Violence exposure, psychological trauma, and suicide risk in a community sample of dangerously violent adolescents.

OBJECTIVE: To examine violence exposure, violent behaviors, psychological trauma, and suicide risk in a community sample of dangerously violent adolescents by comparison with a matched community sample of nonviolent adolescents. METHOD: Anonymous self-report questionnaires were administered in the 1992-1993 school year to students in grades 9 through 12, in six public high schools located in Ohio and Colorado (N = 3,735). From this sample, 484 adolescents (349 males, 135 females) who reported attacking someone with a knife or shooting at someone within the past year (i.e., dangerously violent adolescents) were drawn. Four hundred eighty-four controls were also selected and matched on gender, age in years, ethnicity, area of residence, and family structure. RESULTS: Dangerously violent adolescents reported higher levels of exposure to violence and victimization than did matched controls. Dangerously violent females were more likely to score in the clinical range of depression, anxiety, posttraumatic stress, anger, and dissociation than were control females and violent males; they also had significantly higher levels of suicide potential. CONCLUSIONS: Students who have been known to commit violent acts should be adequately assessed for violence exposure and symptoms of psychological trauma, with special attention given to the suicide potential of violent females.

Microvascular transplantation of the rat submandibular gland.

Xerostomia results from salivary gland irradiation during treatment of head and neck malignancies. In addition to having difficulty with speech and swallowing, these patients experience loss of taste, dental caries, and chronic fungal infections. The paired submandibular glands provide 70 percent of the normal salivary flow and are difficult to shield during radiation therapy. Another sicca condition, xerophthalmia, may result from facial nerve injury or other medical disorders and results in pain, corneal ulceration, and possible vision loss. Treatment options for xerostomia are limited, and management of xerophthalmia usually focuses on the eyelids, rather than the fundamental problem of inadequate secretory protection. In this study, a rat model for submandibular gland microvascular transplantation was developed to assess the feasibility of salivary tissue transfer. Sixteen rats underwent submandibular gland transplantation from the neck to the groin. Fourteen of these rats underwent microvascular anastomosis of the vascular pedicle. Ten glands were assessed for viability at 4 days after transplantation, and four glands were examined after 7, 10, 14, or 21 days. By gross and histologic examination, 93 percent of transplanted glands showed expected long-term viability after at least 4 postoperative days. Microvascular techniques were shown to be applicable to the transplantation of submandibular gland salivary tissue. This has not previously been shown in a rat model. It is possible that submandibular glands could be transplanted to the eye for treatment of xerophthalmia and out of the neck during irradiation of the head and neck, with subsequent replantation after treatment as a means of preventing permanent xerostomia.

The relationship between children's threats of violence and violent behaviors.

BACKGROUND: We sought to examine the relationship between students' threats of interpersonal violence and self-reported violent behaviors. METHODS: Anonymous self-report questionnaires were administered to students in grades 3 through 12 in schools located in Colorado, Arizona, and Ohio. A survey of 9487 students from 33 public schools was performed. Ages ranged from 7 to 19 years. Across the 3 samples, the percentage of African Americans ranged from 6% to 35%, whites from 31% to 57%, and Hispanics from 5% to 51%. RESULTS: Multivariate logistic regression analyses revealed that threatening others infrequently or frequently (compared with not threatening others) was significantly associated with violent behaviors. Students who infrequently threatened were about 3 to 4 times more likely to report exhibiting each of the violent behaviors than students who did not threaten others (odds ratio [OR] = 4.08-5.86). The relationship between frequently threatening others and violent behaviors was especially strong (OR = 7.19-24.30) and highest for the most severe forms of violence, knife attacks (OR = 15.39-24.30) and shootings (OR = 18.42). CONCLUSIONS: Findings suggest that students' threats of harm toward others should be taken seriously, and that policies and procedures should be developed to ensure that children who threaten others receive proper assessment and management. Arch Pediatr Adolesc Med. 2000;154:785-790

Prevention of pharyngoesophageal spasm after laryngectomy with a half-muscle closure technique.

Because pharyngoesophageal spasm can limit successful voice restoration after total laryngectomy, 24 patients underwent a modified pharyngeal closure in an effort to avoid this problem. All patients underwent total laryngectomy with appropriate neck dissections and pharyngeal closure with a half-muscle closure technique in which only one side of the remnant constrictor muscles was used to reinforce the primary closure. Twenty-three patients underwent voice restoration. Twenty-two (96%) had a functional voice, and 1 patient (4%) had pharyngoesophageal spasm that required a secondary myotomy. One fistula (4%) occurred and resolved with conservative measures. Quantitative voice analysis demonstrated no significant differences between half-closure patients and control patients for fundamental frequency (96 Hz versus 101 Hz) or intensity (57 dB versus 64 dB). Extensive qualitative analysis by trained and naive listeners revealed no differences. This preliminary report indicates the half-muscle closure modification of the pharyngeal closure at primary laryngectomy may provide a simple and effective means of avoiding pharyngoesophageal spasm and maintaining an effective voice without increased complications.

Contributors to violent behavior among elementary and middle school children.

OBJECTIVE: To examine the relative contributions of exposure to violence, parental monitoring, and television-viewing habits to children's self-reported violent behaviors. The study hypothesized that: 1) children's exposure to violence would be associated positively with self-reported violent behaviors; 2) parental monitoring would be associated negatively with children's violent behaviors; and 3) the number of daily television-viewing hours and a preference for watching violent television shows would be associated positively with children's violent behaviors. METHODS: The study used a survey design with an anonymous self-report questionnaire administered to students (grades 3-8) in 11 public schools. A total of 2245 students participated in the study, representing 80% of the students attending the participating schools during the survey. The subjects were from 7 to 15 years of age; 51% were male, 57% were white, 33% percent were black, and 5% were Hispanic. RESULTS: Hierarchical multiple regression analysis of the total sample revealed that the combination of demographic variables, parental monitoring, television-viewing habits, and exposure to violence explained 45% of students' self-reported violent behaviors. Violence exposure and parental monitoring were the most influential contributors in explaining children's violent behaviors, accounting for 24% and 5% of the variance in violent behaviors, respectively. CONCLUSIONS: All three hypotheses were supported. A significant association was demonstrated linking violence exposure, lack of parental monitoring, and television-viewing habits with children's self-reported violent behaviors within a diverse sample of elementary and middle school students. Our findings support the importance of parental monitoring of children and emphasize the need to identify and to provide services to youth who are exposed to violence.

Transmucosal fine-needle aspiration diagnosis of intraoral and intrapharyngeal lesions.

OBJECTIVES: The effectiveness of fine-needle aspiration biopsy (FNAB) for the diagnosis of neck, thyroid, and salivary gland masses is well documented. Very few reports explore the potential of an intraoral FNAB approach for the diagnosis of submucosal lesions. We describe our technique and present case examples of pertinent differential diagnostic entities. We recommend an expanded role for FNAB of the oral cavity and oropharynx. STUDY DESIGN: Retrospective review. METHODS: A uniform technique was employed for transmucosal FNAB of 76 patients with intraoral masses. In applicable cases, cytology results were compared with traditional biopsy methods and permanent histopathologic specimens for accuracy. RESULTS: Our experience demonstrates the high sensitivity (93%) and specificity (86%) of intraoral FNAB when compared with biopsy by conventional means. FNAB provides distinct advantages for the cytologic diagnosis of submucosal lesions, which may be difficult to reach and adequately sample through conventional biopsy. FNAB of the tonsil and tonsillar fossa provides a safe and effective means of diagnosing both lymphoma and squamous cell cancer. Transmucosal FNAB via the mouth led to rapid diagnosis of a number of benign and malignant lesions. Applying this uniform FNAB technique, we had no significant complications. CONCLUSION: We recommend transmucosal FNAB as an effective means for highly accurate diagnosis of submucosal lesions of the oral cavity and oropharynx. CLINICAL RELEVANCE: Traditional biopsy techniques in the oral cavity may require anesthesia and may have diagnostic difficulties, particularly for submucosal lesions. Transmucosal FNAB overcomes these shortcomings by providing a minimally invasive means to rapid diagnosis of intraoral lesions.

Effects of sound pressure levels on fundamental frequency in tracheoesophageal speakers.

The quality of tracheoesophageal (TE) voice after laryngectomy is dependent on numerous factors. The relative contribution of specific variables is not well described. To evaluate the modulation of fundamental frequency (F0) pitch in TE speakers after total laryngectomy and voice restoration, we instructed 11 TE speakers to complete a series of vocal tasks under standardized conditions. All patients underwent standard laryngectomy with appropriate neck dissection and full-course radiation therapy. Each speaker produced 4 sustained phonations at distinct levels. Sound pressure level (SPL) intensity and F0 measurements were taken for each level. Statistical analysis to assess the relative effect of SPL on F0 demonstrated a statistically significant effect. However, the knowledge of SPL allowed only a 9% greater prediction of F0, indicating that factors other than SPL are integral to the modulation of F0 by TE speakers. These data lend further support to the theory that TE voice is an active process incorporating the myoelastic properties of the pharyngoesophageal segment as well as the properties of aerodynamic flow.

Metastatic head and neck cancer: role and usefulness of FDG PET in locating occult primary tumors.

PURPOSE: To assess the usefulness of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) of the head and neck in locating occult primary lesions in patients with metastatic cervical adenopathy. MATERIALS AND METHODS: Seventeen patients with metastatic cervical adenopathy of unknown primary origin were referred for FDG PET of the head and neck. All patients had undergone correlative anatomic imaging within 1 month of FDG PET. Surgical, clinical, and histopathologic findings were used to assess the performance of FDG PET. RESULTS: Increased apical lung uptake at FDG PET led to a biopsy-proved diagnosis of primary lung cancer in two patients. Of the remaining 15 patients, 10 had a focus of increased activity; directed biopsy of these sites led to confirmation of a primary carcinoma in seven patients. Correlative anatomic imaging failed to demonstrate the primary sites of disease in two of these seven patients. None of the five patients with negative FDG PET studies have manifested evidence of a primary site of disease during follow-up of 8-42 months (mean, 29 months). CONCLUSION: FDG PET allows effective localization of the unknown primary site of origin in metastatic head and neck cancer and can contribute substantially to patient care.

Viewing preferences, symptoms of psychological trauma, and violent behaviors among children who watch television.

OBJECTIVE: To examine the extent to which children's television-viewing practices are associated with symptoms of psychological trauma and aggressive behaviors. The following three hypotheses were tested: (1) children who report watching greater amounts of television per day will report higher levels of trauma symptoms than children who report lesser amounts of television viewing; (2) children who report watching greater amounts of television per day will report higher levels of violent behaviors than children who report watching lesser amounts of television per day; and (3) children who report a preference for action and fighting programs will report higher levels of violent behaviors than children who report a preference for other types of television programs. METHOD: The study used a survey design in which an anonymous self-report questionnaire was administered to students in grades 3 through 8 in 11 Ohio public schools during the 1995-1996 school year (N = 2,245). RESULTS: All three hypotheses were supported. CONCLUSION: Heavy television viewing by children may indicate the presence of problems such as depression, anxiety, and violent behaviors; such viewing should be screened for by psychiatrists and other mental health professionals working with children.

Clinical utility of positron emission tomography with 18F-fluorodeoxyglucose in detecting residual/recurrent squamous cell carcinoma of the head and neck.

PURPOSE: The use of positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) to detect residual/recurrent squamous cell carcinoma of the head and neck has been tested only in small groups of patients. Our purpose, therefore, was to evaluate the ability of this technique to detect the presence of tumor at both primary and nodal sites in a large cohort of patients. METHODS: All patients referred for PET scanning over a 2.5-year period with a question of residual or recurrent squamous cell carcinoma of the head and neck were identified. Thirty-five of 44 patients had sufficient follow-up to be meaningful to our analysis (range, 6-33 months). PET scans were interpreted visually with knowledge of the clinical history and correlative anatomic imaging findings. Detection of disease involving primary and nodal sites was assessed independently. Additionally, because each patient had been referred in an attempt to resolve a specific clinical problem, the usefulness of PET in accurately addressing these questions was assessed. RESULTS: At the primary site, sensitivity and specificity for residual/recurrent disease were 100% and 64%, respectively; for nodal disease, sensitivity and specificity were 93% and 77%, respectively. In helping to resolve the clinical question being asked, the positive predictive value of the test result was 65% and the negative predictive value was 91%. CONCLUSION: The high sensitivity and negative predictive value of PET scanning in our cohort of patients suggest an important role for this technique in the care of patients with suspected residual/recurrent head and neck carcinoma. The lower figures obtained for specificity and positive predictive value reflect the fact that increased FDG uptake may be due to either tumor or inflammation.

Violence exposure and emotional trauma as contributors to adolescents' violent behaviors.

OBJECTIVE: To investigate the degree to which violence exposure and symptoms of psychological trauma are related to adolescents' own violent behaviors. DESIGN AND SETTING: Anonymous self-report questionnaire administered to students in 6 public high schools (grades 9-12). PARTICIPANTS: Sixty-eight percent of the students attending the participating schools during the survey participated in the study (N=3735). Ages ranged from 14 to 19 years; 52% were female; and 35% were African American, 33% white, and 23% Hispanic. RESULTS: Multiple regression analysis determined that violence exposure and symptoms of psychological trauma together explained more than 50% of the variance in both male and female self-reported violent behavior. The independent effects of exposure to violence explained about one quarter of the variance in both male and female adolescents' violent behaviors. Anger was found to be the leading trauma symptom. CONCLUSION: Our findings suggest that health clinicians and other professionals who encounter adolescents should routinely screen them for both exposure to violence and symptoms of anger.

Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx.

Although tracheoesophageal voice restoration is accepted after reconstruction of the neopharynx with the pectoralis major myocutaneous flap, the character of such voice is not well described. Six patients reconstructed with the pectoralis major flap after laryngopharyngectomy underwent successful voice restoration with the Blom-Singer prosthesis. Voice was evaluated by a standardized protocol and compared with voices of control subjects treated with total laryngectomy and similar voice restoration. The patients with pectoralis major flaps produced similar intensity levels for soft voice (53.7 dB vs. 55.6 dB) and loud voice (61.3 dB vs. 65.3 dB) when compared with controls (p > 0.05). No significant differences (p > 0.05) were noted for fundamental frequency (F0) between patients with pectoralis major flaps and controls for soft (62.3 Hz vs. 85.4 Hz) and loud (109.8 Hz vs. 133.8 Hz) voice. Jitter was also comparable. Trained and naive listeners completed qualitative analyses for 10 parameters and judged that control patients had significantly better voice for most parameters. This finding demonstrates that dependable voice is attainable after pectoralis major flap reconstruction of the neopharynx. Although this voice does not differ significantly from voice after standard laryngectomy for acoustic parameters, perceptual analysis does reveal significant differences.

Alloplastic and microvascular restoration of the mandible: a comparison study.

The evolution of mandibular reconstruction following composite resection is advanced by improved alloplastic prosthesis and reliable microvascular free tissue transfers. A 42-case, 6-year experience is presented using both methods at the University of California, San Francisco. The advantages and complications of both are discussed. The authors conclude that the success rate for lateral defect restoration is equivalent with either technique, and that the anterior defects are more reliably reconstructed with free tissue transfer. The advantage of microvascular flaps in the anterior defect must be gauged against the physical status of the patient, disease extent, and likelihood of dental rehabilitation by interosseous fixation.

Cytochrome P-450 3A: interactions with dermatologic therapies.

Recent case reports and studies suggest that interactions involving the cytochrome P-450 mixed function oxidase system are important causes of medication toxicity and decreased efficacy during combination drug therapy. The cytochrome P-450 3A3/4 isoenzyme is involved in many significant drug interactions. New and familiar drugs continue to be implicated as having potentially serious interactions with this group of enzymes. An understanding of the basic principles of these interactions may have a major impact on patient outcome.