Usability and feasibility of a take-home methadone web-application for opioid treatment program patients: A Small Business Innovation Research mixed methods study.

BACKGROUND: Most patients in opioid treatment programs (OTPs) attend daily for observed dosing. A Stage IA (create and adapt) and a Stage IB (feasibility and pilot) mixed method studies tested a web-application (app) designed to facilitate access to take-home methadone. METHODS: A Stage IA, intervention development study, used qualitative interviews to assess the usability (ease of use) and feasibility (ability to implement) of a take-home methadone app. The Stage IA market research was a two-week test with 96 patient participants from four OTPs. Qualitative interviews were completed with 20 systematically selected individuals who used the take-home app and 20 OTP clinicians (five each from the four OTPs). The Stage IB Small Business Innovation Research (SBIR) study (24 patients and 8 clinicians in a single OTP) included quantitative assessments of the app's usability, acceptability, appropriateness, and feasibility. Thematic analysis coded participant and staff assessments of the take-home app. RESULTS: Stage IA patients (mean age = 41 years; 52 % men, 57 % White) and IB patients (mean age = 38 years, 54 % men, 79 % White) described the app as "easy to use." Compared to unsupervised take-homes, some patients preferred using the take-home app. In Stage IB, patients rated the app highly on standardized measures of usability, acceptability, appropriateness, and feasibility. Clinician ratings were more ambivalent. Patients rated in-clinic dosing as more disruptive than unsupervised take-homes and take-homes using the app. DISCUSSION: A Stage IA study informed the development and maturation of a Stage IB feasibility pilot study. Overall, the take-home app's usability, acceptability, appropriateness, and feasibility were rated positively. Clinical staff ratings were less positive, but individuals commented that using the app a) enhanced patient quality of life, b) provided new tools for counselors, and c) offered competitive advantages. The SBIR award enhanced market research with more complete and systematic data collection and analysis.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes.

BACKGROUND: Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. METHODS: Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. RESULTS: Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). CONCLUSION: With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

The Impact of Combined Risk-Reducing Gynecological Surgeries on Outcomes in DIEP Flap and Tissue-Expander Breast Reconstruction.

INTRODUCTION: In addition to prophylactic mastectomies, BRCA1 and BRCA2 mutation carriers are increasingly choosing to undergo risk-reducing procedures such as hysterectomies and salpingo-oophorectomies. Sometimes these surgeries are performed in the same visit as a mastectomy or a revisionary reconstruction procedure. Literature lacks descriptions of complications and trends for these combined surgeries. METHODS: Group 1 patients (n = 10, flaps = 20) had abdominal gynecologic procedures at the time of deep inferior epigastric artery perforator flap (DIEP flap) reconstruction. Group 2 patients (n = 29, breasts = 58) had gynecologic procedures at the time of mastectomy and tissue-expander placement. Group 3 patients (n = 141, breasts = 257) had mastectomy and tissue-expander reconstruction without gynecologic procedures and were used as a control group for group 2. Group 4 patients (n = 357, flaps = 673) had autologous breast reconstruction without gynecologic procedures and were used as a control for group 1. Categorical variables such as complications and flap loss were analyzed using χ2 tests. Continuous variables such as age, body mass index (BMI), operative time, length of stay were analyzed with 2-tailed t tests. Multivariate analyses were run to control for group differences. RESULTS: Groups 1 and 4 were equivalent in age and comorbidities, except group 1 (32.8 kg/m2) had significantly higher BMI than group 4 (31.4 kg/m2), P = .028. Average operating time was statistically equivalent for group 1 patients (610 minutes) and group 4 patients (503 minutes), P = .289. Average hospital stay was equivalent as well (group 1 = 4.4 days, group 4 = 4.1 days, P = .676). Operative times for group 2 patients (457 minutes) were significantly longer than for group 3 patients (288 minutes), P < .01. Group 2 patients (3 nights) had significantly longer hospital stays than group 3 patients (2 nights), P < .01. Group 1 patients (2/20 flaps, 10%) had a significantly higher rate of flap loss than group 4 patients (8/673 flaps, 1%), P < .01. There were no differences in other flap complications. Additionally, there were no significant differences in postoperative tissue-expander complications between group 2 and group 3. DISCUSSION: Both flap losses in Group 1 patients occurred in a single patient with BMI = 39.3 kg/m2 and a personal history of recurrent DVTs. Additionally, the rates of complications across other measures were equivalent between groups. Thus, despite the increased rate of flap loss in Group 1 (10%) vs Group 4 (1.3%), along with the increased operative times and hospital stays, certain patients can be advised that a prophylactic gynecological procedure is safe to combine with breast reconstruction.

INTRODUCTION: En plus d'opter pour des mastectomies prophylactiques, les porteuses des mutations BRCA1 et BRCA2 choisissent de plus en plus de subir des interventions de réduction des risques, telles que l'hystérectomie et la salpingo-ovariectomie. Il arrive que ces opérations soient exécutées conjointement avec une mastectomie ou une reconstruction. Peu de publications, sinon aucune, décrivent les complications et les tendances relatives à ces interventions combinées. MÉTHODOLOGIE: Les patientes du groupe 1 (n = 10, lambeaux = 20) ont subi une intervention gynécologique abdominale au moment de la reconstruction des lambeaux perforants de l'artère épigastrique inférieure profonde. Celles du groupe 2 (n = 29, seins = 58) ont subi une intervention gynécologique au moment de la mastectomie et de l'expansion tissulaire. Celles du groupe 3 (n = 141, seins = 257), qui ont subi une mastectomie et une expansion tissulaire sans intervention gynécologique, ont fait office de groupe témoin du groupe 2. Enfin, les patientes du groupe 4 (n = 357, lambeaux = 673) ont subi une reconstruction mammaire autologue sans intervention gynécologique et ont joué le rôle de groupe témoin du groupe 1. Les chercheurs ont analysé des variables nominales, comme les complications et la perte des lambeaux, au moyen des tests du chi carré. Ils ont analysé des variables continues, telles que l'âge, l'indice de masse corporelle (IMC), la durée de l'opération et la durée de l'hospitalisation, à l'aide de tests de Student bilatéraux. Ils ont procédé à des analyses multivariées pour déterminer les différences par rapport aux groupes témoins. RÉSULTATS: Les groupes 1 et 4 avaient des âges et des morbidités associées équivalentes, sauf que l'IMC du groupe 1 (32,8 kg/m2) était significativement plus élevé que celui du groupe 4 (31,4 kg/m2), p = 0,028. La durée d'opération moyenne était statistiquement équivalente dans les groupes 1 (610 min) et 4 (503 min), p = 0,289. La durée d'hospitalisation était également équivalente (groupe 1 = 4,4 jours, groupe 4 = 4,1 jours, p = 0,676). La durée d'opération des patientes du groupe 2 (457 min) était significativement plus longue que celle des patients du groupe 3 (288 min), p < 0,01, et les patientes du groupe 2 étaient hospitalisées significativement plus longtemps (trois nuits) que celles du groupe 3 (deux nuits), p < 0,01. Les patientes du groupe 1 (deux lambeaux sur 20, 10 %) présentaient une perte de lambeau significativement plus élevée que celles du groupe 4 (huit lambeaux sur 673, 1 %), p < 0,01. Il n'y avait pas de différence dans les autres complications des lambeaux ni de différence significative entre les groupes 2 et 3 pour ce qui est des complications des expansions tissulaires après l'opération. EXPOSÉ: Dans le groupe 1, les deux pertes de lambeau se sont produites chez une même patiente ayant un IMC = 39,3 kg/m2 et des antécédents de caillots récurrents. Le taux de complications relatives aux autres mesures était équivalent entre les groupes. Ainsi, malgré le nombre plus élevé de pertes de lambeau dans le groupe 1 (10 %) par rapport au groupe 4 (1,3 %), ainsi que la durée plus longue de l'opération et de l'hospitalisation, il est possible d'indiquer à certaines patientes qu'il est sécuritaire de combiner une intervention gynécologique prophylactique avec une reconstruction mammaire.

Revisiting Anastomosis to the Retrograde Internal Mammary System in Stacked Free Flap Breast Reconstruction: An Algorithmic Approach to Recipient-Site Selection.

BACKGROUND: The authors present their stacked flap breast reconstruction experience to facilitate selection of either caudal internal mammary vessels or intraflap vessels for the second recipient anastomosis. METHODS: A retrospective review was conducted of multiflap breast reconstructions (double-pedicled deep inferior epigastric perforator, stacked profunda artery perforator, and stacked profunda artery perforator/deep inferior epigastric perforator) performed at the authors' institution from 2011 to 2018. Data collected included demographics, recipient vessels used, and intraoperative/postoperative flap complications. Complications were compared between cranial, caudal, and intraflap anastomoses. RESULTS: Four hundred stacked flaps were performed in 153 patients. Of 400 arterial anastomoses, 200 (50 percent) were to cranial internal mammary vessels, 141 (35.3 percent) were to caudal internal mammary vessels, and 59 (14.8 percent) were to intraflap vessels. Of 435 venous anastomoses, 145 (33.3 percent) were to caudal internal mammary vessels, 201 (46.2 percent) were to cranial internal mammary vessels, and 89 (20.5 percent) were to intraflap vessels. Intraoperative revision for thrombosis occurred in 12 of 141 caudal (8.5 percent), 14 of 20 cranial (7 percent), and seven of 59 intraflap (11.9 percent) arterial anastomoses (p = 0.373), and in none of caudal, three of 201 cranial (1.5 percent), and two of 89 intraflap (2.2 percent) venous anastomoses (p = 0.559). Postoperative anastomotic complications occurred in 12 of 400 flaps (3 percent) and were exclusively attributable to venous compromise; seven of 12 (58.3 percent) were salvaged, and five of 12 (41.7 percent) were lost. More lost flaps were caused by caudal [four of five (80 percent)] versus cranial [one of five (20 percent)] or intraflap (zero of five) thrombosis (p = 0.020). CONCLUSION: If vessel features are equivalent between the caudal internal mammary vessels and intraflap vessels, intraflap vessels should be used for second site anastomosis in stacked flap reconstructions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.