Beyond a physical symptom: the importance of psychosocial factors in multiple sclerosis pain.

BACKGROUND AND PURPOSE: Pain affects around two-thirds of people with Multiple Sclerosis (pwMS). Biomedical treatments show limited efficacy. A recently developed cognitive-behavioural model of Multiple Sclerosis (MS) pain suggests several psychosocial factors may worsen pain and related disability. The current study investigated whether psychosocial factors drawn from this model explain significant amounts of the variance in pain severity and interference over and above measures of disease severity and pain subtype. METHODS: Six hundred and twelve pwMS experiencing pain completed a U.K. wide cross-sectional survey including valid and reliable psychometric questionnaires. Hierarchical regressions determined the relative contribution of disease severity and psychosocial factors to predicting pain severity and interference. RESULTS: All psychosocial factors including distress, negative beliefs about pain and its consequences, and avoidance of activity, were related to pain outcomes, explaining a further 24% and 30% of the variance in pain severity and interference after controlling for demographic and disease variables. Findings were similar for neuropathic and non-neuropathic pain subgroups. CONCLUSIONS: All pwMS reported significant pain and associated disability even though over 90% were taking pain medication. Psychosocial factors identified as important in predicting pain severity and, to a greater extent, pain interference are potentially modifiable and may be important treatment targets for both pain subtypes.

Radioisotopic localization of (90)Yttrium-ibritumomab tiuxetan in patients with CD20+ non-Hodgkin's lymphoma.

PURPOSE: (90)Yttrium-ibritumomab-tiuxetan (Zevalin) is an effective treatment for relapsed or refractory low-grade, follicular, or transformed B-cell NHL. The purpose of this study is to assess whether tissue and cellular localization of (90)Y-ibritumomab-tiuxetan determined by autoradiography and radioactivity localized to tumor tissue might enhance our understanding of the mechanism of action of radioimmunotherapy. METHODS: Eight eligible patients had CD20+ NHL, a bulky peripheral lymph node, and were scheduled for (90)Y-ibritumomab-tiuxetan treatment. 2-Deoxy-2-[F-18]fluoro-D: -glucose-positron emission tomography/computed tomography (FDG-PET/CT) was performed prior to treatment and at 12 weeks after therapy for assessment of response. Bone marrow, lymph node, and blood samples were collected 114 +/- 3 h after 14.8 MBq/kg (90)Y-ibritumomab-tiuxetan and processed for histology, scintillation counting, and microscopic autoradiography. RESULTS: Pericellular membrane localization of (90)Y-ibritumomab-tiuxetan to lymphoma cells was observed by autoradiography in the involved areas of lymph node with absence of significant localization in histologically normal sections of bone marrow. Pericellular radioactivity and the highest quantitative radioactivity were observed in lymph node samples of responding patients. CONCLUSIONS: (90)Y-ibritumomab-tiuxetan localizes to the surface membrane of CD20+ lymphoma cells in affected lymph nodes. The patients with the highest quantitative concentration of radioactivity to the lymph node as determined by scintillation counting were observed to have a clinical and FDG-PET/CT response.

The global problem of child maltreatment: Perspectives on mechanisms of influence and illness presentation.

Child abuse and neglect negatively impact both neurological and psychological development. Patterns of abuse are learned and repeated in families. Adverse childhood experiences are a risk factor for psychopathology later in life, including borderline personality disorder (BPD). BPD is prevalent in clinical populations in the United States, but its prevalence has not been well-documented in most other parts of the world. The aim of this paper is to explore the impact of culture upon the intergenerational transmission of childhood maltreatment and the clinical presentation of abused children. To facilitate this exploration, we will consider the cases of four adolescent girls in unique socioeconomic and cultural settings around the world: Liberia, El Salvador, India, and a Congolese immigrant in France. Each of these girls endorsed some features of BPD, but only two met full criteria. In societies in which externalizing behaviors are not acceptable, children may internalize their distress or separate from their families. Defining BPD in terms of internal experience makes it more difficult to identify, but it would allow for the inclusion of cases in which symptoms may manifest differently while the underlying problem is similar.

Synthesis and analgetic activity of 1,2,3,4,5,6-hexahydro-1,6-methano-3-benzozocines.

1,2,3,4,5,6-Hexahydro-1,6-methano-3-benzazocine (1) has been synthesized via a four-step sequence from benzo-norbornadiene. This compound and its N-methyl derivative are more active than codeine in the mouse hot-plate antinociceptive assay and will not suppor morphine dependence in Rhesus monkeys.

Fluoroscopic foley catheter removal of esophageal foreign bodies in children: experience with 415 episodes.

OBJECTIVE: This study sought to investigate the safety and efficacy of the fluoroscopic Foley catheter technique (FFCT) for removal of esophageal foreign bodies (EEBs) in children, and to identify factors associated with decreased success. DESIGN/SETTING/PATIENTS: An 11-year retrospective review of all pediatric patients undergoing the FFCT for removal of EFBs at a tertiary-care children's hospital was performed. RESULTS: Four-hundred and fifteen cases are reported. The median age was 29 months (range, 4 to 193); children < or = 24 months accounted for 45% (185) of the cases. Of all episodes 86% (355) involved children without known esophageal pathology. Coins comprised 76% (316) of the EFBs. The FFCT was successful in 91% (378) of the cases. In the 60 episodes involving children with underlying esophageal pathology, the technique had an 83% success rate compared to 92% in children without known pathology (P < .05). There were 290 patients where the duration of impaction was known. The success rate was 96% if the duration was 3 days or less compared to 50% if the duration was longer (P < .0001). Though the overall success in children < or = 24 months was less than older children (88% vs 94%, P < .05), this effect disappeared when corrected for duration of impaction. Minor complications occurred in 2% of the episodes, and major complications were noted in 1%. CONCLUSIONS: The FFCT appears to be a safe and effective method for removal of EFBs especially in children without underlying esophageal lesions and a duration of impaction < or = 3 days. Major complications are rare.

Modified Norwood procedure with a high-flow cardiopulmonary bypass strategy results in low mortality without late arch obstruction.

OBJECTIVE: The results of our modification of the stage I Norwood procedure, in which we use only autologous tissue to reconstruct the aortic arch, were reviewed. A high-flow, low-pressure cardiopulmonary bypass protocol (with phenoxybenzamine), before and after a period of deep hypothermic circulatory arrest, was used. METHODS: Between 1993 and 1999, 59 patients, aged 1 to 353 days (median 4 days) and weighing 1.7 to 6.8 kg (median 3.2 kg), underwent a modified Norwood procedure. The ascending aortic diameter ranged from 1.5 to 8 mm (median 3 mm). The modified Blalock-Taussig shunt was 3 mm in 21 patients (36%) and 3.5 mm or larger in 38 patients (64%). RESULTS: Deep hypothermic circulatory arrest and cardiopulmonary bypass times ranged from 15 to 64 minutes (median 37 minutes) and 44 to 144 minutes (median 88 minutes), respectively. Early postoperative survival was 83%. By univariate analysis, early mortality was associated with an ascending aortic diameter of 2.5 mm or less (P =.01). Weight, circulatory arrest and bypass times, diagnosis (hypoplastic left heart syndrome vs variant), shunt size, and date of the procedure did not affect survival. For a median follow-up period of 37 months (range 4-63 months), 42 (61%) patients underwent bidirectional cavopulmonary shunts, 10 (17%) had Fontan operations, and 1 patient underwent transplantation after a bidirectional cavopulmonary shunt. Eight patients subsequently died, for a 1-year actuarial survival of 72% (95% confidence interval: 60%-84%). Neoaortic arch obstruction was corrected in 3 patients (5%). CONCLUSIONS: At intermediate-term follow-up, our modification of the Norwood procedure together with our perioperative strategies has resulted in acceptable outcomes with a low incidence of neoaortic arch obstruction. Patients with a small ascending aortic diameter have emerged as a high-risk group, but a recent technical modification may improve the outlook for these patients.

Effect of RSV bronchiolitis practice guidelines on resource utilization.

We sought to determine whether institution of respiratory syncytial virus (RSV) practice guidelines decreased resource utilization for a heterogeneous population of children hospitalized with RSV bronchiolitis. Patients less than 24 months old with RSV bronchiolitis at a pediatric referral center were identified by retrospective chart review for consecutive RSV seasons. Before the guidelines were instituted patients were less likely to have a documented physician's assessment of response to albuterol, were more likely to have received supplemental oxygen and cardiorespiratory monitoring, and to be discharged on an albuterol regimen. Patients received more albuterol treatments. After the guidelines were in place fewer resources were utilized in the care of patients with RSV bronchiolitis. RSV practice guidelines may simplify and streamline the care of a heterogeneous population of children with bronchiolitis.

Non-interpretive mechanisms in psychoanalytic therapy. The 'something more' than interpretation. The Process of Change Study Group.

It is by now generally accepted that something more than interpretation is necessary to bring about therapeutic change. Using an approach based on recent studies of mother-infant interaction and non-linear dynamic systems and their relation to theories of mind, the authors propose that the something more resides in interactional intersubjective process that give rise to what they will call 'implicit relational knowing'. This relational procedural domain is intrapsychically distinct from the symbolic domain. In the analytic relationship it comprises intersubjective moments occurring between patient and analyst that can create new organisations in, or reorganise not only the relationship between the interactants, but more importantly the patient's implicit procedural knowledge, his ways of being with others. The distinct qualities and consequences of these moments (now moments, 'moments of meeting') are modelled and discussed in terms of a sequencing process that they call moving along. Conceptions of the shared implicit relationship, transference and countertransference are discussed within the parameters of this perspective, which is distinguished from other relational theories and self-psychology. In sum, powerful therapeutic action occurs within implicit relational knowledge. They propose that much of what is observed to be lasting therapeutic effect results from such changes in this intersubjective relational domain.

Adventure in the outdoors. Its importance in the development of an adolescent boy.

This exploration of how the analyst works uses a 15-year-old boy's description of an adventure in the outdoors as the starting point for a sequence of associations which led first to a passage from a Wordsworth poem and then to memories from the analyst's own childhood. The related themes of rite of passage and adolescent mourning are elaborated.

Isolated partial, transient hypoglossal nerve injury following acupuncture.

We report a case of isolated unilateral hypoglossal nerve injury following ipsilateral acupuncture for migraines in a 53-year-old lady. The palsy was partial, with no associated dysarthria, and transient. Further examination and imaging was negative. Cranial nerve injuries secondary to acupuncture are not reported in the literature, but are a theoretical risk given the location of the cranial nerves in the neck. Anatomical knowledge is essential in those administering the treatment, and those reviewing patients with possible complications.

Feeding difficulties and growth delay in children with hypoplastic left heart syndrome versus d-transposition of the great arteries.

The objective of this study was to identify the incidence of feeding difficulties in infants with hypoplastic left heart syndrome (HLHS) and d-transposition of the great arteries (d-TGA). Congenital heart disease is a risk factor for growth failure. The etiologies include poor caloric intake, inability to utilize calories effectively, and increased metabolic demands. The goals of our study were to (1) identify feeding difficulties in infants with HLHS and d-TGA and (2) assess their growth in the first year of life. We performed a chart review of 27 consecutive infants with HLHS and 26 with d-TGA. Descriptive statistics were generated for demographic and clinical variables within each group and are presented as means +/- standard deviations. HLHS and d-TGA groups were compared on time to achieving nutritional goals using the log rank test, on complication rate using the chi-square test, and on weight using the t-test. A significance level of 0.05 was used for all tests. Birth weight was similar for both the HLHS and d-TGA groups (3.19 +/- 0.69 vs 3.35 +/- 0.65 kg, respectively; p = 0.38). Infants with HLHS weighed less than those with d-TGA at l month (3.29 +/- 0.58 vs 3.70 +/- 0.60 kg, respectively; p = 0.021), 6 months (6.27 +/- 1.06 vs 7.31 +/- 1.02 kg, p = 0.003), and 12 months of age (8.40 +/- 1.11 vs 9.49 +/- 1.01 kg, p = 0.006). Time to achieving full caloric intake (at least 100 kcal/kg/day) for the HLHS group (24 +/- 11.9 days) was significantly longer than for the d-TGA group (12.0 +/- 11.2 days, p < 0.001). In addition, infants with HLHS had a higher incidence of feeding-related complications that those with d-TGA (48 vs 4%, respectively; p = 0.001). Compared to the d-TGA group, infants with HLHS weighed less at follow-up, took longer to reach nutritional goals, and had a much higher incidence of feeding-related complications.

Resective surgery to treat refractory status epilepticus in children with focal epileptogenesis.

Prolonged high-dose suppressive therapy (HDST) is a mainstay in the management of refractory status epilepticus (RSE), albeit with high morbidity and mortality. The authors studied 10 patients who were carefully selected for epilepsy surgery after failing prolonged (>2 weeks) HDST. Status epilepticus was stopped acutely in all of them with no mortality and no substantial morbidity. At follow-up (median 7 months), 7 (70%) of 10 patients were seizure free, and 3 (30%) of 10 had significant improvement in their epilepsy.

Can pediatricians define and apply the concept of brain death?

OBJECTIVE: We sought to determine pediatric residents' and attending physicians' ability to define brain death, their ability to apply this standard of death to a clinical scenario, and their knowledge regarding the legal necessity of confirmatory testing when determining death by brain criteria. We compared resident and attending self-confidence at discussing brain death with their ability to define brain death and apply this concept to a clinical scenario. METHODOLOGY: A questionnaire was sent to 136 residents, postgraduate years 1 through 3, at four accredited pediatric training programs in the United States. Participation was tracked by return address. One follow-up request for participation was made. A similar procedure was followed for 140 faculty pediatricians at two of the institutions. Demographic information including level of training, subspecialty training, training program, and formal ethics training was collected. Respondents defined brain death, interpreted a clinical scenario, and stated whether confirmatory testing is legally required to determine death by brain criteria. Respondents rated their confidence at explaining brain death to a patient's family on a scale from 1 to 5. RESULTS: Eighty-seven percent (118/136) of resident surveys were returned. Thirty-six percent (42/118) of the residents correctly defined brain death. Forty-three percent (51/118) of residents correctly interpreted the clinical scenario. Fifty-five percent (65/118) of the residents correctly recognized that brain death could be determined without a confirmatory test. Residents who correctly defined brain death were as confident as those who did not (2.8 +/- 1 vs 1.5 +/- 1). Residents who correctly interpreted the clinical scenario were as confident as those who did not (2.6 +/- 1 vs 1.9 +/- 0.9). Eighty percent (112/140) of attending physician surveys were returned. Thirty-nine percent (44/112) of attending physicians correctly defined brain death. Fifty-three percent (59/112) correctly interpreted the clinical scenario. Fifty-eight percent (65/112) recognized that brain death can be diagnosed without confirmatory testing. All pediatric intensivists (n = 12) correctly answered all three questions. Their performance was significantly better than other pediatricians. Attendings who correctly defined brain death were more confident than those who did not (4.2 +/- 1 vs 1.1 +/- 0. 9). Attendings who correctly interpreted the clinical scenario were more confident than those who did not (3.8 +/- 1.2 vs 2.2 +/- 1.2). CONCLUSIONS: Pediatric residents and attendings have difficulty defining and applying the concept of brain death. This concept is difficult to grasp and internalize for many pediatricians. To ensure that critical decisions are made by knowledgeable physicians and well-informed families, more effective educational strategies need to be identified.

The use of children's religious ideas in their psychiatric evaluation.

Children's religious ideas provide a source of projective material that can be relevant clinically in a child's psychiatric evaluation. Areas that are sometimes revealed include (1) information about the child's parental introjects; (2) level of superego formation; (3) level of defense formation; (4) areas that are most anxiety provoking for the child. This religious material is frequently ignored, but can be a particularly useful adjunct when the usual child-evaluative techniques do not reveal a complete picture.