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

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

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

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

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

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

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

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

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

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

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

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

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

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

Use of bone anchors for flap fixation in burned patients.

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

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

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

Effects of an informational CD-ROM on anxiety and knowledge before aesthetic surgery: a randomised trial.

This trial aimed to assess the value of visual information by CD ROM before aesthetic breast reduction or abdominoplasty. All included patients were given an information leaflet about the procedure and completed a Spielberger state-trait anxiety inventory (STAI form Y-1) questionnaire to assess situational anxiety. The patient was then randomly assigned to watch or not to watch an informational CD ROM. The day before surgery the patient completed a second anxiety questionnaire and a knowledge questionnaire. Eighty patients were included, 40 were assigned the CD ROM and 40 no CD ROM. Patients who watched the CD ROM were significantly less anxious than those who did not (Mean STAI 45 [38.2-46.3] vs 55 [49.9-63.8]). Furthermore they also scored higher in the knowledge questionnaire as far as the purpose and the procedural details of the surgery were concerned. However, no statistical difference of knowledge regarding the potential complications of the procedure was found.

A scanning electron microscopical study of the two sides of polypropylene mesh (Marlex) and PTFE (Gore Tex) mesh 2 years after complete abdominal wall reconstruction. A study of 15 cases.

The use of biomaterials for the repair of abdominal wall defect is becoming common and safe. It has been 20 years since the senior author developed a method to reconstruct the very large transfixing abdominal wall defect with a combination of two biomaterials (Gore Tex) PTFE as a neo peritoneum and polypropylene superficial to this in order to give rigidity to the abdominal wall) and a superficial flap. An observation at the electron microscopy level of the two sides of the implants' surfaces was performed. At the time of a late abdominal wall surgical revision on 15 patients, the prosthesis fragments have been analyzed at the electron microscopy level. The aim of our study was to analyze the late evolution of the different sides of these prostheses. Our results showed, for the first time in vivo, that there is an impressive stability of the deep side of PTFE ultra structure after implantation, a significant difference of the two sides of PTFE at the ultrastructural level and the creation of an intermediate tissue between the two meshes. In contrast, the polypropylene invariably gave rise to adhesions and colonisation by the surrounding tissues. Findings confirmed that the structure and porosity of a biomaterial play a key role in the appearance of adhesions and their consistency.