Gender-based differences in letters of recommendation in applications for general surgery residency programs in Canada.

BACKGROUND: In Canada, residency programs do not have many objective measures for ranking candidates. Instead, ranking relies on subjective measures such as letters of reference, which can be affected by the genders of the writer and the applicant. Our study assesses letters of recommendation for a general surgery program in Canada to categorize differences in reference letters based on the genders of applicant and letter writer. METHODS: We assessed 215 reference letters from 51 general surgery candidates for systematic differences in the descriptors used for male and female applicants and differences based on male and female authorship. RESULTS: Female applicants were more often described as mature, pleasant and flexible. Male applicants were more often described as having initiative, completing research, earning awards and performing extracurricular activities. Female writers were more likely to highlight an applicant's interest, initiative, response to feedback, knowledge of their limits, flexibility, communication, achievement in research and awards, confidence and ability to be a good assistant. Significantly more female applicants had female letter writers, compared with male applicants. CONCLUSION: These differences may affect the acceptance of applicants based on their gender and the genders of people who recommend them. Future research is required to explore how these differences in how applicants are described may affect residency selection committees' perceptions and rankings of applicants.

Impostorism and anxiety contribute to burnout among resident physicians.

PURPOSE: Physician burnout is an issue that has come to the forefront in the past decade. While many factors contribute to burnout the impact of impostorism and self-doubt has largely been ignored. We investigated the relationship of anxiety and impostorism to burnout in postgraduate medical learners. MATERIALS AND METHODS: Postgraduate learners in four diverse training programs: Family Medicine (FM), Paediatric Medicine (PM), Anesthesiology (AN), and General Surgery (GS) were surveyed to identify the incidence of impostorism (IP), anxiety, and burnout. IP, anxiety, and burnout were evaluated using the Clance Impostor Phenomenon Scale (CIPS), Maslach Burnout Inventory-Human Services Survey (MBI-HSS), and the General Anxiety Disorder-7 (GAD-7) questionnaires, respectively. Burnout was defined as meeting burnout criteria on all three domains. Relationships between IP, anxiety, and burnout were explored. RESULTS: Two hundred and sixty-nine residents responded to the survey (response rate 18.8%). Respondents were distributed evenly between specialties (FM = 24.9%, PM = 33.1%, AN = 20.4%, GS = 21.6%). IP was identified in 62.7% of all participants. The average score on the CIPS was 66.4 (SD = 14.4), corresponding to 'frequent feelings of impostorism.' Female learners were at higher risk for IP (RR = 1.27, 95% CI: 1.03-1.57). Burnout, as defined by meeting burnout criteria on all three subscales, was detected in 23.3% of respondents. Significant differences were seen in burnout between specialties (p = 0.02). GS residents were more likely to experience burnout (31.7%) than PM and AN residents (26.7 and 10.0%, respectively, p = 0.02). IP was an independent risk factor for both anxiety (RR = 3.64, 95% CI:1.96-6.76) and burnout (RR = 1.82, 95% CI: 1.07-3.08). CONCLUSIONS: Impostorism is commonly experienced by resident learners independent of specialty and contributes to learner anxiety and burnout. Supervisors and Program Directors must be aware of the prevalence of IP and the impact on burnout. Initiatives to mitigate IP may improve resident learner wellness and decrease burnout in postgraduate learners.

From Formation to Closure: Aggregate Morbidity and Mortality Associated With Defunctioning Loop Ileostomies.

BACKGROUND: Defunctioning loop ileostomies are used commonly, but there are significant morbidities. OBJECTIVE: This study aimed to describe the morbidity and mortality associated with the formation and closure of defunctioning loop ileostomies. DESIGN: This descriptive study is based on electronic health records and claims data. SETTINGS: This study was conducted at academic and community hospitals in Ontario, Canada. PATIENTS: Adult patients who had a low anterior resection with concurrent defunctioning loop ileostomy from 2002 to 2014 were included. MAIN OUTCOME MEASURES: Outcomes of interest included 30-day major complications, acute kidney injury, transfusion, and deep space infection. The rate of ileostomy reversal and the percentage of permanent ostomies were also collected. RESULTS: The cohort consists of 4658 patients who underwent low anterior resection with concurrent defunctioning loop ileostomy. The 30-day, 90-day, and 1-year mortality rates of these patients were 1.2%, 2.2%, and 5.1%. The rate of reoperation was 5.5%, the rate of hospital readmission was 13.4%, the rate of major complications was 28.5%, the rate of deep organ/space infection requiring percutaneous intervention was 5.2%, and the rate of acute kidney injury requiring hospitalization was 10.4%. Eighty-six percent had their ileostomy reversed, leaving 13.2% with a permanent ostomy. After ileostomy reversal, 30-day and 90-day mortality rates were 0.6% and 0.9%. The rate of major complications was 10.3%, bowel obstruction 7%, ventral hernia 10.5%, deep space infection 1.7%, and repeat operation 2.3%. LIMITATIONS: This study is based on electronic health records and claims data and, thus, the accuracy of results depends on the accuracy of data administration' which can be variable across institutions. CONCLUSIONS: Morbidity and mortality of defunctioning loop ileostomies are significant. One in 8 patients will have a permanent ostomy. See Video Abstract at http://links.lww.com/DCR/B810 . DESDE LA FORMACIN HASTA EL CIERRE AGREGADA MORBILIDAD Y MORTALIDAD ASOCIADA CON LAS ILEOSTOMAS EN ASA DERIVATIVA: ANTECEDENTES:Las ileostomías en asa derivativa se utilizan con frecuencia, pero existen morbilidades importantes.OBJETIVO:Describir la morbilidad y mortalidad asociadas con la formación y cierre de ileostomías en asa derivativa.DISEÑO:Estudio descriptivo basado en historias clínicas electrónicas y datos de reclamaciones.ENTORNO CLINICO:Hospitales académicos y comunitarios en Ontario, Canadá.PACIENTES:Pacientes adultos sometidos a resección anterior baja con concurrente ileostomía en asa derivativa de 2002 a 2014.PRINCIPALES MEDIDAS DE VALORACION:Los resultados de interés incluyeron complicaciones mayores a los 30 días, lesión renal aguda, transfusión e infección del espacio profundo. También se recolectó la tasa de reversión de la ileostomía y el porcentaje de ostomías permanentes.RESULTADOS:La cohorte consistió de 4658 pacientes sometidos a resección anterior baja con concurrente ileostomía en asa derivativa. La mortalidad de estos pacientes, a treinta días, 90 días y un año, fue del 1,2%, 2,2% y 5,1%, respectivamente. La tasa de reintervención fue del 5,5%, el reingreso hospitalario fue del 13,4%, la complicación mayor fue del 28,5%, la infección profunda de órganos / espacios que requirieron intervención percutánea fue del 5,2%, y la lesión renal aguda que requirió hospitalización fue del 10,4%. Ochenta y seis por ciento tuvieron reversión de su ileostomía, dejando al 13.2% con una ostomía permanente. Después de la reversión de la ileostomía, la mortalidad a los 30 días y 90 días fue de 0,6% y 0,9%, respectivamente. La tasa de complicaciones mayores fue del 10,3%, obstrucción intestinal del 7%, hernia ventral del 10,5%, infección del espacio profundo del 1,7% y reintervención del 2,3%.LIMITACIONES:El estudio se basa en registros médicos electrónicos y datos de reclamos y, por lo tanto, la precisión de los resultados depende de la precisión en la administración de datos, que pueden variar entre instituciones.CONCLUSIONES:La morbilidad y la mortalidad de las ileostomías en asa derivativa son significativas. Uno de cada 8 pacientes tendrá una ostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/B810 . (Traducción-Dr. Fidel Ruiz Healy ).

Prophylactic Negative Pressure Wound Therapy for Closed Laparotomy Incisions: A Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: The aim of this study was to determine whether negative pressure wound therapy (NPWT) applied to primarily closed incisions decreases surgical site infections (SSIs) following open abdominal surgery. BACKGROUND: SSIs are a common cause of morbidity following open abdominal surgery. Prophylactic NPWT has shown promise for SSI reduction. However, the results of randomized controlled trials (RCTs) conducted among patients undergoing laparotomy have been inconsistent. METHODS: We performed a meta-analysis of English language RCTs comparing the use of prophylactic NPWT to standard dressings on primarily closed laparotomy incisions following open abdominal surgery. Medline, EMBASE, Cochrane Library, and CINAHL databases were searched from inception to December 31, 2018, for relevant studies. A random-effects model was used for statistical analysis. RESULTS: Five RCTs totaling 792 patients were included in our meta-analysis after application of our exclusion and inclusion criteria. There was no significant difference in the risk of SSIs identified among those patients who had NPWT compared to standard dressings; relative risk (RR) 0.56 (95% confidence interval 0.30-1.03, P = 0.064). There was significant statistical heterogeneity across studies (I = 67.4%; P = 0.015). CONCLUSION: The adoption of NPWT for routine SSI prophylaxis following laparotomy is currently not supported and should be used primarily in the context of a clinical trial.

Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled Trial.

OBJECTIVE: Determine if negative pressure wound therapy (NPWT) reduces surgical site infection (SSI) in primarily closed incision after open and laparoscopic-converted colorectal surgery. BACKGROUND: SSIs after colorectal surgery are a common cause of morbidity. The prophylactic effect of NPWT has not been established. We undertook this study to evaluate if, among patients undergoing open colorectal resection, NPWT, as compared with standard postoperative dressings, is associated with a reduction in the rate of postoperative SSI. METHODS: In a randomized, controlled trial, 300 patients undergoing elective open colorectal surgery were assigned to receive prophylactic NPWT or standard gauze dressing. The primary end-point was 30-day SSI, as assessed by wound care experts blinded to treatment arm. Secondary outcomes included length of stay. Statistical analysis was performed on an intention-to-treat basis. A priori subgroup analysis was planned for patients who received a stoma at the time of initial operation. RESULTS: The incidence of SSI at 30-days postoperatively was no different between experimental and control groups (32% vs 34% respectively, P = 0.68). Length of stay was also no different at a median of 7 days (IQR 5) for both groups. Among patients receiving a stoma, there was also no difference in SSI between the experimental and control groups (38% vs 33% respectively, P = 0.66). CONCLUSIONS: Prophylactic use of NPWT on primarily closed incisions after open colorectal surgery was not associated with a decrease in SSI rate when compared with standard gauze dressing. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov (NCT02007018).

Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections.

OBJECTIVE: To evaluate the trends associated with diagnosis and treatment of urinary tract infections (UTI) in a home-based primary care population of Veterans Health System patients from 2006 to 2015. DESIGN: Retrospective cohort study. SETTING: Veterans Healthcare System. PARTICIPANTS: Home-based primary care patients treated for UTI from 2006 to 2015. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Appropriate therapy was determined based on the McGeer criteria. Multivariate logistic regression was used to determine factors leading to appropriate UTI treatment. RESULTS: Of 366 available patients, 68 (18.6%) were tested for a UTI. Appropriate therapy occurred in 26% of patients. Allergy to any antibiotic increased the odds of appropriate treatment (odds ratio [OR] = 5.6, 95% confidence interval [CI] 1.5-23.2). Flank pain and increased urinary frequency also increased the likelihood of being treated appropriately (OR = 25.9, 95% CI 2.9-584.0 and OR = 4.49, 95% CI 0.99-21.2, respectively). CONCLUSION: Antibiotics were overused for treating UTIs in the homebound population. Patients with flank pain, increased urinary frequency, and antibiotic allergy were more likely to receive appropriate treatment. Pharmacists, therefore, have a viable opportunity to increase appropriate antibiotic prescribing in the home-based primary care population.

Early Rescue from Acute Severe Clostridium Difficile: A Novel Treatment Strategy.

BACKGROUND: Severe Clostridium difficile infections (CDI) can lead to significant impediments to effective treatment. We developed a novel treatment protocol utilizing bedside gastrointestinal lavage (GIL) for the management of patients with severe, complicated CDI. We describe the development and early outcomes of non-operative bedside GIL in hospitalized patients with severe, complicated CDI following the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework at the Idea stage. We compared our results with those of a cohort of patients managed with colectomy. METHODS: We conducted a retrospective cohort study of hospitalized patients with severe, complicated CDI who failed conventional medical therapy and were referred for surgical consultation at two academic tertiary-care hospitals between January 2009 and January 2015. After surgical assessment, the attending surgeon decided to proceed either with bedside GIL or directly to colectomy. Bedside GIL involved nasojejunal tube insertion followed by flushing with 8 L of polyethylene glycol 3350/electrolyte solution over 48 h. Both patient groups received standard medical treatment with vancomycin 500 mg q 6 h enterally and metronidazole 500 mg intravenously three times daily for 14 d. The main outcomes of interest were the incidence of colectomy, complications, and mortality rate. RESULTS: Nineteen and seventeen patients underwent GIL and direct colectomy, respectively. There were no significant differences between the groups in terms of demographics, American Society of Anesthesiologists class, disease severity, need for intensive care unit admission, mechanical ventilation, vasopressor use, serum lactate concentration, or proportion presenting with hypotension, acute kidney injury, or a white blood cell count >16,000/mcL or <4,000/mcL (p > 0.1). The in-hospital mortality rate was 26% (5/19) and 41% (7/17) for the GIL and colectomy groups, respectively (p = 0.35). Only one patient in the GIL group failed the protocol, requiring colectomy. There were no significant differences in complications in the two groups. CONCLUSIONS: Bedside GIL appeared to be safe for the treatment of patients with severe, complicated CDI who had failed conventional medical therapy. It did not appear to increase the risk of morbidity or death compared with the traditional strategy of proceeding directly to colectomy.

Benefits of multimodal enhanced recovery pathway in patients undergoing kidney transplantation.

BACKGROUND: Use of enhanced recovery after surgery (ERAS) pathways to accelerate functional recovery and reduce length of stay (LOS) has rarely been investigated in kidney transplantation (KTX). MATERIALS AND METHODS: Consecutive adult isolated KTXs between July 2015 and July 2016 (ERAS, n = 139) were compared with a historical cohort between January 2014 and July 2015 (HISTORIC, n = 95). RESULTS: Enhanced recovery after surgery recipients were significantly more likely to receive kidneys that were non-local (56.1% vs 4.2%), higher Kidney Donor Profile Index (36-85, 58.4% vs 45.2%; >85, 15.2% vs 10.7%), cold ischemia time ≥30 h (62.4% vs 4.7%), induced with antithymocyte globulin (97.1% vs 87.4%), and to develop delayed graft function (46.4% vs 25.0%). LOS was shorter by 1 day among ERAS (mean 4.59) compared to HISTORIC patients (mean 5.65) predominantly due to a shift in discharges within 3 days (32.4% vs 4.2%); 30-day readmission to the hospital (27.3% vs 27.4%) or emergency room visit (9.4% vs 7.4%) was similar. There was one 30-day death in the ERAS group and none in the HISTORIC group. Return to bowel function and early meal consumption were significantly associated with ERAS, however, with somewhat higher diarrhea and emesis rates. CONCLUSION: ERAS following KTX correlated with lower LOS without change in readmissions or ER visits despite higher delayed graft function rates.

Impact of Penicillin Allergy on Time to First Dose of Antimicrobial Therapy and Clinical Outcomes.

PURPOSE: The objective of this study was to evaluate the impact of a listed penicillin allergy on the time to first dose of antibiotic in a Veterans Affairs hospital. Additional clinical outcomes of patients with penicillin allergies were compared with those of patients without a penicillin allergy. METHODS: A retrospective chart review of veterans admitted through the emergency department with a diagnosis of pneumonia, urinary tract infection, bacteremia, and sepsis from January 2006 to December 2015 was conducted. The primary outcome was time to first dose of antibiotic treatment, defined as the time from when the patient presented to the emergency department to the medication administration time. Secondary outcomes included total antibiotic therapy duration and treatment outcomes, including mortality, length of stay, and 30-day readmission rate. FINDINGS: A total of 403 patients were included in the final analysis; 57 patients (14.1%) had a listed penicillin allergy. The average age of the population was 75 years and 99% of the population was male. The mean time to first dose of antibiotic treatment for patients with a penicillin allergy was prolonged compared with those without a penicillin allergy (236.1 vs 186.6 minutes; P = 0.03), resulting in an approximately 50-minute delay. Penicillin-allergic patients were more likely to receive a carbapenem or fluoroquinolone antibiotic (P < 0.0001). IMPLICATIONS: Patients with a penicillin allergy had a prolonged time to first dose of antibiotic therapy. No significant differences were found in total antibiotic duration, length of stay, or 30-day readmission rate. The small sample size, older population, and single-center nature of this study may limit the generalizability of the present findings to other populations.

Decreased mortality in patients prescribed vancomycin after implementation of antimicrobial stewardship program.

BACKGROUND: The impact of an antimicrobial stewardship program (ASP) on 30-day mortality rates was evaluated in patients prescribed vancomycin in a Veterans Affairs hospital. METHODS: A retrospective chart review of patients receiving a minimum of 48 hours of vancomycin during October 2006-July 2014. A multivariate logistic regression analysis was used to determine predictors of mortality. Interventions of the ASP consist of appropriate antibiotic selection, dosing, microbiology, and treatment duration. RESULTS: Death occurred in 12.4% of 453 patients. Of the 56 deaths, 64.3% occurred during prestewardship versus 35.7% during stewardship (P = .021). Increased mortality was associated with pre-ASP (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.13-4.27), age (unit OR, 1.08; 95% CI, 1.05-1.12), nephrotoxicity (OR, 3.24; 95% CI, 1.27-8.01), and hypotension (OR, 3.28; 95% CI, 1.42-7.44). Patients treated in the intensive care unit were associated with increased mortality. Patients in the stewardship group experienced lower rates of mortality, which may be caused by interventions initiated by the stewardship team, including minimizing nephrotoxicity and individualized chart review. CONCLUSIONS: Mortality in patients treated with vancomycin was decreased after antimicrobial stewardship was implemented. As anticipated, older age, hypotension, nephrotoxicity, and intensive care unit admission were associated with an increased incidence of mortality.

Changing the Learning Curve in Novice Laparoscopists: Incorporating Direct Visualization into the Simulation Training Program.

OBJECTIVE: A major challenge in laparoscopic surgery is the lack of depth perception. With the development and continued improvement of 3D video technology, the potential benefit of restoring 3D vision to laparoscopy has received substantial attention from the surgical community. Despite this, procedures conducted under 2D vision remain the standard of care, and trainees must become proficient in 2D laparoscopy. This study aims to determine whether incorporating 3D vision into a 2D laparoscopic simulation curriculum accelerates skill acquisition in novices. DESIGN: Postgraduate year-1 surgical specialty residents (n = 15) at the Schulich School of Medicine and Dentistry, at Western University were randomized into 1 of 2 groups. The control group practiced the Fundamentals of Laparoscopic Surgery peg-transfer task to proficiency exclusively under standard 2D laparoscopy conditions. The experimental group first practiced peg transfer under 3D direct visualization, with direct visualization of the working field. Upon reaching proficiency, this group underwent a perceptual switch, changing to standard 2D laparoscopy conditions, and once again trained to proficiency. RESULTS: Incorporating 3D direct visualization before training under standard 2D conditions significantly (p < 0.0.5) reduced the total training time to proficiency by 10.9 minutes or 32.4%. There was no difference in total number of repetitions to proficiency. Data were also used to generate learning curves for each respective training protocol. CONCLUSIONS: An adaptive learning approach, which incorporates 3D direct visualization into a 2D laparoscopic simulation curriculum, accelerates skill acquisition. This is in contrast to previous work, possibly owing to the proficiency-based methodology employed, and has implications for resource savings in surgical training.

Male veterans with complicated urinary tract infections: Influence of a patient-centered antimicrobial stewardship program.

BACKGROUND: The influence of antimicrobial stewardship programs (ASPs) on outcomes in male veterans treated for complicated urinary tract infection has not been determined. METHODS: This was a retrospective cohort study encompassing the study period January 1, 2005-October 31, 2014, which was conducted at a 150-bed Veterans Affairs Healthcare System facility in Buffalo, NY. Male veterans admitted for treatment of complicated urinary tract infection were identified using ICD-9-CM codes. Outcomes before and after implementation of a patient-centered ASP, including duration of antibiotic therapy, length of hospitalization, readmission within 30 days, and Clostridium difficile infection were compared. Interventions resulting from the ASP were categorized. RESULTS: Of the 1,268 patients screened, 241 met criteria for inclusion in the study (n = 118 and n = 123 in the pre-ASP and ASP group, respectively). Duration of antibiotic therapy was significantly shorter in the ASP group (10.32 days vs 11.96 days; P < .0001), as was length of hospitalization (5.76 days vs 6.76 days; P = .015). There was no difference in 30-day readmission. A total of 170 interventions were identified that resulted from the ASP (1.39 interventions per patient). CONCLUSIONS: ASPs may be useful to improve clinical outcomes in men with complicated urinary tract infection. Implementation of an ASP was associated with significant decreases in duration of antibiotic therapy and length of hospitalization, without adversely affecting 30-day readmission rates.

Impact of Antimicrobial Stewardship on Outcomes in Hospitalized Veterans With Pneumonia.

PURPOSE: The purpose of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on outcomes for inpatients with pneumonia, including length of stay, treatment duration, and 30-day readmission rates. METHODS: A retrospective chart review comparing outcomes of veterans admitted with pneumonia before (2005-2006) and after (2013-2014) implementation of an ASP was conducted; pneumonia was defined according to International Classification of Diseases, Ninth Revision (ICD-9) codes. Infectious diseases physicians and pharmacist in the ASP provided appropriate recommendations to the primary medicine teams. Bivariate analysis of baseline characteristics and comorbid conditions were performed between the time frames. Least squares regression was used to analyze length of stay, time of IV to PO conversions, and duration of antibiotics. Multivariate logistic regressions were used to determine odds of 30-day readmission and odds of Clostridium difficile infections between time periods. FINDINGS: There were 86 patients in the pre-ASP period and 88 patients in the ASP period. Mean length of stay decreased from 8.1 to 6.6 days (P = 0.02), total duration of antibiotic therapy decreased from 12 to 8.5 days (P < 0.0001), and time of IV to PO antibiotic conversions decreased from 5.3 to 3.9 days (P = 0.0003), before ASP and during ASP, respectively. The odds ratio of 30-day readmission before ASP was 2.78 and 0.36 during the ASP (P = 0.05). The odds ratios of Clostridium difficile infections before ASP was 2.08 and 0.48 during the ASP (P = 0.37). IMPLICATIONS: The ASP interventions were associated with shorter durations of therapy, shorter lengths of stay, and lower rates of readmission and Clostridium difficile infections within 30 days. Limitations of this study are retrospective cohort design, small study population, limited study population diversity, and non-concurrent cohort times periods.

GPs with enhanced surgical skills: a questionable solution for remote surgical services.

SUMMARY: The Canadian College of Family Physicians recently decided to recognize family physicians with enhanced surgical skills (ESS) and has proposed a 1-year curriculum of surgical training. The purpose of this initiative is to bring or enhance surgical services to remote and underserviced areas. We feel that this proposed curriculum is overly ambitious and unrealistic and that it is unlikely to produce surgeons, or a system, capable of delivering high-quality surgical services. The convergence of a new training curriculum for general surgeons, coupled with the current oversupply of surgeons, provide an alternate pathway to meet the needs of these communities. A long-term solution will also require alternate funding models, a sophisticated and coordinated national locum service and a national review of the population and infrastructure requirements necessary for both sustainable resident surgical services and surgical outreach services.

Negative pressure wound therapy use to decrease surgical nosocomial events in colorectal resections (NEPTUNE): study protocol for a randomized controlled trial.

BACKGROUND: Surgical site infections (SSIs) are the second most common form of nosocomial infection. Colorectal resections have high rates of SSIs secondary to the inherently contaminated intraluminal environment. Negative pressure wound therapy dressings have been used on primarily closed incisions to reduce surgical site infections in other surgical disciplines. No randomized control trials exist to support the use of negative pressure wound therapy following elective open colorectal resection to reduce surgical site infection. METHODS/DESIGN: In this single-center, superiority designed prospective randomized open blinded endpoint controlled trial, patients scheduled for a colorectal resection via a laparotomy will be considered eligible. Patients undergoing laparoscopic resection will be enrolled but only randomized and included if the operation is converted to an open procedure. Exclusion criteria are patients receiving an abdominoperineal resection or a palliative procedure, as well as pregnant patients and those with an adhesive allergy. After informed consent, 300 patients will be randomized to the use of a standard adhesive gauze dressing or to a negative pressure wound device. Patients will be followed in hospital and reassessed on post-operative day 30. The primary outcome measure is SSI within the first 30 post-operative days. Secondary outcomes include the length of hospital stay, the number of return visits related to a potential or actual SSI, cost, and the need for homecare. The primary endpoint analysis follows the intention-to-treat principle. DISCUSSION: NEPTUNE is the first randomized controlled trial to investigate the role of incisional negative pressure wound therapy in decreasing the rates of surgical site infections in the abdominal incisions of patients following an elective, open colorectal resection. This low-risk intervention may help decrease the morbidity and costs associated with the development of an SSI in our patients. TRIAL REGISTRATION: NCT02007018--clinicaltrials.gov; 5 December 2013.

Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections.

The Centers for Disease Control and Prevention has promoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community. This study examined upper respiratory tract infections included in the campaign to determine the degree to which antibiotics were appropriately prescribed and subsequent admission rates in a veteran population. This study was a retrospective chart review conducted among outpatients with a diagnosis of a respiratory tract infection, including bronchitis, pharyngitis, sinusitis, or nonspecific upper respiratory tract infection, between January 2009 and December 2011. The study found that 595 (35.8%) patients were treated appropriately, and 1,067 (64.2%) patients received therapy considered inappropriate based on the Get Smart Campaign criteria. Overall the subsequent readmission rate was 1.5%. The majority (77.5%) of patients were prescribed an antibiotic. The most common antibiotics prescribed were azithromycin (39.0%), amoxicillin-clavulanate (13.2%), and moxifloxacin (7.5%). A multivariate regression analysis demonstrated significant predictors of appropriate treatment, including the presence of tonsillar exudates (odds ratio [OR], 0.6; confidence interval [CI], 0.3 to 0.9), fever (OR, 0.6; CI, 0.4 to 0.9), and lymphadenopathy (OR, 0.4; CI, 0.3 to 0.6), while penicillin allergy (OR, 2.9; CI, 1.7 to 4.7) and cough (OR, 1.6; CI, 1.1 to 2.2) were significant predictors for inappropriate treatment. Poor compliance with the Get Smart Campaign was found in outpatients for respiratory infections. Results from this study demonstrate the overprescribing of antibiotics, while providing a focused view of improper prescribing. This article provides evidence that current efforts are insufficient for curtailing inappropriate antibiotic use.

Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis.

BACKGROUND: Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. OBJECTIVE: The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma. DATA SOURCES: Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings. STUDY SELECTION: Two reviewers independently screened studies and assessed the risk of bias. INTERVENTIONS: Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered. MAIN OUTCOME MEASURES: The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.' RESULTS: : One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis. LIMITATIONS: This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses. CONCLUSIONS: Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.