Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks.

BACKGROUND: The adoption of advanced laparoscopic techniques for complex surgical procedures has raised the concern that the leak rate might be higher than for open surgery, particularly in the surgeon's early experience or in difficult cases. In this study, the sealing effect of fibrin glue on leaking gastrointestinal anastomoses was evaluated in an experimental swine model. METHODS: A standardized gastrojejunostomy was performed on 20 female pigs (mean weight, 47.7 +/- 5.7 kg). A leak was created on the anterior surface of the anastomosis. The animals were randomized to either fibrin glue or no treatment of the leak. Clinical conditions and vital signs, including body temperature, heart rate and, respiratory rate, were collected three times a day. Preoperative and postoperative complete and differential blood count and lactate dehydrogenase levels were determined. Postmortem analysis was performed when the animals were killed. RESULTS: Clinical signs of peritonitis developed in the control animals by the second or third postoperative day. Findings that confirmed the presence of an anastomotic leak at the postmortem examination were the presence of food or gastrojejunal juices in the abdominal cavity, a localized abscess, or a positive air leak test. Fibrin glue treatment prevented the development of peritonitis in all the animals. Complete sealing of the leak was observed on postoperative day 7 in all treated animals, except one in which an asymptomatic contained leak developed. The postoperative total white blood count was significantly increased in the untreated group (24.69 +/- 5.5 vs 12.74 +/- 3.7 10(3)/ul p < 0.001, paired t-test), as compared with the treated group (15. 55 +/- 2.4 vs 14.89 +/- 2.7 10(3)/ul; p = 0.24). CONCLUSION: In this study, fibrin glue showed reproducible sealing effects on leaking gastrojejunal anastomoses. Fibrin glue application may be a valuable approach for the treatment of gastrointestinal anastomotic leaks.

Self-managed versus agency-provided personal assistance care for individuals with high level tetraplegia.

OBJECTIVE: To determine whether a finite population, with severe physical disability, had better perceived quality of life, health status, and lower cost depending on whether they used agencies for their caregivers or hired, trained, and reimbursed their caregivers, independently. DESIGN AND SETTING: A survey, including demographics and portions of the Rand-36, LSI-A, PASI, PIP and CHART. The interviews were completed by telephone, by the leading author. PARTICIPANTS: Seventy-one persons who had sustained spinal cord lesions between C1 and C4. All were at least 1 year postinjury and had received rehabilitation at a local hospital in Englewood, Colorado. Ten additional persons came from the leading author's case management caseload or from a Boston rehabilitation center. They were interviewed in person for pretesting. MAIN OUTCOME MEASURES: Chi square, t tests, and multiple regression analysis, which controlled for potentially confounding group differences. Individuals were placed in two cohorts. Twenty-nine persons received primarily agency provided care and 42 individuals used personal care attendants. RESULTS: The self-managed group showed significantly better health outcomes, with fewer rehospitalizations and diminished preventable complications. They also experienced greater life satisfaction and significantly lower costs. Those in the self-managed care group had significantly higher composite scores on Rand-36, indicating higher perception of recent health status. Significant differences in mean PIP scores indicated that members of the self-managed care cohort perceived greater control over day-to-day lives. PASI scores showed that persons in this cohort had greater satisfaction with their caregivers and costs. Cost benefit analysis showed appreciable lowering of costs in the self-managed care group. CONCLUSIONS: The self-managed care group had many more hours of paid attendant care, whereas the agency provider group had almost equal amounts of care from paid and unpaid providers. Persons using self-managed care reported having fewer medical problems, fewer hospitalizations and better perception of health. Participants declared greater satisfaction in having a choice of caregivers. Persons who were self-managing their care spent less money and used more hours of paid care. The financial burden borne both by the individual and society and the emotional burden borne by families and friends were diminished by the persons managing their care individually.

Intersection of economics, history, and human biology: secular trends in stature in nineteenth-century Sioux Indians.

An unusual confluence of historical factors may be responsible for nineteenth-century Sioux being able to sustain high statures despite enduring adverse conditions during the early reservation experience. An exceptionally long span of Dakota Sioux history was examined for secular trends using a cross-sectional design. Two primary sources were used: One anthropometric data set was collected in the late nineteenth century under the direction of Franz Boas, and another set was collected by James R. Walker in the early twentieth century. Collectively, the data represent the birth years between 1820 and 1880 for adult individuals 20 years old or older. Adult heights (n = 1197) were adjusted for aging effects and regressed on age, with each data set and each sex analyzed separately. Tests for differences between the adult means of age cohorts by decade of birth (1820-1880) were also carried out. Only one sample of adults showed any convincing secular trend (p < 0.05): surprisingly, a positive linear trend for Walker's sample of adult males. This sample was also the one sample of adults that showed significant differences between age cohorts. The failure to find any negative secular trend in this population of Amerindians is remarkable, given the drastic socioeconomic changes that occurred with the coming of the reservation period (ca. 1868). Comparisons with contemporary white Americans show that the Sioux remained consistently taller than whites well into the reservation period and that Sioux children (Prince 1989) continued to grow at highly favorable rates during this time of severe conditions. A possible explanation for these findings involves the relatively favorable level of subsistence support received by most of the Sioux from the US government, as stipulated by various treaties. Conservative estimates suggest that the Sioux may have been able to sustain net levels of per capita annual meat consumption that exceeded the US average for several years before 1893.

Low-frequency electromagnetic (eddy-current) holography for imaging in conductors.

Typical eddy-current system test data consist of the values of the system's probe impedance. The wave theory that links the phase response of the eddy-current probe impedance to the defect location relative to the probe is presented. The technique of phase multiplying the diffraction-limited hologram generated from the probe impedance is discussed. The effects and limitations of this technique are illustrated with a mathematical model of the eddy-current probe. Experimental data are presented that confirm the theoretical analysis and illustrate the ability to focus eddy-current holographic data by using backward wave propagation.

The Dansac mini cap: a new method of waterproof ear protection.

The best method of providing waterproof protection for susceptible ears remains a contentious issue. Many evaluations have concentrated on the efficacy of intraluminal plugs in normal or model ears. We describe a new method, using a jejunostomy shower cap (Dansac mini cap), which avoids intraluminal insertion. This method has proved useful in some patients who have failed to avoid repeated otorrhoea after water exposure despite using a wide range of intraluminal ear plugs. The shower caps are best avoided in children because of teasing.

Latency and amplitude tuning curves of the N1 and N2 components of the cochlear nerve compound action potential.

Compound action potential tuning curves (CAP TCs) generated by masking the N1 component of the CAP provide a means of assessing the ability of the cochlea to selectively tune to certain stimuli. This paper examines some of the factors which can influence this TC when a moderately intense (i.e. 40-80 dB SPL) probe stimulus is used. At these levels, each of the four corners of the trapezoidal stimulus envelope is capable of generating a CAP. Also, short stimulus rise times can merge the CAPs produced by the first two corners, but this does not appear to have a major effect on the CAP TC. It was shown that the N2 component of the CAP for the first corner of the stimulus is equally capable of producing a well-tuned TC. Another study has shown that, in addition to amplitude decrements, one can use latency increases as a criterion for CAP TCs. We have demonstrated that latency TCs are more finely tuned than amplitude TCs at high levels, especially when the stimulus rise time is short.