During adolescence, teenagers are expected to develop standards of behavior and reconcile them with their perceptions of adult standards. In this context, music, a powerful medium in the lives of adolescents, offers conflicting values. The explicit sexual and violent lyrics of some forms of music often clash with the themes of abstinence and rational behavior promoted by adult society. Identification with rock music, particularly those styles that are rejected by adults, functions to separate adolescents from adult society. Some forms of rock music extend well beyond respectability in fulfilling this definitional role. Total immersion into a rock subculture, such as heavy metal, may be both a portrait of adolescent alienation and an unflattering reflection of an adolescent's perception of the moral and ethical duplicity of adult society. Physicians should be aware of the role of music in the lives of adolescents and use music preferences as clues to the emotional and mental health of adolescents.

In light of the recent growth in public financial support for the rapid expansion of drug abuse treatment capacity, the unique effectiveness of methadone hydrochloride treatment in reducing intravenous opioid abuse and the associated sharing of injection equipment is reviewed and discussed, and its potential effect on preventing the spread of acquired immunodeficiency syndrome is examined. In addition to methadone, treatment variables that clinical research suggests are integral to effective treatment are identified. Methadone treatment is one of the most helpful means of reducing the risk of acquired immunodeficiency syndrome available, provided that programs of quality are expanded. The medical profession and universities are urged to take steps to ensure quality effort in prevention and treatment.

Early medical intervention in human immunodeficiency virus disease has far-reaching implications for the health care system of the United States. Several factors are enabling the medical community to begin intervention prior to a patient's diagnosis of acquired immunodeficiency syndrome. These factors include an understanding of the biologic markers of disease progression; advances in antiviral therapeutics; and an improved ability to control the most common presenting opportunistic infection, Pneumocystis carinii pneumonia. Providing adequate ambulatory care for large numbers of asymptomatic human immunodeficiency virus-infected individuals and coordinating inner-city health care facilities will become critical. Important questions regarding service provision need to be adequately addressed. The cost of yearly treatment, estimated to be $5 billion per year, will require a major financial commitment at all levels of government and the private sector. Effective early intervention in human immunodeficiency virus disease may alter the course of one of the most devastating epidemics in modern history. Planning for its implementation should begin immediately.

The automatic implantable cardioverter defibrillator was conceived by Mirowski as an implantable device for detection and termination of ventricular fibrillation. Since the initial human implant of the defibrillator in 1980, there has been a dramatic expansion of the clinical experience with more than 5000 implants. The technology of the device, which is now capable of sensing and terminating both ventricular tachycardia and fibrillation, has evolved rapidly. Although still not an ideal antiarrhythmic device, it has already had a major impact on arrhythmic mortality with a marked reduction in the sudden death rates in a high-risk patient population.

Large numbers of homeless adolescents can be found in this country, with estimates of their numbers ranging from 500,000 to more than 2 million. Some are runaways while others are involuntarily without shelter, often having been forced out of their homes. Most receive no help from social service agencies and their lack of skills forces them into a marginal existence, leaving them vulnerable to abuse and victimization. Health problems are numerous and health care is generally inadequate for several reasons, including a lack of treatment facilities, the behavior of the adolescents themselves, the ability of providers to deal with such youths, and the questionable legal status of homeless adolescents. The Council on Scientific Affairs urges that reliable and up-to-date data on the extent of homelessness among adolescents and the nature of their needs be generated and that guidelines for the medical care of such youths be developed.

Using criteria adopted by the US Preventive Services Task Force, we evaluated use of the dipstick urinalysis to screen for bacteriuria. When the leukocyte esterase and nitrite dipstick tests are combined, the positive predictive value for detecting bacteriuria exceeded 12% in groups with a 5% or higher prevalence of bacteriuria: women who are pregnant, diabetic, or over 60 years of age and all institutionalized elderly. Conventional antimicrobial regimens for asymptomatic bacteriuria have proved efficacious only for pregnant women. We conclude that pregnant women should be screened for bacteriuria, but with the more sensitive urine culture, because treatment prevents serious fetal and maternal sequelae. Dipstick screening may be justified in women who are over 60 years of age or diabetic. The prevalence of bacteriuria in other groups is too low to justify screening.

We review evidence on the value of dipstick urinalysis screening for hemoglobin and protein in asymptomatic adults. In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory and no recommendation can presently be made for or against hematuria screening. A population-based randomized, controlled trial of hematuria screening in the elderly is urgently needed. Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders.

An integrated view of the pathogenesis of scleroderma should include vascular, immunologic, and fibrotic processes. This review introduces the mast cell into this picture, emphasizing recent knowledge gained from a study of experimental chronic graft-vs-host disease and scleroderma itself. In both of these situations, increased mast cell activity occurs. A link between the activation of both endothelial cells and fibroblasts may be provided by the family of heparin-binding growth factors. These cytokines are produced by many cells and are bound, protected, and enhanced by heparin, which may be provided by the activated mast cells. These and other growth factors may be responsible for endothelial proliferation and excess collagen production by fibroblasts. This enlarged schema should provide additional points for therapeutic intervention in scleroderma.

The DATTA panelists did not achieve a definitive consensus on the use of chymopapain chemonucleolysis for a protruding lumbar disk contained by the annulus. Concerns about safety, especially the risk of anaphylaxis and the risk of damage to the spinal cord, were frequent. The effectiveness of this procedure for this indication was also questioned by many of the panelists. The panel did agree that chemonucleolysis is unacceptable as either safe or effective for use in patients with a herniated lumbar disk that is extruding nucleus pulposus through the annulus. Accordingly, diagnostic imaging of any suspect disk must be performed before chemonucleolysis can be deemed appropriate for any individual patient. Current imaging techniques are not infallible and cannot confer an absolute sense of security when seeming to indicate a nonextruded protruding disk.

Calcium entry blockers will be increasingly used for the treatment of hypertension. The currently available calcium entry blockers are similar in antihypertensive efficacy but differ in their effects on the atrioventricular node and the degree of peripheral vasodilatory action. The new generation of dihydropyridine calcium entry blockers exhibits more specific vasodilatory actions with a less negative inotropic effect, which may affect their use in patients with congestive heart failure. The responsiveness to these drugs is little affected by race or age. Because of their mild natriuretic action, the concomitant use of dietary sodium restriction or diuretics may be less necessary. Short-term administration of calcium entry blockers preserves or improves renal function; however, their long-term effect has not been documented. Calcium entry blockers have not exhibited protection against coronary heart disease, but experimental evidence supports the continued search for cardioprotection. Calcium entry blockers are important drugs for the treatment of hypertension; the second generation may provide additional benefits because of its more specific pharmacologic actions.

Academic medicine is entrusted by society with the responsibility to undertake several important social missions toward improving the health of the public, including education, patient care, and research. This trust is given implicit authority by generous public funding and considerable autonomy. Medical academia can take pride in its successes, manifested by a premier scientific establishment, the development and use of sophisticated medical technologies and drugs, and the recent dramatic declines in death rates from heart disease and stroke. Academic medicine, however, has been relatively unresponsive to a number of vexing public problems, including skyrocketing expenditures for medical care, substandard indexes of population health, uneven quality of care, an unfavorable geographic and specialty mix of physicians, and widespread disability from long-term medical and psychiatric problems. Although there are many cogent reasons why academic medicine has chosen to define its task relatively narrowly (the nature of its funding successes, the intractability of the social problems, and the attractiveness of the biomedical model), the central issue is how well academic medicine is fulfilling its responsibilities to the public. To the degree that academic medicine defines its central mission narrowly, it may violate its implicit social contract and jeopardize its primary source of financial support. Alternatively, in recognition of its public responsibilities, academic medicine can choose to expand its current activities to be more responsive to the health concerns of the general population.

Under a federal law, each state by January 1, 1993, must provide for safe disposal of its low-level radioactive wastes. Most of the wastes are from using nuclear power to produce electricity, but 25% to 30% are from medical diagnosis, therapy, and research. Exposures to radioactivity from the wastes are much smaller than those from natural sources, and federal standards limit public exposure. Currently operating disposal facilities are in Beatty, Nev, Barnwell, SC, and Richland, Wash. National policy encourages the development of regional facilities. Planning a regional facility, selecting a site, and building, monitoring, and closing the facility will be a complex project lasting decades that involves legislation, public participation, local and state governments, financing, quality control, and surveillance. The facilities will utilize geological factors, structural designs, packaging, and other approaches to isolate the wastes. Those providing medical care can reduce wastes by storing them until they are less radioactive, substituting nonradioactive compounds, reducing volumes, and incinerating. Physicians have an important role in informing and advising the public and public officials about risks involved with the wastes and about effective methods of dealing with them.

The hazards of ionizing radiation have aroused concern since a short time after the discovery of x-rays and natural radioactivity in the 1890s. Misuse of x-rays and radium prompted efforts to encourage radiation safety and to set limits on exposure, culminating in the first recommended "tolerance doses" in 1934. After World War II, the problems of radiation protection became more complex because of the growing number of people subjected to radiation injury and the creation of radioactive elements that had never existed before the achievement of atomic fission. Judging the hazards of radiation became a matter of spirited controversy. Major public debates over the dangers of radioactive fallout from atmospheric bomb testing in the 1950s and early 1960s and the risks of nuclear power generation in later periods focused attention on the uncertainties about the consequences of exposure to low-level radiation and the difficulties of resolving them.

For nearly 50 years, nerve agents have constituted a serious threat that has stimulated extensive efforts to develop effective medical countermeasures. Recent progress in producing pharmacologic defenses suggests that humans can be largely protected from the lethal and prolonged incapacitating effects of these compounds on a chemical battlefield. Current research on new approaches to binding and inactivating nerve agents may further decrease their potential as a threat against protected persons.

The threat of chemical and biological weapons of mass destruction has intensified because of improved delivery systems and advances in chemistry, genetics, and other sciences. Possible US responses to this threat include deterrence, defenses, and/or disarmament, including a reaffirmation of the Biological and Toxin Weapons Convention of 1972, which is now in jeopardy. This article discusses the history of chemical and biological warfare, existing and potential weapons, the proliferation of weapons and delivery systems, ways to prevent the use of these weapons, and ways to protect populations from their effects.

Tear gas has gained widespread acceptance as a means of controlling civilian crowds and subduing barricaded criminals. The most widely used forms of tear gas have been o-chlorobenzylidenemalononitrile and omega-chloroacetophenone. Proponents of their use claim that, if used correctly, the noxious effects of exposure are transient and of no long-term consequences. The use of tear gas in recent situations of civil unrest, however, demonstrates that exposure to the weapon is difficult to control and indiscriminate, and the weapon is often not used correctly. Severe traumatic injury from exploding tear gas bombs as well as lethal toxic injury have been documented. Moreover, available toxicological data are deficient as to the potential of tear gas agents to cause long-term pulmonary, carcinogenic, and reproductive effects. Published and recent unpublished in vitro tests have shown o-chlorobenzylidenemalononitrile to be both clastogenic and mutagenic. Sadly, the nature of its use renders analytic epidemiologic investigation of exposed persons difficult. In 1969, eighty countries voted to include tear gas agents among chemical weapons banned under the Geneva Protocol. There is an ongoing need for investigation into the full toxicological potential of tear gas chemicals and renewed debate on whether their use can be condoned under any circumstances.