A laparoscopic approach to the surgical management of enterocutaneous fistula in a wound healing by secondary intention.

Traditional surgical management of a chronic enterocutaneous fistula requires laparotomy, but the optimal site of incision is unclear. Laparoscopy and adhesiolysis may offer an alternative approach. Two cases of non-healing enterocutaneous fistula within chronic, granulating wounds are described. The laparoscope was placed subcostally using the Hasson technique with additional ports placed under direct vision. After clearing the anterior abdominal wall of all but the fistula-containing bowel, an incision was made circumferentially around the granulation bed. Resection and primary anastomosis was performed in standard fashion. Lateral component separation allowed primary wound closure. Both patients were discharged without sequelae and doing well at last follow-up (mean 12 months). A laparoscopic approach to non-healing enterocutaneous fistulas seems safe and technically feasible. When combined with lateral component separation, it may result in reduction of inadvertent enterotomies and optimal management of the wound without the use of prosthetic mesh.

Unemployment rates, single parent density, and indices of child poverty: their relationship to different categories of child abuse and neglect.

OBJECTIVE: There were two main research questions: First, is there a relationship between rates of child physical abuse, child sexual abuse and child neglect and levels of female and male unemployment, single-parent density and child poverty in the immediately local area; and second, is this relationship different for different categories of abuse and neglect and different categories of deprivation? METHOD: Using archival data--registered cases of abuse and neglect and official data on child population, social worker ratio, unemployment rates, single-parent density, means-tested clothing grants and free school meals for children--a multiple correlational analysis was carried out of the 5,551 referrals and 1,450 registered cases of abuse and neglect in Glasgow, Scotland for the years 1991 through to 1993. RESULTS: Substantial correlations were found with all indices of deprivation but particularly physical abuse with rates of male unemployment. Lower and more variable correlations were found with female unemployment rates. Sexual abuse and neglect rates showed a less consistent relationship with the indices of deprivation. In general male unemployment rates alone accounted for two-thirds of the variance in total abuse and neglect rates, other factors adding little or nothing to this. CONCLUSIONS: The results demonstrate the importance of selecting small and relatively homogeneous areas for this kind of analysis to achieve ecological validity. Male unemployment rates at this level allow for the ranking of areas in terms of priority need.

Acute myocardial infarction with normal coronary artery: a case report and review of literature.

A 17-year-old girl with no risk factors for coronary artery disease had acute myocardial infarction. She received thrombolytic therapy with tissue-type plasminogen activator. An extensive workup for the cause of myocardial infarction revealed protein S deficiency. Angiography showed normal coronary arteries. We speculate that the cause of myocardial infarction was coronary spasm or thrombus formation, which was successfully dissolved by thrombolytic therapy. This is the eighth case report of acute myocardial infarction in a patient with normal coronaries and protein S deficiency. We reviewed the literature concerning myocardial infarction and normal coronaries and protein S deficiency. This case report and review of the literature suggest the need to extend the concept of classic risk factors for coronary artery disease in young patients with myocardial infarction and normal coronary arteries.

Everyday matters in the lives of nursing home residents: wish for and perception of choice and control.

OBJECTIVES: This study examined the importance that nursing home residents and nursing assistants ascribed to control and choice over everyday issues, the satisfaction of residents with their control and choice over these issues, and the nursing assistants' impressions of the extent to which control and choice exist for nursing home residents on everyday matters. DESIGN: Cross-sectional in-person interviews with a stratified representative sample of nursing home residents and nursing assistants using semi-structured interview protocols with both fixed-choice and open-ended questions. SETTING: A random sample of 25 nursing homes in the Twin Cities, MN area; a random sample of five nursing homes in North Little Rock, AR; all five nursing homes in Sante Fe, NM; and five purposively selected nursing homes in each of New York City and Los Angeles, CA. PARTICIPANTS: One hundred thirty-five cognitively intact residents, three from each facility, were selected and included the resident council chair, one randomly selected short-stay resident, and one randomly selected long-stay resident from each facility. Also participating were 134 nursing assistants (1 selected randomly from each shift from those employed at least two-thirds time and who had worked in the facility for at least 3 months). MEASUREMENTS: The most important measurements were ordinal-level ratings of the importance of choice and control for nursing home residents over 10 selected areas of everyday life; ordinal measures of residents' satisfaction with their choice and control over these areas; and nursing assistants' ratings of the extent to which they thought it possible for residents to achieve choice and control. Open-ended comments were also elicited. Also measured were demographic data, ADL status, frequency of trips away from the nursing home, frequency of receiving visitors, and (for nursing assistants) length of employment, wages, job satisfaction, and extent to which they knew the residents under their care. MAJOR RESULTS: Cognitively intact nursing home residents attach importance to choice and control over matters such as bedtime, rising time, food, roommates, care routines, use of money, use of the telephone, trips out of the nursing home, and initiating contact with a physician. Nursing assistants view such control as important to residents. Residents and staff differ significantly in the importance attached to particular items, with staff placing lower importance than residents on use of the telephone and personal expenditures and higher importance on control and choice over visitors and formal nursing home activities. Residents were not very satisfied with their control and choice, and nursing assistants viewed them as unlikely to experience control and choice. Nursing home, resident, and staff characteristics were not associated with the patterns of results. CONCLUSIONS: A self-defeating cycle has been identified where neither resident nor staff are optimistic about achieving more resident control and choice, which both groups perceive as desirable. To end this cycle, suggestions are offered for structuring the role of the nursing assistant, physician and nurse leadership, changes in nursing home routines and practices, and public policy changes.

Echocardiographic diagnosis of pericardial cyst.

A 52-year-old woman was seen with atypical chest pain. A routine chest roentgenogram revealed an enlarged cardiac silhouette. Results of transthoracic echocardiography performed using the standard views was normal. Because of the discrepancy between the findings of chest roentgenogram and transthoracic echocardiography, a biplane transesophageal echocardiogram was obtained and revealed the presence of a pericardial cyst.

Intracranial hemorrhage complicating acute myocardial infarction in the era of thrombolytic therapy.

Cerebrovascular accidents are one of the most serious causes of morbidity in patients sustaining an acute myocardial infarction. In patients who do not receive thrombolytic therapy, the most common form of stroke is thromboembolic, occurring in up to 2.4% of patients, predominantly in those sustaining large anterior infarctions. In patients receiving thrombolytic therapy, intracranial hemorrhage is the most common form of stroke, occurring in 0.1% to 1.4%. Predisposing conditions for intracranial bleeding include low body weight, female sex, advanced age, use of oral anticoagulant medication before the administration of lytic therapy, diastolic blood pressure greater than 110 mm Hg, and the specific thrombolytic agent administered. Hematologic management of the patient sustaining a hemorrhagic cerebrovascular accident should include (1) discontinuance of thrombolytic therapy, anticoagulants, and antiplatelet agents and (2) infusion of cryoprecipitate to replenish fibrinogen. In certain cases, administration of fresh frozen plasma, protamine sulfate, and exogenous platelets may be required. Finally, evacuation of the hematoma may provide the most definitive form of treatment in selected cases.

Double-blind, placebo-controlled study of the effects of carvedilol in patients with moderate to severe heart failure. The PRECISE Trial. Prospective Randomized Evaluation of Carvedilol on Symptoms and Exercise.

BACKGROUND: Carvedilol has improved the symptomatic status of patients with moderate to severe heart failure in single-center studies, but its clinical effects have not been evaluated in large, multicenter trials. METHODS AND RESULTS: We enrolled 278 patients with moderate to severe heart failure (6-minute walk distance, 150 to 450 m) and a left ventricular ejection fraction < or = 0.35 at 31 centers. After an open-label, run-in period, each patient was randomly assigned (double-blind) to either placebo (n = 145) or carvedilol (n = 133; target dose, 25 to 50 mg BID) for 6 months, while background therapy with digoxin, diuretics, and an ACE inhibitor remained constant. Compared with placebo, patients in the carvedilol group had a greater frequency of symptomatic improvement and lower risk of clinical deterioration, as evaluated by changes in the NYHA functional class (P = .014) or by a global assessment of progress judged either by the patient (P = .002) or by the physician (P < .001). In addition, treatment with carvedilol was associated with a significant increase in ejection fraction (P < .001) and a significant decrease in the combined risk of morbidity and mortality (P = .029). In contrast, carvedilol therapy had little effect on indirect measures of patient benefit, including changes in exercise tolerance or quality-of-life scores. The effects of the drug were similar in patients with ischemic heart disease or idiopathic dilated cardiomyopathy as the cause of heart failure. CONCLUSIONS: These findings indicate that, in addition to its favorable effects on survival, carvedilol produces important clinical benefits in patients with moderate to severe heart failure treated with digoxin, diuretics, and an ACE inhibitor.

Cardiogenic shock due to huge right atrial thrombus.

An unusual case is reported of right atrial thrombus associated with cardiogenic shock. The role of two-dimensional echocardiography in detection of blood clots is highlighted.

A longitudinal study of dental students' personality type preferences.

The Myers-Briggs Type Indicator was administered to five classes of students at the beginning and end of their dental education. The 161 students who completed both tests were categorized according to personality type. The Spearman rank-order correlation of the two sets of data was calculated and tested. Changes in personality type between the tests were noted using two different standards. The first standard defined change as any alteration in the four-letter MBTI designation and thus was a measure of change in type. The second standard defined change utilizing the 95 percent confidence interval of the continuous score of each of the four MBTI scales and thus was a measure of change in the underlying construct, personality. The first standard indicated 75.8 percent of students change type; the second indicated 11.2 percent changed personality. These data are consistent with previously reported studies, but raise questions regarding what is being measured and how the data are being analyzed.

Chronic peroral immunization of conventional laboratory rats with mutans streptococci leads to stable acquired suppression of salivary antibodies.

Prior investigations have demonstrated that salivary antibody responses to mutans streptococci are dose-dependent and temporary. The purpose of this study was to evaluate the stability of antibody suppression established by mutans streptococci. Streptococcus mutans 6715-15 was provided in food to conventional rats for 18 weeks. Antigen was withdrawn for 10 weeks and then resumed for an additional 6 weeks. Saliva and serum from nonimmunized controls and from experimental rats were tested with a quantitative enzyme-linked immunosorbent assay for IgA and IgG antibodies to whole bacterial cells and to soluble antigen. Results show that salivary antibodies were stimulated by primary peroral immunization, that IgA was the dominant isotype and that IgA antibodies were primarily directed against soluble antigen. This study also shows that immunity is not maintained, even while challenge continues, and that once suppression is established, immunized animals do not recover their ability to respond, even if exposure is stopped for 10 weeks before re-exposure.

Effect of coronary occlusion and myocardial viability on myocardial activity of technetium-99m-sestamibi.

The timing effect of sestamibi administration with respect to the onset of myocardial ischemia and reperfusion was studied in swine. In different groups of animals sestamibi was administered prior to coronary artery occlusion, during occlusion, or 1/2 hour following reperfusion. Sestamibi administered prior to coronary occlusion resulted in an insignificant decrease in 99mTc activity in the ischemic zone. However, infarct zone activity was reduced to 62 +/- 14% of the nonischemic zone. In contrast, administration during coronary occlusion resulted in similar significant reductions of both ischemic and infarct zone activity. Administration of sestamibi during reperfusion resulted in normal ischemic zone activity and markedly reduced activity in the infarct zone. Significantly reduced activity in the infarct zone was found to be independent of the timing of sestamibi administration with respect to the onset of myocardial ischemia and/or reperfusion. Thus, cell viability appears required for uptake and retention of isotope activity.

Effect of early reperfusion on use of triphenyltetrazolium chloride to differentiate viable from non-viable myocardium in area of risk.

STUDY OBJECTIVE - The aim of the study was to assess the value of triphenyltetrazolium chloride (TTC) staining as an indicator of non-viable myocardium after early reperfusion of ischaemic myocardium. DESIGN - Left anterior descending artery occlusion was performed in pigs for various lengths of time and at two different sites (proximal and distal). After 120 min reperfusion, TTC was injected distal to the occlusion while the remainder of the myocardium was stained with Evans Blue. Myocardial enzymes were measured in non-ischaemic zone, regions of risk and in necrotic zones and related to staining characteristics. SUBJECTS - 31 male Hampshire pigs, weight 34-39 kg, were studied. Twelve were excluded because of resistant ventricular fibrillation or poorly defined areas of infarction. In the remaining 19 pigs, proximal occlusion was carried out in 15 and distal in four. Occlusion lasted for 15 min in six animals, for 30 min in eight (four of which were the animals with distal occlusions), and for 45 min in five. MEASUREMENTS and RESULTS - Biopsies from non-ischaemic zones, regions of risk and necrotic zones were analysed for creatine kinase and lactate dehydrogenase. In the 15 min group, myocardial creatine kinase in the region of risk (red stained) was similar to the non-ischaemic (blue) zone, but in the 30 min distal occlusion group it was reduced. After 30 and 45 min of proximal occlusion, creatine kinase activity in the necrotic (white) zone was reduced compared to the red zone in the same group, and in the red zone of both groups it was reduced compared to the non-ischaemic area. CONCLUSIONS - The red zone, as defined by TTC staining, may be associated with significant creatine kinase depletion after relatively brief periods of occlusion and subsequent reperfusion. This suggests that the red region may be a heterogeneous area of dead and viable cells.