Jennifer Y. Wang

Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country.

HYPOTHESIS Surgical trainees in the United States have a growing interest in both clinical experiences and structured training opportunities in global health. Global health training and exposure can be integrated into a surgical residency program. DESIGN The global health activities of surgical residents and faculty in 1 department were evaluated from January 1, 1998, to June 1, 2008, using a survey and personal interviews. RESULTS From January 1, 1998, to December 31, 2002, 4 faculty members made more than 20 overseas volunteer medical expeditions, but only 1 resident participated in global health activities. In 2003, a relationship with a surgical training program in a developing country was established. Ten residents and 12 faculty members have made overseas trips during the last 5 years, and 1 international surgeon has visited the United States. During their research block, 4 residents completed 1- to 3-month clinical rotations and contributed to mentored research projects. Three residents completed a university-based Global Health Clinical Scholars Program, and 3 obtained masters degrees in public health. A joint conference in injury-trauma research was also conducted. A faculty member is based overseas with clinical and research responsibilities, and another is completing a masters degree in public health. CONCLUSIONS Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries. Legitimate academic experiences improve the success of these programs. Reciprocity with collaborative partners must be ensured, and sustained commitment and funding remain a great challenge to such programs. The long-term effect on the development of global health careers is yet to be determined.

The Constipation Severity Instrument: A Validated Measure

PurposeThis study was designed to develop and test the validity and reliability of the Constipation Severity Instrument.MethodsScale development was conducted in two stages: 1) 74 items were generated through a literature review and focus groups of constipated patients and medical providers; and 2) a preliminary instrument was administered to 191 constipated patients and 103 healthy volunteers. Test-retest reliability of the constipated group was assessed (N = 90). Content, convergent, divergent, and discriminant validity were evaluated by using other validated measures by performing one-way analysis of variance and Pearson correlations.ResultsExploratory and confirmatory factor analysis revealed three subscales: obstructive defecation, colonic inertia, and pain. Internal consistency (α = 0.88–0.91) and test-retest reliability (intraclass correlation coefficients = 0.84–0.91) were high for all subscales. Constipated patients were grouped by Rome II criteria: functional constipation (22 percent), pelvic floor dyssynergia (15 percent), constipation predominant irritable bowel syndrome (23 percent), and no specific criteria (40 percent). Those with constipation predominant irritable bowel syndrome or pelvic floor dyssynergia scored higher on the Obstructive Defecation and Colonic Inertia subscales than those with functional constipation or no specific criteria (P = 0.001–0.058). Subjects with functional constipation had much lower scores on the pain subscale than constipation predominant irritable bowel syndrome, functional constipation, or no specific criteria (P < 0.009).The Constipation Severity Instrument subscale and total score correlated very highly with the subscales and total score of the Patient Assessment of Constipation Symptom measure. The Constipation Severity Instrument subscales discriminated well between constipated patients and healthy volunteers (P < 0.001) and demonstrated excellent divergent validity. Higher Constipation Severity Instrument scores inversely correlated with general quality of life.ConclusionsThe Constipation Severity Instrument is a reliable and valid instrument for assessing constipated patients. Administration of the Constipation Severity Instrument to other constipated patients will further validate its use.

Dartos Muscle Interposition Flap for the Treatment of Rectourethral Fistulas

PurposeRectourethral fistula is a rare complication of pelvic surgery, trauma, or inflammation. The many techniques for repairing these fistulas vary in their success rates. Our goal was to describe the use of a dartos muscle interposition flap for repair of these fistulas.MethodsWe performed a retrospective review of eight patients who underwent repair of a rectourethral fistula with a dartos muscle interposition flap. We describe the success rate and patient-related factors that may have affected success. The technique of dartos muscle interposition is described and compared with other previously described techniques.ResultsSix of eight patients had healing of their fistulas documented by follow-up cystogram.ConclusionsDartos muscle interposition is a straightforward technique that can result in successful fistula repair but should not be used in patients with risk factors for poor wound healing, such as an immunocompromised state or previous radiation therapy.

A valid and reliable measure of constipation-related quality of life.

PURPOSE: Few existing measures assess constipation-specific quality of life. This study sought to develop a valid and reliable quality-of-life measure for constipation. METHODS: First, we created a preliminary instrument that assessed quality-of-life domains affected by constipation: body image, eating, mood, and relationships with others. We conducted focus groups both with patients with constipation seeking treatment and the health care providers who treat them. Next, a 59-item questionnaire was given to 240 subjects with constipation (83% female) and 103 healthy volunteers (63% female). Test-retest reliability and discriminant, convergent, and divergent validity were assessed. RESULTS: Exploratory factor analysis revealed four domains: Social Impairment (five items), Distress (six items), Eating Habits (three items), and Bathroom Attitudes (four items). Internal consistency and test-retest reliability for all subscales was high (Cronbach’s alpha = 0.89; intraclass correlation coefficient = 0.87). All domains discriminated well between subjects with constipation and healthy volunteers (P < 0.001). Convergent validity was excellent: all subscales correlated highly with the Irritable Bowel Syndrome Quality of Life Scale total score (P < 0.001) and the Medical Outcomes Study Short Form-36 physical component and mental component summary scores (P < 0.001). Scores from our Constipation-Related Quality of Life measure were not significantly correlated with the Social Desirability Scale, demonstrating divergent validity. CONCLUSIONS: Our findings support the reliability and validity of the Constipation-Related Quality of Life measure. Future validation of the Constipation-Related Quality of Life measure for assessing changes in quality of life in response to treatments for constipation is needed.

Gender-specific differences in pelvic organ function after proctectomy for inflammatory bowel disease.

BACKGROUND: Significant concern exists regarding the effect of proctectomy on sexual function in patients with IBD. Little is known about gender-specific differences. OBJECTIVE: This study aimed to examine sexual function and quality of life in men and women with IBD before and after proctectomy. DESIGN: This is a prospective cohort study. SETTING: The study was conducted at a colorectal surgery center. PATIENTS: The patients included in this study have IBD and underwent proctectomy or proctocolectomy. INTERVENTION: The treatment provided was proctectomy or proctocolectomy. MAIN OUTCOME MEASURES: Validated questionnaires were used to assess sexual function, quality of life, bowel habits, and urinary symptoms, and were completed before and 6 months after surgery. RESULTS: Sixty-six participants (41 men and 25 women) were evaluated at baseline and 6 months after proctocolectomy or completion proctectomy. A total of 48 IPAAs (31 men and 17 women) and 18 end ileostomies (10 men and 8 women) were created. Men reported improved scores on the International Index of Erectile Function (P = .003), a modified Sexual Function Questionnaire (P = .001), Inflammatory Bowel Disease Quality of Life (P < .001), and SF-36 (Mental Component Summary, P = .003; Physical Component Summary, P = .001) after surgery. Women had improvement in the desire subscale of the Female Sexual Function Index (P = .03), Inflammatory Bowel Disease Quality of Life scores (P = .04), and SF-36 (Mental Component Summary, P = .02; Physical Component Summary, P = .02). There was no gender difference in the magnitude of change in scores before and after surgery for any of the measures. LIMITATIONS: Small sample size and sexually inactivity in 50% of cohort may have had an impact on our findings. CONCLUSIONS: Both men and women reported improvements in general and IBD-specific quality of life after surgery, but only men demonstrated several areas of improved sexual function. Women reported improved sexual desire but no other sexual function improvement. The postsurgical gender difference in sexual function, despite similar improvements in quality of life, may be accounted for by unexamined aspects of female sexual function.