American journal of obstetrics and gynecology, Jan 19, 2015
The TOPAS™ system is a posterior anal sling that is a minimally invasive, self-fixating polypropy... more The TOPAS™ system is a posterior anal sling that is a minimally invasive, self-fixating polypropylene mesh intended to treat fecal incontinence (FI) in women who have failed conservative therapy. We are reporting one year outcome in a prospective, multi-center study under Investigational Device Exemption, evaluating this new treatment modality. A total of 152 women were implanted with the TOPAS™ system at 14 centers in the United States. FI was assessed preoperatively and at the 12 month follow up with a 14 day bowel diary, Cleveland Clinic Incontinence Scores (CCIS) and Fecal Incontinence Quality of Life (FIQOL) questionnaires. Treatment success was defined as reduction in number of FI episodes of 50% or more compared to baseline. Missing bowel diary data were considered treatment failures. The Wilcoxon signed-rank test was used to compare changes observed at 12 month versus baseline. Mean age was 59.6 years old (sd 9.7). The mean duration of FI was 110 mos (range 8-712). Mean leng...
Dietary fiber supplements are used to manage fecal incontinence (FI), but little is known about t... more Dietary fiber supplements are used to manage fecal incontinence (FI), but little is known about the fiber type to recommend or the level of effectiveness of such supplements, which appear related to the fermentability of the fiber. The aim of this single-blind, randomized controlled trial was to compare the effects of three dietary fiber supplements (carboxymethylcellulose [CMC], gum arabic [GA], or psyllium) with differing levels of fermentability to a placebo in community-living individuals incontinent of loose/liquid feces. The primary outcome was FI frequency; secondary outcomes included FI amount and consistency, supplement intolerance, and quality of life (QoL). Possible mechanisms underlying supplement effects were also examined. After a 14-day baseline, 189 subjects consumed a placebo or 16g total fiber/day of one of the fiber supplements for 32 days. FI frequency significantly decreased after psyllium supplementation versus placebo, in both intent-to-treat and per-protocol mixed model analyses. CMC increased FI frequency. In intent-totreat analysis, the number of FI episodes/week after supplementation was estimated to be 5.5 for Placebo, 2.5 for Psyllium, 4.3 for GA, and 6.2 for CMC. Only psyllium consumption resulted in a gel in feces. Supplement intolerance was low. QoL scores did not differ among groups. Patients with FI may experience a reduction in FI frequency after psyllium supplementation, and decreased FI frequency has been shown to be an important personal goal of treatment for patients with FI. Formation of a gel in feces appears to be a mechanism by which residual psyllium improved FI.
Human studies have shown that dietary fiber affects stool composition and consistency. Because fe... more Human studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. To compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. Thirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. In the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by nonsignificant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. Supplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.
Recruitment of participants to clinical trials remains a significant challenge, especially for re... more Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). The Fiber Study, a randomized controlled trial on symptom management for FI, successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported. Keywords recruitment; retention; cultural diversity; randomized controlled trials; fecal incontinence; fiber Recruitment of participants to clinical trials remains a significant challenge, with many studies failing to recruit the needed number of participants (Gallagher-Thompson, et al., 2006). The focus of this clinical trial, fecal incontinence (FI), is a health problem with significant social stigma attached to it (
Background-Knowledge about adverse symptoms over time from fiber supplementation is lacking. Purp... more Background-Knowledge about adverse symptoms over time from fiber supplementation is lacking. Purpose-To compare the severity of adverse gastrointestinal (GI) symptoms during supplementation with dietary fiber or placebo over time in adults with fecal incontinence. Secondary aims were to determine the relationship between symptom severity and emotional upset and their association with study attrition and reducing fiber dose. Methods-Subjects (N=189, 77% female, 92% white, (age = 58 years, SD = 14) with fecal incontinence were randomly assigned to placebo or a supplement of 16g total dietary fiber/day from one of three sources: gum arabic, psyllium, or carboxymethylcellulose. They reported GI symptoms daily during baseline (14 days), incremental fiber dosing (6 days), and two segments of steady full fiber dose (32 days total). Results-Severity of symptoms in all groups was minimal. Adjusting for study segment and day, a greater feeling of fullness in the psyllium group was the only symptom that differed from symptoms in the placebo group. Odds of having greater severity of flatus, belching, fullness, and bloating were 1.2-2.0 times greater in the steady dose segment compared to baseline. There was a positive association between symptom severity and emotional upset. Subjects with a greater feeling of fullness or bloating or higher scores for total symptom severity or emotional upset were more likely to withdraw from the study sooner or reduce fiber dose. Conclusions-Persons with fecal incontinence experience a variety of GI symptoms over time. Symptom severity and emotional upset appear to influence fiber tolerance and study attrition. Supplements seemed well tolerated.
Journal of Wound, Ostomy & Continence Nursing, 2011
Purpose-The use of disposable absorbent products by community-dwelling people with fecal incontin... more Purpose-The use of disposable absorbent products by community-dwelling people with fecal incontinence was described. Differences in product use or evaluation based on sex, age, or severity of fecal incontinence were evaluated. Suggestions for modifying absorbent products to be more suitable for fecal incontinence were described. Methods-A survey was administered to 189 community-living individuals with fecal incontinence at the start of a clinical trial about the effects of dietary fiber on fecal incontinence Results-An absorbent product was used to manage fecal incontinence by 45% (86/189) of respondents. More women (88%, 76/86, p = .009) and older persons 65 + years (44%, 38/86, p =. 001) wore an absorbent product. Participants who wore an absorbent product for fecal incontinence had a higher (worse) usual fecal incontinence severity score (median 4.75, range 1-27, p = .006). Sixty three users wore pantiliners and were the only ones who used more than three products per day. Feminine hygiene products were worn more than incontinence products. Half of users were satisfied with the product they used. Evaluations of product features differed by type of product; odor control had some of the lowest ratings. Conclusions-Community-living individuals with FI, especially women and older individuals, tend to wear absorbent products. Perceptions of FI severity, preference, leakage of liquid stool, and presence of urinary incontinence influence the product type and pattern of wear. Participants report that modification of several features of absorbent products might make them more suitable for FI and increase satisfaction.
Journal of Wound, Ostomy and Continence Nursing, 2000
In our clinical and research experience, persons with fecal incontinence anecdotally report alter... more In our clinical and research experience, persons with fecal incontinence anecdotally report altered diet intake to avoid incontinence. The purpose of this study was to compare the dietary intake of 39 persons with fecal incontinence living in the community with that of age- and gender-matched control subjects who had normal bowel function. The diets of both groups were compared with recommended dietary allowances (RDAs) for their constituent nutrients. Subjects prospectively recorded the type, amount, and method of preparing all foods and beverages ingested for 8 consecutive days. Diet records were analyzed using the Nutritionist IV software program. The main outcome measures were the amounts and percentage of the RDAs of macronutrients and micronutrients in the subjects' diets. There were no significant differences in the intake of total kilocalories, protein, fat, dietary fiber, caffeine, or lactose by the fecal incontinence and control groups. The fecal incontinence group had a greater intake of carbohydrates, manganese, and vitamin B(1) compared with the control group. Diets of both groups exceeded 100% of the RDA for protein, phosphorus, iron, sodium, potassium, Vitamins B(1), B(2), B(3), B(12), and C and folate. Diets of both groups had less than 50% of the RDA for biotin, chromium, copper, and manganese but did not differ significantly. The percentages of the RDA for calcium and vitamin D were 84% +/- 6% and 56% +/- 8% for the fecal incontinence group and 90 +/- 8 (P =.6) and 69 +/- 11 for the control group (P =.4). The diets of persons with fecal incontinence were similar to those of control subjects with normal bowel function. Both the fecal incontinence and control groups may improve their nutritional patterns by lowering sodium and protein intake and increasing dietary fiber and monounsaturated fat intake. Calcium and vitamin D supplementation may improve dietary deficiencies and lower disease risks. Including a nutritional assessment and consultation in the care of persons with fecal incontinence to improve their general health and prevent disease is recommended, but consideration must be given to altered diet patterns perceived by the patient to prevent fecal incontinence.
... James Church, MD, For the Collaborative Group, and Ann Lowry, MD, Clifford Simmang, MD, For T... more ... James Church, MD, For the Collaborative Group, and Ann Lowry, MD, Clifford Simmang, MD, For The American Society of Colon and Rectal ... St. John JB, McDermott FT, Hopper JL, Debney EA, Johnson WR, Hughes ES, Cancer risk in relatives of patients with common colorectal ...
Anal sphincter injury is a serious complication of childbirth, which may result in persistent ana... more Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States. METHODS: Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients. RESULTS: Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P < 0.05), and manometric results were reduced. Three of these seven patients had a thirddegree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section. CONCLUSIONS: The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.
It should be recognized that these guidelines should not be deemed inclusive of all proper method... more It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
Subtotal colectomy reliably increases bowel-movement frequency in patients with slow-transit cons... more Subtotal colectomy reliably increases bowel-movement frequency in patients with slow-transit constipation, but its impact on quality of life is unknown. The purpose of this study was to assess the relationship between functional outcomes and quality of life after subtotal colectomy for slow-transit constipation. We reviewed the charts and operative reports of all patients who underwent subtotal colectomy for slow-transit constipation from January 1992 to June 2001. We sent them a 54-question survey that inquired about bowel function and included a modified 36-item gastrointestinal quality-of-life index. Using Pearson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s R, we correlated gastrointestinal quality-of-life index scores with specific functional outcomes. Of 112 patients (109 females), 28 had been lost to follow-up and 2 had died. In all, 75 surveys (67 percent) were returned. Most of these 75 patients (81 percent) were at least somewhat pleased with their bowel-movement frequency, but 41 percent cited abdominal pain; 21 percent, incontinence; and 46 percent, diarrhea at least some of the time. The overall mean gastrointestinal quality-of-life index score was 103 +/- 22 of a maximum possible score of 144 (mean score for healthy controls, 126 +/- 13). We found no correlation between frequency of bowel movements and gastrointestinal quality-of-life index score (R = -0.03). Abdominal pain, diarrhea, and incontinence each had a statistically significant negative impact on gastrointestinal quality-of-life index scores (P = 0.01). Patients who required permanent ileostomy had low gastrointestinal quality-of-life index scores (68 +/- 24). The vast majority (93 percent) of patients stated they would undergo subtotal colectomy again if given a second chance. Subtotal colectomy for slow-transit constipation increases bowel-movement frequency; however, the persistence of abdominal pain and the development of postoperative incontinence or diarrhea adversely affect quality of life. Although most patients in the present study were satisfied with their results, quality-of-life scores should be used to assess postoperative outcome.
BACKGROUND: Preoperative chemoradiation therapy in patients with rectal cancer results in patholo... more BACKGROUND: Preoperative chemoradiation therapy in patients with rectal cancer results in pathologic complete response in approximately 10% to 30% of patients. accurate predictive factors for obtaining pathologic complete response would likely influence the selection of patients best treated by chemoradiation therapy as the primary treatment without radical surgery. OBJECTIVE: the aim of this study was to evaluate the impact of tumor size, stage, location, circumferential extent, patient characteristics, and pretreatment Cea levels on the development of pathologic complete response after chemoradiation therapy. DESIGN: this study is a retrospective review. SETTINGS AND PATIENTS: five hundred thirty patients treated with preoperative chemoradiation therapy and radical surgery for rectal adenocarcinoma between 1998 and 2011 were identified. a total of 469 patients remained after excluding patients with a history of pelvic radiation (n = 2), previous transanal endoscopic microsurgery or polypectomy of the primary lesion (n = 15), concurrent malignant tumor (n = 14), and no information about pre-or posttreatment t stage in the chart (n = 30). Preoperative Cea levels were available for 267 patients (57%). INTERVENTIONS: Preoperative chemoradiation therapy and total mesorectal excision were performed in patients with rectal cancer. MAIN OUTCOME: the primary outcome measured was pathologic complete response. RESULTS: ninety-six patients (20%) were found to have a pathologic complete response in the operative specimen. low pretreatment Cea (3.4 vs 9.6 ng/ml; p = 0.008) and smaller mean tumor size (4.2 vs 4.7 cm; p = 0.02) were significantly associated with pathologic complete response. low Cea levels and interruption in chemoradiation therapy were significant predictors of pathologic complete response in the multivariate analysis. When stratifying for smoking status, low Cea level was significantly associated with pathologic complete response only in the group of nonsmokers (p = 0.02). LIMITATIONS: this study was limited by its retrospective design, missing Cea values, and lack of tumor regression grade assessment. CONCLUSIONS: We demonstrated an association between low pretreatment Cea levels, interruption in chemoradiation therapy, and pathologic complete response in patients treated with neoadjuvant chemoradiation therapy for locally advanced rectal cancer. the predictive value of Cea in smokers can be limited, and further studies are needed to evaluate the impact of smoking on the predictive value of Cea levels for pathologic complete response in rectal cancer.
Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one ... more Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition.
Conflict occurs frequently in any workplace; health care is not an exception. The negative conseq... more Conflict occurs frequently in any workplace; health care is not an exception. The negative consequences include dysfunctional team work, decreased patient satisfaction, and increased employee turnover. Research demonstrates that training in conflict resolution skills can result in improved teamwork, productivity, and patient and employee satisfaction. Strategies to address a disruptive physician, a particularly difficult conflict situation in healthcare, are addressed.
PURPOSE: This study was designed to evaluate the outcome of anterior sphincteroplasty in a large ... more PURPOSE: This study was designed to evaluate the outcome of anterior sphincteroplasty in a large series with ten-year follow-up. METHODS: The long-term results in 191 con-secutive patients who were a median of ten years from sphincteroplasty were assessed. A ...
American journal of obstetrics and gynecology, Jan 19, 2015
The TOPAS™ system is a posterior anal sling that is a minimally invasive, self-fixating polypropy... more The TOPAS™ system is a posterior anal sling that is a minimally invasive, self-fixating polypropylene mesh intended to treat fecal incontinence (FI) in women who have failed conservative therapy. We are reporting one year outcome in a prospective, multi-center study under Investigational Device Exemption, evaluating this new treatment modality. A total of 152 women were implanted with the TOPAS™ system at 14 centers in the United States. FI was assessed preoperatively and at the 12 month follow up with a 14 day bowel diary, Cleveland Clinic Incontinence Scores (CCIS) and Fecal Incontinence Quality of Life (FIQOL) questionnaires. Treatment success was defined as reduction in number of FI episodes of 50% or more compared to baseline. Missing bowel diary data were considered treatment failures. The Wilcoxon signed-rank test was used to compare changes observed at 12 month versus baseline. Mean age was 59.6 years old (sd 9.7). The mean duration of FI was 110 mos (range 8-712). Mean leng...
Dietary fiber supplements are used to manage fecal incontinence (FI), but little is known about t... more Dietary fiber supplements are used to manage fecal incontinence (FI), but little is known about the fiber type to recommend or the level of effectiveness of such supplements, which appear related to the fermentability of the fiber. The aim of this single-blind, randomized controlled trial was to compare the effects of three dietary fiber supplements (carboxymethylcellulose [CMC], gum arabic [GA], or psyllium) with differing levels of fermentability to a placebo in community-living individuals incontinent of loose/liquid feces. The primary outcome was FI frequency; secondary outcomes included FI amount and consistency, supplement intolerance, and quality of life (QoL). Possible mechanisms underlying supplement effects were also examined. After a 14-day baseline, 189 subjects consumed a placebo or 16g total fiber/day of one of the fiber supplements for 32 days. FI frequency significantly decreased after psyllium supplementation versus placebo, in both intent-to-treat and per-protocol mixed model analyses. CMC increased FI frequency. In intent-totreat analysis, the number of FI episodes/week after supplementation was estimated to be 5.5 for Placebo, 2.5 for Psyllium, 4.3 for GA, and 6.2 for CMC. Only psyllium consumption resulted in a gel in feces. Supplement intolerance was low. QoL scores did not differ among groups. Patients with FI may experience a reduction in FI frequency after psyllium supplementation, and decreased FI frequency has been shown to be an important personal goal of treatment for patients with FI. Formation of a gel in feces appears to be a mechanism by which residual psyllium improved FI.
Human studies have shown that dietary fiber affects stool composition and consistency. Because fe... more Human studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. To compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. Thirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. In the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by nonsignificant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. Supplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.
Recruitment of participants to clinical trials remains a significant challenge, especially for re... more Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). The Fiber Study, a randomized controlled trial on symptom management for FI, successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported. Keywords recruitment; retention; cultural diversity; randomized controlled trials; fecal incontinence; fiber Recruitment of participants to clinical trials remains a significant challenge, with many studies failing to recruit the needed number of participants (Gallagher-Thompson, et al., 2006). The focus of this clinical trial, fecal incontinence (FI), is a health problem with significant social stigma attached to it (
Background-Knowledge about adverse symptoms over time from fiber supplementation is lacking. Purp... more Background-Knowledge about adverse symptoms over time from fiber supplementation is lacking. Purpose-To compare the severity of adverse gastrointestinal (GI) symptoms during supplementation with dietary fiber or placebo over time in adults with fecal incontinence. Secondary aims were to determine the relationship between symptom severity and emotional upset and their association with study attrition and reducing fiber dose. Methods-Subjects (N=189, 77% female, 92% white, (age = 58 years, SD = 14) with fecal incontinence were randomly assigned to placebo or a supplement of 16g total dietary fiber/day from one of three sources: gum arabic, psyllium, or carboxymethylcellulose. They reported GI symptoms daily during baseline (14 days), incremental fiber dosing (6 days), and two segments of steady full fiber dose (32 days total). Results-Severity of symptoms in all groups was minimal. Adjusting for study segment and day, a greater feeling of fullness in the psyllium group was the only symptom that differed from symptoms in the placebo group. Odds of having greater severity of flatus, belching, fullness, and bloating were 1.2-2.0 times greater in the steady dose segment compared to baseline. There was a positive association between symptom severity and emotional upset. Subjects with a greater feeling of fullness or bloating or higher scores for total symptom severity or emotional upset were more likely to withdraw from the study sooner or reduce fiber dose. Conclusions-Persons with fecal incontinence experience a variety of GI symptoms over time. Symptom severity and emotional upset appear to influence fiber tolerance and study attrition. Supplements seemed well tolerated.
Journal of Wound, Ostomy & Continence Nursing, 2011
Purpose-The use of disposable absorbent products by community-dwelling people with fecal incontin... more Purpose-The use of disposable absorbent products by community-dwelling people with fecal incontinence was described. Differences in product use or evaluation based on sex, age, or severity of fecal incontinence were evaluated. Suggestions for modifying absorbent products to be more suitable for fecal incontinence were described. Methods-A survey was administered to 189 community-living individuals with fecal incontinence at the start of a clinical trial about the effects of dietary fiber on fecal incontinence Results-An absorbent product was used to manage fecal incontinence by 45% (86/189) of respondents. More women (88%, 76/86, p = .009) and older persons 65 + years (44%, 38/86, p =. 001) wore an absorbent product. Participants who wore an absorbent product for fecal incontinence had a higher (worse) usual fecal incontinence severity score (median 4.75, range 1-27, p = .006). Sixty three users wore pantiliners and were the only ones who used more than three products per day. Feminine hygiene products were worn more than incontinence products. Half of users were satisfied with the product they used. Evaluations of product features differed by type of product; odor control had some of the lowest ratings. Conclusions-Community-living individuals with FI, especially women and older individuals, tend to wear absorbent products. Perceptions of FI severity, preference, leakage of liquid stool, and presence of urinary incontinence influence the product type and pattern of wear. Participants report that modification of several features of absorbent products might make them more suitable for FI and increase satisfaction.
Journal of Wound, Ostomy and Continence Nursing, 2000
In our clinical and research experience, persons with fecal incontinence anecdotally report alter... more In our clinical and research experience, persons with fecal incontinence anecdotally report altered diet intake to avoid incontinence. The purpose of this study was to compare the dietary intake of 39 persons with fecal incontinence living in the community with that of age- and gender-matched control subjects who had normal bowel function. The diets of both groups were compared with recommended dietary allowances (RDAs) for their constituent nutrients. Subjects prospectively recorded the type, amount, and method of preparing all foods and beverages ingested for 8 consecutive days. Diet records were analyzed using the Nutritionist IV software program. The main outcome measures were the amounts and percentage of the RDAs of macronutrients and micronutrients in the subjects&#39; diets. There were no significant differences in the intake of total kilocalories, protein, fat, dietary fiber, caffeine, or lactose by the fecal incontinence and control groups. The fecal incontinence group had a greater intake of carbohydrates, manganese, and vitamin B(1) compared with the control group. Diets of both groups exceeded 100% of the RDA for protein, phosphorus, iron, sodium, potassium, Vitamins B(1), B(2), B(3), B(12), and C and folate. Diets of both groups had less than 50% of the RDA for biotin, chromium, copper, and manganese but did not differ significantly. The percentages of the RDA for calcium and vitamin D were 84% +/- 6% and 56% +/- 8% for the fecal incontinence group and 90 +/- 8 (P =.6) and 69 +/- 11 for the control group (P =.4). The diets of persons with fecal incontinence were similar to those of control subjects with normal bowel function. Both the fecal incontinence and control groups may improve their nutritional patterns by lowering sodium and protein intake and increasing dietary fiber and monounsaturated fat intake. Calcium and vitamin D supplementation may improve dietary deficiencies and lower disease risks. Including a nutritional assessment and consultation in the care of persons with fecal incontinence to improve their general health and prevent disease is recommended, but consideration must be given to altered diet patterns perceived by the patient to prevent fecal incontinence.
... James Church, MD, For the Collaborative Group, and Ann Lowry, MD, Clifford Simmang, MD, For T... more ... James Church, MD, For the Collaborative Group, and Ann Lowry, MD, Clifford Simmang, MD, For The American Society of Colon and Rectal ... St. John JB, McDermott FT, Hopper JL, Debney EA, Johnson WR, Hughes ES, Cancer risk in relatives of patients with common colorectal ...
Anal sphincter injury is a serious complication of childbirth, which may result in persistent ana... more Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States. METHODS: Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients. RESULTS: Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P < 0.05), and manometric results were reduced. Three of these seven patients had a thirddegree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section. CONCLUSIONS: The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.
It should be recognized that these guidelines should not be deemed inclusive of all proper method... more It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
Subtotal colectomy reliably increases bowel-movement frequency in patients with slow-transit cons... more Subtotal colectomy reliably increases bowel-movement frequency in patients with slow-transit constipation, but its impact on quality of life is unknown. The purpose of this study was to assess the relationship between functional outcomes and quality of life after subtotal colectomy for slow-transit constipation. We reviewed the charts and operative reports of all patients who underwent subtotal colectomy for slow-transit constipation from January 1992 to June 2001. We sent them a 54-question survey that inquired about bowel function and included a modified 36-item gastrointestinal quality-of-life index. Using Pearson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s R, we correlated gastrointestinal quality-of-life index scores with specific functional outcomes. Of 112 patients (109 females), 28 had been lost to follow-up and 2 had died. In all, 75 surveys (67 percent) were returned. Most of these 75 patients (81 percent) were at least somewhat pleased with their bowel-movement frequency, but 41 percent cited abdominal pain; 21 percent, incontinence; and 46 percent, diarrhea at least some of the time. The overall mean gastrointestinal quality-of-life index score was 103 +/- 22 of a maximum possible score of 144 (mean score for healthy controls, 126 +/- 13). We found no correlation between frequency of bowel movements and gastrointestinal quality-of-life index score (R = -0.03). Abdominal pain, diarrhea, and incontinence each had a statistically significant negative impact on gastrointestinal quality-of-life index scores (P = 0.01). Patients who required permanent ileostomy had low gastrointestinal quality-of-life index scores (68 +/- 24). The vast majority (93 percent) of patients stated they would undergo subtotal colectomy again if given a second chance. Subtotal colectomy for slow-transit constipation increases bowel-movement frequency; however, the persistence of abdominal pain and the development of postoperative incontinence or diarrhea adversely affect quality of life. Although most patients in the present study were satisfied with their results, quality-of-life scores should be used to assess postoperative outcome.
BACKGROUND: Preoperative chemoradiation therapy in patients with rectal cancer results in patholo... more BACKGROUND: Preoperative chemoradiation therapy in patients with rectal cancer results in pathologic complete response in approximately 10% to 30% of patients. accurate predictive factors for obtaining pathologic complete response would likely influence the selection of patients best treated by chemoradiation therapy as the primary treatment without radical surgery. OBJECTIVE: the aim of this study was to evaluate the impact of tumor size, stage, location, circumferential extent, patient characteristics, and pretreatment Cea levels on the development of pathologic complete response after chemoradiation therapy. DESIGN: this study is a retrospective review. SETTINGS AND PATIENTS: five hundred thirty patients treated with preoperative chemoradiation therapy and radical surgery for rectal adenocarcinoma between 1998 and 2011 were identified. a total of 469 patients remained after excluding patients with a history of pelvic radiation (n = 2), previous transanal endoscopic microsurgery or polypectomy of the primary lesion (n = 15), concurrent malignant tumor (n = 14), and no information about pre-or posttreatment t stage in the chart (n = 30). Preoperative Cea levels were available for 267 patients (57%). INTERVENTIONS: Preoperative chemoradiation therapy and total mesorectal excision were performed in patients with rectal cancer. MAIN OUTCOME: the primary outcome measured was pathologic complete response. RESULTS: ninety-six patients (20%) were found to have a pathologic complete response in the operative specimen. low pretreatment Cea (3.4 vs 9.6 ng/ml; p = 0.008) and smaller mean tumor size (4.2 vs 4.7 cm; p = 0.02) were significantly associated with pathologic complete response. low Cea levels and interruption in chemoradiation therapy were significant predictors of pathologic complete response in the multivariate analysis. When stratifying for smoking status, low Cea level was significantly associated with pathologic complete response only in the group of nonsmokers (p = 0.02). LIMITATIONS: this study was limited by its retrospective design, missing Cea values, and lack of tumor regression grade assessment. CONCLUSIONS: We demonstrated an association between low pretreatment Cea levels, interruption in chemoradiation therapy, and pathologic complete response in patients treated with neoadjuvant chemoradiation therapy for locally advanced rectal cancer. the predictive value of Cea in smokers can be limited, and further studies are needed to evaluate the impact of smoking on the predictive value of Cea levels for pathologic complete response in rectal cancer.
Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one ... more Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition.
Conflict occurs frequently in any workplace; health care is not an exception. The negative conseq... more Conflict occurs frequently in any workplace; health care is not an exception. The negative consequences include dysfunctional team work, decreased patient satisfaction, and increased employee turnover. Research demonstrates that training in conflict resolution skills can result in improved teamwork, productivity, and patient and employee satisfaction. Strategies to address a disruptive physician, a particularly difficult conflict situation in healthcare, are addressed.
PURPOSE: This study was designed to evaluate the outcome of anterior sphincteroplasty in a large ... more PURPOSE: This study was designed to evaluate the outcome of anterior sphincteroplasty in a large series with ten-year follow-up. METHODS: The long-term results in 191 con-secutive patients who were a median of ten years from sphincteroplasty were assessed. A ...
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