Pediatric Liver Transplantation: Selection Criteria and Post-transplant Medical Management

Pediatric liver transplantation remains the gold standard for life-threatening acute and chronic liver diseases and multiple liver-based inherited metabolic defects. Advances in surgical techniques, better perioperative care and immunosuppression regimes have resulted in excellent long-term graft and patient survival. The success of pediatric liver transplantation does however bring the additional challenge of long-term patient outcomes including graft hepatitis-related fibrosis and suboptimal biopsychosocial outcomes. In this review, authors will explore the current landscape of pediatric liver transplantation including indications, timing of referral for liver transplantation, surgical techniques and long-term outcomes such as recurrence of pre-transplant liver disease, idiopathic graft hepatitis and biopsychosocial outcomes. Ultimately, early identification and management of potential issues long-term helps ensure our recipients achieve a "meaningful survival".

The 9-Item Patient Health Questionnaire (PHQ-9): an aid to assessment of patient-reported functional outcomes after spinal surgery

BACKGROUND CONTEXT

Preoperative depression is increasingly understood as an important predictor of patient outcomes after spinal surgery. In this study, we examine the relationship between depression and patient-reported functional outcomes (PRFOs), including disability and pain, at various time points postoperatively.

PURPOSE

The objective of this study was to analyze the use of depression, as measured by the 9-Item Patient Health Questionnaire (PHQ-9), as a means of assessing postoperative patient-reported disability and pain.

STUDY DESIGN/SETTING

This study includes an analysis of prospective non-randomized spine registry compiled through an academic multispecialty group practice model.

PATIENT SAMPLE

A total of 1,000 spinal surgery patients from an affiliated surgical registry, enrolled from January 2010 onward, were included in this study.

OUTCOME MEASURES

Pain was assessed via the visual analog scale (VAS) for leg or back pain. Disability was measured by the Oswestry Disability Index (ODI). Depression was measured by the PHQ-9.

METHODS

Patient data were collected preoperatively and at 1, 4, 10, and 24 months postoperatively. Data were analyzed via analysis of variance and Pearson correlation coefficient.

RESULTS

All patient stratifications analyzed experienced improvements in pain and ability postoperatively, as measured by the VAS and the ODI, respectively. Moderately and severely depressed patients (as measured by preoperative PHQ-9) experienced decreases in the mean PHQ-9 score of -6.00 and -7.96 24 months after surgery, respectively.

CONCLUSIONS

In all groups, spinal surgery was followed by relief of pain and improved PRFO. Preoperative depression, as measured by the PHQ-9, predicted postoperative PRFO. Patients with moderate to severe depression as measured by the PHQ-9 experienced large mean decreases in the PHQ-9 score postoperatively. As a psychosocial metric, the PHQ-9 is a useful method of assessing value-added service of a spinal surgery.

Effects of noxious stimulation and pain expectations on neuromuscular control of the spine in patients with chronic low back pain

BACKGROUND CONTEXT

Alterations of the neuromuscular control of the lumbar spine have been reported in patients with chronic low back pain (LBP). During trunk flexion and extension tasks, the reduced myoelectric activity of the low back extensor musculature observed during full trunk flexion is typically absent in patients with chronic LBP.

PURPOSE

To determine whether pain expectations could modulate neuromuscular responses to experimental LBP to a higher extent in patients with chronic LBP compared with controls.

STUDY DESIGN

A cross-sectional, case-control study.

PATIENT SAMPLE

Twenty-two patients with nonspecific chronic LBP and 22 age- and sex-matched control participants.

METHODS

Trunk flexion-extension tasks were performed under three experimental conditions: innocuous heat, noxious stimulation with low pain expectation, and noxious stimulation with high pain expectation. Noxious stimulations were delivered using a contact heat thermode applied on the skin of the lumbar region (L4-L5), whereas low or high pain expectations were induced by verbal and visual instructions.

OUTCOME MEASURES

Surface electromyography of erector spinae at L2-L3 and L4-L5, as well as lumbopelvic kinematic variables were collected during the tasks. Pain was evaluated using a numerical rating scale. Pain catastrophizing, disability, anxiety, and fear-avoidance beliefs were measured using validated questionnaires.

RESULTS

Two-way mixed analysis of variance revealed that pain was significantly different among the three experimental conditions (F2,84=317.5; p<.001). Increased myoelectric activity of the low back extensor musculature during full trunk flexion was observed in the high compared with low pain expectations condition at the L2-L3 level (F2,84=9.5; p<.001) and at the L4-L5 level (F2,84=3.7; p=.030). At the L4-L5 level, this effect was significantly more pronounced for the control participants compared with patients with chronic LBP (F2,84=3.4; p=.045). Pearson correlation analysis revealed that increased lumbar muscle activity in full flexion induced by expectations was associated with higher pain catastrophizing in patients with chronic LBP (r=0.54; p=.012).

CONCLUSIONS

Repeated exposure to pain appears to generate rigid and less variable patterns of muscle activation in patients with chronic LBP, which attenuate their response to pain expectations. Patients with high levels of pain catastrophizing show higher myoelectric activity of lumbar muscles in full flexion and exhibit greater neuromechanical changes when expecting strong pain.