[The application of extracorporeal membrane oxygenation in children in China]

Objective: To investigate the application of extracorporeal membrane oxygenation (ECMO) in pediatrics in China as well as the outcomes. Methods: Data was conducted by questionnaire to investigate the use of ECMO in children under the age of 18 in China by June 30, 2017. All patients were divided into two age groups: pediatric patients (29 d-18 y) and neonates (1-28 d); Also by the causes of ECMO treating including cardiac, respiratory and extracorporeal cardiopulmonary resuscitation (ECPR). The form included the numbers of ECMO cases, weaned and discharged cases, according to the different ages and causes. In addition, the departments that routinely participate in ECMO management were acquired. Results: Totally 43 tertiary hospitals were enrolled, of which 30 have implemented ECMO for the children patients (comprising pediatrics and neonates), including 14 general hospitals, 5 cardiothoracic specialty hospitals and 11 children's or women and children's hospitals. ECMO for pediatrics and neonates was firstly carried out at mainland China in 2004. To the deadline of investigation, 800 patients were supported with ECMO, among which 658 were pediatrics, much more than 142 of neonates. As to pediatrics, 453 were supported with ECMO for cardiac indications with 287 (63.4%) weaned off and 215 (47.5%) survived to discharge; for respiratory causes, 79 cases were registered with 47 (59.5%) weaned off and 36 (45.6%) discharged; for ECPR, 126 were enrolled with 62 (49.2%) successfully weaned off and 48 (38.1%) discharged. In contrast, neonatal patients undergoing cardiac ECMO contained 79 cases, with 39 (49.4%) weaned off and 26 (32.9%) discharged; due to respiratory causes, 40 neonates were included, with 26 (65.0%) weaned off and 21 (52.5%) discharged; 23 neonatal patients consisted of ECPR cause and 10 (43.5%) of them successfully weaned off, but only 6 (26.1%) finally survived. Among the 30 hospitals conducted ECMO for pediatrics and neonates, the average number of departments for ECMO management is 4.03±1.87. Conclusions: Although ECMO used for children in mainland China is relatively late, a certain number of cases have been accumulated, and there is still a gap compared with the international standard. Meanwhile, each hospital has preliminarily built up its own ECMO team.

[Improving outcomes of patients with heterotaxy and functional single ventricle: a 10-year follow-up of 70 cases in a single institution]

Objective: To review current-era palliation outcomes of patients with heterotaxy and functional single ventricle in a single institution. Methods: The clinical data of 70 consecutive patients with heterotaxy undergoing multistage single ventricle palliation in Guangzhou Women and Children's Medical Center from January 2008 to December 2017 were retrospectively reviewed, and the prognosis factors for mortality were analyzed. There were 53 male and 17 female patients.The median age was 13.3 months (range: 6 days to 150 months). Single ventricle multistage palliation included 1(st) stage palliation surgery, 2(nd) bidirectional Glenn shunt, and 3(rd) stage modified Fontan.The Kaplan-Meier method was used to estimate the probability of survival. Multivariate analysis was performed by Cox regression model. Results: Sixty-two patients had right atrial isomerism while eight had left atrial isomerism. Eighteen patients (25.7%) required the first stage palliation. Fifty-five patients received the Glenn shunt, and the Fontan procedure was completed in 27 patients. Overall, mortality occurred in 17 patients (24.3%) including 9 after the first stage palliation, 6 after the Glenn shunt, and 2 following the Fontan procedure. Survival estimates for the entire cohort following surgery were 81% (95%CI: 72% to 90%), 74%(95%CI: 64% to 85%), and 74% (95%CI: 64% to 85%) at 1 year, 5 years and 10 years, respectively. Survival estimates following the first stage palliation were 56% (95%CI: 33% to 79%) and 49% (95%CI: 26% to 73%) at 1 year and 5 years, respectively. Multivariate Cox regression analysis revealed that total anomalous pulmonary venous connection (TAPVC) (HR=6.16, 95%CI: 1.65 to 22.95, P=0.007), atrioventricular valve regurgitation more than moderate (HR=3.81, 95%CI: 1.32 to 10.94, P=0.013) and required the first palliation surgery (HR=4.58, 95%CI: 1.34 to 15.72, P=0.016) were prognosis factors for overall mortality. Conclusions: The management of heterotaxy patients with functional single ventricle remains challenging, and the outcomes are continously improving in china. TAPVC, atrioventricular valve regurgitation more than moderate and required the first palliation surgery still are prognosis factors for overall mortality in heterotaxy syndrome.

Data Sharing, Clinical Trials, and Biomarkers in Precision Oncology: Challenges, Opportunities, and Programs at the Department of Veterans Affairs

Cancer genomic research reveals that a similar cancer clinical phenotype (e.g., non-small cell lung cancer) can arise from various mutations in tumor DNA. Thus, organ of origin is not a definitive classification. Further, targeted therapy for cancer patients (precision oncology) capitalizes on knowledge of individual patient mutational status to deliver treatment directed against the protein products of these mutations with the goal of reducing toxicity and enhancing efficacy relative to traditional nontargeted chemotherapy.

Working with low back pain: workplace and individual psychosocial determinants of limited duty and lost time

BACKGROUND

Few studies have identified the risk factors associated with lost time in employees working with occupational low back pain (OLBP) despite the presence of pain. Such data could assist in the development of evidenced-based secondary prevention programs.

METHODS

The present investigation was a case-control study (n = 421) of demographic, health behavior, ergonomic, workplace and individual psychosocial factors hypothesized to be associated with lost time in young, full-time employees (i.e., soldiers) with OLBP. Analyses of the burden of OLBP in terms of the number of days on limited duty and lost time status were also computed.

RESULTS

Logistic regression analysis indicated that female gender, education beyond HS/GED, longer time working in military, higher levels of daily life worries, no support from others, higher levels of ergonomic exposure, stressful work, increased peer cohesion, and greater perceived effort at work placed a worker at a greater likelihood for OLBP-related lost work time. Lower levels of innovation, involvement, and supervisor support were also associated with lost time. Linear regression indicated that the number of days of lost time and limited duty was associated with lower levels of physical health and higher levels of symptom severity.

CONCLUSIONS

The results support the potential utility of interventions targeting ergonomic, workplace and individual psychosocial risk factors in secondary prevention.

Working with low back pain: workplace and individual psychosocial determinants of limited duty and lost time

BACKGROUND

Few studies have identified the risk factors associated with lost time in employees working with occupational low back pain (OLBP) despite the presence of pain. Such data could assist in the development of evidenced-based secondary prevention programs.

METHODS

The present investigation was a case-control study (n = 421) of demographic, health behavior, ergonomic, workplace and individual psychosocial factors hypothesized to be associated with lost time in young, full-time employees (i.e., soldiers) with OLBP. Analyses of the burden of OLBP in terms of the number of days on limited duty and lost time status were also computed.

RESULTS

Logistic regression analysis indicated that female gender, education beyond HS/GED, longer time working in military, higher levels of daily life worries, no support from others, higher levels of ergonomic exposure, stressful work, increased peer cohesion, and greater perceived effort at work placed a worker at a greater likelihood for OLBP-related lost work time. Lower levels of innovation, involvement, and supervisor support were also associated with lost time. Linear regression indicated that the number of days of lost time and limited duty was associated with lower levels of physical health and higher levels of symptom severity.

CONCLUSIONS

The results support the potential utility of interventions targeting ergonomic, workplace and individual psychosocial risk factors in secondary prevention.

Back and upper extremity disorders among enlisted U.S. Marines: burden and individual risk factors

Although musculoskeletal disorders of the low back and upper extremities can affect military readiness, little is known about their extent and risk factors in the U.S. Marine Corps. Using the Defense Medical Epidemiology and Defense Medical Surveillance System databases, back and upper extremity diagnostic categories were among the top four sources of outpatient visits and duty limitation among enlisted Marines. Back disorders were also found to be the fifth most common cause for lost time. Subsequently, high-risk occupations were identified, age-related trends for clinic visit rates were determined, and rate ratios were computed for the top 15 low back and upper extremity diagnoses among enlisted Marines from 1997 through 1998. Occupational categories with the highest rates of musculoskeletal-related outpatient visits included image interpretation, auditing and accounting, disturbsing, surveillance/target acquisition, and aircraft launch equipment. Significantly increasing linear trends in rates across age groups were found for most diagnoses. For 1998, age-specific rate ratios indicated significantly higher rates for most low back and upper extremity disorders for females; lower rank (i.e., E1-E4) was also a risk, but for fewer diagnoses. The findings emphasize the need to identify modifiable (e.g., work-related, individual) risk factors and to develop focused primary and secondary prevention programs for musculoskeletal disorders in the Marine Corps. Subsequently, these efforts can assist in reducing associated effects, maximizing resource utilization, and enhancing operational readiness.

Job stress, upper extremity pain and functional limitations in symptomatic computer users

BACKGROUND

Research suggests that exposure to occupational stressors are related to the presence and/or exacerbation of work-related upper extremity symptoms in office workers. Also worker's response to work demands and/or job stressors (i.e., workstyle) may exacerbate symptom severity and impact function. The present study examines the association among work demands, job stress and workstyle on pain and function.

METHODS

124 symptomatic female office workers completed a questionnaire measuring demographics, medical history, work demands, perception of the work environment, workstyle, pain intensity, functional impact, and time lost from work.

RESULTS

Heightened job stress and the tendency to continue to work in a way that contributes to pain to ensure high quality (dimension of workstyle) were related to pain intensity at work and decreased function. These variables, in addition to hours worked per year, were related to increased pain experienced across the work week. The model tested did not predict the occurrence of lost time.

CONCLUSIONS

The present findings provide support for the association between job stress, workstyle, upper extremity pain and function. While it is not possible to determine the exact direction of the observed relationships, these results are consistent with prior research indicating the potential significance of job stress and workstyle on symptom exacerbation and functional limitations. Implications for evaluation and intervention are discussed.

Development of a screen for predicting clinical outcomes in patients with work-related upper extremity disorders

This study prospectively examined the extent to which a set of medical, physical, ergonomic, occupational psychosocial, and individual psychosocial variables would predict clinical outcome associated with a diverse set of work-related upper extremity disorders in recently diagnosed individuals. This investigation was designed to develop a tool for use in a clinical setting to assist in identifying patients at risk for poorer outcome. Outcome was measured at 1, 3, and 12 months after completing a baseline questionnaire. Outcome status was based on a median split of a standardized composite index (symptoms, function, workdays lost, and mental health). Logistic regression indicated that predictors of poorer outcome at 1 month were: upper extremity comorbidity (risk ratio [RR], 1.58), pain severity (RR, 1.45), ergonomic risk exposure (RR, 1.07), low job support (RR, 1.03), and pain coping style (RR, 1.54). At 3 months, poorer outcome was predicted by: symptom severity (RR, 10.46), job stress (RR, 1.20), and pain coping style (RR, 1.98). The number of prior treatments/providers (RR, 1.77), past recommendation for surgery (RR, 6.43), and pain coping style were found to predict poorer outcome at 12 months. Sensitivity and specificity, respectively, for the models were 77.4% and 71.8% at 1 month, 80.6% and 82.4% at 3 months, and 80.6% and 83.3% at 12 months. The results indicate that baseline measures of ergonomic and psychosocial stress, pain severity, and pain coping style predict clinical outcome at shorter intervals, whereas number of past treatments/providers, recommendation for surgery and pain coping style predict longer-term outcome. The resulting prognostic screen provides a simple tool that assesses the multidimensional nature of work-related upper extremity disorders and predicts clinical outcome. Furthermore, the findings suggest the importance of early intervention that addresses both physical and psychosocial stressors at work. Specific recommendations to reduce the impact of observed risk factors are discussed.

Predictors of occupational low back disability: implications for secondary prevention

Over the past decade, studies have identified a combination of demographic, physical/medical, ergonomic, and psychosocial factors in the development of work disability related to occupational low back pain. Using such data on disability risk factors, investigators have begun to develop risk identification and disability prevention programs. As part of an ongoing effort to develop a secondary prevention program, the present case-control study identified the relative contribution of demographic, physical demand, physical fitness, as well as occupational and individual psychosocial variables to back-related work disability in the US Army. Soldiers (n = 174) diagnosed with a lumbosacral strain and medically discharged from the Army were compared with non-disabled controls (n = 173). Dependent measures were obtained from the US Army Health Risk Appraisal (HRA). For cases, these data pre-dated disability determination by 1 to 3 years. For controls, the HRA was completed during the same time period. Significant predictors of low back disability were: age (odds ratio [OR] = 1.13 per year), lower rank (E2/E3) (OR = 4.08/OR = 3.02), infrequent aerobic exercise (OR = 2.2), higher work stress (OR = 2.71), worries (OR = 2.17), and lower social support (OR = 5.07). The model correctly classified 73.13% of all subjects. These results highlight the importance of considering age, status level in the organization, frequency of aerobic exercise, occupational stress, general worries, and social support for the early detection of soldiers at increased risk for back-related disability. Additionally, the findings support past research indicating the multivariate nature of work disability and emphasize the importance of considering such factors in future secondary prevention efforts.

Clinical management of carpal tunnel syndrome: a 12-year review of outcomes

Carpal tunnel syndrome (CTS) is a disorder frequently encountered by occupational health care specialists. The health care management of this disorder has involved a diverse set of clinical procedures. The present article is a review of the literature related to CTS with an emphasis on occupational-related CTS. MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycLIT, and NIOSHTIC databases from 1985-1997 were searched for treatment outcome studies related to CTS. Treatments of interest included surgery, physical therapy, drug therapy, chiropractic treatment, biobehavioral interventions, and occupational rehabilitation. A systematic review of the effects of these interventions on symptoms, medical status, function, return to work, psychological well-being, and patient satisfaction was completed. Compared to other treatments, the majority of studies assessed the effects of surgical interventions. Endoscopic release was associated with higher levels of physical functioning and fewer days to return to work when compared to open release. Limited evidence indicated: 1) steroid injections and oral use of B6 were associated with pain reduction; 2) in comparison to splinting, range of motion exercises appeared to be associated with less pain and fewer days to return to work; 3) cognitive behavior therapy yielded reductions in pain, anxiety, and depression; and, 4) multidisciplinary occupational rehabilitation was associated with a higher percentage of chronic cases returning to work than usual care. Workers' compensation status was associated with increased time to return to work following surgery. Conclusions are preliminary due to the small number of well-controlled studies, variability in duration of symptoms and disability, and the broad range of reported outcome measures. While there are several opinions regarding effective treatment, there is very little scientific support for the range of options currently used in practice. Despite the emerging evidence of the multivariate nature of CTS, the majority of outcome studies have focused on single interventions directed at individual etiological factors or symptoms and functional limitations secondary to CTS.

Occupational upper-extremity-related disability: demographic, physical, and psychosocial factors

Occupational upper-extremity disorders have been associated with prolonged pain and work disability. Using the U.S. Army Physical Disability Agency database, the present case-control studies (n = 434 and n = 342) investigated the contribution of demographic, physical, occupational psychosocial, and individual psychosocial factors to work disability in soldiers with upper-extremity disorders. Age (odds ratio [OR] = 1.11), rank (private E-2: OR = 3.79; private first class: OR = 4.39; specialist or corporal: OR = 2.17), ethnic group (white: OR = 1.54), and occupational stress ("often": OR = 2.46) were found to predict disability. The results highlight the importance of occupational stress as a predictor of disability and the potential utility of addressing this factor in the development of empirically based disability prevention strategies. This investigation also emphasizes the need for research that delineates the biobehavioral mechanisms linking occupational stress to prolonged symptoms and subsequent work disability.

Effects of total coumarins of Fructus cnidii on skeleton of ovariectomized rats

Total coumarins of Fructus Cnidii (TCFC), 5 g.kg-1 by intragastric gavage, 6 d/wk, x 7 wk, was effective for prevention of bone loss in ovariectomized (OVX) rats. In comparison to aging control rats, the proximal tibia of placebo-treated OVX rats were characterized by an increase in eroded perimeter (+298%), label perimeter (+77%), osteoid perimeter (+47%), mineral apposition rate (+32%) and bone formation rate (+130%). These changes indicated a high bone turnover in OVX rats leading to a rapid bone loss (-44%) in proximal tibial metaphysis. In contrast, the TCFC-treated OVX rats showed an increase of cancellous bone area (+41%) compared with placebo-treated OVX rats and decrease in all the above indices of bone turnover to near aging control levels except that of the osteoid area (+88%) which was higher than that in aging control, but mineralization lag time did not show significant changes. The results suggested that the TCFC inhibited the high bone turnover and reversed the bone loss at early menopausal stage.

Delayed maternal death after perimortem cesarean section

We report a case of perimortem cesarean section performed on a multigravida with congestive heart failure. This patient had a past history of repeated episodes of acute myocarditis and this time, congestive heart failure attacked her at the 36th week of gestation. The maternal condition deteriorated rapidly with frequent attacks of ventricular fibrillation and cardiac arrest, which gradually became unresponsive to active cardio-pulmonary resuscitation (CPR). The fetal condition also worsened accordingly. Cesarean section was therefore performed and a 2590 gm depressed female baby was delivered in less than one minute after skin incision and about twenty-seven minutes after the maternal condition became extremely unstable. The Apgar scores were 1 at one min, 4 at five min and 6 at ten min. The mother improved soon after delivery of the fetus and her consciousness returned. However, her condition deteriorated again and she died four hours after operation. The fetus survived and follow-up 21 months after delivery was normal.

Comparison of induced versus non-induced labor in post-term pregnancy. A randomized prospective study

OBJECTIVE

To determine the proper management of pregnancy in uncomplicated cases going beyond 42 weeks.

DESIGN

Randomized controlled trial of induction of labor at or shortly after the 42-week limit, versus close monitoring without induction except when indicated for medical reasons.

SETTING

Hospital's obstetrical department

STUDY POPULATION

188 pregnant women, randomly allocated to two groups with 94 in each.

INTERVENTIONS

Induction of labor by stripping of membranes and i.v. oxytocin infusion, with artificial rupture of membranes when the cervical opening was 3 cm or more in diameter. The control group was followed with clinical, biochemical and electronic tests, intervention being applied according to needs.

END POINTS

Frequency and modes of operative delivery, maternal and perinatal morbidity and mortality.

MAIN RESULTS

The distribution of gestational age (in weeks) at birth was almost identical in the two groups, but there were more operative deliveries in the control group than in the induction group (64 versus 48, p less than 0.05). Maternal complications and perinatal morbidity rates were equally distributed between the groups. There was one perinatal death in the induction group and two deaths among the controls.

CONCLUSION

With due reservation for small numbers, routine induction after term may result in fewer operative deliveries. No other advantage has been demonstrated when compared with close monitoring and intervention when medically indicated.