Topical Review: Getting into the head of youth with chronic pain: how theory of mind deficits may relate to the development and maintenance of pediatric pain.

OBJECTIVE: Theory of mind (ToM) is the ability to understand the thoughts, feelings, and mental states of others and is critical for effective social and psychological functioning. ToM deficits have been associated with various psychological disorders and identified in adult pain populations. For youth with chronic pain, ToM deficits may underlie the biological, psychological, and social factors that contribute to their experience of pain, but this remains poorly understood. METHODS: This topical review explored the extant literature in the areas of ToM and chronic pain, particularly for pediatric populations, with respect to biological, psychological, and social elements of the biopsychosocial model of pain. RESULTS: ToM deficits may be present alongside previously identified biological, psychological, and social correlates of pediatric pain, as a vulnerability, mechanism, and/or consequence. Biologically, ToM deficits may relate to cortisol abnormalities and neurobiological substrates of pain processing. Psychologically, ToM deficits may stem from pain-focused cognitions, thus impacting relationships and fueling impairment. Socially, chronic pain may preclude normative development of ToM abilities through social withdrawal, thereby exacerbating the experience of pain. CONCLUSION: Taken together, ToM deficits may be associated with increased risk for the development and/or maintenance of pediatric chronic pain, and pediatric chronic pain may similarly confer risk for ToM deficits. Future research should investigate the nature of ToM abilities in youth with chronic pain to test these hypotheses and ultimately inform ToM-focused and pain-based interventions, as this ability has been demonstrated to be modifiable.

A Conceptual Framework for Understanding the Role of Adverse Childhood Experiences in Pediatric Chronic Pain.

OBJECTIVES: This review outlines a conceptual framework adapted from the biopsychosocial model of pain to examine the relationship between adverse childhood experiences (ACEs) and chronic pain in youth to highlight the state of current research and guide future efforts. METHODS: A review of the literature was performed in the areas of ACEs and health outcomes with general adult and pediatric populations in addition to studies within the pain literature. Potential relationships between ACEs, chronic pain, and its impact in youth are outlined and discussed. RESULTS: The literature suggests an association between adverse outcomes of ACEs and chronic pain in children and adolescents although causal links have not been confirmed. However, ACEs are associated with multiple risk factors identified in the biopsychosocial model of pain, and may serve to exacerbate or confer heightened risk for pain and poor outcomes. DISCUSSION: Adverse experiences in childhood may be associated with greater risk for the development/maintenance of chronic pain in youth. More research is needed on ACEs and how they uniquely affect the biopsychosocial mechanisms underlying chronic pain in children throughout the lifespan.

Modeling pediatric vaccination guidelines in a data warehouse.

Frequent updates and complexity of vaccination schedules can make it difficult for pediatric practices to ensure adherence to immunization guidelines. To address this problem, Partners HealthCare System (PHS) has created a quality reporting utility to manage pediatric immunizations and to support quality improvement initiatives. The rules-based solution uses reference database tables to model the logic for each vaccine.

Soluble intercellular adhesion molecule-1 and E-selectin as markers of disease activity and endothelial activation in juvenile idiopathic arthritis.

OBJECTIVE: To determine whether soluble forms of the adhesion molecules intercellular adhesion molecule-1 (ICAM-1) and E-selectin correlate with clinical measures or other markers of endothelial activation in children with juvenile idiopathic arthritis (JIA) over time. METHODS: A total of 28 children with JIA were studied every 3 months over 2 years. At each interval, serum was tested for soluble (s)ICAM-1 and sE-selectin, plasma for fibrin d-dimer and von Willebrand factor (vWF), and the following clinical variables were recorded: erythrocyte sedimentation rate (ESR), physician and parent global assessments, swollen and limited joint counts, and functional assessment by Childhood Health Assessment Questionnaire. Concentrations of the adhesion molecules were also determined once in 30 age matched healthy children. RESULTS: Among all JIA subtypes, baseline sICAM-1 was elevated compared to controls; sE-selectin was higher in patients with systemic disease compared to other subtypes and controls. sE-selectin correlated with ESR, but there were no other correlations between concentrations of either adhesion molecule or any other clinical variables or vWF antigen. sICAM-1 was higher in those with elevated compared to normal d-dimer. There were no differences between mean sICAM-1 and sE-selectin before or during disease flare or improvement periods, except for an increase in sICAM-1 with flares in patients with systemic disease. CONCLUSION: sICAM-1 is elevated in children with active JIA. sE-selectin is only elevated in children with active systemic disease. Although some relationships were found between the adhesion molecules and other variables, they did not correlate with most variables, and did not parallel the disease course. Thus, we cannot recommend the routine use of these molecules as clinical biomarkers of disease activity. This study confirms that endothelial activation is key to the pathogenesis of JIA, especially in the systemic subtype.

Synovial fluid levels of E-selectin and intercellular adhesion molecule-1: relationship to joint inflammation in children with chronic arthritis.

E-selectin and intercellular adhesion molecule (ICAM)-1 are crucial to the inflammatory response in chronic inflammatory arthritis. Soluble (s) levels of these molecules in sera and synovial fluid (SF) correlate with some clinical parameters and synovial tissue expression of the same molecules in rheumatoid arthritis. Studies of sera from children with chronic inflammatory arthritis corroborate this information; corresponding SF data are relatively lacking. We thus studied SF sE-selectin and sICAM-1 in 28 children with active juvenile rheumatoid arthritis or a spondyloarthropathy. Levels were correlated with erythrocyte sedimentation rate (ESR), SF leukocyte counts, duration of disease, and duration of response to concomitant intra-articular corticosteroid injection. Levels were compared according to use of methotrexate and/or sulfasalazine. Synovial fluid sE-selectin correlated with ESR and SF leukocyte counts. There was a trend toward lower sICAM-1 in patients treated with sulfasalazine and/or methotrexate. We conclude that SF levels of sE-selectin accurately reflect intra-synovial inflammation. Soluble ICAM-1 levels may reflect the effects of disease-modifying agents.