Development of a patient decision aid for patients with breast cancer who consider immediate breast reconstruction after mastectomy

Purpose

The aim of this study was to develop a patient decision aid (pDA) that could support patients with breast cancer (BC) in making an informed decision about breast reconstruction (BR) after mastectomy.

Methods

The development included four stages: (i) Establishment of a multidisciplinary team; (ii) Needs assessment consisting of semi‐structured interviews in patients and a survey among healthcare professionals (HCPs); (iii) Creation of content, design and technical system; and (iv) Acceptability and usability testing using a think‐aloud approach in patients and interviews among HCPs and representatives of the Dutch Breast Cancer Patient Organization.

Results

From the needs assessment, three themes were identified: Challenging period to make a decision, Diverse motivations for a personal decision and Information needed to make a decision about BR. HCPs valued the development of a pDA, especially to prepare patients for consultation. The pDA that was developed contained three parts: first, a consultation sheet for oncological breast surgeons to introduce the choice; second, an online tool including an overview of reconstructive options, the pros and cons of each option, information on the consequences of each option for daily life, exercises to clarify personal values and patient stories; and third, a summary sheet with patients’ values, preferences and questions to help inform and guide the discussion between the patient and her plastic surgeon. The pDA was perceived to be informative, helpful and easy to use by patients and HCPs.

Conclusion

Consistent with information needs, a pDA was developed to support patients with BC who consider immediate BR in making an informed decision together with their plastic surgeon.

Patient or Public Contribution

Patients participated in the needs assessment and in acceptability and usability testing.

The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: Technique and long-term outcome of a cohort study

BACKGROUND

The ischial region is the site most affected by pressure sores and has the highest recurrence and complication rates compared to other affected sites. We developed a practical and safe pedicled flap for reconstruction of ischial pressure sores based on the rich available perforators from the internal pudendal artery and the surplus of skin at the infragluteal fold.

METHODS

A retrospective cohort study was conducted in all patients who underwent ischial pressure ulcer reconstruction using the PIPAP flap between March 2010 and March 2017. The skin flap was designed along the gluteal fold. The skin perforators of the pudendal artery were marked with a Doppler probe in the medial region of the gluteal fold. Surgery was performed in the jackknife position, and flaps were elevated in the suprafascial plane. Patients were assessed for minor (requiring no additional surgery) and major complications (requiring additional surgery).

RESULTS

Twenty-seven patients (34 flaps) were identified. The median follow-up period was 38 months (IQR 37). Primary closure of the donor-site was achieved in all procedures, only one flap required muscle flap transposition in order to fill the dead space. The mean operating time was 60 ± 21 minutes. In six flaps (9%) wound healing problems were noted that did not require an additional operative procedure. Among the nine flaps (27%) that required a second procedure, 3 (9%) were necessary due to recurrent ulcers.

CONCLUSIONS

The PIPAP flap is a safe and reliable alternative for ischial pressure sore reconstruction, certainly when compared to available techniques. Moreover, it has significant advantages over other techniques including minimal donor-site morbidity, preservation of posterior thigh skin, buttock-line integrity and reliable vascularity.

Nasofrontal outflow tract visibility in computed tomography imaging of frontal sinus fractures

The choice of frontal sinus fracture treatment is based on multiple factors, one of which is injury to the nasofrontal outflow tract (NFOT). Computed tomography (CT) imaging of the NFOT can play an important role in the decision process. We sought to assess the visibility of the NFOT on CT scans in frontal sinus fractures. Patients with frontal sinus fractures (including the posterior table) receiving a CT scan from April 1st 2001 to December 31st 2009 were included. Scans were retrospectively assessed for available views (axial, coronal, and sagittal), slice thickness, inclusion of the anatomical NFOT region in the scanned area, and visibility of the NFOT. A total of 170 patients were included. In majority (71%) of patients NFOT was visible on one or more views, whereas in 33% (N = 56) of patients had three complete views (complete anatomical NFOT region scanned in three views). In this subgroup, the ability to assess the NFOT increased to 89%. When selecting patients with three complete views of ≤ 2 mm slice thickness (N = 47), the ability to assess the NFOT increased to 96%. In conclusion, when assessing the NFOT using CT imaging, having three complete views (axial, coronal, and sagittal) and a ≤ 2 mm slice thickness greatly increases the NFOT visibility.

Redarkening of port-wine stains 10 years after pulsed-dye-laser treatment

BACKGROUND

Although pulsed-dye-laser therapy is currently the gold standard for the treatment of port-wine stains, few objective data are available on its long-term efficacy. Using objective color measurements, we performed a 10-year follow-up of a previously conducted prospective clinical study of the treatment of port-wine stains with a pulsed-dye laser.

METHODS

We invited the patients to undergo repeated color measurements performed by the same procedures as in the previous study. The results at long-term follow-up were compared with color measurements obtained before treatment and after completion of an average of five laser treatments of the complete port-wine stain. A questionnaire was used to investigate patients' satisfaction with the treatment and their perception of long-term changes in the stain.

RESULTS

Of the 89 patients from whom color measurements were obtained in the previous study, 51 were included in this study. The patients had received a median of seven additional treatment sessions since the last color measurement, which had been made after an average of five treatments. The median length of follow-up was 9.5 years. On average, the stain when measured at follow-up was significantly darker than it was when measured after the last of the initial five laser treatments (P=0.001), but it was still significantly lighter than it was when measured before treatment (P<0.001). Fifty-nine percent of patients were satisfied with the overall treatment result. Six percent of patients reported that the stain had become lighter since their last treatment, 59% that it was unchanged, and 35% that it had become darker.

CONCLUSIONS

Using objective color measurements, we observed significant redarkening of port-wine stains at long-term follow-up after pulsed-dye-laser therapy. Patients should be informed about the possibility of redarkening before beginning treatment.

The vascular response induced by transmyocardial laser revascularization is determined by the size of the channel scar: Results of CO2, holmium and excimer lasers

BACKGROUND AND OBJECTIVES

To investigate the angiogenic effect of CO2, Ho:YSGG, and XeCl excimer TMLR in a rat model with morphologic characteristics of chronic myocardial ischemia.

STUDY DESIGN/MATERIALS AND METHODS

Two channels (200-320 microm) were created per rat heart. After 14 days, vessel numbers and densities in and around laser scars were assessed.

RESULTS

Capillary densities in the laser scars were equal between the three lasers ( approximately 130 vessels/mm2) but much lower than in control areas ( approximately 2,100 vessels/mm2). Vessel densities excluding capillaries were significantly higher in Ho:YSGG and CO2 scars compared to excimer scars, while only Ho:YSGG scars contained significantly more large vessels (diameter > or = 20 microm) than control areas. Only rarely, extension of vascular growth into adjacent myocardium was observed in any of the three groups.

CONCLUSIONS

These results indicate that the angiogenic response following TMLR is limited to the channel scar and related to the scar size rather than the specific laser type.

Transmyocardial revascularization using an XeCl excimer laser: Results of a randomized trial

BACKGROUND

CO2 and holmium:yttrium aluminum garnet (YAG) transmyocardial laser revascularization (TMLR) are used to treat patients with refractory angina. A randomized trial to investigate the efficacy and safety of XeCl excimer TMLR was performed.

METHODS

Thirty patients with refractory angina were randomized in pairs to excimer TMLR or maximal medication. We assessed angina, quality of life (QOL), exercise time, myocardial perfusion, and ventricular wall motion at base line and at 3, 6, and 12 months after TMLR.

RESULTS

TMLR patients manifested a significantly better outcome with respect to angina class and quality of life. One TMLR patient died perioperatively versus none in the control group. After TMLR angina decreased from class 3.8 +/- 0.4 at base line to 1.9 +/- 0.9 at 12 months versus 3.9 +/- 0.3 to 3.7 +/- 0.6 in the control group, respectively (p = 0.000001). At 12 months a decrease of greater than or equal to two angina classes was indicated in 11 out of 14 TMLR patients versus none in the control group (p = 0.00001). Improved myocardial perfusion or exercise time was not indicated despite a small decrease in reversible wall motion abnormality score.

CONCLUSIONS

Excimer TMLR significantly relieves angina and improves QOL without evidence of improved cardiac perfusion or function.

Cardiac denervation after clinical transmyocardial laser revascularization: short-term and long-term iodine 123–labeled meta-iodobenzylguanide scintigraphic evidence

OBJECTIVES

This study was designed to investigate whether transmyocardial laser revascularization induces myocardial denervation and to correlate this with myocardial perfusion and clinical status.

METHODS

Transmyocardial laser revascularization was performed with a Holmium:YAG (n = 3) or xenon chloride excimer laser (n = 5). Preoperative and postoperative iodine 123-labeled meta-iodobenzylguanide SPECT scintigraphy to assess cardiac innervation and perfusion scintigraphy were also performed. Furthermore, New York Heart Association functional angina class and quality of life were assessed.

RESULTS

In all patients postoperative iodine 123-labeled meta-iodobenzylguanide SPECT showed significantly decreased uptake and therefore sympathetic myocardial denervation at up to 16 months' follow-up (average preoperative and postoperative summed defect scores of 14.8 +/- 5.3 and 24.5 +/- 4.2, respectively; P =.00005). In 86% of segments, the decreased meta-iodobenzylguanide uptake could be correlated to the treated area. In all patients angina was reduced by 2 or more classes at 12 months' follow-up, and quality of life improved significantly.

CONCLUSIONS

Transmyocardial laser revascularization-induced improvement of angina and quality of life can be explained by destruction of nociceptors or cardiac neural pathways, changing the perception of anginal pain.

Improved quality of life after XeCl excimer transmyocardial laser revascularization: results of a randomized trial

BACKGROUND AND OBJECTIVES

We assessed quality of life (QOL) after XeCl transmyocardial laser revascularization (TMLR).

STUDY DESIGN/MATERIALS AND METHODS

Thirty patients were randomized to receive XeCl excimer TMLR or optimal cardiac medication (controls). QOL was assessed at baseline, 1, 3, 6, and 12 months using three different questionnaires: The Medical Outcomes Study Short Form-24 (MOS SF-24), the EuroQol Standardized Questionnaire, and the Seattle Angina Questionnaire (SAQ). The primary outcome measure was the change in score between baseline and 12 months.

RESULTS

TMLR patients scored significantly better compared to controls in the MOS SF-24 social functioning, energy, general health, and bodily pain domains, in the EuroQol usual activity domain and the EuroQol Visual Analogue Scale, and in the SAQ physical limitation, angina frequency and disease perception domains.

CONCLUSIONS

QOL significantly improved after XeCl excimer TMLR compared to medication. These results are similar to reported improvements in QOL after CO(2) and Ho:YAG TMLR.

Transmyocardial laser revascularisation and other treatment modalities for angina pectoris

Ischaemic heart disease is one of the leading causes of morbidity and mortality in the western world. This paper provides an overview of the different treatments for one of the most common manifestations of ischaemic heart disease: angina pectoris. Besides the currently available conventional methods, several alternative treatments are described, with a special focus on transmyocardial laser revascularisation.

The old spontaneously hypertensive rat as a model for transmyocardial laser revascularisation research

Animal models used in transmyocardial laser revascularisation (TMLR) research lack the increased fibrosis observed in patients with chronic myocardial ischaemia. This pathology has also been described in patients with chronic elevated afterload, and therefore we evaluated the spontaneously hypertensive rat (SHR) as a model for TMLR research. We compared (1) the myocardial pathology of SHR with the pathology of three TMLR patients, (2) the reaction to TMLR in SHR and human myocardium using three different lasers, and (3) myocardial hypoxia in SHR myocardium and (healthy) Wistar rat myocardium. SHR and human myocardium both showed increased fibrosis and a similar myocardial reaction to TMLR (comparable morphology of fibrotic TMLR channel scars). More hypoxic cells were observed in SHR than in Wistar control rat myocardium. The similarities between SHR and human chronic ischaemic myocardium make the SHR a suitable model for TMLR research.

35 years of experimental research in transmyocardial revascularization: what have we learned?

In the past 35 years many experimental studies have been performed to investigate the revascularization potential of transmyocardial revascularization and the possible working mechanisms underlying the observed clinical improvement in angina pectoris after this treatment. In this review of the experimental literature, the various methods that have been used to create transmyocardial channels and the most supported hypotheses on the working mechanism (channel patency, angiogenesis and myocardial denervation) are discussed and evaluated.

Angiogenesis three months after clinical transmyocardial laser revascularization using an excimer laser

BACKGROUND AND OBJECTIVE

We present for the first time histologic findings 3 months after clinical transmyocardial laser revascularization using a XeCl excimer laser.

STUDY DESIGN/MATERIALS AND METHODS

Histology was performed on a patient who died from a noncardiac cause 3 months post-excimer TMLR.

RESULTS

In the treated myocardium, no patent channels were found but scars were seen with a linear distribution and in continuity with circumscribed small fibrotic endocardial and epicardial scars. The scars were highly vascularized by new vessels, ranging from small capillaries to large thin walled, and sometimes branching ectatic vessels. Sprouting of vessels into the adjacent myocardium was also observed.

CONCLUSION

These results suggest that angiogenesis might play a role in the clinical improvement after TMLR.

Alternative surgical exposure of the rat heart in vivo using a simple abdominal approach

Access to the heart in laboratory rats is usually performed via a median sternotomy or a lateral thoracotomy. An alternative, less traumatic approach to the in vivo rat heart with improved survival is described. The technique uses an upper median laparotomy extending alongside the xyphoid bone. The xyphoid bone is retracted in a rostral direction, and a T-shaped cut is made in the diaphragm thus opening the thoracic cavity. Using a retractor the opening in the diaphragm is spread and the heart is exposed. We performed this abdominal approach in 23 anaesthetised and mechanically ventilated (for 2 h) rats and found physiologic intra-operative haemodynamics, a good postoperative recovery and 0% mortality.