Contemporary Management of Chylous Ascites after Retroperitoneal Surgery: Development of an Evidence-Based Treatment Algorithm.

PURPOSE: Chylous ascites (CA) is an uncommon complication that occurs from traumatic disruption of lymphatic channels after retroperitoneal surgery. The purpose of this study was to generate an evidence-based management strategy for CA by reviewing the current literature and available treatment modalities. MATERIALS AND METHODS: A MEDLINE® literature review was performed for "chylous ascites." Individual patient data were extracted from case series and reports to create an efficacy analysis. Treatment modality, drain output, time to escalation of care and time to resolution were recorded. The efficacy analysis was utilized to generate a data-driven treatment algorithm. RESULTS: The literature review yielded 1,953 articles, from which 146 studies contributed data for 523 patients. The efficacy analysis included 245 patients, 168 (69%) of whom were managed successfully with conservative management (CM), at a median time to resolution of 11 days. Forty-eight patients underwent lymphangiography±embolization after CM, with a success rate of 85%. Thirty-one (12%) patients underwent surgical exploration. When treating CA, the patients who underwent stepwise management with CM followed by lymphangiography if CM failed experienced a resolution rate of 96.7%. An evidence-based treatment algorithm was created to guide treatment selection and duration of therapy before escalating to additional forms of therapy. CONCLUSIONS: In this report, we describe the largest conglomeration of iatrogenic CA cases from a literature review (523 cases) and efficacy analysis (245 cases), and created the first evidence-based treatment algorithm for this condition. Treatment success is substantial when using a stepwise combination of CM followed by lymphangiography±embolization.

Bilateral testicular adrenal rest tumors in a patient with nonclassical congenital adrenal hyperplasia.

INTRODUCTION: Solid testis tumors in post-pubertal males usually represent germ cell malignancies; however, other uncommon or rare histologies must be considered. CASE PRESENTATION: We present a case of an 18-year-old male undergoing attempted bilateral partial orchiectomies for suspected germ cell tumors. Tumor pathology, laboratory results, radiographic studies, and post-surgical elevated adrenocorticotropic hormone levels supported the diagnosis of testicular adrenal rest tumors secondary to previously undiagnosed nonclassical congenital adrenal hyperplasia. CONCLUSION: Testicular adrenal rest tumors are rare in patients with nonclassical congenital adrenal hyperplasia and may be accompanied by adrenal insufficiency and hypogonadism, which can be treated with glucocorticoid therapy and testosterone replacement. Differential diagnosis of tumors is challenging but necessary for proper symptom-based management.

BUILDING EVALUATION PARTNERSHIPS WITH TRIBAL COMMUNITIES FOR HOME VISITING.

The goal of this current descriptive study was to examine the roles and relationships of evaluators with the tribal communities in which they work. First, we describe a participatory community research model with a strong capacity-building component as the standard for assessing successful working partnerships between evaluators, programs, tribes, and tribal organizations. This model serves as a yardstick against which we examine the success and challenges of program-evaluation partnerships. Second, we report on a survey of tribal Maternal, Infant, and Early Childhood Home Visiting program leaders and outline their impressions of successes and challenges related to program-evaluation partnerships. Survey participants discussed the importance of working with evaluators who have deep investment in and understanding of the tribal community; respect for cultural relevance and honor for cultural ways; collaboration that includes transparency, trust, and translation of research for community leaders and members; a focus on strength-based design without losing the need to consider challenges; and relationships of mutual trust that can weather addressing stressors when issues of conflict, limited resources, and/or mixed expectations arise.

Exploring the Use of Theory in a National Text Message Campaign: Addressing Problem Recognition and Constraint Recognition for Publics of Pregnant Women.

Infant mortality is associated with access to healthcare, knowledge, and health literacy. Text4baby, the largest national texting health initiative, seeks to address these factors. However, no research has examined the program's theoretical framework, an aspect that may impact its success. To address this gap, Text4baby's use of theory was evaluated through a content analysis of Text4baby messages and interviews with Text4baby content developers. We compared the main variables of health behavior theories framing Text4baby messages with the situational theory of publics and its factors of problem recognition and constraint recognition. The situational theory of publics provides an understanding of the types of publics that might emerge from Text4baby's audiences of pregnant women. Aware, latent, and active publics are defined by the situational theory and are created out of problem recognition and constraint recognition along with a level of personal involvement in the issue of prenatal health. We used content analysis and interviewing to explore how Text4baby prenatal messages were constructed using theory and to offer lessons learned for prenatal health campaigns. The multi-methodological approach to understanding meaning construction in the production of these text messages and how meaning played out in the messages is a useful framework for text message campaigns.

Meeting at the crossroads: collaboration between information technology departments and health sciences libraries.

OBJECTIVE: The purposes of this survey were to determine the nature and extent of collaboration between health sciences libraries and their information technology (IT) departments, to identify strengths and issues connected to this relationship, and to provide examples demonstrating exceptional collaborative success. METHODS: A fourteen-question survey was sent to a broad selection of health care and academic libraries through a variety of email discussion lists and was limited to one response per institution. Convenience sampling was used to collect the responses. RESULTS: An overwhelming majority of libraries described the relationship with their IT departments as good or excellent, and there were a variety of creative joint initiatives underway. Opportunities exist for continued and expanded library/IT collaboration. CONCLUSIONS: Good quality relationships between libraries and their IT departments are essential due to the interconnected nature of their services, and fortunately, this appears to be the norm at a variety of institutions. Mutual respect, open communication, realization of each department's mission, and responsiveness to each other's needs are part of what makes these relationships successful, which in turn leads to successful collaborative ventures that bode well for the future of both services.

Essential conditions for the implementation of comprehensive school health to achieve changes in school culture and improvements in health behaviours of students.

BACKGROUND: Comprehensive School Health (CSH) is an internationally recognized framework that holistically addresses school health by transforming the school culture. It has been shown to be effective in enhancing health behaviours among students while also improving educational outcomes. Despite this effectiveness, there is a need to focus on how CSH is implemented. Previous studies have attempted to uncover the conditions necessary for successful operationalization, but none have described them in relation to a proven best practice model of implementation that has demonstrated positive changes to school culture and improvements in health behaviours. METHODS: The purpose of this research was to identify the essential conditions of CSH implementation utilizing secondary analysis of qualitative interview data, incorporating a multitude of stakeholder perspectives. This included inductive content analysis of teacher (n = 45), principal (n = 46), and school health facilitator (n = 34) viewpoints, all of whom were employed within successful CSH project schools in Alberta, Canada between 2008 and 2013. RESULTS: Many themes were identified, here called conditions, that were divided into two categories: 'core conditions' (students as change agents, school-specific autonomy, demonstrated administrative leadership, dedicated champion to engage school staff, community support, evidence, professional development) and 'contextual conditions' (time, funding and project supports, readiness and prior community connectivity). Core conditions were defined as those conditions necessary for CSH to be successfully implemented, whereas contextual conditions had a great degree of influence on the ability for the core conditions to be obtained. Together, and in consideration of already established 'process conditions' developed by APPLE Schools (assess, vision, prioritize; develop and implement an action plan; monitor, evaluate, celebrate), these represent the essential conditions of successful CSH implementation. CONCLUSIONS: Overall, the present research contributes to the evidence-base of CSH implementation, ultimately helping to shape its optimization by providing school communities with a set of understandable essential conditions for CSH implementation. Such research is important as it helps to support and bolster the CSH framework that has been shown to improve the education, health, and well-being of school-aged children.

Identifying and understanding Indigenous ways of evaluating physical activity programs.

Indigenous evaluation frameworks have not been investigated in the context of American Indian and Alaska Native (AI/AN) physical activity programs, an important area given the relationship between effective physical activity programs and quality of life among these populations. To address this gap, staff members of AI/AN physical activity programs were interviewed to explore their understanding of and experiences with evaluation. Findings suggest that Indigenous evaluation is perceived as narrative and holistic, Indigenous knowledge is used in program decision making, though it is not always acknowledged as evaluation, and there is not a universally desired way to evaluate AI/AN physical activity programs.

Promoting Physical Activity Among Native American Youth: a Systematic Review of the Methodology and Current Evidence of Physical Activity Interventions and Community-wide Initiatives.

Promoting physical activity using environmental, policy, and systems approaches could potentially address persistent health disparities faced by American Indian and Alaska Native children and adolescents. To address research gaps and help inform tribally led community changes that promote physical activity, this review examined the methodology and current evidence of physical activity interventions and community-wide initiatives among Native youth. A keyword-guided search was conducted in multiple databases to identify peer-reviewed research articles that reported on physical activity among Native youth. Ultimately, 20 unique interventions (described in 76 articles) and 13 unique community-wide initiatives (described in 16 articles) met the study criteria. Four interventions noted positive changes in knowledge and attitude relating to physical activity but none of the interventions examined reported statistically significant improvements on weight-related outcomes. Only six interventions reported implementing environmental, policy, and system approaches relating to promoting physical activity and generally only shared anecdotal information about the approaches tried. Using community-based participatory research or tribally driven research models strengthened the tribal-research partnerships and improved the cultural and contextual sensitivity of the intervention or community-wide initiative. Few interventions or community-wide initiatives examined multi-level, multi-sector interventions to promote physical activity among Native youth, families, and communities. More research is needed to measure and monitor physical activity within this understudied, high risk group. Future research could also focus on the unique authority and opportunity of tribal leaders and other key stakeholders to use environmental, policy, and systems approaches to raise a healthier generation of Native youth.

Piloting Health Text Messages for Rural Low-Income Mothers: Effects of Source Similarity and Simple Action Steps.

Approximately 85% of people living in rural settings own a cell phone, and of those, 76% send or receive text messages. Thus, text messaging may be an effective way to reach rural low-income mothers with important information and resources that will improve their health and well-being. This exploratory study examined the utility of using text messaging for disseminating health information to rural low-income mothers. Researchers tested messages that were personalized and sent from a source similar to participants, a mom named Ms. Peg. Ms. Peg sent text messages about physical activity, oral health, nutrition, and health insurance-facts and tips that addressed barriers and lifestyles in rural low-income contexts-over a 4-week period. Participants completed a prequestionnaire assessing healthy behaviors, text message use and preference, and demographic information. Participants then received two text messages for 4 weeks. Findings indicated that participants were satisfied receiving information through text messages, with half finding it "easy" and "convenient." The majority reported being highly motivated by the messages, and for 41% the messages were associated with self-efficacy and intention to act. Close to half of the participants found the use of personalization effective and perceived the messages as "relatable."

Self-Reported Physical Activity Among American Indian Adults From Two Diverse Regions.

PURPOSE: Physical activity may be a protective factor against the disproportionate rates of chronic diseases faced by American Indians. Nevertheless, few studies report any cultural adoptions made to capture physical activity behaviors among this hard-to-reach population. Existing studies reporting the prevalence of physical activity among American Indians are often aggregated and tend to obscure regional, local, and tribal-level variations. This study examines the prevalence of physical activity and inactivity levels, along with associated factors, among rural dwelling American Indian adults from 2 distinct regions. METHODS: Baseline self-reported data were collected using a culturally modified version of the International Physical Activity Questionnaire (IPAQ) short form during the Obesity Research Prevention and Evaluation of Intervention Effectiveness in Native North Americans trial (OPREVENT) among rural American Indian adults (aged 18-75 years) from 5 tribal communities in Michigan and New Mexico. FINDINGS: Most participants were classified as moderately physically active (43.5%), and the majority reported access to physical activity facilities (83.5%). Michigan participants reported engaging in more moderate and total physical activity than those in New Mexico (P < .001) and reported spending less time sitting (P < .001). CONCLUSIONS: Differences in physical activity among the American Indian communities may be due to regional variations in occupations, climate, and tribal and community support and infrastructure. The unexpected high level of activity evokes uncertainty in the accuracy and appropriateness of the data collection instrument. Research is needed to understand culturally appropriate approaches to measure physical activity and inactivity among rural American Indians.

'We usually just start dancing our Indian dances': urban American Indian (AI) female youths' negotiation of identity, health and the body.

In this article, we utilise qualitative research techniques to explore how 14 urban American Indian (AI) females (aged 11-17) living in the state of Maryland discursively construct and experience health and the body, as well as how/if traditional culture shapes their understandings. In doing so, we address a significant gap in the knowledge base concerning the health beliefs of urban AI youth, and build upon research utilising a decolonising approach. Using a two-step process of thematic analysis and poststructuralist discourse analysis, we arrived at three key findings: (1) while youths are taught (and learn) mainstream lessons about health and bodily norms (mostly at school), they negotiate these lessons in complex and at times contradictory ways; (2) they do not view their AI status as conferring more or less risk upon them or their community; and (3) AI identity appears to be fluid in nature, becoming more salient, even a resource, in certain situations. We conclude with a discussion of the importance of spaces within the urban context in shaping youths' embodied subjectivities, and in particular, contrast the space of the school with that of the urban AI community centre.

Implementing Comprehensive School Health in Alberta, Canada: the principal's role.

Comprehensive School Health (CSH) is an internationally recognized framework that moves beyond the individual to holistically address school health, leading to the development of health-enhancing behaviors while also improving educational outcomes. Previous research has suggested that principal support for CSH implementation is essential, but this role has yet to be explored. Therefore, the purpose of this research was to examine the role of the principal in the implementation of a CSH project aimed at creating a healthy school culture. This research was guided by the grounded ethnography method. Semi-structured interviews were conducted with APPLE School principals (n = 29) to qualitatively explore their role in creating a healthy school culture. A model consisting of five major themes emerged, suggesting that the principal played a fluid role throughout the CSH implementation process. Principals (i) primed the cultural change; (ii) communicated the project's importance to others; (iii) negotiated concerns and collaboratively planned; (iv) held others accountable to the change, while enabling them to take ownership and (v) played an underlying supportive role, providing positive recognition and establishing ongoing commitment. This research provides recommendations to help establish effective leadership practices in schools, conducive to creating a healthy school culture.

Strengthening communication education in an undergraduate nursing curriculum.

As effective communication is an essential professional competency that is conceptualized and developed during undergraduate education, the purpose of this study was to investigate and reinforce the role of communication in the nursing undergraduate curriculum. Analysis of faculty and student focus group discussions revealed the benefit of purposefully structuring and explicitly articulating communication education throughout the undergraduate curriculum for increased accessibility and visibility of communication education, expanded ranges of available teaching and learning methods and resources, and strengthened ability to address undermining mixed communication messages. These findings have implications for how to specifically include communication education in a learning-centered undergraduate curriculum.

The contribution of cognition and spasticity to driving performance in multiple sclerosis.

OBJECTIVE: To examine the independent and combined impact of cognitive dysfunction and spasticity on driving tasks involving high cognitive workload and lower-limb mobility in persons with multiple sclerosis (MS). DESIGN: Single-visit cohort study. SETTING: Clinical research center. PARTICIPANTS: Participants included 17 drivers with MS and 14 referent controls. The group with MS exhibited a broad range of cognitive functioning and disability. Of the 17 patients with MS, 8 had significant spasticity in the knee used to manipulate the accelerator and brake pedals (based on the Modified Ashworth Scale). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A brief neuropsychologic test battery and 2 driving simulations. Simulation 1 required participants to maintain a constant speed and lane position while attending to a secondary task. Simulation 2 required participants to adjust their speed to accelerations and decelerations of a lead car in front of them. RESULTS: Patients with MS showed greater variability in lane position (effect size, g=1.30), greater difficulty in maintaining a constant speed (g=1.25), and less ability to respond to lead car speed changes (g=1.85) compared with controls. Within the MS group, in a multivariate model that included neuropsychologic and spasticity measures, cognitive functioning was the strongest predictor of difficulty in maintaining lane position during the divided attention task and poor response time to lead car speed changes, whereas spasticity was associated with reductions in accuracy of tracking the lead car movements and speed maintenance. CONCLUSIONS: In this preliminary study, cognitive and physical impairments associated with MS were related to deficits in specific components of simulated driving. Assessment of these factors may help guide the clinician regarding the types of driving behaviors that would put patients with MS at an increased risk for an automobile crash.

Visual attention deficits are associated with driving accidents in cognitively-impaired HIV-infected individuals.

Previous research has found HIV-associated neuropsychological (NP) dysfunction to be associated with impaired driving skills. To determine whether specific impairments in visual attention impart an increased accident risk, we assessed 21 HIV seronegative (HIV-) and 42 seropositive (HIV+) participants on NP tests and the Useful Field of View (UFOV), a computerized test of visual attention. HIV+ participants performed significantly worse than the HIV- participants on the UFOV, particularly on the Divided Attention subtest. Poor UFOV performance was associated with higher accident rates in the past year, with a trend for NP impairment to also predict more accidents. The highest number of accidents occurred in the group with a "high risk" UFOV designation and NP impairment; this category correctly classified 93% of HIV+ participants as to who did, and did not, have an accident. Clinicians should attend to visual attention as well as general cognitive status in estimating which patients are at risk for impaired driving.