Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement.

INTRODUCTION: The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. METHODS: One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. RESULTS: Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. CONCLUSIONS: We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

Increasing Lynch syndrome identification through establishment of a hereditary colorectal cancer registry.

BACKGROUND: Lynch syndrome contributes to 5% of all colorectal cancers. Patients seen in most surgical clinics have limited or no family histories documented and are rarely assessed for hereditary syndromes. In 2007 a clinic-based hereditary colorectal cancer registry was established to screen for Lynch syndrome and facilitate genetic counseling/testing. OBJECTIVE: To evaluate the effectiveness of the hereditary colorectal cancer registry to identify high-risk colorectal cancer patients and have them referred for genetic counseling/testing for Lynch syndrome. DESIGN: A retrospective review and cohort comparison of both prospectively collected and retrospective data. SETTING: The colorectal surgical clinic at Vanderbilt University Medical Center. PATIENTS: All newly diagnosed colorectal cancer patients seen between January 2006 and October 2010. MAIN OUTCOME MEASURES: To assess the identification of colorectal cancer patients at high risk for Lynch syndrome and for the occurrence of genetic counseling/testing before and after the establishment of a hereditary registry by comparing the results from the colorectal cancer patients seen the year prior to the establishment of the registry (January - December 2006, "control period") with those patients seen after initiation of the registry (January 2007 - October 2010, "registry period"). RESULTS: During the "registry period," 495 colorectal cancer patients were seen in the clinic and 257 (51.9%) were high risk for Lynch syndrome. Forty-nine patients (9.8%) underwent genetic testing, with 27 (5.4%) positive for a gene mutation, of which half were >50 years old. By comparison, in 2006, 115 colorectal cancer patients were seen in the clinic but only 4 patients (3.5%) went on for further assessment, and only 1 had genetic testing. Retrospective assessment showed that at least 22 patients (19.1%) had warranted further investigation in 2006. LIMITATIONS: This was a single-institution, retrospective review. CONCLUSION: Establishment of a hereditary colorectal cancer registry with a clinic-based protocol improves identification of Lynch syndrome.

The ileus and oddities after colorectal surgery.

Colorectal surgery is a necessity for many disease processes such as diverticulitis, ulcerative colitis, Crohn disease, and colorectal cancers as well as for the many complications of such conditions. The incidence of overall complications related to colorectal surgery has been reported to be between 10% and 30%. Prevention is the necessary key to avoid complications and this may be improved by adequate selection of appropriate procedures for the patient, good surgical technique, and good postoperative care. Nevertheless, complications do occur intraoperatively or postoperatively and must be managed in a timely manner to improve overall patient outcomes. Such complications include paralytic ileus, anastomotic leak, abdominal sepsis, acute mesenteric ischemia, anastomotic bleeding and hemorrhage, wound infection, anastomotic dehiscence and fistula formation, small bowel obstruction, and genitourinary complications.

The ileus and the oddities after colorectal surgery, continued.

In this second part of a series, complications related to colorectal surgery are highlighted and discussed, including anastomotic bleeding and hemorrhage, wound infection, anastomotic dehiscence and fistula formation, small bowel obstruction, and genitourinary complications. Prevention of complications may be improved by adequate selection of appropriate procedures for the patient, good surgical technique, and good postoperative care.

Colorectal surgery NP fellowship: A transition to autonomy.

ABSTRACT: The colorectal surgery advanced practice fellowship was developed for the purpose of providing a successful transition to the colorectal advanced practice specialty and was based on the success of the NP utilization model. The success of the fellowship led to NP practice autonomy, job satisfaction, and retention.

The correlation Between anal pap cytology and histologic outcomes in HIV-Positive males.

BACKGROUND: Anal intraepithelial neoplasia is a precursor to anal carcinoma. The use of anal pap cytology has been accepted as a screening method for anal carcinoma, however sensitivity and specificity vary. MATERIALS AND METHODS: Retrospective cohort study involving 155 HIV-positive males with abnormal anal cytology and surgical resection. RESULTS: 155 patients met inclusion criteria. 31.6% were diagnosed with atypical cytology, 61.9% with low-grade cytology, and 6.4% with high-grade cytology. At surgery, 19.4% were diagnosed with condylomata, 34.8% with anal intraepithelial neoplasia 1, 17.4% with anal intraepithelial neoplasia 2, 27.1% with anal intraepithelial neoplasia 3 and 1.3% with anal carcinoma. There was a positive correlation between high-grade anal cytology and high-grade histology (r = 0.27; p = 0.0008). Comparison of risk factors showed no significant association. CONCLUSION: Anal cytology has a significant correlation with surgical histology. There were still instances of high-grade lesions being found after low-grade cytology. This highlights the necessity of patients with low-grade cytology undergoing anoscopic evaluation.

Superior mesenteric vein thrombosis after bowel resection in patients with inflammatory bowel disease.

Superior mesenteric vein thrombosis is one of many causes of mesenteric ischemia and may occur after intestinal surgery in patients with inflammatory bowel disease. While hypercoagulability is a known complication of inflammatory bowel disease, other risk factors may also coexist and play a role in the development of superior mesenteric vein thrombosis. The true etiology of hypercoagulability that seems to be present in the face of inflammatory bowel disease is unknown but thought to be related to multiple factors including vitamin deficiency, the inflammatory process, prothrombotic conditions, hypercoagulable states, and other abnormalities of coagulation. Symptoms of superior mesenteric vein thrombosis are often vague, leading to a delay in diagnosis, increasing not only the mortality rate but also the need for surgical intervention rather than medical management. Once diagnosed, patients are managed with anticoagulation alone or in combination with surgical intervention. Most patients improve and will continue anticoagulation therapy ranging from 3 months to lifelong treatment, depending on the origin of the hypercoagulable state and the extent of condition.

Anal condyloma acuminatum.

Anal condyloma acuminatum is a human papillomavirus (HPV) that affects the mucosa and skin of the anorectum and genitalia. Anal condyloma acuminatum is the most commonly diagnosed sexually transmitted disease in the United States. To date, there are more than 100 HPV types, with HPV-6, HPV-10, and HPV-11 predominately found in the anogenital region and causing approximately 90% of genital warts. Risk factors for anal condyloma acuminatum include multiple sex partners, early coital age, anal intercourse, and immunosuppression. Transmission occurs by way of skin-to-skin contact through sexual intercourse, oral sex, anal sex, or other contact involving the genital area. The virus may remain latent for months to years until specific mechanisms cause production of viral DNA, leading to the presentation of anal condyloma acuminatum.Patients with anal condyloma acuminatum may be asymptomatic or present with presence of painless bumps, itching, and discharge or bleeding. It is not uncommon to have involvement of more than one area, and multiple lesions may also be present and extend into the anal canal or rectum. To date, there is no serologic testing or culture to detect anal condyloma acuminatum; therefore, diagnosis is made clinically or by detection of HPV DNA. Multiple factors determine the choice of treatment, which may range from patient-applied medications to surgical intervention. Despite treatment choice, recurrence rates are high, indicating the importance of patient education on prevention of HPV infection and reinfection. Unfortunately, at this time, no cure exists for anal condyloma acuminatum; however, recently Gardasil and Cervarix (in Australia only) vaccines have become available and are showing promising results.

HPV knowledge and vaccination rates in college-aged males: Implications for practice.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is linked to anogenital cancers. College-aged males are at high risk for contracting HPV due to a lack of HPV knowledge and low vaccination rates. NPs are responsible for providing this education and in return can help reduce infection transmission.

HPV awareness and vaccination rates in college-aged male athletes.

College-aged males are at high risk for human papillomavirus (HPV); however, vaccination rates remain low, suggesting minimal HPV knowledge. Therefore, an educational intervention was developed and implemented to determine if an increase in HPV knowledge, perceived HPV risk, intention and perceived self-efficacy to obtain the vaccine, and vaccination rates were observed.

Concept Analysis: Health-Promoting Behaviors Related to Human Papilloma Virus (HPV) Infection.

PROBLEM: The concept of health-promoting behaviors incorporates ideas presented in the Ottawa Charter of Public Health and the nursing-based Health Promotion Model. Despite the fact that the concept of health-promoting behaviors has a nursing influence, literature suggests nursing has inadequately developed and used this concept within nursing practice. A further review of literature regarding health promotion behaviors and the human papilloma virus suggest a distinct gap in nursing literature. METHOD: This article presents a concept analysis of health-promoting behaviors related to the human papilloma virus in order to encourage the application of the concept into nursing practice, promote continued nursing research regarding this concept, and further expand the application of health-promoting behaviors to other situations and populations within the nursing discipline. CONCLUSION: Attributes of health-promoting behaviors are presented and include empowerment, participation, community, and a positive concept of health. Antecedents, consequences, and empirical referents are also presented, as are model, borderline, and contrary cases to help clarify the concept. Recommendations for human papilloma virus health-promoting behaviors within the nursing practice are also provided.

Comparison of quality of life of persons who have experienced amputations and persons who have had bowel resections.

Comparing the quality of life of persons who have experienced amputations and persons who have had bowel resections illustrates the impact of chronic disease upon all aspects of a patient's life. Because the purpose of nursing research is to bring about knowledge to better direct patient care, understanding the impact of chronic illness contributes to an improvement in the quality of life of these patients. By appreciating the patient's perspective concerning the illness, the nurse can better educate the patient in all aspects of the disease process. Based on Jean Watson's Theory of Human Caring, this study acknowledged the need for evidence-based nursing practice to care for the well-being of the patient in a holistic manner. Our hypothesis was adult patients after Crohn disease-related bowel resection experience a better quality of life than do adult patients with peripheral vascular disease related amputation. This descriptive comparative study had a sample of patients with Crohn disease and resection (n = 28) and patients with peripheral vascular amputation (n = 16). The instrument used to measure quality of life was the RAND-36 Item Health Survey 1.0. Results revealed significant differences between the patients with bowel resection and those with peripheral vascular amputation with regard to physical functioning, general health, and role limitations related to physical health. No significant differences existed between the two groups in terms of energy/fatigue, emotional well-being, social functioning, role limitations related to emotional problems, and pain. Results from the data may indicate that the incorporation of more education regarding social, emotional, physiological, and psychological aspects of postoperative life may be of importance to evidence based nursing practice. This addition may also lead to better adjustment to postoperative life for patients and improve overall quality of life.

Statement on nursing: a personal perspective.

Contemporary nursing is based on a conglomerate of theoretical nursing models. These models each incorporate four central concepts: person, health, environment, and nursing. By defining these concepts, nurses develop an individual framework from which they base their nursing practice. As an aspiring nurse practitioner in the gastroenterology field, I have retrospectively assessed my personal definitions of person, health, environment, and nursing. From these definitions, I am able to incorporate specific theoretical frameworks into my personal belief system, thus formulating a basis for my nursing practice. This foundation is comprised of the influence of nursing theorists Jean Watson, Sister Callista Roy, Kolcaba, Florence Nightingale, and Ida J. Orlando; the Perioperative Patient-Focused Model; Watson's Theory of Human Caring; theories regarding transpersonal human caring and healing; and feminist theories. Therefore, this article describes self-examination of nursing care by defining central nursing concepts, acknowledging the influence of nursing theorists and theories, and developing a personal framework from which I base my nursing practice.