linear relationship between dural buckling and increasing osteotomy closure. Finally, VCR closure correlated with a mean maximal decrease in spinal cord tension of 87.2% from baseline at 10 mm of closure and also showed a direct linear relationship between dural buckling and increases in osteotomy closure. CONCLUSIONS: In this cadaveric experiment, the SPO did not lead to appreciable tension reduction, while a substantial response was seen with both the PSO and VCR. The rate of tension reduction may be steeper for the VCR than the PSO. Adequate tension relief while minimizing dural buckling may be optimal with 12-16 mm of posterior osteotomy closure based on this cadaveric experiment.

Lateral retroperitoneal transpsoas approach to the lumbar spine for the treatment of spondylodiscitis.

Spondylodiscitis is an infection of the intervertebral disc and adjacent vertebrae. With the advent of minimally invasive spinal surgery, less invasive approaches have been considered for the treatment of discitis. To date, however, there have been no reported cases of a minimally invasive lateral retroperitoneal transpsoas approach for the treatment of spondylodiscitis. The authors report a case of medically refractory discitis in a patient with multiple comorbidities who underwent a successful limited debridement via a lateral transpsoas corridor. This case describes a minimally invasive approach used to treat a patient with lumbar discitis/osteomyelitis who was otherwise a suboptimal surgical candidate.

Blood pressure regulation to prevent progression of blunt traumatic intracranial hemorrhage in stable patients.

BACKGROUND: Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients. METHODS: A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval. RESULTS: Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD. CONCLUSIONS: A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated. LEVEL OF EVIDENCE III: Prognostic, Level II study.

Nerve root anomalies: implications for transforaminal lumbar interbody fusion surgery and a review of the Neidre and Macnab classification system.

Lumbar nerve root anomalies are uncommon phenomena that must be recognized to avoid neural injury during surgery. The authors describe 2 cases of nerve root anomalies encountered during mini-open transforaminal lumbar interbody fusion (TLIF) surgery. One anomaly was a confluent variant not previously classified; the authors suggest that this variant be reflected in an amendment to the Neidre and Macnab classification system. They also propose strategies for identifying these anomalies and avoiding injury to anomalous nerve roots during TLIF surgery. Case 1 involved a 68-year-old woman with a 2-year history of neurogenic claudication. An MR image demonstrated L4-5 stenosis and spondylolisthesis and an L-4 nerve root that appeared unusually low in the neural foramen. During a mini-open TLIF procedure, a nerve root anomaly was seen. Six months after surgery this patient was free of neurogenic claudication. Case 2 involved a 60-year-old woman with a 1-year history of left L-4 radicular pain. Both MR and CT images demonstrated severe left L-4 foraminal stenosis and focal scoliosis. Before surgery, a nerve root anomaly was not detected, but during a unilateral mini-open TLIF procedure, a confluent nerve root was identified. Two years after surgery, this patient was free of radicular pain.

Big boys don't cry: male secondary school students' attitudes to depression.

OBJECTIVES: In an earlier qualitative study we explored the attitudes of young men aged 15-19 (Group A) to mental health and, in particular, to engaging with the various mental health services available. We found that the participants perceived stigma in connection with mental ill health and they displayed particularly strong negative attitudes in relation to both doctors and medication. The investigation was then repeated with students who had been given a short (less than two-hour) programme called 'Beat the Blues' (BTB) about mental health (Group B) in order to assess the effect of that exposure by comparing the attitudes of the two groups of students. This present phase of the analysis is a quantitative examination of the written responses by both Groups A and B to an administered questionnaire. METHODS: A total of 42 young men took part in eight focus groups held in boys-only Dublin secondary schools, described in Burke et al. A questionnaire, administered to each participant, examined the students' attitudes to depression and mental illness. The results were analysed by computer using SPSS to search for any trends and any contrasts between groups A and B and among the different socio-economic groups (SEGs) within the sample. RESULTS: Almost no statistically significant differences were found between groups A and B. However, some differences were found among the SEGs. In particular, very significant differences (p < 0.01 in each case), were found in attitudes towards depression, with increasing support for statements such as "People with depression just need to snap out of it", "Drinking alcohol can help cure depression" and "Depression is only an excuse for laziness" found among the lower SEGs. A very high percentage of students indicated their desire to talk to someone in times of personal stress; this was almost always their best friend or their mother. However, most students said they would be uncomfortable if a friend raised such a topic. CONCLUSION: The main conclusion - that a single exposure to a positive programme about depression produces little or no effect - is hardly unexpected. Nonetheless, there are indications of a great willingness among older secondary students to learn about and discuss mental health issues. Furthermore, the highly negative attitudes among students from the lowest socio-economic group in this study would seem to indicate that the greatest need for education about mental health lies with working-class adolescents. Hence, it is recommended that a programme of multiple interventions be introduced into the senior cycle of secondary education.

Male secondary school student's attitudes towards using mental health services.

OBJECTIVES: The rate of suicide among young men is rising. However, young men are reluctant to use mental health services. In this study we explored young men's attitudes towards mental illness and mental health services, as well as their willingness to use these services. METHODS: Four focus groups were conducted in two Dublin schools. A total of 18 students participated in the study. RESULTS: Students held negative views towards mental health services, particularly in respect to psychiatric hospitals and medication. Students were not well informed about whom to contact if they had depression and were very conscious about the stigma of going to see a 'professional'. Many students did not recognise depression as being a mental illness and could not differentiate between depression and feeling sad. CONCLUSIONS: This study shows that a lack of knowledge and understanding about mental illness, combined with prejudice against mental health professionals and fear of stigma, are important barriers to access of mental health services for young men.

Suicide and the reluctance of young men to use mental health services.

Young men are grossly over represented in Irish suicide statistics, yet this group is the least likely to use mental health services. This paper outlines why young men are reluctant to access mental health services, framing the problem in the context of risk factors for suicide such as binge drinking and social change. The paper argues that de-stigmatising mental illness and encouraging young men to seek help for emotional problems should be a priority for policymakers.