Pain location and widespread pain in youth with orthopaedic conditions: Exploration of the reliability and validity of a body map.

BACKGROUND: Pain location and widespread pain are important but underexamined dimensions of paediatric pain. Body map tools to assess pain location in youth have been used for several decades, but few studies have established reliability and validity of these measures. The purpose of this study was to explore the reliability and validity of a pain body map among youth with orthopaedic conditions before surgery. METHOD: Youth ages 10-17 years completed the body map and other self-reported outcomes at their preoperative clinic visit and at their day of surgery. RESULTS: Most (91.7%) youth had small discrepancy between body map scores at preoperative clinic visit (baseline) and day of surgery (second assessment), and site-to-site agreement ranged from 78% to 98%. Those with back and lower extremity diagnoses had high correspondence between body map sites and diagnostic sites. Body map scores and widespread pain were associated with other dimensions of pain, as well as other patient-reported outcomes. Higher pain intensity and widespread pain predicted greater discrepancy between body map scores. CONCLUSIONS: These results support the use of body map tools in further research examining widespread pain among youth by demonstrating adequate reliability, descriptive validity and associative validity. SIGNIFICANCE: These results contribute to the limited information regarding psychometric properties of paediatric pain body maps, provide novel information about widespread pain among youth undergoing orthopaedic surgeries, and pave the way for improved assessment and treatment of paediatric pain.

Childhood exposure to ambient polycyclic aromatic hydrocarbons is linked to epigenetic modifications and impaired systemic immunity in T cells.

BACKGROUND: Evidence suggests that exposure to polycyclic aromatic hydrocarbons (PAHs) increases atopy; it is unclear how PAH exposure is linked to increased severity of atopic diseases. OBJECTIVE: We hypothesized that ambient PAH exposure is linked to impairment of immunity in atopic children (defined as children with asthma and/or allergic rhinitis) from Fresno, California, an area with elevated ambient PAHs. METHODS: We recruited 256 subjects from Fresno, CA. Ambient PAH concentrations (ng/m(3) ) were measured using a spatial-temporal regression model over multiple time periods. Asthma diagnosis was determined by current NHLBI criteria. Phenotyping and functional immune measurements were performed from isolated cells. For epigenetic measurements, DNA was isolated and pyrosequenced. RESULTS: We show that higher average PAH exposure was significantly associated with impaired Treg function and increased methylation in the forkhead box protein 3 (FOXP3) locus (P < 0.05), conditional on atopic status. These epigenetic modifications were significantly linked to differential protein expression of FOXP3 (P < 0.001). Methylation was associated with cellular functional changes, specifically Treg dysfunction, and an increase in total plasma IgE levels. Protein expression of IL-10 decreased and IFN-γ increased as the extent of PAH exposure increased. The strength of the associations generally increased as the time window for average PAH exposure increased from 24 hr to 1 year, suggesting more of a chronic response. Significant associations with chronic PAH exposure and immune outcomes were also observed in subjects with allergic rhinitis. CONCLUSIONS AND CLINICAL RELEVANCE: Collectively, these results demonstrate that increased ambient PAH exposure is associated with impaired systemic immunity and epigenetic modifications in a key locus involved in atopy: FOXP3, with a higher impact on atopic children. The results suggest that increased atopic clinical symptoms in children could be linked to increased PAH exposure in air pollution.

Motherhood during the teen years: a developmental perspective on risk factors for childbearing.

The role of peer relations in childhood and behavioral and family characteristics in early adolescence as risk factors for adolescent childbearing was investigated. Sociometric surveys across third, fourth, and fifth grade and parent and child measures of behavioral and family functioning at sixth and eighth grade were collected in a lower income, urban sample of 308 African American females. Results replicated earlier findings on the role of childhood aggression as a predictor of teen motherhood. In addition, girls who displayed stable patterns of childhood aggression were at significantly higher risk not only to have children as teenagers but to have more children and to have children at younger ages. Results also indicated that females who were depressed in midadolescence were at greater risk to become parents between age 15 and 19 years. These findings demonstrate the need to take a differentiated approach to understanding teen childbearing and varying developmental pathways in the prediction of teen motherhood.

Cerebral vasculopathy in sickle cell anemia: diagnostic contribution of positron emission tomography.

Children with sickle cell anemia (SS) have an increased risk for cerebral vasculopathy with stroke (CVA) and cognitive impairment. The present study examines the extent to which adding positron emission tomography (PET) to magnetic resonance imaging (MRI) can improve the detection of cerebral vasculopathy. Whereas MRI has been the prime modality for showing anatomical lesions, PET excels at assessing the functional metabolic state through glucose utilization 2-deoxy-2 [18F] fluoro-D-glucose (FDG) and microvascular blood flow ([15O]H2O). Forty-nine SS children were studied. Among them, 19 had clinically overt CVA, 20 had life-threatening hypoxic episodes or soft neurologic signs, and 10 were normal based on neurological history and examination. For the entire sample of 49 subjects, 30 (61%) had abnormal MRI findings, 36 (73%) had abnormal PET findings, and 44 (90%) showed abnormalities on either the MRI or the PET or both. Of the 19 subjects with overt CVA, 17 had abnormal MRI (89%), 17 had abnormal PET (89%), and 19 (100%) had either abnormal MRI or PET or both. Among the 20 subjects with soft neurologic signs, 10 (50%) had abnormal MRI, 13 (65%) had abnormal PET, and 17 (85%) had abnormal MRI and/or PET. Six (60%) of the 10 neurologically normal subjects had abnormal PET. Among the 30 subjects with no overt CVA, 25 (83%) demonstrated imaging abnormalities based on either MRI or PET or both, thus, silent ischemia. Lower than average full-scale intelligence quotient (FSIQ) was associated with either overt CVA or silent ischemic lesions. Four subjects who received chronic red blood cell transfusion showed improved metabolic and perfusion status on repeat PET scans. In conclusion, (1) the addition of PET to MRI identified a much greater proportion of SS children with neuroimaging abnormalities, particularly in those who had no history of overt neurologic events. (2) PET lesions are more extensive, often bihemispheric, as compared with MRI abnormalities. (3) PET may be useful in management as a tool to evaluate metabolic improvement after therapeutic interventions, and (4) the correlation of PET abnormalities to subsequent stroke or progressive neurologic dysfunction requires further study.

Medical-resource use for suspected tuberculosis in a New York City hospital.

OBJECTIVE: To compare resource use by diagnostic outcome among hospital admissions during which tuberculosis (TB) was suspected. DESIGN: Retrospective study based on chart review and microbiology laboratory data. SETTING: The department of medicine in a municipal hospital serving central Brooklyn, New York. PARTICIPANTS: We identified all adult admissions in 1993 during which TB was suspected. We assigned each admission to one of four mutually exclusive groups defined by the results of microbiological tests (acid-fast bacilli [AFB] smear and culture): culture-positive and smear-positive (C+S+); culture-positive and smear-negative (C+S-); culture-negative and smear-positive (C-S+); or culture-negative and smear-negative (C-S-). Each admission was divided into two separate periods to which the utilization of medical resources was assigned: the diagnostic and the postdiagnostic periods, which were separated by the date of receipt of the first definitive culture report. RESULTS: Data on 519 admissions (93 C+S+; 57 C+S-; 30 C-S+; and 339 C-S-) were analyzed. Although C+S+ were more likely than other groups to have an admitting diagnosis of TB, approximately one quarter of the admissions without TB (C-S+, C-S-) were admitted with the principal diagnosis of TB. For the four groups, C+S+, C+S-, C-S+, and C-S-, the respective rates of TB isolation and anti-TB treatment, and median lengths of isolation were 98%, 87%, and 34 days; 74%, 74%, and 7 days; 83%, 83%, and 15 days; and 44%, 29%, and 0 days. During the diagnostic period, the rate and length of isolation were similar in the AFB-smear-positive groups (C+S+ and C-S+). We estimated that admissions without culture-proven TB (C-S+ and C-S-) accounted for 3,174 (36%) of the 8,712 days of TB isolation expended and for 65% of the 16,671 days of anti-TB treatment. The vast majority of this resource consumption (2,737 [86%] of 3,174 days of isolation) occurred during the diagnostic period before a definitive culture result was known. CONCLUSIONS: Our results suggest that prolonged diagnostic uncertainty and misclassification of cases due to false-positive and false-negative smears are associated with substantial medical-resource consumption. New diagnostic modalities that reduce the period of diagnostic uncertainty could reduce the utilization of resources later found to be unnecessary.

Comorbidity of conduct and depressive problems at sixth grade: substance use outcomes across adolescence.

The comorbidity of conduct and depressive problems and substance use outcomes were examined in a community-based sample of 340 African American males and females. Alcohol, tobacco, and marijuana use were examined at Grades 6, 8, and 10 based on the following group membership at sixth grade: (a) comorbid conduct and depressive problems; (b) conduct problems only; (c) depressive problems only; (d) neither conduct nor depressive problems. Overall, the two conduct problem groups displayed the highest levels of substance use, although at some time points, comorbid youth displayed significant higher substance use levels. Subjects with depressive problems only displayed levels of substance use that were equivalent to subjects in the nonproblem group. Results highlight the importance of controlling for comorbid symptoms, possible interactive effects between conduct and depressive problems, and implications for treatment and prevention of substance use.

Effects of donor age and brain-derived neurotrophic factor on the survival of dopaminergic neurons and axonal growth in postnatal rat nigrostriatal cocultures.

Early postnatal rat brain tissue can be grown for several weeks as organotypic slice cultures by the roller-tube method. We have here used this method to study the effects of donor age and brain-derived neurotrophic factor (BDNF) on the survival and growth of tyrosine hydroxylase immunoreactive (TH-i), dopaminergic (DA) neurons during the postnatal period when their nerve fibers normally innervate the striatal target. Tissue slices of ventral mesencephalon (VM) and striatum were prepared from newborn and 7-day-old rats and cocultured for 3--3 1/2 weeks with different combinations of the two donor ages. After immunocytochemical staining the number of TH-i, ventral mesencephalic neurons were counted, and the growth of TH-i fibers into the striatal part of the cocultures was evaluated. Co-cultures, with both VM and striatal slices prepared from newborn rats, contained a significantly higher number of TH-i neurons and displayed a significantly increased innervation of the striatal slices compared with other combinations of donor ages. Addition of BDNF resulted in both an increased survival of TH-i neurons and an increased growth of TH-i fibers into the cocultured striatal slices. Significant neurotrophic effect of BDNF did, however, require young donor age of both VM and striatal slices. It is suggested that BDNF induces more cells, possibly progenitor cells, to express TH immunoreactivity. Alternatively BDNF may suppress apoptotic cell death documented by others to occur in the postnatal rat substantia nigra pars compacta. Irrespective of the mechanisms, survival of more TH-i neurons was related to an increased innervation of the striatal slices by TH-i nerve fibers. The observed effects of BDNF on both survival and fiber growth of TH-i neurons indicate a potential role of BDNF for treatment of Parkinson's disease or grafts of immature DA neurons transplanted to patients with Parkinson's disease. A significant trophic effect of BDNF did, however, seem to depend on young developmental age of both striatum and VM. Parallel treatment with striatal neurotrophic factors may therefore be a necessary prerequisite to a trophic effect of BDNF under clinical conditions.

Tuberculosis reemerges: the captain remains aboard.

The resurgence of tuberculosis and the emergence of multidrug resistant tuberculosis have led to renewed interest in this ancient disease. Advances in the field of molecular biology have increased our understanding of the epidemiology and transmission of infection. This has had a particular impact on the documentation of, and the subsequent development of guidelines to prevent, the nosocomial transmission of tuberculosis. Molecular techniques have dominated the efforts of investigators to improve diagnostic methods and therapeutic options. Recent information regarding the mechanism of developing protective immunity to tuberculosis may lead to the development of more effective vaccines and a role for immunotherapy in treatment. National and international organizations have formulated guidelines for the diagnosis and treatment of disease and infection. The development of a global response to the problem of tuberculosis in order to ensure the establishment of long-lasting control is needed.

A continuous striatal infusion of 6-hydroxydopamine produces a terminal axotomy and delayed behavioral effects.

Rat models of Parkinson's disease typically employ a rapid nigral injection of 6-hydroxydopamine (6-OHDA) to produce a near-complete loss of nigrostriatal dopamine neurons, and thus, model end stage disease. The present report describes the use of a continuous, low dose infusion of 6-OHDA into the striatum which produces a terminal axotomy of nigrostriatal dopamine neurons and protracted behavioral response. A solution of 6-OHDA in 0.4% ascorbate, delivered at 37 degrees C from osmotic minipumps, was stable for 8 days as determined by its retained toxicity to a dopaminergic neuroblastoma cell line. The continuous infusion of 0.2 mu g 6-OHDA per h did not affect the striatal uptake of [3H]%GABA, [3H]choline, or [3H]glutamate but reduced [3H]dopamine uptake by 55% within 1.5 days after the start of the infusion. The striatal infusion of 6-OHDA produced a dose-dependent reduction of striatal dopamine and DOPAC levels but did not alter HVA, 5-HT, or 5-HIAA. An increase in amphetamine-induced ipsiversive rotations occurred within 1.5 days after the acute striatal injection of 20 mu g or 30 mu g of 6-OHDA but required 4 days to develop with the continuous 6-OHDA infusion. The topography of the lesion mapped by [3H]mazindol binding showed that, beginning by 1.5 days, a diffuse depletion of terminals encompassed much of the striatum in the 30 mu g acute injection group, whereas in the continuously infused rats, the lesion was apparent only by 4 days and was restricted to a smaller and more completely lesioned area. Unlike acutely lesioned animals, continuously infused rats revealed no obvious loss of dopamine neurons in the pars compacta by 5 weeks after 6-OHDA. The continuous striatal infusion of 6-OHDA can produce a topographically limited terminal axotomy of dopamine neurons and a protracted behavioral impairment.

Tuberculosis: a survey and review of current literature.

Despite being a treatable and preventable disease, tuberculosis will kill an estimated 30 million people during the current decade. Tuberculosis is a global problem, and increases in case rates are occurring not only in the developing countries of the world but also in several industrialized nations, such as the United States. Coincident with the resurgence of tuberculosis in the United States, there has also been an alarming increase in the number and proportion of cases caused by strains of Mycobacterium tuberculosis that are resistant to multiple first-line drugs. The increase in multiple-drug resistant tuberculosis has re-taught physicians about the importance of pursuing and ensuring treatment until cure. The HIV epidemic is playing a pivotal and permissive role in the resurgence of tuberculosis morbidity and mortality in those populations where tuberculosis and HIV are prevalent and overlap. Co-infection with HIV distorts the natural history and clinical expression of tuberculosis. Molecular biology has yielded important insights into the mechanisms of drug resistance and provided powerful tools for the rapid diagnosis and epidemiologic study of this disease.

Prevalence of asymptomatic nasopharyngeal carriage of Chlamydia pneumoniae in subjectively healthy adults: assessment by polymerase chain reaction-enzyme immunoassay and culture.

Although Chlamydia pneumoniae is a well-described and common respiratory tract pathogen, up to 90% of infections with this organism are thought to be asymptomatic. Because asymptomatic infection with C. pneumoniae has not been studied in a systematic manner, we conducted a prospective study of healthy adults to establish the prevalence of asymptomatic infection. Nasopharyngeal swab specimens were obtained from 104 subjectively healthy people and evaluated by culture and polymerase chain reaction-enzyme immunoassay (PCR-EIA) for the presence of the organism. Serum obtained from 103 of these individuals was tested by microimmunofluorescence for the titer of specific antibody to C. pneumoniae. For two individuals, C. pneumoniae was identified in nasopharyngeal specimens by culture and/or PCR-EIA; one of these individuals had an IgG titer of 1:256, whereas the other had no detectable antibody. Of the remaining 101 individuals with negative culture and PCR-EIA results, 19 fulfilled presently accepted serological criteria for acute infection; i.e., the IgM titer was > or = 1:16, the IgG titer was > or = 1:512, or both. On the basis of our findings, we conclude that asymptomatic upper airway infection and carriage with C. pneumoniae occur among subjectively healthy persons; we also propose that such individuals may represent a reservoir for this organism in the community. Further, this study demonstrates that currently available diagnostic tests for C. pneumoniae may be unable to accurately distinguish between infection responsible for respiratory tract disease and that representing carriage.

Effects of BDNF on dopaminergic, serotonergic, and GABAergic neurons in cultures of human fetal ventral mesencephalon.

The neurotrophin brain-derived neurotrophic factor (BDNF) was tested for its ability to promote the survival and regulation of expression of phenotypic markers of dopaminergic, serotonergic, and GABAergic neurons in free-floating roller tube cultures of human fetal ventral mesencephalon. This culture system contains neurons of the anlage of the substantia nigra as well as that of the rostral raphe nucleus. Dopaminergic neuron number and tyrosine hydroxylase (TH) fiber density was monitored by TH immunocytochemistry. Measurement of dopamine (DA) content, TH enzymatic activity, serotonin (5-HT) content, and glutamic acid decarboxylase (GAD) activity were used as indices of their respective neurotransmitter function. The presence of GABAergic and serotonergic neurons in this culture system was confirmed by GABA and 5-HT immunocytochemistry. In cultures maintained in the presence of BDNF (10 ng/ml), the density of TH-positive cells was increased by 2.5-fold (P F 0.05), and the TH-positive fiber density was increased by 3.5-fold (P F 0.01), relative to control cultures. Similarly, the relative increases in DA content and TH activity were 2.6- and 2.3-fold, respectively, in the BDNF-treated cultures (P F 0.01 and P F 0.01). On a per neuron basis, DA content and TH activity were not markedly changed by BDNF treatment, suggesting that the increases in DA content and TH activity are due to more DA neurons surviving. Relative elevations were also observed in serotonin content (2.0-fold, P F 0.01) and GAD enzymatic activity (1.4-fold, P F 0.01). Future studies will need to determine whether these changes result from the direct action of BDNF on these neurons or through some indirect mechanism. The results demonstrate that BDNF has beneficial effects on cultured human fetal tissue, which may be relevant in optimizing neuronal transplantation techniques, and that multiple systems are simultaneously influenced by BDNF.

Comparison of the effects of the neurotrophins on the morphological structure of dopaminergic neurons in cultures of rat substantia nigra.

The effect of the various neurotrophin family members on the morphological structure of dopaminergic neurons was compared in dissociated cultures of embryonic rat ventral mesencephalon. Cultures were maintained in vitro in the presence of brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), neurotrohin-4/5 (NT-4/5), nerve growth factor (NGF) or no added growth factors. Three-dimensional reconstructions of 48 neurons were made in each of the experimental groups following immunocytochemical staining for tyrosine hydroxylase to detect dopaminergic neurons. In addition [3H]mazindol binding analyses were carried out in replicate cultures in order to quantify the effects of the neurotrophins on the number of dopamine uptake sites. Among the neurotrophins tested, NT-4/5 influenced the proximal morphological parameters most, as determined by a 36% increase in the soma profile area and 35% in the number of stem neurites. Analysis of neuritic size and complexity in these cultures revealed that combined neuritic length and number of segments/cell were increased by 45 and 40% respectively. A change in neurite complexity in the NT-4/5 treated cultures was further confirmed using Scholl's concentric sphere analysis. In addition, relative to the control, NT-4/5 increased the neuronal differentiation as evidenced by increases in varicosity density and [3H]mazindol binding by 114 and 101% respectively. BDNF and, to a lesser extent, NT-3 also increased both proximal parameters and parameters of differentiation, but were without effect on parameters of neuritic size and complexity. No effects on neuronal structure were observed in NGF treated cultures. These findings demonstrate that BDNF, NT-3 and NT-4/5 influence the morphological differentiation of dopaminergic neurons in vitro, suggesting they may play a role in the structural development and plasticity of these neurons in the mesencephalon.