Skin cancer is among the most frequently occurring malignancies worldwide, which creates a great need for an effective patient-reported outcome measure. Providing shorter questionnaires reduces ...patient burden and increases patients' willingness to complete forms. The authors set out to use computerized adaptive testing to reduce the number of items needed to predict results for scales of the FACE-Q Skin Cancer Module, a validated patient-reported outcome measure that measures health-related quality of life and patient satisfaction in facial surgery.
Computerized adaptive testing generates tailored questionnaires for patients in real time based on their responses to previous questions. The authors used an open-source computerized adaptive testing simulation software to run item responses for the five scales from the FACE-Q Skin Cancer Module (i.e., scar appraisal, satisfaction with facial appearance, appearance-related psychosocial distress, cancer worry, and satisfaction with information about appearance). Each simulation continued to administer items until prespecified levels of precision were met, estimated by standard error. Mean and maximum item reductions between the original fixed-length short forms and the simulated versions were evaluated.
The number of questions that patients needed to answer to complete the FACE-Q Skin Oncology Module was reduced from 41 items in the original form to a mean of 23 ± 0.55 items (range, 15 to 29) using the computerized adaptive testing version. Simulated computerized adaptive testing scores maintained a high correlation (0.98 to 0.99) with the score from the fixed-length short forms.
Applying computerized adaptive testing to the FACE-Q Skin Cancer Module can reduce the length of assessment by more than 50 percent, with virtually no loss in precision. It is likely to play a critical role in the implementation in clinical practice.
Background and ObjectiveContinuing (micro)surgical developments result in satisfactory aesthetic outcomes after autologous breast reconstruction. However, sensation recovers poorly and remains a ...source of dissatisfaction and potential harm. Sensory nerve coaptation is a promising technique to improve sensation in the reconstructed breast. MethodsIn this literature review an overview of current knowledge about sensory recovery in autologous breast reconstruction and the role of innervated flaps is presented. A thorough PubMed search was conducted, using the terms "autologous breast reconstruction", "innervated" and "sensation". Key Content and FindingsThe breast skin is predominantly innervated by the second until sixth intercostal nerve. Some nerves can occasionally be spared during mastectomy, especially during nipple-sparing mastectomy, but transection of sensory nerves is inevitable and leads to impaired sensation. Besides unpleasant, this is unanticipated by patients and negatively influences quality of life. Coaptation between the third anterior intercostal nerve and a sensory nerve from the donor site improves sensory recovery. The donor site and nerve vary, depending on the flap type chosen. The sensory nerves from the commonly used abdominal DIEP flap originate from the 7th until 12th thoracic spinal nerves. Non-abdominal flaps, including the back, buttocks, or thigh area, can also be accompanied with a sensory nerve. Nerve coaptation can be performed directly, or by using grafts or conduits to obtain tensionless repair if necessary. It can be utilized in both immediate as well as delayed autologous breast reconstruction. No adverse outcomes of nerve coaptation have been described. And, most importantly: improved sensory recovery improves patient satisfaction and quality of life. ConclusionsRestoring sensation is, besides restoring aesthetic appearance, an important goal in breast reconstruction. Current evidence unambiguously demonstrates superiority of innervated flaps compared to non-innervated flaps. Sensory recovery initiates earlier and it approaches normal sensation more closely in innervated flaps, without associated risks or extensive increase in operating time. This improves patient satisfaction and quality of life. It is, therefore, a valuable addition to autologous breast reconstruction. These findings encourage implementation of sensory nerve coaptation in standard clinical care.
Diagnosing colorectal cancer (CRC) at an early stage improves survival. To what extent any delay affects outcome once patients are symptomatic is still unclear.Our objectives were to evaluate the ...association between diagnostic delay and survival in symptomatic patients with early stage CRC and late stage CRC.
Prospective population-based observational study evaluating daily clinical practice in Northern Holland. Diagnostic delay was determined through questionnaire-interviews. Dukes' stage was classified into two groups: early stage (Dukes A or B) and late stage (Dukes C or D) cancer. Patients were followed up for 3.5 years after diagnosis.
In total, 272 patients were available for analysis. Early stage CRC was present in 136 patients while 136 patients had late stage CRC. The mean total diagnostic delay (SE) was 31 (1.5) weeks in all CRC patients. No significant difference was observed in the mean total diagnostic delay in early versus late stage CRC (p = 0.27).In early stage CRC, no difference in survival was observed between patients with total diagnostic delay shorter and longer than the median (Kaplan-Meier, log-rank p = 0.93).In late stage CRC, patients with a diagnostic delay shorter than the median had a shorter survival than patients with a diagnostic delay longer than the median (log-rank p = 0.01). In the multivariate Cox regression model with survival as dependent variable and median delay, age, open access endoscopy, number and type of symptoms as independent variables, the odd's ratio for survival in patients with long delay (>median) versus short delay (</=median) was 1.8 (95% confidence interval (CI) 1.1 to 3.0; p = 0.01). Tumor-site was not associated with patient survival. When separating late stage CRC in Dukes C and Dukes D tumors, a shorter delay was associated with a shorter survival in Dukes D tumors only and not in Dukes C tumors.
In symptomatic CRC patients, a longer diagnostic and therapeutic delay in routine clinical practice was not associated with an adverse effect on survival. The time to CRC diagnosis and initiation of treatment did not differ between early stage and late stage colorectal cancer.
Cutaneous vascular reactivity to local heating in free flaps has not been characterized. We aimed to assess local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep ...inferior epigastric perforator (DIEP) flaps.
We conducted a cross-sectional study of 21 female patients with an uncomplicated unilateral delayed DIEP breast reconstruction at least 2 years after surgery. DIEP flaps and contralateral breasts were subjected to direct local heating, and skin blood flow was assessed using laser-Doppler flowmetry. To evaluate sensory-nerve-fiber function, touch perception thresholds were assessed using a 20-piece Touch-test™ Sensory Evaluator, and cutaneous warm detection and heat pain thresholds were measured using a TSA-II device.
Of the participants, 10 had a reinnervated DIEP flap with a single coapted nerve (mean flap weight, 610 ± 296 g) and 11 had a noninnervated DIEP flap (mean flap weight, 613 ± 169 g). Mean age was 58 ± 11 years, mean follow-up time was 5 ± 1 years, and mean BMI was 24 ± 3 kg/m
. DIEP flaps exhibited significantly weaker cutaneous vasodilation in response to local heating than contralateral breasts (median peak skin blood flow, 59 25th-75th percentile, 36-71 a.u. for DIEP flaps versus 94 74-141 a.u. for contralateral breasts; p < .001). The magnitude of the response was similar between reinnervated and noninnervated flaps (median peak skin blood flow, 55 25th-75th percentile, 39-68 a.u. for reinnervated DIEP flaps versus 66 36-77 a.u. for noninnervated DIEP flaps; p = .75). Of participants with reinnervated DIEP flaps, 90% perceived heat pain below the 50°C safety threshold, as compared to 36% of participants with noninnervated DIEP flaps (two-tailed p = .02).
Our results suggest that free flap transfer causes longstanding impairment, yet not complete abolition, of both the sensory nerve-mediated and nitric oxide-dependent local heating-induced cutaneous vasodilatory systems. We found no statistical evidence that flap reinnervation improves the ability to raise skin blood flow in response to local heating.
Postsimulation facilitator-guided debriefing (PSFGD) is the process of intentional discussion of thoughts, actions, and events that took place during simulation amongst the facilitator(s) and ...trainees. Despite the significance of delivering high-quality debriefings, there is a lack of evidence-based guidelines. Our study aimed to provide an instructional video demonstration of a PSFGD of a fatality.
Fifty surgical interns participated in a burn simulation scenario in two groups. Group 1 (control, or "no exposure," n = 25) consisted of residents who received oral postsimulation debriefing from an independent faculty member who had no exposure to our instructional video on how to debrief effectively. Group 2 (intervention, or "exposure," n = 25) consisted of interns who were debriefed by the second faculty member who did watch our instructional video before the simulation and learned about "advocacy and inquiry" techniques. The outcome measures were the Debriefing Assessment for Simulation in Healthcare score and the postdebrief multiple-choice question (MCQ) quiz scores to assess debriefers' performance and interns' knowledge consolidation, respectively.
The "exposure" group presented statistically significantly higher values for the Debriefing Assessment for Simulation in Healthcare score (
< 0.001) and MCQ score (
< 0.001) compared with the "no exposure" group.
Debriefers who followed the methodology as demonstrated in our instructional video were considered more competent, and the residents achieved higher MCQ scores. The quality of the debriefing ensures improved critical thinking and problem-solving skills. Safer practice and better patient outcomes are achieved by developing debriefing programs for educators.
Endoscopic surveillance after curative colorectal cancer (CRC) resection is routine. However, there is controversy whether the 1-year interval between preoperative and postoperative colonoscopy is ...justified owing to improved colonoscopy standards. We aimed to assess the yield of surveillance colonoscopies 1 year after CRC surgery.
We performed a retrospective cohort study of 572 patients (54.9% male; mean age, 66.2 ± 9.9 y), who underwent curative surgical resection of a first CRC from June 2013 through April 2016 in the Northwest region of The Netherlands. Patients were included if a complete clearing colonoscopy was performed before surgery and the interval between the preoperative and postoperative colonoscopy was 12 months (range, 6-20 mo), conforming to Dutch guidelines. The primary outcome of the study was the yield of CRC at the surveillance colonoscopy performed 1 year after curative resection. A secondary outcome was the yield of advanced neoplasia.
After a mean surveillance interval of 13.7 months (±2.8 mo), 10 of 572 patients (1.7%; 95% CI, 0.7%-2.8%) received a diagnosis of CRC. Of these, 5 CRCs were apparently metachronous cancers (3 were stage III or IV) and 5 were recurrences at the anastomosis (1 was stage IV). In 11.4% of patients (95% CI, 8.9%-13.8%), advanced neoplasia was detected at the 1-year follow-up colonoscopy. Synchronous advanced neoplasia at baseline colonoscopy was a risk factor for detection of advanced neoplasia at the follow-up colonoscopy (odds ratio, 2.2; 95% CI, 1.3-3.8; P ≤ .01).
Despite high colonoscopy quality, the yield of CRC at surveillance colonoscopy 1 year after CRC resection was 1.7%. These were metachronous CRCs and recurrences, often of advanced stage. The high yield justifies the recommendation of a 1-year surveillance interval after surgical CRC resection.
Importance
It is unknown how often breast implant illness (BII) is the indication for revision in women with silicone breast implants.
Objective
To examine how often women with silicone breast ...implants have their implants explanted or replaced because of BII compared with local postoperative complications.
Design, Setting, and Participants
A legacy cohort study on breast implant revision surgery was conducted between April 1, 2015, and December 31, 2020, and a prospective cohort study on breast implantation and revision surgery was conducted between April 1, 2015, and December 31, 2019 (with follow-up until December 31, 2020). Data were obtained from the Dutch Breast Implant Registry. Data analysis was performed from September 2021 to August 2022.
Exposures
Silicone breast implant.
Main Outcomes and Measures
Breast implant revision with the indication BII or local postoperative complications.
Results
All 12 882 cosmetic breast implants (6667 women; mean SD age, 50.6 12.7 years) and 2945 reconstructive breast implants (2139 women, mean SD age, 57.9 11.3 years) in the legacy cohort and all 47 564 cosmetic breast implants (24 120 women, mean SD age, 32.3 9.7 years) and 5928 reconstructive breast implants (4688 women, mean SD age, 50.9 11.5 years) in the prospective cohort were included for analysis. In the prospective cohort, 739 cosmetic breast implants (1.6%) were revised after a median (IQR) time to reoperation of 1.8 (0.9-3.1) years, and 697 reconstructive breast implants (11.8%) were revised after a median (IQR) time to reoperation of 1.1 (0.5-1.9) years. BII was registered as the reason for revision in 35 cosmetic revisions (4.7%) and 5 reconstructive revisions (0.7%) in the prospective cohort, corresponding to 0.1% of the inserted implants. In the legacy cohort, 536 cosmetic revisions (4.2%) and 80 reconstructive breast implant revisions (2.7%) were performed because of BII.
Conclusions and Relevance
In this cohort study of women with silicone breast implants, BII was an uncommon indication for revision compared with local complications, both in the short and long term. In contrast to the increasing public interest in BII, these results showed that local complications are a far more common reason for breast implant revision.
Review: ischaemia–reperfusion injury in flap surgery van den Heuvel, Marieke G.W; Buurman, Wim A; Bast, Aalt ...
Journal of plastic, reconstructive & aesthetic surgery,
06/2009, Letnik:
62, Številka:
6
Journal Article
Recenzirano
Summary Ischaemia–reperfusion injury is the mechanism underlying (partial) flap loss. This is not only a traumatic event for the patient, it also causes increased patient morbidity Kerrigan CL, ...Stotland MA. Ischemia reperfusion injury: a review. Microsurgery 1993; 14 :165–75 as well as prolonged hospitalisation, increasing medical consumption and costs. For surgeons who perform flap surgery, it is important to have knowledge of ischaemia–reperfusion injury in order to prevent it. In this article, an update on the recent research on ischaemia–reperfusion is given. The production of reactive oxygen species, neutrophil influx, depletion of NO and apoptosis are discussed as well.
In the original publication Table 1 has been removed as the authors did not obtain permission to reproduce the BODY-Q scale. A revised Table 1 is provided in this correction.
PDF
