Self-efficacy and self-management behaviors in patients with chronic kidney disease

Although past research has examined self-management among patients with end-stage renal disease (ESRD), little is known about self-management in patients with chronic kidney disease (CKD). In this cross-sectional survey (no intervention), 174 patients with CKD (serum creatinine > or =1.7 mg/dL) completed self-reported measures of self-efficacy, physical and mental functioning, and self-management. The purpose of the study was to explore the association between patients' perceived self-efficacy and their self-management behaviors. Five types of self-management behaviors were measured: communication with caregivers, partnership in care, self-care, self-advocacy, and medication adherence. Controlling for other relevant variables including age, education, diabetic status, hypertension, serum creatinine, physical functioning, and mental health functioning, higher perceived self-efficacy scores were associated with increased communication, partnership, self-care, and medication-adherence behaviors. In this study, patients' perceived self-efficacy was a more consistent correlate of self-management behavior than were demographic or health characteristics. Because self-management has been associated with positive patient outcomes, fostering self-management by supporting patient self-efficacy may have long-term benefits.     

Differences in treatments and outcomes for idiopathic scoliosis patients treated in the United States from 1998 to 2007: impact of socioeconomic variables and ethnicity

Background contextScoliosis is a significant cause of disability and health-care resource utilization in the United States.PurposeOur aim was to evaluate potential disparities in the selection of treatments and outcomes for idiopathic scoliosis patients on a national level. To date, only one study has examined inpatient complications, discharge disposition, and mortality with respect to scoliosis treatment on a national scale.Study design/settingRetrospective review of cases having a primary diagnosis of idiopathic scoliosis using the nationwide inpatient sample (NIS) administrative data from 1998 to 2007.Patient sampleThe NIS data were queried to identify patients with a primary diagnosis of idiopathic scoliosis (International Classification of Diseases, Ninth Revision [ICD-9] diagnosis code: 737.30) admitted routinely. Surgically treated patients were identified as those patients who underwent a spinal fusion (ICD-9-Clinical Modification code: 81.08) as a principal procedure.Outcome measuresRates of surgical versus nonsurgical treatments were measured as were inhospital complications and mortality rates.MethodsNo external funding was received for this work. Univariate and multivariate analyses evaluated race, sex, socioeconomic factors, and hospital characteristics as predictors of surgical versus nonsurgical treatments, as well as inhospital complications and mortality rates.ResultsThe study analyzed 9,077 surgically and 1,098 nonsurgically treated patients with idiopathic scoliosis. Univariate analysis showed both patient- and hospital-level variables as strongly associated with surgical versus nonsurgical treatments and outcomes. Multivariate analysis revealed that Caucasians and private insurance patients were more likely to undergo surgical treatment (p<.05) even when controlling for comorbidities. Additionally, Caucasians had a reduced risk of nonroutine discharge compared with non-Caucasians (p=.03). Large hospitals had higher surgery rates (p=.08) than small- or medium-sized facilities and a lower risk of mortality (p=.04). Caucasians (65.1%) were more commonly admitted to large teaching hospitals than African American (59.8%) or Hispanic (41.8%) patients.ConclusionsDifferences were found in the selection of surgical versus nonsurgical treatments, as well as inhospital morbidity for hospitalized idiopathic scoliosis patients based on ethnic and socioeconomic variables. This may in part be because of differences in access to the resources of large teaching hospitals for different ethnic and socioeconomic groups or variability in severity of scoliosis among these groups that was not captured in this database.     

Interactions Between Cytomegalovirus, Human Herpesvirus-6, and the Recurrence of Hepatitis C After Liver Transplantation

Recurrence of hepatitis C (HCV) following liver transplantation is common. Herpesvirus reactivation following transplant may have an immunomodulatory effect resulting in increased HCV replication. We studied whether cytomegalovirus (CMV) and human herpesvirus-6 (HHV-6) may be associated with HCV recurrence and viral load after transplant. We prospectively followed 66 HCV liver-transplant recipients with serial viral load testing for CMV and HHV-6. Infection and viral load were correlated with the development of biopsy-proven HCV recurrence and HCV viral loads. Histologic recurrence of HCV occurred in 41/66 (62.1%) patients. In the primary analysis, CMV infection and disease, and HHV-6 infection were not associated with HCV recurrence. Peak CMV and HHV-6 viral loads were not significantly different in patients with and without recurrence. No correlation was observed between HCV viral loads at 1 and 3 months post-transplant and peak HHV-6 or CMV viral loads. In a subgroup analysis, HHV-6 infection was associated with the development of more severe recurrence (hepatitis and/or fibrosis score > or = 2) (p = 0.01). Also, fibrosis scores at last follow up were higher in patients with CMV disease (1.67 vs. 0.56; p = 0.016) and in patients with HHV-6 infection (1.18 vs. 0.55; p = 0.031). In conclusion, HHV-6 and CMV infection and viral load were not associated with increased overall rates of HCV recurrence or HCV viral load after liver transplantation but may be associated with more severe forms of recurrence.     

General surgeons and their surgical practices.

The work characteristics of general surgeons were studied as part of a national study of surgeon manpower. General surgeons were found to work long hours relative to other surgical specialists. Although general surgeons' operative workloads ranked fourth among the 10 surgical specialties, they were only modest in comparison with the surgeons with the highest operative loads (thoracic surgeons). The major conclusion is that the supply of general surgeons is more than adequate to meet the need for general surgeon consultants.     

Nonphysician Practice of Dermatologic Surgery: The Texas Perspective

BACKGROUND: Increases in complications resulting from the nonphysician practice of dermatologic procedures have been reported nationally. This investigation was initiated owing to growing concern regarding the nonphysician practice of medicine in Texas. OBJECTIVE: The objective was to survey dermatologists in Texas to determine the number of patients seeking corrective treatment owing to complications from dermatologic procedures performed by nonphysicians. METHODS: A total of 488 dermatologists in Texas were surveyed and seven patients who experienced complications were interviewed by phone. RESULTS: Nearly 53% of responding physicians noted increased complications resulting from nonphysician practice of medicine. Approximately 33% of responding physicians reported that complications were known to have occurred in the absence of an on-site supervising physician. CONCLUSION: The increase in the number of complications owing to nonphysician practice of medicine in Texas mirrors the increases that have been reported nationally. The serious complications reported underscore the need for improved awareness and regulatory changes by state boards of medicine.     

Trunk muscle and lumbar ligament contributions to dynamic lifts with varying degrees of trunk flexion

This study was done to assess the interplay between muscular and ligamentous sources of extensor moment during dynamic lifting with various loads and flexion angles of the trunk segment for 15 subjects lifting a total of 150 loads. Ligament forces predicted from an anatomically detailed biomechanical model did not generally contribute more than 60 Nm for most of the lifts because the lumbar spine was only flexed to a moderate and constant degree for each load condition. In contrast, additional moment demands associated with increases in hand load were supported by muscle. Although the compression forces on the L4-5 intervertebral disc were fairly insensitive to the interplay between the recruitment of muscle and ligament, the shear force was significantly higher with a greater degree of lumbar flexion. The risk of injury may be influenced more by the degree of lumbar flexion than the choice of stoop or squat technique.     

The loads on the lumbar spine during work at an assembly line. The risks for fatigue injuries of vertebral bodies

This study was performed in an attempt to determine the total spinal compressive load during assembly line work to find a possible association with the many complaints of back pain. A flexion analyzer was used to register trunk movements, and analysis of postures and lifted weights was done from video recordings. The load on the spine at the L3 level was calculated through a biomechanical model, meant for analysis of static, sagittally symmetric postures and lifting tasks. Maximum lift tests were performed before and after a full work day. The peak load on the L3-L4 level when lifting corresponded to an average 22% of the load at the lift test. The mean load during a work cycle was 818 N. It was concluded that the many complaints of back pain could not be attributed to high peak loads, repetitivity of the lifts, or large load doses. Monotony, stress, and low job satisfaction are more likely factors of greater importance.     

Physicians' choice for their own hernia repairs

BACKGROUND AND PURPOSE: While the optimal method of inguinal herniorrhaphy is controversial, there is growing acceptance that laparoscopic hernia repair is a legitimate alternative to conventional techniques. This study sought to determine if physicians as patients had different preferences for their own hernia repairs than nonphysician patients. PATIENTS AND METHODS: Total endoscopic preperitoneal (TEP) herniorrhaphy was introduced into the author's practice in 1995. Open herniorrhaphies (OH) were performed under local anesthesia and were almost all tension-free repairs. Patients were given the option of surgical technique after a discussion with the author, although patients with primary unilateral hernias were encouraged to undergo a tension-free OH. A prospective database was kept and subsequently analyzed. RESULTS: In the 3 years from June 1, 1995, to June 1, 1998, a total of 138 OH and 77 TEP repairs were performed. There were 19 physicians among the 215 patients. During the 3-year period, the annual percentage of laparoscopic herniorrhaphies increased from 27% (21/79) to 46% (32/70) (P = 0.024). The shift in physician preference for TEP from 16% (1/6) in 1995 to 75% (6/8) in 1997 was more dramatic than the shift in the population at large: 22% (20/73) to 42% (26/62). All patients undergoing TEP repair for recurrent hernias stated their recovery was easier than after their original OH. Four of seven physicians with recurrent hernias also had bilateral hernias. None required hospitalization. The median time to return to work was 4 days in the TEP physician group and 7 days in the physician OH group. The median time to return to work was 10 days in the TEP nonphysician group and 16 days in the OH nonphysician group. CONCLUSIONS: Physicians cared for by the author are increasingly choosing a laparoscopic approach for their hernia repairs even when they have primary unilateral hernias. Patients return to work more rapidly after TEP repairs than after OH.     

Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis

OBJECTIVE: A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence. SUMMARY BACKGROUND DATA: Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy. METHODS: A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed. RESULTS: Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3; CI: 1.9-5.6; P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1). CONCLUSIONS: The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.     

Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck.

Of 193 patients with penetrating wounds of the neck, 76 had only surgical exploration; 57 had only nonsurgical exploration including one or more of the following: arteriography, bronchoscopy, laryngoscopy, esophagoscopy, and contrast-swallow esophagogram; and 60 had both surgical and nonsurgical exploration. Eighty-six patients were wounded by gunshot, 108 by stabbing. Presenting signs and symptoms were an unreliable method of predicting presence or absence of injury. Overall negative rate of surgical exploration was 50% (54% of the stabbings and 45% of the gunshots). Accuracy of nonsurgical exploration was assessed by comparing to surgery. Arteriography was 100% accurate, a combination of bronchoscopy and laryngoscopy was 100% accurate, contrast-swallow esophagogram was 90% accurate, and esophagoscopy was 86% accurate. The literature was reviewed regarding the accuracy of nonsurgical as well as surgical exploration. The one complication attributed to nonsurgical exploration was a symptomatic anemia, while there were two wound infections resulting in increased length of stay associated with negative surgical exploration. Overall mortality rate was 5.6%. The average length of stay for nonsurgical exploration only was 2.8 days, for negative surgical exploration was 4.2 days, and for positive surgical exploration was 9.5 days. Financial cost of a negative surgical exploration was $3185, while for four-vessel cerebral arteriography with panendoscopy it was $3492. More studies need to be done, particularly concerning venography and esophagoscopy. However, considering the fact that surgical exploration should by no means be considered 100% accurate, the data in this study support the fact that arteriography with panendoscopy represents an equally safe and acceptable method of exploration of penetrating wounds of the neck for stable patients without specific signs and symptoms of injury and can be expected to result in a reduced number of negative surgical explorations and their associated morbidity as well as a reduced length of hospital stay, although at a slightly higher financial cost when compared to mandatory surgical exploration.     

Treatment of acute penetrating injuries of the spine: a retrospective analysis

A retrospective review of 160 cases of penetrating spinal injury (PSI) was undertaken to assess the benefits and risks of operative treatment. Criteria for operation included incomplete deficits, worsening neurological status, and associated visceral perforation. Of the 160 cases, 142 had gunshot wounds (GSW) and 18 had stab wounds (SW). Laminectomy, with or without intradural exploration, was undertaken in 23% of cases. No significant differences in outcome were found between the surgical and nonsurgical groups. Meningitis, CSF leakage, and wound infections were complications that occurred more often in the surgically treated group (22%) than the conservatively managed group (7%). It has not been possible to demonstrate a benefit of surgery in PSI in this retrospective study. A prospective study is proposed that would allow better control of the variables affecting outcome.     

Invasive treatment of pancreatic fluid collections with surgical and nonsurgical methods

Pancreatic fluid collections (PFC) can be drained surgically or nonsurgically with endoscopic or radiologic techniques. To define subgroups of patients with PFC who would benefit from the new modalities, we reviewed a period (1977 to 1990) during which both surgical and nonsurgical invasive techniques were available. Patients with phlegmon or necrosis at initial diagnosis were excluded. Sixty-five patients (35 male, 30 female) underwent 1 or more drainage procedures. A mean postprocedure follow-up of 10.2 months was available for 59 patients. Initial management was nonsurgical in 80% of patients. Procedures in patients with follow-up comprised invasive nonsurgical drainage (n = 25), invasive nonsurgical drainage plus surgery (n = 22), and surgery only (n = 12). Results for each group, respectively, were: morbidity, 20%, 20%, and 24%; mortality, 8%, 5%, and 0%; and successful drainage, 92%, 82%, and 83%. The choice of management appeared to be based on etiology and radiologic characteristics. Patients with nonalcohol- and nonbiliary-associated pancreatitis without a radiographically defined wall were more common in the invasive nonsurgical group and were successfully treated without surgery. Nonsurgical invasive techniques are efficacious in the treatment of PFC in this subgroup of patients.     

WORK LOADS OF A SAMPLE OF GENERAL SURGEONS IN N.S.W

The work loads of 34 general surgeons in New South Wales during a six week period in 1977 have been determined. Data was obtained on the number of elective, emergency and supervised procedures, and of elective and emergency first consultations. The operative work loads were assessed by a simple grading system, and also by the “hernia-equivalent” method which relates the work involved in a given operation to that for an adult unilateral inguinal herniorrhaphy. The latter is arbitrarily given a score of one. The hernia-equivalent scores for academics, country and city surgeons were similar. The mean hernia-equivalent rating for the 2,321 operations assessed was 1.1; thus, the “typical” operation was equivalent to a herniorrhaphy. The mean number of operations per week was 11.4, or 12.6 hernia- equivalents. Assuming a 48-week working year, these figures represent an annual work load of 547 operations, or 605 hernia-equivalents. Comparison of these results with those obtained in the U.S.A. (the “SOSSUS” report) indicates that these work loads are almost three times those found for board-certified general surgeons in the U.S.A.     

Work loads of a sample of general surgeons in N.S.W.

The work loads of 34 general surgeons in New South Wales during a six week period in 1977 have been determined. Data was obtained on the number of elective, emergency and supervised procedures, and of elective and emergency first consultations. The operative work loads were assessed by a simple grading system, and also by the "hernia-equivalent" method which relates the work involved in a given operation to that for an adult unilateral inguinal herniorrhaphy. The latter is arbitrarily given a score of one. The hernia-equivalent scores for academics, country and city surgeons were similar. The mean hernia-equivalent rating for the 2,321 operations assessed was 1.1; thus, the "typical" operation was equivalent to a herniorrhaphy. The mean number of operations per week was 11.4, or 12.6 hernia-equivalents. Assuming a 48-week working year, these figures represent an annual work load of 547 operations, or 605 hernia-equivalents. Comparison of these results with those obtained in the U.S.A. (the "SOSSUS" report) indicates that these work loads are almost three times those found for board-certified general surgeons in the U.S.A.     

Secondary traumatic stress among disaster mental health workers responding to the September 11 attacks

Relationships between secondary traumatic stress (STS) symptoms and therapist characteristics and assignment variables were examined for 81 disaster mental health (DMH) workers who responded to the terrorist attacks of September 11, 2001. Higher STS was associated with therapist variables of heavier prior trauma caseload, less professional experience, youth, and therapist's discussion of his or her own trauma or trauma work in his or her own therapy. Therapist gender and personal trauma history were not significantly related to STS. Assignment variables associated with higher STS included longer length of assignment and more time spent with child clients, firefighters (who suffered great losses in the tragedy), or clients who discussed morbid material. Recommendations for practice include informing DMH recruits of therapist risk factors and assigning at-risk DMH workers to lower-risk assignments.     

Long-term results of subtalar fusions after operative versus nonoperative treatment of os calcis fractures.

From 1984 to 1994, 40 patients with a subtalar fusion were reexamined in long-term follow-up. The evaluation of the overall results was carried out with three different scoring systems. The calcaneal fractures were primarily treated nonsurgically in 23 patients (57.5%), and 17 patients (42.5%) had undergone ORIF. Complete pain relief was achieved in 52.5% of patients; 65% revealed a restriction in a range of motion in the ankle joint, and in 62% a grade 1 arthritis of the ankle joint was found. The statistical analysis could only reveal a tendency for a better outcome in the operative group compared with the nonsurgical group, although within the operated group, the majority of the os calcis fractures were more severe than in the nonsurgical group.     

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

Purpose

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

Methods

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

Results

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the B?hler angle (P?P?=?0.0009) and width (P?P?=?0.0004) and more were able to resume pre-injury work (P?=?0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P?=?0.49). However, operative management was associated with a higher risk of complications (P?=?0.008).

Conclusions

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.     

Patient-oriented outcomes from low back surgery: a community-based study

STUDY DESIGN: This study used a prospective cohort design. OBJECTIVE: To examine factors associated with favorable self-reported patient outcomes 1 year after elective surgery for degenerative back problems. SUMMARY OF BACKGROUND DATA: Many previous studies addressing the results of low back surgery have been conducted in academic institutions or by single surgeons. As part of a quality improvement effort, surgeons in private practice led a community-based outcomes management project in Washington State. METHODS: Patients ages 18 and older with the following diagnoses were eligible for the study: degenerative changes, herniated disc, instability, and spinal stenosis. Nine orthopedists and neurosurgeons enrolled a total of 281 patients. Participants were asked to complete baseline and 1-year follow-up surveys. Data concerning diagnoses, clinical signs, and operative procedures were provided by the surgeons. The researchers examined sociodemographic characteristics, self-reported symptoms before surgery, preoperative clinical signs, diagnoses, and operative procedures associated with three primary outcomes: better functioning, improved quality of life, and overall treatment satisfaction. RESULTS: Follow-up surveys were completed by 236 (84%) of the enrolled patients. Approximately two thirds of the study participants reported much better functioning (65%), a great quality of life improvement (64%), and a very positive perspective about their treatment outcome (68%). The following variables were associated with worse patient outcomes: older age, previous low back surgery, workers' compensation coverage, and consultation with an attorney before surgery. Patients undergoing a fusion procedure were more likely to report good outcomes. CONCLUSIONS: The authors' experience indicates that community-based outcomes data collection efforts are feasible and can be incorporated into usual clinical practice. The study results indicate that compensation payments and litigation are two important predictors of poor outcomes after low back surgery in community practice.Because of small numbers, varied diagnoses, and possible selection bias, the findings with respect to fusion should be interpreted cautiously.     

Peroperative cholangiography in cholelithiasis. Results of a multivariate analysis]

This study was done to select patients with a low risk of common bile duct (CBD) stones in whom operative cholangiography could be avoided. Operative cholangiography was performed upon 511 patients. Two different groups of patients were identified: patients with CBD stones visualized by CBD exploration (n = 90) and patients with no CBD stones at the time of operative cholangiography (n = 42). Multivariate analysis (stepwise logistic regression) showed that five variables were correlated with the presence of CBD stones: size of CBD equal to or greater than 12 millimeters, gallstones equal to or less than 10 millimeters, advanced age, chronic or acute cholecystitis and pas history of biliary colic. Using a scoring system, a group of patients with a low risk (less than 2%) of CBD stones could be easily determined. In this group of patients, operative cholangiography may be avoided.     

Who are our future surgeons? Characteristics of medical school graduates planning surgical careers: analysis of the 1997 to 2004 Association of American Medical Colleges' Graduation Questionnaire National Database

BACKGROUND: Identification of correlates of contemporary US medical graduates' surgical career plans can provide insights about the emerging surgical workforce composition and inform future recruitment efforts. STUDY DESIGN: We analyzed individualized records of 95,176 graduates who completed the 1997 to 2004 Association of American Medical Colleges Graduation Questionnaire for associations between planning a general-surgery or a surgical-specialty (orthopaedic surgery, neurologic surgery, plastic surgery, urology, or otolaryngology) career and a set of medical-school experience, professional-setting preference, and demographic variables. RESULTS: Graduates who reported better quality of their surgery clerkship experience and career-setting preference of "university faculty" compared with "nonuniversity clinical practice" were more likely to plan general-surgery or surgical-specialty careers compared with nonsurgical careers (each p < 0.001). Women and graduates from combined MD/PhD programs and those who planned to practice in underserved areas were less likely to plan general-surgery or surgical-specialty careers compared with nonsurgical careers (each p < 0.001). Graduates of nonwhite race or ethnicity and from combined MD/other-degree (non-PhD) programs were more likely to plan general-surgery careers (p < 0.001). Compared with 1997 graduates, 1998 to 2004 graduates were less likely to plan general-surgery careers than surgical-specialty careers (each p < or = 0.001), and 1999 to 2004 graduates were more likely to plan surgical-specialty careers than nonsurgical careers (each p < or = 0.006). CONCLUSIONS: Contemporary graduates planning surgical careers represent a relatively narrow spectrum of US medical graduates, and those planning general-surgery careers differ in numerous ways from those planning surgical-specialty careers. Targeted efforts are warranted to recruit US medical graduates qualified to meet the nation's future health-care needs and advance the profession of surgery.