Cumulative effects of multiple pain sites in youth with chronic pain.

BACKGROUND: The experience of persistent pain in multiple locations is common in youth. Based on current literature, youth with multiple pain sites (MPS) are at risk of experiencing poorer emotional outcomes and a spread of symptoms into late adolescence and adulthood. Little is known regarding the association between MPS with physical and school functioning domains, particularly after initiation of multidisciplinary pain treatment. Therefore, the objective of this study was to examine the association of MPS with disability and school functioning among youth with chronic pain. METHODS: A total of 195 patients with chronic pain, aged 8-17, and their parents completed measures assessing patient distress and functioning at a multidisciplinary pain clinic evaluation and at 4-month follow-up. RESULTS: At evaluation, 63% of patients presented with MPS; 25% reporting MPS endorsed pain in five or more locations. When controlling for relevant demographic and emotional distress factors, MPS were associated with lower school functioning at evaluation with a persistent trend at follow-up. Although MPS were not a significant predictor of pain-related disability at evaluation, it emerged as significant at follow-up. CONCLUSIONS: Potentially due to the MPS load and the inverse effects that such a pain state has on function, such patients may be at risk for poorer health and school-related outcomes. The mechanisms influencing these relationships appear to extend beyond psychological/emotional factors and warrant further investigation in order to aid in our understanding of youth with MPS. SIGNIFICANCE: Youth with MPS may be at risk for experiencing poorer physical and school functioning in comparison with single-site peers, despite treatment initiation. Further research is warranted to inform assessment and treatment approaches for this subgroup of patients.

Empathic understanding: a review of the concept and some theoretical considerations.

A review of the psychoanalytic literature shows that empathy has always played an important part in the practice of psychoanalysis, but that as a concept it has not been well understood. This confusion and a certain mistrust of empathy that it engenders were traced to an incomplete understanding of the meaning of the term, and to the lack of an affect theory that could explain the communication involved in the empathic process. These problems were examined and suggestions for their resolution were made. A line of affective development that culminated in empathic understanding was proposed. An operational approach to empathy was described and the role of empathy as the basis for and the prelude to psychoanalytic interpretation was discussed.

Psychoanalytic interpretation and cognitive transformation.

Psychoanalytic metapsychology should be recognized for what it is, namely a theory of cognition and affect that is not derived directly from clinical data but is advanced in order to provide the development background that will let us deal with the clinical findings of psychoanalysis as aberrations of and deviations from the normal and expected evolution of the thinking process. Its cornerstone is Freud's belief that thought depends on the forging of links between the sensory perception of objects and their appropriate verbal descriptions. He made no secret of his dissatisfaction with his metapsychology and repeatedly revised it in an attempt to encompass those clinical discoveries of psychoanalysis that outstripped the explanatory power of that metapsychology and demonstrated its shortcomings. Using what we now know about normal development in infancy and childhood through the work of Piaget, Vygotsky and other investigators, it is possible to formulate an explanatory theory that does justice to the varied and complex findings uncovered by the application of the psychoanalytic method. For example, the significance of Freud's postulated second censorship between the preconscious and consciousness, as well as the importance of the defence of disavowal that Freud emphasized in his writings after 1927, can now be accounted for with a theory of thought formation that was not available to the founder of psychoanalysis. The implications of this proposed reformulation for psychoanalytic interpretation and for the application of psychoanalysis to an increasingly wide range of psychopathology is discussed in some detail.

[Primary epiphyseal osteomyelitis in children].

A 4-year-old boy was hospitalized for suspected hematogenous osteomyelitis of the distal femur. Bone scan and repeated radiographs showed a rare condition, primary epiphyseal osteomyelitis. Needle biopsy and aspiration were negative. Penbritin and orbenil, 2 g of each, gave complete clinical and radiographic healing 7 weeks after initial treatment.

Early diagnosis at the CDH clinic.

In 1978, 488 of 8,211 registered newborn babies in the Haifa area were referred to us for suspected congenital dislocation of the hip. The findings were as follows: normal, 53%; justifying further follow-up, 40.5%; subluxation, 4% (19 cases); and dislocation, 2.5% (12 cases). The infants with subluxation or dislocation were not older than six months. Treatment of dislocation included: open reduction, 1; closed reduction under general anesthesia, 4; and reduction and treatment by abduction splints, 7. After this treatment, all hips were stable. Abduction splints were used in the 19 subluxation cases; there was no aseptic necrosis of the femoral head. All infants with minor deviations in the hip joints, such as consistent limited abduction, delayed appearance of epiphyseal ossification center or acetabular dysplasia, were deliberately grouped under "justifying follow-up." It is possible that these minor deviations harbor the buds of early osteoarthritis.

Timing and competence of neural crest formation.

Neural crest cells can be induced by an interaction between neural plate and ectoderm. To clarify the timing and nature of these inductive interactions, we have examined the time of competence of the neural plate to become neural crest as well as the time of neural fold specification. The neural plate is competent to respond to inductive interactions with the nonneural ectoderm for a limited period, rapidly losing its responsive ability after stage 10. In contrast, nonneural ectoderm from numerous stages retains the ability to induce neural crest cells from competent neural plate. When neural folds are explanted to test their ability to produce neural crest without further tissue interactions, we find that folds derived from all rostrocaudal levels of the open neural plate are already specified to express the neural crest marker Slug. However, additional signals may be required for maintenance of Slug expression, since the transcript is later down-regulated in vitro in the absence of tissue interactions. Taken together, these results suggest that there are multiple stages of neural crest induction. The earliest induction must have occurred by the end of gastrulation, since the newly formed neural fold population is already specified to form neural crest. However, isolated neural folds eventually down-regulate Slug, suggesting a second phase that maintains neural crest formation. Thus, induction of the neural crest may involve multiple and sustained tissue interactions.