recently published papers important to your practice james r. scott, md i have no conflict of...
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RECENTLY PUBLISHED PAPERS IMPORTANT TO YOUR PRACTICE RECENTLY PUBLISHED PAPERS IMPORTANT TO YOUR PRACTICE
JAMES R. SCOTT, MD
I have no conflict of interest to disclose.
OBJECTIVES OBJECTIVES
TO BE FAMILIAR WITH PRACTICE CHANGING STUDIES IN PAST YEAR
TO ANTICIPATE INTENDED AND UNINTENDED CONSEQUENCES
TO APPLY THIS INFORMATION
IN YOUR OWN PRACTICE
MY TOP STUDIES FOR 2014 THAT WILL AFFECT OR CHANGE YOUR PRACTICEMY TOP STUDIES FOR 2014 THAT WILL AFFECT OR CHANGE YOUR PRACTICE
GENERAL THEMES WERE SAFETY, QUALITY BASED ON EVIDENCE & COST
SELECTED ONLY PRACTICAL NEW PAPERS FOR EVERYDAY PATIENT CARE
1/2 OBSTETRICS & 1/2 GYNECOLOGY CHALLENGE: TO TRANSLATE IMPERSONAL
& DOGMATIC STATISTICS INTO INDIVIDUALIZED CARE OF REAL PEOPLE
CHOOSING WISELY INITIATIVEJoint Commission, >50 National Medical SocietiesCHOOSING WISELY INITIATIVEJoint Commission, >50 National Medical Societies
PAPER/ABSTRACT/ DEFINITION OF
OVERUSE
DEFINITION OF OVERUSE
TESTS OR TREATMENTS
THAT PROVIDE NO
BENEFIT TO PATIENTS,
POTENTIALLY EXPOSING
THEM TO HARM
TRULY NECESSARY FREE FROM HARM NOT DUPLICATIVE SUPPORTED BY
EVIDENCEE
LAST YEAR ACOG LIST – PHYSICIANS SHOULD STOP DOING: LAST YEAR ACOG LIST – PHYSICIANS SHOULD STOP DOING:
Elective inductions or Cesareans before 39 wks Elective inductions between 39-41 wks unless
cervix is favorable Routine annual Pap tests in women age 30-65 Treating patients with mild dysplasia less than
2 years duration Screening for ovarian cancer in women at
average risk http://www.choosingwisely.org
DON’T: Use Terbutaline for > 48 hrs to prevent
preterm birth Use Robotic surgery when not indicated Perform pelvic ultrasounds in asymptomatic
non-pregnant women Perform urodynamic testing in women with
simple SUI Prescribe bed rest during pregnancy Routinely Transfuse for Hb over 7 g/dl
HEADS UP: CURRENTLY UNDER CONSIDERATION FOR SECOND LISTHEADS UP: CURRENTLY UNDER CONSIDERATION FOR SECOND LIST
PROPHYLACTIC ANTIBIOTICS FOR CESAREAN Obstet Gynecol 2014;124(2):338.PROPHYLACTIC ANTIBIOTICS FOR CESAREAN Obstet Gynecol 2014;124(2):338.
BOTTOM LINE
• Only 59% Received Appropriate Pre-Op Antibiotics
• 3.2% Got Wrong Dose or Wrong Antibiotic
SIGNIFICANCE
• Post Op Infections Cost $10,000 (Ave) and > Hospital Stay
• Proper Prophylaxis Lowers Infection Rates by 65% MPT 0P
INFECTIONS COST >$L STAY
PROPE LOWERS INF
CLINICALLY IMPORTANT CLINICALLY IMPORTANT
SIMPLE REGIMEN– 1 GM IV OF CHEAPEST CEPHALOSPORIN
(ex. Cefazolin/Ancef) BEFORE SKIN INCISION FOR ALL HYSTERECTOMIES & CESAREANS
– USE 2 GM FOR OBESE PT – ADD 1 GM AT 3 HOURS or WITH >1500 ML
BLOOD LOSS “TIME OUT” CHECKLIST CHECK OUT YOUR HOSPITAL -
MONITORED BENCHMARK
AN ASIDE – RECENT FDA WARNINGS FOR ANTIBIOTICS TO KNOW ABOUTAN ASIDE – RECENT FDA WARNINGS FOR ANTIBIOTICS TO KNOW ABOUT
AZITHROMYCIN (ZITHROMAX) – Can Prolong QT Interval Arrhythmia & Death (rare)
FLOURIQUINOLONES Such as CIPROFLOXIN (CIPRO) Can Cause Acute Neuropathy
CLARIYTHROMYCIN (BIAXIN) Combined with Calcium-Channel Blockers (PROCARDIA) can cause Kidney Damage, Hypotension & Death
THE ONGOING VBAC SAGA BJOG Jan 2014 ur After Caesarean Delivery: Evidence and Experience. BJOG Jan 2013 (insert exact reference)
ANOTHER CONSEQUENCE OF HIGH CESAREAN RATEIntrapartum Management Similar to Pt Without Previous Cesarean EXCEPT:
– Induction with Unripe Cervix
– Oxytocin Stimulation– Surveillance for
Uterine Rupture
UNIVERSITY OF UTAH UNIVERSITY OF UTAH
33 YR OLD G-6 P-4 @ 40 WKS CESAREAN WITH LAST DELIVERY WANTS VBAC IN LABOR ABNORMAL FHR TRACING EMERGENCY CESAREAN DELIVERED
IN ~15 MINUTES BABYS: APGARS - 0,3,4 CORD pH 6.76 NBICU – COOLING PROTOCOL
MEDIA: VBAC REFUSALS CUT OPTIONS The New York Times April 14, 2014
MEDIA: VBAC REFUSALS CUT OPTIONS The New York Times April 14, 2014
CASPER, WYO. – When Marie became pregnant again, she wanted a VBAC. But she quickly learned that the only full-service hospital within easy driving distance (in Casper) had a policy against VBACs. So she traveled 180 miles to a hospital in Cheyenne willing to perform the procedure.
MY VIEW MY VIEW
VBAC REMAINS DILEMMA WITH NO PERFECT ANSWER
SUPPORT VBAC BUT BE CAREFUL EVALUATE, COMMON SENSE, JUDGEMENT ITS ALL ABOUT UTERINE RUPTURE – RARE
BUT CAN BE DEVASTATING FOR MOTHER, BABY (AND PHYSICIAN)
HOW MUCH RISK WILLING TO ASSUME? BE PREPARED AND BE AROUND
SOLUTION: PREVENT FIRST CESAREANObstet Gynecol 2014;(3):693-711.
BOTTOM LINE• Active Labor Begins at
6 cm Cervical Dilation
(not 4 cm)• Arrest of Labor Use
Pitocin• At least 4 hours of
Adequate Contractions• Second Stage – Allow
Multips to Push for at Least 2 hours & Primips for at Least 3 hours
GROWING CONSENSUS GROWING CONSENSUS
TOO MANY UNNECESSARY CESAREANS HARD TO BELIEVE THAT 33% OF WOMEN
NEED TO BE DELIVERED ABDOMINALLY COMING BACK TO HAUNT US WITH
ACRETAS & MATERNAL MORBIDITY MY PREDICTION - WILL TAKE YEARS
FOR BACKLASH & DOCS TO START DOING SOMETHING TO LOWER RATE
BETTER TO START NOW
INCREASING PROBLEM:PLACENTA ACCRETAINCREASING PROBLEM:PLACENTA ACCRETA
FALLOPIAN TUBE IS ORIGIN OF MANY OVARIAN CANCERS AJOG 2013;209(5):409-14.ancer. AJOG 2013;209(5):409-14.
TOTAL SALPINGECTOMY AT HYSTERECTOMY AND TUBAL STERILIZATIONAJOG 2014;210:471-82
• Hysterectomy with Salpingectomy or Salpingectomy instead of T.L. vs Controls
• 43,931 Women• Increased O.R. Time
by 10-16 min.• Safe – No Increased
Complications over Control Group
IMPLICATIONS: CONSIDER SALPINGECTOMY IMPLICATIONS: CONSIDER SALPINGECTOMY
1 in 70 Lifetime risk of Ovarian CA No Effective Screening Majority of “Ovarian” Cancers Arise in
Distal Fallopian Tube Salpingectomy Could Decrease Risk by 40% Exact Long-term Risks and Benefits Not Yet
Defined DISCUSS WITH PATIENT
MALIGNANCY IN ENDOMETRIAL POLYPS (1027 Cases) Europ J Obstet Gynecol Reprod Biol 2014;(Oct 29)
• pi BOTTOM LINE• Benign – 95.8%• Pre-Malignant – 2.7%• Malignant – 1.54%• NOTE: HIGHER THAN
PREVIOUSLY THOUGHT
• Post Menopausal Women at Greater Risk & Greater Risk for Endometrial Cancer
MERINA IUD AS CONSERVATIVE Rx FOR ENDOMETRIAL HYPERPLASIA AND EARLY CANCER BJOG 2014;121:477-86.
• BOTTOM LINE• Option for Fertility
Preservation in Young Women
• Excellent response & regression rate (100%) at 6 mo.
• Works well in hyperplasia, less so in endometrial cancer
• All Need Close Monitoring• & Endometrial Sampling
DISSEMINATION OF BENIGN DISEASE AFTER MORCELLATION REQUIRING CYTOREDUCTIVE SURGERY Obstet Gynecol 2014; Dec 5 online
3 CASES• Symptoms 6-12 mo. Postop • Abdominal Pain, GI & GU Sx,
Bowel Obstruction• Masses & Widespread
Intraperitoneal Implants on Imaging
• Required Exploratory Laparotomy & Radical Surgery
RESECTED SPLEEN &THREE ATTACHED“MORCELLOMAS”
BOTTOM LINE
• Morcellator Can Spread Endometriosis, Benign Leiomyomatous Tissue
• Looks Like Malignancy• Serious Complication• Requires Radical
Surgery and Extensive Cytoreduction
LIVE BIRTH AFTER UTERINE TRANSPLANTATIONThe Lancet 2014; (Oct 5): 6736(14):61728-1.
• BOTTOM LINE• Infertility from congenital
absence of uterus or previous hysterectomy
• Ethical issues - immunosuppression
• Difficult Surgery IVF • 9 transplanted, 2 rejected• 3 pregnancies so far
SURGICAL TECHNIQUE
PREVIEW OF THINGS TO COME POINT-OF-CARE HANDHELD ULTRASOUND PREVIEW OF THINGS TO COME POINT-OF-CARE HANDHELD ULTRASOUND
SUPERIOR TO PHYSICAL
EXAM: First Year Medical
Students Outperformed Board Certified Cardiologists Using Stethascope in Diagnosing Cardiac Abnormalities
? SAME FOR FUTURE PELVIC & OB EXAMS
NEJM 2014;370(12):1083s
“POCKET” ULTRASOUND MACHINES “POCKET” ULTRASOUND MACHINES
CONSIDERATIONSCONSIDERATIONS
Cost ~ $8000 @ Present Resistance From Radiology Requires Training & Experience “Incidentalomas” Few Studies Yet to Prove Value
Medical Schools Already Incorporating Probably Improve Diagnostic Skills Physicians & Patients Like It
GOOD PATIENT CARE:
EVIDENCE BASED
MEDICINE IMPORTANT
BUT SO ARE: ACCESS COMPASSION COMMUNICATION CLINICAL
JUDGEMENT COMMON SENSE
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