Lily R. Mundy

The BREAST-Q in surgical research: A review of the literature 2009–2015

BACKGROUND Health outcomes research has gained considerable traction over the past decade as the medical community attempts to move beyond traditional outcome measures such as morbidity and mortality. Since its inception in 2009, the BREAST-Q has provided meaningful and reliable information regarding health-related quality of life (HRQOL) and patient satisfaction for use in both clinical practice and research. In this study, we review how researchers have used the BREAST-Q and how it has enhanced our understanding and practice of plastic and reconstructive breast surgery. METHODS An electronic literature review was performed to identify publications that used the BREAST-Q to assess patient outcomes. Studies developing and/or validating the BREAST-Q or an alternate patient-reported outcome measure (PROM), review papers, conference abstracts, discussions, comments and/or responses to previously published papers, studies that modified a version of BREAST-Q, and studies not published in English were excluded. RESULTS Our literature review yielded 214 unique articles, 49 of which met our inclusion criteria. Important trends and highlights were further examined. DISCUSSION The BREAST-Q has provided important insights into breast surgery highlighted by literature concerning autologous reconstruction, implant type, fat grafting, and patient education. The BREAST-Q has increased the use of PROMs in breast surgery and provided numerous important insights in its brief existence. The increased interest in PROMs as well as the underutilized potential of the BREAST-Q should permit its continued use and ability to foster innovations and improve quality of care.

Contemporary Outcomes of Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock at a Large Tertiary Care Center.

Refractory cardiogenic shock (RCS) is associated with significant morbidity and mortality, and current mainstays of medical therapy appear inadequate. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) represents an increasingly accepted therapy for RCS. Demographics, past medical history, preoperative characteristics, outcomes, and adverse events were collected for consecutive patients who received VA-ECMO support for RCS at our institution from March 2007 to December 2013. One hundred and seventy-nine patients with a mean age of 56.9 ± 16.1 years were included. Etiologies of RCS included postcardiotomy shock in 70 patients (39%), acute myocardial infarction in 46 patients (26%), primary graft failure in 17 patients (10%), and acute decompensated heart failure in 24 patients (13%). Mean arterial pressure before VA-ECMO support was 59.4 ± 22.8 mm Hg and 30.7% (n = 55) were undergoing active cardiopulmonary resuscitation at the time of cannulation. Overall, 38.6% of patients (n = 69) survived to discharge and 44.7% of patients (n = 80) survived to 30 days. Myocardial recovery was achieved in 79.7% of survivors (n = 55) and 39.1% were transitioned to a more durable device. Univariate analysis identified age (p = 0.002) and etiology of RCS (p = 0.041) as the most significant predictors of in-hospital mortality. Venoarterial extracorporeal membrane oxygenation for RCS appears successful as salvage therapy. Age and etiology should be considered when evaluating patients for VA-ECMO.

Important role of mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock

OBJECTIVES Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) remains associated with significant mortality despite the widespread application of early revascularization strategies. Recent evidence suggests that the use of intra-aortic balloon pump (IABP) counterpulsation does not improve mortality in this cohort of patients. We summarize our experience with mechanical circulatory support (MCS) therapy for AMI/CS. METHODS This is a retrospective review of 61 patients who received MCS therapy for AMI/CS at our institution between March 2007 and March 2013. RESULTS Mean age was 60.2 ± 10.3 years; mean ejection fraction was 24 ± 15% and 29% of patients were receiving active cardiopulmonary resuscitation at the time of support initiation. Prior to the initiation of MCS, 70.5% of patients had an IABP. Mean arterial pressure improved significantly with MCS (63 mmHg prior to MCS, 82 mmHg after MCS, P ≤ 0.01). Mean length of support was 9.5 ± 11.0 days, and overall survival to 30 days was 59.0%. Among 30-day survivors, 44.4% required device exchange to a durable MCS device. Ultimately, only 31% (52.8% of patients who survived to 30 days) achieved myocardial recovery. CONCLUSIONS Short-term MCS therapy with subsequent aggressive use of durable MCS device may improve the unacceptably high mortality rate in AMI/CS. Rigorous prospective studies of MCS therapy in AMI/CS are warranted.

Breast Cancer and Reconstruction: Normative Data for Interpreting the Breast-q

Background: The BREAST-Q is a patient-reported outcome instrument used to evaluate outcomes in patients undergoing breast cancer surgery and reconstruction. Normative values for the BREAST-Q breast cancer modules have not been established, limiting data interpretation. Methods: Participants were recruited by means of the Army of Women, an online community of women (with and without breast cancer), to complete Mastectomy, Breast Conserving Therapy, and Reconstruction preoperative BREAST-Q scales. Inclusion criteria were women aged 18 years or older without a history of breast surgery or breast cancer. Analysis included descriptive statistics, a linear multivariate regression, and a comparison of the generated normative data to previously published BREAST-Q findings. Results: The BREAST-Q was completed by 1201 women. The mean patient age was 54 ± 13 years, mean body mass index 26 ± 6 kg/m2, and 38 percent (n = 455) had a bra cup size of D or greater. Mean ± SD scores for BREAST-Q scales were as follows: Satisfaction with Breasts (58 ± 18), Psychosocial Well-being (71 ± 18), Sexual Well-being (56 ± 18), Physical Well-being-Chest (93 ± 11), and Physical Well-being Abdomen (78 ± 20). Women with a body mass index of 30 kg/m2 or greater, cup size of D or greater, age younger than 40 years, and annual income less than

Optimizing Successful Outcomes in Complex Spine Reconstruction Using Local Muscle Flaps.

40,000 reported lower scores. Comparing normative scores to published data in breast cancer patients, Satisfaction with Breasts scores were higher after autologous reconstruction and lower after mastectomy; Sexual Well-being scores were lower after mastectomy and breast conserving therapy; and Physical Well-being Chest scores were lower after mastectomy, breast conserving therapy, and reconstruction. Conclusion: These are the first published normative scores for the BREAST-Q breast cancer modules and provide a clinical reference point for the interpretation of data.

Patient-Reported Outcome Instruments for Surgical and Traumatic Scars: A Systematic Review of their Development, Content, and Psychometric Validation

Background: Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. The literature shows that wound complication rates in this patient population approach 19 percent and, in very high-risk patients (i.e., prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or history of radiation therapy), as high as 40 percent and with reoperation rates as high as 12 percent. The authors investigated whether prophylactic closure of spinal wounds with muscle flaps improves outcomes. Methods: A retrospective review was performed of 102 reconstructions (in 96 patients) in which spinal wound closure was performed by means of paraspinous, trapezius, or latissimus muscle advancement flaps by a single plastic surgeon (J.A.S.) from 2006 to 2014. Data regarding presurgical diagnosis, patient demographics, and incidence of postoperative complications were recorded. Results: One hundred two reconstructions were included, with follow-up ranging from 2 to 60 months. Eighty-eight reconstructions were classified as very high-risk for wound complications, defined as those having prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or prior radiation therapy. Within the very high-risk group, there were six wound complications (6.8 percent), three of which (3.4 percent) required reoperation. Conclusions: In this study, there is a markedly lower rate (6.8 percent) of postoperative wound complications compared with historical controls after closure of spinal wounds with local muscle flaps in very high-risk patients. These data encourage safe and routine use of muscle flaps for closure in this cohort of patients undergoing spinal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Preoperative Platelet Count Predicts Lower Extremity Free Flap Thrombosis: A Multi-Institutional Experience.

BackgroundPatient-reported outcomes (PROs) are of growing importance in research and clinical care and may be used as primary outcomes or as compliments to traditional surgical outcomes. In assessing the impact of surgical and traumatic scars, PROs are often the most meaningful. To assess outcomes from the patient perspective, rigorously developed and validated PRO instruments are essential.MethodsThe authors conducted a systematic literature review to identify PRO instruments developed and/or validated for patients with surgical and/or non-burn traumatic scars. Identified instruments were assessed for content, development process, and validation under recommended guidelines for PRO instrument development.ResultsThe systematic review identified 6534 articles. After review, we identified four PRO instruments meeting inclusion criteria: patient and observer scar assessment scale (POSAS), bock quality of life questionnaire for patients with keloid and hypertrophic scarring (Bock), patient scar assessment questionnaire (PSAQ), and patient-reported impact of scars measure (PRISM). Common concepts measured were symptoms and psychosocial well-being. Only PSAQ had a dedicated appearance domain. Qualitative data were used to inform content for the PSAQ and PRISM, and a modern psychometric approach (Rasch Measurement Theory) was used to develop PRISM and to test POSAS. Overall, PRISM demonstrated the most rigorous design and validation process, however, was limited by the lack of a dedicated appearance domain.ConclusionsPRO instruments to evaluate outcomes in scars exist but vary in terms of concepts measured and psychometric soundness. This review discusses the strengths and weaknesses of existing instruments, highlighting the need for future scar-focused PRO instrument development.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Acute Treatment Patterns for Lower Extremity Trauma in the United States: Flaps versus Amputation

Background: Thrombocytosis in patients undergoing lower extremity free tissue transfer may be associated with increased risk of microvascular complications. This study assessed whether preoperative platelet counts predict lower extremity free flap thrombosis. Methods: All patients undergoing lower extremity free tissue transfer at Duke University from 1997 to 2013 and at the University of Pennsylvania from 2002 to 2013 were retrospectively identified. Logistic regression was used to assess whether preoperative platelet counts independently predict flap thrombosis, controlling for baseline and operative factors. Results: A total of 565 patients underwent lower extremity free tissue transfer, with an overall flap thrombosis rate of 16 percent (n = 91). Elevated preoperative platelet counts were independently associated with both intraoperative thrombosis (500 ± 120 versus 316 ± 144 × 109/liter; p < 0.001) and postoperative thrombosis (410 ± 183 versus 320 ± 143 × 109/liter; p = 0.040) in 215 patients who sustained acute lower extremity trauma within 30 days before reconstruction. In acute trauma patients, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 403 × 109/liter; OR, 4.08; p < 0.001) and a two-fold increased risk of postoperative thrombosis (cutoff value, 361 × 109/liter; OR, 2.16; p = 0.005). In patients who did not sustain acute trauma, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 352 × 109/liter; OR, 3.82; p = 0.002). Conclusions: Acute trauma patients with elevated preoperative platelet counts are at increased risk for lower extremity free flap complications. Prospective evaluation is warranted for guiding risk stratification and targeted treatment strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Abstract 25: Normative Values for the BREAST-Q

Background Treatment algorithms for large soft tissue defects in lower extremity trauma are not clearly defined. The aim of this study is to determine if there are geographic or demographic differences in the management of open tibia fractures with soft tissue defects requiring either soft tissue reconstruction or amputation in the United States (US). Methods A retrospective analysis was performed on the Nationwide Inpatient Sample (NIS), 2000 to 2011. We evaluated flap and amputation rates in the open tibia fractures with soft tissue defects based on geographic and socioeconomic factors. Results From 2000 to 2011, there were 175,283 open tibia fractures in the US; 7.2% (n = 12,620) had a concomitant soft tissue defect requiring either flap or amputation. The overall flap rate was 73.2% (n = 9,235). When compared with the South at 68%, flap rates were highest in the West at 79% (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI] = 1.49, 2.86; p < 0.0001), followed by the Northeast at 77% (AOR = 1.63; 95% CI = 1.22, 2.19; p = 0.001), and the Midwest at 74% (AOR = 1.76; 95% CI = 1.25, 2.47; p = 0.001). Flap rates were lower in the rural hospitals in the West (AOR = 0.24; 95% CI = 0.07, 0.84; p = 0.03) and Northeast (AOR = 0.55; 95% CI = 0.37, 0.82; p = 0.003) when compared with the urban hospitals. Flap rates were highest in the highest income quartile at 77% (AOR = 1.53; 95% CI = 1.05, 2.25; p = 0.03) compared with 72% in the lowest income quartile. Conclusions Reconstruction rates were significantly higher in three major US regions when compared with the South, urban hospitals in the West and Northeast, and the highest income quartile.

Normative Data for Interpreting the BREAST-Q: Augmentation

PURPOSE: Non-syndromic sagittal and/or metopic craniosynostosis, occurring once in every 4,000 live births, accounts for half of all craniosynostosis cases. Despite success in identifying the genes underlying rare syndromic craniosynostoses, mutations in these genes are very rarely found in their non-syndromic counterparts. We considered that the often sporadic occurrence of non-syndromic craniosynostosis might frequently be attributable to de novo mutation or incomplete penetrance of rare transmitted variants.