Pathways to risk among inner-city African-American adolescent females: the influence of gang membership.

Differential rates of participation in three categories of risk behaviors (i.e., sexual activity, substance use, violence) were explored, comparing gang members to nonmembers, within a sample of 1,143 inner-city African American adolescent females. The relationship between gang membership and risk behavior also was examined, by exploring the association between a variety of microsystemic influences (e.g., gang, family, school) and participation in risk behaviors. MANOVA analyses indicated that gang members, relative to nonmembers, reported higher rates of participation in each of the three categories of risk behaviors. Stepwise linear regression analyses indicated that gang membership was the variable with the most consistent predictive ability, across all categories of risk, as it entered early in all equations and remained in all three final models after controlling for other statistically significant contextual variables. Findings suggest that intervention efforts aimed at reducing adolescent females' participation in sexual activity, substance use, and violence should consider the influence of gang membership on the participation in these behaviors.

Effects of removing the negatively charged N-terminal region of the salivary acidic proline-rich proteins by human leucocyte elastase.

Human leucocyte elastase from inflammatory gingival crevicular exudates (gingival crevicular fluid) contacts saliva and saliva-coated tooth surfaces coronal to the gingival margin. Major components of saliva are the salivary acidic proline-rich proteins (PRPs). These acidic PRPs, via the numerous negatively charged amino acid residues located predominantly within their amino-terminal region, bind to the hydroxyapatite mineral of the tooth surface and become part of the salivary pellicle. Thus the potential for human leucocyte elastase-mediated removal of the negatively charged amino-terminal region of acidic PRP variants (PRP-1, PRP-2, PRP-3, PRP-4, PIF-s and PIF-f) was examined. It was determined that each of the acidic PRP variants was susceptible to fragmentation by human leucocyte elastase, in which the 16 amino-terminal segment was removed, leaving the respective residual fragment named as the transitional product (tr). The transitional products were termed PRP-1tr, PRP-2tr (PIF-str), PRP-3tr and PRP-4tr (PIF-ftr). Each of the residual transitional products of acidic PRP had an amino-terminal beginning with serine residue no. 17, determined by amino acid sequencing. When samples of human leucocyte elastase-treated acidic PRPs were placed on native polyacrylamide gels and electrophoresed, the respective transitional products moved more slowly than the parental acidic PRP molecules, reflecting the loss of a portion of the negatively charged section. In comparison to the acidic PRPs, the acidic PRP transitional products had markedly reduced binding to hydroxyapatite. The transitional products were resistant to further enzymatic digestion as a function of increased incubation time and appeared to exert an antihuman leucocyte elastase effect. However, when increased concentrations of human leucocyte elastase were incubated with the acidic PRP, a more extensive digestion occurred, leaving a residual peptide with an amino-terminal beginning with alanine residue no. 44. Interestingly, intact acidic PRPs if prebound to hydroxyapatite particles, resisted digestion by human leucocyte elastase. In summary, human leucocyte elastase was capable of digesting fluid-phase (unbound) acidic PRP in a manner that eliminated part of their negatively charged region, which subsequently reduced their binding to hydroxyapatite. High concentrations of human leucocyte elastase, arriving from inflammatory gingival crevicular exudates, may interrupt the normal binding of fluid-phase acidic PRPs to hydroxyapatite.

Anatomical observation of a craniomandibular muscle originating from the skull base: the sphenomandibularis.

This study describes a hitherto unreported, functionally distinct craniomandibular muscle as observed in 25 cadaveric specimens and MRI scans of clinical patients. The muscle was consistently observed as originating from the maxillary surface of the sphenoid bone and inserting on the temporal crest (internal oblique line) of the mandible. This anatomic observation should broaden our understanding of craniomandibular function and may have clinical implications regarding retro-orbital pain.

Anatomic relation between the rectus capitis posterior minor muscle and the dura mater.

STUDY DESIGN: Anatomic study of the suboccipital region, specifically the deep muscles of the suboccipital triangle, was performed in cadaveric specimens. OBJECTIVE: To observe and describe the relationship between the deep suboccipital musculature and the spinal dura. SUMMARY OF BACKGROUND DATA: A review of the literature revealed no reports describing a physical connection between suboccipital musculature and the spinal dura. METHODS: Dissections of the suboccipital region were performed in 10 embalmed and one fresh sagittally hemisected head and neck specimens. RESULTS: A connective tissue bridge between the rectus capitis posterior minor muscle and the dorsal spinal dura at the atlanto-occipital junction was observed in every specimen. The fibers of the connective tissue bridge were oriented primarily perpendicular to the dura. This arrangement of fibers appears to resist movement of the dura toward the spinal cord. CONCLUSIONS: Awareness of the physical relation between the rectus capitis posterior minor muscle and spinal dura via this connective tissue bridge should lessen the potential risk of dural damage during surgery. This connective tissue bridge may help resist dural infolding during head and neck extension.

Thoracic epidural abscess.

Twenty-one cases of thoracic spinal epidural abscess occurring over a 10-year period were retrospectively reviewed. Diagnosis was made by MRI or myelography and confirmed in the operative cases. A bacterial agent was isolated in 18 of the cases (86%). When measured, the erythrocyte sedimentation rate was elevated in all cases. Four patients who presented without neurologic deficits remained intact. All patients who presented with neurological deficits underwent surgical intervention in addition to intravenous antibiotics. Of the 15 patients who presented with a paraparesis of less than antigravity strength, five eventually were independent ambulators and continent. A good outcome resulted in 80% of those who underwent decompression within 24 h, as opposed to only 10% of the patients decompressed after 24 h. Good results can be obtained despite severe neurologic compromise when treated by rapid diagnosis and decompression of the spinal canal.

Scalloping deformity of the corpus callosum following ventricular shunting.

PURPOSE: To describe six patients who underwent ventriculoperitoneal (V-P) shunting for hydrocephalus and developed scalloping deformity of the dorsal surface of the corpus callosum, and to evaluate the cause and frequency of this phenomenon. MATERIALS AND METHODS: MR images of 35 patients whose hydrocephalus was successfully corrected by V-P shunting were studied. To elucidate the possible anatomic basis for the scalloping deformity, gross examination of the corpus callosum relative to the adjacent anatomical structures was performed using autopsy specimens. RESULTS: Of the 35 patients who underwent successful V-P shunting, six (17%) developed a scalloping deformity of the corpus callosum. The deformity was noted exclusively in the body of the corpus callosum. This phenomenon was observed in both obstructive and communicating hydrocephalus regardless of the patient's age, but was particularly noted in patients with tectal tumors. CONCLUSION: The cause of this phenomenon may be a combination of long-standing hydrocephalus and normal pericallosal artery anatomy. Prolonged hydrocephalus softens the corpus callosum and the branches of the pericallosal arteries tether the corpus callosum to the overlying cingulate cortex at periodic intervals.

Effect of THAM upon outcome in severe head injury: a randomized prospective clinical trial.

Although mortality and morbidity rates from head injury have been reduced substantially by improved prehospital interventions, intensive care, and aggressive management of intracranial pressure (ICP), successful treatment of the primary brain injury has been elusive. In experimental models, tromethamine (THAM) has been effective in treating head injury; this drug acts by entering the cerebrospinal fluid compartment, reducing cerebral acidosis and ICP, and reversing the adverse effects of prophylactic hyperventilation on early recovery. In this randomized prospective clinical trial, THAM was studied to determine if it had beneficial effects in the early management of severe head injuries and if the adverse effects of hyperventilation could be prevented. A total of 149 patients with severe head injury (Glasgow Coma Scale scores of < or = 8) were randomly assigned to either a control or a THAM group. Both groups of patients matched in terms of clinical parameters, including age, sex, number of surgical mass lesions, number in each Glasgow Coma Scale stratum, and first ICP measurement. All patients were treated by a standard management protocol, intubated, mechanically ventilated, and maintained in the pCO2 range of 32 to 35 mm Hg for 5 days. Tromethamine was administered as a 0.3-M solution in an initial loading dose (body weight x blood acidity deficit, average 4.27 cc/kg/hr) given over 2 hours, followed by a constant infusion of 1 ml/kg/hr for 5 days. Outcome was measured at 3, 6, and 12 months postinjury. Although analysis indicated no significant difference in outcome between these two groups at 3 months, 6 months, and 1 year, there was a difference regarding ICP. The time that ICP was above 20 mm Hg in the first 48 hours postinjury was less in patients treated with THAM (p < 0.05). Also, the number of patients requiring barbiturate coma was significantly less in the THAM group (5.48% vs. 18.4%, p < 0.05). The authors conclude that THAM ameliorates the deleterious effect of prolonged hyperventilation, may be beneficial in ICP control, and warrants further study as to the dosage and timing of administration.

Spinal epidural abscess: a report of 40 cases and review.

Despite modern medical advances, the morbidity and mortality rates associated with spinal epidural abscess remain significant, and the diagnosis often is elusive. A retrospective study was undertaken to define better the incidence and clinical features of this infection, and to establish current diagnostic and therapeutic guidelines. Forty cases of spinal epidural abscess were encountered at our institution between July 1979 and March 1991. All medical records and radiological images were reviewed. We report a significant increase in the incidence of epidural abscess after June 1988 (p = 0.0195). Sixteen patients used drugs intravenously, and six had undergone spinal procedures. Twelve patients were misdiagnosed in various emergency rooms or clinics and discharged. Localized back pain, fever, and neurological deficit remained the typical clinical manifestations. Erythrocyte sedimentation rate was elevated uniformly when measured (21 cases). Magnetic resonance imaging was diagnostic specifically in 23 of 24 instances. The majority of patients underwent surgical drainage, but five selected patients were managed nonoperatively. The highly variable presentation of spinal epidural abscess may confuse the diagnosis and delay indicated surgical intervention. Localized back pain in a febrile patient at significant risk for epidural abscess warrants erythrocyte sedimentation rate measurement. The presence of erythrocyte sedimentation rate elevation or evidence of spinal cord compression on physical examination are indications for immediate magnetic resonance imaging examination with contrast enhancement. Surgical drainage with sustained intravenous antibiotic treatment remains the cornerstone of therapy. Nonoperative management may be considered in selected cases.

Bodysurfing accidents resulting in cervical spinal injuries.

During the summers of 1987 and 1988, 14 cervical spine injuries sustained during bodysurfing accidents at the beaches around Ocean City, Maryland presented to our Neurotrauma service. All the patients were men, predominantly in their middle years (mean age = 40), and otherwise healthy. Likely mechanisms of injury suggested by radiography and computed tomography-myelography included hyperflexion, hyperextension, and axial loading. Clinically, neurologic deficits were found in 10 patients (71%), of whom 2 were complete sensorimotor quadriplegics below the level of injury, and 8 were incomplete injuries. Of the eight incomplete injuries, two-thirds were central cord syndromes associated with narrow spinal canals and prominent osteophytes, and one-third had Brown-Sequard or anterior cord syndromes. After initial anatomic realignment by closed or open reduction, the injured cervical spines were stabilized either externally or internally. Two patients underwent laminectomies. These bodysurfing accidents, in marked contrast to other types of shallow water-diving accidents, predominantly involved older men and produced incomplete injuries. It is concluded that bodysurfing is peculiarly hazardous to healthy, middle-aged men, especially those endowed with a narrow spinal canal with or without osteophyte formation.

Operative management of bilateral facet dislocation.

Fifty-two patients with acute traumatic bilateral locked facets were treated at one trauma center during a 3 1/2-year period (July, 1987, to December, 1990). The patients presented with complete motor quadriplegia (34 cases), incomplete myelopathy (13 cases), or intact long-tract function (five cases). The injuries occurred at C2-3 (one patient, with intact function), C4-5 (12 patients), C5-6 (16 patients), C6-7 (19 patients), and C7-T1 (four patients). Immediate traction (with increasing weight and serial x-ray studies) and/or induction of general anesthesia and muscle relaxation reduced the dislocation in 40 patients, but 12 needed prompt operative reduction as their injuries failed to reduce within 4 hours. Stabilization was indicated for all patients, but three did not undergo surgery: two elderly patients with complete injuries (one refused surgery and one died), and one patient with multiple injuries (fusion was achieved by halo-vest immobilization for 3 months). Of the 49 patients treated operatively, 23 (44.2%) underwent surgery on the day of injury and 26 on a delayed basis (mean 8.7 days postinjury). Surgical treatment included fusion of the posterior facet to a spinous process (44 cases), an anterior Caspar plate technique (three cases), and both procedures (two cases). Of these 49 patients, three (6.1%) with complete injuries died due to an adult respiratory distress syndrome. Improvement of cord function, judged by functional grade change, was observed at discharge in 15 patients (31.9%) and in 15 (71.4%) of the 21 patients with a 1-year follow-up period. Of the 34 patients with complete myelopathy on admission, three are ambulatory after 1 year, and 13 others have gained function in at least one nerve root. It is concluded that prompt reduction (nonoperative or surgical) and internal stabilization facilitate recovery even in neurologically compromised patients, and that early operative intervention is a wiser option than conservative management. This report also documents a higher incidence of this injury without deficit (five of the 52 cases) than reported in other series.

Anterior decompression in cervical spine trauma: does the timing of surgery affect the outcome?

To clarify the ideal timing of anterior decompression and stabilization for all patients with cervical spine trauma as well as its efficacy for patients with complete deficits, we reviewed the records of 103 consecutive patients with cervical spine trauma (50 incomplete deficits, Group A; 53 complete deficits, Group B) who underwent this procedure during a 5-year period at the Shock Trauma Center. We subdivided each group according to time of surgery: early and delayed (less than 24 and greater than 24 hours past injury, respectively). In Group A, 10 patients underwent early surgery and 40 patients underwent delayed surgery (range, 2 to 77 days past injury; mean, 13 days). One patient (2.5%) in the delayed group died. The following data refer to the early and delayed subgroups, respectively: average acute hospitalization, 20 and 22 days; patient motor score improvement (at discharge), 37.2 and 45.0%; functional grade improvement (at discharge), 5 (50.0%) and 9 (22.5%) patients. At 1-year follow-up, every patient who had had a deficit had progressed to a higher functional grade. In Group B, 35 patients underwent early surgery and 18 underwent delayed surgery (range, 2 to 45 days past injury; mean, 13 days). One patient (2.9%) in the early group died. The following data refer to the early and delayed subgroups, respectively: average acute hospitalization, 38.7 and 45.2 days (P less than 0.05); respiratory care (number of daily suction procedures), 6.0 and 9.86 (P less than 0.05); patient motor score improvement (at discharge), 3.9 and 4.5%; functional grade improvement (at discharge), 4 (11.4%) and 1 (5.6%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Inpatient capillary glucose monitoring: a useful adjunct to the management of diabetes in community hospitals.

Nursing personnel in two rural hospitals were taught to measure capillary blood glucose with a reflectance meter. Reflectance meter readings correlated well with laboratory blood glucose on all hospital units (R = .977 to .944) and were clinically useful. Measurements on a designated diabetes unit showed the closest correlation to laboratory measurements (P less than or equal to .001). Capillary blood glucose measurements are a feasible alternative to urine glucose testing in community hospitals.

Acute myelofibrosis: correlation of radiographic, bone scan, and biopsy findings.

Acute myelofibrosis is a rare hematologic malignancy which usually follows a rapidly progressive, fatal course. A case of acute myelofibrosis and severe focal bone pain is described showing bone scan and plain radiograph findings. A biopsy of one of the abnormal bony areas revealed malignant cells, necrosis and fibrosis, and abnormal, exuberant new bone formation, which may account for what is seen on the radiographic and radionuclide studies. The etiology and optimal management of this rare and often rapidly fatal disease remain to be defined.

Thrombotic thrombocytopenic purpura in human immunodeficiency (HIV)-seropositive males.

Two male patients with thrombotic thrombocytopenic purpura (TTP) were found to have antibodies to the human immunodeficiency virus (HIV). In one patient, platelet-associated antibody levels were measured serially and were found to be initially elevated, but the levels decreased with initiation of successful therapy. The simultaneous occurrence of these two conditions in two of three patients admitted for TTP within the previous 2 years at this institution suggests an association between the two diseases. The precise nature of this association remains speculative inasmuch as the pathogenesis of TTP remains uncertain.

Imaging modalities of craniosynostosis with surgical and pathological correlation.

Premature fusion of the sutures of the skull has been extensively analyzed and several diagnostic imaging modalities have been proposed. Radiographic, scintigraphic and computed tomographic features of craniosynostosis have been reported. This study was initiated (a) to determine the value and accuracy of plain skull radiography, skull scintigraphy and cranial CT; and (b) to determine the optimal imaging modality for the evaluation of a clinically suspected craniosynostosis. The study is based on 36 patients with clinical suspicion of craniosynostosis who underwent craniectomy and cranioplasty. One hundred and three sutures were pathologically and/or surgically evaluated. The overall accuracy rate for skull radiography was 89%, skull scintigraphy, 66%, and cranial CT, 94%. Routine skull series are adequate in the majority of cases of craniosynostosis. Skull scintigraphy is less accurate, more costly, and has a limited role in the evaluation of craniosynostosis. Cranial CT should be reserved for those cases in which the findings in the routine skull series are not clearly positive or negative, or in cases of more complex craniofacial anomalies.

Remission and exacerbation of tumor-related nephrotic syndrome with treatment of the neoplasm.

A 61-year-old man presented with nephrotic syndrome in March 1978. Renal biopsy revealed mesangial and endocapillary proliferation with no underlying cause found. One year later, evaluation of back pain resulted in the finding of undifferentiated adenocarcinoma with compression fracture of the T-11 vertebra. Local irradiation relieved the pain and ameliorated the nephrotic syndrome. In 1981 the nephrotic syndrome recurred. Evaluation revealed metastases to the right pelvis and to the brain without an identifiable primary lesion. Irradiation of these lesions reduced protein excretion to 50 to 150 mg/day. A gastric carcinoma was later found. Exacerbation of nephrotic syndrome may herald exacerbation of tumor activity as occurs in Hodgkin's disease. Survival with tumor-related nephrotic syndrome is not invariably poor, and treatment of metastases may be worthwhile in similar patients in whom only partial tumor reduction is possible.

Medical cure of apparent brain abscesses.

Two children with apparent brain abscesses were cured with antibiotic therapy. Review of the literature reveals clinical and experimental evidence that both cerebritis and an encapsulated abscess may appear as an enhancing ring lesion on cranial computed tomography. Patients reported to have had brain abscesses cured without surgery actually may have had cerebritis. There are only preliminary hints as to how to differentiate patients with cerebritis from those with an abscess. More experience is necessary to develop criteria to determine which patients may be appropriately treated with antibiotic therapy alone.