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

BAKRI BALLOON CAN ALSO BE USED IN EMERGENCY AFTER C-HYST

INFLATABLE AORTIC BALLOON NEW AND PROMISING OPTION (REBOA CATHETER)

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%

COMPLETE SET COMMERCIALLY AVAILABLE

• 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

PHYSICIAN PROGRAMS, BOOKS, COUNSELLORS, COURSES, SCRIBES

GOOD PATIENT CARE:

EVIDENCE BASED MEDICINE IMPORTANTBUT SO ARE:

• COMPASSION• COMMUNICATION• CLINICAL JUDGEMENT• COMMON SENSE