Variables impacting prolonged post-anesthesia care unit length of stay in gynecologic cancer patients in the era of same day minimally invasive hysterectomy.

OBJECTIVES: Minimally invasive surgery for treatment of gynecologic malignancies is associated with decreased pain, fewer complications, earlier return to activity, lower cost, and shorter hospital stays. Patients are often discharged the day of surgery, but occasionally stay overnight due to prolonged post-anesthesia care unit (PACU) stays. The objective of this study was to identify risk factors for prolonged PACU length of stay (LOS). METHODS: This is a single institution retrospective review of patients who underwent minimally invasive hysterectomy for gynecologic cancer from 2019 to 2022 and had a hospital stay <24-h. The primary outcome was PACU LOS. Demographics, pre-operative diagnoses, and surgical characteristics were recorded. After Box-Cox transformation, linear regression was used to determine significant predictors of PACU LOS. RESULTS: For the 661 patients identified, median PACU LOS was 5.04 h (range 2.16-23.76 h). On univariate analysis, longer PACU LOS was associated with increased age (ρ = 0.106, p = 0.006), non-partnered status [mean difference (MD) = 0.019, p = 0.099], increased alcohol use (MD = 0.018, p = 0.102), increased Charlson Comorbidity Index (CCI) score (ρ = 0.065, p = 0.097), and ASA class ≥3 (MD = 0.033, p = 0.002). Using multivariate linear regression, increased age (R2 = 0.0011, p = 0.043), non-partnered status (R2 = 0.0389, p < 0.001), and ASA class ≥3 (R2 = 0.0250, p = 0.023) were associated with increased PACU LOS. CONCLUSIONS: Identifying patients at risk for prolonged PACU LOS, including patients who are older, non-partnered, and have an ASA class ≥3, may allow for interventions to improve patient experience, better utilize hospital resources, decrease PACU overcrowding, and limit postoperative admissions and complications. The relationship between non-partnered status and PACU LOS is the most novel relationship identified in this study.

"To prescribe or not to prescribe, that is the question": Perspectives on opioid prescribing for chronic, cancer-related pain from clinicians who treat pain in survivorship.

BACKGROUND: Opioid pain management in cancer survivorship is a complex and understudied topic. METHODS: The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2). RESULTS: The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences. CONCLUSIONS: Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.

Associations of Health Care Utilization and Therapeutic Alliance in Patients with Advanced Cancer.

Introduction: Therapeutic alliance (TA), or the extent to which patients feel a sense of caring and trust with their physician, may have an impact on health care utilization. We sought to determine if TA is associated with: (1) emergency department (ED) visits within 30 days of death and (2) hospice enrollment. Methods and Materials: This is a secondary analysis of data from a randomized clinical trial. We used restricted cubic splines to assess the relationship between TA scores and health care utilization. Results: Six hundred seventy-two patients were enrolled in the study, with 331 (49.3%) dying within 12 months. Patients with higher TA were less likely to have an ED visit in the last 30 days of life, but there was no evidence of a relationship between TA and enrollment in hospice. Conclusions: Higher TA was associated with decreased ED visits within 30 days of death. There was no association between TA and rates of hospice enrollment. Clinical Registration Number: NCT02712229.

Barriers to adequate pain control among women with cervical cancer: exploring unmet pain control needs in Ghana.

BACKGROUND: Pain because of cervical cancer is a significant health issue globally, especially in women with advanced disease. However, little is known about unmet needs for pain control in low-resource settings where the burden of cervical cancer is the greatest. OBJECTIVE: This study aimed to quantify the level of pain that women with cervical cancer in Ghana experience, explore attitudes toward pain and pain medications, and determine the barriers to adequate pain control. STUDY DESIGN: A cross-sectional survey was conducted on 100 adult women with a histopathologic diagnosis of cervical cancer presenting for care at Komfo Anokye Teaching Hospital in Ghana. In addition, a descriptive analysis was conducted among all participants and the subgroup of women who reported pain but did not report pain medication use. RESULTS: Among 100 participants with cervical cancer, the mean age was 59.5 years, and the median parity was 6.0 (interquartile range, 5.0-6.0); moreover, most participants presented with inoperable stage II or greater cervical cancer (99 of 100 [99%]). Of 100 participants, 80 (80%) had pain caused by their cervical cancer, with more than half (51 of 100 [51%]) rating their pain as a 3, 4, or 5 on a 5-point scale. Most participants reported pain significant enough to impact their sleep (58 of 99 [58.6%]) and their ability to carry out daily activities (54 of 100 [54%]). Furthermore, 55 of 100 participants (55%) took pain medications in the last week; however, only 5 of 54 participants (9.3%) reported complete improvement in their pain, and most participants (30 of 54 [55.6%]) felt they needed a stronger pain medication. Barriers to adequate pain control included the healthcare provider's focus on pain, with 14.1% of women reporting that their healthcare providers never asked about their pain (14 of 99 [14.1%]). In addition, participants' attitudes toward pain control demonstrated that 34 of 95 participants (35.8%) believed that they should be able to tolerate their cervical cancer pain without medication. Among participants who ever took pain medication, 16 of 58 (27.6%) were bothered that they took pain medication, and 19 of 58 (32.7%) were concerned that they used too much medication. Most participants were able to afford (51 of 58 [88%]) and access (56 of 58 [96.6%]) pain medications and did not worry their supply would run out (56 of 58 [96.6%]). CONCLUSION: Most patients had significant pain because of cervical cancer, and many of them endorsed needing more pain medications than what they were prescribed. The etiologies of the unmet need for pain control included missed opportunities to discuss pain control at clinic visits and patients' attitudes toward pain management. Financial and access barriers to obtaining pain medications were minimal.

Determinants of cervical cancer screening uptake among women with access to free screening: A community-based study in peri-urban Ghana.

OBJECTIVE: Cervical cancer can be prevented by regular screening; however, screening rates are low in developing countries. We evaluated the proportion of women screened, modalities of screening utilized, and factors influencing uptake among Ghanaian women with access to free screening services. METHODS: Participants were women aged 25-65 in Asokore-Mampong, Ghana. A structured questionnaire collected socio-demographic characteristics, risk factors, knowledge of, and utilization of cervical cancer screening. Adjusted logistic regression evaluated predictors of screening. RESULTS: Of 710 participants, the majority had heard of cervical cancer (64.6%) and screening (57.7%). Screening utilization was 24.6%. Visual inspection with acetic acid was the most common screening method (97.1%). For those who had never been screened, common reasons were believing they were healthy (21.7%), fearing pain (12.9%), lacking awareness of screening (11.8%), and being too busy (11.6%). Participants who were aged 35-44 (aOR 1.82; 95% CI 1.09-3.03; p = 0.023), married (aOR 3.98; 95% CI 1.68-9.40; p = 0.002), formally employed (aOR 9.31; 95% CI 2.86-30.35; p <0.001), and had higher cervical cancer knowledge (aOR 3.98; 95% CI 2.64-6.02; p <0.001) were more likely to have been screened. CONCLUSION: Despite geographic proximity to a health center that provides free cervical cancer screening, screening uptake among Ghanaian women remains low.

Factors associated with late-stage presentation of cervical cancer in Ghana.

Objective: To explore factors associated with late clinical presentation among Ghanaian women with cervical cancer. Design: This is a cross-sectional survey using a paper questionnaire. Setting: Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Participants: Participants were women presenting for cervical cancer care at KATH. Inclusion criteria were histologically diagnosed cervical cancer and age ≥18 years. The exclusion criteria was age <18. All women presenting from August 2018-August 2019 were recruited. Main outcome measures: The primary outcome was the proportion of participants presenting with late-stage cervical cancer, defined as stage II or higher. Results: Of 351 total participants, 33.6% were unemployed, 35.3% had no formal education, and 96.6% had an average monthly income of less than five hundred Ghana cedis ($86 USD). Time from symptoms to seeing a doctor ranged from fewer than two weeks (16.0%) to more than twelve months (8.6%). Participants' most common barrier in seeking healthcare was financial constraints (50.0%). Most participants presented at late-stage cervical cancer (95.2%, n=334), with only 4.8% (n=17) presenting at stage I. Of participants presenting with late-stage cervical cancer, the vast majority had never had a Papanicolaou (Pap) smear (99.1%) nor a recent gynecologic exam (99.3%). After adjusting for age, parity, and distance to a healthcare facility, a late-stage presentation was associated with lower income and living in a rural area. Conclusions: In Ghana, 95% of women with cervical cancer seek care at a late clinical stage, defined as stage II or greater, when the cancer is inoperable. Funding: None declared.

Attitudes, experiences, and training on comprehensive abortion care: A nationwide survey of trainee physicians in Ghana.

This cross-sectional study assessed attitudes and experiences with abortion care among physician trainees in Ghana. Participants were 27 Obstetrics/Gynecology (OBGYN) residents and 138 house officers. An electronic survey evaluated attitudes, training, clinical experience, and technical skills with abortion care. The majority of participants believe that women should have access to safe abortion. However, only 51.6% of OBGYN residents and 40.9% of house officers want to currently perform abortions as a trainee, primarily due to religious or ethical beliefs. Among house officers, increased likelihood of performing abortions in their future practice is associated with greater exposure to abortion training, (OR 1.40, p=0.032), fewer years practicing medicine (OR 0.26, p=0.010), and believing abortion laws should be liberalized (OR 3.62, p=0.03). Overall, we demonstrate that only two-thirds of physician trainees in Ghana are likely to perform abortion care after completing training, and greater exposure to abortion training is associated with an increased likelihood of performing abortions.

Using ThinPrep Papanicolaou test samples to evaluate sexually transmitted infection screening practices.

INTRODUCTION: We sought to evaluate the use of Papanicolaou samples as a screening tool for sexually transmitted infections (STIs). METHODS: Retrospective chart review analyzing Papanicolaou samples for STI. Samples were processed and results compared to clinical data to assess this technique's viability. Cases and controls were matched by sample date. Characteristics of women with STI testing were compared in bivariate analyses. RESULTS: We analyzed 50 STI-positive and 50 date-matched samples. Thirteen (26.0%) of the STI-positive patients were not screened at their visit. Women without STI screening were older (39.5 vs. 30.0 years, P = 0.001); non-Hispanic White (65.9% vs. 46.4%, P = 0.05); and married (60.0% vs. 26.9%, P = 0.005) than women with STI screening. Fifty-eight were offered and accepted STI testing at their visit; 37 samples were STI-positive: 17 (29.3%) Mycoplasma genitalium (Mgen), 10 (17.2%) chlamydia, 6 (10.3%) trichomoniasis, 1 (1.7%) gonorrhea, and 3 (5.2%) had two STIs. Among the 42 patients without STI testing, 12 (28.6%) had positive samples: 6 (14.3%) chlamydia, 5 (12.0%) Mgen, and 1 (2.4%) trichomoniasis. CONCLUSIONS: Over one-quarter of STI-positive patients were not screened; though low-risk by current screening criteria, a significant number may harbor untreated STIs; using Papanicolaou samples may allow for increased screening in this population.