The questionnaire was constructed as follows. On Page 1, the aims of the study were not revealed to subjects to avoid bias in their responses. This page contained questions about subjects' information and ‘pre-explanation compliance’. It consisted of the following items: (
Fig. 1). 1. Sex, 2. Age, 3. Profession (doctor, medical student, or non-medical personnel), 4. Compliance to hirudotherapy on a scale of 0–10.
Once subjects had completed their responses to Page 1, they were instructed to read the explanation and case reports on Pages 2 and 3. There were no time restrictions and, if required, subjects were provided with thorough explanations of difficult terms such as ‘necrosis’ and ‘venous congestion’. The explanation was as follows.
Explanation of the medical use of leeches (Fig. 2)
‘The skin is our body's primary defense, and it helps to maintain our health by preventing infections from entering the body. Defects in the skin and soft tissues can be caused by tumor removal, bedsores, or trauma, and these defects can be treated by disinfection, a negative pressure wound therapy system, skin graft, or flap surgery. Of these, flap surgery is a method of reconstructing severe tissue defects, and includes local flap surgery, regional flap surgery, and free flap surgery. For the flap to survive, it needs to be provided with an arterial blood supply and venous blood drainage. Even if the flap has a blood supply, once it has been oxygenated, it cannot survive if failure of the blood to drain causes venous congestion. Although leeches have been used in medicine since the distant past, people feel a sense of disgust at their appearance and their blood-feeding behavior. However, leaches are very useful for treating venous congestion, which is difficult to correct with surgery.’
Next, the subjects were provided with images and an explanation about patients who had undergone breast reconstruction at our hospital using a transverse rectus abdominis myocutaneous flap, had been at risk of flap necrosis due to postoperative venous congestion, and had achieved a positive outcome by using hirudotherapy.
The first case introduced in the questionnaire. A 55-year-old woman who underwent breast-conserving surgery for left breast cancer 18 months previously had developed a soft tissue defect after 1 postoperative year due to infection of the inserted mesh (above). Reconstruction surgery was performed using a transverse rectus abdominis myocutaneous flap, but congestion in the medial margin of the flap led to a risk of necrosis. This was treated by hirudotherapy, and the flap color improved within 5 days (below, right).
The second case introduced in the questionnaire (
Fig. 3). A woman underwent modified radical mastectomy for right breast cancer 8 years previously; reconstruction surgery was performed using a transverse rectus abdominis myocutaneous flap, but congestion developed in the upper, lateral, and inferior portions of the flap (above). Hirudotherapy was performed, and most of the congestion was alleviated within 6 days (below).
At the bottom of Page 3, the same questions as Page 1 were presented again, in order to check the subjects' ‘post-explanation compliance’. Finally, a 6th question was presented to exclude subjects who had prior knowledge about hirudotherapy.
The improvement in compliance following the explanation was analyzed for all subjects. Subsequently, the subjects were divided into subgroups according to profession, sex, and age, and the improvement in compliance was analyzed for each subgroup.
In order to analyze the effects of profession, sex, and age on compliance, a one-way analysis of variance (ANOVA) was performed for the three conditions of pre-explanation, post-explanation, and change following explanation. Tukey's method was used for post-hoc testing.
In order to investigate the effects of medical knowledge on compliance, the subjects were divided by profession, into subgroups of 50 doctors, 50 medical students, and 100 non-medical personnel.
In order to investigate the effects of sex on compliance, the 100 non-medical personnel were divided into subgroups of 48 males and 52 females. In order to investigate the effects of age on compliance, the 100 non-medical personnel were divided into subgroups of 29 subjects in their twenties, 20 subjects in their thirties, 27 subjects in their forties, and 24 subjects in their fifties.