Brain Function and Pain Interference After Pediatric Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: Intensive interdisciplinary pain treatments (IIPTs) are programs that aim to improve functioning in youth with severe chronic pain. Little is known about how the brain changes after IIPT; however, decreased brain responses to emotional stimuli have been identified previously in pediatric chronic pain relative to healthy controls. We examined whether IIPT increased brain responses to emotional stimuli, and whether this change was associated with a reduction in pain interference. PATIENTS AND METHODS: Twenty youths with chronic pain aged 14 to 18 years were scanned using functional magnetic resonance imaging, pre and post-IIPT. During the functional magnetic resonance imaging, patients were presented with emotional stimuli (ie, faces expressing happiness/fear), neutral expressions, and control (ie, scrambled) images. Patients completed a measure of pain interference pre and post-IIPT. Paired t tests were used to examine differences in brain activation in response to emotional versus neutral stimuli, pre to post-IIPT. Data from significant brain clusters were entered into linear mixed models to examine the relationships between brain activation and impairment pre and post-IIPT. RESULTS: Patients demonstrated a decrease in middle frontal gyrus (MFG) activation in response to emotional stimuli (happy + fear) relative to scrambled images, between pre and post-IIPT ( P < 0.05). Lower MFG activation was associated with lower pain interference, pre and post-IIPT ( P < 0.05). CONCLUSION: Contrary to our hypothesis, IIPT was associated with a reduction in MFG activation to emotional stimuli, and this change was associated with reduced pain interference. The MFG is a highly interconnected brain area involved in both pain chronification and antinociception. With further validation of these results, the MFG may represent an important biomarker for evaluating patient treatment response and target for future pain interventions.

Sleep disturbances, altered brain microstructure and chronic headache in youth.

Chronic headache (persistent or recurrent headache for 3-months or longer) is highly prevalent among youth. While sleep disturbances have been associated with headache, their inter-relationship with brain connectivity remains unknown. This observational study examined whether self-report and actigraphy measures of sleep were associated with alterations to white matter tracts (i.e., uncinate fasciculus and cingulum) in youth with chronic headache versus healthy controls. Thirty youth aged 10-18 years with chronic headache and thirty controls underwent an MRI. Diffusion tensor images were obtained and mean fractional anisotropy values of the cingulum and uncinate were extracted. One-week prior to their MRI, youth wore an actigraph to obtain sleep duration, wake after sleep onset and sleep efficiency measures. Moreover, they completed questionnaires regarding their sleep quality and pain symptomatology. Linear regression was applied to examine the relationships between sleep (self-report and actigraphy), fractional anisotropy, and number of headache days per month. Self-report and actigraphy measures of sleep did not differ between patients and controls. However, poorer self-reported sleep quality was associated with lower fractional anisotropy values in the left uncinate (P = 0.05). Lower left uncinate fractional anisotropy was related to increased headache frequency (P = 0.002) in youth with chronic headache. Therefore, alterations to connectivity may be associated with the relationship between altered perceptions of sleep and headache chronicity.

Increased hippocampal efficiency is associated with greater headache frequency in adolescents with chronic headache.

Adults with chronic headache have altered brain hippocampal efficiency networks. Less is known about the mechanisms underlying chronic headache in youth. In total, 29 youth with chronic headache (10-18 years), and 29 healthy, age- and sex-matched controls tracked their headache attacks daily for 1-month period. Following this, they underwent a resting state functional magnetic resonance imaging scan and self-reported on their pubertal status, post-traumatic stress, anxiety, and depression symptoms. Graph-based topological analyses of brain networks, rendering hippocampal efficiency values were performed. T-tests were used to compare hippocampal efficiency metrics between patients and controls. Linear regression was used to examine significant hippocampal efficiency metrics in relation to headache frequency in patients, controlling for age, sex, pubertal status, post-traumatic stress, anxiety, and depression symptoms. Patients had higher right hippocampal global efficiency, shorter right hippocampal path length, and higher right hippocampal clustering coefficient compared to controls (P < 0.05). Higher right hippocampal global efficiency, shorter right hippocampal path length, and higher right hippocampal clustering coefficients were positively associated with greater headache frequency (P < 0.05). The hippocampus is largely involved in memory formation and retrieval, and this data provides additional support for previous findings demonstrating the importance of the hippocampus and pain memories for the chronification of pain.

Baseline Factors Associated with Pain Intensity, Pain Catastrophizing, and Pain Interference in Intensive Interdisciplinary Pain Treatment for Youth.

Background: More could be known about baseline factors related to desirable Intensive Interdisciplinary Pain Treatment (IIPT) outcomes. This study examined how baseline characteristics (age, gender, child pain catastrophizing (PCS-C), pain interference, pain intensity, anxiety, depression, paediatric health-related quality of life (PedsQLTM), and parent catastrophizing (PCS-P)) were associated with discharge and 3-month follow-up scores of PCS-C, pain intensity, and pain interference. Methods: PCS-C, pain intensity, and pain interference T-scores were acquired in 45 IIPT patients aged 12-18 at intake (baseline), discharge, and 3-month follow-up. Using available and imputed data, linear mixed models were developed to explore associations between PCS-C, pain intensity, and pain interference aggregated scores at discharge and follow-up with baseline demographics and a priori selected baseline measures of pain, depression, anxiety, and PCS-C/P. Results: PCS-C and pain interference scores decreased over time compared to baseline. Pain intensity did not change significantly. Baseline PCS-C, pain interference, anxiety, depression, and PedsQLTM were associated with discharge/follow-up PCS-C (available and imputed data) and pain interference scores (available data). Only baseline pain intensity was significantly associated with itself at discharge/follow-up. Conclusions: Participants who completed the IIPT program presented with reduced PCS-C and pain interference over time. Interventions that target pre-treatment anxiety and depression may optimize IIPT outcomes.

Changes in Brain GABA and Glutamate and Improvements in Physical Functioning Following Intensive Pain Rehabilitation in Youth With Chronic Pain.

Intensive interdisciplinary pain treatments (IIPT) have been developed to treat youth with unmanaged chronic pain and functional disability. Dysregulation of metabolites gamma-aminobutyric acid (GABA) and glutamate are thought to play a role in the chronification of pain due to imbalances in inhibition and excitation in adults. Using magnetic resonance spectroscopy (MRS), we investigated the effect of IIPT on GABA and Glx (glutamate + glutamine) in 2 pain-related brain regions: the left posterior insula (LPI) and the anterior cingulate cortex (ACC). Data were collected in 23 youth (mean age = 16.09 ± 1.40, 19 female) at entry and discharge from a hospital-based outpatient IIPT. GABA and Glx were measured using GABA-edited MEGA-PRESS and analyzed using Gannet. Physical measures including a 6-minute walk test were recorded, and patients completed the PLAYSelf Physical Literacy Questionnaire, PROMIS Pain Interference Questionnaire, and Functional Disability Inventory. LPI GABA (P < .05) significantly decreased, but not ACC GABA (P > .05), following IIPT. There were no significant Glx changes (P > .05). The decrease in LPI GABA was associated with increased distance in the 6-minute walk test (P < .001). IIPT may decrease GABAergic inhibitory tone within the LPI, thereby promoting plasticity and contributing to improvements in physical outcomes with IIPT. PERSPECTIVE: Regional GABA changes are associated with a reduction in pain interference and improvement in physical function in youth following intensive pain rehabilitation. GABA may serve as a possible biomarker for IIPT; and may also further aid in the development of IIPT, and other treatments for chronic pain in youth.

The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review.

OBJECTIVES: Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions. METHODS: An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison. RESULTS: From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating. DISCUSSION: A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

Trauma and pain sensitization in youth with chronic pain.

Introduction: Chronic pain (pain lasting ≥3 months) co-occurs with internalizing mental health issues, such as posttraumatic stress symptoms (PTSS), at high rates in youth. The mechanisms underlying these relationships remain unclear. Posttraumatic stress symptoms, including re-experiencing (eg, intrusive memories), alterations in cognition and mood, hyperarousal, and avoidance could lead to altered neuronal processing, pain sensitization, and greater reports of pain. However, the relationships between PTSS and pain sensitization in youth with chronic pain are not known. Methods: Youth (n = 165) aged 10 to 18 years were recruited from outpatient multidisciplinary chronic pain programs. Symptoms of PTSS were assessed using psychometrically sound questionnaires. Youth also underwent a cold-pressor task, the most commonly used experimental pain induction technique. During this task, they reported on their expected pain, actual pain intensity, and pre- and post-state pain catastrophizing. Their pain threshold was recorded. A multivariate general linear model was used to examine the relationships between PTSS, ratings of pain intensity, state pain catastrophizing, and pain threshold, controlling for age, gender, ethnicity, anxiety, and depressive symptoms. Results: Higher PTSS were associated with greater pain thresholds (P = 0.03) and higher pre- and post-state pain catastrophizing (P ≤ 0.05). Conclusions: Individuals with higher PTSS may avoid or dissociate from pain-inducing stimuli, thus leading to higher pain thresholds. However, individuals with higher PTSS also tend to catastrophize prior to and following exposure to pain. Avoidant and pain catastrophizing behaviors may serve to perpetuate chronic pain conditions. Future research is needed to determine how PTSS are related to pain sensitization prior to the development of chronic pain in at-risk youth.

Youth and parent perceptions on participating in specialized multidisciplinary pain rehabilitation options: A qualitative timeline effect analysis.

Background: Little is known about how the specialized treatment journey is perceived by youth with pain-related disability and their parents. Aims: Describe and compare the treatment effects and outcomes as perceived by youth and their parents enrolled in intensive interdisciplinary pain treatment (IIPT) or multimodal treatment (MMT). Methods: Eleven IIPT youth and five parents and three MMT youth and five parents were recruited. All were asked to complete a treatment journey timeline, followed by separately conducted semistructured interviews. Transcribed interviews were analyzed using reflective thematic analysis. Results: The main themes spanned the treatment trajectory. All participants described similar initial struggles (Theme 1). Positive and negative treatment effects associated with acquisitions and disruptions (Theme 2), and outcomes post-discharge related to supports and realities (Theme 3) emerged. Knowledge, skills, and support acquisition during treatment and feeling empowered and confident to self-manage postdischarge were identified as IIPT benefits. However, the change effort and life disruptions required and the difficulty transitioning to real life postprogram were acknowledged as detrimental IIPT impacts. Continuing with life as usual and maintaining supports in daily contexts (e.g., school personnel, friends) were reported MMT benefits. However, the challenges of managing pain, treatment adherence within the competing demands of daily realities, and the lack of support to integrate strategies were emphasized as detrimental MMT impacts. Conclusions: Detailed impacts of two specialized multidisciplinary pain rehabilitation interventions on the lives of youth with pain-related disability and their parents are described. The treatments benefits and previously unexplored detrimental effects are unveiled.

Contexte: On en sait peu sur les parcours de traitement spécialisés tels que perçus par les jeunes ayant une incapacité liée à la douleur et par leurs parents.Objectifs: Décrire et comparer les effets et les résultats du traitement tels qu'ils sont perçus par les jeunes inscrits à un traitement interdisciplinaire intensif de la douleur ou à un traitement multimodal, ainsi que par leurs parents.Méthodes: Onze jeunes inscrits à un traitement interdisciplinaire intensif de la douleur et cinq parents, ainsi que trois jeunes inscrits à un traitement multimodal et cinq parents, ont été recrutés. Tous ont été invités à décrire le calendrier de leur parcours de traitement, puis à participer à des entrevues semi-structurées menées séparément. Les entrevues transcrites ont été analysées à l'aide d'une analyse thématique réflexive.Résultats: Les principaux thèmes couvraient la trajectoire du traitement. Tous les participants ont décrit des difficultés initiales similaires (Thème 1). L'association des effets positifs et négatifs du traitement avec les acquis et les perturbations (Thème 2), et les issues liées au soutien et aux réalités suite à leur congé (Thème 3) ont émergé. L'acquisition de connaissances et d'habiletés, l'accès à du soutien et le sentiment d'autonomisation et de confiance en sa capacité d'autoprise en charge après le congé ont été répertoriés comme des avantages du traitement interdisciplinaire intensif de la douleur. Toutefois, les efforts de changement requis et les perturbations de la vie nécessaires, ainsi que les difficultés de la vie réelle après le programme, ont été considérés comme des répercussions négatives du traitement interdisciplinaire intensif de la douleur. La possibilité de poursuivre la vie comme d'habitude et de conserver le soutien dans des contextes de la vie quotidienne (ex. : personnel scolaire, amis) ont été rapportés comme des avantages du traitement multimodal. Toutefois, les défis liés à la prise en charge de la douleur, l'adhésion au traitement dans le cadre des exigences concurrentes des réalités quotidiennes, ainsi que le manque de soutien pour intégrer les stratégies, ont été mis en relief comme des effets néfastes du traitement multimodal.Conclusions: Les effets détaillés de deux interventions multidisciplinaires spécialisées en matière de réadaptation pour la douleur dans la vie de jeunes atteints d'une incapacité liée à la douleur et de leurs parents ont été décrits. Les avantages des traitements et leurs effets néfastes qui n'avaient pas encore été étudiés ont été dévoilés.

Subclinical post-traumatic stress symptomology and brain structure in youth with chronic headaches.

BACKGROUND/AIMS: Post-traumatic stress symptoms (PTSS) and chronic pain often co-occur at high rates in youth. PTSS may alter brain structure thereby contributing to headache chronicity. This study examined whether PTSS and altered limbic circuitry were associated with headache frequency in youth. METHODS: Thirty youth aged 10-18 years with chronic headaches and 30 age- and sex-matched controls underwent a 3T MRI scan. Volumes of the hippocampus and amygdala were obtained from T1-weighted images. Mean fractional anisotropy (FA, an index of white matter structure) axial and radial diffusivity values of the cingulum and uncinate fasciculus were extracted from diffusion-weighted images. Youth reported on their headaches daily, for one-month, and self-reported pubertal status, emotion regulation, adverse childhood experiences (ACEs) and PTSS using validated measures. Volumes of the hippocampus and amygdala and diffusivity values of the cingulum and uncinate were compared between patients and controls. Hierarchical linear regressions were used to examine the association between PTSS, subcortical volumes and/or diffusivity values and headache frequency. RESULTS: Mean FA values of the cingulum were higher in patients compared to controls (P = 0.02, Cohen's d = 0.69). Greater PTSS (P = 0.04), smaller amygdala volumes (P = 0.01) and lower FA of the cingulum (P = 0.04) were associated with greater headache frequency, after accounting for age, puberty, pain duration, emotion regulation, and ACEs (Adjusted R2 ≥ 0.15). Headache frequency was associated with increases in radial diffusivity (P = 0.002, Adjusted R2 = 0.59), as opposed to axial diffusivity (n.s.). CONCLUSIONS: PTSS, smaller amygdalar volume, and poorer cingulum structural connectivity were associated with headache frequency in youth, and may underlie headache chronicity.

Is the use of specific time cut-off or "golden period" for primary closure of acute traumatic wounds evidence based? A systematic review.

The time cut-off for primary closure of acute wounds is not clearly defined in the literature or in the surgical textbooks. It is even unclear whether the wound age increases wound infection rate. The scarcity of scientific evidence may explain the diverse wound management practices. To give guidance for further research in the field, this systematic review assessed recent evidence on the impact of wound age on the infection rate and on the selection of wound closure method. Using predefined criteria, we systematically searched Cochrane Central Register of Controlled Trials/CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Scopus, Web of Science Core Collection, Current Contents, SciELO Citation Index, KCI-Korean Journal Database, Russian Science Citation Index, BIOSIS Citation Index, Data Citation Index, LILACS/Latin American and Caribbean Health Sciences Literature, and African Index Medicus; as well as online trial registries: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform/WHO ICTRP, and CenterWatch. Nine studies met the selection criteria and were included in the review. This review could not establish the time frame for primary closure of wounds. The time intervals mentioned in many surgical textbooks were supported by only a few low-quality studies. More important factors to be considered when delaying primary closure of acute wounds were the history of diabetes, wound location, wound length, and the presence of a foreign body.

Evaluating and Enhancing the Preparation of Patients and Families before Pediatric Surgery.

Surgery can be a difficult and unfamiliar experience for children and their families. We examined the ability of existing information to help families feel better prepared for surgery at the Alberta Children's Hospital (ACH) and evaluated the best way to enhance its content and accessibility. We developed an online survey for families who have had surgery at ACH. Participants were recruited through pre-existing patient networks and from the ACH Short Stay Unit (SSU) between October 2018 and October 2019. The survey asked participants to evaluate the information available to prepare them for surgery and requested suggestions for improvement. Our survey results show that those who completed the in-person Surgery 101 program felt significantly more prepared for surgery. Of those who did not attend; 40% would have been interested in participating but were unaware that the program existed; and 17% planned to attend but were unable to; due to work or travel distance. Participants felt additional resources via online content or paper handouts would be most valuable. We used this information to prepare an online accessible summary of the Surgery 101 program and tour in the form of a video to reach more Albertan families preparing for surgery for their children.

Is It Worth It? A Comparison of an Intensive Interdisciplinary Pain Treatment and a Multimodal Treatment for Youths With Pain-related Disability.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of an intensive interdisciplinary pain treatment (IIPT) day-hospital program as compared with an outpatient multimodal treatment (MMT) for youth with chronic pain. MATERIALS AND METHODS: A nonrandomized pretest posttest with control group design was used. A battery of patient-oriented measures assessing pain interference, quality of life, and depressive symptoms were completed at treatment commencement and at 3, 6, and 12 months after treatment by 44 youths enrolled in the IIPT and 138 youths engaged in the MMT, with various chronic pain conditions. Data were analyzed using longitudinal mixed-effects models. RESULTS: The main outcomes were the score difference from baseline of patient-oriented measures across 3 timepoints within 12 months of intervention initiation for both treatment groups. IIPT participants demonstrated greater improvement in pain interference, as compared with MMT at 3 and 12 months. Initially, health-related quality of life scores improved similarly in both groups, but greater improvement was seen in the MMT group at 12 months. Depressive symptom scores did not improve with either intervention. Only pain interference scores reached statistically and clinically significant difference levels. DISCUSSION: This study supports the benefits of specialized rehabilitation interventions, including both MMT and IIPT programs, for youths with chronic pain. The findings also suggest that IIPT might have a greater long-term effect for helping youths, in particular those with high pain interference scores.

The role of narrative in the development of children's pain memories: influences of father- and mother-child reminiscing on children's recall of pain.

Negatively biased memories for pain (ie, recalled pain is higher than initial report) robustly predict future pain experiences. During early childhood, parent-child reminiscing has been posited as playing a critical role in how children's memories are constructed and reconstructed; however, this has not been empirically demonstrated. This study examined the role of parent-child reminiscing about a recent painful surgery in young children's pain memory development. Participants included 112 children (Mage = 5.3 years; 60% boys) who underwent a tonsillectomy and one of their parents (34% fathers). Pain was assessed in hospital and during the recovery phase at home. Two weeks after surgery, parents and children attended a laboratory visit to participate in a structured narrative elicitation task wherein they reminisced about the surgery. Four weeks after surgery, children completed an established pain memory interview using the same previously administered scales through telephone. Narratives were coded for style (elaboration) and content (pain and emotion) based on coding schemes drawn from the developmental psychology literature. Findings revealed that a more elaborative parental reminiscing style in addition to greater use of emotional words predicted more accurate/positively biased pain memories. Greater parental use of pain words predicted more negatively biased pain memories. Although there were no sex and parent-role differences in pain memory biases, mothers and fathers differed in how they reminisced with their boys vs girls. This research underscores the importance of parent-child reminiscing in children's pain memory development and may be used to inform the development of a parent-led memory reframing intervention to improve pediatric pain management.

Socialization of Pain Memories: Parent-Child Reminiscing About Past Painful and Sad Events.

OBJECTIVE: Parent-child reminiscing about past negative events has been linked to a host of developmental outcomes. Previous research has identified two distinct between-parent reminiscing styles, wherein parents who are more elaborative (vs. repetitive) have children with more optimal outcomes. To date, however, research has not examined how parents and children talk about past painful experiences nor compared parent-child reminiscing about past painful versus other distressing events despite key developmental differences in how young children respond to pain versus sadness in others. This study aimed to fill that gap. METHODS: Seventy-eight children aged 4 to 7 years underwent a tonsillectomy. Two weeks postsurgery, children and one of their parents discussed past autobiographical events (i.e., the tonsillectomy, another painful event, a sad event). Parent-child conversations were coded using established coding schemes to capture parental reminiscing style, content, and autonomy support. RESULTS: Findings revealed robust differences in parent-child reminiscing about painful versus sad events. Parents were less elaborative, used less emotionally negative words and explanations, and were less supportive of their children's autonomy while reminiscing about past painful versus sad events. CONCLUSIONS: These findings demonstrate that through reminiscing, parents may socialize children about pain in a way that is different from other distressing events (e.g., sadness). Future research should examine the influence of differential reminiscing about pain versus sadness on developmental and health outcomes.

Role of anxiety in young children's pain memory development after surgery.

Pediatric pain is common, and memory for it may be distressing and have long-lasting effects. Children who develop more negatively biased memories for pain (ie, recalled pain is higher than initial pain report) are at risk of worse future pain outcomes. In adolescent samples, higher child and parent catastrophic thinking about pain was associated with negatively biased memories for postsurgical pain. This study examined the influence of child and parent anxiety on the development of younger children's postsurgical pain memories. Seventy-eight children undergoing a tonsillectomy and one of their parents participated. Parents reported on their anxiety (state and trait) before surgery, and trained researchers observationally coded children's anxiety at anaesthesia induction. Children reported on their postsurgical pain intensity and pain-related fear for 3 days after discharge. One month after surgery, children recalled their pain intensity and pain-related fear using the same scales previously administered. Results revealed that higher levels of postsurgical pain and higher parent trait anxiety predicted more negatively biased memories for pain-related fear. Parent state anxiety and child preoperative anxiety were not associated with children's recall. Children who developed negatively biased pain memories had worse postsurgical pain several days after surgery. These findings underscore the importance of reducing parental anxiety and effective postsurgical pain management to potentially buffer against the development of negatively biased pain memories in young children.

General anesthetics and cytotoxicity: possible implications for brain health.

BACKGROUND: The search for agents that bring about faster induction and quicker recovery in the operating room have yielded numerous anesthetics whose mechanisms of action and potential toxic side effects remain unknown, especially in the young and aging brain. OBJECTIVE: Taking advantage of our clinical and basic science expertise, here we subject the reader to an interesting perspective vis-à-vis the current applications of general anesthetics, and present evidence for their neurotoxic effects on the developing and elderly brains. RESULTS: Recent studies have called into question the safety of general anesthetics, especially with regards to potentially significant detrimental impacts on the developing brains of young children, and cognitive decline in the elderly - often following multiple episodes of anesthesia. Despite accumulating evidence from animal studies demonstrating that general anesthesia leads to neurodegeneration and cognitive impairment, to date a clear consensus on the impact of anesthetics in humans remains elusive. Because a direct impact of anesthetics on human neuronal networks is often difficult to deduce experimentally, most laboratories have resorted to animal models - albeit with limited success in translating these findings back to the clinic. Moreover, the precise mechanisms that lead to potential cognitive, learning, and memory decline in young and elderly patients also remain to be fully defined. CONCLUSIONS: This review will focus primarily on the cytotoxic effects of anesthetics, and offer some practical resolutions that may attenuate their long-term harm. An urgent need for studies on animal models and an increased focus on highly controlled prospective epidemiological studies is also reinforced.

Mental Health Comorbidities in Pediatric Chronic Pain: A Narrative Review of Epidemiology, Models, Neurobiological Mechanisms and Treatment.

Chronic pain during childhood and adolescence can lead to persistent pain problems and mental health disorders into adulthood. Posttraumatic stress disorders and depressive and anxiety disorders are mental health conditions that co-occur at high rates in both adolescent and adult samples, and are linked to heightened impairment and disability. Comorbid chronic pain and psychopathology has been explained by the presence of shared neurobiology and mutually maintaining cognitive-affective and behavioral factors that lead to the development and/or maintenance of both conditions. Particularly within the pediatric chronic pain population, these factors are embedded within the broader context of the parent-child relationship. In this review, we will explore the epidemiology of, and current working models explaining, these comorbidities. Particular emphasis will be made on shared neurobiological mechanisms, given that the majority of previous research to date has centered on cognitive, affective, and behavioral mechanisms. Parental contributions to co-occurring chronic pain and psychopathology in childhood and adolescence will be discussed. Moreover, we will review current treatment recommendations and future directions for both research and practice. We argue that the integration of biological and behavioral approaches will be critical to sufficiently address why these comorbidities exist and how they can best be targeted in treatment.

The effect of unanticipated perioperative death on anesthesiologists.

PURPOSE: Unanticipated perioperative death (UPD) is a significant event for the anesthesiologist that has not been widely studied. An anonymous questionnaire was used to obtain information about the frequency of UPD, anesthesiologists' most significant UPD, and their opinions regarding UPD. METHODS: A questionnaire was mailed to all anesthesiologists who were registered with the College of Physicians and Surgeons of Alberta in 2005 (n = 285). RESULTS: The study achieved a 63% response rate. Sixty-four percent of respondents had been in practice for more than ten years, and 53% of respondents had experienced at least one UPD. After the UPD, 46% of the respondents performed further elective cases the same day, although 62% of them indicated that this was not advisable. Personal consequences were reported. Twenty-five percent felt they were being blamed for the event, and 10% thought about the UPD on a daily basis for more than a year afterwards. Mortality and morbidity reviews were common, and disciplinary consequences occurred infrequently. Sixty-four percent of anesthesiologists' most significant UPDs were elective cases. The etiology of death was thought to be anesthesia-related in only 11% of the UPDs. Although most respondents agreed that supportive and educational activities in the aftermath were advisable, such activities occurred in a minority of cases. CONCLUSIONS: Alberta anesthesiologists are likely to experience UPD during their careers, and the experience can be associated with important personal consequences. Support for the anesthesiologist is inconsistent, and many continued to perform elective cases immediately following UPD. These conditions were not supported by the majority of respondents.

Prepared endotracheal tubes: are they a potential source for pathogenic microorganisms?

UNLABELLED: Prepared endotracheal tubes (PETTs) are frequently used for unanticipated difficult intubation, but their storage time is highly variable and institution-dependent. We sought to determine first, if open, unused PETTs are a potential source of pathogenic microorganisms, and second, if PETTs can provide a medium for bacterial survival after deliberate contamination. A stylet was inserted into a 7-mm ETT, and this system was ethylene oxide sterilized. The PETTs were placed in 20 different locations and sampled 8 times in a 4-wk period. Growth was determined after 48-h incubation, and the microorganism was identified. In Phase 2, the PETT (n = 40) was swabbed with a fresh suspension of H. influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus faecium, or a negative control. Nonvirulent bacteria were cultured from 13 of 160 (8.1%) samples and from 15 of 320 (4.7%) samples in Phases 1 and 2, respectively. No PETT grew the same bacteria more than once. In Phase 2, after 24 h, only E. faecium was recovered. Based on this study, the pathogenic potential of PETTs is very small, and they can be safely used for up to 1 mo. This practice could translate to significant cost reduction for operating room budgets. IMPLICATIONS: Prepared endotracheal tubes (PETTs) are back-up airway equipment to be used in the case of a difficult intubation. A short PETT shelf life because of unknown safe storage time results in significant budget costs. This blinded, controlled study examined the pathogenic potential of PETTs in the operating room environment.