RECENTLY PUBLISHED PAPERSIMPORTANT TO YOUR PRACTICE
JAMES R. SCOTT, MD
I have no conflict of interest to disclose.
OBJECTIVES
• TO BE FAMILIAR WITH PRACTICE CHANGING STUDIES IN PAST YEAR
• TO APPLY THIS INFORMATIONIN YOUR OWN PRACTICE
SELECTION OF STUDIES
• ONLY PRACTICAL NEW PAPERS FOR EVERYDAY PATIENT CARE
• AVOIDED ABOG MOC & OTHER TOPICS COVERED THIS WEEK
• BOTH OB & GYN
SCIENTIFIC PUBLISHING RAPIDLY CHANGING
• MEDICAL JOURNALS ON-LINE AND “PUBLISH AHEAD OF PRINT”
• ONLINE VERSIONS ONLY• SOCIAL MEDIA – TWITTER, FACEBOOK,
LINKEDIN, BLOGS, PODCASTS• READER BEWARE - MISLEADING
CONTENT & PREDATORY JOURNALS
JAMA 2017;318(14):1333-4, 1367-76
• 750 women ages 30-44• Trying to conceive • Biomarkers for Ovarian
Reserve: Anti-Mullerian hormone (AMH)
• Outcome: Conception rate by 6 and 12 cycles
• No difference in conception rate with low vs normal AMH levels
• CONCLUSION Caution Women About Using AMH to Assess Fertility
ONLINE COMMERCIAL FERTILITY TESTING
• NEW STARTUPS OFFERING THESE TESTS FOR “OVARIAN RESERVE”
• Anti-Mullerian Hormone (AMH), FSH • $149.00 – $325.00• Egg-Q, LetsGetChecked, Modern Fertility,
Future Family (and some fertility clinics)
PLAN TO CONTINUE DESPITE EVIDENCE AGAINST
JAMA 2017;318(21):2083-4.
MAIN CHANGES• NEW DEFINITION: BP >130/80 (instead
of >140/90)• TREATMENT target now lower• Antihypertensive drug Rx guided by BP
& presence of CV disease, diabetes, or >10% risk of developing CVD
• More emphasis on monitoring BP at home
IMPLICATIONS• No. of adults in US labled as hypertensive
suddenly increases from 32% to 46%• Additional 31 million will now need treatment• Increase in multiple drugs, some expensive HOWEVER - Meta-analysis just out showed
no decrease in CV events when BP lowered below 140/90 JAMA Intern Med 2018;178:28-36
WHAT SHOULD BE DONE?
MY TAKE QUESTION – How practical & feasible
in clinical practice? May increase falls & adverse events Wait to see how things settle out Common Sense Should Prevail –>
Discuss with patient & individualize
ACOG 2015 COMMITTEE OPINION ON PROPHYLACTIC SALPINGECTOMY
• 1 in 70 Lifetime risk of Ovarian CA• Majority of “Ovarian” Cancers Arise in
Distal Fallopian Tube• Salpingectomy Could Decrease Risk by 40%• *Exact Long-term Risks & Benefits Not Yet
Defined (needed RCTs will take many years)Approach to hysterectomy (Vaginal) should
NOT be influenced by theoretical benefit
FEASIBILITY OF SALPINGECTOMY WITH VAGINAL HYSTERECTOMY AJOG 2017;217(5):605-6
BOTTOM LINE• Vaginal salpingectomy
completed in 81%• 19% converted to
alternate route• Minimal complications
or increased time• Discuss with patient
preoperatively
ACOG NEW (2017) STATEMENT ON VAGINAL HYSTERECTOMY AND SALPINGECTOMY FOR OVARIAN CANCER PREVENTION
• Vaginal hysterectomy still approach of choicewhenever feasible.
• Can be safely performed in nulliparas and with history of one or more cesareans.
• Salpingectomy usually can be accomplished.
(LAVH another option)
PRESCRIPTION DRUG PROBLEMS 2018
• Public outrage at prices & huge profits• New cancer drugs $100,000-150,000 per year• 17OHP@ $300/preg Makena @ $15,000/preg• $Billions spent on advertising – more than R&D• TV advertising (not allowed anywhere in world
but U.S. and New Zealand)• Medicare can’t negotiate (Lobbyists)
WHAT CAN PHYSICIANS DO?
POLYPHARMACY AND DEPRESCIBING
• 1 in 5 older adults take 6 or more meds
• Patients and physicians overestimate benefits & underestimate harms
• Adverse reactions and impaired physical and cognitive function
• Do Periodic Medicine Reviews
• Discuss With Patient
STABILITY OF ACTIVE INGREDIENTS IN LONG-EXPIRED PRESCRIPTION MEDICATIONSArch Intern Med 2012;172(21):1685-7.
BOTTOM LINE• Drug expiration dates
typically range from 12-60 mo.
• Most retain full potency for decades
• Extending drug expiration dates could yield enormous health care savings
• Unopened Medications expired for 28-40 yrs
• Various analgesics, sleeping pills, tranquilizers
• Analyzed for potency• 86% still had
concentrations of at least 90%
FACTS
BOTTOM LINE• No reports in literature of
anyone harmed by any expired medication
• Huge waste• Safe to use• Useful for you & your
patients to know • *(Not advocating keeping
dangerous drugs around)
• Drug companies propose expiration date to FDA – Most expire in 2-3 years
• Hospitals destroy $800 million of outdated drugs per year
• With long-term care, pharmacies and consumer medicine cabinets in the $Billions
INITIAL PRESCRIPTIONS AND LONG-TERM OPIOID USE MMWR Morb Mortal Wkly Rep 2017;66:265-9.
• Likelihood of chronic use increases with each additional day
• Sharpest increase After 5th and 31st day on Rx
• Highest probability of dependence at 1 & 3 years:– 10 or 30 day supply– Second refill
• 80% Heroin addiction begins with Opioid prescription
Obstet Gynecol 2017;130(6):1261-8.
102 postoperative patients l Laparoscopic (43%)
Vaginal (41%) Abdominal (16%)
Median opioid prescribed: 40 tablets of 5 mg hydrocodone
Follow up X 2 Weeks
• Patients used approximately ½ of opioids prescribed
• Median excess – 22 unused tablets
• BOTTOM LINE: Twice amount of opioids were prescribed as patients needed
GUIDELINE FOR DISCHARGE OPIOID PRESCRIPTIONS AFTER SURGICAL PROCEDURES J Am Coll Surg 2017;130:1261-8. • Best predicted by usage
on day before discharge• None used (41%) No
prescription needed• 1-3 pills used (33%) 15
pills @ discharge• 4 or more pills used (26%) 30 pills @ discharge
• Would decrease amount of opioids by 40%
Message – Prescribe only minimal requiredTransfer to non-opioid pain med as soon as possible
LYMPHATIC – VENULE ANASTOMOSIS IN BREAST CANCER-RELATED LYMPHEDEMABreast Cancer Res Treat 2017;165(2):321-7.
• Microsurgical anastomosesbetween lymphatic and venoussystem
• Circumference reduced by 49%• Excess volume reduced by 57%• 54% discontinued compression
garmentsVery Effective in Reducing Arm Volume Difference and Improving QOL
LIPOSUCTION FOR LYMPHEDEMA NEJM 2017;377(18):1788-9.
SIMPLER PROCEDURE ALSO EFFECTIVE – SOME ARE NOW BEGINNING TO COMBINE PROCEDURES.
TRANEXAMIC ACID FOR POSTPARTUM HEMORRHAGEA systematic review and meta-analysis. Medicine 2017;96(1):579-88
• 25 ARTICLES, 4747 PTS• ALL RCTs WITH PLACEBO
CONTROLS • CESAREAN - REDUCED
BLOOD LOSS BY 141 ml• VAGINAL DELIVERY –
REDUCED BLOOD LOSS BY 41 ml
• NO INCREASED DVT OR SERIOUS SIDE EFFECTS
CONCLUSIONS• SAFE• “MODERATELY”
EFFECTIVE • ONLY IF GIVEN
WITHIN 3 HOURS OF DELIVERY
TRANEXAMIC ACID (TXA) FOR MANAGEMENT OF OBSTETRIC HEMORRHAGEObstet Gynecol 2017; 130:765-9
RECOMMENDATIONS• WHEN PPH DIAGNOSED, GIVE TXA EARLY AS
POSSIBLE - WITHIN 3 HOURS OF DELIVERY• DOSE: 1 GM IV & REPEAT IN 30 MINUTES IF
BLEEDING PERSISTS• NO EVIDENCE THAT TXA GIVEN BEFORE
DELIVERY EFFECTIVE IN PREVENTING PPH
PLACENTA ACCRETA-PERCRETATXA will not help in severe PPH
• Percreta will continue to increase
• Maternal deaths under-reported• Be prepared – Protocols• Catastrophic Uncontrolled
bleeding despite C-Hyst• All in DIC after 20-30 u blood• My advice – “Pack and go back”• New Options
OFF LABEL use –Not approved by FDA for this.
Now Being used by some as Umbrella Pack After C-Hyst• Fills to 700 ml• Cost - $400
EBB BALLOON SYSTEM COMMERCIALLY AVAILABLE
ENDOVASCULAR BALLOON OCCLUSION OF AORTA(REBOA) IN HEMORRHAGIC SHOCK. Systematic ReviewJ Trauma Acute Care Surg 2016;80(2):324-34.
NOTE: ALL PATIENTS WITH SEVERE PPH & PERCRETA SURVIVED
• 41 Studies: PPH (5), GI Bleeding (3), Pelvic Surgery (8), Trauma (15), Ruptured Aortic Aneurism (10)
• Total of 857 Critically Ill Patients: – In Shock – 75%– Increased Systolic BP by mean of 53 mm Hg– Overall mortality still 49%
• Word catheter (n=82) or Marsupialization (n=79)
• Word placed in office, Marsupialization in O.R.
• Pain scores comparableRECURRENCE RATE:
• Word – 10 (12%)• Marsupiaization – 8 (10%)
CONCLUSIONS• Comparable
recurrence rates • Word catheter
quicker & cheaper
BURNOUT ~ 50% OF OB/GYNs
59 yr old Hates to come to work Frustrated with system
DEFINITION• Emotional Exhaustion• Cynicism• Low sense of personal
accomplishment at work
CAUSES• EXCESSIVE WORKLOAD• EMR & CHARTING• RULES, REGULATIONS
& DOCUMENTATION• DECREASED TIME FOR
PATIENTS• WORKLIFE BALANCE• LOSS OF CONTROL
>300 PAPERS ON PHYSICIAN BURNOUT IN 2017Nothing so far has been very effective butwe better figure out what to do about it.
PRESENT SYSTEM UNSUSTAINABLEWHAT CAN BE DONE?
• Multipronged Approach
• Need Enlightened Leaders to change excessive profit orientation
• Return to purpose of medicine
• Stress management• Family & friends• Take a break – PARK
CITY SKI MEETING