Characteristics and health outcomes associated with activation for self-management in patients with non-specific low back pain: A cross-sectional study.

BACKGROUND: Research has shown that the course of non-specific low back pain (LBP) is influenced by, among other factors, patients' self-management abilities. Therefore, clinical guidelines recommend stimulation of self-management. Enhancing patients' self-management potentially can improve patients' health outcomes and reduce future healthcare costs for non-specific LBP. OBJECTIVES: Which characteristics and health outcomes are associated with activation for self-management in patients with non-specific LBP? DESIGN: Cross-sectional study. METHOD: Patients with non-specific LBP applying for primary care physiotherapy were asked to participate. Multivariable linear regression analysis was performed to analyze the multivariable relationship between activation for self-management (Patient Activation Measure, range 0-100) and a range of characteristics, e.g., age, gender, and health outcomes, e.g., self-efficacy, pain catastrophizing. RESULTS: The median activation for self-management score of the patients with non-specific LBP (N = 208) was 63.10 (IQR = 19.30) points. The multivariable linear regression analysis revealed that higher self-efficacy scores (B = 0.54), female gender (B = 3.64), and a middle educational level compared with a high educational level (B = -5.47) were associated with better activation for self-management in patients with non-specific LBP. The goodness-of-fit of the model was 17.24% (R2 = 0.17). CONCLUSIONS: Patients with better activation for self-management had better self-efficacy, had a higher educational level, and were more often female. However, given the explained variance better understanding of the factors that influence the complex construct of self-management behaviour in patients who are not doing well might be needed to identify possible barriers to engage in self-management.

Prospective, randomized evaluation of the efficacy of fibrin sealant as a topical hemostatic agent at the cannulation site in neonates undergoing extracorporeal membrane oxygenation.

BACKGROUND: The topical hemostatic effect of fibrin sealant that has been solvent/detergent treated and plasminogen depleted was evaluated in a multicenter prospective, randomized controlled study at the cannulation site wound of infants undergoing extracorporeal membrane oxygenation (ECMO). METHODS: The test group received standard cauterization and Fibrin sealant, while the control group was given cauterization alone to control hemostasis at this site. Efficacy data were available on 173 randomized study subjects of whom 149 met study entry criteria. All were managed according to standard ECMO practice. RESULTS: Fibrin sealant reduced the risk of bleeding, was associated with less shed blood, and was associated with shorter duration of hemorrhage. Further, control infants showed an increased bleeding risk with less depressed fibrinogen levels and prothrombin time elevations >18 seconds prior to ECMO. CONCLUSION: Fibrin sealant is useful as a topical hemostatic agent in patients with coagulopathy not responding to standard surgical techniques.

Acute abdomen. Outcomes.

The outcome for children with common surgical conditions that cause an acute abdomen is discussed. These conditions include appendicitis, intussusception, malrotation, inflammatory bowel disease, intestinal obstructions, and nonorganic pain. Emphasis is placed on surgical intervention and disease processes that significantly affect outcome. The outcome of many of the diseases discussed is strongly influenced by the timing of diagnosis and treatment. These children should have prompt care and intervention to prevent morbidity and mortality. In addition, many children who present with common pediatric surgical emergencies have other medical conditions and are best treated in an environment that has a multidisciplinary team to handle their care and decrease the long-term complications.

An overview of extracorporeal membrane oxygenation therapy.

A brief overview of extracorporeal membrane oxygenation and its use in infants and children is presented. The history, selection, operative procedure, daily management and complications are discussed. The international results are shown.

Modern treatment modalities for neonatal and pediatric respiratory failure.

BACKGROUND: Respiratory failure secondary to a variety of causes remains a significant cause of morbidity and mortality in the pediatric population. Newer therapies are appearing frequently in an attempt to decrease the number of deaths from this disease state. We briefly review the current literature on some of the newer modalities including: high-frequency ventilation, surfactant, liquid ventilation, and nitric oxide. We then present our experience from the past 11 years in the most invasive, yet successful, therapy for acute respiratory failure-extracorporeal membrane oxygenation (ECMO). METHODS: Retrospective review of all patients treated with ECMO from September 1983 to December 1994 was undertaken. Data were collected from bedside ECMO flow sheets and the standardized data entry forms submitted to the Extracorporeal Life Support Organization. All statistical analyses were performed using a standard statistical software program. RESULTS: During the study period, 194 neonates and 47 pediatric patients were treated with ECMO. The survival rate in the neonatal population is 82% and in the pediatric population it is 40%. The neonatal patients required an average of 153 hours of support while the pediatric patients required 220 hours (P = 0.008). CONCLUSIONS: While the newer treatment modalities discussed may have an important role in treating neonatal and pediatric respiratory failure in the near future, ECMO remains a cornerstone of the modern treatment modalities. Although somewhat invasive, ECMO is effective therapy with increasing survival rates each year.

Trends in pediatric ostomy surgery: intestinal diversion for necrotizing enterocolitis and biliary diversion for biliary hypoplasia syndromes.

Ostomies are placed in children for different indications than in the older population. Many ostomies of childhood are placed because of congenital or neonatal problems that require temporary or long-term diversion to stabilize the neonatal patient. Necrotizing enterocolitis, the most common reason for placement of neonatal colostomies and ileostomies, is increasing in frequency as more prematurely born infants survive. Recently, there has been an increase in treatment of various biliary hypoplasia syndromes with biliary cutaneous diversion. Children with biliary hypoplasia syndromes are a challenging group of patients who frequently can be helped by ostomies. This article reviews current information on biliary cutaneous diversion for the biliary hypoplasia syndromes and intestinal diversion for necrotizing enterocolitis.

Calculous disease of the biliary tract in infants after neonatal extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) can be lifesaving support for neonates with fulminant respiratory failure. In the 121 patients that we have placed on ECMO since 1983, bleeding, infection, and intracranial hemorrhage have constituted most of the major complications. We have also encountered two cases of biliary calculi in post-ECMO infants. The hemolysis, total parenteral nutrition, diuretics, and prolonged fasting associated with ECMO may predispose neonates to early calculous disease of the biliary tract and may require surgical intervention. Evaluation of abdominal pain or jaundice in infants and children who have been supported with ECMO should include examination of the biliary tree. Cholecystectomy should be seriously considered for infants with cholelithiasis.

Pediatric extracorporeal membrane oxygenation in posttraumatic respiratory failure.

The leading cause of death in the pediatric population in the United States is trauma. A retrospective review of patients treated with extracorporeal membrane oxygenation (ECMO) for traumatic respiratory failure was performed. Eight children were treated at the Ochsner Medical Foundation and additional data on six children were available from the National Registry. Six children developed respiratory failure as a result of blunt trauma and eight as a result of near drowning. Standard venoarterial ECMO was used with a circuit very similar to that used in neonatal ECMO. Vascular access was via the common carotid artery and the internal jugular vein. Ventilatory support was weaned to minimal settings during ECMO. Central hyperalimentation and systemic antibiotics were used in all of the cases. Four of six children survived in the blunt trauma group; three of eight children survived in the near drowning group. Although significant conclusions cannot be drawn from a small group of patients the average pre-ECMO PO2 for survivors was 87 mm Hg, whereas for nonsurvivors the average PO2 was only 46 mm Hg. Ventilatory support for both groups was not remarkably different, and the average PCO2 was lower in the nonsurvivor group. The cause of death in this group of patients is usually multisystem organ failure. In the four patients treated at Ochsner who did not survive, all had positive blood cultures and presumed systemic sepsis. ECMO has been demonstrated to be very successful in neonatal respiratory failure. Predicting mortality and morbidity in pediatric respiratory failure has been more difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

Is primary repair of gastroschisis and omphalocele always the best operation?

Optimal surgical management of neonates with gastroschisis and omphalocele remains controversial. Suggested benefits of primary fascial closure include earlier return of gastrointestinal function, decreased hospital stay, less sepsis, less risk of postoperative intestinal obstruction and fistulae, and lower mortality. Between 1978 and 1989, 40 neonates with gastroschisis or omphalocele underwent repair. Primary fascial repair was performed in 30 children, 18 of whom had a gastroschisis and 12 of whom had an omphalocele. Ten children had staged repair with the use of a silastic silo; seven of these had a gastroschisis and three an omphalocele. Comparison between the groups was made regarding birth weight, days on the ventilator before and after surgery, days to first feeding, days in the hospital after surgery, postoperative complications, and survival. There was no significant difference in birth weight, days on the ventilator, days to first feeding, and postoperative days in the hospital. There were nine complications in nine patients (30%) with primary repair and four complications in two patients (20%) with staged repair. Two infants died after primary repair (6.7%), and one (10%) died after staged closure. It was concluded that silastic silo repair and primary fascial closure are both acceptable alternatives. Primary closure is attractive whenever possible to avoid additional operations.

Extracorporeal membrane oxygenation for nonneonatal respiratory failure.

Extracorporeal membrane oxygenation (ECMO) has been used for 20 years in neonates and children with cardiac and respiratory failure. The number of neonates treated with ECMO has increased exponentially, but the number of older children treated is small. The selection and exclusion criteria for pediatric ECMO are poorly defined, and the results vary because of variable selection criteria and institutional experience with the technique. In order to help define the role of pediatric ECMO, we reviewed our experience in noneonatal pediatric respiratory failure. We have treated 22 patients ranging in age from 1 to 105 months and ranging in weight from 3 to 35 kg. Eighteen patients met the criteria for adult respiratory distress syndrome, two had respiratory syncytial virus pneumonia, and one had severe barotrauma complicating the management of reactive airway disease. All patients were considered by the referring institutions and by us to be failing conventional management as evidenced by hypoxia, hypercarbia, excessive ventilatory pressures, or progressive barotrauma. All were considered likely to die with continued conventional management. Sixteen of the 22 patients had complications (73%), but half of the last 10 patients had no complications. Hemorrhagic complications occurred in 12 patients. Mechanical complications included membrane failure, raceway rupture, pump malfunction, and improper cannula positioning. Other complications included culture-proven infection and renal failure. Eleven of the 22 patients survived (50%); nine of the last 12 survived (75%). These results suggest that ECMO may be a useful technique in selected pediatric patients with respiratory failure. Survival and complication rates improve as experience with the technique increases.

Thymic enlargement in children.

The presence of an anterior mediastinal mass in an infant or child is a diagnostic and therapeutic challenge. Few papers in the literature specifically address subtypes of thymic tumors in the pediatric population and their treatment. Our purpose was to determine which children are at significant risk of having a malignant thymic tumor. Four children were younger than 18 months old. Of these, two (50%) had respiratory distress from tracheal compression although all four had benign tumors. Of the 14 older children, only two were symptomatic, both of these from myasthenia gravis rather than the size of the mass compressing surrounding structures. Four of the 14 masses (29%) were malignant although none of the four were symptomatic. Children with benign tumors lived significantly longer than those with malignant tumors. The significant incidence of malignancy in thymic tumors when the patient is 18 months or older necessitates surgical exploration with complete removal of the mass. Children younger than 18 months require close follow-up and a trial of corticosteroids. Surgery is necessary if the mass enlarges or becomes symptomatic.

Analysis of the two-team approach to anterior spinal fusion.

An anterior approach to the spine via a thoracoabdominal incision offers the surgeon many advantages. The major vascular structures are visualized, stabilization of a long segment of the spine is strong, and recovery is speedy. Nevertheless, this is a major operation and one with potential morbidity and mortality. At Children's Hospital of New Orleans, the Pediatric Surgery and Pediatric Orthopedic Surgery Services work together to reduce these risks and in so doing maintain an acceptable morbidity. With this two-team approach; we operated on the spines of 39 patients between 1978 and 1988. The most common indications for operation included idiopathic scoliosis, neuromuscular disease, and congenital abnormalities. A thoracoabdominal approach was used in 32 patients, a thoracic approach in four patients, and an abdominal approach in three patients. Twenty-nine patients experienced 65 complications; 45 of these complications were respiratory in nature. There were no postoperative deaths. Factors unrelated to the incidence of postoperative complications included age, volume of crystalloid infused during operation, volume of blood replacement, and length of anesthesia.

The perioperative management of neonates with congenital oropharyngeal teratomas.

Oropharyngeal teratomas are rare congenital neoplasms that distort orofacial anatomy and often cause respiratory embarrassment at birth. Immediate management of such lesions should include establishment of a secure upper airway, radiographic exclusion of midline central nervous system anomalies, and early surgical excision to prevent asphyxia or permanent disfigurement. Perioperative assessment and surgical management are reported for three oropharyngeal teratomas.

Retrohepatic vena cava reconstruction with polytetrafluoroethylene graft.

The case of an 18-month-old male who underwent a right hepatic lobectomy for hepatoblastoma with extensive involvement of the retrohepatic vena cava is presented. The retrohepatic vena cava was replaced with an expanded polytetrafluoroethylene graft. This graft was proved patent by ultrasonography 2 years after operation. The child has no evidence of recurrent hepatoblastoma. The results of grafting the retrohepatic vena cava have been notoriously poor. It is widely believed that a prosthetic vena cava graft cannot be expected to remain patent. Our experience with polytetrafluoroethylene and previous reports using Dacron and polytetrafluoroethylene have shown that long-term patency of retrohepatic vena cava replacement with synthetic graft can be successful.

Carotid artery repair after pediatric extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO), which has been shown to dramatically improve survival in selected neonatal patients, is now being used in some centers for pediatric patients with respiratory and cardiac failure. One of the major concerns with ECMO support is the permanent ligation of the right common carotid artery. We have used ECMO to support 10 pediatric patients with cardiac failure and 22 patients with respiratory failure. Thirty-one were cannulated via the common carotid artery and internal jugular vein on the right. Five of the last six patients with respiratory failure survived. One was on ECMO for 21 days, so the carotid artery was not amenable to repair. In the other four survivors the common carotid artery was reconstructed at the time of decannulation. In one patient, a segment of the artery was resected because of an intimal injury, and a primary anastomosis was performed. In all four, color Doppler studies of the artery prior to discharge were normal. None had clinical evidence of emboli, and a cranial computed tomography (CT) scan was normal in all four patients. These data suggest that in many pediatric patients supported with ECMO, reconstruction of the common carotid artery can be performed with low risk of embolic complications. Long-term follow-up is needed.

Ventilatory management casebook. Congenital diaphragmatic hernia meeting criteria for extracorporeal membrane oxygenation.

Respiratory distress in newborns with CDH is the result of the interaction of pulmonary hypertension and pulmonary hypoplasia. Many patients will demonstrate adequate pulmonary parenchyma after repair as evidenced by adequate oxygenation and ventilation. Patients should be classified into groups of predicted mortality using Bohn's criteria. Patients in groups A, B, and D may be managed conventionally if blood gases can be kept in the normal range. These patients should be supported with ECMO if unresponsive to conventional management. In those patients with adequate gas exchange who fall into the C group, transfer to an ECMO center should be undertaken early, since mortality with continued conventional management is predictable. Some patients never demonstrate a "honeymoon" period, and mortality can be reliably predicted in this group as well by using Bohn's criteria. Because the relative significance of pulmonary hypoplasia compared with pulmonary hypertension in an individual patient cannot be reliably determined, any patient who has respiratory failure after repair of CDH should be supported with ECMO when conventional techniques fail as long as no contraindications exist. At least one institution will withhold ECMO therapy if lung parenchyma is judged inadequate as predicted by the inability to achieve a preductal PaO2 greater than 100 mm Hg and PaCO2 less than 50 mm Hg with maximal conventional therapy. In our experience, however, some patients can survive with ECMO support when all other indicators would suggest hypoplasia incompatible with life. Therefore, we do not believe any patient should be refused ECMO support when conventional measures fail.(ABSTRACT TRUNCATED AT 250 WORDS)