National efforts have intensified to reduce opioid prescriptions because of the opioid crisis. However, little is known about the relationship between peripheral arterial disease (PAD) and high-risk opioid use, according to Nathan K. Itoga, MD, of Stanford University, Calif. “As a vascular surgery resident, I wanted to know how I could do my part in reducing opioid prescriptions. However, I didn’t know if vascular patients were at risk for high opioid use. The impetus for this study was the lack of studies regarding opioid use in patients with vascular disease,” said Dr. Itoga.

Dr. Itoga will present a study in Thursday’s Scientific Session 2 that he and his colleagues performed to evaluate the relationship between PAD and high opioid use and to assess whether PAD treatment impacts high opioid use.

The researchers used the 2007-2015 Truven Marketscan database, a deidentified national private insurance claims database, to identify patients with 2 ICD-9 diagnosis codes of PAD 2 months apart with at least 2 years of continuous enrollment. Critical limb ischemia (CLI) was defined as rest pain, ulcers, or gangrene.

“Our primary outcome was high opioid use, defined as 2 opioid prescriptions within a 1-year period,” said Dr. Itoga. Opioid prescriptions were excluded if filled within 90 days of a PAD-related procedure, as identified by CPT codes for lower extremity open/endovascular revascularization or amputation. A total of 182,186 patients with PAD met the inclusion criteria, 27.1% of whom had CLI. The mean follow-up was 5.29 years. An average of 24.4% of patients with PAD met the high opioid use criteria in any given calendar year, with a significant decreasing trend for patients meeting criteria beginning in 2010 (P less than .01), said Dr. Itoga. Among the high opioid users, 26.0% continued to meet the criteria for 5 years. High opioid use was found to be significantly more common for patients with CLI (32.2%) compared to PAD patients without CLI (vs. 21.4%). During years of high opioid use, an average of 5.9 yearly prescriptions was filled.

According to multivariate analysis, illicit drug use and back pain were the strongest significant predictors of high opioid use (P less than .001).

A new diagnosis of PAD significantly increased the incidence of high opioid use (21.3% before PAD diagnosis vs. 26.9% after diagnosis, P less than .01). This association with a new diagnosis of CLI increased high opioid use from 27.5% before CLI diagnosis to 37.7% after CLI diagnosis (P less than .01), highlighting the increased risk in this patient population. A total of 45,028 patients (24.7%) underwent 88,229 PAD-related procedures. After exclusion of periprocedural opioid prescriptions (18% of all opioid prescriptions), the yearly percentage of high opioid users increased from 25.6% pretreatment to 29.2% post treatment, also a significant difference (P less than .01).

“Our research shows that patients with PAD are at increased risk for high opioid use, with nearly one-quarter meeting described criteria. CLI additionally increases opioid utilization, and treatment of PAD does not appear to decrease high opioid use,” he said. “In addition to heightened awareness and active opioid management, our findings warrant further investigation into causes and deterrence of high-risk opioid use,” Dr. Itoga concluded. 

Thursday, June 21, 2018
1:30 - 3:00 p.m.
HCC, Ballroom A/B
S2: Scientific Session 2

National efforts have intensified to reduce opioid prescriptions because of the opioid crisis. However, little is known about the relationship between peripheral arterial disease (PAD) and high-risk opioid use, according to Nathan K. Itoga, MD, of Stanford University, Calif. “As a vascular surgery resident, I wanted to know how I could do my part in reducing opioid prescriptions. However, I didn’t know if vascular patients were at risk for high opioid use. The impetus for this study was the lack of studies regarding opioid use in patients with vascular disease,” said Dr. Itoga.

Dr. Itoga will present a study in Thursday’s Scientific Session 2 that he and his colleagues performed to evaluate the relationship between PAD and high opioid use and to assess whether PAD treatment impacts high opioid use.

The researchers used the 2007-2015 Truven Marketscan database, a deidentified national private insurance claims database, to identify patients with 2 ICD-9 diagnosis codes of PAD 2 months apart with at least 2 years of continuous enrollment. Critical limb ischemia (CLI) was defined as rest pain, ulcers, or gangrene.

“Our primary outcome was high opioid use, defined as 2 opioid prescriptions within a 1-year period,” said Dr. Itoga. Opioid prescriptions were excluded if filled within 90 days of a PAD-related procedure, as identified by CPT codes for lower extremity open/endovascular revascularization or amputation. A total of 182,186 patients with PAD met the inclusion criteria, 27.1% of whom had CLI. The mean follow-up was 5.29 years. An average of 24.4% of patients with PAD met the high opioid use criteria in any given calendar year, with a significant decreasing trend for patients meeting criteria beginning in 2010 (P less than .01), said Dr. Itoga. Among the high opioid users, 26.0% continued to meet the criteria for 5 years. High opioid use was found to be significantly more common for patients with CLI (32.2%) compared to PAD patients without CLI (vs. 21.4%). During years of high opioid use, an average of 5.9 yearly prescriptions was filled.

According to multivariate analysis, illicit drug use and back pain were the strongest significant predictors of high opioid use (P less than .001).

A new diagnosis of PAD significantly increased the incidence of high opioid use (21.3% before PAD diagnosis vs. 26.9% after diagnosis, P less than .01). This association with a new diagnosis of CLI increased high opioid use from 27.5% before CLI diagnosis to 37.7% after CLI diagnosis (P less than .01), highlighting the increased risk in this patient population. A total of 45,028 patients (24.7%) underwent 88,229 PAD-related procedures. After exclusion of periprocedural opioid prescriptions (18% of all opioid prescriptions), the yearly percentage of high opioid users increased from 25.6% pretreatment to 29.2% post treatment, also a significant difference (P less than .01).

“Our research shows that patients with PAD are at increased risk for high opioid use, with nearly one-quarter meeting described criteria. CLI additionally increases opioid utilization, and treatment of PAD does not appear to decrease high opioid use,” he said. “In addition to heightened awareness and active opioid management, our findings warrant further investigation into causes and deterrence of high-risk opioid use,” Dr. Itoga concluded. 

Thursday, June 21, 2018
1:30 - 3:00 p.m.
HCC, Ballroom A/B
S2: Scientific Session 2

National efforts have intensified to reduce opioid prescriptions because of the opioid crisis. However, little is known about the relationship between peripheral arterial disease (PAD) and high-risk opioid use, according to Nathan K. Itoga, MD, of Stanford University, Calif. “As a vascular surgery resident, I wanted to know how I could do my part in reducing opioid prescriptions. However, I didn’t know if vascular patients were at risk for high opioid use. The impetus for this study was the lack of studies regarding opioid use in patients with vascular disease,” said Dr. Itoga.

Dr. Itoga will present a study in Thursday’s Scientific Session 2 that he and his colleagues performed to evaluate the relationship between PAD and high opioid use and to assess whether PAD treatment impacts high opioid use.

The researchers used the 2007-2015 Truven Marketscan database, a deidentified national private insurance claims database, to identify patients with 2 ICD-9 diagnosis codes of PAD 2 months apart with at least 2 years of continuous enrollment. Critical limb ischemia (CLI) was defined as rest pain, ulcers, or gangrene.

“Our primary outcome was high opioid use, defined as 2 opioid prescriptions within a 1-year period,” said Dr. Itoga. Opioid prescriptions were excluded if filled within 90 days of a PAD-related procedure, as identified by CPT codes for lower extremity open/endovascular revascularization or amputation. A total of 182,186 patients with PAD met the inclusion criteria, 27.1% of whom had CLI. The mean follow-up was 5.29 years. An average of 24.4% of patients with PAD met the high opioid use criteria in any given calendar year, with a significant decreasing trend for patients meeting criteria beginning in 2010 (P less than .01), said Dr. Itoga. Among the high opioid users, 26.0% continued to meet the criteria for 5 years. High opioid use was found to be significantly more common for patients with CLI (32.2%) compared to PAD patients without CLI (vs. 21.4%). During years of high opioid use, an average of 5.9 yearly prescriptions was filled.

According to multivariate analysis, illicit drug use and back pain were the strongest significant predictors of high opioid use (P less than .001).

A new diagnosis of PAD significantly increased the incidence of high opioid use (21.3% before PAD diagnosis vs. 26.9% after diagnosis, P less than .01). This association with a new diagnosis of CLI increased high opioid use from 27.5% before CLI diagnosis to 37.7% after CLI diagnosis (P less than .01), highlighting the increased risk in this patient population. A total of 45,028 patients (24.7%) underwent 88,229 PAD-related procedures. After exclusion of periprocedural opioid prescriptions (18% of all opioid prescriptions), the yearly percentage of high opioid users increased from 25.6% pretreatment to 29.2% post treatment, also a significant difference (P less than .01).

“Our research shows that patients with PAD are at increased risk for high opioid use, with nearly one-quarter meeting described criteria. CLI additionally increases opioid utilization, and treatment of PAD does not appear to decrease high opioid use,” he said. “In addition to heightened awareness and active opioid management, our findings warrant further investigation into causes and deterrence of high-risk opioid use,” Dr. Itoga concluded. 

Thursday, June 21, 2018
1:30 - 3:00 p.m.
HCC, Ballroom A/B
S2: Scientific Session 2

Innovative approaches to minimally invasive repair of the aorta will be featured during Thursday morning’s William J. von Liebig Forum.

“This year, the forum’s focus is on complex aortic endografting for a wide variety of aortic diseases, predominantly thoracoabdominal aortic aneurysms and aortic dissections,” said session co-moderator Matthew Eagleton, MD, chief of the division of vascular and endovascular surgery at Massachusetts General Hospital in Boston. “Surgeons who treat aortic disease will learn about new devices and new techniques that they will want to incorporate into their practice. They’ll also learn whether some of the techniques and procedures they are currently employing are still worth doing or may have unforeseen risks. Should they change their practices and approaches to patients with complex aortic disease, or should they continue down the road and recognize that it’s safe for patients?” The session will feature eight abstracts from vascular surgeons in the United States and Europe that will accentuate some of the newer, advanced technology, said session co-moderator R. Clement Darling III, MD, chief of the division of vascular surgery at Albany Medical Center Hospital in New York.

“To minimize the complications of complex aortic aneurysm repair, endovascular technology has to be evaluated, and we need to know what works, what doesn’t, and what are the long-term outcomes,” he said. “These presentations will help us understand the best techniques and the best current and future technology in percutaneous repair of complex aneurysms from the aortic arch down to the abdominal aorta.”

The program kicks off with a talk by Emanuel R. Tenorio, MD, PhD, of the Mayo Clinic about a prospective, nonrandomized study to evaluate cone beam computed tomography for technical assessment of standard and complex endovascular aortic repair. In other presentations, Tilo Kölbel, MD, PhD, of the University Heart Center Hamburg in Germany will discuss a single-center experience with a double-branched aortic arch endograft, technology not yet available in the United States. A U.S. national consortium, organized to better assess outcomes for endovascular therapy for complex aortic disease, will discuss their work with target artery outcomes after branched and fenestrated endovascular repair of pararenal and thoracoabdominal aortic aneurysms in the U.S. IDE (investigational device exemption) experience, and a group from Bologna, Italy, will discuss the risk of aneurysm rupture and target visceral vessel occlusion during the lead period of custom-made fenestrated/branched endografts.

Additional talks will go over percutaneous large-bore axillary artery access techniques for complicated EVAR (endovascular aneurysm repair) and current guidelines and indications for repair of abdominal aortic aneurysms.

One concern for much of this new technology is durability, Dr. Darling said. Jason Hurd, MD, of the University of Washington, Seattle, will discuss the long-term durability of a physician-modified endograft.

“We in the U.S. don’t have access to some of the technology that’s available worldwide, and there are physicians out there who do modifications of their own endografts,” Dr. Eagleton said. “This study happens to look at a prospectively maintained database from a physician-sponsored IDE study to specifically look at outcomes with regard to physician modification. The results of this are very important for us to know – is this something we can do for patients [who] need it, or is this something we should just shy away from completely? We don’t know the answer.”

Thursday
8:30 – 10 a.m.
HCC, Ballroom A/B
S1: William J. von Liebig Forum

Innovative approaches to minimally invasive repair of the aorta will be featured during Thursday morning’s William J. von Liebig Forum.

“This year, the forum’s focus is on complex aortic endografting for a wide variety of aortic diseases, predominantly thoracoabdominal aortic aneurysms and aortic dissections,” said session co-moderator Matthew Eagleton, MD, chief of the division of vascular and endovascular surgery at Massachusetts General Hospital in Boston. “Surgeons who treat aortic disease will learn about new devices and new techniques that they will want to incorporate into their practice. They’ll also learn whether some of the techniques and procedures they are currently employing are still worth doing or may have unforeseen risks. Should they change their practices and approaches to patients with complex aortic disease, or should they continue down the road and recognize that it’s safe for patients?” The session will feature eight abstracts from vascular surgeons in the United States and Europe that will accentuate some of the newer, advanced technology, said session co-moderator R. Clement Darling III, MD, chief of the division of vascular surgery at Albany Medical Center Hospital in New York.

“To minimize the complications of complex aortic aneurysm repair, endovascular technology has to be evaluated, and we need to know what works, what doesn’t, and what are the long-term outcomes,” he said. “These presentations will help us understand the best techniques and the best current and future technology in percutaneous repair of complex aneurysms from the aortic arch down to the abdominal aorta.”

The program kicks off with a talk by Emanuel R. Tenorio, MD, PhD, of the Mayo Clinic about a prospective, nonrandomized study to evaluate cone beam computed tomography for technical assessment of standard and complex endovascular aortic repair. In other presentations, Tilo Kölbel, MD, PhD, of the University Heart Center Hamburg in Germany will discuss a single-center experience with a double-branched aortic arch endograft, technology not yet available in the United States. A U.S. national consortium, organized to better assess outcomes for endovascular therapy for complex aortic disease, will discuss their work with target artery outcomes after branched and fenestrated endovascular repair of pararenal and thoracoabdominal aortic aneurysms in the U.S. IDE (investigational device exemption) experience, and a group from Bologna, Italy, will discuss the risk of aneurysm rupture and target visceral vessel occlusion during the lead period of custom-made fenestrated/branched endografts.

Additional talks will go over percutaneous large-bore axillary artery access techniques for complicated EVAR (endovascular aneurysm repair) and current guidelines and indications for repair of abdominal aortic aneurysms.

One concern for much of this new technology is durability, Dr. Darling said. Jason Hurd, MD, of the University of Washington, Seattle, will discuss the long-term durability of a physician-modified endograft.

“We in the U.S. don’t have access to some of the technology that’s available worldwide, and there are physicians out there who do modifications of their own endografts,” Dr. Eagleton said. “This study happens to look at a prospectively maintained database from a physician-sponsored IDE study to specifically look at outcomes with regard to physician modification. The results of this are very important for us to know – is this something we can do for patients [who] need it, or is this something we should just shy away from completely? We don’t know the answer.”

Thursday
8:30 – 10 a.m.
HCC, Ballroom A/B
S1: William J. von Liebig Forum

Innovative approaches to minimally invasive repair of the aorta will be featured during Thursday morning’s William J. von Liebig Forum.

“This year, the forum’s focus is on complex aortic endografting for a wide variety of aortic diseases, predominantly thoracoabdominal aortic aneurysms and aortic dissections,” said session co-moderator Matthew Eagleton, MD, chief of the division of vascular and endovascular surgery at Massachusetts General Hospital in Boston. “Surgeons who treat aortic disease will learn about new devices and new techniques that they will want to incorporate into their practice. They’ll also learn whether some of the techniques and procedures they are currently employing are still worth doing or may have unforeseen risks. Should they change their practices and approaches to patients with complex aortic disease, or should they continue down the road and recognize that it’s safe for patients?” The session will feature eight abstracts from vascular surgeons in the United States and Europe that will accentuate some of the newer, advanced technology, said session co-moderator R. Clement Darling III, MD, chief of the division of vascular surgery at Albany Medical Center Hospital in New York.

“To minimize the complications of complex aortic aneurysm repair, endovascular technology has to be evaluated, and we need to know what works, what doesn’t, and what are the long-term outcomes,” he said. “These presentations will help us understand the best techniques and the best current and future technology in percutaneous repair of complex aneurysms from the aortic arch down to the abdominal aorta.”

The program kicks off with a talk by Emanuel R. Tenorio, MD, PhD, of the Mayo Clinic about a prospective, nonrandomized study to evaluate cone beam computed tomography for technical assessment of standard and complex endovascular aortic repair. In other presentations, Tilo Kölbel, MD, PhD, of the University Heart Center Hamburg in Germany will discuss a single-center experience with a double-branched aortic arch endograft, technology not yet available in the United States. A U.S. national consortium, organized to better assess outcomes for endovascular therapy for complex aortic disease, will discuss their work with target artery outcomes after branched and fenestrated endovascular repair of pararenal and thoracoabdominal aortic aneurysms in the U.S. IDE (investigational device exemption) experience, and a group from Bologna, Italy, will discuss the risk of aneurysm rupture and target visceral vessel occlusion during the lead period of custom-made fenestrated/branched endografts.

Additional talks will go over percutaneous large-bore axillary artery access techniques for complicated EVAR (endovascular aneurysm repair) and current guidelines and indications for repair of abdominal aortic aneurysms.

One concern for much of this new technology is durability, Dr. Darling said. Jason Hurd, MD, of the University of Washington, Seattle, will discuss the long-term durability of a physician-modified endograft.

“We in the U.S. don’t have access to some of the technology that’s available worldwide, and there are physicians out there who do modifications of their own endografts,” Dr. Eagleton said. “This study happens to look at a prospectively maintained database from a physician-sponsored IDE study to specifically look at outcomes with regard to physician modification. The results of this are very important for us to know – is this something we can do for patients [who] need it, or is this something we should just shy away from completely? We don’t know the answer.”

Thursday
8:30 – 10 a.m.
HCC, Ballroom A/B
S1: William J. von Liebig Forum

This year’s SVS Foundation’s Resident Research Award is being presented to Kaspar M. Trocha, MD, for his research on vein graft disease. As a member of the laboratories of C. Keith Ozaki, MD, and James Mitchell, MD, along with co-first author Peter Kip, MD, and microsurgeon Ming Tao, MD, the group studies the effects of food intake immediately before surgery on vascular adaptations.

Dietary restriction (reducing food intake without malnutrition) has been a topic of special interest in the science community for decades, and restricting calories in the long term has been shown to extend life and health span in a variety of species. It can also protect from overexuberant responses to trauma and ischemia-reperfusion.

Dr. Mitchell found that the benefits from long-term food restriction could be acquired as rapidly as in a few days, pointing to a potential for implementing dietary restriction recommendations prior to elective surgery.

The response to stress benefits seen following brief dietary interventions are mediated by the gaseous signaling molecule hydrogen sulfide (H₂S). H₂S is strongly upregulated by dietary restriction and this “rotten egg” gas seems to be protective for the cardiovascular system and has been demonstrated to be involved in vasodilation, inflammation, and atherogenesis, according to the researchers. The group’s experiments thus tested short-term protein restriction (a more feasible dietary approach for patients that observed to induce H₂S) in a microsurgical mouse vein graft model.

The team discovered that cutting all protein from the animal diet for just 1 week before surgery led to increased levels of the enzyme cystathionine-gamma-lyase (CGL) that makes H₂S, higher levels of the protective gaseous molecule, less early vein graft inflammation, and less eventual occlusive vein graft disease even though the animals were returned to their usual high-fat diet postop. The group also confirmed these results by constructing a new mouse strain that overexpresses CGL, and these mice were protected from vein graft disease. Conversely, blocking this enzyme negated all the beneficial effects of the dietary restriction.

According to Dr. Trocha and his colleagues, “short-term pre-operative protein restriction and manipulation of H₂S stand as novel, economical approaches to enhance vein graft durability and perhaps even lessen peri-operative complications, and we are in the early stages of testing this strategy in vascular surgery patients.”

Dr. Trocha’s research was supported by the Harvard-Longwood Research Training in Vascular Surgery NIH T32 Grant and Dr. Ozaki’s NIH and American Heart Association grants. The Resident Research Award is given to one individual each year as determined by the SVS Research and Education Committee with the intent of motivating physicians early in their training to pursue their interest in research that explores the biology of vascular disease and potential translational therapies. The recognition includes plenary presentation at the Vascular Annual Meeting, a $5,000 award and a 1-year complimentary subscription to the Journal of Vascular Surgery. 

This year’s SVS Foundation’s Resident Research Award is being presented to Kaspar M. Trocha, MD, for his research on vein graft disease. As a member of the laboratories of C. Keith Ozaki, MD, and James Mitchell, MD, along with co-first author Peter Kip, MD, and microsurgeon Ming Tao, MD, the group studies the effects of food intake immediately before surgery on vascular adaptations.

Dietary restriction (reducing food intake without malnutrition) has been a topic of special interest in the science community for decades, and restricting calories in the long term has been shown to extend life and health span in a variety of species. It can also protect from overexuberant responses to trauma and ischemia-reperfusion.

Dr. Mitchell found that the benefits from long-term food restriction could be acquired as rapidly as in a few days, pointing to a potential for implementing dietary restriction recommendations prior to elective surgery.

The response to stress benefits seen following brief dietary interventions are mediated by the gaseous signaling molecule hydrogen sulfide (H₂S). H₂S is strongly upregulated by dietary restriction and this “rotten egg” gas seems to be protective for the cardiovascular system and has been demonstrated to be involved in vasodilation, inflammation, and atherogenesis, according to the researchers. The group’s experiments thus tested short-term protein restriction (a more feasible dietary approach for patients that observed to induce H₂S) in a microsurgical mouse vein graft model.

The team discovered that cutting all protein from the animal diet for just 1 week before surgery led to increased levels of the enzyme cystathionine-gamma-lyase (CGL) that makes H₂S, higher levels of the protective gaseous molecule, less early vein graft inflammation, and less eventual occlusive vein graft disease even though the animals were returned to their usual high-fat diet postop. The group also confirmed these results by constructing a new mouse strain that overexpresses CGL, and these mice were protected from vein graft disease. Conversely, blocking this enzyme negated all the beneficial effects of the dietary restriction.

According to Dr. Trocha and his colleagues, “short-term pre-operative protein restriction and manipulation of H₂S stand as novel, economical approaches to enhance vein graft durability and perhaps even lessen peri-operative complications, and we are in the early stages of testing this strategy in vascular surgery patients.”

Dr. Trocha’s research was supported by the Harvard-Longwood Research Training in Vascular Surgery NIH T32 Grant and Dr. Ozaki’s NIH and American Heart Association grants. The Resident Research Award is given to one individual each year as determined by the SVS Research and Education Committee with the intent of motivating physicians early in their training to pursue their interest in research that explores the biology of vascular disease and potential translational therapies. The recognition includes plenary presentation at the Vascular Annual Meeting, a $5,000 award and a 1-year complimentary subscription to the Journal of Vascular Surgery. 

This year’s SVS Foundation’s Resident Research Award is being presented to Kaspar M. Trocha, MD, for his research on vein graft disease. As a member of the laboratories of C. Keith Ozaki, MD, and James Mitchell, MD, along with co-first author Peter Kip, MD, and microsurgeon Ming Tao, MD, the group studies the effects of food intake immediately before surgery on vascular adaptations.

Dietary restriction (reducing food intake without malnutrition) has been a topic of special interest in the science community for decades, and restricting calories in the long term has been shown to extend life and health span in a variety of species. It can also protect from overexuberant responses to trauma and ischemia-reperfusion.

Dr. Mitchell found that the benefits from long-term food restriction could be acquired as rapidly as in a few days, pointing to a potential for implementing dietary restriction recommendations prior to elective surgery.

The response to stress benefits seen following brief dietary interventions are mediated by the gaseous signaling molecule hydrogen sulfide (H₂S). H₂S is strongly upregulated by dietary restriction and this “rotten egg” gas seems to be protective for the cardiovascular system and has been demonstrated to be involved in vasodilation, inflammation, and atherogenesis, according to the researchers. The group’s experiments thus tested short-term protein restriction (a more feasible dietary approach for patients that observed to induce H₂S) in a microsurgical mouse vein graft model.

The team discovered that cutting all protein from the animal diet for just 1 week before surgery led to increased levels of the enzyme cystathionine-gamma-lyase (CGL) that makes H₂S, higher levels of the protective gaseous molecule, less early vein graft inflammation, and less eventual occlusive vein graft disease even though the animals were returned to their usual high-fat diet postop. The group also confirmed these results by constructing a new mouse strain that overexpresses CGL, and these mice were protected from vein graft disease. Conversely, blocking this enzyme negated all the beneficial effects of the dietary restriction.

According to Dr. Trocha and his colleagues, “short-term pre-operative protein restriction and manipulation of H₂S stand as novel, economical approaches to enhance vein graft durability and perhaps even lessen peri-operative complications, and we are in the early stages of testing this strategy in vascular surgery patients.”

Dr. Trocha’s research was supported by the Harvard-Longwood Research Training in Vascular Surgery NIH T32 Grant and Dr. Ozaki’s NIH and American Heart Association grants. The Resident Research Award is given to one individual each year as determined by the SVS Research and Education Committee with the intent of motivating physicians early in their training to pursue their interest in research that explores the biology of vascular disease and potential translational therapies. The recognition includes plenary presentation at the Vascular Annual Meeting, a $5,000 award and a 1-year complimentary subscription to the Journal of Vascular Surgery. 

SAN DIEGO – A pair of small studies suggest that cyber-based interventions with private online meeting areas – like those available on Facebook – could help lift depression and encourage less marijuana use in young people with cannabis use disorder.

“Even individuals who are not looking to quit their use of cannabis have some degree of ambivalence about the extent of their use of it,” said study researcher Suzette Glasner, PhD, in an interview. “When given tools to explore the consequences of their use and change if they want to, they do find reasons and effective ways to change or reduce their use – even if they don’t quit completely.”

SAN DIEGO – A pair of small studies suggest that cyber-based interventions with private online meeting areas – like those available on Facebook – could help lift depression and encourage less marijuana use in young people with cannabis use disorder.

“Even individuals who are not looking to quit their use of cannabis have some degree of ambivalence about the extent of their use of it,” said study researcher Suzette Glasner, PhD, in an interview. “When given tools to explore the consequences of their use and change if they want to, they do find reasons and effective ways to change or reduce their use – even if they don’t quit completely.”

SAN DIEGO – A pair of small studies suggest that cyber-based interventions with private online meeting areas – like those available on Facebook – could help lift depression and encourage less marijuana use in young people with cannabis use disorder.

“Even individuals who are not looking to quit their use of cannabis have some degree of ambivalence about the extent of their use of it,” said study researcher Suzette Glasner, PhD, in an interview. “When given tools to explore the consequences of their use and change if they want to, they do find reasons and effective ways to change or reduce their use – even if they don’t quit completely.”

Use of oral estrogens declined by half during 2007-2015 in women aged 50 years and older, but trends have varied for other forms of estrogen, according to a commercial database with prescription claims for more than 12 million women.

The prevalence of prescriptions for noncontraceptive oral estrogen dropped from 83 per 1,000 women in 2007 to 42 per 1,000 in 2015 for women aged 50 years and older, Joel L. Weissfeld, MD, MPH, of the Office of Surveillance and Epidemiology at the Center for Drug Evaluation and Research at the Food and Drug Administration, and his associates reported based on data from IQVIA Real World Data Adjudicated Claims – U.S. Database.

rfranki@mdedge.com

SOURCE: Weissfeld JL et al. Menopause. 2018;25(6):611-14.

Use of oral estrogens declined by half during 2007-2015 in women aged 50 years and older, but trends have varied for other forms of estrogen, according to a commercial database with prescription claims for more than 12 million women.

The prevalence of prescriptions for noncontraceptive oral estrogen dropped from 83 per 1,000 women in 2007 to 42 per 1,000 in 2015 for women aged 50 years and older, Joel L. Weissfeld, MD, MPH, of the Office of Surveillance and Epidemiology at the Center for Drug Evaluation and Research at the Food and Drug Administration, and his associates reported based on data from IQVIA Real World Data Adjudicated Claims – U.S. Database.

rfranki@mdedge.com

SOURCE: Weissfeld JL et al. Menopause. 2018;25(6):611-14.

Use of oral estrogens declined by half during 2007-2015 in women aged 50 years and older, but trends have varied for other forms of estrogen, according to a commercial database with prescription claims for more than 12 million women.

The prevalence of prescriptions for noncontraceptive oral estrogen dropped from 83 per 1,000 women in 2007 to 42 per 1,000 in 2015 for women aged 50 years and older, Joel L. Weissfeld, MD, MPH, of the Office of Surveillance and Epidemiology at the Center for Drug Evaluation and Research at the Food and Drug Administration, and his associates reported based on data from IQVIA Real World Data Adjudicated Claims – U.S. Database.

rfranki@mdedge.com

SOURCE: Weissfeld JL et al. Menopause. 2018;25(6):611-14.

Diabetic foot ulcer healing is predictable with the Wound, Ischemia, and foot Infection (WIfI) classification system when used alone or with multivariable risk-adjustment analysis, according to a study published in the Journal of Vascular Surgery.

The research was conducted by Caitlin W. Hicks, MD, of Johns Hopkins University, Baltimore, and her colleagues as a retrospective study using prospective database information from enrolled type 1 and type 2 medication-dependent diabetic patients presenting to the multidisciplinary diabetic limb preservation service at Johns Hopkins Hospital from June 2012 to July 2017. The cohort of 310 patients with diabetic foot ulcer (DFU) in the study had a median age of 59 years and was composed of 60.3% men, with 60.0% of patients being black.

Rebecca L. Slebodnik/MDedge News

SOURCE: Hicks CW et al. J Vasc Surg. 2018 Apr 2. doi: 10.1016/j.jvs.2017.12.079.

Diabetic foot ulcer healing is predictable with the Wound, Ischemia, and foot Infection (WIfI) classification system when used alone or with multivariable risk-adjustment analysis, according to a study published in the Journal of Vascular Surgery.

The research was conducted by Caitlin W. Hicks, MD, of Johns Hopkins University, Baltimore, and her colleagues as a retrospective study using prospective database information from enrolled type 1 and type 2 medication-dependent diabetic patients presenting to the multidisciplinary diabetic limb preservation service at Johns Hopkins Hospital from June 2012 to July 2017. The cohort of 310 patients with diabetic foot ulcer (DFU) in the study had a median age of 59 years and was composed of 60.3% men, with 60.0% of patients being black.

Rebecca L. Slebodnik/MDedge News

SOURCE: Hicks CW et al. J Vasc Surg. 2018 Apr 2. doi: 10.1016/j.jvs.2017.12.079.

Diabetic foot ulcer healing is predictable with the Wound, Ischemia, and foot Infection (WIfI) classification system when used alone or with multivariable risk-adjustment analysis, according to a study published in the Journal of Vascular Surgery.

The research was conducted by Caitlin W. Hicks, MD, of Johns Hopkins University, Baltimore, and her colleagues as a retrospective study using prospective database information from enrolled type 1 and type 2 medication-dependent diabetic patients presenting to the multidisciplinary diabetic limb preservation service at Johns Hopkins Hospital from June 2012 to July 2017. The cohort of 310 patients with diabetic foot ulcer (DFU) in the study had a median age of 59 years and was composed of 60.3% men, with 60.0% of patients being black.

Rebecca L. Slebodnik/MDedge News

SOURCE: Hicks CW et al. J Vasc Surg. 2018 Apr 2. doi: 10.1016/j.jvs.2017.12.079.

St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.

I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.

Experiences that may alter a reported rate

I list here a few circumstances of a CD on maternal request:

• A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
• A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
• An elderly primagravida with an in vitro fertilization pregnancy requests a CD.

Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.

Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.

Rethinking my position

Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.

Uterine rupture

A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.

That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.

The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO₂, 95 mm Hg; pO₂, 19.9 mm Hg; HCO₃, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO₂, 45 mm Hg; pO₂, 35 mm Hg; HCO₃, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.

After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.

The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.

The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.

Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.

Read Dr. Kanofsky’s solution to using this metric.

Depressed baby

A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.

Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.0⁰F. The fetal heart rate tracings were reassuring.

Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.

A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO₂, 57 mm Hg; pO₂, 17 mm Hg; HCO₃, 20.2 mmol/L; and BE, –19.1 mmol/L.

The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.

Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?

Is there a solution?

With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.

Better metrics of quality and safety that might be more helpful to measure include:

• Prophylactic oxytocin after delivery of the baby’s anterior shoulder
• Since “6 is the new 4,” in order to increase the NTSV rate, we could measure¹:
  • patients admitted before active labor
  • patients receiving an epidural before active labor.
• Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.

I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.

Experiences that may alter a reported rate

I list here a few circumstances of a CD on maternal request:

• A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
• A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
• An elderly primagravida with an in vitro fertilization pregnancy requests a CD.

Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.

Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.

Rethinking my position

Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.

Uterine rupture

A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.

That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.

The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO₂, 95 mm Hg; pO₂, 19.9 mm Hg; HCO₃, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO₂, 45 mm Hg; pO₂, 35 mm Hg; HCO₃, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.

After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.

The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.

The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.

Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.

Read Dr. Kanofsky’s solution to using this metric.

Depressed baby

A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.

Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.0⁰F. The fetal heart rate tracings were reassuring.

Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.

A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO₂, 57 mm Hg; pO₂, 17 mm Hg; HCO₃, 20.2 mmol/L; and BE, –19.1 mmol/L.

The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.

Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?

Is there a solution?

With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.

Better metrics of quality and safety that might be more helpful to measure include:

• Prophylactic oxytocin after delivery of the baby’s anterior shoulder
• Since “6 is the new 4,” in order to increase the NTSV rate, we could measure¹:
  • patients admitted before active labor
  • patients receiving an epidural before active labor.
• Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.

I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.

Experiences that may alter a reported rate

I list here a few circumstances of a CD on maternal request:

• A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
• A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
• An elderly primagravida with an in vitro fertilization pregnancy requests a CD.

Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.

Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.

Rethinking my position

Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.

Uterine rupture

A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.

That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.

The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO₂, 95 mm Hg; pO₂, 19.9 mm Hg; HCO₃, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO₂, 45 mm Hg; pO₂, 35 mm Hg; HCO₃, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.

After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.

The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.

The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.

Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.

Read Dr. Kanofsky’s solution to using this metric.

Depressed baby

A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.

Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.0⁰F. The fetal heart rate tracings were reassuring.

Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.

A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO₂, 57 mm Hg; pO₂, 17 mm Hg; HCO₃, 20.2 mmol/L; and BE, –19.1 mmol/L.

The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.

Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?

Is there a solution?

With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.

Better metrics of quality and safety that might be more helpful to measure include:

• Prophylactic oxytocin after delivery of the baby’s anterior shoulder
• Since “6 is the new 4,” in order to increase the NTSV rate, we could measure¹:
  • patients admitted before active labor
  • patients receiving an epidural before active labor.
• Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

Click to read supplement. 

In this supplement to Internal Medicine News, Christine Frissora, MD provides an overview of the burdens that patients with IBS-D experience. Three clinical efficacy and safety studies surrounding an FDA-approved treatment are also examined.

Topics include:

• IBS-D diagnosis and treatment challenges

• The role of microbial imbalance and altered gut microbiota

• A treatment option for relief of IBS-D symptoms

Click to read supplement. 

XIFI.0273.USA.18
 

Click to read supplement. 

In this supplement to Internal Medicine News, Christine Frissora, MD provides an overview of the burdens that patients with IBS-D experience. Three clinical efficacy and safety studies surrounding an FDA-approved treatment are also examined.

Topics include:

• IBS-D diagnosis and treatment challenges

• The role of microbial imbalance and altered gut microbiota

• A treatment option for relief of IBS-D symptoms

Click to read supplement. 

XIFI.0273.USA.18
 

Click to read supplement. 

In this supplement to Internal Medicine News, Christine Frissora, MD provides an overview of the burdens that patients with IBS-D experience. Three clinical efficacy and safety studies surrounding an FDA-approved treatment are also examined.

Topics include:

• IBS-D diagnosis and treatment challenges

• The role of microbial imbalance and altered gut microbiota

• A treatment option for relief of IBS-D symptoms

Click to read supplement. 

XIFI.0273.USA.18
 

Nails should not be overlooked in treating common scabies, cautioned Marie Chinazzo, MD, of Centre Hospitalier Régional et Universitaire Tours, France, and her associates.

Nails can harbor mites, representing a potential source for relapse, not only in children, but also in adults.

wikimedia commons

Few studies have addressed scabies on the nails, which is typically observed in immunocompromised adults with crusted scabies, but also rarely in healthy adults and children.

In an observational, multicenter, prospective study conducted between June 2015 and January 2017, 47 pediatric patients with common scabies, including 3 children under 2 years of age, presented with mites on the first toenail/thumbnail; two of them had already completed treatment and were experiencing relapse. All children with dermatologic diagnosis that was confirmed by visual inspection of “the delta sign” (presence of the mite seen as a triangle representing the head) using dermoscopy or by microscopic identification of Sarcoptes scabiei were included in the study. Dermatologists were required to complete a standardized questionnaire for each participant. Full body inspections and nail samplings also were done.

Clinical nail damage, consisting of hyperkeratosis, onycholysis, onychoschizia, and pachyonychia, appeared in 5 of the 47 patients (11%). No other cause of nail damage was determined in four of the cases, for which mites were not directly visualized, the researchers noted. The report was published in the Journal of Pediatrics.

Of the 47 confirmed cases, 26 were female; 23 were under 2 years of age; 20 were 2-12 years; and 4 were older than 12. Ten cases presented with significant medical history; none were classified as immunocompromised.

Fully 42 of the 47 children (89%) reported pruritus, and of these, 64% also had pruritus present in the family home; 60% of siblings and 45% of parents were affected.

None were diagnosed with crusted scabies. The mean delay from disease onset to diagnosis was 55 days. In 38% of cases, previous treatment for scabies had been rendered.

Treatments varied based on presentation. Ivermectin, esdepallethrin, and 40% urea were repeated after 10 days in at least one case. In another case, an entire family was treated once with topical 5% permethrin; once the child experienced relapse, oral ivermectin was employed. In the case of an 18-month-old girl with pruritus and skin lesions, topical corticosteroid was used for 10 days until such time that dermatoscopy revealed the “delta sign” and 5% topical permethrin was added.

The authors observed that nail scabies in the medical literature is more commonly seen in immunocompromised patients with crusted scabies and higher concentrations of parasites. They were able to locate only three other reports, all in adults, of nail scabies occurring with common scabies.

“Treatment of nail scabies is difficult and is not highly evidence based,” cautioned Dr. Chinazzo and her associates. The primary study limitations were the small patient population and that nail sampling was taken only from the first fingers and toes, which could mean that the number of mites present is actually underestimated, they added.

The authors had no relevant financial disclosures.

SOURCE: Chinazzo M et al. J Pediatr. 2018. doi: 10.1016/j.jpeds.2018.01.038.

Nails should not be overlooked in treating common scabies, cautioned Marie Chinazzo, MD, of Centre Hospitalier Régional et Universitaire Tours, France, and her associates.

Nails can harbor mites, representing a potential source for relapse, not only in children, but also in adults.

wikimedia commons

Few studies have addressed scabies on the nails, which is typically observed in immunocompromised adults with crusted scabies, but also rarely in healthy adults and children.

In an observational, multicenter, prospective study conducted between June 2015 and January 2017, 47 pediatric patients with common scabies, including 3 children under 2 years of age, presented with mites on the first toenail/thumbnail; two of them had already completed treatment and were experiencing relapse. All children with dermatologic diagnosis that was confirmed by visual inspection of “the delta sign” (presence of the mite seen as a triangle representing the head) using dermoscopy or by microscopic identification of Sarcoptes scabiei were included in the study. Dermatologists were required to complete a standardized questionnaire for each participant. Full body inspections and nail samplings also were done.

Clinical nail damage, consisting of hyperkeratosis, onycholysis, onychoschizia, and pachyonychia, appeared in 5 of the 47 patients (11%). No other cause of nail damage was determined in four of the cases, for which mites were not directly visualized, the researchers noted. The report was published in the Journal of Pediatrics.

Of the 47 confirmed cases, 26 were female; 23 were under 2 years of age; 20 were 2-12 years; and 4 were older than 12. Ten cases presented with significant medical history; none were classified as immunocompromised.

Fully 42 of the 47 children (89%) reported pruritus, and of these, 64% also had pruritus present in the family home; 60% of siblings and 45% of parents were affected.

None were diagnosed with crusted scabies. The mean delay from disease onset to diagnosis was 55 days. In 38% of cases, previous treatment for scabies had been rendered.

Treatments varied based on presentation. Ivermectin, esdepallethrin, and 40% urea were repeated after 10 days in at least one case. In another case, an entire family was treated once with topical 5% permethrin; once the child experienced relapse, oral ivermectin was employed. In the case of an 18-month-old girl with pruritus and skin lesions, topical corticosteroid was used for 10 days until such time that dermatoscopy revealed the “delta sign” and 5% topical permethrin was added.

The authors observed that nail scabies in the medical literature is more commonly seen in immunocompromised patients with crusted scabies and higher concentrations of parasites. They were able to locate only three other reports, all in adults, of nail scabies occurring with common scabies.

“Treatment of nail scabies is difficult and is not highly evidence based,” cautioned Dr. Chinazzo and her associates. The primary study limitations were the small patient population and that nail sampling was taken only from the first fingers and toes, which could mean that the number of mites present is actually underestimated, they added.

The authors had no relevant financial disclosures.

SOURCE: Chinazzo M et al. J Pediatr. 2018. doi: 10.1016/j.jpeds.2018.01.038.

Nails should not be overlooked in treating common scabies, cautioned Marie Chinazzo, MD, of Centre Hospitalier Régional et Universitaire Tours, France, and her associates.

Nails can harbor mites, representing a potential source for relapse, not only in children, but also in adults.

wikimedia commons

Few studies have addressed scabies on the nails, which is typically observed in immunocompromised adults with crusted scabies, but also rarely in healthy adults and children.

In an observational, multicenter, prospective study conducted between June 2015 and January 2017, 47 pediatric patients with common scabies, including 3 children under 2 years of age, presented with mites on the first toenail/thumbnail; two of them had already completed treatment and were experiencing relapse. All children with dermatologic diagnosis that was confirmed by visual inspection of “the delta sign” (presence of the mite seen as a triangle representing the head) using dermoscopy or by microscopic identification of Sarcoptes scabiei were included in the study. Dermatologists were required to complete a standardized questionnaire for each participant. Full body inspections and nail samplings also were done.

Clinical nail damage, consisting of hyperkeratosis, onycholysis, onychoschizia, and pachyonychia, appeared in 5 of the 47 patients (11%). No other cause of nail damage was determined in four of the cases, for which mites were not directly visualized, the researchers noted. The report was published in the Journal of Pediatrics.

Of the 47 confirmed cases, 26 were female; 23 were under 2 years of age; 20 were 2-12 years; and 4 were older than 12. Ten cases presented with significant medical history; none were classified as immunocompromised.

Fully 42 of the 47 children (89%) reported pruritus, and of these, 64% also had pruritus present in the family home; 60% of siblings and 45% of parents were affected.

None were diagnosed with crusted scabies. The mean delay from disease onset to diagnosis was 55 days. In 38% of cases, previous treatment for scabies had been rendered.

Treatments varied based on presentation. Ivermectin, esdepallethrin, and 40% urea were repeated after 10 days in at least one case. In another case, an entire family was treated once with topical 5% permethrin; once the child experienced relapse, oral ivermectin was employed. In the case of an 18-month-old girl with pruritus and skin lesions, topical corticosteroid was used for 10 days until such time that dermatoscopy revealed the “delta sign” and 5% topical permethrin was added.

The authors observed that nail scabies in the medical literature is more commonly seen in immunocompromised patients with crusted scabies and higher concentrations of parasites. They were able to locate only three other reports, all in adults, of nail scabies occurring with common scabies.

“Treatment of nail scabies is difficult and is not highly evidence based,” cautioned Dr. Chinazzo and her associates. The primary study limitations were the small patient population and that nail sampling was taken only from the first fingers and toes, which could mean that the number of mites present is actually underestimated, they added.

The authors had no relevant financial disclosures.

SOURCE: Chinazzo M et al. J Pediatr. 2018. doi: 10.1016/j.jpeds.2018.01.038.