Preadmission use of antidepressants and risk of complications and death after colorectal cancer surgery: a nationwide population-based cohort study.

AIM: Few studies have evaluated how preadmission use of antidepressants affects outcomes in colorectal cancer (CRC) patients after they have undergone surgery. Therefore, our aim is to examine whether preadmission use of antidepressants increased the risk of complications and death in patients who underwent CRC surgery. METHOD: Using the Danish Colorectal Cancer Group Database we identified patients who underwent CRC surgery in Denmark from 2005 to 2012. We identified prescriptions for antidepressants redeemed within 1 year prior to surgery and categorized patients as current users (≤ 90 days), former users (91-365 days) and nonusers. All patients were followed from surgery to 30 days thereafter or to death. We calculated 30-day rates of complications, intensive care unit (ICU) admission and mortality and compared these between users and nonusers using logistic and Cox regression adjusting for potential confounders. RESULTS: Of 27 374 patients, 8.9% were current users and 3.0% were former users. Antidepressant users were older and had more comorbidity but a similar cancer stage. Compared with nonusers, current users had a higher risk of postoperative reoperation [adjusted odds ratio (aORs) = 1.15 (95% CI 1.02-1.30)], medical complications [aORs = 1.41 (95% CI 1.25-1.60)] and increased ICU admission rate [adjusted hazard ratio (aHR) = 1.32 (95% CI 1.21-1.45)]. The 30-day mortality was 11.4% for current users, 9.1% for former users and 6.2% for nonusers [aHR = 1.34 (95% CI 1.17-1.53) for current vs nonusers]. CONCLUSION: Patients with preadmission use of antidepressants had a higher risk of complications and ICU admission, and higher 30-day mortality following CRC surgery than nonusers.

Faculty development for clinical teachers in dental education.

UNLABELLED: Dental education has been reviewed, and suggestions for further enhancement include the implementation of faculty development activities to enhance teaching and learning environments. PURPOSE: The aim of this study was to gain insight into the participants' perceptions of outcomes of faculty development for clinical teachers and clinical learning environments as well as into the sustainability of such outcomes. METHODS: The program was organized in the form of (i) a 2-day seminar; (ii) collegial supervision and development projects; and (iii) a 1-day follow-up seminar. The participants' perceptions from the five-first programs were studied. A Web-based questionnaire was sent to all participants, that is 3-27 months after completion of the program (follow-up survey). RESULTS: The outcomes of the program (response rate 70%) indicate a strong impact of the program on the clinical teachers' competence and on the clinical learning environments. The teachers report that they think more about what their students really learn, have become more conscious about how they supervise and have been stimulated to become better teachers. The learning environment as well as collaboration, and calibration between teachers have improved. The novice teachers report greater benefits than do the experienced teachers. The participants initiated a variety of development projects during the program. The majority of the participants continued the development activities. CONCLUSIONS: The faculty development program presented confirms that faculty development activities for clinical teachers based on theories of learning and experiences documented in the literature can be implemented with positive outcomes for individual teachers and for the learning environments.

[Problem-based learning--documented effects and theoretical foundations]. / Problembasert laering--dokumenterte effekter og teoretisk forankring.

Since problem-based learning is becoming more popular in medical education, the interest in the effects of and theoretical foundations for, such educational strategies is increasing. This article reviews research on the effects of problem-based learning, and relevant research on the development of knowledge and learning. In conclusion it is shown that the learning effects are contingent on how problem-based learning is implemented in the curriculum.

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings.

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.

Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications.

During an 8-year period, 238 barium double-contrast studies performed in 162 patients with continent ileostomy reservoirs who had signs and symptoms of late complications (malfunction of the valve, nonspecific inflammation of the mucosa, stenoses, hernias, and fistulas) showed radiologic abnormalities. The aim of the present study is to depict the radiologic findings in patients with late complications of continent ileostomy reservoirs. With radiologic examination, the correct diagnosis of valve malfunction was made in 96% of patients with surgically proven valve defects. We were able to differentiate between various types of valve dysfunction and complications related to the fixation of the reservoir to the abdominal wall. Inflammatory mucosal changes and fistulas of the reservoir and the afferent ileal segment were depicted with a high degree of accuracy. Barium double-contrast radiologic examination proved to be very valuable in the work-up of patients with dysfunction of continent ileostomy reservoirs. The method was of particular value in assessing the cause of valve dysfunction and in the appraisal of the afferent ileal segment.

Comparison between radiologic and endoscopic evaluation of the continent ileostomy reservoir.

The present study was performed to compare the results of radiologic examination and endoscopy in 156 patients with continent ileostomy reservoirs. Data from clinical follow-up and findings at revisional surgery were used for confirmation of diagnosis. One hundred and one patients had the clinical diagnosis nonspecific inflammation, 48 had symptoms of valve dysfunction, and 7 were studied because of suspected valve-shunting fistulas. For moderate and severe inflammation the findings on radiographs and at endoscopy were in accordance, whereas slight inflammation was more frequently reported by radiology than endoscopy. Radiology overdiagnosed slight inflammation. One disadvantage of endoscopy in patients with inflammation was that the afferent ileal segment could be reached in only 56%. By radiology 41 of 44 defective valves were identified (93%), whereas endoscopy disclosed only 24 defective valves (55%). The combined efforts of radiologic examination and endoscopy only managed to diagnose three of the seven patients with valve-shunting fistulas (two by radiologic and one by endoscopic examination). In conclusion, the retrograde double-contrast examination is a valuable complement in the assessment of patients with continent ileostomies and appears to be superior to endoscopy in the diagnosis of valve dysfunction and in depicting the afferent ileal segment.

Replacement of the bladder by the urethral Kock pouch: functional results, urodynamics and radiological features.

After cystoprostatectomy for cancer of the bladder 43 men were provided with a detubularized, low pressure ileal reservoir (Kock pouch) connected to the urethra. Reflux was prevented by an intussusception valve. There was no operative mortality and few early complications. At followup the mean postoperative observation time was 13 months, with a range of 5 to 20 months. Late complications included manifestations of local tumor recurrence or distant metastases in 9 patients within 6 months postoperatively, which made adequate functional evaluation impossible. In 18 patients reflux to the upper urinary tract due to eversion or sliding of the antireflux valve occurred at various postoperative intervals. In 16 of these patients incontinence developed as a consequence of the reflux. Surgical correction of the failing antireflux valve restored reflux prevention and continence. Within 3 to 6 months the capacity of the reservoirs had reached an ultimate volume of approximately 600 ml. Pressure waves exceeding 40 cm. water seldom occurred in the mature reservoirs and then only at high filling volumes. The mean urethral resting resistance to flow was 64 cm. water. The configuration and function of the upper urinary tract improved or stabilized postoperatively. Of 34 evaluable patients 30 were continent during the day with a voiding frequency of 3 to 5 times and dry at night with a frequency of 0 to 2.

Urinary diversion to the augmented and valved rectum: preliminary results with a novel surgical procedure.

A new method for urinary diversion to the rectum was elaborated in animal experiments and currently has been used in 19 patients. Reflux of the rectal content to the colon and to the upper urinary tract is prevented by the fashioning of an intussusception valve at the rectosigmoid junction. The rectum is augmented by anastomosing an ileal patch to the anterior rectal wall. A transverse colostomy protects the construction for 6 to 8 weeks. Of the 19 patients 3 had local recurrence or metastasis within 6 months. Thus, 16 patients with a followup of 3 to 14 months are evaluable. All patients are continent during the daytime with an emptying frequency of 3 to 5 times and dry at night with a frequency of 0 to 2. In 3 patients partial sliding of the sigmoid intussusception valve occurred causing reflux of rectal contents to the sigmoid and to the right ureter in 1. Reflux to the upper urinary tract has not been revealed in any of the other patients. With 1 exception excretory urography has demonstrated either improvement or stabilization of the upper urinary tract post-operatively. The rectal capacity increased from 200 to 700 ml. after 6 months. With the reservoir full the mean basal pressure was 17 cm. water and the mean maximum pressure was 24 cm. water.

Urinary diversion to the augmented and valved rectum. An experimental study in dogs.

A new model for diverting urine to the rectum was tried in dogs. An intussusception valve was constructed at the junction of the sigmoid colon and the rectum allowing passage only in aboral direction. The rectum was augmented by patching it with an opened and folded ileal segment. The ureters were implanted into the rectum by a new anti-reflux method. All three dogs survived the operation. The volume of the augmented rectum increased from 80-150 ml at operation to a maximum of 750 ml six months after the operation. The pressure in the rectum did not exceed 18 cm of water during maximal filling. No reflux to the bowel proximal to the intussusception valve or to the ureters could be observed even during maximal filling of the augmented rectum. No signs of obstruction of the fecal stream by the intussusception valve were seen. In three out of five implanted renal units strictures developed at the implantation sites and resulted in impaired renal function. In the two renal units without strictures, no impairment of kidney function was found. Involuntary leak from the anus was not observed and no masceration was found around the anus. These experiments are regarded as very encouraging an a clinical trial is now under way.