Evidence-based prescribing of opioids after laparotomy: A quality-improvement initiative in gynecologic oncology.

Introduction: Across specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy. Methods: In 2021, open surgical gynecologic oncology patients were called 2-4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2-4 weeks after surgery to again assess their opioid use at home. Results: Data from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p < 0.01) and self-reported use of opioids at home decreased from 22.5 to 7.5 OME (p = 0.05). The refill rate did not differ (12.6 % pre- and 11.6 % post-intervention, p = 0.82). The surplus of opioids our patients reported having at home decreased from 1264 doses of 5 mg oxycodone tabs in the pre-intervention cohort, to 490 doses in the post-intervention cohort, a 61 % reduction. Conclusions: An evidence-based approach for prescribing opioids to patients after laparotomy decreased the surplus of opioids we introduced into our patients' communities without impacting refill rates.

Exploring the relationship between language, postoperative pain, and opioid use.

BACKGROUND: Racial and ethnic disparities in pain management are well documented. Differences in pain assessment and management by language have not been studied in the postoperative setting in gynecologic surgery. OBJECTIVE: This study aimed to investigate the association between language and immediate postoperative pain management by comparing pain assessments and perioperative opioid use in non-English speakers and English speakers. STUDY DESIGN: This was a retrospective cohort study comparing perioperative outcomes between non-English-speaking patients and English-speaking patients who had undergone a gynecologic oncology open surgery between July 2012 and December 2020. The primary language was extracted from the electronic medical record. Opioid use is expressed in oral morphine equivalents. Proportions are compared using chi-square tests, and mean values are compared using 2-sample t tests. Although interpreter services are widely available in our institution, the use of interpreters for any given inpatient-provider interaction is not documented. RESULTS: Between 2012 and 2020, 1203 gynecologic oncology patients underwent open surgery, of whom 181 (15.1%) were non-English speakers and 1018 (84.9%) were English speakers. There was no difference between the 2 cohorts concerning body mass index, surgical risk score, or preoperative opioid use. Compared with the English-speaking group, the non-English-speaking group was younger (57 vs 54 years old, respectively; P<.01) and had lower rates of depression (26% vs 14%, respectively; P<.01) and chronic pain (13% vs 6%, respectively; P<.01). Although non-English-speaking patients had higher rates of hysterectomy than English-speaking patients (80% vs 72%, respectively; P=.03), there was no difference in the rates of bowel resections, adnexal surgeries, lengths of surgery, intraoperative oral morphine equivalents administered, blood loss, use of opioid-sparing modalities, lengths of hospital stay, or intensive care unit admissions. In the postoperative period, compared with English-speaking patients, non-English-speaking patients received fewer oral morphine equivalents per day (31.7 vs 43.9 oral morphine equivalents, respectively; P<.01) and had their pain assessed less frequently (7.7 vs 8.8 checks per day, respectively; P<.01) postoperatively. English-speaking patients received a median of 19.5 more units of oral morphine equivalents daily in the hospital and 205.1 more units of oral morphine equivalents at the time of discharge (P=.02 and P=.04, respectively) than non-English-speaking patients. When controlling for differences between groups and several factors that may influence oral morphine equivalent use, English-speaking patients received a median of 15.9 more units of oral morphine equivalents daily in the hospital cohort and similar oral morphine equivalents at the time of discharge compared with non-English-speaking patients. CONCLUSION: Patients who do not speak English may be at risk of undertreated pain in the immediate postoperative setting. Language barrier, frequency of pain assessments, and provider bias may perpetuate disparity in pain management. Based on this study's findings, we advocate for the use of regular verbal pain assessments with language-concordant staff or medical interpreters for all postoperative patients.

The past, present, and future of opioid prescribing: Perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021.

Objective: To describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates. Methods: Part one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge. Results: 1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients. Conclusion: Inpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients' actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.

Postoperative narcotic use in patients with ovarian cancer on an Enhanced Recovery After Surgery (ERAS) pathway.

OBJECTIVES: To determine the impact of an ERAS pathway on post-discharge narcotic use for patients with ovarian cancer undergoing open surgery. METHODS: This was a retrospective cohort study of women who underwent open ovarian cancer surgeries in 2014 prior to ERAS ("pre-ERAS") and in 2016/2018 after ERAS was instituted ("ERAS"). Patients taking chronic narcotics were excluded. A statewide prescription monitoring program was used to identify narcotic prescriptions filled in the three months after surgery. Quantity of narcotic medication is referenced in morphine milligram equivalents (MME). RESULTS: 42 pre-ERAS and 94 ERAS patients were included. The groups were similar in age, BMI, diabetes, tobacco use, mean number of prior abdominal/pelvic surgeries, and advanced stage disease. ERAS patients had a shorter hospital stay (6.7 days pre-ERAS vs 4.2 days ERAS, p = 0.003), used less narcotic in the 24 h prior to discharge (74.0 MME pre-ERAS vs 25.8 MME ERAS, p = 0.002), and filled prescriptions at time of discharge for less narcotic (519.9 MME pre-ERAS vs 339.7 MME ERAS, p = 0.011). After hospital discharge, ERAS patients filled fewer additional prescriptions (52.4% pre-ERAS, vs 29.4% ERAS, p = 0.012). In total, ERAS patients filled prescriptions for 55% fewer narcotics in the three months after surgery than the pre-ERAS group (1101.4 MME pre-ERAS vs 492.1 MME ERAS, p < 0.001). CONCLUSIONS: Institution of an ERAS protocol appears to decrease the narcotic needs of patients in the three months after ovarian cancer surgery.

Intraperitoneal ports placed at the time of bowel resection for treatment of ovarian cancer: Complications and surgical outcomes.

OBJECTIVES: To determine if intraperitoneal (IP) ports placed concurrently with bowel resection during surgical treatment of ovarian cancer is associated with more complications than those ports placed without concurrent bowel resection. METHODS: The medical records of all patients who had an IP port placed at our institution between 2005 and 2016 were reviewed. Two groups were analyzed: IP ports placed with bowel resection (IP-BR) and those without (IP). RESULTS: Of 306 patient charts reviewed, 31% had a surgery with IP port placement and concurrent bowel resection (IP-BR). Demographics were similar except for mean BMI (25.6 IP-BR vs 27.4 IP, p = 0.007). More IP-BR patients had stage IIIC disease (83.3% IP-BR vs 56.9% IP, p ≤0.01). Patients were cytoreduced to R0 in 48.7% IP-BR vs 56.4% IP (p = 0.253). For adjuvant treatment, IV chemotherapy was administered before IP chemotherapy in 90.4% IP-BR (median 2 cycles), and 50.3% IP, (median 2 cycles, p < 0.01). Ultimately 80.2% IP-BR (median 4 cycles) and 77.8% IP (median 5 cycles) received IP chemotherapy (p = 0.65). Rates of total IP port complications were similar (19.2% IP-BR vs 23.2% IP, p = 0.397), including IP port infections (0% IP-BR vs 0.7% IP, p = 0.5). Eleven percent of IP-BR patients had a bowel complication (e.g. obstruction or perforation) while IP port was in situ vs 2.7% IP (p = 0.01). Only 2.7% IP-BR and 6% IP discontinued IP chemotherapy due to IP port complication (p = 0.3). CONCLUSIONS: Patients who have IP ports placed concurrently with a bowel resection do not appear to have more complications, nor lower rates of IP chemotherapy administration.

Urinary fistula and incontinence.

It is estimated that as many as 3.5 million women worldwide suffer from obstetric urinary fistula. This public health tragedy is a result of obstructed labor and inadequate access to health care, and its eradication lies in prevention and treatment. Efforts at prevention should be made through targeted education and public intervention for improved nutrition, access to health care, and women's social status. Diagnosis and treatment in limited resource settings can occur, and there are specific recommendations regarding nonsurgical and surgical approaches to care. Treatment success may be complicated by social, psychological, and clinical factors, with reintegration a primary concern for this group of women.

Giving Voice to the Experiences of Rwandan Women With Urogenital Fistula.

BACKGROUND: Urogenital fistula is a debilitating condition that women can develop following obstructed labor. The primary objective of this study was to reveal illness narratives of Rwandan women with urogenital fistula to appreciate their unique experiences. The secondary aim was to identify common themes that emerged when women discussed their experiences living with fistula. METHODS: Women presenting for urogenital fistula repair at Kibagabaga Hospital were asked to participate in the study. Eleven participants were asked questions designed to elicit their understanding of their condition and the social and emotional consequences of their fistula. All interviews were anonymous. Transcribed interviews were examined for relative themes to categorize responses into larger domains. FINDINGS: Common themes were identified from the interviews on topics of what barriers existed to having a successful delivery, the socioeconomic and psychosocial consequences of developing a fistula, and each woman's understanding of her fistula. Excerpts from patients' illness narratives illustrated these themes. CONCLUSIONS: These narratives can be used to appreciate the variations in each woman's understanding of her medical condition and the changes that occurred in her life as a result of her fistula. Through patients' narratives, physicians can improve their appreciation of cultural differences to design targeted educational and preventive interventions.

Demographic and delivery characteristics associated with obstetric fistula in Kigali, Rwanda.

OBJECTIVE: To assess the characteristics of Rwandan women undergoing surgical correction of obstetric fistula. METHODS: A retrospective, cross-sectional study was conducted of women undergoing surgery to repair obstetric fistula as part of a program run by the International Organization for Women and Development in Kigali, Rwanda, between April 1, 2010, and February 28, 2011. Data were collected from medical records, including demographics, obstetric history, and results of the physical examination. RESULTS: A total of 65 women underwent fistula surgery in the study period. Among 59 women for whom relevant data were available, 43 (73%) reported that the fetus did not survive the pregnancy during which the fistula developed. Delivery had occurred in a healthcare facility for 49 (82%) of 60 women. Delivery was by cesarean in 31 (48%) women included in the analyses. Cervicovesical or uterovesical fistula occurred more frequently among women who underwent cesarean delivery (9 [29%]) than among those who underwent vaginal delivery (3 [9%] of 34; P=0.04). There was no difference in the number of fetal or neonatal deaths between the two groups (P=0.2). CONCLUSION: Approximately half of the women in the sample delivered by cesarean, and these women were more likely to have a fistula involving the uterus or cervix.

Epidemiologic profile of women presenting to the National Hospital of Niamey, Niger for vaginal fistula repair.

OBJECTIVE: To describe the epidemiologic profile of women with vaginal fistulas presenting to the surgical mission trips of the International Organization for Women and Development (IOWD) at the National Hospital of Niamey, Niger. METHODS: In a cross-sectional retrospective study, data were assessed from a database of women who attended the IOWD at the National Hospital of Niamey, Niger, from October 2003 to April 2009. The database was compiled from the history and physical examination forms for each patient visit. RESULTS: During the study period, there were 1323 data entries and 896 initial patient visits. Overall, 580 women presented with obstetric fistulas. The median age was 29 years; the mean age at marriage was 16 years; 73.7% were married. The median age at first delivery was 18 years; the mean number of past full-term pregnancies was 3; the mean parity was 4. Vaginal (66.3%) or cesarean (27.7%) delivery was a common predisposing factor for developing an obstetric fistula. Overall, 97.4% of women labored for 24 hours or more; 75.4% delivered in hospital; 82.9% had a stillbirth. CONCLUSION: Women presenting to the IOWD for fistula repair have specific epidemiologic characteristics. Better understanding of these characteristics might help to formulate future public health programs for fistula prevention.

Yellow fever vaccine seroconversion in travelers.

To assess immunity after yellow fever (YF) 17D live-attenuated vaccination, we measured the antibody levels before vaccination and at 21 days and 8 months after vaccination in YF-naïve travelers. Thirty subjects were enrolled in the study, with 100% providing sera at 21 days and 86.6% providing sera at 8 months. All subjects seroconverted by day 21, and the geometric mean titers of the anti-YF antibodies decreased between day 21 and month 8 from 6,451 to 1,246. This study corroborates the high rates of seroconversion achieved by the live-attenuated YF vaccine.