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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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INCREASING PROBLEM:PLACENTA ACCRETAINCREASING PROBLEM:PLACENTA ACCRETA
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FALLOPIAN TUBE IS ORIGIN OF MANY OVARIAN CANCERS AJOG 2013;209(5):409-14.ancer. AJOG 2013;209(5):409-14.
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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
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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
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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
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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
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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
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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
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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
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SURGICAL TECHNIQUE
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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
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“POCKET” ULTRASOUND MACHINES “POCKET” ULTRASOUND MACHINES
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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
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GOOD PATIENT CARE:
EVIDENCE BASED
MEDICINE IMPORTANT
BUT SO ARE: ACCESS COMPASSION COMMUNICATION CLINICAL
JUDGEMENT COMMON SENSE