Managing incisional wounds with Prevena VAC therapy in lower-extremity vascular surgery: A comparative study.

BACKGROUND: Vascular surgical site infections have been reported with an overall incidence of 5-10% for patients undergoing arterial interventions and as high as 10-20% for lower-limb bypass grafting procedures. Given that vascular surgery patients are known to be at a higher risk of postoperative wound infections and other complications, our objective was to evaluate a potential method to reduce such complications. This study compares the rate of wound healing complications between incisional negative pressure wound therapy (NPWT) and conventional dressings in vascular surgery patients with infra-inguinal incisions. The primary endpoint is complete closure of the wound at the 2-week follow-up appointment. Secondary endpoints include frequency infections requiring antibiotics, need for wound revision, and wound dehiscence. METHODS: A prospective cohort study with retrospective control group was performed following infra-inguinal vascular surgeries for peripheral arterial disease at the Mount Carmel Health System. The patients included in this study were those who underwent a lower-extremity vascular procedure with primary closure of an incision distal to the groin between January 2014 and July 2018. Patients that had received an infra-inguinal incision with primary closure were included. Patients in the experimental group who had a Prevena Wound VAC were compared with a retrospectively obtained control arm treated with conventional dressings. Data regarding wound healing and complications, specifically infections and wound dehiscence, were obtained. RESULTS: A total of 201 patients were recruited in our study: 64 in the Prevena group and 137 in the control group. There was a significant reduction in the number of open wounds in the Prevena group compared to the control group at the 2-week follow-up (10.9% Prevena vs 33.6% control; p = .0005). When evaluated in aggregate, there was a statistically significant reduction in the number of patients who succumbed to any complication in the Prevena arm compared with traditional dressings (13 (20.3%) Prevena vs 72 (52.6%) control; p < .0001). CONCLUSION: The results of our study suggest there should be a significant consideration for the use of NPWT as a prophylactic measure to reduce the risk of wound complications of primarily closed infra-inguinal incisions in vascular surgery patients following common vascular procedures. Its use is particularly effective for patients at enhanced risk of infection, especially those with poor vascularization from BMI, smoking, and diabetes. This leads to decreased trends in antibiotic use, ED visits, readmissions, and surgical revisions, which translates to decreased utilization of hospital resources and economic burden.

Under pressure: What individual characteristics lead to performance of high-quality chest compressions during CPR practice sessions?

Aim: Despite well-established protocols for cardiopulmonary resuscitation training, performance during real-life cardiac arrests can be suboptimal. Understanding personal characteristics which could influence performance of high-quality chest compressions could provide insight into the practice-performance gap. This study examined chest compression performance, while employing feedback and introducing code team sounds as an anxiety-inducing factor in registered nurses using a cardiopulmonary resuscitation training manikin. Methods: Participants included 120 registered nurses with basic life support certification randomized to one of the following groups: no feedback and no code team sounds, feedback without code team sounds, or feedback with code team sounds. Chest compression sessions occurred at baseline, 30-days and 60-days. Demographic variables and anxiety level were also collected. The primary outcome was chest compression performance, defined as average percent of time with correct rate and percent with correct depth as captured by the defibrillator. Statistical analysis included linear mixed effects analysis. Results: The effect of feedback on chest compression performance depended on the value of other parameters. The benefit of feedback on the primary outcome depended on: age, with feedback less beneficial among older participants (p = 0.0413); and time, with feedback more beneficial with repetition (p = 0.011). These interactions also affected the outcome percent of time with correct compression depth. Increased anxiety was associated with decreased percent correct compression depth (p < 0.001). Conclusion: Feedback emerged as important in determining chest compression performance. Chest compression quality was limited by the performer's age and anxiety level. Future research should focus on identifying factors related to individual characteristics which may influence chest compression performance.

Coffee administration to promote return of bowel function after small bowel resection: A randomized, controlled trial.

BACKGROUND: Prolonged ileus occurs in 10%-24% of patients undergoing abdominal surgery. Several trials have found coffee administration reduces postoperative ileus, but this has not been evaluated for small bowel resection. METHODS: Following small bowel resection, patients were randomized to caffeinated coffee or warm water three times a day until the time of first flatus or first bowel movement. Primary outcomes were time from end of procedure to: 1) nasogastric tube removal; and 2) when the discharge order was written. Outcomes were compared using Kaplan-Meier survival curves. RESULTS: Thirty-nine patients received coffee and 40 water. Median days to nasogastric tube removal was 3.4 for the coffee and 4.0 for the water groups (p = 0.002). Median days to discharge order was 6.7 for the coffee and 7.7 for the water groups (p = 0.01). CONCLUSION: Coffee was safe and decreased time to nasogastric tube removal and hospital stay in patients undergoing small bowel resection.

Impact of the COVID-19 Pandemic on Orthopedic Surgery Residency Training.

This study sought to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopedic surgery residency training across the United States. A 26-question online survey was created and sent to all orthopedic surgery residency programs across the United States. Areas of emphasis in the survey included the pandemic's effect on work hours, operative experience, didactics, and medical student recruitment. There were 142 respondents to the survey. One hundred seventeen (82.4%) respondents stated that their residency changed to an alternative/surge schedule during the pandemic. Regarding the degree to which the pandemic affected their training, 77 (54.2%) respondents gave a rating of 8 to 10 on a scale of 0 to 10. Similarly, 94 (66.2%) residents indicated that their operative experience had decreased significantly. Twenty-two (15.5%) residents expected that their next year clinical abilities would not be affected. One hundred thirty-seven (96.5%) residents stated their program transitioned to online didactics. Responses regarding the effectiveness of online didactics were mixed. One hundred twenty-six (88.7%) respondents stated the pandemic would negatively affect the 2021 National Residency Matching Program match. This study demonstrated that the COVID-19 pandemic greatly affected orthopedic surgery residency training in the United States. Resident operative experience decreased significantly, and most respondents indicated a switch to online didactics. Effects were also felt to extend to fourth-year scheduling and the 2021 National Residency Matching Program match. [Orthopedics. 2023;46(5):315-319.].

Removal of Indwelling Urinary Catheter Two Days After Colovesical Fistula Repair: a Single-Arm Prospective Trial.

BACKGROUND: Colovesical fistulas are uncommon but associated with significant morbidity and reduced quality of life. In cases with diverticular etiology, surgical management involves single-stage colonic resection with anastomosis and simple or no bladder repair. No single approach to postoperative bladder management has been widely accepted. Although historically a Foley catheter remained in place for about 2 weeks, elevated risk of the attendant complications has motivated exploring shorter durations. This study examined the feasibility and safety of removing the Foley catheter on postoperative day two. METHODS: Patients with colovesical fistula due to diverticular disease undergoing colectomy with simple or no bladder repair were enrolled in this single-arm prospective trial conducted at a large community health system. The primary outcome was removal of the Foley catheter on postoperative day two after negative cystogram without re-insertion prior to hospital discharge. Secondary outcomes were complications after Foley catheter removal and hospital length of stay. Ninety-five percent confidence intervals were calculated for the outcomes. RESULTS: Twenty-four patients were enrolled. About half (54%) of procedures were open, with 33% requiring simple bladder repair. Ninety-six percent (95% confidence interval, 79-99%) of patients had their Foley catheter removed on postoperative day two after a negative cystogram. There were no complications. Mean (range) hospital length of stay was 4.3 (2-6) days. DISCUSSION: Foley catheter removal after negative cystogram on postoperative day two appears to be feasible and safe in the setting of diverticulitis-related colovesical fistula repair. Further research on a larger number of patients should confirm these findings.

Postlaparotomy pain management: Comparison of patient-controlled analgesia pump alone, with subcutaneous bupivacaine infusion, or with injection of liposomal bupivacaine suspension.

OBJECTIVE: Efforts to achieve balance between effective pain management and opioid-related adverse events (ORAEs) have led to multimodal analgesia regimens. This study compared opioids delivered via patient-controlled analgesia (PCA) plus liposomal bupivacaine, a long-acting local anesthetic with potential to be an effective component of such regimens, to opioids delivered through PCA alone or PCA plus subcutaneous bupivacaine infusion (ONQ), following laparotomy. DESIGN: Prospective, randomized controlled trial. SETTING: Single, tertiary-care institution. PATIENTS: One hundred patients undergoing nonemergent laparotomy. INTERVENTIONS: Patients were randomly assigned to one of three study treatments: PCA only (PCAO), PCA with ONQ, or PCA with injectable liposomal bupivacaine suspension (EXP). MAIN OUTCOME MEASURES: Cumulative opioid use, daily mean patient-reported pain scores, and ORAEs through 72 hours postoperatively. RESULTS: On average, the EXP (n = 31) group exhibited less than 50 percent of the total opioid consumption of the PCAO (n = 36) group, and less than 60 percent of that for the ONQ (n = 33) group. Postoperative days 1 and 3 pain scores were significantly lower for the EXP group as compared to the ONQ and PCAO groups (p ≤ 0.005). Fewer patients in the EXP group (19.4 percent) experienced ORAEs compared to the PCAO (41.1 percent) and ONQ (45.5 percent) groups (p = 0.002). CONCLUSIONS: Laparotomy patients treated with liposomal bupivacaine as part of a multimodal regimen consumed less opioids, had lower pain scores, and had fewer ORAEs. The role of liposomal bupivacaine in the postoperative care of laparotomy patients merits further study.

Role of climatic factors in the incidence of dengue in Port Sudan City, Sudan.

BACKGROUND: Dengue fever outbreaks have occurred in Port Sudan City, Sudan, during the last 2 decades. Climatic factors may play a role in dengue incidence. AIMS: This study aimed at discribing the relationship between climatic factors and dengue fever incidence in Port Sudan during 2008-2013. METHODS: This ecological study entailed secondary data analysis of dengue fever cases and climate information to explore which climatic factors predict the incidence of dengue fever. The Wilcoxon rank sum test and multiple linear regression examined the association between number of dengue fever cases and climatic factors during lag times of 1-6 months. RESULTS: Relative humidity and maximum and minimum temperatures were correlated with dengue incidence in Port Sudan at different time intervals during 2008-2010. Precipitation and relative humidity were correlated with dengue fever during 2011-2013. However, 3-5-month lagged relative humidity was the strongest explanatory variable for the incidence of dengue. CONCLUSION: Dengue transmission appears sensitive to climatic variability. Elucidating the role of climatic factors in dengue fever helps in risk assessment and prevention of epidemics.

Bedside Ultrasound Versus Chest Radiography for Detection of Pulmonary Edema: A Prospective Cohort Study.

OBJECTIVES: Chest radiography has been the preferred imaging study to assess pulmonary congestion. However, chest radiography interpretation is influenced by the level of expertise and high interobserver variability. Lung ultrasound (US) may produce more objective findings through evaluation of vertical comet tail artifacts known as B-lines, which are created by a decrease in the ratio of alveolar air to fluid pulmonary content. Few studies have directly compared chest radiography to bedside US against a reference standard for the diagnosis of pulmonary edema. This study compared the sensitivity and specificity of bedside US and chest radiography in diagnosing pulmonary edema. METHODS: This prospective observational cohort study involved adult patients presenting to the emergency department of an urban tertiary hospital with dyspnea. The primary outcome was the presence or absence of pulmonary edema, as indicated by B-lines on a bedside lung US examination or radiologist-interpreted chest radiography. Patients underwent a US examination within about 1 hour of chest radiography. The final diagnosis from the discharge summary served as the reference standard. RESULTS: Ninety-nine patients were enrolled; 32.3% had congestive heart failure, and 40.4% had chronic obstructive pulmonary disease. Bedside US showed significantly higher sensitivity (96%) compared to chest radiography (65%; P < .001). Of 18 patients with negative radiographic findings and a discharge diagnosis of pulmonary edema, 16 (89%) had positive US findings (P < .001). CONCLUSIONS: Bedside US has the potential to identify pulmonary edema more accurately than chest radiography. As current practice within the United States uses chest radiography, reflecting American College of Cardiology Foundation/American Heart Association guidelines for management of heart failure, the results of this study warrant further evaluation.

Patient Satisfaction With Propofol for Outpatient Colonoscopy: A Prospective, Randomized, Double-Blind Study.

BACKGROUND: Previous literature has shown that propofol has ideal anesthetic properties for patients undergoing colonoscopy, a common procedure at outpatient surgery centers. However, there is a paucity of information regarding patient satisfaction with propofol. OBJECTIVE: The aim of this study was to evaluate patient satisfaction with propofol compared with nonpropofol (fentanyl/midazolam) anesthesia for outpatient colonoscopies. Safety and complications were secondary end points. DESIGN: This study was a double-blind, randomized, parallel-group controlled clinical trial (NCT 02937506). SETTING: This study was conducted at a single ambulatory surgery center at an urban teaching community health system. PATIENTS: Patients were scheduled for outpatient colonoscopy. Those with high-risk cardiac or pulmonary disease were excluded. INTERVENTIONS: Anesthesia personnel administered either fentanyl/midazolam (n = 300) or propofol (n = 300) for sedation during outpatient colonoscopy. A single, highly experienced endoscopist performed all colonoscopies. MAIN OUTCOME MEASURES: The primary outcomes measured were patient satisfaction (5-point Likert scale) and procedure complications. Data were collected on the day of endoscopy by the nursing staff of the postanesthesia care unit. A subinvestigator blinded to the randomization called patients 24 to 72 hours after discharge to obtain data on postprocedure problems and status of resumption of normal activities. Analysis was intention-to-treat. RESULTS: Fewer patients who received propofol remembered being awake during the procedure (2% vs 17% for fentanyl, p < 0.0001) and were more likely to rate the amount of anesthesia received as being "just right" (98.7% vs 91.3% for fentanyl, p = 0.0002) and state that they were "very satisfied" with their anesthesia (86.3% vs 74% for fentanyl, p = 0.0005). Twenty-six percent of fentanyl procedures were rated "difficult" compared with 4.3% for propofol (p < 0.0001), and complications were fewer in the propofol group (2.7% vs 11.7%, p < 0.0001). LIMITATIONS: The endoscopist could not be completely blinded to the anesthetic administered. CONCLUSIONS: Patients prefer propofol over a combination of fentanyl/midazolam as their anesthetic for outpatient colonoscopies. From a patient and provider perspective, propofol appears to be superior to fentanyl/midazolam for outpatient colonoscopy. See Video Abstract at http://links.lww.com/DCR/A445.

Orthostatic hypotension in patients with dementia: clinical features and response to treatment.

OBJECTIVE: To evaluate orthostatic hypotension (OH) prevalence, risk factors, signs and symptoms, and treatment response in patients with dementia. BACKGROUND: No previous studies had systematically delineated the clinical features of OH in patients with dementia and determined the effects of treatment. Diagnosing this treatable disorder may prevent the severe consequences of falls, syncope, confusion, ischemic brain injury, and death; mortality risk rises with worsening OH. Lesser consequences include skin injuries, sprains, fractures, and subdural hematomas. METHODS: We reviewed the charts of 188 patients with dementia who had been treated by author D.F., a solo neurologist/neurobehaviorist. About half of the patients had been diagnosed with OH. D.F. had treated the OH until the patients had much improved blood pressure and symptoms, were asymptomatic, or no longer met OH diagnostic criteria. We collected data on diagnoses, blood pressures, and clinical features before and after treatment. RESULTS: Our patients' most frequent OH signs and symptoms were mental fluctuations (65.6% of patients), excessive sleeping in chairs (29.2%), slow falls without losing consciousness (20.8%), lethargy or fatigue (15.6%), and dizziness (13.5%). All 5 of these signs and symptoms improved significantly with treatment. CONCLUSIONS: Patients with dementia were less likely to have traditional OH symptoms like dizziness than to have mental fluctuations and confusion, drowsiness, and slow falls. Blaming these problems on worsening dementia and neglecting OH as a potential cause may delay diagnosis and specific treatments that can improve patients' safety, daily function, and quality of life.

Minimally invasive surgery adoption into an established surgical practice: impact of a fellowship-trained colleague.

BACKGROUND: Practicing general surgeons adopt minimally invasive techniques using training opportunities such as weekend courses, videos, hands-on conferences, and traveling proctors with varying success. By integrating a fellowship-trained surgeon into an established practice, we show that minimally invasive techniques can be readily adopted. METHODS: A retrospective review of operative reports from July 2004 through June 2008 obtained the number of laparoscopic and open appendectomies, colectomies, ventral/incisional hernias, and inguinal hernias performed by five practicing surgeons. Three time intervals were formed: 18 months before arrival of the MIS-trained surgeon, a 12-month transition period, and the 18 months following. Only cases performed by the five surgeons, and not by the MIS-trained surgeon, were included. A survey elicited the opinions of the five surgeons on various aspects of the transition, including barriers and effectiveness of different methods for learning MIS techniques. RESULTS: A total of 4,016 cases were reviewed. The percentage of total cases performed laparoscopically increased from 12.1 to 48.3 %. Laparoscopic appendectomies significantly increased across time periods from 19 to 80 % (p < 0.0001). Adoption of laparoscopic ventral/incisional hernia repairs increased from 4.8 to 20.1 % (p = 0.0322). Laparoscopic inguinal hernias increased from 0.6 to 31.1 % (p < 0.0001). Finally, laparoscopic colectomies significantly increased from 25 to 52 % (p < 0.0001). Survey responses indicated that "mentoring by a colleague with MIS training" was superior to other methods for learning MIS procedures (p = 0.0327-0.0516). CONCLUSIONS: The integration of a fellowship-trained MIS colleague into a general surgery practice resulted in a 300 % increase in the proportion of appendectomies, ventral hernias, inguinal hernias, and colectomies performed laparoscopically by the other members of the practice. When surveyed, the surgeons felt that mentoring by a colleague with MIS training was the most effective method for adopting MIS procedures into their practice.

Weight and body fat changes in postpartum depot-medroxyprogesterone acetate users.

BACKGROUND: Although postpartum depot-medroxyprogesterone acetate (DMPA) recipients often cite weight gain as the reason for discontinuing DMPA, little is known about body composition changes in postpartum DMPA recipients. STUDY DESIGN: Women who used DMPA during the postpartum year were measured on several anthropometric dimensions of body composition and compared with women who elected surgical sterilization with bilateral partial salpingectomy (BPS). RESULTS: After 1 year, DMPA recipients did not differ from the BPS group in weight or percent body fat changes. Almost half the women using DMPA returned to pregravid weight; nearly half gained weight. Higher pre-pregnancy body mass index was associated with weight gain among DMPA recipients. CONCLUSIONS: DMPA recipients who were overweight or obese before pregnancy may have greater risk for weight gain in the first year postpartum. However, when counseling women, the risk for DMPA-related weight gain should be balanced against the potential for increased weight from subsequent pregnancies.

Visually guided male urinary catheterization: a feasibility study.

INTRODUCTION: Ten percent to 15% of urinary catheterizations involve complications. New techniques to reduce risks and pain are indicated. This study examines the feasibility and safety of male urinary catheterization by nursing personnel using a visually guided device in a clinical setting. METHODS: The device, a 0.6-mm fiber-optic bundle inside a 14F triple-lumen flexible urinary catheter with a lubricious coating, irrigation port, and angled tip, connects to a camera, allowing real-time viewing of progress on a color monitor. Two emergency nurses were trained to use the device. Male patients 18 years or older presenting to the emergency department with an indication for urinary catheterization using a standard Foley or Coudé catheter were eligible to participate in the study. Exclusion criteria were a current suprapubic tube or gross hematuria prior to the procedure. Twenty-five patients were enrolled. Data collected included success of placement, total procedure time, pre-procedure pain and maximum pain during the procedure, gross hematuria, abnormalities or injuries identified if catheterization failed, occurrence of and reason for equipment failures, and number of passes required for placement. RESULTS: All catheters were successfully placed. The median number of passes required was 1. For all but one patient, procedure time was ≤ 17 minutes. A median increase in pain scores of 1 point from baseline to the maximum was reported. Gross hematuria was observed in 2 patients. DISCUSSION: The success rate for placement of a Foley catheter with the visually guided device was 100%, indicating its safety, accuracy, and feasibility in a clinical setting. Minimal pain was associated with the procedure.

Implementation and early outcomes of a peer-led traffic safety initiative for high school students.

Compared with other age groups, teenagers have the lowest rate of safety belt use. We sought to determine whether an ongoing, student-led initiative would be effective in increasing safety belt use among high school students compared with another school in which the intervention did not take place. At the intervention school, there was a statistically significant increase of 15% in observed safety belt use and evidence of increased knowledge regarding proper safety belt use. High schools can be effective in changing the traffic safety behaviors of its students.

Robotic radical prostatectomy at a teaching community hospital: outcomes and safety.

OBJECTIVES: This study describes the early experience of robotic prostatectomy exclusively at a teaching community hospital. METHODS: This is a retrospective report of 153 consecutive patients on whom 4 physicians were the operating surgeon. RESULTS: The average hospital stay was 1.5 days, the mean operative time was 175 minutes, and the estimated operative blood loss was <300mL. The perioperative complication rate was 7.8% (12/153). The prostate-specific antigen failure rate was 2% (2/114). Urinary continence was maintained in 98% of patients 9 months after surgery. Postoperative Gleason scores differed significantly from preoperative biopsy results (P<0.001). Pathological records reported positive margins in 35% (54/153) of specimens. T3 tumors had positive margins more than twice as often as T2 tumors (P<0.002). Surgeon experience correlated with shorter operative times (P=0.001), but not with positive margins. Increasing body mass index was associated with increased operating time (P<0.001). CONCLUSIONS: Robotic prostatectomy appears to be a safe and successful option for prostate cancer treatment in a teaching community hospital.

Frequency and characteristics of coagulopathy in trauma patients treated with a low- or high-plasma-content massive transfusion protocol.

A massive transfusion protocol (MTP) in which most non-RBC transfusions were laboratory result-driven was updated to a 1:1:1 RBC/plasma/platelet formula-driven protocol. Platelet count, fibrinogen level, and prothrombin time (PT) were monitored. In the patients who survived the first 12 hours, the results of coagulation tests were analyzed. Irrespective of the MTP or transfused RBC/plasma ratio, a majority of patients became coagulopathic, usually within the first 2 hours, and a fibrinogen deficiency (fibrinogen level, <100 mg/dL [2.9 µmol/L]) was almost always the initial abnormality. The laboratory value trends under each MTP were indistinguishable: PTs were prolonged and platelet counts and fibrinogen levels fell during the first 100 minutes and then corrected back toward baseline. More than 80% of patients in each group were noncoagulopathic at 12 hours. A 1:1:1 formula-driven MTP did not affect the frequency, nature, or duration of coagulopathy according to laboratory test results.

Vaginal-perianal compared with vaginal-rectal cultures for detecting group B streptococci during pregnancy.

OBJECTIVE: To estimate whether vaginal-perianal cultures could be an alternative to the recommended vaginal-rectal screening cultures for the detection of group B streptococci (GBS) during pregnancy, and to compare patient pain and discomfort between the two collection methods. METHODS: Patients included were aged 18 or older and at 35-37 weeks of gestation. After consent, each patient underwent collection of a vaginal-perianal followed by a vaginal-rectal culture. Patients rated their pain on a 0-to-10 scale for each collection method and indicated whether one method had more discomfort than the other. The primary outcome of the study was the proportion of patients whose vaginal-perianal and vaginal-rectal culture results agreed with one another. RESULTS: Data were collected from 193 patients. The overall agreement rate between the vaginal-perianal and vaginal-rectal cultures was 186 out of 193 (96.4%; lower 95% confidence bound was 93.4%), yielding a 91.1% sensitivity and 98.5% specificity. There were two false positives and five false negatives. The GBS detection rates were similar between the two collection methods (P = .257). On average, pain was 3.4 points for the vaginal-rectal method and 1.2 points for the vaginal-perianal method (P<.001). More than two-thirds of the patients stated that the vaginal-perianal collection method had less discomfort than the vaginal-rectal method. CONCLUSION: Agreement was high between the recommended vaginal-rectal and the studied vaginal-perianal collection methods. Patients indicated less pain and discomfort with the vaginal-perianal collection method. Therefore, vaginal-perianal cultures may be reasonable, patient-preferred alternatives for the recommended vaginal-rectal cultures for detection of GBS during pregnancy. LEVEL OF EVIDENCE: II.

The effect of tissue compression on circular stapler line failure.

BACKGROUND: Anastomotic leak after gastrointestinal anastomosis is a well-known and serious complication, yet there is no standardized approach to reliably create an anastomosis with sufficient mechanical properties to consistently avoid an anastomotic leak. The purpose of this study was to evaluate the relationships among combined tissue thickness, tissue compression, closed staple limb length, and mechanical strength of an anastomosis created with a circular stapler, as measured by maximum intraluminal pressure obtained at the time of leakage. METHODS: Using 27 porcine stomachs and 27 porcine small-intestine segments, we measured tissue thickness and assessed the tissue compression at three different anvil closure distances created by a circular stapling device. Maximum intraluminal pressure was determined by infusing colored water into the porcine materials and increasing the pressure until leakage from the anastomosis occurred. RESULTS: Tissue compression increased as the closure distance narrowed between the anvil and circular stapler (p < .0001). A tissue compression of ≥6 PSI correlated strongly with a maximum intraluminal pressure of ≥18 mmHg (43% for <6 PSI vs. 90% for ≥6 PSI; p = .02); tissue compression ≥12 PSI was necessary to obtain an acute maximum intraluminal pressure of ≥22 mmHg in 13 of 15 of our samples (p = .04). CONCLUSIONS: Maximum intraluminal pressure of an anastomosis in this porcine model correlated most strongly with the compression of the tissue involved in the anastomosis. This experimental model provides a framework for constructing a systematic approach to creating an anastomosis with sufficient mechanical strength. However, this study was not intended to establish the upper range of tissue compression beyond which a permanent tissue injury may occur.

Randomized trial assessing the impact of a musculoskeletal intervention for pain before participating in a weight management program.

PURPOSE: Obesity increases the risk of developing physical disability and pain. Persons with a body mass index (BMI) of 30 kg/m or more have an increased risk for osteoarthritis compared with those with a BMI between 25 and 29 kg/m. The purpose of this study was to examine the effect of treatment directed at reducing musculoskeletal pain on weight loss in obese subjects prior to participation in a 6-month weight management (WM) program. METHODS: Subjects (BMI > or = 30 kg/m; n = 54, female = 41, male = 13) with musculoskeletal pain, as assessed by a visual analog scale score of more than 5, were randomized to a physician musculoskeletal evaluation with treatment and physical therapy prior to participation in a 6-month WM program (intervention) or direct entry into the WM program (control) between November 10, 2003, and January 20, 2005. RESULTS: Seventy-six percent of subjects completed the study (intervention, n = 18 [67%]; control, n = 23 [85%], P = .10). The intervention group demonstrated a significant decrease in visual analog scale score after musculoskeletal therapy (2.3 +/- 1.8, P < .0001). Despite a reduction in pain levels in the intervention group compared with the control group at the start of the WM program, there were no significant differences between the groups in percentage weight loss (P = .80), body fat composition (P = .20), or BMI (P = .06), all significantly improved in both groups. CONCLUSIONS: Musculoskeletal and physical therapy intervention directed at decreasing musculoskeletal pain in obese individuals prior to participation in a WM program reduces reported musculoskeletal pain for those participants completing the program but does not significantly improve weight loss over 6 months, compared with individuals with comparable musculoskeletal pain who enter directly into a WM program.