Low-Dose Rivaroxaban as Extended Prophylaxis Reduces Postdischarge Venous Thromboembolism in Patients With Malignancy and IBD.

BACKGROUND: Despite guidelines suggesting the use of extended prophylaxis for prevention of venous thromboembolism in patients with colorectal cancer and perhaps IBD, routine use is low and scant data exist regarding oral forms of therapy. OBJECTIVE: The purpose was to compare the incidence of postdischarge venous thromboembolism in patients given extended prophylaxis with low-dose rivaroxaban. DESIGN: We used propensity matching to compare pre- and postintervention analyses from a 2-year period before instituting extended prophylaxis. SETTING: All colorectal patients at a single institution were prospectively considered for extended prophylaxis. PATIENTS: Patients with a diagnosis of IBD or colorectal cancer who underwent operative resection were included. INTERVENTIONS: Those considered for extended prophylaxis were prescribed 10 mg of rivaroxaban for 30 days postsurgery. MAIN OUTCOME MEASURES: The primary outcome was venous thromboembolism incidence 30 days postdischarge. The secondary outcome was bleeding rates, major or minor. RESULTS: Of the 498 patients considered for extended prophylaxis, 363 were discharged with rivaroxaban, 81 on baseline anticoagulation, and 54 without anticoagulation. Propensity-matched cohorts based on stoma creation, operative approach, procedure type, and BMI were made to 174 historical controls. After excluding cases of inpatient venous thromboembolism, postoperative rates were lower in the prospective cohort (4.8% vs 0.6%, p = 0.019). In the prospective group, 36 episodes of bleeding occurred, 26 (7.2%) were discharged with rivaroxaban, 8 (9.9%) discharged on other anticoagulants, and 2 (3.7%) with no postoperative anticoagulation. Cases of major bleeding were 1.1% (4/363) in the rivaroxaban group, and each required intervention. LIMITATIONS: The study was limited to a single institution and did not include a placebo arm. CONCLUSIONS: Among patients with IBD and colorectal cancer, extended prophylaxis with low-dose rivaroxaban led to a significant decrease in postdischarge thromboembolic events with a low bleeding risk profile. See Video Abstract . RIVAROXABN EN DOSIS BAJAS COMO PROFILAXIS PROLONGADA REDUCE LA TROMBOEMBOLIA VENOSA POSTERIOR AL ALTA, EN PACIENTES CON NEOPLASIAS MALIGNAS Y ENFERMEDAD INFLAMATORIA INTESTINAL: ANTECEDENTES:A pesar de las normas que sugieren el uso de profilaxis extendida para la prevención del tromboembolismo venoso en pacientes con cáncer colorrectal y tal vez enfermedad inflamatoria intestinal, el uso rutinario es bajo y existen escasos datos sobre las formas orales de terapia.OBJETIVO:Comparar la incidencia de tromboembolismo venoso posterior al alta, en pacientes que recibieron profilaxis prolongada con dosis bajas de rivaroxabán.DISEÑO:Utilizamos el emparejamiento de propensión para comparar un análisis previo y posterior a la intervención de un período de 2 años antes de instituir la profilaxis extendida.AJUSTE:Todos los pacientes colorrectales en una sola institución fueron considerados prospectivamente para profilaxis extendida.PACIENTES:Incluidos pacientes con diagnóstico de enfermedad inflamatoria intestinal o cáncer colorrectal sometidos a resección quirúrgica.INTERVENCIONES:A los considerados para profilaxis extendida se les prescribió 10 mg de rivaroxabán durante 30 días postoperatorios.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la incidencia de tromboembolismo venoso 30 días después del alta. El resultado secundario fueron las tasas de hemorragia, mayor o menor.RESULTADOS:De los 498 pacientes considerados para profilaxis extendida, 363 fueron dados de alta con rivaroxabán, 81 con anticoagulación inicial y 54 sin anticoagulación. Se realizaron cohortes emparejadas por propensión basadas en la creación de la estoma, abordaje quirúrgico, tipo de procedimiento y el índice de masa corporal en 174 controles históricos. Después de excluir los casos de tromboembolismo venoso hospitalizado, las tasas posoperatorias fueron más bajas en la cohorte prospectiva (4,8% frente a 0,6%, p = 0,019). En el grupo prospectivo ocurrieron 36 episodios de hemorragia, 26 (7,2%) fueron dados de alta con rivaroxaban, 8 (9,9%) fueron dados de alta con otros anticoagulantes y 2 (3,7%) sin anticoagulación posoperatoria. Los casos de hemorragia mayor fueron del 1,1% (4/363) en el grupo de rivaroxabán y cada uno requirió intervención.LIMITACIONES:Limitado a una sola institución y no incluyó un grupo de placebo.CONCLUSIONES:Entre los pacientes con enfermedad inflamatoria intestinal y cáncer colorrectal, la profilaxis extendida con dosis bajas de rivaroxabán condujo a una disminución significativa de los eventos tromboembólicos posteriores al alta, con un perfil de riesgo de hemorragia bajo. (Traducción-Dr. Fidel Ruiz Healy).

Durable Approaches to Recurrent Rectal Prolapse Repair May Require Avoidance of Index Procedure.

BACKGROUND: Surgical treatment of recurrent rectal prolapse is associated with unique technical challenges, partially determined by the surgical approach used for the index operation. Success rates are variable, and data to determine the best approach in patients with recurring prolapse are lacking. OBJECTIVE: The study aimed to assess current surgical approaches to patients with prior rectal prolapse repairs and to compare short-term outcomes of de novo and redo procedures, including recurrence of rectal prolapse. DESIGN: Retrospective analysis of a prospective database. SETTINGS: The Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement database. De-identified surgeons at more than 25 sites (81% high volume) self-reported patient demographics, prior repairs, symptoms of incontinence and obstructed defecation, and operative details, including history of concomitant repairs and prior prolapse repairs. PATIENTS: Patients who were offered surgery for full thickness rectal prolapse. INTERVENTIONS: Incidence and type of repair used for prior rectal prolapse surgery were recorded. Primary and secondary outcomes of index and redo operations were calculated. Patients undergoing rectal prolapse re-repair (redo) were compared with patients undergoing first (de novo) rectal prolapse repair. The incidence of rectal prolapse recurrence in de novo and redo operations was quantified. OUTCOMES: The primary outcome of rectal prolapse recurrence in de novo and redo settings. RESULTS: Eighty-nine (19.3%) of 461 patients underwent redo rectal prolapse repair. On short-term follow-up, redo patients had prolapse recurrence rates similar to those undergoing de novo repair. However, patients undergoing redo procedures rarely had the same operation as their index procedure. LIMITATIONS: Self-reported, de-identified data. CONCLUSION: Our results suggest that recurrent rectal prolapse surgery is feasible and can offer adequate rates of rectal prolapse durability in the short term but may argue for a change in surgical approach for redo procedures when clinically feasible. See Video Abstract . LOS ENFOQUES DURADEROS PARA LA REPARACIN DEL PROLAPSO RECTAL RECURRENTE PUEDEN REQUERIR EVITAR EL PROCEDIMIENTO NDICE: ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal recurrente se asocia con desafíos técnicos únicos, determinados en parte por el abordaje quirúrgico utilizado para la operación inicial. Las tasas de éxito son variables y faltan datos para determinar el mejor abordaje en pacientes con prolapso recurrente.OBJETIVO:Evaluar los enfoques quirúrgicos actuales para pacientes con reparaciones previas de prolapso rectal y comparar los resultados a corto plazo de los procedimientos de novo y rehacer, incluida la recurrencia del prolapso rectal.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.AJUSTE:Base de datos de mejora prospectiva de la calidad del Consorcio multicéntrico de trastornos del suelo pélvico. Cirujanos no identificados en más de 25 sitios (81% de alto volumen) informaron datos demográficos de los pacientes, reparaciones previas, síntomas de incontinencia y defecación obstruida y detalles operativos, incluido el historial de reparaciones concomitantes y reparaciones previas de prolapso.INTERVENCIONES:Se registro la incidencia y el tipo de reparación utilizada para la cirugía de prolapso rectal previa. Se calcularon los resultados primarios y secundarios de las operaciones de índice y reoperacion. Se compararon los pacientes sometidos a una nueva reparación (reoperacion) de prolapso rectal con pacientes sometidos a una primera reparación (de novo) de prolapso rectal. Se cuantificó la incidencia de recurrencia del prolapso rectal en operaciones de novo y rehacer.RESULTADOS:El resultado primario de recurrencia del prolapso rectal en entornos de novo y redo. Ochenta y nueve (19,3%) de 461 pacientes se sometieron a una nueva reparación del prolapso rectal. En el seguimiento a corto plazo, los pacientes reoperados tuvieron tasas de recurrencia de prolapso similares a los de los sometidos a reparación de novo. Sin embargo, los pacientes sometidos a procedimientos de rehacer rara vez tuvieron la misma operación que su procedimiento índice.LIMITACIONES:Datos no identificados y autoinformados.CONCLUSIONES/DISCUSIÓN:Nuestros resultados sugieren que la cirugía de prolapso rectal recurrente es factible y puede ofrecer tasas adecuadas de durabilidad del prolapso rectal en el corto plazo, pero puede abogar por un cambio en el enfoque quirúrgico para rehacer los procedimientos cuando sea clínicamente factible. (Traducción-Dr. Mauricio Santamaria ).

Prevalence of mental disorders among Australian females: Comparison according to motherhood status using Australian birth cohort data.

PURPOSE: Studies examining mental disorders among women have primarily focused on either depression, anxiety, or substance use disorders and not included the broader spectrum of mental disorders. Mixed evidence exists on the prevalence rates of mental disorders among mothers. This study compares the prevalence of different mental disorders and mental comorbidities between mothers and non-mothers and assesses correlates of mental disorders among mothers. METHODS: A population-based birth cohort design was adopted, consisting of 40,416 females born in Queensland, Australia, in 1983/84. Linked administrative data from hospital admissions were used to identify mental disorders. Cumulative incidence curves of different mental disorders were created separately for mothers and non-mothers. RESULTS: Mental disorder prevalence among females by age 29-31 years was 7.8% (11.0% for mothers and 5.2% for non-mothers). Mothers were overrepresented in almost all categories of mental disorders, with overrepresentation becoming more pronounced with age. Mothers with a mental disorder were more likely to be unmarried, Indigenous, young at birth of first child, have greater disadvantage, and have a single child, compared to mothers without a mental disorder. Nearly half of the mothers (46.9%) had received a mental disorder diagnosis before having their first child. CONCLUSIONS: Mothers, particularly unmarried, Indigenous, having greater disadvantage, and younger at birth of first child, represent a unique group with high vulnerability to mental disorders, that begins in childhood and is amplified with age. Presence of significant mental disorder comorbidities among females highlights the critical importance of a comprehensive, integrated approach to prevent and address multiple comorbidities.

Child Sexual Abuse Victimization Amongst Detained Adolescents and Incarcerated Young Adults: Findings from an Australian Population-Based Birth Cohort Study.

To guide prevention and intervention efforts, the prevalence and impact of child sexual abuse (CSA) victimization among detained and incarcerated populations requires further examination, particularly with consideration of multi-type maltreatment experiences and sex-based variations. This longitudinal population-based study explores these relationships in an Australian birth cohort comprising all individuals born in Queensland in 1983 and 1984 (n = 82,409; 48.68% female). Data include all notified and substantiated harm(s) from child protection services (0 to 17 years), and sentences to youth detention and/or adult incarceration between ages 10 and 30. Findings indicate greater prevalence of CSA amongst detained/incarcerated individuals compared to the general population but emphasize the impact of cooccurring maltreatment (particularly neglect) on the likelihood of custodial outcomes. Important sex-based differences were noted in the intersection of CSA victimization and detention/incarceration. Findings reinforce the need for trauma-informed practices when working with custodial populations, particularly females, and highlight opportunities for prevention of detention/incarceration in at-risk populations, in line with a broader public health approach to child protection.

Prospective Memory Training in Older Adults: A Systematic Review and Meta-Analysis.

Prospective memory (PM), which enables one to remember to carry out delayed intentions, is crucial for everyday functioning. PM commonly deteriorates upon cognitive decline in older adults, but several studies have shown that PM in older adults can be improved by training. The current study aimed to summarise this evidence by conducting a qualitative systematic analysis and quantitative meta-analysis of the effects of PM training in older adults, for which systematic searches were conducted across seven databases (Cochrane Library, Embase, PubMed, PsycInfo, Web of Science, CINAHL and Scopus). Forty-eight studies were included in the qualitative analysis, and 43% of the assessed PM training interventions showed positive gains in enhancing PM. However, the methodological quality varied across the studies, with 41% of the non-randomised control trials (non-RCTs) rated as having either serious or critical risk of bias. Therefore, only 29 RCTs were included in the subsequent quantitative meta-analysis. We found a significant and moderate immediate efficacy (Hedges' g = 0.54) of PM training in enhancing PM performance in older adults, but no significant long-term efficacy (Hedges' g = 0.20). Two subgroup analyses also revealed a robust training efficacy across the study population (i.e., healthy and clinical population) and the number of training sessions (i.e., single session and programme-based). Overall, this study provided positive evidence to support PM training in older adults. Further studies are warranted to explore the mechanisms by which PM training exerts its effects, and better-quality RCTs are needed to provide more robust evidence supporting our findings.

Preoperative Immuno-Nutrition and Complications After Colorectal Surgery: Results of a 2-Year Prospective Study.

INTRODUCTION: Preoperative immuno-nutrition has been associated with reductions in infectious complications and length of stay, but remains unstudied in the setting of an enhanced recovery protocol. The objective was to evaluate outcomes after elective colorectal surgery with the addition of a preoperative immuno-nutrition supplement. METHODS: In October 2017, all major colorectal surgeries were given an arginine-based supplement prior to surgery. The control group consisted of cases within the same enhanced recovery protocol from three years prior. The primary outcome was a composite of overall morbidity. Secondary outcomes were infectious complications and length of stay with subgroup analysis based on degrees of malnutrition. RESULTS: Of 826 patients, 514 were given immuno-nutrition prospectively and no differences in complication rates (21.5% versus 23.9%, P = 0.416) or surgical site infections (SSIs) (6.4% versus 6.9%, P = 0.801) were observed. Hospitalization was slightly shorter in the immuno-nutrition cohort (5.0 [3.0, 7.0], versus 5.5 days [3.6, 7.9], P = 0.002). There was a clinically insignificant difference in prognostic nutrition index scores between cohorts (35.2 ± 5.6 versus 36.1 ± 5.0, P = 0.021); however, subgroup analysis (< 33, 34-38 and > 38) failed to demonstrate an association with complications (P = 0.275) or SSIs (P = 0.640) and immuno-nutrition use. CONCLUSIONS: Complication rates and SSIs were unchanged with the addition of immuno-nutrition before elective colorectal surgery. The association with length of stay is small and without clinical significance; therefore, the routine use of immuno-nutrition in this setting is of questionable benefit.

Psychiatric illness and the risk of reoffending: recurrent event analysis for an Australian birth cohort.

BACKGROUND: Psychiatric illness is a well-established risk factor for criminal justice system involvement, but less is known about the relationships between specific psychiatric illnesses and reoffending. Research typically examines reoffending as a single discrete event. We examined the relationship between different psychiatric disorders and types of reoffending while accounting for multiple reoffending events over time. METHODS: Data were drawn from a population cohort of 83,039 individuals born in Queensland, Australia, in 1983 and 1984 and followed to age 29-31 years. Psychiatric diagnoses were drawn from inpatient health records and offending information was drawn from court records. Descriptive and recurrent event survival analyses were conducted to examine the association between psychiatric disorders and reoffending. RESULTS: The cohort included 26,651 individuals with at least one proven offence, with 3,580 (13.4%) of these individuals also having a psychiatric disorder. Individuals with any psychiatric disorder were more likely to reoffend compared to those without a disorder (73.1% vs. 56.0%). Associations between psychiatric disorders and reoffending varied across age. Individuals with a psychiatric disorder only started to accumulate more reoffending events from ~ 27 years, which accelerated up to age 31 years. There were both specificity and common effects in the associations between different psychiatric disorders and types of reoffending. CONCLUSIONS: Findings demonstrate the complexity and temporal dependency of the relationship between psychiatric illness and reoffending. These results reveal the heterogeneity present among individuals who experience psychiatric illness and contact with the justice system, with implications for intervention delivery, particularly for those with substance use disorders.

Does Concomitant Pelvic Organ Prolapse Repair at the Time of Rectopexy Impact Rectal Prolapse Recurrence Rates? A Retrospective Review of the Prospectively Collected Pelvic Floor Disorders Consortium Quality Improvement Database Pilot.

BACKGROUND: Pelvic organ prolapse is reported in 30% of women presenting with rectal prolapse. Combined repair is a viable option to avoid the need for future pelvic floor interventions. However, the added impact of adding a modicum of middle compartment suspension by closing the pouch of Douglas during a rectal prolapse repair has not been studied. OBJECTIVE: The study aimed to assess the impact of middle compartment suspension on the durability of rectal prolapse repair. We also aimed to determine whether adding some form of pouch of Douglas closure to achieve middle compartment suspension leads to any improvements in the rates or severity of postoperative constipation or in the rates or severity of postoperative fecal incontinence. DESIGN: This study was a retrospective analysis of a multicenter prospective database. SETTING: Data were analyzed from the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery database. Deidentified surgeons at more than 20 sites (75% academic, 81% high volume) self-reported patient demographics, previous repairs, symptoms of fecal incontinence and obstructed defecation, and operative details, including addition of concomitant gynecologic repairs, use of mesh, posterior or ventral dissection, and sigmoidectomy. PATIENTS: Patients were included who underwent abdominal repair for rectal prolapse. INTERVENTIONS: Abdominal rectopexy procedures with and without middle compartment suspension were compared. Middle compartment suspension was defined as excision and closure of the pouch of Douglas with some degree of colpopexy or culdoplasty. MAIN OUTCOME MEASURES: The primary outcome of prolapse recurrence and secondary outcomes of incontinence and constipation were calculated via univariate and multivariable regression by comparing those who underwent rectopexy with and without middle compartment suspension. RESULTS: Of the 198 patients (98% female, age 60.2 ± 15.6 years) who underwent abdominal repairs (59% robotic), 138 patients (70%) underwent some concomitant middle compartment suspension. Patients who had an added middle compartment suspension seemed to have lower early rectal prolapse recurrences. On multivariable regression to control for age, previous repairs, and the use of mesh, addition of some form of pouch of Douglas repair was associated with a decrease in short-term recurrences. LIMITATIONS: Our data need to be interpreted cautiously. Future studies are critically needed to further explore this observation, with an a priori, prospective definition of middle compartment suspension, validated measurement of concomitant pathology, and longer follow-up. CONCLUSION: Our results suggest that some middle compartment suspension at the time of rectal prolapse repair may improve short-term durability of rectal prolapse repair. See Video Abstract at http://links.lww.com/DCR/C30 . LA REPARACIN CONCOMITANTE DEL PROLAPSO DE RGANOS PLVICOS EN EL MOMENTO DE LA RECTOPEXIA AFECTA LAS TASAS DE RECURRENCIA DEL PROLAPSO RECTAL UNA REVISIN RETROSPECTIVA DE UNA BASE DE DATOS RECOPILADA PROSPECTIVAMENTE DEL CONSORCIO SOBRE LA MEJORA DE LA CALIDAD DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:El prolapso de órganos pélvicos se informa en el 30 % de las mujeres que presentan prolapso rectal y la reparación combinada es una opción viable para evitar la necesidad de futuras intervenciones del suelo pélvico. Sin embargo, no se ha estudiado el impacto adicional de agregar un mínimo de suspensión del compartimento medio cerrando el fonde de saco de Douglas durante una reparación de prolapso rectal.OBJETIVO:Nuestro objetivo fue evaluar el impacto de la suspensión del compartimento medio con respecto a la durabilidad de la reparación del prolapso rectal. Quisimos de igual manera determinar si el agregado de algún tipo de cierre del fondo de saco de Douglas para lograr la suspensión del compartimento medio conduce a alguna mejora en las tasas o la gravedad del estreñimiento posoperatorio así como en las tasas o la gravedad de la incontinencia fecal posoperatoria.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.ESCENARIO:Base de datos Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement. Cirujanos no identificados en >20 sitios (75% académicos, 81% de alto volumen) datos demográficos de pacientes auto informados, reparaciones previas, síntomas de incontinencia fecal y defecación obstruida, y detalles quirúrgicos, incluida la suma de reparaciones ginecológicas concomitantes, uso de malla, disección anterior o posterior y sigmoidectomía.INTERVENCIONES:Se compararon los procedimientos de rectopexia abdominal con y sin suspensión del compartimento medio). La suspensión del compartimento medio se definió como la escisión y cierre del fondo de saco de Douglas con algún grado de colpopexia o culdoplastia.RESULTADOS:El resultado principal de la recurrencia del prolapso y los resultados secundarios de incontinencia y estreñimiento se calcularon mediante regresión uni y multivariable al comparar los que fueron sometidos a rectopexia con y sin suspensión del compartimento medio.PACIENTES:Pacientes sometidos a reparación abdominal por prolapso rectal.RESULTADOS:De los 198 pacientes (98% mujeres, edad 60,2 ± 15,6 años) sometidas a reparaciones abdominales (59% robótica), 138 (70%) fueron sometidas igualmente y de manera concomitante a alguna suspensión del compartimento medio. Los pacientes a los que se les añadió una suspensión del compartimento medio parecían tener menores recurrencias tempranas del prolapso rectal y, en la regresión multivariable para controlar la edad, las reparaciones previas y el uso de malla, la adición de alguna forma de reparación del fondo de saco de Douglas se asoció con una disminución de las recurrencias a corto plazo.LIMITACIONES:Nuestros datos deben interpretarse con cautela. Se necesitan de manera critica, estudios futuros para explorar más a fondo esta observación, con una definición prospectiva a priori de la suspensión del compartimento medio, una medición validada de la patología concomitante y un seguimiento más prolongado.CONCLUSIONES:Nuestros resultados sugieren que alguna suspensión del compartimento medio en el momento de la reparación del prolapso rectal puede mejorar la durabilidad a corto plazo de la reparación del prolapso rectal. Consulte Video Resumen en http://links.lww.com/DCR/C30 . (Traducción-Dr. Osvaldo Gauto ).

Psychiatric disorders and offending in an Australian birth cohort: Overrepresentation in the health and criminal justice systems for Indigenous Australians.

OBJECTIVE: Most studies that examine psychiatric illness in people who offend have focused on incarcerated samples, with little known about the larger population of individuals with criminal justice system contact. We examine the overlap between proven offences and psychiatric diagnoses with an emphasis on experiences for Indigenous Australians. METHODS: In a population-based birth cohort of 45,141 individuals born in Queensland, Australia, in 1990 (6.3% Indigenous), psychiatric diagnoses were identified from hospital admissions between ages 4/5 and 23/24 years and proven offences were identified from court records (spanning ages 10-24 years). Prevalence rates for offending, psychiatric diagnoses and their overlap were examined for Indigenous and non-Indigenous individuals. Associations between specific psychiatric diagnoses and types of offending were examined using logistic regressions. RESULTS: There were 11,134 (24.7%) individuals with a finalised court appearance, 2937 (6.5%) with a diagnosed psychiatric disorder and 1556 (3.4%) with a proven offence and diagnosed psychiatric disorder, with Indigenous Australians significantly overrepresented across all outcomes. Compared with non-Indigenous Australians, Indigenous Australians were younger at their first court finalisation (Cohen's d = -0.62, 95% confidence interval = [-0.67, -0.57]), experienced a higher number of finalisations (d = 0.94, 95% confidence interval = [0.89, 1.00]) and offences (d = 0.64, 95% confidence interval = [0.59, 0.69]) and were more likely to receive custodial (d = 0.41, 95% confidence interval = [0.36, 0.46]) or supervised (d = 0.55, 95% confidence interval = [0.50, 0.60]) sentences. The overlap between offending and psychiatric illness was more pronounced for Indigenous Australians compared with non-Indigenous Australians (14.8% vs 2.7%). Substance use disorders were the most prevalent psychiatric diagnosis among individuals with a court finalisation (9.2%). CONCLUSIONS: Indigenous Australians were significantly overrepresented in court finalisations and psychiatric diagnoses. Indigenous Australians with a psychiatric diagnosis were at highest risk of experiencing a court appearance, emphasising the importance of culturally appropriate mental health responses being embedded into the criminal justice system.

Evading Detection: What Do We Know about Men Charged with Extrafamilial Child Sexual Abuse following Delayed Detection?

Most child sexual abuse (CSA) remains unreported and undetected. Despite this, much of what we know about perpetrators of CSA is derived from samples of convicted CSA offenders. Significant knowledge gaps remain about those who have evaded detection. This study addresses this gap with an in-depth content analysis of the case files of ten convicted child sexual offenders (CSOs) with the longest detection lag, selected from a broader group (n = 349) of men incarcerated at the Massachusetts Treatment Center (MTC). Participants were examined on a range of offender characteristics including Adverse Childhood Experiences (ACEs), cognitive distortions, antisocial traits, indicators of pedophilia and Machiavellian or narcissistic traits, offense facilitating factors, and grooming behavior. A tentative profile emerged with the following characteristics: direct experience of childhood abuse, various cognitive distortions, specialized rather than versatile criminal history, pedophilic traits, Machiavellian traits, and engaging in a range of offense-facilitating behaviors including grooming. We provide insight into offenders who evade detection for CSA and set the foundation for further research to inform prevention strategies for law enforcement agencies and child-serving organizations.

Use of a standardized discharge checklist with daily post-operative C-reactive protein monitoring does not impact readmission rates after colon and rectal surgery.

PURPOSE: Elevated CRP has been associated with infectious complications after colorectal surgery but has not been evaluated in a prospective fashion as part of a discharge checklist. The objective of this study was to evaluate the effectiveness of a multi-component "discharge criteria checklist" that included daily use of CRP in decreasing hospital readmission rates after colorectal surgery. METHODS: This is a prospective before and after study design that included consecutive patients undergoing major colorectal operations at a single university-affiliated community hospital over a 2-year period. The primary outcome was inpatient or emergency department readmission after 30 days. Selected pre- and peri-operative factors associated with readmissions were then examined in a multivariate analysis model. RESULTS: The study included a total of 1546 patients. Surgical indications were inflammatory bowel disease (15%), colorectal cancer (24%), and benign disease (60%); 9.5% were emergencies. The readmission rates for each group were similar, 17.3% and 17.0%, for the control and discharge checklist groups, respectively (p=0.88). On multivariate analysis of the discharge checklist group dataset, only age, sex, surgical acuity and operating time were statistically significant risk factors. The difference of median CRP values on the day of discharge of those readmitted compared to those not readmitted (35 vs 32 mg/L) was not statistically significant (p=0.28). CONCLUSIONS: The institution of a "discharge checklist" did not impact post-operative hospital readmissions. Not only were readmissions unchanged by the use of a CRP threshold at discharge, but CRP levels at the time of discharge were not associated with readmissions.

Measuring Engagement in Antisocial Behavior During Late Adolescence and Early Adulthood for Typically Developing Youth.

Research examining the nature and extent of participation in antisocial behavior (ASB) in typically developing individuals during late adolescence and early adulthood remains rare. A self-report instrument for measuring participation in ASB was developed and administered to an Australian sample of 404 youth (64.9% females) aged 17 to 22-years using item-response theory methods. All participants reported involvement in multiple forms of ASB, although this involvement was skewed toward less serious behaviors, suggesting that engagement in these behaviors were common for typically developing youth. Unlike previous research, few sex differences were detected, with females' self-reported involvement in ASB similar to that of males. A need for ongoing longitudinal research in typically developing samples was highlighted, particularly on the transition to adulthood.

Concordance Between Registry and Administrative Data in the Determination of Comorbidity: A Multi-institutional Study.

OBJECTIVE: To characterize agreement between administrative and registry data in the determination of patient-level comorbidities. BACKGROUND: Previous research finds poor agreement between these 2 types of data in the determination of outcomes. We hypothesized that concordance between administrative and registry data would also be poor. METHODS: A cohort of inpatient operations (length of stay 1 day or greater) was obtained from a consortium of 8 hospitals. Within each hospital, National Surgical Quality Improvement Program (NSQIP) data were merged with intra-institutional inpatient administrative data. Twelve different comorbidities (diabetes, hypertension, congestive heart failure, hemodialysis-dependence, cancer diagnosis, chronic obstructive pulmonary disease, ascites, sepsis, smoking, steroid, congestive heart failure, acute renal failure, and dyspnea) were analyzed in terms of agreement between administrative and NSQIP data. RESULTS: Forty-one thousand four hundred thirty-two inpatient surgical hospitalizations were analyzed in this study. Concordance (Cohen Kappa value) between the 2 data sources varied from 0.79 (diabetes) to 0.02 (dyspnea). Hospital variation in concordance (intersite variation) was quantified using a test of homogeneity. This test found significant intersite variation at a level of P < 0.001 for each of the comorbidities except for dialysis (P = 0.07) and acute renal failure (P = 0.19). These findings imply significant differences between hospitals in their generation of comorbidity data. CONCLUSION: This study finds significant differences in how administrative versus registry data assess patient-level comorbidity. These differences are of concern to patients, payers, and providers, each of which had a stake in the integrity of these data. Standardized definitions of comorbidity and periodic audits are necessary to ensure data accuracy and minimize bias.

Population-Based Analysis of Adherence to Postdischarge Extended Venous Thromboembolism Prophylaxis After Colorectal Resection.

BACKGROUND: Prevention of venous thromboembolism after colorectal surgery remains challenging. National guidelines endorse thromboembolism prophylaxis for 4 weeks after colorectal cancer resection. Expert consensus favors extended prophylaxis after IBD surgery. The actual frequency of prescription after resection remains unknown. OBJECTIVE: This study aimed to assess prescription of extended, postdischarge venous thromboembolism prophylaxis after resection in Michigan. DESIGN: This is a retrospective review of elective colorectal resections within a statewide collaborative receiving postdischarge, extended-duration prophylaxis. SETTING: This study was conducted between October 2015 and February 2018 at an academic center. PATIENTS: A total of 5722 patients (2171 with colorectal cancer, 266 with IBD, and 3285 with other). MAIN OUTCOME MEASURES: We compared the prescription of extended, postdischarge prophylaxis over time, between hospitals and by indication. RESULTS: Of 5722 patients, 373 (6.5%) received extended-duration prophylaxis after discharge. Use was similar between patients undergoing surgery for cancer (282/2171, 13.0%) or IBD (31/266, 11.7%, p = 0.54), but was significantly more common for both patients undergoing surgery for cancer or IBD in comparison with patients with other indications (60/3285, 1.8%, p < 0.001). Use increased significantly among patients with cancer (6.8%-16.8%, p < 0.001) and patients with IBD (0%-15.1%, p < 0.05) over the study period. For patients with other diagnoses, use was rare and did not vary significantly (1.5%-2.3%, p = 0.49). Academic centers and large hospitals (>300 beds) were significantly more likely to prescribe extended-duration prophylaxis for all conditions (both p < 0.001), with the majority of prophylaxis concentrated at only a few hospitals. LIMITATIONS: This study was limited by the lack of assessment of actual adherence, small number of observed venous thromboembolism events, small sample of patients with IBD, and restriction to the state of Michigan. CONCLUSIONS: The use of extended-duration venous thromboembolism prophylaxis after discharge is increasing, but remains uncommon in most hospitals. Efforts to improve adherence may require quality implementation initiatives or targeted payment incentives. See Video Abstract at http://links.lww.com/DCR/B193. ANÁLISIS POBLACIONAL DE LA ADHERENCIA A LA PROFILAXIS ANTI-TROMBÓTICA EXTENDIDA (TEV) EN PACIENTES DE ALTA LUEGO DE UNA RESECCIÓN COLORECTAL.: La prevención del tromboembolismo venoso después de cirugía colorrectal sigue siendo un desafío. Las guías nacionales han aprobado la profilaxia del tromboembolismo durante cuatro semanas luego de una resección de cáncer colorrectal. El consenso de expertos favorece la profilaxia extendida solamente después de la cirugía por enfermedad inflamatoria intestinal. La frecuencia real de prescripción después de la resección colorrectal sigue siendo desconocida.Evaluar la prescripción de profilaxia prolongada de tromboembolismo venoso después del alta luego de una resección colorrectal en Michigan.Revisión retrospectiva de las resecciones colorrectales electivas seguidas de una profilaxia de larga duración con el apoyo de todo el estado (MI).Este estudio se realizó entre octubre de 2015 y febrero de 2018 en un solo centro académico.Un universo de 5722 pacientes operados (2171 por cáncer colorrectal, 266 por enfermedad inflamatoria intestinal, 3285 por otros diagnósticos).Se comparó la prescripción de profilaxia prolongada después del alta según la duración, los hospitales y la indicación.De 5722 pacientes, 373 (6.5%) recibieron profilaxia de duración prolongada después del alta. El uso fue similar entre pacientes sometidos a cirugía por cáncer (282/2171, 13.0%) o enfermedad inflamatoria intestinal (31/266, 11.7%, p = 0.54), pero fue significativamente más común para ambos en comparación con pacientes con otras indicaciones (60/3285, 1.8%, p < 0.001). El uso aumentó significativamente entre pacientes con cáncer (6.8% a 16.8% (p < 0.001)) y en pacientes con enfermedad inflamatoria intestinal (0% a 15.1%, p < 0.05) durante el período de estudio. Para pacientes con otros diagnósticos, su utilización fue rara y no varió significativamente (1.5% a 2.3%, p = 0.49). Los centros académicos y los grandes hospitales (>300 camas) tenían mayor probabilidad de prescribir la profilaxia de duración extendida en todas las afecciones (ambas p < 0.001), pero la mayoría de las profilaxis se concentraron el algunos pocos grandes hospitales.Este estudio estuvo limitado por la falta de evaluación de actuales adherentes, por el pequeño número de eventos tromboembólicos venosos observados, por la pequeña muestra de pacientes con enfermedad inflamatoria intestinal y debido a ciertas restricciones en el estado de Michigan.El uso de profilaxia para el tromboembolismo venoso de duración prolongada después del alta está en aumento, pero su uso sigue siendo poco frecuente en la mayoría de los hospitales. Los esfuerzos para mejorar la adherencia al tratamiento pueden requerir iniciativas de mejoría en la calidad o incentivos específicos de reembolso. Consulte Video Resumen en http://links.lww.com/DCR/B193. (Traducción-Dr. Xavier Delgadillo).

The Effect of Chronic Preoperative Opioid Use on Surgical Site Infections, Length of Stay, and Readmissions.

BACKGROUND: Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery. OBJECTIVE: The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes. DESIGN: This is a retrospective review of administrative data supplemented by individual chart review. SETTING: This study was conducted in a single-institution, multisurgeon, community colorectal training practice. PATIENTS: All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected. MAIN OUTCOME MEASURES: Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions. RESULTS: Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay. LIMITATIONS: Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes. CONCLUSIONS: Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Predictors of hernia after loop ileostomy closure: a single-center retrospective review.

PURPOSE: Our aims were to determine the rate of incisional hernia after closure of a loop ileostomy (LI) and to identify any perioperative risk factors that may be associated with hernia development. METHODS: We performed an IRB-approved retrospective review that included consecutive patients who underwent LI closure from January 1, 2012, to December 31, 2014. The primary outcome was identification of hernia on physical exam or by abdominal imaging. A stepwise logistic regression analysis was used to determine predictors of ileostomy site hernia. RESULTS: A total of 243 consecutive patients had LI closure during the study timeframe. The overall rate of hernia formation was 11.9% (29/243). The median time to discovery of the hernia was 16.4 (range, 2.2-55.9) months with a median follow-up time of 49 months. Although LI performed in conjunction with sigmoidectomy for diverticulitis consisted of only 19% of ileostomy cases, 62% of hernias were (18/29) identified in this cohort. Rates of hernia formation increased with respect to body mass index (underweight 0%; normal 4.6%; overweight 13.8%; obese 21%). The multivariable model identified increased BMI (underweight/normal weight versus overweight: OR 4.13, 95% CI 1.06-16.04; underweight/normal weight versus obese: OR 8.74, 95% CI 2.17-35.23) and surgical indication (reference variable: diverticulitis; rectal cancer: OR 0.21, 95% CI 0.06-0.76; Crohn's/ulcerative colitis: OR 0.06, 95% CI 0.01-0.53; other: OR 0.15, 95% CI 0.04-0.64) as significant predictors of ileostomy site hernia. CONCLUSION: The development of a hernia at the site of LI closure was influenced mostly by BMI, surgical indication, and operative time.

Sigmoidectomy for Diverticulitis-A Propensity-Matched Comparison of Minimally Invasive Approaches.

BACKGROUND: As the availability and use of robotic surgery increases, current data suggest comparable outcomes to laparoscopic surgery but at an increased cost. Elective sigmoid resection for diverticular disease is the most common colorectal application of robotic surgery and there is limited comparative data specifically for this indication. METHODS: We identified all elective cases of laparoscopic- and robot-assisted surgery for diverticular disease among a practice of 7 colorectal surgeons within an established enhanced recovery protocol. We performed propensity matching based on surgical indications (recurrent disease, ongoing symptoms, or fistula), stoma creation, and body mass index to create a matched cohort. Our primary outcomes were return of bowel function, length of stay, opioid use, and pain scores during the first 72 h postoperatively. Secondary outcomes were operative room and hospital charges. RESULTS: From 2011 to 2016, 69 robotic cases were propensity matched from a group of 222 laparoscopic cases to create a 1:1 case ratio that was equivalent in terms of patient demographics and operative indications. Time to first bowel movement was slightly quicker in the robotic group (1 [1] versus 2 [1.5], P = 0.09), while length of stay (3.5 [1.6] versus 3.6 [1.4] d, P = 0.64) was equivalent. Pain scores were lower in the robotic group on day 0 (4.6 versus 6.1, P = 0.0001), but similar on day 1 and day 2 (4.3 versus 4.1, P = 0.62 and 3.8 versus 3.3, P = 0.19). There was no difference in postoperative 72-h opioid use between groups (110.8 MME [144.5] versus 97.4 MME [101.5], P = 0.70). In the robotic arm operating room charges were slightly more ($2835 ± $394 versus $2196 ± $359, P < 0.0001), but total hospital charges were over significantly increased ($41,159 [$7840] versus $25,761 [$11,689], P < 0.0001). CONCLUSIONS: Via a carefully matched cohort of elective sigmoid resection for diverticular disease at a single community institution, we have demonstrated that laparoscopic- and robotic-assisted surgery result in clinically equivalent return of bowel function, length of stay, postoperative pain, and opioid use.

Diverticulitis recurrence after percutaneous abscess drainage.

PURPOSE: Recurrent diverticulitis has been reported in 30-50% of patients who recover from an episode of diverticular-associated abscess. Our aim was to review the outcomes of patients who underwent non-operative management after percutaneous drainage (PD) of colonic diverticular abscess. METHODS: All patients with a diverticular-associated abscess were identified between 2001 and 2012. Individual charts were queried for peri-procedural data and follow-up. The most recent follow-up data were acquired via the electronic medical record or telephone call. RESULTS: A total of 165 patients underwent PD of diverticular-associated abscesses. Abscess locations were pelvic (n = 122), abdominal (n = 36), and both (n = 7), while median abscess size was 6.1 ± 2.2 cm. One hundred eighteen patients clinically improved following non-operative management, and 81 of these patients did not undergo subsequent colonic resection within 4 months of PD. Of these, 8 died within 12 months. Among the remaining 73 patients, there were no significant differences in demographics or abscess variables compared to those who underwent elective surgery within 4 months. Only 7 of 73 patients had documented episodes of recurrences, while 22 patients later had elective surgery (1.1 ± 1.2 years from the index case). Five-year colectomy-free survival was 55% (95%CI 42-66%), while the recurrence-free survival at 5 years was 77% (95%CI 65-86%). All recurrences were managed non-operatively initially and one patient went on to have elective resection. CONCLUSION: A sizable number of patients successfully recover from complicated diverticulitis following PD. Subsequent non-operative management carries an acceptable risk for recurrent episodes and may be considered as a reasonable management option.