Workplace Exposures.

Workplace exposure in colorectal surgery is unique compared with other surgical specialties and generally underreported. Although the most common device-associated exposure in surgery is suture needle injury, colorectal surgeons are increasingly exposed to gastrointestinal-related infectious agents, radiation, and other hazards in multiple different clinical settings. Highlighting the unique workplace exposures in colorectal surgery may help increase awareness, improve education, and identify possible targets for early intervention in order to minimize these risks.

Detecting clinically relevant new information in clinical notes across specialties and settings.

BACKGROUND: Automated methods for identifying clinically relevant new versus redundant information in electronic health record (EHR) clinical notes is useful for clinicians and researchers involved in patient care and clinical research, respectively. We evaluated methods to automatically identify clinically relevant new information in clinical notes, and compared the quantity of redundant information across specialties and clinical settings. METHODS: Statistical language models augmented with semantic similarity measures were evaluated as a means to detect and quantify clinically relevant new and redundant information over longitudinal clinical notes for a given patient. A corpus of 591 progress notes over 40 inpatient admissions was annotated for new information longitudinally by physicians to generate a reference standard. Note redundancy between various specialties was evaluated on 71,021 outpatient notes and 64,695 inpatient notes from 500 solid organ transplant patients (April 2015 through August 2015). RESULTS: Our best method achieved at best performance of 0.87 recall, 0.62 precision, and 0.72 F-measure. Addition of semantic similarity metrics compared to baseline improved recall but otherwise resulted in similar performance. While outpatient and inpatient notes had relatively similar levels of high redundancy (61% and 68%, respectively), redundancy differed by author specialty with mean redundancy of 75%, 66%, 57%, and 55% observed in pediatric, internal medicine, psychiatry and surgical notes, respectively. CONCLUSIONS: Automated techniques with statistical language models for detecting redundant versus clinically relevant new information in clinical notes do not improve with the addition of semantic similarity measures. While levels of redundancy seem relatively similar in the inpatient and ambulatory settings in the Fairview Health Services, clinical note redundancy appears to vary significantly with different medical specialties.

Elective Colectomy for Diverticulitis in Transplant Patients: Is It Worth the Risk?

BACKGROUND: The aim of this study was to determine morbidity and mortality for transplant patients undergoing elective colectomy for diverticulitis and determine the impact of recurrent diverticulitis on postoperative complications. METHODS: We identified transplant recipients that underwent elective colectomy for diverticulitis between 2000 and 2015 at a tertiary care institution. Patient and procedure variables, postoperative complications, length of stay, 30-day readmission, and mortality were identified through retrospective chart review. Complication rates were compared between patients with one previous episode of diverticulitis versus two or more. RESULTS: Thirty transplant recipients underwent colectomy for primary (n = 13) or recurrent (n = 17) diverticulitis. Primary anastomosis was performed in 26 (87%) with proximal diversion in 10 (38%). The overall complication rate was 57%, with surgical site infection being the most common (23%). There were no anastomotic leaks at the colorectal anastomosis or reoperations. Median length of stay was 8 days (range 4-23). Postoperative complications were not significantly different between groups (54 vs. 59%, p = 0.94). CONCLUSIONS: Postoperative morbidity after elective colectomy for diverticulitis in transplant recipients was common. There were no differences in complications for patients with primary versus recurrent diverticulitis. Fear of postoperative complications from recurrent diverticulitis should not be a reason to recommend elective colectomy after an initial attack of diverticulitis in transplant patients.

Immune status does not predict high-risk HPV in anal condyloma.

BACKGROUND: More than 90% of anal condyloma is attributed to nonhigh risk strains of human papillomavirus (HPV), thus patients with anal condyloma do not necessarily undergo HPV serotyping unless they are immunocompromised (IC). We hypothesized that IC patients with anal condyloma have a higher risk of high-risk HPV and dysplasia than nonimmunocompromised (NIC) patients. METHODS: We performed a retrospective chart review of patients who underwent surgical treatment by a single surgeon for anal condyloma from 1/2000 to 1/2012. HPV serotyping was performed on all patient samples. We compared incidence of high-risk HPV and dysplasia in condyloma specimens from IC and NIC patients. RESULTS: High-risk HPV was identified in 14 specimens with serotypes 16, 18, 31, 33, 51, 52, and 67. Twenty-two cases (18.3%) had dysplasia. Invasive carcinoma was identified in one IC patient. The prevalence of dysplasia or high-risk HPV was not significantly different between IC and NIC groups. High-risk HPV was a significant independent predictor of dysplasia (odds ratio [OR] = 5.2; 95% CI = 1.24-21.62). Immune status, however, was not a significant predictor of high-risk HPV (OR = 1.11; 95% CI = 0.16-5.12) nor dysplasia (OR = 0.27; 95% CI = 0.037-1.17). CONCLUSIONS: IC patients did not have a significantly higher prevalence or risk of high-risk HPV or dysplasia in our study. HPV typing of all condylomata, regardless of immune status, should be considered as it may help predict risk of neoplastic transformation or identify NIC patients with an increased risk of developing anal intraepithelial neoplasia.

A common variant in MTHFR influences response to chemoradiotherapy and recurrence of rectal cancer.

An important determinant of the pathogenesis and prognosis of various diseases is inherited genetic variation. Single-nucleotide polymorphisms (SNPs), variations at a single base position, have been identified in both protein-coding and noncoding DNA sequences, but the vast majority of millions of those variants are far from being functionally understood. Here we show that a common variant in the gene MTHFR [rs1801133 (C>T)] not only influences response to neoadjuvant chemoradiotherapy in patients with rectal cancer, but it also influences recurrence of the disease itself. More specifically, patients with the homozygous ancestral (wild type) genotype (C/C) were 2.91 times more likely (291% increased benefit) to respond to neoadjuvant chemoradiotherapy {95% CI: [1.23, 6.89]; P=0.0150} and 3.25 times more likely (325% increased benefit) not to experience recurrence of the disease {95% CI: [1.37, 7.72]; P=0.0079} than patients with either the heterozygous (C/T) or the homozygous mutation (T/T) genotype. These results identify MTHFR as an important genetic marker and open up new, pharmacogenomic strategies in the treatment and management of rectal cancer.

Systematic Review of Candidate Single-nucleotide Polymorphisms as Biomarkers for Responsiveness to Neoadjuvant Chemoradiation for Rectal Cancer.

BACKGROUND/AIM: Treatment of rectal cancer has improved significantly with the addition of neoadjuvant chemoradiation. Certain patients have experienced a complete pathological response to chemoradiation, as observed in surgically resected tissue samples, thus calling into question the necessity of radical surgery in this population of patients. Pharmacogenetic studies now implicate the role that genetic biomarkers, such as single nucleotide polymorphisms, play in an individual's response to chemoradiation. The aim of this review was to provide a comprehensive evaluation of a group of candidate single nucleotide polymorphisms associated with chemoradiotherapy response and an assessment of techniques that can be used to easily identify the presence of these single nucleotide polymorphisms in patient samples. MATERIALS AND METHODS: Relevant primary research articles were identified in the Medline Database from January 1, 2006 to May 31, 2012. We included nine relevant articles addressing the correlation between six candidate single nucleotide polymorphisms and one candidate variable number tandem repeat in six genes, namely thymidylate synthase, epidermal growth factor, epidermal growth factor receptor, superoxide dismutase 2, interleukin-13, and cyclin D1, with tumor down-staging and patient survival after neoadjuvant chemotherapy or chemoradiotherapy. RESULTS: Specific alleles of each of the candidate single nucleotide polymorphisms were significantly associated with either a major response in tumor down-staging or a minor to non-existent response following neoadjuvant chemotherapy, individually or in combination with other single nucleotide polymorphisms. However, studies present conflicting results regarding the effect of certain candidate single nucleotide polymorphisms on tumor down-staging. CONCLUSION: Through further research into candidate single nucleotide polymorphisms and potential identification of other polymorphisms, clinicians may be able to create individualized treatment plans in accordance with the genotype of individual patients with rectal cancer, in order to reduce morbidity and mortality.

Early removal of urinary catheters after rectal surgery is associated with increased urinary retention.

BACKGROUND: Urinary retention after rectal resection is common and managed prophylactically by prolonging urinary catheterization. However, because indwelling urinary catheterization is a well-established risk factor for urinary tract infection, the ideal timing for urinary catheter removal following a rectal resection is unknown. OBJECTIVE: We hypothesized that early urinary catheter removal (on or before postoperative day 2) would be associated with urinary retention. DESIGN: This study is a retrospective review of medical records. SETTING: This study was conducted at a colorectal surgery service at a tertiary care academic teaching hospital. PATIENTS: Adults undergoing rectal resection operations by colorectal surgeons in 2005 to 2010 were selected. MAIN OUTCOME MEASURE: The primary outcome measured was urinary retention. RESULTS: Of 205 patients included, 41 (20%) developed urinary retention. Male sex (OR, 3.9; 95% CI, 1.7-9), increased intraoperative intravenous fluid (OR for each liter, 1.2; 95% CI, 1.04-1.48), and urinary catheter removal on postoperative day 2 or earlier (OR, 3.8; 95% CI, 1.4-10.5) were associated with urinary retention on multivariable analysis. Early catheter removal was not associated with decreased urinary tract infection rates (p = 0.29) but was associated with shorter length of stay (6.5 vs 8.9 days; p = 0.005). LIMITATIONS: The retrospective nature of this study did not allow for a precise definition of urinary retention. Preoperative urinary function was not available, and the patient sample was heterogeneous, including several indications for rectal resection. Urinary catheters were not removed per protocol and therefore subject to bias. The study is likely underpowered to detect differences in urinary tract infection between urinary catheter removal groups. CONCLUSION: In patients undergoing rectal resection, we found that urinary catheter removal on or before postoperative day 2 was associated with urinary retention (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A172).

Quality-of-life measures in fecal incontinence: is validation valid?

BACKGROUND: Multiple health measurement scales have been used to study patients with fecal incontinence, but none have met the needs for clinical use and research perfectly. These include severity scales and generic and condition-specific quality-of-life scales. Several different approaches have been used to develop and evaluate the internal and external validity of these scales. OBJECTIVE: As a step toward an improved quality-of-life instrument for fecal incontinence, the present study aimed to provide a critical review of the psychometric methodology of existing generic and condition-specific quality-of-life scales by using a standard measurement model. DESIGN: This study is a retrospective review. SETTINGS: Two investigators experienced in psychometric methodology reviewed source articles from frequently used fecal incontinence quality-of-life scales. PATIENTS: Patients with fecal incontinence were identified. MAIN OUTCOME MEASURES: The primary outcome measured was the demonstration of at least 1 reliability criterion, content validity, construct validity, and either criterion validity or discriminative validity. RESULTS: A total of 12 scales were identified. The reported methodology varied considerably. Most scales demonstrated convergent validity and test-retest reliability, whereas very few scales demonstrated internal consistency or predictive validity. Generic scales were found to be reliable and valid, but not responsive to condition severity. There was a wide range of methodology used in scale development and a wide diversity in the psychometric rigor. LIMITATIONS: Variations in scale construction, data reporting, and validity testing made the evaluation of fecal incontinence quality-of -life scales by using a standardized measurement model difficult. CONCLUSIONS: Identifying deficiencies in validity testing and reporting of existing scales is vital for future creation of a useful validated instrument to measure quality of life in patients with fecal incontinence.

Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial.

BACKGROUND: Surgical site infection after stoma reversal is common. The optimal skin closure technique after stoma reversal has been widely debated in the literature. OBJECTIVE: We hypothesized that pursestring near-complete closure of the stoma site would lead to fewer surgical site infections compared with conventional primary closure. DESIGN: This study was a parallel prospective multicenter randomized controlled trial. SETTINGS: This study was conducted at 2 university medical centers. PATIENTS: Patients (N = 122) presenting for elective colostomy or ileostomy reversal were selected. INTERVENTIONS: Pursestring versus conventional primary closure of stoma sites were compared. MAIN OUTCOME MEASURES: Stoma site surgical site infection within 30 days of surgery, overall surgical site infection, delayed healing (open wound for >30 days), time to wound epithelialization, and patient satisfaction were the primary outcomes measured. RESULTS: The pursestring group had a significantly lower stoma site infection rate (2% vs 15%, p = 0.01). There was no difference in delayed healing or patient satisfaction between groups. Time to epithelialization was measured in only 51 patients but was significantly longer in the pursestring group (34.6 ± 20 days vs 24.1 ± 17 days, p = 0.02). LIMITATIONS: This study was limited by the variability in procedures and surgeons, the limited follow-up after 30 days, and the inability to perform blinding. CONCLUSION: Pursestring closure after stoma reversal has a lower risk of stoma site surgical site infection than conventional primary closure, although wounds may take longer to heal with the use of this approach. REGISTRATION NUMBER: NCT01713452 (www.clinicaltrials.gov).

Colorectal surgery after kidney transplantation: characteristics of early vs. late posttransplant interventions.

BACKGROUND: The majority of colorectal complications after kidney transplantation reportedly occur <1 year of transplant. We aimed to identify differences in complications in the early and late posttransplant period. METHODS: We retrospectively reviewed kidney transplant recipients undergoing colorectal resection from 1 June 2000 to 1 June 2012 at a single institution, comparing patients by posttransplant year (<1 vs. >1 year). Measured outcomes included major complications, postoperative length of stay, perioperative mortality, reoperations, and readmissions. RESULTS: We identified 45 patients aged 31-77 (median 55). Gastrointestinal malignancy (31 %), diverticular disease (24 %), and ischemic colitis (16 %) were the most common indications for surgery. The early group (n = 9) had more cases of ischemic colitis (44 vs. 6 %, p = 0.01), emergent operations (100 vs. 33 %, p = 0.0003), blood transfusion (78 vs. 31 %, p = 0.02), longer length of stay (23.2 ± 12 vs. 11.7 ± 10 days, p = 0.02), and higher mortality rate (33 vs. 6 %, p = 0.05 compared to the late group (n = 36)). There were no significant differences in major complications, reoperations, or readmissions. CONCLUSIONS: Kidney transplant recipients undergoing colorectal resection <1 year of transplant have a higher incidence of emergency surgery and ischemic colitis compared with those with >1 year posttransplant. Despite these findings, patients with grafts <1 year had a similar postoperative complication rate to patients with grafts >1 year.

Outcomes after transanal endoscopic microsurgery with intraperitoneal anastomosis.

BACKGROUND: Transanal endoscopic microsurgery has gained increasing popularity as a treatment alternative for early stage rectal neoplasms. With continued advances in technique and experience, more proximal rectal tumors are being surgically managed by using transanal endoscopic microsurgery with an intraperitoneal anastomosis. OBJECTIVE: The purpose of this study was to review the outcomes of patients who have undergone intraperitoneal anastomosis with the use of the transanal endoscopic microsurgery technique. DESIGN: A prospective, single-surgeon database documented 445 consecutive patients undergoing transanal endoscopic microsurgery from October 1, 1996 through January 1, 2012. We retrospectively reviewed information from all patients who underwent transanal endoscopic microsurgery with an intraperitoneal anastomosis in this prospective database. SETTINGS: All procedures took place in an inpatient hospital setting. PATIENTS: All patients satisfied workup criteria to undergo surgery for rectal neoplasm. INTERVENTIONS: All patients underwent transanal endoscopic microsurgery for rectal neoplasm. MAIN OUTCOME MEASURES: Size and pathology of lesion, length of procedure, hospital stay, estimated blood loss, margin status, and complications were the outcomes measured. RESULTS: Twenty-eight patients who underwent transanal endoscopic microsurgery had definitively documented intraperitoneal entry and anastomosis. Median follow-up was 12 months (range, 0.5-111 months). There were no operative mortalities. Procedure-related complications included urinary retention (11%), fever (11%), and fecal seepage (4%). Four patients (14%) had positive margins on final pathology. One patient (3%) required abdominal exploration for an anastomotic leak but did not require diversion. LIMITATIONS: Although this study analyzes prospectively collected data, it is nonetheless a retrospective analysis that can introduce bias. Because this is a single-center study with a relatively homogenous population, the results may not be generalizable. Our sample size may also be underpowered to detect clinically significant outcomes. CONCLUSIONS: Transanal endoscopic microsurgery with intraperitoneal anastomosis can be safely performed without fecal diversion by experienced surgeons.

Using language models to identify relevant new information in inpatient clinical notes.

Redundant information in clinical notes within electronic health record (EHR) systems is ubiquitous and may negatively impact the use of these notes by clinicians, and, potentially, the efficiency of patient care delivery. Automated methods to identify redundant versus relevant new information may provide a valuable tool for clinicians to better synthesize patient information and navigate to clinically important details. In this study, we investigated the use of language models for identification of new information in inpatient notes, and evaluated our methods using expert-derived reference standards. The best method achieved precision of 0.743, recall of 0.832 and F1-measure of 0.784. The average proportion of redundant information was similar between inpatient and outpatient progress notes (76.6% (SD=17.3%) and 76.7% (SD=14.0%), respectively). Advanced practice providers tended to have higher rates of redundancy in their notes compared to physicians. Future investigation includes the addition of semantic components and visualization of new information.

Navigating longitudinal clinical notes with an automated method for detecting new information.

Automated methods to detect new information in clinical notes may be valuable for navigating and using information in these documents for patient care. Statistical language models were evaluated as a means to quantify new information over longitudinal clinical notes for a given patient. The new information proportion (NIP) in target notes decreased logarithmically with increasing numbers of previous notes to create the language model. For a given patient, the amount of new information had cyclic patterns. Higher NIP scores correlated with notes having more new information often with clinically significant events, and lower NIP scores indicated notes with less new information. Our analysis also revealed "copying and pasting" to be widely used in generating clinical notes by copying information from the most recent historical clinical notes forward. These methods can potentially aid clinicians in finding notes with more clinically relevant new information and in reviewing notes more purposefully which may increase the efficiency of clinicians in delivering patient care.

Clostridium difficile infection increases mortality risk in lung transplant recipients.

BACKGROUND: Clostridium difficile infection (CDI) and associated mortality in solid organ transplant recipients is rising, but data are scarce in lung transplant recipients. We aimed to characterize CDI and its effect on mortality in a large cohort of lung transplant recipients. METHODS: Lung transplant recipients were identified from our transplant database from 2000 to 2011. Cox proportional hazard models were used to calculate hazard ratios for CDI and death after adjusting for potential confounders identified from bivariate analysis. RESULTS: We identified 388 patients (196 female, 192 male), with a median age of 56 years (range, 8-75 years), during the study period. CDI developed after transplant in 89 (22.9%), with 27 (7.0%) developing CDI during the initial hospitalization at a mean diagnosis of 12.7 ± 11.4 days. Incidence varied widely each year (median, 24%; range, 5%-32%), with the highest rates in 2007 to 2008. Post-operative length of stay was identified as a significant predictor of CDI (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03). Early CDI was an independent significant predictor of death (HR, 1.96; 95% CI, 1.14-3.36) as well as CDI anytime after transplant (HR, 1.61; 95% CI, 1.02-2.52). CONCLUSIONS: CDI rates varied widely from 2000 through 2011, with the highest rates in 2007 to 2008. Lung transplant recipients who developed CDI had a higher risk of death, especially when CDI occurred in the first 6 months after transplant.

Calcineurin inhibitors and Clostridium difficile infection in adult lung transplant recipients: the effect of cyclosporine versus tacrolimus.

BACKGROUND: Tacrolimus (FK506) has a superior immunosuppressive effect compared with cyclosporine (CSA) without a significant increase in generalized infectious complications. Differences in specific infections such as Clostridium difficile (CDI) have not been reported. We investigated the relationship between calcineurin inhibitors and CDI, hypothesizing that choice of calcineurin inhibitor (CSA or FK506) after lung transplantation would have no effect on the incidence of CDI. METHODS: We performed a retrospective chart review of lung transplant recipients between June 1, 2000, and December 31, 2005, at a single institution. Positive CDI assays through December 11, 2011, were also recorded. We used Student's t- and chi-squared tests (α = 0.05) to compare CSA and FK506 groups. We calculated adjusted hazard ratios for CDI using Cox proportional hazard models. RESULTS: We identified 217 lung transplant recipients: 106 patients in the CSA group and 111 patients in the FK506 group. A total of 31 patients (27.9%) in the FK506 group developed CDI postoperatively compared with 20 patients (18.9%) in the CSA group (P = 0.16). The adjusted hazard ratio for CDI in the FK506 group was not significantly higher (1.53; 95% confidence interval, 0.78-2.98). There was no significant difference in the intensive care unit or total length of stay, in-hospital incidence rate, time to first CDI episode, or recurrence rate between groups. CONCLUSIONS: The CDI rates were not significantly higher in the FK506 group than the CSA group in our study. These data are consistent with previous studies on FK506 that show no increase in infectious complications over CSA, and demonstrate its continued safety in lung transplantation.

The rise of Clostridium difficile infection in lung transplant recipients in the modern era.

PURPOSE: Clostridium difficile infection (CDI) rates have been rising in recent years. We aimed to characterize CDI in lung transplant recipients in the modern era and hypothesized that CDI would increase the mortality risk. METHODS: We performed a retrospective chart review of patients undergoing transplantation at our center from 1/2006 to 7/2011. Attributes of CDI+ and CDI- groups were compared using Student's t- and chi-square tests (α = 0.05). Multivariate Cox proportional hazard models were used to control for confounding factors. RESULTS: Overall CDI incidence was 22.5%. Seven of 151 patients (4.6%) developed CDI during the initial hospitalization after transplantation (mean time 10.6 ± 6 d) while 27 patients (19.7%) developed CDI after discharge (mean time 467 ± 471 d). Incidence rate was 224.6 cases/100 000 patient-days compared to 110 cases/100 000 patient-days (rate for entire hospital). CDI was not predictive of mortality (HR 2.06, 95% CI 0.94-4.52). CONCLUSION: CDI rates in lung transplant recipients are high in the modern era. No risk factors for CDI were identified. Although not statistically significant, CDI+ patients had a higher risk of death. The economic burden of CDI and trend toward worse outcomes for CDI patients have important implications for post-operative surveillance of CDI-related complications and need for CDI prophylaxis.

Tonsillar carcinoma metastatic to the spleen presenting as trauma: a case report.

BACKGROUND: Cancers of the head and neck rarely metastasize to the spleen. To the best of our knowledge, there is no reported case of a tonsillar carcinoma metastasizing to the spleen. METHOD AND RESULTS: This patient had a splenic capsular rupture likely related to his metastases that presented as a traumatic splenic injury. The patient had received neoadjuvant chemotherapy followed by concurrent chemoradiotherapy. Two months after completion of radiotherapy, he fell out of bed. The next day he had acute abdominal pain and hypotension. CT findings were consistent with splenic rupture, and he underwent splenectomy. Pathologic assessment of the specimen showed metastatic SCC. CONCLUSION: New splemic lesions in patients with head and neck cancer should be investigated.