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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. [ABSTRACT FROM AUTHOR]

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% (R 2  = 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., Competing Interests: Declaration of competing interest None declared., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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.

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.

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.

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)

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.

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.

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.

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.

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)

Wilms' tumors account for the vast majority of renal neoplasms in infants and children. Common areas for metastases include the lung, liver, and contralateral kidney. Less common sites include the bone, skin, brain, and orbit. We report a case of Wilms' tumor in a 13-month-old boy who, after radical left nephrectomy, developed a left testicular mass that turned out to be metastatic Wilms' tumor. The epidemiology, case history, review of the literature, and possible etiology of this rare site of metastatic Wilms' tumor are discussed.

Congenital bronchoesophageal fistula is a rare anomaly that normally appears in adult life. Because of a recent case, we reviewed the literature on this lesion. There have been several reviews in the past but none has included all cases. The largest review included only two thirds of the cases (1966). Including our case, the number of reported cases is 100.

Fifty-five children and adolescents with blunt and penetrating small bowel injuries were treated during a 17-year period. Fourteen patients had blunt injuries, and there were no deaths in this group. The remaining 41 patients had penetrating small bowel injuries, with a mortality of 10 per cent. A decision to operate based on physical examination can be made in the pediatric age group without unduly delaying operation or increasing mortality.

In cases of congenital esophageal stenosis, tracheobronchial remnants in the distal esophagus should be considered a possible diagnosis. The cause is thought to be esophageal sequestration of a tracheobronchial anlage before embryologic separation. Primary resection of the stenotic portion of the esophagus with re-anastomosis is recommended. Such a case is reported.

A patient with an extremely large insulinoma but short duration of symptoms is reported on. Fasting hypoglycemia, hyperinsulinism, and angiography were the modalities used to diagnose and locate the tumor.

Thirty-two infants were treated for congenital diaphragmatic hernia at our institution from 1979 to 1984. Eight were in no or minimal distress at birth and had operative intervention when they were more than 24 hours old; survival was 100%. The remaining 24 neonates required immediate intubation and ventilation followed by operation at less than 12 hours of age. Overall survival was 54%; survival was 31% (4 of 13 patients, Group 1) in the first three years of the series and 82% (9 of 11 patients, Group 2) in the last three years (p less than 0.001). Apgar score, gestational age, birth weight, and incidence of associated congenital heart disease were equal for the two groups (all, p greater than 0.05). The two groups also were examined with reference to alveolar-arterial oxygen differences P(A-a)O2 and mean airway pressure (MAP). The best preoperative P(A-a)O2 was greater than 600 mm Hg for 7 neonates in Group 1 and 6 in Group 2, and survival was 0% and 71%, respectively (p less than 0.001). Infants with a postoperative MAP of 13 cm H2O or greater had a higher mortality (100% in Group 1 and 50% in Group 2, p greater than 0.05). Our treatment protocol was studied to determine those methods related to improved survival. Sodium bicarbonate infusion was used earlier in Group 2 as a prophylaxis against persistent fetal circulation (PFC) (p greater than 0.05). The incidence of severe PFC dropped from 85 to 54% (p greater than 0.05). Higher ventilator rates rather than pressures were used to achieve equally effective ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory failure is the leading cause of death in the newborn. Conventional therapy is very successful with 80% of infants weaned from ventilatory support. For neonates with severe respiratory failure, unresponsive to maximal medical therapy, extracorporeal membrane oxygenation (ECMO) offers an alternative means of management. Venoarterial bypass is achieved by cannulating the right atrium via the internal jugular vein and the aortic arch via the right common carotid artery. A 5-inch roller pump is used to circulate the blood through a 0.4 or 0.8 m2 silicone membrane lung. Management includes heparinization, intravenous alimentation, antibiotic coverage, and reduction of FiO2 and airway pressure. Thirty infants aged 12 to 186 hours were placed on ECMO. Each met strict criteria designed to predict greater than 90% mortality. Time on bypass ranged from 37 to 250 hours. Success, defined by weaning from ECMO and ventilatory support, was achieved in 23. Twenty-one remain alive; 18 have excellent outcome with normal growth and development although follow-up is short (1 to 19 mos). These results corroborate reports from the pioneers of the technique and further support the use of ECMO for neonates with respiratory failure unresponsive to conventional therapy.

The inhibitory effect of vitamin A on tumor establishment and growth has been studied in two animal models. The C57L/J hepatoma, when placed in C57L/J mice receiving inoculations of vitamin A, showed slow growth and the hosts had significantly prolonged survival over untreated mice. The V-2 carcinoma, when implanted in the corneas of New Zealand white rabbits receiving injections of vitamin A, showed decreased vascular response in the limbic vessels. The absence of an induced vascular response prevents vascularization of the tumor and subsequent tumor growth. The evidence suggests that vitamin A may exert its inhibitory effect by modifying the normal vascular response to neoplastic tissue.

This report describes four children with polysplenia syndrome seen in our hospital during the past year. Each had gastrointestinal abnormalities as their predominant problem, and two presented with gastrointestinal duplications not previously reported with this syndrome.

Stimulated by a report in 1974, we have reviewed all abdominoperineal resections in a Univeristy-affiliated community hospital. From 1964--1973, 67 such procedures were performed. There were 65 adenocarcinomas, one squamous cell cancer, and one carcinoid tumor. Dukes' classification was A-4, B-22, C-39, D-4. Postoperative complications occurred in 55.1% of patients. Late complications occurred in 22% of patients. Five-year follow-up was possible in 34 patients with an overall survival of 50%.

A neonate underwent nephrectomy for a congenital mesoblastic nephroma which was found to be ruptured at the time of removal. Two years after operation there is no evidence of recurrent tumor. Present evidence is that nephrectomy alone is adequate treatment for mesoblastic nephroma, but close observation is mandatory if rupture has occurred. Recurrence should be countered with adjunctive chemotherapy.

In the past ten years, 28 patients with primary tumors of the liver have been treated. There were 11 benign tumors, including four hamartomas, three patients with focal nodular hyperplasia, and two each with congenital cysts and hemangioma. Hamartomas and masses of focal nodular hyperplasia should be excised when possible, but both are benign lesions; therefore life threatening excisions at the porta hepatis should be avoided. Cysts are often resectable, but when occupying all lobes of the liver, they can be successfully managed by marsupialization into the free peritoneal cavity. If resectable, hemangiomas should be removed; when occupying most of the liver as they often do, patients may be subject to platelet trapping or to cardiac failure. In some instances these lesions have been controlled by steroids, radiation therapy or hepatic artery ligation. Of 17 malignant tumors seen, 12 proved to be hepatoblastomas. Nine of the 12 patients underwent liver resection, of whom four are cured, (33%). There were three children with hepatocellular carcinomas and two with embryonal rhabdomyosarcoma. One child from each of these groups is cured by surgical excision. At present the only known cures in children with primary malignant liver neoplasms have been achieved by operative removal.

Emergency care of the injured child can be rapid and efficient if the treatment facility is properly prepared to manage children. At Ochsner Foundation Hospital, a mobile tool cabinet is used to store the materials needed for standard pediatric emergency care. The initial evaluation involves rapid assessment of pulmonary function and cardiac action and control of external hemorrhage. Secondary evaluation covers all other areas of the body, with possible problems assessed in descending order of seriousness. In many cases, after initial care and stabilization, the severely injured child should be transported to a pediatric intensive care or trauma unit for definitive treatment.

Volvulus of the sigmoid colon is rare in children. The authors have reviewed a total of 29 cases, including five from our institution. The most common clinical picture is crampy abdominal pain and abdominal distention. In contrast to adults, in children plain abdominal films will often not yield a diagnosis. Barium enema examination can be done to locate the obstruction. Nonoperative reduction was successful in 27 per cent of all reported cases, while operative treatment was necessary in 69 per cent of pediatric patients reported. Recurrence following derotation by any means was rare. However, adequate long-time follow-up is lacking. From available data, it seems that in most cases resection is not necessary. Primary resection may be indicated for recurrence or if the bowel is compromised. Mortality was 14 per cent, occurring in poor risk patients, the very young, and patients with associated anomalies. A redundant sigmoid may undergo intermittent torsion over a period of years, making diagnosis difficult. At laparotomy, these patients have scarred striae on the sigmoid mesocolon.

This communication describes a bizarre esophageal anomaly (abortive H-tracheoesophageal malformation) in a 4-yr-old boy. Our review of the literature failed to uncover an exact duplicate of the surgical findings in this case, which were corrected by an end-to-end anastomosis.

Mesenchymal hamartoma of the chest wall is a rare lesion that presents as a chest wall mass. Four infants are reported, three of whom underwent extensive chest wall resection.

Extraction of endobronchial foreign bodies using the Fogarty catheter has been widely accepted. An unsuccessful application of this technique complicated by pneumothorax and catheter tip separation is presented. Avoidance of complications resulting from forceful instrumentation is emphasized.

Fifty-three neonates and seven pediatric patients were treated with extracorporeal membrane oxygenation from September 1983 until April 1986. Venoarterial bypass was achieved by cannulating the right atrium via the right internal jugular vein and the aortic arch via the right common carotid artery. In the neonatal group, 40 infants with acute respiratory failure were treated, and 36 (90%) survived. Five infants with congenital heart disease were treated and three (60%) survived. Among the eight patients with congenital diaphragmatic hernia, there were three (38%) survivors. In the pediatric group, four patients were treated for ventricular failure after cardiac operations. Two were weaned from bypass, with one long-term survivor. Three patients with acute respiratory failure were treated, with one survivor. salvaging high-risk neonates with minimal morbidity and mortality. It has also been useful in the support of infants with congenital heart disease and congenital diaphragmatic hernia. In pediatric patients one cannot expect to get results that are comparable to those found in neonates. Still, this modality can be useful in salvaging some moribund patients with pulmonary or cardiac failure, or both.

Hydrohematometrocolpos anomalies denote the different types of accumulation of fluid and menstrual products in the vagina and the uterus. They are rare conditions due to an intact hymen, vaginal membrane, or vaginal atresia. They may present at different times during development. The method of presentation is variable, and the presence of other genitourinary abnormalities and anorectal anomalies makes prompt diagnosis and treatment necessary. Review of our experiences with these conditions for the last ten years reveals a total of ten cases. This study reports three cases in detail and describes the others in tabular form.

A case of hernia reduction en masse is reviewed. Discussion of the pathogenesis, diagnosis, and operative approach suggests that the use of taxis in the reduction of incarcerated hernia should be tempered by awareness of potential complications including mass reduction. Diagnosis is by history with the persistence of intestinal obstruction after reduction is a key feature. A preperitoneal approach is recommended for facility of reduction, resection, and anatomic hernia repair.

Respiratory failure is the leading cause of death in the neonatal period. The anatomic and functional basis for this, particularly in full-term infants, most often is persistent pulmonary hypertension of the neonate (PPHN). This condition is reversible but can cause very severe and unrelenting respiratory failure and ultimate death when uncontrolled. Recent technologic advances have expanded the scope of therapy available for PPHN, resulting in increasing therapeutic success for these critically ill infants. This article reviews the anatomic and functional anomalies of PPHN, as well as the methods of diagnosis and discusses current treatment.