Obesity impedes functional improvement in youth with chronic pain: An initial investigation.

BACKGROUND: Youth with chronic pain are at higher risk for obesity than the general population. In youth with chronic pain, obesity exacerbates pain-specific activity limitations, and in adults with chronic pain, obesity perpetuates a cycle of disability. The current study examined whether weight status predicts functional disability outcomes over time in youth with chronic pain. METHODS: Data were obtained from a retrospective chart review of patients who consented to participate in a longitudinal outcomes study. The Child Activity Limitations Questionnaire was used to assess functional disability at intake, 1-, and 3-month follow-up. Height and weight were measured at intake. A linear mixed model was used to test whether weight status and time predicted functional disability. Trend analysis with polynomial contrasts was used to test whether improvements in functional disability showed a linear trend over time. RESULTS: The linear mixed model analysis showed a main effect of weight, suggesting that youth with higher BMI demonstrated less improvement in functional disability over time. The trend analysis suggested that improvements in functional disability were consistent with a linear trend for both healthy weight and overweight participants, but not for obese participants. CONCLUSION: These findings demonstrate that obesity impedes improvement in functioning for youth with chronic pain. Despite multidisciplinary pain treatment, youth with comorbid chronic pain and obesity demonstrate greater functional disability at follow-up and little improvement over time. These results support the need for interventions specifically tailored to the unique challenges faced by youth with comorbid chronic pain and obesity. SIGNIFICANCE: This study shows that obesity impedes improvement in functioning for youth with chronic pain. On the basis of these findings, interventions should be tailored to the unique challenges of this population.

Gabapentin in phantom limb pain management in children and young adults: report of seven cases.

Seven children and young adults with phantom limb pain (PLP) were treated with gabapentin. PLP resolved in six patients within two months. One patient still had symptoms to a lesser degree. Mean follow up time was 1.74 years. Gabapentin may be a useful adjunct to pain management in patients with PLP symptoms.

Complementary therapies for acute pediatric pain management.

A wide variety of tools to adequately treat pediatric pain is beneficial. The methods discussed herein typically involve the use of many areas of expertise to manage pain. Massage therapists, biofeedback technicians, physician-acupuncturists, child-life specialists, psychologists, and physical or occupational therapists can all be used as allies to battle acute pain in children. The incorporation of alternative forms of pain management, including education, relaxation techniques, hypnosis, guided imagery, biofeedback, and even acupuncture, to the standard methods may improve the management of children with acute pain. The management of children with pain does not have to be with an "either/or" approach using traditional pharmacologic methods or the cognitive and alternative therapies discussed here. Many areas need research to provide evidence that these therapies work well. What is known now suggests that the use of these adjunctive methods of pain management may complement pharmacologic pain management, thereby bringing physicians closer to optimal care of children with acute pain.

Social adaptability, cognitive abilities, and other predictors for children's reactions to surgery.

STUDY OBJECTIVE: To examine the relationship between social adaptability, cognitive abilities, and other personality characteristics to perioperative anxiety. STUDY DESIGN: Prospective cohort investigation. PATIENTS: 60 children ASA physical status I and II, age 3 to 10 years. SETTING: Tertiary care children's hospital. MEASUREMENTS: Temperament (EASI), cognitive abilities (KABC), and adaptive behavior (Vineland) were evaluated in a group of children undergoing surgery. Parental coping style (MBBS) and parental state (STAI-S) and trait (STAI-T) anxiety were assessed as well. On the day of surgery, anxiety of the child was measured at the preoperative holding area and during induction of anesthesia (m-YPAS). MAIN RESULTS: Univariate correlational analysis demonstrated that young age (r = -0.27), poor social adaptability (Vineland) (r = -0.38), shy and inhibited personality (EASI; temperament) (r = -0.33), higher intelligence (KABC) (r = 0.29), increased parental anxiety (r = 0.44), and parental high-monitoring coping style (r = -0.25) are all associated with higher levels of perioperative anxiety. Stepwise multivariate regression analysis has demonstrated that controlling for the variables above, parental anxiety (p = 0.004), child's social adaptive capabilities (p = 0.04), and child's temperament (sociability) (p = 0.04) are independent predictors for increased perioperative anxiety (R(2) = 0.38, F = 5.5, p = 0.003). CONCLUSIONS: Anesthesiologists need to pay close attention to the families of pediatric surgical children who are socially maladjusted, shy and inhibited, and have anxious parents.

Consequences of inadequate analgesia during painful procedures in children.

OBJECTIVE: To explore the effect of inadequate analgesia for painful procedures (bone marrow aspiration, lumbar puncture, or both) on the pain of subsequent procedures. DESIGN: A cohort of patients with cancer who had participated in a placebo-controlled, randomized study that documented the efficacy of oral transmucosal fentanyl citrate for painful procedures rated the pain associated with subsequent procedures performed with open-label oral transmucosal fentanyl. PARTICIPANTS: Twenty-one children undergoing diagnostic procedures who had been participants in previous study. INTERVENTION: All children were given oral transmucosal fentanyl, 15 to 20 microgram/kg, prior to the procedure; at its conclusion they were asked to rate the associated pain. RESULTS: In children younger than 8 years (n = 13), mean pain ratings during each subsequent procedure were consistently higher for those who had received placebo (n = 8) in the original study compared with those who had received the active drug (n = 5). A repeated-measures analysis of variance suggests that this difference is statistically significant (P = .04). Older children (n = 8) did not show this pattern. CONCLUSION: Inadequate analgesia for initial procedures in young children may diminish the effect of adequate analgesia in subsequent procedures.

The use of oral transmucosal fentanyl citrate for painful procedures in children.

OBJECTIVE: To investigate the efficacy and safety of oral transmucosal fentanyl (OTFC) in providing analgesia and sedation for painful diagnostic procedures in children. DESIGN: Randomized, placebo-controlled clinical trial. METHOD: Forty-eight children referred to the University Connecticut Division of Pediatric Hematology/Oncology for bone marrow aspiration or lumbar puncture were randomized to receive either OTFC (15 to 20 micrograms/kg) or a placebo lollipop. Thirty minutes after administration, the procedure was begun. An anesthesiologist monitored the child's heart rate, blood pressure, and oxygen saturation every 10 minutes. At the conclusion of the procedure, the nurse, the child's parent, and all children over 8 years of age were asked to rate the pain associated with the procedure using a 1 to 10 visual analogue scale. Young children (less than 8) used a modified scale, the Oucher, yielding a 0 to 5 score. RESULTS: Significant differences in pain ratings between the OTFC and placebo groups were noted on the pain scores of the parents (P = .005), nurses (P = .001), younger children (P = .006), and older children (P = .013), and median pain scores in the OTFC group were reduced to tolerable levels. Vomiting (P = .003) and itching (P = .001) were more common in the OTFC group, but no clinically significant vital sign deviations occurred. CONCLUSION: OTFC is safe and effective for use in relieving the pain of pediatric procedures, but frequency of vomiting may restrict its clinical usefulness.

The management of pain in children.

There are now safe and effective techniques which can decrease significantly the amount of pain a child will experience in an acute care setting. For such techniques to work, however, the importance of pain management in children must be recognized. It should be assumed that anything that will hurt an adult will also hurt a child and that children are, in fact, often more sensitive to hospital procedures than are adults. Pain assessment should be a part of the child's care plan, and developmentally appropriate ways of recognizing pain should be in place in all hospitals that care for children. Behavioral and pharmacologic techniques should be tailored to the needs of the individual child. The skill of physicians should be assessed not only by their cure of illnesses, but by the comfort they provide in the process.

Transient lymphoblastosis and thrombocytopenia in Gianotti-Crosti syndrome.

Gianotti-Crosti Syndrome, or papular acrodermatitis of childhood, represents a characteristic rash that is irregularly associated with hepatitis B infection. The authors report papular acrodermatitis in a 10-month-old child with leukopenia, thrombocytopenia, circulating lymphoblasts, and acute anicteric hepatitis B. Physical examination revealed a densely distributed papular rash on the patient's extremities and face and neck, but not on his trunk, buttocks, palms, or soles. Laboratory investigation revealed a normal bone marrow and positive hepatitis B serology. This case reinforces the fact that hematologic findings should not dissuade the work-up of papular acrodermatitis for hepatitis B or other less commonly associated viruses.

Septicemia in pediatric oncology patients: the significance of viridans streptococcal infections.

One hundred nine consecutive episodes of septicemia were retrospectively evaluated in 61 children with malignancy. In addition, the records of all pediatric oncology patients who received high-dose cytarabine (HDAC) chemotherapy were reviewed. Gram-positive organisms accounted for 82.6% of the septicemic episodes. In the total group, coagulase-negative staphylococci and viridans streptococci accounted for 35.8% and 28.4% of the episodes, respectively. In granulocytopenic patients, viridans streptococci were the most common pathogens (36.8%). In the subset of patients who received HDAC, 62.5% of the septicemic episodes were caused by viridans streptococci. Pulmonary complications developed in nine (29%) of the total cases of viridans streptococcal sepsis, whereas these complications occurred in only eight (10.3%) of the septic episodes caused by other organisms. In patients who had viridans septicemia, prior treatment with HDAC did not increase the incidence of pulmonary complications. In septic children with malignancy, our results demonstrate a high incidence of gram-positive organisms, including viridans streptococci, which were once regarded as culture contaminants.

Severe hyponatremia after repeated intravenous administration of desmopressin.

Desmopressin (DDAVP) has recently been found to improve hemostasis in patients with congenital or acquired disorders of coagulation and to reduce operative blood loss in patients with normal hemostasis undergoing certain surgical procedures. Despite its potent antidiuretic effect, severe hyponatremia after the intravenous administration of DDAVP is felt to be rare. We report four cases of severe hyponatremia with serious clinical sequelae occurring in patients with underlying coagulopathies who were treated prophylactically with DDAVP to improve hemostasis prior to surgical procedures. Each patient received multiple (3-22) doses of DDAVP and was given intravenous hydration with hypotonic solutions before developing clinical signs and laboratory evidence of hyponatremia. We believe that the risk of significant hyponatremia after treatment with intravenous DDAVP may be higher than is generally appreciated and that patients undergoing surgical procedures, who often receive multiple doses of DDAVP and intravenous hydration, are at particular risk for this complication. Hypotonic intravenous solutions should be avoided and serum sodium levels should be monitored frequently in those patients receiving multiple doses of DDAVP.

The use of continuous infusion of factor concentrates in the treatment of hemophilia.

Bolus infusion of clotting factor concentrates remains the most common approach to the treatment or prevention of bleeding in patients with hemophilia. Although successful use of continuous infusion of such concentrates has been reported by several groups, this alternative treatment method has not achieved widespread popularity. We report here our experience in one hemophilia center with the use of continuous infusion of factor VIII and factor IX concentrates in 13 patients, 11 with hemophilia A, and 2 with hemophilia B. All patients were treated successfully for bleeding episodes (e.g., hemarthroses, intracranial, or gastrointestinal bleeding) or for surgical procedures (appendectomy, thoracotomy, etc.). Three patients with low titer factor VIII inhibitors were treated successfully with constant infusion therapy, requiring a mean dose of factor VIII concentrate 2.3 fold (8.20 u/kg/h) higher than that of the patients without inhibitors (3.63 u/kg/h) to maintain a circulating plasma level of factor VIII of 1 u/ml. The use of constant infusion of clotting factor concentrates is safe, efficacious, and more convenient than bolus therapy of factor concentrates and should be considered for hospitalized hemophilia patients requiring replacement therapy.

Effect of vitamin E on FMLP-induced activation of rabbit polymorphonuclear leukocytes.

Granulocytes of vitamin E-treated rabbits were compared to granulocytes from placebo-treated rabbits. Granulocytes were isolated from rabbit peripheral blood by a new method employing Percoll and gelatin sedimentation. Vitamin E-treated cells showed less adherence to rabbit aortic endothelium when stimulated with FMLP. FMLP receptor numbers and affinity were not significantly different. Resting cell surface and baseline transmembrane potential were similar in both cell types. Decrease in cell surface potential with FMLP was comparable in vitamin E- and placebo-treated cells. Vitamin E-treated PMN depolarized more and hyperpolarized more rapidly than placebo cells. Thus vitamin E-treated PMNs show differences in the early events of PMN activation. These may contribute to the lower stimulated adherence observed with vitamin E-treated cells.

Intracellular pH changes during neutrophil activation: Na+/H+ antiport.

Activation of the Na+/H+ antiport mechanism was studied in human neutrophils by monitoring intracellular pH with a carboxyfluorescein derivative. N-formyl-methionyl-leucyl-phenylalanine (FMLP) and phospholipase C (PLC) induced biphasic pH changes. Amiloride, which inhibits the antiport, completely blocked alkalinization but enhanced acidification. Polymyxin B, which inhibits protein kinase C, only blocked alkalinization. Activation with phorbol 12-myristate 13-acetate (PMA) led to alkalinization only; this was inhibited by amiloride or polymyxin B. Thus, during polymorphonuclear leukocyte (PMN) activation, intracellular alkalinization appears to be mediated by an amiloride-sensitive Na+/H+ antiport. Antiport activity can also be blocked indirectly by inhibition of protein kinase C activity. Early intracellular acidification does not appear to require kinase activity but is observed when phospholipids are remodeled with PLC. The antiport was also activatable by hypertonic buffered media. This response did not appear to be mediated by protein kinase C because it was unaffected by polymyxin B. Finally, superoxide generation was investigated. It is affected by, but not soley controlled by, either antiport or protein kinase C activity.

Cell alkalinization is not necessary and increased sodium influx is not sufficient for stimulated superoxide production.

Preincubation of rabbit neutrophils for 5 min with the protein kinase C inhibitor H7 causes inhibition of the rise in intracellular pH but not the increase in Na+ influx or stimulated oxidative burst produced by the chemotactic factor formyl-methionyl-leucyl-phenylalanine. On the other hand, the stimulated superoxide production, but not the increase in Na+ influx produced by phorbol 12-myristate 13-acetate, is inhibited by H7. The effect is more pronounced on the rate than the extent of the stimulated superoxide release. Furthermore, cell acidification produced by the phorbol ester but not by the chemotactic factor is decreased in the presence of H7. These results suggest that most of the stimulated Na+ influx is not coupled to H+ efflux, in the case of the chemoattractant, the rise in intracellular pH is not necessary for stimulated superoxide production, the increase in Na+ influx, in the case of the phorbol ester, is not sufficient for the stimulation of the oxidative burst, and the sources of the H+ responsible for the stimulated pH drop are the various metabolic activities of the cell, including NADPH oxidation and activation of the hexose monophosphate shunt.

Oncologic emergencies I. Metabolic and space-occupying consequences of cancer and cancer treatment.

Proper management of the consequences of cancer and cancer treatment is necessary to give affected children the increased chances of survival that recent therapeutic advances offer them. This article discusses the pathophysiology, diagnosis, and management of those metabolic and space-occupying consequences that are likely to face the primary care physician.

Oncologic emergencies II. Hematologic and infectious complications of cancer and cancer treatment.

Proper supportive care of the child with cancer is necessary to maximize the child's quality and length of life. This article discusses the pathophysiology, diagnosis, and management of the common hematologic and infectious complications of childhood cancer that the primary care physician must face.

Glycoprotein-180 deficiency: genetics and abnormal neutrophil activation.

Neutrophil function was studied in a patient with polymorphonuclear leukocyte (PMN) glycoprotein-180 deficiency and in her parents. PMNs of the patient had abnormal chemotaxis, phagocytosis, adherence, surface charge, and membrane-associated events of activation. Selective defects to C3b, immunoglobulin G (IgG), phorbol myristate acetate (PMA) and N-formyl-methionyl-leucyl-phenylalanine (FMLP) are described, although C3b receptor density was normal. The parents were found to have abnormal adherence to nylon-wool fibers, abnormal transmembrane potential depolarization with PMA, and reduced amounts of glycoprotein-180 in their PMNs. These studies provide further evidence that the oxidative burst has several different pathways for activation. They demonstrate that the absence of a single PMN surface glycoprotein is associated with a broad spectrum of PMN functional abnormalities. Finally, the observations made in the parents support an autosomal recessive mode of inheritance.