ABSTRACT
This cross-sectional study assesses whether populations in socioeconomically disadvantaged regions in the US lack timely access to pediatric trauma centers.
Subject(s)
Health Services Accessibility , Trauma Centers , Wounds and Injuries , Humans , Trauma Centers/statistics & numerical data , Wounds and Injuries/epidemiology , Child , United States/epidemiology , Socioeconomic Factors , Adolescent , Male , Female , Child, Preschool , Socioeconomic Disparities in HealthABSTRACT
INTRODUCTION: Malignant bowel obstruction (MBO) is a common complication of patients with advanced malignancies and has poor prognosis. Currently, there are limited guidelines for MBO management or predicting outcomes for these patients. OBJECTIVE: To identify patient factors associated with readmission and mortality after hospital admission for MBO. PARTICIPANTS: A 5-year retrospective review was performed from 2017 to 2022 at a single tertiary institution to evaluate patients admitted for MBO. All patients had advanced cancer of gastrointestinal or gynecologic primary. Patient demographics, socioeconomic factors, tumor characteristics, and inpatient outcomes were collected. Multivariable analyses were performed to determine variables predicting hospital readmission for recurrent MBO and 90-day mortality. RESULTS: 210 patients were included. Mean age was 61 years, 28% were male, and 19% did not primarily speak English. 35% of patients lived over 50 miles from the hospital. On multivariable analysis, non-English speaking patients exhibited increased risk of readmission for MBO (OR = 2.82, P = .039). Older age was associated with decreased risk for MBO readmission (OR = .96, P = .007). Ascites was associated with increased mortality (OR = 2.17, P = .043). Earlier palliative care (PC) consultation predicted decreased readmission (OR = .24, P < .001) yet increased mortality at 90 days (OR = 3.20, P = .003). CONCLUSION: Patient age, primary language, and PC consult were predictors for MBO readmission, which may impact 90-day mortality. Given the palliative nature of MBO, modifiable factors such as PC consultation and multidisciplinary goals of care discussions should be prioritized in order to reduce readmissions and focus on quality of life (QOL) for this patient population.
Subject(s)
Intestinal Obstruction , Patient Readmission , Humans , Male , Female , Intestinal Obstruction/mortality , Intestinal Obstruction/etiology , Middle Aged , Patient Readmission/statistics & numerical data , Retrospective Studies , Aged , Risk Factors , Palliative Care , Gastrointestinal Neoplasms/complications , Gastrointestinal Neoplasms/mortality , Age FactorsSubject(s)
Cytoreduction Surgical Procedures , Enhanced Recovery After Surgery , Hyperthermic Intraperitoneal Chemotherapy , Pain Management , Pain, Postoperative , Humans , Cytoreduction Surgical Procedures/methods , Pain, Postoperative/etiology , Pain, Postoperative/therapy , Hyperthermic Intraperitoneal Chemotherapy/methods , Pain Management/methods , Combined Modality Therapy , Peritoneal Neoplasms/therapy , Peritoneal Neoplasms/secondary , PrognosisABSTRACT
BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center. METHODS: A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs). RESULTS: A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012). CONCLUSIONS: ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.
Subject(s)
Analgesics, Opioid , Cytoreduction Surgical Procedures , Enhanced Recovery After Surgery , Hyperthermic Intraperitoneal Chemotherapy , Pain Management , Pain, Postoperative , Peritoneal Neoplasms , Humans , Female , Male , Retrospective Studies , Middle Aged , Pain, Postoperative/etiology , Pain, Postoperative/therapy , Peritoneal Neoplasms/therapy , Pain Management/methods , Analgesics, Opioid/administration & dosage , Analgesics, Opioid/therapeutic use , Follow-Up Studies , Combined Modality Therapy , Prognosis , Aged , Analgesia, Epidural/methodsABSTRACT
This cross-sectional study examines burn incidence rates and accessibility of American Burn Associationverified or self-designated burn centers from 2013 to 2019.
Subject(s)
Burns , Health Services Accessibility , Humans , Burns/therapy , United StatesABSTRACT
BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are complex operations for the treatment of peritoneal metastases. Enhanced recovery after surgery (ERAS) protocols are intended to standardize preoperative, intraoperative, and postoperative pathways, with the goal of improving patient care. This study describes feasibility and outcomes after implementing an ERAS protocol for CRS/HIPEC at a tertiary academic center. METHODS: A single-institution experience of CRS/HIPEC was reviewed from January 2020 to March 2023. Patients were categorized according to whether they underwent CRS/HIPEC before or after ERAS initiation. Outcomes and protocol adherence were evaluated. RESULTS: A total of 115 CRS/HIPEC operations were included-74 before and 41 after ERAS implementation. Median age was younger in the post-ERAS group, whereas sex, comorbidities, peritoneal carcinomatosis index, operation performed, and operative time were similar between groups. The most common primary cancer sites were gynecologic (40%), appendiceal (24%), and colorectal (22%). Adherence to all postoperative ERAS components was 76%. More post-ERAS patients ambulated by postoperative day (POD) 1 (90% vs. 54%; p < 0.001), tolerated liquid diet by POD 2 (88% vs. 32%; p < 0.001), and had foley removed by POD 3 (86% vs. 43%; p < 0.001). There was a trend toward decreased length of stay in the post-ERAS cohort (7 vs. 8 days; p = 0.092), with no difference in major complications, intensive care unit admission, or 30-day readmission. CONCLUSIONS: Despite the heterogeneity of CRS/HIPEC operations, implementing an ERAS protocol for our patients was feasible and resulted in postoperative outcomes and adherence comparable with that of other major abdominal surgeries. This supports the potential for success in ERAS programs for CRS/HIPEC patients.