The patient advisor, an organizational resource as a lever for an enhanced oncology patient experience (PAROLE-onco): a longitudinal multiple case study protocol.

BACKGROUND: Quebec is one of the Canadian provinces with the highest rates of cancer incidence and prevalence. A study by the Rossy Cancer Network (RCN) of McGill university assessed six aspects of the patient experience among cancer patients and found that emotional support is the aspect most lacking. To improve this support, trained patient advisors (PAs) can be included as full-fledged members of the healthcare team, given that PA can rely on their knowledge with experiencing the disease and from using health and social care services to accompany cancer patients, they could help to round out the health and social care services offer in oncology. However, the feasibility of integrating PAs in clinical oncology teams has not been studied. In this multisite study, we will explore how to integrate PAs in clinical oncology teams and, under what conditions this can be successfully done. We aim to better understand effects of this PA intervention on patients, on the PAs themselves, the health and social care team, the administrators, and on the organization of services and to identify associated ethical and legal issues. METHODS/DESIGN: We will conduct six mixed methods longitudinal case studies. Qualitative data will be used to study the integration of the PAs into clinical oncology teams and to identify the factors that are facilitators and inhibitors of the process, the associated ethical and legal issues, and the challenges that the PAs experience. Quantitative data will be used to assess effects on patients, PAs and team members, if any, of the PA intervention. The results will be used to support oncology programs in the integration of PAs into their healthcare teams and to design a future randomized pragmatic trial to evaluate the impact of PAs as full-fledged members of clinical oncology teams on cancer patients' experience of emotional support throughout their care trajectory. DISCUSSION: This study will be the first to integrate PAs as full-fledged members of the clinical oncology team and to assess possible clinical and organizational level effects. Given the unique role of PAs, this study will complement the body of research on peer support and patient navigation. An additional innovative aspect of this study will be consideration of the ethical and legal issues at stake and how to address them in the health care organizations.

French translation and cross-cultural adaptation of the Michigan Hand Outcomes Questionnaire and the Brief Michigan Hand Outcomes Questionnaire.

Patient-Reported Outcome Measures (PROMs) are important clinical devices for evaluating injuries and surgeries of the hand. However, some of the most widely used questionnaires, such as the MHQ and bMHQ, are currently unavailable in French, which prevents them from being used in the French Canadian province of Quebec as well as in other French-speaking nations. We therefore intend to develop valid and culturally adapted French translations of the afore-mentioned questionnaires. Two independent bilingual translators converted all English questionnaires to French. Two distinct translators then translated the French versions back to English in reverse-blinded fashion. Discrepancies between the original and second English versions were examined by a committee of four bilingual healthcare professionals before final French translations of all documents were produced. Thirty patients bilingual in French and English were then asked to complete the original and French versions of the MHQ and bMHQ. Their answers were compared in order to assess the accuracy of our translation. In light of these findings, revised French versions were produced. French versions of the MHQ and bMHQ questionnaires produced metrological qualities of validity and fidelity with an inter-class correlation superior to 0.90 and a kappa coefficient of 0.81 to 1. Clinical applicability revealed the distribution of scores according to disease process was reproducible between the English and French versions. PROM translation requires a rigorous process in order to achieve strong metrological qualities in both the original and translated versions. We produced French translations of the MHQ and bMHQ by abiding to the Beaton method of cross-cultural adaptation of self-reported measures.

The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy.

INTRODUCTION: In the management of breast cancer radiation therapy plays a substantive role in decreasing local recurrence and increasing overall survival. Still, there exists controversy concerning compromised radiation delivery plans and suboptimal delivery after immediate autologous breast reconstruction. Our study aims to assess the oncologic safety of immediate breast reconstruction (IBR) with a Deep inferior epigastric perforator flap (DIEP), in the setting of adjuvant radiation therapy. METHODS: We conducted a retrospective analysis using a prospectively maintained database of all consecutive women undergoing breast reconstruction with a DIEP flap in the setting of radiation therapy. Independent variables included patient age, cancer stage, tumor grade type and subtype, adjuvant and neoadjuvant chemotherapy, hormonal therapy, diabetes mellitus, and tobacco use. Main outcome variables were: local recurrence, distant metastasis, patient demise and total flap failure. RESULTS: From July 2008 to January 2014, and out of 450 patients who underwent reconstruction with a DIEP flap, 62 were considered eligible. Thirty patients (48%) had IBR followed by radiation therapy and 32 (52%) had delayed reconstruction preceded by radiation therapy. The two groups were comparable with respect to the independent variables. Local recurrence occurred in 3.2% of patients; 3.3% in the immediate group and 3.1% in the delayed (P=0.963). Distant metastasis occurred in 6.4% of patients: 10% in the immediate group and 3.1% in the delayed (P=0.27). Breast cancer related mortality occurred in 4.8%: 6.7% in the immediate group and 3.1% in the delayed (P=0.52). CONCLUSION: Immediate reconstruction with a DIEP flap in the setting of adjuvant radiation therapy is an acceptable approach and appears not to influence the oncologic efficacy of radiation treatment. Further prospective studies are advocated.

Replantation vs revision amputation in single digit zone II amputations.

The objective of this study was to compare the functional outcomes of zone II amputations treated with either replantation or revision amputation at our institution to better aid patients in their decision making process regarding these treatment options. We conducted a comparative retrospective study. All cases of single digit amputations received at our replantation center between 2007 and 2011 were screened for single digit zone II injuries. These patients were stratified based on the treatment received: replantation vs revision amputation. Patients were called and invited to participate in the research project. Those who accepted to enter the study were asked to complete the Quick-DASH, the Beck Depression Inventory-short form, and a custom made questionnaire. There were seventeen patients with single digit zone II replantation and fourteen patients with similar injuries who underwent revision amputation and agreed to take part in the study. Our data revealed that the duration of sick leave, occupation after injury, professional and social reintegration, discontinued activities, and self-confidence were not statistically different between the two groups. The average hospital stay and the follow-up period of replanted individuals were longer. The replantation group did not have higher levels of pain or cold intolerance, and the global functional and esthetic satisfaction levels were similar between the two groups. Also, Beck Depression Inventory and Quick-DASH scores were not statistically different. Yet, significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation. From a functional viewpoint, our study suggests that revision amputation is not superior to replantation in zone II single digit amputations. This is valuable information that should be given to patients when deciding on the treatment process and to insure a proper informed consent.

Osteocutaneous free flaps for mandibular reconstruction: systematic review of their frequency of use and a preliminary quality of life comparison.

OBJECTIVES: To determine whether the fibula free flap is the most frequently used osteocutaneous flap for mandible reconstruction, and whether it provides quality of life, depression and anxiety advantages. METHODS: A systematic review of the public Medline database was conducted. Thirteen patients who underwent mandibular reconstruction at our hospital centre completed questionnaires to evaluate quality of life, depression and anxiety outcomes. RESULTS: The most frequently used free flaps are those of the fibula (n = 982), radial forearm (n = 201), iliac crest (n = 113), subscapular system (n = 50) and rib-serratus (n = 7). In our patient population, there was a trend towards a better quality of life in those with a fibula free flap. However, patients in this group were significantly younger than patients with other flap types (p = 0.025). Patients with a subscapular system free flap were more depressed (p = 0.031); however, they had large through-and-through defects. CONCLUSION: The flap used most frequently in the literature is the fibula free flap. Comparative quality of life data are lacking, and homogeneous populations should be used to reach significant conclusions.

Building a multidisciplinary team for burn treatment - Lessons learned from the Montreal tendon transfer experience.

Multidisciplinary teams (MDTs) represent a recognized component of care in the treatment of complex conditions such as burns. However, most institutions do not provide adequate support for the formation of these teams. Furthermore, the majority of specialists lack the managerial skills required to create a team and have difficulties finding the proper tools. Our objective is to provide an insight for health care professionals, who wish to form a MDT for burn treatment, on the challenges that are likely to be faced, and to identify key elements that may facilitate the establishment of such a project. The setting for this was a plastic surgery department and rehabilitation center at a national reference center. A qualitative analysis was performed on all correspondences related to our tetraplegia project, from 2006 to 2008. To guide our thematic analysis, we used a form of systems theory known as the complexity theory. The qualitative analysis was performed using the NVivo software (Version 8.0 QSR International Melbourne, Australia). Lastly, the data was organized in chronologic order. Three main themes emerged from the results: knowledge acquisition, project organizational setup and project steps design. These themes represented respectively 24%, 50% and 26% of all correspondences. Project steps design and knowledge acquisition correspondences increased significantly after the introduction of the mentor team to our network. We conclude that an early association with a mentor team is beneficial for the establishment of a MDT.

Les équipes multidisciplinaires (EMD) représentent une composante des soins reconnue dans le traitement de conditions complexes telles que les brûlures. Cependant, la plupart des institutions ne fournissent pas de soutien adéquat pour la formation de ces équipes. En outre, la majorité des spécialistes ne possède pas les compétences de gestion nécessaires pour créer une équipe et éprouvent souvent des difficultés à trouver les outils appropriés. Notre objectif est de fournir aux professionnels de soins de santé, qui souhaitent former une équipe multidisciplinaire pour le traitement des brûlures, un aperçu sur les défis susceptibles d'être confronter et d'identifier les éléments clés qui faciliteront la mise en place d'un tel projet. Cette étude a eu lieu dans un département de chirurgie plastique et un centre de réadaptation affilié à un centre de référence national. Une analyse qualitative a été effectuée sur toutes les correspondances relatives à notre projet de tétraplégie, de 2006 à 2008. Pour guider notre analyse thématique, nous avons utilisé une forme de la théorie des systèmes connu comme la théorie de la complexité. L'analyse qualitative a été réalisée en utilisant le logiciel NVivo (version 8.0 QSR International, Melbourne, Australie). Enfin, les données ont été organisées en ordre chronologique. Trois thèmes principaux ont émergé à partir des résultats: l'acquisition de connaissances, la configuration et l'organisation du projet ainsi que la conception des étapes du projet. Ces thèmes représentaient respectivement 24 %, 50 % et 26 % de toutes les correspondances. Les correspondances en lien avec la conception du projet et l'acquisition des connaissances ont considérablement augmenté suite à l'introduction de l'équipe de mentors à notre réseau. Nous concluons qu'une association précoce avec une équipe de mentors est bénéfique à la mise en place d'une équipe multidisciplinaire.

["The ambulatory surgery of breast reduction: The adaptation to a North-American practice"]. / La chirurgie ambulatoire de réduction mammaire : l'adaptation à une pratique nord-américaine.

OBJECTIVE: After the recent publication of the prospective study of feasibility of mammary reduction in ambulatory setting by Guilbert et al., we would like to present our North-American experience and share some data from the last year. METHODS: We obtained four data from our medical archives: the total number of reduction mammaplasties done during the last year, the number of cases done in ambulatory setting, the number of cases done with hospitalization, and the number of conversions (ambulatory cases transformed into hospitalizations lasting more than 24 hours) RESULTS: Two hundred and eighteen bilateral mammary reductions were completed between March 2011 and April 2012. Of these 218 cases, 97% were planned for a surgery in ambulatory setting whereas only six were planned with hospitalization. Moreover, only seven of the 212 cases in ambulatory setting required a conversion to a brief hospitalization. CONCLUSION: Cost-effectiveness, low rate of complication, and high satisfaction rate are all advantages of surgery in ambulatory setting. Our 10-year experience with this mode of care confirms these benefits.

Chimaeric subscapular system free flap for complex oro-facial defects.

BACKGROUND: Ablation of locally advanced head and neck cancers generally results in large composite oro-facial defects. Due to the often-large segment of mandible missing, as well as the need to provide skin coverage and oral lining, reconstructive options are limited. We present our experience in oncologic head and neck reconstruction using chimaeric subscapular system free flaps. METHODS: We performed a retrospective chart review of patients presenting important through-and-through oro-facial defects following ablation of T3, T4a or T4b tumours in two university centres between 2005 and 2011. All defects were reconstructed with a subscapular system free flap that was harvested in a dorsal decubitus position. RESULTS: Sixteen patients (15 M, 1 F; mean age=60 years) underwent mandibular reconstruction with latissimus dorsi flaps with one or two skin paddles and one bony component based on the angular branch of the thoracodorsal artery. Fifteen patients received adjuvant radiotherapy. We experienced no flap loss. Donor-site complications were minimal, albeit a limitation of shoulder range of motion was found in four patients. Eight patients presented postoperative complications requiring re-intervention. Fourteen patients were able to recommence oral nutrition and their diction returned to normal in all but one. The mean follow-up period was 25 months. Aesthetic results were satisfactory upon atrophy of the latissimus dorsi muscle. CONCLUSIONS: In cases of extensive oro-facial defects involving a large mandibular segment, reconstruction with subscapular system free-tissue transfer is a safe and reliable technique that offers satisfactory functional and aesthetic results.

[Residency in plastic surgery: comparison between the French and the Canadian Royal College programs]. / L'apprentissage de la chirurgie plastique :comparaison de la formation française et duprogramme de résidence canadien du Collège royal.

BACKGROUND: Learning plastic surgery in Montreal is different from learning plastic surgery in a French university. In Canada, all residency programs are accredited by a national structure: the Royal College of Physicians and Surgeons. We tried to highlight the differences that exist between the French and a North American academic system. MATERIAL AND METHOD: With the different rules and law that governs academic education in both countries, we analyzed the following elements: the residency selection, the program of plastic surgery (content and organisation), the system of evaluation and the diplomas. RESULT: The training of a Canadian plastic surgeon is very controlled. The recommendations of the Royal College guarantee to the resident who enters a program to have the means to acquire a complete training in quantity and in quality. On the four studied items, none is completely similar between both countries. Each having advantages and inconveniences as, for example, the selection of residency by interview or by the classifying national exam. CONCLUSION: Actually, few French plastic surgery programs could satisfy the requirements of the Royal College on several points, however without failing the training of French plastic surgeons. Nevertheless, we could be inspired by several elements (rotation in private practice,grouping together several academic hospitals. . .) to improve our system of training.

Calcium polyuronate dressing supplemented with zinc and manganese (trionic®) in necrotizing dermohypodermitis of the extremities: a randomized multicentre study.

Background. For the burn surgeon, the treatment of necrotizing soft tissue infections is one of the most demanding surgical emergencies, requiring "radical excisions" of the infected tissue and reconstruction. During the infection period, the excised sites are treated with application of gauzes soaked in saline solution. When the septic period is over, the excision sites are usually covered by sterile paraffin gauze dressing. Our aim was to evaluate a new calcium polyuronate dressing enriched with zinc and manganese ions (test group) versus the reference therapeutic combination (control group) from the septic period to the grafting of skin. Materials and methods. A multicentre, prospective, controlled, randomized clinical trial was conducted from November 2003 to July 2005. The primary endpoint was the waiting period for carrying out the skin graft and the percentage of grafted patients at 28 days after the last excision. The secondary endpoints were blood loss, exudates amounts, and pain during dressing changes. Results. Twenty-five patients were included, 14 with the new dressing and 11 with the reference therapeutic combination. The average waiting period for skin graft was 18 days in the test group versus 27.1 days in the control group (p = 0.128). All the patients in the test group received their grafts within 28 days after the last excision, compared with 60% (p = 0.043) in the control group. Bleeding during dressing change was statistically lower in the test group: 45.5% of the patients did not bleed compared with 0% in the control group (p = 0.045). Treatments were well tolerated. Conclusion. The properties of this new calcium polyuronate enriched with zinc and manganese ions seem to accelerate granulation tissue development, allowing skin grafting earlier in favourable conditions with less bleeding and less pain during dressing renewal.

Early management, with a minimal initial hospitalization length, of major self-inflicted rifle wounds to the face by a single latissimus dorsi free musculocutaneous flap: a 10-year experience.

OBJECTIVE: Severe ballistic injuries to the face create complex, composite defects of 2 facial subunits. These injuries have an extremely high economic impact for the Medicare system. The surgical goal with these patients is to restore basic functions of the face with a rapid morphological improvement. Our hypothesis is as follows: Early restoration of facial segments with a single free multiple island latissimus dorsi flap without primary bone reconstruction can significantly reduce hospitalization time and allow earlier psychiatric therapy with good morphological results. SURGICAL METHOD: (1) Large debridement, bony stabilization with external fixation, and tracheotomy. (2) Definitive early reconstruction of soft tissue with composite free latissimus dorsi-scapular musculocutaneous flap. (3) Several refinements will optimize the results. STUDY DESIGN: Retrospective case series of lower- and middle-face composite facial close-range high-energy gunshot wound patients were evaluated. Age, gender, mechanism of injury, anatomic subsites involved, surgical procedures, flaps utilized, complications, functional outcomes, time of tracheotomy closure, hospitalization duration, and beginning of psychiatric treatment were analyzed. RESULTS: Twelve defects were gunshot wounds, 12 free latissimus dorsi flaps, and no flap losses. Patients received psychiatric treatment after 22 days (7-29); the tracheotomy was removed in 10 patients with normal alimentation in all cases. Mean hospitalization duration was 21 days. CONCLUSIONS: Free tissue transfer techniques allow early reconstruction of the soft tissue framework of the face with a single multiple-island flap. Rapid restitution of facial compartments at a soft tissue level can dramatically reduce duration of hospitalization.

Comparative analysis between scientific and the media communication following facial transplantation.

PURPOSE: Our aim was to analyze the communications about three outstanding medical reports. Was there any difference in the reports of the three allografts? Was there a correlation between the media and the scientific world? METHODS: The Internet sites of three major newspapers were used for the media database. Those results were compared with PubMed between 2005 and 2007 using these key words: "facial graft," "facial allograft," "composite tissue allograft," and names of surgeons of the graft. We did a comparative analysis using a word processor and a quality analysis software. RESULTS: We analyzed 51 articles from the media and six from the PubMed database. In PubMed, 100% of the articles were on the first graft and respected the privacy of the patient compared to 67% of the media who unveiled the identity. CONCLUSION: The communication following a medical premiere depends on the team, which performes the act. We observed a major difference between the three cases. Ethical considerations are different for the media and for scientists. The communication management of a medical premiere takes preparation and evaluation.

[Is muscle the best coverage for leg Gustilo IIIb fractures? A retrospective comparative study]. / Le muscle est-il la meilleure couverture pour les fractures ouvertes de jambe Gustillo IIIb ? Etude rétrospective comparative.

UNLABELLED: Well-vascularized muscle flaps have been the traditional gold standard for coverage of open fracture of the lower extremity. The last 15 years have brought the fasciocutaneous and perforator flaps and raised the issue of the type of coverage required for open fracture of the lower extremity. In recent years, in selected compromised patient, we have been using nonmuscular flaps for reconstruction. The goal of this study is to compare the results of fasciocutaneous reconstruction to those of classical muscular flaps. PATIENTS AND METHODS: A comparative retrospective study, including all patients from 2002 to 2006 requiring a coverage of a Gustillo III b fracture of the lower extremity, is done. The type of flaps, the fracture localization, the infection rate, the time required for consolidation of the fracture and the complication rate are reviewed. An independent university laboratory verified the statistical analysis. RESULTS: Twenty patients have experienced coverage by muscular flaps and 18 by fasciocutaneous flaps. We found a skin fistula and a chronic infection in the muscular-flap group, and two skin fistulae in the fasciocutaneous flaps group. The overall surgical results were comparable, except the bony union delay shorter in the fasciocutaneous flaps group. CONCLUSION: Muscle coverage is not mandatory to cover bone in the lower leg. The fasciocutaneous flaps can provide a good alternative for muscle-flap coverage. There is no significant difference as far as consolidation and infection are concerned, between the coverage by muscular or fasciocutaneous flaps.

[Dynamic external traction system for management of distal displaced fractures of the head of the proximal phalanx]. / Traitement des fractures instables de la tête de la première phalange par fixateur externe dynamique.

INTRODUCTION: Phalangeal fractures are generally underestimated injuries, but result in pain, stiffness, instability, degenerative arthritis and loss of finger function. Treatment varies from open reduction with internal fixation giving perfect anatomical reduction but a risk of side effects, to orthopaedic treatment with variable results. Unstable fractures must be fixed rigidly to minimize joint immobilization. It is this concept of solid fixation and early mobilization, which directed us in the choice of dynamic external distraction in the management of these fractures. MATERIAL AND METHOD: The authors present a prospective study of twelve patients treated for unstable fractures of the proximal interphalangeal joint by closed reduction and dynamic external distractor, we describe this simple device created with pins and rubber bands and examine the functional clinical results. RESULTS: The average follow-up period was 7.5 months. We only noted one pin-track infection. Three patients complained of pain at postoperative follow up. In this series, the total active motion varied from 70 degrees to 120 degrees (average 94.16 degrees), the mean lack of extension was 5.6 degrees (from 0 to 15 degrees). Ten patients had good mobility and were satisfied. DISCUSSION: Different traction devices for the management of displaced intraarticular phalangeal fractures have been reported. Most of them are complex to construct and expensive. The traction system is simple to assemble, economical and it allows early active motion of the affected digits. We consider that it is an effective mode of treatment for the management of complex intraarticular phalangeal fractures.

Reducing the number of sentinel nodes removed in melanoma patients: a prospective study.

CONTEXT: Since 1992, sentinel lymph node (SLN) biopsy was generally applied to melanoma for tumor staging. As the literature points out, an increasing number of nodes are being removed for each procedure, driving up the cost for this procedure and wandering away from the defining concept of sentinel lymph node. AIMS: The objective of the current study was to show that the number of sentinel lymph node s removed can be minimized without influencing the reliability of tumor staging. MATERIALS AND METHODS: We conducted a single-arm prospective study in patients with stage I melanoma. For each patient, the sentinel lymph node was identified using the hand-held gamma probe technique. We removed only the hottest nodes as well as the nodes with radioactivity greater than 70% compared to the hottest. We analyzed the characteristics of each melanoma, the success rate of this procedure, how many nodes were removed and how many had micro metastases. STATISTICAL ANALYSIS: The results were compared to those of the literature, previously published Porter study using the chi-square test. RESULTS: We included 90 patients. The success rate of this technique was 100%. We dissected 1.3 sentinel lymph nodes for each patient, with 22% positive SLN. Statistical analyses point out a better selectivity of our study for a similar rate of pathological positivity and recurrence compared to the literature. CONCLUSIONS: Our technique for decreasing the number of sentinel lymph nodes removed is reliable. The removal of minimal number of nodes doesn't compromise the sensitivity of tumor staging, while it does reduce the cost of the procedure.

[Effect of information by images on patients' anxiety and comprehension before esthetic surgery on the abdominal wall: a prospective randomised trial with 60 patients]. / Impact de l'introduction d'images sur l'anxiété et la connaissance des patientes avant une abdominoplastie esthétique. Une étude prospective randomisée incluant 60 patientes.

Informed consent is a legal and ethical requirement before every surgical procedure especially when it comes to esthetic surgery. Obtaining a satisfactory understanding of the risks and benefits of the operation by patients remains a critical problem. This trial aimed to assess the value of visual information. Patients scheduled to undergo abdominoplasty were approached during the first preoperative consultation. All patients were given an information leaflet about the procedure and completed a Spielberger state trait anxiety inventory (state-trait inventory, STAI form Y-1): questionnaire to assess baseline anxiety. The patients were then randomly assigned to watch or not watch the information CD-Rom during the second preoperative consultation. The day before surgery the patient completed a second anxiety questionnaire and a knowledge questionnaire. 67 patients were screened, 2 declined to participate and 5 were unable to complete the form. Of the remaining 60 patients 30 were assigned to look at the CD-Rom and the remaining 30 not. The groups were similar in regards to age, sex, education and initial anxiety score. Patients who watched the CD-Rom were significantly less anxious before a esthetic surgery than those who did not (Mean STAI 45 for the "image group" [38.2-46.3] vs 55 for the "no image group" [49.9-63.8]). Furthermore they also scored higher in the knowledge questionnaire than the "no image" group as far as the purpose and the procedural details of the surgery were concerned. However statistical difference of knowledge regarding the potential complications of the procedure was not found.