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The article presents the poem "Service With a Smile," by J. C. Reilly. First Line: Just past the bridge at Walshingham Square; Last Line: like a glimpse of Chelli's sly smirk.

Presents the poem "Louisiana Ghazal," by JC Reilly. First Line: Wisteria blooms spill drowsily as blueberry syrup to Pelican Alley; Last Line: sketches this scene in sentiment, who in youth loved and knew Pelican Alley.

Background: On May 6, 1887 at a meeting of the West London Medico-Chirurgical Society, original observations attributed to D. H. Goodsall described an association between the secondary (external) sinus opening and the location of the primary (internal) opening of an anal fistula: posterior external sinuses had a midline origin and anterior external sinuses took a straight path to their internal origin-eponymously known as Goodsall's Rule. However, over the last century, published reports support the midline as the primary (internal) origin of all anal fistulas, thus challenging the predictive accuracy of Goodsall's Rule and prompting this expansive review., Methods: A literature search was performed for studies describing the relationship between the secondary (external) opening and the primary (internal) opening of anal fistulas, including recent reports of the positive predictive value (PPV) of Goodsall's Rule. The studies were evaluated to determine the validity of Goodsall's observations., Results: The midline was the dominant, primary (internal) opening site of all anal fistulas with up to 95% accuracy. Goodsall's Rule was inaccurate when applied to anal fistulas with an anterior off-midline external sinus opening which tend to mirror posterior off-midline external sinuses and curve to a midline origin, rather than take a straight course to a primary (internal) opening, as predicted by Goodsall. Use of the Midline Rule had superior predictive accuracy, reflected in an increase in overall PPV of the location of the primary (internal) origin from 49% using Goodsall's Rule to 71% using the Midline Rule (57-62% for men, 31-90% for women)., Conclusions: Goodsall's Rule falls short in predicting the natural course of anal fistulas with an anterior off-midline external sinus opening, especially for women. Given the increased risk of fecal incontinence related to surgical intervention for anterior-based anal fistulas, especially in women, dependence on Goodsall's Rule to guide the surgeon may result in "disastrous consequences". The preponderance of evidence over the last century favors the Midline Rule as a more accurate predictor of the true and natural course of anal fistulas, regardless of the location of the external sinus opening.

Background: Increasing numbers of people with dementia are presenting to acute care facilities for management of medical conditions and co-morbidities. They require an individual approach to care due to the confusion and disorientation which may accompany their illness. Current evidence syntheses on this topic explore how staff, family and carers view their care. This review aims to complement previous work in the area by exploring care from the perspective of the patient living with dementia., Objectives: The aim of this qualitative evidence synthesis was to explore the experiences and perceptions of patients living with dementia on the care they receive in acute settings., Design: Qualitative evidence synthesis systematically draws the findings from individual studies together to create valid, reliable and meaningful evidence for healthcare policy development. Framework synthesis was utilised and guided by the VIPS framework; Values, Individualised, Perspective, and Social and psychological. The VIPS framework has previously been used for exploring staffs' views of care in the acute setting and provides guidance to caring for people with dementia., Review Methods: Following screening, data were extracted and appraised using Critical Appraisal Skills Programme. Framework synthesis, incorporating thematic synthesis, was conducted and the confidence in findings was assessed using GRADE CERQual., Data Sources: Seven qualitative studies that explored care in acute hospitals as experienced or perceived by the person living with dementia., Results: The VIPS framework helped to capture views of care. Patients often experienced rushed and task- based approaches, poor communication, and exclusion in some cases. The environments were clearly unsuitable, sometimes exacerbating behaviours of concern, thus leading to unnecessary restraint due to an inability to protect this group., Conclusions: Further research needs to be conducted in testing existing or developing new interventions to improve the physical environment, the systems of care and to provide more person-centred approaches to care. Organisational structures must ensure patients are cared for in a dementia friendly environment by a dementia trained workforce. At local level, involving support workers, eliminating unnecessary care practices, and facilitating individual choices of patients are recommended., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse., Methods: Consecutive patients were identified from a surgical database and evaluated by chart review., Results: Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications., Conclusions: Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.

Purpose: The purpose of this study was to evaluate cryptoglandular fistula surgery outcomes in men with common types of fistulae., Method: A database review identified study patients. Exclusion criteria included history of previous fistula, previous anorectal surgery, inflammatory bowel disease, pelvic radiation, complex fistula, age <21 years, and absence of follow-up., Results: Four hundred twenty-five patients met criteria for review. Mean follow-up was 5.8 years. Concurrent abscess at presentation was strongly associated with poorer outcomes. New-onset seepage is more common with seton treatment (P = 0.01), but seepage resolution occurred less commonly with fistulotomy (P <0.01)., Conclusions: Although both treatments are highly successful, men treated with primary fistulotomy are more likely to heal than seton patients. Fistulotomy patients have less early postoperative seepage than seton patients, but when this is present it is less likely to resolve. Presentation with concurrent abscess is strongly associated with poorer outcomes.

Purpose: Previous studies identified reduction in pain and complications with stapled hemorrhoidopexy relative to conventional hemorrhoidectomy. Previously, the presence of resected squamous epithelium and a staple line height <20 mm above the dentate line were predictive of postoperative pain. The purpose of this study was to further investigate and refine the role of staple height in the prediction of postoperative outcomes., Methods: From July 2002 to October 2004, 75 patients with symptomatic Grade 3 and 4 mixed hemorrhoids underwent stapled hemorrhoidopexy in two teaching institutions with prospective data collection. All procedures were performed under the direct supervision of two colorectal teaching staff. The majority were performed under monitored anesthesia care as outpatient procedures. Preoperative, intraoperative, and postoperative patient characteristics were evaluated. This included demographics, staple line height, specimen histology, complications, days to return to work, duration of narcotic pain medicine, and preoperative/postoperative tone and seepage. The results were subjected to statistical analysis using t-test and ANOVA., Results: Seventy-five patients with a median age of 49 (range, 25-87) years were identified. Histology identified 62 specimens with columnar and/or transitional cells, 10 with squamous epithelium, and 3 with muscle present. Overall complication rate was 14 percent. Complications included three readmissions for pain control, three acute postoperative anal fissures, two postoperative bleeds (with one requiring examination under anesthesia without intervention), one patient with subcutaneous emphysema, and one admission for fecal impaction. Staple line height was not a statistically significant predictor of postoperative complication. Median return to work was 14 (range, 1-31) days. Median duration of narcotic use was six (range, 0-40) days. Patients with a staple line height>22 mm required a significantly shorter duration of narcotic pain management (P=0.024). Median follow-up was 24 (range, 9-253) days. Staple line heights below 20 mm had a mean return to work of 15 days. A staple line height>20 mm had a mean return to work of nine days. Staple line height was inversely related to return to work (P=0.01)., Conclusions: A hemorrhoidopexy staple line>or=22 mm above the dentate line correlates with a significantly shorter need for postoperative narcotics (P=0.024) and an earlier return to work (P=0.017). Staple line distance above the dentate line meaningfully impacts comfort-based outcomes.

Background: Debate exists regarding whether the use of topical agents and Botox injections are as efficacious as sphincterotomy for the treatment of chronic anal fissure., Methods: A retrospective review was performed to assess changes in management and outcomes of chronic anal fissure care in a community based colorectal practice between the individual years 1994 and 2003., Results: Forty-seven patients in 1994 underwent lateral partial internal sphincterotomy and had a 100% healing rate. Thirty-nine patients were treated in 2003, with 32 undergoing Botox injection and 7 undergoing sphincterotomy initially. Of the Botox patients, 35% had recurrence, and 7 subsequently required sphincterotomy. Ultimate healing rates in 2003 were 97%. Time to heal was markedly prolonged in 2003 compared with 1994. Complication rates were similar, and there was no lifestyle-altering incontinence., Conclusions: Our review documents a significant change in the community approach to chronic fissure management. The addition of multiple treatment modalities prolongs time to healing from initial evaluation, but they allowed 72% of patients to avoid the need for permanent sphincter division while maintaining ultimate rates of healing.

Background: Major comorbidities are recognized risk factors in colorectal surgery. We examine here the feasibility and safety of laparoscopic colorectal surgery (LC) in the complicated, high-risk patient., Methods: From July 2003 to October 2004, 107 consecutive patients undergoing LC were prospectively studied. Complicated patients were defined as age >80 years, body mass index (BMI) >30, and/or American Society of Anesthesiology level III or IV. A group of case-matched controls undergoing open surgery (OC) during a similar time period were retrospectively reviewed. The 2 groups were compared and assessed for major and minor morbidity and mortality., Results: Overall morbidity was higher in the OC group 52% versus 26%. Minor complications compared at 31% OC versus 9% LC and major at 21% and 17%, respectively. With LC, advancement to discharge was more rapid and discharge home more likely than to a care facility., Conclusion: With proper patient selection and laparoscopic experience, LC can be performed in the complicated patient without undue morbidity and mortality.

FluMist is the first live attenuated, cold-adapted intranasal influenza vaccine (LAIV) approved for the prevention of influenza A and B. Clinical trials have shown that annual vaccination with LAIV is effective for the prevention of influenza. LAIV appears well tolerated in healthy patients 5-49 years of age. The most common adverse events are abdominal pain, chills, cough, diarrhea, headache, irritability, lethargy, muscle aches, otitis media, rhinitis, sinusitis, sore throat, and vomiting. FluMist has a novel intranasal route of administration that allows for influenza prevention without a painful intramuscular injection. Barriers preventing acceptance of LAIV include defining the appropriate patient population, cost, and insurance coverage.

Purpose: Historically, there has been reluctance to use nonabsorbable synthetic mesh for repair of abdominal-wall defects in an operative field in which the presence of open bowel is accompanied by the potential for contamination. Some believe the risk of wound infection and mesh removal in this setting to be unacceptably high. The purpose of this study was to evaluate the safety and efficacy of nonabsorbable mesh used for hernia repair in the presence of a stoma or at the time of colon resection., Methods: All patients undergoing elective surgical implantation of mesh with concomitant open bowel from 1987 to 2001 were retrospectively reviewed. Computer database identified all patients undergoing parastomal hernia repair, ventral hernia repair with a stoma present, hernia repair with concomitant bowel resection, and colostomy closure with repair of hernia. No patients so identified were excluded. Follow-up was attained on all patients by chart review and telephone survey. The data was statistically analyzed by chi-squared test using a P value of <0.05 for statistical significance., Results: Twenty-nine patients were identified as having undergone 30 elective hernia repairs using nonabsorbable mesh. The repairs were performed in the presence of a stoma or in conjunction with bowel resection. All patients received bowel preparation. Included were 11 patients undergoing parastomal hernia repair (37 percent), 14 patients undergoing ventral hernia repair in the setting of open bowel (47 percent), and 5 patients in whom mesh repair of ventral and parastomal hernias were performed simultaneously (16 percent). Hernias recurred in 13 patients (43 percent). Overall recurrence for mesh repair at a parastomal site was 63 percent; overall recurrence at an incisional hernia site was 21 percent. The risk of wound complications after mesh placement in the setting of open bowel was assessed. Wound seromas developed after surgery in four patients (13 percent). Seromas were all treated successfully by aspiration. Wound infections occurred after surgery in two patients (7 percent). Wound infection occurred exclusively in sites of parastomal repair representing 2 of 16 (13 percent) of parastomal hernia sites. Infection with fistula necessitated mesh removal in one of these two cases. No chronic sinuses were observed. Incidences of recurrence and wound infection were statistically independent of type of hernia, variety of mesh, or operative approach., Conclusion: After bowel preparation, nonabsorbable mesh can be used for elective repair of incisional hernia in the presence of open bowel with an expectation of minor morbidity, minimal risk of infection, and an acceptable rate of recurrence. Nonabsorbable mesh can be used for elective repair of parastomal hernia in a similar setting with a low risk of infection independent of surgical approach. Although safe, local mesh repair of parastomal hernia was, in this study, accompanied by a high rate of recurrence.

Cystic fibrosis affects 1/2500 individuals and is the most common lethal autosomal recessive disease in people of northern European descent. It is characterized by chronic infections with mucoid Pseudomonas aeruginosa and progressive deterioration of respiratory function. Much research has focused on the inflammatory component of the disease. Macrolide antibiotics are postulated to suppress inflammatory mediators and interfere with biofilm formation produced by P. aeruginosa. In vitro studies show promising results, and a limited number of human studies reported improvements in respiratory function with the drugs. Macrolide antibiotics are generally safe and well tolerated and may prove to be effective in patients with cystic fibrosis.

Purpose: Pemphigoid is a well-recognized cutaneous lesion, occurring rarely in peristomal skin. We report the diagnosis and successful treatment of localized pemphigoid lesions adjacent to a colostomy., Methods: We review the chart, immunofluorescence study, treatment, and follow-up of a patient with bullous lesions at a colostomy site., Result: Pemphigoid of the pericolostomy skin was diagnosed by immunofluorescence study and successfully treated with antibiotic., Conclusion: Diagnosis of bullous pemphigoid should be considered in the differential diagnosis of a bullous lesion adjacent to a colostomy site. Diagnosis is easily made, and treatment is simple and efficacious.

Purpose and Methods: From 1979 through 1991, four patients of 631 admissions (0.6 percent) for Crohn's disease in Erie, Pennsylvania, presented with life-threatening gastrointestinal hemorrhage. These and 34 similar cases from the medical literature were reviewed to provide a composite of those at risk and elucidate appropriate diagnostic and therapeutic maneuvers., Results: The study revealed a preponderance of young men (2:1 ratio) with an average age of 35 (range, 14-89) years, the majority of whom had known Crohn's disease (60 percent) for an average of 4.6 (range, 0-18) years. The site of bleeding resembled the general distribution for Crohn's disease, with small bowel disease predominating (66 percent involved the ileum). The five cases of exsanguination (13 percent of the total) were all men with known Crohn's disease (average, 5.8 years) involving the ileum alone or in part. Mesenteric arteriography was positive in 17 patients, providing precise preoperative localization resulting in no mortality in this group. Excluding those who presented with exsanguination, surgery was necessary to cease hemorrhage in 91 percent (30/33) of patients. Ileocolectomy was the most frequently performed procedure (53 percent). In follow-up, only one patient required further surgical resection for recurrent bleeding (3.5 percent), and two other patients (7 percent) required further therapy for nonhemorrhagic recurrence., Conclusion: Crohn's disease may be responsible for life-threatening gastrointestinal hemorrhage and even exsanguination. Many of the characteristics of these patients resemble the general Crohn's disease population. Surgical resection provides excellent palliation. A long-term benign course can be expected in this subgroup of Crohn's disease patients.

This study was undertaken to determine the significance of polyomavirus nuclear inclusions in urine cytology specimens. Thirty-two such cases were identified and patient follow-up was instituted. We have determined that there is no detectable urologic damage in such patients. In a minority of cases inclusions were found in subsequent urines but they ultimately disappeared within 3 mo. In a minority of the patients (35 percent) there was evidence of diseases associated with immunosuppression or administration of immunosuppressive drugs.

We examined 6,132 cervical smears, applying strict criteria separating hematoidin cockleburrs from crystalline bodies. We found only crystalline bodies in 37 cases. There was a significant increase in the incidence of crystalline bodies in women taking oral contraceptives and in pregnant women. The bodies were not associated with an increase in complications of pregnancy or of abnormal births. A review of the literature led us to the conclusion that in cervical smears two types of crystalline structures may be found. One of these is the hematoidin body, which is related to hemorrhage during pregnancy and is probably associated with an increase in complications of pregnancy or abnormal births; the other, crystalline bodies, is not. We also conclude that crystalline bodies are much more common than hematoidin bodies. We found an unexpectedly high association of crystalline bodies with low grade squamous intraepithelial lesion (CIN1) in cervical smears.

To examine the predictive accuracy of Goodsall's rule, the records of 216 patients (155 men and 61 women) who underwent surgery for complete submuscular anal fistulas from 1982 to 1989 were retrospectively reviewed. In accordance with Goodsall's rule, 90 percent of 124 patients with an external opening posterior to the transverse anal line had anal fistulas tracking to the midline (87 percent men and 97 percent women). Only 49 percent of the 92 patients with an external opening anterior to the transverse anal line had anal fistulas that tracked in the radial fashion predicted by Goodsall (57 percent men and 31 percent women). Instead, 71 percent of these patients (62 percent men and 90 percent women) had anterior fistulas tracking to the midline. Overall, 81 percent (77 percent men and 93 percent women) of patients had complete submuscular anal fistulas that coursed to the midline (51 percent midline posterior and 30 percent midline anterior). In summary, Goodsall's rule is accurate only when applied to complete submuscular anal fistulas with posterior external anal openings. The rule is inaccurate in describing the course of complete submuscular anal fistulas with an anterior external opening. The men in this group had anal fistulas that defied Goodsall's rule in an unpredictable manner, whereas 90 percent of the women had fistulas tracking to a midline anterior origin.

In order to determine the feasibility, yield, and impact of routine total colonoscopy on the management of large-bowel cancer, 157 cancer patients underwent 175 colonoscopic procedures; 13.6 per cent of the cancers had been missed on double-contrast barium enema examination. Among 92 patients undergoing perioperative colonoscopy, the lesion was reached in 90 per cent and the cecum in 60 per cent; 7.6 per cent demonstrated synchronous cancers, all curable, and all missed on barium-enema examination. Seventy-eight patients underwent colonoscopy at an average of 3.7 years after treatment of the index cancer; 7.7 per cent demonstrated metachronous cancers, all curable, two-thirds of which were missed on barium-enema examination. Benign polyps were noted in 62 per cent of the patients studied; 77 per cent of those polyps, 1 cm or greater in size, were missed on barium-enema examination. Polyps were found proximal to the cancer in 60 per cent of the patients with polyps. Approximately 85 per cent of those with multiple cancers demonstrated benign polyps. Preoperative total colonoscopy with periodic postoperative colonoscopy at an interval of three to five years are essential in the reliable detection of synchronous cancers and for the detection of metachronous cancers at an earlier, more favorable stage.