Colorectal Cancer Prevention in Lung Transplant Recipients: The Need for an Enhanced Surveillance Protocol.

BACKGROUND: Solid organ transplant recipients are at increased risk for noncutaneous neoplasms, including colorectal cancer (CRC). We evaluated precancerous lesions detected by post-transplant surveillance colonoscopy to infer the rate at which new adenomas develop in this population. STUDY DESIGN: We reviewed all patients who underwent lung transplant between January 2013 and August 2017 at our institution. Those with post-transplant survival <1 year, personal history of CRC, previous lung transplant, and lack of pretransplant colonoscopy were excluded. RESULTS: During the study period, 411 patients underwent lung transplant; 237 met inclusion criteria. Median age at transplant was 63.6 (interquartile range [IQR] 59.2-68.3) years. Most recipients were immunosuppressed with a combination of prednisone, tacrolimus, and mycophenolate mofetil. At least 1 adenoma was found in 92 patients (38.8%) pretransplant and in 118 patients (49.8%) from 1 to 5 years post-transplant, with 68.6% identified at 1 year. Most adenomas were identified proximal to the splenic flexure. Multiple (≥3) adenomas were found in 31.4% of positive colonoscopies. Within 5 years after transplant, patients with a positive pretransplant colonoscopy had significantly more positive post-transplant colonoscopies than patients with a negative pretransplant colonoscopy (63.0% vs 41.4%, p < 0.001). No de novo CRC was identified. CONCLUSIONS: Lung transplant recipients have a significantly higher risk of adenoma formation than average-risk adults (25%-30% national detection rate). This increase occurs in the early post-transplant period (within 3 years). An enhanced CRC surveillance protocol for lung transplant recipients is needed.

Management and Outcomes of Diverticulitis After Lung Transplantation.

INTRODUCTION: Most lung transplant patients are older than 50 years. Complications from colonic diverticula are not uncommon, especially with chronic immunosuppression. However, limited data exist regarding the optimal management of these patients. We sought to investigate the incidence, risk factors, and outcomes of diverticulitis after lung transplant. METHODS: We conducted a retrospective study to review patients undergoing lung transplant between 2007 and 2016 with posttransplant acute colonic diverticulitis. Patients were grouped based on medical or surgical management. RESULTS: Of 512 transplant recipients, 17 (3.32%) developed 26 episodes of diverticulitis over a median follow-up of 39 months. Nine patients had documented diverticulosis on pretransplant colonoscopy. These patients had a higher incidence of surgical intervention for diverticulitis, were more likely to have recurrent diverticulitis, and had longer lengths of stay than patients without pretransplant diverticulosis. Six (35.3%) of 17 patients required surgery (ie, Hartmann procedure; 4 during the initial episode and 2 during their third and fourth episodes); 11 patients (64.7%) were managed with antibiotics alone. Patients in the surgical group presented earlier posttransplant (P = .004) and were on higher doses of tacrolimus (P = .03). Six (46.1%) of 13 patients with medically managed first episodes of diverticulitis experienced recurrence. No recurrence occurred after surgical management. No deaths were attributable to diverticulitis in either group. CONCLUSIONS: Patients with pretransplant diverticulosis experienced earlier, more complicated episodes of diverticulitis posttransplant than patients without. Surgical patients received higher doses of tacrolimus and presented earlier than medical patients. Uncomplicated diverticulitis in posttransplant patients can be managed medically, even in the case of recurrent, uncomplicated disease.

Patient Perception of Medical Student Professionalism: Does Attire Matter?

INTRODUCTION: Patient compliance and outcomes have been shown to be influenced by the quality of the doctor-patient relationship. In addition, the effect of physician attire on the patient's perception of the physician has been long appreciated. Data shows that professional attire is preferred by patients. Whereas treating physicians are the backbone of patient management, medical students are often a patient's first encounter in a teaching clinic. Patient perception of the student may impact their rating of the attending physician. Despite this, medical students are often dressed wearing scrubs in surgery clinic. The purpose of this study was to determine if patient perception of medical students would be affected by the students' attire. METHODS: A 7-item, validated professionalism scale was used to survey surgery clinic patients whose initial examinations were performed by a medical student. Students were blinded and randomly assigned to wear professional attire versus scrubs. Patients' responses of 'strongly agree' were compared to lower ratings for each item. RESULTS: One hundred twenty-three patients completed our survey, 63 (51.2%) wearing scrubs and 60 (48.8%) in professional attire. The average age was 49.7 ± 15.8 years. In the professional attire group, there was no significant association for any of the 7 items. However, in the scrubs group, all 7 items were significant such that a higher proportion of patients under the age of 60 rated medical students wearing scrubs higher than did patients aged 60 and above. CONCLUSION: Students in scrubs were perceived to be less knowledgeable, competent, and professional by older patients. In contrast, younger patients seemed unaffected by the dress of medical students in clinic. Older patients may judge the medical community's growing acceptance of more casual attire in the workplace as less professional, potentially affecting patient satisfaction. Surgical educators should require a standard of professional attire for students in clinic.

Scholarly Output by Army General Surgery Residents.

INTRODUCTION: To characterize and compare the scholarly activity of applicants to Army First Year Graduate Medical Education (FYGME) general surgery positions over the course of a residency. METHODS: All applicants for the 2011-2012 Army FYGME positions in general surgery were included. Applications were used to obtain demographics and peer-reviewed publications. Publications were verified using PubMed and Google Scholar. Applicants were tracked for acceptance to a FYGME position, graduation from a general surgery program, and future publications. Comparisons were made between selectees and non-selectees. RESULTS: There were 46 applicants for 22 positions. Seven of the selectees (32%) had prior publications versus three non-selectees (12%; p < 0.109). Eighteen of the selectees went on to complete a general surgery residency by 2017. Of those who completed a general surgery residency, 16 (89%) have at least one publication with the mean number of publications of 4.0 versus 10 (43%), and of those not selected had at least one publication and the mean number of publications was 0.7 (p < 0.05). CONCLUSIONS: The majority of applications for general surgery residencies have no prior research publications. However, after 6 years, graduates of a general surgery residency have significantly published out those not selected for training.

Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center.

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group (P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Letting the Numbers Speak for Themselves: A Simple Approach to Cost Reduction for Laparoscopic Appendectomy.

Instrument choices are influenced primarily by a surgeon's training and individual preference. Cost is often of secondary interest, particularly in the absence of any contracted fiscal obligation to the hospital. The purpose of this study was to evaluate how a simple intervention involving dissemination of cost data among a surgeon peer group influenced behavior with respect to surgical instrument choice. Cost data for laparoscopic appendectomies between July-December 2016 were disseminated to surgeons belonging to the same department of a teaching hospital. Each surgeon was provided his or her own cost data along with blinded data for his or her peers for comparison. Cost for each disposable instrument used among the group was provided for reference. Costs of laparoscopic appendectomy performed after the intervention (June-December 2017) were compared with costs before the intervention, for both individual surgeons and the group as a whole. A random effects linear regression model clustered on surgeon was then used to assess the average cost saving of the intervention while accounting for the intracorrelation of surgeon costs. One outlier was removed from the analysis, resulting in a cohort of 89 cases before the intervention and 74 postintervention. After outlier removal, data were normally distributed. The mean cost per case decreased for 10 of the 11 surgeons analyzed (minimum decrease of $7 to maximum decrease of $725). The remaining surgeon increased from an average of $985 ± 235 pre-intervention to $1003 ± 227 postintervention. The average cost saving for the group was $238 ± 226 and was associated with an average reduction in cost of 21 per cent. A linear regression analysis clustered on surgeon suggested the intervention was associated with an average saving of $260 (ß = -260, SE = 39, P < 0.001). After dissemination of cost data among surgeon peers, a reduction in costs was observed. Most notably, significant savings occurred in the absence of any mandate or incentive to reduce costs. Providing cost data to surgeons to facilitate natural competition among peers is a simple and effective tool for reducing operating room costs.

Pneumatosis intestinalis in solid organ transplant recipients.

Pneumatosis intestinalis (PI) is an uncommon medical condition in which gas pockets form in the walls of the gastrointestinal tract. The mechanism by which this occurs is poorly understood; however, it is often seen as a sign of serious bowel ischemia, which is a surgical emergency. Since the early days of solid organ transplantation, PI has been described in recipients of kidney, liver, heart, and lung transplant. Despite the dangerous connotations often associated with PI, case reports dating as far back as the 1970s show that PI can be benign in solid organ transplant recipients. This is an important observation, as operative intervention in these patients carries greater risk than surgical procedures in the general population. The higher operative risks in the transplant population are partly due to their immunosuppressed status and poor wound healing. Furthermore, no clear consensus exists on the optimal management of PI. Various treatment strategies such as bowel rest, antibiotics, and parenteral feeding have been implemented with similar levels of success. With the increasing use of solid organ transplantation, PI is being recognized with increasing frequency. In this review, we provide a summary of the incidence, presentation, diagnosis, and management of PI, particularly as it affects recipients of solid organ transplantation.

A 54-Year-Old Man Presenting With an Abnormal Abdominal CT Scan 8 Months After Double Lung Transplant.

A 54-year-old man who had undergone bilateral sequential lung transplant for idiopathic pulmonary fibrosis was admitted to the hospital for further evaluation of an abnormal abdominal CT scan. Three months previously a gastrojejunostomy tube had been placed after he was found to have evidence of silent aspiration with oral intake. At a recent clinic visit, he denied abdominal pain or problems with the feeding tube. He described frequent diarrhea since placement of the feeding tube.

The evolution of colorectal cancer genetics-Part 1: from discovery to practice.

Colorectal cancer (CRC) is an increasing burden on our society. Identifying those who are at the greatest risk and improving triage for treatment will have the greatest impact on healthcare. CRC is a prime paradigm for cancer genetics: the majority of disease results from stages of progression lending itself to prevention by early detection of the pre-disease (neoplastic) state. Approximately 10% represent well defined hereditary cancer syndromes. Hereditary CRC has the added benefit that many are slow growing and family members are armed with the knowledge of potential risk of associated carcinomas and empowerment to reduce the disease burden. This knowledge provides the indication for early endoscopic and/or surgical intervention for prevention or treatment of an entire family cohort. The molecular basis of CRC allows enhanced characterization of carcinomas, leading to targeted therapies.

The evolution of colorectal cancer genetics-Part 2: clinical implications and applications.

The genetic understanding of colorectal cancer (CRC) continues to grow, and it is now estimated that 10% of the population has a known hereditary CRC syndrome. This article will examine the evolving surgical and medical management of hereditary CRC syndromes, and the impact of tumor genetics on therapy. This review will focus on the most common hereditary CRC-prone diseases seen in clinical practice, which include Lynch syndrome (LS), familial adenomatous polyposis (FAP) & attenuated FAP (AFAP), MutYH-associated polyposis (MAP), and serrated polyposis syndrome (SPS). Each section will review the current recommendations in the evaluation and treatment of these syndromes, as well as review surgical management and operative planning. A highly detailed multigeneration cancer family history with verified genealogy and pathology documentation whenever possible, coupled with germline mutation testing when indicated, is critically important to management decisions. Although caring for patients with these syndromes remains complex, the application of this knowledge facilitates better treatment of both individuals and their affected family members for generations to come.

Ehlers-danlos syndrome-hypermobility type and hemorrhoids.

Ehlers-Danlos syndrome-hypermobility type (EDS-HT) is a connective tissue disorder associated with chronic musculoskeletal pain. The diagnosis is based on simple clinical examination, although it is easily overlooked. Herein we present a case of EDS-HT associated with hemorrhoids and suggest that there may be an association between the two conditions.

Identification of an APC Variant in a Patient with Clinical Attenuated Familial Adenomatous Polyposis.

Introduction. The objective of this case report is to discuss an unclassified germline variant of the adenomatous polyposis coli (APC) gene identified in an older patient with attenuated familial adenomatous polyposis syndrome (AFAP). Methods. We present a case report of a 66-year-old man diagnosed with AFAP. Colonoscopy found multiple polyps and invasive adenocarcinoma arising in the transverse colon. Samples were tested for mutations in the APC gene. Results. DNA sequencing of germline DNA identified a cytosine (C) to thymine (T) transition at nucleotide 1240, heterozygous. The C to T transition at codon 414 is predicted to convert an arginine residue to a cysteine that is possibly pathogenic. Analysis of the patient's colon tumor DNA indicated that the tumor had lost the mutant variant allele and retained only the normal allele, suggesting that the variant may not be significant. Conclusions. The p.R414C variant has been described previously as a germline mutation of probable pathogenicity. This substitution should be considered an unclassified variant and possibly not pathogenic. These findings support the need for further genetic testing of tissue, as well as for developing a mechanism for testing all variants, as this could significantly impact the lives of patients and their family members.

Excess of extracolonic non-endometrial multiple primary cancers in MSH2 germline mutation carriers over MLH1.

BACKGROUND: The lynch syndrome (LS) tumor spectrum involves colorectal cancer (CRC), endometrial cancer (EC), and less frequently various extracolonic non-endometrial cancers (non-EC). The organ-specific survival rates of these patients are well defined, however, the collective survival of all-cancers combined (CRC + EC + non-EC) are unclear. METHODS: Fifty-two MSH2 patients and 68 MLH1 patients were followed for a median of 6.3 years after diagnosis of first cancer, regardless of type. The proportions of CRC only, EC, non-EC, and multiple primary cancers were compared between the two genotypes. Kaplan-Meier curves were developed for survival comparisons. RESULTS: MSH2 patients present less frequently with only CRC (37% MSH2, 62% MLH1, P = 0.0096), manifest more multiple primary cancers (38% MSH2, 18% MLH1, P = 0.013), develop more extracolonic cancers (62% MSH2, 38% MLH1, P = 0.003), non-EC only cancers (46% MSH2, 24% MLH1, P = 0.028) and carry a greater risk for urinary tract cancer (UTC) (13.4% MSH2, 1.5% MLH1, P = 0.024). There was no difference in 10-year survival between the two groups (P = 0.4). CONCLUSION: The additional propensity for UTC in MSH2 carriers argues in favor of UTC screening in MSH2 individuals. Other types of cancer screening should be tailored to the expression history of the specific LS mutation.

Retained pill camera at an entero-uracho-vesical fistula site in a patient with Crohn's disease.

An 18-year-old female patient with Crohn's disease had abdominal pain secondary to a retained pill camera. After several weeks of medical management, the camera spontaneously passed. However, the patient also had an intra-abdominal abscess that worsened, despite medical therapy. Surgical therapy was recommended and a 5cm infected urachal cyst with entero-urachal and vesico-urachal fistulas was discovered. An en-bloc resection of the entire area was performed to include the urachal cyst, the adherent portion of the dome of the bladder, and 15cm of associated ileum. The bladder was repaired, a suprapubic catheter was placed, and an ileo-ileal anastamosis was performed. Microscopic findings were consistent with active Crohn's disease and fistula formation. The entero-uracho-vesical fistula site was likely the site of the retained pill camera. The patient did well postoperatively and was discharged on postoperative day six without complications.

Management of Adenocarcinoma in the Setting of Recently Operated Perianal Paget's Disease.

Perianal Paget's disease only rarely presents with a synchronous invasive anal or rectal cancer. The purpose of this study is to present a case of an otherwise healthy patient who developed perianal Paget's disease. He was then found to have an invasive rectal adenocarcinoma, after having undergone an extensive resection and reconstruction with a bilateral V-to-Y reconstruction. This report describes an overview of perianal Paget's disease, the management of this disease in association with anal or rectal cancer, and our patient's outcome.

Acute hepatic failure associated with arteriovenous fistulae for hemodialysis.

We present the case of a 63-year-old woman who was admitted to the intensive care unit for altered mental status and hypotension 3 weeks after creation of an arteriovenous fistula (AVF). She was found to have high-output heart failure and evidence of acute hepatic failure. High-output heart failure is a known complication of AVF creation, but hepatic failure after AVF has not been previously described. We present such a case.

Methamphetamine-induced paralytic ileus.

Methamphetamine abuse has become a significant problem in the United States with recent surveys reporting that nearly 10 million Americans have tried methamphetamine at least once. Methamphetamine is a stimulant drug that causes the release of monoamine neurotransmitters. Among its most deleterious effects are its ability to produce tachycardia, hypertension, and ischemia. However, it also has the potential to cause clinically significant effects outside of the cardiovascular system although a case of paralytic ileus caused by methamphetamine use has not been described before in the literature. Described is a case in which a patient presented with chest and abdominal pain after methamphetamine use. The patient was ultimately diagnosed with a methamphetamine-induced paralytic ileus.

Negative-pressure pulmonary edema following a lateral internal sphincterotomy.

Negative-pressure pulmonary edema (NPPE) is an infrequent but known postoperative complication following endotracheal intubation and general anesthesia. We report a case of a healthy 24-year-old man requiring intensive care unit management for NPPE following a routine surgical procedure. This article discusses how rare but serious the complication of NPPE can be; it also describes the diagnosis, evaluation, and treatment from one institution's experience.