Number of Siblings in Childhood, Social Outcomes in Adulthood.

In many parts of the world, fertility has declined in important ways in the last century. What are the consequences of this demographic change? Our study expands the empirical basis for understanding the relationship between number of siblings in childhood and social outcomes among adults. An important recent study found that for each additional sibling an individual grows up with, the likelihood of divorce as an adult declines by three percent. We expand this work by: (1) determining whether the original pattern replicates in the National Longitudinal Study of Adolescent to Adult Health and (2) extending the analysis beyond divorce to consider whether growing up with siblings is related to pro-social adult behaviors (relationships with parents, friends, and views on conflict management with one's partner). Our results confirm a negative association between number of siblings and divorce in adulthood. We find mixed results related to other pro-social adult behaviors.

Socioeconomic, Ethnic, Racial, and Gender Gaps in Children's Social/Behavioral Skills: Do They Grow Faster in School or out?

Children's social and behavioral skills vary considerably by socioeconomic status (SES), race and/or ethnicity, and gender, yet it is unclear to what degree these differences are due to school or nonschool factors. We observe how gaps in social and behavioral skills change during school and nonschool (summer) periods from the start of kindergarten entry until the end of second grade in a recent and nationally representative sample of more than 16,000 children (the Early Childhood Longitudinal Study Kindergarten Class of 2010-11). We find that large gaps in social and behavioral skills exist at the start of kindergarten entry, and these gaps favor high-SES, white, and female children. Over the next three years, we observed that the gaps grow no faster when school is in than when school is out. In the case of social and behavioral skills, it appears that schools neither exacerbate inequality nor reduce it.

Inequality in Reading and Math Skills Forms Mainly before Kindergarten: A Replication, and Partial Correction, of "Are Schools the Great Equalizer?"

When do children become unequal in reading and math skills? Some research claims that inequality grows mainly before school begins. Some research claims that schools cause inequality to grow. And some research-including the 2004 study "Are Schools the Great Equalizer?"-claims that inequality grows mainly during summer vacations. Unfortunately, the test scores used in the Great Equalizer study suffered from a measurement artifact that exaggerated estimates of inequality growth. In addition, the Great Equalizer study is dated and its participants are no longer school-aged. In this article, we replicate the Great Equalizer study using better test scores in both the original data and a newer cohort of children. When we use the new test scores, we find that variance is substantial at the start of kindergarten and does not grow but actually shrinks over the next two to three years. This finding, which was not evident in the original Great Equalizer study, implicates the years before kindergarten as the primary source of inequality in elementary reading and math. Total score variance grows during most summers and shrinks during most school years, suggesting that schools reduce inequality overall. Changes in inequality are small after kindergarten and do not replicate consistently across grades, subjects, or cohorts. That said, socioeconomic gaps tend to shrink during the school year and grow during the summer, while the black-white gap tends to follow the opposite pattern.

Number of Siblings During Childhood and the Likelihood of Divorce in Adulthood.

Despite fertility decline across economically developed countries, relatively little is known about the social consequences of children being raised with fewer siblings. Much research suggests that growing up with fewer siblings is probably positive, as children tend to do better in school when sibship size is small. Less scholarship, however, has explored how growing up with few siblings influences children's ability to get along with peers and develop long-term meaningful relationships. If siblings serve as important social practice partners during childhood, individuals with few or no siblings may struggle to develop successful social lives later in adulthood. With data from the General Social Surveys 1972-2012, we explore this possibility by testing whether sibship size during childhood predicts the probability of divorce in adulthood. We find that, among those who ever marry, each additional sibling is associated with a three percent decline in the likelihood of divorce, net of covariates.

The (Conditional) Resource Dilution Model: State- and Community-Level Modifications.

One of the most consistent patterns in the social sciences is the relationship between sibship size and educational outcomes: those with fewer siblings outperform those with many. The resource dilution (RD) model emphasizes the increasing division of parental resources within the nuclear family as the number of children grows, yet it fails to account for instances when the relationship between sibship size and education is often weak or even positive. To reconcile, we introduce a conditional resource dilution (CRD) model to acknowledge that nonparental investments might aid in children's development and condition the effect of siblings. We revisit the General Social Surveys (1972-2010) and find support for a CRD approach: the relationship between sibship size and educational attainment has declined during the first half of the twentieth century, and this relationship varies across religious groups. Findings suggest that state and community resources can offset the impact of resource dilution-a more sociological interpretation of sibship size patterns than that of the traditional RD model.

Validation of a radiographic model for the assessment of mesh migration.

BACKGROUND: The natural history of laparoscopically placed mesh remains uncharacterized. Mesh migration is not infrequently discovered at reoperation and implicated as a cause of hernia recurrence, and it has also been associated with more serious complications, such as enteric and bladder erosion and fistula formation. To date, there is no noninvasive method by which to reliably assess the in-vivo behavior of laparoscopically placed mesh. In this study, we devised and validated a safe and noninvasive model, utilizing computed radiography (CR), for measuring postoperative mesh migration that may be applied to the clinical setting. METHODS: The anatomical structures of the inguinal region were recreated using a skeletal male pelvic model. A sheet of commercially available surgical mesh, marked with three 5mm surgical clips at its medial and superior corners, was moved along the inguinal ligament wire for various random distances. The mesh displacement was measured from the model, and a CR film was obtained. The corresponding mesh displacement was then measured on the CR using two different calibration methods (calibration disk and clip measurement). RESULTS: A total of 60 measurements were made and recorded. There were no statistically significant differences between the true (as measured from the model) and CR-measured distances of mesh migration. In comparing the two methods, only method 1 (calibration disk) showed a tendency towards a significant difference when lateral or superior displacement was measured, but correlation remained excellent (r(2) = 0.99). All other measurements showed no significant difference and excellent correlation (r(2) > 0.96). Pearson's correlation coefficients showed no significant inter-rater variability using either of these methods. CONCLUSION: Our CR model reliably provides a noninvasive means to characterize mesh movement in the postoperative clinical setting. This should provide an instrument to facilitate future clinical evaluation of mesh migration in human trials.

Does platelet administration affect mortality in elderly head-injured patients taking antiplatelet medications?

A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) (P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.

Recurrence of primary breast lymphoma in contralateral breast: case report and review of the literature.

Lymphoma presenting as a breast mass is rare, although well documented. Although recurrence rates can reach approximately 50%, recurrence in the contralateral breast is rare. We report a case of recurrent primary breast lymphoma (PBL), which was discovered on screening mammography after a 5-year disease-free interval from initial diagnosis.

Evaluation of endoscopic full-thickness plication on anti-reflux valve competency.

BACKGROUND: We sought to investigate the efficacy of endoscopically created, full-thickness plications on the competency of the anti-reflux barrier when placed at different positions on the stomach adjacent to the gastroesophageal junction. METHODS: Explanted human cadaver stomachs and esophagi were used. An endoscopic plication system (Plicator, NDO Surgical, Mansfield, Massachusetts) was then fitted over a pediatric gastroscope and passed through the esophagus into the stomach. A full-thickness plication implant was then deployed at 1 of 3 positions (fundus, anterior, and between the anterior and the lesser curvature) on the explanted stomach within 1 cm of the gastroesophageal junction. Intragastric pressure was measured before and after plication at the time of visible reflux from the esophagus (reflux threshold) using a water-perfused manometer. RESULTS: Five explanted stomachs were used. The mean reflux threshold before plication (baseline) was 1.7 mm Hg. A single plication at each position resulted universally in a significantly increased reflux threshold over the baseline value (p < 0.006). The greatest reflux threshold was observed when plication was performed on the anterior wall of the stomach, although this reflux pressure did not achieve statistical significance over the other 2 positions. A second plication performed adjacent to the initial plication at the fundus (n = 2) and anterior (n = 2) positions did increase reflux threshold; however, this increase also failed to achieve statistical significance. CONCLUSIONS: These results suggest that an endoscopic, full-thickness plication system can inhibit gastroesophageal reflux effectively in an explanted stomach model. Although anterior plication resulted in the greatest intragastric pressure at reflux, it was not significantly different from intragastric pressure recorded at the other plication positions. A second plication adjacent to the first showed incremental effect, but larger studies are warranted to understand its clinical significance.

Childhood body mass index gain during the summer versus during the school year.

The nationwide increase in obesity affects all population sectors, but the impact on children is of special concern because overweight children are prone to becoming overweight adults. Contrary to the opinion of experts, research suggests that schools may be more part of the solution than the problem. Recent seasonal comparison research (comparing children's outcomes during the summer and during school year) reports that children gain body mass index (BMI) nearly twice as fast during the summer as during the school year. Whereas most children experience healthier BMI gain during the school year than the summer, this is especially the case for black and Hispanic children and for children already overweight.

Gastrointestinal staple line reinforcement.

Gastrointestinal resections and anastomoses are commonly performed using stapling devices in a wide range of open and laparoscopic procedures. Whether they are hand-sewn or stapled, anastomoses have an associated leak rate that can impart significant morbidity or mortality to a procedure. In addition, bleeding from staple lines can cause additional complications. Staple line reinforcement is one intervention that has been postulated to reduce both the leak rate and associated bleeding risk. This can be accomplished with either material applied exogenously to the staple line, as in an engineered absorbable biomaterial, or it may use a material - either absorbable or nonabsorbable - that is incorporated into the staple line. A number of reinforcements are currently available but all add time and cost to the procedures in which they are used. However, preventing the complications associated with leak and hemorrhage from staple lines may justify the added cost of these devices. A review of the available published literature was performed to review the current data pertaining to the reinforcement of living tissue and anastomoses with these various reinforcements available to surgeons.

The effect of school on overweight in childhood: gain in body mass index during the school year and during summer vacation.

OBJECTIVES: To determine whether school or nonschool environments contribute more to childhood overweight, we compared children's gains in body mass index (BMI) when school is in session (during the kindergarten and first-grade school years) with their gains in BMI when school is out (during summer vacation). METHODS: The BMIs of 5380 children in 310 schools were measured as part of the Early Childhood Longitudinal Study, Kindergarten Cohort. We used these measurements to estimate BMI gain rates during kindergarten, summer, and first grade. RESULTS: Growth in BMI was typically faster and more variable during summer vacation than during the kindergarten and first-grade school years. The difference between school and summer gain rates was especially large for 3 at-risk subgroups: Black children, Hispanic children, and children who were already overweight at the beginning of kindergarten. CONCLUSIONS: Although a school's diet and exercise policies may be less than ideal, it appears that early school environments contribute less to overweight than do nonschool environments.

Comparison of pleurodesis by erythromycin, talc, doxycycline, and diazepam in a rabbit model.

BACKGROUND: Patients with malignant pleural effusion, recurrent spontaneous pneumothorax, and recurrent benign pleural effusions may have significant relief of their symptoms with chemical pleurodesis. Talc is the most frequently used chemical sclerosant; however, it has been known to induce Adult Respiratory Distress Syndrome (ARDS). Other agents such as doxycycline and erythromycin have documented efficacy as sclerosing agents in the pleura, but they are not in widespread clinical use and have significant documented adverse reactions. Diazepam may represent a potential sclerosing agent in the pleura, because of its local inflammatory profile in other tissues. MATERIALS AND METHODS: Overall, 33 adult New Zealand White rabbits (Oryctolagus cuniculus) were randomized to 5 treatment groups. Each group received an intrapleural injection via 5 Fr silastic tubes of one of the following agents: 35-mg/kg erythromycin in 2 ml of saline, 70-mg/kg talc in 2 ml of saline, 10-mg/kg doxycycline in 2 ml of saline, 0.4-mg/kg diazepam in 2 ml of saline, or 2 ml of saline as a control. The animals were euthanized and necropsied 30 days after injection. The pleural surfaces were assessed for macroscopic and microscopic evidence of surrounding inflammation and fibrosis. RESULTS: Doxycycline resulted in severe pleural inflammation and fibrosis with pulmonary hemorrhage, whereas talc-treated animals had less effective fibrosis and granulomas. A trend toward higher mortality occurred in doxycycline-treated animals. Erythromycin demonstrated similar fibrosis (p=0.487) to doxycycline and had less inflammation (p<0.001). Diazepam treatment had little effect in the pleural cavity. CONCLUSIONS: This study demonstrates that erythromycin may be the ideal sclerosing agent. It had the advantage of maximal fibrosis with minimal inflammation. Although doxycycline was the most potent pleural sclerosant, it caused severe local tissue damage. Talc treatment resulted in only mild fibrosis, and diazepam was ineffective.

Ecthyma gangrenosum in a patient with toxic epidermal necrolysis.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are a spectrum of disease characterized by a delayed hypersensitivity reaction that involves the skin and mucous membranes and typically is associated with either recent upper respiratory infection or with certain medications. Ecthyma gangrenosum is a rare necrotizing vasculitis that most commonly affects immunocompromised and burn patients and is often a sequela of Pseudomonas aeruginosa bacteremia. The cutaneous lesions of ecthyma gangrenosum are characterized by an erythematous halo surrounding a dark gray or black nodule. P. aeruginosa preferentially invades the venules, resulting in secondary thrombosis of the arterioles, tissue edema, and separation of the epidermis. Management of ecthyma gangrenosum includes systemic treatment with antipseudomonal antibiotics and débridment of the lesions, as well as improving the patient's immune status if possible. We present a case of a patient admitted to the burn unit for toxic epidermal necrolysis who developed pseudomonal bacteremia with ecthyma gangrenosum.

Functional comparison of staple line reinforcements in lung resection.

PURPOSE: Staple line reinforcement with bovine pericardium and expanded polytetrafluoroethylene during lung resections has shown reduction in air leak incidence and duration. Small intestinal submucosa and polyglycolic acid-trimethylene carbonate, have been introduced as new reinforcements for nonpulmonary staple lines. We hypothesize that reinforcement of staple lines in lungs with commercially available materials will decrease staple line leak at increased pressures. DESCRIPTION: We evaluated 8 staple lines per reinforcement material (4 groups) and a control group (n = 40) in healthy living pigs. After resections (up to four per animal), the lungs were tested sequentially using hand ventilation to increasing pressures (5-75 cm H2O). The occurrence of pressure at which leaks was recorded. EVALUATION: All reinforced staple lines exhibited higher mean leak threshold when compared with the controls; however only small intestinal submucosa achieved significance when compared with the controls. CONCLUSIONS: Commercially available reinforcements allow pulmonary staple lines to tolerate higher intrabronchial pressures without demonstrating air leak. In addition, reinforcement with small intestinal submucosa imparts a significant advantage to the other reinforcements in terms of pulmonary staple line leak rate.

Functional assessment of a new staple line reinforcement in lung resection.

BACKGROUND: A major complication of lung resection is prolonged leaking at the staple line. Staple-line reinforcement is performed routinely during these procedures using bovine pericardium (peri-strips) and expanded polytetrafluorethylene. Both materials have been shown previously to increase staple-line durability and reduce the overall incidence of prolonged air leaking after lung resection, specifically in lung volume-reduction surgery. Small intestinal submucosa (SIS) has had many applications in human tissues consequent to its absorption and healing profile, which are well documented in human and animal models. However, it had not been studied in reinforcement of pulmonary staple lines. MATERIALS AND METHODS: We hypothesized that SIS reinforcement of staple lines in healthy lung tissue would increase durability, as determined by leak rates at increased airway pressures as compared to nonreinforced staple lines. Eight healthy juvenile Yorkshire-cross pigs were subjected to bilateral apical lung resections; one side was reinforced with SIS. The lungs were then inflated to sequentially increase intrabronchial pressures (5-75 cm H2O) for 60-second intervals while the chest was filled with saline under direct visualization monitoring for air leak. RESULTS: Staple lines reinforced with porcine small intestinal submucosa had significantly better durability as determined by Kaplan-Meier survival calculations with respect to leak rate as a function of pressure. CONCLUSION: Reinforcement of staple lines with SIS allows pulmonary staple lines to tolerate significantly higher intrabronchial pressures without demonstrating air leak at the staple line.

Increased burst pressure in gastrointestinal staple-lines using reinforcement with a bioprosthetic material.

BACKGROUND: Leakage at an anastomosis is a major and often catastrophic complication of gastrointestinal (GI) surgery. Staple-line reinforcement with one of the several materials commercially available has been utilized to reduce the incidence of this complication. The bioprosthetic material, small intestinal submucosa (SIS, Surgisis((R)); Cook, Inc., Bloomington, IN) has found widespread applications in surgery. However, its ability to improve the durability of staple-lines in GI surgery in terms of burst pressure has not been documented. We hypothesized that SIS reinforcement of staple-lines in healthy living GI tissue would increase durability, as determined by leak rates at increased intraluminal pressures, compared to unreinforced staple-lines. METHODS: Two healthy Yorkshire-Cross pigs were subjected to midline laparotomy and underwent small intestinal division (n=28) with GIA stapling devices. Half of the staple-lines were reinforced with SIS. The staple-lines were then exposed to increased intraluminal pressures by means of a constant-rate dye solution infusion, until staple-lines exhibited visible leakage of the dye solution. The intraluminal pressure was recorded at the time of visible leakage. RESULTS: Staple-lines reinforced with SIS had significantly better durability as determined by analysis of variance and Kaplan-Meier survival calculations, with respect to leak rate as a function of intraluminal pressure (P<0.003). The mean burst pressure of the unreinforced staple-lines was 53 mmHg, while those staple-lines reinforced with SIS had a mean burst pressure of 83 mmHg. CONCLUSION: Reinforcement of stapled GI anastomoses with SIS significantly increases anastomotic burst pressure. These findings suggest a role for this material in GI surgery.