LAS VEGAS – To appropriately manage patients on opioids who develop constipation, one of the most important distinctions to make is whether the condition was caused by the pain treatment or was just exacerbated by it, according to Darren M. Brenner, MD.

Because of the rampant use of opioids, the answer to that question is increasingly relevant to clinical practice, said Dr. Brenner, associate professor of medicine (gastroenterology and hepatology) and surgery at Northwestern University, Chicago.

Andrew D. Bowser/MDedge News

“From my own clinical experience, you will miss a third of your population that has constipation,” Dr. Brenner said, noting that some patients will instead think of their condition in terms of incomplete evacuation or decreased stool frequency.

Step 2 of the algorithm, therefore, is to assess for signs and symptoms of functional constipation in all patients, regardless of whether they report the condition.

The recently published Rome IV diagnostic criteria included a new category for opioid-induced constipation. According to the new definition, opioid-induced constipation must include new or worsening symptoms, such as fewer than three solid bowel movements per week, and straining, blockage sensation, or manual maneuvers on at least 25% of bowel movements, among other symptoms listed in the report.

If patients do have constipation meeting these criteria, then step 3 of the algorithm is to determine whether the symptoms were present prior to taking opioids.

If onset of constipation is related to the start of opioid treatment, options may include prescribing peripherally acting mu-opioid receptor antagonists (PAMORAs). By contrast, onset unrelated to the start of opioids, also known as opioid-exacerbated constipation, may require treatment according to the underlying cause. For example, slow-transit constipation may respond to laxatives, while evacuation disorders may be treated with surgery, biofeedback, or physical therapy.

The hardest group to identify, according to Dr. Brenner, is individuals whose symptoms were so minor that they didn’t even realize they had constipation symptoms prior to opioids.

Because treatment protocols for opioid-induced and opioid-exacerbated constipation are so different, “we must tease these people out,” Dr. Brenner said.

Global Academy and this news organization are owned by the same parent company.

Dr. Brenner reported disclosures related to Allergan, Daiichi Sankyo, Ironwood Pharmaceuticals, Prius Medical, Salix Pharmaceuticals, Synergy Pharmaceuticals, Shionogi, and others.

LAS VEGAS – To appropriately manage patients on opioids who develop constipation, one of the most important distinctions to make is whether the condition was caused by the pain treatment or was just exacerbated by it, according to Darren M. Brenner, MD.

Because of the rampant use of opioids, the answer to that question is increasingly relevant to clinical practice, said Dr. Brenner, associate professor of medicine (gastroenterology and hepatology) and surgery at Northwestern University, Chicago.

Andrew D. Bowser/MDedge News

“From my own clinical experience, you will miss a third of your population that has constipation,” Dr. Brenner said, noting that some patients will instead think of their condition in terms of incomplete evacuation or decreased stool frequency.

Step 2 of the algorithm, therefore, is to assess for signs and symptoms of functional constipation in all patients, regardless of whether they report the condition.

The recently published Rome IV diagnostic criteria included a new category for opioid-induced constipation. According to the new definition, opioid-induced constipation must include new or worsening symptoms, such as fewer than three solid bowel movements per week, and straining, blockage sensation, or manual maneuvers on at least 25% of bowel movements, among other symptoms listed in the report.

If patients do have constipation meeting these criteria, then step 3 of the algorithm is to determine whether the symptoms were present prior to taking opioids.

If onset of constipation is related to the start of opioid treatment, options may include prescribing peripherally acting mu-opioid receptor antagonists (PAMORAs). By contrast, onset unrelated to the start of opioids, also known as opioid-exacerbated constipation, may require treatment according to the underlying cause. For example, slow-transit constipation may respond to laxatives, while evacuation disorders may be treated with surgery, biofeedback, or physical therapy.

The hardest group to identify, according to Dr. Brenner, is individuals whose symptoms were so minor that they didn’t even realize they had constipation symptoms prior to opioids.

Because treatment protocols for opioid-induced and opioid-exacerbated constipation are so different, “we must tease these people out,” Dr. Brenner said.

Global Academy and this news organization are owned by the same parent company.

Dr. Brenner reported disclosures related to Allergan, Daiichi Sankyo, Ironwood Pharmaceuticals, Prius Medical, Salix Pharmaceuticals, Synergy Pharmaceuticals, Shionogi, and others.

LAS VEGAS – To appropriately manage patients on opioids who develop constipation, one of the most important distinctions to make is whether the condition was caused by the pain treatment or was just exacerbated by it, according to Darren M. Brenner, MD.

Because of the rampant use of opioids, the answer to that question is increasingly relevant to clinical practice, said Dr. Brenner, associate professor of medicine (gastroenterology and hepatology) and surgery at Northwestern University, Chicago.

Andrew D. Bowser/MDedge News

“From my own clinical experience, you will miss a third of your population that has constipation,” Dr. Brenner said, noting that some patients will instead think of their condition in terms of incomplete evacuation or decreased stool frequency.

Step 2 of the algorithm, therefore, is to assess for signs and symptoms of functional constipation in all patients, regardless of whether they report the condition.

The recently published Rome IV diagnostic criteria included a new category for opioid-induced constipation. According to the new definition, opioid-induced constipation must include new or worsening symptoms, such as fewer than three solid bowel movements per week, and straining, blockage sensation, or manual maneuvers on at least 25% of bowel movements, among other symptoms listed in the report.

If patients do have constipation meeting these criteria, then step 3 of the algorithm is to determine whether the symptoms were present prior to taking opioids.

If onset of constipation is related to the start of opioid treatment, options may include prescribing peripherally acting mu-opioid receptor antagonists (PAMORAs). By contrast, onset unrelated to the start of opioids, also known as opioid-exacerbated constipation, may require treatment according to the underlying cause. For example, slow-transit constipation may respond to laxatives, while evacuation disorders may be treated with surgery, biofeedback, or physical therapy.

The hardest group to identify, according to Dr. Brenner, is individuals whose symptoms were so minor that they didn’t even realize they had constipation symptoms prior to opioids.

Because treatment protocols for opioid-induced and opioid-exacerbated constipation are so different, “we must tease these people out,” Dr. Brenner said.

Global Academy and this news organization are owned by the same parent company.

Dr. Brenner reported disclosures related to Allergan, Daiichi Sankyo, Ironwood Pharmaceuticals, Prius Medical, Salix Pharmaceuticals, Synergy Pharmaceuticals, Shionogi, and others.

NEWPORT BEACH, CALIF. – A revised hematopoietic stem cell transplantation comorbidity index developed for adolescents and young adults is useful for predicting nonrelapse mortality in this specific population, according to Brian Friend, MD.

In a retrospective study of 241 patients aged 15-39 years who underwent a first allogeneic hematopoietic stem cell transplant (HCT) between 2005 and 2015 at the University of California, Los Angeles, nonrelapse mortality incidence was particularly high, with rates of 26%, 28%, and 30% at 1, 2, and 3 years, respectively, Dr. Friend, a clinical research fellow at the David Geffen School of Medicine, Los Angeles, reported in a poster at the Acute Leukemia Forum of Hemedicus.

Sharon Worcester/MDedge News

“We sought to develop a modified HCT-CI that would be more practical and efficient in predicting outcomes of adolescent and young adult patients,” he wrote.

Data were collected on 15 comorbidities included in the original HCT-CI study, as well as the psychosocial risk factors. The relationship between multiple variables and the incidence of nonrelapse mortality was investigated via the Fine and Gray competing risk model with adjustments for patient- and transplant-specific factors.

A few things were “looked at differently,” he said, explaining, for example, that multiple cardiovascular risk factors were combined into one since they are rare in younger patients.

The study demonstrated that an index including only a few comorbidities important in adolescents and young adults is more predictive in these younger patients vs. adults, suggesting that a simpler model is more practical and useful, Dr. Friend said.

A larger study is planned in conjunction with the Center for International Blood and Marrow Transplant Research (CIBMTR). The researchers for that study will take an in-depth look at this younger population in an effort to develop a novel risk score for them. Other future efforts will focus on developing interventions to target high risk patients – and in particular, modifiable risk factors – with a focus on preventive measures, he said.

Dr. Friend reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – A revised hematopoietic stem cell transplantation comorbidity index developed for adolescents and young adults is useful for predicting nonrelapse mortality in this specific population, according to Brian Friend, MD.

In a retrospective study of 241 patients aged 15-39 years who underwent a first allogeneic hematopoietic stem cell transplant (HCT) between 2005 and 2015 at the University of California, Los Angeles, nonrelapse mortality incidence was particularly high, with rates of 26%, 28%, and 30% at 1, 2, and 3 years, respectively, Dr. Friend, a clinical research fellow at the David Geffen School of Medicine, Los Angeles, reported in a poster at the Acute Leukemia Forum of Hemedicus.

Sharon Worcester/MDedge News

“We sought to develop a modified HCT-CI that would be more practical and efficient in predicting outcomes of adolescent and young adult patients,” he wrote.

Data were collected on 15 comorbidities included in the original HCT-CI study, as well as the psychosocial risk factors. The relationship between multiple variables and the incidence of nonrelapse mortality was investigated via the Fine and Gray competing risk model with adjustments for patient- and transplant-specific factors.

A few things were “looked at differently,” he said, explaining, for example, that multiple cardiovascular risk factors were combined into one since they are rare in younger patients.

The study demonstrated that an index including only a few comorbidities important in adolescents and young adults is more predictive in these younger patients vs. adults, suggesting that a simpler model is more practical and useful, Dr. Friend said.

A larger study is planned in conjunction with the Center for International Blood and Marrow Transplant Research (CIBMTR). The researchers for that study will take an in-depth look at this younger population in an effort to develop a novel risk score for them. Other future efforts will focus on developing interventions to target high risk patients – and in particular, modifiable risk factors – with a focus on preventive measures, he said.

Dr. Friend reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – A revised hematopoietic stem cell transplantation comorbidity index developed for adolescents and young adults is useful for predicting nonrelapse mortality in this specific population, according to Brian Friend, MD.

In a retrospective study of 241 patients aged 15-39 years who underwent a first allogeneic hematopoietic stem cell transplant (HCT) between 2005 and 2015 at the University of California, Los Angeles, nonrelapse mortality incidence was particularly high, with rates of 26%, 28%, and 30% at 1, 2, and 3 years, respectively, Dr. Friend, a clinical research fellow at the David Geffen School of Medicine, Los Angeles, reported in a poster at the Acute Leukemia Forum of Hemedicus.

Sharon Worcester/MDedge News

“We sought to develop a modified HCT-CI that would be more practical and efficient in predicting outcomes of adolescent and young adult patients,” he wrote.

Data were collected on 15 comorbidities included in the original HCT-CI study, as well as the psychosocial risk factors. The relationship between multiple variables and the incidence of nonrelapse mortality was investigated via the Fine and Gray competing risk model with adjustments for patient- and transplant-specific factors.

A few things were “looked at differently,” he said, explaining, for example, that multiple cardiovascular risk factors were combined into one since they are rare in younger patients.

The study demonstrated that an index including only a few comorbidities important in adolescents and young adults is more predictive in these younger patients vs. adults, suggesting that a simpler model is more practical and useful, Dr. Friend said.

A larger study is planned in conjunction with the Center for International Blood and Marrow Transplant Research (CIBMTR). The researchers for that study will take an in-depth look at this younger population in an effort to develop a novel risk score for them. Other future efforts will focus on developing interventions to target high risk patients – and in particular, modifiable risk factors – with a focus on preventive measures, he said.

Dr. Friend reported having no financial disclosures.

[email protected]

WASHINGTON, DC—Neuroimaging is a core competency for epileptologists, according to an overview presented at the 71st Annual Meeting of the American Epilepsy Society. Neurologists trained in this subspecialty must bring “value-added” skills to the routine reports that radiologists provide—ensuring that both a proper diagnostic protocol and a quality-assurance mindset are in place so that when images are used, they are of sufficient quality to exclude wrong diagnoses.

Ultimately, it is the role of the epileptologist to review these images in the context of other localizing data and to work with radiologists in an integrative way, said Graeme Jackson, MD, Senior Deputy Director of the Florey Institute of Neuroscience and Mental Health in Melbourne.

What Is the Protocol?

In a presentation comprised largely of imaging studies in cases across the lifespan—infant, young child, teenager, adult, and senior citizen—Dr. Jackson discussed the diagnostic information essential for all patients with epilepsy: a clinical history for context, an EEG for function, and structural MRI with an epilepsy protocol for structure.

To map out the proper protocol, clinicians have to contend with many choices for MRI studies. Eventually, the process results in images. One pathway leads to a report from the radiologist, and another pathway leads to the epileptologist’s review.

Epileptologists are responsible for obtaining images that are adequate—not just taking what they get, said Dr. Jackson. “The radiologist is sitting there—[with] probably 2,000 images … a couple of minutes and a lot of cases.” As the “epileptologist, you have the advantage of having other information. You have the focus [and] the hypotheses.… It is critical that they be reviewed and iterated, particularly in difficult cases.”

Four “Can’t Miss” Imaging Diagnoses

The top four missed imaging diagnoses in epilepsy are obvious abnormalities, hippocampal sclerosis, malformations of cortical development, and a diagnosis of nothing, in which the clinician must be confident because the implicit observation is that the brain is completely structurally normal. Clinicians sometimes miss subtle things that can only be identified by looking correctly in the proper location, said Dr. Jackson.

In contrast to the four “can’t miss” diagnoses, focal cortical dysplasia, bilateral hippocampal sclerosis, temporal encephalocele, and parahippocampal dysplasia are among the many subtle lesions that clinicians can easily miss.

Examining a Case Study

Dr. Jackson assessed the case of Rachel, age 17, who has BOSD. This form of dysplasia encompasses localized seizures and can present at any time from infancy to adulthood. Although these entities are often intractable, 90% of patients who undergo resection of the cortical BOSD remain seizure-free.

Rachel had her first seizure at age 15. It lasted a few seconds and caused her to drop her ice cream. Her facial appearance was blank and she was pointing her right index finger, said Dr. Jackson. Her condition evolved into intractable tonic-clonic seizures at night, resulting in multiple medication use and side effects. After imaging revealed that Rachel—a left-dominant-language individual with aspirations to be a teacher—had a tiny abnormality at the base of the sulci, she underwent surgery.

“Before surgery, we could never convince our radiologist that this was abnormal,” said Dr. Jackson. “But because we believe these small BOSDs could cause this sort of epilepsy, we convinced our surgeon to take a tiny resection … that just took out [an] area of abnormal connectivity.”

The surgery was so precise that Rachel has been seizure-free for nearly three years, reported Dr. Jackson. “We did quite a remarkable job of taking out exactly that bit and only that bit within the middle of her language area,” he said. “When [Rachel] came out of the anesthetic, she was much more interactive, and [we] noticed the personality change.… She did not have that delay we often see in patients, even though she was on the same medications.”

“Really tiny bits of the brain can drive pretty nasty epilepsy,” said Dr. Jackson. Since Rachel’s procedure, she has graduated college and earned her first degree. “I published this [research] just to make the point that not all epilepsy [cases] are like this, but there are some, and we should try to find them.”

—Fred Balzac

Suggested Reading

Abou-Hamden A, Lau M, Fabinyi G, et al. Small temporal pole encephaloceles: a treatable cause of “lesion negative” temporal lobe epilepsy. Epilepsia. 2010;51(10):2199-2202.

Hofman PA, Fitt GJ, Harvey AS, et al. Bottom-of-sulcus dysplasia: imaging features. AJR Am J Roentgenol. 2011;196(4):881-885.

Jackson GD, Pedersen M, Harvey AS. How small can the epileptogenic region be?: a case in point. Neurology. 2017;88(21):2017-2019.

Jackson GD, Berkovic SF, Duncan JS, et al. Optimizing the diagnosis of hippocampal sclerosis using MR imaging. AJNR Am J Neuroradiol. 1993;14(3):753-762.

Jackson GD, Berkovic SF, Tress BM, et al. Hippocampal sclerosis can be reliably detected by magnetic resonance imaging. Neurology. 1990;40(12):1869-1875.

Pillay N, Fabinyi GC, Myles TS, et al. Parahippocampal epilepsy with subtle dysplasia: A cause of “imaging negative” partial epilepsy. Epilepsia. 2009;50(12):2611-2618.

WASHINGTON, DC—Neuroimaging is a core competency for epileptologists, according to an overview presented at the 71st Annual Meeting of the American Epilepsy Society. Neurologists trained in this subspecialty must bring “value-added” skills to the routine reports that radiologists provide—ensuring that both a proper diagnostic protocol and a quality-assurance mindset are in place so that when images are used, they are of sufficient quality to exclude wrong diagnoses.

Ultimately, it is the role of the epileptologist to review these images in the context of other localizing data and to work with radiologists in an integrative way, said Graeme Jackson, MD, Senior Deputy Director of the Florey Institute of Neuroscience and Mental Health in Melbourne.

What Is the Protocol?

In a presentation comprised largely of imaging studies in cases across the lifespan—infant, young child, teenager, adult, and senior citizen—Dr. Jackson discussed the diagnostic information essential for all patients with epilepsy: a clinical history for context, an EEG for function, and structural MRI with an epilepsy protocol for structure.

To map out the proper protocol, clinicians have to contend with many choices for MRI studies. Eventually, the process results in images. One pathway leads to a report from the radiologist, and another pathway leads to the epileptologist’s review.

Epileptologists are responsible for obtaining images that are adequate—not just taking what they get, said Dr. Jackson. “The radiologist is sitting there—[with] probably 2,000 images … a couple of minutes and a lot of cases.” As the “epileptologist, you have the advantage of having other information. You have the focus [and] the hypotheses.… It is critical that they be reviewed and iterated, particularly in difficult cases.”

Four “Can’t Miss” Imaging Diagnoses

The top four missed imaging diagnoses in epilepsy are obvious abnormalities, hippocampal sclerosis, malformations of cortical development, and a diagnosis of nothing, in which the clinician must be confident because the implicit observation is that the brain is completely structurally normal. Clinicians sometimes miss subtle things that can only be identified by looking correctly in the proper location, said Dr. Jackson.

In contrast to the four “can’t miss” diagnoses, focal cortical dysplasia, bilateral hippocampal sclerosis, temporal encephalocele, and parahippocampal dysplasia are among the many subtle lesions that clinicians can easily miss.

Examining a Case Study

Dr. Jackson assessed the case of Rachel, age 17, who has BOSD. This form of dysplasia encompasses localized seizures and can present at any time from infancy to adulthood. Although these entities are often intractable, 90% of patients who undergo resection of the cortical BOSD remain seizure-free.

Rachel had her first seizure at age 15. It lasted a few seconds and caused her to drop her ice cream. Her facial appearance was blank and she was pointing her right index finger, said Dr. Jackson. Her condition evolved into intractable tonic-clonic seizures at night, resulting in multiple medication use and side effects. After imaging revealed that Rachel—a left-dominant-language individual with aspirations to be a teacher—had a tiny abnormality at the base of the sulci, she underwent surgery.

“Before surgery, we could never convince our radiologist that this was abnormal,” said Dr. Jackson. “But because we believe these small BOSDs could cause this sort of epilepsy, we convinced our surgeon to take a tiny resection … that just took out [an] area of abnormal connectivity.”

The surgery was so precise that Rachel has been seizure-free for nearly three years, reported Dr. Jackson. “We did quite a remarkable job of taking out exactly that bit and only that bit within the middle of her language area,” he said. “When [Rachel] came out of the anesthetic, she was much more interactive, and [we] noticed the personality change.… She did not have that delay we often see in patients, even though she was on the same medications.”

“Really tiny bits of the brain can drive pretty nasty epilepsy,” said Dr. Jackson. Since Rachel’s procedure, she has graduated college and earned her first degree. “I published this [research] just to make the point that not all epilepsy [cases] are like this, but there are some, and we should try to find them.”

—Fred Balzac

Suggested Reading

Abou-Hamden A, Lau M, Fabinyi G, et al. Small temporal pole encephaloceles: a treatable cause of “lesion negative” temporal lobe epilepsy. Epilepsia. 2010;51(10):2199-2202.

Hofman PA, Fitt GJ, Harvey AS, et al. Bottom-of-sulcus dysplasia: imaging features. AJR Am J Roentgenol. 2011;196(4):881-885.

Jackson GD, Pedersen M, Harvey AS. How small can the epileptogenic region be?: a case in point. Neurology. 2017;88(21):2017-2019.

Jackson GD, Berkovic SF, Duncan JS, et al. Optimizing the diagnosis of hippocampal sclerosis using MR imaging. AJNR Am J Neuroradiol. 1993;14(3):753-762.

Jackson GD, Berkovic SF, Tress BM, et al. Hippocampal sclerosis can be reliably detected by magnetic resonance imaging. Neurology. 1990;40(12):1869-1875.

Pillay N, Fabinyi GC, Myles TS, et al. Parahippocampal epilepsy with subtle dysplasia: A cause of “imaging negative” partial epilepsy. Epilepsia. 2009;50(12):2611-2618.

WASHINGTON, DC—Neuroimaging is a core competency for epileptologists, according to an overview presented at the 71st Annual Meeting of the American Epilepsy Society. Neurologists trained in this subspecialty must bring “value-added” skills to the routine reports that radiologists provide—ensuring that both a proper diagnostic protocol and a quality-assurance mindset are in place so that when images are used, they are of sufficient quality to exclude wrong diagnoses.

Ultimately, it is the role of the epileptologist to review these images in the context of other localizing data and to work with radiologists in an integrative way, said Graeme Jackson, MD, Senior Deputy Director of the Florey Institute of Neuroscience and Mental Health in Melbourne.

What Is the Protocol?

In a presentation comprised largely of imaging studies in cases across the lifespan—infant, young child, teenager, adult, and senior citizen—Dr. Jackson discussed the diagnostic information essential for all patients with epilepsy: a clinical history for context, an EEG for function, and structural MRI with an epilepsy protocol for structure.

To map out the proper protocol, clinicians have to contend with many choices for MRI studies. Eventually, the process results in images. One pathway leads to a report from the radiologist, and another pathway leads to the epileptologist’s review.

Epileptologists are responsible for obtaining images that are adequate—not just taking what they get, said Dr. Jackson. “The radiologist is sitting there—[with] probably 2,000 images … a couple of minutes and a lot of cases.” As the “epileptologist, you have the advantage of having other information. You have the focus [and] the hypotheses.… It is critical that they be reviewed and iterated, particularly in difficult cases.”

Four “Can’t Miss” Imaging Diagnoses

The top four missed imaging diagnoses in epilepsy are obvious abnormalities, hippocampal sclerosis, malformations of cortical development, and a diagnosis of nothing, in which the clinician must be confident because the implicit observation is that the brain is completely structurally normal. Clinicians sometimes miss subtle things that can only be identified by looking correctly in the proper location, said Dr. Jackson.

In contrast to the four “can’t miss” diagnoses, focal cortical dysplasia, bilateral hippocampal sclerosis, temporal encephalocele, and parahippocampal dysplasia are among the many subtle lesions that clinicians can easily miss.

Examining a Case Study

Dr. Jackson assessed the case of Rachel, age 17, who has BOSD. This form of dysplasia encompasses localized seizures and can present at any time from infancy to adulthood. Although these entities are often intractable, 90% of patients who undergo resection of the cortical BOSD remain seizure-free.

Rachel had her first seizure at age 15. It lasted a few seconds and caused her to drop her ice cream. Her facial appearance was blank and she was pointing her right index finger, said Dr. Jackson. Her condition evolved into intractable tonic-clonic seizures at night, resulting in multiple medication use and side effects. After imaging revealed that Rachel—a left-dominant-language individual with aspirations to be a teacher—had a tiny abnormality at the base of the sulci, she underwent surgery.

“Before surgery, we could never convince our radiologist that this was abnormal,” said Dr. Jackson. “But because we believe these small BOSDs could cause this sort of epilepsy, we convinced our surgeon to take a tiny resection … that just took out [an] area of abnormal connectivity.”

The surgery was so precise that Rachel has been seizure-free for nearly three years, reported Dr. Jackson. “We did quite a remarkable job of taking out exactly that bit and only that bit within the middle of her language area,” he said. “When [Rachel] came out of the anesthetic, she was much more interactive, and [we] noticed the personality change.… She did not have that delay we often see in patients, even though she was on the same medications.”

“Really tiny bits of the brain can drive pretty nasty epilepsy,” said Dr. Jackson. Since Rachel’s procedure, she has graduated college and earned her first degree. “I published this [research] just to make the point that not all epilepsy [cases] are like this, but there are some, and we should try to find them.”

—Fred Balzac

Suggested Reading

Abou-Hamden A, Lau M, Fabinyi G, et al. Small temporal pole encephaloceles: a treatable cause of “lesion negative” temporal lobe epilepsy. Epilepsia. 2010;51(10):2199-2202.

Hofman PA, Fitt GJ, Harvey AS, et al. Bottom-of-sulcus dysplasia: imaging features. AJR Am J Roentgenol. 2011;196(4):881-885.

Jackson GD, Pedersen M, Harvey AS. How small can the epileptogenic region be?: a case in point. Neurology. 2017;88(21):2017-2019.

Jackson GD, Berkovic SF, Duncan JS, et al. Optimizing the diagnosis of hippocampal sclerosis using MR imaging. AJNR Am J Neuroradiol. 1993;14(3):753-762.

Jackson GD, Berkovic SF, Tress BM, et al. Hippocampal sclerosis can be reliably detected by magnetic resonance imaging. Neurology. 1990;40(12):1869-1875.

Pillay N, Fabinyi GC, Myles TS, et al. Parahippocampal epilepsy with subtle dysplasia: A cause of “imaging negative” partial epilepsy. Epilepsia. 2009;50(12):2611-2618.

Patients with multiple sclerosis (MS) who are treated with natalizumab can have small progressive multifocal leukoencephalopathy (PML) lesions on MRI, yet have undetectable JC virus (JCV) DNA in their CSF, according to a cross-sectional, retrospective study published online ahead of print March 12 in JAMA Neurology.

The findings show that for some people with MS, PML diagnosis could be delayed if CSF sampling is negative and patients are asymptomatic, potentially resulting in worse functional outcomes and survival rates, according to Martijn T. Wijburg, MD, a neurologist at the MS Center at VU University Medical Center in Amsterdam, and colleagues.

The study also described a potential correlation between PML lesion volume and JCV copy numbers. “To our knowledge, this is the first study that shows an association between total PML lesion volume measured by brain MRI and CSF JCV polymerase chain reaction [PCR] results in patients with [natalizumab-associated PML]. This finding may have considerable implications for patient care,” said the authors.

A Retrospective Study

PML, a lytic infection of glial and neuronal cells by the JCV, can be diagnosed when a patient exhibits clinical symptoms, when JCV DNA is detected in CSF by PCR, and when specific brain lesions are seen on MRI, according to a consensus statement from the Neuroinfectious Disease section of the American Academy of Neurology.

Dr. Wijburg and his coinvestigators reviewed data from Dutch and Belgian patients considered to have natalizumab-associated PML between January 2007 and December 2014. Patients were required to meet one of the following criteria:

• Definite or probable PML, based on positive PCR and MRI findings suggestive of PML, with or without PML symptoms.
• In the absence of a positive PCR, the presence of all four of the following features: high risk of PML development, such as positive anti-JCV serostatus and natalizumab treatment duration greater than 12 months; no MS disease activity prior to PML suspicion; MRI lesions highly suggestive of PML, with lesion characteristics as previously reported and absence of lesion characteristics suggestive of other diseases, as judged by an experienced neuroradiologist; and a lesion evolution on follow-up MRI scans suggestive of PML, including development of immune reconstitution inflammatory syndrome.

In the study of 56 patients (37 women), nine patients (16.1%) had undetectable JCV DNA in CSF, and 14 (25%) were asymptomatic for PML. At the time of PML diagnosis, the median age was 45, and the median natalizumab treatment duration was 43 months. Patients with a positive PCR had larger total PML lesion volumes than did those with undetectable JCV DNA (median volume, 22.9 mL vs 6.7 mL). Logistic regression showed that a smaller PML lesion volume significantly increased the probability for undetectable JCV DNA.

The research team also observed a positive correlation between PML lesion volume and JCV copy numbers. PML lesion volume was greater in patients with PML symptoms and in patients with more widespread lesion dissemination. But no association was found between PCR results and PML lesion dissemination, signs of inflammation, or PML symptoms.

Results Suggest Need for Pharmacovigilance

The findings suggest that patients with a smaller PML lesion volume were more likely to have a negative test result for JCV, which may lead to a delayed diagnosis of PML. Patients with smaller lesion volume were also more likely to be asymptomatic, which may further delay diagnosis.

“This [finding] can result in a therapeutic dilemma. Unjustly excluding PML may have serious consequences (eg, when switching from [natalizumab] to even more potent immunosuppressive treatments, such as alemtuzumab),” said the authors.

“In patients with [natalizumab-associated PML], both the probability for a positive CSF JCV PCR result and the JCV viral load are associated with the total PML lesion volume.... As a consequence, patients with smaller PML lesion volumes are more likely to have undetectable JCV DNA, and PML can thus not reliably be excluded based on a negative PCR.”

Strict pharmacovigilance by MRI “will lead to identification of smaller [PML] lesions that associate with a higher likelihood of negative PCR results, which hampers a formal diagnosis of [PML] and may complicate patient treatment,” said the authors.

Meticulous clinical and MRI follow-up, in combination with repeated CSF JCV PCR testing, was warranted in these patients, they added. Complementary PML diagnostic approaches, such as assessing intrathecal antibody synthesis to JCV by determining the CSF JCV antibody index, may also be of additional value.

“Furthermore, undetectable JCV DNA does not completely preclude the presence of JCV DNA. Further development and improvement of ultrasensitive PCR assays may improve the diagnostic accuracy in the future.”

MRI Alone Cannot Yet Support Diagnosis

“Dr. Wijburg and colleagues raise an important point in our understanding of the development of PML by showing that small brain lesions may be present at what may be the start of JCV infection when the virus is still undetectable in CSF,” said Eugene O. Major, PhD, a consultant in the Division of Neuroimmunology and Neurovirology at NINDS in Bethesda, Maryland, in an accompanying editorial. “However, it is not yet clear how well the relationship between viral load in CSF and MRI brain lesions approximates the stages of the disease and the processes with which it affects its target brain cells.”

Repeat testing may be worthwhile when CSF testing is negative, because some patients test positive weeks after testing negative, he added. “Suspicion for PML may be increased when MRI shows signs of PML despite negative CSF testing, but it is too early to rely on MRI alone for diagnosis.”

Dr. Major has received consulting fees while serving on independent adjudication committees for Takeda/Millennium, Roche/Genentech, and GlaxoSmithKline.He has patent rights at the NIH as coinventor of the Ultrasensitive Quantitative PCR Multiplex assay for the detection of JCV DNA–distinguishing viral variants.

—Nicola Garrett

Suggested Reading

Major EO. Progressive multifocal leukoencephalopathy lesions and JC virus: the limits and value of imaging. JAMA Neurol. 2018 Mar 12 [Epub ahead of print].

Wijburg MT, Kleerekooper I, Lissenberg-Witte BI, et al. Association of progressive multifocal leukoencephalopathy lesion volume with JC virus polymerase chain reaction results in cerebrospinal fluid of natalizumab-treated patients with multiple sclerosis. JAMA Neurol. 2018 Mar 12 [Epub ahead of print].

Patients with multiple sclerosis (MS) who are treated with natalizumab can have small progressive multifocal leukoencephalopathy (PML) lesions on MRI, yet have undetectable JC virus (JCV) DNA in their CSF, according to a cross-sectional, retrospective study published online ahead of print March 12 in JAMA Neurology.

The findings show that for some people with MS, PML diagnosis could be delayed if CSF sampling is negative and patients are asymptomatic, potentially resulting in worse functional outcomes and survival rates, according to Martijn T. Wijburg, MD, a neurologist at the MS Center at VU University Medical Center in Amsterdam, and colleagues.

The study also described a potential correlation between PML lesion volume and JCV copy numbers. “To our knowledge, this is the first study that shows an association between total PML lesion volume measured by brain MRI and CSF JCV polymerase chain reaction [PCR] results in patients with [natalizumab-associated PML]. This finding may have considerable implications for patient care,” said the authors.

A Retrospective Study

PML, a lytic infection of glial and neuronal cells by the JCV, can be diagnosed when a patient exhibits clinical symptoms, when JCV DNA is detected in CSF by PCR, and when specific brain lesions are seen on MRI, according to a consensus statement from the Neuroinfectious Disease section of the American Academy of Neurology.

Dr. Wijburg and his coinvestigators reviewed data from Dutch and Belgian patients considered to have natalizumab-associated PML between January 2007 and December 2014. Patients were required to meet one of the following criteria:

• Definite or probable PML, based on positive PCR and MRI findings suggestive of PML, with or without PML symptoms.
• In the absence of a positive PCR, the presence of all four of the following features: high risk of PML development, such as positive anti-JCV serostatus and natalizumab treatment duration greater than 12 months; no MS disease activity prior to PML suspicion; MRI lesions highly suggestive of PML, with lesion characteristics as previously reported and absence of lesion characteristics suggestive of other diseases, as judged by an experienced neuroradiologist; and a lesion evolution on follow-up MRI scans suggestive of PML, including development of immune reconstitution inflammatory syndrome.

In the study of 56 patients (37 women), nine patients (16.1%) had undetectable JCV DNA in CSF, and 14 (25%) were asymptomatic for PML. At the time of PML diagnosis, the median age was 45, and the median natalizumab treatment duration was 43 months. Patients with a positive PCR had larger total PML lesion volumes than did those with undetectable JCV DNA (median volume, 22.9 mL vs 6.7 mL). Logistic regression showed that a smaller PML lesion volume significantly increased the probability for undetectable JCV DNA.

The research team also observed a positive correlation between PML lesion volume and JCV copy numbers. PML lesion volume was greater in patients with PML symptoms and in patients with more widespread lesion dissemination. But no association was found between PCR results and PML lesion dissemination, signs of inflammation, or PML symptoms.

Results Suggest Need for Pharmacovigilance

The findings suggest that patients with a smaller PML lesion volume were more likely to have a negative test result for JCV, which may lead to a delayed diagnosis of PML. Patients with smaller lesion volume were also more likely to be asymptomatic, which may further delay diagnosis.

“This [finding] can result in a therapeutic dilemma. Unjustly excluding PML may have serious consequences (eg, when switching from [natalizumab] to even more potent immunosuppressive treatments, such as alemtuzumab),” said the authors.

“In patients with [natalizumab-associated PML], both the probability for a positive CSF JCV PCR result and the JCV viral load are associated with the total PML lesion volume.... As a consequence, patients with smaller PML lesion volumes are more likely to have undetectable JCV DNA, and PML can thus not reliably be excluded based on a negative PCR.”

Strict pharmacovigilance by MRI “will lead to identification of smaller [PML] lesions that associate with a higher likelihood of negative PCR results, which hampers a formal diagnosis of [PML] and may complicate patient treatment,” said the authors.

Meticulous clinical and MRI follow-up, in combination with repeated CSF JCV PCR testing, was warranted in these patients, they added. Complementary PML diagnostic approaches, such as assessing intrathecal antibody synthesis to JCV by determining the CSF JCV antibody index, may also be of additional value.

“Furthermore, undetectable JCV DNA does not completely preclude the presence of JCV DNA. Further development and improvement of ultrasensitive PCR assays may improve the diagnostic accuracy in the future.”

MRI Alone Cannot Yet Support Diagnosis

“Dr. Wijburg and colleagues raise an important point in our understanding of the development of PML by showing that small brain lesions may be present at what may be the start of JCV infection when the virus is still undetectable in CSF,” said Eugene O. Major, PhD, a consultant in the Division of Neuroimmunology and Neurovirology at NINDS in Bethesda, Maryland, in an accompanying editorial. “However, it is not yet clear how well the relationship between viral load in CSF and MRI brain lesions approximates the stages of the disease and the processes with which it affects its target brain cells.”

Repeat testing may be worthwhile when CSF testing is negative, because some patients test positive weeks after testing negative, he added. “Suspicion for PML may be increased when MRI shows signs of PML despite negative CSF testing, but it is too early to rely on MRI alone for diagnosis.”

Dr. Major has received consulting fees while serving on independent adjudication committees for Takeda/Millennium, Roche/Genentech, and GlaxoSmithKline.He has patent rights at the NIH as coinventor of the Ultrasensitive Quantitative PCR Multiplex assay for the detection of JCV DNA–distinguishing viral variants.

—Nicola Garrett

Suggested Reading

Major EO. Progressive multifocal leukoencephalopathy lesions and JC virus: the limits and value of imaging. JAMA Neurol. 2018 Mar 12 [Epub ahead of print].

Wijburg MT, Kleerekooper I, Lissenberg-Witte BI, et al. Association of progressive multifocal leukoencephalopathy lesion volume with JC virus polymerase chain reaction results in cerebrospinal fluid of natalizumab-treated patients with multiple sclerosis. JAMA Neurol. 2018 Mar 12 [Epub ahead of print].

Patients with multiple sclerosis (MS) who are treated with natalizumab can have small progressive multifocal leukoencephalopathy (PML) lesions on MRI, yet have undetectable JC virus (JCV) DNA in their CSF, according to a cross-sectional, retrospective study published online ahead of print March 12 in JAMA Neurology.

The findings show that for some people with MS, PML diagnosis could be delayed if CSF sampling is negative and patients are asymptomatic, potentially resulting in worse functional outcomes and survival rates, according to Martijn T. Wijburg, MD, a neurologist at the MS Center at VU University Medical Center in Amsterdam, and colleagues.

The study also described a potential correlation between PML lesion volume and JCV copy numbers. “To our knowledge, this is the first study that shows an association between total PML lesion volume measured by brain MRI and CSF JCV polymerase chain reaction [PCR] results in patients with [natalizumab-associated PML]. This finding may have considerable implications for patient care,” said the authors.

A Retrospective Study

PML, a lytic infection of glial and neuronal cells by the JCV, can be diagnosed when a patient exhibits clinical symptoms, when JCV DNA is detected in CSF by PCR, and when specific brain lesions are seen on MRI, according to a consensus statement from the Neuroinfectious Disease section of the American Academy of Neurology.

Dr. Wijburg and his coinvestigators reviewed data from Dutch and Belgian patients considered to have natalizumab-associated PML between January 2007 and December 2014. Patients were required to meet one of the following criteria:

• Definite or probable PML, based on positive PCR and MRI findings suggestive of PML, with or without PML symptoms.
• In the absence of a positive PCR, the presence of all four of the following features: high risk of PML development, such as positive anti-JCV serostatus and natalizumab treatment duration greater than 12 months; no MS disease activity prior to PML suspicion; MRI lesions highly suggestive of PML, with lesion characteristics as previously reported and absence of lesion characteristics suggestive of other diseases, as judged by an experienced neuroradiologist; and a lesion evolution on follow-up MRI scans suggestive of PML, including development of immune reconstitution inflammatory syndrome.

In the study of 56 patients (37 women), nine patients (16.1%) had undetectable JCV DNA in CSF, and 14 (25%) were asymptomatic for PML. At the time of PML diagnosis, the median age was 45, and the median natalizumab treatment duration was 43 months. Patients with a positive PCR had larger total PML lesion volumes than did those with undetectable JCV DNA (median volume, 22.9 mL vs 6.7 mL). Logistic regression showed that a smaller PML lesion volume significantly increased the probability for undetectable JCV DNA.

The research team also observed a positive correlation between PML lesion volume and JCV copy numbers. PML lesion volume was greater in patients with PML symptoms and in patients with more widespread lesion dissemination. But no association was found between PCR results and PML lesion dissemination, signs of inflammation, or PML symptoms.

Results Suggest Need for Pharmacovigilance

The findings suggest that patients with a smaller PML lesion volume were more likely to have a negative test result for JCV, which may lead to a delayed diagnosis of PML. Patients with smaller lesion volume were also more likely to be asymptomatic, which may further delay diagnosis.

“This [finding] can result in a therapeutic dilemma. Unjustly excluding PML may have serious consequences (eg, when switching from [natalizumab] to even more potent immunosuppressive treatments, such as alemtuzumab),” said the authors.

“In patients with [natalizumab-associated PML], both the probability for a positive CSF JCV PCR result and the JCV viral load are associated with the total PML lesion volume.... As a consequence, patients with smaller PML lesion volumes are more likely to have undetectable JCV DNA, and PML can thus not reliably be excluded based on a negative PCR.”

Strict pharmacovigilance by MRI “will lead to identification of smaller [PML] lesions that associate with a higher likelihood of negative PCR results, which hampers a formal diagnosis of [PML] and may complicate patient treatment,” said the authors.

Meticulous clinical and MRI follow-up, in combination with repeated CSF JCV PCR testing, was warranted in these patients, they added. Complementary PML diagnostic approaches, such as assessing intrathecal antibody synthesis to JCV by determining the CSF JCV antibody index, may also be of additional value.

“Furthermore, undetectable JCV DNA does not completely preclude the presence of JCV DNA. Further development and improvement of ultrasensitive PCR assays may improve the diagnostic accuracy in the future.”

MRI Alone Cannot Yet Support Diagnosis

“Dr. Wijburg and colleagues raise an important point in our understanding of the development of PML by showing that small brain lesions may be present at what may be the start of JCV infection when the virus is still undetectable in CSF,” said Eugene O. Major, PhD, a consultant in the Division of Neuroimmunology and Neurovirology at NINDS in Bethesda, Maryland, in an accompanying editorial. “However, it is not yet clear how well the relationship between viral load in CSF and MRI brain lesions approximates the stages of the disease and the processes with which it affects its target brain cells.”

Repeat testing may be worthwhile when CSF testing is negative, because some patients test positive weeks after testing negative, he added. “Suspicion for PML may be increased when MRI shows signs of PML despite negative CSF testing, but it is too early to rely on MRI alone for diagnosis.”

Dr. Major has received consulting fees while serving on independent adjudication committees for Takeda/Millennium, Roche/Genentech, and GlaxoSmithKline.He has patent rights at the NIH as coinventor of the Ultrasensitive Quantitative PCR Multiplex assay for the detection of JCV DNA–distinguishing viral variants.

—Nicola Garrett

Suggested Reading

Major EO. Progressive multifocal leukoencephalopathy lesions and JC virus: the limits and value of imaging. JAMA Neurol. 2018 Mar 12 [Epub ahead of print].

Wijburg MT, Kleerekooper I, Lissenberg-Witte BI, et al. Association of progressive multifocal leukoencephalopathy lesion volume with JC virus polymerase chain reaction results in cerebrospinal fluid of natalizumab-treated patients with multiple sclerosis. JAMA Neurol. 2018 Mar 12 [Epub ahead of print].

Medical students and nurses who listen to 15 seconds of single-channel sonified EEGs may detect seizures with 95% to 98% sensitivity, thus outperforming neurologists who review traditional visual EEG displays, according to the results of a single-center study published in the April issue of Epilepsia.

“Individuals without EEG training can detect ongoing seizures or seizurelike rhythmic and periodic patterns by merely listening to short clips of sonified EEG,” said Josef Parvizi, MD, PhD, Professor of Neurology at Stanford University Medical Center in California, and his associates. “Ours is also the first study to test the capability of a sonification method to detect a range of significant abnormalities when it is used by clinical staff (eg, physicians, nurses, and students).”

—Amy Karon

Suggested Reading

Parvizi J, Gururangan K, Razavi B, Chafe C. Detecting silent seizures by their sound. Epilepsia. 2018;59(4):877-884.

Medical students and nurses who listen to 15 seconds of single-channel sonified EEGs may detect seizures with 95% to 98% sensitivity, thus outperforming neurologists who review traditional visual EEG displays, according to the results of a single-center study published in the April issue of Epilepsia.

“Individuals without EEG training can detect ongoing seizures or seizurelike rhythmic and periodic patterns by merely listening to short clips of sonified EEG,” said Josef Parvizi, MD, PhD, Professor of Neurology at Stanford University Medical Center in California, and his associates. “Ours is also the first study to test the capability of a sonification method to detect a range of significant abnormalities when it is used by clinical staff (eg, physicians, nurses, and students).”

—Amy Karon

Suggested Reading

Parvizi J, Gururangan K, Razavi B, Chafe C. Detecting silent seizures by their sound. Epilepsia. 2018;59(4):877-884.

Medical students and nurses who listen to 15 seconds of single-channel sonified EEGs may detect seizures with 95% to 98% sensitivity, thus outperforming neurologists who review traditional visual EEG displays, according to the results of a single-center study published in the April issue of Epilepsia.

“Individuals without EEG training can detect ongoing seizures or seizurelike rhythmic and periodic patterns by merely listening to short clips of sonified EEG,” said Josef Parvizi, MD, PhD, Professor of Neurology at Stanford University Medical Center in California, and his associates. “Ours is also the first study to test the capability of a sonification method to detect a range of significant abnormalities when it is used by clinical staff (eg, physicians, nurses, and students).”

—Amy Karon

Suggested Reading

Parvizi J, Gururangan K, Razavi B, Chafe C. Detecting silent seizures by their sound. Epilepsia. 2018;59(4):877-884.

PART 1

• Leading best gynecologic surgical care into the next decade
• Optimal surgical management of stage 3 and 4 pelvic organ prolapse
• Patient experience: It’s not about satisfaction

‌

‌

Andrew P. Cassidenti, MD
Chief, Female Pelvic Medicine and Reconstructive Surgery
Kern Medical,
Bakersfield, California

Amanda White, MD
Assistant Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Vivian Aguilar, MD
Assistant Professor, Obstetrics and Gynecology
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Rebecca G. Rogers, MD
Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Associate Chair, Clinical Integration and Operations
Dell Medical School, University of Texas
Austin, Texas

Patrick Culligan, MD
Director, Urogynecology and The Center for Female Pelvic Health
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Sarah Huber, MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Vincent R. Lucente, MD, MBA
Chief, Gynecology, St. Luke’s University Health Network
Medical Director, The Institute for Female Pelvic Medicine and Reconstructive Surgery
Allentown, Pennsylvania

Jessica B. Ton, MD
AAGL Fellow, Minimally Invasive Gynecologic Surgery
St. Luke’s University Health Network
Bethlehem, Pennsylvania

James I. Merlino, MD
President and Chief Medical Officer of Advisory and Strategic Consulting
Press Ganey Associates
Cleveland, Ohio

Amy A. Merlino, MD
Maternal Fetal Medicine Specialist
Department of Obstetrics and Gynecology
Enterprise Chief Informatics Officer
Cleveland Clinic, Cleveland, Ohio

PART 2

• Deep infiltrating endometriosis: Evaluation and management
• What’s new in simulation training for hysterectomy

‌

‌

‌

‌

Rosanne M. Kho, MD
Head, Section of Benign Gynecology
Women’s Health Institute
Department of Obstetrics and Gynecology
Cleveland Clinic
Cleveland, Ohio

Mauricio S. Abrão, MD
Associate Professor and
Director, Endometriosis Division
Department of Obstetrics and Gynecology
São Paulo University Medical School
São Paulo, Brazil

Alicia Scribner, MD, MPH
Director, Ob/Gyn Simulation Curriculum
Madigan Army Medical Center
Tacoma, Washington
Clinical Instructor
Department of Obstetrics and Gynecology
University of Washington, Seattle

Christine Vaccaro, DO
Medical Director, Andersen Simulation Center
Madigan Army Medical Center
Tacoma, Washington
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Washington, Seattle
Uniformed Services University of Health Sciences
Bethesda, Maryland

PART 1

• Leading best gynecologic surgical care into the next decade
• Optimal surgical management of stage 3 and 4 pelvic organ prolapse
• Patient experience: It’s not about satisfaction

‌

‌

Andrew P. Cassidenti, MD
Chief, Female Pelvic Medicine and Reconstructive Surgery
Kern Medical,
Bakersfield, California

Amanda White, MD
Assistant Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Vivian Aguilar, MD
Assistant Professor, Obstetrics and Gynecology
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Rebecca G. Rogers, MD
Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Associate Chair, Clinical Integration and Operations
Dell Medical School, University of Texas
Austin, Texas

Patrick Culligan, MD
Director, Urogynecology and The Center for Female Pelvic Health
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Sarah Huber, MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Vincent R. Lucente, MD, MBA
Chief, Gynecology, St. Luke’s University Health Network
Medical Director, The Institute for Female Pelvic Medicine and Reconstructive Surgery
Allentown, Pennsylvania

Jessica B. Ton, MD
AAGL Fellow, Minimally Invasive Gynecologic Surgery
St. Luke’s University Health Network
Bethlehem, Pennsylvania

James I. Merlino, MD
President and Chief Medical Officer of Advisory and Strategic Consulting
Press Ganey Associates
Cleveland, Ohio

Amy A. Merlino, MD
Maternal Fetal Medicine Specialist
Department of Obstetrics and Gynecology
Enterprise Chief Informatics Officer
Cleveland Clinic, Cleveland, Ohio

PART 2

• Deep infiltrating endometriosis: Evaluation and management
• What’s new in simulation training for hysterectomy

‌

‌

‌

‌

Rosanne M. Kho, MD
Head, Section of Benign Gynecology
Women’s Health Institute
Department of Obstetrics and Gynecology
Cleveland Clinic
Cleveland, Ohio

Mauricio S. Abrão, MD
Associate Professor and
Director, Endometriosis Division
Department of Obstetrics and Gynecology
São Paulo University Medical School
São Paulo, Brazil

Alicia Scribner, MD, MPH
Director, Ob/Gyn Simulation Curriculum
Madigan Army Medical Center
Tacoma, Washington
Clinical Instructor
Department of Obstetrics and Gynecology
University of Washington, Seattle

Christine Vaccaro, DO
Medical Director, Andersen Simulation Center
Madigan Army Medical Center
Tacoma, Washington
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Washington, Seattle
Uniformed Services University of Health Sciences
Bethesda, Maryland

PART 1

• Leading best gynecologic surgical care into the next decade
• Optimal surgical management of stage 3 and 4 pelvic organ prolapse
• Patient experience: It’s not about satisfaction

‌

‌

Andrew P. Cassidenti, MD
Chief, Female Pelvic Medicine and Reconstructive Surgery
Kern Medical,
Bakersfield, California

Amanda White, MD
Assistant Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Vivian Aguilar, MD
Assistant Professor, Obstetrics and Gynecology
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Rebecca G. Rogers, MD
Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Associate Chair, Clinical Integration and Operations
Dell Medical School, University of Texas
Austin, Texas

Patrick Culligan, MD
Director, Urogynecology and The Center for Female Pelvic Health
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Sarah Huber, MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Vincent R. Lucente, MD, MBA
Chief, Gynecology, St. Luke’s University Health Network
Medical Director, The Institute for Female Pelvic Medicine and Reconstructive Surgery
Allentown, Pennsylvania

Jessica B. Ton, MD
AAGL Fellow, Minimally Invasive Gynecologic Surgery
St. Luke’s University Health Network
Bethlehem, Pennsylvania

James I. Merlino, MD
President and Chief Medical Officer of Advisory and Strategic Consulting
Press Ganey Associates
Cleveland, Ohio

Amy A. Merlino, MD
Maternal Fetal Medicine Specialist
Department of Obstetrics and Gynecology
Enterprise Chief Informatics Officer
Cleveland Clinic, Cleveland, Ohio

PART 2

• Deep infiltrating endometriosis: Evaluation and management
• What’s new in simulation training for hysterectomy

‌

‌

‌

‌

Rosanne M. Kho, MD
Head, Section of Benign Gynecology
Women’s Health Institute
Department of Obstetrics and Gynecology
Cleveland Clinic
Cleveland, Ohio

Mauricio S. Abrão, MD
Associate Professor and
Director, Endometriosis Division
Department of Obstetrics and Gynecology
São Paulo University Medical School
São Paulo, Brazil

Alicia Scribner, MD, MPH
Director, Ob/Gyn Simulation Curriculum
Madigan Army Medical Center
Tacoma, Washington
Clinical Instructor
Department of Obstetrics and Gynecology
University of Washington, Seattle

Christine Vaccaro, DO
Medical Director, Andersen Simulation Center
Madigan Army Medical Center
Tacoma, Washington
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Washington, Seattle
Uniformed Services University of Health Sciences
Bethesda, Maryland

Due to an increase in minimally invasive approaches to hysterectomy, including vaginal and laparoscopic approaches, gynecologic surgeons may need to turn to simulation training to augment practice and hone skills. Simulation is useful for all surgeons, especially for low-volume surgeons, as a warm-up to sharpen technical skills prior to starting the day’s cases. Additionally, educators are uniquely poised to use simulation to teach residents and to evaluate their procedural competency.

In this article, we provide an overview of the 3 approaches to hysterectomy—vaginal, laparoscopic, abdominal—through medical modeling and simulation techniques. We focus on practical issues, including current resources available online, cost, setup time, fidelity, and limitations of some commonly available vaginal, laparoscopic, and open hysterectomy models.

Simulation directly influences patient safety. Thus, the value of simulation cannot be overstated, as it can increase the quality of health care by improving patient outcomes and lowering overall costs. In 2008, the American College of Obstetricians and Gynecologists (ACOG) founded the Simulations Working Group to establish simulation as a pillar in education for women’s health through collaboration, advocacy, research, and the development and implementation of multidisciplinary simulations-based educational resources and opportunities.

Refer to the ACOG Simulations Working Group Toolkit online to see the objectives, simulation, and videos related to each module. Under the “Hysterectomy” section, you will find how to construct the “flower pot” model for abdominal and vaginal hysterectomy, as well as the AAGL vaginal and laparoscopic hysterectomy webinars. All content is reaffirmed frequently to keep it up to date. You can access the toolkit, with your ACOG login and passcode, at https://www.acog.org/About-ACOG/ACOG-Departments/Simulations-Consortium/Simulations-Consortium-Tool-Kit.

For a comprehensive gynecology curriculum to include vaginal, laparoscopic, and abdominal approaches to hysterectomy, refer to ACOG’s Surgical Curriculum in Obstetrics and Gynecology page at https://cfweb.acog.org/scog/. This page lists the standardized surgical skills curriculum for use in training residents in obstetrics and gynecology by procedure. It includes:

• the objective, description, and assessment of the module
• a description of the simulation
• a description of the surgical procedure
• a quiz that must be passed to proceed to evaluation by a faculty member
• an evaluation form to be downloaded and printed by the learner.

Takeaway. Value of Simulation = Quality (Improved Patient Outcomes) ÷ Direct and Indirect Costs.

Simulation models for training in vaginal hysterectomy

According to the Accreditation Council for Graduate Medical Education (ACGME), the minimum number of vaginal hysterectomies is 15; this number represents the minimum accepted exposure, however, and does not imply competency. Exposure to vaginal hysterectomy in residency training has significantly declined over the years, with a mean of only 19 vaginal hysterectomies performed by the time of graduation in 2014.¹

A wide range of simulation models are available that you either can construct or purchase, based on your budget. We discuss 3 such models below.

The Miya model

The Miya Model Pelvic Surgery Training Model (Miyazaki Enterprises) consists of a bony pelvic frame and multiple replaceable and realistic anatomic structures, including the uterus, cervix, and adnexa (1 structure), vagina, bladder, and a few selected muscles and ligaments for pelvic floor disorders (FIGURE 1). The model incorporates features to simulate actual surgical experiences, such as realistic cutting and puncturing tensions, palpable surgical landmarks, a pressurized vascular system with bleeding for inadequate technique, and an inflatable bladder that can leak water if damaged.

Mounted on a rotating stand with the top of the pelvis open, the Miya model is designed to provide access and visibility, enabling supervising physicians the ability to give immediate guidance and feedback. The interchangeable parts allow the learner to be challenged at the appropriate skill level with the use of a large uterus versus a smaller uterus.

New in 2018 is an “intern” uterus and vagina that have no vascular supply and a single-layer vagina; this model is one-third of the cost of the larger, high-fidelity uterus (which has a vascular supply and additional tissue layers).

The Miya model reusable bony pelvic frame has a one-time cost of a few thousand dollars. Advantages include its high fidelity, low technology, light weight, portability, and quick setup. To view a video of the Miya model, go to https://www.youtube.com/watch?time_continue=49&v=A2RjOgVRclo. To see a simulated vaginal hysterectomy, visit https://www.youtube.com/watch?time_continue=13&v=dwiQz4DTyy8.

The gynecologic surgeon and inventor, Dr. Douglas Miyazaki, has improved the vesicouterine peritoneal fold (usually the most challenging for the surgeon) to have a more realistic, slippery feel when palpated.

This model’s weaknesses are its cost (relative to low-fidelity models) and the inability to use energy devices.

Takeaway. The Miya model is a high-fidelity, portable vaginal hysterectomy model with a reusable base and consumable replacement parts. It can be tailored to the learner’s desired level of difficulty.

The Gynesim model

The Gynesim Vaginal Hysterectomy Model, developed by Dr. Malcolm “Kip” Mackenzie (Gynesim), is a high-fidelity surgical simulation model constructed from animal tissue to provide realistic training in pelvic surgery (FIGURE 2).

These “real tissue models” are hand-constructed from animal tissue harvested from US Department of Agriculture inspected meat processing centers. The models mimic normal and abnormal abdominal and pelvic anatomy, providing realistic feel (haptics) and response to all surgical energy modalities. The “cassette” tissues are placed within a vaginal approach platform, which is portable.

Each model (including a 120- to 240-g uterus, bladder, ureter, uterine artery, cardinal and uterosacral ligaments, and rectum) supports critical gaps in surgical techniques such as peritoneal entry and cuff closure. Gynesim staff set up the entire laboratory, including the simulation models, instruments, and/or cameras; however, surgical energy systems are secured from the host institution.

The advantages of this model are its excellent tissue haptics and the minimal preparation time required from the busy gynecologic teaching faculty, as the company performs the setup and breakdown. Disadvantages include the model’s cost (relative to low-fidelity models), that it does not bleed, its one-time use, and the need for technical assistance from the company for setup.

This model can be used for laparoscopic and open hysterectomy approaches, as well as for vaginal hysterectomy. For more information, visit the Gynesim website at https://www.gynesim.com/vaginal-hysterectomy/.

Takeaway. The high-fidelity Gynesim model can be used to practice vaginal, laparoscopic, or open hysterectomy approaches. It offers excellent tissue haptics, one-time use “cassettes” made from animal tissue, and compatibility with energy devices.

The milk jug model

The milk jug and fabric uterus model, developed by Dr. Dee Fenner, is a low-cost simulation model and an alternative to the flower pot model (described later in this article). The bony pelvis is simulated by a 1-gallon milk carton that is taped to a foam ring. Other materials used to make the uterus are fabric, stuffing, and a needle and thread (or a sewing machine). Each model costs approximately $5 and takes approximately 15 minutes to create. For instructions on how to construct this model, see the Society for Gynecologic Surgeons (SGS) award-winning video from 2012 at https://vimeo.com/123804677.

The advantages of this model are that it is inexpensive and is a good tool with which novice gynecologic surgeons can learn the basic steps of the procedure. The disadvantages are that it does not bleed, is not compatible with energy devices, and must be constructed by hand (adding considerable time) or with a sewing machine.

Takeaway. The milk jug model is a low-cost, low-fidelity model for the novice surgeon that can be quickly constructed with the use of a sewing machine.

Read about simulation models for training in laparoscopic hysterectomy.

Simulation models for training in laparoscopic hysterectomy

While overall hysterectomy numbers have remained relatively stable during the last 10 years, the proportion of laparoscopic hysterectomy procedures is increasing in residency training.¹ Many toolkits and models are available for practicing skills, from low-fidelity models on which to rehearse laparoscopic techniques (suturing, instrument handling) to high-fidelity models that provide augmented reality views of the abdominal cavity as well as the operating room itself. We offer a sampling of 4 such models below.

The FLS trainer system

The Fundamentals of Laparoscopic Surgery (FLS) Trainer Box (Limbs & Things Ltd) provides hands-on manual skills practice and training for laparoscopic surgery (FIGURE 3). The FLS trainer box uses 5 skills to challenge a surgeon’s dexterity and psychomotor skills. The set includes the trainer box with a camera and light source as well as the equipment needed to perform the 5 FLS tasks (peg transfer, pattern cutting, ligating loop, and intracorporeal and extracorporeal knot tying). The kit does not include laparoscopic instruments or a monitor.

The FLS trainer box with camera costs $1,164. The advantages are that it is portable and can be used to warm-up prior to surgery or for practice to improve technical skills. It is a great tool for junior residents who are learning the basics of laparoscopic surgery. This trainer’s disadvantages are that it is a low-fidelity unit that is procedure agnostic. For more information, visit the Limbs & Things website at https://www.fls-products.com.

Notably, ObGyn residents who graduate after May 31, 2020, will be required to successfully complete the FLS program as a prerequisite for specialty board certification.² The FLS program is endorsed by the American College of Surgeons and is run through the Society of American Gastrointestinal and Endoscopic Surgeons. The FLS test is proctored and must be taken at a testing center.

Takeaway. The FLS trainer box is readily available, portable, relatively inexpensive, low-tech, and has valid benchmarks for proficiency. The FLS test will be required for ObGyn residents by 2020.

The SimPraxis software trainer

The SimPraxis Laparoscopic Hysterectomy Trainer (Red Llama, Inc) is an interactive simulation software platform that is available in DVD or USB format (FIGURE 4). The software is designed to review anatomy, surgical instrumentation, and specific steps of the procedure. It provides formative assessments and offers summative feedback for users.

The SimPraxis training software would make a useful tool to familiarize medical students and interns with the basics of the procedure before advancing to other simulation trainers. The software costs $100. For more information, visit https://www.3-dmed.com/product/simpraxis%C3%82%C2%AE-laparoscopic-hysterectomy-trainer.

Takeaway. The SimPraxis software is ideal for novice learners and can be used on a home or office computer.

The LapSim virtual reality trainer

The LapSim Haptic System (Surgical Science) is a virtual reality skills trainer. The hysterectomy module includes right and left uterine artery dissection, vaginal cuff opening, and cuff closure (FIGURE 5). One advantage of this simulator is its haptic feedback system, which enhances the fidelity of the training.

The LapSim simulator includes a training module for students and early learners and modules to improve camera handling. The virtual reality base system costs $70,720, and the hysterectomy software module is an additional $15,600.

For more information, visit the company’s website at https://surgicalscience.com/systems/lapsim/. For an informational video, go to https://surgicalscience.com/systems/lapsim/video/.

Takeaway. The LapSim is an expensive, high-fidelity, virtual reality simulator with enhanced haptics and software for practicing laparoscopic hysterectomy.

The LAP Mentor virtual reality simulator

The LAP Mentor VR (3D Systems) is another virtual reality simulator that has modules for laparoscopic hysterectomy and cuff closure (FIGURE 6). The trainee uses a virtual reality headset and becomes fully immersed in the operating room environment with audio and visual cues that mimic a real surgical experience.

The hysterectomy module allows the user to manipulate the uterus, identify the ureters, divide the superior pedicles, mobilize the bladder, expose and divide the uterine artery, and perform the colpotomy. The cuff closure module allows the user to suture the vaginal cuff using barbed suture. The module also can expose the learner to complications, such as bladder, ureteral, colon, or vascular injury.

The LAP Mentor VR base system costs $84,000 and the modules cost about $15,000. For additional information, visit the company’s website at http://simbionix.com/simulators/lap-mentor/lap-mentor-vr-or/.

Takeaway. The LAP Mentor is an expensive, high-fidelity simulation platform with a virtual reality headset that simulates a laparoscopic hysterectomy (with complications) in the operating room.

Read about simulations models for robot-assisted lap hysterectomy and abdominal hysterectomy.

Simulation models for training in robot-assisted laparoscopic hysterectomy

All robot-assisted simulation platforms have highly realistic graphics, and they are expensive (TABLE). However, the da Vinci Skills Simulator (backpack) platform is included with the da Vinci Si and Xi Systems. Note, though, that it can be challenging to access the surgeon console and backpack at institutions with high volumes of robot-assisted surgery.

Other options that generally reside outside of the operating room include Mimic’s FlexVR and dV-Trainer and the Robotix Mentor by 3D Systems (FIGURES 7–11). Mimic’s new technology, called MaestroAR (augmented reality), allows trainees to manipulate virtual robotic instruments to interact with anatomic regions within augmented 3D surgical video footage, with narration and instruction by Dr. Arnold Advincula.

Newer software by Simbionix allows augmented reality to assist the simulation of robot-assisted hysterectomy with the da Vinci Xi backpack and RobotiX platforms.

Models for training in abdominal hysterectomy

In the last 10 years, there has been a 30% decrease in the number of abdominal hysterectomies performed by residents.¹ Because of this decline in operating room experience, simulation training can be an important tool to bolster residency experience.

There are not many simulation models available for teaching abdominal hysterectomy, but here we discuss 2 that we utilize in our residency program.

Adaptable task trainer

The Surgical Female Pelvic Trainer (SFPT) (Limbs & Things Ltd), a pelvic task trainer primarily used for simulation of laparoscopic hysterectomy, can be adapted for abdominal hysterectomy by removing the abdominal cover (FIGURE 12). This trainer can be used with simulated blood to increase the realism of training. The SFPT trainer costs $2,190. For more information, go to https://www.limbsandthings.com/us/our-products/details/surgical-female-pelvic-trainer-sfpt-mk-2.

Takeaway. The SFPT is a medium-fidelity task trainer with a reusable base and consumable replacement parts.

ACOG’s do-it-yourself flower pot model

The flower pot model (developed by the ACOG Simulation Working Group, Washington, DC) is a comprehensive educational package that includes learning objectives, simulation construction instructions, content review of the abdominal hysterectomy, quiz, and evaluation form.³ ACOG has endorsed this low-cost model for residency education. Each model costs approximately $20, and the base (flower pot) is reusable (FIGURE 13).Construction time for each model is 30 to 60 minutes, and learners can participate in the construction. This can aid in anatomy review and familiarization with the model prior to training in the surgical procedure.

The learning objectives, content review, quiz, and evaluation form can be used for the flower pot model or for high-fidelity models.

The advantages of this model are the low cost and that it provides enough fidelity to teach each of the critical steps of the procedure. The disadvantages include that it is a lower-fidelity model, requires a considerable amount of time for construction, does not bleed, and is not compatible with energy devices. This model also can be used for training in laparoscopic and vaginal hysterectomy. For more information, visit ACOG’s Surgical Curriculum website at https://cfweb.acog.org/scog/.

Takeaway. ACOG’s flower pot model for hysterectomy training is a comprehensive, low-cost, low-fidelity simulation model that requires significant setup time.

Simulation’s offerings

Simulation training is the present and future of medicine that bridges the gap between textbook learning and technical proficiency. Although in this article we describe only a handful of the simulation resources available, we hope that you will incorporate such tools into your practice for continuing education and skill development. Utilize peer-reviewed resources, such as the ACOG curriculum module and evaluation tools for abdominal, laparoscopic, and vaginal hysterectomy, which can be used with any simulation model to provide a comprehensive and complimentary learning experience.

The future of health care depends on the commitment and ingenuity of educators who embrace medical simulation’s purpose: improved patient safety, effectiveness, and efficiency. Join the movement!

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Due to an increase in minimally invasive approaches to hysterectomy, including vaginal and laparoscopic approaches, gynecologic surgeons may need to turn to simulation training to augment practice and hone skills. Simulation is useful for all surgeons, especially for low-volume surgeons, as a warm-up to sharpen technical skills prior to starting the day’s cases. Additionally, educators are uniquely poised to use simulation to teach residents and to evaluate their procedural competency.

In this article, we provide an overview of the 3 approaches to hysterectomy—vaginal, laparoscopic, abdominal—through medical modeling and simulation techniques. We focus on practical issues, including current resources available online, cost, setup time, fidelity, and limitations of some commonly available vaginal, laparoscopic, and open hysterectomy models.

Simulation directly influences patient safety. Thus, the value of simulation cannot be overstated, as it can increase the quality of health care by improving patient outcomes and lowering overall costs. In 2008, the American College of Obstetricians and Gynecologists (ACOG) founded the Simulations Working Group to establish simulation as a pillar in education for women’s health through collaboration, advocacy, research, and the development and implementation of multidisciplinary simulations-based educational resources and opportunities.

Refer to the ACOG Simulations Working Group Toolkit online to see the objectives, simulation, and videos related to each module. Under the “Hysterectomy” section, you will find how to construct the “flower pot” model for abdominal and vaginal hysterectomy, as well as the AAGL vaginal and laparoscopic hysterectomy webinars. All content is reaffirmed frequently to keep it up to date. You can access the toolkit, with your ACOG login and passcode, at https://www.acog.org/About-ACOG/ACOG-Departments/Simulations-Consortium/Simulations-Consortium-Tool-Kit.

For a comprehensive gynecology curriculum to include vaginal, laparoscopic, and abdominal approaches to hysterectomy, refer to ACOG’s Surgical Curriculum in Obstetrics and Gynecology page at https://cfweb.acog.org/scog/. This page lists the standardized surgical skills curriculum for use in training residents in obstetrics and gynecology by procedure. It includes:

• the objective, description, and assessment of the module
• a description of the simulation
• a description of the surgical procedure
• a quiz that must be passed to proceed to evaluation by a faculty member
• an evaluation form to be downloaded and printed by the learner.

Takeaway. Value of Simulation = Quality (Improved Patient Outcomes) ÷ Direct and Indirect Costs.

Simulation models for training in vaginal hysterectomy

According to the Accreditation Council for Graduate Medical Education (ACGME), the minimum number of vaginal hysterectomies is 15; this number represents the minimum accepted exposure, however, and does not imply competency. Exposure to vaginal hysterectomy in residency training has significantly declined over the years, with a mean of only 19 vaginal hysterectomies performed by the time of graduation in 2014.¹

A wide range of simulation models are available that you either can construct or purchase, based on your budget. We discuss 3 such models below.

The Miya model

The Miya Model Pelvic Surgery Training Model (Miyazaki Enterprises) consists of a bony pelvic frame and multiple replaceable and realistic anatomic structures, including the uterus, cervix, and adnexa (1 structure), vagina, bladder, and a few selected muscles and ligaments for pelvic floor disorders (FIGURE 1). The model incorporates features to simulate actual surgical experiences, such as realistic cutting and puncturing tensions, palpable surgical landmarks, a pressurized vascular system with bleeding for inadequate technique, and an inflatable bladder that can leak water if damaged.

Mounted on a rotating stand with the top of the pelvis open, the Miya model is designed to provide access and visibility, enabling supervising physicians the ability to give immediate guidance and feedback. The interchangeable parts allow the learner to be challenged at the appropriate skill level with the use of a large uterus versus a smaller uterus.

New in 2018 is an “intern” uterus and vagina that have no vascular supply and a single-layer vagina; this model is one-third of the cost of the larger, high-fidelity uterus (which has a vascular supply and additional tissue layers).

The Miya model reusable bony pelvic frame has a one-time cost of a few thousand dollars. Advantages include its high fidelity, low technology, light weight, portability, and quick setup. To view a video of the Miya model, go to https://www.youtube.com/watch?time_continue=49&v=A2RjOgVRclo. To see a simulated vaginal hysterectomy, visit https://www.youtube.com/watch?time_continue=13&v=dwiQz4DTyy8.

The gynecologic surgeon and inventor, Dr. Douglas Miyazaki, has improved the vesicouterine peritoneal fold (usually the most challenging for the surgeon) to have a more realistic, slippery feel when palpated.

This model’s weaknesses are its cost (relative to low-fidelity models) and the inability to use energy devices.

Takeaway. The Miya model is a high-fidelity, portable vaginal hysterectomy model with a reusable base and consumable replacement parts. It can be tailored to the learner’s desired level of difficulty.

The Gynesim model

The Gynesim Vaginal Hysterectomy Model, developed by Dr. Malcolm “Kip” Mackenzie (Gynesim), is a high-fidelity surgical simulation model constructed from animal tissue to provide realistic training in pelvic surgery (FIGURE 2).

These “real tissue models” are hand-constructed from animal tissue harvested from US Department of Agriculture inspected meat processing centers. The models mimic normal and abnormal abdominal and pelvic anatomy, providing realistic feel (haptics) and response to all surgical energy modalities. The “cassette” tissues are placed within a vaginal approach platform, which is portable.

Each model (including a 120- to 240-g uterus, bladder, ureter, uterine artery, cardinal and uterosacral ligaments, and rectum) supports critical gaps in surgical techniques such as peritoneal entry and cuff closure. Gynesim staff set up the entire laboratory, including the simulation models, instruments, and/or cameras; however, surgical energy systems are secured from the host institution.

The advantages of this model are its excellent tissue haptics and the minimal preparation time required from the busy gynecologic teaching faculty, as the company performs the setup and breakdown. Disadvantages include the model’s cost (relative to low-fidelity models), that it does not bleed, its one-time use, and the need for technical assistance from the company for setup.

This model can be used for laparoscopic and open hysterectomy approaches, as well as for vaginal hysterectomy. For more information, visit the Gynesim website at https://www.gynesim.com/vaginal-hysterectomy/.

Takeaway. The high-fidelity Gynesim model can be used to practice vaginal, laparoscopic, or open hysterectomy approaches. It offers excellent tissue haptics, one-time use “cassettes” made from animal tissue, and compatibility with energy devices.

The milk jug model

The milk jug and fabric uterus model, developed by Dr. Dee Fenner, is a low-cost simulation model and an alternative to the flower pot model (described later in this article). The bony pelvis is simulated by a 1-gallon milk carton that is taped to a foam ring. Other materials used to make the uterus are fabric, stuffing, and a needle and thread (or a sewing machine). Each model costs approximately $5 and takes approximately 15 minutes to create. For instructions on how to construct this model, see the Society for Gynecologic Surgeons (SGS) award-winning video from 2012 at https://vimeo.com/123804677.

The advantages of this model are that it is inexpensive and is a good tool with which novice gynecologic surgeons can learn the basic steps of the procedure. The disadvantages are that it does not bleed, is not compatible with energy devices, and must be constructed by hand (adding considerable time) or with a sewing machine.

Takeaway. The milk jug model is a low-cost, low-fidelity model for the novice surgeon that can be quickly constructed with the use of a sewing machine.

Read about simulation models for training in laparoscopic hysterectomy.

Simulation models for training in laparoscopic hysterectomy

While overall hysterectomy numbers have remained relatively stable during the last 10 years, the proportion of laparoscopic hysterectomy procedures is increasing in residency training.¹ Many toolkits and models are available for practicing skills, from low-fidelity models on which to rehearse laparoscopic techniques (suturing, instrument handling) to high-fidelity models that provide augmented reality views of the abdominal cavity as well as the operating room itself. We offer a sampling of 4 such models below.

The FLS trainer system

The Fundamentals of Laparoscopic Surgery (FLS) Trainer Box (Limbs & Things Ltd) provides hands-on manual skills practice and training for laparoscopic surgery (FIGURE 3). The FLS trainer box uses 5 skills to challenge a surgeon’s dexterity and psychomotor skills. The set includes the trainer box with a camera and light source as well as the equipment needed to perform the 5 FLS tasks (peg transfer, pattern cutting, ligating loop, and intracorporeal and extracorporeal knot tying). The kit does not include laparoscopic instruments or a monitor.

The FLS trainer box with camera costs $1,164. The advantages are that it is portable and can be used to warm-up prior to surgery or for practice to improve technical skills. It is a great tool for junior residents who are learning the basics of laparoscopic surgery. This trainer’s disadvantages are that it is a low-fidelity unit that is procedure agnostic. For more information, visit the Limbs & Things website at https://www.fls-products.com.

Notably, ObGyn residents who graduate after May 31, 2020, will be required to successfully complete the FLS program as a prerequisite for specialty board certification.² The FLS program is endorsed by the American College of Surgeons and is run through the Society of American Gastrointestinal and Endoscopic Surgeons. The FLS test is proctored and must be taken at a testing center.

Takeaway. The FLS trainer box is readily available, portable, relatively inexpensive, low-tech, and has valid benchmarks for proficiency. The FLS test will be required for ObGyn residents by 2020.

The SimPraxis software trainer

The SimPraxis Laparoscopic Hysterectomy Trainer (Red Llama, Inc) is an interactive simulation software platform that is available in DVD or USB format (FIGURE 4). The software is designed to review anatomy, surgical instrumentation, and specific steps of the procedure. It provides formative assessments and offers summative feedback for users.

The SimPraxis training software would make a useful tool to familiarize medical students and interns with the basics of the procedure before advancing to other simulation trainers. The software costs $100. For more information, visit https://www.3-dmed.com/product/simpraxis%C3%82%C2%AE-laparoscopic-hysterectomy-trainer.

Takeaway. The SimPraxis software is ideal for novice learners and can be used on a home or office computer.

The LapSim virtual reality trainer

The LapSim Haptic System (Surgical Science) is a virtual reality skills trainer. The hysterectomy module includes right and left uterine artery dissection, vaginal cuff opening, and cuff closure (FIGURE 5). One advantage of this simulator is its haptic feedback system, which enhances the fidelity of the training.

The LapSim simulator includes a training module for students and early learners and modules to improve camera handling. The virtual reality base system costs $70,720, and the hysterectomy software module is an additional $15,600.

For more information, visit the company’s website at https://surgicalscience.com/systems/lapsim/. For an informational video, go to https://surgicalscience.com/systems/lapsim/video/.

Takeaway. The LapSim is an expensive, high-fidelity, virtual reality simulator with enhanced haptics and software for practicing laparoscopic hysterectomy.

The LAP Mentor virtual reality simulator

The LAP Mentor VR (3D Systems) is another virtual reality simulator that has modules for laparoscopic hysterectomy and cuff closure (FIGURE 6). The trainee uses a virtual reality headset and becomes fully immersed in the operating room environment with audio and visual cues that mimic a real surgical experience.

The hysterectomy module allows the user to manipulate the uterus, identify the ureters, divide the superior pedicles, mobilize the bladder, expose and divide the uterine artery, and perform the colpotomy. The cuff closure module allows the user to suture the vaginal cuff using barbed suture. The module also can expose the learner to complications, such as bladder, ureteral, colon, or vascular injury.

The LAP Mentor VR base system costs $84,000 and the modules cost about $15,000. For additional information, visit the company’s website at http://simbionix.com/simulators/lap-mentor/lap-mentor-vr-or/.

Takeaway. The LAP Mentor is an expensive, high-fidelity simulation platform with a virtual reality headset that simulates a laparoscopic hysterectomy (with complications) in the operating room.

Read about simulations models for robot-assisted lap hysterectomy and abdominal hysterectomy.

Simulation models for training in robot-assisted laparoscopic hysterectomy

All robot-assisted simulation platforms have highly realistic graphics, and they are expensive (TABLE). However, the da Vinci Skills Simulator (backpack) platform is included with the da Vinci Si and Xi Systems. Note, though, that it can be challenging to access the surgeon console and backpack at institutions with high volumes of robot-assisted surgery.

Other options that generally reside outside of the operating room include Mimic’s FlexVR and dV-Trainer and the Robotix Mentor by 3D Systems (FIGURES 7–11). Mimic’s new technology, called MaestroAR (augmented reality), allows trainees to manipulate virtual robotic instruments to interact with anatomic regions within augmented 3D surgical video footage, with narration and instruction by Dr. Arnold Advincula.

Newer software by Simbionix allows augmented reality to assist the simulation of robot-assisted hysterectomy with the da Vinci Xi backpack and RobotiX platforms.

Models for training in abdominal hysterectomy

In the last 10 years, there has been a 30% decrease in the number of abdominal hysterectomies performed by residents.¹ Because of this decline in operating room experience, simulation training can be an important tool to bolster residency experience.

There are not many simulation models available for teaching abdominal hysterectomy, but here we discuss 2 that we utilize in our residency program.

Adaptable task trainer

The Surgical Female Pelvic Trainer (SFPT) (Limbs & Things Ltd), a pelvic task trainer primarily used for simulation of laparoscopic hysterectomy, can be adapted for abdominal hysterectomy by removing the abdominal cover (FIGURE 12). This trainer can be used with simulated blood to increase the realism of training. The SFPT trainer costs $2,190. For more information, go to https://www.limbsandthings.com/us/our-products/details/surgical-female-pelvic-trainer-sfpt-mk-2.

Takeaway. The SFPT is a medium-fidelity task trainer with a reusable base and consumable replacement parts.

ACOG’s do-it-yourself flower pot model

The flower pot model (developed by the ACOG Simulation Working Group, Washington, DC) is a comprehensive educational package that includes learning objectives, simulation construction instructions, content review of the abdominal hysterectomy, quiz, and evaluation form.³ ACOG has endorsed this low-cost model for residency education. Each model costs approximately $20, and the base (flower pot) is reusable (FIGURE 13).Construction time for each model is 30 to 60 minutes, and learners can participate in the construction. This can aid in anatomy review and familiarization with the model prior to training in the surgical procedure.

The learning objectives, content review, quiz, and evaluation form can be used for the flower pot model or for high-fidelity models.

The advantages of this model are the low cost and that it provides enough fidelity to teach each of the critical steps of the procedure. The disadvantages include that it is a lower-fidelity model, requires a considerable amount of time for construction, does not bleed, and is not compatible with energy devices. This model also can be used for training in laparoscopic and vaginal hysterectomy. For more information, visit ACOG’s Surgical Curriculum website at https://cfweb.acog.org/scog/.

Takeaway. ACOG’s flower pot model for hysterectomy training is a comprehensive, low-cost, low-fidelity simulation model that requires significant setup time.

Simulation’s offerings

Simulation training is the present and future of medicine that bridges the gap between textbook learning and technical proficiency. Although in this article we describe only a handful of the simulation resources available, we hope that you will incorporate such tools into your practice for continuing education and skill development. Utilize peer-reviewed resources, such as the ACOG curriculum module and evaluation tools for abdominal, laparoscopic, and vaginal hysterectomy, which can be used with any simulation model to provide a comprehensive and complimentary learning experience.

The future of health care depends on the commitment and ingenuity of educators who embrace medical simulation’s purpose: improved patient safety, effectiveness, and efficiency. Join the movement!

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Due to an increase in minimally invasive approaches to hysterectomy, including vaginal and laparoscopic approaches, gynecologic surgeons may need to turn to simulation training to augment practice and hone skills. Simulation is useful for all surgeons, especially for low-volume surgeons, as a warm-up to sharpen technical skills prior to starting the day’s cases. Additionally, educators are uniquely poised to use simulation to teach residents and to evaluate their procedural competency.

In this article, we provide an overview of the 3 approaches to hysterectomy—vaginal, laparoscopic, abdominal—through medical modeling and simulation techniques. We focus on practical issues, including current resources available online, cost, setup time, fidelity, and limitations of some commonly available vaginal, laparoscopic, and open hysterectomy models.

Simulation directly influences patient safety. Thus, the value of simulation cannot be overstated, as it can increase the quality of health care by improving patient outcomes and lowering overall costs. In 2008, the American College of Obstetricians and Gynecologists (ACOG) founded the Simulations Working Group to establish simulation as a pillar in education for women’s health through collaboration, advocacy, research, and the development and implementation of multidisciplinary simulations-based educational resources and opportunities.

Refer to the ACOG Simulations Working Group Toolkit online to see the objectives, simulation, and videos related to each module. Under the “Hysterectomy” section, you will find how to construct the “flower pot” model for abdominal and vaginal hysterectomy, as well as the AAGL vaginal and laparoscopic hysterectomy webinars. All content is reaffirmed frequently to keep it up to date. You can access the toolkit, with your ACOG login and passcode, at https://www.acog.org/About-ACOG/ACOG-Departments/Simulations-Consortium/Simulations-Consortium-Tool-Kit.

For a comprehensive gynecology curriculum to include vaginal, laparoscopic, and abdominal approaches to hysterectomy, refer to ACOG’s Surgical Curriculum in Obstetrics and Gynecology page at https://cfweb.acog.org/scog/. This page lists the standardized surgical skills curriculum for use in training residents in obstetrics and gynecology by procedure. It includes:

• the objective, description, and assessment of the module
• a description of the simulation
• a description of the surgical procedure
• a quiz that must be passed to proceed to evaluation by a faculty member
• an evaluation form to be downloaded and printed by the learner.

Takeaway. Value of Simulation = Quality (Improved Patient Outcomes) ÷ Direct and Indirect Costs.

Simulation models for training in vaginal hysterectomy

According to the Accreditation Council for Graduate Medical Education (ACGME), the minimum number of vaginal hysterectomies is 15; this number represents the minimum accepted exposure, however, and does not imply competency. Exposure to vaginal hysterectomy in residency training has significantly declined over the years, with a mean of only 19 vaginal hysterectomies performed by the time of graduation in 2014.¹

A wide range of simulation models are available that you either can construct or purchase, based on your budget. We discuss 3 such models below.

The Miya model

The Miya Model Pelvic Surgery Training Model (Miyazaki Enterprises) consists of a bony pelvic frame and multiple replaceable and realistic anatomic structures, including the uterus, cervix, and adnexa (1 structure), vagina, bladder, and a few selected muscles and ligaments for pelvic floor disorders (FIGURE 1). The model incorporates features to simulate actual surgical experiences, such as realistic cutting and puncturing tensions, palpable surgical landmarks, a pressurized vascular system with bleeding for inadequate technique, and an inflatable bladder that can leak water if damaged.

Mounted on a rotating stand with the top of the pelvis open, the Miya model is designed to provide access and visibility, enabling supervising physicians the ability to give immediate guidance and feedback. The interchangeable parts allow the learner to be challenged at the appropriate skill level with the use of a large uterus versus a smaller uterus.

New in 2018 is an “intern” uterus and vagina that have no vascular supply and a single-layer vagina; this model is one-third of the cost of the larger, high-fidelity uterus (which has a vascular supply and additional tissue layers).

The Miya model reusable bony pelvic frame has a one-time cost of a few thousand dollars. Advantages include its high fidelity, low technology, light weight, portability, and quick setup. To view a video of the Miya model, go to https://www.youtube.com/watch?time_continue=49&v=A2RjOgVRclo. To see a simulated vaginal hysterectomy, visit https://www.youtube.com/watch?time_continue=13&v=dwiQz4DTyy8.

The gynecologic surgeon and inventor, Dr. Douglas Miyazaki, has improved the vesicouterine peritoneal fold (usually the most challenging for the surgeon) to have a more realistic, slippery feel when palpated.

This model’s weaknesses are its cost (relative to low-fidelity models) and the inability to use energy devices.

Takeaway. The Miya model is a high-fidelity, portable vaginal hysterectomy model with a reusable base and consumable replacement parts. It can be tailored to the learner’s desired level of difficulty.

The Gynesim model

The Gynesim Vaginal Hysterectomy Model, developed by Dr. Malcolm “Kip” Mackenzie (Gynesim), is a high-fidelity surgical simulation model constructed from animal tissue to provide realistic training in pelvic surgery (FIGURE 2).

These “real tissue models” are hand-constructed from animal tissue harvested from US Department of Agriculture inspected meat processing centers. The models mimic normal and abnormal abdominal and pelvic anatomy, providing realistic feel (haptics) and response to all surgical energy modalities. The “cassette” tissues are placed within a vaginal approach platform, which is portable.

Each model (including a 120- to 240-g uterus, bladder, ureter, uterine artery, cardinal and uterosacral ligaments, and rectum) supports critical gaps in surgical techniques such as peritoneal entry and cuff closure. Gynesim staff set up the entire laboratory, including the simulation models, instruments, and/or cameras; however, surgical energy systems are secured from the host institution.

The advantages of this model are its excellent tissue haptics and the minimal preparation time required from the busy gynecologic teaching faculty, as the company performs the setup and breakdown. Disadvantages include the model’s cost (relative to low-fidelity models), that it does not bleed, its one-time use, and the need for technical assistance from the company for setup.

This model can be used for laparoscopic and open hysterectomy approaches, as well as for vaginal hysterectomy. For more information, visit the Gynesim website at https://www.gynesim.com/vaginal-hysterectomy/.

Takeaway. The high-fidelity Gynesim model can be used to practice vaginal, laparoscopic, or open hysterectomy approaches. It offers excellent tissue haptics, one-time use “cassettes” made from animal tissue, and compatibility with energy devices.

The milk jug model

The milk jug and fabric uterus model, developed by Dr. Dee Fenner, is a low-cost simulation model and an alternative to the flower pot model (described later in this article). The bony pelvis is simulated by a 1-gallon milk carton that is taped to a foam ring. Other materials used to make the uterus are fabric, stuffing, and a needle and thread (or a sewing machine). Each model costs approximately $5 and takes approximately 15 minutes to create. For instructions on how to construct this model, see the Society for Gynecologic Surgeons (SGS) award-winning video from 2012 at https://vimeo.com/123804677.

The advantages of this model are that it is inexpensive and is a good tool with which novice gynecologic surgeons can learn the basic steps of the procedure. The disadvantages are that it does not bleed, is not compatible with energy devices, and must be constructed by hand (adding considerable time) or with a sewing machine.

Takeaway. The milk jug model is a low-cost, low-fidelity model for the novice surgeon that can be quickly constructed with the use of a sewing machine.

Read about simulation models for training in laparoscopic hysterectomy.

Simulation models for training in laparoscopic hysterectomy

While overall hysterectomy numbers have remained relatively stable during the last 10 years, the proportion of laparoscopic hysterectomy procedures is increasing in residency training.¹ Many toolkits and models are available for practicing skills, from low-fidelity models on which to rehearse laparoscopic techniques (suturing, instrument handling) to high-fidelity models that provide augmented reality views of the abdominal cavity as well as the operating room itself. We offer a sampling of 4 such models below.

The FLS trainer system

The Fundamentals of Laparoscopic Surgery (FLS) Trainer Box (Limbs & Things Ltd) provides hands-on manual skills practice and training for laparoscopic surgery (FIGURE 3). The FLS trainer box uses 5 skills to challenge a surgeon’s dexterity and psychomotor skills. The set includes the trainer box with a camera and light source as well as the equipment needed to perform the 5 FLS tasks (peg transfer, pattern cutting, ligating loop, and intracorporeal and extracorporeal knot tying). The kit does not include laparoscopic instruments or a monitor.

The FLS trainer box with camera costs $1,164. The advantages are that it is portable and can be used to warm-up prior to surgery or for practice to improve technical skills. It is a great tool for junior residents who are learning the basics of laparoscopic surgery. This trainer’s disadvantages are that it is a low-fidelity unit that is procedure agnostic. For more information, visit the Limbs & Things website at https://www.fls-products.com.

Notably, ObGyn residents who graduate after May 31, 2020, will be required to successfully complete the FLS program as a prerequisite for specialty board certification.² The FLS program is endorsed by the American College of Surgeons and is run through the Society of American Gastrointestinal and Endoscopic Surgeons. The FLS test is proctored and must be taken at a testing center.

Takeaway. The FLS trainer box is readily available, portable, relatively inexpensive, low-tech, and has valid benchmarks for proficiency. The FLS test will be required for ObGyn residents by 2020.

The SimPraxis software trainer

The SimPraxis Laparoscopic Hysterectomy Trainer (Red Llama, Inc) is an interactive simulation software platform that is available in DVD or USB format (FIGURE 4). The software is designed to review anatomy, surgical instrumentation, and specific steps of the procedure. It provides formative assessments and offers summative feedback for users.

The SimPraxis training software would make a useful tool to familiarize medical students and interns with the basics of the procedure before advancing to other simulation trainers. The software costs $100. For more information, visit https://www.3-dmed.com/product/simpraxis%C3%82%C2%AE-laparoscopic-hysterectomy-trainer.

Takeaway. The SimPraxis software is ideal for novice learners and can be used on a home or office computer.

The LapSim virtual reality trainer

The LapSim Haptic System (Surgical Science) is a virtual reality skills trainer. The hysterectomy module includes right and left uterine artery dissection, vaginal cuff opening, and cuff closure (FIGURE 5). One advantage of this simulator is its haptic feedback system, which enhances the fidelity of the training.

The LapSim simulator includes a training module for students and early learners and modules to improve camera handling. The virtual reality base system costs $70,720, and the hysterectomy software module is an additional $15,600.

For more information, visit the company’s website at https://surgicalscience.com/systems/lapsim/. For an informational video, go to https://surgicalscience.com/systems/lapsim/video/.

Takeaway. The LapSim is an expensive, high-fidelity, virtual reality simulator with enhanced haptics and software for practicing laparoscopic hysterectomy.

The LAP Mentor virtual reality simulator

The LAP Mentor VR (3D Systems) is another virtual reality simulator that has modules for laparoscopic hysterectomy and cuff closure (FIGURE 6). The trainee uses a virtual reality headset and becomes fully immersed in the operating room environment with audio and visual cues that mimic a real surgical experience.

The hysterectomy module allows the user to manipulate the uterus, identify the ureters, divide the superior pedicles, mobilize the bladder, expose and divide the uterine artery, and perform the colpotomy. The cuff closure module allows the user to suture the vaginal cuff using barbed suture. The module also can expose the learner to complications, such as bladder, ureteral, colon, or vascular injury.

The LAP Mentor VR base system costs $84,000 and the modules cost about $15,000. For additional information, visit the company’s website at http://simbionix.com/simulators/lap-mentor/lap-mentor-vr-or/.

Takeaway. The LAP Mentor is an expensive, high-fidelity simulation platform with a virtual reality headset that simulates a laparoscopic hysterectomy (with complications) in the operating room.

Read about simulations models for robot-assisted lap hysterectomy and abdominal hysterectomy.

Simulation models for training in robot-assisted laparoscopic hysterectomy

All robot-assisted simulation platforms have highly realistic graphics, and they are expensive (TABLE). However, the da Vinci Skills Simulator (backpack) platform is included with the da Vinci Si and Xi Systems. Note, though, that it can be challenging to access the surgeon console and backpack at institutions with high volumes of robot-assisted surgery.

Other options that generally reside outside of the operating room include Mimic’s FlexVR and dV-Trainer and the Robotix Mentor by 3D Systems (FIGURES 7–11). Mimic’s new technology, called MaestroAR (augmented reality), allows trainees to manipulate virtual robotic instruments to interact with anatomic regions within augmented 3D surgical video footage, with narration and instruction by Dr. Arnold Advincula.

Newer software by Simbionix allows augmented reality to assist the simulation of robot-assisted hysterectomy with the da Vinci Xi backpack and RobotiX platforms.

Models for training in abdominal hysterectomy

In the last 10 years, there has been a 30% decrease in the number of abdominal hysterectomies performed by residents.¹ Because of this decline in operating room experience, simulation training can be an important tool to bolster residency experience.

There are not many simulation models available for teaching abdominal hysterectomy, but here we discuss 2 that we utilize in our residency program.

Adaptable task trainer

The Surgical Female Pelvic Trainer (SFPT) (Limbs & Things Ltd), a pelvic task trainer primarily used for simulation of laparoscopic hysterectomy, can be adapted for abdominal hysterectomy by removing the abdominal cover (FIGURE 12). This trainer can be used with simulated blood to increase the realism of training. The SFPT trainer costs $2,190. For more information, go to https://www.limbsandthings.com/us/our-products/details/surgical-female-pelvic-trainer-sfpt-mk-2.

Takeaway. The SFPT is a medium-fidelity task trainer with a reusable base and consumable replacement parts.

ACOG’s do-it-yourself flower pot model

The flower pot model (developed by the ACOG Simulation Working Group, Washington, DC) is a comprehensive educational package that includes learning objectives, simulation construction instructions, content review of the abdominal hysterectomy, quiz, and evaluation form.³ ACOG has endorsed this low-cost model for residency education. Each model costs approximately $20, and the base (flower pot) is reusable (FIGURE 13).Construction time for each model is 30 to 60 minutes, and learners can participate in the construction. This can aid in anatomy review and familiarization with the model prior to training in the surgical procedure.

The learning objectives, content review, quiz, and evaluation form can be used for the flower pot model or for high-fidelity models.

The advantages of this model are the low cost and that it provides enough fidelity to teach each of the critical steps of the procedure. The disadvantages include that it is a lower-fidelity model, requires a considerable amount of time for construction, does not bleed, and is not compatible with energy devices. This model also can be used for training in laparoscopic and vaginal hysterectomy. For more information, visit ACOG’s Surgical Curriculum website at https://cfweb.acog.org/scog/.

Takeaway. ACOG’s flower pot model for hysterectomy training is a comprehensive, low-cost, low-fidelity simulation model that requires significant setup time.

Simulation’s offerings

Simulation training is the present and future of medicine that bridges the gap between textbook learning and technical proficiency. Although in this article we describe only a handful of the simulation resources available, we hope that you will incorporate such tools into your practice for continuing education and skill development. Utilize peer-reviewed resources, such as the ACOG curriculum module and evaluation tools for abdominal, laparoscopic, and vaginal hysterectomy, which can be used with any simulation model to provide a comprehensive and complimentary learning experience.

The future of health care depends on the commitment and ingenuity of educators who embrace medical simulation’s purpose: improved patient safety, effectiveness, and efficiency. Join the movement!

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Endometriosis affects up to 10% of women of reproductive age or, conservatively, about 6.5 million women in the United States.^1,2 There are 3 types of endometriosis—superficial, ovarian, and deep—and in the past each of these was assumed to have a distinct pathogenesis.³ Deep infiltrating endometriosis (DIE) is the presence of one or more endometriotic nodules deeper than 5 mm. In a study at a large tertiary-care center, 40% of patients with endometriosis had deep disease.⁴ DIE is associated with more severe pain and infertility.⁵ In patients with endometriosis, diagnosis is commonly made 7 to 9 years after the initial pelvic pain presentation.⁶ For these reasons, well-directed history taking and proper evaluation and treatment should be pursued to relieve pain and optimize outcomes.

CASE Young woman with intensifying pelvic pain

Mary is a 26-year-old social worker who presents to her ObGyn with symptoms of worsening pain during as well as outside her periods. What additional information would you want to obtain from Mary, given her chief symptom of pain?

Investigate the type of pain

It is important to ask the patient about her menstrual and sexual history, her thoughts regarding near- and long-term fertility, and the type and severity of her pain symptoms. The 5 pain symptoms specific to pelvic pain are dysmenorrhea, dyspareunia, dysuria, dyschezia, and noncyclic pelvic pain. A visual analog scale (VAS) for pain as well as pelvic pain questionnaires can be used to guide evaluation options and monitor treatment outcomes. In addition, it is of paramount importance to understand the differential diagnoses that can present as pelvic pain (TABLE).

CASE Continued: Mary’s history

Mary reports that she always has had painful periods and that she was started on oral contraceptive pills for pain control and regulation of her periods soon after the onset of menses, when she was 12 years old. In college, she was prescribed oral contraceptive pills for contraception. Recently engaged, she is interested in becoming pregnant in 3 years.

A year ago, Mary discontinued the pills because of their adverse effects. Now she has severe pain during (VAS score, 8/10) and outside (VAS score, 7) her monthly periods. Because of this pain, she has taken time off from work twice within the past 6 months. She has pain during intercourse (VAS score, 7) and some pain with bowel movements during her menses (VAS score, 4). Pelvic examination reveals a normal-sized uterus and adnexa as well as a tender nodule in the rectovaginal septum.

What diagnostic tests and imaging would you obtain?

Imaging’s role in diagnosis

At many advanced centers for endometriosis, DIE is successfully diagnosed with specific magnetic resonance imaging (MRI) or transvaginal ultrasound (TVUS) protocols. In a recent review, MRI’s pooled sensitivity and specificity for rectosigmoid endometriosis were 92% and 96%, respectively.⁷ Choice of imaging for DIE depends on the skills and experience of the clinicians at each center. At a large referral center in São Paulo, Brazil, TVUS with bowel preparation had better sensitivity and specificity for deep retrocervical and rectosigmoid disease compared with MRI and digital pelvic examination.⁸ In addition, at a center in the United States, we found that proficiency in performing TVUS for DIE was achieved after 70 to 75 cases, and the exam took an average of only 20 minutes.⁹

Despite recent advances in imaging, most gynecologic societies still hold that endometriosis is to be definitively diagnosed with histologic confirmation from tissue biopsies during surgery. Although surgery remains the diagnostic gold standard, it does not mean that all patients with pelvic pain should undergo diagnostic laparoscopy with tissue biopsies.

The combination of compelling clinical signs, symptoms, and imaging findings (such as absence of findings for ovarian and deep endometriosis) can be used to make a presumptive nonsurgical (that is, clinical) diagnosis of endometriosis. Major societies recommend empiric medical therapy (for example, combination oral contraceptives) for the pain associated with superficial endometriosis.^10,11 When there is no response to treatment, or when a patient declines or has contraindications to medical therapy, diagnostic laparoscopy with excision of endometriosis should be considered.

CASE Continued: Diagnosis

Mary undergoes TVUS with bowel preparation, which reveals a normal uterus and adnexa and the presence of 2 lesions, a 2×1.5-cm retrocervical lesion and a 1.8×2-cm rectosigmoid lesion 9 cm above the anal verge. The rectosigmoid lesion involves the external muscularis and compromises 30% of the bowel circumference.

How would you manage the bowel DIE?

Read about management options and individualized care.

Management options: Factor in the variables

DIE can involve the ureters and bladder, the retrocervical and rectovaginal spaces, the appendix, and the bowel. Lesions can be single or multifocal. Although our institutions’ imaging with MRI and TVUS is highly accurate, we additionally recommend the use of colonoscopy (with directed biopsies if appropriate) to evaluate patients who present with rectal bleeding, large endometriotic rectal nodules, or have a family history of bowel cancer.

While many studies have found that surgical resection of DIE improves pain and quality of life, surgery can have significant complications.¹² Observation is adequate for asymptomatic patients with DIE. Medical treatment may be offered to patients with mild pain (there is no evidence of a reduction in lesion size with medical therapy). In cases of surgical treatment, we encourage the involvement of a multidisciplinary surgical team to reduce complications and optimize outcomes.

Patients with DIE, significant pain (VAS score, >7), and multiple failed in vitro fertilization treatments are candidates for surgery. When bowel endometriosis is noted on imaging, factors such as size, depth, number of lesions, circumferential involvement, and distance from the anal verge are all used to determine the surgical approach. Rectosigmoid lesions smaller than 3 cm can be treated more conservatively—for example, with shaving or anterior resection with manual repair using disk staplers. Segmental resection generally is indicated for rectosigmoid lesions larger than 3 cm, involvement deeper than the submucosal layer, multiple lesions, circumferential involvement of more than 40%, and the presence of obstructed bowel symptoms.^13,14

In patients with DIE who present with both infertility and pain, antimüllerian hormone level and TVUS follicular count are used to evaluate ovarian reserve. As surgical treatment may further reduce ovarian reserve in patients with DIE and infertility, we counsel them regarding assisted reproductive technology options before surgery.

CASE Resolved

After thorough discussion, Mary opts to try a different combination oral contraceptive pill formulation. The pills improve her pain symptoms significantly (VAS score, 4), and she decides to forgo surgery. She will be followed up closely on an outpatient basis with serial TVUS imaging.

Individualize management based on patient parameters

Imaging has been used for the nonsurgical diagnosis of DIE for many years, and this practice increasingly is being accepted and adopted. A presumptive nonsurgical diagnosis of endometriosis can be made based on the clinical signs and symptoms obtained from a thorough history and physical examination, in addition to the absence of imaging findings for ovarian and deep endometriosis.

According to guidelines from major ObGyn societies, such as the American College of Obstetricians and Gynecologists and the European Society of Human Reproduction and Embryology, empiric medical therapy (including combination oral contraceptives, progesterone-containing formulations, and gonadotropin-releasing hormone agonists) can be considered for patients with presumed endometriosis presenting with pain.¹⁵

When surgery is chosen, the surgeon must obtain crucial information on the characteristics of the lesion(s) and involve a multidisciplinary team to achieve the best outcomes for the patient.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Endometriosis affects up to 10% of women of reproductive age or, conservatively, about 6.5 million women in the United States.^1,2 There are 3 types of endometriosis—superficial, ovarian, and deep—and in the past each of these was assumed to have a distinct pathogenesis.³ Deep infiltrating endometriosis (DIE) is the presence of one or more endometriotic nodules deeper than 5 mm. In a study at a large tertiary-care center, 40% of patients with endometriosis had deep disease.⁴ DIE is associated with more severe pain and infertility.⁵ In patients with endometriosis, diagnosis is commonly made 7 to 9 years after the initial pelvic pain presentation.⁶ For these reasons, well-directed history taking and proper evaluation and treatment should be pursued to relieve pain and optimize outcomes.

CASE Young woman with intensifying pelvic pain

Mary is a 26-year-old social worker who presents to her ObGyn with symptoms of worsening pain during as well as outside her periods. What additional information would you want to obtain from Mary, given her chief symptom of pain?

Investigate the type of pain

It is important to ask the patient about her menstrual and sexual history, her thoughts regarding near- and long-term fertility, and the type and severity of her pain symptoms. The 5 pain symptoms specific to pelvic pain are dysmenorrhea, dyspareunia, dysuria, dyschezia, and noncyclic pelvic pain. A visual analog scale (VAS) for pain as well as pelvic pain questionnaires can be used to guide evaluation options and monitor treatment outcomes. In addition, it is of paramount importance to understand the differential diagnoses that can present as pelvic pain (TABLE).

CASE Continued: Mary’s history

Mary reports that she always has had painful periods and that she was started on oral contraceptive pills for pain control and regulation of her periods soon after the onset of menses, when she was 12 years old. In college, she was prescribed oral contraceptive pills for contraception. Recently engaged, she is interested in becoming pregnant in 3 years.

A year ago, Mary discontinued the pills because of their adverse effects. Now she has severe pain during (VAS score, 8/10) and outside (VAS score, 7) her monthly periods. Because of this pain, she has taken time off from work twice within the past 6 months. She has pain during intercourse (VAS score, 7) and some pain with bowel movements during her menses (VAS score, 4). Pelvic examination reveals a normal-sized uterus and adnexa as well as a tender nodule in the rectovaginal septum.

What diagnostic tests and imaging would you obtain?

Imaging’s role in diagnosis

At many advanced centers for endometriosis, DIE is successfully diagnosed with specific magnetic resonance imaging (MRI) or transvaginal ultrasound (TVUS) protocols. In a recent review, MRI’s pooled sensitivity and specificity for rectosigmoid endometriosis were 92% and 96%, respectively.⁷ Choice of imaging for DIE depends on the skills and experience of the clinicians at each center. At a large referral center in São Paulo, Brazil, TVUS with bowel preparation had better sensitivity and specificity for deep retrocervical and rectosigmoid disease compared with MRI and digital pelvic examination.⁸ In addition, at a center in the United States, we found that proficiency in performing TVUS for DIE was achieved after 70 to 75 cases, and the exam took an average of only 20 minutes.⁹

Despite recent advances in imaging, most gynecologic societies still hold that endometriosis is to be definitively diagnosed with histologic confirmation from tissue biopsies during surgery. Although surgery remains the diagnostic gold standard, it does not mean that all patients with pelvic pain should undergo diagnostic laparoscopy with tissue biopsies.

The combination of compelling clinical signs, symptoms, and imaging findings (such as absence of findings for ovarian and deep endometriosis) can be used to make a presumptive nonsurgical (that is, clinical) diagnosis of endometriosis. Major societies recommend empiric medical therapy (for example, combination oral contraceptives) for the pain associated with superficial endometriosis.^10,11 When there is no response to treatment, or when a patient declines or has contraindications to medical therapy, diagnostic laparoscopy with excision of endometriosis should be considered.

CASE Continued: Diagnosis

Mary undergoes TVUS with bowel preparation, which reveals a normal uterus and adnexa and the presence of 2 lesions, a 2×1.5-cm retrocervical lesion and a 1.8×2-cm rectosigmoid lesion 9 cm above the anal verge. The rectosigmoid lesion involves the external muscularis and compromises 30% of the bowel circumference.

How would you manage the bowel DIE?

Read about management options and individualized care.

Management options: Factor in the variables

DIE can involve the ureters and bladder, the retrocervical and rectovaginal spaces, the appendix, and the bowel. Lesions can be single or multifocal. Although our institutions’ imaging with MRI and TVUS is highly accurate, we additionally recommend the use of colonoscopy (with directed biopsies if appropriate) to evaluate patients who present with rectal bleeding, large endometriotic rectal nodules, or have a family history of bowel cancer.

While many studies have found that surgical resection of DIE improves pain and quality of life, surgery can have significant complications.¹² Observation is adequate for asymptomatic patients with DIE. Medical treatment may be offered to patients with mild pain (there is no evidence of a reduction in lesion size with medical therapy). In cases of surgical treatment, we encourage the involvement of a multidisciplinary surgical team to reduce complications and optimize outcomes.

Patients with DIE, significant pain (VAS score, >7), and multiple failed in vitro fertilization treatments are candidates for surgery. When bowel endometriosis is noted on imaging, factors such as size, depth, number of lesions, circumferential involvement, and distance from the anal verge are all used to determine the surgical approach. Rectosigmoid lesions smaller than 3 cm can be treated more conservatively—for example, with shaving or anterior resection with manual repair using disk staplers. Segmental resection generally is indicated for rectosigmoid lesions larger than 3 cm, involvement deeper than the submucosal layer, multiple lesions, circumferential involvement of more than 40%, and the presence of obstructed bowel symptoms.^13,14

In patients with DIE who present with both infertility and pain, antimüllerian hormone level and TVUS follicular count are used to evaluate ovarian reserve. As surgical treatment may further reduce ovarian reserve in patients with DIE and infertility, we counsel them regarding assisted reproductive technology options before surgery.

CASE Resolved

After thorough discussion, Mary opts to try a different combination oral contraceptive pill formulation. The pills improve her pain symptoms significantly (VAS score, 4), and she decides to forgo surgery. She will be followed up closely on an outpatient basis with serial TVUS imaging.

Individualize management based on patient parameters

Imaging has been used for the nonsurgical diagnosis of DIE for many years, and this practice increasingly is being accepted and adopted. A presumptive nonsurgical diagnosis of endometriosis can be made based on the clinical signs and symptoms obtained from a thorough history and physical examination, in addition to the absence of imaging findings for ovarian and deep endometriosis.

According to guidelines from major ObGyn societies, such as the American College of Obstetricians and Gynecologists and the European Society of Human Reproduction and Embryology, empiric medical therapy (including combination oral contraceptives, progesterone-containing formulations, and gonadotropin-releasing hormone agonists) can be considered for patients with presumed endometriosis presenting with pain.¹⁵

When surgery is chosen, the surgeon must obtain crucial information on the characteristics of the lesion(s) and involve a multidisciplinary team to achieve the best outcomes for the patient.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Endometriosis affects up to 10% of women of reproductive age or, conservatively, about 6.5 million women in the United States.^1,2 There are 3 types of endometriosis—superficial, ovarian, and deep—and in the past each of these was assumed to have a distinct pathogenesis.³ Deep infiltrating endometriosis (DIE) is the presence of one or more endometriotic nodules deeper than 5 mm. In a study at a large tertiary-care center, 40% of patients with endometriosis had deep disease.⁴ DIE is associated with more severe pain and infertility.⁵ In patients with endometriosis, diagnosis is commonly made 7 to 9 years after the initial pelvic pain presentation.⁶ For these reasons, well-directed history taking and proper evaluation and treatment should be pursued to relieve pain and optimize outcomes.

CASE Young woman with intensifying pelvic pain

Mary is a 26-year-old social worker who presents to her ObGyn with symptoms of worsening pain during as well as outside her periods. What additional information would you want to obtain from Mary, given her chief symptom of pain?

Investigate the type of pain

It is important to ask the patient about her menstrual and sexual history, her thoughts regarding near- and long-term fertility, and the type and severity of her pain symptoms. The 5 pain symptoms specific to pelvic pain are dysmenorrhea, dyspareunia, dysuria, dyschezia, and noncyclic pelvic pain. A visual analog scale (VAS) for pain as well as pelvic pain questionnaires can be used to guide evaluation options and monitor treatment outcomes. In addition, it is of paramount importance to understand the differential diagnoses that can present as pelvic pain (TABLE).

CASE Continued: Mary’s history

Mary reports that she always has had painful periods and that she was started on oral contraceptive pills for pain control and regulation of her periods soon after the onset of menses, when she was 12 years old. In college, she was prescribed oral contraceptive pills for contraception. Recently engaged, she is interested in becoming pregnant in 3 years.

A year ago, Mary discontinued the pills because of their adverse effects. Now she has severe pain during (VAS score, 8/10) and outside (VAS score, 7) her monthly periods. Because of this pain, she has taken time off from work twice within the past 6 months. She has pain during intercourse (VAS score, 7) and some pain with bowel movements during her menses (VAS score, 4). Pelvic examination reveals a normal-sized uterus and adnexa as well as a tender nodule in the rectovaginal septum.

What diagnostic tests and imaging would you obtain?

Imaging’s role in diagnosis

At many advanced centers for endometriosis, DIE is successfully diagnosed with specific magnetic resonance imaging (MRI) or transvaginal ultrasound (TVUS) protocols. In a recent review, MRI’s pooled sensitivity and specificity for rectosigmoid endometriosis were 92% and 96%, respectively.⁷ Choice of imaging for DIE depends on the skills and experience of the clinicians at each center. At a large referral center in São Paulo, Brazil, TVUS with bowel preparation had better sensitivity and specificity for deep retrocervical and rectosigmoid disease compared with MRI and digital pelvic examination.⁸ In addition, at a center in the United States, we found that proficiency in performing TVUS for DIE was achieved after 70 to 75 cases, and the exam took an average of only 20 minutes.⁹

Despite recent advances in imaging, most gynecologic societies still hold that endometriosis is to be definitively diagnosed with histologic confirmation from tissue biopsies during surgery. Although surgery remains the diagnostic gold standard, it does not mean that all patients with pelvic pain should undergo diagnostic laparoscopy with tissue biopsies.

The combination of compelling clinical signs, symptoms, and imaging findings (such as absence of findings for ovarian and deep endometriosis) can be used to make a presumptive nonsurgical (that is, clinical) diagnosis of endometriosis. Major societies recommend empiric medical therapy (for example, combination oral contraceptives) for the pain associated with superficial endometriosis.^10,11 When there is no response to treatment, or when a patient declines or has contraindications to medical therapy, diagnostic laparoscopy with excision of endometriosis should be considered.

CASE Continued: Diagnosis

Mary undergoes TVUS with bowel preparation, which reveals a normal uterus and adnexa and the presence of 2 lesions, a 2×1.5-cm retrocervical lesion and a 1.8×2-cm rectosigmoid lesion 9 cm above the anal verge. The rectosigmoid lesion involves the external muscularis and compromises 30% of the bowel circumference.

How would you manage the bowel DIE?

Read about management options and individualized care.

Management options: Factor in the variables

DIE can involve the ureters and bladder, the retrocervical and rectovaginal spaces, the appendix, and the bowel. Lesions can be single or multifocal. Although our institutions’ imaging with MRI and TVUS is highly accurate, we additionally recommend the use of colonoscopy (with directed biopsies if appropriate) to evaluate patients who present with rectal bleeding, large endometriotic rectal nodules, or have a family history of bowel cancer.

While many studies have found that surgical resection of DIE improves pain and quality of life, surgery can have significant complications.¹² Observation is adequate for asymptomatic patients with DIE. Medical treatment may be offered to patients with mild pain (there is no evidence of a reduction in lesion size with medical therapy). In cases of surgical treatment, we encourage the involvement of a multidisciplinary surgical team to reduce complications and optimize outcomes.

Patients with DIE, significant pain (VAS score, >7), and multiple failed in vitro fertilization treatments are candidates for surgery. When bowel endometriosis is noted on imaging, factors such as size, depth, number of lesions, circumferential involvement, and distance from the anal verge are all used to determine the surgical approach. Rectosigmoid lesions smaller than 3 cm can be treated more conservatively—for example, with shaving or anterior resection with manual repair using disk staplers. Segmental resection generally is indicated for rectosigmoid lesions larger than 3 cm, involvement deeper than the submucosal layer, multiple lesions, circumferential involvement of more than 40%, and the presence of obstructed bowel symptoms.^13,14

In patients with DIE who present with both infertility and pain, antimüllerian hormone level and TVUS follicular count are used to evaluate ovarian reserve. As surgical treatment may further reduce ovarian reserve in patients with DIE and infertility, we counsel them regarding assisted reproductive technology options before surgery.

CASE Resolved

After thorough discussion, Mary opts to try a different combination oral contraceptive pill formulation. The pills improve her pain symptoms significantly (VAS score, 4), and she decides to forgo surgery. She will be followed up closely on an outpatient basis with serial TVUS imaging.

Individualize management based on patient parameters

Imaging has been used for the nonsurgical diagnosis of DIE for many years, and this practice increasingly is being accepted and adopted. A presumptive nonsurgical diagnosis of endometriosis can be made based on the clinical signs and symptoms obtained from a thorough history and physical examination, in addition to the absence of imaging findings for ovarian and deep endometriosis.

According to guidelines from major ObGyn societies, such as the American College of Obstetricians and Gynecologists and the European Society of Human Reproduction and Embryology, empiric medical therapy (including combination oral contraceptives, progesterone-containing formulations, and gonadotropin-releasing hormone agonists) can be considered for patients with presumed endometriosis presenting with pain.¹⁵

When surgery is chosen, the surgeon must obtain crucial information on the characteristics of the lesion(s) and involve a multidisciplinary team to achieve the best outcomes for the patient.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The overall 5-year survival rate for non-Hodgkin lymphoma (NHL) is 71.4%, according to the National Cancer Institute.

That number falls neatly into the middle of the range for survival by stage at diagnosis, with stage I (81.8%) and stage II (75.3%) disease on the high side and stage III (69.1%) and stage IV (61.7%) on the low side, the most recent data from the Surveillance, Epidemiology, and End Results (SEER) Program show. Five-year survival for NHL of unknown stage at diagnosis is 76.4%.

[email protected]

The overall 5-year survival rate for non-Hodgkin lymphoma (NHL) is 71.4%, according to the National Cancer Institute.

That number falls neatly into the middle of the range for survival by stage at diagnosis, with stage I (81.8%) and stage II (75.3%) disease on the high side and stage III (69.1%) and stage IV (61.7%) on the low side, the most recent data from the Surveillance, Epidemiology, and End Results (SEER) Program show. Five-year survival for NHL of unknown stage at diagnosis is 76.4%.

[email protected]

The overall 5-year survival rate for non-Hodgkin lymphoma (NHL) is 71.4%, according to the National Cancer Institute.

That number falls neatly into the middle of the range for survival by stage at diagnosis, with stage I (81.8%) and stage II (75.3%) disease on the high side and stage III (69.1%) and stage IV (61.7%) on the low side, the most recent data from the Surveillance, Epidemiology, and End Results (SEER) Program show. Five-year survival for NHL of unknown stage at diagnosis is 76.4%.

[email protected]

SAN DIEGO – Patients with chronic kidney disease (CKD) and those on renin angiotensin system inhibitors and/or diuretics should have their renal function monitored during periods of overanticoagulation, results from a large retrospective study suggest.

“Unfortunately, warfarin-related nephropathy is quite hard to study,” Hugh Traquair, MD, the study’s lead author, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The best way to establish diagnosis is with a kidney biopsy. No one is very keen to stick a needle into a kidney when someone’s overanticoagulated. It’s been observed previously that acute kidney injury related to over-anticoagulation is more common in people with CKD, but we don’t know more about risk factors.”

Doug Brunk/MDedge News

The median age of the 292 patients was 79 years, 55% were male, 30% were taking aspirin, and 77% were taking renin angiotensin inhibitors and/or diuretics. The control group consisted of 93 patients with a 12-month time in therapeutic range of 100%. The median age of controls was 68 years, 67% were male, and 9% had CKD. None of the controls had an AKI, said Dr. Traquair, a second-year internal medicine resident in the department of medicine at McMaster University.

Of the 292 patients with an INR of 4 or greater, 13% had an AKI, and the incidence of AKI was significantly higher in the CKD patients, compared with those who had a normal baseline creatinine level (19% vs. 10%; odds ratio, 2.1; P less than .05).

In a binomial logistic regression model, diuretic use was the only significant predictor of AKI (OR 3.4; P less than .05). The researchers also found that of the 52 patients with an INR of 4 or greater who did not use renin angiotensin system inhibitors and/or diuretics and did not have CKD, only 1 had an AKI (2%).

“We don’t know that all of these episodes of AKI are related to warfarin, but we do see a definite increase of AKI after an episode of overanticoagulation (an INR greater than 4),” Dr. Traquair said. “In patients who are at risk for AKI, monitoring their kidney function after an episode of overanticoagulation is probably warranted.”

Dr. Traquair reported having no financial disclosures.

[email protected]

SOURCE: Traquair H et al. THSNA 2018, Poster 79.

SAN DIEGO – Patients with chronic kidney disease (CKD) and those on renin angiotensin system inhibitors and/or diuretics should have their renal function monitored during periods of overanticoagulation, results from a large retrospective study suggest.

“Unfortunately, warfarin-related nephropathy is quite hard to study,” Hugh Traquair, MD, the study’s lead author, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The best way to establish diagnosis is with a kidney biopsy. No one is very keen to stick a needle into a kidney when someone’s overanticoagulated. It’s been observed previously that acute kidney injury related to over-anticoagulation is more common in people with CKD, but we don’t know more about risk factors.”

Doug Brunk/MDedge News

The median age of the 292 patients was 79 years, 55% were male, 30% were taking aspirin, and 77% were taking renin angiotensin inhibitors and/or diuretics. The control group consisted of 93 patients with a 12-month time in therapeutic range of 100%. The median age of controls was 68 years, 67% were male, and 9% had CKD. None of the controls had an AKI, said Dr. Traquair, a second-year internal medicine resident in the department of medicine at McMaster University.

Of the 292 patients with an INR of 4 or greater, 13% had an AKI, and the incidence of AKI was significantly higher in the CKD patients, compared with those who had a normal baseline creatinine level (19% vs. 10%; odds ratio, 2.1; P less than .05).

In a binomial logistic regression model, diuretic use was the only significant predictor of AKI (OR 3.4; P less than .05). The researchers also found that of the 52 patients with an INR of 4 or greater who did not use renin angiotensin system inhibitors and/or diuretics and did not have CKD, only 1 had an AKI (2%).

“We don’t know that all of these episodes of AKI are related to warfarin, but we do see a definite increase of AKI after an episode of overanticoagulation (an INR greater than 4),” Dr. Traquair said. “In patients who are at risk for AKI, monitoring their kidney function after an episode of overanticoagulation is probably warranted.”

Dr. Traquair reported having no financial disclosures.

[email protected]

SOURCE: Traquair H et al. THSNA 2018, Poster 79.

SAN DIEGO – Patients with chronic kidney disease (CKD) and those on renin angiotensin system inhibitors and/or diuretics should have their renal function monitored during periods of overanticoagulation, results from a large retrospective study suggest.

“Unfortunately, warfarin-related nephropathy is quite hard to study,” Hugh Traquair, MD, the study’s lead author, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The best way to establish diagnosis is with a kidney biopsy. No one is very keen to stick a needle into a kidney when someone’s overanticoagulated. It’s been observed previously that acute kidney injury related to over-anticoagulation is more common in people with CKD, but we don’t know more about risk factors.”

Doug Brunk/MDedge News

The median age of the 292 patients was 79 years, 55% were male, 30% were taking aspirin, and 77% were taking renin angiotensin inhibitors and/or diuretics. The control group consisted of 93 patients with a 12-month time in therapeutic range of 100%. The median age of controls was 68 years, 67% were male, and 9% had CKD. None of the controls had an AKI, said Dr. Traquair, a second-year internal medicine resident in the department of medicine at McMaster University.

Of the 292 patients with an INR of 4 or greater, 13% had an AKI, and the incidence of AKI was significantly higher in the CKD patients, compared with those who had a normal baseline creatinine level (19% vs. 10%; odds ratio, 2.1; P less than .05).

In a binomial logistic regression model, diuretic use was the only significant predictor of AKI (OR 3.4; P less than .05). The researchers also found that of the 52 patients with an INR of 4 or greater who did not use renin angiotensin system inhibitors and/or diuretics and did not have CKD, only 1 had an AKI (2%).

“We don’t know that all of these episodes of AKI are related to warfarin, but we do see a definite increase of AKI after an episode of overanticoagulation (an INR greater than 4),” Dr. Traquair said. “In patients who are at risk for AKI, monitoring their kidney function after an episode of overanticoagulation is probably warranted.”

Dr. Traquair reported having no financial disclosures.

[email protected]

SOURCE: Traquair H et al. THSNA 2018, Poster 79.