articles+ search results

aromatherapy, essential oil, scar quality, skin care, split-thickness skin graft donor site, Medicine (General), and R5-920

Background and Objectives: Essential oils are a complementary treatment and can play an important role in scar care. The aim of this study was to evaluate and compare the efficacy of a new essential oil (regeneration oil) with a control group on scar quality in healed split-thickness skin graft donor sites. Materials and Methods: A single-center blinded randomized controlled study was performed on 30 patients with healed split-thickness skin graft donor site. The patients were randomly allocated into blended regeneration oil (n = 14) and pure almond oil (n = 16) groups. Application of the assigned oil occurred twice a day for 6 months. Scarring (Patient and Observer Scar Assessment Scale), itching (ITCH Assessment Scale) and scar discoloration (colorimetry) of the donor sites were assessed after 1, 3 and 6 months. Results: We found no statistically significant differences between the groups in any applied parameter. We observed comparable outcomes (scar quality, itchiness, colorit) in healed split-thickness skin graft donor sites for both oils. Conclusions: Regeneration oil and control oil presented comparable results regarding scar quality, itchiness and colorit in healed split-thickness skin graft donor sites after 6 months of application. Both oils are suitable for skin/scar care in split-thickness skin graft donor sites.

History of scholarship and learning. The humanities, AZ20-999, and Social Sciences

Abstract In 2020, the COVID-19 pandemic impacted global life and transitioned economies and societal perceptions of life as we knew it. Professional and social life mostly ground to a nadir during the first lockdown in Europe in March. As a consequence, measures aimed at preventing the spread of the virus were established in medical facilities also and elective plastic surgery procedures were temporarily suspended in our clinic and others. A majority of the population, including those potentially contemplating plastic surgery procedures, spent most of their time at home with ample time available to research information about surgical procedures and other topics online. This investigation analyzes the relevance of plastic surgery during the pandemic on the basis of online search behavior patterns. Online traffic data from the online platform http://www.mooci.org were extracted using Google Analytics over a period of 6 months. The parameters analyzed were: pageviews, session duration, and bounce rate. Additionally, differentiation by areas of interest has been obtained. The data were compared and analyzed before and after the beginning of the first hard lockdown in Austria, Germany, and Switzerland. There were no significant differences in regard to pageviews and session duration when comparing time points before and after the beginning of the hard lockdown. The bounce rate exhibited a significant decrease after the beginning of the lockdown, implying a more conscious search for information and greater absorption and retention. There was no difference that could conclusively be attributed to the pandemic in terms of specific areas of interest researched. Society’s demand for information about plastic-surgical procedures continues to be steadily prevalent—despite, or even in particular, during a global pandemic. Providing reliable and readily available information about plastic surgery procedures is an important component of a functioning doctor–patient relationship and informed consent. This information may reflect society’s increased interest in plastic surgery during the pandemic, or be simply reflective of more spare time at hand to allow for such research. Further studies should investigate the relevance of elective procedures over the entire course of the pandemic.

Computer applications to medicine. Medical informatics and R858-859.7

Objective In contrast to the rising amount of financial investments for research and development in medical technology worldwide is the lack of usability and clinical readiness of the produced systems. We evaluated an augmented reality (AR) setup under development for preoperative perforator vessel mapping for elective autologous breast reconstruction. Methods In this grant-supported research pilot, we used magnetic resonance angiography data (MR-A) of the trunk to superimpose the scans on the corresponding patients with hands-free AR goggles to identify regions-of-interest for surgical planning. Perforator location was assessed using MR-A imaging (MR-A projection) and Doppler ultrasound data (3D distance) and confirmed intraoperatively in all cases. We evaluated usability (System Usability Scale, SUS), data transfer load and documented personnel hours for software development, correlation of image data, as well as processing duration to clinical readiness (time from MR-A to AR projections per scan). Results All perforator locations were confirmed intraoperatively, and we found a strong correlation between MR-A projection and 3D distance measurements (Spearman r = 0.894). The overall usability (SUS) was 67 ± 10 (=moderate to good). The presented setup for AR projections took 173 min to clinical readiness (=availability on AR device per patient). Conclusion In this pilot, we calculated development investments based on project-approved grant-funded personnel hours with a moderate to good usability outcome resulting from some limitations: assessment was based on one-time testing with no previous training, a time lag of AR visualizations on the body and difficulties in spatial AR orientation. The use of AR systems can provide new opportunities for future surgical planning, but has more potential for educational (e.g., patient information) or training purposes of medical under- and postgraduates (spatial recognition of imaging data associated with anatomical structures and operative planning). We expect future usability improvements with refined user interfaces, faster AR hardware and artificial intelligence-enhanced visualization techniques.

public health, sex ratio, surgery, skin neoplasms, incidence, and Medicine

Facial skin cancer (FSC) is prone to incomplete excision due to the sophisticated anatomy and the aesthetic importance of the face. In this study, we sought to investigate to what extent sex-specific differences and other operation-, patient-, and cancer-specific factors influence the re-resection rate in FSC surgery, in order to provide personalized treatment strategies to patients. In this retrospective study, patients (>18 years) undergoing surgical excision of an FSC were enrolled. Each patient’s demographic data, cancer location, the surgical team, primary and secondary surgeries were analyzed. Overall, 469 patients (819 surgeries) were included. The mean age was 69 ± 15 years. No significant association between sex-specific factors (surgeon’s sex (OR: 1.09, 95% CI: 0.76–1.56) or patient’s sex (OR: 0.85, 95% CI: 0.62–1.17), surgeon–patient sex concordance and discordance) and the likelihood of secondary surgery were found. However, healing by secondary intention (OR: 4.28; 95% CI: 1.94–9.45) and cancer location showed an increased re-resection rate. In conclusion, FSC surgery is a safe method unaffected by sex-specific factors, which had no impact on the re-resection rate. However, in further analysis, the likelihood of a re-resection was influenced by other factors such as healing by secondary intention and cancer location. This knowledge might be useful to provide an algorithm for personalized treatment strategies in the future.

carpal tunnel syndrome, pain, persistence, recurrence, revision carpal tunnel release, revision surgery, and Medicine

Background: Prolonged symptoms of carpal tunnel syndrome (CTS) after primary carpal tunnel release (CTR) can reduce the quality of life and lead to multiple referrals across specialties. The following study aimed to identify differences in symptoms, signs, and intraoperative findings between recurrent and persistent CTS cases to avoid undesired outcomes after primary CTR. Methods: A retrospective analysis was conducted on revision CTRs performed between 2005 and 2015 using literature-based definitions for recurrent (a relapse of symptoms occurs following a symptom-free period of ≥3 months) and persistent (symptoms persisting longer than three months after surgical release) CTS. The parameters assessed were symptoms, clinical signs, and intraoperative findings. Results: Out of 53 cases, 85% (n = 45) were external referrals, whereby our own revision rate was 0.67% (n = 8/1199). Paresthesia and numbness were frequent in both groups; however, abnormal postoperative pain was reported more often in persistent cases (86%; n = 30/35) in comparison to recurrent cases (50%; n = 9/18; p = 0.009). Scarring around the median nerve was observed in almost all recurrent cases (94%; n = 17/18) and in 40% (n = 14/35) of persistent cases (p < 0.001). Incomplete division of the palmar ligament was the primary cause for revision in the persistent cohort (49%; n = 17/35). Conclusions: For patients experiencing symptoms for more than three months after CTR, primarily presenting as pain, it is advisable to consider referring the patient to a certified hand clinic for additional evaluation.

Surgery and RD1-811

Background:. After body contouring surgery of the lower trunk (CSLT), the definition, rate (4%–70%), and documentation of complications vary. Objectives:. We analyzed the effect of risk factors on the outcome based on the Clavien-Dindo classification (CDC) after CSLT surgery and polled postoperative satisfaction among patients. Methods:. All patients undergoing CSLT from 2001 to 2016 were included and were classified according to the CDC for postoperative events. Statistical analysis included proportional odds logistic regression analysis. We polled patients to grade their satisfaction with the postoperative result and whether they would have the operation performed again. Results:. A total of 265 patients were included: 60 (22.6%), 25 (9.4%), 28 (10.6%), and 21 (7.9%) were in CDC grades I, II, IIIa, and IIIb, respectively. A high preoperative body mass index significantly increased the odds for a postoperative event requiring revision surgery under general anesthesia (CDC grade IIIb, odds ratio 0.93, 95% confidence interval 0.89–0.97, P = 0.001). One-hundred twenty-eight patients (48.3%) participated in the poll: 101 (78.9%) were either happy or content with the postoperative results, and 117 (91.4%) would have the procedure performed again, including all nine patients with CDC grade IIIb. Conclusions:. Our results confirm that a high body mass index is a statistically significant risk factor for requiring major revision surgery after CSLT. Despite being a complication prone intervention, postoperative satisfaction after CSLT was ranked favorably in our sample. We recommend that the CDC be used in all surgical specialties to evaluate complications and permit future comparability of pooled data.

bone, case report, free tissue flaps, infection, lower extremity, microsurgery, Medicine (General), and R5-920

This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient’s return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation.

n/a, Biology (General), QH301-705.5, Chemistry, and QD1-999

The process of burn injury is multifaceted and involves a whole spectrum of inflammatory responses that can have significant implications for burn patients, including local, regional, and systemic effects [...]

BIA-ALCL, smooth, textured, breast implants, jones classification, and Medicine

Breast-Implant-Associated Anaplastic Large-Cell Lymphoma (BIA-ALCL) is a rare low-incidence type of T-cell non-Hodgkin lymphoma, arising in the capsule around breast implants, and predominantly associated with the use of macro-textured breast implants. The purpose of this study was to use an evidence-based approach to systematically identify clinical studies comparing smooth and textured breast implants in women with regard to the risk of developing BIA-ALCL. Methods: A literature search in PubMed in April 2023 and the article reference list of the French National Agency of Medicine and Health Products decision from 2019 were screened for applicable studies. Only clinical studies where the Jones surface classification could be applied (required information: breast implant manufacturer) for comparison of smooth and textured breast implants were considered. Results: From a total of 224 studies, no articles were included due to the lack of fit to the strict inclusion criteria. Conclusions: Based on the scanned and included literature, implant surface types in relation to the incidence of BIA-ALCL were not evaluated in clinical studies and data from evidence-based clinical sources plays a minor to no role in this context. An international database that combines breast implant-related data from (national, opt-out) medical device registries is, therefore, the best available option to obtain relevant long-term breast implant surveillance data on BIA-ALCL.

in vitro skin models, in vitro wound healing, chronic wounds, hypertrophic scars, keloids, Biology (General), and QH301-705.5

Skin wound healing is essential to health and survival. Consequently, high amounts of research effort have been put into investigating the cellular and molecular components involved in the wound healing process. The use of animal experiments has contributed greatly to the knowledge of wound healing, skin diseases, and the exploration of treatment options. However, in addition to ethical concerns, anatomical and physiological inter-species differences often influence the translatability of animal-based studies. Human in vitro skin models, which include essential cellular and structural components for wound healing analyses, would improve the translatability of results and reduce animal experiments during the preclinical evaluation of novel therapy approaches. In this review, we summarize in vitro approaches, which are used to study wound healing as well as wound healing-pathologies such as chronic wounds, keloids, and hypertrophic scars in a human setting.

in vitro skin models, reconstructed human epidermis, human skin equivalent, Biology (General), and QH301-705.5

The skin serves as an important barrier protecting the body from physical, chemical and pathogenic hazards as well as regulating the bi-directional transport of water, ions and nutrients. In order to improve the knowledge on skin structure and function as well as on skin diseases, animal experiments are often employed, but anatomical as well as physiological interspecies differences may result in poor translatability of animal-based data to the clinical situation. In vitro models, such as human reconstructed epidermis or full skin equivalents, are valuable alternatives to animal experiments. Enormous advances have been achieved in establishing skin models of increasing complexity in the past. In this review, human skin structures are described as well as the fast evolving technologies developed to reconstruct the complexity of human skin structures in vitro.

Rose Bengal, wound healing, wound healing models, chick chorioallantoic membrane, Biology (General), QH301-705.5, Chemistry, and QD1-999

Wound healing is a complex process requiring an adequate supply of the wound area with oxygen and nutrients by neo-vascularization, to renew tissue. Local ischemia can result in the formation of chronic wounds. Since there is a lack of wound healing models for ischemic wounds, we aimed to develop a new one, based on chick chorioallantoic membrane (CAM) integrated split skin grafts and induction of ischemia with photo-activating Rose Bengal (RB) in a two-part study: (1) investigation of the thrombotic effect of photo-activated RB in CAM vessels and (2) investigation of the influence of photo-activated RB on CAM integrated human split skin xenografts. In both study phases, we observed a typical pattern of vessel changes after RB activation with a 120 W 525/50 nm green cold light lamp in the region of interest: intravascular haemostasis and a decrease in vessel diameter within 10 min of treatment. In total, the diameter of 24 blood vessels was measured before and after 10 min of illumination. Mean relative reduction of vessel diameter after treatment was 34.8% (12.3%–71.4%; p < 0.001). The results indicate that the present CAM wound healing model can reproduce chronic wounds without inflammation due to the statistically significant reduction of blood flow in the selected area using RB. Combined with xenografted human split skin grafts, we established the set up for a new chronic wound healing model for the research of regenerative processes following ischemic damage of the tissue.

3D printing, upper extremity, rapid prototyping, patient-specific, and Medicine

Three-dimensional printing for medical applications in surgery of the upper extremity has gained in popularity as reflected by the increasing number of publications. This systematic review aims to provide an overview of the clinical use of 3D printing in upper extremity surgery. Methods: We searched the databases PubMed and Web of Science for clinical studies that described clinical application of 3D printing for upper extremity surgery including trauma and malformations. We evaluated study characteristics, clinical entity, type of clinical application, concerned anatomical structures, reported outcomes, and evidence level. Results: We finally included 51 publications with a total of 355 patients, of which 12 were clinical studies (evidence level II/III) and 39 case series (evidence level IV/V). The types of clinical applications were for intraoperative templates (33% of a total of 51 studies), body implants (29%), preoperative planning (27%), prostheses (15%), and orthoses (1%). Over two third of studies were linked to trauma-related injuries (67%). Conclusion: The clinical application of 3D printing in upper extremity surgery offers great potential for personalized approaches to aid in individualized perioperative management, improvement of function, and ultimately help to benefit certain aspects in the quality of life.

plastic surgery, reconstructive surgery, burn care, simulation training, medical education, trauma management, and Medicine

Background: Management of burn injuries presents a complex and challenging situation for medical staff, especially for inexperienced young doctors. However, training on how to treat burn victims in the clinical setting is rarely taught in undergraduate medical classes. We have created the “SIMline”, a simulation training program explicitly designed for coaching medical students in burn management. Methods: A total of 43 students participated in the “SIMline” course, which took place at the training facility at the Medical University of Graz, between 2018 and 2019. The course provided theoretical classes, practical exercises, and a full-scale care process simulation training. The learning progress of the students was monitored via a formative integrated test. Results: Students showed great progress throughout the course of the “SIMline” program, as their test scores improved by an average of 88%. The passing rate was 0% at the first exam (prior to course) as compared to 87% at the final exam, taken after the training. Conclusions: Comprehensive practical training programs in burn care are underrepresented in medical education. The “SIMline” course presents a novel and effective approach in training medical students in burn management. However, follow-up evaluation is necessary to confirm long-term educational benefits.

Medicine (General) and R5-920

Objective The increasing prevalence of obesity is a major health problem worldwide. Several non-surgical treatments are now available that reduce body and subcutaneous fat mass. We aimed to determine the efficacy of mild cold for body mass reduction. Methods Novel cooling wear, which induces mild cooling via evaporation, was worn by 29 women with overweight for 4 weeks. Specifically, the participants wore a cooling waist belt and chaps for 1 hour per day. Non-invasive lipometry was used to determine their subcutaneous adipose tissue thicknesses, and the total weight loss, abdominal circumference, and body mass index (BMI) of the participants were measured. Results The participants achieved a significant total weight loss of 0.7 kg (0.9%), and significant reductions in BMI (0.2 kg/m 2 ) and abdominal circumference (1.9 cm, 1.7%). Furthermore, there was a trend towards a reduction in abdominal subcutaneous fat thickness and a significant reduction in thickness of the anterior thigh was noted. A questionnaire-based evaluation indicated high usability and comfort of the cooling wear. Conclusion There is a high and growing demand for non-invasive treatment strategies for obesity. Cooling wear represents a novel and promising approach that may be of particular use for individuals who do not require bariatric surgery.

hypertrophic scar, fibrosis, animal model, inflammation, hypoxia, Duroc pig, Biology (General), QH301-705.5, Chemistry, and QD1-999

Hypertrophic scars continue to be a major burden, especially after burns. Persistent inflammation during wound healing appears to be the precipitating aspect in pathologic scarring. The lack of a standardized model hinders research from fully elucidating pathophysiology and therapy, as most therapeutic approaches have sparse evidence. The goal of this project was to investigate the mechanisms of scar formation after prolonged wound inflammation and to introduce a method for generating standardized hypertrophic scars by inducing prolonged inflammation. Four wound types were created in Duroc pigs: full-thickness wounds, burn wounds, and both of them with induced hyperinflammation by resiquimod. Clinical assessment (Vancouver Scar Scale), tissue oxygenation by hyperspectral imaging, histologic assessment, and gene expression analysis were performed at various time points during the following five months. Native burn wounds as well as resiquimod-induced full-thickness and burn wounds resulted in more hypertrophic scars than full-thickness wounds. The scar scale showed significantly higher scores in burn- and resiquimod-induced wounds compared with full-thickness wounds as of day 77. These three wound types also showed relative hypoxia compared with uninduced full-thickness wounds in hyperspectral imaging and increased expression of HIF1a levels. The highest number of inflammatory cells was detected in resiquimod-induced full-thickness wounds with histologic features of hypertrophic scars in burn and resiquimod-induced wounds. Gene expression analysis revealed increased inflammation with only moderately altered fibrosis markers. We successfully created hypertrophic scars in the Duroc pig by using different wound etiologies. Inflammation caused by burns or resiquimod induction led to scars similar to human hypertrophic scars. This model may allow for the further investigation of the exact mechanisms of pathological scars, the role of hypoxia and inflammation, and the testing of therapeutic approaches.

antimicrobial dressings, antiseptic, bacterial nanocellulose, biofilm, chronic wounds, and Medicine

Introduction: Pathogenic biofilms are an important factor for impaired wound healing, subsequently leading to chronic wounds. Nonsurgical treatment of chronic wound infections is limited to the use of conventional systemic antibiotics and antiseptics. Wound dressings based on bacterial nanocellulose (BNC) are considered a promising approach as an effective carrier for antiseptics. The aim of the present study was to investigate the antimicrobial activity of antiseptic-loaded BNC against in vitro biofilms. Materials and Methods: BNC was loaded with the commercially available antiseptics Prontosan® and Octenisept®. The silver-based dressing Aquacel®Ag Extra was used as a positive control. The biofilm efficacy of the loaded BNC sheets was tested against an in vitro 24-hour biofilm of Staphylococcus aureus and Candida albicans and a 48-hour biofilm of Pseudomonas aeruginosa. In vivo tests using a porcine excisional wound model was used to analyze the effect of a prolonged treatment with the antiseptics on the healing process. Results: We observed complete eradication of S. aureus biofilm in BNC loaded with Octenisept® and C. albicans biofilm for BNC loaded with Octenisept® or Prontosan®. Treatment with unloaded BNC also resulted in a statistically significant reduction in bacterial cell density of S. aureus compared to untreated biofilm. No difference on the wound healing outcome was observed for the wounds treated for seven days using BNC alone in comparison to BNC combined with Prontosan® or with Octenisept®. Conclusions: Based on these results, antiseptic-loaded BNC represents a promising and effective approach for the treatment of biofilms. Additionally, the prolonged exposure to the antiseptics does not affect the healing outcome. Prevention and treatment of chronic wound infections may be feasible with this novel approach and may even be superior to existing modalities.

blepharoplasty, complication, Clavien–Dindo Classification, satisfaction, perception, aesthetic cosmetic facial plastic reconstructive surgery, and Medicine

The postsurgical Clavien–Dindo classification in minor surgery can improve perception and communication (Investigation on Blepharoplasty). Background: Minor surgery lacks a standardized postoperative complication classification. This leads to the presentation of inaccurate postsurgical complication rates and makes comparisons challenging, especially for patients seeking information. This study aims to evaluate a standardized five-step complication grading system (Clavien–Dindo Classification, CDC) on the example of blepharoplasty, which is the most performed minor aesthetic surgery worldwide. Methods: A retrospective observational exploratory study of patients (N = 344) who received a bilateral upper eyelid blepharoplasty under local anesthesia from the same surgical staff was performed. Data were retrieved from the electronic patient record: the CDC grading and the surgeon-reported complications (N = 128) at the first follow-up on day 7. In addition, a telephone survey with patients (N = 261) after 6 months was performed, which consisted of 7 complication-related yes/no questions. Results: Based on the CDC, 41.6% of patients were classified as having no complications, and 58.4% had one. Furthermore, 1 patient (0.3%) received a revision under general anesthesia (CDC IIIb), 18 patients (5.2%) were re-operated under local anesthesia (CDC IIIa), 23 patients (6.7%) required pharmacological intervention (CDC II), and 159 patients (46.2%) had a complication from the normal postoperative course and received supportive treatment (CDC I). Moreover, 90.5% of the mentioned complications accounted for Grade I and II; 94% of the patients subjectively experienced no complications; 51% of patients were pleased with the surgery even though a complication occurred according to the CDC; 34% of complications escaped the awareness of the surgeon. Conclusions: Grade I and II complications occurred frequently. Complications escaped the perception of the patients and surgeons. The classification identifies a wide variety of postsurgical complications and allows a standardized comparison in minor surgery objectively. Potential: The CDC in minor procedures can improve the (institutional) preoperative communication with patients regarding potential postoperative expectations. Furthermore, the classification can be a useful tool to detect complication-related costs, identify insurance-related requests, and support evidence in medicolegal disputes. The example of blepharoplasty can be translated to various other and even less invasive procedures.

skin neoplasms, melanoma, lymph node excision, drainage, seroma therapy, and Medicine

Postoperative complications such as seroma formation and wound-site infection occur following completion axillary lymph node dissection (ALND) for melanoma. We analyzed the impact of time-to-drain removal and drainage volume on seroma formation after ALND. We retrospectively analyzed data from 118 patients after completion ALND for melanoma. Primary endpoints were daily amount of drainage volume, seroma formation and time-to-drain removal. Secondary endpoints included patient-related, disease-specific and perioperative parameters as well as the number of histologically analyzed lymph nodes and surgical complications graded by the Clavien–Dindo classification (CDCL). Statistical analyses were performed using logistic regression models. Drain removal around the 8th postoperative day was statistically associated with a lower risk for the occurrence of seroma formation (p < 0.001). Patients with an increased drainage volume during the early postoperative days were more prone to develop seroma after drain removal. With 49% (CDCL I and II), most complications were managed conservatively, while only 5.9% (CDCL III) required revision surgery (CDCL overall: 55.9%). ALND is a safe procedure with a low rate of severe CDCL III type of complications. To decrease seroma evacuation, our results imply that drains should be removed around the 8th postoperative day to reduce the risk of infection, readmission or prolonged hospitalization.

Healthcare quality improvement, Comparative effectiveness research, Surveys, Patient-centred care, Patient education, Public aspects of medicine, and RA1-1270

Abstract Background Low health literacy has been associated with poor health outcome and impaired use of healthcare services. The hospital discharge letter represents a key source of medical information for patients and can be used to address the problem of low health literacy. The aim of this project was to develop and evaluate a new, patient-directed, version of the discharge letter. Methods Based upon two conventional discharge letters (CDL; one surgical and one medical letter), two new, patient-friendly discharge letters (PFDL) were designed following 5 key principles: short sentences, few abbreviations, large font size, avoidance of technical terms and no more than 4 pages length. Medical undergraduates were randomized into two blinded groups (CDL, PFDL) and asked to assess the assigned letter for the 3 domains structure, content and patient-friendliness. Subsections were rated on a 6-point Likert scale (1 = completely agree, 6 = completely disagree), the results of the survey were compared using the Mann-Whitney-U-Test with a p