YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.

PURPOSE: YouTube is a global medium used predominantly by young adults (aged 18-49 years). This study examined the quality of YouTube information regarding ACL injury and reconstruction. METHODS: YouTube was searched on the 13th of June 2015 for "ACL" and "anterior cruciate ligament" with/without associated terms of "injury", "reconstruction", and "surgery". Videos were evaluated by two independent reviewers [EF (Reviewer 1), (Reviewer 2)] using two recognized information scoring systems (Modified DISCERN (MD) 0-5 and JAMA Benchmark 0-4) and an adaptation of a score designed for written ACL information [ACL Specific Score (ASS) 0-25]. The ASS categorized scores as very good (21-25), good (16-20), moderate (11-15), poor (6-10), and very poor (0-5). Number of views/likes/dislikes, animation, and continent of origin and source (e.g., corporate/educational) were recorded. Correlation of video characteristics with number of views was examined using the analysis of variance (ANOVA) model. Agreement between reviewers was assessed by Interclass Correlation Co-efficient (ICC). RESULTS: Following a filtering process of the 964,770 identified videos, 39 videos were retained. The mean MD score was 2.3 (standard deviation (SD) ±0.9) for Reviewer 1 and 2.2 (SD ±0.9) for Reviewer 2 (ICC = 0.7). The mean JAMA score was 2.5(SD ±0.7) for Reviewer 1 and 2.3 (SD ±0.7) for Reviewer 2 (ICC = 0.8). The mean ASS was 6.3 (SD ±3.5) for Reviewer 1 and 4.6 (SD ±2.9) for Reviewer 2 (ICC = 0.9). Five videos achieved moderate score (13%), while 15 (38%) and 19 (49%) scored as poor and very poor, respectively. There was no correlation between number of views and video quality/video source for any scoring system. CONCLUSION: The majority of videos viewed on YouTube regarding ACL injury and treatment are of low quality.

Lymphocyte ecto-5'-nucleotidase deficiency in agammaglobulinemia.

Fresh peripheral blood lymphocytes from eight patients with congenital agammaglobulinemia demonstrate reduced ecto-5'-nucleotidase activity when compared to the mean activity of normal subjects and patients with other forms of immunoglobulin deficiency. A specific defect of ecto-5'-nucleotidase is further suggested by normal values for lymphocyte ecto-adenosinetriphosphatase and ecto-nonspecific phosphatase. The data provide evidence for an enzyme deficiency in this X-linked, B lymphocyte deficiency syndrome.

Abnormalities in the distribution of serum immunoglobulin concentrations in juvenile rheumatoid arthritis.

Concentrations of serum IgG. IgA, and IgM were determined in 200 patients with juvenile rheumatoid arthritis. The relative frequency distribution of IgG and IgM approached that of a log-normal curve; however, there was marked skewing of the distribution of the serum concentrations of IgA. The prevalence of selective IgA deficiency was 4%. In order to permit further intragroup comparisons, the serum immunoglobulin concentrations were standardized by comparison to a sex-age matched control group. By this process it was found that there was concordance of the serum levels of IgG with IgA, and IgG with IgM. The standardized concentrations of IgA and IgM were less in females than males. The aberration in distribution of serum IgA concentrations found in this study, and the relative inability of females to respond to their disease by increasing specific serum immunoglobulin levels, add further data supporting the concept of immunodeficiency in the pathogenesis of juvenile rheumatoid arthritis.

Immune induction of human monocyte plasminogen activator. Characteristics of an assay for cell-mediated immunity.

We characterized immunologic induction of monocyte plasminogen activator (PA) to determine whether assay for PA induction reliably detected cell-mediated immunity (CMI). Mononuclear leukocytes (MNL) were incubated in teflon-lined culture tubes for 1-4 days in the presence or absence of phytohemagglutinin-P (PHA), concanavalin A (Con A) or Candida antigen. PA activity of the monocytes in those suspensions was then measured using a micro fibrin plate assay. Monocytes in stimulated MNL had more PA activity than monocytes in unstimulated MNL. Maximal differences between stimulated and unstimulated cells were seen after 2 days of culture. Dose-response studies demonstrated that PA induction occurred at submitogenic concentrations of stimuli. Peak induction was seen using suboptimally mitogenic concentrations of PHA, Con A and Candida antigen. PA induction in response to Candida stimulation corresponded with skin test results. More than 90% of healthy adults tested had positive assays to all stimuli. LPS, in picogram concentrations, induced PA activity in the absence of lymphocytes, but such induction was prevented by polymyxin B. Supernates from activated MNL also induced PA in purified monocytes. This indirect assay of PA induction was less sensitive than direct assay of the MNL. A standard indirect assay for leukocyte inhibitory factor (LIF) was also less sensitive than the direct PA induction assay. The direct PA induction assay is sensitive and convenient and requires small volumes of blood. It may prove valuable in in vitro analysis of cell-mediated immunity in health and disease.

Medical management of children with juvenile rheumatoid arthritis.

One of the most important and changing areas of research in paediatric rheumatology is the optimum approach to the treatment of children with chronic arthritis. Until recently all medications for children with arthritis were nonspecific in terms of our understanding, albeit poor, of the pathogenesis of these diseases. Of current therapies, low dose, once-a-week methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to administration of a nonsteroidal anti-inflammatory drug. Thereby, it has displaced the more traditional slower acting anti-rheumatic drugs, although one or more of them are often combined with methotrexate in the polypharmaceutical approach to childhood arthritis. Better and more specific agents are needed, especially for systemic onset disease, unremitting polyarticular involvement, and certain complications such as resistant chronic uveitis. At this time the introduction of the cyclo-oxygenase 2 inhibitors and etanercept (soluble tumour necrosis factoralpha.p75 fusion protein) may herald an era of more specific and effective therapy.

Comparative efficacy and safety of advanced drug therapy in children with juvenile rheumatoid arthritis.

Results from three randomized placebo-controlled trials were combined in a meta-analysis to compare the clinical utility of four advanced drug therapy agents used to treat juvenile rheumatoid arthritis (JRA): D-penicillamine (10 mg/kg/d), hydroxychloroquine (6 mg/kg/d), auranofin (oral gold, 0.15 to 0.20 mg/kg/d), and two low dose levels of methotrexate [5MTX, 5 mg/M2/wk; 10MTX, 10 mg/M2/wk]. A total of 520 children with JRA were enrolled into these trials. Only 10MTX resulted in significantly greater improvement than placebo in variables that assess effectiveness: physician's global assessment, a composite index, and erythrocyte sedimentation rate. Treatment effect sizes were the largest in the 10MTX group for all articular disease indices. The short-term safety profiles were similar across all treatment groups. It is concluded that the current trend among pediatric rheumatologists to use oral methotrexate as the first advanced drug therapy in JRA is appropriate and that the minimum effective dose is 10 mg/M2/wk.

Pediatric rheumatology: fellowship training requirements and survey of specialty needs.

This article documents the growth of pediatric rheumatology in the decade since Park City I as an emerging academic pediatric subspecialty. Current staffing patterns are surveyed for our medical schools and estimates of future requirements for fellowship training are provided. Impediments to the necessary growth of this subspecialty for the needs of clinical practice and research are outlined and criteria for certification are reviewed.

Current status of the medical treatment of children with juvenile rheumatoid arthritis.

Based on clinical experience and the aforementioned studies, a number of opinions can be entertained concerning the historically traditional conservative management of children with JRA. 1. Because the inflammatory changes of JRA on the bones and joints once established are irreversible in most children, there are ample theoretical reasons to start more effective therapy (if available) early. 2. Most of the currently available drugs control inflammation only partially or temporarily. 3. Most children stop taking the various SAARDS after approximately 2 years of disease because of lack of efficacy or the development of toxicity. 4. Whereas corticosteroids are the most potent and effective anti-inflammatory agents, long-term use in children, even in low dosage, is severely limited, especially by their effect on growth. 5. Methotrexate appears to be the most effective of the alternative agents and much safer than expected when used in the currently recommended protocol. 6. More effective therapy must await a better understanding of the pathogenesis of JRA, although currently available medications might be used more rationally by taking into consideration available pharmacologic studies.

Abnormalities in skeletal growth in children with juvenile rheumatoid arthritis.

A review of the acquisition of peak skeletal mass in normal children and studies that have been reported for children with JRA lead to the following tentative conclusions: (1) The appendicular skeleton is predominantly the overall status of skeletal mineralization; (2) a failure to develop adequate bone mineralization is virtually universal in children with JRA and is characterized by a failure of bone formation. A failure to undergo the normal increase in bone mass during puberty is common in children with JRA and markedly decreases their potential to achieve an adequate peak skeletal mass; (3) the onset of accelerated skeletal maturation with puberty is a critical period of potential intervention in JRA. Conversely, therapeutic interventions later during adolescence offer less promise of reversal of inadequate bone mineralization; and (4) the most important therapeutic maneuver is likely to be control of the inflammation process, although there is hope, at present unsubstantiated, that supplemental dietary calcium and vitamin D, and normalization of physical activity, many lead to some "catch-up" mineralization.

Methotrexate in juvenile rheumatoid arthritis. Do the benefits outweigh the risks?

Juvenile rheumatoid arthritis (JRA) is a heterogeneous group of autoimmune diseases resulting in chronic idiopathic peripheral arthritis. The aetiology of JRA is unclear, and current pharmacotherapy is ameliorative rather than curative. Nonsteroidal anti-inflammatory drugs are given initially, but only one-third to one-fourth of patients are managed adequately with these agents. Advanced therapeutic drugs, frequently referred to as disease-modifying antirheumatic drugs or second-line agents, are given to the child with aggressive or resistant disease. Among these, the antimetabolite methotrexate has proven to be the most effective in alleviating articular disease manifestations and reducing laboratory parameters of inflammation. When given orally in low dosages (10 to 15 mg/m2/week), methotrexate is well tolerated, without evidence of substantial bone marrow suppression or severe hepatotoxicity. Extensive long term tolerability data are not yet available for children, but longitudinal studies in adult patients with rheumatoid arthritis suggest that the drug may be given safely for extended periods in many patients. Paediatric rheumatologists are beginning to give higher dosages of methotrexate (up to 1 mg/kg/week) parenterally with some success. The long term consequences of higher dose methotrexate in children are unknown. Methotrexate has now become, and will probably remain for some time, the drug of first choice for children with recalcitrant JRA.

Predicting pain among children with juvenile rheumatoid arthritis.

OBJECTIVE: Children and adolescents with juvenile rheumatoid arthritis (JRA) often report pain as a major symptom that affects their daily activities. Little is known about the factors that contribute to pain, however. Demographic, disease status, and social-psychologic variables were used to predict pain of JRA. METHODS: Participants were 37 girls and 23 boys who were 7 to 17 years old. Measures included the Hopelessness Scale for Children, the Sadness Scale from the Differential Emotions Scale--IV, and the Social Support Questionnaire--Revised. A pain visual analogue scale served as the criterion measure. RESULTS: Reported pain was modestly correlated with disease duration and age. A hierarchical regression indicated that the predictor variables accounted for a modest amount of variance in pain scores. CONCLUSIONS: The results suggest that the factors contributing to pain in children with JRA are different from those in adults with rheumatoid arthritis (RA). Research is needed to identify the psychologic and socioenvironmental variables that influence pain among children with JRA.

Disease and family contributors to adaptation in juvenile rheumatoid arthritis and juvenile diabetes.

OBJECTIVE: Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness. METHODS: A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls. RESULTS: Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems. CONCLUSION: Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

Trajectories of adaptation in pediatric chronic illness: the importance of the individual.

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Comparing information-gathering strategies of medical students and physicians in diagnosing simulated medical cases.

Using a broad range of written patient management problems (PMPs), this study examined (1) how each of three medical information-gathering processes (history-taking, physical examination, and diagnostic studies) influenced 175 second-year medical students' formulations of the differential (i.e., plausible) and the principal (i.e., most probable) diagnoses for each of 14 PMPs, and (2) the extent to which these results paralleled the emphases that experienced clinicians placed on these same information-gathering processes regarding each of the same PMPs. The results suggest that in ten of the 14 PMPs the students appeared to rely on specific information-gathering strategies in formulating their diagnoses, and that both similarities and differences existed between the levels of emphasis placed by the students and physicians on each of the three processes. In general, the physicians placed greater emphasis on the importance of the history, whereas the students relied more on diagnostic studies. These variations have implications for selecting medical problems for purposes of instruction and evaluation of students.

Osteopenia and osteoporosis in children.

The purpose of this paper is to review the normal physiologic processes of skeletal accretion, abnormalities that may occur in children with chronic illnesses, and therapeutic maneuvers that the clinician may be able to employ to prevent or partially correct abnormalities of skeletal growth. Skeletal maturation in children is dependent upon bone formation exceeding resorption, whereas in adults these two fundamental processes of homeostasis are closely balanced. Skeletal growth is effectively completed at the end of the period of adolescent growth acceleration with closure of the epiphyses. An important determinant of future fracture risk and osteoporosis is the peak bone mass achieved during this second decade of life. If the hereditarily determined peak bone mass is not established during that time, the patient will enter young adulthood with osteopenia, an increased fracture risk, and accelerated postmenopausal osteoporosis or involutional osteoporosis. Thus osteopenia and osteoporosis have their origins in childhood and adolescence.

Miscellaneous conditions associated with arthritis in children.

Miscellaneous conditions associated with arthritis in children are reviewed as distinct entities in the differential diagnosis of the many types of juvenile arthritis reviewed here and in other articles.

Bone mineral metabolism in children with juvenile rheumatoid arthritis.

Osteopenia has emerged as a major determinant of the outcome of children with juvenile rheumatoid arthritis. Although vertebral compression fractures and fractures of long bones were recognized historically as important clinical developments in the course of disease, a decrease in skeletal mass could only be quantitated and documented early in disease by the recent introduction of bone absorptiometry. This article is limited to recent data from studies on osteopenia in juvenile rheumatoid arthritis and suggests directions of future research that have relevance to current unanswered questions in prevention or management.