The Menopause Visual Analogue Scale: a new tool for measuring the severity and response to treatment of symptoms throughout the menopausal transition.

OBJECTIVES: This study aimed to assess the reliability and validity of the Menopause Visual Analogue Scale (MVAS) in measuring symptoms throughout the menopausal transition. METHODS: Two independent samples of women undergoing the menopausal transition completed both the MVAS and the Greene Climacteric Scale (GCS) at a women's mental health clinic between 2008 and 2016. Data for the first sample were obtained using a retrospective chart review of patients seen between 2008 and 2012 (N1 = 75) and data for the second sample came from a prospective study conducted between 2013 and 2016 (N2 = 86). Internal consistency was assessed using Cronbach's α and Pearson's correlation coefficient was used to evaluate concurrent validity. Bland-Altman plots were developed to assess the degree of agreement between the scales. RESULTS: Internal consistency for the physical and psychological domains of the MVAS was 0.80-0.81 and 0.92-0.94, respectively. Pearson's correlations between the MVAS and the GCS were high for both physical (rphys = 0.74-0.76, p < 0.01) and psychological (rpsych = 0.70-0.72, p < 0.01) components in both samples. Changes in MVAS physical and psychological scores in response to treatment were correlated with changes in GCS physical and psychological scores (rphys = 0.69, p < 0.01; rpsych = 0.49, p < 0.01) in the second sample. Bland-Altman plots indicate low to moderate levels of agreement between most portions of the MVAS and the GCS. CONCLUSIONS: These findings suggest that the MVAS has potential for assessing both severity and change in symptoms throughout the menopausal transition, subject to exploring limitations identified in the analysis and application to other populations.

Parent participation in community activities and the persistence of criminality.

This study assessed whether the lack of parental participation in community activities during late childhood is significantly related to the persistence of criminal activity from adolescence to adulthood. A prospective, longitudinal investigation of a representative cohort of 548 boys from a middle-sized Swedish community was employed. A pattern-oriented analysis identified five configurations of boys who showed different profiles of social and academic competence at the age of 13 years. The configurations were compared with respect to persistent criminality among the boys for parents who did, and who did not, show stable participation in a community activity when their sons were in late childhood. Fathers engaged in a community activity had sons with significantly lower rates of persistent criminality. This result was most marked for youth with low school achievement, and multiple problem profiles of social and academic disadvantage. The findings held after controlling for family socioeconomic status. Mother's participation in community activities was statistically dependent on father participation but was not related to persistent offending among multiple problem boys. Results are discussed in terms of the different impact associated with mother and father community activity participation on persistent offending, and the holistic perspective to development guiding this research.

Effect of radiation on skin expansion and skin flap viability in pigs.

The aim of the present study was to investigate the effect of radiation treatment both on skin tissue expansion with the chronic inflation of subcutaneous expanders and on skin flap viability in surgically delayed and expanded skin in the pig. One flank in each of six pigs (initially weighing 17 +/- 1.8 kg) was randomly assigned for radiation treatment, and the contralateral flank served as a nonirradiated control. Three mirror-image, 8 x 10 cm, rectangular templates were marked on each flank; these templates were randomly assigned to the construction of a delayed skin flap (group A), a skin flap raised on expanded skin (group B), or a skin flap raised on expanded skin with a capsulectomy before flap surgery (group C). Radiation treatment was performed using sequential radiation with three fractions per week (810 cGy/fraction) for 2 weeks, with a total dose of 4,860 cGy. Twelve weeks after radiation treatment, skin expanders (8 x 10 cm) were installed subcutaneously in the locations assigned for skin expansion. Skin expansion by the inflation of subcutaneous skin expanders with saline twice weekly was started 8 weeks later and lasted for 3 weeks. Two weeks after surgical delay and the last skin expansion, 8 x 20 cm skin flaps were raised on the locations assigned for delayed skin flaps, expanded skin flaps, and expanded skin flaps with a capsulectomy. Skin flap viability was assessed 24 hours later using a fluorescein dye-staining technique. Skin expansion by the inflation of subcutaneous expanders with saline was slower (p < 0.05) in the radiated skin (39 +/- 6 ml/filling) than in the nonirradiated control skin (51 +/- 6 ml/filling). Radiation reduced the overall area of expanded skin by 23 percent (p < 0.05) compared with the control. Radiation treatment also reduced skin viability by 36 percent (p < 0.05) in the delayed skin flaps, 27 percent (p = 0.10) in the expanded skin flaps, and 36 percent (p < 0.05) in the expanded skin flaps with a capsulectomy when compared with their contralateral, nonirradiated controls. There were no significant differences in skin viability among these three types of skin flaps within the radiated and nonirradiated groups. Taken together, these observations indicate that radiation treatment reduced the effectiveness of the surgical delay procedure, the amount of subcutaneous skin expansion (by an increase in skin area), and skin flap viability. However, a capsulectomy alone did not affect the viability of skin flaps raised on expanded skin.

School extracurricular activity participation as a moderator in the development of antisocial patterns.

This research involves a longitudinal study of antecedents and moderators in the development of antisocial patterns. Participants included 695 boys and girls who were interviewed annually from childhood to the end of high school and again at ages 20 and 24. Cluster analyses identified four configurations of boys and girls that were reasonably homogeneous with respect to behavior and academic performance at the beginning of the investigation. When tracked over time, the configurations differed significantly in patterns of early school dropout and criminal arrests. Boys and girls in the "multiple risk configuration" were more likely than those in other configurations to show long-term antisocial patterns. Participation in school extracurricular activities was associated with reduced rates of early dropout and criminal arrest among high-risk boys and girls. The decline in antisocial patterns was dependent on whether the individuals' social network also participated in school extracurricular activities.

Leisure activities and adolescent antisocial behavior: the role of structure and social context.

The goal of this study was to understand better how the structure and social context of adolescent leisure activities relates to antisocial behavior. A representative sample of 703 14-year-olds and their parents were assessed concerning adolescent involvement in community-based leisure activities, peer and adult social relations, and antisocial behavior. Results showed that participation in highly structured leisure activities was linked to low levels of antisocial behavior, while participation in activities with low structure (i.e. a youth recreation center) was associated with high levels of antisocial behavior. Overall the results were similar for boys and girls; however, the combination of involvement in a low structured activity and the absence of any highly structured participation appeared especially problematic for boys' antisocial behavior. Participants of low structured activities were also characterized by deviant peer relations, poor parent-child relations, and they received low support from their activity leader compared to adolescents engaged in more structured community activities. Findings are discussed in terms of their implication for prevention research.

A developmental approach to prevention research: configural antecedents of early parenthood.

A developmental framework emphasizing the combined impact of correlated constraints within and without the individual was applied to a prospective longitudinal study of early parenthood. The purpose was to use a person-approach to the analysis of longitudinal data to clarify risk for early parenthood and to generate hypotheses about potentially useful intervention strategies. Respondents were 475 youth who were assessed annually from seventh grade through the end of high school and, again, at ages 20 and 24. The risk patterns associated with parenthood were the same for both sexes. Individuals with a middle-school configuration of low socioeconomic status, high aggression, low academic skills, low popularity, and prior grade failure were most likely to become parents by early adulthood. Risk for early parenthood increased substantially for respondents who dropped out of school early, regardless of their initial risk status.

Treatment of osteonecrosis of the femoral head by free vascularized fibular grafting: an analysis of surgical outcome and patient health status.

OBJECTIVE: To evaluate the limb-specific outcome and general health status of patients with osteonecrosis of the femoral head treated with vascularized fibular grafting. DESIGN: A retrospective review. SETTING: A single tertiary care centre. PATIENTS: Fifty-five consecutive patients with osteonecrosis of the femoral head who underwent fibular grafting (8 bilaterally). INTERVENTION: Vascularized fibular grafting. OUTCOME MEASURES: Limb-specific scores (Harris Hip Score, St. Michael's Hospital Hip Score), general health status (Nottingham Health Profile, SF-36 health status survey) and radiographic outcome measures (Steinberg stage). RESULTS: Patients were young (mean age 34 years, range from 18 to 52 years) and 80% had advanced osteonecrosis (Steinberg stages IV and V). Fifty-nine hips were followed up for an average of 50 months (range from 24 to 117 months) after vascularized fibular grafting. Sixteen hips (27%) were converted to total hip arthroplasty (THA). To date, 73% of hips treated with vascularized fibular grafting have required no further surgery. Preoperative and postoperative Harris Hip Scores were 57.3 and 83.6 respectively (p < 0.001). As measured by patient-oriented health status questionnaires (SF-36, Nottingham Health Profile) and compared with population controls, patients had normal mental health scores and only slight decreases in physical component scores. CONCLUSIONS: Free vascularized fibular grafting for osteonecrosis of the femoral head provides satisfactory pain relief, functional improvement and general health status and halts the progression of symptomatic disease.

Salvage after severe lower-extremity trauma: are the outcomes worth the means?

Advances in reconstructive surgery have allowed for impressive salvage after severe lower-extremity trauma but not without complications when compared with immediate below-knee amputation. Several amputation index scores have been developed to help predict successful salvage as defined by a viable rather than a functional extremity. The purpose of this study was to evaluate retrospectively the predictive value of the amputation index scores and to assess prospectively overall health status and specific dysfunction in successful limb salvage and primary and secondary amputation by administering standardized generic and specific outcomes questionnaires (Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and MacMaster Universities Osteoarthritis Index). A retrospective chart review identified 55 severe lower-extremity injuries (Gustilo Type IIIB and IIIC) over a 12-year period (1984 to 1996). Forty-six severe open tibial fractures in 45 patients underwent attempted salvage. All required soft-tissue coverage by either local or free flap or vascular repair for leg salvage. The attempted-salvage group was subdivided into successful salvage and secondary amputation. The other nine patients underwent a primary amputation. There were no statistically significant differences in terms of patient demographics or other injuries (Injury Severity Score) in the three groups. Forty-eight of 54 patients with an average 5-year follow-up completed a validated generic and specific outcomes health questionnaire. In the attempted-salvage group, 89 percent of patients had a successful salvage and 11 percent came to a secondary amputation. The amputation index scores correctly predicted an amputation in 32 percent of patients. The magnitude of the amputation index scores did not correlate with the physical outcomes scores and were not found to add any significant value of information to the surgeon's decision making. Patients undergoing primary and secondary amputation had a worse physical outcomes score (28 versus 38) than successful salvage (p < 0.007). Even so, the SF-36 (physical component score) outcomes score for this group of injured extremities, regardless as to whether salvaged or amputated, was as low as or lower than that of many serious medical illnesses, suggesting that severe lower-extremity trauma impairs health as much as or more than being seriously ill. The mental component score in this group was comparable to that of a healthy population (49 versus 50), which implies the disability is primarily physical rather than psychological. Ninety-two percent of patients preferred their salvaged leg to an amputation at any stage of their injury, and none would have preferred a primary amputation.

Donor site morbidity following vascularized fibular grafting.

We examined donor site morbidity in thirty-nine patients with avascular necrosis of the femoral head treated by curettage and transplantation of a free ipsilateral fibular graft. Utilising our donor site morbidity questionnaire, scar, functional loss, wound healing, complications, and pain were analysed. Subjective complaints and objective findings were evaluated and compared. Subjective complaints were common and included a sense of instability in 42% and a sense of weakness in 37%. However, objective findings were limited. No clinical instability could be elicited and only great toe flexion (29%) and extension (43%) were found to be mildly weak. Only one patient required reoperation for a donor site problem (2%). Eighty-nine percent were pain free at time of follow-up, and 93% felt the scar was good. Range of motion of the knee and ankle of the donor site leg was not different from the nonoperated leg. Donor site morbidity for avascular necrosis of the femoral head is low.

The histopathological changes in irradiated vs. nonradiated tissue-expanded skin in the porcine model.

This study examined the histological changes following irradiation on nonexpanded and tissue-expanded pigskin. Six Yorkshire pigs received 4860 cGy radiation to one flank with the opposite side serving as the control. A histopathological comparison of tissue expansion in irradiated tissue to nonradiated tissue showed a reduction in the thickness of the dermal and subcutaneous layers, with less prominent rete ridges and a thicker stratum spinosum (p < 0.05). Nonexpanded irradiated tissue showed a reduction of thickness in the dermis and subcutaneous layer, less prominent rete ridges, and a thicker stratum spinosum layer (p < 0.05) when compared with nonradiated tissue. Tissue-expanded irradiated tissue showed no significant differences (p > 0.05) in any of these parameters when compared with nonexpanded irradiated tissue. This study demonstrates that radiation produced a significant change in porcine skin, but tissue expansion did not further alter the histological changes associated with irradiation.

Do extracurricular activities protect against early school dropout?

This study examined the relation between involvement in school-based extracurricular activities and early school dropout. Longitudinal assessments were completed for 392 adolescents (206 girls, 186 boys) who were initially interviewed during 7th grade and followed up annually to 12th grade. A person-oriented cluster analysis based on Interpersonal Competence Scale ratings from teachers in middle schools (i.e., 7th-8th grades) identified configurations of boys and girls who differed in social-academic competence. Early school dropout was defined as failure to complete the 11th grade. Findings indicate that the school dropout rate among at-risk students was markedly lower for students who had earlier participated in extracurricular activities compared with those who did not participate (p < .001). However, extracurricular involvement was only modestly related to early school dropout among students who had been judged to be competent or highly competent during middle school.

Sternotomy infections: sternal salvage and the importance of sternal stability.

OBJECTIVE: To review the management of sternal wound infection after cardiovascular surgery. DESIGN: Retrospective case study. SETTING: All management took place in a single tertiary-care university hospital. PATIENTS: Twenty-one consecutive patients seen over a 3-year period who had infected median sternotomy incisions after cardiovascular surgery. INTERVENTIONS: Surgical eradication of infection, including sternal débridement and rewiring or placement of vascularized muscle flaps, or both. MAIN OUTCOME MEASURES: Resolution of infection and restoration of sternal stability. RESULTS: The development of sternal wound infection was found to be associated with sternal instability. In 12 of 17 patients treated initially with sternal débridement and rewiring the infection was cured. Vascularized muscle flap transfers were required to eradicate the infection in the remaining patients. CONCLUSIONS: Sternal débridement and rewiring is an effective initial treatment for sternal wound infections in selected patients. Some patients may require placement of muscle flaps for definitive treatment.

Lateral-arm free flap for reconstruction in the head and neck.

OBJECTIVE: To describe the role of the lateral-arm free flap in reconstruction of head and neck defects following ablative oncologic surgery and to discuss the anatomy of this flap as well as indications for its use. DESIGN: A prospective study of all patients undergoing a lateral-arm free flap was performed. Up to 3 years of follow-up was obtained. SETTING: Tertiary referral centre. METHOD: A total of 12 lateral-arm free flaps were utilized to reconstruct defects ranging in size from 4 x 7 to 10 x 7 cm. Maximum width of the flap was 7 cm. A mean area of 55 cm2 was harvested. MAIN OUTCOME MEASURES: Flap survival, morbidity, speech intelligibility, and oral function and intake were assessed. RESULTS: The vascular pedicle was reliable with vessel diameters of 1.5 mm, and length of 6 to 7 cm. All flaps survived, and minimal donor site morbidity was encountered. Nine patients maintained good speech with adequate intelligibility while 10 patients maintained adequate oral intake. CONCLUSIONS: Functional results can be obtained with the lateral-arm free flap. A consistent pedicle of good length and size was found. It is our flap of choice in older, thinner individuals when the width of the donor site is less than 7 cm, which allows for primary closure.

Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand.

High-resolution ultrasound is capable of detecting foreign bodies of practically any composition. The purpose of this study was to determine in a controlled manner the sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand. Each of 15 fresh-frozen cadaver hands was divided into 21 standardized sites for potential foreign body insertion. Foreign bodies consisted of two sizes of three different materials (wood, glass, and metal). Foreign bodies were randomly assigned to 50% of the available sites. The empty sites served as controls. All hands were scanned by a single radiologist using high-resolution ultrasound at a frequency of 10 MHz. The radiologist was unaware of which specimens contained foreign bodies. Of the 166 foreign bodies inserted in total, 156 were detected by ultrasound. Ten sites were falsely analyzed as negative, for a sensitivity of 94%. There was one false positive result and 148 true negatives. The specificity was therefore 99%. The high specificity of ultrasound allows foreign body presence to be confirmed given a positive result. A combination of ultrasound and x-ray films should allow for diagnosis and localization of virtually all foreign bodies in the hand.

Extremity arteriovenous malformations: review of a series.

OBJECTIVE: To examine the diagnosis and treatment of arteriovenous malformations in adults, because of the tendency of the condition to recur. DESIGN: Chart and literature review. SETTING: Three tertiary-care hospitals. PATIENTS: Twelve adults with diffuse arteriovenous malformations of the extremities. INTERVENTIONS: Surgery of embolotherapy. MAIN OUTCOME MEASURE: Recurrence. RESULTS: Of the 12 cases reviewed, the arteriovenous malformations recurred in 8 patients; 2 of these were well, 6 months and 2 years after a second or third treatment. Two others were well, 2 months and 5 years after surgery or embolotherapy. One pregnant woman, whose case is described in detail, received no treatment, and her arteriovenous malformation diminished in size after her child was born. The outcome in the last patient is unknown. CONCLUSION: Diffuse arteriovenous malformations recur after ablative treatment.

Effect of wrist position on extensor mechanism after disruption separation.

A cadaveric study was performed on extensor tendon separation and excursion after extensor zone I (distal interphalangeal [DIP]) joint and III (proximal interphalangeal [PIP]) level lacerations and treatment. An average 1.5 mm tendon gap with 30 degrees lag following laceration at the DIP joint level and a 1.1 mm average tendon gap with 18 degrees (10 degrees-25 degrees) extension loss at the PIP level was demonstrated. Splinting zone I injuries with the DIP joints in 5 degrees hyperextension and zone III injuries with the PIP joint in 0 degrees extension eliminated tendon separation in all passive joint positions except when the wrist and metacarpophalangeal joints were placed in flexion. This position produced a 0.9 mm gap with a laceration at the DIP level and 1.0 and 2.0 mm gap at the PIP level, with a central slip and central slip and lateral band laceration, respectively. The tendon gaps were eliminated by placing the wrist in extension. This suggests that splinting of the wrist in neutral to mild extension and the joint underlying the tendon injury in full extension, while leaving the other joints free to move, would optimize treatment results.

The oxygen optode: an improved method of assessing flap blood flow and viability.

The ability of a newly developed, implantable PO2 electrode to detect vascular occlusion in an isolated skin flap model was evaluated. Cutaneous groin flaps, based on the superficial epigastric artery and vein, were raised in twelve rabbits. An optochemical, oxygen-sensing electrode (Oxygen Optode--InnerSpace, Inc.), was inserted in the subcutaneous tissue of each flap. Inspired oxygen, location of the probe, ambient temperature, and temperature of the isolated, pedicled flaps were controlled. After equilibration of the electrode in the flaps at baseline oxygen levels, selective, reversible occlusion of the artery, vein, and combined vascular pedicle was carried out. The tissue PO2 in the flaps were continuously monitored over the periods of vascular compromise and subsequent reperfusion. The rates of change in tissue PO2 over time (mean +/- SEM) following arterial, venous, or combined occlusion were not statistically different. The ability to confirm vascular compromise by challenging the organism with 100% inspired oxygen was also examined. A rise in tissue PO2 levels above baseline was noted on oxygen challenge with both artery and vein patent. At no time was a rise in tissue PO2 seen during oxygen challenge with arterial or combined arteriovenous occlusion. Measurements of tissue PO2 obtained by the Oxygen Optode are felt to reliably reflect vascular occlusion of the isolated epigastric skin flap perfusion in the rabbit model.

Anatomic basis of local muscle flaps in the distal third of the leg.

Soft-tissue defects of the distal third of the tibia are considered to be the realm of free-tissue transfer. We have found clinically that several local muscles can be used reliably in this area. The purposes of this study were: (1) to evaluate the potential use of the local muscles for soft-tissue coverage in the lower third of the leg and (2) to obtain numerical data that could be used preoperatively in the selection of potential local muscle flaps. All potential muscles, excluding the gastrocnemius, plantaris, and popliteus, from 10 fresh frozen legs were examined and the following details recorded: (1) the distance above the medial malleolus that the muscle bellies ended (musculotendinous junction), (2) the distance between the medial malleolus and the distal end of the transposed flaps (reach), (3) the area of tibia that could be covered, and (4) the vascular supply to these muscles. The soleus, extensor digitorum longus and peroneus tertius, extensor hallucis longus, peroneus brevis, and flexor digitorum longus were found to be the most anatomically suited muscles for local transposition to selected lower-third defects. We have worked with these muscles clinically and have found them to be useful and reliable when chosen appropriately.

Patient satisfaction with reduction mammaplasty: an early survey.

There is an abundant volume of literature available on the varying techniques of reduction mammaplasty, possible complications, and long-term evaluations from the surgeon's perspective. However, there is very little to be found on the patient's perspective and personal experience with this procedure during the perioperative and early postoperative period. This article deliberately concentrates on patients' experiences and impressions during the first and second postoperative months. A prospective study was undertaken to look at patients' personal experiences and satisfaction with different aspects of their reduction mammaplasty and their overall satisfaction with the procedure. Thirty-one consecutive patients were recruited during a six-month period and evaluated one month postoperatively. Twenty-seven of these patients were evaluated again two months postoperatively. The overall satisfaction rate was high: 80.6% for the one-month survey group and 88.9% for the two-month survey group. There was a high incidence of minor complications (38%) and a significant number of the patients (32.3% of the one-month survey group and 33.3% of the two-month survey group) felt the need for more preoperative discussion.