More problems, more money: Identifying and predicting high-cost rescue after colorectal surgery.

Background: Successful rescue after elective surgery is associated with increased healthcare costs, but costs vary widely. Treating all rescue events the same may overlook targeted opportunities for improvement. The purpose of this study was to predict high-cost rescue after elective colorectal surgery. Methods: We identified adult patients in the National Inpatient Sample (2016-2021) who underwent elective colectomy or proctectomy. Rescued patients were defined as those who underwent additional major procedures. Three groups were stratified: 1) uneventful recovery; 2) Low-cost rescue; 3) High-cost rescue. Multivariable Poisson regression was used to identify preoperative clinical predictors of high-cost versus low-cost rescue. Results: We identified 448,590 elective surgeries, and rescued patients composed 4.8 %(21,635) of the total sample. The median increase in costs in rescued patients was $25,544(p < 0.001). Median total inpatient costs were $95,926 in the most expensive rescued versus $34,811 in the less expensive rescued versus $16,751 in the uneventfully discharged(p < 0.001). When comparing the secondary procedures between the less expensive and most expensive rescued groups, the most expensive had an increased proportion of reoperation (73.4 % versus 53.0 %,p < 0.001). When controlling for other factors and stratification by congestive heart failure due to an interaction effect, a reoperation was independently associated with high-cost rescue (RR with CHF = 3.29,95%CI:2.69-4.04; RR without CHF = 2.29,95%CI:1.97-2.67). Conclusions: High-cost rescue after colorectal surgery is associated with disproportionately greater healthcare utilization and reoperation. For cost-conscious care, preemptive strategies that reduce reoperation-related complications can be prioritized.

Management of Colonic Emergencies.

The etiology of colonic emergencies includes a wide-ranging and diverse set of pathologic conditions. Fortunately, for the surgeon treating a patient with one of these emergencies, the surgical management of these various causes is limited to choosing among proximal diversion, segmental colectomy with or without proximal diversion, or a total abdominal colectomy with end ileostomy (or rarely, an ileorectal anastomosis). The nuanced complexity in these situations usually revolves around the nonsurgical and/or endoscopic options and deciding when to proceed to the operating room.

Direct stick embolization of a rectal venous malformation via transanal minimally invasive surgery.

Rectal venous malformations (VMs) are rare clinical entities with variable patterns of presentation. Treatment requires unique, targeted strategies based on the symptoms, associated complications, and location, depth, and extent of the lesion. We present a rare case of a large, isolated rectal VM treated by direct stick embolization (DSE) using transanal minimally invasive surgery (TAMIS). A 49-year-old man had presented with a rectal mass incidentally detected on computed tomography urography. Magnetic resonance imaging and endoscopy revealed an isolated rectal VM. Elevated D-dimer levels concerning for localized intravascular coagulopathy warranted the use of prophylactic rivaroxaban. To avoid invasive surgery, DSE using TAMIS was performed successfully without complications. His postoperative recovery was uneventful, aside from a self-limiting and expected course of postembolization syndrome. To the best of our knowledge, this is the first reported case of TAMIS-assisted DSE of a colorectal VM. TAMIS shows promise for more widespread use in the minimally invasive, interventional management of colorectal vascular anomalies.

Assessment and correlation of anxiety, depression and serum cortisol levels in patients with oral submucous fibrosis and leukoplakia: A clinicohematological study.

Context: Potentially malignant disorders (PMDs) of the oral cavity like oral submucous fibrosis (OSMF) and leukoplakia are known to be caused due to addictive habits, while serum cortisol is accepted to be a stress hormone. Aim: The present study was aimed to assess and correlate the anxiety, depression and serum cortisol levels in habit-associated PMDs such as OSMF and leukoplakia and compare it with healthy subjects. Materials and Methods: Ninety patients were included in the study and were divided into three Groups, namely Group I (OSMF), Group II (leukoplakia) and Group III (control group). Serum cortisol levels and severity of anxiety and depression using the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) were recorded and correlated. Results: A significant correlation existed between serum cortisol level and levels of both anxiety and depression between Group I and II as compared to the control group. Conclusion: There exists a definite correlation between serum cortisol levels and the levels of anxiety and depression in patients with leukoplakia and OSMF, with increasing levels of serum cortisol and higher values in both the HAM-A and HAM-D scales in patients with both OSMF and leukoplakia. PMDs such as leukoplakia and OSMF have an established cancer-causing potential. Anxiety and depression although prevalent are underdiagnosed and poorly understood. Hence, a holistic approach in the treatment of such pathologies including hematological investigations and psychological evaluation should be mandatorily made a part of the workup and treatment plan.

So You Want to be a Program Director? Career Paths of Colon and Rectal Surgery Residency Program Directors.

BACKGROUND: The trajectory of colon and rectal surgery residency program director (PD) career paths has not been well described, leaving those who aspire for the position with minimal guidance. The goal of this study is to characterize their career paths in the United States. By understanding their experiences, the path to train and educate the next generation of colon and rectal surgeons as a PD will be better illuminated. STUDY DESIGN: This study was an anonymous, cross-sectional survey of all junior and senior colon and rectal surgery residency PDs in the United States during April and May of 2022. PDs were divided into junior and senior PDs. Results were compared using 2-sided independent t-tests and Kruskall-Wallis tests. RESULTS: Of 65 colon and rectal surgery PDs, 48% (31/65) completed the survey which encompassed demographics, leadership, education, research, and time utilization. Participants were primarily white and male, although increased female representation was identified among the junior PDs (50%). Junior PDs were also more likely to hold associate or assistant professor positions at time of appointment (p = 0.01) and a majority of all PDs (64%) previously or currently held a leadership position in a national or regional surgical association. When appointed, senior PDs reported increased teaching time. CONCLUSIONS: This multi-institutional analysis of colon and rectal surgery residency PDs identified a trend towards equal gender representation and diversity amongst upcoming junior PDs. All respondents were appointed to PD from within the institution. Other key experiences included previous leadership roles and associate or assistant professor positions at time of appointment. While it is impossible to create a single recommended template for every aspiring colon and rectal surgery educator to advance to a PD position, this study provides guideposts along that career path.

Do Cultures From Percutaneously Drained Intra-abdominal Abscesses Change Treatment? A Retrospective Review.

BACKGROUND: Routinely obtaining intraoperative cultures for abdominal infections is not a currently recommended evidence-based practice. Yet, cultures are frequently sent from these infections when they are managed by image-guided percutaneous drains. OBJECTIVE: This study aimed to determine the utility of cultures from percutaneously drained intra-abdominal abscesses. DESIGN: Retrospective medical record review. SETTING: Single university-affiliated institution. PATIENTS: Inpatients with an intra-abdominal abscess secondary to diverticulitis or appendicitis between 2013 and 2021 managed with image-guided percutaneous drain, excluding those with active chemotherapy, HIV, or solid organ transplant, were included in the study. MAIN OUTCOME MEASURES: Frequency culture data from percutaneous drains changed antimicrobial therapy. RESULTS: There were 221 patients who met the inclusion criteria. Of these, 56% were admitted for diverticulitis and 44% for appendicitis. Patients were 54% female and had a median age of 62 years (range, 18-93), and 14% were active smokers. The median length of hospitalization was 8 days (range, 1-78) and the median antibiotics course was 8 days (range, 1-22). Culture data from percutaneous drains altered antimicrobial therapy in 8% of patients (16/211). A culture was obtained from 95% of drains, with 78% of cultures with growth. Cultures grew multiple bacteria in 66% and mixed variety without speciation in 13%. The most common pathogen was the Bacteroides family at 33% of all bacteria. The most common empiric antibiotic regimens were ceftriaxone used in 33% of patients and metronidazole used in 40% of patients. Female sex ( p = 0.027) and presence of bacteria with any antibiotic resistance ( p < 0.01) were associated with higher likelihood of cultures influencing antimicrobial therapy. LIMITATIONS: Retrospective and single institution's microbiome. CONCLUSIONS: Microbiology data from image-guided percutaneous drains of abdominal abscesses altered antimicrobial therapy in 8% of patients, which is lower than reported in previously published literature on cultures obtained surgically. Given this low rate, similar to the recommendation regarding cultures obtained intraoperatively, routinely culturing material from drains placed in abdominal abscesses is not recommended. See Video Abstract at http://links.lww.com/DCR/C64 . LOS CULTIVOS DE ABSCESOS INTRA ABDOMINALES DRENADOS PERCUTNEAMENTE CAMBIAN EL TRATAMIENTO UNA REVISIN RETROSPECTIVA: ANTECEDENTES:La obtención rutinaria de cultivos intra-operatorios para infecciones abdominales no es una práctica basada en evidencia actualmente recomendada. Sin embargo, con frecuencia se envían cultivos de estas infecciones cuando se manejan con drenajes percutáneos guiados por imágenes.OBJETIVO:Determinar la utilidad de los cultivos de abscesos intra-abdominales drenados percutáneamente.DISEÑO:Revisión retrospectiva de gráficos.ESCENARIO:Institución única afiliada a la universidad.PACIENTES:Pacientes hospitalizados con absceso intra-abdominal secundario a diverticulitis o apendicitis entre 2013 y 2021 manejados con drenaje percutáneo guiado por imagen, excluyendo aquellos con quimioterapia activa, VIH o trasplante de órgano sólido.PRINCIPALES MEDIDAS DE RESULTADO:Los datos de cultivo de frecuencia de los drenajes percutáneos cambiaron la terapia antimicrobiana.RESULTADOS:Hubo 221 pacientes que cumplieron con los criterios de inclusión. De estos, el 56% ingresaron por diverticulitis y el 44% por apendicitis. El 54% de los pacientes eran mujeres, tenían una edad media de 62 años (18-93) y el 14% eran fumadores activos. La duración de hospitalización media fue de 8 días (rango, 1-78) y la mediana del curso de antibióticos fue de 8 días (rango, 1-22). Los datos de cultivo de drenajes percutáneos alteraron la terapia antimicrobiana en el 7% (16/221) de los pacientes. Se obtuvo cultivo del 95% de los drenajes, con un 79% de cultivos con crecimiento. Los cultivos produjeron múltiples bacterias en el 63% y variedad mixta sin especiación en el 13%. El patógeno más común fue la familia Bacteroides con un 33% de todas las bacterias. El régimen de antibiótico empírico más común fue ceftriaxona y metronidazol, utilizados en el 33% y el 40% de los pacientes, respectivamente. El sexo femenino ( p = 0,027) y la presencia de bacterias con alguna resistencia a los antibióticos ( p < 0,01) se asociaron con una mayor probabilidad de que los cultivos influyeran en la terapia antimicrobiana.LIMITACIONES:Microbioma retrospectivo y de una sola institución.CONCLUSIONES:Los datos microbiológicos de los drenajes percutáneos guiados por imágenes de los abscesos abdominales alteraron la terapia antimicrobiana en el 7% de los pacientes, que es inferior a la literatura publicada previamente sobre cultivos obtenidos quirúrgicamente. Dada esta baja tasa, similar a la recomendación sobre cultivos obtenidos intraoperatoriamente, no se recomienda el cultivo rutinario de material de drenajes colocados en abscesos abdominales. Consulte Video Resumen en http://links.lww.com/DCR/C64 . (Traducción-Dr. Mauricio Santamaria.

How Far Is Too Far? Cost-Effectiveness Analysis of Regionalized Rectal Cancer Surgery.

BACKGROUND: Regionalized rectal cancer surgery may decrease postoperative and long-term cancer-related mortality. However, the regionalization of care may be an undue burden on patients. OBJECTIVE: This study aimed to assess the cost-effectiveness of regionalized rectal cancer surgery. DESIGN: Tree-based decision analysis. PATIENTS: Patients with stage II/III rectal cancer anatomically suitable for low anterior resection were included. SETTING: Rectal cancer surgery performed at a high-volume regional center rather than the closest hospital available. MAIN OUTCOME MEASURES: Incremental costs ($) and effectiveness (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and effectiveness. RESULTS: Regionalized surgery economically dominated local surgery. Regionalized rectal cancer surgery was both less expensive on average ($50,406 versus $65,430 in present-day costs) and produced better long-term outcomes (10.36 versus 9.51 quality-adjusted life years). The total costs and inconvenience of traveling to a regional high-volume center would need to exceed $15,024 per patient to achieve economic breakeven alone or $112,476 per patient to satisfy conventional cost-effectiveness standards. These results were robust on sensitivity analysis and maintained in 94.6% of scenario testing. LIMITATIONS: Decision analysis models are limited to policy level rather than individualized decision-making. CONCLUSIONS: Regionalized rectal cancer surgery improves clinical outcomes and reduces total societal costs compared to local surgical care. Prescriptive measures and patient inducements may be needed to expand the role of regionalized surgery for rectal cancer. See Video Abstract at http://links.lww.com/DCR/C83 . QU TAN LEJOS ES DEMASIADO LEJOS ANLISIS DE COSTOEFECTIVIDAD DE LA CIRUGA DE CNCER DE RECTO REGIONALIZADO: ANTECEDENTES:La cirugía de cáncer de recto regionalizado puede disminuir la mortalidad posoperatoria y a largo plazo relacionada con el cáncer. Sin embargo, la regionalización de la atención puede ser una carga indebida para los pacientes.OBJETIVO:Evaluar la rentabilidad de la cirugía oncológica de recto regionalizada.DISEÑO:Análisis de decisiones basado en árboles.PACIENTES:Pacientes con cáncer de recto en estadio II/III anatómicamente aptos para resección anterior baja.AJUSTE:Cirugía de cáncer rectal realizada en un centro regional de alto volumen en lugar del hospital más cercano disponible.PRINCIPALES MEDIDAS DE RESULTADO:Los costos incrementales ($) y la efectividad (años de vida ajustados por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilístico multivariable modeló la incertidumbre en las probabilidades, los costos y la efectividad.RESULTADOS:La cirugía regionalizada predominó económicamente la cirugía local. La cirugía de cáncer de recto regionalizado fue menos costosa en promedio ($50 406 versus $65 430 en costos actuales) y produjo mejores resultados a largo plazo (10,36 versus 9,51 años de vida ajustados por calidad). Los costos totales y la inconveniencia de viajar a un centro regional de alto volumen necesitarían superar los $15,024 por paciente para alcanzar el punto de equilibrio económico o $112,476 por paciente para satisfacer los estándares convencionales de rentabilidad. Estos resultados fueron sólidos en el análisis de sensibilidad y se mantuvieron en el 94,6% de las pruebas de escenarios.LIMITACIONES:Los modelos de análisis de decisiones se limitan al nivel de políticas en lugar de la toma de decisiones individualizada.CONCLUSIONES:La cirugía de cáncer de recto regionalizada mejora los resultados clínicos y reduce los costos sociales totales en comparación con la atención quirúrgica local. Es posible que se necesiten medidas prescriptivas e incentivos para los pacientes a fin de ampliar el papel de la cirugía regionalizada para el cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C83 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Do You Get What You Pay For? The Relationship of Price and Quality in Hospital Provided Procedures.

INTRODUCTION: Starting in 2021, Centers for Medicare and Medicaid Services required hospitals to provide pricing information to allow consumers to compare prices. Patients perceived that the quality of these services also impacts decision-making. This study examines the relationship between procedure price and quality from the patients' perspective. MATERIALS AND METHODS: Unnegotiated prices of procedures were extracted from hospital websites. Hospital quality was defined as the U.S. News & World Report's score for the specialty performing the procedure. Regional differences in markets were corrected with the Wage Price Index. Spearman's correlations were used for analysis between price and quality. RESULTS: Overall, 67% (1225/1815) of hospitals had a pricing document. Compliance by procedure was poor with a low of 7% for Current Procedural Terminology (CPT) 93000 and a high of 27% for CPTs 93452 and 62323. Wide variability of prices for all procedures was noted. The smallest difference in price range listed was for CPT 45380 with a 32× difference between the minimum and maximum ($310-$10,023) with the first, second, and third quartiles being $1457, $2759, and $4276, respectively. The largest difference in price range was for CPT 55700 with a 5036× difference between the minimum and maximum ($9-$45,322) with the first, second, and third quartiles being $1638, $2971, and $5342, respectively. Correlation between price and quality was low, with the strongest being rho = 0.369 (P = 0.02) for CPT 93000. CONCLUSIONS: Compliance with price transparency was low with large variability in prices for the same procedure. There was no correlation between hospital price and quality. As currently implemented, poor compliance and wide price variability may limit patients' understanding of procedure costs.

Elective Colectomy in a Patient with Active Ulcerative Colitis and Metastatic Melanoma Enabling Successful Treatment with Immune Checkpoint Inhibitors.

Checkpoint inhibitor immunotherapy has significantly advanced treatment of a growing number of advanced malignancies. A consequences of immune system activation that leads to tumor cell destruction by checkpoint inhibitor therapy is the development of immune-related adverse events, some of which can be life threatening. There are limited data on the use of checkpoint inhibitor therapy in patients with preexisting autoimmunity owing to concerns that underlying autoimmune disease may be exacerbated by checkpoint inhibitor treatment. Decisions to treat these patients are made after careful consideration of the risks and benefits of treatment. We describe a patient with active and severe ulcerative colitis with metastatic melanoma who underwent elective colectomy prior to initiation of anti-PD-1 and anti-CTLA-4. The patient had excellent tumor response without flare of his ulcerative colitis suggesting that in select patients with high-risk inflammatory bowel disease, elective colectomy may be an effective treatment option.

Tuberculosis Penis with 'Watering Can Penis' Appearance: Report of a Rare Case with Retrograde Urethrography and Voiding Cystourethrography Findings.

BACKGROUND: A 'watering can penis' secondary to penile tuberculosis is an extremely rare clinical entity. Retrograde Urethrography - Voiding Cystourethrography evaluation of the urethra and the urinary bladder plays a very important role in the diagnostics as well as further management of the urethral abnormalities. To the best of our knowledge, this is only the second case in literature where a 'watering can penis' was noted secondary to penile TB. This is also the first documented case of 'watering can penis' as a consequence of venereal transmission of TB. CASE REPORT: A 50-year-old male presented with multiple discharging sinuses along the penis. RGU revealed multiple, contrast-filled, narrow, irregular, fistulous tracts arising from the pendulous part of the anterior urethra. This distal segment of the pendulous part of the anterior urethra also showed significant distortion and irregular, beaded narrowing. VCUG showed a markedly-contracted and small-capacity urinary bladder with a thickened, irregular and edematous wall with multiple hypertrophied trabeculae along its walls. The patient was administered anti-tubercular treatment. At the end of this treatment regimen, a repeat RGU-VCUG will be performed and decision regarding urethroplasty and further management will be planned depending upon the presence of any remaining fistulas or strictures involving the urethra. CONCLUSIONS: 'Watering can penis' as a result of penile TB is a very rare clinical entity. The differential diagnoses of a 'watering can penis' should be kept in mind in the evaluation of these patients. RGU and VCUG evaluation is an important conventional imaging modality used in the evaluation of urethral strictures and fistulas in case of 'watering can penis'.

Plastic Surgery and Suicide: A Clinical Guide for Plastic Surgeons.

Several studies have identified an increased risk of suicide among patient populations which a plastic surgeon may have a high risk of encountering: women undergoing breast augmentation, cosmetic surgery patients, and breast cancer patients. No formal guidelines exist to assist a plastic surgeon when faced with such a patient, and not every plastic surgery team has mental health clinicians that are readily accessible for consultation or referral. The goal of this clinical guide is to offer plastic surgeons a set of practical approaches to manage potentially suicidal patients. In addition, the authors review a screening tool, which can assist surgeons when encountering high-risk patients.

Efficacy of Specific Plant Products on Microorganisms Causing Dental Caries.

INTRODUCTION: Dental caries and periodontal diseases are the most common oral diseases seen globally, both in developed and developing countries. Oral microorganisms that is gram positive and gram negative bacteria are known to be involved in causation of these diseases. Nowadays commercially available dentrifices and mouth rinses are known to contain ingredients that can alter the oral microbial flora and have undesirable side effects such as vomiting, diarrhoea, disarrangement of oral, intestinal flora and tooth staining. Naturally available plant products are known to be less harmful with fewer side effects and also economical for the patient. AIM: The aim of this study was to determine the antimicrobial properties of 10 naturally available plant products against oral microorganisms causing caries and to check the efficacy of these products in-vitro and to use these in mouth washes and dentrifices. MATERIALS AND METHODS: Sample of caries material was scrapped out from the extracted teeth and transferred to liquid broth, streaked over the agar media to allow for the growth of microorganisms. Plant products like clove oil, neem, ginger-garlic paste, tea tree oil, ginger, garlic, cinnamon oil, green tea, eucalyptus oil and turmeric were used. Antimicrobial efficacy of these products, was estimated by measuring zones of inhibition in the nutrient agar media. RESULTS: Clove oil was the most effective of all products against microorganisms causing caries with zone of inhibition - 30mm followed by ginger-garlic paste - 25mm, Neem - 15mm, tea tree oil - 15mm. CONCLUSION: Based on the above results, it can be inferred that these natural products have the maximum efficacy against microorganisms and can be recommended in dentifrices, mouth rinses, topical gels, etc.

Senior Surgical Resident Confidence in Performing Flexible Endoscopy: What Can We Do Differently?

INTRODUCTION: The American Board of Surgery endoscopy requirements for general surgery training are evolving. In 2006, the Residency Review Committee in Surgery increased the total number of endoscopy cases required before completion of general surgery residency training. This requirement is set to change further, given the new Flexible Endoscopic Curriculum that would be a requirement for applicants graduating surgical training during or after the 2017 to 2018 academic year. Given these changes, our goal was to evaluate the confidence of senior surgical residents performing flexible endoscopy. METHODS: A survey was developed and sent to general surgery residents nationally, querying them regarding demographics and program-specific characteristics; additionally they were asked to rate their confidence level in performing flexible upper endoscopy and colonoscopy on a Likert scale of 1 to 5. We then compared those residents who indicated confidence (Likert scale 4-5) to those who did not (Likert scale 1-3). For the purpose of this study, only senior (postgraduate year 4 and 5) general surgery residents were assessed. RESULTS: We received 1176 responses from senior surgical residents: 56% of these were postgraduate year 5 residents, 65% male, 68% from University Programs, and 56% from programs associated with a Veteran's Affairs Hospital; 33% were from programs in the Northeast, 29% in the South, 24% in the Midwest, and 14% in the West; 75% were going on to additional fellowship training after the completion of residency; 42% indicated that they would go into academic practice and 32% into private practice; 66.7% reported confidence performing upper endoscopy and 52.7% reported confidence performing colonoscopy. Male gender, overall operative volume, and graduating from a medium-sized program or program in the South were associated with increased confidence performing flexible endoscopy. CONCLUSIONS: A large percentage of senior residents do not report confidence in performing flexible endoscopy. Although increasing the number of cases required for graduation has likely helped improve the training of residents in endoscopy, additional improvements in training are required. The Flexible Endoscopic Curriculum helps standardize the curriculum and demonstrate that the graduating resident has the fundamental knowledge and skills required in the performance of endoscopy. Simulation training and dedicated endoscopic rotations during the course of residency training could help improve endoscopy training and proficiency for future graduating residents.

Are graduating surgical residents confident in performing open vascular surgery? Results of a national survey.

INTRODUCTION: General surgical training has changed significantly over the past decade with work-hour restrictions, increasing use of minimally invasive techniques, and increasing specialization, leading to decreased resident exposure to open operative techniques. Furthermore, the presence of vascular surgery fellows and the advent of dedicated vascular surgery residencies have had the potential to diminish further the vascular surgery experience of general surgery residents. Given these changes, this study was undertaken to assess the confidence of graduating general surgery residents in performing certain key open vascular maneuvers, approaches that might be required in a general surgery practice, and to determine factors associated with variations in reported confidence. METHODS: A survey was developed and sent to graduating chief surgical residents nationally. We queried them regarding demographics and program characteristics and asked them to rate their confidence (rated 1-5 on a Likert scale) in performing a vascular anastomosis and 4 specific vascular control maneuvers. We then compared those who indicated confidence with those who did not. RESULTS: We received 653 responses from fifth-year (postgraduate year 5) surgical residents: 69% men, 67.5% from university programs, and 51% from programs affiliated with a Veterans Affairs hospital; additionally, 22% were from small programs, 34% from medium programs, and 44% from large programs. Although 70% of respondents indicated confidence performing a vascular anastomosis, less than 25% indicated confidence performing each of the 4 specified vascular maneuvers. Age, program size, future fellowship plans, surgical volume, estimated percentage of cases performed laparoscopically, and geographic location were all associated with variations in reported confidence. CONCLUSIONS: Graduating general surgical residents indicated a significant lack of confidence in performing specific open vascular surgical maneuvers. This decreased confidence varied regionally and was associated with both demographic and program-specific factors.

Anorectal human papillomavirus: current concepts.

Increased anorectal human papillomavirus (HPV) infection is related to the recent trends in sexual behavior in both homosexual and heterosexual groups and prevalence of infection with human immunodeficiency virus (HIV). Clinical presentation and natural history depend on the serotype involved. HPV 6 and 11 are found in the benign wart. Local control can be achieved with a wide selection of surgical and topical techniques. HPV 16, 18, and 31 are found in dysplastic lesions and have the potential to progress to invasive anal squamous cell carcinoma. Recognition and early management of dysplastic lesions is crucial to prevent the morbidity and mortality associated with anal cancer. While low-grade lesions can be closely observed, high-grade lesions should be eradicated. Different strategies can be used to eradicate the disease while preserving anorectal function. Studies on the efficacy of vaccination on anorectal HPV showed promising results in select population groups and led to the recent expansion of current vaccination recommendations.

Sexually transmitted infections of the anus and rectum.

Sexually transmitted infections (STIs) represent a significant public health concern. Several STIs, once thought to be on the verge of extinction, have recently reemerged. This change is thought to be partially related to an increase in STIs of the anus and rectum. Importantly, the global human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) epidemic has contributed to the emergence of particular anorectal lesions that require specialized approaches. In this report, we review common anorectal STIs that are frequently referred to colorectal surgeons in the United States. Epidemiology, clinical presentation, and management are summarized, including the latest treatment recommendations. The particularity of anorectal diseases in HIV/AIDS is addressed, along with recent trends in anal cytology and human papillomavirus vaccination.

Cost-effectiveness analysis of baclofen and chlordiazepoxide in uncomplicated alcohol-withdrawal syndrome.

OBJECTIVES: Benzodiazepines (BZDs) are the first-line drugs in alcohol-withdrawal syndrome (AWS). Baclofen, a gamma-aminobutyric acidB (GABAB) agonist, controls withdrawal symptoms without causing significant adverse effects. The objective of this study was to compare the cost-effectiveness of baclofen and chlordiazepoxide in the management of uncomplicated AWS. MATERIALS AND METHODS: This was a randomized, open label, standard controlled, parallel group study of cost-effectiveness analysis (CEA) of baclofen and chlordiazepoxide in 60 participants with uncomplicated AWS. Clinical efficacy was measured by the Clinical Institute Withdrawal Assessment for alcohol (CIWA-Ar) scores. Lorazepam was used as supplement medication if withdrawal symptoms could not be controlled effectively by the study drugs alone. Both direct and indirect medical costs were considered and the CEA was analyzed in both patient's perspective and third-party perspective. RESULTS: The average cost-effectiveness ratio (ACER) in patient's perspective of baclofen and chlordiazepoxide was Rs. 5,308.61 and Rs. 2,951.95 per symptom-free day, respectively. The ACER in third-party perspective of baclofen and chlordiazepoxide was Rs. 895.01 and Rs. 476.29 per symptom-free day, respectively. Participants on chlordiazepoxide had more number of symptom-free days when compared with the baclofen group on analysis by Mann-Whitney test (U = 253.50, P = 0.03). CONCLUSION: Both study drugs provided relief of withdrawal symptoms. Chlordiazepoxide was more cost-effective than baclofen. Baclofen was relatively less effective and more expensive than chlordiazepoxide.