A Pharmacist-Led Process to Monitor Discrepant Urine Drug Screen Results.

Background: A urine drug screen (UDS) is a common risk-mitigation strategy tool for prescribing controlled substances, particularly opioids. Due to their complexity, UDS results can be misinterpreted and thereby have profound impacts on the patient-clinician relationship. From 2021 to 2022, a clinical dashboard to review potentially discrepant UDS results-based on a comparison of the results to the patient's medication list-was made available by the Veterans Health Administration. Methods: This quality improvement project implemented a process for weekly clinical pharmacist reviews of the UDS dashboard. Significant discrepant UDS results were reviewed in depth. From June 2022 through September 2022, 700 UDSs were performed and 60 patients had significant discrepancies that warranted in-depth review. Results: Pharmacist interventions during the review included 39 collaborations with medication prescribers to discuss follow up (65%), 25 queries to a prescription drug monitoring program (42%), and 9 confirmatory UDS on the original sample (15%). In-depth reviews were required for about 4 patients weekly, with a mean length of 14 minutes. Conclusions: A pharmacist-led process to monitor discrepant UDS results led to opportunities for collaboration with prescribers and positively impacted confirmatory testing at a rural veterans affairs health system.

Breast augmentation using a free lateral thoracic artery perforator flap from the contralateral breast: A case report.

When performing breast reconstruction, reduction of the contralateral breast is often required to achieve symmetry. The tissue that would otherwise be discarded from the reduced breast has been utilized as a free flap. This has the benefit of minimizing donor site morbidity, and combining the principles of "spare-part-surgery" and replacing "like-with-like." The purpose of this paper is to report the procedure, outcome, and potential controversies of using a free lateral thoracic artery perforator flap for contralateral breast reconstruction. We present a 32-year-old with congenital breast asymmetry previously corrected with an implant. The patient required tertiary breast reconstruction for capsular contracture, and a simultaneous left breast reduction. There was no history of breast cancer. The reconstruction proceeded as follows; the right sided breast implant was removed. On the left breast, a wise pattern reduction with a superomedial pedicle was instigated. Intraoperatively, four perforating arteriovenous pedicles perfusing the reduced tissue were identified; of which the lateral thoracic artery perforator was selected. The flap weight was 296 g. The lateral thoracic pedicle was anastomosed to the right internal mammary vessels. The flap survived completely. The post-operative course was uneventful and without complication. The patient was followed up for 1 year and was pleased with the final result. The application of the LTAP free flap may cautiously be extended to oncological breast reconstruction. For patients to be suitable, they would need a large remaining breast to provide adequate tissue for reconstruction, up-to-date breast screening and a low risk of developing breast cancer in the future.

The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study.

The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.

Free tissue transfer after unsatisfactorily implant-based breast reconstruction, a cohort study.

Breast reconstruction can be performed using implants or autologous tissue, either alone or in combination. Implants typically require re-operation during the patient's lifetime, often for adverse capsular contracture. Conversion from implants to autologous tissue may improve symptoms and deliver a definitive reconstruction. This is known as salvage breast reconstruction. In this paper we evaluate the indications, outcomes, complications and cost implications of salvage breast reconstruction in our regional centre and report these in line with the STROBE guidelines. Retrospective casenote analysis of all salvage breast reconstruction patients from January 2018 to January 2020 was performed. Nineteen patients were identified, with a median age of 52 years. Indications were all capsular contracture other than two each of implant rupture and patient request. Thirty-two perforator free flaps; 29 deep inferior epigastric, two profunda artery and one lateral thoracic artery flap were performed. Median time from first implant to free flap reconstruction was nine years. Median hospital stay was five days. No total flap losses and one partial flap loss occurred. Three patients underwent secondary procedures to the breast to improve the aesthetic outcome. All patients reported improvement in symptoms and appearance. For implant-intolerant patients adequately counselled and accepting of the post-operative downtime, salvage reconstruction with autogenous tissue offers a lasting solution. The upfront healthcare costs are higher with a free tissue transfer, but may become comparable longer term given the multiple exchange of implant procedures required over a patient's lifetime.

A free intercostal artery perforator flap as a salvage operation for a planned lumbar artery perforator flap with aberrant anatomy in breast reconstruction: A case report.

When autologous breast reconstruction is planned but abdominal tissue is not available, the lumbar artery perforator flap provides an alternative choice with minimal donor site morbidity. The lumbar and posterior intercostal arteries supply adjacent perforasomes on the posterolateral flank. The purpose of this report is to highlight the salvage of an autologous breast reconstruction free flap using a dorsal perforator of the posterior intercostal artery, when the planned lumbar artery perforators were not suitable. The patient was a 74-year-old with recurrent left-sided breast cancer requiring immediate breast reconstruction. A lumbar perforator flap was planned as an oblique ellipse 19 × 10 cm. Intraoperatively, the two identified perforators traveled superiorly up to the 12th rib and therefore originated from the intercostal rather than lumbar arteries. The internal mammary artery and the vena comitants were used as recipient vessels, anastomosed to an interposition graft. Postoperatively, the patient was discharged home after 7 days without complication. Six months later, the patient was pleased with the reconstruction and had negligible donor site morbidity. The dorsal intercostal artery perforator flap therefore provides a salvage option when presumed lumbar artery perforators are dissected and found to be intercostal in origin.

True occipital artery aneurysm: A surgical case report and literature review.

True occipital artery aneurysms are exceptionally rare. To our knowledge only five reports of true occipital artery aneurysm have been previously described.1-5 We present a rare case of a 70-year-old gentleman with a true occipital artery aneurysm associated with alopecia areata. This case report adds to the current lack of literature on true occipital artery aneurysms and summarises their presentation, investigation and management.

Segmental fracture of the scaphoid.

We present a rare case of segmental fracture of the scaphoid. This case highlights the importance of using appropriate imaging modalities to assess the presence and morphology of fractures.

Management of a 15-year-old scaphoid non-union.

Scaphoid non-union affects wrist joint function and is often associated with a predictable pattern of degenerative change. A 30-year-old man presented with a symptomatic 15-year-old right scaphoid fracture with secondary scaphoid non-union advanced collapse of his right wrist. There was no evidence of avascular necrosis. The initial injury was from a fall onto his outstretched hand. We performed a right scaphoid open reduction, internal fixation and iliac crest bone graft. One year after the operation, the patient had good wrist function and grip strength. A CT scan showed union of the fracture. Studies have shown that if the time between initial fracture and treatment of non-union exceeds 5 years, the chances of healing of the non-union are markedly reduced. In our case, despite the long duration between timing of injury and surgery, there was union and good return of function.

Backpack palsy with Horner's syndrome.

Traumatic injuries to the brachial plexus are typically high impact and can be debilitating, life-changing injuries. Backpack palsy is a rare but well-established cause of brachial plexus injury, arising as a result of heavy backpack use. We present an unusual case of backpack palsy with Horner's syndrome.

The effects of a semi-rigid soled shoe compared to walking barefoot on knee adduction moment.

BACKGROUND/PURPOSE: On a background of literature suggesting that certain rigid soled shoes may increase the knee adduction moment during gait this study was performed to look at specific postoperative shoe - the Medishoe. This shoe is used on a daily basis in a district general hospital orthopaedic department for patients post-operatively to protect wounds and fixations. METHODS: Using force plates and an opto-electronic motion capture system with retroreflective markers the knee adduction moment was estimated in ten healthy subject both with and without the shoe during normal gait. The angle at which the ground reaction acted with respect to the ground in the coronal plane as well as the tibiofemoral angle were also calculated using the Qualsys software - both with and without the Medishoe. RESULTS: Two-tailed paired t-tests using a 95% confidence interval showed that there was no significant difference between the two groups in the estimated knee adduction moment (p = 0.238), tibiofemoral angle (p = 0.4952) and the angle of the ground reaction force to the ground (p = 0.059). CONCLUSION: There was no significant difference in the estimated knee adduction moment between the two groups, although there was a statistical trend to an alteration in the angle of the ground reaction force. Further work involving a greater number of subjects and a three dimensional model would further answer the question as to whether these or other post-operative shoes have a significant effect on the knee adduction moment.