Otolaryngology Needs in a Free Clinic Providing Indigent Care.

OBJECTIVES/HYPOTHESIS: To determine the otolaryngology needs in a free clinic providing care to medically indigent patients, as perceived by the patients and health care providers. STUDY DESIGN: Cross-sectional survey. METHODS: A survey was administered to patients and health care providers of a free clinic from September 2014 through January 2015 in an urban, inner-city location. RESULTS: One hundred and thirty-seven patients (35.8% male, age 50.8 ± 13.0 years) completed the survey. Mean household income was $29,838 ± $10,425; 32.1% spoke English; 54.7% were employed; 10.2% had health insurance; and 37.2% had seen a primary care provider outside of the free clinic. The top three otolaryngology symptoms among patients were sleep apnea/snoring (39.4%), heartburn/reflux (30.7%), and dizziness (29.9%). Eleven health care providers (45% male, age 50.5 ± 15.3 years, 63.6% physician, 36% nurse) completed the survey. Providers perceived the following otolaryngology complaints as the most prevalent, in descending order: cough, nasal congestion, reflux/heartburn, sore throat, and ear infection/otalgia. Providers felt that sleep apnea and hearing loss were the less common otolaryngology complaints, whereas surveyed patients indicated these symptoms with high frequency. The most requested diagnostic tool among patients and providers was chest X-rays. CONCLUSION: There are unmet otolaryngology needs in a free clinic. Medically indigent patients have significant barriers to accessing health care. Patient and provider perceptions of top otolaryngology complaints differed, but both identified access to chest X-rays as a major unmet need. Knowledge of patient perceptions may help providers elicit the breadth of otolaryngology complaints. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1321-1326, 2016.

Thromboprophylaxis and major oncologic surgery performed with epidural analgesia.

OBJECTIVE: To evaluate clinical outcomes in patients with cancer undergoing major abdominal surgery who received preoperative indwelling epidural catheters (ECs) and no postoperative thromboprophylaxis. DESIGN: Retrospective analysis of a prospective database. SETTING: Tertiary referral medical center. PATIENTS Between January 1, 2009, and July 31, 2011, 119 patients, with a mean age of 64.5 years (range, 34-95 years), underwent major abdominal oncologic surgery with an indwelling EC. MAIN OUTCOME MEASURES: Records of all patients were reviewed for age, duration of surgery, hospital length of stay, and clinical outcomes. All patients underwent lower extremity venous duplex ultrasonography prior to hospital discharge. RESULTS: The average operative time was 338 minutes. Mean (SD) intensive care unit stay was 2.8 (1.4) days (range, 1-7 days). Patients ambulated by postoperative day 1 or 2. Most ECs were removed on postoperative day 4. There were no major complications from the EC. Fifty-two patients (44%) were treated with deep venous thrombosis prophylaxis on postoperative day 4 after removal of the EC. Lower extremity duplex studies showed 8 patients (6.7%) had an acute thrombus. One patient (0.8%) developed an asymptomatic proximal deep venous thrombosis and 7 patients (5.9%) developed distal superficial thrombi. No patient developed a pulmonary embolus. CONCLUSIONS Thromboembolic complications following major abdominal surgery for cancer may be reduced with the use of ECs. Epidural catheters may directly prevent deep venous thrombosis through sympathetic blockade, resulting in increased blood flow to the lower extremities. This effect may also be attributable to earlier ambulation. These results suggest that patients who have an EC and do not receive concurrent postoperative thromboprophylaxis do not have an increased risk for thromboembolic events.