Treating Saddlebag Deformity after Massive Weight Loss: Vertical versus Lower Body Lift.

SUMMARY: The saddlebag deformity remains a persistent and difficult-to-treat problem after body-contouring surgery. A new way to handle the saddlebag deformity is with the vertical lower body lift (VLBL). This retrospective cohort study evaluated the overall reconstruction outcome of the VLBL in 16 patients (32 saddlebags) and compared it to standard lower body lift (LBL). The BODY-Q and the Pittsburgh Rating Scale (PRS)-Saddlebag Scale were used in the evaluation process. Surgical outcomes regarding the saddlebag deformity were in favor of the VLBL technique in patients with marked saddlebag deformity. A 1.16 decrease in mean PRS saddlebag score (relative change of 61.7%) was observed for the VLBL group versus a mean decrease of 0.29 (relative change of 21.6%) in the LBL group. BODY-Q end point and change in scores did not differ between the VLBL and LBL groups at 3-month follow-up, but at 1-year follow-up, they were in favor of the VLBL group in the body appraisal domain. Patients were highly satisfied with the contour and appearance of their lateral thigh, despite the extra scarring caused by this novel technique. Therefore, the authors advise clinicians to consider performing a VLBL instead of the standard LBL in patients with notable saddlebag deformities after massive weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Self-Reliance and Postoperative Hand Recovery After Simultaneous, Bilateral Endoscopic Carpal Tunnel Release: A Prospective Study.

PURPOSE: Outcomes and recovery of endoscopic carpal tunnel release (ECTR) have been broadly examined in studies. The total recovery time can potentially be reduced by performing simultaneous, bilateral ECTR. In this study we prospectively investigated days to self-reliance. As secondary outcomes, we investigated direct postoperative recovery of hand function and pre and postoperative symptom severity after simultaneous, bilateral ECTR. METHODS: In this single-center prospective case series, we included all patients willing to participate after undergoing bilateral ECTR between December 2015 and July 2019. Every patient recorded days to self-reliance (when a patient could perform basic activities of daily living without the need for assistance from another person) and completed a preoperative and postoperative Boston Carpal Tunnel Questionnaire (BCTQ) evaluating postoperative hand function and pre and postoperative symptom severity. RESULTS: In total, 81 patients received simultaneous, bilateral ECTR. Median days until self-reliance was 4; mean number of days was 4.9. Concerning BCTQ scores, postoperative functional status increased significantly each day, and mean BCTQ score decreased gradually from intense difficulty to little difficulty in daily tasks over a period of 7 days. Preoperative BCTQ symptom severity showed significant improvement compared to postoperative symptoms, evolving from medium to slight symptoms. CONCLUSIONS: Simultaneous, bilateral ECTR offers recovery to self-reliance in 4 to 5 days with a gradual and significant increase of hand function in the following postoperative days. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Applying Computerized Adaptive Testing to the FACE-Q Skin Cancer Module: Individualizing Patient-Reported Outcome Measures in Facial Surgery.

BACKGROUND: Skin cancer is among the most frequently occurring malignancies worldwide, which creates a great need for an effective patient-reported outcome measure. Providing shorter questionnaires reduces patient burden and increases patients' willingness to complete forms. The authors set out to use computerized adaptive testing to reduce the number of items needed to predict results for scales of the FACE-Q Skin Cancer Module, a validated patient-reported outcome measure that measures health-related quality of life and patient satisfaction in facial surgery. METHODS: Computerized adaptive testing generates tailored questionnaires for patients in real time based on their responses to previous questions. The authors used an open-source computerized adaptive testing simulation software to run item responses for the five scales from the FACE-Q Skin Cancer Module (i.e., scar appraisal, satisfaction with facial appearance, appearance-related psychosocial distress, cancer worry, and satisfaction with information about appearance). Each simulation continued to administer items until prespecified levels of precision were met, estimated by standard error. Mean and maximum item reductions between the original fixed-length short forms and the simulated versions were evaluated. RESULTS: The number of questions that patients needed to answer to complete the FACE-Q Skin Oncology Module was reduced from 41 items in the original form to a mean of 23 ± 0.55 items (range, 15 to 29) using the computerized adaptive testing version. Simulated computerized adaptive testing scores maintained a high correlation (0.98 to 0.99) with the score from the fixed-length short forms. CONCLUSIONS: Applying computerized adaptive testing to the FACE-Q Skin Cancer Module can reduce the length of assessment by more than 50 percent, with virtually no loss in precision. It is likely to play a critical role in the implementation in clinical practice.

Deriving an overall appearance domain score by applying bifactor IRT analysis to the BODY-Q appearance scales.

PURPOSE: With the BODY-Q, one can assess outcomes, such as satisfaction with appearance, in weight loss and body contouring patients using multiple scales. All scales can be used independently in any given combination or order. Currently, the BODY-Q cannot provide overall appearance scores across scales that measure a similar super-ordinate construct (i.e., overall appearance), which could improve the scales' usefulness as a benchmarking tool and improve the comprehensibility of patient feedback. We explored the possibility of establishing overall appearance scores, by applying a bifactor model to the BODY-Q appearance scales. METHODS: In a bifactor model, questionnaire items load onto both a primary specific factors and a general factor, such as satisfaction with appearance. The international BODY-Q validation patient sample (n = 734) was used to fit a bifactor model to the appearance domain. Factor loadings, fit indices, and correlation between bifactor appearance domain and satisfaction with body scale were assessed. RESULTS: All items loaded on the general factor of their corresponding domain. In the appearance domain, all items demonstrated adequate item fit to the model. All scales had satisfactory fit to the bifactor model (RMSEA 0.045, CFI 0.969, and TLI 0.964). The correlation between the appearance domain summary scores and satisfaction with body scale scores was found to be 0.77. DISCUSSION: We successfully applied a bifactor model to BODY-Q data with good item and model fit indices. With this method, we were able to produce reliable overall appearance scores which may improve the interpretability of the BODY-Q while increasing flexibility.

Computerized Quality of Life Assessment: A Randomized Experiment to Determine the Impact of Individualized Feedback on Assessment Experience.

BACKGROUND: Quality of life (QoL) assessments, or patient-reported outcome measures (PROMs), are becoming increasingly important in health care and have been associated with improved decision making, higher satisfaction, and better outcomes of care. Some physicians and patients may find questionnaires too burdensome; however, this issue could be addressed by making use of computerized adaptive testing (CAT). In addition, making the questionnaire more interesting, for example by providing graphical and contextualized feedback, may further improve the experience of the users. However, little is known about how shorter assessments and feedback impact user experience. OBJECTIVE: We conducted a controlled experiment to assess the impact of tailored multimodal feedback and CAT on user experience in QoL assessment using validated PROMs. METHODS: We recruited a representative sample from the general population in the United Kingdom using the Oxford Prolific academic Web panel. Participants completed either a CAT version of the World Health Organization Quality of Life assessment (WHOQOL-CAT) or the fixed-length WHOQOL-BREF, an abbreviated version of the WHOQOL-100. We randomly assigned participants to conditions in which they would receive no feedback, graphical feedback only, or graphical and adaptive text-based feedback. Participants rated the assessment in terms of perceived acceptability, engagement, clarity, and accuracy. RESULTS: We included 1386 participants in our analysis. Assessment experience was improved when graphical and tailored text-based feedback was provided along with PROMs (Δ=0.22, P<.001). Providing graphical feedback alone was weakly associated with improvement in overall experience (Δ=0.10, P=.006). Graphical and text-based feedback made the questionnaire more interesting, and users were more likely to report they would share the results with a physician or family member (Δ=0.17, P<.001, and Δ=0.17, P<.001, respectively). No difference was found in perceived accuracy of the graphical feedback scores of the WHOQOL-CAT and WHOQOL-BREF (Δ=0.06, P=.05). CAT (stopping rule [SE<0.45]) resulted in the administration of 25% fewer items than the fixed-length assessment, but it did not result in an improved user experience (P=.21). CONCLUSIONS: Using tailored text-based feedback to contextualize numeric scores maximized the acceptability of electronic QoL assessment. Improving user experience may increase response rates and reduce attrition in research and clinical use of PROMs. In this study, CAT administration was associated with a modest decrease in assessment length but did not improve user experience. Patient-perceived accuracy of feedback was equivalent when comparing CAT with fixed-length assessment. Fixed-length forms are already generally acceptable to respondents; however, CAT might have an advantage over longer questionnaires that would be considered burdensome. Further research is warranted to explore the relationship between assessment length, feedback, and response burden in diverse populations.

Computerised adaptive testing accurately predicts CLEFT-Q scores by selecting fewer, more patient-focused questions.

BACKGROUND: The International Consortium for Health Outcome Measurement (ICHOM) has recently agreed upon a core outcome set for the comprehensive appraisal of cleft care, which puts a greater emphasis on patient-reported outcome measures (PROMs) and, in particular, the CLEFT-Q. The CLEFT-Q comprises 12 scales with a total of 110 items, aimed to be answered by children as young as 8 years old. OBJECTIVE: In this study, we aimed to use computerised adaptive testing (CAT) to reduce the number of items needed to predict results for each CLEFT-Q scale. METHOD: We used an open-source CAT simulation package to run item responses over each of the full-length scales and its CAT counterpart at varying degrees of precision, estimated by standard error (SE). The mean number of items needed to achieve a given SE was recorded for each scale's CAT, and the correlations between results from the full-length scales and those predicted by the CAT versions were calculated. RESULTS: Using CATs for each of the 12 CLEFT-Q scales, we reduced the number of questions that participants needed to answer, that is, from 110 to a mean of 43.1 (range 34-60, SE < 0.55) while maintaining a 97% correlation between scores obtained with CAT and full-length scales. CONCLUSIONS: CAT is likely to play a fundamental role in the uptake of PROMs into clinical practice given the high degree of accuracy achievable with substantially fewer items.

[Pyoderma gangrenosum: a complication following surgery for carpal tunnel syndrome]. / Pyoderma gangrenosum.

BACKGROUND: Pyoderma gangrenosum is a rare condition with an unpredictable disease course. The condition is accompanied by tissue decay and recognition often comes late. Pyoderma gangrenosum has clinical features similar to an infection, but does not react to antibiotics. The condition can develop following a surgical procedure or can be worsened by one. To date, only one other case of pyoderma gangrenosum following surgery for carpal tunnel syndrome has been described in the literature. CASE DESCRIPTION: A 60-year-old man developed painful ulcers shortly after surgery for carpal tunnel syndrome, a clinical picture representing a serious infection. Antibiotics and surgical debridement did not lead to improvement. Cultures from the wound did not contain micro-organisms. Following histological investigation a diagnosis of pyoderma gangrenosum was made. Administration of a high dosage of prednisone led to a swift improvement and the wound healed. CONCLUSION: Timely recognition of pyoderma gangrenosum is essential to prevent unnecessary surgical treatment and worsening of the condition. Systemic glucocorticoids are the treatment of first choice for pyoderma gangrenosum.

Streamlining the Assessment of Patient-Reported Outcomes in Weight Loss and Body Contouring Patients: Applying Computerized Adaptive Testing to the BODY-Q.

BACKGROUND: The BODY-Q is a widely used patient-reported outcome measure of surgical outcomes in weight loss and body contouring patients. Reducing the length of the BODY-Q assessment could overcome implementation barriers in busy clinics. A shorter BODY-Q could be achieved by using computerized adaptive testing, a method to shorten and tailor assessments while maintaining reliability and accuracy. In this study, the authors apply computerized adaptive testing to the BODY-Q and assess computerized adaptive testing performance in terms of item reduction and accuracy. METHODS: Parameters describing the psychometric properties of 138 BODY-Q items (i.e., questions) were derived from the original validation sample (n = 734). The 138 items are arranged into 18 scales reflecting Appearance, Quality of Life, and Experience of Care domains. The authors simulated 1000 administrations of the computerized adaptive testing until a stopping rule, reflecting assessment accuracy of standard error less than 0.55, was met. The authors describe the reduction of assessment length in terms of the mean and range of items administered. The authors assessed accuracy by determining correlation between full test and computerized adaptive testing scores. RESULTS: The authors ran 54 simulations. Mean item reduction was 36.9 percent (51 items; range, 48 to 138 items). Highest item reduction was achieved for the Experience of Care domain (56.2 percent, 22.5 items). Correlation between full test scores and the BODY-Q computerized adaptive test scores averaged 0.99. CONCLUSIONS: Substantial item reduction is possible by using BODY-Q computerized adaptive testing. Reduced assessment length using BODY-Q computerized adaptive testing could reduce patient burden while preserving the accuracy of clinical patient-reported outcomes for patients undergoing weight loss and body contouring operations.

Development of the BODY-Q Chest Module Evaluating Outcomes following Chest Contouring Surgery.

BACKGROUND: Plastic surgery to improve chest appearance is becoming increasingly popular. The BODY-Q is a patient-reported outcome instrument designed for weight loss and/or body contouring. In this article, the authors describe the development of a new module for masculinizing chest contouring surgery. METHODS: Qualitative methods were used to develop the BODY-Q Chest Module, which was subsequently field-tested in Canada, the United States, The Netherlands, and Denmark between June of 2016 and June of 2017. Participants were aged 16 years or older and seen for gynecomastia, weight loss, or transman chest surgery. Data were collected using either a Web-based application or paper questionnaire. Rasch measurement theory analysis was performed. RESULTS: The sample included 739 participants (i.e., 174 gynecomastia, 224 weight loss, and 341 gender-affirming). Rasch measurement theory analysis refined a 10-item chest scale and a five-item nipple scale. All items had ordered thresholds and good item fit, and scales evidenced reliability [i.e., person separation index and Cronbach alpha values were 0.95 and 0.98 (chest scale) and 0.87 and 0.94 (nipple scale), respectively]. Scores for both scales correlated more strongly with similar (satisfaction with the body) versus dissimilar (psychological and social function) BODY-Q scales. The mean scores for the chest and nipple scales were significantly higher (p < 0.001 on independent samples t tests) in participants who were postoperative compared with preoperative. CONCLUSION: This new BODY-Q Chest Module is a clinically meaningful and scientifically sound patient-reported outcome instrument that can be used to measure outcomes for masculinizing chest contouring surgery.

Breast-sharing Technique in a Unilateral Mastectomy Patient.

Breast reconstruction patients frequently desire consecutive or simultaneous contralateral breast reduction. When combining the requirements of both autologous breast reconstruction with symmetrizing breast reduction, a 2-staged contralateral pedicled breast sharing is a dignified alternative. We present a 60-year-old woman with a radical mastectomy and adjuvant radiotherapy. On the contralateral side, she had a hypertrophic breast with a desire for reduction mammaplasty. A 2-stage procedure for breast sharing was planned. A preoperative computed tomography scan, to assess the status of the fourth intercostal mammary perforator (IMAP), was performed. After the first procedure, symmastia was evident. Water-assisted liposuction and quilting sutures to the sternal periosteum were applied in a second procedure to correct the symmastia. We preserved the fourth intercostal perforator to provide optimal vascularization. Water-assisted liposuction and quilting sutures were used to correct the remaining symmastia and contributed to the aesthetics of both breasts. A drawback of this procedure is the need for multiple stages. Furthermore, oncological safety should be considered and surgeons should be aware of the risk for venous congestion. Breast-sharing could be a feasible alternative reconstruction for women seeking unilateral breast reconstruction with contralateral breast hypertrophy. It reduces the need for free-flap surgery and subsequent donor-site morbidity. Considering the fact that the contralateral breast must be of significant size, the indication for this type of reconstruction is limited.

[A woman with a rare gastrointestinal bleeding]. / Een vrouw met een zeldzame tractus-digestivusbloeding.

A 70-year old woman came to the emergency department with dyspnea and syncope. Hemoglobin level was 2,9 mmol/l (reference: 7,6-9,9 mmol/l). Gastroscopy was negative, CT-abdomen showed a hypervascular jejunal tumour. Laparoscopic jejunal segment resection was performed with resection of the tumour, after which the hemoglobin level improved. Pathological examination showed a gastrointestinal stromal tumour.