Mastectomies prophylactiques épargnant le complexe aréolo-mamelonnaire: sécurité oncologique, satisfaction des patientes et résultats esthétiques

Résumé Introduction L’efficacité de la mastectomie prophylactique est bien démontrée. La mastectomie NSM (nipple-sparing mastectomy) peut potentiellement améliorer les résultats esthétiques, mais elle n’est pas pratiquée d’emblée en raison de doutes face à sa sécurité oncologique. Objectif Évaluer la faisabilité et la sécurité oncologique de la NSM dans un contexte prophylactique ainsi que les résultats esthétiques et la satisfaction des patientes. Méthodologie Une étude rétrospective fut conduite chez toutes les femmes ayant subi une mastectomie prophylactique suivie d’une reconstruction mammaire immédiate au centre hospitalier de l’Université de Montréal (CHUM) entre1997 et 2008. Les données concernant les facteurs de risque de cancer, les complications post-opératoires et les incidences de cancer furent notées. La satisfaction des patientes était évaluée par questionnaire. Deux chirurgiens ont évalué les résultats esthétiques sur des photos. Résultats Soixante et onze patientes ont subi 86 mastectomies prophylactiques, dont 21 NSM et 65 SSM (skin-sparing mastectomy). Suivant une SSM, 34 CAM (complexe aréolo- mamelonaire) furent reconstruits. Une nécrose totale s’est produite dans 2 CAM préservés et dans 2 CAM reconstruits. Le taux général de complications était significativement plus élevé parmi les CAM reconstruits. La satisfaction des patientes quant à l’apparence du CAM était significativement plus élevée dans le groupe NSM et les résultats esthétiques, meilleurs. Avec un temps de suivi moyen de 50 mois, aucune incidence au niveau du CAM n’est survenue. i Conclusion Les NSM offrent de meilleures résultats, n’augmentent pas les complications post- opératoire et semblent sécuritaires au plan oncologique.

What is the new medicines use review ‘patient survey’ attempting to capture in the context of existing patient satisfaction with pharmacy questionnaires and a new conceptual framework?

The community pharmacy service medicines use review (MUR) was introduced in 2005 ‘to improve patient knowledge, concordance and use of medicines’ through a private patient–pharmacist consultation. The MUR presents a fundamental change in community pharmacy service provision. While traditionally pharmacists are dispensers of medicines and providers of medicines advice, and patients as recipients, the MUR considers pharmacists providing consultation-type activities and patients as active participants. The MUR facilitates a two-way discussion about medicines use. Traditional patient–pharmacist behaviours transform into a new set of behaviours involving the booking of appointments, consultation processes and form completion, and the physical environment of the patient–pharmacist interaction moves from the traditional setting of the dispensary and medicines counter to a private consultation room. Thus, the new service challenges traditional identities and behaviours of the patient and the pharmacist as well as the environment in which the interaction takes place. In 2008, the UK government concluded there is at present too much emphasis on the quantity of MURs rather than on their quality.[1] A number of plans to remedy the perceived imbalance included a suggestion to reward ‘health outcomes’ achieved, with calls for a more focussed and scientific approach to the evaluation of pharmacy services using outcomes research. Specifically, the UK government set out the main principal research areas for the evaluation of pharmacy services to include ‘patient and public perceptions and satisfaction’as well as ‘impact on care and outcomes’. A limited number of ‘patient satisfaction with pharmacy services’ type questionnaires are available, of varying quality, measuring dimensions relating to pharmacists’ technical competence, behavioural impressions and general satisfaction. For example, an often cited paper by Larson[2] uses two factors to measure satisfaction, namely ‘friendly explanation’ and ‘managing therapy’; the factors are highly interrelated and the questions somewhat awkwardly phrased, but more importantly, we believe the questionnaire excludes some specific domains unique to the MUR. By conducting patient interviews with recent MUR recipients, we have been working to identify relevant concepts and develop a conceptual framework to inform item development for a Patient Reported Outcome Measure questionnaire bespoke to the MUR. We note with interest the recent launch of a multidisciplinary audit template by the Royal Pharmaceutical Society of Great Britain (RPSGB) in an attempt to review the effectiveness of MURs and improve their quality.[3] This template includes an MUR ‘patient survey’. We will discuss this ‘patient survey’ in light of our work and existing patient satisfaction with pharmacy questionnaires, outlining a new conceptual framework as a basis for measuring patient satisfaction with the MUR. Ethical approval for the study was obtained from the NHS Surrey Research Ethics Committee on 2 June 2008. References 1. Department of Health (2008). Pharmacy in England: Building on Strengths – Delivering the Future. London: HMSO. www. official-documents.gov.uk/document/cm73/7341/7341.pdf (accessed 29 September 2009). 2. Larson LN et al. Patient satisfaction with pharmaceutical care: update of a validated instrument. JAmPharmAssoc 2002; 42: 44–50. 3. Royal Pharmaceutical Society of Great Britain (2009). Pharmacy Medicines Use Review – Patient Audit. London: RPSGB. http:// qi4pd.org.uk/index.php/Medicines-Use-Review-Patient-Audit. html (accessed 29 September 2009).

A conceptual framework of patient satisfaction with a pharmacy adherence service

Background Patients do not adhere to their medicines for a host of reasons which can include their underlying beliefs as well as the quality of their interactions with healthcare professionals. One way of measuring the outcome of pharmacy adherence services is to assess patient satisfaction but no questionnaire exists that truly captures patients' experiences with these relatively new services. Objective Our objective was to develop a conceptual framework specific to patient satisfaction with a community pharmacy adherence service based on criteria used by patients themselves. Setting The study was based in community pharmacies in one large geographical area of the UK (Surrey). All the work was conducted between October 2008 and September 2010. Methods This study involved qualitative non-participant observation and semi-structured interviewing. We observed the recruitment of patients to the Medicines Use Review (MUR) service and also actual MUR consultations (7). We also interviewed patients (15). Data collection continued until no new themes were identified during analysis. We analysed interviews to firstly create a comprehensive account of themes which had significance within the transcripts, then created sub-themes within super-ordinate categories. We used a structure-process-outcome approach to develop a conceptual framework relating to patient satisfaction with the MUR. Favourable ethical opinion for this study was received from the NHS Surrey Research Ethics Committee on 2nd June 2008. Results Five super-ordinate themes linked to patient satisfaction with the MUR service were identified, including relationships with healthcare providers; attitudes towards healthcare providers; patients' experience of health, healthcare and medicines; patients' views of the MUR service; the logistics of the MUR service. In the conceptual framework, structure was conceptualised as existing relationships, environment, and time; process was conceptualised as related to recruitment and consultation stages; and outcome as two concepts of immediate patient outcomes and satisfaction on reflection. Conclusion We identified and highlighted factors that can influence patient satisfaction with the MUR service and this led to the development of a conceptual framework of patient satisfaction with the MUR service. This can form the basis for developing a questionnaire for measuring patient satisfaction with this and similar pharmacy adherence services. Impact of findings on practice * Pharmacists and researchers can access the relevant ideas presented here in relation to patient satisfaction with pharmacy adherence services. * Researcher can use the conceptual framework as a basis for measuring the quality of pharmacy adherence services. * Community pharmacists can improve the quality of healthcare they provide by realizing concepts relevant to patient satisfaction with adherence services.

Why cancer patients choose in-patient complementary therapy in palliative care: a qualitative study at Arokhayasala Hospice in Thailand

Cancer patients often choose complementary and alternative medicine (CAM) in palliative care, often in addition to conventional treatment and without medical advice or approval. Herbal medicines (HM) are the most commonly used type of CAM, but rarely available on an in-patient basis for palliative care. The motivations which lead very ill patients to travel far to receive such therapies are not clear. A qualitative study was therefore carried out to investigate influences on choosing to attend a CAM herbal hospice, to identify cancer patients’ main concerns about end-of-life care. Semi-structured interviews with 32 patients were conducted and analysed using thematic analysis. Patients were recruited from Arokhayasala, a Buddhist cancer hospice in Thailand which provides CAM, in the form of HM, a restricted diet, Thai yoga, deep-breathing exercises, meditation, chanting, Dhamma, laughter and music therapy, free-of-charge. The main factors influencing decision-making were a positive attitude towards HMs and previous use of them, dissatisfaction with conventional treatment, the home environment and their relationships with hospital doctors. Patients’ own perceptions and experiences were more important in making the decision to use CAM, and especially HM, in palliative cancer care than referral by healthcare professionals or scientific evidence of efficacy. Patients were prepared to travel far and live away from home to receive such care, especially as it was cost-free. In view of patients’ previously stated satisfaction with the regime at the Arokhayasala, these findings may be relevant to the provision of in-patient cancer palliative care to other patients.

The most severe parkinsonian patients are most improved with duodenal levodopa infusion

Objectives:To find variables correlated to improvement with intraduodenal levodopa/carbidopa infusion (Duodopa) in order to identify potential candidates for this treatment. Two clinical studies comparing Duodopa with oral treatments in patients with advanced Parkinson’s disease have shown significant improvement in percent on-time on a global treatment response scale (TRS) based on hourly and half-hourly clinical ratings and in median UPDRS scores.Methods:Data from study 1 comparing infusion with Sinemet CR (12 patients, Nyholm et al, Clin Neuropharmacol 2003; 26(3): 156-163) and study 2 comparing infusion with individually optimised conventional combination therapies (18 patients, Nyholm et al, Neurology, in press) were used. Measures of severity were defined as total UPDRS score and scores for sections II and III, percent functional on-time and mean squared error of ratings on the TRS and as mean of diary questions about mobility and satisfaction (only study 2). Absolute improvement was defined as difference in severity, and relative improvement was defined as percent absolute improvement/severity on oral treatment. Pearson correlation coefficients between measures of improvement and other variables were calculated.Results:Correlations (r2>0.28, p<0.05) between severity during oral treatment and absolute improvement on infusion were found for: Total UPDRS, UPDRS III and TRS ratings (studies 1 and 2) and for diary question 1 (mobility) and UPDRS II (study 2). Correlation to relative improvement was found for total UPDRS (study 2, r2=0.47). Figure 1 illustrates absolute improvement in total UPDRS vs. total UPDRS during oral treatment (study 2).Conclusion:Correlating different measures of severity and improvement revealed that patients with more severe symptoms were most improved and that the relation between severity and improvement was linear within the studied groups. The result, which was reproducible between two clinical studies, could be useful when deciding candidates for the treatment.

Patient satisfaction with maxillofacial prosthesis. Literature review

Obturators and facial prostheses are important not only in rehabilitation and aesthetics, but also in patient re-socialisation. The level of reintegration is directly related to the degree of satisfaction with rehabilitation. So, the maxillofacial prosthetics must provide patient satisfaction during treatment. This study aimed to search information in database and conduct a literature review on patient satisfaction with maxillofacial prosthesis. The problems experienced by these patients may decrease when specialists keep the patient on regular inspection. Rehabilitation through alloplasty or prosthetic restoration provides satisfactory conditions in aesthetics and well-being and reinstates individuals in familial and social environment. (C) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Quality of life and stimulus perception in patients' rehabilitated with complete denture

The objective of this study was to evaluate and correlate quality of life (QoL), and stimulus perception of complete denture users, before and after the insertion of new prostheses. We selected 60 patients using bimaxillary complete conventional dentures who needed to replace their prostheses. During anamnesis, we collected demographic data and applied the Oral Health Impact Profile for Edentulous Patients (OHIP-EDENT) questionnaire and stimulus perception questionnaire (PERCEPTION). Before installation of new prostheses, the patients responded to OHIP-EDENT questionnaire, and on the day of installation, they responded to PERCEPTION questionnaire. At the patients 3-month follow-up, we re-administered the OHIP-EDENT and PERCEPTION questionnaires. The Wilcoxon and MacNemar tests were used to compare patient responses between the time points analysed. Most of the OHIP-EDENT items showed a highly significant impact of the new prostheses on oral health (P = 0.003). The PERCEPTION questionnaire data indicated that the patients experienced significant improvements (P < 0.05) in terms of their sensations with the new prostheses. Cross-lagged data analysis did not show any causality between the OHIP-EDENT and PERCEPTION questionnaires (ZPF test, P = 0.772). We concluded that the treatment was effective with respect to the patients QoL and their adaptation to the new prostheses.

A comparison of patient satisfaction between treatment with conventional complete dentures and overdentures in the elderly: a literature review

Background:It has been stated that mandibular overdentures are more satisfactory than conventional dentures, but problems relating to the use of retrospective ratings, lack of control group and sequential provision of treatment may compromise the findings.Objective:To establish a comparison between treatment with conventional complete dentures and implant-retained overdentures in elderly patients by conducting a literature review.Materials and methods:A search of English language peer-review literature was completed using Medline up to 2008 focusing on evidence-based research. Randomised clinical trials (RCTs) and longitudinal prospective studies were favoured in the review, using a general hierarchical classification. Articles that did not focus exclusively on the comparison of patient satisfaction between complete dentures and overdentures were excluded from further evaluation. The last search was conducted in February 2008. Key terms included quality of life, patient satisfaction, edentulism, complete denture and overdenture.Results:Among the 90 articles found in the initial search, 27 met the inclusion criteria. This included 18 RCTs and eight prospective and one cohort study. Most of the articles stated superiority of the mandibular implant-retained overdenture therapy over the conventional complete denture regarding patient satisfaction and quality of life.Conclusion:Even with implant treatment presenting higher patient satisfaction and improvement of quality of life, it was not possible to establish a direct comparison between the studies due to differences in adopted methodologies.

Quality of life (QoL) in relation to disease severity in Brazilian Parkinson's patients as measured using the WHOQOL-BREF

This study aimed at evaluating and describing the QoL and its association with the severity of disease among Brazilian Parkinson's disease (PD) patients. In this cross-sectional study 68 PD patients were interviewed using the World Health Organization Quality of Life instrument Short Form (WHOQOL-BREF) and the Hoehn-Yahr (HY) scale. Analysis of variance, chi(2), Kruskal-Wallis and Mann-Whitney U-tests, Spearman and Cronbach reliability coefficients were used to analyze the data. The results indicate: (1) physical capacity was the domain that showed the most deterioration; (2) severity of PD is associated with QoL measured by WHOQOL-BREF; (3) overall QoL, working capacity, activities of daily living (ADL) and self-esteem are affected in both transitional periods in the progression of PD (mild to moderate and moderate to advanced). Satisfaction with general health, pain, energy, positive feelings, personal relationship and satisfaction with home are affected in the first period of transition while mobility, body image, sexual activity and access to information are affected in the second. This study mainly shows specific facets that are affected depending on the specific periods of PD progression, which can help to understand the impact of the disease, the effectiveness of care, and the demand for health care resources. (C) 2007 Elsevier B.V. All rights reserved.

Patients' Expectations Before and Evaluation After Dental Implant Therapy

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Communication that values patient autonomy is associated with satisfaction with care: a systematic review

Question: Which communication factors used by clinicians during patient-clinician interactions are associated with satisfaction with care? Design: Systematic review with meta-analysis of studies investigating the association of verbal or nonverbal factors or interaction styles used by clinicians with patient satisfaction during an encounter between clinician and patient. Participants: Clinicians interacting with patients in primary care or rehabilitation settings. Results: Twenty-seven studies investigated 129 verbal, nonverbal, and interaction style factors. of these, 38 factors were consistently associated with satisfaction. Verbal factors concerning clinicians involving, facilitating, and supporting patients were associated with satisfaction with care. Most communication factors presented a fair correlation (r >= 0.21 but < 0.41) with satisfaction with care. Nonverbal factors such as time spent discussing prevention and time spent reading patient charts had a fair association with satisfaction with care (correlations range from 0.21 to 0.40). A moderate association was found between interaction styles such as caring (pooled r = 0.51, 95% CI 0.42 to 0.60) and satisfaction with care. Over half (58%) of the 129 identified factors never associated with satisfaction with care and the remainder associated inconsistently. Conclusion: The number of potential modifiable communication factors associated with satisfaction with care and the magnitude of their association partially support interventions to train clinicians in communication skills that value patient autonomy. [Oliveira VC, Refshauge KM, Ferreira ML, Pinto RZ, Beckenkamp PR, Negrao Filho RF, Ferreira PH (2012) Communication that values patient autonomy is associated with satisfaction with care: a systematic review. Journal of Physiotherapy 58: 215-229]

Psychological evaluation of patients scheduled for orthognathic surgery.

Using a questionnaire, 41 patients scheduled for orthognathic surgery were evaluated pre- and postoperatively to determine some of their psychological characteristics and treatment outcome from the patient's standpoint. Among other conclusions, the results showed that some patients may not fully understand the details of their deformity, despite a full explanation by the orthodontist and surgeon. Expectations regarding treatment outcome may be unrealistic even in patients with valid self-motivation for surgery. Social adjustment usually improves after treatment. Functional changes were noticed by over 80% of the patients and esthetic changes in over 90%.

Evaluation of temporomandibular joint noise in partially edentulous patients.

In order to evaluate the presence of TMD (temporomandibular disorder), dissatisfaction related to the use of removable partial dentures (RPD) and the effect of the treatment on temporomandibular joint noises, 13 female patients with Kennedy class I and II mandibular arch were selected. Another 13 young, asymptomatic, dentate patients, also female, were used as reference. After four years, 38.4% were found to have a moderate or severe degree of TMD. Over the four years, the degree of TMD increased in 46.15% of the patients, was not affected in 20.07%, while in 15.38% it decreased or the patients remained free from signs and symptoms. About 30% of the patients at the second year and 46% after the fourth year, had complaints regarding retention and stability. It was concluded that there is no relationship between TMD and the condition of partially edentulous Kennedy class I and II, but patient dissatisfaction increased after the second year and temporomandibular joint noise was reduced significantly with the replacement of the teeth.

Oral health-related quality of life and satisfaction before and after treatment with complete dentures in a Dental School in Brazil

Purpose: The aim of this study was to evaluate the impact of treatment with new complete dentures on oral health-related quality of life and satisfaction of edentulous patients attending the Prosthodontic Department in a Dental School in Brazil. Methods: A total of 70 edentulous subjects (37-86 years) treated by undergradute students at the Araçatuba Dental School, University of State of São Paulo, were accessed. A specific questionnaire for edentulous patients (EDENT) based on the Oral Health Impact Profile (OHIP-EDENT) was applied to collect information on patient oral health-related quality of life. Questions related to the personal satisfaction of the edentulous patients with their complete dentures were also included. The patients were accessed before the treatment, and 3 months after receiving the new dentures. Results: After rehabilitation with new complete dentures, all domains of OHIP-EDENT showed significant improvements. There was also a significant improvement in patient satisfaction after placement of new complete dentures. Furthermore, it was possible to observe association between upper denture satisfaction and age. Conclusion: Conventional complete dentures may have a positive impact on oral health-related quality of life and satisfaction of edentulous patients. © 2012 Japan Prosthodontic Society.

Correlation of previous experience, patient expectation and the number of post-delivery adjustments of complete dentures with patient satisfaction in a Brazilian population

A number of variables may influence the outcome of complete denture therapy. The objective of this study was to verify possible correlations between previous experience with dentures, patient expectation and the number of post-delivery adjustments with patient satisfaction after treatment. One hundred patients (mean age 61·9 ± 10·3) rated their previous experiences with complete dentures and their expectations before and satisfaction after treatment on a visual analogue scale (VAS) using scores from 0 (worst results) to 10 (best results). The number of post-delivery adjustments and other patient-related clinical variables was also noted. Patient expectation scores were higher than previous experience scores and satisfaction after treatment scores. Positive and weak correlations were found between previous chewing experiences with complete dentures, with regard to chewing expectations and comfort of use. Phonetics and comfort of use in previous experiences presented a positive correlation with expectations for chewing, aesthetics, phonetics and comfort of use. Groups of patients with different levels of education presented significant differences in expectation scores regarding comfort of use as well. A negative and weak correlation was found between phonetics satisfaction and the number of post-delivery adjustments. Patients' expectations for the therapy were higher than their satisfaction after treatment. Previous experiences with complete dentures could slightly influence patients' expectations and satisfaction, whereas lower scores for previous experience with complete dentures caused lower scores for both expectation and satisfaction. Patients' educational levels and the number of post-delivery adjustments influenced negatively the expectations about comfort of use and patient satisfaction, respectively. © 2013 John Wiley & Sons Ltd.