Integrating accompanying patients into clinical oncology teams: limiting and facilitating factors.

OBJECTIVES: Since 2018, four establishments in Quebec have been instrumental in implementing the PAROLE-Onco program, which introduced accompanying patients (APs) into healthcare teams to improve cancer patients' experience. APs are patient advisors who have acquired specific experiential knowledge related to living with cancer, using services, and interacting with healthcare professionals. They are therefore in a unique and reliable position to be able to provide emotional, informational, cognitive and navigational support to patients who are dealing with cancer. We aimed to explore APs' perspectives regarding the limiting and facilitating factors in terms of how they are integrated into the clinical oncology teams. METHODS: A qualitative study based on semi-structured interviews and focus groups was conducted with 20 APs at the beginning of their intervention (T1) and, two years later, during a second data collection (T2). Limiting and facilitating factors of APs' integration into clinical teams were analyzed in terms of governance, culture, resources and tools. RESULTS: The limited factors raised by APs to be integrated into clinical teams include the following: confusion about the specific roles played by APs, lifting the egos of certain professionals who feel they are already doing what APs typically do, lack of identification of patient needs, absence of APs in project governance organizational boundaries, and team members' availability. Various communication challenges were also raised, resulting in the program being inadequately promoted among patients. Also mentioned as limiting factors were the lack of time, space and compensation. Creating opportunities for team members to meet with APs, building trust and teaching team members how APs' activities complement theirs were enhancing factors. Other facilitators include APs being involved in decision-making committees, being leaders in promoting the PAROLE-Onco program to patients and clinical team members and creating opportunities to communicate with team members to help enhance their work and provide feedback to improve patient services. Awareness of APs' added value for the team and patients is also a key facilitator. Regarding tools, offering accompanying services by telephone allows both patients and APs to benefit from the flexibility they need. CONCLUSION: Over time, APs were able to identify optimal factors for successful implementation. Recommendations include APs and professionals working in co-construction on organization, leadership, resources and status factors. This could help catalyze a change in culture within health establishments and allow people dealing with cancer to benefit from the experiential knowledge of other patients within their clinical team.

Accompanying patients in clinical oncology teams: Reported activities and perceived effects.

INTRODUCTION: Since 2018, four establishments in Quebec, Canada, have decided to implement the PAROLE-Onco programme, which introduced accompanying patients (APs) in healthcare teams to improve the experience of cancer patients. APs are patient advisors who have had a cancer treatment experience and who conduct consultations to complement the service offered by providing emotional, informational and educational support to patients undergoing treatments (e.g., radiotherapy, chemotherapy, surgery), mostly for breast cancer. We aimed to explore the evolution of APs' perspectives regarding their activities within the clinical oncology teams as well as the perceived effects of their intervention with patients, the clinical team and themselves. METHODS: A qualitative study based on semistructured interviews and focus groups was conducted with APs at the beginning of their intervention (T1) and 2 years afterwards (T2). The themes discussed were APs' activities and the perceived effects of their interventions on themselves, on the patients and on the clinical team. RESULTS: In total, 20 APs were interviewed. In T2, APs' activities shifted from listening and sharing experiences to empowering patients by helping them become partners in their care and felt generally more integrated into the clinical team. APs help patients feel understood and supported, alleviate stress and become partners in the care they receive. They also alleviate the clinical team's workload by offering a complementary service through emotional support, which, according to them, helps patients feel calmer and more prepared for their appointments with healthcare professionals. They communicate additional information about their patients' health journey, which makes the appointment more efficient for healthcare professionals. When APs accompany patients, they feel as if they can make a difference in patients' lives. Their activities are perceived by some as an opportunity to give back but also as a way of giving meaning to their own experience, in turn serving as a learning experience. CONCLUSION: By mobilizing their experiential knowledge, APs provide emotional, informational, cognitive and navigational support, which allows patients to be more empowered in their care and which complements professionals' scientific knowledge, thereby helping to refine their sensitivity to the patients' experiences. PATIENT OR PUBLIC CONTRIBUTION: Two patient-researchers have contributed to the study design, the conduct of the study, the data analysis and interpretation, as well as in the preparation and writing of this manuscript.

Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study.

The most common complications of irradiated implant-based mammary reconstruction are fibrosis and capsular contracture. The indications for postmastectomy adjuvant radiotherapy have considerably broadened. Facing an increased number of patients who will require radiotherapy, most guidelines recommend delaying reconstruction after radiotherapy to prevent long-term fibrotic complications. Does radiotherapy permanently alter cellular properties which will adversely affect implant-based reconstruction? If so, is there a benefit in delaying reconstruction after radiotherapy? Our in vitro model simulates two implant-based mammary reconstruction approaches: the irradiated implant and the delayed implant reconstructions by using an implant inset beneath healthy non-irradiated tissue post radiotherapy. We performed cell culture of fibroblasts and endothelial cells to simulate these two surgical conditions. Irradiated fibroblasts simulate the capsular tissue seen around the breast implant. The delayed reconstruction approach is simulated by non-irradiated fibroblasts conditioned with supernatant culture media obtained from irradiated endothelial cells. Irradiation induced fibrosis through fibroblast differentiation into myofibroblasts, as demonstrated by increased α-smooth-muscle actin levels in fibroblasts. This constitutes the basis for scar tissue contraction observed in irradiated implant-based breast reconstruction. Irradiation of endothelial cells induced irreversible cell cycle arrest known as senescence and secretion of the profibrotic connective tissue growth factor. Non-irradiated fibroblasts conditioned with culture media obtained from irradiated endothelial cells exhibited myofibroblast differentiation and the expression of fibrotic phenotype akin to capsular contracture. Our results demonstrate that radiotherapy causes irreversible cellular changes, which permanently alter the microenvironment in favor of fibrosis. Given that these changes are permanent, delaying reconstruction does not present an advantage in preventing capsular contracture.

Microvascular replantation of head and neck amputated parts: A systematic review.

BACKGROUND: As opposed to upper and lower extremity amputations representing a considerable volume of admissions, the prowess of microsurgeons is seldom solicited in complex cases of head and neck replantation. Our aim was to determine the rate of successful replantation of craniofacial parts in a systematic review of the literature. METHODS: We performed a systematic review of English literature using PubMed/MEDLINE for every replantation of a head and neck parts. Articles selected for analysis required to describe microvascular surgical techniques to be considered a replantation. The measured endpoint for a successful replantation was survival at hospital discharge. RESULTS: From 113 articles from the literature, reported cases of replanted craniofacial parts included 90 scalps, 56 ears, 34 lips, 26 noses, 1 eyebrow, and 1 midface. A significant majority of amputations were described as an avulsion mechanism (78.4%), as opposed to cutting/sharp (17.3%) or crush-type (1.9%). The overall success rate at hospital discharge was 72.1%, with a partial failure at 20.2% and a complete failure at 7.7%. CONCLUSION: Urgent replantation of head and neck amputated parts allow patients to recover in a timely manner and to decrease the need for secondary reconstructive procedures. The significant rate of success is a strong argument in favor of promoting access to care for replantation of craniofacial parts.

Pulmonary Artery Sealing Using the HARMONIC ACE+ Shears for Video-Assisted Thoracoscopic Surgery Lobectomy.

BACKGROUND: The standard technique for pulmonary arterial (PA) branch sealing in video-assisted thoracoscopic surgery lobectomy consists of vascular endostaplers. We evaluated the immediate efficacy of an ultrasonic energy vessel-sealing device for sealing PA branches and compared it with the gold standard (endostapler) in an ex vivo model. METHODS: This was a prospective cohort study. Immediately after anatomical lung resection, PA vessel sealing was achieved using the HARMONIC ACE+ Shears (ACE; Ethicon, Cincinnati, OH) sealing device or a vascular endostapler (VES) in a 3:1 ratio based on vessel diameter. The vessel was slowly pressurized, and the bursting pressure was recorded. RESULTS: A total of 137 PA branches were sealed in specimens from 43 patients, of which 90 vessels were sealed with ACE and 47 were sealed with VES. The mean PA branch diameter was 6.0 mm (range, 1.7 mm to 24.0 mm; standard deviation, 3.1 mm Hg). The mean bursting pressure was 333.0 mm Hg (range, 84.0 mm Hg to 1415.1 mm Hg; standard deviation, 231.4 mm Hg) in the ACE group and 114.2 mm Hg (range, 0 mm Hg to 840.0 mm Hg; standard deviation, 124.7) in the VES group (p < 0.001). There were no complete sealing failures in the ACE group. Electron microscopy of ACE-sealed PA vessels demonstrated adventitial sealing with partial preservation of the collagen bundles and media with a sealed matrix of melted collagen. CONCLUSIONS: PA branches sealed using the HARMONIC ACE+ in a simulated ex vivo model were able to sustain high intraluminal pressures. ACE-sealed vessels burst at mean bursting pressures equal to or greater than the VES-stapled vessels.

Super-drained distally based neurofasciocutaneous sural flap: a case series and review of literature.

OBJECTIVE: The distally based neurofasciocutaneous sural flap is central to the armamentarium for the reconstruction of leg's distal third, ankle, and hindfoot. Despite the use of adapted techniques aimed at increasing the flap's reliability, venous congestion remains a frequently encountered problem. We present a venous super-drainage technique used by the senior author to reduce venous congestion and improve flap reliability when harvesting larger flaps. METHODS: A retrospective chart review, from January 2002 to October 2008, at 2 tertiary care centers, was conducted on all cases of inferior limb reconstruction with reverse sural flaps on defects greater than 10 × 5 cm. In addition, a literature review was carried out to examine the average sural flap surface area and reported complications published from 1992 to 2012. We then compared our results with those published in the literature. RESULTS: A total of 15 flaps were identified. Mean flap dimensions were 14 × 8.5 cm (mean area = 115.27 cm(2); 95% confidence interval, 99.28-131.26). None of the flaps developed complications (arterial or venous insufficiency, partial/complete necrosis). The average flap surface area in the literature is 55.08 cm(2), with a 22% rate of total complications. We harvested significantly larger flaps (P < .001) with a significantly lower total complication rate (P < .05) when compared with that reported in the literature. CONCLUSION: Anastomosing the proximal end of the lesser saphenous vein with a vein at the defect site improves venous outflow, effectively reducing the incidence of venous congestion, increases the potential flap size, and improves reliability.

Patient advisors for victims of traumatic amputation: a critical intervention / Le patient-ressource chez les victimes d'amputation traumatique

Patient advisors for victims of traumatic amputation: a critical intervention. Since 2014, the Centre of Expertise in Reimplantation and Microsurgical Revascularization at the University of Montreal (CEVARMU) has been recruiting on an ad hoc basis former patients, who have completed the rehabilitation process, to accompany and support new patients at the Centre during their care process. Considered full-fledged partners of the care team, these patient advisors are invited to meet with patients who are hospitalized or in the rehabilitation process to not only share their experience but also ensure that the treatment plans proposed to the patients are well understood and meet their needs. Around forty interventions have been conducted by five patient advisors, helping to strengthen the credibility of professional interventions, break down patients' isolation, and give new meaning to the work of health professionals.

Le patient-ressource chez les victimes d'amputation traumatique. Depuis 2014, le Centre d'expertise en réimplantation ou revascularisation microchirurgicale d'urgence (CEVARMU) fait appel, sur une base ponctuelle, à d'anciens patients ayant terminé leur processus de réadaptation afin d'accompagner et de soutenir les patients nouvellement arrivés au centre dans leur propre processus de soins. Considérés comme des partenaires à part entière de l'équipe, ces patients-ressources sont invités à venir rencontrer, sur une base bénévole, les patients hospitalisés ou qui sont en processus de réadaptation afin de témoigner de leur expérience mais aussi de s'assurer que les plans de traitement proposés aux patients soient bien compris par ces derniers et qu'ils répondent à leurs besoins. Une quarantaine d'interventions ont été réalisées par cinq patientsressources et ont permis de renforcer la crédibilité des interventions des professionnels, de briser l'isolement des patients et de redonner du sens au travail des professionnels.

Monitoring buried jejunum free flaps with a sentinel: a retrospective study of 20 cases.

OBJECTIVES/HYPOTHESIS: The free jejunum transfer has become a widely used reconstruction option after total laryngopharyngectomy. The aim of this study was to evaluate the effectiveness of using an exteriorized jejunal segment for flap monitoring. STUDY DESIGN: Case series. METHODS: Twenty patients with tumors involving the pharynx, larynx, or cervical esophagus were subjected to total laryngopharyngectomy and neck dissection. The resulting esophageal defect was reconstructed with a free jejunal flap based on a major branch of the superior mesenteric artery and vein. After completion of anastomoses with the recipient vessels, the flap was divided into two segments of common vascular supply. The smaller segment was exteriorized in the cervical region for direct monitoring of serosal color, temperature, peristalsis, and bleeding during the postoperative period. This sentinel was resected once the viability of the flap was judged appropriate. RESULTS: Of the 20 patients who had free jejunum transfers for pharyngoesophageal reconstruction, 14 had an uneventful postoperative course, and six needed re-exploration due to signs of arterial insufficiency in the sentinel segment. On re-exploration, four flaps were found to have arterial thrombosis and two had no abnormality at the anastomotic site. One of the flaps that developed thrombosis was subsequently lost. CONCLUSIONS: Monitoring of buried free jejunal flap with a sentinel is an effective method of assessing flap viability after total laryngopharyngectomy and guides re-exploration in cases of anastomotic complications.

A new dorsal decubitus position for raising subscapular-based flaps.

Flaps based on the subscapular vascular system are reliable and versatile tools that provide excellent coverage for a wide range of tissue deficits. Raising these flaps in the described dorsal decubitus position permits two surgical teams to work simultaneously while obviating the need for intra-operative position changes. In cases where a subscapular-based flap is deemed the most suitable option for reconstruction, the dorsal decubitus technique eliminates many of the limitations associated with the traditional lateral decubitus approach without compromising the range of tissue obtainable.

Negative-pressure therapy versus standard wound care: a meta-analysis of randomized trials.

BACKGROUND: Several randomized controlled trials comparing negative-pressure therapy to standard wound care for chronic wounds have been published. Although these studies suggest a benefit for negative-pressure therapy, the majority of the review articles on the topic conclude that the studies are inconclusive. The authors conducted a quantitative meta-analysis of the effectiveness of negative-pressure therapy for the management of chronic wounds. METHODS: The MEDLINE, EMBASE, and Cochrane databases were searched from 1993 to March of 2010 for randomized controlled trials comparing negative-pressure therapy to standard wound care for chronic wounds. Measures of wound size and time to healing, along with the corresponding p values, were extracted from the randomized controlled trials. Relative change ratios of wound size and ratios of median time to healing were combined using a random effects model for meta-analysis. RESULTS: Ten trials of negative-pressure therapy versus standard wound care were found. In the negative-pressure therapy group, wound size had decreased significantly more than in the standard wound care group (relative change ratio, 0.77; 95 percent confidence interval, 0.63 to 0.96). Time to healing was significantly shorter in the negative-pressure therapy group in comparison with the standard wound care group (ratio of median time to healing, 0.74; 95 percent confidence interval, 0.70 to 0.78). CONCLUSIONS: This quantitative meta-analysis of randomized trials suggests that negative-pressure therapy appears to be an effective treatment for chronic wounds. An effect of publication bias cannot be ruled out. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Dorsal decubitus positioning: a novel method to harvest the latissimus dorsi flap for massive upper extremity defect reconstruction.

The latissimus dorsi, whether taken as a muscle or with a skin paddle, is one of the most useful flaps in the reconstructive surgeon's arsenal. With its predictable type V vascular pedicle, this broad muscle can be elevated on its dominant thoracodorsal pedicle or used in a reverse manner on its secondary thoracic and lumbar perforators. Traditionally harvested in a lateral decubitus position, over the last 10 years we have chosen to elevate this muscle in a dorsal decubitus position, enabling 2 surgical teams to operate simultaneously. With only one cushion placed along the vertebral column between the scapulas, each element of the subscapular system, including scapular bone, can be used to reconstruct complex upper limb defects. A vertical incision in front of the anterior axillary line is performed to identify the anterior border of the muscle, followed by a dissection in the submuscular plane to reveal the thoracodorsal pedicle and its branches. When a more complex chimeric flap is required, scapular bone, serratus muscle, and scapular or parascapular fasciocutaneous flaps are all available. To achieve the longest length possible, the pedicle can be isolated from the axillary vessels. The most common complications are related to donor site, with seroma and delayed wound healing being the most prevalent. Complaints of shoulder pain and functional disability were rare and mostly encountered in the first 2 weeks postoperatively.

Flexibility of Thiel's embalmed cadavers: the explanation is probably in the muscles.

INTRODUCTION: The flexibility of cadavers conserved using Thiel's embalming method remains unexplained. We aimed to perform microscopic comparison of muscle and tendon fibres from fresh cadavers (FC), formaldehyde-preserved cadavers (FPC) and cadavers conserved by Thiel's method (TC). METHODS: Muscle and tendon biopsies performed on FC, FPC and TC were conditioned and stained by Masson's trichrome, Sirius red and Ramon y Cajal, then studied under optical microscope. Alignment and integrity of the muscle and tendon fibres were studied. RESULTS: We observed a modification of the muscle fibres in all specimens from TC, regardless of the type of staining used. The muscle fibres taken from FC and FPC were relatively well conserved, both in terms of alignment and integrity. We did not observe any modification of collagen in either muscle or tendon fibres. CONCLUSIONS: The considerable fragmentation of the muscle proteins, probably caused by certain corrosive chemicals, (e.g. boric acid) present in Thiel's embalming solution, could explain the suppleness of the TC. However, we cannot exclude the possibility of alterations in tendon or muscle collagen, since the experimental methods we used, did not allow for the study of collagen ultrastructure.

Lateral mediastinal tracheostomy in benign disease: an uncommon procedure for a rare indication.

Tracheostomy is sometimes required for long-term ventilation in patients with a challenging cervical anatomy. We present a case of a patient requiring prolonged mechanical ventilation with prohibitive cervical anatomy for standard tracheostomy secondary to severe ankylosing spondylitis and a cervical spine fracture.

Use of bone anchors for flap fixation in burned patients.

UNLABELLED: Mitek or Arim anchors were developed for use in orthopaedic surgery to facilitate soft tissue fixation to bone. We believe this tool can be useful in difficult cases when securing various flaps to bone, we present a retrospective study of deep thickness burns patients. MATERIALS AND METHODS: We conducted a retrospective study, including severely burned patients who underwent flap reconstruction with Mitek or Arim anchor fixation between 1999 and 2007 in our unit. Characteristics analysed included indications for surgery, and postoperative complications. RESULTS: Nine patients (nine flaps) were included, seven men and two women with age ranging from 22 to 59 years old. Flaps were as follows: one gracilis, two latissimus dorsi, four medial gastrocnemius and two lateral gastrocnemius flaps. Indications for reconstruction were: open fractures or joint exposure in severely burned patient. Only one complication was noted: partial flap necrosis with infection of the bone anchor necessitating ablation and a new mobilisation of the flap. CONCLUSION: Mitek anchors are a useful tool in plastic surgery. Suture anchors are used when coverage poses a risk of shearing away from the bone or adequate periosteum and soft tissue is not available for standard suture techniques. The anchor system provides a simple, fast, and efficient technique for flap fixation.

Osteoid osteoma of the capitate: a case report and literature review.

Osteoid osteoma is a benign bone tumor that rarely affects the carpal bones. Because of its nonspecific presentation in the wrist, it remains a diagnostic challenge. We report an unusual case of osteoid osteoma in the capitate where the diagnosis was delayed and the presentation was that of an aggressive natured lesion with considerable functional incapacitation. Diagnosis was made by computed tomographic scan of the wrist and surgical excision lead to a dramatic relief of symptoms.