Claire Temple-Oberle

Intra-lesional interleukin-2 therapy for in transit melanoma

Intra‐lesional interleukin‐2 (IL‐2) is effective in treating in transit melanoma metastases. Results from multiple studies were examined to evaluate the efficacy of IL‐2 for in transit disease. In the published literature, complete response ranged from 0% to 69% per patient, and 41% to 96% per lesion, with excellent tolerability. Combining the results of six studies show complete response in 50% of patients and 78% of lesions. Intra‐lesional IL‐2 should be considered early in the course of treatment for in transit disease, ahead of other, more toxic therapies. J. Surg. Oncol. 2014 109:327–331.

Evidence-Based Microsurgical Skill-Acquisition Series Part 1: Validated Microsurgical Models—A Systematic Review

OBJECTIVES The purpose of this study is to (1) systematically review all the literature pertaining to microsurgical training models and to (2) determine which of these are specific to and validated for microsurgery training. DESIGN PubMed, MEDLINE (OVID/EBSCO), Google Scholar, and Cochrane Central Register of Controlled Trials were searched using preset terms. The last search date was in July 2012. Articles of all languages, years of publication, sample sizes, and model types pertaining to microsurgery were included. The eligibility criteria included the use of a microsurgical training model on a subject group with statistical analysis and measures of validation. Two assessors independently reviewed the articles and their references. RESULTS Of the 238 articles reviewed, 9 articles met the criteria. Those excluded were predominantly model descriptions that had not been validated in a set of learners. The 9 models whose performances were assessed in a group of learners included an online curriculum, nonliving prosthetics and biologics, and the live rat femoral artery model. Each model was evaluated for content, construct, face, and criterion (concurrent and predictive) validity, as well as selection and observation/expectant bias. Content, construct, concurrent, and face validities were consistently demonstrated for all 9 models. Selection bias was also reliably well controlled with random allocation of participants to each study group. Observation/expectant bias was controlled in 6 of the 8 papers. Predictive validity, an arguably more difficult factor to measure, was only present in 1 article. CONCLUSIONS Despite a plethora of papers describing microsurgical learning tools, only 9 were discovered that provided validation of the proposed method of microsurgical skills acquisition. This review depicts the need for basic, yet well-designed studies that substantiate the effectiveness of microsurgical training models by using a subject group and demonstrating a statistical improvement with employment of the model. Ease of access, cost, and assessment tools used also require attention.

Evidence-based microsurgical skills acquisition series part 2: validated assessment instruments--a systematic review.

OBJECTIVES To systematically review literature pertaining to microsurgical skill assessment tools to determine those specific to, and validated for, microsurgery training. DESIGN Multiple databases were searched with preset terms. The search dates included all years up to May 2014. The eligibility criteria included the presence of statistical comparison with a control group and the presence of a measure of validation. The articles and their references were independently reviewed by 2 assessors. Each assessment tool was evaluated for content, construct, face, and criterion validities as well observation/expectant bias and interrater/intrarater reliability. For individual studies, we screened for expectant and selection bias. RESULTS Of the 261 articles reviewed, 10 articles and 1 abstract were included. Those excluded were predominantly assessment tools that did not evaluate microsurgical skill or articles where no assessment tool was described. The assessment tools identified in this review include a self-assessment tool where trainees rate their skill confidence from 1 to 5, stereoscopic visual acuity as a predictor for microsurgical performance, an objective motion-tracking electronic device--the Imperial College of Surgical Assessment Device, and 6 global rating scales. Content, construct, and face validities were consistently demonstrated in addition to observation/expectant bias and interrater reliability. Criterion validity was only demonstrated for half of the instruments and intrarater reliability for only 1. CONCLUSIONS Overall, 10 articles and 1 abstract described validated methods. Reliability and validity were demonstrated by 6 global rating scales (University of Western Ontario microsurgical skills acquisition, structured assessment of microsurgery skills, and video-based objective structured assessment of technical skill). Motion analysis using the Imperial College of Surgical Assessment Device is a valid objective measure of skill.

Shared decision-making: applying a person-centered approach to tailored breast reconstruction information provides high satisfaction across a variety of breast reconstruction options.

A person‐centered approach to co‐decision‐making using tailored information respects each womans preferences and may heighten breast reconstruction satisfaction.

The breast reconstruction satisfaction questionnaire (BRECON‐31): An affirmative analysis

To verify the subscale structure of the BRECON‐31 using a test sample of women naïve to the questionnaire.

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model

Background: Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction. Methods: Length of stay, emergency room visits, and complications within 30 days of surgery were compared among three groups: traditional recovery after surgery, transition (some elements of enhanced recovery protocol, not transitioned to outpatient care), and enhanced recovery after surgery (day surgery, provided with standardized perioperative education and multimodal analgesia). Prospective data collection allowed quality-of-recovery assessment using a validated questionnaire for enhanced recovery/transition groups. Results were statistically analyzed (analysis of variance/chi-square). Results: The traditional recovery, transition, and enhanced recovery cohorts comprised 29, 11, and 29 patients, respectively. No significant differences were present regarding age, smoking status, preoperative radiation, single stage direct-to-implant versus tissue expander, bilateral versus unilateral surgery, or immediate versus delayed reconstruction among groups. Average length of stay was 1.6 nights in both the traditional recovery and transition groups, compared with 0 nights in the enhanced recovery group (p < 0.001). Enhanced recovery patients had less severe pain (p = 0.02) and nausea (p = 0.01), and better enjoyed their food (p = 0.0002) and felt more rested (p = 0.02) than their transition counterparts. There were no differences in the number of emergency room visits among the three groups (p = 0.88). There was no difference in the rate of hematoma (p = 0.36), infection requiring intravenous antibiotics (p = 0.36), or infection requiring explantation (p = 0.36) among the three groups. Conclusion: An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely, with improved patient satisfaction and same-day discharge and with no increase in complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Development of a breast reconstruction satisfaction questionnaire (BRECON-31): principal components analysis and clinimetric properties.

A reliable, valid questionnaire is essential to assess patient satisfaction with breast reconstruction.

Incidental Internal Mammary Nodes during Recipient Vessel Dissection in Breast Reconstruction: Are They Significant?

Summary: Internal mammary (IM) lymph nodes may be exposed during recipient vessel preparation in free-flap breast reconstruction, and in rare cases, positivity of these nodes may affect treatment in patients with breast cancer. This systematic review examines the incidence and significance of IM nodes identified by plastic surgeons. Eligibility criteria included free-flap breast reconstruction with concurrent IM node biopsy. Data were analyzed for incidence of IM node biopsy and nodal positivity. Ten studies met inclusion criteria, with a total of 2055 patients and 717 nodes submitted to pathology. Incidence of IM positivity ranged approximately from 1% to 11%, for a calculated gross overall incidence of 2.9%. Of 59 patients with a positive IM node, 50 patients received additional adjuvant therapy, with insufficient data to determine the effect of treatment on survival.

Delivering Breast Reconstruction Information to Patients: Women Report on Preferred Information Delivery Styles and Options

Purpose: To discover missed opportunities for providing information to women undergoing breast reconstruction in an effort to decrease regret and improve patient education, teaching modalities, and satisfaction. Method: Thirty- to 45-minute semi-structured interviews were conducted exploring patient experiences with information provision on breast reconstruction. Purposeful sampling was used to include women with a variety of reconstruction types at different time points along their recovery. Using grounded theory methodology, 2 independent reviewers analyzed the transcripts and generated thematic codes based on patient responses. BREAST-Q scores were also collected to compare satisfaction scores with qualitative responses. Results: Patients were interested in a wide variety of topics related to breast reconstruction including the pros and cons of different options, nipple-sparing mastectomies, immediate breast reconstruction, oncological safety/monitoring and the impact of chemotherapy and radiotherapy, secondary procedures (balancing, nipple reconstruction), post-operative recovery, and long-term expectations. Patients valued accessing information from multiple sources, seeing numerous photographs, being guided to reliable information online, and having access to a frequently asked questions file or document. Information delivery via interaction with medical personnel and previously reconstructed patients was most appreciated. Compared with BREAST-Q scores for satisfaction with the plastic surgeon (mean: 95.7, range: 60-100), informational satisfaction scores were lower at 74.7 (50-100), confirming the informational gaps expressed by interviewees. Conclusions: Women having recently undergone breast reconstruction reported key deficiencies in information provided prior to surgery and identified preferred information delivery options. Addressing women’s educational needs is important to achieve appropriate expectations and improve satisfaction.

Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care

Purpose: The purpose of this study was to examine the perceived satisfaction and barriers to care for transgender patients after they decide to undergo gender-affirming surgery (GAS). Method: A survey consisting of 21 multiple-choice and short-answer questions was distributed to transgender organizations and online forums across Canada and the United States. The data were then analyzed using descriptive statistics. Results: There were 32 participants, 12 who identified as female to male and 20 as male to female. The mean age was 36 years, with a range of 18 to 81 years. The mean age of their first GAS was 33 years, and the range of wait time was 6 months to 7 years. Most of the participants received information about GAS from transgender websites and transgender surgery clinics (91% and 50%, respectively). Most participants (74%) felt like they had access to appropriate care and 89% felt like their surgeons provided enough information about GAS. There were 38% of participants who would change their experience with GAS. Participants stated several barriers toward receiving GAS: financial (73%), finding a physician (65%), and access to information (63%). Surgical transition was important to the quality of life for 91% of participants and 100% were happy with their decision to undergo GAS. Conclusions: Transgender participants demonstrated that GAS is important to their quality of life and this study showed significant barriers to GAS.