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Bak MTJ, van Ruler O, Stassen L, Ruiterkamp M, Arkenbosch JHC, Dijkstra G, Campmans-Kuijpers MJE, van Meeteren NLU, Bongers BC, Romberg-Camps M, van der Marel S, Hoentjen F, van Dongen KW, West R, van der Woude J, de Vries AC. Preoperative screening and prehabilitation strategies prior to ileocolic resection in patients with Crohn's disease are not incorporated in routine care. Int J Colorectal Dis 2023; 38:254. [PMID: 37855846 PMCID: PMC10587192 DOI: 10.1007/s00384-023-04537-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Recently, recommendations on perioperative care have been published to optimize postoperative outcomes in preoperative patients with inflammatory bowel disease. This study evaluated the current use of preoperative screening and prehabilitation strategies (PS) prior to elective ileocolic resection (ICR) in patients with Crohn's disease (CD). METHODS Patients with CD who underwent an elective ICR were identified from a Dutch prospective cohort study. Primary endpoint was to evaluate to what extent IBD-relevant PS were applied in patients with CD prior to ICR according to the current recommendations. RESULTS In total, 109 CD patients were included. Screening of nutritional status was performed in 56% of the patients and revealed malnutrition in 46% of these patients. Of the malnourished patients, 46% was referred to a dietitian. Active smoking and alcohol consumption were reported in 20% and 28%; none of these patients were referred for a cessation program. A preoperative anemia was diagnosed in 61%, and ferritin levels were assessed in 26% of these patients. Iron therapy was started in 25% of the patients with an iron deficiency anemia. Exposure to corticosteroids at time of ICR was reported in 29% and weaned off in 3%. Consultation of a dietitian, psychologist, and physiotherapist was reported in 36%, 7%, and 3%. Physical fitness was assessed in none of the patients. CONCLUSION PS are not routinely applied and not individually tailored in the preoperative setting prior to elective ICR in patients with CD. Prior to implementation, future research on the costs and effectiveness of PS on postoperative outcomes and quality of life is necessary.
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Affiliation(s)
- Michiel Thomas Jan Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, Rotterdam, GD, The Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle Aan Den IJssel, The Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marit Ruiterkamp
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, Rotterdam, GD, The Netherlands
| | - Jeanine Hubertina Catharina Arkenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, Rotterdam, GD, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Nico Leonard Ulrich van Meeteren
- Department of Anesthesiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Top Sector Life Sciences & Health (Health~Holland), The Hague, The Netherlands
| | - Bart Chateau Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology and Hepatology, Geriatrics and Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Sander van der Marel
- Department of Gastroenterology and Hepatology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | | | - Rachel West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, Rotterdam, GD, The Netherlands
| | - Annemarie Charlotte de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, Rotterdam, GD, The Netherlands.
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Siriwardena AK, Serrablo A, Fretland ÅA, Wigmore SJ, Ramia-Angel JM, Malik HZ, Stättner S, Søreide K, Zmora O, Meijerink M, Kartalis N, Lesurtel M, Verhoef C, Balakrishnan A, Gruenberger T, Jonas E, Devar J, Jamdar S, Jones R, Hilal MA, Andersson B, Boudjema K, Mullamitha S, Stassen L, Dasari BVM, Frampton AE, Aldrighetti L, Pellino G, Buchwald P, Gürses B, Wasserberg N, Gruenberger B, Spiers HVM, Jarnagin W, Vauthey JN, Kokudo N, Tejpar S, Valdivieso A, Adam R. The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE. HPB (Oxford) 2023; 25:985-999. [PMID: 37471055 DOI: 10.1016/j.hpb.2023.05.360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management. METHODS This project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements. RESULTS Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term "early metachronous metastases" applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with "late metachronous metastases" applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSIONS The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.
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Affiliation(s)
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Stephen J Wigmore
- Hepatobiliary and Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jose M Ramia-Angel
- Department of Surgery, University Hospital of Guadalajara, Guadalajara, Spain
| | - Hassan Z Malik
- Liver Surgery Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
| | - Kjetil Søreide
- Department of Surgery, Bergen University Hospital, Bergen, Norway
| | - Oded Zmora
- Department of Colorectal Surgery, Shamir Medical Center, Tel Aviv, Israel
| | - Martijn Meijerink
- Department of Radiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | | | | | - Cornelis Verhoef
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Anita Balakrishnan
- Cambridge Hepato-Pancreato-Biliary Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Thomas Gruenberger
- Department of Surgery, HPB Center, Health Network Vienna, Clinic Favoriten and Sigmund Freud University, Vienna, Austria
| | - Eduard Jonas
- Department of Surgery, Groote Schuur Hospital, Cape Town
| | - John Devar
- Department of Surgery, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Saurabh Jamdar
- Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Robert Jones
- Liver Surgery Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Bodil Andersson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Karim Boudjema
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, Hôpital Pontchaillou, Rennes, France
| | | | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bobby V M Dasari
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Adam E Frampton
- Hepato-Pancreato-Biliary Unit, Royal Surrey County Hospital, Guildford, UK
| | - Luca Aldrighetti
- Department of Surgery, Vita Salute San Raffaele University & IRCCS San Raffaele Hospital, Milan, Italy
| | - Gianluca Pellino
- Department of Colorectal Surgery, Vall D'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Pamela Buchwald
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Bengi Gürses
- Department of Radiology, Koc University Medical Faculty, Istanbul, Turkey
| | - Nir Wasserberg
- Department of Surgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Israel
| | - Birgit Gruenberger
- Department of Medical Oncology and Haematology, Landesklinikum Wiener Neustadt, Lower Austria, Austria
| | - Harry V M Spiers
- Cambridge Hepato-Pancreato-Biliary Unit, Addenbrooke's Hospital, Cambridge, UK
| | - William Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | | | | | - René Adam
- Hepatobiliary and Transplant Unit, Hôpital Paul Brousse, Paris, France
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3
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Siriwardena AK, Serrablo A, Fretland ÅA, Wigmore SJ, Ramia-Angel JM, Malik HZ, Stättner S, Søreide K, Zmora O, Meijerink M, Kartalis N, Lesurtel M, Verhoef K, Balakrishnan A, Gruenberger T, Jonas E, Devar J, Jamdar S, Jones R, Hilal MA, Andersson B, Boudjema K, Mullamitha S, Stassen L, Dasari BVM, Frampton AE, Aldrighetti L, Pellino G, Buchwald P, Gürses B, Wasserberg N, Gruenberger B, Spiers HVM, Jarnagin W, Vauthey JN, Kokudo N, Tejpar S, Valdivieso A, Adam R. Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE. Br J Surg 2023; 110:1161-1170. [PMID: 37442562 PMCID: PMC10416695 DOI: 10.1093/bjs/znad124] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/13/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management. METHODS This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements. RESULTS Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSION The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.
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Affiliation(s)
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Stephen J Wigmore
- Hepatobiliary and Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Hassan Z Malik
- Liver Surgery Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
| | - Kjetil Søreide
- Department of Surgery, Bergen University Hospital, Bergen, Norway
| | - Oded Zmora
- Department of Colorectal Surgery, Shamir Medical Centre, Tel Aviv, Israel
| | - Martijn Meijerink
- Department of Radiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | | | | | - Kees Verhoef
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Anita Balakrishnan
- Cambridge Hepato-Pancreato-Biliary Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas Gruenberger
- Department of Surgery, Hepatopancreatobiliary Centre, Health Network Vienna, Clinic Favoriten and Sigmund Freud University, Vienna, Austria
| | - Eduard Jonas
- Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - John Devar
- Department of Surgery, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Saurabh Jamdar
- Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Robert Jones
- Liver Surgery Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Bodil Andersson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Karim Boudjema
- Department of Hepatobiliary, Pancreatic and Digestive surgery, Hôpital Pontchaillou, Rennes, France
| | | | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bobby V M Dasari
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Adam E Frampton
- Hepato-Pancreato-Biliary Unit, Royal Surrey County Hospital, Guildford, UK
| | - Luca Aldrighetti
- Department of Surgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Milan, Italy
| | - Gianluca Pellino
- Department of Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Pamela Buchwald
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Bengi Gürses
- Department of Radiology, Koc University Medical Faculty, Istanbul, Turkey
| | - Nir Wasserberg
- Department of Surgery, Beilinson Hospital, Rabin Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Birgit Gruenberger
- Department of Medical Oncology and Haematology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Harry V M Spiers
- Cambridge Hepato-Pancreato-Biliary Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - William Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, New York, USA
| | | | - Norihiro Kokudo
- Department of Surgery, National Centre for Global Health and Medicine, Tokyo, Japan
| | | | - Andres Valdivieso
- Hepatopancreatobiliary Surgery and Liver Transplant, HU Cruces, Bilbao, Spain
| | - René Adam
- Hepatobiliary and Transplant Unit, Hôpital Paul Brousse, Paris, France
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4
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Rezazadeh Ardabili A, van Esser D, Wintjens D, Cilissen M, Deben D, Mujagic Z, Russ F, Stassen L, van Bodegraven AA, Wong D, Winkens B, Jonkers D, Romberg-Camps M, Pierik MJ. Development and validation of a remote monitoring tool for assessment of mild, moderate, and severe infections in Inflammatory Bowel Disease. J Crohns Colitis 2023:7043219. [PMID: 36795060 DOI: 10.1093/ecco-jcc/jjad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Immunomodulators and biologicals are cornerstones in the management of Inflammatory Bowel Disease (IBD), but are associated with increased risk of infections. Post-marketing surveillance registries are pivotal to assess this risk, yet mainly focus on severe infections. Data on the prevalence of mild and moderate infections are scarce. We developed and validated a remote monitoring tool for real-world assessment of infections in IBD patients. METHODS A 7-item Patient-Reported Infections Questionnaire (PRIQ) covering 15 infection categories was developed with a 3-month recall period. Infection severity was defined as mild (self-limiting or topical treatment), moderate (oral antibiotics, antivirals or antifungals) or severe (hospitalisation or IV treatment). Comprehensiveness and comprehensibility were ascertained through cognitive interviewing of 36 IBD outpatients. After implementation in telemedicine platform myIBDcoach, a prospective multicentre cohort study was performed between June 2020 and June 2021 in 584 patients to assess diagnostic accuracy. Events were cross-checked with GP and pharmacy data (gold standard). Agreement was evaluated using linear-weighted kappa with cluster-bootstrapping to account for within-patient level correlation. RESULTS Patient understanding was good and interviews did not result in reduction of PRIQ-items. During validation, 584 IBD patients (57.8% female, mean age 48.6 [SD: 14.8], disease duration 12.6 years [SD: 10.9]) completed 1386 periodic assessments, reporting 1626 events. Linear-weighted kappa for agreement between PRIQ and gold standard was 0.92 (95%CI 0.89-0.94). Sensitivity and specificity for infection (y/n) were 93.9% (95%CI 91.8-96.0) and 98.5% (95%CI 97.5-99.4). CONCLUSIONS The PRIQ is a valid and accurate remote monitoring tool to assess infections in IBD patients, providing means to personalise medicine based on adequate benefit-risk assessments.
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Affiliation(s)
- Ashkan Rezazadeh Ardabili
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dirk van Esser
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dion Wintjens
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mia Cilissen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Debbie Deben
- Department of Clinical Pharmacy, Clinical pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Zlatan Mujagic
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Fritzi Russ
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Laurents Stassen
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Adriaan A van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Dennis Wong
- Department of Clinical Pharmacy, Clinical pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Daisy Jonkers
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Marie J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
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5
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Ishizawa T, McCulloch P, Stassen L, van den Bos J, Regimbeau JM, Dembinski J, Schneider-Koriath S, Boni L, Aoki T, Nishino H, Hasegawa K, Sekine Y, Chen-Yoshikawa T, Yeung T, Berber E, Kahramangil B, Bouvet M, Diana M, Kokudo N, Dip F, White K, Rosenthal RJ. Assessing the development status of intraoperative fluorescence imaging for anatomy visualisation, using the IDEAL framework. BMJ Surg Interv Health Technologies 2022; 4:e000156. [DOI: 10.1136/bmjsit-2022-000156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022] Open
Abstract
ObjectivesIntraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: visualising anatomy, assessing tissue perfusion, identifying/localising cancer and mapping lymphatic systems. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging used to visualise anatomical structures using the IDEAL framework, a framework designed to describe the stages of innovation in surgery and other interventional procedures.DesignIDEAL staging based on a thorough literature review.SettingAll publications on intraoperative fluorescence imaging for visualising anatomical structures reported in PubMed through 2020 were identified for five surgical procedures: cholangiography, hepatic segmentation, lung segmentation, ureterography and parathyroid identification.Main outcome measuresThe IDEAL stage of research evidence was determined for each of the five procedures using a previously described approach.Results225 articles (8427 cases) were selected for analysis. Current status of research evidence on fluorescence imaging was rated IDEAL stage 2a for ureterography and lung segmentation, IDEAL 2b for hepatic segmentation and IDEAL stage 3 for cholangiography and parathyroid identification. Enhanced tissue identification rates using fluorescence imaging relative to conventional white-light imaging have been documented for all five procedures by comparative studies including randomised controlled trials for cholangiography and parathyroid identification. Advantages of anatomy visualisation with fluorescence imaging for improving short-term and long-term postoperative outcomes also were demonstrated, especially for hepatobiliary surgery and (para)thyroidectomy. No adverse reactions associated with fluorescent agents were reported.ConclusionsIntraoperative fluorescence imaging can be used safely to enhance the identification of anatomical structures, which may lead to improved postoperative outcomes. Overviewing current research knowledge using the IDEAL framework aids in designing further studies to develop fluorescence imaging techniques into an essential intraoperative navigation tool in each surgical field.
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Dip F, Boni L, Bouvet M, Carus T, Diana M, Falco J, Gurtner GC, Ishizawa T, Kokudo N, Lo Menzo E, Low PS, Masia J, Muehrcke D, Papay FA, Pulitano C, Schneider-Koraith S, Sherwinter D, Spinoglio G, Stassen L, Urano Y, Vahrmeijer A, Vibert E, Warram J, Wexner SD, White K, Rosenthal RJ. Consensus Conference Statement on the General Use of Near-infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study. Ann Surg 2022; 275:685-691. [PMID: 33214476 PMCID: PMC8906245 DOI: 10.1097/sla.0000000000004412] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed. OBJECTIVE In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety. METHODS A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively. RESULTS Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus. CONCLUSIONS Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.
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Affiliation(s)
- Fernando Dip
- Hospital de Clinicas Buenos Aires, University of Buenos Aires, Buenos Aires, Argentina
- Cleveland Clinic Florida, Weston, FL
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico University of Milan, Milan, Italy
| | | | | | - Michele Diana
- IHU Strasbourg, Institute of Image-Guided Surgery and IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France
| | - Jorge Falco
- University Hospital Das Clinicas, Buenos Aires, Argentina
| | | | | | - Norihiro Kokudo
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | | | | | | | - Francis A Papay
- Cleveland Clinic, Lerner College of Medicine at Case Western Reserve University, Cleveland, OH
| | | | | | | | - Giuseppe Spinoglio
- FPO Candolo Institute for Cancer Research and Treatment I.R.C.C.S, Turin, Italy
| | - Laurents Stassen
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Eric Vibert
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Jason Warram
- University of Alabama at Birmingham, Birmingham, AL
| | | | - Kevin White
- ScienceRight Research Consulting London, Ontario, Canada
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7
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Dominguez LC, Dolmans D, de Grave W, Donkers J, Sanabria A, Stassen L. Supervisors' transformational leadership style and residents' job crafting in surgical training: the residents' views. Int J Med Educ 2022; 13:74-83. [PMID: 35349982 PMCID: PMC9017501 DOI: 10.5116/ijme.622d.e2f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/13/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aims to explore the effects of three supervisors' leadership styles (transformational, transactional, and laissez-faire) on residents' job crafting. METHODS Sequential explanatory mixed-methods. First, a purposive sample of residents rated the leadership style of their supervisors and their own job crafting on the Multifactor Leadership Questionnaire and the Dutch Job Crafting Scale. The effects were tested through linear mixed effects regression analysis. Thereafter we conducted semi-structured interviews with residents and conducted a thematic analysis. RESULTS A total of 116 residents participated. A transformational style had a positive effect on residents' job crafting (b = .19, t(112) =3.76, p=. 009), whereas the transactional and laissez-faire styles did not. This could be explained by the fact that residents felt a positive influence of the supervisors with such style on the atmosphere for training, on the job resources available to them, and on their modelling function for how to handle the demands of the environment. CONCLUSIONS A transformational style of the supervisor has a positive effect on residents' job crafting. Future research should explore the supervisors' perspective, as well as the effectiveness of leadership training for supervisors with a focus on resident outcomes, such as job crafting.
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Affiliation(s)
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Willem de Grave
- Department of Educational Development and Research, School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Jeroen Donkers
- Department of Educational Development and Research, School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Alvaro Sanabria
- Department of Surgery, Universidad de la Sabana, Chía, Colombia
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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8
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Spota A, Al-Taher M, Felli E, Morales Conde S, Dal Dosso I, Moretto G, Spinoglio G, Baiocchi G, Vilallonga R, Impellizzeri H, Martin-Martin GP, Casali L, Franzini C, Silvestri M, de Manzini N, Castagnola M, Filauro M, Cosola D, Copaescu C, Garbarino GM, Pesce A, Calabrò M, de Nardi P, Anania G, Carus T, Boni L, Patané A, Santi C, Saadi A, Rollo A, Chautems R, Noguera J, Grosek J, D'Ambrosio G, Ferreira CM, Norcic G, Navarra G, Riva P, Quaresima S, Paganini A, Rosso N, De Paolis P, Balla A, Sauvain MO, Gialamas E, Bianchi G, La Greca G, Castoro C, Picchetto A, Franchello A, Tartamella L, Juvan R, Ioannidis O, Kosir JA, Bertani E, Stassen L, Marescaux J, Diana M. Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry. Surg Endosc 2021; 35:7142-7153. [PMID: 33492508 DOI: 10.1007/s00464-020-08234-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. METHODS Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. RESULTS A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. CONCLUSION The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.
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Affiliation(s)
- Andrea Spota
- IRCAD Research Institute Against Digestive Cancer, Strasbourg, France
- Scuola di Specializzazione in Chirurgia Generale, Università Degli Studi di Milano, Milano, Italy
| | - Mahdi Al-Taher
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Eric Felli
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Salvador Morales Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General Surgery, University Hospital Virgen del Rocío, University of Sevilla, Sevilla, Spain
- General and Digestive Unit, Hospital Quironsalud Sagrado Corazon, Sevilla, Spain
| | | | | | | | - Gianluca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | | | | | | | | | | | | | | | | | - Davide Cosola
- Clinica Chirurgica, University of Trieste, Trieste, Italy
| | | | - Giovanni Maria Garbarino
- San Pietro Fatebenefratelli Hospital, Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Roma, Italy
| | | | | | | | | | | | - Luigi Boni
- Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, University of Milan, Milano, Italy
| | | | | | - Alend Saadi
- Réseau Hospitalier Neuchâtelois, Neuchatel, Switzerland
| | | | | | | | - Jan Grosek
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Giancarlo D'Ambrosio
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | | | - Gregor Norcic
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Pietro Riva
- Unit of Foregut Surgery, IRCCS Humanitas Clinical and Research Center, Rozzano, Milano, Italy
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Alessandro Paganini
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | | | | | - Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | | | | | | | | | - Carlo Castoro
- Unit of Foregut Surgery, IRCCS Humanitas Clinical and Research Center, Rozzano, Milano, Italy
| | - Andrea Picchetto
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | | | | | - Robert Juvan
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | | | | | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacques Marescaux
- IRCAD Research Institute Against Digestive Cancer, Strasbourg, France
| | - Michele Diana
- IRCAD Research Institute Against Digestive Cancer, Strasbourg, France.
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
- ICube Lab, Photonics for Health, University of Strasbourg, Strasbourg, France.
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9
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Abstract
This AMEE guide aims to emphasize the value of active learner involvement in the design and development of education, referred to as co-creation, and provides practical tips for medical educators interested in implementing co-created educational initiatives at their own institutions. Starting with definitions of co-creation and related terms, we then describe its benefits and summarize the literature in medical and higher education to provide an appropriate context and a shared mental model for health professions educators across the world. Potential challenges and barriers to implementation of co-creation in practice are described in detail from the perspective of learners, teachers, and institutions. Challenges are linked to relevant principles of Self-Determination Theory, Positioning Theory and theory on Psychological Safety, to provide direction and fundamental reasons for implementation of co-creation. Finally, solutions to listed challenges and practical approaches to education design and implementation using co-creation are described in detail. These tips include strategies for supporting learners and teachers in the process, enhancing the collaboration between them, and ensuring appropriate support at the organizational level.
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Affiliation(s)
- Karen D Könings
- Educational Development and Research and School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Serge Mordang
- Educational Development and Research and School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Frank Smeenk
- Educational Development and Research and School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Pulmonary Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - Laurents Stassen
- Educational Development and Research and School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Subha Ramani
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Research and Scholarship, Harvard Macy Institute, Boston, MA, USA
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10
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Domínguez LC, Dolmans D, Restrepo J, de Grave W, Sanabria A, Stassen L. How Surgical Leaders Transform Their Residents to Craft Their Jobs: Surgeons' Perspective. J Surg Res 2021; 265:233-244. [PMID: 33957575 DOI: 10.1016/j.jss.2021.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgeons should transform their residents to take the lead in their jobs and optimize their working conditions, so-called job crafting. We investigated the actions undertaken by surgeons with a transformational leadership style to encourage residents' job crafting, about which there is at present a paucity of information. METHODS We performed a qualitative study based on principles of constructivist grounded theory. In-depth interviews were held with a purposive sample of surgeons who were perceived as transformational leaders by their residents. During data analysis (open, axial, and selective coding), we compared inductive codes with deductive codes drawn from the job demands-resources and transformational leadership theories to reach a consensus on the interpretation of data and identification of the main themes. RESULTS Sixteen surgeons participated. Surgeons undertook five actions that enhanced job crafting in residents. They: one) modeled positive behaviors of a good surgeon; two) used a stepwise individual approach toward autonomy; three) connected with the resident as a person; four) supported residents in handling complications and errors; and five) they coached the resident to deal with competing interests. These actions had four consequences for residents. They led to: one) more responsibilities in patient care; two) more constructive relationships in the workplace; three) less pressure from workload and surgical care duties; and four) less personal difficulties and errors in patient care. CONCLUSIONS The actions undertaken by surgeons with a transformational leadership style have a positive association with the residents' ability to craft their jobs. This knowledge has implications for surgeons' leadership development with a view to workplace education.
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Affiliation(s)
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Jorge Restrepo
- Department of Medical Education, Universidad de la Sabana, Chía, Colombia
| | - Willem de Grave
- Department of Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Alvaro Sanabria
- Department of Surgery, Universidad de la Sabana, Chía, Colombia
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands
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11
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Wimalasiri-Yapa B, Frentiu F, Stassen L, Gumiel R. Temperature modulates innate immunity in Aedes aegypti during chikungunya virus infection. Int J Infect Dis 2020. [DOI: 10.1016/j.ijid.2020.09.1278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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Al-Taher M, Okamoto N, Felli E, Agnus V, Barberio M, Gioux S, Bouvy N, Stassen L, Marescaux J, Diana M. Noninvasive Near-Infrared Fluorescence Imaging of the Ureter During Robotic Surgery: A Demonstration in a Porcine Model. J Laparoendosc Adv Surg Tech A 2020; 30:962-966. [DOI: 10.1089/lap.2020.0399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Mahdi Al-Taher
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nariaki Okamoto
- Research Institute against Digestive Cancer, IRCAD, Strasbourg, France
| | - Eric Felli
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
| | - Vincent Agnus
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
| | - Manuel Barberio
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
| | - Sylvain Gioux
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- ICUBE Laboratory, Photonics Instrumentation for Health, Strasbourg, France
| | - Nicole Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacques Marescaux
- Research Institute against Digestive Cancer, IRCAD, Strasbourg, France
| | - Michele Diana
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- Research Institute against Digestive Cancer, IRCAD, Strasbourg, France
- ICUBE Laboratory, Photonics Instrumentation for Health, Strasbourg, France
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13
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Noben CYG, Stammen LA, Vaassen S, Haeren R, Stassen L, Mook WV, Essers B. Discrete choice experiment on educating value-based healthcare. Postgrad Med J 2020; 97:515-520. [PMID: 32796111 DOI: 10.1136/postgradmedj-2019-137190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/19/2020] [Accepted: 06/20/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Identifying costs and values in healthcare interventions as well as the ability to measure and consider costs relative to value for patients are pivotal in clinical decision-making and medical education. This study explores residents' preferences in educating value-based healthcare (VBHC) during postgraduate medical education. Exploring residents' preferences in VBHC education, in order to understand what shapes their choices, might contribute to improved medical residency education and healthcare as a whole. METHODS A discrete choice experiment (DCE) examined which conditions for educating VBHC are preferred by residents. DCE gives more insight into the trade-off's residents make when choosing alternatives, and which conditions for educating VBHC have the most influence on residents' preference. RESULTS This DCE shows that residents prefer knowledge on both medical practice as well as the process of care-to be educated by an expert on VBHC together with a clinician. They prefer limited protected time to conduct VBHC initiatives (thus while at work) and desire the inclusion of VBHC in formal educational plans. CONCLUSION When optimising graduate and postgraduate medical education curricula, these preferences should be considered to create necessary conditions for the facilitation and participation of residents in VBHC education and the set-up of VBHC initiatives.
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Affiliation(s)
- Cindy Y G Noben
- Academy of Postgraduate Medical Education, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Lorette A Stammen
- Department of Educational Development and Research, Maastricht University - Location Randwyck, Maastricht, Netherlands
| | - Sanne Vaassen
- Pediatrics, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Roel Haeren
- Neurosurgery, Maastricht University Medical Centre+, Maastricht, Netherlands.,Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Laurents Stassen
- Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Walther van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Department of Educational Development and Research, Maastricht University, Maastricht, Netherlands
| | - Brigitte Essers
- Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, Netherlands
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14
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Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A, Ellul P, Fiorino G, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gisbert JP, Gomollon F, González Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Kucharzik T, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B, Zmora O. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2020; 14:155-168. [PMID: 31742338 DOI: 10.1093/ecco-jcc/jjz187] [Citation(s) in RCA: 253] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Alessandro Armuzzi
- IBD Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS - Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland; Department of Human Medicine, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | | | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa', IIS Aragón, CIBEREHD, Zaragoza, Spain
| | | | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Sub-department of Gastroenterology and Hepatology, University Hospital Bratislava and Faculty of Medicine, Comenius University Bratislava, Slovakia
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal Medicine, Riga Stradiņš University, Riga, Latvia
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Faculty of Medicine, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
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15
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Torres J, Bonovas S, Doherty G, Kucharzik T, Gisbert JP, Raine T, Adamina M, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, El-Hussuna A, Ellul P, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gomollon F, González-Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Spinelli A, Stassen L, Uzzan M, Vavricka S, Verstockt B, Warusavitarne J, Zmora O, Fiorino G. ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment. J Crohns Colitis 2020; 14:4-22. [PMID: 31711158 DOI: 10.1093/ecco-jcc/jjz180] [Citation(s) in RCA: 642] [Impact Index Per Article: 160.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Glen Doherty
- Centre for Colorectal Disease, St Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus Fondazione Policlinico Gemelli Universita Cattolica, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Department of Human Medicine, University of Witten/Herdecke, Witten, Germany
| | | | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa'; IIS Aragón, CIBEREHD, Zaragoza, Spain
| | - Marien González-Lorenzo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Comenius University Medical School, Bratislava, Slovakia
| | - Pascal Juillerat
- Division of Gastroenterology & Hepatology, Inselspital Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal medicine, Riga Stradiņš university, Riga, Latvia
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Milan, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, TARGID-IBD, KU Leuven, Leuven, Belgium
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
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Stammen L, Slootweg I, Stalmeijer R, Janssen L, Stassen L, Scheele F, Driessen E. The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care. Teach Learn Med 2019; 31:402-411. [PMID: 30909747 DOI: 10.1080/10401334.2019.1583566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Phenomenon: Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Approach: Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, n = 5; elderly care, n = 8; family medicine, n = 5; internal medicine, n = 6; orthopedic surgery, n = 6; surgery, n = 6). An iterative grounded theory approach was used to analyze the qualitative data. Findings: Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Insights: Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.
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Affiliation(s)
- Lorette Stammen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Irene Slootweg
- b Department of Public Health and Primary Care, Leiden University Medical Centre , Leiden , The Netherlands
| | - Renée Stalmeijer
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Linda Janssen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Laurents Stassen
- c Department of Surgery, Maastricht University Medical Center , Maastricht , The Netherlands
| | - Fedde Scheele
- d VU School of Medical Sciences, Amsterdam UMC, Athena Institute , Amsterdam , The Netherlands
- e OLVG Amsterdam , Amsterdam , The Netherlands
| | - Erik Driessen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
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Clark R, Shah K, Brown A, Israr M, Starr D, Stassen L. Is eminectomy effective in the management of closed lock? Int J Oral Maxillofac Surg 2019. [DOI: 10.1016/j.ijom.2019.03.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Dominguez LC, Stassen L, de Grave W, Sanabria A, Alfonso E, Dolmans D. Taking control: Is job crafting related to the intention to leave surgical training? PLoS One 2018; 13:e0197276. [PMID: 29856750 PMCID: PMC5983422 DOI: 10.1371/journal.pone.0197276] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/30/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The intention to leave surgical training, hereinafter referred as proxy of "attrition," is associated with poor well-being in the workplace. Attrition is suggested to diminish when residents possess job-crafting skills, that is, the ability to redefine their job in meaningful ways and maximize well-being at work by increasing structural and social resources and challenges and decreasing hindering demands. However, the evidence supporting this relationship is scant. This study sought to: 1) investigate to what extent residents possess job-crafting skills and compare residents' levels of job-crafting skills across years of residency training; 2) investigate the relationship between job crafting, well-being as measured by burnout and work-engagement rates, and the intention to leave; and 3) compare the levels of job-crafting skills and well-being between residents with and without serious intentions to leave. METHODS This cross sectional study was conducted in fifteen residency programs in Colombia. Surgical residents completed different questionnaires including the Dutch Job Crafting Scale (DJCS), MBI-Human Services Survey (MBI-HSS), Utrecht Work Engagement Scale (UWES-17) and an adapted version of the Nurse Turnover Intention Scale (NTIS). The objectives were addressed by independent analyses of variance (ANOVA), structural equation modeling techniques (SEM) and independent t-tests, respectively. RESULTS A total of 202 residents participated. Residents generally scored high on their job-crafting skills to increase structural and social resources as well as challenging demands, but were less positive about their skills to reduce hindering demands. No differences across years of training were found. Job crafting correlated positively with work-engagement, which was inversely related to the intention to leave. Conversely, job crafting correlated negatively with burnout, which bore a positive relationship to the intention to leave. Residents with serious intentions to leave exhibited lower levels of most job-crafting skills and work-engagement, compared to those without such intentions. CONCLUSIONS This study adds evidence that attrition is a process mediated by residents' well being at work, which can be molded by their job-crafting endeavors. Future research is needed to evaluate the effectiveness of interventions aimed at cultivating resident's job-crafting abilities in order to reduce attrition.
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Affiliation(s)
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Willem de Grave
- Department of Educational Development and Research, School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Alvaro Sanabria
- Department of Surgery, Universidad de la Sabana, Chía, Colombia
- Fundación Colombiana de Cancerología—Clínica Vida, Medellín, Colombia
| | - Edgar Alfonso
- University of Lyon, University Jean Monnet-St-Etienne, LASPI, Saint-Etienne, France
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
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Huston M, Stassen L. Microplates making a macro impact on mandibular osteosynthesis. Int J Oral Maxillofac Surg 2017. [DOI: 10.1016/j.ijom.2017.02.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Katsamouris AN, Megerman J, Stassen L, Brewster DC, Abbott WM. Use of Transcutaneous Oxygen Tension Before, During, and After Arterial Reconstructive Surgery. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857448702100107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diagnostic and predictive value of transcutaneous oxygen tension (tcPO2) measurements in patients undergoing lower extremity arterial recon structive surgery were evaluated. Foot tcPO2 was measured preoperatively in 114 patients, intraoperatively in 59 patients, and again seven days after surgery in 82 patients. Preoperative tcPO 2 values less than 30 mmHg were indicative of severe limb ischemia in 90% of patients with rest pain, impending gangrene, or ischemic ulcer. Fifteen minutes after revascularization, tcPO2 greater than 30 mmHg was predictive of a "good" result (determined clinically at one month) in 94% of patients, whereas values less than 30 mmHg predicted a "poor" result in 70% of patients. Measurements obtained seven days postoperatively exhibited an improved negative predictive tcPO2 value (85%) as compared with those ob tained intraoperatively. TCPO2 changes induced by oxygen inhalation were the most promising predictor of the outcome of surgery. TCPO2 was uniformly more reliable than hemodynamic tests (pulse volume recording and Doppler systolic pressure) when more severe disease was present and vice versa; their comple mentary nature suggests the two techniques can be used together to maximize noninvasive diagnostic value.
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Affiliation(s)
| | - Joseph Megerman
- Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Laurents Stassen
- Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David C. Brewster
- Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - William M. Abbott
- Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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21
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Maas M, Lambregts DMJ, Nelemans PJ, Heijnen LA, Martens MH, Leijtens JWA, Sosef M, Hulsewé KWE, Hoff C, Breukink SO, Stassen L, Beets-Tan RGH, Beets GL. Assessment of Clinical Complete Response After Chemoradiation for Rectal Cancer with Digital Rectal Examination, Endoscopy, and MRI: Selection for Organ-Saving Treatment. Ann Surg Oncol 2015. [PMID: 26198074 PMCID: PMC4595525 DOI: 10.1245/s10434-015-4687-9] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The response to chemoradiotherapy (CRT) for rectal cancer can be assessed by clinical examination, consisting of digital rectal examination (DRE) and endoscopy, and by MRI. A high accuracy is required to select complete response (CR) for organ-preserving treatment. The aim of this study was to evaluate the value of clinical examination (endoscopy with or without biopsy and DRE), T2W-MRI, and diffusion-weighted MRI (DWI) for the detection of CR after CRT. Methods This prospective cohort study in a university hospital recruited 50 patients who underwent clinical assessment (DRE, endoscopy with or without biopsy), T2W-MRI, and DWI at 6–8 weeks after CRT. Confidence levels were used to score the likelihood of CR. The reference standard was histopathology or recurrence-free interval of >12 months in cases of wait-and-see approaches. Diagnostic performance was calculated by area under the receiver operator characteristics curve, with corresponding sensitivities and specificities. Strategies were assessed and compared by use of likelihood ratios. Results Seventeen (34 %) of 50 patients had a CR. Areas under the curve were 0.88 (0.78–1.00) for clinical assessment and 0.79 (0.66–0.92) for T2W-MRI and DWI. Combining the modalities led to a posttest probability for predicting a CR of 98 %. Conversely, when all modalities indicated residual tumor, 15 % of patients still experienced CR. Conclusions Clinical assessment after CRT is the single most accurate modality for identification of CR after CRT. Addition of MRI with DWI further improves the diagnostic performance, and the combination can be recommended as the optimal strategy for a safe and accurate selection of CR after CRT.
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Affiliation(s)
- Monique Maas
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Doenja M J Lambregts
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patty J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luc A Heijnen
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Milou H Martens
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jeroen W A Leijtens
- Department of Surgery, Laurentius Hospital Roermond, Roermond, The Netherlands
| | - Meindert Sosef
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Orbis Medical Centre, Sittard, The Netherlands
| | - Christiaan Hoff
- Department of Surgery, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Stephanie O Breukink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Geerard L Beets
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Øresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, Marteau P, Zmora O, Kotze PG, Espin-Basany E, Tiret E, Sica G, Panis Y, Faerden AE, Biancone L, Angriman I, Serclova Z, de Buck van Overstraeten A, Gionchetti P, Stassen L, Warusavitarne J, Adamina M, Dignass A, Eliakim R, Magro F, D'Hoore A. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis 2015; 9:4-25. [PMID: 25304060 DOI: 10.1016/j.crohns.2014.08.012] [Citation(s) in RCA: 226] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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23
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Stassen L, Khosa AD, Israr M. The value of the 'buccal pad of fat' in the reconstruction of oral defects following removal of intraoral tumours--a clinical assessment. Ir Med J 2013; 106:13-15. [PMID: 23472369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The buccal pad of fat (BPF) is an important structure found in the orofacial region of humans. It is larger in infants and gradually becomes smaller in adults. We present twenty seven (27) cases with an average age of 60 years, with a variety of pathological lesions in which we have used the BPF to reconstruct the defects following resection of tumours. Twenty (74%) patients were diagnosed with Squamous Cell Carcinma. The commonest surgical sites were the soft palate and maxilla (46%). A clinical analysis of the value of BPF in reconstruction was made by using assessment criteria, mouth opening, cosmesis, fistula formation, approved by the ethical committee of the Hospital. Our findings show that the BPF is an excellent pedicled graft for the reconstruction of defects up to 10x5.5x1.1 cm in size. The donor site had no morbidity in terms of fuctions including, mouth opening (normal), masticatory movement, deglution, motor / sensory loss and patients were unaffected cosmetically (no temporal hollwing). There was no abnormal finding e.g. fistula, Frey's syndrome, speech and movement of the soft palate was unaffected. Salivary function was not affected (parotid duct). Speech outcomes were normal. We used a pre-surgery constructed blow--down soft or a preformed acrylic plate to support the fat pad in 13 (50%) patients, secured with mini screws. The use of a splint to support and protect the flap allowed early feeding.
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Affiliation(s)
- L Stassen
- Department of Oral & Maxillofacial Surgery, National Maxillofacial Unit, St James's Hospital, Lames's St, Dublin 8
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24
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Fransen S, Stassen L, Bouvy N. Single incision laparoscopic cholecystectomy: A review on the complications. J Minim Access Surg 2012; 8:1-5. [PMID: 22303080 PMCID: PMC3267328 DOI: 10.4103/0972-9941.91771] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 03/30/2011] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND: The aim of this study was to establish the incidence of postoperative complications after single incision laparoscopic cholecystectomy. MATERIALS AND METHODS: A literature search was performed using the PubMed database. Search terms included single incision laparoscopic cholecystectomy, single port cholecystectomy, minimal invasive laparoscopic cholecystectomy, nearly scarless cholecystectomy and complications. RESULTS: A total of 38 articles meeting the selection criteria were reviewed. A total of 1180 patients were selected to undergo single incision laparoscopic cholecystectomy. Introduction of extra ports was necessary in 4% of the patients. Conversion to open cholecystectomy was required in 0.4% of the patients. Laparoscopic cholangiography was attempted in 4% of the patients. The incidence of major complications requiring surgical intervention or ERCP with stenting was 1.7%. The mortality rate was zero. CONCLUSION: Although the number of complications after single incision laparoscopic cholecystectomy seems favourable, it is too early to conclude that single incision laparoscopic cholecystectomy is a safe procedure. Large randomised controlled trials will be necessary to further establish its safety.
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Affiliation(s)
- Sofie Fransen
- Department of Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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25
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Shah K, Stassen L, Boyappati R, Flood V. Measurement of functional outcomes and quality of life scores in completed resected early SCC of tongue and floor of mouth which are reconstructed using loco-regional techniques. Br J Oral Maxillofac Surg 2011. [DOI: 10.1016/j.bjoms.2011.03.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Botden S, Strijkers R, Fransen S, Stassen L, Bouvy N. The use of curved vs. straight instruments in single port access surgery, on standardized box trainer tasks. Surg Endosc 2011; 25:2703-10. [PMID: 21437738 PMCID: PMC3142334 DOI: 10.1007/s00464-011-1633-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 02/17/2011] [Indexed: 12/02/2022]
Abstract
Background Single-port access (SPA) surgery is a novel surgical technique to create nearly “scarless” surgery. SPA surgery appears to be safe and feasible, but the exposure and handling of tissue may not be optimal. Therefore, the performance of SPA surgery with different instruments used and conventional laparoscopy is compared. Methods Fifteen participants (>50 laparoscopic procedures) performed three basic tasks (translocation, clip & cut, and tissue dissection, based on the fundamentals of laparoscopic surgery) in the box trainer in laparoscopy and SPA settings with both (conventional) crossed and curved instruments. All participants completed a questionnaire, which asked their opinion on the use of instruments and preference. Results Translocation was performed significantly faster in both laparoscopy and SPA crossed than SPA curved (means, 130.3 and 137.7 vs. 170.7 sec; p < 0.001 and p = 0.005). The errors also were less in laparoscopy and SPA crossed (means, 0.9 and 1.2 vs. 1.6), but not significant. The time to complete the dissection was almost equal between laparoscopy and SPA curved settings, but took longer for SPA crossed, although not significantly (148.1 and 150.8 vs. 179.5 sec). The errors only differed significantly between laparoscopy and SPA crossed (means, 0.5 vs. 1.27; p = 0.044). Fourteen participants still favored conventional laparoscopy and one SPA curved. They also thought SPA curved was better than crossed (means, 3.6 vs. 2.47; p = 0.003) and that exposure is superior in curved (means, 3.4 vs. 2.27; p = 0.002). Conclusions Although conventional laparoscopy may appear most effective for proper dissection and exposure of tissue, single-port access surgery shows potential. Especially in the tissue dissection task, there is no significant difference in time or errors between conventional laparoscopy and SPA surgery, using specially designed curved instruments. Although the participants favor conventional laparoscopy, this could evolve to a more accepting mind when SPA surgery becomes more available and used in the clinical setting.
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Affiliation(s)
- Sanne Botden
- Department of Surgery, Maastricht University Medical Centre, P. Debyeplein 25, Postal box 5800, 6202 AZ, Maastricht, The Netherlands.
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Brandt-Kerkhof A, van Mierlo M, Schep N, Renken N, Stassen L. Follow-up period of 13 years after endoscopic total extraperitoneal repair of inguinal hernias: a cohort study. Surg Endosc 2010; 25:1624-9. [PMID: 21170663 PMCID: PMC3071468 DOI: 10.1007/s00464-010-1462-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 10/13/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic inguinal hernia repair was introduced in the Netherlands in the early 1990s. The authors' institution was among the first to adopt this technique. In this study, long-term hernia recurrence among patients treated by the total extraperitoneal (TEP) approach for an inguinal hernia is described. A cohort study was conducted. METHODS Between January 1993 and December 1997, 346 TEP hernia repairs were performed for 318 patients. After a mean follow-up period of 13-years, a senior resident examined each patient. An experienced surgeon subsequently examined the patients with a diagnosis of recurrent hernia. Data were collected on an intention-to-treat basis, meaning that conversions were included in the analysis. Univariant tests were used to analyze age older than 50 years, chronic obstructive pulmonary disease, body mass index, smoking habit, hernia type, history of open hernia repair, conversion, and surgeon as potential risk factors. RESULTS The analysis included 191 patients (62%) with 213 hernias. Of the original 318 patients, 59 patients died, and 68 were lost to follow-up evaluation. Perioperatively, 105 lateral, 55 medial, and 53 pantalon hernias were observed. Of the 213 hernias, 176 were primary and 37 were recurrent. The overall recurrence rate was 8.9% (8.5% for primary and 10.8% for recurrent hernias). Of the total study group, 48% of the patients experienced a bilateral inguinal hernia during their lifetime. No predicting factor for recurrent hernia could be identified. CONCLUSIONS The current long-term results for TEP repair of primary and secondary inguinal hernia show an overall recurrence rate of 8.9%, which is slightly higher than in previous studies. The thorough examination at follow-up assessment, the learning curve effect, and the intention-to-treat-analysis may have influenced the observed recurrence rate. Also, the percentage of bilateral hernias was higher than known to date. Therefore, examination of the contralateral side should be standard procedure.
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Kambal W, Ryan D, Stassen L. P61 Review of the use of a modified obturator “the Bung” in post operative management of large keratocysts. Br J Oral Maxillofac Surg 2010. [DOI: 10.1016/s0266-4356(10)60152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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29
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Smith G, Stassen L, Flint S. Treating osteoporosis. Ir Med J 2009; 102:88-89. [PMID: 19489199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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30
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Wouters M, Karim H, Wijnhoven B, Stassen L, Steup W, Tilanus H, Tollenaar R. 33 ORAL Centralization of oesophageal resections for cancer: does it actually improve clinical outcome? Eur J Surg Oncol 2006. [DOI: 10.1016/s0748-7983(06)70468-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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van Waes O, van der Elst M, Stassen L, Tjebbes F. Laparoscopic diagnosis and treatment of idiopathic segmental infarction of the greater omentum. Case report. Surg Endosc 2001; 15:1226. [PMID: 11727107 DOI: 10.1007/s00464-001-4203-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Acute pain at the right side of the abdomen rarely is caused by idiopathic segmental infarction of the greater omentum (ISIGO). In most cases the patient is presumed to suffer from appendicitis or cholecystitis. Although some radiologic signs might suggest ISIGO, this rare clinical entity mostly is diagnosed perioperatively and confirmed by postoperative pathologic findings. In the reported case, a patient is described with acute right-side abdominal pain of unknown origin, in whom ISIGO was encountered during diagnostic laparoscopy and successfully resected. Because of this minimally invasive approach, the patient was discharged the day after surgery and returned to work after 5 days. The pathogenesis, symptoms, and treatment methods are discussed.
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Affiliation(s)
- O van Waes
- Department of Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 3-11, 2625 AD, Delft, The Netherlands.
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Seymour R, Stassen L, Moore U, Hawkesford J, Oshima T, Suggi M, Nimmo W. A Double-Blind, Placebo-Controlled Study of the Tolerability and Efficacy of a New Kappa-Opioid Receptor Agonist (R-84760) in Patients with Pain after Dental Surgery. Clin Drug Investig 2000. [DOI: 10.2165/00044011-200020060-00003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Allen PF, Watson G, Stassen L, McMillan AS. Peri-implant soft tissue maintenance in patients with craniofacial implant retained prostheses. Int J Oral Maxillofac Surg 2000; 29:99-103. [PMID: 10833145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The aim of this pilot study was to describe the effectiveness of a hygiene protocol prescribed for patients receiving craniofacial implant retained prostheses. Eleven subjects receiving either orbital or auricular prostheses were instructed by a hygienist in debris removal procedures. Patients were re-examined on at least four occasions over the following 18 months, and tissue health around the implant abutments was evaluated using standard criteria. In most cases, adequate debris removal was demonstrated, particularly when hygiene procedures were reinforced at the second follow-up visit. Barriers to maintenance of tissue health included inadequate space between fixtures and thickness of skin around abutments. Occasionally, prostheses had to be replaced due to inappropriate cleaning methods. The intensive hygiene regimen helped maintain tissue health around implant abutments, although it was demanding in terms of professional time.
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Affiliation(s)
- P F Allen
- Department of Restorative Dentistry, University of Newcastle upon Tyne, UK.
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Allen P, Watson G, Stassen L, McMillan A. Peri-implant soft tissue maintenance in patients with craniofacial implant retained prostheses. Int J Oral Maxillofac Surg 2000. [DOI: 10.1016/s0901-5027(00)80005-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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35
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Allen PF, Watson G, Stassen L, McMillan AS. Peri-implant soft tissue maintenance in patients with craniofacial implant retained prostheses. Int J Oral Maxillofac Surg 2000. [DOI: 10.1034/j.1399-0020.2000.290205.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
The Cleft Palate Index and, more recently, the Craniofacial Anomalies Register--CARE--have been in operation since 1982. This paper summarizes its development and plans for the future. CARE is a multidisciplinary committee involving all specialties involved in the treatment of this group of patients therefore it should and can be well placed to co-ordinate the cleft data arising from these patients.
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Affiliation(s)
- M Hammond
- Department of Orthodontics, Dudley Group & Hospitals NHS Trust, Corbett Hospital, Stourbridge, West Midlands, UK
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Hammond M, Stassen L. Do you CARE? A national register for cleft lip and palate patients. Craniofacial Anomalies Register. Br J Oral Maxillofac Surg 1999; 37:81-6. [PMID: 10371305 DOI: 10.1054/bjom.1999.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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38
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Abstract
The Cleft Palate Index and more recently the Craniofacial Anomalies Register--CARE--have been in operation since 1982. This paper summarises its development and plans for the future. CARE is a multi-disciplinary committee involving all specialties involved in the treatment of this group of patients. It therefore should and can be well placed to coordinate the cleft data arising from these patients.
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Affiliation(s)
- M Hammond
- Department of Orthodontics, Dudley Group of Hospitals NHS Trust, Corbett Hospital, Stourbridge, UK
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Stassen L. Citation for the presentation of the De Puy Prize 1996 to Mr David Patton. Br J Oral Maxillofac Surg 1997; 35:145. [PMID: 9235049 DOI: 10.1016/s0266-4356(97)90694-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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40
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Ratcliffe JF, Doig C, Stassen L. Herniography in an uncommon inguinal hernia. J R Coll Surg Edinb 1986; 31:188-9. [PMID: 3772865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Murphy DM, Stassen L, Carr ME, Gillespie WA, Cafferkey MT, Falkiner FR. Bacteraemia during prostatectomy and other transurethral operations: influence of timing of antibiotic administration. J Clin Pathol 1984; 37:673-6. [PMID: 6725613 PMCID: PMC498844 DOI: 10.1136/jcp.37.6.673] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The relation between the timing of prophylactic antibiotic administration and the occurrence of bacteraemia during transurethral operations was studied in 112 patients whose urine was infected before operation. Blood cultures taken during operation were positive in 15 (60%) of 25 patients who did not receive appropriate antibiotics, in 13 (21%) of 63 patients who were given appropriate antibiotics less than 24 h before operation, and in none of 24 patients in whom antibiotic "cover" was started more than 24 h before operation. In all cases the bacteraemia was transient. No patient developed septicaemia. The implications of these findings for the optimum timing of antibiotic administration to patients with preoperative bacteriuria are discussed.
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