Comprehensive Consultation Research Articles

European landscape in astrobiology, results of the AstRoMap consultation

Astrobiology is a multidisciplinary field of research, which encompasses scientists ranging from cosmology, astronomy, planetary sciences, physics, chemistry, geology, paleontology to biology. In order to map the existing astrobiological expertise in Europe a comprehensive community consultation has been performed within the AstRoMap (Astrobiology Road Mapping) project that is supported by the European Commission FP7 framework. From this information a data base of scientists (European and beyond) interested in astrobiology and planetary exploration (see: http://www.astromap.eu/database.html) has been established. It reflects the demography and research and teaching activities of the astrobiology community, as well as their professional profiles and involvement in astrobiology projects. The database provides an ideal platform for networking between scientists interested in the various fields of astrobiology. Considering future aspects of astrobiology in Europe, the need for more astrobiology-dedicated funding programs at the EU level, especially for cross-disciplinary groups, was stressed. This might eventually lead to the creation of a European laboratory of Astrobiology, or even of a European Astrobiology Institute.

Medication adherence behaviors of Medicare beneficiaries.

BackgroundMedication adherence is crucial for positive outcomes in the management of chronic conditions. Comprehensive medication consultation can improve medication adherence by addressing intentional and unintentional nonadherence. The Medicare Part D prescription drug benefit has eliminated some cost barriers. We sought to examine variables that impact self-reported medication adherence behaviors in an ambulatory Medicare-beneficiary population and to identify the factors that influence what information is provided during a pharmacist consultation.MethodsMedicare beneficiaries who attended health fairs in northern California were offered medication therapy management (MTM) services during which demographic, social, and health information, and responses to survey questions regarding adherence were collected. Beneficiaries were also asked which critical elements of a consultation were typically provided by their community pharmacist. Survey responses were examined as a function of demographic, socioeconomic, and health-related factors.ResultsOf the 586 beneficiaries who were provided MTM services, 575 (98%) completed the adherence questions. Of responders, 406 (70%) reported taking medications “all of the time”. Of the remaining 169 (30%), the following reasons for nonadherence were provided: 123 (73%) forgetfulness; 18 (11%) side effects; and 17 (10%) the medication was not needed. Lower adherence rates were associated with difficulty paying for medication, presence of a medication-related problem, and certain symptomatic chronic conditions. Of the 532 who completed survey questions regarding the content of a typical pharmacist consultation, the topics included: 378 (71%) medication name and indication; 361 (68%) administration instructions; 307 (58%) side effects; 257 (48%) missed-dose instructions; and 245 (46%) interactions. Subsidy recipients and non-English speakers were significantly less likely to be counseled on drug name, indication, and side effects. The presence of certain health conditions was also associated with missing consultation elements.ConclusionWhile Medicare beneficiaries are generally adherent to medication therapy, adherence barriers must be identified and addressed during comprehensive medication consultation.

Prenatal ultrasonography and postnatal follow-up of a case of McKusick-Kaufman syndrome

ObjectiveMcKusick-Kaufman syndrome (MKS) is a rare autosomal recessive syndrome characterized by hydrometrocolpos (HMC) and postaxial polydactyly (PAP). It is very difficult to diagnose MKS prenatally because of overlapping manifestations and associated anomalies with other syndromes. Herein, we present a case of MKS with prenatal ultrasound illustrating a fetal abdominal cystic mass. Case ReportA 33-year-old woman, gravida 3 para 2, was referred to our obstetrics clinic at 34 weeks’ gestation for fetal abdominal cyst detected by prenatal ultrasound. Our ultrasound illustrated a fetal abdominal cystic mass with two communicating components (suspected HMC) and polydactyly involving both hands and feet. At birth, the gross appearance revealed abdominal distention, vulva edema, and PAP. MKS was highly suspected. Abdominal computed tomography (CT) at 3 days of life showed HMC with a transverse vaginal septum. At 3 months of age, she received colpotomy and vaginal reconstruction to relieve the abdominal distension by HMC. Then she accepted corrections of PAP of both hands and feet at 8 months and 10 months. At 5 years of age, her body and mental development did not show any retardation. Pediatric ophthalmologic examination revealed no specific findings. Given the above evidences, the diagnosis of MKS was finally made at 5 years of age. ConclusionRare syndromes like MKS may need early comprehensive evaluations and consultations. Although prenatal diagnosis might be impossible for MKS, prenatal awareness by fetal ultrasound is very helpful to assist early management and maternal transfer. The final diagnosis and appropriate management of MKS requires the collaboration of obstetricians, geneticists, pediatricians, and ophthalmologists as soon as abnormal signs are detected in utero.

The Needs and Expectations of Overseas Liver Transplant Recipients' Families in Taiwan: Across Different Transplantation Stages

AimsThis study explored the needs and expectations of Taiwanese overseas liver transplant recipients' families (OLTRFs) across three liver transplantation stages. Patients and MethodsAn exploratory qualitative method was applied to a purposive sample of OLTRFs who received guided face-to-face, semi-structured interviews. Data were subjected to content analysis. ResultsNineteen OLTRF members (15 females, 4 males) aged between 29 and 71 years (mean, 55.1 years) for 19 patients who had end-stage liver diseases were interviewed regarding overseas liver transplantation (OLT) across three stages: pre-departure (first stage), stay in mainland China (second stage), and re-entry into Taiwan (third stage). Five types of needs across OLT stages were reported: (a) knowing precise operation schedule in advance (first to second stages); (b) sharing the caring burdens (second to third stages); (c) knowing the updated health status if possible (all stages); (d) obtaining timely psychological support (all stages); and (e) effective communications between health professionals in Taiwan and mainland China to ensure the caring quality (all stages). Furthermore, five expectations were reported: (a) more donor sources (first stage); (b) comprehensive caring strategies for OLT (first stage); (c) a comprehensive consultation system and timely assistance channels for OLT recipients and their families (second to third stages); (d) a legal and accessible therapy process (all stages); and (e) the cooperation with foreign countries and allowed experience sharing for better quality of patient care (all stages). ConclusionsMost ethnic Chinese believe that family is an integrated system; moreover, there is close attachment between OLT recipients and their families. The needs and expectations of the recipients' family across three transplantation stages were first reported in this project. With this knowledge, the health providers of related countries are empowered by a better understanding of the family's needs and expectations of these OLT recipients at different stages.

Development and Preliminary Testing Of The Post-Transplant Multimorbidity Index (PTMI)

BackgroundComorbid health conditions, both those present before transplant and those acquired as late effects of allogeneic hematopoietic stem cell transplantation (alloHSCT) and the treatment of chronic graft-versus-host disease (cGVHD), represent an important covariate. While the Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) (Sorror et al. Cancer, 2008; 112(9):1992-2001) has been developed to predict non-relapse mortality and overall survival in allo-HSCT recipients, many of the chronic comorbid conditions that develop in the allogeneic post-transplant setting are not represented in the HCT-CI, and its predictive validity has had limited study in long-term transplant survivors. The objectives of this study were to: (i) establish a new measure of multimorbidity for the post-transplant setting (Post-Transplant Multimorbidity Index [PTMI]), and (ii) explore its content validity. MethodsBased on a review of the literature and the most commonly used comorbidity measures, the PTMI was developed to reflect a broad and inclusive list of comorbid conditions that may arise in the post-transplant setting. Preliminary definitions to establish the presence of each of these conditions were developed. To enhance longitudinal comparisons, the conditions and definitions from the HCT-CI were nested within the PTMI. The conditions and definitions were iteratively refined (SM and DW) through application in a cohort of 30 post-transplant patients. Subsequently, the PTMI, HCT-CI, Charlson Comorbidity Scale (CCS), and the Functional Comorbidity Index (FCI) were comparatively evaluated in a cohort of 50 alloHSCT survivors referred for comprehensive cGVHD consultation. The evaluation cohort was a mean age of 42 (range 23-68) years and a median of 33.5 (range 13-208) months post-transplant. All but two (late acute GVHD n=1; no cGVHD n=1) had active cGVHD that had been present for a median of 27 (range 3-197) months. A majority had severe cGVHD (NIH global severity score 1 n=4; 2 n=8; 3 n=36) and 90% were currently receiving systemic immunosuppression. ResultsApplying the PTMI, HCT-CI, CCS and FCI to our evaluation cohort yielded a mean of 5 (SD±2.5), 1.5 (SD±1.23), 1.39 (SD±0.78), and 2.18 (SD±1.16) co-occurring conditions, respectively. On average the HCT-CI, CCS, and FCI missed the identification of one or more comorbidities 71%, 75%, and 43% of the time. Conditions that were prevalent in the cohort but missed by the other comorbidity measures included osteoporosis, avascular necrosis, hypertriglyceridemia, hypothyroidism, BMI<22, and secondary solid malignancy (excluding nonmelanoma skin cancer) after transplant. Using the PTMI, the two most prevalent comorbid conditions were osteoporosis (64%) and underweight/sarcopenia (BMI<22) (46%), whereas the FCI identified osteoporosis and depression as most prevalent, and the HCT-CI psychiatric disturbance and peptic ulcer, and the CCS history of malignancy and peptic ulcer disease, as the two most prevalent comorbidities, respectively. ConclusionsOur results offer preliminary evidence that the PTMI improves the identification of chronic comorbid conditions in long-term transplant survivors with cGVHD, and demonstrate that the choice of a measure is an important methodologic issue in the design of epidemiologic studies of comorbidity in post-transplant survivors with cGVHD. Prospective studies evaluating the measurement properties of the PTMI are ongoing in post-transplant survivors with and without active chronic GVHD. With continued testing and refinement, we anticipate that this new measure will have utility for risk-adjustment and stratification in both observational studies and clinical trials in the post-transplant setting. Disclosures:No relevant conflicts of interest to declare.

A Newly Introduced Comprehensive Consultation Fee in the National Health Insurance System in Japan: A Promotive Effect of Multidisciplinary Medical Care in the Field of Radiation Oncology—Results from a Questionnaire Survey

The consultation fee for outpatient radiotherapy was newly introduced in the national health insurance system in Japan in April 2012. We conducted a survey on the use of this consultation fee and its effect on clinical practices. The health insurance committee of the Japanese Society of Therapeutic Radiology and Oncology conducted a questionnaire survey. The questionnaire form was mailed to 160 councilors of the Society, the target questionees. A total of 94 answers (58% of the target questionees) sent back were used for analyses. The analyses revealed that 75% of the hospitals charged most of the patients who receive radiotherapy in an outpatient setting a consultation fee. The introduction of the consultation fee led to some changes in radiation oncology clinics, as evidenced by the response of 'more careful observations by medical staff' in 37% of questionees and a 12% increase in the number of full-time radiation oncology nurses. It was also shown that the vast majority (92%) of radiation oncologists expected a positive influence of the consultation fee on radiation oncology clinics in Japan. Our questionnaire survey revealed the present status of the use of a newly introduced consultation fee for outpatient radiotherapy, and the results suggested its possible effect on promoting a multidisciplinary medical care system in radiation oncology departments in Japan.

Treatment of cervical paragangliomas: Is surgery the only way?

PurposeTo analyze the results after surgery or stereotactic radiotherapy (SRT) in the treatment of cervical paragangliomas. Against this background, the decision-making algorithm used in the treatment of carotid body tumors (CBTs) and vagal paragangliomas (VPs) was reevaluated relative to the existing literature on the topic. Materials and methodsRetrospective study between 2000 and 2012. A total of 27 CBTs and nine VPs in 32 patients were treated. Shamblin class I: 59.3% (n=16); class II: 29.6% (n=8); class III: 11.1% (n=3). Treatment modalities were surgery, radiotherapy, or observation. The end points for analysis were long-term tumor control and integrity of the cranial nerves. Results21 CBTs and seven VPs underwent surgery; SRT was performed in three CBTs and two VPs. Three CBTs were clinically observed. Permanent nerve paresis followed after surgery for CBTs in five patients (20%) and in all patients with VPs. No impaired cranial nerve function resulted after SRT. The median follow-up period was 4.7years. The tumor control rate after therapy for CBTs and VPs was 100%. One CBT that received clinical observation showed slow tumor progression. ConclusionsA surgical procedure should be regarded as the treatment of choice in patients with small CBTs. In larger CBTs, particularly in elderly patients with unimpaired cranial nerves, radical surgery should be regarded critically. As surgery for VPs caused regularly impairment of cranial nerves with functional disturbances of various degrees a comprehensive consultation with the patient is mandatory and nonsurgical strategies should be discussed.

Fundamental aspects of advanced nursing practice in the field of medical aesthetics

Not only is there is diversity in qualifications, level of competencies and responsibilities of nurses in aesthetic medicine, but there is also limited empirical data to support the role. Being a medical aesthetic practitioner involves working autonomously, making clinical decisions based on comprehensive consultations and carrying out physical assessments of patients. However, owing to the lack of regulations and standards for education in medical aesthetics, many nurses may feel isolated and inadequately prepared when entering the field. This article explores the fundamental aspects of advanced practice and provides practical advice for nurses to ensure their practice meets requirements.

The Undervaluation of Evaluation and Management Professional Services: The Lasting Impact of Current Procedural Terminology Code Deficiencies on Physician Payment

The Resource-Based Relative Value Scale (RBRVS) is fundamentally undermined by the following foundational errors: (1) The full range of office-based evaluation and management (E/M) activities are not captured by the Current Procedural Terminology (CPT) code choices, (2) it places relatively high values on procedural services, (3) there is no measure of intensity for complex outpatient E/M care, and (4) its maintenance and update have been delegated to select professional societies. Limitations imposed on the development of the RBRVS dating back to the early 1980s have not been corrected. The repertoire of codes for physician office-based E/M work must be expanded to create a new topology of choices with new outpatient code families with discrete service code levels, such as comprehensive outpatient consultation care, comprehensive outpatient primary care, and limited outpatient consultation care. Service code relative values must be based on representative samples and reliable survey data, draw from the broader literature on work intensity, and be developed with accountable and representative professional engagement.

AB1067 Eighteen cases of crowned dens syndrome: Presentation and diagnosis

BackgroundEighteen cases of crowned dens syndrome: presentation and diagnosis.ObjectivesTo etablish the clinical, biological and radiological criteria of crowned dens syndrome, a little known etiology of acute neck pain.MethodsWe carried out...

Eighteen cases of crowned dens syndrome: Presentation and diagnosis

Background and purposeCrowned dens syndrome is an ill-known etiology of acute neck pain. MethodsWe carried out a retrospective study of 18 cases of patients with crowned dens syndrome, assessing clinical and radiological features. ResultsThe results of our study are comparable to data from the literature. The clinical presentation of acute febrile neck pain, occipital headache and multidirectional stiff neck especially affects women aged over 60. No predisposing factor was recognized. However, a history of peripheral joint chondrocalcinosis may reinforce the diagnosis. In more than 50% of cases, laboratory tests showed a marked inflammatory syndrome. The diagnosis was obtained with cervical CT-scan focusing on the C1/C2 joint. This gold standard test was able to show a calcification of the cruciform ligament in connection with deposits of calcium pyrophosphate crystals in almost 80% of cases. Other imaging tests provided little information, including standard radiographs of the cervical spine. MRI can eliminate some differential diagnoses such as infections or neurological emergencies. Complications are infrequent. The standard treatment is based on anti-inflammatory drugs (NSAID, colchicine) or corticosteroids. These treatments are highly effective: a drammatic full recovery of cervical mobility may be observed within 48hours. In over half of cases, a different diagnosis was initially made, responsible of unnecessary additional tests and treatment. ConclusionA comprehensive consultation, a complete clinical examination and a precise analysis of the imaging will avoid certain investigations and rule out differential diagnoses.

Defining the Content of an Opportunistic Osteoarthritis Consultation With Primary Health Care Professionals: A Delphi Consensus Study

To define the core content for an opportunistic consultation between a health care professional (HCP) and a patient with osteoarthritis (OA) in primary care. An ideas generation round and a 2-round Delphi postal consensus study allowed participants to rank the importance of tasks for an opportunistic consultation. The study was conducted with a lay group (n = 18) and 3 groups of HCPs (n = 30 for general practitioners, n = 19 for practice nurses, and n = 37 for allied health professionals). The ideas generation round formulated 35 consultation tasks. There was a 50% response rate to the 2-round postal exercise (n = 52). Consensus was reached on 12 tasks for an opportunistic OA consultation using a >80% level of agreement across all groups. Three of these consultation tasks were defined at 100%. The 3 tasks were questions asked by the HCP about how things are going with the condition, the type and amount of pain the patient has, and whether the patient is taking regular analgesia. In a Delphi study to define the content of an opportunistic primary care OA consultation, 12 consultation tasks provided the content of a comprehensive consultation. Three of these tasks with 100% agreement could be adopted in any multidisciplinary consultation for OA in primary care. Inquiring about the condition, the type and amount of pain the patient has, and whether analgesia is being taken forms a core set of questions that are considered important by both lay and health professional groups in an opportunistic consultation.

Abstract 262: Low Self-Efficacy Correlates with Increased Cardiovascular Disease Risk

Background: Cardiovascular disease (CVD) is largely a preventable illness contingent upon the ability of patients to adhere to healthy lifestyle choices. Self-efficacy is a strong predictor of a patient’s ability to adopt healthy lifestyle change. We sought to examine correlations between self-efficacy and CVD risk. Methods: The Integrative Cardiac Health Project is an interdisciplinary CVD prevention program that seeks to improve modifiable CVD risk factors among military healthcare beneficiaries. Participants are provided comprehensive assessments and consultations within the disciplines of exercise, nutrition, stress and sleep to identify and modify CVD risk. Upon initiation of the program, participants complete a battery of assessments including anthropomorphic measurements, fasting laboratory studies and validated surveys for self-efficacy and sleep. Sleep surveys include the Berlin Questionnaire for sleep apnea, Pittsburgh Sleep Quality Index (PSQI) for global assessment of sleep quality, and the visual analog fatigue score. In this retrospective analysis, patients were sorted into low and high self-efficacy groups using the midpoint of the range of self-efficacy scores. Patients with low (10 to &lt;16.25 points) and high (16.25 to 22.5 points) self-efficacy scores were compared utilizing t-tests. Results: Of 71 participants (mean age 52 yrs, 33 men (46%)), 25 (35.2%) had low self-efficacy scores. Subjects with low self-efficacy scores demonstrated numerous CVD risk factors (See table). Conclusions: Self-efficacy and CVD risk profiles appear to be inversely related. To lower CVD risk and improve adherence to healthy lifestyle change, strategies to improve patient self-efficacy must be a primary consideration.

Evaluación del componente infantil del Seguro Público de Salud de la Provincia de Buenos Aires

Evaluate if the Insurance strengthened the primary care role and enhanced healthcare access and comprehensiveness. Through a household survey (n=2 413; year 2006) we collected data on utilization of health services by under 8 year old beneficiaries from 8 municipalities. We used hypothesis tests to identify significant differences between municipal profiles of Insurance implementation and beneficiaries grouped by utilization patterns. Although more than 95% of children received medical healthcare in each municipality (using the Insurance and other services), the Insurance utilization varied significantly by municipal profile. Access to comprehensive healthcare and consultation rates were significantly higher for those beneficiaries who used the Insurance along with other health services, compared with those who only used the Insurance services. Use of hospitals was significantly lower within Insurance users. The Insurance was more effective when implemented and used in conjunction with the municipal networks of health services.

Comprehensive Allergy Consultation Minimizes Risk of Hypersensitivity Reaction During Subsequent Anesthesia

In patients with a history of hypersensitivity reaction (HSR) during anesthesia, data are lacking on success of strategies to minimize risk with subsequent anesthesia. Identification of the specific cause of HSR to anesthesia remains challenging.

Are you ready for health care teams?

As I look towards the future to identify opportunities for myself and other pharmacists, I see a health care system that embraces a team approach to patient care and gives pharmacists an important role on the team to ensure safe and effective medication use. As I look towards the future to identify opportunities for myself and other pharmacists, I see a health care system that embraces a team approach to patient care and gives pharmacists an important role on the team to ensure safe and effective medication use. As pharmacists, we encounter drug therapy problems every day, from medication nonadherence and the need for additional therapy to problems related to dosing and adverse drug reactions. We also are aware of the consequences of improper medication use for our patients, including hospitalizations, institutionalizations, and death. Our health care system is changing, and pharmacists have to be ready. Part of that change is the formation of accountable care organizations (ACOs), patient-centered medical homes, and payment systems that reward positive patient outcomes. is the time for pharmacists to step up, define their role as medication experts, and become sought out and integrated within the team. ■The time is coming when pharmacists will be integrated in health care teams.■Pharmacists must be proactive and engage in discussions about joining these teams. ■The time is coming when pharmacists will be integrated in health care teams.■Pharmacists must be proactive and engage in discussions about joining these teams. Recently, I came across an article about integrated pharmacists within a health care system that demonstrated positive results.1.Isetts B.J. Brummel A.R. de Oliveira D.R. Moen D.W. Managing drug-related morbidity and mortality in the patient-centered medical home.Med Care. 2012; 50: 997-1001Crossref PubMed Scopus (41) Google Scholar ■The health care system studied is Fairview Health Services of Minneapolis-St. Paul.■A team approach is used in the care of patients, all team members have responsibilities in comprehensive medication therapy management (MTM), and patients are engaged participants within their own care.■Pharmacists within the system provide comprehensive MTM consultations, home and telephonic visits, and joint visits with other health care team members. They also engage in collaborative practice agreements for patients with chronic conditions.■The authors looked at the results over a 15-month period, comparing 4 Fairview clinics to 38 other clinics within the state.•Spending growth was 11% less in the Fairview clinics.•Median per member per month health care costs were significantly lower in the Fairview clinics.•More of Fairview's patients with diabetes (40%) achieved all five performance benchmark treatment goals than did patients at the other statewide clinics (17.5%).•More than 4,000 drug therapy problems were resolved in the Fairview clinics. Throughout my career, I have always supported the notion of the health care team, the role of pharmacists as medication managers, and a fair reimbursement system that rewards the efforts of all team members. Although movement towards these goals has been slow in past years, I am beginning to think that the time is coming when pharmacists will be more integrated within the team. The difficulty for all of us is trying to determine what the final system will look like, how pharmacists will be integrated within the system (i.e., employed or contracted), and how pharmacists and other team members will be paid. I know that health care systems within my community are part of a statewide effort to develop and implement ACOs, but pharmacy has not had a strong presence yet in this process. This is not the time for pharmacists to sit back and wait to see what happens. This is the time for us to be proactive and to engage in the discussions that local health systems are having regarding health care reform and the formation of ACOs. Pharmacists should prepare themselves to provide patient care services important to ACOs, including comprehensive medication management, medication adherence programs, medication reconciliation services, management and monitoring of patients on high-risk medications, and identification and resolution of drug therapy problems. I believe that pharmacists will be sought out for their clinical expertise relating to drug therapy within America's new health care system. It will not be enough to make sure that the right drug is in the right bottle with the right directions; health professionals will also have to ensure that patients achieve their therapeutic goals. This requires a new set of skills, including critical thinking, problem solving, and interpersonal communication. Pharmacists will need to become interventionists by recognizing drug therapy problems, communicating therapeutic recommendations, and regularly documenting their activities. This can be an intimidating frightening time for us more seasoned pharmacists, but I also recognize the wonderful opportunity for our profession. The time has come for our profession to step it up another notch. Are you ready? Column coordinator [email protected] Co-owner and Director of Clinical Services, Towncrest and Medical Plaza Pharmacies Iowa City

Peer consultation on relationship between PAC profile and toxicity of petroleum substances

An expert peer consultation panel reviewed a report by the PAC Analysis Task Group, which hypothesized that systemic, developmental, and reproductive toxicity observed in repeated-dose dermal toxicity studies was related to polycyclic aromatic compound (PAC) content. Peer consultations seek to solicit scientific and technical input from experts on the scientific basis and merits of the subject report. This peer consultation panel included nine scientists with expertise in petroleum chemistry, biostatistics, toxicology, risk assessment, structure activity, and reproductive and developmental toxicology. The panel evaluated the technical quality of the PAC report and provided recommendations for improving the statistical and biological approaches. The PAC report authors revised their methods and documentation, which are published elsewhere in this supplement. A review of the post peer consultation manuscripts confirmed that many of the key suggestions from expert panel members were considered and incorporated. In cases where the PAC report authors did not fully incorporate panel suggestions from the peer consultation, they have provided an explanation and support for their decision. This peer consultation demonstrates the value of formal engagement of peers in development of new scientific methods and approaches.

Implementation of Bone Health Protocols in an Orthopedic Specialty Practice

Implementation of Bone Health Protocols in an Orthopedic Specialty Practice

Fee structure models in dairy practice

Veterinary services, including production medicine consulting, have traditionally been delivered on an hourly fee basis. This method of compensation for both the veterinarian and producer often fails to demonstrate the full value of the service provided. It also does not allow true alignment of the consultant with the livestock enterprise. Implementation of a comprehensive consultation model that relies on data-based decision making, along with a charging mechanism that allows the veterinarian to be compensated based on value, fosters a win-win relationship between both entities.

A Method of Preoperatively Assessing the Volume of Abdominal Tissue Available for an Autologous Breast Reconstruction

Sir:FigureWe have developed an office-based method of assessing the volume of abdominal tissue available for breast reconstruction that has proved to be accurate, reproducible, and noninvasive, yet relatively simple, quick, cost-effective, and of no inconvenience to our patients. We prospectively evaluated 30 sequential immediate deep inferior epigastric artery perforator flap breast reconstructions (25 unilateral and five bilateral). For assessment of breast weight, we used Bostwick's graph1 to preoperatively calculate the patient's breast weight based on their cup size and chest wall circumference. We validated this by weighing the mastectomy specimen (actual breast weight). For assessment of flap volume, standard flap markings were used and the elliptical flap was considered as two identical triangles. The area of each triangle was calculated using the standard formula: area of triangle = height × width × ½. The following measurements were obtained: width was measured by dropping a vertical line from the umbilicus to the suprapubic region, and height was measured from this line to the apex of the triangle (Fig. 1).Fig. 1: The marked elliptical flap area is considered as two identical triangles, with each triangle's area being calculated using the formula width (W) × height (H) × ½.To calculate the volume of the flap, the thickness of the abdominal skin and fat were measured using a metal calliper while the abdominal panniculus was grasped by the assistant (Fig. 2). Three measurements were taken and the average of these was used. This measurement was divided by 2 (as the abdominal wall is folded onto itself during the measurement) and multiplied by the area of the flap. Therefore, the final formula for calculation of the flap volume is as follows: calculated flap volume = (height × width × ½) × 2 × (flap thickness × ½).Fig. 2: The thickness of the flap is measured using a metal calliper while the abdominal panniculus is grasped by the assistant.These calculations were validated by measuring the thickness and weight of the flap (actual flap weight) once harvested. The average calculated breast weight was 585 g (range, 345 to 1560 g) and the average actual breast weight was 505 g (range, 295 to 1510 g), giving an average percentage error of 16 percent. The average calculated flap volume was 1306.6 ml (range, 468 to 2758.5 ml) and the average actual flap volume was 1371 g (range, 480 to 2880 g), giving an average percentage error of 4.74 percent. The average flap thickness as measured with calipers was 3.15 cm (range, 2 to 4.7 cm) and the average flap thickness measured perioperatively was 3.85 cm (range, 2.5 to 5.4 cm). We have developed a reliable method for the preoperative assessment of flap volume using simple mathematical principles that has proved to be an invaluable tool during our first consultation, both in managing patient expectations and in constructing an operative plan. It has been particularly useful (1) to confidently inform patients of the size of the reconstructed breast; (2) in bilateral reconstructions, to assess whether a sufficient volume of flap is available; and (3) to determine whether a contralateral reduction will be required. In these highly litigious times, such a comprehensive consultation is vital for the purposes of both informed consent and ensuring that the patient's expectations mirror our own. In addition, perioperative decisions can be facilitated.1 If a hemiflap provides sufficient volume, the superficial inferior epigastric artery pedicle can be used.2,3 In the case of large-volume (>1000 ml) breast reconstructions, the consideration of whether to raise a free transverse rectus abdominis musculocutaneous or a deep inferior epigastric artery perforator flap and in the latter how many perforators are required can be facilitated.4 We have described a validated method of calculating the abdominal flap volume available to patients undergoing autologous breast reconstruction. This technique is simple, consistently reliable, and cost effective, and has allowed us to refine our practice. Pari-Naz Mohanna, F.R.C.S.(Plast.) Jian Farhadi, F.M.H. GKT Cancer Reconstruction Service, St. Thomas' Hospital, London, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.