Compared to white patients, minority patients have lower rates of total knee replacement (TKR), but higher rates of adverse health outcomes associated with this procedure, according to a study in the Journal of Bone and Joint Surgery.

The study analyzed data on 547,380 patients from 8 racially diverse states who underwent TKR from 2001 to 2008. Race was categorized as white, black, Hispanic, Asian, Native American, and mixed race.

In comparison to the white patients, minorities had lower rates of TKR. Minorities also were less likely to undergo TKR in a high-volume hospital. In addition, the risk for in-hospital mortality and the rate of complications following TKR were significantly higher for patients who were black, Native American, or mixed race.

Compared to white patients, minority patients have lower rates of total knee replacement (TKR), but higher rates of adverse health outcomes associated with this procedure, according to a study in the Journal of Bone and Joint Surgery.

The study analyzed data on 547,380 patients from 8 racially diverse states who underwent TKR from 2001 to 2008. Race was categorized as white, black, Hispanic, Asian, Native American, and mixed race.

In comparison to the white patients, minorities had lower rates of TKR. Minorities also were less likely to undergo TKR in a high-volume hospital. In addition, the risk for in-hospital mortality and the rate of complications following TKR were significantly higher for patients who were black, Native American, or mixed race.

Compared to white patients, minority patients have lower rates of total knee replacement (TKR), but higher rates of adverse health outcomes associated with this procedure, according to a study in the Journal of Bone and Joint Surgery.

The study analyzed data on 547,380 patients from 8 racially diverse states who underwent TKR from 2001 to 2008. Race was categorized as white, black, Hispanic, Asian, Native American, and mixed race.

In comparison to the white patients, minorities had lower rates of TKR. Minorities also were less likely to undergo TKR in a high-volume hospital. In addition, the risk for in-hospital mortality and the rate of complications following TKR were significantly higher for patients who were black, Native American, or mixed race.

“STOP USING RECTAL MISOPROSTOL FOR THE TREATMENT OF POSTPARTUM HEMORRHAGE CAUSED BY UTERINE ATONY”Robert L. Barbieri, MD (Editorial; July 2016)

The BEPCOP strategy for uterine atony

I appreciated Dr. Barbieri’s editorial about oxytocics for postpartum uterine atony and have personally noted the poor effectiveness of rectal misoprostol. I was reminded of his previous editorial that recommended administering intravenous (IV) oxytocin to postcesarean delivery patients for about 6 to 8 hours to reduce the risk of postoperative hemorrhage.

At my current hospital we usually use postpartum oxytocin, 30 units in 500 mL of 5% dextrose in water (D5W) for vaginal deliveries, and that infusion typically is administered for only 1 to 2 hours. Cesarean delivery patients receive oxytocin, 20 units in 1,000 mL of Ringer’s lactate, over the first 1 to 2 hours postoperatively. As an OB hospitalist I have been summoned occasionally to the bedside of patients who have uterine atony and hemorrhage, which usually occurs several hours after their oxytocin infusion has finished.

With this in mind I developed a proactive protocol that I call BEPCOP, an acronym for “Barnes’ Excellent Post Cesarean Oxytocin Protocol.” This involves simply running a 500-mL bag of oxytocin (30 units in 500 mL of D5W) at a constant rate of 50 mL/hour, which provides 50 mU/min oxytocin over the first 10 hours postdelivery.

I recommend BEPCOP for every cesarean delivery patient, as well as for any vaginally delivered patients who are at increased risk for atony, such as those with prolonged labor, large babies, polyhydramnios, multifetal gestation, chorioamnio‑nitis, and history of hemorrhage after a previous delivery, and for patients who are Jehovah’s Witnesses. It is important to reduce the rate of the mainline IV bag while the oxytocin is infusing to reduce the risk of fluid overload.

Since starting this routine I have seen a noticeable decrease in postpartum and postcesarean uterine atony.

E. Darryl Barnes, MD
Mechanicsville, Virginia
 

Nondissolving misoprostol is ineffective

There is something about misoprostol that is not mentioned in Dr. Barbieri’s editorial. There are 2 types of misoprostol: the proprietary formulation (Cytotec, Pfizer) and the generic form (probably the one used in most hospitals, and possibly also the one used in the randomized studies alluded to).

The generic form, manufactured overseas, is literally insoluble. In my experience, these undissolved tabletsare expelled intact from the rectum5 hours after insertion and they therefore do nothing. The proprietary brand of misoprostol dissolves instantly in the rectum, and the results are dramatic to say the least.

Helio Zapata, MD
Skokie, Illinois

Bundles of care protocols useful in critical events

We often assume the etiology of the postpartum hemorrhage (PPH) is purely and exclusively uterine atony. A frequent clinical scenario is as follows: A hospital birth is conducted by a trained attendant, in a US learning hospital, on a parturient assessed as being at low risk; the single circulating nurse is busy at the keyboard complying with the data entry requirements; the just-delivered patient is enjoying skin-to-skin contact as recommended; and the new father is obtaining all the appropriate pictorial material when a massive vaginal bleed ensues, diagnosed as due to uterine atony. There is little time to remember the results of the randomized controlled trials condemning the use of misoprostol, or the effectiveness of the individual components of the AMTSL (active management of the third stage of labor). The IV oxytocin at the prescribed dose is running wide open, extra personnel are summoned to help, the first doses of methylergonovine are given, and the misoprostol tablets are stored in the nearby drawer as prescribed by the institution’s protocol.

Currently, a multi-state, multi-institutional initiative spearheaded by the American College of Obstetricians and Gynecologists and known as AIM (Alliance for Innovation in Maternity Care) supports the use of “bundles of care” to standardize obstetric care as recommended by the Joint Commission and the Society for Maternal-Fetal Medicine. One of the “bundles” addresses PPH. It is understood that each institution may adjust the steps in accord with its individual capabilities. Included in the algorithm is the use of rectal misoprostol 800 to 1,000 μg.¹⁻⁵

The International Federation of Gynecology and Obstetrics, in referencing the Blum trial,⁶ states that the results indicated misoprostol was noninferior to oxytocin at controlling bleeding (90% vs 89%) and preventing additional blood loss (31% vs 34%).⁷ Misoprostol’s contraindications and side effects are recognized by all investigators. In the field of obstetrics, changes are slow in permeating into daily practice.⁸ Dr. Barbieri’s recommendation, originating from an influential academic institution, opens the door to continue the dialog on a critical clinical event.

Federico G. Mariona, MD
Dearborn, Michigan

References

1. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015;212(3):272–280.
2. Obstetric hemorrhage checklist. Beaumont Health, Michigan. October 2015.
3. California Maternal Quality Care Collaborative, California Department of Public Health. OB hemorrhage toolkit, Version 2.0. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Published March 24, 2015. Accessed August 24, 2015.
4. Main EK, Goffman D, Scavone BM, et al; National Partnership for Maternal Safety Council on Patient Safety in Women’s Health Care. Consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015;126(1):155–162.
5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 76: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039–1047.
6. Blum J, Winikoff B, Raghavan S, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double blind randomised, non-inferiority trial. Lancet. 2010;375(9710):217–223.
7. International Federation of Gynecology and Obstetrics. Treatment of post-partum haemorrhage with misoprostol. FIGO guideline, annotated version. http://www.figo.org/sites/default/files/uploads/project-publications/Miso/PPH%20treatment/Annotated%20versions/Treatment%20of%20PPH%20with%20Misoprostol_Annotated_2012_English.pdf. Published May 2012. Accessed August 24, 2015.
8. Mariona FG, Roura LC. The role of placental alpha macroglobulin-1 amnisure in determining the status of the fetal membranes; its associations with preterm birth. Traditions, traditions. J Matern Fetal Neonatal Med. 2016;29(6):1016–1020.

Rectal misoprostol has merit

It is well established in medicine that IV medications have a rapid onset of action. Therefore, IV uterotonics would be the first choice to control PPH. Most likely they will control the majority of uterine atony.

However, the causes of uterine atony are numerous, and they most commonly include prolonged labor and/or infection. Like any fatigued muscle, there is rebound relaxation. Intravenous uterotonics have a very short half-life and have a maximum total dose. Repeating oxytocin 40 U in a 1,000-mL infusion over 15 minutes carries the risk of water intoxication due to the antidiuretic effect.

Misoprostol 800 to 1,000 mg when used rectally will have a longer effect—up to 4 hours—and fewer side effects. It should be used in combination with other parenteral uterotonics to act in synergistic way. This way the more serious cases of PPH can be reduced or even prevented.

Raymond Michael, MD
Marshall, Minnesota

Dr. Barbieri responds

I deeply appreciate the perspectives provided by Drs. Barnes, Zapata, Mariona, and Michael. The obstetricians and gynecologists who read OBG Management have vast clinical experience, expertise, and exceptional insights. By sharing our knowledge with each other we best advance the care provided to women and their families.

As a hospitalist, Dr. Barnes is privileged to care for women at the highest-risk time of their pregnancy. I think his BEPCOP proactive protocol to reduce the rate of PPH is superb and urge him to publish his experience. I appreciate Dr. Zapata’s insight that misoprostol tablets from different manufacturers have markedly different rates of dissolution. I agree with him that I have seen entire, undissolved misoprostol tablets expelled from the rectum many hours after they were administered for the treatment of PPH. If the tablet does not dissolve, it certainly cannot work. Dr. Mariona’s guidance to adhere to protocol bundles and continuously improve and update the bundles is absolutely critical to advancing health care for pregnant women. Dr. Michael rightly points out that one advantage of misoprostol is that it has a longer half-life than many parenteral uterotonics. However, in my practice I prefer Dr. Barnes’ BEPCOP protocol involving the multi-hour administration of oxytocin to prevent and treat a PPH.

“STOP USING RECTAL MISOPROSTOL FOR THE TREATMENT OF POSTPARTUM HEMORRHAGE CAUSED BY UTERINE ATONY”Robert L. Barbieri, MD (Editorial; July 2016)

The BEPCOP strategy for uterine atony

I appreciated Dr. Barbieri’s editorial about oxytocics for postpartum uterine atony and have personally noted the poor effectiveness of rectal misoprostol. I was reminded of his previous editorial that recommended administering intravenous (IV) oxytocin to postcesarean delivery patients for about 6 to 8 hours to reduce the risk of postoperative hemorrhage.

At my current hospital we usually use postpartum oxytocin, 30 units in 500 mL of 5% dextrose in water (D5W) for vaginal deliveries, and that infusion typically is administered for only 1 to 2 hours. Cesarean delivery patients receive oxytocin, 20 units in 1,000 mL of Ringer’s lactate, over the first 1 to 2 hours postoperatively. As an OB hospitalist I have been summoned occasionally to the bedside of patients who have uterine atony and hemorrhage, which usually occurs several hours after their oxytocin infusion has finished.

With this in mind I developed a proactive protocol that I call BEPCOP, an acronym for “Barnes’ Excellent Post Cesarean Oxytocin Protocol.” This involves simply running a 500-mL bag of oxytocin (30 units in 500 mL of D5W) at a constant rate of 50 mL/hour, which provides 50 mU/min oxytocin over the first 10 hours postdelivery.

I recommend BEPCOP for every cesarean delivery patient, as well as for any vaginally delivered patients who are at increased risk for atony, such as those with prolonged labor, large babies, polyhydramnios, multifetal gestation, chorioamnio‑nitis, and history of hemorrhage after a previous delivery, and for patients who are Jehovah’s Witnesses. It is important to reduce the rate of the mainline IV bag while the oxytocin is infusing to reduce the risk of fluid overload.

Since starting this routine I have seen a noticeable decrease in postpartum and postcesarean uterine atony.

E. Darryl Barnes, MD
Mechanicsville, Virginia
 

Nondissolving misoprostol is ineffective

There is something about misoprostol that is not mentioned in Dr. Barbieri’s editorial. There are 2 types of misoprostol: the proprietary formulation (Cytotec, Pfizer) and the generic form (probably the one used in most hospitals, and possibly also the one used in the randomized studies alluded to).

The generic form, manufactured overseas, is literally insoluble. In my experience, these undissolved tabletsare expelled intact from the rectum5 hours after insertion and they therefore do nothing. The proprietary brand of misoprostol dissolves instantly in the rectum, and the results are dramatic to say the least.

Helio Zapata, MD
Skokie, Illinois

Bundles of care protocols useful in critical events

We often assume the etiology of the postpartum hemorrhage (PPH) is purely and exclusively uterine atony. A frequent clinical scenario is as follows: A hospital birth is conducted by a trained attendant, in a US learning hospital, on a parturient assessed as being at low risk; the single circulating nurse is busy at the keyboard complying with the data entry requirements; the just-delivered patient is enjoying skin-to-skin contact as recommended; and the new father is obtaining all the appropriate pictorial material when a massive vaginal bleed ensues, diagnosed as due to uterine atony. There is little time to remember the results of the randomized controlled trials condemning the use of misoprostol, or the effectiveness of the individual components of the AMTSL (active management of the third stage of labor). The IV oxytocin at the prescribed dose is running wide open, extra personnel are summoned to help, the first doses of methylergonovine are given, and the misoprostol tablets are stored in the nearby drawer as prescribed by the institution’s protocol.

Currently, a multi-state, multi-institutional initiative spearheaded by the American College of Obstetricians and Gynecologists and known as AIM (Alliance for Innovation in Maternity Care) supports the use of “bundles of care” to standardize obstetric care as recommended by the Joint Commission and the Society for Maternal-Fetal Medicine. One of the “bundles” addresses PPH. It is understood that each institution may adjust the steps in accord with its individual capabilities. Included in the algorithm is the use of rectal misoprostol 800 to 1,000 μg.¹⁻⁵

The International Federation of Gynecology and Obstetrics, in referencing the Blum trial,⁶ states that the results indicated misoprostol was noninferior to oxytocin at controlling bleeding (90% vs 89%) and preventing additional blood loss (31% vs 34%).⁷ Misoprostol’s contraindications and side effects are recognized by all investigators. In the field of obstetrics, changes are slow in permeating into daily practice.⁸ Dr. Barbieri’s recommendation, originating from an influential academic institution, opens the door to continue the dialog on a critical clinical event.

Federico G. Mariona, MD
Dearborn, Michigan

References

1. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015;212(3):272–280.
2. Obstetric hemorrhage checklist. Beaumont Health, Michigan. October 2015.
3. California Maternal Quality Care Collaborative, California Department of Public Health. OB hemorrhage toolkit, Version 2.0. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Published March 24, 2015. Accessed August 24, 2015.
4. Main EK, Goffman D, Scavone BM, et al; National Partnership for Maternal Safety Council on Patient Safety in Women’s Health Care. Consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015;126(1):155–162.
5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 76: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039–1047.
6. Blum J, Winikoff B, Raghavan S, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double blind randomised, non-inferiority trial. Lancet. 2010;375(9710):217–223.
7. International Federation of Gynecology and Obstetrics. Treatment of post-partum haemorrhage with misoprostol. FIGO guideline, annotated version. http://www.figo.org/sites/default/files/uploads/project-publications/Miso/PPH%20treatment/Annotated%20versions/Treatment%20of%20PPH%20with%20Misoprostol_Annotated_2012_English.pdf. Published May 2012. Accessed August 24, 2015.
8. Mariona FG, Roura LC. The role of placental alpha macroglobulin-1 amnisure in determining the status of the fetal membranes; its associations with preterm birth. Traditions, traditions. J Matern Fetal Neonatal Med. 2016;29(6):1016–1020.

Rectal misoprostol has merit

It is well established in medicine that IV medications have a rapid onset of action. Therefore, IV uterotonics would be the first choice to control PPH. Most likely they will control the majority of uterine atony.

However, the causes of uterine atony are numerous, and they most commonly include prolonged labor and/or infection. Like any fatigued muscle, there is rebound relaxation. Intravenous uterotonics have a very short half-life and have a maximum total dose. Repeating oxytocin 40 U in a 1,000-mL infusion over 15 minutes carries the risk of water intoxication due to the antidiuretic effect.

Misoprostol 800 to 1,000 mg when used rectally will have a longer effect—up to 4 hours—and fewer side effects. It should be used in combination with other parenteral uterotonics to act in synergistic way. This way the more serious cases of PPH can be reduced or even prevented.

Raymond Michael, MD
Marshall, Minnesota

Dr. Barbieri responds

I deeply appreciate the perspectives provided by Drs. Barnes, Zapata, Mariona, and Michael. The obstetricians and gynecologists who read OBG Management have vast clinical experience, expertise, and exceptional insights. By sharing our knowledge with each other we best advance the care provided to women and their families.

As a hospitalist, Dr. Barnes is privileged to care for women at the highest-risk time of their pregnancy. I think his BEPCOP proactive protocol to reduce the rate of PPH is superb and urge him to publish his experience. I appreciate Dr. Zapata’s insight that misoprostol tablets from different manufacturers have markedly different rates of dissolution. I agree with him that I have seen entire, undissolved misoprostol tablets expelled from the rectum many hours after they were administered for the treatment of PPH. If the tablet does not dissolve, it certainly cannot work. Dr. Mariona’s guidance to adhere to protocol bundles and continuously improve and update the bundles is absolutely critical to advancing health care for pregnant women. Dr. Michael rightly points out that one advantage of misoprostol is that it has a longer half-life than many parenteral uterotonics. However, in my practice I prefer Dr. Barnes’ BEPCOP protocol involving the multi-hour administration of oxytocin to prevent and treat a PPH.

“STOP USING RECTAL MISOPROSTOL FOR THE TREATMENT OF POSTPARTUM HEMORRHAGE CAUSED BY UTERINE ATONY”Robert L. Barbieri, MD (Editorial; July 2016)

The BEPCOP strategy for uterine atony

I appreciated Dr. Barbieri’s editorial about oxytocics for postpartum uterine atony and have personally noted the poor effectiveness of rectal misoprostol. I was reminded of his previous editorial that recommended administering intravenous (IV) oxytocin to postcesarean delivery patients for about 6 to 8 hours to reduce the risk of postoperative hemorrhage.

At my current hospital we usually use postpartum oxytocin, 30 units in 500 mL of 5% dextrose in water (D5W) for vaginal deliveries, and that infusion typically is administered for only 1 to 2 hours. Cesarean delivery patients receive oxytocin, 20 units in 1,000 mL of Ringer’s lactate, over the first 1 to 2 hours postoperatively. As an OB hospitalist I have been summoned occasionally to the bedside of patients who have uterine atony and hemorrhage, which usually occurs several hours after their oxytocin infusion has finished.

With this in mind I developed a proactive protocol that I call BEPCOP, an acronym for “Barnes’ Excellent Post Cesarean Oxytocin Protocol.” This involves simply running a 500-mL bag of oxytocin (30 units in 500 mL of D5W) at a constant rate of 50 mL/hour, which provides 50 mU/min oxytocin over the first 10 hours postdelivery.

I recommend BEPCOP for every cesarean delivery patient, as well as for any vaginally delivered patients who are at increased risk for atony, such as those with prolonged labor, large babies, polyhydramnios, multifetal gestation, chorioamnio‑nitis, and history of hemorrhage after a previous delivery, and for patients who are Jehovah’s Witnesses. It is important to reduce the rate of the mainline IV bag while the oxytocin is infusing to reduce the risk of fluid overload.

Since starting this routine I have seen a noticeable decrease in postpartum and postcesarean uterine atony.

E. Darryl Barnes, MD
Mechanicsville, Virginia
 

Nondissolving misoprostol is ineffective

There is something about misoprostol that is not mentioned in Dr. Barbieri’s editorial. There are 2 types of misoprostol: the proprietary formulation (Cytotec, Pfizer) and the generic form (probably the one used in most hospitals, and possibly also the one used in the randomized studies alluded to).

The generic form, manufactured overseas, is literally insoluble. In my experience, these undissolved tabletsare expelled intact from the rectum5 hours after insertion and they therefore do nothing. The proprietary brand of misoprostol dissolves instantly in the rectum, and the results are dramatic to say the least.

Helio Zapata, MD
Skokie, Illinois

Bundles of care protocols useful in critical events

We often assume the etiology of the postpartum hemorrhage (PPH) is purely and exclusively uterine atony. A frequent clinical scenario is as follows: A hospital birth is conducted by a trained attendant, in a US learning hospital, on a parturient assessed as being at low risk; the single circulating nurse is busy at the keyboard complying with the data entry requirements; the just-delivered patient is enjoying skin-to-skin contact as recommended; and the new father is obtaining all the appropriate pictorial material when a massive vaginal bleed ensues, diagnosed as due to uterine atony. There is little time to remember the results of the randomized controlled trials condemning the use of misoprostol, or the effectiveness of the individual components of the AMTSL (active management of the third stage of labor). The IV oxytocin at the prescribed dose is running wide open, extra personnel are summoned to help, the first doses of methylergonovine are given, and the misoprostol tablets are stored in the nearby drawer as prescribed by the institution’s protocol.

Currently, a multi-state, multi-institutional initiative spearheaded by the American College of Obstetricians and Gynecologists and known as AIM (Alliance for Innovation in Maternity Care) supports the use of “bundles of care” to standardize obstetric care as recommended by the Joint Commission and the Society for Maternal-Fetal Medicine. One of the “bundles” addresses PPH. It is understood that each institution may adjust the steps in accord with its individual capabilities. Included in the algorithm is the use of rectal misoprostol 800 to 1,000 μg.¹⁻⁵

The International Federation of Gynecology and Obstetrics, in referencing the Blum trial,⁶ states that the results indicated misoprostol was noninferior to oxytocin at controlling bleeding (90% vs 89%) and preventing additional blood loss (31% vs 34%).⁷ Misoprostol’s contraindications and side effects are recognized by all investigators. In the field of obstetrics, changes are slow in permeating into daily practice.⁸ Dr. Barbieri’s recommendation, originating from an influential academic institution, opens the door to continue the dialog on a critical clinical event.

Federico G. Mariona, MD
Dearborn, Michigan

References

1. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015;212(3):272–280.
2. Obstetric hemorrhage checklist. Beaumont Health, Michigan. October 2015.
3. California Maternal Quality Care Collaborative, California Department of Public Health. OB hemorrhage toolkit, Version 2.0. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Published March 24, 2015. Accessed August 24, 2015.
4. Main EK, Goffman D, Scavone BM, et al; National Partnership for Maternal Safety Council on Patient Safety in Women’s Health Care. Consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015;126(1):155–162.
5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 76: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039–1047.
6. Blum J, Winikoff B, Raghavan S, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double blind randomised, non-inferiority trial. Lancet. 2010;375(9710):217–223.
7. International Federation of Gynecology and Obstetrics. Treatment of post-partum haemorrhage with misoprostol. FIGO guideline, annotated version. http://www.figo.org/sites/default/files/uploads/project-publications/Miso/PPH%20treatment/Annotated%20versions/Treatment%20of%20PPH%20with%20Misoprostol_Annotated_2012_English.pdf. Published May 2012. Accessed August 24, 2015.
8. Mariona FG, Roura LC. The role of placental alpha macroglobulin-1 amnisure in determining the status of the fetal membranes; its associations with preterm birth. Traditions, traditions. J Matern Fetal Neonatal Med. 2016;29(6):1016–1020.

Rectal misoprostol has merit

It is well established in medicine that IV medications have a rapid onset of action. Therefore, IV uterotonics would be the first choice to control PPH. Most likely they will control the majority of uterine atony.

However, the causes of uterine atony are numerous, and they most commonly include prolonged labor and/or infection. Like any fatigued muscle, there is rebound relaxation. Intravenous uterotonics have a very short half-life and have a maximum total dose. Repeating oxytocin 40 U in a 1,000-mL infusion over 15 minutes carries the risk of water intoxication due to the antidiuretic effect.

Misoprostol 800 to 1,000 mg when used rectally will have a longer effect—up to 4 hours—and fewer side effects. It should be used in combination with other parenteral uterotonics to act in synergistic way. This way the more serious cases of PPH can be reduced or even prevented.

Raymond Michael, MD
Marshall, Minnesota

Dr. Barbieri responds

I deeply appreciate the perspectives provided by Drs. Barnes, Zapata, Mariona, and Michael. The obstetricians and gynecologists who read OBG Management have vast clinical experience, expertise, and exceptional insights. By sharing our knowledge with each other we best advance the care provided to women and their families.

As a hospitalist, Dr. Barnes is privileged to care for women at the highest-risk time of their pregnancy. I think his BEPCOP proactive protocol to reduce the rate of PPH is superb and urge him to publish his experience. I appreciate Dr. Zapata’s insight that misoprostol tablets from different manufacturers have markedly different rates of dissolution. I agree with him that I have seen entire, undissolved misoprostol tablets expelled from the rectum many hours after they were administered for the treatment of PPH. If the tablet does not dissolve, it certainly cannot work. Dr. Mariona’s guidance to adhere to protocol bundles and continuously improve and update the bundles is absolutely critical to advancing health care for pregnant women. Dr. Michael rightly points out that one advantage of misoprostol is that it has a longer half-life than many parenteral uterotonics. However, in my practice I prefer Dr. Barnes’ BEPCOP protocol involving the multi-hour administration of oxytocin to prevent and treat a PPH.

TREATING GRAM-NEGATIVE BACTERIAL INFECTIONS

Allergan reports an updated label approved by the US Food and Drug Administration (FDA) for AVYCAZ^® (ceftazidime and avibactam) in combination with metronidazole for the treatment of complicated intraabdominal infections caused by designated susceptible microorganisms. The label change was made after completion of a Phase 3 trial evaluating the safety and efficacy of AVYCAZ in combination with metronidazole. Results of the trial also included data from subsets of patients with infections due to ceftazidime- nonsusceptible pathogens and with pathogens producing certain extended-spectrum beta-lactamases (ESBLs).

First FDA-approved in February 2015, AVYCAZ is an antibiotic developed to treat certain Gram-negative bacterial infections. It consists of ceftazidime, a third- generation cephalosporin, and avibactam, a non-ß lactam ß-lactamase inhibitor.

Allergan says that AVYCAZ has demonstrated in vitro activity against Enterobacteriaceae in the presence of some beta-lactamases and ESBLs of the following groups: TEM, SHV, CTX-M, Klebsiella pneumoniae carbapenemase, AmpC, and certain oxacillinases. AVYCAZ also demonstrated in vitro activity against Pseudomonas aeruginosa in the presence of some AmpC beta-lactamases, and certain strains lacking outer membrane porin.

FOR MORE INFORMATION, VISIT: www.avycaz.com
 

ANTI-STICK SOLUTION FOR ELECTROSURGICAL INSTRUMENTS

Electro Lube is a mixture of natural, nonsynthetic, nonflammable, nonallergenic biocompatible phospholipids with no known side effects associated with patient use. It can be used on a variety of monopolar and bipolar instrumentation including: cutting forceps, Kleppingers, bipolar forceps, Bovie pencils, suction coagulators, robots, curved hot scissors, spatula electrodes, and l-hook electrodes.

FOR MORE INFORMATION, VISIT: www.electrolubesurgical.com

ORAL TREATMENT FOR PPH

A semi-synthetic ergot alkaloid, Methergine is indicated for routine management of uterine atony, hemorrhage, and subinvolution of the uterus following delivery of the placenta, and for control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. Methergine provides specific and rapid (onset of action under 10 minutes) uterotonic action on the smooth muscle of the uterus to increase contractions, resulting in restricting blood loss.

The Methergine dosing schedule is one tablet (0.2 mg) 3 or 4 times daily in the puerperium for a maximum of 1 week. The most common adverse event is hypertension, associated in several cases with seizure and/or headache. Methylergonovine maleate is also available as an intramuscular injection.

FOR MORE INFORMATION, VISIT: www.methergine.com
 

FREE MEDICAL BILLING CALCULATOR

ChartLogic, Inc. has launched its Medical Billing Analysis Calculator, a free, online, interactive tool that provides key billing metrics and compares those results to Medical Group Management Association (MGMA) benchmarks for a practice’s specialty. The calculator consists of an input section where practice specialty, annual charges, annual collections, outstanding accounts receivable (A/R), number of annual encounters, and contractual adjustments are entered. The tool, accessible on desktop or mobile devices, then calculates the practice’s billing analysis, including average reimbursement per encounter, net collection percentages, average monthly collections, and A/R data and displays the results beside specialty benchmarks. After submission, the user can alter the inputs or request more information from a ChartLogic billing expert.

ChartLogic’s goal as a medical billing service is to increase a practice’s performance. Services include a full ambulatory EHR suite with electronic medical records, practice management tools, e-prescribing, a patient portal, and more.

FOR MORE INFORMATION, VISIT: www.chartlogic.com

TREATING GRAM-NEGATIVE BACTERIAL INFECTIONS

Allergan reports an updated label approved by the US Food and Drug Administration (FDA) for AVYCAZ^® (ceftazidime and avibactam) in combination with metronidazole for the treatment of complicated intraabdominal infections caused by designated susceptible microorganisms. The label change was made after completion of a Phase 3 trial evaluating the safety and efficacy of AVYCAZ in combination with metronidazole. Results of the trial also included data from subsets of patients with infections due to ceftazidime- nonsusceptible pathogens and with pathogens producing certain extended-spectrum beta-lactamases (ESBLs).

First FDA-approved in February 2015, AVYCAZ is an antibiotic developed to treat certain Gram-negative bacterial infections. It consists of ceftazidime, a third- generation cephalosporin, and avibactam, a non-ß lactam ß-lactamase inhibitor.

Allergan says that AVYCAZ has demonstrated in vitro activity against Enterobacteriaceae in the presence of some beta-lactamases and ESBLs of the following groups: TEM, SHV, CTX-M, Klebsiella pneumoniae carbapenemase, AmpC, and certain oxacillinases. AVYCAZ also demonstrated in vitro activity against Pseudomonas aeruginosa in the presence of some AmpC beta-lactamases, and certain strains lacking outer membrane porin.

FOR MORE INFORMATION, VISIT: www.avycaz.com
 

ANTI-STICK SOLUTION FOR ELECTROSURGICAL INSTRUMENTS

Electro Lube is a mixture of natural, nonsynthetic, nonflammable, nonallergenic biocompatible phospholipids with no known side effects associated with patient use. It can be used on a variety of monopolar and bipolar instrumentation including: cutting forceps, Kleppingers, bipolar forceps, Bovie pencils, suction coagulators, robots, curved hot scissors, spatula electrodes, and l-hook electrodes.

FOR MORE INFORMATION, VISIT: www.electrolubesurgical.com

ORAL TREATMENT FOR PPH

A semi-synthetic ergot alkaloid, Methergine is indicated for routine management of uterine atony, hemorrhage, and subinvolution of the uterus following delivery of the placenta, and for control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. Methergine provides specific and rapid (onset of action under 10 minutes) uterotonic action on the smooth muscle of the uterus to increase contractions, resulting in restricting blood loss.

The Methergine dosing schedule is one tablet (0.2 mg) 3 or 4 times daily in the puerperium for a maximum of 1 week. The most common adverse event is hypertension, associated in several cases with seizure and/or headache. Methylergonovine maleate is also available as an intramuscular injection.

FOR MORE INFORMATION, VISIT: www.methergine.com
 

FREE MEDICAL BILLING CALCULATOR

ChartLogic, Inc. has launched its Medical Billing Analysis Calculator, a free, online, interactive tool that provides key billing metrics and compares those results to Medical Group Management Association (MGMA) benchmarks for a practice’s specialty. The calculator consists of an input section where practice specialty, annual charges, annual collections, outstanding accounts receivable (A/R), number of annual encounters, and contractual adjustments are entered. The tool, accessible on desktop or mobile devices, then calculates the practice’s billing analysis, including average reimbursement per encounter, net collection percentages, average monthly collections, and A/R data and displays the results beside specialty benchmarks. After submission, the user can alter the inputs or request more information from a ChartLogic billing expert.

ChartLogic’s goal as a medical billing service is to increase a practice’s performance. Services include a full ambulatory EHR suite with electronic medical records, practice management tools, e-prescribing, a patient portal, and more.

FOR MORE INFORMATION, VISIT: www.chartlogic.com

TREATING GRAM-NEGATIVE BACTERIAL INFECTIONS

Allergan reports an updated label approved by the US Food and Drug Administration (FDA) for AVYCAZ^® (ceftazidime and avibactam) in combination with metronidazole for the treatment of complicated intraabdominal infections caused by designated susceptible microorganisms. The label change was made after completion of a Phase 3 trial evaluating the safety and efficacy of AVYCAZ in combination with metronidazole. Results of the trial also included data from subsets of patients with infections due to ceftazidime- nonsusceptible pathogens and with pathogens producing certain extended-spectrum beta-lactamases (ESBLs).

First FDA-approved in February 2015, AVYCAZ is an antibiotic developed to treat certain Gram-negative bacterial infections. It consists of ceftazidime, a third- generation cephalosporin, and avibactam, a non-ß lactam ß-lactamase inhibitor.

Allergan says that AVYCAZ has demonstrated in vitro activity against Enterobacteriaceae in the presence of some beta-lactamases and ESBLs of the following groups: TEM, SHV, CTX-M, Klebsiella pneumoniae carbapenemase, AmpC, and certain oxacillinases. AVYCAZ also demonstrated in vitro activity against Pseudomonas aeruginosa in the presence of some AmpC beta-lactamases, and certain strains lacking outer membrane porin.

FOR MORE INFORMATION, VISIT: www.avycaz.com
 

ANTI-STICK SOLUTION FOR ELECTROSURGICAL INSTRUMENTS

Electro Lube is a mixture of natural, nonsynthetic, nonflammable, nonallergenic biocompatible phospholipids with no known side effects associated with patient use. It can be used on a variety of monopolar and bipolar instrumentation including: cutting forceps, Kleppingers, bipolar forceps, Bovie pencils, suction coagulators, robots, curved hot scissors, spatula electrodes, and l-hook electrodes.

FOR MORE INFORMATION, VISIT: www.electrolubesurgical.com

ORAL TREATMENT FOR PPH

A semi-synthetic ergot alkaloid, Methergine is indicated for routine management of uterine atony, hemorrhage, and subinvolution of the uterus following delivery of the placenta, and for control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. Methergine provides specific and rapid (onset of action under 10 minutes) uterotonic action on the smooth muscle of the uterus to increase contractions, resulting in restricting blood loss.

The Methergine dosing schedule is one tablet (0.2 mg) 3 or 4 times daily in the puerperium for a maximum of 1 week. The most common adverse event is hypertension, associated in several cases with seizure and/or headache. Methylergonovine maleate is also available as an intramuscular injection.

FOR MORE INFORMATION, VISIT: www.methergine.com
 

FREE MEDICAL BILLING CALCULATOR

ChartLogic, Inc. has launched its Medical Billing Analysis Calculator, a free, online, interactive tool that provides key billing metrics and compares those results to Medical Group Management Association (MGMA) benchmarks for a practice’s specialty. The calculator consists of an input section where practice specialty, annual charges, annual collections, outstanding accounts receivable (A/R), number of annual encounters, and contractual adjustments are entered. The tool, accessible on desktop or mobile devices, then calculates the practice’s billing analysis, including average reimbursement per encounter, net collection percentages, average monthly collections, and A/R data and displays the results beside specialty benchmarks. After submission, the user can alter the inputs or request more information from a ChartLogic billing expert.

ChartLogic’s goal as a medical billing service is to increase a practice’s performance. Services include a full ambulatory EHR suite with electronic medical records, practice management tools, e-prescribing, a patient portal, and more.

FOR MORE INFORMATION, VISIT: www.chartlogic.com

For years, pediatricians have sought a blessing from the American Academy of Pediatrics that acknowledged it was valid for members to dismiss families from their practice if they refused to vaccinate despite all attempts to persuade them. Now, a new clinical report has essentially delivered just that.

The report does not represent an official policy change from the AAP, but it does for the first time acknowledge that “firing” patients who persistently refuse vaccination is “an acceptable option” (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-2146).

“A number of pediatricians feel so strongly that if they don’t agree on vaccines, which are so basic to the delivery of care and have made such a big difference in children’s lives, how will they agree on a number of other things they’ll need to discuss?” Kathryn M. Edwards, MD, director of the Vanderbilt Vaccine Research Program, Nashville, Tenn., and a coauthor of the report, explained in an interview.

The AAP has received pressure from its members over recent years as increasing numbers of pediatricians choose to dismiss some or all of their patients whose parents were resolved not vaccinate, coauthor Jesse M. Hackell, MD, a practicing pediatrician and managing partner at Pomona Pediatrics, an affiliate of Boston Children’s Health Physicians, said in an interview.

In fact, a new study has revealed that 12% of pediatricians reported dismissing vaccine-refusing families in 2013, up from 6% in 2006. At the same time, the proportion of families refusing vaccines has nearly doubled in the same time.

“There was a groundswell of opinion that enough is enough and we can’t provide quality care if we can’t provide something we know is so important,” Dr. Hackell said. “We felt the Academy needed to stop being so adamantly opposed to the possibility of dismissal – not to recommend dismissal but simply to state it is an acceptable option.”

The AAP responds to fellows’ concerns

While the AAP continues to recommend doctors attempt to persuade families as long as possible to vaccinate, the new report discusses dismissal as a viable option as long as it adheres to relevant state laws that prohibit abandonment of patients.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view,” the report states. “Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option.”

The report does note that some practice settings, such as hospitals or large health care organizations, may not allow dismissal of patients, and that pediatricians “should carefully evaluate the availability of other qualified providers for the family” if they live in an area with limited access to pediatric care.

But the report finally acknowledges those pediatricians who are “just philosophically wired to not accept vaccine refusals,” Stuart A. Cohen, MD, an assistant professor of pediatrics at the University of California, San Diego, and chair of AAP District 9 in California, said in an interview.

“It really interferes with your physician-patient relationship,” Dr. Cohen said, who was not a coauthor of the report.

Now, if pediatricians feel it necessary to dismiss nonvaccinating patients, “then the Academy understands because of concerns for other patients, but it must be done in a way that’s respectful and tries to ensure patients understand the safety and necessity of vaccines,” Dr. Edwards said.

The report still includes the AAP recommendation that “pediatricians continue to engage with vaccine-hesitant parents, provide other health care services to their children, and attempt to modify their opposition to vaccines.” And a number of members of the AAP’s infectious diseases and bioethics committees were uncomfortable with dismissing patients, Dr. Edwards said, but “there were certain people who needed this, who needed some blessing that this was not inappropriate after all the other things the pediatrician had done.”

Vaccines undergo thorough testing for safety and effectiveness

But the report also aims to provide pediatricians with strategies for doing everything possible first.

“We needed to address enabling the clinician to have some very specific talking points to use and not get involved in a philosophical discussion that can take an hour,” Dr. Hackell said. “They need to make a clear statement that vaccines are important, and if you don’t get them, bad things like death can happen.”

The report therefore provides a comprehensive overview of vaccine development, from the initial identification of the need for a vaccine through the various phases of clinical testing and ongoing postlicensure monitoring. This background information can arm pediatricians with foundational knowledge that’s helpful in talking with patients.

“Vaccine development is a long and arduous process, often lasting many years and involving a combination of public and private partnerships,” the report states. “The current system for developing, testing and regulating vaccines requires that the vaccines demonstrate both safety and efficacy before licensure and that long-term safety is monitored.”

The report briefly explains the multiple mechanisms for continuing to track and study adverse events and other safety concerns:

• Vaccine Adverse Events Reporting System (VAERS). A voluntary passive reporting system used to identify potential safety signals.

• Vaccine Safety Datalink (VSD). A network of linked databases from health care systems across the United States involving millions of individuals

• Post-Licensure Rapid Immunization Safety Monitoring system (PRISM). A system which monitors vaccine safety using health insurance claims data from 107 million individuals .

• Clinical Immunization Safety Assessment Project (CISA). A system that answers individual health care providers’ specific questions on vaccine safety.

Vaccine hesitancy and vaccine exemptions

Opposition to vaccination is not new, the report states, describing it as dating back to Edward Jenner’s smallpox vaccine in the early 1800s.

“Although vaccine hesitancy is not a new phenomenon, it may have a greater effect on public health today,” the report states. “With the ease of global travel, vaccine-preventable diseases are spread more quickly and may unexpectedly appear in areas where health care professionals are unfamiliar with their clinical presentation.”

The historical presence of vaccination opposition has led to circumstances in the United States today in which parents can seek nonmedical exemptions from vaccines in 47 states, and their use has increased with their availability. Yet, the increase in use of exemptions and of “alternative” immunization schedules runs the risk of eroding the herd immunity that protects the community, the report notes.

“For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines,” the authors write. The American Medical Association and the Infectious Diseases Society of America espouse this position, and the AAP is developing a similar statement.

“Families should not have to fear going to school or the grocery store or a house of worship and worry about their kids getting sick,” said Dr. Cohen. “We now strongly say that we need to work with legislators, families, and other advocates for children at the state level to spread more laws like California’s SB 277 that would abolish philosophical exemptions.”

Dr. Cohen also emphasized the importance of communicating to parents that there are no valid “alternative schedules” for vaccination. There is the Centers for Disease Control and Prevention recommended schedule and anything else is a “nonrecommended vaccine schedule because it hasn’t been studied.” That change in terminology drives home the point that the CDC schedule is the only one fully tested for safety and effectiveness.

Meanwhile, however, pediatricians need the tools to address vaccine hesitancy, starting with understanding it. The report describes the pattern of disease incidence, vaccine uptake, disease reduction, adverse event increase and resulting vaccine hesitancy, punctuated by periodic outbreaks that restore eroded confidence in vaccines.

“When diseases are present, parents are worried and want a vaccine, and when they’re gone, they don’t,” Dr. Edwards said. “We need to remember that there is a dependence on the maintenance of herd immunity by immunization by your neighbors.”

Specific strategies to counter vaccine hesitancy

Just over half of physicians spend 10-19 minutes discussing vaccines with concerned parents, and 8% spend at least 20 minutes with such parents, found a study cited in the report. Other research has found these discussions take a toll on doctors’ job satisfaction.

Yet pediatricians remain the single biggest influence on parents’ vaccination decisions, cited by nearly 80% of parents in one large study.

“The pediatrician should appreciate that vaccine-hesitant parents are a heterogeneous group and that specific parental vaccine concerns should be individually identified and addressed,” the report states. “Although many techniques for working with vaccine-hesitant parents have been suggested, scant data are available to determine the efficacy of these methods.”

It goes on to recommend that physicians should discuss the development and safety testing of vaccines “in a nonconfrontational dialogue with the parents while listening to and acknowledging their concerns.”

Pediatricians should not, however, delay vaccines or limit the number per visit – thereby deviating from the CDC recommended and AAP-endorsed schedule – unless it’s the only way a parent agrees to vaccinate.

Another strategy is the presumptive approach: Present all vaccine recommendations as required immunizations that the provider expects a parent to agree to, although pediatricians should consider their experience and relationship with a family since this approach may not work well for some parents.

The report also emphasizes the potential effectiveness of personalizing vaccine conversations by having doctors share their own experience, such as the fact that they vaccinated themselves, their children, and/or their grandchildren.

“Parents often are more likely to be persuaded by stories and anecdotes about the successes of vaccines,” the authors write. “Personal examples of children who were sick with vaccine-preventable illnesses can be much more effective than simply reading the numbers of children infected with a disease each year.”

The report also offers several suggestions for reducing the pain from administering vaccinations: administering vaccines quickly without aspirating; saving the most painful injection for last; holding the child upright; providing tactile stimulation; breastfeeding or providing sweet solutions and topical anesthetics after administration; and using distraction, such as deep breathing, pinwheels, or toys to decrease children’s pain and anxiety.

But the bottom line is that pediatricians have one key message they must communicate to parents, the report states: “The clear message parents should hear is that vaccines are safe and effective, and serious disease can occur if your child and family are not immunized.”

For years, pediatricians have sought a blessing from the American Academy of Pediatrics that acknowledged it was valid for members to dismiss families from their practice if they refused to vaccinate despite all attempts to persuade them. Now, a new clinical report has essentially delivered just that.

The report does not represent an official policy change from the AAP, but it does for the first time acknowledge that “firing” patients who persistently refuse vaccination is “an acceptable option” (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-2146).

“A number of pediatricians feel so strongly that if they don’t agree on vaccines, which are so basic to the delivery of care and have made such a big difference in children’s lives, how will they agree on a number of other things they’ll need to discuss?” Kathryn M. Edwards, MD, director of the Vanderbilt Vaccine Research Program, Nashville, Tenn., and a coauthor of the report, explained in an interview.

The AAP has received pressure from its members over recent years as increasing numbers of pediatricians choose to dismiss some or all of their patients whose parents were resolved not vaccinate, coauthor Jesse M. Hackell, MD, a practicing pediatrician and managing partner at Pomona Pediatrics, an affiliate of Boston Children’s Health Physicians, said in an interview.

In fact, a new study has revealed that 12% of pediatricians reported dismissing vaccine-refusing families in 2013, up from 6% in 2006. At the same time, the proportion of families refusing vaccines has nearly doubled in the same time.

“There was a groundswell of opinion that enough is enough and we can’t provide quality care if we can’t provide something we know is so important,” Dr. Hackell said. “We felt the Academy needed to stop being so adamantly opposed to the possibility of dismissal – not to recommend dismissal but simply to state it is an acceptable option.”

The AAP responds to fellows’ concerns

While the AAP continues to recommend doctors attempt to persuade families as long as possible to vaccinate, the new report discusses dismissal as a viable option as long as it adheres to relevant state laws that prohibit abandonment of patients.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view,” the report states. “Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option.”

The report does note that some practice settings, such as hospitals or large health care organizations, may not allow dismissal of patients, and that pediatricians “should carefully evaluate the availability of other qualified providers for the family” if they live in an area with limited access to pediatric care.

But the report finally acknowledges those pediatricians who are “just philosophically wired to not accept vaccine refusals,” Stuart A. Cohen, MD, an assistant professor of pediatrics at the University of California, San Diego, and chair of AAP District 9 in California, said in an interview.

“It really interferes with your physician-patient relationship,” Dr. Cohen said, who was not a coauthor of the report.

Now, if pediatricians feel it necessary to dismiss nonvaccinating patients, “then the Academy understands because of concerns for other patients, but it must be done in a way that’s respectful and tries to ensure patients understand the safety and necessity of vaccines,” Dr. Edwards said.

The report still includes the AAP recommendation that “pediatricians continue to engage with vaccine-hesitant parents, provide other health care services to their children, and attempt to modify their opposition to vaccines.” And a number of members of the AAP’s infectious diseases and bioethics committees were uncomfortable with dismissing patients, Dr. Edwards said, but “there were certain people who needed this, who needed some blessing that this was not inappropriate after all the other things the pediatrician had done.”

Vaccines undergo thorough testing for safety and effectiveness

But the report also aims to provide pediatricians with strategies for doing everything possible first.

“We needed to address enabling the clinician to have some very specific talking points to use and not get involved in a philosophical discussion that can take an hour,” Dr. Hackell said. “They need to make a clear statement that vaccines are important, and if you don’t get them, bad things like death can happen.”

The report therefore provides a comprehensive overview of vaccine development, from the initial identification of the need for a vaccine through the various phases of clinical testing and ongoing postlicensure monitoring. This background information can arm pediatricians with foundational knowledge that’s helpful in talking with patients.

“Vaccine development is a long and arduous process, often lasting many years and involving a combination of public and private partnerships,” the report states. “The current system for developing, testing and regulating vaccines requires that the vaccines demonstrate both safety and efficacy before licensure and that long-term safety is monitored.”

The report briefly explains the multiple mechanisms for continuing to track and study adverse events and other safety concerns:

• Vaccine Adverse Events Reporting System (VAERS). A voluntary passive reporting system used to identify potential safety signals.

• Vaccine Safety Datalink (VSD). A network of linked databases from health care systems across the United States involving millions of individuals

• Post-Licensure Rapid Immunization Safety Monitoring system (PRISM). A system which monitors vaccine safety using health insurance claims data from 107 million individuals .

• Clinical Immunization Safety Assessment Project (CISA). A system that answers individual health care providers’ specific questions on vaccine safety.

Vaccine hesitancy and vaccine exemptions

Opposition to vaccination is not new, the report states, describing it as dating back to Edward Jenner’s smallpox vaccine in the early 1800s.

“Although vaccine hesitancy is not a new phenomenon, it may have a greater effect on public health today,” the report states. “With the ease of global travel, vaccine-preventable diseases are spread more quickly and may unexpectedly appear in areas where health care professionals are unfamiliar with their clinical presentation.”

The historical presence of vaccination opposition has led to circumstances in the United States today in which parents can seek nonmedical exemptions from vaccines in 47 states, and their use has increased with their availability. Yet, the increase in use of exemptions and of “alternative” immunization schedules runs the risk of eroding the herd immunity that protects the community, the report notes.

“For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines,” the authors write. The American Medical Association and the Infectious Diseases Society of America espouse this position, and the AAP is developing a similar statement.

“Families should not have to fear going to school or the grocery store or a house of worship and worry about their kids getting sick,” said Dr. Cohen. “We now strongly say that we need to work with legislators, families, and other advocates for children at the state level to spread more laws like California’s SB 277 that would abolish philosophical exemptions.”

Dr. Cohen also emphasized the importance of communicating to parents that there are no valid “alternative schedules” for vaccination. There is the Centers for Disease Control and Prevention recommended schedule and anything else is a “nonrecommended vaccine schedule because it hasn’t been studied.” That change in terminology drives home the point that the CDC schedule is the only one fully tested for safety and effectiveness.

Meanwhile, however, pediatricians need the tools to address vaccine hesitancy, starting with understanding it. The report describes the pattern of disease incidence, vaccine uptake, disease reduction, adverse event increase and resulting vaccine hesitancy, punctuated by periodic outbreaks that restore eroded confidence in vaccines.

“When diseases are present, parents are worried and want a vaccine, and when they’re gone, they don’t,” Dr. Edwards said. “We need to remember that there is a dependence on the maintenance of herd immunity by immunization by your neighbors.”

Specific strategies to counter vaccine hesitancy

Just over half of physicians spend 10-19 minutes discussing vaccines with concerned parents, and 8% spend at least 20 minutes with such parents, found a study cited in the report. Other research has found these discussions take a toll on doctors’ job satisfaction.

Yet pediatricians remain the single biggest influence on parents’ vaccination decisions, cited by nearly 80% of parents in one large study.

“The pediatrician should appreciate that vaccine-hesitant parents are a heterogeneous group and that specific parental vaccine concerns should be individually identified and addressed,” the report states. “Although many techniques for working with vaccine-hesitant parents have been suggested, scant data are available to determine the efficacy of these methods.”

It goes on to recommend that physicians should discuss the development and safety testing of vaccines “in a nonconfrontational dialogue with the parents while listening to and acknowledging their concerns.”

Pediatricians should not, however, delay vaccines or limit the number per visit – thereby deviating from the CDC recommended and AAP-endorsed schedule – unless it’s the only way a parent agrees to vaccinate.

Another strategy is the presumptive approach: Present all vaccine recommendations as required immunizations that the provider expects a parent to agree to, although pediatricians should consider their experience and relationship with a family since this approach may not work well for some parents.

The report also emphasizes the potential effectiveness of personalizing vaccine conversations by having doctors share their own experience, such as the fact that they vaccinated themselves, their children, and/or their grandchildren.

“Parents often are more likely to be persuaded by stories and anecdotes about the successes of vaccines,” the authors write. “Personal examples of children who were sick with vaccine-preventable illnesses can be much more effective than simply reading the numbers of children infected with a disease each year.”

The report also offers several suggestions for reducing the pain from administering vaccinations: administering vaccines quickly without aspirating; saving the most painful injection for last; holding the child upright; providing tactile stimulation; breastfeeding or providing sweet solutions and topical anesthetics after administration; and using distraction, such as deep breathing, pinwheels, or toys to decrease children’s pain and anxiety.

But the bottom line is that pediatricians have one key message they must communicate to parents, the report states: “The clear message parents should hear is that vaccines are safe and effective, and serious disease can occur if your child and family are not immunized.”

For years, pediatricians have sought a blessing from the American Academy of Pediatrics that acknowledged it was valid for members to dismiss families from their practice if they refused to vaccinate despite all attempts to persuade them. Now, a new clinical report has essentially delivered just that.

The report does not represent an official policy change from the AAP, but it does for the first time acknowledge that “firing” patients who persistently refuse vaccination is “an acceptable option” (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-2146).

“A number of pediatricians feel so strongly that if they don’t agree on vaccines, which are so basic to the delivery of care and have made such a big difference in children’s lives, how will they agree on a number of other things they’ll need to discuss?” Kathryn M. Edwards, MD, director of the Vanderbilt Vaccine Research Program, Nashville, Tenn., and a coauthor of the report, explained in an interview.

The AAP has received pressure from its members over recent years as increasing numbers of pediatricians choose to dismiss some or all of their patients whose parents were resolved not vaccinate, coauthor Jesse M. Hackell, MD, a practicing pediatrician and managing partner at Pomona Pediatrics, an affiliate of Boston Children’s Health Physicians, said in an interview.

In fact, a new study has revealed that 12% of pediatricians reported dismissing vaccine-refusing families in 2013, up from 6% in 2006. At the same time, the proportion of families refusing vaccines has nearly doubled in the same time.

“There was a groundswell of opinion that enough is enough and we can’t provide quality care if we can’t provide something we know is so important,” Dr. Hackell said. “We felt the Academy needed to stop being so adamantly opposed to the possibility of dismissal – not to recommend dismissal but simply to state it is an acceptable option.”

The AAP responds to fellows’ concerns

While the AAP continues to recommend doctors attempt to persuade families as long as possible to vaccinate, the new report discusses dismissal as a viable option as long as it adheres to relevant state laws that prohibit abandonment of patients.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view,” the report states. “Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option.”

The report does note that some practice settings, such as hospitals or large health care organizations, may not allow dismissal of patients, and that pediatricians “should carefully evaluate the availability of other qualified providers for the family” if they live in an area with limited access to pediatric care.

But the report finally acknowledges those pediatricians who are “just philosophically wired to not accept vaccine refusals,” Stuart A. Cohen, MD, an assistant professor of pediatrics at the University of California, San Diego, and chair of AAP District 9 in California, said in an interview.

“It really interferes with your physician-patient relationship,” Dr. Cohen said, who was not a coauthor of the report.

Now, if pediatricians feel it necessary to dismiss nonvaccinating patients, “then the Academy understands because of concerns for other patients, but it must be done in a way that’s respectful and tries to ensure patients understand the safety and necessity of vaccines,” Dr. Edwards said.

The report still includes the AAP recommendation that “pediatricians continue to engage with vaccine-hesitant parents, provide other health care services to their children, and attempt to modify their opposition to vaccines.” And a number of members of the AAP’s infectious diseases and bioethics committees were uncomfortable with dismissing patients, Dr. Edwards said, but “there were certain people who needed this, who needed some blessing that this was not inappropriate after all the other things the pediatrician had done.”

Vaccines undergo thorough testing for safety and effectiveness

But the report also aims to provide pediatricians with strategies for doing everything possible first.

“We needed to address enabling the clinician to have some very specific talking points to use and not get involved in a philosophical discussion that can take an hour,” Dr. Hackell said. “They need to make a clear statement that vaccines are important, and if you don’t get them, bad things like death can happen.”

The report therefore provides a comprehensive overview of vaccine development, from the initial identification of the need for a vaccine through the various phases of clinical testing and ongoing postlicensure monitoring. This background information can arm pediatricians with foundational knowledge that’s helpful in talking with patients.

“Vaccine development is a long and arduous process, often lasting many years and involving a combination of public and private partnerships,” the report states. “The current system for developing, testing and regulating vaccines requires that the vaccines demonstrate both safety and efficacy before licensure and that long-term safety is monitored.”

The report briefly explains the multiple mechanisms for continuing to track and study adverse events and other safety concerns:

• Vaccine Adverse Events Reporting System (VAERS). A voluntary passive reporting system used to identify potential safety signals.

• Vaccine Safety Datalink (VSD). A network of linked databases from health care systems across the United States involving millions of individuals

• Post-Licensure Rapid Immunization Safety Monitoring system (PRISM). A system which monitors vaccine safety using health insurance claims data from 107 million individuals .

• Clinical Immunization Safety Assessment Project (CISA). A system that answers individual health care providers’ specific questions on vaccine safety.

Vaccine hesitancy and vaccine exemptions

Opposition to vaccination is not new, the report states, describing it as dating back to Edward Jenner’s smallpox vaccine in the early 1800s.

“Although vaccine hesitancy is not a new phenomenon, it may have a greater effect on public health today,” the report states. “With the ease of global travel, vaccine-preventable diseases are spread more quickly and may unexpectedly appear in areas where health care professionals are unfamiliar with their clinical presentation.”

The historical presence of vaccination opposition has led to circumstances in the United States today in which parents can seek nonmedical exemptions from vaccines in 47 states, and their use has increased with their availability. Yet, the increase in use of exemptions and of “alternative” immunization schedules runs the risk of eroding the herd immunity that protects the community, the report notes.

“For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines,” the authors write. The American Medical Association and the Infectious Diseases Society of America espouse this position, and the AAP is developing a similar statement.

“Families should not have to fear going to school or the grocery store or a house of worship and worry about their kids getting sick,” said Dr. Cohen. “We now strongly say that we need to work with legislators, families, and other advocates for children at the state level to spread more laws like California’s SB 277 that would abolish philosophical exemptions.”

Dr. Cohen also emphasized the importance of communicating to parents that there are no valid “alternative schedules” for vaccination. There is the Centers for Disease Control and Prevention recommended schedule and anything else is a “nonrecommended vaccine schedule because it hasn’t been studied.” That change in terminology drives home the point that the CDC schedule is the only one fully tested for safety and effectiveness.

Meanwhile, however, pediatricians need the tools to address vaccine hesitancy, starting with understanding it. The report describes the pattern of disease incidence, vaccine uptake, disease reduction, adverse event increase and resulting vaccine hesitancy, punctuated by periodic outbreaks that restore eroded confidence in vaccines.

“When diseases are present, parents are worried and want a vaccine, and when they’re gone, they don’t,” Dr. Edwards said. “We need to remember that there is a dependence on the maintenance of herd immunity by immunization by your neighbors.”

Specific strategies to counter vaccine hesitancy

Just over half of physicians spend 10-19 minutes discussing vaccines with concerned parents, and 8% spend at least 20 minutes with such parents, found a study cited in the report. Other research has found these discussions take a toll on doctors’ job satisfaction.

Yet pediatricians remain the single biggest influence on parents’ vaccination decisions, cited by nearly 80% of parents in one large study.

“The pediatrician should appreciate that vaccine-hesitant parents are a heterogeneous group and that specific parental vaccine concerns should be individually identified and addressed,” the report states. “Although many techniques for working with vaccine-hesitant parents have been suggested, scant data are available to determine the efficacy of these methods.”

It goes on to recommend that physicians should discuss the development and safety testing of vaccines “in a nonconfrontational dialogue with the parents while listening to and acknowledging their concerns.”

Pediatricians should not, however, delay vaccines or limit the number per visit – thereby deviating from the CDC recommended and AAP-endorsed schedule – unless it’s the only way a parent agrees to vaccinate.

Another strategy is the presumptive approach: Present all vaccine recommendations as required immunizations that the provider expects a parent to agree to, although pediatricians should consider their experience and relationship with a family since this approach may not work well for some parents.

The report also emphasizes the potential effectiveness of personalizing vaccine conversations by having doctors share their own experience, such as the fact that they vaccinated themselves, their children, and/or their grandchildren.

“Parents often are more likely to be persuaded by stories and anecdotes about the successes of vaccines,” the authors write. “Personal examples of children who were sick with vaccine-preventable illnesses can be much more effective than simply reading the numbers of children infected with a disease each year.”

The report also offers several suggestions for reducing the pain from administering vaccinations: administering vaccines quickly without aspirating; saving the most painful injection for last; holding the child upright; providing tactile stimulation; breastfeeding or providing sweet solutions and topical anesthetics after administration; and using distraction, such as deep breathing, pinwheels, or toys to decrease children’s pain and anxiety.

But the bottom line is that pediatricians have one key message they must communicate to parents, the report states: “The clear message parents should hear is that vaccines are safe and effective, and serious disease can occur if your child and family are not immunized.”

Delayed delivery blamed for brain injury: $9.6M

At 5:00 AM, the ObGyn called for emergency cesarean delivery, requesting assistance from a surgeon and surgical scrub technician. The baby was delivered at 5:28 AM with a nuchal cord. She was limp, blue, and not breathing, with Apgar scores of 0, 2, and 3, at 1, 5, and 10 minutes, respectively. After full resuscitation, the baby was transferred to another hospital where she was treated for hypoxic-ischemic encephalopathy with therapeutic hypothermia; a feeding tube was placed.

At trial, the 3.5-year-old child is totally blind, has cerebral palsy, a seizure disorder, speech and language impairments, and continues to require frequent suctioning. She will require 24-hour licensed nursing care for life.

PARENTS’ CLAIM:

Standard of care required delivery before 4:00 AM due to fetal distress. The ObGyn was negligent in delaying cesarean delivery.

DEFENDANTS’ DEFENSE:

The ObGyn observed that labor was progressing, indicating that vaginal delivery was appropriate. A cesarean delivery was not required earlier because FHR variability persisted, showing that the fetus was not acidotic. Delivery occurred less than 30 minutes after cesarean delivery was ordered, consistent with guidelines. The infant’s injury was caused by an unpredictable cord accident and had nothing to do with an alleged delivery delay.

VERDICT:

The case was filed as a Federal Tort Claims Act case because the ObGyn was employed by a federal clinic. A California judge awarded $9,609,305 after concluding that the cesarean delivery should have occurred earlier. The hospital settled for a confidential amount.

Mother dies of PPH: $9.2 million

A woman gave birth by cesarean delivery. Shortly after surgery ended at 10:55 PM, the mother started hemorrhaging. Uterotonics and blood products were ordered. The patient was hypotensive, tachycardic, hypovolemic, and possibly still bleeding. She was transferred from the operating room (OR) to the intensive care unit (ICU) at 12:35 AM. Her ObGyn left the hospital at 12:52 AM. At 3:13 AM, a Code Blue was called and the patient was placed on a mechanical ventilator. She died 5 days later after her family elected to remove life support.

ESTATE’S CLAIM:

The ObGyn’s postoperative care of the patient was negligent. After surgery, he was absent from the OR and did not follow up with the patient after he left the hospital. The ICU nurses’ notes indicated that the patient was still actively bleeding when she entered the ICU. Despite repeated calls to the critical care specialist, the patient was left untreated by any physician until Code Blue was called.

PHYSICIANS’ DEFENSE:

After the hospital reached a pretrial confidential settlement, the suit continued against the ObGyn and critical care specialist.

The ObGyn reported that he remained in the OR and left only after placing an intrauterine balloon and administering medications that successfully controlled the PPH. He disputed the accuracy of the ICU nurses’ notes that related that the patient’s vital signs indicating active bleeding “at all times.”

The critical care specialist contended that he had recommended that the patient be kept in the OR instead of transferring her to ICU. He denied hearing from the ICU staff after 12:35 AM.

VERDICT:

A $9,284,464 California verdict was returned against the ObGyn. The jury found the critical care specialist not guilty.

Delayed delivery blamed for brain injury: $9.6M

At 5:00 AM, the ObGyn called for emergency cesarean delivery, requesting assistance from a surgeon and surgical scrub technician. The baby was delivered at 5:28 AM with a nuchal cord. She was limp, blue, and not breathing, with Apgar scores of 0, 2, and 3, at 1, 5, and 10 minutes, respectively. After full resuscitation, the baby was transferred to another hospital where she was treated for hypoxic-ischemic encephalopathy with therapeutic hypothermia; a feeding tube was placed.

At trial, the 3.5-year-old child is totally blind, has cerebral palsy, a seizure disorder, speech and language impairments, and continues to require frequent suctioning. She will require 24-hour licensed nursing care for life.

PARENTS’ CLAIM:

Standard of care required delivery before 4:00 AM due to fetal distress. The ObGyn was negligent in delaying cesarean delivery.

DEFENDANTS’ DEFENSE:

The ObGyn observed that labor was progressing, indicating that vaginal delivery was appropriate. A cesarean delivery was not required earlier because FHR variability persisted, showing that the fetus was not acidotic. Delivery occurred less than 30 minutes after cesarean delivery was ordered, consistent with guidelines. The infant’s injury was caused by an unpredictable cord accident and had nothing to do with an alleged delivery delay.

VERDICT:

The case was filed as a Federal Tort Claims Act case because the ObGyn was employed by a federal clinic. A California judge awarded $9,609,305 after concluding that the cesarean delivery should have occurred earlier. The hospital settled for a confidential amount.

Mother dies of PPH: $9.2 million

A woman gave birth by cesarean delivery. Shortly after surgery ended at 10:55 PM, the mother started hemorrhaging. Uterotonics and blood products were ordered. The patient was hypotensive, tachycardic, hypovolemic, and possibly still bleeding. She was transferred from the operating room (OR) to the intensive care unit (ICU) at 12:35 AM. Her ObGyn left the hospital at 12:52 AM. At 3:13 AM, a Code Blue was called and the patient was placed on a mechanical ventilator. She died 5 days later after her family elected to remove life support.

ESTATE’S CLAIM:

The ObGyn’s postoperative care of the patient was negligent. After surgery, he was absent from the OR and did not follow up with the patient after he left the hospital. The ICU nurses’ notes indicated that the patient was still actively bleeding when she entered the ICU. Despite repeated calls to the critical care specialist, the patient was left untreated by any physician until Code Blue was called.

PHYSICIANS’ DEFENSE:

After the hospital reached a pretrial confidential settlement, the suit continued against the ObGyn and critical care specialist.

The ObGyn reported that he remained in the OR and left only after placing an intrauterine balloon and administering medications that successfully controlled the PPH. He disputed the accuracy of the ICU nurses’ notes that related that the patient’s vital signs indicating active bleeding “at all times.”

The critical care specialist contended that he had recommended that the patient be kept in the OR instead of transferring her to ICU. He denied hearing from the ICU staff after 12:35 AM.

VERDICT:

A $9,284,464 California verdict was returned against the ObGyn. The jury found the critical care specialist not guilty.

Delayed delivery blamed for brain injury: $9.6M

At 5:00 AM, the ObGyn called for emergency cesarean delivery, requesting assistance from a surgeon and surgical scrub technician. The baby was delivered at 5:28 AM with a nuchal cord. She was limp, blue, and not breathing, with Apgar scores of 0, 2, and 3, at 1, 5, and 10 minutes, respectively. After full resuscitation, the baby was transferred to another hospital where she was treated for hypoxic-ischemic encephalopathy with therapeutic hypothermia; a feeding tube was placed.

At trial, the 3.5-year-old child is totally blind, has cerebral palsy, a seizure disorder, speech and language impairments, and continues to require frequent suctioning. She will require 24-hour licensed nursing care for life.

PARENTS’ CLAIM:

Standard of care required delivery before 4:00 AM due to fetal distress. The ObGyn was negligent in delaying cesarean delivery.

DEFENDANTS’ DEFENSE:

The ObGyn observed that labor was progressing, indicating that vaginal delivery was appropriate. A cesarean delivery was not required earlier because FHR variability persisted, showing that the fetus was not acidotic. Delivery occurred less than 30 minutes after cesarean delivery was ordered, consistent with guidelines. The infant’s injury was caused by an unpredictable cord accident and had nothing to do with an alleged delivery delay.

VERDICT:

The case was filed as a Federal Tort Claims Act case because the ObGyn was employed by a federal clinic. A California judge awarded $9,609,305 after concluding that the cesarean delivery should have occurred earlier. The hospital settled for a confidential amount.

Mother dies of PPH: $9.2 million

A woman gave birth by cesarean delivery. Shortly after surgery ended at 10:55 PM, the mother started hemorrhaging. Uterotonics and blood products were ordered. The patient was hypotensive, tachycardic, hypovolemic, and possibly still bleeding. She was transferred from the operating room (OR) to the intensive care unit (ICU) at 12:35 AM. Her ObGyn left the hospital at 12:52 AM. At 3:13 AM, a Code Blue was called and the patient was placed on a mechanical ventilator. She died 5 days later after her family elected to remove life support.

ESTATE’S CLAIM:

The ObGyn’s postoperative care of the patient was negligent. After surgery, he was absent from the OR and did not follow up with the patient after he left the hospital. The ICU nurses’ notes indicated that the patient was still actively bleeding when she entered the ICU. Despite repeated calls to the critical care specialist, the patient was left untreated by any physician until Code Blue was called.

PHYSICIANS’ DEFENSE:

After the hospital reached a pretrial confidential settlement, the suit continued against the ObGyn and critical care specialist.

The ObGyn reported that he remained in the OR and left only after placing an intrauterine balloon and administering medications that successfully controlled the PPH. He disputed the accuracy of the ICU nurses’ notes that related that the patient’s vital signs indicating active bleeding “at all times.”

The critical care specialist contended that he had recommended that the patient be kept in the OR instead of transferring her to ICU. He denied hearing from the ICU staff after 12:35 AM.

VERDICT:

A $9,284,464 California verdict was returned against the ObGyn. The jury found the critical care specialist not guilty.

The interactive video case module “Appropriate Use of Targeted Oral Anticoagulants to Prevent Stroke in Patients with Nonvalvular Atrial Fibrillation” evaluates the current guidelines and scientific evidence regarding oral anticoagulation for stroke prevention in patients with NVAF. The activity includes thorough discussions on initial management of patients with NVAF, appropriate situations for oral anticoagulation in the presence of NVAF, appropriate choice of oral anticoagulant, reversal of oral anticoagulation, as well as guidelines for oral anticoagulation and stroke prevention in NVAF patients and in special-population NVAF patients.

This free module offers up to 1.0 AMA PRA Category 1 Credit and can be found at www.shmlearningportal.org under “SHM Consults.”

The interactive video case module “Appropriate Use of Targeted Oral Anticoagulants to Prevent Stroke in Patients with Nonvalvular Atrial Fibrillation” evaluates the current guidelines and scientific evidence regarding oral anticoagulation for stroke prevention in patients with NVAF. The activity includes thorough discussions on initial management of patients with NVAF, appropriate situations for oral anticoagulation in the presence of NVAF, appropriate choice of oral anticoagulant, reversal of oral anticoagulation, as well as guidelines for oral anticoagulation and stroke prevention in NVAF patients and in special-population NVAF patients.

This free module offers up to 1.0 AMA PRA Category 1 Credit and can be found at www.shmlearningportal.org under “SHM Consults.”

The interactive video case module “Appropriate Use of Targeted Oral Anticoagulants to Prevent Stroke in Patients with Nonvalvular Atrial Fibrillation” evaluates the current guidelines and scientific evidence regarding oral anticoagulation for stroke prevention in patients with NVAF. The activity includes thorough discussions on initial management of patients with NVAF, appropriate situations for oral anticoagulation in the presence of NVAF, appropriate choice of oral anticoagulant, reversal of oral anticoagulation, as well as guidelines for oral anticoagulation and stroke prevention in NVAF patients and in special-population NVAF patients.

This free module offers up to 1.0 AMA PRA Category 1 Credit and can be found at www.shmlearningportal.org under “SHM Consults.”

Over the past two months, data from hospitalists have been collected through a survey with AmericanEHR. This feedback was incorporated into a white paper written by SHM’s IT Committee, “Hospitalists’ Attitudes Toward EHR Systems,” which will be released in October. Visit www.hospitalmedicine.org/ITEHR for updates.

Over the past two months, data from hospitalists have been collected through a survey with AmericanEHR. This feedback was incorporated into a white paper written by SHM’s IT Committee, “Hospitalists’ Attitudes Toward EHR Systems,” which will be released in October. Visit www.hospitalmedicine.org/ITEHR for updates.

Over the past two months, data from hospitalists have been collected through a survey with AmericanEHR. This feedback was incorporated into a white paper written by SHM’s IT Committee, “Hospitalists’ Attitudes Toward EHR Systems,” which will be released in October. Visit www.hospitalmedicine.org/ITEHR for updates.

Apixaban tablets

Photo courtesy of Pfizer

and Bristol-Myers Squibb

ROME—Novel oral anticoagulants (NOACs) are as effective as warfarin for preventing stroke but may cause less intracranial hemorrhage (ICH) in patients with atrial fibrillation, according to research presented at ESC Congress 2016.

For this study, investigators compared 3 NOACs—dabigatran, rivaroxaban, and apixaban—to warfarin in a “real-world” setting.

They found that patients had a similar risk of stroke regardless of which drug they received.

However, the risk of ICH was lower with dabigatran and apixaban than with warfarin. There was no significant difference in ICH risk between warfarin and rivaroxaban.

Laila Staerk, PhD, of Gentofte Hospital Copenhagen University Hospital in Hellerup, Denmark, presented these results at the congress as abstract 1875.* The study was supported by Velux Foundations.

“There has been a need to investigate safety and effectiveness of NOACs versus warfarin in a ‘real-world’ population, and our Danish registries provide this opportunity,” Dr Staerk said.

The study included 43,299 atrial fibrillation patients from Danish nationwide administrative registries. Roughly 42% of the patients were taking warfarin, 29% were taking dabigatran, 16% were taking apixaban, and 13% were taking rivaroxaban.

“The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomized trials,” Dr Staerk said.

During follow-up, stroke occurred in 1054 patients, and there were 261 intracranial bleeds.

The risk of having a stroke within 1 year was similar between the treatment groups. The absolute standardized risk was 2.01% for warfarin, 2.06% for rivaroxaban, 2.12% for dabigatran, and 2.46% for apixaban.

At 1 year, the standardized absolute risk of ICH was significantly lower in patients treated with dabigatran or apixaban—0.26% and 0.40%, respectively—than in those treated with warfarin—0.60% (P<0.05). The standardized absolute risk of ICH was 0.47% with rivaroxaban, which was not significantly different than the risk with warfarin.

“The results suggest that, although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute 1-year risk of intracranial bleeding,” Dr Staerk said.

“Our results complement the large, randomized, phase 3 trials by providing ‘real-world’ data on stroke and intracranial bleeding with NOACs versus warfarin since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials.”

“Registry studies have some limitations, such as the observational design, residual confounding, and confounding by drug indication. In the future, it would be exciting to see a head-to-head, randomized trial performed to compare the different NOAC treatments in patients with atrial fibrillation.”

*Information in the abstract differs from that presented at the meeting.

Apixaban tablets

Photo courtesy of Pfizer

and Bristol-Myers Squibb

ROME—Novel oral anticoagulants (NOACs) are as effective as warfarin for preventing stroke but may cause less intracranial hemorrhage (ICH) in patients with atrial fibrillation, according to research presented at ESC Congress 2016.

For this study, investigators compared 3 NOACs—dabigatran, rivaroxaban, and apixaban—to warfarin in a “real-world” setting.

They found that patients had a similar risk of stroke regardless of which drug they received.

However, the risk of ICH was lower with dabigatran and apixaban than with warfarin. There was no significant difference in ICH risk between warfarin and rivaroxaban.

Laila Staerk, PhD, of Gentofte Hospital Copenhagen University Hospital in Hellerup, Denmark, presented these results at the congress as abstract 1875.* The study was supported by Velux Foundations.

“There has been a need to investigate safety and effectiveness of NOACs versus warfarin in a ‘real-world’ population, and our Danish registries provide this opportunity,” Dr Staerk said.

The study included 43,299 atrial fibrillation patients from Danish nationwide administrative registries. Roughly 42% of the patients were taking warfarin, 29% were taking dabigatran, 16% were taking apixaban, and 13% were taking rivaroxaban.

“The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomized trials,” Dr Staerk said.

During follow-up, stroke occurred in 1054 patients, and there were 261 intracranial bleeds.

The risk of having a stroke within 1 year was similar between the treatment groups. The absolute standardized risk was 2.01% for warfarin, 2.06% for rivaroxaban, 2.12% for dabigatran, and 2.46% for apixaban.

At 1 year, the standardized absolute risk of ICH was significantly lower in patients treated with dabigatran or apixaban—0.26% and 0.40%, respectively—than in those treated with warfarin—0.60% (P<0.05). The standardized absolute risk of ICH was 0.47% with rivaroxaban, which was not significantly different than the risk with warfarin.

“The results suggest that, although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute 1-year risk of intracranial bleeding,” Dr Staerk said.

“Our results complement the large, randomized, phase 3 trials by providing ‘real-world’ data on stroke and intracranial bleeding with NOACs versus warfarin since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials.”

“Registry studies have some limitations, such as the observational design, residual confounding, and confounding by drug indication. In the future, it would be exciting to see a head-to-head, randomized trial performed to compare the different NOAC treatments in patients with atrial fibrillation.”

*Information in the abstract differs from that presented at the meeting.

Apixaban tablets

Photo courtesy of Pfizer

and Bristol-Myers Squibb

ROME—Novel oral anticoagulants (NOACs) are as effective as warfarin for preventing stroke but may cause less intracranial hemorrhage (ICH) in patients with atrial fibrillation, according to research presented at ESC Congress 2016.

For this study, investigators compared 3 NOACs—dabigatran, rivaroxaban, and apixaban—to warfarin in a “real-world” setting.

They found that patients had a similar risk of stroke regardless of which drug they received.

However, the risk of ICH was lower with dabigatran and apixaban than with warfarin. There was no significant difference in ICH risk between warfarin and rivaroxaban.

Laila Staerk, PhD, of Gentofte Hospital Copenhagen University Hospital in Hellerup, Denmark, presented these results at the congress as abstract 1875.* The study was supported by Velux Foundations.

“There has been a need to investigate safety and effectiveness of NOACs versus warfarin in a ‘real-world’ population, and our Danish registries provide this opportunity,” Dr Staerk said.

The study included 43,299 atrial fibrillation patients from Danish nationwide administrative registries. Roughly 42% of the patients were taking warfarin, 29% were taking dabigatran, 16% were taking apixaban, and 13% were taking rivaroxaban.

“The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomized trials,” Dr Staerk said.

During follow-up, stroke occurred in 1054 patients, and there were 261 intracranial bleeds.

The risk of having a stroke within 1 year was similar between the treatment groups. The absolute standardized risk was 2.01% for warfarin, 2.06% for rivaroxaban, 2.12% for dabigatran, and 2.46% for apixaban.

At 1 year, the standardized absolute risk of ICH was significantly lower in patients treated with dabigatran or apixaban—0.26% and 0.40%, respectively—than in those treated with warfarin—0.60% (P<0.05). The standardized absolute risk of ICH was 0.47% with rivaroxaban, which was not significantly different than the risk with warfarin.

“The results suggest that, although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute 1-year risk of intracranial bleeding,” Dr Staerk said.

“Our results complement the large, randomized, phase 3 trials by providing ‘real-world’ data on stroke and intracranial bleeding with NOACs versus warfarin since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials.”

“Registry studies have some limitations, such as the observational design, residual confounding, and confounding by drug indication. In the future, it would be exciting to see a head-to-head, randomized trial performed to compare the different NOAC treatments in patients with atrial fibrillation.”

*Information in the abstract differs from that presented at the meeting.

ROME—A short-term course of dual antiplatelet therapy (DAPT) may be non-inferior to a longer course in patients who have a certain type of drug-eluting stent (DES), according to research presented at ESC Congress 2016.

Patients in this study, known as NIPPON, had the Nobori bioabsorbable abluminal-coated stent and received 6 months or 18 months of DAPT, which consisted of aspirin plus clopidogrel or ticlopidine.

The results showed similar rates of net adverse clinical and cerebrovascular events, as well as similar rates of bleeding complications, whether patients received DAPT for 6 months or 18 months.

“Based on these findings, a combination of short[-term] DAPT and a newer DES with bioabsorbable abluminal coating should be able to minimize the incidence of thrombotic events and bleeding complications simultaneously,” said Masato Nakamura, MD, PhD, of Toho University Ohashi Medical Center in Tokyo, Japan.

However, Dr Nakamura also noted that this study had limitations, so the results should be interpreted with caution.

Dr Nakamura presented the results at the congress as abstract 2218.

The study enrolled 3775 patients with coronary artery disease or acute myocardial infarction who had undergone percutaneous coronary intervention and stent placement at 130 Japanese institutions.

All patients had received the Nobori bioabsorbable abluminal-coated stent, with DAPT consisting of aspirin (81–162 mg/day) combined with clopidogrel (75 mg/day) or ticlopidine (200 mg/day).

An interim analysis of the study data showed slow enrolment and substantially lower events than expected, so the study was terminated early.

Dr Nakamura presented results from the first 2772 patients to be followed for at least 18 months.

There was no significant difference in the occurrence of the primary endpoint—net adverse clinical and cerebrovascular events—among patients randomized to either short-term or long-term DAPT—1.92% and 1.45%, respectively—confirming the non-inferiority of short-term therapy.

The rate of bleeding events was similar between the treatment arms as well—0.73% in the long-term arm and 0.96% in the short-term arm—as was the rate of stent thrombosis—0.07% in both arms.

“The results of the present study should be interpreted with caution before trying to draw firm conclusions,” Dr Nakamura said. “The interpretation of the NIPPON trial is complicated by the fact that the event rate was lower than the expected incidence of the primary endpoint in both groups. Therefore, the statistical power may not have been adequate to fully assess the risk of [the] primary endpoint.”

Dr Nakamura also noted that the follow-up period may not have been long enough to draw conclusions about the optimum duration of DAPT for patients with DES.

Furthermore, the early termination of the study, in conjunction with the enrollment of relatively low-risk subjects, suggests the study’s results may not be generalizable to high-risk patients. Similarly, as antiplatelet therapy was mainly limited to clopidogrel, the use of more potent antiplatelet agents may have led to different conclusions.

This study was funded by Associations for Establishment of Evidence in Interventions Studies. Dr Nakamura has received research grant support and honoraria from Terumo Corporation, Sanofi, and Daiichi Sankyo.

ROME—A short-term course of dual antiplatelet therapy (DAPT) may be non-inferior to a longer course in patients who have a certain type of drug-eluting stent (DES), according to research presented at ESC Congress 2016.

Patients in this study, known as NIPPON, had the Nobori bioabsorbable abluminal-coated stent and received 6 months or 18 months of DAPT, which consisted of aspirin plus clopidogrel or ticlopidine.

The results showed similar rates of net adverse clinical and cerebrovascular events, as well as similar rates of bleeding complications, whether patients received DAPT for 6 months or 18 months.

“Based on these findings, a combination of short[-term] DAPT and a newer DES with bioabsorbable abluminal coating should be able to minimize the incidence of thrombotic events and bleeding complications simultaneously,” said Masato Nakamura, MD, PhD, of Toho University Ohashi Medical Center in Tokyo, Japan.

However, Dr Nakamura also noted that this study had limitations, so the results should be interpreted with caution.

Dr Nakamura presented the results at the congress as abstract 2218.

The study enrolled 3775 patients with coronary artery disease or acute myocardial infarction who had undergone percutaneous coronary intervention and stent placement at 130 Japanese institutions.

All patients had received the Nobori bioabsorbable abluminal-coated stent, with DAPT consisting of aspirin (81–162 mg/day) combined with clopidogrel (75 mg/day) or ticlopidine (200 mg/day).

An interim analysis of the study data showed slow enrolment and substantially lower events than expected, so the study was terminated early.

Dr Nakamura presented results from the first 2772 patients to be followed for at least 18 months.

There was no significant difference in the occurrence of the primary endpoint—net adverse clinical and cerebrovascular events—among patients randomized to either short-term or long-term DAPT—1.92% and 1.45%, respectively—confirming the non-inferiority of short-term therapy.

The rate of bleeding events was similar between the treatment arms as well—0.73% in the long-term arm and 0.96% in the short-term arm—as was the rate of stent thrombosis—0.07% in both arms.

“The results of the present study should be interpreted with caution before trying to draw firm conclusions,” Dr Nakamura said. “The interpretation of the NIPPON trial is complicated by the fact that the event rate was lower than the expected incidence of the primary endpoint in both groups. Therefore, the statistical power may not have been adequate to fully assess the risk of [the] primary endpoint.”

Dr Nakamura also noted that the follow-up period may not have been long enough to draw conclusions about the optimum duration of DAPT for patients with DES.

Furthermore, the early termination of the study, in conjunction with the enrollment of relatively low-risk subjects, suggests the study’s results may not be generalizable to high-risk patients. Similarly, as antiplatelet therapy was mainly limited to clopidogrel, the use of more potent antiplatelet agents may have led to different conclusions.

This study was funded by Associations for Establishment of Evidence in Interventions Studies. Dr Nakamura has received research grant support and honoraria from Terumo Corporation, Sanofi, and Daiichi Sankyo.

ROME—A short-term course of dual antiplatelet therapy (DAPT) may be non-inferior to a longer course in patients who have a certain type of drug-eluting stent (DES), according to research presented at ESC Congress 2016.

Patients in this study, known as NIPPON, had the Nobori bioabsorbable abluminal-coated stent and received 6 months or 18 months of DAPT, which consisted of aspirin plus clopidogrel or ticlopidine.

The results showed similar rates of net adverse clinical and cerebrovascular events, as well as similar rates of bleeding complications, whether patients received DAPT for 6 months or 18 months.

“Based on these findings, a combination of short[-term] DAPT and a newer DES with bioabsorbable abluminal coating should be able to minimize the incidence of thrombotic events and bleeding complications simultaneously,” said Masato Nakamura, MD, PhD, of Toho University Ohashi Medical Center in Tokyo, Japan.

However, Dr Nakamura also noted that this study had limitations, so the results should be interpreted with caution.

Dr Nakamura presented the results at the congress as abstract 2218.

The study enrolled 3775 patients with coronary artery disease or acute myocardial infarction who had undergone percutaneous coronary intervention and stent placement at 130 Japanese institutions.

All patients had received the Nobori bioabsorbable abluminal-coated stent, with DAPT consisting of aspirin (81–162 mg/day) combined with clopidogrel (75 mg/day) or ticlopidine (200 mg/day).

An interim analysis of the study data showed slow enrolment and substantially lower events than expected, so the study was terminated early.

Dr Nakamura presented results from the first 2772 patients to be followed for at least 18 months.

There was no significant difference in the occurrence of the primary endpoint—net adverse clinical and cerebrovascular events—among patients randomized to either short-term or long-term DAPT—1.92% and 1.45%, respectively—confirming the non-inferiority of short-term therapy.

The rate of bleeding events was similar between the treatment arms as well—0.73% in the long-term arm and 0.96% in the short-term arm—as was the rate of stent thrombosis—0.07% in both arms.

“The results of the present study should be interpreted with caution before trying to draw firm conclusions,” Dr Nakamura said. “The interpretation of the NIPPON trial is complicated by the fact that the event rate was lower than the expected incidence of the primary endpoint in both groups. Therefore, the statistical power may not have been adequate to fully assess the risk of [the] primary endpoint.”

Dr Nakamura also noted that the follow-up period may not have been long enough to draw conclusions about the optimum duration of DAPT for patients with DES.

Furthermore, the early termination of the study, in conjunction with the enrollment of relatively low-risk subjects, suggests the study’s results may not be generalizable to high-risk patients. Similarly, as antiplatelet therapy was mainly limited to clopidogrel, the use of more potent antiplatelet agents may have led to different conclusions.

This study was funded by Associations for Establishment of Evidence in Interventions Studies. Dr Nakamura has received research grant support and honoraria from Terumo Corporation, Sanofi, and Daiichi Sankyo.

Cancer patient receiving

chemotherapy

Photo by Rhoda Baer

The European Society of Cardiology (ESC) has launched a novel position paper, under the auspices of its Committee for Practice Guidelines, on the cardiac toxicity of anticancer therapies.

The paper is a summary and evaluation of relevant scientific evidence that is intended to assist health professionals in selecting the best strategies for preventing and managing cardiac toxicity in patients with cancer, including leukemia, lymphoma, and multiple myeloma.

The paper was published in European Heart Journal and on the ESC website.

The document reviews the potential cardiovascular complications of anticancer therapies.

The complications are divided into 9 categories: myocardial dysfunction and heart failure, coronary artery disease, valvular disease, arrhythmias, arterial hypertension, thromboembolic disease, peripheral vascular disease and stroke, pulmonary hypertension, and pericardial complications.

For each type of complication, the authors outline which patients are at risk and how to detect and prevent the possible side effects. Recommendations are given on how to treat and follow patients who develop that type of cardiotoxicity.

Cardiotoxicity is detected using electrocardiogram, cardiac imaging, and biomarkers. Prevention and treatment may involve the use of cardioprotective drugs (such as angiotensin converting enzyme inhibitors or beta-blockers) and adopting a healthy lifestyle (eating a healthy diet, not smoking, exercising regularly, and controlling body weight).

Regarding long-term surveillance for cancer survivors, the paper says patients should be informed of their increased risk of cardiovascular disease at the outset of cancer treatment and supported to make lifestyle changes. They should be told to report early signs and symptoms of cardiovascular disease promptly.

The paper also emphasizes the importance of establishing multidisciplinary teams to provide the best care for cancer patients and survivors. These should include cardiologists, oncologists, nurses, and heart failure and imaging specialists. Ultimately, cardio-oncology centers with a structured service are needed.

The authors note that under- or over-diagnosis of cardiovascular disease sometimes results in failure to prevent adverse events or inappropriate interruption of a potentially life-saving anticancer treatment.

“We need to be clear when it’s a must to stop the treatment, when we should reduce the dose, or when we can continue with the therapy,” said author Jose Luis Zamorano, MD, of University Hospital Ramón in Madrid, Spain. “This position paper provides guidance in this area.”

“We hope the paper will increase awareness about heart disease in cancer patients and survivors and stimulate more research in this area,” added author Patrizio Lancellotti, MD, PhD, of University of Liège Hospital in Liège, Belgium.

“More information is needed on when to screen and monitor patients and on the cardiovascular effects of new anticancer therapies.”

Cancer patient receiving

chemotherapy

Photo by Rhoda Baer

The European Society of Cardiology (ESC) has launched a novel position paper, under the auspices of its Committee for Practice Guidelines, on the cardiac toxicity of anticancer therapies.

The paper is a summary and evaluation of relevant scientific evidence that is intended to assist health professionals in selecting the best strategies for preventing and managing cardiac toxicity in patients with cancer, including leukemia, lymphoma, and multiple myeloma.

The paper was published in European Heart Journal and on the ESC website.

The document reviews the potential cardiovascular complications of anticancer therapies.

The complications are divided into 9 categories: myocardial dysfunction and heart failure, coronary artery disease, valvular disease, arrhythmias, arterial hypertension, thromboembolic disease, peripheral vascular disease and stroke, pulmonary hypertension, and pericardial complications.

For each type of complication, the authors outline which patients are at risk and how to detect and prevent the possible side effects. Recommendations are given on how to treat and follow patients who develop that type of cardiotoxicity.

Cardiotoxicity is detected using electrocardiogram, cardiac imaging, and biomarkers. Prevention and treatment may involve the use of cardioprotective drugs (such as angiotensin converting enzyme inhibitors or beta-blockers) and adopting a healthy lifestyle (eating a healthy diet, not smoking, exercising regularly, and controlling body weight).

Regarding long-term surveillance for cancer survivors, the paper says patients should be informed of their increased risk of cardiovascular disease at the outset of cancer treatment and supported to make lifestyle changes. They should be told to report early signs and symptoms of cardiovascular disease promptly.

The paper also emphasizes the importance of establishing multidisciplinary teams to provide the best care for cancer patients and survivors. These should include cardiologists, oncologists, nurses, and heart failure and imaging specialists. Ultimately, cardio-oncology centers with a structured service are needed.

The authors note that under- or over-diagnosis of cardiovascular disease sometimes results in failure to prevent adverse events or inappropriate interruption of a potentially life-saving anticancer treatment.

“We need to be clear when it’s a must to stop the treatment, when we should reduce the dose, or when we can continue with the therapy,” said author Jose Luis Zamorano, MD, of University Hospital Ramón in Madrid, Spain. “This position paper provides guidance in this area.”

“We hope the paper will increase awareness about heart disease in cancer patients and survivors and stimulate more research in this area,” added author Patrizio Lancellotti, MD, PhD, of University of Liège Hospital in Liège, Belgium.

“More information is needed on when to screen and monitor patients and on the cardiovascular effects of new anticancer therapies.”

Cancer patient receiving

chemotherapy

Photo by Rhoda Baer

The European Society of Cardiology (ESC) has launched a novel position paper, under the auspices of its Committee for Practice Guidelines, on the cardiac toxicity of anticancer therapies.

The paper is a summary and evaluation of relevant scientific evidence that is intended to assist health professionals in selecting the best strategies for preventing and managing cardiac toxicity in patients with cancer, including leukemia, lymphoma, and multiple myeloma.

The paper was published in European Heart Journal and on the ESC website.

The document reviews the potential cardiovascular complications of anticancer therapies.

The complications are divided into 9 categories: myocardial dysfunction and heart failure, coronary artery disease, valvular disease, arrhythmias, arterial hypertension, thromboembolic disease, peripheral vascular disease and stroke, pulmonary hypertension, and pericardial complications.

For each type of complication, the authors outline which patients are at risk and how to detect and prevent the possible side effects. Recommendations are given on how to treat and follow patients who develop that type of cardiotoxicity.

Cardiotoxicity is detected using electrocardiogram, cardiac imaging, and biomarkers. Prevention and treatment may involve the use of cardioprotective drugs (such as angiotensin converting enzyme inhibitors or beta-blockers) and adopting a healthy lifestyle (eating a healthy diet, not smoking, exercising regularly, and controlling body weight).

Regarding long-term surveillance for cancer survivors, the paper says patients should be informed of their increased risk of cardiovascular disease at the outset of cancer treatment and supported to make lifestyle changes. They should be told to report early signs and symptoms of cardiovascular disease promptly.

The paper also emphasizes the importance of establishing multidisciplinary teams to provide the best care for cancer patients and survivors. These should include cardiologists, oncologists, nurses, and heart failure and imaging specialists. Ultimately, cardio-oncology centers with a structured service are needed.

The authors note that under- or over-diagnosis of cardiovascular disease sometimes results in failure to prevent adverse events or inappropriate interruption of a potentially life-saving anticancer treatment.

“We need to be clear when it’s a must to stop the treatment, when we should reduce the dose, or when we can continue with the therapy,” said author Jose Luis Zamorano, MD, of University Hospital Ramón in Madrid, Spain. “This position paper provides guidance in this area.”

“We hope the paper will increase awareness about heart disease in cancer patients and survivors and stimulate more research in this area,” added author Patrizio Lancellotti, MD, PhD, of University of Liège Hospital in Liège, Belgium.

“More information is needed on when to screen and monitor patients and on the cardiovascular effects of new anticancer therapies.”