How energy benchmarking in healthcare facilities supports greenhouse gas emission reduction.

Energy benchmarking of Horizon Health Network's facilities has been the foundation of an energy management system for the health authority that has led to greenhouse gas emission reductions. Benchmarking energy consumption and appropriately understanding the true impact of energy consumption is the first step in setting target greenhouse gas emission reduction. ENERGY STAR® Portfolio Manager® is the benchmarking tool used by Service New Brunswick for all Government of New Brunswick owned buildings, including all 41 owned Horizon healthcare facilities. This web-based tracking tool then produces benchmarks which supports identification of energy conservation opportunities and efficiencies. Progress for energy conservation and efficiency measures can then be monitored and reported. Since 2013, this approach has supported 52,400 metric tonnes reduction in greenhouse gas emission from Horizon facilities.

Longitudinal Study of Psychosocial Outcomes Following Surgery in Women with Unilateral Nonhereditary Breast Cancer.

INTRODUCTION: Rates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery. PATIENTS AND METHODS: We performed a prospective cohort study of women with unilateral, sporadic stage 0-III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant. RESULTS: A total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001). CONCLUSIONS: Psychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Preconsultation Educational Group Intervention Can Address the Knowledge Gap in Postmastectomy Breast Reconstruction.

BACKGROUND: Whether to undergo postmastectomy breast reconstruction (PMBR) is a challenging, preference-sensitive decision. It is therefore paramount to optimize decision quality through ensuring patients' knowledge and aligning treatments with their personal preferences. This study assessed the effects of a preconsultation educational group intervention (PEGI) on patient knowledge, state-trait anxiety, and decisional conflict (patient uncertainty in decision making) during the decision-making process. METHODS: This phase 3 randomized controlled trial assessed effects of a PEGI in women without active breast cancer undergoing delayed PMBR, or prophylactic mastectomy with immediate PMBR. Both groups underwent routine education before consultation. In addition, the intervention group underwent a PEGI composed of presentations from a plastic surgeon and nurse, a value clarification exercise, and shared experiences from PMBR patients before the consultation with the plastic surgeon. Before and 1-week after consultation, outcome measures were assessed using the Decisional Conflict Scale, State-Trait Anxiety Inventory, and the BREAST-Q. RESULTS: Of the 219 women deemed eligible, a total of 156 women were recruited and randomized. Treatment fidelity was 96% and retention was 88%. At baseline, there were no significant differences in terms of demographic or clinical status, knowledge, state-trait anxiety, and decisional conflict. Patient knowledge about PMBR improved in both groups; however, the degree of knowledge attainment was significantly greater in the PEGI group (24.5% improvement in the intervention group compared with 13.5% in the routine education group, P < 0.001). The reduction in decisional conflict from baseline to follow-up was greater in the intervention group compared with the routine education; however, the difference only approached significance (P = 0.09). CONCLUSIONS: The provision of a preconsultation educational group intervention has been shown to significantly close the knowledge gap on PMBR in patients seeking delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction compared with routine education alone.

Cartoon Images on E-juice Labels: A Descriptive Analysis.

INTRODUCTION: Although previous studies have found cartoons in electronic cigarette (e-cigarette) advertisements, social media posts, and a small sample of labels, there has yet to be an analysis of cartoons located on the labels attached to bottles of e-juice (the solution that contains nicotine and other chemicals). As such, the objective of this study was to analyze the prevalence and types of cartoons on e-juice labels. METHODS: Two researchers independently analyzed the presence and types of cartoons on the labels of e-juice flavors available on eliquid.com. Based on the Master Settlement Agreement's definition of a cartoon, the cartoons were placed into five categories: (1) comically exaggerated people, (2) comically exaggerated animals, (3) comically exaggerated creatures, (4) anthropomorphic creatures, or (5) extra-human creatures. RESULTS: There was a total of 1587 brands that offered 7135 e-juice products. Of those, 311 brands (19%) offered 1359 products (19%) that contained cartoons on the e-juice labels. From the labels that contained cartoons, 790 (58%) were of comically exaggerated people, 247 (18%) were of anthropomorphic creatures, 212 (16%) were of comically exaggerated animals, 73 (5%) were of comically exaggerated creatures, and 37 (3%) were of extra-human creatures. CONCLUSIONS: Given the previous success of Joe Camel on youth tobacco use, the prevalence of cartoon images found in this study is noteworthy. In addition, the number of brands that had cartoons on e-juice labels indicates that this issue is pervasive among businesses that sell e-juice. IMPLICATIONS: This study adds to the body of knowledge on this topic by describing a concerning number of cartoons located on e-juice labels, indicating a need for policy that prohibits the use of cartoon images in e-cigarette packaging.

Predictors of uptake of contralateral prophylactic mastectomy in women with nonhereditary breast cancer.

BACKGROUND: The rates of contralateral prophylactic mastectomy (CPM) are increasing in women with breast cancer. Previous retrospective research has examined clinical and demographic predictors of the uptake of CPM. However, to the authors' knowledge, there has been very little prospective research to date that has examined psychosocial functioning prior to breast cancer surgery to determine whether psychosocial functioning predicts uptake of CPM. The current study was conducted to evaluate demographic, clinical, and psychosocial predictors of the uptake of CPM in women with unilateral breast cancer without a BRCA1 or BRCA2 mutation. METHODS: Women with unilateral non-BRCA-associated breast cancer completed questionnaires prior to undergoing breast cancer surgery. Participants completed demographic and psychosocial questionnaires assessing anxiety, depression, cancer-related distress, optimism/pessimism, breast satisfaction, and quality of life. Pathological and surgical data were collected from medical charts. RESULTS: A total of 506 women consented to participate, 112 of whom (22.1%) elected to undergo CPM. Age was found to be a significant predictor of CPM, with younger women found to be significantly more likely to undergo CPM compared with older women (P < .0001). The rate of CPM was significantly higher in women with noninvasive breast cancer compared with those with invasive breast cancer (P < .0001). Women who elected to undergo CPM had lower levels of presurgical breast satisfaction (P = .01) and optimism (P = .05) compared with women who did not undergo CPM. CONCLUSIONS: Psychosocial functioning at the time of breast cancer surgery decision making impacts decisions related to CPM. Women who have lower levels of breast satisfaction (body image) and optimism are more likely to elect to undergo CPM. It is important for health care providers to take psychosocial functioning into consideration when discussing surgical options.

A cost-effectiveness analysis of DIEP vs free MS-TRAM flap for microsurgical breast reconstruction.

BACKGROUND AND OBJECTIVES: The deep inferior epigastric perforator (DIEP) flap may be associated with less long-term donor-site morbidity compared with free muscle-sparing transverse rectus abdominis myocutaneous flap (MS-TRAM) flap. However, DIEP flaps may have longer operative time and higher rates of acute postoperative complications. We performed a cost-effectiveness analysis (CEA) that compared the long-term costs and patient-reported outcomes between the two flaps. METHODS: A retrospective cohort of women who received free MS-TRAM or DIEP flap reconstruction between January 2008 and December 2012, with a minimum of 2-year follow-up, were recruited. Cost data of the primary reconstruction and any subsequent hospitalization due to complications from the reconstruction within 2 years were obtained. Each patient received a BREAST-Q questionnaire at 2 years post-reconstruction. RESULTS: In total, 227 patients (180 DIEP, 47 free MS-TRAM) were included. DIEP patients had significantly fewer abdominal hernia (P = 0.04). The adjusted-incremental cost-effectiveness ratios found that DIEP flap was more cost-effective to free MS-TRAM flap in the domains of "Physical Well-Being of the Abdomen" and "Satisfaction with Outcome." CONCLUSIONS: DIEP flap is the more cost-effective method of autologous breast reconstruction in the long-term compared with free MS-TRAM flap with respect to patient-reported abdominal well-being and overall satisfaction with the outcome.

The influence of dispositional optimism on decision regret to undergo major breast reconstructive surgery.

BACKGROUND & OBJECTIVES: It is not known if optimism influences regret following major reconstructive breast surgery. We examined the relationship between dispositional optimism, major complications and decision regret in patients undergoing microsurgical breast reconstruction. METHODS: A consecutive series of 290 patients were surveyed. Independent variables were: (1) dispositional optimism and (2) major complications. The primary outcome was Decision Regret. A multivariate regression analysis determined the relationship between the independent variables, confounders and decision regret. RESULTS: Of the 181 respondents, 63% reported no regret after breast reconstruction, 26% had mild regret, and 11% moderate to severe regret. Major complications did not have a significant effect on decision regret, and the impact of dispositional optimism was not significant in Caucasian women. There was a significant effect in non-Caucasian women with less optimism who had significantly higher levels of mild regret 1.36 (CI 1.02-1.97) and moderate to severe regret 1.64 (CI 1.0-93.87). CONCLUSIONS: This is the first paper to identify a subgroup of non-Caucasian patients with low dispositional optimism who may be at risk for developing regret after microsurgical breast reconstruction. Possible strategies to ameliorate regret may involve addressing cultural and language barriers, setting realistic expectations, and providing more support during the pre-operative decision-making phase.

A randomized controlled trial of mindfulness-based stress reduction to manage affective symptoms and improve quality of life in gay men living with HIV.

UNLABELLED: To determine whether MBSR groups would help gay men living with HIV improve psychosocial functioning and increase mindfulness compared to treatment-as-usual (TAU). METHODS: 117 participants were randomized 2:1 to MBSR or TAU. No new psychosocial or psychopharmacological interventions were initiated within 2 months of baseline. Standardized questionnaires were administered pre-, postintervention and at 6 months. An intent-to-treat analysis found significant benefits of MBSR: at post-intervention and 6 months follow up, MBSR participants had significantly lower avoidance in IES and higher positive affect compared to controls. MBSR participants developed more mindfulness as measured by the Toronto Mindfulness Scale (TMS) including both TMS subscales, curiosity and decentering, at 8-week and 6 months. For the sample as a whole, increase in mindfulness was significantly correlated with reduction in avoidance, higher positive affect and improvement in depression at 6 months. MBSR has specific and clinically meaningful effects in this population.

Higher Distress in Patients with Breast Cancer Is Associated with Declining Breast Reconstruction.

BACKGROUND: Distress among newly diagnosed patients with breast cancer is common and may have an impact on their surgical decision-making. The revised Edmonton Symptom Assessment System (ESAS-r) is a validated instrument that provides an estimate of patients' total distress, and no previous study has related preoperative scores to the choice to have breast reconstruction. METHODS: Women with breast cancer treated at the Princess Margaret Cancer Centre in 2014 were reviewed, and patient and tumor characteristics were collected from local databases. Breast reconstruction status was obtained from patients' electronic medical records until April 2017. A multivariable logistic regression model assessed for an independent association between preoperative ESAS-r total distress scores and patients' decision to have breast reconstruction. RESULTS: A total of 312 patients were analyzed. ESAS-r values had an overall median score of 10.0 and ranged from 0 to 69 (interquartile range, 17). Of these patients, 82 chose to undergo breast reconstruction surgery (26.8%). Multivariable logistic regression analysis showed that higher ESAS-r scores were associated with patients forgoing breast reconstruction surgery (lumpectomy-alone group: odds ratio estimate, 1.034 [1.004-1.064], P = 0.025; mastectomy-alone group: odds ratio estimate, 1.031 [1.004-1.059], P = 0.023). CONCLUSIONS: This study of patients with breast cancer found that higher distress scores as measured by the ESAS-r were associated with reduced breast reconstruction. Distress in patients with breast cancer is important to address, as it is often treatable, and its resolution may unmask a desire for breast reconstruction, which has known benefits psychosocially.

The BRCA Self-Concept Scale: a new instrument to measure self-concept in BRCA1/2 mutation carriers.

UNLABELLED: Genetic testing for BRCA1/2 has psychosocial impacts including those related to views of personal health, sense of self and identity and body image. The centrality of a person's self-concept in maintaining physical and psychosocial well-being has been well recognized; however, to date research exploring altered self-concept related to carrier knowledge is limited. OBJECTIVE: The objective of the study was to develop and validate a scale to measure the self-concept among individuals testing positive for BRCA1/2 mutations. METHODS: The study was conducted in two phases: phase I: item generation and refinement and phase II: scale selection and initial validation. During phase I, scale items were generated through individual interviews and focus groups of women with BRCA1/2 mutations, including women with or without a prior diagnosis of cancer. In phase II items were selected based on several criteria resulting in a 25-item scale, which underwent a reliability analyses and preliminary validation with 115 women. A second sample of 126 women was used to conduct further validation and samples were pooled to conduct factor analysis and the final scale selection. RESULTS: A 17-item self-concept scale emerged having three factors: stigma, vulnerability and mastery demonstrating evidence for an instrument with promising psychometric properties (total scale alpha=0.90). CONCLUSIONS: The scale has direct relevance for research in facilitating our understanding of the specific aspects of the self, which are vulnerable to BRCA1/2 testing and which play a role in clinical outcomes, to facilitate the development and specific testing of interventions and may be used as an outcome measure. Specific measurement tools for genetic populations will ultimately assist in the clinical management of these populations.

The phases of disclosing BRCA1/2 genetic information to offspring.

OBJECTIVE: Women who carry a genetic mutation for hereditary breast/ovarian cancer (BRCA1 or BRCA2) are at high risk to develop cancer. A positive genetic test result also has implications for a BRCA1/2 carrier's offspring who each have a 50% chance of inheriting the mutation. The dissemination of BRCA1/2-related information by carriers to offspring is not well understood. Our study examines the experiences of BRCA1/2 carriers in communicating genetic information to their offspring using a grounded theory approach. METHODS: Qualitative data were obtained from a multi-site group therapy trial for BRCA1/2 carriers with primary themes identified and coded using the constant comparison technique and verified by team members. RESULTS: Female participants had a mean age of 45.4 years, 83% were married, 71% had children (ranging from ages 2 to 30 years) and 45.9% had a prior diagnosis of cancer. Dissemination of genetic information by BRCA1/2 carriers to their offspring was described as a process involving several distinct phases with specific challenges within each phase. Several themes were identified including dilemmas on 'if' and 'when' to disclose to offspring, concerns should offspring receive a positive test result for BRCA1/2, dilemmas around feeling a need to protect versus the need to inform, and women as being the primary communicators. CONCLUSION: These findings have implications for genetic counselling as well as follow-up.

Development and testing of a decision aid for women considering delayed breast reconstruction.

BACKGROUND: The decision to have post-mastectomy breast reconstruction (PMBR) is highly complex and many women feel ill equipped to make this decision. Decision aids have been advocated to promote patient involvement in decision-making by streamlining and standardizing communication between the patient and the health care professional. In this study, we report on the development and testing of a decision aid (DA) for breast cancer survivors considering delayed PMBR. METHODS: The DA was developed and evaluated in three phases. The first phase included the development of the DA with input and review by practitioners and key stakeholders. The second phase involved pilot testing of the feasibility and acceptability of the DA with a convenience sample of women with delayed PMBR. The third phase involved a pretest/post-test evaluation of the DA for women who were making decisions about their PMBR options. RESULTS: The DA was developed using the Ottawa Decision Support Framework. In the second phase of the study, 21 women completed the acceptability survey, of whom 100% reported that they would recommend the DA to other women. In the third phase, decisional conflict decreased significantly (p < 0.001) and knowledge increased significantly (p < 0.001) from prior to using the DA to 1-2 weeks after using the DA. CONCLUSIONS: The DA is feasible and acceptable to women considering delayed PMBR. Furthermore, the DA is effective at reducing decisional conflict and increasing knowledge about delayed PMBR. The DA is an appropriate tool to be used in addition with standard care in women considering PMBR.

Preoperative Computed Tomographic Angiogram Measurement of Abdominal Muscles Is a Valuable Risk Assessment for Bulge Formation after Microsurgical Abdominal Free Flap Breast Reconstruction.

BACKGROUND: A major shortcoming associated with abdominal tissue breast reconstruction is long-term abdominal wall morbidity. Although abdominal muscle size on computed tomographic angiography has been correlated with morbidity following many abdominal operations, it has not been studied for breast reconstruction. Therefore, the authors evaluated the association between preoperative computed tomography angiography-derived measurements of abdominal core muscles and postoperative abdominal wall morbidity after abdominal tissue breast reconstruction. METHODS: In this retrospective matched case-control study of women who underwent microsurgical abdominal flap breast reconstruction at one institution between January 2011 and June 2015, the authors evaluated all cases of postoperative bulge/hernia, matched by type of abdominal flap and body mass index in a ratio of 1:2 to controls without bulge/hernia. The authors obtained morphometric measurements of abdominal core muscles on preoperative computed tomographic angiographs. Using univariable and multivariable logistic regressions, the authors examined the effects of clinical risk factors and computed tomographic angiography morphometric measurements on postoperative bulge/hernia formation. RESULTS: Of the 589 patients who underwent abdominal free flap breast reconstruction, symptomatic bulges/hernias were identified in 35 patients (5.9 percent). When compared to the 70 matched controls, multivariable analysis showed that decreased area of rectus abdominis muscle (OR, 0.18; p < 0.01) and increased inter-rectus abdominis distance (OR, 1.14; p < 0.01) on computed tomographic angiography were significant risk factors associated with postoperative bulge/hernia. CONCLUSION: Preoperative computed tomographic angiography allows objective measurements of the patient's abdominal muscle anatomy that provide valuable prognostic information on the risk of bulge/hernia formation following abdominally based microsurgical breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Incidentalomas associated with abdominal and pelvic CT angiograms for abdominal-based breast free flap reconstruction.

Computed tomography angiography (CTA) is routinely performed prior to breast reconstruction using deep inferior epigastric perforator (DIEP) flaps to provide better surgical planning and improve preoperative decision making. These investigations occasionally result in unexpected findings in otherwise asymptomatic women. Unexpected findings on imaging in a population of women with previous breast cancer or strong breast cancer risk factors can lead to undue stress and anxiety. The aim of this study is to determine the incidence of unexpected findings in preoperative CT angiograms and to correlate these with patient and breast cancer characteristics. A retrospective chart review from May 2008 to December 2012 was performed reviewing all patients who underwent DIEP flap breast reconstruction. Radiology reports of their preoperative CT angiograms, details of unexpected findings, patients' past medical and cancer history, additional radiological investigations, outcomes, and interventions were reviewed. In total, 360 patients met the inclusion criteria for the study. Sixty-four percent of the patients who underwent CTA imaging had incidental findings. Further imaging was suggested in 48% of this group. The most common incidentalomas were hepatic (47%), bone (24%), and renal (20%). "Incidentalomas" were associated with patients' underlying comorbidities (p = 0.001) and age (p = 0.01). "Radiographically suspicious incidentalomas" were associated with the underlying comorbidities (p = 0.001). The radiologists most commonly suggested investigation methods such as ultrasound (41%), another CT (28%), bone scan (21%), and magnetic resonance imaging (MRI; 14%). No incidentalomas were found to be malignant on further recommended investigation in this study and no breast cancer reconstruction was delayed as a result of the discovery of incidentalomas or their subsequent investigations. It is important to counsel patients of the possibility of incidental findings and the resulting sequelae prior to CTA investigations for breast cancer reconstruction and involve them in shared decision making if additional investigations are required.

A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study.

BACKGROUND: This is the first study to use generic distress, cancer-specific, and procedure-specific measures to prospectively evaluate psychological responses, body image, sexuality, and health-related quality of life in immediate compared with delayed breast reconstruction. METHODS: Consecutive patients undergoing autologous immediate and delayed breast reconstruction (June of 2009 to December of 2010) completed the Hospital Anxiety and Depression Scale, Body Image Scale, Sexuality Scale, and BREAST-Q preoperatively and postoperatively (6, 12, and 18 months). Linear mixed-effects analyses between each outcome and time point were performed. RESULTS: One hundred six women underwent mastectomy with immediate (n = 30) and delayed breast reconstruction (n = 76). Before reconstruction, 26 percent of patients had abnormal anxiety scores and 9 percent had abnormal depression scores, with no significant differences between groups. Patients awaiting delayed breast reconstruction had significantly impaired prereconstruction body image (p = 0.01) and sexuality (p = 0.01) and worse satisfaction with breast (p < 0.01), psychological (p < 0.01), and sexual well-being (p < 0.01). At 18 months after immediate and delayed breast reconstruction, there was significant improvement in anxiety, depression, body image, sexuality, and health-related quality of life. CONCLUSIONS: This single-center study shows that mastectomy with immediate breast reconstruction may protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with those waiting for delayed breast reconstruction. In patients who are oncologically eligible and strongly interested in breast reconstruction, efforts should be made to provide immediate breast reconstruction to decrease the interval of psychosocial distress, poor body image, and impaired sexuality.

The experience of loss and anticipation of distress in colorectal cancer patients undergoing genetic testing.

OBJECTIVE: The purpose of this paper is to describe pretest psychological functioning in a sample of colorectal cancer (CRC) patients undergoing genetic testing. We also explored the relationship among demographic, medical, family history and loss variables and current pretest distress, and those related to anticipated posttest distress. METHODS: This paper reports pretest findings from a prospective, longitudinal psychosocial survey. Data are presented on 220 CRC patients at pretest. RESULTS: We found a subgroup of CRC patients that are currently distressed and anticipate becoming depressed if they receive a positive genetic test result. There were significant associations among pretest distress, family history of CRC and loss related to CRC and anticipation of becoming depressed at posttest. CONCLUSIONS: The findings suggest that a subgroup of CRC patient's experience or anticipate distress that may warrant attention. Family history of CRC and losses related to CRC may be important indicators of posttest adjustment.

Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: a double-blind, placebo-controlled, randomized trial.

BACKGROUND: The analgesic efficacy of the transversus abdominis plane peripheral nerve block following abdominal tissue breast reconstruction has not been studied in a randomized controlled trial. METHODS: The authors conducted a double-blind, placebo-controlled, 1:1 allocation, two-arm parallel group, superiority design, randomized controlled trial in patients undergoing microsurgical abdominally based breast reconstruction. Intraoperatively, epidural catheters were inserted under direct vision through the triangle of Petit on both sides of the abdomen into the transversus abdominis plane just before rectus fascial closure. Patients received either bupivacaine (study group) or saline (placebo group) through the catheters for 2 postoperative days. All patients received hydromorphone by means of a patient-controlled analgesic pump. The primary outcome was the difference in the parenteral opioid consumption on each postoperative day between the groups. The secondary outcome measures included the following: total in-hospital opioid; antinausea medication; pain, nausea, and sedation scores; Quality of Recovery Score; time to ambulation; and hospital stay duration. RESULTS: Between September of 2011 and June of 2013, 93 patients were enrolled: 49 received bupivacaine and 44 received saline. There were 11 postoperative complications (13 percent); none were related to the catheter. Primary outcomes were completed by 85 of 93 patients (91.3 percent); the mean parenteral morphine consumption was significantly reduced on postoperative day 1 in the bupivacaine group (20.7±20.1 mg) compared with 30.0±19.1 mg in the control group (p=0.02). There were no significant differences in secondary outcomes. CONCLUSION: Following abdominally based breast reconstruction, transversus abdominis plane peripheral nerve block is safe and significantly reduces morphine consumption in the early postoperative period. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Transversus abdominis plane block following abdominally based breast reconstruction: study protocol for a randomized controlled trial.

BACKGROUND: Breast reconstruction using the free muscle-sparing transversus abdominus myocutaneous or deep inferior epigastric perforator flaps are common methods for restoring mastectomy defects for breast cancer patients. Despite its increasing popularity and safety, the abdominal donor site remains a major source of postoperative pain. Conventional postoperative pain relief protocol consists primarily of a patient-controlled anesthesia device delivering intravenous opioids. Opioids can cause numerous side effects such as sedation, headache, nausea, vomiting, breathing difficulties and bladder and bowel dysfunction. A promising approach to provide postoperative pain control of the abdominal incision is the newly developed transversus abdominis plane peripheral nerve block. METHODS/DESIGN: This study is a double-blind, placebo-controlled, randomized controlled trial designed to rigorously test the effectiveness of a transversus abdominis plane catheter delivering intermittent local anesthetic in reducing postoperative abdominal pain following abdominal tissue breast reconstruction. The primary objective of this study is compare the mean total opioid consumption in the first postoperative 48 hours between the control and study groups including the patient-controlled anesthesia amounts and oral narcotic doses converted to intravenous morphine equivalent units. The secondary outcome measures include the following parameters: total in-hospital cumulative opioid consumption; daily patient-reported pain scores; total in-hospital cumulative anti-nausea consumption; nausea and sedation scores; and Quality of Recovery score; time to first bowel movement, ambulation, and duration of hospital stay. DISCUSSION: Autologous breast reconstruction using abdominal tissue is rapidly becoming the reconstructive option of choice for postmastectomy patients across North America. A substantial component of the pain experienced by patients after this abdominally based procedure is derived from the abdominal wall incision. By potentially decreasing the need for systemic opioids and their associated side effects, this transversus abdominis plane block study will utilize the most scientifically rigorous double-blind, placebo-controlled, randomized controlled trial methodology to potentially improve both clinical care and health outcomes in breast cancer surgery patients. TRIAL REGISTRATION: Clinicaltrials.gov NCT01398982.