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Importance: Women with interstitial cystitis/bladder pain syndrome (ICBPS) face isolation and treatment challenges. Group medical visits using Centering models have successfully treated other conditions but have not been explored in ICBPS. Objective(s): This study aimed to describe ICBPS pain and symptom control comparing standard treatment alone versus standard treatment augmented with Centering visits. Study Design: This prospective cohort study recruited women with ICBPS receiving standard care (control) or standard care augmented with group Centering. We administered validated questionnaires at baseline and monthly for 12 months. The primary outcome was change in the pain numerical rating scale, with Patient-Reported Outcomes Measurement Information System Pain Interference Scale and Bladder Pain/Interstitial Cystitis Symptom Score change as secondary measures. Result(s): We enrolled 45 women (20 Centering, 25 controls). Centering had significantly better numerical rating scale pain scores at 1 month (mean difference [diff], -3.45) and 2 months (mean diff, -3.58), better Patient-Reported Outcomes Measurement Information System Pain Interference Scale scores at 1 month (mean diff, -10.62) and 2 months (mean diff, -9.63), and better Bladder Pain/Interstitial Cystitis Symptom Score scores at 2 months (mean diff, -13.19), and 3 months (mean diff, -12.3) compared with controls. In modeling, treatment group (Centering or control) and educational levels were both associated with all the outcomes of interest. Beyond 6 months, there were too few participants for meaningful analyses. Conclusion(s): Women with ICBPS participating in a Centering group have, in the short term, less pain, pain interference, and ICBPS-specific symptoms than patients with usual care alone. Larger studies with more follow-up are needed to determine if this treatment effect extends over time.Copyright © 2022 American Urogynecologic Society. All rights reserved.
ABSTRACT
Introduction: With the strain placed on the medical system by the ongoing surges of the Covid-19 pandemic, inpatient surgery is often suspended, and same day discharge rates are increasing. Sacrospinous ligament fixation (SSLF) is an apical suspension procedure performed retroperitoneally;retroperitoneal hemorrhage and nerve injury are potential severe complications. Given these risks, providers vary in their preference for same day discharge vs. routine overnight admission after this procedure. Objective: To establish the safety of outpatient SSLF and evaluate the frequency of complications identified during the hospital stay. Methods: This is a retrospective cohort study of women who underwent SSLF by Urogynecologists at our large, academic institution between March 2018 and October 2021. Patients were identified from the Gynecologic Enhanced Recovery Surgical database, which includes all surgical patients in the department of OBGYN. The data was collected from the electronic medical record (EMR) to track compliance and outcomes in real time for quality improvement purposes during implementation of our enhanced recovery protocol. Institutional IRB approval was obtained. Descriptive statistics were performed. Student's t-test and two-sample tests-of-proportions were used, with a p-value <0.05 denoting statistical significance. Results: A total of 165 patients underwent SSLF;23 were outpatient, and 142 were admitted for at least one night. Over 90% of patients in both groups identified as white, non-Hispanic, and English-speaking. The mean BMI for both groups was 28.8 kg/m2. The outpatient group was younger (57.9 years compared to 64.7 years;P = 0.0051);outpatients were more likely to have commercial insurance (P = 0.0143) and inpatients to have Medicare (P = 0.0282). Almost double the proportion of those in the inpatient group had anxiety and depression, but this did not achieve statistical significance. Outpatients were more likely to be never smokers (P = 0.0175) and use narcotics preoperatively (P = 0.0385). They had a lower mean ASA score (P = 0.0067), Charleston Comorbidity Index score (P = 0.0452), total length of surgery (P < 0.001), total length of anesthesia (P < 0.001), and estimated blood loss (P = 0.0142). Those who went home the same day were more likely to have been the first case (P = 0.0123), and same-day discharge rates increased significantly after the onset of the Covid-19 pandemic (P = 0.0039). Both complications that required operative intervention were identified in the post-anesthesia care unit on the day of surgery. Notably, 30-day post-operative complications were proportionally lower in the outpatient group, but this did not achieve significance. Most of the complications were urinary tract infections, including the sole complication identified in the outpatient group. Conclusions: With the ongoing Covid-19 pandemic and rapidly evolving practice patterns, it is important to establish the safety of outpatient surgery. Our study demonstrates that outpatient SSLF is safe for appropriately selected patients after routine post-operative monitoring including serial vital signs and assessment of neuropathic pain. Severe complications requiring reoperation can often be identified immediately after surgery. Thirty-day post-operative complication rates did not significantly differ between patients undergoing outpatient versus inpatient SSLF.
ABSTRACT
The SARS-CoV-2 pandemic poses new challenges and requires new solutions for problems previously not faced by our generation. This particularly applies to the field of opioid dependence therapy due to the physical and psychological vulnerability of patients and the treatment model that often requires daily attendance. An overview is given of the responses of the physicians and the recommendations of medical societies in Germany during the year 2020 with a special focus on the lockdown periods and the challenges and guidelines for the patients, patient organizations and physicians, both outpatient and in prison. Reduced travel and empty inner cities led to reduced patient income combined with closed patient organizations during lockdown, leading to a temporary increase of patients in opioid dependence therapy. New hygiene procedures had to be implemented. A temporary change in the German Narcotics Prescription Ordinance, including longer periods for take-home prescriptions, allowed for ongoing supply with improved social distancing. Depot buprenorphine significantly reduces the risk of infection by avoiding the daily commute and presence at the practice with many other patients. This is even more favourable in prison settings by greatly reducing the movement of prisoners and diversion of drugs.
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Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.
ABSTRACT
BACKGROUND: Patients with inflammatory bowel disease (IBD) are subject to frequent emergency department (ED) visits. In order to decrease unnecessary ED utilization, we established an urgent care hotline (IBD URGENT) at a private community gastroenterology practice to triage pressing concerns from our patients with IBD. However, at the beginning of the Coronavirus disease 2019 (COVID-19) pandemic in Mar 2020, in-person visits were converted to telehealth visits, which could have adversly impacted patient care. Therefore, we examined the impact of the COVID- 19 pandemic on the access and utilization of urgent healthcare by patients with IBD. METHODS: In Jun 2018 we implemented a triage system involving gastroenterologists, nurses, and support staff to enable patients to contact our practice for urgent IBD issues with the goal of providing a plan of action from a provider within 4 hours of the call. Incoming patient calls were flagged with a red exclamation mark and labeled as “IBD URGENT” in our electronic medical record (eClinicalWorks) if they met any of the following criteria: new, severe abdominal pain;new, severe anal pain;fever greater than 101F;refractory emesis;or anything otherwise deemed urgent by the clinic nurses. Patients were then either advised to present to the ED for immediate evaluation, scheduled for same-day/next-day medical appointment +/- urgent labs, or received medical advice such as medication changes. The number (two-sample ttest) and triage (two-sample Z-test) of IBD URGENT calls were compared between pre-COVID (Jun 2018-Feb 2020) and post-COVID (Mar 2020-Sep 2021). RESULTS: A total of 366 IBD URGENT calls were received and 91% had a response from a provider within 4 hours (Figure 1). The average number of IBD URGENT calls received per month were comparable pre- and post-COVID (10 vs 9, p=0.32). From Mar 2020 onwards, 40% of IBD URGENT calls were managed by urgent appointments, 51% medical advice, and only 9% ED visits, which was comparable to pre-COVID (Table 1). CONCLUSION: It is reassuring that the COVID-19 pandemic did not cause any significant changes to the utilization and triage outcomes of the urgent IBD hotline system in our practice. Timely clinical operational changes to meet the needs of patients with the onset of the pandemic has allowed our proportion of ED visits to remain comparable to pre-COVID despite the decrease in in-person visits. As we return to normal operations, we plan to sustain our urgent hotline service by educating new staff and by reminding our patients of the IBD URGENT service. We believe this service improves quality of care for patients with IBD by avoiding unnecessary ED visits that often include overuse of Computer Tomography (CT) scans and prescription of steroids and narcotics-all associated with significant risks and financial costs.