RECENTLY PUBLISHED PAPERS IMPORTANT TO YOUR PRACTICE JAMES R. SCOTT, MD

Transcription

1 RECENTLY PUBLISHED PAPERS IMPORTANT TO YOUR PRACTICE JAMES R. SCOTT, MD I have no conflict of interest to disclose.

2 OBJECTIVES TO BE FAMILIAR WITH PRACTICE CHANGING STUDIES IN PAST YEAR TO APPLY THIS INFORMATION IN YOUR OWN PRACTICE

3 SELECTION OF STUDIES ONLY PRACTICAL NEW PAPERS FOR EVERYDAY PATIENT CARE AVOIDED ABOG MOC & OTHER TOPICS COVERED THIS WEEK BOTH OB & GYN

4 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

5 JAMA 2017;318(14):1333-4, women ages 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

6 ONLINE COMMERCIAL FERTILITY TESTING NEW STARTUPS OFFERING THESE TESTS FOR OVARIAN RESERVE Anti-Mullerian Hormone (AMH), FSH $ $ Egg-Q, LetsGetChecked, Modern Fertility, Future Family (and some fertility clinics) PLAN TO CONTINUE DESPITE EVIDENCE AGAINST

7 MAIN CHANGES JAMA 2017;318(21): 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

8 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

9 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

10 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

11 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

12 ACOG NEW (2017) STATEMENT ON VAGINAL HYSTERECTOMY AND SALPINGECTOMY FOR OVARIAN CANCER PREVENTION Vaginal hysterectomy still approach of choice whenever feasible. Can be safely performed in nulliparas and with history of one or more cesareans. Salpingectomy usually can be accomplished. (LAVH another option)

13 PRESCRIPTION DRUG PROBLEMS 2018 Public outrage at prices & huge profits New cancer drugs $100, ,000 per year $300/preg $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?

14 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

15 STABILITY OF ACTIVE INGREDIENTS IN LONG- EXPIRED PRESCRIPTION MEDICATIONS Arch Intern Med 2012;172(21): Unopened Medications expired for yrs Various analgesics, sleeping pills, tranquilizers Analyzed for potency 86% still had concentrations of at least 90% BOTTOM LINE Drug expiration dates typically range from mo. Most retain full potency for decades Extending drug expiration dates could yield enormous health care savings

16 FACTS 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 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)

17 INITIAL PRESCRIPTIONS AND LONG-TERM OPIOID USE MMWR Morb Mortal Wkly Rep 2017;66: Likelihood of chronic use increases with each additional day Sharpest increase After 5 th and 31 st 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

18 Obstet Gynecol 2017;130(6): 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

19 GUIDELINE FOR DISCHARGE OPIOID PRESCRIPTIONS AFTER SURGICAL PROCEDURES J Am Coll Surg 2017;130: Best predicted by usage on day before discharge None used (41%) No prescription needed 1-3 pills used (33%) 15 discharge 4 or more pills used (26%) 30 discharge Would decrease amount of opioids by 40% Message Prescribe only minimal required Transfer to non-opioid pain med as soon as possible

20 LYMPHATIC VENULE ANASTOMOSIS IN BREAST CANCER-RELATED LYMPHEDEMA Breast Cancer Res Treat 2017;165(2): Microsurgical anastomoses between lymphatic and venous system Circumference reduced by 49% Excess volume reduced by 57% 54% discontinued compression garments Very Effective in Reducing Arm Volume Difference and Improving QOL

21 LIPOSUCTION FOR LYMPHEDEMA NEJM 2017;377(18): SIMPLER PROCEDURE ALSO EFFECTIVE SOME ARE NOW BEGINNING TO COMBINE PROCEDURES.

22 TRANEXAMIC ACID FOR POSTPARTUM HEMORRHAGE A systematic review and meta-analysis. Medicine 2017;96(1): 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

23 TRANEXAMIC ACID (TXA) FOR MANAGEMENT OF OBSTETRIC HEMORRHAGE Obstet 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

24 PLACENTA ACCRETA-PERCRETA TXA 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 u blood My advice Pack and go back New Options

25 EBB BALLOON SYSTEM COMMERCIALLY AVAILABLE Now Being used by some as Umbrella Pack After C- Hyst Fills to 700 ml Cost - $400 OFF LABEL use Not approved by FDA for this.

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

27 INFLATABLE AORTIC BALLOON NEW AND PROMISING OPTION (REBOA CATHETER)

28 ENDOVASCULAR BALLOON OCCLUSION OF AORTA (REBOA) IN HEMORRHAGIC SHOCK. Systematic Review J Trauma Acute Care Surg 2016;80(2): 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% NOTE: ALL PATIENTS WITH SEVERE PPH & PERCRETA SURVIVED

29 COMPLETE SET COMMERCIALLY AVAILABLE

30 Word catheter (n=82) or Marsupialization (n=79) Word placed in office, Marsupialization in O.R. Pain scores comparable RECURRENCE RATE: Word 10 (12%) Marsupiaization 8 (10%) CONCLUSIONS Comparable recurrence rates Word catheter quicker & cheaper

31 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

32 >300 PAPERS ON PHYSICIAN BURNOUT IN 2017 Nothing so far has been very effective but we better figure out what to do about it.

33 PRESENT SYSTEM UNSUSTAINABLE WHAT 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

34 PHYSICIAN PROGRAMS, BOOKS, COUNSELLORS, COURSES, SCRIBES

35 GOOD PATIENT CARE: EVIDENCE BASED MEDICINE IMPORTANT BUT SO ARE: COMPASSION COMMUNICATION CLINICAL JUDGEMENT COMMON SENSE