Introduction:Results of a quality improvement (QI) project to standardize our opioid prescribing practices following five common outpatient general surgery procedures are presented.Methods: Opioid prescribing habits were reviewed from June to December 2017. QI measures were implemented. We prospectively collected data on opioid prescribing habits and patients' pain management ratings from September 2018 to February 2019.Results: Following implementation, combination pills were less prescribed. More patients were prescribed adjuncts pre-(66% vs. 3%; p < 0.01) and post-operatively (85% vs. 50%; p < 0.01). One-third of pills were prescribed (1363 vs. 4185), with only 520 consumed. Average OME prescribed decreased from 179 to 127 mg (p < 0.001). At follow-up, 52 patients (54%) reported taking 11 pills (1-20) postoperatively for five days. Pain management was rated as good/excellent (88.6%) or fair (9.3%).Conclusions: Using a pragmatic multimodal approach, decreasing opioid prescriptions at discharge allows for adequate pain management.
A provocative "tract for our times," Paul W. Bennett's latest offering, The State of the System: A Reality Check on Canada's Schools (McGill-Queen's University Press, 2020), is a broad yet simplistic overview of the Canadian education system. Dr. Bennett's book is written with verve and is an acidic commentary on a broad range of issues confronting public education. He traces a history from the 1920s, examining the shaping of a modern bureaucratic education system, through to a system focused on accountability and testing, and finally into contemporary times of school management and consolidation. Peppered throughout are Bennett's seemingly fond recollections of days past with the one-room schoolhouse where students walked to their local school. It is through this romanticized lens that Bennett attempts to create a sweeping description of a singular Canadian education system. According to Bennett, "Reforming the System is essentially about parents reclaiming schools. Top-down decision-making, educational managerialism, and rule by the technocrats has run its course" (p. 237). So, how does Bennett's call to action stand within the context of contemporary education, with all of its nuances and complexities?Dr. Bennett has considerable first-hand experience as a long-time commentator on Canadian schools. He has a refined historical appreciation for the grey advocacy literature and commission nostrums, personalities, and panaceas purporting to bring our schools into the 21 st century. In fact, Bennett's book is one among many such jeremiads over Canada's 150-year history that propose "solutions" for purported problems: to make education more humane, less bureaucratic, and as idyllic as possible, thereby restoring the relationships once found in a fictitious Arcadian past. If we are to situate Bennett's tract within any particular tradition of educational reform in North American education, it would be Tyack's and Cuban's (1995) Tinkering toward utopia in the United States, to Lawton et al. (1995) Busting bureaucracy to reclaim our schools, and Michael Katz's (1971) Class, bureaucracy and schools-the illusion of educational change in America, perhaps even as a riposte to J.E. Hodgins' effusive Memorial upon Ryerson's death in 1889 in Canada.Since Bennet touts his book as a reality check, three central "facts" about Canadian education must be kept to the fore when reading such a prospectus, rather than retreating into the saccharine image of a Robert Harris painting of a school trustee meeting.First, Canadian education is a behemoth when considered as a sector and not as a collection of isolated school buildings. That explains many of the difficulties in reforming "the system"-insofar as anyone can discern a single system. Approximately seven million students, or one-sixth of Canada's 37 million citizens under the age of 18 enter a school and are "institutionalized" within it for about 180 to 190 days per year for 12 or 13 years in a series. If we add half a million teachers, school bus drivers, educational assistants...
Summary: Venous flaps are nonphysiologic flaps in which the venous system replaces the vascular circuit found in conventional flaps, serving as inflow as well as outflow. Although a main concern with venous flaps has been their reliability, this can be improved by manipulating their physiology using shunt restriction. The soft, pliable tissue provided by venous flaps coupled with the low donor site morbidity and ease of flap harvest make them ideal for coverage of moderate-sized facial defects, which may be too large for local options yet too small for conventional free flaps. We report the use of a large, 70 cm 2 arterialized venous free flap to reconstruct a complex forehead deficit after basal cell carcinoma resection. Furthermore, we present the first report of the successful use of valvulotomes in the case of a large, reverse flow arterialized venous flap where several in-series valves were found to prevent adequate perfusion of the flap. Upon removal of the valves, complete perfusion of the flap was achieved.
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