The effects of infraocclusion: Part 2. The type of movement of the adjacent teeth and their vertical development.

This second article discusses how the inclusion of a vertical component (the infraocclusion of the deciduous molar) into the otherwise horizontal band of transseptal fibers affects the vertical development of the two adjacent teeth. From the hypothesis proposed in the first article of this series, it seemed logical to assume that the occlusal heights of the teeth adjacent to the affected tooth would themselves be lowered, when measured to the inferior border of the mandible and compared with the height of the occlusal table of the control side. Secondly, since the vertical component affects only one side of each adjacent tooth, these teeth would be tilted about a center of rotation which is much higher (coronal) than is seen in a tooth that merely tips forward as the result of available space in the immediate vicinity in the arch. In this study, both these assumptions were confirmed, with a very high degree of statistical significance.


The effect of corticosteroid-induced osteoporosis on orthodontic tooth movement.

The purpose of this research was to study the effect of corticosteroid-induced osteoporosis on orthodontic tooth movement and relapse. Sixteen 3-month-old New Zealand white rabbits were divided into four equal groups, two treatment and two control. All treatment rabbits were administered daily injections of 15 mg/kg cortisone acetate for 4 days before and during the experimental period. An orthodontic appliance delivering a mesial force of 4 ounces was placed on the maxillary left first molar of all animals. For all groups, measurements of active tooth movement were made after 4, 7, 11, and 14 days. For two of the groups, appliances were removed on day 14, and additional measurements of relapse were made through day 21. With the use of radiodensitometric readings of the humerus bone and histology of the maxilla, osteoporosis was demonstrated in the treatment animals. Mean incremental and cumulative active tooth movement was three to four times greater (p < 0.0001) in the treatment rabbits than in the controls. The treatment group in which relapse was measured demonstrated 100% relapse on day 18, whereas the control group relapsed at a much lesser rate through day 21 and never achieved 100% relapse. Histologic findings appeared to support tooth movement results. In conclusion, the results of this study indicate that rabbits subjected to corticosteroid-induced osteoporosis undergo significantly more rapid orthodontic tooth movement and subsequent relapse than control animals.


Changes in lower third molar position in the young adult.

Changes in position of unerupted lower third molars between 18 and 21 years were examined in a group of 17 men and 24 women with intact lower arches. Mesiodistal third molar angulation, molar space, molar space condition, and buccolingual third molar angulation and the changes in these dimensions were measured on 60 degree cephalograms taken at 18 and 21 years. At 18 years molar space was inadequate by an average of 5.0 mm. Average changes in dimensions were statistically nonsignificant except for an increase in molar space of 0.7 mm. Changes in third molar position ranged from 39 degrees to -46 degrees in the mesiodistal and from 24 degrees to -24 degrees in the buccolingual dimension. Only 10 third molars did not change their mesiodistal angulation. Four third molars erupted fully during the observation period.


An evaluation of the nasolabial angle and the relative inclinations of the nose and upper lip.

The purpose of this study was to develop a consistent and reproducible method of constructing a nasolabial angle that would also permit an evaluation of the relative inclination of the lower border of the nose and the upper lip, as well as their relationship to each other. Comparison of repeated individual measurements of soft tissue profile landmarks on 15 subjects, as completed by four orthodontists, revealed that the proposed method of constructing the nasolabial angle was consistent and reproducible by the same orthodontist and among different orthodontists. Normative data for the three nasolabial parameters were produced from a sample of 104 young white adults determined by the authors to have well-balanced faces. Mean and standard deviation values from this pooled sample demonstrated a lower border of the nose to Frankfort horizontal plane angle at 18 degrees +/- 7 degrees, upper lip to Frankfort horizontal plane angle 98 degrees +/- 5 degrees, and nasolabial angle 114 degrees +/- 10 degrees. No statistically significant difference was demonstrated between the values for men and women in this study, but the women did have a slightly larger nasolabial angle. A linear comparison of the three nasolabial parameters with six skeletal measurements revealed no significant relationship between the soft tissue profile of the nasolabial region and the underlying skeletal relationships.


Comparisons of postsurgical stability of the LeFort I maxillary impaction and maxillary advancement.

The purpose of this study was to determine retrospectively the stability of the LeFort I osteotomy after a one-piece maxillary impaction or advancement. Cephalograms of 31 patients were evaluated before surgery, immediately after surgery, in fixation, and after fixation. Descriptive statistics for the absolute and the relative changes of the various linear and angular parameters were calculated for the different stages. The analysis of variance general linear models procedure was used to compare the impaction group (n = 23) with the advancement group (n = 8). The findings indicated that the two groups could be studied independent of age, sex, surgeon, the presence of pretreatment open bite, and the length of the postsurgical fixation. The findings further indicated the presence of significant differences in the postsurgical changes between the maxillary impaction and the maxillary advancement groups. As an example, during fixation, the maxilla moved superiorly more at point A in the advancement group (mean = 1.89 mm) than in the impaction group (mean = 0.67 mm). The upper incisor movements showed a similar pattern, moving more superiorly for the advancement group (mean = 2.30 mm) than for the impaction group (mean = 0.96 mm). Therefore care should be taken to avoid "burying" the incisors beneath the lip in patients undergoing maxillary advancement, who have minimal exposure of the maxillary incisors before surgery.


Superior repositioning of the maxilla combined with mandibular advancement: mandibular RIF improves stability.

Postsurgical changes in 24 patients who had rigid internal fixation (RIF) of the mandible with screws after combined superior repositioning of the maxilla and mandibular advancement were compared with 53 patients who underwent the same surgery but who had intraosseous wire fixation, skeletal suspension wires, and 8 weeks of maxillomandibular fixation (MMF). During the first 8 weeks after surgery, the mean posterior relapse of the mandible was greater in the MMF group than in the RIF group (for example, -1.1 mm versus 0.15 mm at B point), and the percentage of patients with clinically significant vertical and horizontal changes was greater in the MMF group. By 1 year, there had been slight additional mean relapse in the MMF group (-1.5 mm net relapse at B point, with 42% of the patients showing 2 mm or more relapse). In the RIF group, the mandible was more likely to be repositioned forward than posteriorly (net mean change at B point, 0.7 mm forward; 33% had 2 mm or more forward movement). In the RIF group, all but one of the patients (96%) were judged to have an excellent clinical result; in the MMF group, the corresponding figure was 60%.


The effect of acetylsalicylic acid on orthodontic tooth movement in the guinea pig.

This study examined the influence of acetylsalicylic acid an inhibitor of prostaglandin synthesis, on orthodontic tooth movement induced with light spring forces in the guinea pig. The animal model was shown to permit reliable and accurate recording of tooth movement up to 28 days. Tooth movement was found to be highly correlated with spring forces, indicating that the model provided a sensitive test of the effect of aspirin on tooth movement. Aspirin was administered orally at the rate of 65 mg/kg per day in three divided doses and was found to effectively inhibit prostaglandin synthesis at the level of the bronchioles. However, aspirin did not appear to significantly affect tooth movement. Thus prostaglandins may not be the only mediators of the bone resorption associated with tooth movement induced by light orthodontic forces under these experimental conditions.


An introduction to computerization of the orthodontic practice: practice and communications systems.

This article is the result of an extensive investigation into currently available computer software and hardware systems. It is designed to present an overview of the options that are available, what to reasonably expect computer systems to do and not to do, and to introduce the reader to the terminology of the computer world to assist in evaluating and selecting appropriate software and hardware for office use.


The pain and discomfort experienced during orthodontic treatment: a randomized controlled clinical trial of two initial aligning arch wires.

A randomized controlled clinical trial was performed to compare the nature, prevalence, intensity, and duration of pain related to the use of a relatively recently developed superelastic arch wire and a more traditional multistranded steel arch wire. Other factors likely to influence the pain experience were also investigated. Forty-three subjects participated in the study, the pain response being assessed by each of the visual analogue scales, the questionnaires, and an analgesic consumption record. In 18 of the 43 subjects a standardized preliminary dental extraction procedure was used as a control. Subsequent to the random allocation of an initial arch wire in 43 patients, 22 of them underwent a second arch wire in the opposing arch, the wire again being determined by random allocation. It was found that the prevalence, intensity, and duration of pain after the insertion of the two types of wire was similar but much greater than in the postextraction control phase. The pain score peaked on the morning after the placement of the arch wire, lasting typically for 5 to 6 days. The pain and discomfort experienced after the insertion of the second arch wire was similar to that of the first, no conditioning response being evident. Overall a diurnal variation was found with a tendency to an increase in pain in the evenings and nights, although this did not greatly affect sleep. The pain response was found to be highly and consistently subjective, not related to the dental arch, crowding, sex, or social class; however, a statistically significant association was found between the age and the pain experienced.


Rigid internal fixation and the effects on the temporomandibular joint and masticatory system: a prospective study.

A prospective study of 22 patients who underwent a bilateral sagittal osteotomy to advance the mandible and subsequent rigid internal fixation, were examined for signs and symptoms of temporomandibular joint (TMJ) pain and masticatory dysfunction. A modified Helkimo index was used to analyze the anamnestic, clinical, and occlusal data. In addition, 12 of the cases chosen at random were mounted on a semiadjustable (SAM2) articulator and analyzed with the mandibular position indicator (MPI) to determine the amount and the direction of condylar displacement postoperatively. Anamnestic dysfunction decreased because of a reported decrease in muscular pain, joint noise, headache frequency, and parafunctional habits postoperatively. Clinical dysfunction remained unchanged, with a decrease in muscular soreness but with an increased incidence of joint clicking of 7%. The increased incidence of temporomandibular joint pain postoperatively was 4%. Increase in clinical dysfunction was most often seen in women and older patients. Occlusal dysfunction decreased, with the majority of interferences remaining after surgery as a result of insufficient lingual crown torque of the maxillary buccal segments. Occlusion is thought to have played only a minor role in temporomandibular joint and masticatory dysfunction. Reduction in range of motion was 10%, indicating the added benefit of early mobilization with rigid internal fixation procedures. The MPI study found the condyles inferiorly or inferoposteriorly displaced less than 1 mm from their preoperative position. These findings suggest that rigid internal fixation had no adverse effects on the temporomandibular and masticatory system. The variable responses and results can be attributed, at least in part, to the heterogenous population of patients studied and the variations in surgical techniques employed.


Vertical changes in high-angle Class II, division 1 patients treated with cervical or occipital pull headgear.

Before, after, and 2 years after treatment serial radiographs of two samples of patients with high mandibular plane angle Class II, Division 1 nonextraction who were treated were evaluated retrospectively. One sample comprised patients treated with cervical headgear (CHG), and the other was treated with occipital headgear (OPHG). No significant differences were found when mandibular plane angle or facial height changes, anterior or posterior, were compared. Regarding vertical changes, only maxillary molar height, relative to both sella-nasion and palatal plane, and occlusal plane angle changes were significantly different when cervical and occipital-pull headgear were compared. In both groups of patients, responses to treatment were highly variable and only subtle vertical differences were apparent between mean changes in the cervical and occipital-pull samples.


Mandibular displacement in Angle Class II, division 2 malocclusion.

The effect of the treatment of Angle Class II, Division 2 malocclusion was studied in 22 children by x-ray cephalometry and by recording the relation between the retruded and the intercuspal mandibular positions. The treatment was performed in three phases. In the first phase the upper incisors were proclined, and the deep bite was corrected with an upper removable plate. In the second phase the distal occlusion was corrected with an activator. The result was retained in the third phase with a second activator designed for retention. The relation between the retruded (RCP) and the intercuspal (ICP) mandibular positions was recorded with wax bites and dental casts mounted in a modified gnathothesiometer. The anteroposterior distance between RCP and ICP was large before the start of the treatment. The distance was unchanged after proclination of the upper incisors and correction of the deep bite but decreased after correction of the distal occlusion and increased again somewhat during the retention phase. The proclination of the upper incisors and the correction of the deep bite (phase one of the treatment) did not result in mandibular anterior positioning. This fact and the results of the recordings of the relation between RCP and ICP were interpreted as evidence that the mandible is not posteriorly displaced in Class II, Division 2 malocclusion.


A study of reference lines for mandibular plane angles.

Four mandibular plane angles, MP-sella nasion, MP-Frankfort horizontal, MP-articulare nasion, and MP-gnathion occiput, were compared. Highly significant correlations were found among all four. The relation of an extension of the mandibular plane to the posterior inferior outline of the cranium was found to provide a valid indication of mandibular plane angle. Articulare nasion was found to be the reference line most likely to provide a true indication of the mandibular inclination rather than a reflection of a variation in the reference line itself.


Salivary clearance of sugar before and after insertion of fixed orthodontic appliances.

This study was conducted for the purpose of establishing the possible influence of orthodontic therapy with fixed appliances on salivary clearance of sugar. Fifteen consecutive patients between the ages 12 and 17 years took part in the investigation. Unstimulated salivary flow rate, residual volume of saliva in the mouth after swallowing (RESID), and salivary clearance of sugar was determined on two occasions, before treatment commenced and after a minimum of 3 weeks of appliance wear. Analysis of the data showed that both RESID and salivary flow rate exhibited significantly increased levels during orthodontic therapy. The insertion of fixed appliances did not seem to have any effect on the rate of salivary clearance of sugar. It was assumed that this finding could be a consequence of the combined effects of the changes in salivary flow rate and RESID.


The orthodontic management of congenitally absent maxillary lateral incisors and second premolars: a case report.

The orthodontic management of congenitally missing maxillary lateral incisors and second premolars is the subject of this case report. The primary orthodontic consideration was the maintenance of facial esthetics in a 12-year-old boy while consolidating, aligning, and coordinating the dental arches. The maxillary canines were orthodontically positioned in the lateral incisor spaces. The maxillary posterior teeth, including the deciduous second molars, were protracted to esthetic positions where they could function without interferences. The stability of the occlusion depends on the longevity of the maxillary deciduous second molar roots, which did not resorb during active tooth movement.


Practice and communications systems: a word processor based communications system.

The majority of computerized systems currently available for the orthodontic office have been designed for and aimed at those offices that have a volume practice and frequently have multiple practitioners. The stand-alone practitioner and the small office have been grossly ignored. Systems designed for large practices are frequently too complex, too involved in business administration, and too costly for the small office to use effectively. This article describes how an office communications system can be assembled by using commercially available programs. For background information and definition of terms used in this article, I suggest referring to "An Introduction to the Computerization of the Orthodontic Practice," in the Oct. issue of this Journal.


Pediatric euthanasia.

Pediatric euthanasia is currently practiced in the Netherlands on newborns, infants, children, and adolescents, although exact numbers are not known. Euthanasia in the Netherlands is generally assumed to be active and voluntary, but some cases of pediatric euthanasia would have to be characterized as nonvoluntary. Much of the motivation behind the euthanasia movement and the performance of pediatric euthanasia in the Netherlands is a genuine, compassionate desire to alleviate pain and suffering. In this study, we review the Dutch experience, with particular attention to the current practice of euthanasia on newborns, infants, children, and adolescents. We discuss pediatric euthanasia from an ethical point of view. We assert that more effective pain control, better symptom management, and psychosocial support of the dying and their families would alleviate the perception of suffering, and reduce the perceived need to resort to euthanasia.


Surgical management of congenital heart disease in the 1990s.

To provide a broad overview of recent trends in surgical management of congenital heart disease. Review of recent literature. Major centers for surgical management of congenital heart disease. Analysis of important recent clinical publications. None. Definitive, corrective surgery was previously reserved for children beyond infancy. Recognition of the complications associated with palliative operations as well as the realization that neonates and infants did not fare worse than older children during open heart surgery provided the impetus for primary corrective surgery at an earlier age. Advances in our understanding of perioperative care, improved diagnostic capability, and increasing experience with corrective surgery in association with several different congenital heart lesions has resulted in an established therapeutic approach to surgical management of congenital heart disease in neonates and infants.


Spontaneous chylothorax in Noonan syndrome. Treatment with prednisone.

To describe a case of spontaneous chylothorax in a child with Noonan syndrome successfully treated with prednisone. Case report. A pediatric cardiology referral center for the Rocky Mountain region. An 18-month-old girl with Noonan's syndrome, pulmonary stenosis, and hypertrophic cardiomyopathy who presented with spontaneous chylothorax. The child's chylothorax did not respond to thoracic duct ligation, tetracycline pleurodesis, and pleurectomy during a 2-month period. A low-fat diet was helpful but did not eliminate the problem. Prednisone was started orally at 1 mg/kg per dose twice daily and slowly tapered during 3 months. The chylothorax did not recur during 8 months of follow-up. Prednisone may be useful in the treatment of chylothorax in Noonan syndrome. A controlled clinical trial would be helpful but would be difficult in such a rare complication of an uncommon syndrome.


Diabetic ketoacidosis in cystic fibrosis.

To differentiate the insulin-dependent glucose intolerance associated with cystic fibrosis from type I diabetes mellitus in patients with cystic fibrosis. Patient report. Tertiary care referral center. An 11-year-old boy with cystic fibrosis who developed diabetic ketoacidosis. MEASUREMENT/MAIN RESULT: Biochemical, immunologic, and molecular techniques were used to support the sporadic association of type I diabetes mellitus in a patient with cystic fibrosis. Cystic fibrosis was confirmed by sweat test and further supported by the demonstration of a heterozygous deletion of the F508 locus. Evidence for the diagnosis of type I diabetes mellitus was developed from the clinical presentation of diabetic ketoacidosis with hyperglycemia, ketonemia, and ketonuria. Immunologic evidence included the demonstration of anti-insulin antibodies. The demonstration of homozygous absence of aspartic acid at position 57 of the HLA DQ-beta chain placed this child at high risk of type I diabetes mellitus. The clinical presentation and the presence of immunologic and genetic markers characteristic of type I diabetes mellitus supports the concordance of cystic fibrosis and type I diabetes mellitus in this patient.


An unusual presentation of medium-chain acyl coenzyme A dehydrogenase deficiency.

To report an atypical presentation of medium-chain acyl Coenzyme A dehydrogenase deficiency in a 13-year-old girl with hyperammonemic encephalopathy and orotic aciduria meeting the accepted criteria for diagnosis of a female heterozygous for ornithine transcarbamylase deficiency. Case report and definitive biochemical testing. Children's hospital and university laboratory. One teenager. Diagnosis and treatment with carnitine. Assay ornithine transcarbamylase deficiency had normal results. The diagnosis was confirmed by DNA analysis, which revealed homozygosity for prevalent mutation (the adenine to guanine transition at position 985). Patients with a clinical diagnosis of Reye's syndrome have, in general, an inborn error of metabolism. Medium-chain acyl Coenzyme A dehydrogenase deficiency and other disorders of fatty acid oxidation may present long after infancy. They may mimic the presentation of defects in the urea cycle.


Helmets! All the pros wear them.

To assess the outcome of a multidisciplinary community campaign to increase helmet use and determine the success of a school education and helmet distribution program. Survey research. Large metropolitan area and two elementary schools. Five hundred representative families in a metropolitan area and students enrolled in two elementary schools. A 1-year-long regional media campaign and a helmet distribution program in one elementary school after 4 weeks of safety instruction. Evaluation of the community component 1 year after initiation of the campaign revealed a 23% awareness of the promotion. Factors associated with wearing a helmet in the community included higher income levels, higher level of education, and male sex. The school component survey revealed that 73% of the children in school A reported helmet use vs 23% in school B. This multifaceted approach to affect helmet use demonstrated variable success in our community. This campaign effort achieved its greatest success in promoting community awareness of the importance of helmet use. However, further studies need to be performed to determine the success of the school education and helmet distribution program.


Cognitive assessment of human immunodeficiency virus-exposed children.

To determine (1) the level of impairment in cognitive and motor functioning in human immunodeficiency virus (HIV)-exposed and HIV-infected preschool and school-age children; (2) cognitive strengths and weaknesses that characterize HIV-infected children; and (3) potential contributions of serostatus, neurologic impairment, and prenatal drug-exposure to cognitive functioning. Cross-sectional, single-blind study. Pediatric neurology clinic at a large metropolitan hospital in New York, NY. Forty-one HIV-infected and eight seroreverter school-age children. The McCarthy Scales of Children's Abilities were administered to all children, as was the Neurologic Examination for Children. The obtained mean of the sample on the McCarthy Scales' General Cognitive Index was in the Borderline range, with 44% of the subjects scoring in the Mentally Retarded range. The most severe cognitive deficits were found on the Quantitative, Verbal, and Memory scales (Borderline range). Children infected with HIV with neurologic impairment performed significantly worse than did seroverters and neurologically normal HIV-infected children. There were no significant differences in cognitive functioning due to gender, ethnicity, and prenatal drug exposure. Cognitive deficits were detected in HIV-infected and seroreverted children. The presence of neurologic dysfunction in HIV-infected children markedly intensified these deficits.


Cranial computed tomographic scans have little impact on management of bacterial meningitis.

To assess which clinical features predict an increased likelihood of an abnormal computed tomographic (CT) scan and how frequently CT influences management of bacterial meningitis. Retrospective patient series. University-affiliated hospitals in Dallas, Tex. Three hundred thirty-seven children with bacterial meningitis, of whom 107 (32%) had undergone CT scans. One or more abnormalities were found in 52% of the initial scans. The most frequent indication for CT at our institution was persistent or secondary fever, and in 56% of these children, subdural effusion or empyema was noted. However, findings on CT rarely predicted a need for intervention. In contrast, children with focal seizures or focal neurologic signs were more likely to have brain parenchymal changes. Scans in 19 patients (12%) prompted surgical intervention, most commonly drainage of a subdural collection. The conditions of only nine children (8.4% of those who had undergone CT scans) improved following intervention that was initiated because of findings on CT. Although CT scans are frequently abnormal in children with meningitis, CT seldom reveals findings that require specific intervention.


Fluoride supplementation. A survey of pediatricians and pediatric dentists.

To determine the protocol and use of prescriptions of fluoride supplementation by primary care pediatricians and pediatric dentists in the Houston (Tex) area. Survey mailed to all primary care pediatricians and pediatric dentists listed in the Yellow Pages of the Greater Houston telephone directory. 153 pediatricians and 47 pediatric dentists. Ninety-six percent of the participants prescribed fluoride supplements. Fifty-one percent of the pediatricians and 61% of the dentists considered that the fluoride content of the water was important. Seventy percent of the pediatricians and 30% of the dentists discontinued the use of supplements by age 7 to 10 years. Pediatricians and pediatric dentists should consider the need for water analysis prior to supplementation and should continue the use of fluoride supplements until 16 years of age.


Is acute lymphoblastic leukemia in children virus-related?

The sharp peak in incidence of acute lymphoblastic leukemia at ages 2 and 3 years strongly suggests the effect of an agent, whether viral or not, to which either exposure occurs only in the earliest months of life or to which immunity develops very rapidly. Suspected clusters of childhood leukemia in the neighborhoods of two British nuclear reprocessing facilities led Leo Kinlen to postulate that large-scale immigration into areas that had previously been remote and isolated offers opportunities for spread of viral infections to which most urban populations become immune at a very early age: leukemia may be a rare manifestation of infection by one or more of such viruses. He and his group have presented evidence in support of this hypothesis. Lack of increase in childhood leukemia in the contexts of the massive evacuation of mothers and children from British cities during the Second World War, and of the considerable immigration into previously isolated islands of Greece during the last several decades, indicates that some large movements of children have occurred without providing the circumstances postulated by Kinlen. The marked inverse association of leukemia risk with birth order, noted almost 30 years ago, remains unexplained and deserves to be recalled when considering the possibility of viral involvement in the etiology of acute lymphoblastic leukemia of children.


Risk factors predicting the incidence of second primary breast cancer among women diagnosed with a first primary breast cancer.

This study examined risk factors for development of a contralateral breast cancer among 4,660 US women diagnosed with a first primary breast cancer between 1980 and 1982. The authors believe it to be the first prospective cohort study on this topic that has employed direct patient interviews. All subjects were interviewed within 6 months of the diagnosis of their initial tumor as part of the multi-center, population-based, case-control Cancer and Steroid Hormone Study, and they were followed until the end of 1986 through the Surveillance, Epidemiology, and End Results program. Exclusive of those diagnosed during the initial 6 months after diagnosis of a first primary, 136 second primary breast cancers were identified. Proportional hazards models were used to assess the independent effects of multiple predictors. Specific risk factors evaluated included: age at diagnosis of first primary, exposure to exogenous hormones, menstrual and reproductive histories, tumor characteristics, demographic variables, and treatment modalities. The age-specific incidence rates of second primary breast cancer were higher in all age categories than are the incidence rates of breast cancer in the general population, yet the age at diagnosis of first primary breast cancer was not an important predictor of contralateral breast cancer. The risk of contralateral breast cancer was increased among cohort members who reported a personal history of benign breast biopsy (multivariable-adjusted rate ratio (RR) = 1.69, 95% confidence interval (CI) 1.13-2.53) and in those with an initial tumor that was classified as lobular carcinoma (multivariable-adjusted RR = 1.96, 95% CI 1.17-3.27). Treatment with chemotherapy for the first primary was associated with a lower risk of development of a second breast cancer (multivariable-adjusted RR = 0.56, 95% CI 0.33-0.96), while radiation therapy had little effect on the risk (multivariable-adjusted RR = 1.19, 95% CI 0.78-1.80).


The genetic epidemiology of second primary breast cancer.

It is well established that women with a family history of breast cancer run a higher risk of breast cancer than do women without a family history. The evidence, however, is less clear regarding a possible association between a family history of breast cancer and risk of second primaries. The purpose of this prospective study was to estimate the risk for second primary breast cancer associated with having a family history of breast, endometrial, and ovarian cancers. A cohort of 4,660 women with a first primary breast cancer diagnosed between 1980 and 1982 were interviewed as part of the Cancer and Steroid Hormone Study, a multi-center population-based case-control study, and followed through eight Surveillance, Epidemiology, and End Results (SEER) program registries for 4 to 6 years. Of these women, 136 developed a second primary breast cancer in the contralateral breast at least 6 months after diagnosis of the first primary. Cox proportional hazards modeling techniques were used to model the time to onset of second primary breast cancer while adjusting for multiple predictors. The risk of contralateral breast cancer was elevated among cohort members who reported a history of breast cancer in a first-degree relative (multivariable-adjusted rate ratio (RR) = 1.91, 95% confidence interval (CI) = 1.22-2.99). Early age at onset (< 46 years) in the relative further increased the risk of developing contralateral breast cancer (sister: multivariable-adjusted RR = 3.36, 95% CI 1.62-6.98; mother: multivariable-adjusted RR = 2.35, 95% CI 1.02-5.43). Bilateral breast cancer in mothers was also associated with more than a two and a half-fold increase in risk (multivariable-adjusted RR = 2.55, 95% CI 1.02-6.35). The association between family history of breast cancer and risk of contralateral breast cancer did not vary substantially according to age at onset of the first primary breast cancer. The age-adjusted rate ratio for development of a second primary breast cancer among women with a first-degree relative with endometrial cancer was 2.13 (95% CI 1.04-4.35), while the corresponding rate ratio among women with a family history of ovarian cancer was 1.69 (95% CI 0.42-6.83). There was little evidence that age at onset among the relatives with endometrial or ovarian cancer affected the risk. Some of these findings have not been previously reported and need replication in future studies.


Localization and characterization of calcitonin gene-related peptide mRNA in rat heart.

Calcitonin gene-related peptide (CGRP), a product of the calcitonin/CGRP gene, is a potent vasodilating neuropeptide widely distributed throughout the cardiovascular system, particularly in the heart. Immunocytochemical studies have demonstrated CGRP-containing neurofibrils in the myocardium and in the periadventitia of coronary blood vessels. Based on these studies, it has been assumed that all of the CGRP peptide in the heart is synthesized in neurons whose cell bodies are located outside of the heart. Using Northern blot analysis and a ribonuclease protection assay, we observed in the rat heart low levels of a CGRP-like mRNA species that appeared to be identical to authentic CGRP mRNA produced in the brain and dorsal root ganglia. The ventricles contained somewhat more CGRP mRNA than did the atria. Also, whereas the dorsal root ganglia synthesized both alpha- and beta-CGRP mRNA, only the alpha-CGRP mRNA was detected in the heart. The presence of CGRP mRNA in the heart suggests that the CGRP gene is transcriptionally active in a subpopulation of heart cells, possibly neuronal, which have the potential to synthesize and secrete this neuropeptide. Given the potent coronary vasodilatory and positive chronotropic and inotropic effects of CGRP, the localized synthesis of CGRP in the heart may play a role in modulating cardiovascular function.


Small caliber catheter drainage for spontaneous pneumothorax.

Excellent results have been reported after small caliber catheters were used for iatrogenic pneumothoraces. However, the value of using such catheters for spontaneous pneumothoraces is not clear. The purpose of this study, therefore, is to examine the efficacy of small caliber catheters in managing spontaneous pneumothoraces. Seventy six episodes of spontaneous pneumothorax were treated using a small caliber catheter (No. 5.5 or 7.0 French) connected to a Heimlich valve. All catheters were inserted by physicians. The treatment was considered successful when there was no air leakage and little or no residual pneumothorax. Before the lungs were fully expanded, four patients had died and one had refused to comply with further treatment. The remaining 71 episodes of pneumothoraces were evaluated for efficacy. The treatment was successful in 60 patients (84.5%) and ineffective in the remaining 11. The conventional large caliber tube was inserted in 10 of the 11 failures, but they were successful in only six. No major complications resulting from catheter insertion occurred, and no catheters became occluded. The catheter was easy to insert, and the scar that remained after removal of the catheter was very small. Not only are small caliber catheters effective for managing spontaneous pneumothoraces, they are the initial treatment of choice.


Institutional Review Board (IRB) review lacks impact on the readability of consent forms for research.

Consent forms in research are a source of current and retrospective information for the subject, a "prompt" for the person who is obtaining consent, and a documentation of the "informed" consent process and its adequacy. Occasionally, these forms may be administered by inexperienced trainees or ancillary personnel, and thus stand virtually alone. Therefore, the forms must be inherently comprehensible to the subjects. To test whether this is the case, 65 new applications were randomly selected from 13 consecutive IRB agendas, and their consent documents were computer-analyzed (Flesch/Fry scoring) after correction for expected confounding features, such as lists, tables, and polysyllabic proper names and jargon. Mean U.S. school grade for 70% comprehension (Fry score) was 15.03 +/- 0.19 (standard error of the mean), implying readability by 37.4 +/- 1% of the U.S. adult population. In contrast, a consecutive sampling of 21 Ann Landers columns yielded a mean Fry score of 7.67 +/- 0.5 (p < 0.01; readable by 75 +/- 3%). Fifteen Reader's Digest articles yielded a mean Fry score of 9.95 +/- 0.65 (p < 0.01; readable by 59.1 +/- 3%), and 15 "Talk of the Town" columns from The New Yorker averaged a grade level of 13.3 +/- 0.83; p < 0.01; readable by 42.7% +/- 4.8%). No document was improved by more than one grade level by the IRB review process, and most were unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)


Case report: sustained-release verapamil overdose causing stroke: an unusual complication.

A 47-year-old woman ingested 7.2 gm of sustained-release verapamil. She developed hypotension, idioventricular rhythm, mild acidosis, mild hyperglycemia, and aspiration pneumonia that required antibiotics and mechanical ventilatory support. In addition, she had a stroke, which resulted from left cerebral hemispheric damage, an unusual complication. Stroke is reported only once in the literature. Special problems related to slow release medication and the need to be aware of them are discussed.


Case report: diagnosis of thyroid cancer by bone marrow biopsy in a patient with lymphoma and goiter.

Metastatic follicular thyroid carcinoma was diagnosed by bone marrow biopsy performed during the staging evaluation in a patient with large-cell lymphoma and diffuse goiter who showed lung and bone lesions upon radiologic examination. After thyroidectomy, both sites concentrated radioactive iodine, confirming their thyroid origin and allowing for the appropriate treatment.


Structure and applications of intermolecular DNA triplexes.

Current DNA binding drugs are not sequence specific. Triplex-forming oligonucleotides will bind targeted duplex DNA sites in a sequence-specific manner. A new class of DNA binding molecules based on triple-helical DNA formation promises a sequence-specific method of targeting discrete regions of DNA. DNA modifying molecules linked to third strands have been shown to modify only regions of DNA to which they were targeted. Current research will increase the understanding of triplex DNA structure and will lead to improved DNA binding drugs.


Infections of the central nervous system.

Infections of the central nervous system are common, serious medical conditions. One hundred consecutive adult cases with purulent meningitis of known etiology encountered by the Medical Service at Parkland Memorial Hospital were reviewed. Streptococcus pneumoniae was the most common pathogen (56 cases), followed by Neisseria meningitidis (16 cases) and Listeria monocytogenes (seven cases). Hemophilus influenzae, Staphylococcus aureus, and streptococci each accounted for five cases. An additional 15 patients had purulent meningitis with a pathogen being isolated. Twenty five purulent meningitis cases of known etiology after trauma or neurosurgery were reviewed. Staphylococcus aureus (five cases), Staphylococcus epidermidis (four cases), and gram negative bacilli (14 cases) were the most common pathogens. Review of intracranial suppurative infections demonstrated advances in microbiology, antibiotic therapy, and imaging, leading to improvements in therapy. Subdural empyema continues to be a difficult diagnosis to make and apparently is related to the anatomic pathology of the infectious process. To illustrate salient features about granulomatous meningitis and encephalitis, cases of tuberculous meningitis, herpes simplex encephalitis, St. Louis encephalitis, and encephalitis of undetermined etiology are presented and discussed.


Report of another family with Simpson-Golabi-Behmel syndrome and a review of the literature.

Simpson-Golabi-Behmel Syndrome (SGBS), an X-linked encephalo-tropho-schisis syndrome described in fewer than a dozen families, is characterized by pre- and postnatal overgrowth, "coarse" face, minor facial anomalies and, in more severe cases, multiple congenital anomalies and mental retardation. We report on 2 brothers with overgrowth, macrocephaly, polydactyly, supernumerary nipples, and characteristic facial appearance. In addition, the propositus also had pulmonic stenosis and a cleft palate. The findings present in our patients are compared to those in the original patients and to those in patients described more recently. Despite the fact that our patients have most of the minor and several of the more severe malformations, they are not mentally retarded.


Further delineation of the Simpson-Golabi-Behmel (SGB) syndrome.

The Simpson-Golabi-Behmel syndrome is an X-linked condition characterized by pre- and postnatal overgrowth, "coarse" face, postaxial polydactyly, midline defects, and psychomotor development ranging from normal to mildly retarded. We report on an additional sporadic patient with novel manifestations, contributing to a more thorough delineation of this syndrome.


Proximal 7q interstitial deletion in a severely mentally retarded and mildly abnormal infant.

We describe a boy with an interstitial deletion of 7q [46,XY,del(7)(pter-->q11.21::q11.23-->qter)] and severe mental retardation, bilateral inguinal hernias, plagiocephaly, and mildly abnormal facial appearance. This is the 21st case report involving a proximal 7q deletion, but the first report of this specific deletion in the absence of Zellweger syndrome. Specific genotype-phenotype correlations are still not possible for this region of chromosome 7.


Mucopolysaccharidosis VII as cause of fetal hydrops in early pregnancy.

We report on fetal hydrops presenting at 18 weeks of gestation and diagnosed as beta-glucuronidase deficiency. The parents were first cousins and there were 2 previous similar fetal deaths. beta-Glucuronidase was absent in cultured fetal fibroblasts and lymphoblasts but was normal in the tested relatives. The activities of other lysosomal enzymes were normal.


Mucopolysaccharidosis type VII (beta-glucuronidase deficiency): a chronic variant with an oligosymptomatic severe skeletal dysplasia.

We report on a 20-year-old male with a beta-glucuronidase (GUSB) deficiency mucopolysaccharidosis. He had pectus carinatum, gross thoracic kyphoscoliosis, and hip dysplasia, a picture which became conspicuous after age 4 years. Hepatosplenomegaly, herniae, corneal clouding, and neurological abnormalities were absent. Although he had Alder-type granulations in his polymorphonuclear leukocytes, the urine did not contain a significant excess of mucopolysaccharides. Electron microscopic examination of skin and gingival biopsies, leukocytes, and cultured skin fibroblasts showed numerous single membrane-limited vacuoles either empty or filled with fibrillogranular material; this last tissue did not contain metachromatic granules. Radiographs demonstrated a distinct spondyloepiphyseal dysplasia in which the most striking changes were confined to the thoracic spine (flattening and collapse in T7, T8 and T10 vertebral bodies) and to the femoral capital epiphyses (irregularities and fragmentation). The activity of GUSB in the patient's serum, leukocytes, and fibroblasts was severely decreased; the GUSB activity in the serum and leukocytes from the parents and 2 asymptomatic sibs was subnormal. Immunoblot analysis showed very low levels of cross-reactive material towards anti-GUSB antiserum in the patient's leukocyte and fibroblast extracts. This patient was more severely affected in his skeleton than other described patients with an oligosymptomatic chronic form. This case broadens the clinical and biochemical picture associated with GUSB deficiency and may represent a new variant of the disease.


Autosomal recessive cleft lip/palate, ectodermal dysplasia, and minor acral anomalies: report of a Brazilian family.

We report on a Brazilian woman, born to consanguineous (first cousin) parents (F = 1/16) and presenting cleft lip/palate, ectodermal dysplasia, interdigital webbing, and other malformations. Parental consanguinity and possible recurrence in sibs suggest autosomal recessive inheritance. The nosologic aspects with the Martinez syndrome and with the Zlotogora-Ogur syndrome are discussed.


Constitutional translocation t(4;22) (q12;q12.2) associated with neurofibromatosis type 2.

We report on a female patient with bilateral acoustic neurinomas and other tumors in the central nervous system (neurofibromatosis type 2: NF2) and the constitutional translocation, t(4;22) (q12;q12.2). The precise identification of the translocation breakpoint (q12.2) on chromosome 22 implies the refined localization of a gene responsible for NF2, and would provide a clue to its molecular characterization and to the isolation of the gene. Chromosomes of a paraspinal neurinoma from the patient were also analyzed, and the same karyotype as seen in cultured peripheral lymphocytes was found. The patient's father was also a carrier of the translocation, but he had no clinical symptoms of NF2, nor did other relatives. Several explanations are offered for the different expression of the translocation between the patient and her father.


Experimental fetal alcohol syndrome: proposed pathogenic basis for a variety of associated facial and brain anomalies.

Acute teratogenic exposure of C57Bl/6J mouse embryos to ethanol in vivo results, within 12 hours of initial insult, in excessive cell death in selected cell populations. The patterns of excessive cell death observed following exposure of gestational day 8 embryos (late presomite--approximately 5 somite pair stages) vary somewhat temporospatially, but primarily involve the cell populations at the rim of the anterior neural plate. The cell death patterns appear to be pathogenically correlated with subsequently observed malformations including exencephaly (anencephaly), arhinencephaly, pituitary dysplasia, bilateral or unilateral cleft lip, maxillary hypoplasia, and median facial deficiencies and clefts. The association of these brain and facial malformations in this model, and perhaps in humans, may be accounted for by early insult to the selected cell populations identified in the current investigation.


Long-term evaluation of a child with the branchio-oculo-facial syndrome.

We report on the 12-year development of a child with branchio-oculo-facial syndrome who was initially referred at age 5 months. Of note is his normal intelligence, regular class placement, hypernasal speech, and continued growth along the third centile. The importance of serial observations of patients with rare genetic disorders is emphasized.


Twin studies in familial Mediterranean fever.

Familial Mediterranean fever (FMF) is a genetic disease characterized by recurrent short episodes of fever, accompanied by peritonitis, pleuritis, or arthritis. The disease is almost completely ethnically restricted to patients of Mediterranean descent--Sephardic Jews, Armenians, Anatolian Turks, and Arabs. Although many family studies have been performed, no twin study has been reported as yet. We studied 21 di- and monozygotic twin sets, identified among the 1,943 FMF patients in our registry. Full concordance was observed in all the 10 monozygotic twin sets. In the 11 dizygotic twins, concordance for FMF disease was found in only 3 pairs. Variability in the clinical manifestations and degree of severity have been noted within twins. These findings provide definitive evidence for the genetic cause of FMF. They also support the single gene autosomal recessive model, and provide support for the contention that the lower observed than expected incidence found in FMF is due to genetically affected but clinically undiagnosed patients.


Familial Mediterranean fever: analysis of inheritance and current linkage data.

Familial Mediterranean fever (FMF) is a genetic disorder characterized by recurrent attacks of fever and inflammation of serosal surfaces. Unlike many mendelian disorders, the mode of transmission has been subject to some controversy as segregation analysis studies have always demonstrated fewer "observed" than "expected" affected individuals. Despite efforts to map the gene causing FMF, no definite linkage has been yet identified. This review analyses the epidemiologic and genetic characteristics in order to evaluate critically the inheritance of the disease and provide a perspective on the current biochemical and molecular genetic studies whose aim is to locate the gene for this disease.


Natural history of mosaic trisomy 14 syndrome.

Trisomy 14 mosaicism produces a distinct phenotype. Among the 13 reported and 2 additional patients, the following findings were present in more than 90%: growth retardation (15/15), psychomotor retardation (10/10), broad nose (13/14), "dysplastic" and/or apparently low-set ears (15/15), micrognathia (15/15), short neck (11/12), congenital heart disease (14/15), and micropenis and cryptorchidism (6/6). Other frequent findings were prominent forehead (12/14), hypertelorism (8/13), narrow palpebral fissure (7/9), large mouth (10/14), cleft or highly arched palate (10/14), body asymmetry (8/12), and abnormal skin pigmentation (6/10). Sex ratio was 6M:9F. Four patients died before age 4 months, while at least 2 patients survived through teens. One boy died at age 3 years following cardiac surgery. One girl with tetralogy of Fallot showed a remarkable improvement in health after Blalock-Taussig procedure. Although the surviving patients showed moderate growth and mental retardation, the oldest surviving woman at 29 years demonstrates functional language and appropriate self help skills.


Cutaneous scar at anterior hair line in mother and child with associated frontal bone defect in child.

A large frontal bone defect underlying a "V" shaped scar was noted in a newborn male whose mother had an identical "V" shaped scar at the same location in the anterior hairline. Both had hypertelorism and short palpebral fissures. The mother had no radiographic evidence of skull defect and neither mother nor child had other cutaneous or skeletal anomalies. Cranioplasty was performed on the child using the remaining frontal bones with an excellent cosmetic result. Biopsy performed at operation documented scar tissue extending through the dermis and underlain by thickened dura. Mother and child appear to have a variant form of aplasia cutis congenita, an autosomal dominant trait with wide variation in expression.


Esophageal atresia and tracheoesophageal fistula in two infants born to hyperthyroid women receiving methimazole (Tapazol) during pregnancy.

We report on 2 newborn infants with esophageal atresia and tracheoesophageal fistula (EA + TEF) born to hyperthyroid mothers receiving methimazole (Tapazol) before and during their entire pregnancies. Both mothers were euthyroid during gestation and developed hydramnios diagnosed during weeks 34 and 33 of gestation. Premature delivery (36.2 weeks of gestation) occurred in one case, and both newborn infants were small for date with palpable goiter; one of them had other associated malformations. Hypothyroidism was diagnosed by laboratory tests in both cases. Corrective surgery was undertaken, but both newborn infants developed septicemia and renal insufficiency and died in the first week of life. The EA + TEF and a normally placed enlarged thyroid gland were confirmed at necropsy. These cases represent a previously unreported example of the association of maternal ingestion of methimazole during pregnancy and EA + TEF.


Caroline Crachami, the Sicilian Fairy: a case of bird-headed dwarfism.

One of the most remarkable cases of extreme dwarfism on record is Caroline Crachami, the Sicilian Fairy. She was born in 1815, and was taken to London to be exhibited for money in 1824. Due to her proportional dwarfism, severe intrauterine growth retardation, and typical "bird-headed" profile, Caroline Crachami has by some been diagnosed as a case of the autosomal recessive Seckel syndrome. In this historical vignette, the Sicilian Fairy's life and death are presented in some detail using new material, and the problem of her correct diagnosis is discussed.


6p23 deletion mosaicism in a woman with recurrent abortions and idiopathic hypoprolactinemia.

A woman with a history of recurrent abortions, idiopathic hypoprolactinemia, and an apparent 6p partial deletion mosaicism is described. The breakpoint in the short arm of chromosome 6 was in the p23 region. This deletion could have been caused by a fragile site in 6p23.


Hypoplasia of the corpus callosum and growth hormone deficiency in the XXXXY syndrome.

A 3-year-old Libyan boy with the XXXXY syndrome is described. MRI examination of the brain showed hypoplasia of the corpus callosum. He had growth retardation and endocrine studies demonstrated growth hormone (GH) deficiency. Dermatoglyphic pattern was different from previous reports. At histological examination of the undescended testes, Leydig cells were seen although they are usually not found in this variant of the Klinefelter syndrome.


Child with manifestations of dermotrichic syndrome and ichthyosis follicularis-alopecia-photophobia (IFAP) syndrome.

We report on a boy with short stature, mental retardation, seizures, follicular ichthyosis, generalized alopecia, hypohydrosis, enamel dysplasia, photophobia, congenital aganglionic megacolon, inguinal hernia, vertebral, renal and other anomalies, and a normal chromosome constitution. The clinical findings include all the features that dermotrichic and ichthyosis follicularis-alopecia-photophobia (IFAP) syndrome have in common and in addition those that characterize IFAP syndrome (photophobia, recurrent respiratory infections, etc.), those that are present only in dermotrichic syndrome (nail anomalies, hypohydrosis, megacolon, vertebral defects, etc.) and additional ones (enamel dysplasia, renal anomalies, inguinal hernia, etc.). Two maternal uncles were referred as being affected by alopecia and ichthyosis suggesting X-linked recessive transmission. Various hypotheses concerning the relationship between the 2 syndromes and the present case are discussed.


Tentative assignment of a locus for Rubinstein-Taybi syndrome to 16p13.3 by a de novo reciprocal translocation, t(7;16)(q34;p13.3).

During a systematic chromosomal survey of 7 unrelated patients with Rubinstein-Taybi syndrome, an apparently balanced de novo reciprocal translocation, t(7;16)(q34;p13.3), was detected in an affected boy. The involvement of the region 16p13.3 coincides with the position of one of the breakpoints in another de novo reciprocal translocation associated with Rubinstein-Taybi syndrome, suggesting that a locus for this syndrome maps to 16p13.3.


Ten milestone issues in AOTA history.

This paper identifies 10 professional questions that the author has labeled milestone issues in the history of the American Occupational Therapy Association. Subjects encompassed by these issues are medical control, certified occupational therapy assistants, licensure, proficiency testing, entry-level degrees, treatment media, maintenance of competency, whether occupational therapists serve patients or clients, professional autonomy, and the status of occupational therapy as a profession. Although this paper is primarily a factual record of events and discussions referenced in official publications, the reader will recognize the insertion of author commentary and opinion in several of the issues discussed.


Use of adjunctive modalities in occupational therapy.

This article reminds us that as practice evolves, we must revisit and reaffirm the fundamental philosophy and precepts in which our profession is grounded. The face of practice is fluid. Its superficial appearance is molded by external forces and stresses. These include the changes in the needs of the persons we serve, the emergence of new and different treatment modalities, and the realities of the socioeconomic environment in which we work. Beneath the surface, however, are the basic structures that all of us hold in common. These are our philosophical beliefs that are articulated both in the professional literature and in the ethical principles that we espouse.


Statement: occupational therapy services in work practice.

Occupational therapy practitioners focus on the individual's ability to participate in productive occupations throughout their life span. Through prevention, assessment, and intervention strategies, occupational therapy practitioners often collaborate with other members of the health care team and assist persons to optimize their ability to engage in purposeful occupation while facilitating a safe and successful entry into or return to work.


The US decline in stroke mortality: what does ecological analysis tell us?

We review a study in this issue that concludes, from analyses of ecological associations, that the use of medication to lower high blood pressure has caused at most a small decline in US stroke mortality rates. Our analysis suggests that other possible sources of the decline may be population-wide falls in levels of blood pressure, cigarette smoking, and coronary heart disease mortality, as well as improved treatment of cardiac and respiratory sequelae of stroke. Although the ecological method is powerful for answering questions about medical interventions' population-wide effects on disease, it must be used with care. Of particular concern are variables with meanings that differ between the ecological and the individual levels, the number of ecological units available for analysis, the sample size within the ecological units, and the range of independent variables used in ecological regression.


Antihypertensive treatment and US trends in stroke mortality, 1962 to 1980.

This study examines the association between increases in antihypertensive pharmacotherapy and declines in stroke mortality among 96 US groups stratified by race, sex, age, metropolitan status, and region from 1962 to 1980. Data on the prevalence of controlled hypertension and socioeconomic profiles were obtained from three successive national health surveys. Stroke mortality rates were calculated using data from the National Center for Health Statistics and the Bureau of the Census. The association between controlled hypertension trends and stroke mortality declines was assessed with weighted regression. Prior to 1972, there was no association between trends in controlled hypertension and stroke mortality declines (beta = 0.04, P = .69). After 1972, groups with larger increases in controlled hypertension experienced slower rates of decline in stroke mortality (beta = 0.16, P = .003). Faster rates of decline were modestly but consistently related to improvements in socioeconomic indicators only for the post-1972 period. These results do not support the hypothesis that increased antihypertensive pharmacotherapy has been the primary determinant of recent declines in stroke mortality. Additional studies should address the association between declining stroke mortality and trends in socioeconomic resources, dietary patterns, and cigarette smoking.


Correlates of nonadherence to hypertension treatment in an inner-city minority population.

Adherence to treatment is a key factor in achieving blood pressure control among hypertensives. We examined correlates of nonadherence to hypertension treatment in an inner-city minority population. Subjects (n = 202) were interviewed as part of a case-control study of severe, uncontrolled hypertension conducted in two New York City hospitals in 1989-91. All subjects were African American or Hispanic. Self-reported nonadherence to drug treatment for hypertension was measured using a five-item scale, and the sample was dichotomized as more (n = 87) or less (n = 115) adherent. Multiple logistic regression analysis was used to adjust for demographic and other covariates. Nonadherence was associated with having blood pressure checked in an emergency room (adjusted odds ratio [OR] = 7.9; 95% confidence interval [CI] = 1.75, 35.77; P < .01), lack of a primary care physician (adjusted OR = 2.9; 95% CI = 1.37, 6.02; P < .01), current smoking (adjusted OR = 2.4; 95% CI = 1.10, 5.22; P = .03), and younger age (adjusted OR = 1.03, 95% CI = 1.00, 1.06; P = .03). Changing the locus of care for hypertension from emergency rooms to primary care physicians may improve adherence to hypertension treatment in minority populations.


Obesity and cardiovascular disease risk factors in black and white girls: the NHLBI Growth and Health Study.

Obesity may be a possible explanation for the higher cardiovascular disease mortality in Black women compared with White women. The National Heart, Lung, and Blood Institute Growth and Health Study (NGHS) is designed to assess factors associated with the development of obesity in Black and White preadolescent girls and its effects on major cardiovascular-disease risk factors. NGHS is a 5-year cohort study of 2379 girls, aged 9 through 10 years at entry. Anthropometry, blood pressure, and maturation staging are measured annually, and blood lipids biannually. Information on education, income, and family composition is also obtained from parents. At baseline, compared with White girls, Black girls were slightly older, biologically more mature, taller, heavier, and had higher Quetelet Indices, skinfolds, and blood pressures. Black girls had lower triglycerides and higher HDL cholesterol than White girls. Total cholesterol and LDL cholesterol were similar in the two groups. Baseline descriptive characteristics of the NGHS cohort showed that, in subjects aged 9 and 10 years, racial differences in obesity and blood pressure were already present.


Correlates of obesity in young black and white women: the CARDIA Study.

Although differences in obesity between Blacks and Whites are well documented in adult women, less information is available on potential correlates of these differences, especially in young adults. The association between behavioral and demographic factors and body size was assessed in 2801 Black and White women aged 18 to 30 years. Black women had significantly higher age-adjusted mean body mass index and subscapular skinfold thickness than did White women. Obesity had different associations with age and education across racial groups. A positive relationship between age and obesity was seen in Black women but not in White women, whereas a negative association between education and body size was noted only in White women. Potential contributing factors to the increased prevalence of obesity in Black women include a more sedentary lifestyle, higher energy intake, earlier menarche, and earlier age at first childbirth. The difference in obesity across race could not be explained completely by these factors, since within virtually all strata, Black women had higher body mass indexes. Further investigation is needed to develop interventional strategies to prevent or reduce excess levels of obesity in Black women.


HMO vs fee-for-service care of older persons with acute myocardial infarction.

Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.


Assessing providers of coronary revascularization: a method for peer review organizations.

Current methods to evaluate quality of care are usually limited to reviews of individual cases or comparisons of hospital mortality rates. We present an alternative method that compares complication rates adjusted for patient characteristics. Detailed clinical data that were specifically designed for quality comparisons of providers of revascularization procedures were abstracted from the medical records of 1998 Medicare patients, in 16 hospitals, who had coronary artery bypass surgery and 2091 patients, in 16 hospitals, who had angioplasty. Providers were ranked on the basis of an unadjusted risk, a risk adjusted for detailed clinical information, and a risk adjusted only for patient comorbidities. Complication rates differed significantly and substantially among the hospitals. Clinical adjustment changed the hospital rankings for the bypass surgery hospitals, but not for the angioplasty hospitals. Adjustment for comorbidities did not affect hospital rankings for either procedure. When sample sizes are limited, adverse outcome rates may be a more sensitive measure of quality of care than mortality rates. Rates that are unadjusted or adjusted only for comorbidities may be inadequate for evaluating some providers of bypass surgery.


The mortality of lead smelter workers: an update.

Mortality studies of lead workers have shown excesses of nonmalignant renal disease and cerebrovascular disease. Animal studies and one human study have shown excess kidney cancer. We have updated a mortality study of male lead smelter workers (n = 1990). An analysis was conducted using standard life table techniques. The updated analysis added 11 years of follow-up and 363 new deaths. The original study had found elevated but nonsignificant risks for kidney cancer, stroke, and nonmalignant renal disease, probably attributable to lead exposure. Deaths from accidents and nonmalignant respiratory disease were significantly elevated, but probably not as a result of lead exposure. In the updated study, no new deaths from nonmalignant renal disease occurred (9 observed, standardized mortality ratio = 1.21). Three more deaths from kidney cancer were observed, yielding a standardized mortality ratio of 1.93 (9 observed, 95% CI = 0.88, 3.67), which increased for those who had worked in areas with the highest lead exposure (8 observed, standardized mortality ratio = 2.39, 95% CI = 1.03, 4.71). Cerebrovascular disease remained elevated for those with more than 20 years of exposure (26 observed, standardized mortality ratio = 1.41, 95% CI = 0.92, 2.07). This cohort with high lead exposure showed a diminishing excess of death from nonmalignant renal disease, a continued excess from kidney cancer, and an excess of cerebrovascular disease only in those with longest exposure to lead.


US National Health Data on Asian Americans and Pacific Islanders: a research agenda for the 1990s.

In spite of over 30 years of periodic nationwide surveys, we have thus far only the most rudimentary estimates of the determinants of the health of Asian Americans and Pacific Islanders. This paper explores ways to improve the capability of the National Center for Health Statistics (NCHS) to collect national health data on these populations. The NCHS "race" coding practices are reviewed, their limitations stated, ways to improve the numerator and denominator data discussed, and a research agenda presented. Resources can be intensified to produce better denominator data, and to improve the collection of detailed ethnicity information for the numerators, in at least the three states (California, New York, and Hawaii) where the majority of Asian/Pacific Islanders lived in 1990. Subsequently, these efforts should be extended to the 10 states where 79% of these individuals reside or to the top 15 metropolitan areas where they are concentrated. If the recommendations are implemented, several coordinated multisite, multiwave epidemiologic surveys can be conducted using standardized interview instruments and data collection procedures that will capitalize on the geographic distribution of Asian/Pacific Islanders.


Planning professional education at schools of public health.

Professional education in public health should equip graduates with adequate knowledge and skills to manage diverse and complex problems. How best to address this challenge is widely debated. We describe the Harvard School of Public Health's self-evaluation and development of a practice-oriented program. As part of Harvard's schoolwide review of the master of public health (MPH), self-administered questionnaires were distributed to all MPH students, 1987 to 1989, and international and US alumni, 1979 to 1986. Extensive discussions were conducted with relevant student and faculty groups. Survey results provided a basis for educational policy and curricular changes that culminated in a revised MPH that targets key areas of public health practice. Examples from the Harvard experience are provided. Information derived from student and alumni surveys can be highly effective in the process of guiding curricular change at schools of public health. This should be coupled with a strategic approach to gain faculty support for proposed innovations. Ongoing monitoring and modification of the new curriculum is essential.


Ultraviolet light exposure and lens opacities: the Beaver Dam Eye Study.

Exposure to sunlight may be a risk factor for the development of cataract. The relationships between exposure to sunlight and to the ultraviolet-B (UVB) component of light and the prevalence of lens opacities were examined in the Beaver Dam Eye Study. Persons 43 to 84 years of age residing in Beaver Dam, Wisconsin, were examined using standardized photographic assessments of lens opacities. A questionnaire about medical history and exposure to light was administered. After adjusting for other risk factors, men who had higher levels of average annual ambient UVB light were 1.36 times more likely to have more severe cortical opacities than men with lower levels. However, UVB exposure was not found to be associated with nuclear sclerosis or posterior subcapsular opacities in men. Moreover, no associations with UVB exposure were found for women, who were less likely to be exposed to UVB. Exposure to UVB light may be associated with the severity of cortical opacities in men. However, the lack of an association in women, the group more likely to have cortical opacities, suggests that other factors may be more important in the pathogenesis of lens opacities.


The social impact of dental problems and visits.

The purpose of this analysis was to assess selected social consequences of maintaining oral health and treating oral diseases. The associations among socioeconomic and demographic factors with time lost from work or school and reductions in normal activities are explored. Data were gathered as part of the 1989 National Health Interview Survey from 50,000 US households (117,000 individuals), representing 240 million persons. The oral health care supplement was analyzed using the software SUDAAN to produce standard errors for estimates based on complex multistage sample designs. Because of dental visits or problems, 148,000 hours of work were lost per 100,000 workers, 117,000 hours of school were lost per 100,000 school-age children, and 17,000 activity days beyond work and school time were restricted per 100,000 individuals in 1989. Exploratory analyses suggest that sociodemographic groups have different patterns of such time loss and of reduced normal activities. Overall, there is low social impact individually from dental visits and oral conditions. At the societal level, however, such problems and treatments among disadvantaged groups appear to have a greater impact.


Lead exposure in the construction industry: results from the California Occupational Lead Registry, 1987 through 1989.

The construction industry is exempt from the medical monitoring portions of the US Federal Occupational Safety and Health Administration General Industry Lead Standard. Of 28 construction workers reported to the California Occupational Lead Registry through March 1989, 11 (39%) had blood lead levels of 2.90 mumol/L (60 micrograms/dL) or greater, the level at which immediate removal from lead exposure is mandated in nonconstruction industries. Many workers had not been warned of possible lead exposure. The exemption of the construction industry from the General Industry Lead Standard should be reconsidered.


Potential lead exposures from lead crystal decanters.

We measured the concentrations of lead leached into 4% acetic acid, white port, and a synthetic alcoholic beverage that were stored in lead crystal decanters for 1-, 2-, and 10-day periods at room temperature. In decanters from 14 different manufacturers, measured lead concentrations ranged from 100 to 1800 micrograms/L. The pH of the leaching medium is probably the dominant factor determining the extent of lead leached, with greater leaching occurring at lower pH values. The consumption of alcoholic beverages stored in lead crystal decanters is judged to pose a hazard.


Hair dye use and multiple myeloma in white men.

In recent reports, multiple myeloma has been linked to use of hair coloring products containing mutagenic and carcinogenic chemicals. A population-based case-control study in Iowa of 173 White men with multiple myeloma and 650 controls obtained information on hair dye use. Risk of multiple myeloma was significantly elevated (OR = 1.9) among hair dye users and was greatest among those using hair dyes at least once a month for a year or more (OR = 4.3). These data, along with results from other studies, suggest that use of hair dyes contributes to the development of multiple myeloma.


Men's disclosure of HIV test results to male primary sex partners.

We evaluated disclosure of human immunodeficiency virus (HIV) antibody status to a main sex partner and the impact on the relationship in men who have sex with men and who are enrolled in the Acquired Immunodeficiency Syndrome (AIDS) Community Demonstration Projects cohorts. Eighty-nine percent of both seronegative and seropositive men disclosed the results to their main sex partner. Seventy percent of the seronegative men and 82% of the seropositive men who did so reported that the relationship remained "as strong as ever" after 6 months. Most men who did not disclose their test results to their main partner reported being "single" after 6 months.


Trends in tans and skin protection in Australian fashion magazines, 1982 through 1991.

We rated 3971 photographs of models from midsummer editions of six Australian fashion magazines from 1982-1983 to 1990-1991 for tan on a 9-point scale, for the presence of hats, for sun-protective clothing, and for shade setting. With the exception of the 1990-1991 sample, there was an increasing proportion of light tans over the years. Men were more likely to be deeply tanned than were women. The proportion of models wearing hats followed an increasing linear trend across the five periods. Three quarters of the outdoor photographs were taken in unshaded settings. In unshaded settings, 17% of the women and 5% of the men wore hats.


The slavery hypothesis for hypertension among African Americans: the historical evidence.

The slavery hypothesis for hypertension has stated that the high blood pressures sometimes measured in African Americans are caused by one or more of these conditions: first, salt deficiency in the parts of Africa that supplied slaves for the Americas; second, the trauma of the slave trade itself; third, conditions of slavery in the United States. A review of the historical evidence shows that there was no salt deficiency in those parts of Africa, nor do present-day West Africans have a high incidence of hypertension. Historical evidence does not support the hypothesis that deaths aboard slave ships were caused mainly by conditions that might be conductive to hypertension, such as salt-depleting diseases. Finally, the hypothesis has depended heavily on evidence from the West Indies, which is not relevant for the United States. There is no evidence that diet or the resulting patterns of disease and demography among slaves in the American South were significantly different from those of other poor southerners.


Ultrasonography of chronic tendon injuries in the groin.

Ultrasonography was used in the diagnosis of 36 patients with chronic groin pain localized to the tendons of the rectus abdominis, rectus femoris, adductor muscles, hamstring muscles, and the gluteal muscles. Abnormal findings, such as focal sonolucent areas and discontinuity of tendon fibers, that are indicative of nonhealed partial ruptures were found in 28 patients. These findings differed clearly from the asymptomatic contralateral side, which was used for comparison. The abnormalities were located in three different sites: at the tendon insertion, within the tendon, and at the tendomuscular junction. Ten patients were treated surgically and the findings at surgery correlated well with the ultrasonographic findings of partial tendon tears: 9 were true-positive and 1 was a true-negative. Ultrasonography appears to be a valuable method in the diagnosis of chronic groin pain.


Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes.

Eighteen tenotomies of the adductor longus tendon were performed in 16 consecutive male athletes (aged 20 to 42) as treatment for chronic groin pain. The criteria for surgery was a history of long-standing (range, 2.5 to 48 months) and distinct pain at the origin of the adductor longus muscle, refractory to conservative treatment. At followup 35 months (range, 4 to 84) after surgery, all patients were improved or free of symptoms. All but 1 of the athletes returned to the same sport within a mean of 6.6 weeks, and 12 of 16 returned to competitive sports within a mean of 14 weeks after surgery. A majority of the patients (10 of 16) returned to full athletic activity, whereas 5 of 16 performed at a reduced level. One patient discontinued his sports activity due to other causes. In conclusion, when conservative treatment fails, tenotomy of the adductor longus tendon gives good long-term functional results in the treatment of chronic groin pain that is localized at the origin of the adductor longus muscle. A decreased muscle strength was observed in this study and did not seem to influence participation in sports.


Meniscal transplantation using fresh and cryopreserved allografts. An experimental study in goats.

A comparative study of three subgroups of meniscal transplants was undertaken in the goat model: Group 1 (autograft) involved removal and immediate reimplantation of the meniscus; Group 2, fresh meniscal allografts; and Group 3, cryopreserved (30 days) meniscal allografts. Six months after surgery, tissues were evaluated for gross degenerative changes, proteoglycan concentration (as assessed by uronic acid), water content, vascularity, histology, and cell viability. The contralateral knee served as control for all comparisons. There was no statistical difference in the amount of arthritis present and all transplants demonstrated an essentially normal peripheral vascularity compared to controls. Sections revealed reduced numbers of cells in the central portions of the transplanted menisci and these viable cells demonstrated different behavior in multiplication in tissue culture compared to contralateral controls. Grossly and microscopically, the implanted menisci differed little from the controls. The measurement of proteoglycan concentration and water content of the transplanted meniscal cartilage suggest alterations that may affect the long-term mechanical properties. The autograft specimens showed the water content was very slightly increased (3% to 6%), while the proteoglycan concentration was increased (42% in terms of uronic acid). In contrast, the water content of the fresh allograft group and the cryopreserved group was increased 12% to 24%. Proteoglycan concentration in these groups was decreased up to 56% in portions of some menisci compared to controls. Fresh and cryopreserved meniscal allografts showed peripheral healing, revascularization, cellularity, and incorporation, and grossly appeared good at 6 months in the goat model. The biochemical changes in the extracellular matrix at 6 months raises questions on the long-term function of these transplanted menisci.


Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography.

Eighty-two athletes with 86 clinical navicular stress fractures, all imaged with computerized tomography, were followed for an average of 33 months (range, 6 to 108) after diagnosis. Initial treatment consisted of at least 6 weeks of nonweightbearing cast immobilization for 22 fractures, at least 6 weeks of limitation of activity with continued weightbearing for 34 fractures, and a period of less than 6 weeks of conservative treatment for another 19 fractures. Five patients attempted to continue playing sports. Six patients had immediate surgery. Nineteen of 22 patients (86%) who had initial non-weightbearing cast immobilization treatment returned to sports, compared with only 9 of 34 patients (26%) who initially continued weightbearing with limited activity (P < 0.001). After failure of the latter treatment, successful outcomes were seen for 6 of 7 patients (86%) treated with nonweightbearing cast immobilization, while 11 of 15 patients (73%) who had one surgical procedure were able to return to sports. These results indicate that nonweightbearing cast immobilization is the treatment of choice for navicular stress fractures. Also, this treatment compares favorably with surgical treatment for patients who present after failed weightbearing treatments. Computerized tomographic appearances of healing fractures do not necessarily mirror clinical union, and postimmobilization management should be monitored clinically.


Augmented repair and early mobilization of acute anterior cruciate ligament injuries.

This paper describes a technique for repair of the anterior cruciate ligament with protection of that repair by a synthetic augmentation device. Of 61 patients who underwent surgery 24 to 57 months (mean, 38.3) before data accumulation, 57 returned for followup. Subjectively, 53 (93%) patients reported a good or excellent functional result; however, only 29 (51%) of the patients returned to their preinjury sports level. Objectively, a radiographic Lachman test was performed on both the injured and the noninjured knee of all 57 patients. The preoperative mean difference between the knees was 8.6 mm (range, 4.6 to 17.2) and at followup it was 2.4 mm (range, -0.9 to 11.8). Radiographic abduction and adduction stress tests demonstrated stable healing of the (unrepaired) collateral ligament lesions (varus stress = 0.1 mm and valgus stress = 0.4 mm mean side-to-side difference), indicating that suturing of ruptured collateral ligaments is not necessary when the knee is centrally stabilized with the augmentation device. These results indicate that successful repair of the anterior cruciate ligament is frequently possible when enhanced with an augmentation device.


Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint.

The purpose of this study was to determine the contributions of specific capsuloligamentous structures to restraining superior-inferior translation of the glenohumeral joint. Eleven cadaveric shoulders were tested using a four degrees-of-freedom test apparatus. The humerus was free to translate in three planes and free to flex and extend when a superior and inferior force of 50 N was applied. Testing was performed in three positions of abduction (0 degree, 45 degrees, and 90 degrees) and three positions of rotation (neutral, maximum internal, and external). Shoulders were tested intact, vented, and after division of specific capsuloligamentous structures. The primary restraint to inferior translation of the adducted shoulder was the superior glenohumeral ligament. The coracohumeral ligament appeared to have no significant suspensory role. With progressive abduction, the anterior and posterior portions of the glenohumeral ligament become the main static stabilizers resisting inferior translation: the anterior portion was the primary capsular restraint at 45 degrees of abduction, while the posterior portion was the primary restraint at 90 degrees of abduction, neutral rotation. Our results indicate that clinical assessment of glenohumeral translation in the superior-inferior plane should be performed in multiple positions of abduction and rotation.


A multivariate risk analysis of selected playing surfaces in the National Football League: 1980 to 1989. An epidemiologic study of knee injuries.

This study focuses on the injury rates for natural grass and AstroTurf surfaces and the risk factors of game position and type of play. We examined the game-related knee sprains, medial collateral ligament sprains, and anterior cruciate ligament sprains that occurred in the National Football League during the 1980 to 1989 seasons. The findings are controlled for categories of severity (number of games missed due to injury), position, and situation (rushing or passing) at the time of injury. The analysis of the data incorporates epidemiologic techniques associated with incidence density ratios. The data show that there is a statistically significant difference between the higher AstroTurf injury rates for knee sprains. When knee sprains are separated into medial collateral ligament sprains and anterior cruciate ligament sprains, only the anterior cruciate ligament sprains show a statistically significant higher injury rate for AstroTurf. When simultaneous control variables are considered, significantly more knee sprains occurred to backs on rushing plays and linemen on passing plays. When controlling the data for severity, only the Category II injuries (three or more games missed) sustained by linemen on passing plays had statistically significant higher injury rates for the AstroTurf. For medial collateral ligament sprains, only the Category II injuries for linemen on passing plays remain statistically significant. The data for the ACL sprains show statistically significant differences between the injury rate on natural grass and the injury rate on Astro Turf under conditions of special teams play.


A prospective comparison of computerized arthrotomography and magnetic resonance imaging of the glenohumeral joint.

Twenty-five patients with shoulder instability or shoulder pain of undetermined etiology were prospectively evaluated with magnetic resonance imaging and computerized arthrotomography. Actual lesions were determined by arthroscopy or at the time of open surgical repair. The images obtained were interpreted independently by three radiologists blinded to both surgical results and the results of previous diagnostic tests. Sensitivity, specificity, and accuracy were determined for each imaging technique for a variety of pathologic entities, including anterior and posterior labral abnormalities, capsular redundancy, biceps-labral complex abnormalities, humeral head (Hill-Sachs) impression lesions, and glenohumeral loose bodies. Analysis of imaging techniques also included construction of receiver operator curves for labral abnormalities. Magnetic resonance imaging showed better diagnostic results in the evaluation of glenoid labral and humeral head impression lesions (P < 0.05). Both imaging techniques were equally successful in identifying biceps-labral lesions and intraarticular loose bodies within the glenohumeral joint. Neither imaging technique was consistent in the evaluation of capsular redundancy. Receiver operator curve analysis confirmed that magnetic resonance imaging was the more accurate imaging study in evaluating anterior and posterior glenoid labral abnormalities.


Arthroscopic labral debridement. A three-year follow-up study.

This is a retrospective review of 40 patients who underwent arthroscopic labral debridement of the shoulder. All patients were active participants in sports involving use of the shoulder. All patients presented with shoulder pain. Only 40% were found to have distinct glenohumeral instability on examination. At surgery, all patients had labral injury. Ten patients had anterosuperior labral tears, 20 had anteroinferior labral tears or detachments, and 10 had posteroinferior labral tears or detachments. Outcome was assessed at a minimum of 2 years (average, 43 months) postoperatively. Overall, only 7% of the patients had significant symptomatic relief at followup. However, 72% noted relief of symptoms during the 1st year after surgery, but there was deterioration over time. Arthroscopic labral debridement is not an effective long-term solution for symptomatic relief in the overhead athlete.


The anterior cruciate ligament-deficient knee with varus alignment. An analysis of gait adaptations and dynamic joint loadings.

Thirty-two patients with an ACL-deficient knee and lower limb varus alignment and 16 healthy controls were analyzed during level walking using a force-plate and optoelectronic system. The forces and moments of the lower limb and knee joint were measured and knee joint loads and ligament tensile forces were calculated using a mathematical model. The majority of patients (20 of 32) had an abnormally high adduction moment at the affected knee. The adduction moment showed a statistically significant correlation to high medial tibiofemoral compartment loads and high lateral soft tissue forces, but not to the degree of varus alignment on standing roentgenograms. Fifteen of 32 knees had abnormally high lateral soft tissue forces. We interpreted these gait findings as indicative of a medial shift in the center of maximal joint pressure and an increase in lateral soft tissue forces to achieve coronal plane stability. Further, there is the likelihood of separation of the lateral tibiofemoral joint and "condylar lift-off" during periods of the stance phase. If this occurs, all of the load-bearing forces would shift to the medial tibiofemoral joint and relatively large tensile forces would occur in the lateral soft tissue restraints. The flexion moment, as related to the quadriceps muscle force, was significantly lower than the control knees in 40% of the involved knees, and the extension moment, as related to the hamstring muscle force, was significantly higher in 50% of the involved knees. We interpret this finding as a gait adaptation tending to diminish quadriceps muscle activity and enhance hamstring muscle activity to provide dynamic anteroposterior stability of the knee joint. The fundamental assumption of this paper is that any combination of conditions leading to higher medial joint forces is associated with factors leading to more rapid degeneration of the medial compartment in patients with ACL deficiency, varus deformity, and lax lateral ligaments.


Psychological moods and subjectively perceived behavioral and somatic changes accompanying anabolic-androgenic steroid use.

To assess physiological and psychological states accompanying anabolic-androgenic steroid use, male weight lifters 1) were interviewed regarding their physical training and the patterns and effects of any drug use; 2) completed a written physical and medical history questionnaire, a Profile of Mood States questionnaire, and the Buss-Durkee Hostility Inventory; and 3) were physically examined, including a blood sample and urinalysis. Subjects were divided into current anabolic-androgenic steroid users (N = 12), previous users (N = 14), and nonusers (N = 24). Current and previous users reported the following changes associated with anabolic-androgenic steroid use: increases in enthusiasm, aggression, and irritability; changes in insomnia, muscle size, muscle strength and density; faster recovery from workouts and injuries; and changes in libido. We were unable to confirm these interview and physical and medical history questionnaire responses using standardized and well-accepted psychological inventories. There were no significant differences among groups for any Profile of Moods factor, total mood disturbance, total Buss-Durkee Hostility Inventory score, or any subscale. For current users, there were no significant correlations between either total weekly drug dose or length of time on the current cycle of anabolic-androgenic steroids and any individual scale of the Profile of Mood States, Buss-Durkee Hostility Inventory, Profile of Mood States total mood disturbance, or composite Buss-Durkee Hostility Inventory score. Furthermore, anabolic-androgenic steroid users did not differ in their responses on these inventories from nonusers or from general population norms.(ABSTRACT TRUNCATED AT 250 WORDS)


Magnetic resonance imaging of the posterior cruciate ligament. Clinical use to improve diagnostic accuracy.

This study was undertaken to determine the accuracy of magnetic resonance image scanning in detecting posterior cruciate ligament injury, and to determine those clinical situations where it can add the most useful information. A retrospective study was conducted on 201 patients who underwent surgery after magnetic resonance scanning of their knees. Two additional patients who did not have surgery but had clinical findings grossly positive for posterior cruciate ligament injury were included in the analysis of magnetic resonance imaging accuracy. In all, there were 190 intact and 13 torn posterior cruciate ligaments. In a review of the clinical findings in the 11 patients with surgically documented tears, we found that all 11 had positive magnetic resonance scans. In 4 of the 11, magnetic resonance imaging provided especially useful information regarding the status of the ligament. For the 190 normal ligaments, there were no false-positive scans; for the 13 torn ligaments, there were no false-negative scans. Therefore, specificity and sensitivity estimates for this group were both 100%. Magnetic resonance imaging proved to be an accurate modality for evaluating the integrity of the posterior cruciate ligament. If used in the proper setting, it can provide useful information for diagnosing posterior cruciate ligament injuries.


The effect of harvesting the central one-third of the patellar tendon on patellofemoral contact pressure.

This study assessed whether removing the central one-third of the patellar tendon, with or without side-to-side repair of the patellar tendon defect, would alter patellofemoral pressure. Patellofemoral pressure was assessed by testing five stable knees from five different cadaveric donors on a specially designed hydraulic knee machine. Patellofemoral joint pressures were measured by placing pressure-sensitive film into the patellofemoral articulation. The joint was loaded in a static fashion, with quadriceps forces consistent with walking (647 N) and stair climbing (1923 N), at 30 degrees, 60 degrees, and 90 degrees of knee flexion. Using the same knees, the central one-third of the patellar tendon was then sectioned, and patellofemoral joint pressure measurements were repeated at identical knee flexion angles and quadriceps-forces. Side-to-side repair of the patellar tendon defect was performed and patellofemoral joint pressure measurements were repeated. There were no statistically significant differences between the control and sectioned values or between the control and repaired defect values. These results suggest that harvesting the central one-third of the patellar tendon--with or without side-to-side repair of the patellar tendon defect--does not alter patellofemoral pressures.


A biomechanical evaluation of the iliotibial tract screw tenodesis.

Biomechanical testing of the iliotibial tract screw tenodesis was performed in 10 cadaveric knees under forces approximating in vivo conditions. Force versus displacement curves at various flexion angles were generated with the anterior cruciate ligament intact, with the anterior cruciate ligament sectioned, and after the iliotibial tract screw tenodesis had been performed. Displacement force was measured to 5, 10, and 15 mm. The iliotibial tract screw tenodesis was ineffective in reducing anterior translation of the tibia in the anterior cruciate ligament-deficient knee at forces approximating in vivo conditions.