Journal articles on the topic 'Mid-adolescent performers'

The purpose of this qualitative inquiry was to investigate adolescent choral singers’ philosophical beliefs regarding music-making within three different, mid-sized, Midwestern mixed choirs in the United States. Eighteen participants were interviewed for approximately 40 minutes each. Audio files were transcribed and coded with four themes resulting: (1) music-making as a simultaneously feelingful experience for participants; (2) musical knowing as interpersonal knowing; (3) expressed music as expressed feeling; and (4) music-making as enlightening. Participants verified the data through member checks. The presence of a peer de-briefer helped the investigator work through potential ethical issues. The findings reflect many ideas within the field of music philosophy including aesthetic perception, expressiveness by convention, music-making as distinctly human and art as self-unification. Findings also aligned with past studies regarding participants’ expressed meaning of musical experiences including areas such as social growth, expression of emotion, increased self-confidence, and development of personal character. Future suggestions for study include investigating perspectives of individual performers and participants who engage in different music ensembles to strengthen understanding of contextual factors.

Although previous research has investigated the training-specific adaptations to training in adults, there is a paucity of research aimed at investigating these adaptations in adolescent athletes. As such, adolescent athletes’ training-specific adaptations from three different training interventions were investigated in this study. Sixteen adolescent athletes participated in this study, whereby eight performed both training interventions and eight the non-training control. Pre- and post-testing was performed for each intervention with the testing battery: ultrasonography of the vastus lateralis and lateral gastrocnemius, countermovement jump, squat jump, and isometric mid-thigh pull. The resistance training group had large significant increases in isometric mid-thigh pull relative peak force ( p < 0.01, g = 0.85 (−0.01, 1.71)) and vastus lateralis fascicle length ( p = 0.04, g = 0.94 (0.07, 1.80)). The gymnastics and plyometric group demonstrated large significant changes in vastus lateralis pennation angle ( p = 0.03, g = −0.94 (−1.81, −0.08)) and fascicle length ( p = 0.03, g = 1.07 (0.19, 1.95)), and moderate significant increases in lateral gastrocnemius thickness ( p = 0.01, g = 0.63 (−0.21, 1.47)) and eccentric leg stiffness ( p = 0.03, g = 0.60 (−0.24, 1.44)). No significant changes were observed for any variables in the non-training group. The resistance training evoked increases in lower-body force producing capabilities, whereas the gymnastics and plyometric training evoked changes in muscle structure and inherent muscle qualities.

Background The clavicle is the most commonly fractured bone in the body and accounts for 10–15% of all pediatric fractures. Adult patients with complete midshaft clavicle fractures often undergo surgical management. Pediatric patients have a thicker periosteum, more robust blood supply and a greater healing potential. Controversy exists as to whether to treat adolescents with surgery similar to adults versus with a sling as children are treated. Some orthopaedic surgeons are now operating on adolescent clavicle fractures. Objective The objective of the study was to evaluate the outcomes of displaced midshaft clavicle fractures in adolescent who were treated conservatively with a sling. Methods We performed a retrospective chart review of 25 pediatric patients aged 12–16 with complete midshaft clavicle fracture. The outcomes of the study were bony union and functional outcomes such as pain, problems with ADL measured by the modified Disability of Arm, Shoulder, and Hand (DASH) score. Results All patients in our cohort had excellent outcomes at follow-up visits with no complaints of pain or limitations of activities of daily living. Mean follow-up time was 12 months. All patients had perfect modified DASH score of 18. Injury radiographs demonstrated an average of 13 mm shortening initially and 8 mm shortening in final follow-up. Average fracture angulation at final follow-up was 15°. Normal clavicle angulation at the mid shaft is 8°. All clavicles healed completely with no case of malunion or non-union reported. Conclusion Clavicle fractures are common. Although operative treatment of clavicle fractures in the adult population is gaining popularity due to issues in adults with non-union and malunion, the adolescent population is different. The adolescent clavicle fracture demonstrates robust healing and remodeling and complete return to full function. We therefore recommend that adolescent patients aged 12–16 with complete clavicle fracture be treated conservatively with a sling.

Due to successful surgical treatment of congenital heart defects in infants and children, the number of patients who reach the adolescent/adult age is continuously increasing. Aims: The authors sought to identify the short- and medium-term outcomes of reconstruction of right ventricular outflow tract in adolescents and adults who underwent surgical intervention for congenital heart defect in infancy or early childhood. Methods: Between 2001 and 2012, 48 patients (age: 15–39, mean 21 years) (30 tetralogy of Fallot, 11 pulmonary atresia + ventricular septal defect, 6 transposition of great arteries + ventricular septal defect + left ventricular outflow tract obstruction, and 1 truncus arteriosus) had repeat operation because of right ventricular dysfunction. All patients previously underwent right ventricular outflow tract procedures in early childhood. Results: In 31 patients, the small homograft, and in 9 patients the transannular-paths were replaced for “adult-size” homograft. Bioprosthetic pulmonary valve replacement was performed in pulmonary (6 patients) and homograft annuli (2 patients). In 14 patients, resection of the right ventricular outflow tract aneurism was also necessary to be performed. There was no early and mid-time (10 years) mortality. In 97.5% of patients with homograft-re-implantation, there was no need for repeat intervention for 5 years. Conclusions: The right ventricular outflow tract restoration in adolescents and adults is an effective procedure. The reconstruction should be performed in early adolescent period to prevent right ventricular dysfunction. The authors prefer using bioprosthetic pulmonary valve replacement in patients with adult-size pulmonary or homograft annulus. Orv. Hetil., 2012, 153, 1219–1224.

The literature available on patient oriented outcomes of operative management for clavicle fractures in adolescents is fairly limited. The purpose of this study was to analyze the potential of open reduction and internal fixation for displaced mid-shaft clavicle fractures in adolescent patients. We reviewed our series of surgical cases performed in 19 adolescents (mean age: 14.6 years) with displaced unilateral clavicle fractures. Baseline data acquisition included demographic and radiographic variables. A Synthes® LCP clavicular plate was utilized for fixation in all cases. Follow-up data included functional outcome assessment using the Quick Disability of Arm, Shoulder, and Hand Questionnaire (DASH), the simple shoulder test (SST) and additional binary questions. At a mean follow-up of 16 months, quick DASH scores were 4.0 (range: 0-35.5) and mean number of positive yes responses on the SST for all operative patients was 11 (range: 9-12). All cases proved complete radiological union at the 3-month follow-up. All patients returned to full athletics at a mean time of 14 weeks (range: 12-17 weeks). Two patients had minimal hypertrophic scars while no patient was noted with keloid formation or neurovascular deficit. One patient complained of implant prominence and occasional symptoms of discomfort at the 15 month follow-up and opted for implant removal. This was successfully performed with uneventful full recovery. All patients were fully satisfied with their choice for surgical intervention. Anatomical reduction with internal fixation and early mobilization of adolescent displaced clavicle fractures remains a viable treatment option with predictable results and no major complications in reliable hands.

The first aim was to compare differences between school vulnerability groups, fitness levels, and their combination in adolescent cognitive performance. The second aim was to determine the mediation role of fitness in the association between school vulnerability and cognitive performance. A total of 912 Chilean adolescents aged 10–14 years participated in this study. The school vulnerability index (SVI) assigned by the Chilean Government was categorized into high-, mid-, or low-SVI. Adolescents were classified as fit or unfit according to their global fitness z-score computed from their cardiorespiratory (CRF), muscular (MF), and speed/agility fitness (SAF) adjusted for age and sex. A global cognitive score was estimated through eight tasks based on a neurocognitive battery. Covariance and mediation analyses were performed, adjusted for sex, schools, body mass index, and peak high velocity. Independent analyses showed that the higher SVI, the lower the cognitive performance (F(6,905) = 18.5; p < 0.001). Conversely, fit adolescents presented a higher cognitive performance than their unfit peers (F(5,906) = 8.93; p < 0.001). The combined analysis found cognitive differences between fit and unfit adolescents in both the high- and mid-SVI levels (Cohen’s d = 0.32). No differences were found between fit participants belonging to higher SVI groups and unfit participants belonging to lower SVI groups. Mediation percentages of 9.0%, 5.6%, 7.1%, and 2.8% were observed for the global fitness score, CRF, MF, and SAF, respectively. The mediation effect was significant between low- with mid-high-SVI levels but not between mid- and high-SVI levels. These findings suggest that an adequate physical fitness level should be deemed a protective social factor associated with bridging the cognitive gap linked to school vulnerability in adolescents. This favourable influence seems to be most significant in adolescents belonging to a more adverse social background.

BACKGROUND Osteochondral lesions of the elbow are a difficult entity to treat in high-demand individuals. Pediatric and adolescent patients who typically present with these lesions are upper extremity athletes involved in high demand sports. There has been relatively limited examination in the literature of these patients’ ability to return to sport at midterm follow-up; particularly after non-osteochondral grafting procedures such as fixation and micro-fracture. The purpose of this study was to determine the mid-term outcomes of lesion treatment in a cohort of pediatric and adolescent patients. METHODS This was a retrospective review of a consecutive series of pediatric and adolescent patients who underwent surgical treatment for osteochondral lesions of the elbow. Patients were treated arthroscopically by a single surgeon from 2012 to 2017. All patients had confirmed osteochondral lesions of their elbow confirmed via MRI and underwent surgical intervention after failure of conservative treatment. Data including age, hand dominance, sporting activity, physeal status, imaging, intra-operative findings, procedure performed, post-operative complications, and return to sport were analyzed. RESULTS Twenty patients (twenty-two elbows) underwent surgical treatment with a mean age of 13.05 (±1.89) years with a mean follow-up 1.9 years. Fifteen males and 5 females were involved in the following sports: baseball (10), gymnastics (3), football (2), lacrosse (1), softball (2), and multi-sport (2). Sixty-three percent of the elbows had open physes at the time of surgical intervention. There were 19 capitellar lesions, 2 trochlear lesions, and 1 radial head lesion. The mean lesion size was 8.5 (±3.7) mm X 8.9 (±3.0) mm. Three patients underwent fixation, and the remainder underwent loose body removal and microfracture. No patients had any post-operative complications and all healed radiographically. One patient (4.5%) underwent a re operation due to repeat injury after gymnastics, and underwent an osteochondral autograft procedure. Thirty-percent of patients did not return to the same sport; forty-percent of baseball players and sixty-six percent of gymnasts. CONCLUSIONS / SIGNIFICANCE Osteochondral lesions of the elbow are a challenging entity to treat. Although arthroscopic intervention can be performed safely and result in radiographic healing, there is a high rate of inability to return to sport in patients involved in high impact upper extremity activity such as baseball and gymnastics with either fixation or lesion debridement /microfracture. Further treatment strategies in these patients including cartilage restoration procedures (i.e. OATS) may be warranted in this population.

Previous studies have reported an association between global measures of bilateral strength and change of direction (COD) ability. Yet, little is known about the association between unilateral muscle strength qualities and COD ability. The aim of this study was to explore the associations between unilateral muscle strength qualities and COD measures (COD speed (CODS) and COD deficit) when matched limb-for-limb (i.e., right limb vs. right limb, left limb vs. left limb) in adolescent team-sport athletes. One hundred and fifteen athletes (56 males, 59 females) active in cricket, netball, and basketball participated in this investigation. Each player performed trials of countermovement jump (CMJ), single-leg hop (SLH), isometric mid-thigh pull (IMTP) and eccentric knee extensor torque (ECC-EXT) to assess muscle strength qualities and 505 and modified 505 (505mod) to evaluate COD ability. Moderate-to-large correlations were observed between SLH and CODS (r = −0.43 to −0.67). Another important finding was that CMJ measures demonstrated moderate-to-large correlations with CODS (r = −0.38 to −0.69) and small-to-moderate correlations with COD deficit (r = −0.24 to −0.45). COD is underpinned by distinct muscle strength qualities and each contribute to specific phases of a COD task. It is therefore likely that such connections exist between muscle strength qualities and COD, with all qualities contributing to overall COD ability.

Objectives: Physeal-sparing techniques for anterior cruciate ligament (ACL) reconstruction have previously been described as safe treatment for adolescent ACL tears in patients with open physes, however few studies to date have reported on return-to-sport or patient reported outcome scores for this specific patient population. This study examined patient reported outcomes in children who underwent a physeal-sparing ACL reconstruction with a minimum of two-year follow-up. Methods: Surgical logs of ACLR performed at a single pediatric/adolescent sports medicine center from 2011 to 2016 were reviewed. Patients with open physes who had ACLR with a hybrid physeal sparing or all-epiphyseal technique were identified. Patients were treated by one of two pediatric sports trained orthopedic surgeons. Their demographics, operative reports, rehabilitative course, time to return-to-play, and post-operative course were retrospectively reviewed. Prospective patient reported outcomes scores, ACL-Return to Sport after Injury (ACL-RSI) and International Knee Documentation Committee (IKDC) or Pediatric IKDC (Pedi-IKDC) and return to sport questionnaire including pre-injury primary sport and competition level, ability to return to pre-injury level of competition following ACLR and subsequent ACL injury were collected. Results: There were 49 patients who met inclusion criteria. Prospectively collected data was obtained for 25 patients at an average of 4.6 (range 2.1-8.0) years following surgery. The average chronological age of patients at time of surgery was 12.8 ± 1.4 years with an average bone age of 13.5 ± 1.3 years. At mid-term follow-up, the average chronological age was 17.2 ± 2.0 years. Average Pedi-IKDC or IKDC score was 94.2 ± 9.2 and ACL-RSI Score was 89.2 ± 18.3. There were 23 patients who considered themselves athletes prior to surgery, 8 patients identifying as recreational athletes competing in town or school leagues and 15 patients identifying as competitive athletes participating on youth travel or club leagues. All patients reported the ability to return to their primary sport following ACLR, with 74% returning to the same or higher level of competition, of which 6 were recreational athletes and 11 were competitive athletes. In addition, 6 patients did not complete outcomes data, but had suffered tear of their ipsilateral (3) or contralateral (3) side and were treated at the same facility. These patients were included in calculation of overall re-tear rate of 12.5% (5 patients) and contralateral tear of 25% (8 patients). Conclusion: Mid-term results of patients treated with a hybrid physeal-sparing or all-epiphyseal ACLR were favorable, with adolescents reporting a high level of functional ability and strong psychological readiness to engage in athletic activities. Re-tear and contralateral tear rates were equivalent to other reported studies. These physeal-sparing techniques demonstrate the ability for young athletes to successfully remain physically active and involved in their sports several years following surgery.

Background: Medial patellofemoral ligament (MPFL) reconstruction has gained popularity as a tool to manage recurrent patellar instability. The use of allograft for reconstruction includes benefits of quicker surgical time and obviating donor-site morbidity. In anterior cruciate ligament (ACL) reconstruction hesitancy exists to use allograft in younger patients based on data demonstrating higher graft failure rates. However, a similar trend of allograft failure has not been demonstrated for reconstruction of the MPFL, which has a lower tensile strength than that of the ACL. Hypothesis/Purpose: The purpose of this study is to evaluate outcomes including recurrent instability after MPFL reconstruction utilizing allograft tissue in pediatric and adolescent patients. Methods: A retrospective review was performed to identify patients of a single surgeon with MPFL reconstructions with allograft for recurrent patellar instability with minimum two-year follow-up. Surgical management was recommended after minimum six weeks of nonoperative management including bracing, physical therapy, and activity modification. Pre-operative x-rays were evaluated to assess physeal closure, lower extremity alignment and trochlear morphology, and Insall-Salvati and Caton-Deschamps ratios. MRIs were reviewed to evaluate the MPFL, trochlear morphology, and tibial tubercle trochlear groove distance (TT-TG). The allograft was fixed with a bioabsorbable screw. Descriptive statistics were used to characterize data. The primary outcome was recurrent instability. Results: 20 patients (23 knees) 14 females (17 knees) with average age 15.8 years (range: 11.5-19.6 years) underwent MPFL reconstruction with allograft with average follow-up of 3.6 years (range: 2.2-5.9 years). Physes were open in 8 knees. Average Insall-Salvati ratio was 1.08 ± 0.16 and Caton-Deschamps index was 1.18 ± 0.15. Eighteen patients were noted to have trochlear dysplasia pre-operatively and TT-TG was 15.4 ± 3.9 mm. The three knees (13.0%) with complications had open physes – two (8.7%) had recurrent instability requiring subsequent operation and one sustained a patella fracture requiring open reduction internal fixation. The average Insall-Salvati of these three patients was 1.26 ± 0.21, Caton-Deschamps was 1.18 ± 0.21, and TT-TG was 18.3 ± 3.5mm. There were no growth disturbances noted post-operatively. Conclusion: MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at mid-term follow-up with few complications and low rate of recurrent instability. Anatomic factors for may contribute to recurrent instability and complications post-operatively, though larger numbers are needed for statistical analyses. Further prospective and randomized evaluation comparing autograft to allograft reconstruction is warranted to understand graft failure rates.

This study aimed to investigate sex difference in the functional movement in the adolescent period. Seven hundred and thirty adolescents (365 boys) aged 16–17 years participated in the study. The participants performed standardized Functional Movement Screen™ (FMSTM) protocol and a t-test was used to examine sex differences in the total functional movement screen score, while the chi-square test was used to determine sex differences in the proportion of dysfunctional movement and movement asymmetries within the individual FMSTM tests. Girls demonstrated higher total FMSTM score compared to boys (12.7 ± 2.3 and 12.2 ± 2.4, respectively; p = 0.0054). Sex differences were present in several individual functional movement patterns where boys demonstrated higher prevalence of dysfunctional movement compared to girls in patterns that challenge mobility and flexibility of the body (inline lunge: 32% vs. 22%, df = 1, p = 0.0009; shoulder mobility: 47% vs. 26%, df = 1, p < 0.0001; and active straight leg raise: 31% vs. 9%, df = 1, p < 0.0001), while girls underperformed in tests that have higher demands for upper-body strength and abdominal stabilization (trunk stability push-up: 81% vs. 44%, df = 1, p < 0.0001; and rotary stability: 54% vs. 44%, df = 1, p = 0.0075). Findings of this study suggest that sex dimorphisms exist in functional movement patterns in the period of mid-adolescence. The results of this research need to be considered while using FMSTM as a screening tool, as well as the reference standard for exercise intervention among the secondary school-aged population.

Background: The habits that children inculcate during adolescence remains with them throughout the life. Anaemia is one of the most prevalent health conditions amongst the Girls residing in developing countries. The present study was conducted with the aim to determine the prevalence and risk factors associated with anaemia amongst adolescent girls attending in paediatrics OPD of Nepalgunj Medical College. Materials and methods: The present cross sectional study was performed for a period of one year (February 2016 - March 2017). This study was conducted amongst the girls attending to the Paediatrics department of Nepalgunj Medical College and Teaching Hospital, Nepalgunj. The study included all the girls aged between 10-19 years. Each Girls underwent physical examination under trained supervision to record sign of anaemia like pallor. Body mass index of all the subjects was also calculated. The data obtained was arranged in a tabulated form and analysed using SPSS software. Results: A total of 200 girls were enrolled in this study. The mean age of the study sample was 21.10+/-10.67 years. Majority of the early adolescents (68.5%) had anaemia. Least number (36%) of anaemic patients was seen in mid adolescence. There were 47.5% girls in late adolescence that showed signs of anaemia. There were 47.9% Girls who had passage of worms and 50.1% had no worm infestations. Majority (63.5%) of non anaemic Girls were in their post menarche stage. Conclusion: There were 52% of the girls who were anaemic in our study. The proportion of undernourished girls were significantly higher, therefore body mass index significantly affects anaemia.

Introduction. Balloon valvuloplasty (BVP) is one of the primary therapies for congenital aortic stenosis in children and adolescents. The aim of this interventional procedure is to gain time before possible surgical therapy (aortic valve replacement) until adulthood. Objective. The aim of this study was to evaluate the efficacy, safety and mid-term results of transcatheter BVP in children and adolescent in our Center. Methods. From 2004 to 2011, 50 patients, aged 18 days to 18 years (mean 6.3 years) underwent BVP. Retrospective analysis of the echocardiographic and hemodynamic parameters were performed before and after procedure, especially peak pressure gradient (PG) across the aortic valve, semiquantification of the aortic regurgitation (AR) after the BVP as well as the left ventricle dimensions and functions. Results. The mean peak PG in the whole group decreased from 74.80?27.72 mm Hg to 27.86?13.04 mm Hg (p<0.001) after BVP. In 39 patients (78%), residual PG was lower than 30 mm Hg just after dilation. At the end of follow-up period, 25 patients (50%) had PG above 50 mm Hg, measured by Doppler technique, and four of them underwent re-dilation. Eight patients (16%) had severe AR. During the follow-up period (12-80 months, mean 51 months), six patients (12%) were referred to cardiac surgeons for aortic valve replacement or Ross procedure. Conclusions. This retrospective study analyzes our first experience of BVP as primary therapy of the congenital aortic stenosis. The results confirmed that BVP effectively postponed the need for surgery in children and adolescents toward the adulthood.

PurposePrevious studies on paediatric and adolescent distal humeral fractures have reported an increase in surgical treatment activity. This increase could be hypothesized to reduce the incidence of corrective osteotomies. The aim of this study was to determine the incidence and trends of the primary surgical treatment of distal humeral fractures and corrective osteotomies in children and adolescents.MethodsAll Finns 18 years of age or younger who underwent treatment for distal humeral fracture between 1987 and 2016 were included in this population-based study. Surgical treatment data were obtained from the National Hospital Discharge Register of Finland. In calculating annual surgery incidence rates, the annual mid-year populations were obtained from the Official Statistics Finland. Surgical treatment was categorized into four groups; reposition and casting, osteosynthesis, external fixation and corrective osteotomy.ResultsDuring the 30-year study period, 9017 surgical procedures were performed in Finland with the primary or secondary diagnosis code being a distal humeral fracture. Of these, 6961 (77.2%) were osteosynthesis and the incidence of osteosynthesis (per 100 000 person-years) increased fourfold from 8.2 in 1987 to 34.1 in 2016. In the same 30-year study period, the total number of corrective osteotomies was low (151) with annual variation from one to 16. The incidence of corrective osteotomies (per 100 000 person-years) decreased sevenfold from 0.7 to 0.1.ConclusionThe incidence of surgical treatment with osteosynthesis in distal humeral fractures increased fourfold in Finland between 1987 and 2016. During the same time period, the number of corrective osteotomies diminished significantly.Level of EvidenceIV

Background: Osteochondral lesions (OCL), including osteochondritis dissecans (OCD) and traumatic osteochondral fractures (OCF), are often encountered when treating injuries affecting the pediatric and adolescent knee. There are an array of treatment options depending upon lesion size, location, chronicity, and equally important, surgeon experience. There is a potential for healing in children and adolescents that may not be present in adults and the intent of internal fixation is to reduce and restore the injured hyaline cartilage and underlying bone. Stable fixation utilizing bioabsorbable implants offers a possibility of OCL healing without the need for implant removal or a major restorative procedure such as an osteochondral autograft transfer, osteochondral allograft, or autologous chondrocyte implantation, therefore avoiding the associated costs and potential morbidity. The purpose of our study was to review the mid-term outcomes of internal fixation with bioabsorbable implants of osteochondral injuries of the knee in children and adolescents. Methods: An IRB approved retrospective review of patients younger than 18 years old who had internal fixation of knee OCLs with bioabsorbable implants was performed. All those included had a minimum 2-year follow-up and completed validated outcome scores (Pedi-IKDC, Tegner, Lysholm). Medical records were reviewed from 2009 to 2015 for patient demographics, intraoperative details, and postoperative outcomes. Pedi-IKDC and Tegner-Lysholm functional outcome scores were used to assess overall outcomes at final follow-up. Return to the operating room was recorded. All cases were performed at a single tertiary pediatric institution by a single pediatric fellowship trained orthopedic surgeon. Results: There were a total of 35 children and adolescents that had a knee OCL that underwent internal fixation with bioabsorbable implants. 7 patients were lost to follow-up with a final cohort of 28 of the 35 patients (80%). Average follow-up was 44 months (range 24-97 months). Average age was 14.7 years. Out of the 28 children, 14 had OCD and 14 OCFs. The average number of bioabsorbable darts and screws used per intervention was 2 and 1, respectively. The average Pedi-IKDC and Lysholm scoring at final follow-up was 89.5 and 91, respectively. Five patients returned to the operating room following the primary procedure: 2 for manipulation under anesthesia related to OCL fixation, 1 for a planned staged ACL reconstruction, 1 for MPFL reconstruction for recurrent patella instability following the index procedure, and 1 patient returned secondary to a proud implant that was in-turn debrided. None of the 28 patients underwent a revision cartilage procedure. Conclusion: The use of bioabsorbable implants (screws and darts) in children and adolescents appears to be a safe and efficacious treatment with good functional outcomes at mid-term follow up and in this cohort there was no need for a revision cartilage procedure. Larger multi-center longer-term follow studies are needed.

Background. The use of an arthroereisis implant for the treatment of adolescent flatfoot deformity has been described. However, data that address the outcomes of patients treated with an arthroereisis implant in adults are limited. The purpose of this study was to investigate the radiographic and clinical outcomes and complications following the use of a subtalar arthroereisis implant as an adjunct for correction acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. Methods. A retrospective case-control study was performed querying all patients undergoing surgical flatfoot correction between January 1, 2010 and January 1, 2015. The experimental group included patients undergoing arthroereisis augmentation at the time of flatfoot correction. Patients undergoing the same flatfoot correction without the use of an arthroereisis implant were used as controls. Radiographic measurements were evaluated preoperatively and at final radiographic follow-up and included talonavicular (TN) coverage angle, and lateral talar–first metatarsal angle (T1MA). Patient-reported outcomes were assessed using preoperative visual analog scale (VAS) pain scores and postoperative Short Form–36, VAS, and satisfaction at final orthopedic follow-up. Results. A total of 15 patients underwent flatfoot correction and were augmented with an arthroereisis implant and were matched with 30 controls. Postoperative, mid-term T1MA and regional analysis was found to be improved in the experimental group versus control. Patients undergoing adjunct subtalar arthroereisis demonstrated an increased likelihood of achieving radiographically normal talonavicular coverage <7° compared with our control group at follow-up. Conclusions. The adjunct use of an arthroereisis implant resulted in improved and maintained radiographic and clinical measurements in patients undergoing stage II flatfoot. Clinical Significance. These results suggest utility of a subtalar arthroereisis implant as an adjunct to flatfoot correction with little additional risk of harm to the patient. Levels of Evidence: Level III: Case-control study

In this study, we draw from the literature on sibling configurations and parental age to investigate the effects of these factors on the academic achievement of children. The study investigates the effects of maternal age at first birth, maternal age when the respondent was born, and father's age when the respondent was born on ACT scores, grade point averages over three years, and whether or not the parents are providing financial aid to their students. We examine the effects of sibship size, ordinal position, and gender composition of the sibship on these same variables. The study also investigates the extent to which the relationship between parental age and academic outcomes is linear. The relationship of sibship size, ordinal position, and gender composition on the quality of relationships with parents is investigated. Using a sample of freshmen at a mid-western university, we find consistent positive effects of parental age on high school and early college achievement, as well as consistent negative birth order effects on achievement at the high school level. Students with older parents and fewer older siblings consistently performed better. Sibship size and the proportion of females in the sibship had no effect on academic outcomes. Using self-reported data from children on a childhood measure of parental support and interaction and quality of relationships with parents during late adolescence, we also investigate the impact of parental age at birth, and sibling characteristics on childhood and adolescent family environment. Ordinal position had a significant positive effect on the quality of relationships with parents during adolescence, and sibship size had a significant negative effect. We find a curvilinear effect for paternal age on childhood support and parental involvement, but not for academic achievement or quality of relationships with parents in late adolescence. Parental education had a positive significant impact on childhood support and involvement. Children from larger sibships and who were later born children were less likely to receive financial aid from their parents. The results are discussed as they relate to the literature on parental age and sibling configurations, and in terms of their implications for student retention and success.

<sec><title>Study Design</title><p>Comparative cross-sectional study.</p></sec><sec><title>Purpose</title><p>We measured the vertical ground reaction force (vGRF) of the hip, knee, and ankle joints during normal gait in normal patients, adolescent idiopathic scoliosis (AIS) patients with a Cobb angle &lt;40° and in AIS patients with spinal fusion. We aimed to investigate whether vGRF in the aforementioned joints is altered in these three groups of patients.</p></sec><sec><title>Overview of Literature</title><p>vGRF of the lower limb joints may be altered in these groups of patients. Although it is known that excessive force in the joints may induce early arthritis, there is limited relevant information in the literatures.</p></sec><sec><title>Methods</title><p>We measured vGRF of the hip, knee, and ankle joints during heel strike, early stance, mid stance, and toe-off phases in normal subjects (group 1, n=14), AIS patients with Cobb angle &lt;40° (group 2, n=14), and AIS patients with spinal fusion (group 3, n=13) using a gait analysis platform. Fifteen auto-reflective tracking markers were attached to standard anatomical landmarks in both the lower limbs. The captured motion images were used to define the orientations of the body segments and force exerted on the force plate using computer software. Statistical analysis was performed using independent t-test and analysis of variance to examine differences between the right and left sides as well as those among the different subject groups.</p></sec><sec><title>Results</title><p>The measurements during the four gait phases in all the groups did not show any significant difference (<italic>p</italic>&gt;0.05). In addition, no significant difference was found in the vGRF measurements of all the joints among the three groups (<italic>p</italic>&gt;0.05).</p></sec><sec><title>Conclusions</title><p>A Cobb angle &lt;40° and spinal fusion did not significantly create imbalance or alter vGRF of the lower limb joints in AIS patients.</p></sec>

Abstract Abstract 2979 Poster Board II-952 BACKGROUND AND OBJECTIVES: Post-thrombotic syndrome (PTS) is an important long-term sequela of deep venous thrombosis (DVT) in children, which may involve the upper or lower venous systems (UVS, LVS). The understanding of pediatric PTS has been limited by variability in outcome measurement, and prospective data are particularly lacking for DVT involving the UVS. Validation data have been published for the performance of a pediatric PTS outcome measure (the Manco-Johnson instrument; Figure 1) in the LVS (Goldenberg et al., Blood 2007). The aims of the present work were to: (1) investigate validity of the Manco-Johnson instrument in the UVS in children, via a cross-sectional derivation cohort/validation cohort design; and (2) preliminarily determine the cumulative incidence of PTS in a prospective inception cohort study of children with DVT affecting the UVS. METHODS AND RESULTS: Validation study: All parameters of the Manco-Johnson instrument were assessed in a derivation cohort (n=78) consisting of healthy children aged 12 months to 21 years who were without personal or first-degree family history of thromboembolism before age 55 years, grouped by age as follows: preschool (12 mo – <6 y; n=30); school age (6 - <13 y, n=28); adolescent (13 – 21 y, n=20). Inter-rater reliability in each parameter of the instrument was evaluated in a mixed validation cohort (n=41) of healthy children and patients with history of DVT affecting the UVS. In the derivation cohort, the upper limit of normal values for contralateral difference in upper limb circumference was 1.0 cm for mid-forearm and mid-upper arm measurements, as calculated by the non-parametric method of Tukey. In addition, dilated superficial collateral veins, venous stasis dermatitis, venous stasis ulcers, and chronic pain of the upper limb, chest or neck that limits activities of daily living or aerobic exercise were all absent among these healthy children. Inter-rater reliability, measured as percent agreement, exceeded 95% for all parameters when applied in the validation cohort by mutually-blinded dual examiners trained in the use of the instrument. Prospective inception cohort study: Inclusion criteria consisted of radiologically confirmed DVT of the subclavian vein, brachiocephalic vein, and/or superior vena cava (SVC), and study enrollment between March 2006 and July 2009. All children underwent comprehensive thrombophilia testing and were managed with anticoagulation in accordance with ACCP pediatric guidelines, for a minimum duration of 3 months. In some cases, acute thrombolytic therapy was instituted based upon clinical decisions. Children were evaluated for PTS using the Manco-Johnson instrument at 3-6 months, 12 months, and annually thereafter in long-term follow-up. Repeat imaging was performed at minimum at 3-6 months post-diagnosis, and if persistent, again at 1 year. Prevalence of PTS was analyzed based upon findings at latest follow-up (minimum 1 year post-diagnosis). Individual patient data on diagnostic findings, treatment, thrombus resolution, and PTS outcome are given in Table 1. Among 13 subjects meeting eligibility criteria, median age at DVT diagnosis was 16 years (range: 2 - 21 years). The SVC was involved in one child. Clinical predisposition consisted of central venous catheterization in approximately 50% of cases and an underlying anatomic vascular abnormality (thoracic outlet syndrome, Paget-Schroetter syndrome) in an additional 23%. Thrombophilia at presentation consisted of elevated factor VIII in 70% and antiphospholipid antibodies in nearly 50%. Thrombolysis was employed in the 2 children with anatomic defects and one with catastrophic antiphospholipid antibody syndrome. DVT persisted following a 3-6 course of anticoagulant therapy in 50% of evaluable patients. The cumulative incidence of PTS at 1-2 years among 7 evaluable patients was 29%, and involved both physical findings and functional impairment (i.e., chronic pain limitation) in each case. CONCLUSIONS: The present findings demonstrate the validity of the Manco-Johnson instrument for pediatric PTS outcome measurement involving the UVS. Using this instrument, PTS appears to be common in children with DVT affecting the UVS, and functionally significant. Broader use of the Manco-Johnson instrument for PTS outcome assessment in prospective studies and clinical trials of pediatric DVT is warranted. Disclosures: Off Label Use: The presentation refers to the use of anticoagulants as a drug class in general in the treatment of venous thromboembolism (VTE) in children. Despite their use in the standard care for pediatric VTE, all anticoagulants remain off-label for this indication in children.

Abstract Abstract 3183 Nutritional status of children with cancer is a surprisingly understudied area. While overt malnutrition is not common among US children with cancer, many experience weight loss or mild nutritional deficiencies. The Children's Oncology Group (COG) noted in one study that only 46% of responding institutions conducted a nutrition assessment on newly diagnosed children with cancer and only 52% had criteria for intervention (Ladas et al. 2006). Accordingly, the COG has called for more clinical studies in order to provide evidence-based guidelines for nutritional assessment and interventions for these patients. Zinc, a trace mineral used in hundreds of proteins in the body, is rarely assessed in these children. We hypothesized that there is increased incidence of zn deficiency in US children with cancer compared with the general population, and that low zn levels may be associated with increased incidence of common toxicities of treatment, including diarrhea, mucositis or infection. We report here an interim analysis. We designed a prospective trial of children with cancers diagnosed and treated at Children's Hospital and Research Center Oakland (CHRCO) from January 2011 through August 2012. Fifty children aged 1 mo to 18 years were enrolled and followed over a six month period. Diagnoses included 33 leukemias, 2 lymphomas, 2 CNS tumors and 13 other solid tumors. Children were enrolled within two weeks of diagnosis and prior to start of any supplemental nutrition. Exclusion criteria included prematurity and known malabsorptive or zn wasting syndromes. A control group of 50 healthy children were also recruited. Approval was obtained from the CHRCO IRB. Anthropometric measurements recorded included height, weight, mid upper arm muscle circumference (MUM C) and skinfolds. Laboratory markers measured included plasma zn, copper (cu), ceruloplasmin, serum albumin, c-reactive protein (CRP) and urine zn, cu and creatinine. Dietary assessment was performed using a self-administered food frequency questionnaire. No significant differences were seen in baseline assessments between the case and control groups. Average body mass index (BMI), height z-score and weight z-score were the same between the two groups. However, subanalysis of the solid tumor group showed a decreased BMI of 16.3 vs. 18.5 in the control group, p=0.01. Similarly, there were no differences in dietary intake of major nutrients, with both groups averaging well above the estimated average requirement (EAR). One notable exception was Vitamin D which was low in both groups but significantly lower in the case group, 37% of EAR vs. 55% of EAR, p<0.01. As expected CRP was elevated in the case group at baseline, 0.85 vs. 0.09 in the control group, p=0.01. Similarly cu was elevated at 142.9 ± 51.2 vs. 111 ± 31.2, p<0.01. However, zn was not decreased at baseline, 85.1 ± 20.8 vs. 84.5 ± 10.4. A larger proportion of the case cohort had low zn levels (<70ug/dl) than did the control group (16% vs. 8%) but this did not reach statistical significance. However, zn decreased significantly in the case group over a six month period from 85.1 ± 20.8 to 72.7 ± 15.2, p=0.002. This difference was most marked in the adolescent leukemia/lymphoma group who demonstrated 30% decrease in zn levels and 60% of these subjects had low zn levels at 6 mo. Cu levels also dropped over the 6 month period, from 142.9 ± 51.2 to 123.5 ± 41.9, p=0.01. We performed ANOVA to evaluate zn and cu in the case cohort over time. Zn dropped significantly with a p value of 0.0015, as did cu with a p of 0.0001. Our data showed no significant deficiencies in plasma zn levels in children at diagnosis of cancer. However, plasma cu was elevated. Both zn and cu levels dropped over the initial 6 month course of treatment, most markedly in the leukemia/lymphoma group in contrast to a prior study which showed decreases only in a subgroup of solid tumors and not in the leukemia/lymphoma population (Malvy, et al. 1997). In multivariate analysis, variables correlating with low zn included plasma cu, age, MUMC and BMI. CRP did not correlate with plasma zn levels, suggesting that low zn was a consequence of true nutritional deficit rather than an acute inflammatory response. Not all the data are mature at this time and we have yet to evaluate the relationship between plasma zn levels and toxicities of cancer treatment. Further analyses are needed to identify the conditions contributing to and the consequences of zn deficiency in this population. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 4774 Renal medullary carcinoma (RMC) is a highly aggressive malignant neoplasm originally thought to be unique to individuals with sickle cell trait (SCT). Common symptoms include hematuria, abdominal pain, and weight loss. The disease is usually metastatic at presentation and is almost universally fatal within months of diagnosis. Herein, we describe an adolescent with homozygous hemoglobin SS (Hgb SS) and RMC. This is the third case of RMC reported in Hgb SS, and the first case with prior hydroxyurea therapy (Dimashkieh Arch Pathol Lab Med 2003 and Swartz Urology 2002). In addition to five reported cases in individuals with hemoglobin SC, it now appears that RMC is not unique to individuals with SCT and should instead be considered more inclusively related to the family of sickle hemoglobinopathies (Davis Am J Surg Pathol 1995, Luthra Intern Med 2010, Baig J Natl Med Assoc 2006, Swartz Urology 2002). A 13 year-old African American male with Hgb SS, treated with hydroxyurea since 2 months of age, presented with a several month history of recurrent abdominal pain and microscopic hematuria. An abdominal ultrasound demonstrated normal appearing kidneys that measured 8.4 cm and 9.7 cm on the right and left sides, respectively. He continued to have abdominal pain, often associated with intermittent sickle cell extremity pain. A repeat sonogram was obtained 9 months after the initial ultrasound due to a new complaint of scrotal pain. The formerly normal left kidney now had a 5 cm mass in the mid-to-lower pole, along with moderate caliceal dilation and cortical thinning of the superior pole. Computed tomography (CT) and positron emission tomography scans confirmed the renal mass along with local invasion into the psoas muscle, liver metastases, pulmonary metastases, and retroperitoneal lymphadenopathy. Multiple core needle biopsy specimens were obtained from the left kidney, diagnostic of RMC. Histopathology showed widespread areas of necrosis with only a few areas of viable tumor. The viable tumor cells formed gland-like structures and had infiltrating sheets with rhabdoid features, eosinophilic cytoplasm, and prominent nucleoli. Immunohistochemical analysis demonstrated strong positivity for EMA, P53 (>95%), and PAX8. CD117 was mostly negative, however there were focal areas of weak cytoplasmic reactivity. ALK-1 immunostain, INI-1, p63, and hepar-1 were all negative. Fluorescence in situ hybridization showed no evidence of t(9;22) BCR;ABL rearrangement but did show extra copies of the BCR gene in 73% of cells. Neoadjuvant chemotherapy with 3 cycles of carboplatin, gemcitabine, and paclitaxel and one cycle of carboplatin, gemcitabine and bortezomib resulted in an improvement on imaging in the primary tumor and metastatic sites. A left radical nephrectomy and lymph node dissection were then performed. Pathology showed 10–20% focally viable renal medullary carcinoma within the kidney with evidence of vascular invasion and positive margins. The sampled lymph nodes were free of tumor. Several weeks later he underwent thoracoscopic resection of left pleural and pulmonary nodules, both of which were positive for metastatic disease. Over the next 11 months, he received 5 cycles of chemotherapy consisting of alternating cycles of carboplatin, gemcitabine, paclitaxel and carboplatin, gemcitabine and bortezomib, followed by 5 additional cycles of methotrexate, vinblastine, doxorubicin and cisplatin. Palliative radiation therapy delivered to the psoas muscle for pain management was beneficial. After a brief initial response to therapy, interval imaging studies demonstrated stable disease followed by subsequent florid progression. Given disease progression, his therapy was changed to the tyrosine kinase and vascular endothelial growth factor receptor antagonist, axitinib. Sixteen months from the time diagnosis, he is ambulatory but with widespread metastatic disease. This case highlights the need for a heightened index of suspicion for RMC in all patients with sickle hemoglobinopathies, not just those with SCT. The lack of sensitivity of renal ultrasound in this case and two others suggests that CT may be required for early diagnosis of RMC (Blitman AJR 2005 and Wesche Pediatr Pathol Lab Med 1998). While hydroxyurea is an effective medication with an excellent safety margin in sickle cell disease, the carcinogenic risk of long-term exposure in sick cell disease remains unknown. Disclosures: Off Label Use: Hydroxyurea for sickle cell disease modulation.

Introduction: Growth retardation (GR) and pubertal disturbances are the earliest consequences of iron toxicity resulting from the pituitary iron deposition in children and adolescents with thalassemia major (TM). It is suggested that adequate transfusion regimens together with appropriate management of iron chelation with timely initiation and dose tailoring by close monitoring using surrogate markers of the iron load may achieve a normal pattern of complication-free survival in TM. Objectives: The purpose of this study was to evaluate the fact that the current approach to the management of the disease has provided a normal growth progression and sexual development in patients (pts) with TM. Methods: We recruited male (M) and female (F) TM pts born after 2000 and followed-up (FU) in Ege University Thalassemia Center. The pts. with an acute or chronic illness that may interfere with growth and development or stem cell transplantation recipients were excluded. The Committee of Clinical Investigation at Ege University Hospital (19.02.2020, 20-2.1T/2) approved this study. Height (H) and weight (W) assessments were performed by using the Harpenden stadiometer and puberty was evaluated by Tanner staging at 3 monthly intervals. H-standard deviation scores (h-SDS) were calculated. Target-H based on mid-parental-H for M & F pts was estimated. All pts. were evaluated annually for bone mineral density (BMD) using dual-energy X-ray absorptiometry (Hologic QDR-4500W, USA) after 8 years (y) of age. The mean SDS of the lumbar spine (L1-4) BMD between -1 and -2.5 was defined as osteopenia and &lt;-2.5 as osteoporosis. Growth hormone (GH) secretion was evaluated by L-dopa and insulin tests in pts. with standing-H below the -2 SD. Pts whose GH response to both stimulation tests were less than 5 ng/ml with the monoclonal assay were considered as GH deficient. Transfused pRBC units (U) and average pre-transfusion hemoglobin (Hb) per year were recorded. Serum ferritin (SF) was monitored at monthly intervals. Myocardial (T2*) and liver (R2) iron were assessed by a 1.5 Tesla magnetic resonance imaging (MRI) machine (Siemens, Symphony Vision 16034 scanner) after 8 y. Annual median SF, prescribed chelator(s), mean chelator doses were recorded by reviewing pts' records. Transfusional iron intake (TII) was estimated as the total amount of pure RBCs (each U, 250 ml with 57% Hct) transfused in a y (ml) x 1.08. Daily TII was expressed as annual TII (mg)/ mean kg b.w./days of the y. Results: We recruited 30 TM (28 β/β, 1 β/δβ, and 1 non-deletional HbH) pts (13 F and 17 M). Demographics for the population are summarized in Table1. All pts maintained annual mean pre-transfusion Hb&gt; 9 g/dl. Twenty-two of 24 pts maintained Deferasirox (DFX) chelation during 9 ± 3.6 y (median 9, range 2-13 y) and achieved optimum SF levels at all times (Figure a). The dose tailoring of DFX found parallel to the changes in TII during FU (Figure b). Liver iron concentration (LIC) and myocardial T2* (mT2*) in 22 pts on DFX chelation were between 0.9-5.4 (2.1 ± 1.3 SD) mg Fe/g d.w. and 19.4-43.5 (28 ± 6.7 SD) ms, respectively, in all assessments. The only pt with mT2* of 19.4 ms revealed mT2* of &gt;20 ms on FU scans. The puberty initiated at 12.8 ± 1.1 y in M (n=12) & 11.2 ± 1.3 y in F (n=12) and progressed without hormone replacement in all, regardless of the chelator. Overall, growth reduced compared to the non-thalassemic population after 8 y with clear evidence of growth catch-up by the introduction of puberty. h-SDS detected &lt;-2 in 6 pts in whom one had a familial GR and 5 found GH deficient and received GH therapy. All pts but one developed h-SDS&lt; -2 at 10-12 y-old when they had S1/2 puberty. The pt no 4 who was entirely unresponsive to GH stimulation tests, developed GR at 1 y-old. He remained unresponsive to GH therapy (Table 2). The 14 (%58) and 5 (21%) of 24 pts demonstrated osteopenia and osteoporosis, respectively. Improvement in BMD-SDS was observed following pubertal spurt. Conclusions: Puberty was the main determinant of growth and bone maturation in TM. Despite, puberty has achieved within physiological limits in M & F pts, a slight delay was observed compared to the non-thalassemic population. The relative delay in pubertal spurt may lead to overdiagnosis of growth and bone-maturation failure and unnecessary intervention in adolescent TM pts. This hypothesis as well as the appropriateness of current management guidelines remains to be elucidated. Disclosures No relevant conflicts of interest to declare.

Abstract Study Objectives We compared the basic cognitive functions of adolescents undergoing split (nocturnal sleep + daytime nap) and continuous nocturnal sleep schedules when total sleep opportunity was either below or within the recommended range (i.e. 6.5 or 8 h). Methods Adolescent participants (age: 15–19 year) in the 8-h split (n = 24) and continuous (n = 29) sleep groups were compared with 6.5-h split and continuous sleep groups from a previous study (n = 58). These protocols involved two baseline nights (9-h time-in-bed [TIB]), 5 nights of sleep manipulation, 2 recovery nights (9-h TIB), followed by a second cycle of sleep manipulation (3 nights) and recovery (2 nights). Cognitive performance, subjective sleepiness, and mood were evaluated daily; sleep was assessed using polysomnography. Results Splitting 6.5 h of sleep with a mid-afternoon nap offered a boost to cognitive function compared to continuous nocturnal sleep. However, when total TIB across 24 h increased to 8 h, the split and continuous sleep groups performed comparably in tests evaluating vigilance, working memory, executive function, processing speed, subjective sleepiness, and mood. Conclusions In adolescents, the effects of split sleep on basic cognitive functions vary by the amount of total sleep obtained. As long as the total sleep opportunity across 24 h is within the recommended range, students may fulfill sleep requirements by adopting a split sleep schedule consisting of a shorter period of nocturnal sleep combined with a mid-afternoon nap, without significant impact on basic cognitive functions. Clinical trial registration NCT04044885.

Introduction Aortic valve-sparing root replacement (David's procedure) is an especially appealing treatment option for young patients. Here, we present the short-, mid, and long-term outcomes of this operation in adolescent patients. Methods Between September 1994 and March 2014, 29 patients aged 6 to 21 years underwent the David-I procedure at our center. We conducted a retrospective study with follow-up. Results The mean age was 16.8 ± 3.4 years and 90% (n = 26) were male. Marfan's syndrome was present in 86% (n = 25) of cases. Ninety-seven percent (n = 28) of cases were performed electively, and one case (3%) was performed emergently for acute aortic dissection type A. There were no early perioperative deaths (0%). Follow-up, which was completed on 100% of patients, comprised a total of 394 patient years and a mean follow-up time of 13.6 ± 5.4 years. The estimates for survival at 1, 5, and 10 years after initial surgery were 100, 97, and 93%, respectively. During follow-up, there were four (14%) late deaths and five (17%) aortic valve-related reoperations. The 1-, 5-, and 10-year estimates for freedom from valve-related reoperation were 100, 86, and 83%, respectively. The perioperative mortality for these five reoperations was 0%. Discussion Aortic valve–sparing root replacement can be performed in adolescents with a very low perioperative risk. Long-term survival seems to be affected by connective tissue diseases.

The objectives of this study were to quantify the matches and training workload in micro-cycles of an elite young soccer team considering field position and to explain meso-cycles based on change of weekly acute (wAWL), chronic load (wCWL), acute-to-chronic workload ratio, training monotony (wTM), and training strain (wTS) between early-, mid-, and end-season periods considering playing position and whole team. Twenty-six under-16 elite young soccer players participated in this study, including six wide defenders and wide midfielders (WM), five central defenders (CD) and central midfielders, and four strikers (ST). Daily monitoring was performed by players for 20 weeks with the rating of perceived exertion using the Borg CR-10 scale. In comparison with early-season, results showed that there was a significant increase, in all playing positions, in wAWL and wCWL (except ST) and in wTM (except CD and ST) compared with end-season. On the other hand, there were significant reductions in wTS in CD, WM, and ST at the end-season. According to the results, coaches should consider the field position in different situations. Differences between training workload and matches can be a good guide for coaches, who have a special understanding of what causes the most load in training programs. Excessive training workload can potentially cause injury to adolescent athletes and controlling wTM can prevent this.

Abstract OBJECTIVES Progressive root dilatation is an important complication in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) that may be caused by altered flow dynamics. Aortic wall shear stress (WSS) distribution at rest and under dobutamine stress (DS) conditions using 4D flow magnetic resonance imaging were investigated in relation to thoracic aorta geometry. METHODS 4D flow magnetic resonance imaging was performed in 16 adolescent TGA patients after ASO (rest and DS condition) and in 10 healthy controls (rest). The primary outcome measure was the WSS distribution along the aortic segments and the WSS change with DS in TGA patients. Based on the results, we secondary zoomed in on factors [aortic geometry and left ventricular (LV) function parameters] that might relate to these WSS distribution differences. Aortic diameters, arch angle, LV function parameters (stroke volume, LV ejection fraction, cardiac output) and peak systolic aortic WSS were obtained. RESULTS TGA patients had significantly larger neoaortic root and smaller mid-ascending aorta (AAo) dimensions and aortic arch angle. At rest, patients had significantly higher WSS in the entire thoracic aorta, except for the dilated root. High WSS levels beyond the proximal AAo were associated with the diameter decrease from the root to the mid-AAo (correlation coefficient r = 0.54–0.59, P = 0.022–0.031), not associated with the aortic arch angle. During DS, WSS increased in all aortic segments (P &lt; 0.001), most pronounced in the AAo segments. The increase in LV ejection fraction, stroke volume and cardiac output as a result of DS showed a moderate linear relationship with the WSS increase in the distal AAo (correlation coefficient r = 0.54–0.57, P = 0.002–0.038). CONCLUSIONS Increased aortic WSS was observed in TGA patients after ASO, related to the ASO-specific geometry, which increased with DS. Stress-enhanced elevated WSS may play a role in neoaortic root dilatation and anterior aortic wall thinning of the distal AAo.

Background: In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated. Hypothesis: In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction. Study Design: Case series. Level of Evidence: Level 4. Methods: Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up ≥2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected. Results: A total of 151 patients (mean age 14.8 ± 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury ( P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 ± 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope ≥12° and 4 of 45 (9%) patients with Tegner level ≥8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up. Conclusion: Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents. Clinical Relevance: Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients’ perceived outcomes are good with almost all patients returning to sport activity.

Background: Rates of anterior cruciate ligament (ACL) rupture in young people have increased by >70% over the past two decades. Adolescent and young adult females are at higher risk of ACL injury as compared with their prepubertal counterparts. Purpose: To determine ACL loading during a standardized drop-land-lateral jump in females at different stages of pubertal maturation. Study Design: Controlled laboratory study. Methods: On the basis of the Tanner classification system, 19 pre-, 19 early-/mid-, and 24 late-/postpubertal females performed a standardized drop-land-lateral jump while 3-dimensional body motion, ground-reaction forces, and surface electromyography data were acquired. These data were used to model external biomechanics, lower limb muscle forces, and knee contact forces, which were subsequently used in a validated computational model to estimate ACL loading. Statistical parametric mapping analysis of variance was used to compare ACL force and its causal contributors among the 3 pubertal maturation groups during stance phase of the task. Results: When compared with pre- and early-/midpubertal females, late-/postpubertal females had significantly higher ACL force with mean differences of 471 and 356 N during the first 30% and 48% to 85% of stance, and 343 and 274 N during the first 24% and 59% to 81% of stance, respectively, which overlapped peaks in ACL force. At the point of peak ACL force, contributions from sagittal and transverse plane loading mechanisms to ACL force were higher in late-/postpubertal compared with pre- and early-/midpubertal groups (medium effect sizes from 0.44 to 0.77). No differences were found between pre- and early-/midpubertal groups in ACL force or its contributors. Conclusion: The highest ACL forces were observed in late-/postpubertal females, consistent with recently reported rises of ACL injury rates in females aged 15 to 19 years. It is important to quantify ACL force and its contributors during dynamic tasks to advance our understanding of the loading mechanism and thereby provide guidance to injury prevention. Clinical Relevance: Growth of ACL volume plateaus around 10 years of age, before pubertal maturation, meaning that a late-/postpubertal female could have an ACL of similar size to their less mature counterparts. However, late-/postpubertal females have higher body mass requiring higher muscle forces to accelerate the body during dynamic tasks, which may increase ACL loading. Thus, if greater forces develop in these females, in part because of their increased body mass, these higher forces will be applied to an ACL that is not proportionally larger. This may partially explain the higher rates of ACL injury in late-/postpubertal females.

Abstract Study question Does the uterus sustain direct and long-term damage following radiotherapy, independent of ovarian damage? Summary answer Radiotherapy causes direct and long-term uterine damage. Ovariectomised and hormonally supplemented mice experience uterine artery endothelial dysfunction and pregnancy loss following transfer of healthy blastocysts. What is known already The detrimental off-target impacts of cancer therapies on the ovary are well established, with some fertility preservation techniques available to ensure patients maintain their fertility following gonadotoxic treatment. Low doses of radiotherapy kill the majority of primordial follicle oocytes in the ovary, reducing the ovarian reserve and fertile lifespan. Patients who have received radiotherapy experience higher rates of pregnancy complications including preterm birth, low birth weight, and stillbirth. However, no studies have investigated if radiation inflicts direct, fertility compromising damage to the uterus. Study design, size, duration Adolescent female mice were untreated or exposed to whole body y-irradiation (7Gy), then ovariectomised. Immediate damage was assessed up to 24 hours post-irradiation (n = 4/group). Four weeks following treatment, mice were hormone primed to induce endometrial receptivity (n = 7/group), artificial decidualisation (n = 7–8/group), or receive embryo transfers from healthy, unexposed donor mice to assess embryo implantation (n = 11–13/group), and mid-gestation development (n = 8–10/group). Participants/materials, setting, methods Four week old C57BL6/CBA (F1) female mice were used for this study. Immunofluorescence and in situ hybridisation were utilised to localise markers of immediate DNA damage and cell death following irradiation, and markers of receptivity in hormone primed uteri. Measurements of uterine artery blood flow were recorded using Doppler ultrasonography, and indices of pulsatility and resistance calculated. Uterine artery wire myography was performed to assess competency of endothelial and smooth muscle compartments following irradiation. Main results and the role of chance Within 24 hours of irradiation, DNA damage (yH2AX) and apoptosis (Puma/TUNEL) were elevated in uteri, compared to control. Irradiated mice that received embryo transfers from untreated donors had similar numbers of implantation sites 3-days post-transfer versus controls, however uteri were pale and atrophic suggesting impaired vascularisation. By 10-days post-transfer, implantation sites in irradiated mice were resorbing (p &lt; 0.001), although uterine artery Doppler ultrasound measurements demonstrated no change in pulsatility or resistance indices. When the brain was shielded from irradiation to protect the hypothalamic-pituitary-gonadal axis, resorption still occurred (p &lt; 0.001), suggesting direct uterine damage is the likely cause of pregnancy loss. To investigate uterine damage in the absence of an embryo, endometrial receptivity was induced artificially. Uteri from irradiated animals were lighter compared to control (p &lt; 0.05), however localisation of receptivity markers (E-cadherin, Mucin1, Ki67) was normal. When decidualisation was artificially induced irradiated uteri were also lighter (p &lt; 0.01) indicating impaired decidualisation and reduced capacity to adapt to pregnancy. Wire myography performed on uterine arteries demonstrated endothelial dysfunction in irradiated mice (p &lt; 0.0001). Limitations, reasons for caution Here, only a single age and dose of radiotherapy exposure are modelled. Patients of all ages can receive many doses of radiotherapy in combination with various chemotherapies. Our highly manipulable model enables any treatment variation to be modelled and the effect on the uterus and pregnancy examined. Wider implications of the findings: Reproductive aged cancer patients need to be appropriately counselled regarding the risks to their long-term fertility following treatment. Until now, potential permanent impacts to the uterus following cancer treatment have not been considered. It is clear radiotherapy can impose long-term damage to the uterus and influence pregnancy success and fertility. Trial registration number NA

Abstract Study question Is the cardiometabolic health of adolescents conceived through ART worse than that of their spontaneously-conceived counterparts? Summary answer The majority of cardiometabolic and vascular health parameters of ART-conceived adolescents are more favourable than those of their spontaneously-conceived counterparts of similar age. What is known already It has been proposed that ART induces epigenetic alterations during embryonic development which could lead to cardiometabolic disease later in life. However, individuals requiring ART may themselves be metabolically less healthy than the general population, which could lead to a genetically increased risk of cardiometabolic disorders in the offspring, rather than the ART procedure. The literature pertaining to cardiometabolic health of ART-conceived offspring is contradictory, but generally suggests unfavourable cardiometabolic health parameters. With over 8 million children and adults born through ART worldwide, it is imperative to investigate whether early signs of adverse cardiometabolic differences persist into adolescence and beyond. Study design, size, duration The Growing Up Healthy Study (GUHS) is a prospective study that recruited 303 ART-conceived adolescents, born 1991-2001 in Western Australia. Their health parameters, including cardiometabolic factors, were assessed and compared with spontaneously conceived counterparts of similar socioeconomic background and age from the Raine Study Generation 2 (Gen2). The 2868 Gen2 participants were born 1989-1992 and are representative of the Western Australian adolescent population. At age 16-17 (2013-2017), GUHS participants replicated assessments previously completed by Gen2. Participants/materials, setting, methods Cardiometabolic parameters were compared between 165 GUHS (male = 50.9%) and 1690 Gen2 (male = 49.8%) adolescents. Assessments consisted of a detailed questionnaire; health and demographic parameters, anthropometric assessments; height, weight, body-mass index (BMI), waist circumference and skinfold thickness, fasting serum biochemistry, arterial stiffness and blood pressure assessment using applanation tonometry, assessment of non-alcoholic fatty liver (NAFLD) and thickness of abdominal fat compartments using ultrasonography. Chi2, Fisher’s Exact and Mann-Whitney U tests, performed in SPSS V25, examined cohort differences. Main results and the role of chance GUHS adolescents appeared to be healthier from a cardiometabolic perspective than their Gen2 counterparts. They were leaner, with lower BMI (median: 21.23 vs. 22.06, P = 0.004), lower waist circumference (median: 74.10 vs. 76.75 cm, P = 0.031), and thinner skinfolds (triceps median: 12.1 vs. 14.0 mm, P = 0.019, subscapular median: 10.6 vs. 11.9 mm, P &lt; .001, mid-abdominal median: 16.0 vs. 19.9 mm, P &lt; 0.001, supraspinal median: 10.7 vs. 13.5 mm, P &lt; 0.001). No significant differences were detected in the following serum fasting parameters: glucose, insulin, HOMA-IR, LDL cholesterol, total cholesterol, cholesterol/HDL-ratio, triglycerides, CRP and ALT. HDL cholesterol levels were more favourable in GUHS (P &lt; 0.001). NAFLD was present in 10.9% of GUHS vs. 15.2% of Gen2 adolescents (P = 0.174), with no difference in steatosis severity score (P = 0.309). ART offspring had less subcutaneous adipose tissue (median: 8.0 vs. 14.0 mm, P &lt; .001), more visceral adipose tissue (median: 40.0 vs. 32.0 mm, P &lt; 0.001), with no difference in pre-peritoneal adipose tissue (P = 0.087). Measures of arterial stiffness were lower in GUHS. Pulse wave velocity: median 6.1 vs. 6.4 m/s, P &lt; 0.001 and heart rate corrected augmentation index: median -10.25 vs. -8.00, P = 0.006. No significant differences in blood pressure or heart rate were detected. Stratification by sex did not greatly alter the results. Limitations, reasons for caution Despite the substantial study size and the unique study design, we were unable to differentiate between different types of ART (e.g. IVF vs. ICSI), draw definite conclusions or relate outcomes to cause of infertility. Given the observational character of this study, causation cannot be proven. Wider implications of the findings In this study we did not detect any adverse effect of ART on cardiometabolic health at adolescence, in contrast to some studies. Given the lack of consensus, future well-designed and appropriately-powered studies are necessary to investigate cardiometabolic health in ART adults. Trial registration number not applicable

Introduction This paper offers a survey of familiar popular music performers and songwriters who reference coffee in their work. It examines three areas of discourse: the psychoactive effects of caffeine, coffee and courtship rituals, and the politics of coffee consumption. I claim that coffee carries a cultural and musicological significance comparable to that of the chemical stimulants and consumer goods more readily associated with popular music. Songs about coffee may not be as potent as those featuring drugs and alcohol (Primack; Schapiro), or as common as those referencing commodities like clothes and cars (Englis; McCracken), but they do feature across a wide range of genres, some of which enjoy archetypal associations with this beverage. m.o.m.m.y. Needs c.o.f.f.e.e.: The Psychoactive Effect of Coffee The act of performing and listening to popular music involves psychological elements comparable to the overwhelming sensory experience of drug taking: altered perceptions, repetitive grooves, improvisation, self-expression, and psychological empathy—such as that between musician and audience (Curry). Most popular music genres are, as a result, culturally and sociologically identified with the consumption of at least one mind-altering substance (Lyttle; Primack; Schapiro). While the analysis of lyrics referring to this theme has hitherto focused on illegal drugs and alcoholic beverages (Cooper), coffee and its psychoactive ingredient caffeine have been almost entirely overlooked (Summer). The most recent study of drugs in popular music, for example, defined substance use as “tobacco, alcohol, marijuana, cocaine and other stimulants, heroin and other opiates, hallucinogens, inhalants, prescription drugs, over-the-counter drugs, and nonspecific substances” (Primack 172), thereby ignoring a chemical stimulant consumed by 90 per cent of adult Americans every day (Lovett). The wide availability of coffee and the comparatively mild effect of caffeine means that its consumption rarely causes harm. One researcher has described it as a ubiquitous and unobtrusive “generalised public activity […] ‘invisible’ to analysts seeking distinctive social events” (Cooper 92). Coffee may provide only a relatively mild “buzz”—but it is now accepted that caffeine is an addictive substance (Juliano) and, due to its universal legality, coffee is also the world’s most extensively traded and enthusiastically consumed psychoactive consumer product (Juliano 1). The musical genre of jazz has a longstanding relationship with marijuana and narcotics (Curry; Singer; Tolson; Winick). Unsurprisingly, given its Round Midnight connotations, jazz standards also celebrate the restorative impact of coffee. Exemplary compositions include Burke/Webster’s insomniac torch song Black Coffee, which provided hits for Sarah Vaughan (1949), Ella Fitzgerald (1953), and Peggy Lee (1960); and Frank Sinatra’s recordings of Hilliard/Dick’s The Coffee Song (1946, 1960), which satirised the coffee surplus in Brazil at a time when this nation enjoyed a near monopoly on production. Sinatra joked that this ubiquitous drink was that country’s only means of liquid refreshment, in a refrain that has since become a headline writer’s phrasal template: “There’s an Awful Lot of Coffee in Vietnam,” “An Awful Lot of Coffee in the Bin,” and “There’s an Awful Lot of Taxes in Brazil.” Ethnographer Aaron Fox has shown how country music gives expression to the lived social experience of blue-collar and agrarian workers (Real 29). Coffee’s role in energising working class America (Cooper) is featured in such recordings as Dolly Parton’s Nine To Five (1980), which describes her morning routine using a memorable “kitchen/cup of ambition” rhyme, and Don't Forget the Coffee Billy Joe (1973) by Tom T. Hall which laments the hardship of unemployment, hunger, cold, and lack of healthcare. Country music’s “tired truck driver” is the most enduring blue-collar trope celebrating coffee’s analeptic powers. Versions include Truck Drivin' Man by Buck Owens (1964), host of the country TV show Hee Haw and pioneer of the Bakersfield sound, and Driving My Life Away from pop-country crossover star Eddie Rabbitt (1980). Both feature characteristically gendered stereotypes of male truck drivers pushing on through the night with the help of a truck stop waitress who has fuelled them with caffeine. Johnny Cash’s A Cup of Coffee (1966), recorded at the nadir of his addiction to pills and alcohol, has an incoherent improvised lyric on this subject; while Jerry Reed even prescribed amphetamines to keep drivers awake in Caffein [sic], Nicotine, Benzedrine (And Wish Me Luck) (1980). Doye O’Dell’s Diesel Smoke, Dangerous Curves (1952) is the archetypal “truck drivin’ country” song and the most exciting track of its type. It subsequently became a hit for the doyen of the subgenre, Red Simpson (1966). An exhausted driver, having spent the night with a woman whose name he cannot now recall, is fighting fatigue and wrestling his hot-rod low-loader around hairpin mountain curves in an attempt to rendezvous with a pretty truck stop waitress. The song’s palpable energy comes from its frenetic guitar picking and the danger implicit in trailing a heavy load downhill while falling asleep at the wheel. Tommy Faile’s Phantom 309, a hit for Red Sovine (1967) that was later covered by Tom Waits (Big Joe and the Phantom 309, 1975), elevates the “tired truck driver” narrative to gothic literary form. Reflecting country music’s moral code of citizenship and its culture of performative storytelling (Fox, Real 23), it tells of a drenched and exhausted young hitchhiker picked up by Big Joe—the driver of a handsome eighteen-wheeler. On arriving at a truck stop, Joe drops the traveller off, giving him money for a restorative coffee. The diner falls silent as the hitchhiker orders up his “cup of mud”. Big Joe, it transpires, is a phantom trucker. After running off the road to avoid a school bus, his distinctive ghost rig now only reappears to rescue stranded travellers. Punk rock, a genre closely associated with recreational amphetamines (McNeil 76, 87), also features a number of caffeine-as-stimulant songs. Californian punk band, Descendents, identified caffeine as their drug of choice in two 1996 releases, Coffee Mug and Kids on Coffee. These songs describe chugging the drink with much the same relish and energy that others might pull at the neck of a beer bottle, and vividly compare the effects of the drug to the intense rush of speed. The host of “New Music News” (a segment of MTV’s 120 Minutes) references this correlation in 1986 while introducing the band’s video—in which they literally bounce off the walls: “You know, while everybody is cracking down on crack, what about that most respectable of toxic substances or stimulants, the good old cup of coffee? That is the preferred high, actually, of California’s own Descendents—it is also the subject of their brand new video” (“New Music News”). Descendents’s Sessions EP (1997) featured an overflowing cup of coffee on the sleeve, while punk’s caffeine-as-amphetamine trope is also promulgated by Hellbender (Caffeinated 1996), Lagwagon (Mr. Coffee 1997), and Regatta 69 (Addicted to Coffee 2005). Coffee in the Morning and Kisses in the Night: Coffee and Courtship Coffee as romantic metaphor in song corroborates the findings of early researchers who examined courtship rituals in popular music. Donald Horton’s 1957 study found that hit songs codified the socially constructed self-image and limited life expectations of young people during the 1950s by depicting conservative, idealised, and traditional relationship scenarios. He summarised these as initial courtship, honeymoon period, uncertainty, and parting (570-4). Eleven years after this landmark analysis, James Carey replicated Horton’s method. His results revealed that pop lyrics had become more realistic and less bound by convention during the 1960s. They incorporated a wider variety of discourse including the temporariness of romantic commitment, the importance of individual autonomy in relationships, more liberal attitudes, and increasingly unconventional courtship behaviours (725). Socially conservative coffee songs include Coffee in the Morning and Kisses in the Night by The Boswell Sisters (1933) in which the protagonist swears fidelity to her partner on condition that this desire is expressed strictly in the appropriate social context of marriage. It encapsulates the restrictions Horton identified on courtship discourse in popular song prior to the arrival of rock and roll. The Henderson/DeSylva/Brown composition You're the Cream in My Coffee, recorded by Annette Hanshaw (1928) and by Nat King Cole (1946), also celebrates the social ideal of monogamous devotion. The persistence of such idealised traditional themes continued into the 1960s. American pop singer Don Cherry had a hit with Then You Can Tell Me Goodbye (1962) that used coffee as a metaphor for undying and everlasting love. Otis Redding’s version of Butler/Thomas/Walker’s Cigarettes and Coffee (1966)—arguably soul music’s exemplary romantic coffee song—carries a similar message as a couple proclaim their devotion in a late night conversation over coffee. Like much of the Stax catalogue, Cigarettes and Coffee, has a distinctly “down home” feel and timbre. The lovers are simply content with each other; they don’t need “cream” or “sugar.” Horton found 1950s blues and R&B lyrics much more sexually explicit than pop songs (567). Dawson (1994) subsequently characterised black popular music as a distinct public sphere, and Squires (2002) argued that it displayed elements of what she defined as “enclave” and “counterpublic” traits. Lawson (2010) has argued that marginalised and/or subversive blues artists offered a form of countercultural resistance against prevailing social norms. Indeed, several blues and R&B coffee songs disregard established courtship ideals and associate the product with non-normative and even transgressive relationship circumstances—including infidelity, divorce, and domestic violence. Lightnin’ Hopkins’s Coffee Blues (1950) references child neglect and spousal abuse, while the narrative of Muddy Waters’s scorching Iodine in my Coffee (1952) tells of an attempted poisoning by his Waters’s partner. In 40 Cups of Coffee (1953) Ella Mae Morse is waiting for her husband to return home, fuelling her anger and anxiety with caffeine. This song does eventually comply with traditional courtship ideals: when her lover eventually returns home at five in the morning, he is greeted with a relieved kiss. In Keep That Coffee Hot (1955), Scatman Crothers supplies a counterpoint to Morse’s late-night-abandonment narrative, asking his partner to keep his favourite drink warm during his adulterous absence. Brook Benton’s Another Cup of Coffee (1964) expresses acute feelings of regret and loneliness after a failed relationship. More obliquely, in Coffee Blues (1966) Mississippi John Hurt sings affectionately about his favourite brand, a “lovin’ spoonful” of Maxwell House. In this, he bequeathed the moniker of folk-rock band The Lovin’ Spoonful, whose hits included Do You Believe in Magic (1965) and Summer in the City (1966). However, an alternative reading of Hurt’s lyric suggests that this particular phrase is a metaphorical device proclaiming the author’s sexual potency. Hurt’s “lovin’ spoonful” may actually be a portion of his seminal emission. In the 1950s, Horton identified country as particularly “doleful” (570), and coffee provides a common metaphor for failed romance in a genre dominated by “metanarratives of loss and desire” (Fox, Jukebox 54). Claude Gray’s I'll Have Another Cup of Coffee (Then I’ll Go) (1961) tells of a protagonist delivering child support payments according to his divorce lawyer’s instructions. The couple share late night coffee as their children sleep through the conversation. This song was subsequently recorded by seventeen-year-old Bob Marley (One Cup of Coffee, 1962) under the pseudonym Bobby Martell, a decade prior to his breakthrough as an international reggae star. Marley’s youngest son Damian has also performed the track while, interestingly in the context of this discussion, his older sibling Rohan co-founded Marley Coffee, an organic farm in the Jamaican Blue Mountains. Following Carey’s demonstration of mainstream pop’s increasingly realistic depiction of courtship behaviours during the 1960s, songwriters continued to draw on coffee as a metaphor for failed romance. In Carly Simon’s You’re So Vain (1972), she dreams of clouds in her coffee while contemplating an ostentatious ex-lover. Squeeze’s Black Coffee In Bed (1982) uses a coffee stain metaphor to describe the end of what appears to be yet another dead-end relationship for the protagonist. Sarah Harmer’s Coffee Stain (1998) expands on this device by reworking the familiar “lipstick on your collar” trope, while Sexsmith & Kerr’s duet Raindrops in my Coffee (2005) superimposes teardrops in coffee and raindrops on the pavement with compelling effect. Kate Bush’s Coffee Homeground (1978) provides the most extreme narrative of relationship breakdown: the true story of Cora Henrietta Crippin’s poisoning. Researchers who replicated Horton’s and Carey’s methodology in the late 1970s (Bridges; Denisoff) were surprised to find their results dominated by traditional courtship ideals. The new liberal values unearthed by Carey in the late 1960s simply failed to materialise in subsequent decades. In this context, it is interesting to observe how romantic coffee songs in contemporary soul and jazz continue to disavow the post-1960s trend towards realistic social narratives, adopting instead a conspicuously consumerist outlook accompanied by smooth musical timbres. This phenomenon possibly betrays the influence of contemporary coffee advertising. From the 1980s, television commercials have sought to establish coffee as a desirable high end product, enjoyed by bohemian lovers in a conspicuously up-market environment (Werder). All Saints’s Black Coffee (2000) and Lebrado’s Coffee (2006) identify strongly with the culture industry’s image of coffee as a luxurious beverage whose consumption signifies prominent social status. All Saints’s promotional video is set in a opulent location (although its visuals emphasise the lyric’s romantic disharmony), while Natalie Cole’s Coffee Time (2008) might have been itself written as a commercial. Busting Up a Starbucks: The Politics of Coffee Politics and coffee meet most palpably at the coffee shop. This conjunction has a well-documented history beginning with the establishment of coffee houses in Europe and the birth of the public sphere (Habermas; Love; Pincus). The first popular songs to reference coffee shops include Jaybird Coleman’s Coffee Grinder Blues (1930), which boasts of skills that precede the contemporary notion of a barista by four decades; and Let's Have Another Cup of Coffee (1932) from Irving Berlin’s depression-era musical Face The Music, where the protagonists decide to stay in a restaurant drinking coffee and eating pie until the economy improves. Coffee in a Cardboard Cup (1971) from the Broadway musical 70 Girls 70 is an unambiguous condemnation of consumerism, however, it was written, recorded and produced a generation before Starbucks’ aggressive expansion and rapid dominance of the coffee house market during the 1990s. The growth of this company caused significant criticism and protest against what seemed to be a ruthless homogenising force that sought to overwhelm local competition (Holt; Thomson). In response, Starbucks has sought to be defined as a more responsive and interactive brand that encourages “glocalisation” (de Larios; Thompson). Koller, however, has characterised glocalisation as the manipulative fabrication of an “imagined community”—whose heterogeneity is in fact maintained by the aesthetics and purchasing choices of consumers who make distinctive and conscious anti-brand statements (114). Neat Capitalism is a more useful concept here, one that intercedes between corporate ideology and postmodern cultural logic, where such notions as community relations and customer satisfaction are deliberately and perhaps somewhat cynically conflated with the goal of profit maximisation (Rojek). As the world’s largest chain of coffee houses with over 19,400 stores in March 2012 (Loxcel), Starbucks is an exemplar of this phenomenon. Their apparent commitment to environmental stewardship, community relations, and ethical sourcing is outlined in the company’s annual “Global Responsibility Report” (Vimac). It is also demonstrated in their engagement with charitable and environmental non-governmental organisations such as Fairtrade and Co-operative for Assistance and Relief Everywhere (CARE). By emphasising this, Starbucks are able to interpellate (that is, “call forth”, “summon”, or “hail” in Althusserian terms) those consumers who value environmental protection, social justice and ethical business practices (Rojek 117). Bob Dylan and Sheryl Crow provide interesting case studies of the persuasive cultural influence evoked by Neat Capitalism. Dylan’s 1962 song Talkin’ New York satirised his formative experiences as an impoverished performer in Greenwich Village’s coffee houses. In 1995, however, his decision to distribute the Bob Dylan: Live At The Gaslight 1962 CD exclusively via Starbucks generated significant media controversy. Prominent commentators expressed their disapproval (Wilson Harris) and HMV Canada withdrew Dylan’s product from their shelves (Lynskey). Despite this, the success of this and other projects resulted in the launch of Starbucks’s in-house record company, Hear Music, which released entirely new recordings from major artists such as Ray Charles, Paul McCartney, Joni Mitchell, Carly Simon and Elvis Costello—although the company has recently announced a restructuring of their involvement in this venture (O’Neil). Sheryl Crow disparaged her former life as a waitress in Coffee Shop (1995), a song recorded for her second album. “Yes, I was a waitress. I was a waitress not so long ago; then I won a Grammy” she affirmed in a YouTube clip of a live performance from the same year. More recently, however, Crow has become an avowed self-proclaimed “Starbucks groupie” (Tickle), releasing an Artist’s Choice (2003) compilation album exclusively via Hear Music and performing at the company’s 2010 Annual Shareholders’s Meeting. Songs voicing more unequivocal dissatisfaction with Starbucks’s particular variant of Neat Capitalism include Busting Up a Starbucks (Mike Doughty, 2005), and Starbucks Takes All My Money (KJ-52, 2008). The most successful of these is undoubtedly Ron Sexsmith’s Jazz at the Bookstore (2006). Sexsmith bemoans the irony of intense original blues artists such as Leadbelly being drowned out by the cacophony of coffee grinding machines while customers queue up to purchase expensive coffees whose names they can’t pronounce. In this, he juxtaposes the progressive patina of corporate culture against the circumstances of African-American labour conditions in the deep South, the shocking incongruity of which eventually cause the old bluesman to turn in his grave. Fredric Jameson may have good reason to lament the depthless a-historical pastiche of postmodern popular culture, but this is no “nostalgia film”: Sexsmith articulates an artfully framed set of subtle, sensitive, and carefully contextualised observations. Songs about coffee also intersect with politics via lyrics that play on the mid-brown colour of the beverage, by employing it as a metaphor for the sociological meta-narratives of acculturation and assimilation. First popularised in Israel Zangwill’s 1905 stage play, The Melting Pot, this term is more commonly associated with Americanisation rather than miscegenation in the United States—a nuanced distinction that British band Blue Mink failed to grasp with their memorable invocation of “coffee-coloured people” in Melting Pot (1969). Re-titled in the US as People Are Together (Mickey Murray, 1970) the song was considered too extreme for mainstream radio airplay (Thompson). Ike and Tina Turner’s Black Coffee (1972) provided a more accomplished articulation of coffee as a signifier of racial identity; first by associating it with the history of slavery and the post-Civil Rights discourse of African-American autonomy, then by celebrating its role as an energising force for African-American workers seeking economic self-determination. Anyone familiar with the re-casting of black popular music in an industry dominated by Caucasian interests and aesthetics (Cashmore; Garofalo) will be unsurprised to find British super-group Humble Pie’s (1973) version of this song more recognisable. Conclusion Coffee-flavoured popular songs celebrate the stimulant effects of caffeine, provide metaphors for courtship rituals, and offer critiques of Neat Capitalism. Harold Love and Guthrie Ramsey have each argued (from different perspectives) that the cultural micro-narratives of small social groups allow us to identify important “ethnographic truths” (Ramsey 22). Aesthetically satisfying and intellectually stimulating coffee songs are found where these micro-narratives intersect with the ethnographic truths of coffee culture. 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Introduction Discourses of queer youth suicide regularly represent non-heterosexual young men as vulnerable and as victims who are inherently without strategies for coping with adversity (qv. Rasmussen; Marshall; Driver 3). Alternatively, queer youth are sometimes marked as fundamentally resilient, as avid users of tools of resilience and community such as the internet (Smith & Gray 74; Wexler et al. 566; Hillier & Harrison; Bryson & McIntosh). In the latter approach, protective factors are typically presented as specific to queer youth (e.g., Russell 10), therefore also minoritising and essentialising resilience. Both approaches ignore the diversity of queer young lives and the capacity for a subject to be both vulnerable and resilient—concepts which need to be unpacked if we are to further our understanding of minority lives. Significantly, both approaches also ignore the fact that growing up occurs in a series of transitions, cultural encounters and circumstantial changes. Queer (LGBT) youth are neither all victims and vulnerable, nor are they all self-reliant and resilient. Recent research has indicated that non-heterosexual youth continue to have a higher rate of suicide and self-harm (Cover, Queer Youth Suicide), although this is by no means indicative that vast numbers of LGBTI require support, intervention or preventative measures throughout all aspects of the transition into adult life. This article has two objectives, both of which are best addressed together in order to come at an understanding as how best to frame approaches to queer youth suicide as an ongoing social concern. Firstly, to ask what human, psychological and subjective ‘resilience’ might be said to mean in the context of public discourses of queer youth suicidality, and secondly to ask what a concept of ‘resilience’ does for queer youth identity in terms of relationality. Neither objective, of course, can be met alone in a short article—the purpose here is to open thinking on the topic in ways that question normative assumptions about the conditions of queer youth in the context of liveable lives and the positioning of resilience as reliant on normative accounts of identity. The article begins with a brief overview of the different uses of resilience in the context of broad social representations of queer youth. It goes on to discuss the It Gets Better video site which aimed to produce resilience among predominantly bullied queer youth by ‘imparting hope’. Some remarks on the relationship between identity, sexuality, sociality and resilience will conclude. Resilience and the Queer Youth Subject Developed by Crawford Holling in the 1970s, the concept of resilience was used to describe the capacity of a system to “absorb change and disturbance and still maintain the same relationships between populations or state variables” (Holling 14). In terms of ecology and the physical sciences, the notion of resilience operates within an assumption that future events will not be known but will be unexpected, thereby requiring a capacity to accommodate those events whatever form they take (21). When later used in the psychological sciences, the term resilience likewise assumes disruption and uncertainty in lived experience, requiring a resilient subject to be capable in both learning and adaptation. In the context of queer youth, resilience, then, can be applied to mean an adaptation to new situations which exacerbate vulnerability to suicidality for those who are positioned to seek escape from intolerable emotional pain or the perception of life as unliveable (Cover, Queer Youth Suicide 10, 148). Resilience in this use presumes that, for example, bullying has a detrimental causal relationship with suicidality when it newly occurs if the subject does not have the capacity to adapt and incorporate it into everyday life. Bullying, however, is generally related to suicide only by virtue of its ongoingness rather than it being a sudden shift in social relations. Striking about much of the discourse of resilience in the psychological sciences is that the concept of resilience presumes a unitary subject who is a subject prior to relationality and sociality (e.g. Leipold & Greve; Singh et al.; Smith & Gray). Resilience is thus seen as a capacity to cope with adversity as if adversity arises prior to the subject rather than being a form of relationality that conditions the subject. In that context, the queer youth subject is understood in essentialist terms, whereby sexual subjectivity is represented simultaneously as both a norm and abnormal, and is a factor of subjectivity that is understood to pre-exist sociality. That is, the queer youth subject is queer before relationality with others, thereby before the kinds of relationalities that might demand resilience. An alternative is to understand queer youth not as vulnerable because they are queer, but as subjects constituted in the (inequitably distributed) precarity of corporeal life in sociality, and thereby already formed in (inequitably distributed) resilience to the sorts of shifts, changes and adversities that shift one from an experience of vulnerability to an experience of a life that is unliveable (Butler, Precarious Life; Frames of War). Approaching queer youth suicide from a perspective not of risk but through the simultaneous fostering and critique of resilience opens the possibility of providing solutions that aid younger persons to resist suicidality as a flight from intolerable pain without articulating the self as inviolable and thereby losing the ethical value of the recognition of vulnerability. The question, then, is whether such critique can be found in sites of resilience discourse in relation to queer youth. Queer Youth and It Gets Better The video blogging site It Gets Better (http://www.itgetsbetter.org) was begun by columnist Dan Savage in response to a spate of reported queer student suicides in September/October 2010 in the United States. The site hosts more than a thousand video contributions, many from queer adults who seek to provide hope for younger persons by showing that queer adulthood is markedly different from the experiences of harassment, bullying, loneliness or surveillance experienced by queer youth in school and family environments. This is among the first widely-available communicative media form to address directly queer youth on issues related to suicide, and the first to draw on lived experiences as a means by which to provide resources for queer youth resilience. The fact that these experiences are related through video-logs (vlogs) provides the texts with a greater sense of authenticity and a framework which often addresses youth directly on the topic of suicidality (Cover, Queer Youth Suicide). Savage’s intention was to produce resilience in queer youth by imparting ‘hope for young people facing harassment’ and to create ‘a personal way for supporters everywhere to tell LGBT youth that … it does indeed get better’ (http://www.itgetsbetter.org/pages/about-it-gets-better-project/). Hope, in this context, is represented as the core attribute of queer youth resilience. The tag-line of the site is: Many LGBT youth can’t picture what their lives might be like as openly gay adults. They can’t imagine a future for themselves. So let’s show them what our lives are like, let’s show them what the future may hold in store for them (http://www.itgetsbetter.org/). Hope for the future is frequently presented as hope for an end to school days. In the primary video of the site, Dan Savage’s partner Terry describes his school experiences: My school was pretty miserable … I was picked on mercilessly in school. People were really cruel to me. I was bullied a lot. Beat up, thrown against walls and lockers and windows; stuffed into bathroom stalls. . . . Honestly, things got better the day I left highschool. I didn’t see the bullies every day, I didn’t see the people who harassed me every day, I didn’t have to see the school administrators who would do nothing about it every day. Life instantly got better (http://www.itgetsbetter.org/pages/about-it-gets-better-project/) Such comments present a picture of school life in which the institutional norms of secondary schools that depend so heavily on surveillance, discriminative norms, economies of secrecy and disclosure permit bullying and ostracisation to flourish and become, then, the site of hopelessness in what to many appears at the time as a period of never-ending permanency. Indeed, teen-aged life has often been figured in geographic terms as a kind of hopeless banishment from the realities that are yet to come: Eve Sedgwick referred to that period as ‘that long Babylonian exile known as queer childhood’ (4). The emphatic focus on the institutional environment of highschool rather than family, rural towns, closetedness, religious discourse or feelings of isolation is remarkably important in changing the contemporary way in which the social situation of queer youth suicide has been depicted. The discourse of the It Gets Better project and contributions makes ‘school’ its object—a site that demands resilience of its queer students as the remedy to the detrimental effects of bullying. Here, however, resilience is not depicted as adaptability but the strength to tolerate and, effectively, ‘wait out’, a bullying environment. The focus on bullying that frames the dialogue on queer youth suicide and youth resilience in the It Gets Better videos is the product of a mid-2000s shift in focus to the effects of bullying on LGBT youth in place of critiques of heterosexism, sexual identity, coming out and physical violence (Fodero), regularly depicting bullying as directly causal of suicide (Kim & Leventhal 151; Espelage & Swearer 157; Hegna & Wichstrøm 35). Bullying, in these representations, is articulated as that which is, on the one hand, preventable through punitive institutional policies and, on the other, as an ineradicable fact of living through school years. It is, in the latter depiction, that experience for which younger LGBT persons must manage their own resistance. In depicting school as the site of anti-queer bullying, the It Gets Better project represents queer youth as losing hope of escape from the intolerable pain of bullying in its persistence and repetition. However, the site’s purpose is to show that escape from the school environment to what is regularly depicted as a neoliberal, white and affluent representation of queer adulthood, founded on conservative coupledom (Cover, “Object(ives) of Desire”), careers, urban living, and relative wealth—depictions somewhat different from the reality of diverse queer lives. The shift from the school-bullying in queer youth to the liberal stability of queer adulthood is figured in the It Gets Better discourse as not only possible but as that which should be anticipated. It is in that anticipation that resilience is articulated in a way which calls upon queer youth to manage their own resiliency by having or performing hopefulness. Representing hope as the performative element in queer youth resilience has precedence as a suicide prevention strategy. Hopelessness is a key factor in much of the contemporary academic discussion of suicide risk in general and is often used as a predictor for recognising suicidal behaviour (Battin 13), although it is also particularly associated with suicidality and queer teenagers. Hopelessness is usually understood as despair or desperateness, the lack of expectation of a situation or goal one desires or feels one should desire. For Holden and colleagues, hopelessness is counter to social desirability, which is understood as the capacity to describe oneself in terms by which society judges a person as legitimate or desirable (Holden, Mendonca & Serin 500). Psychological and psychiatric measurement techniques frequently rely on Aaron T. Beck’s Hopelessness Scale, which utilises a twenty-question true/false survey designed to measure feelings about the future, expectation and self-motivation in adults over the age of seventeen years as a predictor of suicidal behaviour. Beck and colleagues attempted to provide an objective measurement for hopelessness rather than leave it treated as a diffuse and vague state of feeling in patients with depression. The tool asks a series of questions, most about the future, presenting a score on whether or not the answers given were true or false. Questions include: ‘I might as well give up because I can’t make things better for myself’; ‘I can’t imagine what my life would be like in ten years’; ‘My future seems dark to me’; and ‘All I can see ahead of me is unpleasantness rather than pleasantness’. Responding true to these indicates hopelessness. Responding false to some of the following also indicates hopelessness: ‘I can look forward to more good times than bad times’; and ‘When things are going badly, I am helped by knowing they can’t stay that way forever’ (Beck). While these questions and the scale are not used uncritically, the relationship between the discursive construction through the questions of what constitutes hopelessness and the aims of the It Gets Better videos are notably comparable. The objective, then, of the videos is to provide evidence and, perhaps, instil hope that would allow such questions to be answered differently, particularly to be able to give a true response to the last question above. Hallway Allies liaison support group, which operates across university campuses and high schools to prevent bullying, stated in this representative way in the introduction to their video contribution: ‘Remember to keep your head up, highschool doesn’t last forever’ (http://www.itgetsbetter.org/video /entry/5wwozgwyruy/). Or, as Rebecca in the introductory statement of another video contribution put it: You may be feeling like this pain will last forever, like you have no control, it’s dark, oppressive and feels like there is no end. I know – I get it. but I promise … hang in there and you’ll find it … Wait – you’ll see – it gets better! (http://www.itgetsbetter.org/video/entry/wxymqzw3oqy/). As can be seen, such video examples respond to a discourse of hopelessness aligned with the framework exemplified by Beck’s scale, prompting queer youth audiences of these videos to imagine a future for themselves, to understand hope in temporal terms of future wellbeing, and to know that the future does not necessarily hold the same kinds of unpleasantness as experienced in the everyday high school environment. Sexual Identity, Resilience and the Normative Lifecycle In the It Gets Better framework, resilience is produced in the knowledge of a queer life that is linear and patterned through stages in relation to institutional forms of belonging (and non-belonging). That is, a queer life is represented as one which undergoes the hardship of being bullied in school, of leaving that institutional environment for a queer adulthood that is built on a myth of safety, pleasure, success and a distinctive break from the environment of the past (as if the psyche or the self is re-produced anew in a phase of a queer lifecycle). Working within a queer theoretical and cultural understanding of identity, sexual subjectivity can be understood as constituted in social and cultural formations. Overturning the previously-held liberal notion of power as the power which represses sex and sexualities, Foucault’s History of Sexuality provided queer theory with an argument in which power, as deployed through discourse and discursive formations, produces the coherent sexual subject. This occurs historically and only in specific periods. In Foucault’s analysis, homosexual identities become conceivable in the Nineteenth Century as a result of specific juridical, medical and criminal discourses (85). From a Foucauldian perspective, there is no subject driven by an inner psyche or a pre-determined desire (as in psychoanalysis). Instead, such subjectivity occurs in and through the power/knowledge network of discourse as it writes or scripts the subject into subjectivity. Canonical queer theorist Judith Butler has been central in extending Foucault’s analysis in ways which are pragmatic for understanding queer youth in the context of growing up and transitioning into adulthood. Her theory of performativity has usefully complexified the ways in which we can understand sexual identity and allowed us to overcome the core assumption in much queer youth research that heterosexual and homosexual identities are natural, mutually-exclusive and innate; instead, allowing us to focus on how the process of subject formation for youth is implicated in the tensions and pressures of a range of cultural, social, organisational and communicative encounters and engagements. Butler projects the most useful post-structuralist discussion of subjectivity by suggesting that the subject is constituted by repetitive performances in terms of the structure of signification that produces retroactively the illusion of an inner subjective core (Butler, Gender Trouble 143). Queer identity becomes a normative ideal rather than a descriptive feature of experience, and is the resultant effect of regimentary discursive practices (16, 18). The non-heterosexual subject, then, is performatively constituted by the very ‘expressions’ that are formed as recognisable identity performances in the context, here, of a set of lifecycle expectations built through a vulnerable queer childhood, being bullied, attaining hope, leaving school and fruition in queer adulthood. Resilience, in the It Gets Better discourse, then, is seen to be produced in understanding the stages of a normative queer life. An issue emerges for how queer youth suicide is understood within this particular formation that posits non-heterosexuality as the problematic source of suicidality emerges in the assumption that the vulnerability to suicidal behaviours for queer youth is the result singularly of sexuality, rather than looking to the fact that sexuality is one facet of identity – an important and sometimes fraught one for adolescents in general – located within a complex of other formations of identity and selfhood. This is part of what Diana Fuss has identified as the “synecdochical tendency to see only one part of a subject’s identity (usually the most visible part) and to make that part stand for the whole” (116). This ignores the opportunity to think through the conditions of queer youth in terms of the interaction between different facets of identity (such as gender and ethnicity, but also personal experience), different contexts in which identity is performed and different institutional settings that vary in response and valuation of non-normative aspects of subjectivity, thereby allowing a vulnerability not to be an attribute of being a queer youth, but to be understood as produced across a nuanced and complex array of factors. While the very concept of resilience invokes both an individualisation of the subject and a disciplinary regime of pastoral care (Foucault, Abnormal), queer youth in the It Gets Better discourse of hope are depicted multiply as: Inherently vulnerable and lacking resilience as a result of an essentialist notion of sexual orientation.Constituted in a relationality within a schooling environment that is conditioned by bullying as the primary expression of diverse socialityFinding resilience only through a self-managed and self-articulated expression of ‘hope’ that is to be produced in the knowledge that there is an ‘escape’ from a school environment. What the discourse of that which we might refer to as “resilient hopefulness” does is represent queer youth reductively as inherently non-resilient. It ignores the multiple expressions of sexual identity, the capacity to respond to suicidality through a critique of normative sexual subjectivity, and the capabilities of queer youth to develop meaningful relationships across all sexual possibilities that are, themselves, forms of resilience or at least mitigations of vulnerability. At the same time, “resilient hopefulness” is produced within a context in which a normative sociality of bullying culture is expressed as timeless and unchangeable (rather than historical and institutional), thereby requiring queer younger persons to undertake the task of managing vulnerability, risk, resilience and identity as an individualised responsibility outside of communities of care. 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