Where do you insert a drain tube during breast reconstruction?

PURPOSE: A drain tube is commonly inserted during breast reconstruction surgery. This leads to a scar in addition to the scar on the breast. This study was performed to investigate how patients feel about the drain scar and to clarify its ideal location. METHODS: A questionnaire survey about the drain scar was distributed to 38 consecutive breast reconstruction patients and a total of 104 female doctors and nurses engaged in breast reconstruction. The drain scars were evaluated using the Japan Scar Workshop (JSW) Scar Scale. RESULTS: A total of 32% of the patients expressed some anxiety about the drain scar. Patients who were anxious about the drain scar had higher scores on the JSW Scar Scale than those who were not anxious. Younger doctors and nurses preferred the drain scar to be on the side of the chest, while older doctors and nurses preferred the drain scars to be at the axilla. CONCLUSIONS: About a third of the patients had some anxiety associated with their drain scar after breast reconstruction surgery, and this anxiety level was correlated with objective assessment of the scar. Thus, more patient involvement or the provision of more information regarding drain placement is required.

Optimal Management of Tethered Surgical Drains: A Cadaver Study.

BACKGROUND: Tethered drains are a complication of drain usage and may result in unintentional retained broken drains, as well as anxiety and uncertainty for the surgeon and the patient. To date, no study has examined the optimal approach for management and removal of tethered drains. METHODS: The study design sought to identify suture size, mechanism of drain fixation (through versus around), points of constriction (one versus multiple) and the efficacy of weighted traction as potential sources of tethered drains by means of four study arms. (1) Arm one compared drains sutured through the tubing versus a tight closure of the surrounding fascia, which were then subjected to weighted suspension. (2) Arm two compared drains sutured into the fascia using eight each of 4-0, 2-0 and 0 vicryl and then subject to manual traction. (3) Arm three compared drains sutured to the fascia through the tubing versus local tissue incarceration followed by manual traction. (4) Lastly, group four examined drains tethered at two distinct points after which they were subject to manual traction. RESULTS: Our results showed a 25% drain retention rate when manual traction was applied to 0 vicryl and 2-0 vicryl suture. In contrast, there were no instances of drain retention when suture was closed with 4-0 vicryl. When evaluating for multiple points of fixation, drains tethered in two locations were retained in 87.5% of trials versus drains with a single tether point (25%) representing a statistical significance (P = 0.041). There was no difference in rates of drain retention when pierced through the tubing versus incarcerated in local fascia. Only one of the 16 drains was successfully removed by weighted suspension (8.3%). Attempts at manual traction following weighted suspension resulted in a 50% drain retention rate which was higher than the rates of immediate manual traction (18.8%). CONCLUSION: Our results found that manual traction is a reasonable first line approach to address drains tethered by all methods and suture sizes. The use of weighted traction for the management of tethered drains is less effective than manual traction and may result in more retained drain fragments. LEVEL OF EVIDENCE: Level IV.

[Effect of pre-surgical stress on recovery of patients undergoing hip replacement procedures]. / Stres przed zabiegiem operacyjnym a przebieg okresu pooperacyjnego u pacjentów po wszczepieniu endoprotezy stawu biodrowego.

The aim of this study was to assess the effect of emotional stress experienced by patients prior to surgery on the process of post-surgical recovery. The study covered 50 hospitalised patients (31 women and 19 men) who underwent hip replacement procedures. The research relied on STAI-X1 anxiety questionnaire, as well as a specially prepared survey and the analysis of medical documentation. The results of the study suggest that fears most frequently listed by patients include fear of pain and anaesthesia, as well as anxieties related to the possibility of medical complications and the need to rely on a stranger. A positive statistical correlation was found between the level of emotional stress and the occurrence of psychological and care problems in the first three days following the surgery (unfounded anxieties, self-removal of drainage, ports or dressing). In addition, a statistically significant relation was found between the emotional stress level before the surgery and the number of times the patient's blood pressure exceeded 140/90 mmHg (p = 0.0408), as well as his or her consumption of analgesics (p = 0.0033), sedatives (p = 0.0340) and soporific drugs (p = 0.0273) in postoperative period.

Who decides? A qualitative study on the decisional roles of patients, their caregivers and doctors on the method of bladder drainage after spinal cord injury.

STUDY DESIGN: Qualitative study using individual in-depth interviews. OBJECTIVE: To explore the roles of patients, their caregivers and doctors when making decisions on the method of bladder drainage after spinal cord injury (SCI). SETTING: Five public hospitals in Malaysia. METHODS: Semistructured (one-to-one) interviews with 17 male patients with SCI, 4 caregivers and 10 rehabilitation professionals. RESULTS: Eight themes describing the respective decisional roles of patients, their caregivers and doctors emerged from the analysis: patient's right and responsibilities, patient as an informed decision maker, forced to accept decision; surrogate decision maker, silent partner; doctor knows best, over-ride patient's decision, or reluctant decision maker. Both patients and doctors acknowledged the importance of patient autonomy but not all patients had the chance to practice it. Some felt that they were forced to accept the doctor's decision and even alleged that the doctor refused to accept their decision. Doctors considered the caregiver as the decision maker in cases that involved minors, elderly and those with tetraplegia. Some patients considered bladder problems an embarrassing subject to discuss with their caregivers and did not want their involvement. Doctors were described as knowledgeable and were trusted by patients and their caregivers to make the most appropriate option. Some doctors were happy to assume this role whereas some others saw themselves only as information providers. CONCLUSIONS: A paternalistic model is prevalent in this decision-making process and there is a discrepancy between patients' preferred and actual decisional roles.

Behavior changes after minor emergency procedures.

OBJECTIVES: Procedures are common in pediatric emergency departments and frequently cause distress from pain and/or anxiety. The objective of this study was to describe the incidence, types, and magnitude of long-term behavior changes after procedures in the emergency setting. METHODS: This is a descriptive pilot study to determine if children display negative behavioral changes after a minor emergency department procedure (abscess drainage or laceration repair). Behavior change was measured at 1 week by telephone follow-up using the 27-item Post Hospitalization Behavior Questionnaire, a well-validated instrument that measures behavior changes across 6 categories: general anxiety, separation anxiety, anxiety about sleep, eating disturbances, aggression toward authority, and apathy/withdrawal. Significant behavior change was defined as 5 or more negative behavior changes on the 27-item questionnaire. RESULTS: Twenty percent of children who underwent abscess drainage (n = 30) and 20% who underwent laceration repair (n = 30) displayed significant negative behavior change at 1 week. Children who displayed significant negative behavior change tended to be younger (3.6 vs 5.9 years) and trended toward being more likely to have received anxiolysis or sedation (16.7% vs 8.3%). Separation anxiety, sleep difficulties, and aggression toward authority were the most common behavior changes. CONCLUSIONS: In this pilot study, a significant percentage of children undergoing common emergency procedures exhibited an appreciable burden of negative behavior change at 1 week; these results demonstrate the need for further rigorous investigation of predictors of these changes and interventions, which can ameliorate these changes.

The impact of tunneled pleural catheters on the quality of life of patients with malignant pleural effusions.

BACKGROUND: Tunneled pleural catheters (TPC) are used in the management of malignant pleural effusions (MPE), but the impact of this palliative procedure on patient quality of life (QoL) has not been well described. OBJECTIVES: To ascertain the impact of TPCs on symptoms and QoL of patients with recurrent MPE. METHODS: Patients with recurrent MPE completed the EORTC QLQ-C30 and LC13 QoL questionnaires at baseline, 2 and 14 weeks; FACIT-TS-G© treatment satisfaction surveys were completed at 14 weeks. RESULTS: A total of 82 patients were recruited. Thirty-seven patients (37/82, 45%) died prior to their 14-week follow-up appointment. Significant improvements in dyspnea at 2 weeks were demonstrated with both dyspnea scores (LC13 baseline score 64.1, 2-week score 43.7, mean change -20.4, n = 56, p < 0.001; C30 baseline score 78.9, 2-week score 46.6, mean change -32.4, n = 68, p < 0.001), as well as with the MRC score (baseline median score 4, 2-week score 3, n = 70, p < 0.001). Global health status/QoL was also significantly improved at 2 weeks (baseline score 34.1, 2-week score 46.3, mean change 12.3, n = 68, p < 0.001). Improvements in cough, fatigue and all functional scales were noted at 2 weeks. The improvements in dyspnea and global health status/QoL were maintained to 14 weeks in surviving subjects and there was further improvement in the MRC score at 14 weeks. Patients who completed the FACIT-TS-G survey demonstrated overall satisfaction with TPC treatment. CONCLUSIONS: TPCs are associated with a significant improvement in global health status, QoL and dyspnea at the 2-week time point in patients with recurrent MPE.

RCT of urethral versus suprapubic catheterization.

OBJECTIVE: To compare the use of intermittent urethral catheterization with indwelling suprapubic catheterization in women undergoing surgery for urodynamic stress incontinence or uterovaginal prolapse. DESIGN: Randomized controlled trial. SETTING: Tertiary referral urogynaecology unit. POPULATION: Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence. METHODS: Women were randomized into one of two groups. Group 1 had bladder drainage using a suprapubic catheter inserted in theatre. The catheter was left on free drainage for 48 hours post-operatively before clamping. Group 2 was catheterized intermittently post-operatively. MAIN OUTCOME MEASURES: Length of post-operative hospital stay: time to resume normal voiding (defined as voided volumes greater than 200 mls and residual urine volumes less than 100 mls on three occasions); number of urinary tract infections (UTIs); catheterization costs; patient experience (determined from questionnaire); and a pain score. RESULTS: 75 women were randomized; 38 to suprapubic catheterization; 37 to intermittent catheterization. Three were withdrawn from study, leaving 36 women in each group. Groups were closely matched for age and type of surgery undertaken. Length of hospital stay and total duration of catheterization were both significantly shorter for the intermittent catheterization group; although there was no difference in the rate of UTI between the two groups. There was no clear patient preference for a specific catheterization method. CONCLUSIONS: The use of intermittent catheterization following urogynaecological surgery is associated with a more rapid return to normal micturition and a shorter hospital stay, although the clinical significance of the difference is perhaps limited.

Accessories or necessities? Exploring consensus on usage of stoma accessories.

Usage and opinion of accessory products in stoma care vary enormously. The aim of this study was to identify what constitutes an accessory product and to find out whether there is any standardization regarding their recommendation. Views of both patients and stoma nurses were examined. Patients identify accessory products as being necessary both physically and psychologically in improving their quality of life. While stoma nurses identify that the psychological effects of having a stoma should never be underestimated, there is still concern regarding the cost of recommending these products and their clinical necessity. It would appear that clinical necessity is based on nurses' opinions and is not always evidence or research based. Since accessory products have been shown to be essential to many patients with a stoma, should stoma nurses be more empathetic when considering their recommendation?

A comparative study of two-piece ostomy appliances.

The quality of life of people with a stoma may be affected by peristomal skin disorders and by frequent unplanned changes of ostomy appliances due to problems with those appliances. The aim of this study was to evaluate two new, two-piece ostomy appliances with mechanical couplings (both from the SenSura range by Coloplast) and their ability to address areas that may be important to the quality of life of people with stomas, including appliance changes, stool seepage and overfilling. The study design featured two comparative, crossover, randomized multi-centre studies that were conducted in Germany. The SenSura appliances were evaluated against established reference appliances. Seventy-three individuals with a colostomy (closed-end appliances) and 75 individuals with an ileostomy (drainable appliances) participated in the studies. The participants tested 4-6 flanges of each type within a maximum period of two weeks. The results demonstrated that there was less seepage of stool observed under the SenSura flange when it was removed (p<0.05). Also, there were fewer unplanned changes (p<0.0005) seen with SenSura than with the reference appliances. The SenSura flanges had better adhesion and flexibility and were easier to remove than the references (p<0.0005), and they had greater resistance to erosion (p<0.05). In conclusion, SenSura performed better than the reference appliances on quality of life indicators - there were fewer unplanned changes and less seepage of stool was observed in patients using the SenSura products.

Breastfeeding experiences of Taiwan nurses on rotational shifts.

The aim of this study was to describe the experiences of ten three-shift nurses, with particular focus on how they make arrangements regarding breastfeeding in relation to their workplaces and work breaks. Using a qualitative approach, data were obtained through semi-structured interviews with ten three-shift nurses who had breastfed for more than six months and who returned to work after childbirth. Snowball sampling was used to recruit participants, each of whom was interviewed for 1.5-2 hours. Content analysis was used to synthesize interview transcripts. The following three predominant themes and nine sub-themes were identified: (1) managing to express milk--finding appropriate times to express milk during day shifts, learning the timing to express milk during night shifts, and expressing all milk from the breasts during early morning 'graveyard' shifts; (2) dealing with the conflict between work and expressing milk--learning to both take care of patients and express milk, coming back to work on time after expressing milk, and finding "good" places to express milk; and (3) viewing breastfeeding as part of life--being with the baby at home more than being out, turning cars into mobile breastfeeding and milk-expressing "rooms", and breastfeeding as an accomplishment. These findings can help nurses and other healthcare professionals provide anticipatory guidance to women who plan to continue to breastfeed after returning to work. Study results can provide a reference for shift workers who continue to breastfeed after they return to work.

Ostomy pouch wear time in the United States.

PURPOSE: The purpose of this study was to determine average pouch wear times of persons with an ostomy living in the United States. SUBJECTS AND SETTING: In this national survey, subjects were identified by ostomy nurses and through ostomy support groups in the United States. Participants responding to a survey represented all 6 geographic regions of the United States identified by US Bureau of Census. DESIGN AND PROCEDURE: Persons with colostomies, ileostomies, and urostomies were queried concerning their average pouch wear time. RESULTS: The mean wear time for ostomy pouches in the United States is 4.8 days. Persons with urostomies reported an average wear time of 5.02 days (SD = 1.74), those with ileostomies reported 5.01 days (SD = 2.25), and those with colostomies reported an average of 4.55 days (SD = 2.08). CONCLUSIONS: This study is the first of its kind to utilize a large, national sample to determine average wear time of ostomy pouches. Further research is needed to establish a benchmark for ostomy pouch wear time in the United States and to determine what factors affect wear time.

Ostomy bag management: comparative study of a new one-piece closed bag.

The aim of this study was to compare the performance of a new one-piece closed ostomy bag, SenSura, to an already established bag with a focus on minimizing problems related to use of stoma bags for individuals with a colostomy. There were 68 Danish participants with a colostomy who tested each bag for 1 week in a randomized, open, comparative, crossover study. The SenSura bag was perceived more secure than the reference bag (p=0.0006). Crucial performance and safety parameters were rated significantly better for SenSura than for the reference bag. The high preference for SenSura (85%) reflected these results (p<0.0001). Individuals with a colostomy can expect a higher sense of security with the SenSura bag than with the reference bag. This may relate to good adhesion, tack, flexibility and effective filter performance. Future studies should examine the long-term effects of SenSura on peristomal skin conditions. To our knowledge, this is the first published comparative study of one-piece closed ostomy bags.

Selecting a urinary catheter and drainage system.

Selecting the most appropriate urinary catheter and drainage system is an important factor towards patient comfort. Inappropriate selection may introduce an array of unnecessary catheter-associated problems and discomfort for the patient. The author has found that nurses may be able to name or recognize catheters they use, but not other makes and models of similar products produced by other companies. Therefore, selecting a catheter and drainage system can be confusing due to the vast array of catheters, materials used and drainage systems available from various companies. Consideration should also be given as to when catheter care begins: before or following catheter insertion. This article is written to help in the selection of a urinary catheter and drainage system which is best suited for the patient.

Catheter valves for indwelling urinary catheters: a systematic review.

This mini-review aimed to systematically review the evidence on the effect of catheter valves compared to free drainage into a bag for patients with indwelling urinary catheters. Data sources used were Medline, British Nursing Index, CINAHL, Ahmed, EMBASE, EBM Reviews, the Cochrane Library and reference lists of relevant papers. Papers considered were controlled trials comparing the use of a catheter valve with the catheter bag that were published as a full report, or detailed abstract (containing sufficient information to critique) in Dutch, German or English. Two studies with a total of 122 subjects were identified. The main outcome measures considered were reduction of incidence of bladder spasm and urinary tract infection (UTI) and patient preference. No statistically difference in the incidence of bladder spasm or UTI was demonstrated but patients showed a clear preference for the valve. Further research into catheter valves is needed, with larger study groups, which include housebound male and female patients, and longer follow-up period.

A comparative study of two types of urinary sheath.

AIM: The aim of this study was to compare the newly developed Conveen Optima urinary sheath with the established Clear Advantage urinary sheath in terms of patient satisfaction and preference. METHOD: This was a randomised, prospective, open, crossover study, in which each participant tested 10 urinary sheaths. RESULTS: Conveen Optima provided a higher feeling of security, was easier to handle and apply and was more comfortable to wear than Clear Advantage. Furthermore, Conveen Optima was easier to apply with gloves. Finally, the overall product preference for the Conveen Optima sheath was 67 per cent. CONCLUSION: The new Conveen Optima urinary sheath was found to perform better than the well-established Clear Advantage sheath. Declaration of interest This study was funded by Coloplast A/S.

Randomized crossover comparison of adhesively coupled colostomy pouching systems.

Ostomy pouching systems affect well being and quality of life, making selection of the appropriate system a key element of ostomy care. Several innovative adhesively coupled, two-piece systems are on the market. They feature flexible low profiles, allowing pouch removal/replacement without changing the skin barrier or wafer. This facilitates inspection or pouch changes without disrupting peristomal skin. Because few controlled trials compare pouching system effectiveness, a prospective, randomized open-label, crossover study was conducted. Under the supervision of ostomy care nurses in six outpatient clinics in Germany, clinical performance of and patient preferences for two adhesively coupled, closed-end pouching systems were compared during normal use. One is a gelatin/pectin-based skin barrier sealed to the pouch with a company-specific adhesive coupling technology (System E); the other, a grooved base plate wafer adhesive pouch coupling system (System F). Seventeen attributes and seven end-of-study measures that included comfort, flexibility, wear time, ease of removal, and overall performance were assessed. Informed, consenting participants were randomly assigned to use one system for five skin barrier/wafer changes or up to 15 days and subsequently switched to the alternative system for a similar period. The 39 participants used a total of 1,645 pouches and 342 skin barriers. All were found safe as determined by incidence and nature of the reported peristomal skin problems, subject withdrawals, and adverse events for both systems. However, System E provided longer pouch wear times (P < 0.01). End-phase ratings favored System E on 10 of the 17 attributes (P < 0.04) and System Fon none. More participants preferred System E on all seven end-of-study measures, five significantly (comfort, flexibility, wear time, ease of removal, and overall performance; (P < 0.02). These participant-reported, ostomy-related outcomes underscore the importance of product evaluation and selection for persons with an ostomy.

Health-related quality of life and pouch function in continent ileostomy patients: a 30-year perspective.

PURPOSE: The principal aim of this study was to assess long-term pouch durability and health-related quality of life in an original series of patients operated on with a continent ileostomy. PATIENTS: Data from 68 of 88 patients who had a continent ileostomy performed at Sahlgrenska University Hospital between 1967 and 1974 were analyzed. Median age at follow-up was 60 (range, 40-89) years and median follow-up was 31 (range, 29-36) years. METHODS: Patients were sent a questionnaire on pouch function along with the Short Form-36 Health Survey 2.0. A random age-matched and gender-matched sample was drawn from the Swedish national Short Form-36 Health Survey norm database to compare with the patient group. RESULTS: The majority of the patients reported good physical condition and satisfactory pouch function. Patients evacuated the pouch a median of four times every 24 hours. Twelve patients (18 percent) had leakages. Forty-four patients (65 percent) had had at least one postoperative revision to restore continence. Generally minor peristomal skin irritation occurred in seven patients (10 percent). Patients with concurrent complaints (mostly age related) reported poorer health-related quality of life. Nevertheless, 78 percent of the patients rated their overall health as good, very good, or excellent. The patients' Short Form-36 Health Survey scores were comparable to reference values. CONCLUSIONS: Although revisional operations may be needed to restore continence, continent ileostomy has a good durability. Pouch function was satisfactory and patients' satisfaction was high. Health-related quality of life levels were similar to those of the general population.