Temporal development of the oral microbiome and prediction of early childhood caries.

Human microbiomes are predicted to assemble in a reproducible and ordered manner yet there is limited knowledge on the development of the complex bacterial communities that constitute the oral microbiome. The oral microbiome plays major roles in many oral diseases including early childhood caries (ECC), which afflicts up to 70% of children in some countries. Saliva contains oral bacteria that are indicative of the whole oral microbiome and may have the ability to reflect the dysbiosis in supragingival plaque communities that initiates the clinical manifestations of ECC. The aim of this study was to determine the assembly of the oral microbiome during the first four years of life and compare it with the clinical development of ECC. The oral microbiomes of 134 children enrolled in a birth cohort study were determined at six ages between two months and four years-of-age and their mother's oral microbiome was determined at a single time point. We identified and quantified 356 operational taxonomic units (OTUs) of bacteria in saliva by sequencing the V4 region of the bacterial 16S RNA genes. Bacterial alpha diversity increased from a mean of 31 OTUs in the saliva of infants at 1.9 months-of-age to 84 OTUs at 39 months-of-age. The oral microbiome showed a distinct shift in composition as the children matured. The microbiome data were compared with the clinical development of ECC in the cohort at 39, 48, and 60 months-of-age as determined by ICDAS-II assessment. Streptococcus mutans was the most discriminatory oral bacterial species between health and current disease, with an increased abundance in disease. Overall our study demonstrates an ordered temporal development of the oral microbiome, describes a limited core oral microbiome and indicates that saliva testing of infants may help predict ECC risk.

CPP-ACP Promotes SnF2 Efficacy in a Polymicrobial Caries Model.

Dental caries is associated with plaque dysbiosis, leading to an increase in the proportions of acidogenic and aciduric bacteria at the expense of alkali-generating commensal species. Stannous fluoride (SnF2) slows the progression of caries by remineralization of early lesions but has also been suggested to inhibit glycolysis of aciduric bacteria. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) promotes fluoride remineralization by acting as a salivary biomimetic that releases bioavailable calcium and phosphate ions, and the peptide complex has also been suggested to modify plaque composition. We developed a polymicrobial biofilm model of caries using 6 bacterial species representative of supragingival plaque that were cultured on sound human enamel and pulsed with sucrose 4 times a day to produce a high cariogenic challenge. We used this model to explore the mechanisms of action of SnF2 and CPP-ACP. Bacterial species in the biofilms were enumerated with 16S rRNA gene sequence analyses, and mineral loss and lesion formation were determined in the enamel directly under the polymicrobial biofilms via transverse microradiography. The model tested the twice-daily addition of SnF2, CPP-ACP, or both. SnF2 treatment reduced demineralization by 50% and had a slight effect on the composition of the polymicrobial biofilm. CPP-ACP treatment caused a similar inhibition of enamel demineralization (50%), a decrease in Actinomyces naeslundii and Lactobacillus casei abundance, and an increase in Streptococcus sanguinis and Fusobacterium nucleatum abundance in the polymicrobial biofilm. A combination of SnF2 and CPP-ACP resulted in a greater suppression of the acidogenic and aciduric bacteria and a significant 72% inhibition of enamel demineralization.

Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial.

OBJECTIVE: Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain. METHODS: We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age >/=50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation. RESULTS: A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (-3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] -5.88, -0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (-3.53; 95% CI -6.52, -0.55) or group rehabilitation (-3.16; 95% CI -6.55, -0.12). CONCLUSION: ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain.

OBJECTIVE: To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program. METHODS: Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness. RESULTS: Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost 224 pounds (95% confidence interval [95% CI] 184 pounds, 262 pounds) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Indiv-rehab cost 314 pounds/person and Grp-rehab 125 pounds/person. Indiv-rehab cost 189 pounds (95% CI 168 pounds, 208 pounds) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP 5,500 pounds. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome. CONCLUSION: Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.

The management of knee pain in primary care: factors associated with consulting the GP and referrals to secondary care.

OBJECTIVES: To investigate the treatment of knee pain in primary care and the factors associated with consulting general practitioners (GPs) and referrals to specialist services. METHODS: Individuals with knee pain were identified through postal questionnaires sent to patients aged 50 and over from two GP practices in southeast London. Patients with knee pain were then invited to the department, where demographic, clinical and service use data were collected. Participants also completed measures of pain, function, handicap and illness beliefs. RESULTS: From the 2940 questionnaires that were sent out, the response rate was 34%. Of these, 49% reported experiencing knee pain in the previous 12 months. Two hundred and thirty-one patients with knee pain attended the department. One hundred and thirty-four (58%) had seen their GP about their knee pain, with 50 (37%) referred on to specialist services. Compared with non-consulters, consulters had more severe disease and higher levels of disability and handicap, and believed the condition was more severe and had major consequences on their lives. Those referred to specialist care had higher levels of handicap and also believed the condition was more severe, with major consequences on their lives, than those not referred. CONCLUSION: In this sample nearly half of those who reported knee pain had not seen their GP and were self-managing their condition. A mixture of physical, social and psychological factors predicted visits to GPs and rates of referral to secondary care. Patient perceptions about knee pain were important predictors of both consultations and referrals, highlighting the need to address both physical and psychosocial factors in relation to help-seeking.

Maxillary incisor palatal erosion: no correlation with dietary variables?

The objectives of the study were to examine a relationship between tooth erosion affecting the palatal aspects of permanent maxillary central incisors with dietary, behavioral and medical variables. The methods included, 251 schoolchildren aged 11 to 13 years were recruited to participate. Each subject had dental impressions of the palatal aspects of both upper central incisors recorded at baseline, 9 and 18 months intervals. From these, electroconductive replicas were fabricated, mapped and compared using a surface matching technique. At the end of the study all participants underwent a structured interview that sought to assay the level of potential erosive dietary, behavioral and medical risk factors. Correlation analyses of the responses given in the final structured interview with the degrees of palatal tooth substance loss (both previous and measured) were under taken. The results showed: (1) The degree of previous erosion did not predict the level of measured ongoing erosion. (2) Brushing the teeth more frequently with fluoridated toothpaste correlated significantly with lower levels of ongoing erosion (P = 0 011). It was concluded that: (1) Evidence of previous palatal erosion did not predict future erosion. (2) The application of topical fluoride as a by-product of tooth brushing may provide an element of protection against palatal erosion. (3) In view of the lack of correlation between exposure to potential risk factors and the level of ongoing palatal tooth surface loss in this study, other factors (such as an individual's susceptibility and salivary buffering power) may well be more important predictors. The clinical relevance included: Preventive advice to patients with dental erosion should not only include the use of topical fluoride, in the form of toothpaste, but recognize individual susceptibility to this condition.

Rationalization of quantitative tooth surface loss data for epidemiological research.

Recent UK National Surveys have revealed a high prevalence of tooth surface loss (TSL) because of erosion in Children and Adolescents. Although digital surface mapping and surface matching techniques may be used to quantify its progression with time, reporting TSL of individuals as a function of either mean depth loss or volume loss, this can be inadequate when transferred for epidemiological analysis. For example, a tooth displaying multiple regions of depth loss may deserve to be distinguished from a tooth with a single localised area of erosion, although the total volume change may be the same. A potential solution, explored here, is to use both the quantitative wear data and colour coded surface representation plots generated by such methods to arrive at a single categorical wear score [1 (< or = 5% of surface exhibits TSL) to 5 (> or = 51% of surface exhibits TSL)]. Two examiners independently categorized, on two separate occasions, the TSL of 53 maxillary incisors (26 subjects observed at baseline and 9 months). Their performance was assessed for intra- and inter-examiner agreement by; (i) calculating the percentage of agreement, (ii) a Wilcoxon matched-pairs signed rank test. Thereafter, in cases of disagreement a consensus score was allocated and a regression analysis of this versus the numerically derived percentage of the surface that had undergone change was carried out. Intra- and inter-examiner agreement was 100 and 88.7% respectively and for the inter-examiner comparison P = 0.0456. The categorical scores and the quantitative wear data correlated linearly (R = 0.82). It is concluded that the method used to rationalize the quantitative TSL data is both reproducible and reflects the quantitative data. Its use should be helpful in epidemiological TSL studies but continued vigilance is required in cases of examiner disagreement.

A novel approach to evaluating the reproducibility of a replication technique for the manufacture of electroconductive replicas for use in quantitative clinical dental wear studies.

The assessment of the progression of tooth surface loss has until recently been limited to either the application of subjective ranking scales or visual comparison of sequential study casts. The development of quantitative measuring techniques offers the potential of greater accuracy and sensitivity. As direct intra-oral measurement is problematical such approaches often utilize impressions of the teeth, recorded at different epochs, to construct replicas for mapping and comparison. This in vitro investigation sought to determine the reproducibility of such an approach taking into account the total process chain. Two inlay cavities (one large, one small) were prepared in the palatal aspect of a plastic maxillary central incisor and restored with two flush fitting inlays. A series of impressions of this tooth were recorded, using a special tray and an addition cured light bodied silicone impression material (President, Coltene, Switzerland), with (a) both inlays in (b) both inlays out (c) large inlay out and small inlay in (d) large inlay in and small inlay out - a total of 16 impressions. Electroconductive replicas were fabricated from these and mapped using a computer controlled probe. Each series simulated wear of the tooth. A surface matching and difference detection algorithm was then used to compare each series of replicas and calculate the proportion of the surface undergoing simulated wear by a direct comparison of (a) matched to (b) or, indirectly as the summation of the results of matches of (a) with (c) and (a) with (d). The mean proportion of the surface with wear calculated directly was 26.6% (s.d.=0.6) and indirectly 26.1% (s.d. = 0.5). A one-way anova revealed no significant difference (P > 0.05). It is concluded that determining wear by this method is highly reproducible.

Linear interpolation error in measured surfaces in a dental erosion study.

An extensive palatal erosion study, which is currently being undertaken at the University of Dundee, aims to detect erosion through the precise mapping of replicas of children's incisors. All perceived sources of error are being scrutinised closely. The error due to the interpolation of surface positions from discrete point measurements has been investigated so that its contribution to the erosion estimates can be gauged. The calculation of the error statistics made use of covariance functions to express the undulation of the tooth surfaces. It has been found that, for the measurement point spacing of 150 microm being used in the current project, the interpolation error for an incisor is typically about 25 microm, to be compared with the root-mean-square error due to tooth impression and replication procedures, assessed as being in the order of +/- 3 microm, and replica measurement, assessed as being in the order of +/- 5 microm. The interpolation error constitutes a surprisingly large proportion of the overall system error. The same error estimation technique can be applied usefully and without difficulty to other research studies concerning erosion or wear in natural or restorative dental surfaces.

Assessment of a procedure for detecting minute levels of tooth erosion.

Over a period of some years, the components of a system for discerning erosion on children's teeth have been progressively developed, for use in an extensive project seeking correlations between erosion and various perceived risk factors. The aim was the detection of minute levels of erosion, based on mappings of the palatal surfaces of the maxillary central incisors in children. Significant challenges were encountered, the primary problem being the impracticality of placing control marks that would aid the realignment of successive measurements. The paper describes the erosion detection system and initial experiences based on the results of the first 100 subjects measured after 9 months. The procedures detected the occurrence of erosion of 50 microm magnitude on about one-quarter of the teeth over the 9 month period, at a precision estimated to be +/- 15 microm. The occurrence of some anomalous incidents prevented the procedure from being fully automatic, and it necessitated human examination of a graphical diagram derived from the surface matching program, but it was nevertheless superior to current practices of examining impressions or replicas entirely by eye.

Evaluation of the accuracy and reproducibility of a replication technique for the manufacture of electroconductive replicas for use in quantitative clinical dental wear studies.

This work sought to evaluate the accuracy and reproducibility of a replication process that formed electroconductive replicas from addition cured silicone impressions for the purposes of monitoring tooth surface loss. Replicas were constructed by painting the surface of impressions with one of three high silver content electroconductive paints [Electrocure (EC), RS Silver Paint (SP) and Electrolube (EB)] and, once dry, backing this up with a cyanoacrylate based gel material (Zapit) and die stone. For each paint an impression was recorded of a gauge block of known step height (1270 microm) and five impressions of the palatal surface of a laboratory standard maxillary central incisor were also recorded. All impressions were taken using an addition cured silicone impression material (President). The resultant electroconductive replicas were mapped using a computer controlled probe. This data was analysed to determine both the replica's step height and, using surface matching techniques, the reproducibility of the replication process. The mean step heights recorded were; EC=1268.43 (s.d.=12.09), SP=1267.09 (s.d. 1.77) and EB 1299.58 (s.d. 14.47). Both EC and SP recorded the step height to within 3 microm. In the repeat replication of the palatal surface of an upper central incisor SP maintained a greater constancy of surface topography (99.6%) that was statistically superior to both EC (P < 0.05) and EB (P < 0.01). The SP was therefore the preferred paint for this technique. Bearing this in mind the replication technique was both accurate and reproducible but vigilance, as to the selection of paint for the process, should be exercised so as not to affect the good accuracy and reproducibility of the technique.

A comparative study of outcome in myositis and other musculoskeletal disorders assessed using the Nottingham health profile.

OBJECTIVE: This study evaluated the comparative impact of myositis and other musculoskeletal disorders on general health using the Nottingham health profile (NHP) as a generic measure of health status. METHODS: A prospective observational study of 113 females with myositis, 142 females with rheumatoid arthritis, 45 females with spinal osteoporosis and 96 females with knee osteoarthritis. RESULTS: All mean NHP section scores were higher in myositis and other musculoskeletal disorders compared to population mean values. Section scores for energy and social isolation were high in myositis compared to all other disorders. Scores for physical disability in myositis were similar to RA. Pain scores were higher in RA and OA compared to myositis. Backwards linear regression models explained 26-42% of the variation in energy and social isolation scores. Emotion and physical section scores were the major determinants and the pattern was similar in all disorders. Disease duration and age had little effect. CONCLUSIONS: Myositis is not simply a disease with physical problems but has wide ranging effects on social and emotional well being. Until disease-specific instruments are available, a generic measure like the NHP can be used to assess problems other than muscle pain and loss of strength.

Conduct of an algorithm in quantifying simulated palatal surface tooth erosion.

In order to test the ability of an algorithm to quantify simulated palatal erosion, a total of 10 extracted permanent upper central incisors were mounted in brass blocks. Baseline impressions were recorded using an addition cured silicone impression material in a metal impression tray. Once set and removed from the teeth, the impressions were coated twice with a high silver content electroconductive paint, applied using a brush, before being backed up with die stone to form an electroconductive replica. Each tooth was then subject to three treatments: application of phosphoric acid etchant gel for 60 s, application of etchant gel for 120 s and immersion for 3 h in Diet Coca-Cola*. After each one the replication process was repeated. Thereafter all replicas were mapped using a computer controlled electrical probe and the resultant digital terrain models (DTMS) compared using a surface matching and difference detection algorithm (SMADDA). Surface matching was unsuccessful only in one instance. As the duration of the insult increased, so did the proportion of the surface that underwent change to a maximum of 33.3%. Anatomical site was significantly (P < 0.05) associated with the susceptibility to erosion. The cingulum periphery appeared most resistant to this. The algorithmic approach offers much scope for monitoring dental erosion as acid dissolution of the tooth's surface appears to occur gradually. The cingulum region appears relatively more resistant to this process than other tooth sites and thus facilitates the process of surface matching. Further testing is however, required to determine precisely the algorithm's upper tolerance level.

Selection of a Bifidobacterium strain to complement resistant starch in a synbiotic yoghurt.

AIMS: To employ an in vitro screening regime to select a probiotic Bifidobacterium strain to complement resistant starch (Hi-maizetrade mark) in a synbiotic yoghurt. METHODS AND RESULTS: Of 40 Bifidobacterium isolates examined, only B. lactis Laftitrade mark B94 possessed all of the required characteristics. This isolate hydrolysed Hi-maizetrade mark, survived well in conditions simulating passage through the gastrointestinal tract and possessed technological properties suitable for yoghurt manufacture. It grew well at temperatures up to 45 degrees C, and grew to a high cell yield in an industrial growth medium. In addition to resistant starch, the organism was able to utilize a range of prebiotics including inulin, and fructo-, galacto-, soybean- and xylo-oligosaccharides. Pulse field gel electrophoresis of restriction enzyme cut chromosomal DNA revealed that B. lactis Laftitrade mark B94 was very closely related to the B. lactis Type Strain (DSM 10140), and to the commercial strains B. lactis Bb-12 and B. lactis DS 920. However, B. lactis Laftitrade mark B94 was the only one of these isolates that could hydrolyse Hi-maizetrade mark. This phenotypic difference did not appear to be due to the presence of plasmid encoded amylase. Bifidobacterium lactis Laftitrade mark B94 survived without substantial loss of viability in synbiotic yoghurt containing Hi-maizetrade mark during storage at 4 degrees C for six weeks. CONCLUSION: Bifidobacterium lactis Laftitrade mark B94 is a promising new yoghurt culture that warrants further investigation to assess its probiotic potential. SIGNIFICANCE AND IMPACT OF THE STUDY: In vitro screening procedures can be used to integrate complementary probiotic and prebiotic ingredients for new synbiotic functional food products.

Presentation of quantitative tooth wear data to clinicians.

OBJECTIVE: The purpose of this study was to ascertain the ease of interpretation and usefulness of different modes of presenting quantitative tooth wear data to clinicians. METHOD AND MATERIALS: A questionnaire that sought to ascertain both the ease of interpretation and usefulness of different modes of presentation for monitoring tooth wear was distributed to 67 clinicians. These modes (contour maps, surface topography and difference plots, and color-coded surface difference plots) were a product of ongoing development that used a mathematic algorithm to detect and quantify wear of teeth with time. A follow-up questionnaire, based on a fusion of the desirable features of surface topography and color-coded surface difference plots, was distributed to 40 of the original respondents to ascertain any improvement in clarity. RESULTS: In all respects, contour maps were rated significantly more difficult to interpret and less useful than the other techniques evaluated. No significant difference was detected between the other modalities. The follow-up questionnaire demonstrated a significantly enhanced utility of the revised plot in informing the clinician as to the worn sites and quantity of wear. CONCLUSION: The combined mode of presentation seems an excellent way of presenting wear results to clinicians for clinical application.

DNA repair in higher plants.

Numerous studies have demonstrated a requirement in plants for repair of DNA damage arising from either intrinsic or extrinsic sources. Investigations also have revealed a capacity for repair of certain types of DNA damage, and conversely, identified mutants apparently defective in such repair. This article provides a concise overview of nuclear DNA repair mechanisms in higher plants, particularly those processes concerned with the repair of UV-induced lesions, and includes surveys of UV-sensitive mutants and genes implicated in DNA repair.

Mathematical shape matching as a tool in tooth wear assessment--development and conduct.

The quantitative assessment of restoration and tooth wear usually requires fixed reference points from which measurements are made. In longitudinal patient follow-up the loss or erosion of such points may preclude measurement and an alternative approach is to seek regions of coincidence and conflict in digital models of before and after wear surfaces, with a continuous refinement of the parameters of the coordinate transformations, until the closest correspondence between them is found. A computer program has been written to implement the algorithm and assess the technique's capacity to find the match between surfaces both artificially generated and from tooth replicas recorded from patients at different epochs. The program was able to achieve the desired ends, demonstrating the utility of the technique in tooth wear assessment but identifying the need to refine the program further to enhance both its difference detection capabilities and level of automation. Examination of the theory and practical experience highlighted certain situations when user understanding is invaluable to ensure a satisfactory solution. This strengthened the investigators' resolve against reliance upon commercially based surface fitting programs whose basis may not be fully understood. Notwithstanding this surface matching is a powerful tool in the investigation of dental wear.

Skeletal muscle sarcoplasmic reticulum Ca(2+)-ATPase gene expression in congestive heart failure.

Congestive heart failure leads to skeletal muscle abnormalities, one of which is a prolongation of sarcoplasmic reticulum Ca2+ flux. The purpose of this study was to determine whether skeletal muscle of spontaneous hypertensive and heart failure rats have alterations in the expression of the sarcoplasmic (or endoplasmic) reticulum Ca(2+)-ATPase (SERCA) gene. Northern analysis revealed that SERCA1, the predominant skeletal muscle isoform, was decreased by 45%, 43%, and 58% in the tibialis anterior, plantaris, and diaphragm muscles, respectively. Ribonuclease protection assay showed that the decrease was due to the adult isoform, SERCA1a, with minor changes in the alternatively spliced neonatal isoform, SERCA1b. There was no change in SERCA1 mRNA levels in gastrocnemius muscles. No change was found in SERCA2a (cardiac/slow skeletal isoform) mRNA or protein levels or in SERCA2b (smooth muscle isoform), dihydropyridine receptor, or alpha-actin mRNA levels in diaphragm muscle. Northern blot and ribonuclease protection assays showed that SERCA2a decreased 61% in the heart while the alternatively spliced isoform, SERCA2b, decreased 27%. Western analysis of the tibialis anterior, diaphragm, and gastrocnemius muscles showed a decrease in SERCA1 protein levels by 46%, 64%, and 42%, respectively, whereas sarcoplasmic reticulum Ca(2+)-ATPase activity, a functional correlate of SERCA expression, was decreased by 38%, 38%, and 40% in the same muscles, SERCA2 protein expression decreased by 36% in the failing heart. Decreases in both mRNA and protein suggest pretranslational control of SERCA1 expression, whereas the lack of decreased SERCA1 mRNA in gastrocnemius muscle suggests translational regulation. The decreased SERCA1 protein expression in all muscles studied probably contributes to contractile abnormalities related to excitation-contraction coupling function in heart failure.

Conversion disorder presenting in a patient with an implantable morphine pump and an epidural abscess resulting in paraplegia.

Conversion disorders are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or medical condition. The psychological symptoms associated with the medical condition must be preceded by conflict or other stressors. We present an individual who developed conversion disorder and paraplegia secondary to a sterile epidural abscess near the tip of her surgically implanted, epidural morphine infusion pump. She manifested at varying times both transient bilateral blindness and pseudoseizures consistent with a diagnosis of conversion disorder. Neurological evaluation for seizure activity and meningitis were negative. The etiology of the sterile epidural abscess remained unknown. The essential features of conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, are discussed. Treatment of patients diagnosed with conversion disorder remains primarily supportive, with the focus on consistency and behavioral management. Extreme caution is suggested in regards to further investigations.