Changes in shoulder muscle size and activity following treatment for breast cancer.

BACKGROUND: Morbidity of the shoulder after breast cancer is a well-known phenomenon. MRI studies have shown muscle morbidity in cervical cancer and prostate cancer. In breast cancer clinical observations and patient reports include muscle morbidity in a number of muscles acting at the shoulder. Several of these muscles lie in the field of surgery and radiotherapy. Timed interaction between muscles that stabilise the shoulder and those acting as prime movers is essential to achieve a smooth scapulohumeral rthythm during functional elevation of the arm. METHOD: CROSS-SECTIONAL STUDY: Seventy-four women treated for unilateral carcinoma of the breast were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). EMG activity of four muscles was recorded during scaption on the affected and unaffected side. Muscle cross sectional area and signal intensity was determined from MRI scans. The association between EMG and covariates was determined using multiple linear regression techniques. RESULTS: Three of the 4 muscles on the affected side demonstrated significantly less EMG activity, particularly when lowering the arm. Upper trapezius demonstrated the greatest loss in activity. Decreased activity in both upper trapezius and rhomboid were significantly associated with an increase in SPADI score and increased time since surgery. Pectoralis major and minor were significantly smaller on the affected side. CONCLUSION: Muscles affected in the long term are the muscles associated with pain and disability yet are not in the direct field of surgery or radiotherapy. Primary muscle shortening and secondary loss of muscle activity may be producing a movement disorder similar to the 'Dropped Shoulder Syndrome'. Exercise programmes should aim not only for range of movement but also for posture correction and education of potential long-term effects.

Ethnic and gender differences in drinking, smoking and drug taking among adolescents in England: a self-report school-based survey of 15 and 16 year olds.

Concern has been mounting about the increasing numbers of adolescents who (ab)use drugs, alcohol and cigarettes. The aim of this study was to establish the prevalence according to gender and ethnicity of drinking, smoking and drug-use in a representative sample of 15 and 16 year olds. The sample consisted of 6020 15- and 16-year-old pupils from 41 schools in England who completed an anonymous self-report survey. There were clear gender and ethnic differences in self-reported substance use. For example, more males than females reported drinking and drug taking. More females reported smoking, but males were more likely to be heavy smokers. Asian, Black and other boys and Black and Asian girls were less likely to report drinking during a typical week compared to White participants. Asian females were less likely to report smoking compared to White females. Cannabis was the most commonly used drug for both genders. Black males were more likely than White males to have used cannabis, opiates and other drugs. However, Asian females were more likely than their White counterparts to have used opiates, but were significantly less likely to have used cannabis. Asian males were more likely than White males to have used ecstasy. The results confirm gender differences in substance use and demonstrate that there are different patterns of substance use between ethnic groups. These findings have implications for targeting prevention campaigns through the media and educational initiatives.

Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital.

BACKGROUND: Deliberate self-harm (DSH) is the strongest risk factor for future suicide. Up-to-date information on the extent of risk is lacking. AIMS: To investigate the risk of suicide after DSH during a long follow-up period. METHOD: A mortality follow-up study to 2000 was conducted on 11 583 patients who presented to hospital after DSH between 1978 and 1997. Data were obtained from a general hospital DSH register in Oxford and the Office for National Statistics, and from equivalent mortality registers in Scotland and Northern Ireland. RESULTS: Three hundred patients had died by suicide or probable suicide. The risk in the first year of follow-up was 0.7% (95% CI 0.6-0.9%), which was 66 (95% CI 52-82) times the annual risk of suicide in the general population. The risk after 5 years was 1.7%, at 10 years 2.4% and at 15 years 3.0%. The risk was far higher in men than in women (hazard ratio 2.8,95% CI 2.2-3.6). In both genders it increased markedly with age at initial presentation. CONCLUSIONS: Following DSH there is a significant and persistent risk of suicide, which varies markedly between genders and age groups. Reduction in the risk of suicide following DSH must be a key element in national suicide prevention strategies.

Intravenous immunoglobulin in the treatment of primary trigeminal neuralgia refractory to carbamazepine: a study protocol [ISRCTN33042138].

BACKGROUND: We have recently reported successful treatment of patients with chronic pain syndromes using human pooled intravenous immunoglobulin (IVIG) in a prospective, open-label cohort study. A randomised, placebo controlled, double blinded study is needed to confirm these results. We chose to study patients with carbamazepine resistant primary Trigeminal Neuralgia (rpTN), as these had responded particularly well to IVIG.A protocol involving the use of IVIG in rpTN is complex for three reasons: 1. The effect of IVIG does not follow simple dose-response rules; 2. The response pattern of patients to IVIG was variable and ranged between no effect at all and pain free remission between two weeks and >1 year; 3. TN is characterized by extremely severe pain, for which operative intervention is (if temporarily) helpful in most patients. DESIGN: A placebo controlled, parallel, add-on model was developed and the primary outcome variable defined as the length of time during which patients remain in the study. Study groups are compared using Kaplan-Maier survival analysis. Patients record their response to treatment ("severe, moderate, slight, no pain"). The study coordinator monitors pain diaries. Severe or moderate pain of three days duration will result in termination of the study for that patient. CONCLUSIONS: This study design utilizes a method of survival analysis and is novel in chronic pain research. It allows for both early departure from the study and voluntary crossover upon non-response. It may be applicable to the analysis of IVIG efficacy in other chronic pain syndromes.

Deliberate self harm in adolescents: self report survey in schools in England.

OBJECTIVE: To determine the prevalence of deliberate self harm in adolescents and the factors associated with it. DESIGN: Cross sectional survey using anonymous self report questionnaire. SETTING: 41 schools in England. PARTICIPANTS: 6020 pupils aged 15 and 16 years. MAIN OUTCOME MEASURE: Deliberate self harm. RESULTS: 398 (6.9%) participants reported an act of deliberate self harm in the previous year that met study criteria. Only 12.6% of episodes had resulted in presentation to hospital. Deliberate self harm was more common in females than it was in males (11.2% v 3.2%; odds ratio 3.9, 95% confidence interval 3.1 to 4.9). In females the factors included in a multivariate logistic regression for deliberate self harm were recent self harm by friends, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem. In males the factors were suicidal behaviour in friends and family members, drug use, and low self esteem. CONCLUSIONS: Deliberate self harm is common in adolescents, especially females. School based mental health initiatives are needed. These could include approaches aimed at educating school pupils about mental health problems and screening for those at risk.