A transversal multicenter study assessing functioning, disability and environmental factors with the comprehensive ICF core set for low back pain in Brazil.

BACKGROUND: Low back pain is a leading cause of disability in Brazil. The multiple aspects of disability in these patients require comprehensive tools for their assessment. The International Classification of Functioning, Disability, and Health (ICF) core set for low back pain is designed to comprehensively describe the experience of such patients with their functioning. AIM: This study aimed to describe functioning and contextual factors and to empirically validate the ICF core set for low back pain. DESIGN: Cross sectional study. SETTING: Three outpatient clinics in Manaus, Maceio and São Paulo, Brazil. Population. 135 low back pain outpatients under rehabilitation. METHODS: Data concerning diagnosis, personal features, and the 78 ICF core set categories for low back pain were collected from clinical charts, physical examinations, tests, and interviews with patients from rehabilitation services in three parts of Brazil. RESULTS: 7.7% of the categories (6 body functions and 10 activity and participation) were affected in less than 20% of the sample, and were thus considered not validated. Pain and other sensations related to the musculoskeletal system were the body most frequently impaired functions. Mobility and domestic life were the chapters of activity and limitation most often described as limited. All environmental factors were qualified as either facilitators or barriers and acted as modulators of disability. CONCLUSION: The comprehensive ICF core sets for low back pain can be used to describe the living experience of such individuals, although efforts to make it operational and enhance the reproducibility of the results are needed to warrant its reliable routine use. CLINICAL REHABILITATION IMPACT: This study highlights the importance of a complete assessment of chronic low back pain and demonstrate the need for multidisciplinary approach.

Motives and decision making of potential living liver donors: comparisons between gender, relationships and ambivalence.

The motives and decision making of potential living liver donors are critical areas for transplant clinicians evaluating these candidates to understand, yet these topics remain relatively unstudied. Thus, we surveyed 77 prospective living liver donors at the point of donation evaluation using structured instruments to gather more information on their approach to and concerns about donation. We collected information on donation decision making, motives for donation and anticipated social and physical concerns about postdonation outcomes. We examined three additional characteristics of donors: gender, the relationship of the donor to the intended recipient and the presence of ambivalence about donation. Women had more concerns about their family/social responsibilities. Those donating to nonimmediate family were more likely to have been asked to donate but less likely to feel they had to donate. However, ambivalent donors were the most distinct having difficulties and concerns across most areas from their motivations for donating, to deciding to be tested and to donate, to concerns about the postdonation outcomes. We discuss the clinical relevance of these findings to donor evaluation and preparation.

Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it?

OBJECTIVE: To determine whether medically unexplained recurrent abdominal pain (RAP) in childhood predicts abdominal pain, irritable bowel syndrome (IBS), other somatic complaints, and psychiatric symptoms and disorders in young adulthood. METHODS: A sample of 28 young adults evaluated for RAP between the ages of 6 and 17 years were compared with 28 individually matched former childhood participants in a study of tonsillectomy and adenoidectomy. RAP caseness was established by structured retrospective chart review requiring agreement by 2 independent reviewers. Standardized assessments of abdominal pain, IBS, other somatic symptoms, psychopathology, perceived health, and history of maltreatment were performed an average of 11.1 years after the index visit. RESULTS: Former RAP patients were significantly more likely than controls to endorse anxiety symptoms and disorders, hypochondriacal beliefs, greater perceived susceptibility to physical impairment, poorer social functioning, current treatment with psychoactive medication, and generalized anxiety in first degree relatives. There were trends suggesting associations between childhood RAP and lifetime psychiatric disorder, depression, migraine, and family history of depression, but group differences on abdominal pain, IBS, other somatic symptoms, and history of maltreatment were not statistically significant. CONCLUSIONS: There is a strong and relatively specific association between childhood RAP and anxiety in young adulthood. Affected children may be at special risk to perceive physical symptoms as threatening, and should be evaluated for psychiatric disorder on initial presentation.

Screen for Child Anxiety-Related Emotional Disorders (SCARED): convergent and divergent validity.

The purpose of this study was to examine the Screen for Child Anxiety-Related Emotional Disorders' (SCARED) divergent and convergent validity and its ability to identify anxious children. The SCARED, the Child Behaviour Checklist (CBCL), and the State-Trait Anxiety Inventory for Children (STAIC) were administered to children, adolescents (n = 295), and their parents attending an outpatient mood and anxiety disorders clinic. DSM-IIIR/IV diagnoses were made using a semistructured interview (n = 130) or a symptom checklist (n = 165). The Multi-Trait Multi-Method Matrix was used to assess construct validity, and Receiver Operating Curve analysis was used to assess the sensitivity and specificity of the SCARED, CBCL, and STAIC. The SCARED correlated significantly better with the CBCL's internalizing factors than with the externalizing factors. In addition, parent and child forms of the SCARED correlated significantly with the trait and state subscales of the STAIC. Children with an anxiety disorder scored significantly higher on the SCARED than children with depression only or disruptive disorders only (P < 0.05), thus demonstrating the discriminant validity of the SCARED. The SCARED is a reliable and valid screening tool for clinically referred children and adolescents with anxiety disorders.

Anxiety disorders in suicidal youth.

OBJECTIVE: To test the hypothesis that anxiety disorders are associated with suicidal ideation and suicide attempts in a child and adolescent sample referred to a clinic. METHOD: The sample comprised 1979 patients aged 5 to 19 years who were assessed using the Schedule for Affective Disorders and Schizophrenia for School Aged Children--Present Episode (K-SADS-P) at an outpatient mood and anxiety disorders clinic. Subjects were stratified by age and categorized into mutually exclusive groups as being nonsuicidal (n = 817), having suicidal ideation (n = 768), or having attempted suicide (n = 394) in the current episode. Psychiatric diagnoses based on DSM-IV criteria were compared to determine if anxiety disorders were a risk factor for suicidal ideation and suicide attempts. Logistic regression was used to control for significant demographic characteristics and comorbid disorders. RESULTS: After stratifying by age, we found no differences across the 3 groups (ideators, attempters, and nonsuicidal youth) in rates of an anxiety disorder in general or in specific rates of panic disorder, agoraphobia, social phobia, simple phobia, and obsessive-compulsive disorder. Two salient findings involving anxiety disorders were noted with regression analysis. In younger children (age < or = 15 years), attempters had a significantly lower prevalence of separation anxiety disorder (SAD), compared with ideators (OR = 0.30; 95%CI, 0.11 to 0.80; P = 0.006) and nonsuicidal youngsters (OR = 0.14; 95%CI, 0.05 to 0.39; P < 0.0001). In older children (age > 15 years), generalized anxiety disorder (GAD) was more prevalent in ideators (OR = 1.65; 95%CI, 1.03 to 2.66; P = 0.03) than in nonsuicidal patients. CONCLUSIONS: Based on this clinical sample, the relation between pediatric anxiety disorder and suicidal ideation and suicide attempts is not straightforward. However, further studies in nonreferred samples are warranted.

Internal drainage of giant acute pseudocysts: the role of video-assisted pancreatic necrosectomy.

BACKGROUND: Internal drainage of giant pancreatic pseudocysts secondary to acute pancreatitis is frequently complicated with postoperative retroperitoneal infection and hemorrhage. Recent data suggest that the risk factor is unrecognized pancreatic necrosis; presumably, pancreatic necrosis becomes infected with bacteria introduced by the cystoenteric anastomosis. HYPOTHESIS: Video-assisted pancreatic necrosectomy, performed at the time of internal drainage, may prevent postoperative retroperitoneal complications in patients with giant acute pseudocysts. DESIGN: A consecutive case-series. SETTING: An urban, university-affiliated, tertiary referral center. PATIENTS: Ten consecutive patients with acute pseudocysts measuring 10 cm or more in major diameter. The mean extent of pancreatic necrosis, as shown by contrast-enhanced computed tomography, was 50%. All patients were operated on electively, at an average time of 7.7 weeks from onset of the attack to surgical treatment. INTERVENTION: Through a midline incision, a 4-cm opening is made at the base of the pseudocyst. Standard laparoscopic instruments are introduced into the pseudocyst and video-assisted pancreatic necrosectomy is performed. The opening is then anastomosed to a Roux-en-Y limb of the jejunum. MAIN OUTCOME MEASURES: Feasibility and safety of video-assisted pancreatic necrosectomy, postoperative morbidity and mortality, hospital stay, and resolution of pseudocysts. RESULTS: Complete necrosectomy was safely performed throughout. There were neither postoperative retroperitoneal complications nor mortality. Mean hospital stay was 8.2 days and all pseudocysts resolved at a mean follow-up of 6.9 months. CONCLUSIONS: Video-assisted pancreatic necrosectomy at the time of internal drainage seems to prevent postoperative retroperitoneal complications in patients with giant acute pseudocysts. Depending on appropriate surgical timing, video-assisted necrosectomy is a feasible and safe procedure.

Age- and sex-related risk factors for adolescent suicide.

OBJECTIVE: To examine the impact of age and sex on adolescent suicide risk. METHOD: A standard psychological autopsy protocol was used to compare 140 suicide victims with 131 community controls. The risk factors for older (> or = 16 years) and younger, and for male and female suicide were compared. RESULTS: Mood disorders, parental psychopathology, lifetime history of abuse, availability of a gun, and past suicide attempt conveyed significant risk for suicide across all 4 demographic groups. Psychopathology, particularly substance abuse (alone and comorbid with mood disorder), was more common and conveyed a much higher risk for suicide in the older versus younger adolescents. Younger suicide victims showed lower suicidal intent. Males chose more irreversible methods, and conduct disorder was both more prevalent and a more significant risk factor in males. CONCLUSIONS: The increased rate of suicide in older versus younger adolescents is due in part to greater prevalence of psychopathology, namely substance abuse, and greater suicidal intent in the older population. The increased rate in males is less easily explained, but it may stem from method choice and the greater prevalence of and risk conveyed by conduct disorder in males.

Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study.

OBJECTIVE: To replicate and extend work on the psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED), a child and parent self-report instrument used to screen for children with anxiety disorders. METHOD: The 41-item version of the SCARED was administered to a new sample of 190 outpatient children and adolescents and 166 parents. The internal consistency, discriminant, and convergent validity were assessed. In addition, using discriminant function analysis, a briefer version of the SCARED was developed. RESULTS: Using item analyses and factor analyses on the 41-item version, 5 factors were obtained: panic/somatic, generalized anxiety, separation anxiety, social phobia, and school phobia. In general, the total score and each of the 5 factors for both the child and parent SCARED demonstrated good internal consistency and discriminant validity (both between anxiety and depressive and disruptive disorders and within anxiety disorders). A reduced version of the SCARED yielded 5 items and showed similar psychometrics to the full SCARED. CONCLUSIONS: In a new sample, the authors replicated their initial psychometric findings that the SCARED is a reliable and valid instrument to screen for childhood anxiety disorders in clinical settings. Furthermore, pending future research, the 5-item SCARED appears to be a promising brief screening inventory for anxiety disorders in epidemiological studies.

Suicide in adolescents with disruptive disorders.

OBJECTIVE: To determine the psychiatric risk factors for suicide in adolescents with disruptive disorders. METHOD: Fifty-nine adolescent suicide completers and 18 community controls, both having a probable or definite current DSM-III diagnosis of disruptive disorders, were compared. RESULTS: Adolescents with disruptive disorders who committed suicide had higher rates of current substance abuse, past suicide attempt, family history of substance abuse, and family history of mood disorder than disruptive community controls. CONCLUSIONS: Disruptive adolescents appear to be at risk for completed suicide when comorbid substance abuse and past history of suicide attempt are present. The risk increases if the adolescents have a past history of physical abuse and if they have parents with substance abuse and mood disorders. Clinicians should be aware of these risk factors and implement active interventions to prevent suicide. Treatment should focus on treating not only the adolescents, but also their family members. The findings of this study also highlight the need for future research in the prevention of suicide in adolescents with disruptive disorders and comorbid substance abuse.

Simultaneous immunoaffinity purification of O6-methyl, O6-ethyl-, O6-propyl- and O6-butylguanine and their analysis by gas chromatography/mass spectrometry.

A sensitive and specific method has been developed for the simultaneous analysis of different O6-alkylguanines. The cross-reactivity of two different antibodies raised against O6-methylguanosine and O6-butylguanosine for a series of O6-alkylguanines was exploited for the immunoaffinity purification of biological samples before quantitative analysis by gas chromatography/mass spectrometry. The method can be applied to the detection of O6-alkylguanines in DNA and appears to be useful for studying chemical carcinogen mechanisms in animals and possibly for the detection of human exposure to alkylating agents.

Detection of O6-butyl- and O6-(4-hydroxybutyl)guanine in urothelial and hepatic DNA of rats given the bladder carcinogen N-nitrosobutyl(4-hydroxybutyl)amine.

N-Nitrosobutyl(4-hydroxybutyl)amine (BBN) is a selective bladder carcinogen in rats. Its organ specificity may depend on several factors, including metabolic activation, DNA alkylation and repair within the target organ. Metabolic activation of BBN, which is asymmetrical, may result in butylating and 4-hydroxybutylating species. To test this view, BBN was administered as a single oral dose of 20 or 120 mg/rat or six doses of 20 mg/rat over 2 weeks. The animals given the single 120 mg dose were killed 3, 6 and 24 h after treatment. Rats given 20 mg or 6 x 20 mg BBN were killed 24 h after the last dose. DNA from liver and urothelial cells was hydrolyzed and analyzed for O6-butylguanine (O6-BuG) and O6-(4-hydroxybutyl)guanine [O6-(4-OH-Bu)G] as their pentafluorobenzyl-trimethylsilyl derivatives by high-resolution gas chromatography--negative ion chemical ionization mass spectrometry with selective ion recording after immunoaffinity extraction. Polyclonal antibodies raised against O6-(4-hydroxybutyl)-guanosine [O6-(4-OH-Bu)GR] were coupled to CNBr-activated Sepharose 4B. This was mixed with a gel coupled to antibodies raised against O6-BuG, already available in the laboratory, and the mixed gel was used for the one-step sample clean-up, enrichment and extraction of O6-(4-OH-Bu)G and O6-BuG from hydrolyzed DNA. O6-BuG in urothelial DNA of rats given a single dose of 120 mg BBN increased from 0.44 +/- 0.12 mumol/mol guanine (mean +/- SE) 3 h after treatment, to 17.9 +/- 7.23 mumol/mol guanine at 24 h. O6-(4-OH-Bu)G in the same tissue was 7.7 +/- 3.19 mumol/mol guanine 3 h after treatment and 12.2 +/- 7.01 mumol/mol guanine at 24 h. O6-BuG and O6-(4-OH-Bu)G were always lower in the liver than in urothelial cells. Twenty-four hours after a single dose of 20 mg BBN, urothelial O6-BuG was 5.41 +/- 1.73 mumol/mol guanine and did not accumulate after six doses of 20 mg/rat BBN, since it was 2.59 +/- 1.23 mumol/mol guanine 24 h after the last dose. O6-BuG in liver DNA was detectable after the single dose of 20 mg, but not after 6 x 20 mg/rat BBN. O6-(4-OH-Bu)G was not detected in either the bladder or the liver after 20 mg or after the six doses of BBN.(ABSTRACT TRUNCATED AT 400 WORDS)

Lack of alachlor induced DNA damage as assayed in rodent liver by the alkaline elution test.

Alachlor was studied in vivo for its capability to induce DNA damage, as evaluated by the alkaline elution test. The experiments were performed in mouse and rat liver after acute or subacute intraperitoneal or per os administrations of the chemical at sublethal dosages. Rat liver was also studied for DNA damage after administration of 2,6-diethylaniline, one of alachlor's major metabolites. Eluted DNA from treated animals was indistinguishable from control DNA. The results show that neither alachlor nor its metabolite cause DNA damage as determined by the number of single strand breaks.

DNA damage induced by alachlor after in vitro activation by rat hepatocytes.

We investigated the ability of alachlor to cause DNA damage by measuring single-strand breaks (SSB) in DNA, after metabolic activation by freshly isolated rat hepatocytes. Incubation of different concentrations of alachlor with rat hepatocytes led to numerous metabolites. The majority, isolated and identified by GC-MS analysis, were products arising from reactions catalyzed by the P-450 monooxygenase system, arylamidase and flavin mixed-function oxidase/cytochrome P-450 monooxygenase. The results, using freshly isolated rat hepatocytes, showed that in these conditions several potentially DNA damaging metabolites were produced; this experimental condition was used to assess DNA damage induced by the mixture of alachlor and its metabolites. The alkaline elution technique showed that at 200 microM and more clearly at 400 microM there were some small fragments that eluted in the first fraction. This fragmentation was probably due to alachlor cytotoxicity. In addition to the small DNA fragments eluting in the first fraction there were other larger DNA fragments. These DNA-SSB were most evident at the alachlor concentration of 400 microM, but also at 200 microM and 100 microM, whereas at 10 microM the DNA elution rate appeared comparable to that of controls. The results suggest that some unstable and DNA-reactive metabolites might interact with DNA causing SSB and such interaction might be important in relation to the mechanism of alachlor-induced DNA damage. However, it may not be possible to clarify whether SSB are the result of direct DNA interaction of the compound or of secondary cellular processes after chemical treatment.

Choledocholithiasis in acute gallstone pancreatitis. Incidence and clinical significance.

A prospective study of choledocholithiasis was performed using 110 patients with presumptive diagnoses of acute gallstone pancreatitis. The incidence of migrating and persistent bile duct stones was determined using stool screening and intraoperative cholangiography, and the clinical significance of continued stone obstruction of the papilla was investigated using ultrasound assessment of migration time and a second evaluation of prognostic signs. Pancreatic inflammation was confirmed at surgery in 51 patients, of whom only 27 had stones in the stools (n = 22) or the bile duct (n = 5), suggesting that choledocholithiasis may not be the sole triggering factor of acute gallstone pancreatitis. Neither delayed migration nor persistent stone obstruction of the papilla promoted pancreatic inflammation.

Biliary and pancreatic obstruction during gallstone migration.

A prospective study on biliary and pancreatic obstruction during gallstone migration was performed in patients without acute pancreatitis. From January to October 1986, 125 patients with upper abdominal pain due to cholelithiasis were admitted to the hospital. Ultrasonography performed in all patients at admission demonstrated a distal bile duct measuring 7 mm or more in 39 patients, who were monitored for diameter changes of the biliary and pancreatic duct every 24 h and their stools screened for gallstones. Patients underwent surgery at least 8 days after admission. Gallstone migration was found preoperatively in 10 patients, of whom 6 had total serum bilirubin values lower than 2 mg/100 ml. Migration time was accurately determined by the sudden decrease in bile duct caliber. Simultaneous dilatation of biliary and pancreatic duct was found in 4 out of 10 patients with migrating gallstones and in 7 out of 23 patients without gallstone migration, though differences proved non-significant. Acute pancreatitis developed in 2 patients with lithiasis of the distal bile duct who ingested a fatty meal against medical advice. Gallstone migration, even of small stones, was preceded by a period of biliary obstruction. Pain and jaundice before migration were not as frequent as expected.