Mapping the estrous cycle to context-specific extinction memory.

In Pavlovian renewal paradigms, intact female rats have previously failed to exhibit renewal of appetitive behavior after extinction. However, when treated with exogenous estradiol, female rats exhibit robust renewal behavior. The current study aims to investigate whether the estrous cycle can influence renewal of appetitive behaviors and activity in brain areas known to support the renewal effect. We further aimed to examine whether the estrous cycle would similarly affect renewal of two different types of appetitive behaviors. We first establish that rats in the proestrous stage of the estrous cycle during extinction exhibit elevated renewal behavior compared with rats in either metestrous/diestrous stages, and only rats in proestrus during extinction training (but not during the renewal test) exhibit elevated renewal behavior. Furthermore, we show that this estrous cycle dependent effect on renewal only applies to the conditioned approach behavior toward the food delivery site but not the conditioned approach behavior toward the light cue associated with food delivery. Finally, we examined FOS activity within the prelimbic and infralimbic areas of the medial prefrontal cortex, the dorsal and ventral hippocampal formation, the paraventricular nucleus of the thalamus, the nucleus accumbens, and areas of the amygdala. Particularly in the hippocampus and amygdala, FOS expression which corresponded to the behavioral differences between groups was observed. Results from this study suggest that context information processing may vary as a function of endogenous female hormones across the gonadal hormone cycle and that encoding and retrieval of this information is accomplished in a state-specific manner. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Factors associated with car seat test failure in late preterm infants: A retrospective chart review.

BACKGROUND: Professional organizations recommend car seat testing of preterm infants before discharge from hospital. Late preterm infants (LPIs, 34(0/7) to 36(6/7) weeks' gestational age) are at the greatest risk for failure, despite often being well. OBJECTIVE: To determine the incidence of car seat testing failure in LPIs and associative factors. METHODS: A retrospective chart review was performed of inborn LPIs admitted to all levels of newborn care between July 1, 2012 and June 30, 2013. Data collected included maternal demographics, labour and delivery history, and neonatal course. Data were analyzed using backward logistic regression. RESULTS: A total of 511 charts were reviewed and 367 LPIs were eligible for inclusion. Of the 313 LPIs tested (mean [± SD] gestational age 36 weeks ±6 days and birth weight 2614±405 g), 80 (26%) failed (95% CI 21% to 31%). Most failed due to desaturations (≥2) of <88% for ≥10 s (n=33 [41%]). Multiple gestation was associated with failure (adjusted OR 2.45 [95% CI 1.44 to 4.18]; P=0.001), and there was a trend toward statistical significance for the variable postnatal age (0.996 [95% CI 0.99 to 1.00]; P=0.05). Infants who passed their car seat test had higher postnatal ages than those who failed (mean difference 39.4 h [95% CI 12.7 h to 66.0 h]; P=0.004). CONCLUSION: Twenty-six percent of LPIs failed car seat testing. Ideally, infants should be tested after an appropriate transitional period. The authors identified factors that may be important in designing future, prospective studies in this area. Future research should evaluate the clinical significance of car seat testing and resource utilization.

HISTORIQUE: Les organisations professionnelles recommandent de vérifier les sièges d'auto des nourrissons prématurés avant leur congé de l'hôpital. Les nourrissons peu prématurés (NPP; de 340/7 à 366/7 semaines d'âge gestationnel) risquent le plus d'échouer cette vérification, même s'ils sont souvent en bonne santé. OBJECTIF: Déterminer l'incidence d'échec de la vérification des sièges d'auto chez les NPP, ainsi que les facteurs s'y associant. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de NPP nés à l'hôpital et admis à tous les niveaux de soins des nouveau-nés entre le 1er juillet 2012 et le 30 juin 2013. Les données colligées incluaient les renseignements démographiques sur la mère, les données sur le travail et l'accouchement et l'évolution néonatale. Les chercheurs ont analysé les données à l'aide de la régression logistique rétrograde. RÉSULTATS: Les chercheurs ont examiné 511 dossiers, et 367 NPP étaient admissibles à l'inclusion. Des 313 NPP vérifiés (âge gestationnel moyen [± ÉT] de 36 semaines ±6 jours et poids de naissance de 2 614±405 g), 80 (26 %) ont échoué (95 % IC 21 % à 31 %), la plupart à cause d'une désaturation (≥2) de moins de 88 % pendant au moins 10 s (n=33 [41 %]). La gestation multiple s'associait à un échec (RC rajusté 2,45 [95 % IC 1,44 à 4,18]; P=0,001), et on remarquait une tendance vers une signification statistique de la variable d'âge postnatal (0,996 [95 % IC 0,99 à 1,00]; P=0,05). Les nourrissons pour qui la vérification du siège d'auto ne posait pas de problème avaient un âge postnatal plus avancé que ceux qui l'échouaient (différence moyenne de 39,4 h [95 % IC 12,7 h à 66,0 h]; P=0,004). CONCLUSION: Vingt-six pour cent des NPP échouaient la vérification du siège d'auto. Dans l'idéal, il faudrait vérifier les nourrissons après une période transitoire pertinente. Les chercheurs ont déterminé des facteurs susceptibles d'être importants pour concevoir de futures études prospectives dans ce domaine. De futures recherches devraient évaluer la signification clinique de la vérification des sièges d'auto et l'utilisation des ressources.

Soft Tissue Mobilization to Resolve Chronic Pain and Dysfunction Associated With Postoperative Abdominal and Pelvic Adhesions: A Case Report.

STUDY DESIGN: Case report. BACKGROUND: Common complications from abdominal and pelvic surgery include adhesions and chronic pain. Laparoscopic adhesiolysis is sometimes used to reduce adhesions and related pain. Physical therapy interventions, such as soft tissue mobilization (STM), may be used for this condition; however, evidence to support its effectiveness is lacking. CASE DESCRIPTION: A 28-year-old woman with a history of 5 abdominal/pelvic surgeries presented with right-sided lower abdominal and anterior hip pain, which had been present since she had undergone a laparoscopic appendectomy with a right ovarian cystectomy surgery 1 year earlier. As an active-duty member in the US Navy, due to pain and weakness, she was unable to perform required curl-ups for her fitness test. Though she had been previously treated both surgically with laparoscopic adhesiolysis and nonsurgically with physical therapy consisting of stretching and strengthening exercises, her pain and function did not improve. She was again evaluated and treated with physical therapy and, based on the examination findings, STM was used to address her pain and dysfunction, which were thought to be related to intra-abdominal adhesions. OUTCOMES: Following 5 sessions of physical therapy over a 3-week period that included STM and therapeutic exercises, followed by 5 additional sessions over a 4-week period that focused on therapeutic exercises, the patient reported substantially decreased pain, improved function, and a full return to previous level of activity, including unrestricted physical training in a military setting. DISCUSSION: The outcomes for this patient suggest that STM may be effective as a conservative treatment option for pain and dysfunction related to intra-abdominal adhesions from abdominal/pelvic surgery. Studies with a higher level of evidence, including potential comparison between STM and traditional laparoscopic adhesiolysis, are needed to further determine benefits of nonsurgical care for this condition.

Baseline Examination Factors Associated With Clinical Improvement After Dry Needling in Individuals With Low Back Pain.

STUDY DESIGN: Quasi-experimental. OBJECTIVES: To explore for associations between demographic, patient history, and physical examination variables and short-term improvement in self-reported disability following dry needling therapy performed on individuals with low back pain (LBP). BACKGROUND: Dry needling is an intervention used with increasing frequency in patients with LBP; however, the characteristics of patients who are most likely to respond are not known. METHODS: Seventy-two volunteers with mechanical LBP participated in the study. Potential prognostic factors were collected from baseline questionnaires, patient history, and physical examination tests. Treatment consisted of dry needling to the lumbar multifidus muscles bilaterally, administered during a single treatment session. Improvement was based on percent change on the Oswestry Disability Index at 1 week. The univariate and multivariate associations between 33 potential prognostic factors and improved disability were assessed with correlation coefficients and multivariate linear regression. RESULTS: Increased LBP with the multifidus lift test (rpb = 0.31, P = .01) or during passive hip flexion performed with the patient supine (rpb = 0.23, P = .06), as well as positive beliefs about acupuncture/dry needling (rho = 0.22, P = .07), demonstrated univariate associations with Oswestry Disability Index improvement. Aggravation of LBP with standing (rpb = -0.27, P = .03), presence of leg pain (rpb = -0.29, P = .02), and any perception of hypermobility in the lumbar spine (rpb = -0.21, P = .09) were associated with less improvement. The multivariate model identified 2 predictors of improved disability with dry needling: pain with the multifidus lift test and no aggravation with standing (R(2) = 0.16, P = .01). CONCLUSION: Increased LBP with the multifidus lift test was the strongest predictor of improved disability after dry needling, suggesting that the finding of pain during muscle contraction should be studied in future dry needling studies. LEVEL OF EVIDENCE: Prognosis, level 1b.

Severely elevated transaminases in an adolescent male with anorexia nervosa.

Anorexia nervosa (AN) is a serious disorder that is associated with numerous medical complications and affects both females and males. Severely elevated transaminases have been reported in adult and younger females. We report the first case of elevated transaminases in an adolescent male with AN. The pathophysiologic mechanism of severely elevated serum transaminases observed in malnourished adolescent males with AN is complex and appears to be multifactorial. We present the first case of an adolescent male with AN who developed severely elevated serum transaminases that normalized with improved nutrition and weight gain. Liver injury in patients with AN is a complex medical complication that appears to be multifactorial in origin. In this case, starvation-induced autophagy in the human liver was considered one of the most likely mechanisms to explain hepatocytic injury in this patient.

Prevalence of hypothalamic-pituitary-adrenal axis suppression in children treated for asthma with inhaled corticosteroid.

OBJECTIVE: To determine the prevalence of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on inhaled corticosteroids (ICS). METHODS: Clinical and demographic variables were recorded on preconstructed, standardized forms. HPA axis suppression was measured by morning serum cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation testing. RESULTS: In total, 214 children participated. Twenty children (9.3%, 95% CI 5.3% to 13.4%) had HPA axis suppression. Odds of HPA axis suppression increased with ICS dose (OR 1.005, 95% CI 1.003 to 1.009, P<0.001). All children with HPA axis suppression were on a medium or lower dose of ICS for their age (200 µg/day to 500 µg/day). HPA axis suppression was not predicted by drug type, dose duration, concomitant use of long-acting beta-agonist or nasal steroid, or clinical features. CONCLUSION: Laboratory evidence of HPA axis suppression exists in children taking ICS for asthma. Children should be regularly screened for the presence of HPA axis suppression when treated with high-dose ICS (>500 µg/day). Consideration should be given to screening children on medium-dose ICS.

OBJECTIF: Déterminer la prévalence de suppression de l'axe hypothalamo-hypophyso-surrénalien (HHA) chez les enfants asthmatiques traités au moyen de corticoïdes par aérosol (CPA). MÉTHODOLOGIE: Les chercheurs ont obtenu des variables cliniques et démographiques à l'aide de formulaires standardisés préétablis. Ils ont mesuré la suppression de l'axe HHA au moyen de taux de cortisol sérique le matin et l'ont confirmée grâce à un test de stimulation à l'hormone adrénocorticotrope (ACTH) à faible dose. RÉSULTATS: Sur les 214 enfants qui ont participé à l'étude, 20 (9,3 %, 95 % IC 5,3 % à 13,4 %) présentaient une suppression de l'axe HHA. Le risque d'une telle suppression augmentait proportionnellement à la dose de CPA (RRR 1,005, 95 % IC 1,003 à 1,009, P<0,001). Tous les enfants présentant une suppression de l'axe HHA prenaient une dose moyenne à faible de CPA compte tenu de leur âge (200 µg/jour à 500 µg/jour). La suppression de l'axe HHA ne pouvait être prédite selon les caractéristiques cliniques, le type de médicament, la durée de la dose ou l'utilisation concomitante de bêta-agonistes à longue durée d'action ou de stéroïdes par voie nasale. CONCLUSION: Il existe des preuves de laboratoire de suppression de l'axe HHA chez les enfants qui prenaient des CPA pour traiter leur asthme. Il faudrait procéder au dépistage régulier de la suppression de l'axe HHA chez des enfants traités au moyen de fortes doses de CPA (plus de 500 µg/jour). Il faut également envisager de dépister les enfants traités au moyen d'une dose moyenne de CPA.

Variability in clinical practice guidelines for sweetening agents in newborn infants undergoing painful procedures.

OBJECTIVE: Sweetening agents have been recommended in position statements and consensus documents for procedural pain management in neonates; however, it is not clear if this has resulted in widespread adoption in clinical practice. The objective of this study was to investigate unit-specific protocols for the use of sweetening agents. METHODS: Structured telephone survey with qualified personnel in special care (level II) nurseries and neonatal intensive care (level III) units across Canada. The frequency and pattern of recommended use of sweetening agents was documented. RESULTS: Eighty-six of 92 units (93.5%) participated. Sixty-four percent recommended sucrose and 2.3% recommended glucose for procedural pain management; 87.7% had a guideline. Sweetening agents were most commonly recommended for venipuncture/venous cannulation (91.2% for both), lumbar puncture (87.7%), and heel lance (82.5%). Dosing guidelines ranged from 0.05 mL of 24% sucrose solution to 3 mL of 25% sucrose solution. Sweeteners were not recommended for infants with necrotizing enterocolitis (77.2%) or those who were nil per os (75%). CONCLUSIONS: Sweetening agents were recommended for procedural pain management in two-thirds of special care nurseries and neonatal intensive care units across Canada with extensive variability in specific dosing guidelines. Audits of pain management practices should therefore account for unit-specific practice guidelines.

Spectrum and management of hypertriglyceridemia among children in clinical practice.

OBJECTIVES: The prevalence and identification of hypertriglyceridemia in youths will likely will increase in the future as a consequence of childhood obesity and increased screening for dyslipidemias. We sought to review our clinical experience with hypertriglyceridemia, evaluate factors associated with increased triglyceride levels, and review treatment options to provide guidance for management. METHODS: Clinical review of data for all patients who had > or =1 elevated triglyceride level (>4 mmol/L [>350 mg/dL]) while being monitored in a specialized lipid disorders clinic was performed. RESULTS: The study population consisted of 76 patients with 761 clinic visits. Hypertriglyceridemia was secondary to lifestyle factors for 13 patients. The rest had primary hypertriglyceridemia, with 32 patients having familial combined hypertriglyceridemia and hypercholesterolemia (type II), 25 patients having primary hypertriglyceridemia (type IV), 4 patients having familial lipase deficiency (type I), and 2 patients having hyperlipoproteinemia E2/E2 phenotype (type III). Triglyceride levels were highest in type I and III hypertriglyceridemia (>10 mmol/L [>900 mg/dL]), followed by type IV and adiposity-related hypertriglyceridemia (>4 mmol/L [>350 mg/dL]) and finally type II familial combined hypertriglyceridemia and hypercholesterolemia (>2 mmol/L [>180 mg/dL]). A total of 34 patients received 37 trials of drug therapy as part of triglyceride level management (bile acid-binding resins, n = 12; fibrates, n = 19; statins, n = 6). Triglyceride levels were found to decrease over time with the use of fibrates, to increase with the use of bile acid-binding resins, and not to change with the use of statins. CONCLUSIONS: Lifestyle modifications remain the primary therapeutic avenue for the management of pediatric hypertriglyceridemia. We propose an algorithm for the management of this heterogeneous population to guide clinicians in their treatment decisions.

Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures.

BACKGROUND: Sucrose is widely used to manage procedural pain in term newborns despite a lack of evidence of its effectiveness for different procedures and infant populations. Our objectives were to evaluate the effectiveness and safety of sucrose in newborns undergoing various medical procedures within 2 days of birth. METHODS: We performed a double-blind, randomized controlled trial. We included newborns (>or= 36 weeks gestation) of diabetic mothers and nondiabetic mothers. Each newborn received 2 mL of a 24%-sucrose or placebo solution before all procedures. We used the Premature Infant Pain Profile to assess pain during intramuscular injection of vitamin K, venipuncture for the newborn screening test and the first 3 heel lances for glucose monitoring (newborns of diabetic mothers only). Scores ranged from from 0 (no pain) to 18 (maximum pain). RESULTS: We included 240 newborns (120 from diabetic mothers, 120 from nondiabetic mothers). The overall mean pain score was lower among newborns who received sucrose than among those who received a placebo (mean difference -1.3, 95% confidence interval [CI] -2.0 to -0.6). We found that pain scores during intramuscular injection did not differ significantly between the sucrose and placebo groups for newborns of diabetic or nondiabetic mothers (newborns of nondiabetic mothers: mean difference -1.1, 95% CI -2.4 to 0.2; newborns of diabetic mothers: mean difference -1.0, 95% CI -2.4 to 0.4). During venipuncture, newborns who received sucrose had lower pain scores compared with those who received a placebo (newborns of nondiabetic mothers: mean difference -3.2, 95% CI -4.6 to -1.8; newborns of diabetic mothers: mean difference -2.4, 95% CI -3.8 to -1.0). Among newborns of diabetic mothers, there was no difference in pain during the first 3 heel lances or mean glucose levels between the sucrose and placebo groups (p = 0.94 and p = 0.29 respectively). INTERPRETATION: We found a modest reduction of pain in newborns of both diabetic and nondiabetic mothers when sucrose was used for all medical procedures performed in the first 2 days after birth. However, when each procedure was analyzed separately, we found that the effectiveness of sucrose was limited to venipuncture for the newborn screening test. (http://Clinicaltrials.gov trial register no. NCT00213213.).

Caregivers' responses to pain in their children in the emergency department.

OBJECTIVE: To explore physiological and anxiety responses of caregivers who witness a venipuncture being performed on their child and the effects of caregivers' responses on child pain and distress. DESIGN: Observational study between March 13, 2006, and June 8, 2006. SETTING: Tertiary-level pediatric emergency department in Toronto, Ontario. PARTICIPANTS: Fifty-five caregivers of children aged 1 month to 18 years. MAIN EXPOSURE: Observing a child receive an intravenous cannulation. OUTCOME MEASURES: The caregiver's heart rate, blood pressure, and anxiety (measured using a 10-cm visual analogue scale). Child-caregiver interactions were measured using the Child-Adult Medical Procedure Interaction Scale-Short Form (child age, > or = 2 years) or the Measure of Adult and Infant Soothing and Distress (child age, < 2 years). Child pain was measured using the Faces Pain Scale-Revised. RESULTS: During cannulation, there was a significant increase in a caregiver's heart rate (median maximum difference = 12 beats per minute; P<.001) and anxiety (median difference = 2.65 cm; P<.001). Mean arterial pressure decreased after cannulation (median difference = 4.4 mm Hg; P = .004). Backward linear regression revealed that 34% of the variability in child cannulation pain was predicted by caregiver anxiety and caregiver distress-promoting behavior; 31% of the variability in a child's distress during cannulation was predicted by caregiver distress-promoting behavior. Caregiver heart rate and anxiety during cannulation and caregiver distress-promoting behavior during recovery accounted for 51% of the variability in the child's distress during recovery. CONCLUSIONS: Caregivers witnessing an intravenous cannulation in their child had elevated heart rate, blood pressure, and anxiety. These responses predicted child pain and distress. Future studies should evaluate interventions designed to decrease distress responses in caregivers.

Children with autism: effect of iron supplementation on sleep and ferritin.

To determine if there is a relationship between low serum ferritin and sleep disturbance in children with autism spectrum disorder, an 8-week open-label treatment trial with oral iron supplementation was conducted as a pilot study. At baseline and posttreatment visits, parents completed a Sleep Disturbance Scale for Children and a Food Record. Blood samples were obtained. Thirty-three children completed the study. Seventy-seven percent had restless sleep at baseline, which improved significantly with iron therapy, suggesting a relationship between sleep disturbance and iron deficiency in children with autism spectrum disorder. Sixty-nine percent of preschoolers and 35% of school-aged children had insufficient dietary iron intake. Mean ferritin increased significantly (16 microg/L to 29 microg/L), as did mean corpuscular volume and hemoglobin, suggesting that low ferritin in this patient group resulted from insufficient iron intake. Similar prevalence of low ferritin at school age as preschool age indicates that children with autism spectrum disorder require ongoing screening for iron deficiency.

Prospective study of a noninvasive treatment for two common congenital toe abnormalities (curly/varus/underlapping toes and overlapping toes).

OBJECTIVE: To assess, in the newborn, the efficacy of a standard taping treatment used in children for two selected congenital toe abnormalities (curly/varus/underlapping toes and overlapping toes), and compare the outcome with the available world literature. METHODS: All children referred by their family physician between January 2004 and January 2006 were included. The newborns were reviewed by one author (WGS) within 10 days of birth, assessed for severity, and the toes were taped in a standard manner if the abnormalities met the study criteria. After one and two months, the same author reviewed the children, and retaped the toes. The children's toes were photographed before the taping and then after three months when the tape was removed permanently. After six months, the children, with their pictures, were sent to a second author (JTS), and were scored for the grade of severity and improvement using standard criteria. RESULTS: The world literature and standard textbooks indicate a 25% spontaneous improvement of these abnormalities. The recommendation is for surgical correction at a later date because intervention with taping has not shown success after the newborn period. No prior studies have been undertaken in the newborn. In the present study of 84 toes, the abnormality occurred in 2.8% of newborns, and 94% of the toes were improved or cured with no complications related to the technique. CONCLUSION: A simple, office-friendly technique of taping underlapping and overlapping toes in the newborn proved successful in 94% of the toes.