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BPD and the broader landscape of neuropsychiatric illness
Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.
In recent papers1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.
There also is electrophysiological (including evoked potential) evidence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.
Particularly when BPD is diagnosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humiliation or cruelty, or head injury, what else is there, if not genetically predisposed alterations in the frontolimbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar disorders, especially bipolar II disorder, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?
Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York
----------------------------------------------------------------------------------------------------------
As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual processing disorders have gone undiagnosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.
An example: For 12 years, I have been treating a patient who has auditory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frustrated her parents, who, in their frustration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her problem was, I changed my technique.
When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.
Over time, she has improved and is more functional. After several years of disability, she returned to work, although she still struggles interpersonally.
With many of such patients, I have had to modify traditional techniques of psychotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychological development, the more I can help my patients.
Howard Wishnie, MD
Cambridge, Massachusetts
Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concurrence with my thinking about BPD. It would have been appropriate to include discussion of neurophysiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.
Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
1. Stone MH. The spectrum of borderline personality disorder: a neurophysiological view. Neuropsychiatric Electrophysiology. In press.
2. Stone MH. A new look at borderline personality disorder and related disorders: hyper-activity in the limbic system and lower centers. Psychodyn Psychiatry. 2013;41(3):437-466.
Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.
In recent papers1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.
There also is electrophysiological (including evoked potential) evidence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.
Particularly when BPD is diagnosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humiliation or cruelty, or head injury, what else is there, if not genetically predisposed alterations in the frontolimbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar disorders, especially bipolar II disorder, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?
Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York
----------------------------------------------------------------------------------------------------------
As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual processing disorders have gone undiagnosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.
An example: For 12 years, I have been treating a patient who has auditory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frustrated her parents, who, in their frustration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her problem was, I changed my technique.
When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.
Over time, she has improved and is more functional. After several years of disability, she returned to work, although she still struggles interpersonally.
With many of such patients, I have had to modify traditional techniques of psychotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychological development, the more I can help my patients.
Howard Wishnie, MD
Cambridge, Massachusetts
Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concurrence with my thinking about BPD. It would have been appropriate to include discussion of neurophysiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.
Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.
In recent papers1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.
There also is electrophysiological (including evoked potential) evidence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.
Particularly when BPD is diagnosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humiliation or cruelty, or head injury, what else is there, if not genetically predisposed alterations in the frontolimbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar disorders, especially bipolar II disorder, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?
Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York
----------------------------------------------------------------------------------------------------------
As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual processing disorders have gone undiagnosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.
An example: For 12 years, I have been treating a patient who has auditory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frustrated her parents, who, in their frustration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her problem was, I changed my technique.
When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.
Over time, she has improved and is more functional. After several years of disability, she returned to work, although she still struggles interpersonally.
With many of such patients, I have had to modify traditional techniques of psychotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychological development, the more I can help my patients.
Howard Wishnie, MD
Cambridge, Massachusetts
Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concurrence with my thinking about BPD. It would have been appropriate to include discussion of neurophysiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.
Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
1. Stone MH. The spectrum of borderline personality disorder: a neurophysiological view. Neuropsychiatric Electrophysiology. In press.
2. Stone MH. A new look at borderline personality disorder and related disorders: hyper-activity in the limbic system and lower centers. Psychodyn Psychiatry. 2013;41(3):437-466.
1. Stone MH. The spectrum of borderline personality disorder: a neurophysiological view. Neuropsychiatric Electrophysiology. In press.
2. Stone MH. A new look at borderline personality disorder and related disorders: hyper-activity in the limbic system and lower centers. Psychodyn Psychiatry. 2013;41(3):437-466.
A Conversation With AAOS President Frederick M. Azar, MD
For the past 8 years, I have interviewed the president of the American Academy of Orthopaedic Surgeons (AAOS) to better understand the role the Academy plays in our professional lives in general and the contributions of the AAOS president in particular.
At the 2014 AAOS Annual Meeting this past March in New Orleans, Frederick M. Azar, MD, assumed leadership of the AAOS as its 82nd president. He brings a wide range of orthopedic experience to this role. He has been an Academy volunteer for the last 20 years, and is Chief of Staff at the Campbell Clinic as well as Professor of Orthopedic Surgery and Director of the Sports Medicine Fellowship at the University of Tennessee-Campbell Clinic. He is team physician for the NBA (National Basketball Association) Memphis Grizzlies (see Dr. Azar’s article in this issue of AJO, pages 267-271) and team physician for the University of Memphis and Christian Brothers University sports teams.
This year the Board of Directors of the Academy completed a revision of the AAOS Strategic Plan, last updated in 2010, under the leadership of David Teuscher, MD. The plan, dubbed “Vision 20/20,” includes the following essential elements:
◾ AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.
◾ AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.
◾ Core Values: Excellence, Professionalism, Leadership, Collegiality, Lifelong Learning
◾ Strategic Domains: Advocacy, Education, Membership, Organizational Excellence, Quality and Patient Value
Fred explained that a fundamental aspect of this revised Strategic Plan is that the AAOS takes ownership of all aspects of musculoskeletal tear, not simply surgical management. (For further reading, please visit: www.aaos.org/about/strategicplan.asp.)
Dr. Azar views his role as president of the AAOS as a temporary steward furthering the goals of the organization and not as a proponent of a particular personal agenda. To that end, Fred hopes to focus on 2 areas during his tenure as captain of the orthopedic ship of state: education and communication.
Paradigm shifts are occurring in health care with the passage of the Affordable Care Act, access to medical information via the Internet, and changes in practice management with the near-universal implementation of electronic medical records. In an effort to address the educational needs of its members, the AAOS will expand its electronic media platform and develop mobile apps, ebooks, webinars, and webcasts. In addition, the new AAOS headquarters in Rosemont, Illinois, will house a state-of-the-art Orthopaedic Learning Center. These improvements in education will contribute to the Academy’s core value of lifelong learning.
Regarding communication, Dr. Azar believes that it is extremely important that we, orthopedic surgeons, share with our patients just how much orthopedic care contributes to their quality of life, thereby showcasing the great value orthopedic surgeons bring to millions of patients. Finally, communication with regulators and policymakers in Washington, DC, is equally important as is membership support
for the Orthopaedic Political Action Committee.
We are indeed fortunate to have someone of Dr. Azar’s caliber lead our organization. His extensive experience as an administrator, Academy volunteer, educator, and clinician makes him ideally suited to lead the AAOS during these
challenging times in health care. ◾
For the past 8 years, I have interviewed the president of the American Academy of Orthopaedic Surgeons (AAOS) to better understand the role the Academy plays in our professional lives in general and the contributions of the AAOS president in particular.
At the 2014 AAOS Annual Meeting this past March in New Orleans, Frederick M. Azar, MD, assumed leadership of the AAOS as its 82nd president. He brings a wide range of orthopedic experience to this role. He has been an Academy volunteer for the last 20 years, and is Chief of Staff at the Campbell Clinic as well as Professor of Orthopedic Surgery and Director of the Sports Medicine Fellowship at the University of Tennessee-Campbell Clinic. He is team physician for the NBA (National Basketball Association) Memphis Grizzlies (see Dr. Azar’s article in this issue of AJO, pages 267-271) and team physician for the University of Memphis and Christian Brothers University sports teams.
This year the Board of Directors of the Academy completed a revision of the AAOS Strategic Plan, last updated in 2010, under the leadership of David Teuscher, MD. The plan, dubbed “Vision 20/20,” includes the following essential elements:
◾ AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.
◾ AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.
◾ Core Values: Excellence, Professionalism, Leadership, Collegiality, Lifelong Learning
◾ Strategic Domains: Advocacy, Education, Membership, Organizational Excellence, Quality and Patient Value
Fred explained that a fundamental aspect of this revised Strategic Plan is that the AAOS takes ownership of all aspects of musculoskeletal tear, not simply surgical management. (For further reading, please visit: www.aaos.org/about/strategicplan.asp.)
Dr. Azar views his role as president of the AAOS as a temporary steward furthering the goals of the organization and not as a proponent of a particular personal agenda. To that end, Fred hopes to focus on 2 areas during his tenure as captain of the orthopedic ship of state: education and communication.
Paradigm shifts are occurring in health care with the passage of the Affordable Care Act, access to medical information via the Internet, and changes in practice management with the near-universal implementation of electronic medical records. In an effort to address the educational needs of its members, the AAOS will expand its electronic media platform and develop mobile apps, ebooks, webinars, and webcasts. In addition, the new AAOS headquarters in Rosemont, Illinois, will house a state-of-the-art Orthopaedic Learning Center. These improvements in education will contribute to the Academy’s core value of lifelong learning.
Regarding communication, Dr. Azar believes that it is extremely important that we, orthopedic surgeons, share with our patients just how much orthopedic care contributes to their quality of life, thereby showcasing the great value orthopedic surgeons bring to millions of patients. Finally, communication with regulators and policymakers in Washington, DC, is equally important as is membership support
for the Orthopaedic Political Action Committee.
We are indeed fortunate to have someone of Dr. Azar’s caliber lead our organization. His extensive experience as an administrator, Academy volunteer, educator, and clinician makes him ideally suited to lead the AAOS during these
challenging times in health care. ◾
For the past 8 years, I have interviewed the president of the American Academy of Orthopaedic Surgeons (AAOS) to better understand the role the Academy plays in our professional lives in general and the contributions of the AAOS president in particular.
At the 2014 AAOS Annual Meeting this past March in New Orleans, Frederick M. Azar, MD, assumed leadership of the AAOS as its 82nd president. He brings a wide range of orthopedic experience to this role. He has been an Academy volunteer for the last 20 years, and is Chief of Staff at the Campbell Clinic as well as Professor of Orthopedic Surgery and Director of the Sports Medicine Fellowship at the University of Tennessee-Campbell Clinic. He is team physician for the NBA (National Basketball Association) Memphis Grizzlies (see Dr. Azar’s article in this issue of AJO, pages 267-271) and team physician for the University of Memphis and Christian Brothers University sports teams.
This year the Board of Directors of the Academy completed a revision of the AAOS Strategic Plan, last updated in 2010, under the leadership of David Teuscher, MD. The plan, dubbed “Vision 20/20,” includes the following essential elements:
◾ AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.
◾ AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.
◾ Core Values: Excellence, Professionalism, Leadership, Collegiality, Lifelong Learning
◾ Strategic Domains: Advocacy, Education, Membership, Organizational Excellence, Quality and Patient Value
Fred explained that a fundamental aspect of this revised Strategic Plan is that the AAOS takes ownership of all aspects of musculoskeletal tear, not simply surgical management. (For further reading, please visit: www.aaos.org/about/strategicplan.asp.)
Dr. Azar views his role as president of the AAOS as a temporary steward furthering the goals of the organization and not as a proponent of a particular personal agenda. To that end, Fred hopes to focus on 2 areas during his tenure as captain of the orthopedic ship of state: education and communication.
Paradigm shifts are occurring in health care with the passage of the Affordable Care Act, access to medical information via the Internet, and changes in practice management with the near-universal implementation of electronic medical records. In an effort to address the educational needs of its members, the AAOS will expand its electronic media platform and develop mobile apps, ebooks, webinars, and webcasts. In addition, the new AAOS headquarters in Rosemont, Illinois, will house a state-of-the-art Orthopaedic Learning Center. These improvements in education will contribute to the Academy’s core value of lifelong learning.
Regarding communication, Dr. Azar believes that it is extremely important that we, orthopedic surgeons, share with our patients just how much orthopedic care contributes to their quality of life, thereby showcasing the great value orthopedic surgeons bring to millions of patients. Finally, communication with regulators and policymakers in Washington, DC, is equally important as is membership support
for the Orthopaedic Political Action Committee.
We are indeed fortunate to have someone of Dr. Azar’s caliber lead our organization. His extensive experience as an administrator, Academy volunteer, educator, and clinician makes him ideally suited to lead the AAOS during these
challenging times in health care. ◾
Low-dose aspirin and preeclampsia prevention: Ready for prime time, but as a “re-run” or as a “new series”?
In November 2013, The American College of Obstetricians and Gynecologists (ACOG) published the results of its Task Force on Hypertension in Pregnancy.1 The Task Force aimed to help clinicians become familiar with the state of research in hypertension during pregnancy as well as to assist us in standardizing management approaches to such patients.
The Task Force reported that, worldwide, hypertensive disorders complicate approximately 10% of pregnancies. In addition, in the United States, the past 20 years have brought a 25% increase in the incidence of preeclampsia. According to past ACOG President James N. Martin, Jr, MD, in the last 10 years, the pathophysiology of preeclampsia has become better understood, but the etiology remains unclear and evidence that has emerged to guide therapy has not translated into clinical practice.1
Related articles:
The latest guidance from ACOG on hypertension in pregnancy. Jaimey E. Pauli, MD (Audiocast, January 2014)
Update on Obstetrics. Jaimey E. Pauli, MD, and John T. Repke, MD (January 2014)
The Task Force document contained 60 recommendations for the prevention, prediction, and management of hypertensive disorders of pregnancy, including preeclampsia, gestational hypertension, chronic hypertension, HELLP syndrome, and preeclampsia superimposed on an underlying hypertensive disorder (see box below). One recommendation was that women at high risk for preeclampsia, particularly those with a history of preeclampsia that required delivery before 34 weeks, could possibly benefit from taking aspirin (60–81 mg) daily starting at the end of the first trimester. They further noted that this benefit could include prevention of recurrent severe preeclampsia, or at least a reduction in recurrence risk.
The ACOG Task Force made its recommendation based on results of a meta-analysis of low-dose aspirin trials, involving more than 30,000 patients,2 suggesting a small decrease in the risk of preeclampsia and associated morbidity. More precise risk reduction estimates were difficult to make due to the heterogeneity of the studies reviewed. And the Task Force further stated that this (low-dose aspirin) approach had no demonstrable acute adverse fetal effects, although long-term adverse effects could not be entirely excluded based on the current data.
Unfortunately, according to the ACOG document, the strength of the evidence supporting their recommendation was “moderate” and the strength of the recommendation was “qualified” so, not exactly a resounding endorsement of this approach, but a recommendation nonetheless.
OBSTETRIC PRACTICE CHANGERS 2014
Hypertension and pregnancy and preventing the first cesarean delivery
John T. Repke, MD, author of this Guest Editorial, recently sat down with Errol R. Norwitz, MD, PhD, fellow OBG Management Board of Editors Member and author of this month’s "Update on Operative Vaginal Delivery." Their discussion focused on individual takeaways from ACOG’s Hypertension in Pregnancy guidelines and the recent joint ACOG−Society of Maternal-Fetal Medicine report on emerging clinical and scientific advances in safe prevention of the primary cesarean delivery.
From their conversation:
Dr. Repke: About 60 recommendations came out of ACOG’s Hypertension in Pregnancy document; only six had high-quality supporting evidence, and I think most practitioners already did them. Many really were based on either moderate- or low-quality evidence, with qualified recommendations. I think this has led to confusion.
Dr. Norwitz, how do you answer when a clinician asks you, “Is this gestational hypertension or is this preeclampsia?”
Click here to access the audiocast with full transcript.
Data suggest aspirin for high-risk women could be reasonable
A recent study by Henderson and colleagues presented a systematic review for the US Preventive Services Task Force (USPSTF) on the potential for low-dose aspirin to prevent morbidity and mortality from preeclampsia.3 The design was a meta-analysis of 28 studies: two large, multisite, randomized clinical trials (RCTs); 13 smaller RCTs of high-risk women, of which eight were deemed “good quality”; and six RCTs and two observational studies of average-risk women, of which seven were deemed to be good quality.
The results essentially supported the notion that low-dose aspirin had a beneficial effect with respect to prevention of preeclampsia and perinatal morbidity in women at high risk for preeclampsia. Additionally, no harmful effects were identified, although the authors acknowledged potential rare or long-term harm could not be excluded.
Questions remain
While somewhat gratifying, the results of the USPSTF systematic review still leave many questions. First, the dose of aspirin used in the studies analyzed ranged from 50 mg/d to 150 mg/d. In the United States, “low-dose” aspirin is usually prescribed at 81 mg/d, so the applicability of this review’s findings to US clinical practice is not exact. Second, the authors acknowledged that the putative positive effects observed could be secondary to so-called “small study effects,” and that when only the larger studies were analyzed the effects were less impressive.
Related article: A stepwise approach to managing eclampsia and other hypertensive emergencies. Baha M. Sibai (October 2013)
In my opinion, both the USPSTF study and the recommendations from the ACOG Task Force provide some reassurance for clinicians that the use of daily, low-dose aspirin by women at high risk for preeclampsia probably does afford some benefit, and seems to be a safe approach—as we have known from the initial Maternal-Fetal Medicine Units (MFMU) trial published in 1993 on low-risk women4 and the follow-up MFMU study on high-risk women.5
The need for additional studies is clear, however. The idea that preeclampsia is the same in every patient would seem to make no more sense than thinking all cancer is the same, with the same risk factors, the same epidemiology and pathophysiology, and the same response to similar treatments. Fundamentally, we need to further explore the different pathways through which preeclampsia develops in women and then apply the strategy best suited to treating (or preventing) their form of the disease—a personalized medicine approach.
In the meantime, most patients who have delivered at 34 weeks or less because of preeclampsia and who are contemplating another pregnancy are really not interested in hearing us tell them that we cannot do anything to prevent recurrent preeclampsia because we are awaiting further studies. At least the ACOG recommendations and the results of the USPSTF’s systematic review provide us with a reasonable, although perhaps not yet optimal, therapeutic option.
Related article: 10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia. Baha M. Sibai (November 2011)
The bottom line
In my own practice, I discuss the option of initiating low-dose aspirin (81 mg/d) as early as 12 weeks’ gestation for patients who had either prior early-onset preeclampsia requiring delivery before 34 weeks’ gestation or preeclampsia during more than one pregnancy.
QUICK POLL
Do you offer low-dose aspirin for preeclampsia prevention?
When faced with a patient with prior preeclampsia in more than one pregnancy or with preeclampsia that resulted in delivery prior to 34 weeks, do you offer low-dose aspirin as an option for preventing preeclampsia?
Visit the Quick Poll on the right column of the OBGManagement.com home page to register your answer and see how your colleagues voted.
WE WANT TO HEAR FROM YOU!
Share your thoughts on this article. Send your Letter to the Editor to: [email protected]
- ACOG Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.
- Duley L, Henderson-Smart DJ, Heher S, King JF. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database Syst Rev. 2007;(2):CD004659.
- Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force [published online ahead of print April 8, 2014]. Ann Intern Med. doi:10.7326/M13-2844.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1993;329(17):1213–1218.
- Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338(11):701–705.
John T. Repke, MD, is University Professor and Chairman of Obstetrics and Gynecology at Penn State University College of Medicine. He is also Obstetrician-Gynecologist-in-Chief at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Dr. Repke serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
John T. Repke, MD, is University Professor and Chairman of Obstetrics and Gynecology at Penn State University College of Medicine. He is also Obstetrician-Gynecologist-in-Chief at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Dr. Repke serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
John T. Repke, MD, is University Professor and Chairman of Obstetrics and Gynecology at Penn State University College of Medicine. He is also Obstetrician-Gynecologist-in-Chief at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Dr. Repke serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
In November 2013, The American College of Obstetricians and Gynecologists (ACOG) published the results of its Task Force on Hypertension in Pregnancy.1 The Task Force aimed to help clinicians become familiar with the state of research in hypertension during pregnancy as well as to assist us in standardizing management approaches to such patients.
The Task Force reported that, worldwide, hypertensive disorders complicate approximately 10% of pregnancies. In addition, in the United States, the past 20 years have brought a 25% increase in the incidence of preeclampsia. According to past ACOG President James N. Martin, Jr, MD, in the last 10 years, the pathophysiology of preeclampsia has become better understood, but the etiology remains unclear and evidence that has emerged to guide therapy has not translated into clinical practice.1
Related articles:
The latest guidance from ACOG on hypertension in pregnancy. Jaimey E. Pauli, MD (Audiocast, January 2014)
Update on Obstetrics. Jaimey E. Pauli, MD, and John T. Repke, MD (January 2014)
The Task Force document contained 60 recommendations for the prevention, prediction, and management of hypertensive disorders of pregnancy, including preeclampsia, gestational hypertension, chronic hypertension, HELLP syndrome, and preeclampsia superimposed on an underlying hypertensive disorder (see box below). One recommendation was that women at high risk for preeclampsia, particularly those with a history of preeclampsia that required delivery before 34 weeks, could possibly benefit from taking aspirin (60–81 mg) daily starting at the end of the first trimester. They further noted that this benefit could include prevention of recurrent severe preeclampsia, or at least a reduction in recurrence risk.
The ACOG Task Force made its recommendation based on results of a meta-analysis of low-dose aspirin trials, involving more than 30,000 patients,2 suggesting a small decrease in the risk of preeclampsia and associated morbidity. More precise risk reduction estimates were difficult to make due to the heterogeneity of the studies reviewed. And the Task Force further stated that this (low-dose aspirin) approach had no demonstrable acute adverse fetal effects, although long-term adverse effects could not be entirely excluded based on the current data.
Unfortunately, according to the ACOG document, the strength of the evidence supporting their recommendation was “moderate” and the strength of the recommendation was “qualified” so, not exactly a resounding endorsement of this approach, but a recommendation nonetheless.
OBSTETRIC PRACTICE CHANGERS 2014
Hypertension and pregnancy and preventing the first cesarean delivery
John T. Repke, MD, author of this Guest Editorial, recently sat down with Errol R. Norwitz, MD, PhD, fellow OBG Management Board of Editors Member and author of this month’s "Update on Operative Vaginal Delivery." Their discussion focused on individual takeaways from ACOG’s Hypertension in Pregnancy guidelines and the recent joint ACOG−Society of Maternal-Fetal Medicine report on emerging clinical and scientific advances in safe prevention of the primary cesarean delivery.
From their conversation:
Dr. Repke: About 60 recommendations came out of ACOG’s Hypertension in Pregnancy document; only six had high-quality supporting evidence, and I think most practitioners already did them. Many really were based on either moderate- or low-quality evidence, with qualified recommendations. I think this has led to confusion.
Dr. Norwitz, how do you answer when a clinician asks you, “Is this gestational hypertension or is this preeclampsia?”
Click here to access the audiocast with full transcript.
Data suggest aspirin for high-risk women could be reasonable
A recent study by Henderson and colleagues presented a systematic review for the US Preventive Services Task Force (USPSTF) on the potential for low-dose aspirin to prevent morbidity and mortality from preeclampsia.3 The design was a meta-analysis of 28 studies: two large, multisite, randomized clinical trials (RCTs); 13 smaller RCTs of high-risk women, of which eight were deemed “good quality”; and six RCTs and two observational studies of average-risk women, of which seven were deemed to be good quality.
The results essentially supported the notion that low-dose aspirin had a beneficial effect with respect to prevention of preeclampsia and perinatal morbidity in women at high risk for preeclampsia. Additionally, no harmful effects were identified, although the authors acknowledged potential rare or long-term harm could not be excluded.
Questions remain
While somewhat gratifying, the results of the USPSTF systematic review still leave many questions. First, the dose of aspirin used in the studies analyzed ranged from 50 mg/d to 150 mg/d. In the United States, “low-dose” aspirin is usually prescribed at 81 mg/d, so the applicability of this review’s findings to US clinical practice is not exact. Second, the authors acknowledged that the putative positive effects observed could be secondary to so-called “small study effects,” and that when only the larger studies were analyzed the effects were less impressive.
Related article: A stepwise approach to managing eclampsia and other hypertensive emergencies. Baha M. Sibai (October 2013)
In my opinion, both the USPSTF study and the recommendations from the ACOG Task Force provide some reassurance for clinicians that the use of daily, low-dose aspirin by women at high risk for preeclampsia probably does afford some benefit, and seems to be a safe approach—as we have known from the initial Maternal-Fetal Medicine Units (MFMU) trial published in 1993 on low-risk women4 and the follow-up MFMU study on high-risk women.5
The need for additional studies is clear, however. The idea that preeclampsia is the same in every patient would seem to make no more sense than thinking all cancer is the same, with the same risk factors, the same epidemiology and pathophysiology, and the same response to similar treatments. Fundamentally, we need to further explore the different pathways through which preeclampsia develops in women and then apply the strategy best suited to treating (or preventing) their form of the disease—a personalized medicine approach.
In the meantime, most patients who have delivered at 34 weeks or less because of preeclampsia and who are contemplating another pregnancy are really not interested in hearing us tell them that we cannot do anything to prevent recurrent preeclampsia because we are awaiting further studies. At least the ACOG recommendations and the results of the USPSTF’s systematic review provide us with a reasonable, although perhaps not yet optimal, therapeutic option.
Related article: 10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia. Baha M. Sibai (November 2011)
The bottom line
In my own practice, I discuss the option of initiating low-dose aspirin (81 mg/d) as early as 12 weeks’ gestation for patients who had either prior early-onset preeclampsia requiring delivery before 34 weeks’ gestation or preeclampsia during more than one pregnancy.
QUICK POLL
Do you offer low-dose aspirin for preeclampsia prevention?
When faced with a patient with prior preeclampsia in more than one pregnancy or with preeclampsia that resulted in delivery prior to 34 weeks, do you offer low-dose aspirin as an option for preventing preeclampsia?
Visit the Quick Poll on the right column of the OBGManagement.com home page to register your answer and see how your colleagues voted.
WE WANT TO HEAR FROM YOU!
Share your thoughts on this article. Send your Letter to the Editor to: [email protected]
In November 2013, The American College of Obstetricians and Gynecologists (ACOG) published the results of its Task Force on Hypertension in Pregnancy.1 The Task Force aimed to help clinicians become familiar with the state of research in hypertension during pregnancy as well as to assist us in standardizing management approaches to such patients.
The Task Force reported that, worldwide, hypertensive disorders complicate approximately 10% of pregnancies. In addition, in the United States, the past 20 years have brought a 25% increase in the incidence of preeclampsia. According to past ACOG President James N. Martin, Jr, MD, in the last 10 years, the pathophysiology of preeclampsia has become better understood, but the etiology remains unclear and evidence that has emerged to guide therapy has not translated into clinical practice.1
Related articles:
The latest guidance from ACOG on hypertension in pregnancy. Jaimey E. Pauli, MD (Audiocast, January 2014)
Update on Obstetrics. Jaimey E. Pauli, MD, and John T. Repke, MD (January 2014)
The Task Force document contained 60 recommendations for the prevention, prediction, and management of hypertensive disorders of pregnancy, including preeclampsia, gestational hypertension, chronic hypertension, HELLP syndrome, and preeclampsia superimposed on an underlying hypertensive disorder (see box below). One recommendation was that women at high risk for preeclampsia, particularly those with a history of preeclampsia that required delivery before 34 weeks, could possibly benefit from taking aspirin (60–81 mg) daily starting at the end of the first trimester. They further noted that this benefit could include prevention of recurrent severe preeclampsia, or at least a reduction in recurrence risk.
The ACOG Task Force made its recommendation based on results of a meta-analysis of low-dose aspirin trials, involving more than 30,000 patients,2 suggesting a small decrease in the risk of preeclampsia and associated morbidity. More precise risk reduction estimates were difficult to make due to the heterogeneity of the studies reviewed. And the Task Force further stated that this (low-dose aspirin) approach had no demonstrable acute adverse fetal effects, although long-term adverse effects could not be entirely excluded based on the current data.
Unfortunately, according to the ACOG document, the strength of the evidence supporting their recommendation was “moderate” and the strength of the recommendation was “qualified” so, not exactly a resounding endorsement of this approach, but a recommendation nonetheless.
OBSTETRIC PRACTICE CHANGERS 2014
Hypertension and pregnancy and preventing the first cesarean delivery
John T. Repke, MD, author of this Guest Editorial, recently sat down with Errol R. Norwitz, MD, PhD, fellow OBG Management Board of Editors Member and author of this month’s "Update on Operative Vaginal Delivery." Their discussion focused on individual takeaways from ACOG’s Hypertension in Pregnancy guidelines and the recent joint ACOG−Society of Maternal-Fetal Medicine report on emerging clinical and scientific advances in safe prevention of the primary cesarean delivery.
From their conversation:
Dr. Repke: About 60 recommendations came out of ACOG’s Hypertension in Pregnancy document; only six had high-quality supporting evidence, and I think most practitioners already did them. Many really were based on either moderate- or low-quality evidence, with qualified recommendations. I think this has led to confusion.
Dr. Norwitz, how do you answer when a clinician asks you, “Is this gestational hypertension or is this preeclampsia?”
Click here to access the audiocast with full transcript.
Data suggest aspirin for high-risk women could be reasonable
A recent study by Henderson and colleagues presented a systematic review for the US Preventive Services Task Force (USPSTF) on the potential for low-dose aspirin to prevent morbidity and mortality from preeclampsia.3 The design was a meta-analysis of 28 studies: two large, multisite, randomized clinical trials (RCTs); 13 smaller RCTs of high-risk women, of which eight were deemed “good quality”; and six RCTs and two observational studies of average-risk women, of which seven were deemed to be good quality.
The results essentially supported the notion that low-dose aspirin had a beneficial effect with respect to prevention of preeclampsia and perinatal morbidity in women at high risk for preeclampsia. Additionally, no harmful effects were identified, although the authors acknowledged potential rare or long-term harm could not be excluded.
Questions remain
While somewhat gratifying, the results of the USPSTF systematic review still leave many questions. First, the dose of aspirin used in the studies analyzed ranged from 50 mg/d to 150 mg/d. In the United States, “low-dose” aspirin is usually prescribed at 81 mg/d, so the applicability of this review’s findings to US clinical practice is not exact. Second, the authors acknowledged that the putative positive effects observed could be secondary to so-called “small study effects,” and that when only the larger studies were analyzed the effects were less impressive.
Related article: A stepwise approach to managing eclampsia and other hypertensive emergencies. Baha M. Sibai (October 2013)
In my opinion, both the USPSTF study and the recommendations from the ACOG Task Force provide some reassurance for clinicians that the use of daily, low-dose aspirin by women at high risk for preeclampsia probably does afford some benefit, and seems to be a safe approach—as we have known from the initial Maternal-Fetal Medicine Units (MFMU) trial published in 1993 on low-risk women4 and the follow-up MFMU study on high-risk women.5
The need for additional studies is clear, however. The idea that preeclampsia is the same in every patient would seem to make no more sense than thinking all cancer is the same, with the same risk factors, the same epidemiology and pathophysiology, and the same response to similar treatments. Fundamentally, we need to further explore the different pathways through which preeclampsia develops in women and then apply the strategy best suited to treating (or preventing) their form of the disease—a personalized medicine approach.
In the meantime, most patients who have delivered at 34 weeks or less because of preeclampsia and who are contemplating another pregnancy are really not interested in hearing us tell them that we cannot do anything to prevent recurrent preeclampsia because we are awaiting further studies. At least the ACOG recommendations and the results of the USPSTF’s systematic review provide us with a reasonable, although perhaps not yet optimal, therapeutic option.
Related article: 10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia. Baha M. Sibai (November 2011)
The bottom line
In my own practice, I discuss the option of initiating low-dose aspirin (81 mg/d) as early as 12 weeks’ gestation for patients who had either prior early-onset preeclampsia requiring delivery before 34 weeks’ gestation or preeclampsia during more than one pregnancy.
QUICK POLL
Do you offer low-dose aspirin for preeclampsia prevention?
When faced with a patient with prior preeclampsia in more than one pregnancy or with preeclampsia that resulted in delivery prior to 34 weeks, do you offer low-dose aspirin as an option for preventing preeclampsia?
Visit the Quick Poll on the right column of the OBGManagement.com home page to register your answer and see how your colleagues voted.
WE WANT TO HEAR FROM YOU!
Share your thoughts on this article. Send your Letter to the Editor to: [email protected]
- ACOG Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.
- Duley L, Henderson-Smart DJ, Heher S, King JF. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database Syst Rev. 2007;(2):CD004659.
- Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force [published online ahead of print April 8, 2014]. Ann Intern Med. doi:10.7326/M13-2844.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1993;329(17):1213–1218.
- Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338(11):701–705.
- ACOG Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.
- Duley L, Henderson-Smart DJ, Heher S, King JF. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database Syst Rev. 2007;(2):CD004659.
- Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force [published online ahead of print April 8, 2014]. Ann Intern Med. doi:10.7326/M13-2844.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1993;329(17):1213–1218.
- Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338(11):701–705.
Have you read Dr. Errol R. Norwitz's Update on Operative Vaginal Delivery? Click here to access.
I perform extracorporeal morcellation; Better vaginal surgery training needed; A patient's perspective
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
I did not anticipate that, in addition to the normal fears and anxieties of upcoming surgery, I would also have to wonder if I will receive a phone call from the medical center telling me I cannot have surgery because morcellation has been prohibited.
I am relatively young, I have no family history of cancer, and I have 7 years’ worth of MRIs and ultrasounds to show that it is extremely unlikely that I have uterine cancer. I am well aware of the risks, and as an informed adult, I feel it is unconscionable for anybody to tell me that I cannot have the surgery of my choice simply because a very small number of women could be at risk. A greater number of women would be more at risk from having open surgery (blood loss, infection, thromboembolism, urinary and bowel incontinence, greater pain, longer recovery, etc.). Nearly every woman older than age 50 in my family has had an abdominal hysterectomy, with a long and painful recovery. I don’t want that.
I am so lucky to live in a time when surgery has advanced and there are less invasive options. This issue is about choice. Women are constantly having choices infringed upon by the government and its agencies. It’s time to return this operative choice to us.
A patient
Los Angeles, California
WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about this or other current articles: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
I did not anticipate that, in addition to the normal fears and anxieties of upcoming surgery, I would also have to wonder if I will receive a phone call from the medical center telling me I cannot have surgery because morcellation has been prohibited.
I am relatively young, I have no family history of cancer, and I have 7 years’ worth of MRIs and ultrasounds to show that it is extremely unlikely that I have uterine cancer. I am well aware of the risks, and as an informed adult, I feel it is unconscionable for anybody to tell me that I cannot have the surgery of my choice simply because a very small number of women could be at risk. A greater number of women would be more at risk from having open surgery (blood loss, infection, thromboembolism, urinary and bowel incontinence, greater pain, longer recovery, etc.). Nearly every woman older than age 50 in my family has had an abdominal hysterectomy, with a long and painful recovery. I don’t want that.
I am so lucky to live in a time when surgery has advanced and there are less invasive options. This issue is about choice. Women are constantly having choices infringed upon by the government and its agencies. It’s time to return this operative choice to us.
A patient
Los Angeles, California
WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about this or other current articles: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
I did not anticipate that, in addition to the normal fears and anxieties of upcoming surgery, I would also have to wonder if I will receive a phone call from the medical center telling me I cannot have surgery because morcellation has been prohibited.
I am relatively young, I have no family history of cancer, and I have 7 years’ worth of MRIs and ultrasounds to show that it is extremely unlikely that I have uterine cancer. I am well aware of the risks, and as an informed adult, I feel it is unconscionable for anybody to tell me that I cannot have the surgery of my choice simply because a very small number of women could be at risk. A greater number of women would be more at risk from having open surgery (blood loss, infection, thromboembolism, urinary and bowel incontinence, greater pain, longer recovery, etc.). Nearly every woman older than age 50 in my family has had an abdominal hysterectomy, with a long and painful recovery. I don’t want that.
I am so lucky to live in a time when surgery has advanced and there are less invasive options. This issue is about choice. Women are constantly having choices infringed upon by the government and its agencies. It’s time to return this operative choice to us.
A patient
Los Angeles, California
WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about this or other current articles: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
Duplicating tests when urgency is not an issue
I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.
When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.
The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.
So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.
I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.
This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.
It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.
The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.
When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.
The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.
So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.
I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.
This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.
It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.
The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.
When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.
The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.
So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.
I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.
This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.
It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.
The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How to save a life in 15 minutes or less
It is important to recognize that as pediatricians we have the unique opportunity to see to the lives of a very vulnerable group of people known as teenagers.
We can all relate to the discomfort of the stone-faced teenager with one-word answers and one foot out the door. There is usually a parent present who is answering all of the questions, and if you are lucky, the patient may put the cell phone down long enough to get an eye exam in, but, we must realize that the 15 minutes of captive audience could be the most important 15 minutes of the teen’s life.
Before we start our exam, we should have a plan in place for what topics we should be addressing. Every thorough physical should include a screen on drugs and alcohol, depression, sexual activity, and violence. In a busy practice, it seems impossible to address these issues in a time-conservative manner, but if we plan ahead, we can be thorough, casual, and informative.
First, you must analyze your own style. If having these discussions is uncomfortable for you, then attempting them without a plan will be disastrous. Many pediatricians just choose to avoid the entire discussion and hope that the parent is parenting and will address the major issues. But fewer than half of all parents talk to their children about the issues that they are faced with daily, and a great majority are ill-informed, or driven by their own beliefs.
First, pediatricians must make a list of hot topics to be discussed. Review the most current data and how they are affecting the teens in your area. Next, whether your talking style is comfortable or not, having a questionnaire that introduces each topic is always helpful (Am. J. Psychiatry 1995;152:1601-7
Lastly, have teenagers come in by themselves. Parents cannot help themselves and will always speak for their children, and most teens will not ask questions that they don’t think their parent will approve of or that relate to private family issues. So, you must set the stage for a comfortable talking environment. By having the questionnaire available, you can use it as a guide to see what issues are affecting the patient.
Knowing current information is also imperative to a good wellness exam. Know what the latest drugs are being used by the teens in the area, and know the street names of drugs (drugabuse.gov/drugs-abuse). Where do the local teens hang out? Major issues happening at the local high schools can help guide your conversations and build trust as patients begin to see you as an active and involved leader in the community.
Depression affects 8% of teens every year. Therefore, there is a guarantee that at least a handful will present in your office every year. Asking the right questions is key to getting helpful answers. Be direct, ask, "Have you ever, or are you now having suicidal ideation?" Over 90% of children and adolescents who commit suicide have a mental disorder (J. Clin. Psychiatry 1999;60 (Suppl. 2):70-4). There is a Web site supported by the American Academy of Pediatrics that has questionnaires to assist in identifying symptoms of depression (brightfutures.aap.org). Knowing the family history of psychiatric disorders can be very helpful in guiding the physician of what questions to ask. Many teens are fearful that they may be having symptoms of a psychiatric disorder, but are too afraid to ask, given the stigma that goes along with it.
Address issues of self-image. If patients are overweight, give tips on healthy eating and exercise. Develop a nutritional plan and track a patient’s progress by having her follow up. Allow her to discuss what make her feel sad or uncomfortable. How is she interacting with her peers, does she fit in or is she often alone?
A wellness exam is not complete without addressing sex and sexuality. No matter how you slice it, talking about sex with a complete stranger will never be easy. Using the questionnaire to bring up the topic helps. Start with generalizations about the risks of unprotected sex and general statistics of sexually transmitted infections in teenagers. Next, a general statement about abstinence is important so that teens realize it is an option. Review the common birth control methods and their risks. Encourage him to have at least one adult that he can trust to discuss delicate issues with and to return to your office if other issues arise.
Teenagers also are under the belief that they are invincible and that bad things only happen to other people. Discuss the leading cause of death in teenagers so they understand the reality of risk taking. Talk about date rape and physical abuse amongst teen couples. In a study done in California, 35% of teens questioned had experienced some form of violence with-in their relationships (Social Work 1986;31:465-8)
Knowing the laws that govern what advice can be given and what information can remain confidential is imperative. A great resource in understanding the basic laws that protect the physician and the patient’s rights is guttmacher.org/statecenter/spibs/spib_OMCL.pdf. Most states provide an online version of their laws governing teens and medical practice.
Establishing a rapport with your teenage patients can be very rewarding. Many teenagers are in search of a listening ear and need guidance in this new and critical era of their life. With a little planning and practice, you will provide with ease the information to help them make good decisions. It is important that we are equipped and ready because you may just save a life!
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Go to pediatricnews.com to view similar columns.
It is important to recognize that as pediatricians we have the unique opportunity to see to the lives of a very vulnerable group of people known as teenagers.
We can all relate to the discomfort of the stone-faced teenager with one-word answers and one foot out the door. There is usually a parent present who is answering all of the questions, and if you are lucky, the patient may put the cell phone down long enough to get an eye exam in, but, we must realize that the 15 minutes of captive audience could be the most important 15 minutes of the teen’s life.
Before we start our exam, we should have a plan in place for what topics we should be addressing. Every thorough physical should include a screen on drugs and alcohol, depression, sexual activity, and violence. In a busy practice, it seems impossible to address these issues in a time-conservative manner, but if we plan ahead, we can be thorough, casual, and informative.
First, you must analyze your own style. If having these discussions is uncomfortable for you, then attempting them without a plan will be disastrous. Many pediatricians just choose to avoid the entire discussion and hope that the parent is parenting and will address the major issues. But fewer than half of all parents talk to their children about the issues that they are faced with daily, and a great majority are ill-informed, or driven by their own beliefs.
First, pediatricians must make a list of hot topics to be discussed. Review the most current data and how they are affecting the teens in your area. Next, whether your talking style is comfortable or not, having a questionnaire that introduces each topic is always helpful (Am. J. Psychiatry 1995;152:1601-7
Lastly, have teenagers come in by themselves. Parents cannot help themselves and will always speak for their children, and most teens will not ask questions that they don’t think their parent will approve of or that relate to private family issues. So, you must set the stage for a comfortable talking environment. By having the questionnaire available, you can use it as a guide to see what issues are affecting the patient.
Knowing current information is also imperative to a good wellness exam. Know what the latest drugs are being used by the teens in the area, and know the street names of drugs (drugabuse.gov/drugs-abuse). Where do the local teens hang out? Major issues happening at the local high schools can help guide your conversations and build trust as patients begin to see you as an active and involved leader in the community.
Depression affects 8% of teens every year. Therefore, there is a guarantee that at least a handful will present in your office every year. Asking the right questions is key to getting helpful answers. Be direct, ask, "Have you ever, or are you now having suicidal ideation?" Over 90% of children and adolescents who commit suicide have a mental disorder (J. Clin. Psychiatry 1999;60 (Suppl. 2):70-4). There is a Web site supported by the American Academy of Pediatrics that has questionnaires to assist in identifying symptoms of depression (brightfutures.aap.org). Knowing the family history of psychiatric disorders can be very helpful in guiding the physician of what questions to ask. Many teens are fearful that they may be having symptoms of a psychiatric disorder, but are too afraid to ask, given the stigma that goes along with it.
Address issues of self-image. If patients are overweight, give tips on healthy eating and exercise. Develop a nutritional plan and track a patient’s progress by having her follow up. Allow her to discuss what make her feel sad or uncomfortable. How is she interacting with her peers, does she fit in or is she often alone?
A wellness exam is not complete without addressing sex and sexuality. No matter how you slice it, talking about sex with a complete stranger will never be easy. Using the questionnaire to bring up the topic helps. Start with generalizations about the risks of unprotected sex and general statistics of sexually transmitted infections in teenagers. Next, a general statement about abstinence is important so that teens realize it is an option. Review the common birth control methods and their risks. Encourage him to have at least one adult that he can trust to discuss delicate issues with and to return to your office if other issues arise.
Teenagers also are under the belief that they are invincible and that bad things only happen to other people. Discuss the leading cause of death in teenagers so they understand the reality of risk taking. Talk about date rape and physical abuse amongst teen couples. In a study done in California, 35% of teens questioned had experienced some form of violence with-in their relationships (Social Work 1986;31:465-8)
Knowing the laws that govern what advice can be given and what information can remain confidential is imperative. A great resource in understanding the basic laws that protect the physician and the patient’s rights is guttmacher.org/statecenter/spibs/spib_OMCL.pdf. Most states provide an online version of their laws governing teens and medical practice.
Establishing a rapport with your teenage patients can be very rewarding. Many teenagers are in search of a listening ear and need guidance in this new and critical era of their life. With a little planning and practice, you will provide with ease the information to help them make good decisions. It is important that we are equipped and ready because you may just save a life!
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Go to pediatricnews.com to view similar columns.
It is important to recognize that as pediatricians we have the unique opportunity to see to the lives of a very vulnerable group of people known as teenagers.
We can all relate to the discomfort of the stone-faced teenager with one-word answers and one foot out the door. There is usually a parent present who is answering all of the questions, and if you are lucky, the patient may put the cell phone down long enough to get an eye exam in, but, we must realize that the 15 minutes of captive audience could be the most important 15 minutes of the teen’s life.
Before we start our exam, we should have a plan in place for what topics we should be addressing. Every thorough physical should include a screen on drugs and alcohol, depression, sexual activity, and violence. In a busy practice, it seems impossible to address these issues in a time-conservative manner, but if we plan ahead, we can be thorough, casual, and informative.
First, you must analyze your own style. If having these discussions is uncomfortable for you, then attempting them without a plan will be disastrous. Many pediatricians just choose to avoid the entire discussion and hope that the parent is parenting and will address the major issues. But fewer than half of all parents talk to their children about the issues that they are faced with daily, and a great majority are ill-informed, or driven by their own beliefs.
First, pediatricians must make a list of hot topics to be discussed. Review the most current data and how they are affecting the teens in your area. Next, whether your talking style is comfortable or not, having a questionnaire that introduces each topic is always helpful (Am. J. Psychiatry 1995;152:1601-7
Lastly, have teenagers come in by themselves. Parents cannot help themselves and will always speak for their children, and most teens will not ask questions that they don’t think their parent will approve of or that relate to private family issues. So, you must set the stage for a comfortable talking environment. By having the questionnaire available, you can use it as a guide to see what issues are affecting the patient.
Knowing current information is also imperative to a good wellness exam. Know what the latest drugs are being used by the teens in the area, and know the street names of drugs (drugabuse.gov/drugs-abuse). Where do the local teens hang out? Major issues happening at the local high schools can help guide your conversations and build trust as patients begin to see you as an active and involved leader in the community.
Depression affects 8% of teens every year. Therefore, there is a guarantee that at least a handful will present in your office every year. Asking the right questions is key to getting helpful answers. Be direct, ask, "Have you ever, or are you now having suicidal ideation?" Over 90% of children and adolescents who commit suicide have a mental disorder (J. Clin. Psychiatry 1999;60 (Suppl. 2):70-4). There is a Web site supported by the American Academy of Pediatrics that has questionnaires to assist in identifying symptoms of depression (brightfutures.aap.org). Knowing the family history of psychiatric disorders can be very helpful in guiding the physician of what questions to ask. Many teens are fearful that they may be having symptoms of a psychiatric disorder, but are too afraid to ask, given the stigma that goes along with it.
Address issues of self-image. If patients are overweight, give tips on healthy eating and exercise. Develop a nutritional plan and track a patient’s progress by having her follow up. Allow her to discuss what make her feel sad or uncomfortable. How is she interacting with her peers, does she fit in or is she often alone?
A wellness exam is not complete without addressing sex and sexuality. No matter how you slice it, talking about sex with a complete stranger will never be easy. Using the questionnaire to bring up the topic helps. Start with generalizations about the risks of unprotected sex and general statistics of sexually transmitted infections in teenagers. Next, a general statement about abstinence is important so that teens realize it is an option. Review the common birth control methods and their risks. Encourage him to have at least one adult that he can trust to discuss delicate issues with and to return to your office if other issues arise.
Teenagers also are under the belief that they are invincible and that bad things only happen to other people. Discuss the leading cause of death in teenagers so they understand the reality of risk taking. Talk about date rape and physical abuse amongst teen couples. In a study done in California, 35% of teens questioned had experienced some form of violence with-in their relationships (Social Work 1986;31:465-8)
Knowing the laws that govern what advice can be given and what information can remain confidential is imperative. A great resource in understanding the basic laws that protect the physician and the patient’s rights is guttmacher.org/statecenter/spibs/spib_OMCL.pdf. Most states provide an online version of their laws governing teens and medical practice.
Establishing a rapport with your teenage patients can be very rewarding. Many teenagers are in search of a listening ear and need guidance in this new and critical era of their life. With a little planning and practice, you will provide with ease the information to help them make good decisions. It is important that we are equipped and ready because you may just save a life!
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Go to pediatricnews.com to view similar columns.
Much to like on the stroke guidelines menu
The devastation of an acute stroke is something relatively few of us have experienced personally, but professionally we see it very regularly. An estimated 690,000-plus adults in the United States suffer an ischemic stroke annually, and an additional 240,000 experience a transient ischemic attack.
The good news is that the current estimated annual rate of future stroke in this patient population (3%-4%) is historically low, thanks to preventive measures, according to the new "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals," which was published online in Stroke in May (Stroke 2014 May 1 [doi: 10.1161/STR.0000000000000024]). This updated guideline gives evidence-based recommendations on secondary stroke prevention as well as primary prevention in those who have suffered a transient ischemic attack (TIA).
This very extensive guide from the American Heart Association and the American Stroke Association addresses a wide variety of scenarios, ranging from general risk factor modification to specific circumstances, such as myocardial infarction and thrombus, cardiomyopathy, pregnancy, arterial dissection, and aortic arch atherosclerosis.
I welcome the recommendation to consider adding clopidogrel 75 mg/day to aspirin for 90 days in patients with a recent (within 30 days) stroke or TIA attributable to high-grade stenosis (70%-99%) of a major intracranial artery. I used to feel rather helpless to improve the long-term outcome in these patients, but now there seems to be something more we can do, other than just using statins and single antiplatelet therapy.
Other new recommendations stress nutrition. One item suggests performing a nutritional assessment for patients with a history of ischemic stroke or TIA. While many patients may never get around to seeing a nutritionist as an outpatient, no matter how often their primary care physician stresses the importance, when they are in the hospital we have a captive audience. So why not order a nutrition consult, along with the consult for physical, occupational, and speech therapy?
After having experienced an acute neurologic event, many patients and their families are highly motivated to make whatever changes are necessary to prevent a future, potentially catastrophic stroke. Reduction of sodium from 3.3 g/day to 2.5 g/day or less is reasonable, according to the guidelines, though lowering intake to less than 1.5 g/day will lower blood pressure even further. A nutritionist’s input into how to attain these levels without eating a diet that tastes like cardboard can be invaluable. The new guidelines also suggest counseling patients to follow a Mediterranean-type diet – emphasizing whole grains, fruits, vegetables, nuts, olive oil, legumes, fish, poultry, and even low-fat dairy products – instead of the traditional low fat diet.
These new recommendations are only the tip of the iceberg, and this document is highly worthwhile for all practicing clinicians.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
The devastation of an acute stroke is something relatively few of us have experienced personally, but professionally we see it very regularly. An estimated 690,000-plus adults in the United States suffer an ischemic stroke annually, and an additional 240,000 experience a transient ischemic attack.
The good news is that the current estimated annual rate of future stroke in this patient population (3%-4%) is historically low, thanks to preventive measures, according to the new "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals," which was published online in Stroke in May (Stroke 2014 May 1 [doi: 10.1161/STR.0000000000000024]). This updated guideline gives evidence-based recommendations on secondary stroke prevention as well as primary prevention in those who have suffered a transient ischemic attack (TIA).
This very extensive guide from the American Heart Association and the American Stroke Association addresses a wide variety of scenarios, ranging from general risk factor modification to specific circumstances, such as myocardial infarction and thrombus, cardiomyopathy, pregnancy, arterial dissection, and aortic arch atherosclerosis.
I welcome the recommendation to consider adding clopidogrel 75 mg/day to aspirin for 90 days in patients with a recent (within 30 days) stroke or TIA attributable to high-grade stenosis (70%-99%) of a major intracranial artery. I used to feel rather helpless to improve the long-term outcome in these patients, but now there seems to be something more we can do, other than just using statins and single antiplatelet therapy.
Other new recommendations stress nutrition. One item suggests performing a nutritional assessment for patients with a history of ischemic stroke or TIA. While many patients may never get around to seeing a nutritionist as an outpatient, no matter how often their primary care physician stresses the importance, when they are in the hospital we have a captive audience. So why not order a nutrition consult, along with the consult for physical, occupational, and speech therapy?
After having experienced an acute neurologic event, many patients and their families are highly motivated to make whatever changes are necessary to prevent a future, potentially catastrophic stroke. Reduction of sodium from 3.3 g/day to 2.5 g/day or less is reasonable, according to the guidelines, though lowering intake to less than 1.5 g/day will lower blood pressure even further. A nutritionist’s input into how to attain these levels without eating a diet that tastes like cardboard can be invaluable. The new guidelines also suggest counseling patients to follow a Mediterranean-type diet – emphasizing whole grains, fruits, vegetables, nuts, olive oil, legumes, fish, poultry, and even low-fat dairy products – instead of the traditional low fat diet.
These new recommendations are only the tip of the iceberg, and this document is highly worthwhile for all practicing clinicians.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
The devastation of an acute stroke is something relatively few of us have experienced personally, but professionally we see it very regularly. An estimated 690,000-plus adults in the United States suffer an ischemic stroke annually, and an additional 240,000 experience a transient ischemic attack.
The good news is that the current estimated annual rate of future stroke in this patient population (3%-4%) is historically low, thanks to preventive measures, according to the new "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals," which was published online in Stroke in May (Stroke 2014 May 1 [doi: 10.1161/STR.0000000000000024]). This updated guideline gives evidence-based recommendations on secondary stroke prevention as well as primary prevention in those who have suffered a transient ischemic attack (TIA).
This very extensive guide from the American Heart Association and the American Stroke Association addresses a wide variety of scenarios, ranging from general risk factor modification to specific circumstances, such as myocardial infarction and thrombus, cardiomyopathy, pregnancy, arterial dissection, and aortic arch atherosclerosis.
I welcome the recommendation to consider adding clopidogrel 75 mg/day to aspirin for 90 days in patients with a recent (within 30 days) stroke or TIA attributable to high-grade stenosis (70%-99%) of a major intracranial artery. I used to feel rather helpless to improve the long-term outcome in these patients, but now there seems to be something more we can do, other than just using statins and single antiplatelet therapy.
Other new recommendations stress nutrition. One item suggests performing a nutritional assessment for patients with a history of ischemic stroke or TIA. While many patients may never get around to seeing a nutritionist as an outpatient, no matter how often their primary care physician stresses the importance, when they are in the hospital we have a captive audience. So why not order a nutrition consult, along with the consult for physical, occupational, and speech therapy?
After having experienced an acute neurologic event, many patients and their families are highly motivated to make whatever changes are necessary to prevent a future, potentially catastrophic stroke. Reduction of sodium from 3.3 g/day to 2.5 g/day or less is reasonable, according to the guidelines, though lowering intake to less than 1.5 g/day will lower blood pressure even further. A nutritionist’s input into how to attain these levels without eating a diet that tastes like cardboard can be invaluable. The new guidelines also suggest counseling patients to follow a Mediterranean-type diet – emphasizing whole grains, fruits, vegetables, nuts, olive oil, legumes, fish, poultry, and even low-fat dairy products – instead of the traditional low fat diet.
These new recommendations are only the tip of the iceberg, and this document is highly worthwhile for all practicing clinicians.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Burning candles
It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.
However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.
There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.
While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.
In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.
Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler."
It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.
However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.
There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.
While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.
In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.
Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler."
It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.
However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.
There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.
While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.
In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.
Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler."
Gynecologic Oncology Consult: Obesity and gynecologic surgery
Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).
While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).
Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.
In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.
In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.
The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.
In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m2, the surgical concerns addressed in this column will continue to pose challenges to surgeons.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.
Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).
While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).
Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.
In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.
In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.
The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.
In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m2, the surgical concerns addressed in this column will continue to pose challenges to surgeons.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.
Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).
While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).
Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.
In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.
In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.
The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.
In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m2, the surgical concerns addressed in this column will continue to pose challenges to surgeons.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.
What Matters: Anxiolytics, hypnotics and eternal sleep
Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.
Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.
Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).
Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).
Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.
The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.
Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."
Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.
Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.
Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).
Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).
Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.
The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.
Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."
Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.
Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.
Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).
Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).
Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.
The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.
Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."
