More than 40% of reproductive-age women reported having unprotected sex in the year after undergoing bariatric surgery, despite recommendations to avoid pregnancy for at least a year, a new study finds. Another 4% of women reported trying to conceive in the 12 months after surgery.

“We were surprised to find such a large percentage of women were not using contraception, and we were also surprised to find so many were actively trying to conceive,” the study’s lead author Marie N. Menke, MD, MPH, of the University of Pittsburgh, said in an interview. “Reproductive-age women who are considering bariatric surgery should be counseled that they should plan to use contraceptives after surgery for about 12-18 months.”

Pregnancy isn’t recommended over that period mainly because of the risks to the fetus, Dr. Menke said. “These risks are different from obesity in general. We don’t know exactly why surgery causes these risks, but ideally, patients would be weight-stable prior to conception.”

In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery provided a Grade D recommendation for a 12-18 month delay in conception (Obesity [Silver Spring] 2013;21[suppl 1]:S1-27). A recent study provided more insight into the potential risks of pregnancy soon after weight-loss procedures. It reported that, compared with those who gave birth more than 4 years later, women who gave birth within 2 years of bariatric surgery had higher risks of premature birth, admission to neonatal intensive care units, and small-for-gestational-age infants (JAMA Surg. 2017 Feb 1;152[2]:1-8).

The current prospective cohort study included women who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals. The women, all aged 18-44 years, answered questions for as long as 7 years, until January 2015 (Obstet Gynecol. 2017 Oct 6. doi: 10.1097/AOG.0000000000002323).

The analysis included 710 women who provided conception data. The median body mass index of the women was 46.3 kg/m². Most patients underwent Roux-en-Y gastric bypass (73%), followed by laparoscopic adjustable gastric banding (23%).

Researchers found that 4.3% of the women tried to conceive in the first year after surgery (95% confidence interval, 2.4-6.3), and 13.1% did so in the second year (95% CI, 9.3-17.0; P less than .001).

During the first year after surgery, 12.7% of women had no intercourse (95% CI, 9.4-16.0), 40.5% had only protected intercourse (95% CI, 35.6-45.4), and 41.5% (95% CI, 36.4-46.6) had unprotected intercourse while not trying to conceive.

Why are the unprotected sex numbers so high? “We wonder if some women simply feel that they cannot get pregnant,” Dr. Menke said. “Our group has previously reported that 42% of women who had attempted to conceive prior to bariatric surgery had a history of infertility. Some of these women went on to deliver a live birth, but many did not.”

The study reports that 183 of the 710 women did ultimately conceive and that the number may be as high as 237 because data were missing for 54 women who may have not wanted to report a nonlive birth. Of the women who reported conceiving, 68.9% had live births, 1.1% had stillbirths, 1.1% had ectopic pregnancies, 21.9% miscarried and 7.1% had abortions.

“We’d really like this research to be a reason to consider presurgical contraceptive counseling as one of the steps prior to bariatric surgery,” Dr. Menke said. “This may include a referral by the bariatric surgeon to a physician would who provide counseling, prescribe, or both.”

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.

More than 40% of reproductive-age women reported having unprotected sex in the year after undergoing bariatric surgery, despite recommendations to avoid pregnancy for at least a year, a new study finds. Another 4% of women reported trying to conceive in the 12 months after surgery.

“We were surprised to find such a large percentage of women were not using contraception, and we were also surprised to find so many were actively trying to conceive,” the study’s lead author Marie N. Menke, MD, MPH, of the University of Pittsburgh, said in an interview. “Reproductive-age women who are considering bariatric surgery should be counseled that they should plan to use contraceptives after surgery for about 12-18 months.”

Pregnancy isn’t recommended over that period mainly because of the risks to the fetus, Dr. Menke said. “These risks are different from obesity in general. We don’t know exactly why surgery causes these risks, but ideally, patients would be weight-stable prior to conception.”

In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery provided a Grade D recommendation for a 12-18 month delay in conception (Obesity [Silver Spring] 2013;21[suppl 1]:S1-27). A recent study provided more insight into the potential risks of pregnancy soon after weight-loss procedures. It reported that, compared with those who gave birth more than 4 years later, women who gave birth within 2 years of bariatric surgery had higher risks of premature birth, admission to neonatal intensive care units, and small-for-gestational-age infants (JAMA Surg. 2017 Feb 1;152[2]:1-8).

The current prospective cohort study included women who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals. The women, all aged 18-44 years, answered questions for as long as 7 years, until January 2015 (Obstet Gynecol. 2017 Oct 6. doi: 10.1097/AOG.0000000000002323).

The analysis included 710 women who provided conception data. The median body mass index of the women was 46.3 kg/m². Most patients underwent Roux-en-Y gastric bypass (73%), followed by laparoscopic adjustable gastric banding (23%).

Researchers found that 4.3% of the women tried to conceive in the first year after surgery (95% confidence interval, 2.4-6.3), and 13.1% did so in the second year (95% CI, 9.3-17.0; P less than .001).

During the first year after surgery, 12.7% of women had no intercourse (95% CI, 9.4-16.0), 40.5% had only protected intercourse (95% CI, 35.6-45.4), and 41.5% (95% CI, 36.4-46.6) had unprotected intercourse while not trying to conceive.

Why are the unprotected sex numbers so high? “We wonder if some women simply feel that they cannot get pregnant,” Dr. Menke said. “Our group has previously reported that 42% of women who had attempted to conceive prior to bariatric surgery had a history of infertility. Some of these women went on to deliver a live birth, but many did not.”

The study reports that 183 of the 710 women did ultimately conceive and that the number may be as high as 237 because data were missing for 54 women who may have not wanted to report a nonlive birth. Of the women who reported conceiving, 68.9% had live births, 1.1% had stillbirths, 1.1% had ectopic pregnancies, 21.9% miscarried and 7.1% had abortions.

“We’d really like this research to be a reason to consider presurgical contraceptive counseling as one of the steps prior to bariatric surgery,” Dr. Menke said. “This may include a referral by the bariatric surgeon to a physician would who provide counseling, prescribe, or both.”

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.

More than 40% of reproductive-age women reported having unprotected sex in the year after undergoing bariatric surgery, despite recommendations to avoid pregnancy for at least a year, a new study finds. Another 4% of women reported trying to conceive in the 12 months after surgery.

“We were surprised to find such a large percentage of women were not using contraception, and we were also surprised to find so many were actively trying to conceive,” the study’s lead author Marie N. Menke, MD, MPH, of the University of Pittsburgh, said in an interview. “Reproductive-age women who are considering bariatric surgery should be counseled that they should plan to use contraceptives after surgery for about 12-18 months.”

Pregnancy isn’t recommended over that period mainly because of the risks to the fetus, Dr. Menke said. “These risks are different from obesity in general. We don’t know exactly why surgery causes these risks, but ideally, patients would be weight-stable prior to conception.”

In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery provided a Grade D recommendation for a 12-18 month delay in conception (Obesity [Silver Spring] 2013;21[suppl 1]:S1-27). A recent study provided more insight into the potential risks of pregnancy soon after weight-loss procedures. It reported that, compared with those who gave birth more than 4 years later, women who gave birth within 2 years of bariatric surgery had higher risks of premature birth, admission to neonatal intensive care units, and small-for-gestational-age infants (JAMA Surg. 2017 Feb 1;152[2]:1-8).

The current prospective cohort study included women who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals. The women, all aged 18-44 years, answered questions for as long as 7 years, until January 2015 (Obstet Gynecol. 2017 Oct 6. doi: 10.1097/AOG.0000000000002323).

The analysis included 710 women who provided conception data. The median body mass index of the women was 46.3 kg/m². Most patients underwent Roux-en-Y gastric bypass (73%), followed by laparoscopic adjustable gastric banding (23%).

Researchers found that 4.3% of the women tried to conceive in the first year after surgery (95% confidence interval, 2.4-6.3), and 13.1% did so in the second year (95% CI, 9.3-17.0; P less than .001).

During the first year after surgery, 12.7% of women had no intercourse (95% CI, 9.4-16.0), 40.5% had only protected intercourse (95% CI, 35.6-45.4), and 41.5% (95% CI, 36.4-46.6) had unprotected intercourse while not trying to conceive.

Why are the unprotected sex numbers so high? “We wonder if some women simply feel that they cannot get pregnant,” Dr. Menke said. “Our group has previously reported that 42% of women who had attempted to conceive prior to bariatric surgery had a history of infertility. Some of these women went on to deliver a live birth, but many did not.”

The study reports that 183 of the 710 women did ultimately conceive and that the number may be as high as 237 because data were missing for 54 women who may have not wanted to report a nonlive birth. Of the women who reported conceiving, 68.9% had live births, 1.1% had stillbirths, 1.1% had ectopic pregnancies, 21.9% miscarried and 7.1% had abortions.

“We’d really like this research to be a reason to consider presurgical contraceptive counseling as one of the steps prior to bariatric surgery,” Dr. Menke said. “This may include a referral by the bariatric surgeon to a physician would who provide counseling, prescribe, or both.”

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.

Image by Betty Pace

Scientists say they have developed an automated system that can identify shapes of red blood cells (RBCs).

The team found their system could classify sickled RBCs “with high accuracy,” which suggests it could be used to help monitor patients with sickle cell disease.

“We have developed the first deep learning tool that can automatically identify and classify red blood cell alteration, hence providing direct quantitative evidence of the severity of the disease,” said George Karniadakis, PhD, of Brown University in Providence, Rhode Island.

Dr Karniadakis and his colleagues described their tool in PLOS Computational Biology.

The researchers wanted to automate the process of identifying RBC shape. So they developed a computational framework that employs a machine-learning tool known as a deep convolutional neural network (CNN).

The framework uses 3 steps to classify the shapes of RBCs in microscopic images of blood.

First, it distinguishes RBCs from the background of each image and from each other. Then, for each cell detected, it zooms in or out until all cell images are a uniform size. Finally, it uses deep CNNs to categorize RBCs by shape.

The researchers validated their new tool using 7000 microscopy images from 8 patients with sickle cell disease. The method successfully classified RBC shape for both oxygenated and deoxygenated cells.

The researchers plan to further improve their deep CNN tool and test it in other diseases that alter the shape and size of RBCs, such as diabetes and HIV. They also plan to explore its usefulness in characterizing cancer cells.

Image by Betty Pace

Scientists say they have developed an automated system that can identify shapes of red blood cells (RBCs).

The team found their system could classify sickled RBCs “with high accuracy,” which suggests it could be used to help monitor patients with sickle cell disease.

“We have developed the first deep learning tool that can automatically identify and classify red blood cell alteration, hence providing direct quantitative evidence of the severity of the disease,” said George Karniadakis, PhD, of Brown University in Providence, Rhode Island.

Dr Karniadakis and his colleagues described their tool in PLOS Computational Biology.

The researchers wanted to automate the process of identifying RBC shape. So they developed a computational framework that employs a machine-learning tool known as a deep convolutional neural network (CNN).

The framework uses 3 steps to classify the shapes of RBCs in microscopic images of blood.

First, it distinguishes RBCs from the background of each image and from each other. Then, for each cell detected, it zooms in or out until all cell images are a uniform size. Finally, it uses deep CNNs to categorize RBCs by shape.

The researchers validated their new tool using 7000 microscopy images from 8 patients with sickle cell disease. The method successfully classified RBC shape for both oxygenated and deoxygenated cells.

The researchers plan to further improve their deep CNN tool and test it in other diseases that alter the shape and size of RBCs, such as diabetes and HIV. They also plan to explore its usefulness in characterizing cancer cells.

Image by Betty Pace

Scientists say they have developed an automated system that can identify shapes of red blood cells (RBCs).

The team found their system could classify sickled RBCs “with high accuracy,” which suggests it could be used to help monitor patients with sickle cell disease.

“We have developed the first deep learning tool that can automatically identify and classify red blood cell alteration, hence providing direct quantitative evidence of the severity of the disease,” said George Karniadakis, PhD, of Brown University in Providence, Rhode Island.

Dr Karniadakis and his colleagues described their tool in PLOS Computational Biology.

The researchers wanted to automate the process of identifying RBC shape. So they developed a computational framework that employs a machine-learning tool known as a deep convolutional neural network (CNN).

The framework uses 3 steps to classify the shapes of RBCs in microscopic images of blood.

First, it distinguishes RBCs from the background of each image and from each other. Then, for each cell detected, it zooms in or out until all cell images are a uniform size. Finally, it uses deep CNNs to categorize RBCs by shape.

The researchers validated their new tool using 7000 microscopy images from 8 patients with sickle cell disease. The method successfully classified RBC shape for both oxygenated and deoxygenated cells.

The researchers plan to further improve their deep CNN tool and test it in other diseases that alter the shape and size of RBCs, such as diabetes and HIV. They also plan to explore its usefulness in characterizing cancer cells.

FDA has approved Aptiom (eslicarbazepine) for an expanded indication to treat partial-onset seizures in children.

Indications: Aptiom was previously approved form the treatment of partial onset seizures in adults. The new approval is for children ages 4 years to 17 years with the same disorder. It is a once daily immediate release anti-epilepsy drug that can be taken whole or crushed, with or without food. The approval is based in part on extrapolation of previous data to support its use in the pediatric population.

Dosage and administration.  The recommended dosage of APTIOM is based on

body weight and is administered orally once daily. The package insert says to increase the dose in weekly intervals based on clinical response and tolerability to the recommended maintenance dosage. The initial pediatric dose is 200 mg/day for a patient 11 to 21 kg, with 200 mg/day as a maximum titration increment.  Maximum dose for a child in this weight range in 400 to 600 mg/day.

Adverse effects.  The most common reactions in adults include dizziness, somnolence, nausea, headache, diplopia, vomiting, fatigue, vertigo, ataxia, blurred vision, and tremor. Adverse reactions are similar in pediatric patients.

Sunovion’s Aptiom (eslicarbazepine acetate) Receives FDA Approval for Expanded Indication to Treat Partial-Onset Seizures in Children and Adolescents 4 Years of Age and Older

http://www.sunovion.us/featured-news/press-releases/20170914a.pdf. Accessed October 16, 2017

FDA has approved Aptiom (eslicarbazepine) for an expanded indication to treat partial-onset seizures in children.

Indications: Aptiom was previously approved form the treatment of partial onset seizures in adults. The new approval is for children ages 4 years to 17 years with the same disorder. It is a once daily immediate release anti-epilepsy drug that can be taken whole or crushed, with or without food. The approval is based in part on extrapolation of previous data to support its use in the pediatric population.

Dosage and administration.  The recommended dosage of APTIOM is based on

body weight and is administered orally once daily. The package insert says to increase the dose in weekly intervals based on clinical response and tolerability to the recommended maintenance dosage. The initial pediatric dose is 200 mg/day for a patient 11 to 21 kg, with 200 mg/day as a maximum titration increment.  Maximum dose for a child in this weight range in 400 to 600 mg/day.

Adverse effects.  The most common reactions in adults include dizziness, somnolence, nausea, headache, diplopia, vomiting, fatigue, vertigo, ataxia, blurred vision, and tremor. Adverse reactions are similar in pediatric patients.

Sunovion’s Aptiom (eslicarbazepine acetate) Receives FDA Approval for Expanded Indication to Treat Partial-Onset Seizures in Children and Adolescents 4 Years of Age and Older

http://www.sunovion.us/featured-news/press-releases/20170914a.pdf. Accessed October 16, 2017

FDA has approved Aptiom (eslicarbazepine) for an expanded indication to treat partial-onset seizures in children.

Indications: Aptiom was previously approved form the treatment of partial onset seizures in adults. The new approval is for children ages 4 years to 17 years with the same disorder. It is a once daily immediate release anti-epilepsy drug that can be taken whole or crushed, with or without food. The approval is based in part on extrapolation of previous data to support its use in the pediatric population.

Dosage and administration.  The recommended dosage of APTIOM is based on

body weight and is administered orally once daily. The package insert says to increase the dose in weekly intervals based on clinical response and tolerability to the recommended maintenance dosage. The initial pediatric dose is 200 mg/day for a patient 11 to 21 kg, with 200 mg/day as a maximum titration increment.  Maximum dose for a child in this weight range in 400 to 600 mg/day.

Adverse effects.  The most common reactions in adults include dizziness, somnolence, nausea, headache, diplopia, vomiting, fatigue, vertigo, ataxia, blurred vision, and tremor. Adverse reactions are similar in pediatric patients.

Sunovion’s Aptiom (eslicarbazepine acetate) Receives FDA Approval for Expanded Indication to Treat Partial-Onset Seizures in Children and Adolescents 4 Years of Age and Older

http://www.sunovion.us/featured-news/press-releases/20170914a.pdf. Accessed October 16, 2017

The diagnosis of psychogenic nonepileptic seizure (PNES) is often delayed—and a history of head trauma can contribute to that delay.

• 49 adult patients who were admitted to the epilepsy unit at the Jefferson Comprehensive Epilepsy Center for PNES were studied to determine how long it took for a correct diagnosis to be reached.
• Of the 49 patients, 39 were women, 10 were men; the study period was 2012 to 2016.
• On average, it took 3 years (median) to arrive at the correct diagnosis.
• A comparison of patients who received an early diagnosis to those whose diagnosis was delayed found that a history of head trauma was the only significant difference between the 2 groups.
• 2 of 19 patients had an early diagnosis (7%) and 11 of 28 patients experienced a delayed diagnosis, which was associated with head trauma (P=0.02).

Asadi-Pooya AA, Tinker J. Delay in diagnosis of psychogenic nonepileptic seizures in adults: A post hoc study [published online ahead of print Sept 15, 2017]. Epilepsy Behav. doi: 10.1016/j.yebeh.2017.08.005.

The diagnosis of psychogenic nonepileptic seizure (PNES) is often delayed—and a history of head trauma can contribute to that delay.

• 49 adult patients who were admitted to the epilepsy unit at the Jefferson Comprehensive Epilepsy Center for PNES were studied to determine how long it took for a correct diagnosis to be reached.
• Of the 49 patients, 39 were women, 10 were men; the study period was 2012 to 2016.
• On average, it took 3 years (median) to arrive at the correct diagnosis.
• A comparison of patients who received an early diagnosis to those whose diagnosis was delayed found that a history of head trauma was the only significant difference between the 2 groups.
• 2 of 19 patients had an early diagnosis (7%) and 11 of 28 patients experienced a delayed diagnosis, which was associated with head trauma (P=0.02).

Asadi-Pooya AA, Tinker J. Delay in diagnosis of psychogenic nonepileptic seizures in adults: A post hoc study [published online ahead of print Sept 15, 2017]. Epilepsy Behav. doi: 10.1016/j.yebeh.2017.08.005.

The diagnosis of psychogenic nonepileptic seizure (PNES) is often delayed—and a history of head trauma can contribute to that delay.

• 49 adult patients who were admitted to the epilepsy unit at the Jefferson Comprehensive Epilepsy Center for PNES were studied to determine how long it took for a correct diagnosis to be reached.
• Of the 49 patients, 39 were women, 10 were men; the study period was 2012 to 2016.
• On average, it took 3 years (median) to arrive at the correct diagnosis.
• A comparison of patients who received an early diagnosis to those whose diagnosis was delayed found that a history of head trauma was the only significant difference between the 2 groups.
• 2 of 19 patients had an early diagnosis (7%) and 11 of 28 patients experienced a delayed diagnosis, which was associated with head trauma (P=0.02).

Asadi-Pooya AA, Tinker J. Delay in diagnosis of psychogenic nonepileptic seizures in adults: A post hoc study [published online ahead of print Sept 15, 2017]. Epilepsy Behav. doi: 10.1016/j.yebeh.2017.08.005.

Three million adults and 470,000 children have epilepsy according to the latest statistics from the Centers for Disease Control and Prevention (CDC).  These figures, based on the 2015 National Health Interview Survey, translate into 1.2% of the US population, an all-time high. Previous estimates, based on 2010 data, indicated that 2.3 million adults and 450,000 children had the disorder.

• The CDC report provides the first ever estimates of the prevalence of epilepsy state by state, with the agency reporting higher volumes in more densely populated states, as expected.
• The lowest prevalence of the neurological disease was noted in Wyoming, with 5900 active cases.
• California was estimated to have 427,700 cases of the disease.
• CDC believes increases from 2010 to 2015 are likely due to population growth.
• Among the limitations of the analysis is the fact that the estimates are based on self-reports, which are subject to bias.
• Underreporting by the public may reflect their reluctance to admit to a disorder because of its stigma and because they fear it could lead to driver’s license restrictions.

Zack MM, Kobau R. National and state estimates of the numbers of adults and children with active epilepsy — United States, 2015. MMWR; 2017;66(31):821-825.

Three million adults and 470,000 children have epilepsy according to the latest statistics from the Centers for Disease Control and Prevention (CDC).  These figures, based on the 2015 National Health Interview Survey, translate into 1.2% of the US population, an all-time high. Previous estimates, based on 2010 data, indicated that 2.3 million adults and 450,000 children had the disorder.

• The CDC report provides the first ever estimates of the prevalence of epilepsy state by state, with the agency reporting higher volumes in more densely populated states, as expected.
• The lowest prevalence of the neurological disease was noted in Wyoming, with 5900 active cases.
• California was estimated to have 427,700 cases of the disease.
• CDC believes increases from 2010 to 2015 are likely due to population growth.
• Among the limitations of the analysis is the fact that the estimates are based on self-reports, which are subject to bias.
• Underreporting by the public may reflect their reluctance to admit to a disorder because of its stigma and because they fear it could lead to driver’s license restrictions.

Zack MM, Kobau R. National and state estimates of the numbers of adults and children with active epilepsy — United States, 2015. MMWR; 2017;66(31):821-825.

Three million adults and 470,000 children have epilepsy according to the latest statistics from the Centers for Disease Control and Prevention (CDC).  These figures, based on the 2015 National Health Interview Survey, translate into 1.2% of the US population, an all-time high. Previous estimates, based on 2010 data, indicated that 2.3 million adults and 450,000 children had the disorder.

• The CDC report provides the first ever estimates of the prevalence of epilepsy state by state, with the agency reporting higher volumes in more densely populated states, as expected.
• The lowest prevalence of the neurological disease was noted in Wyoming, with 5900 active cases.
• California was estimated to have 427,700 cases of the disease.
• CDC believes increases from 2010 to 2015 are likely due to population growth.
• Among the limitations of the analysis is the fact that the estimates are based on self-reports, which are subject to bias.
• Underreporting by the public may reflect their reluctance to admit to a disorder because of its stigma and because they fear it could lead to driver’s license restrictions.

Zack MM, Kobau R. National and state estimates of the numbers of adults and children with active epilepsy — United States, 2015. MMWR; 2017;66(31):821-825.

Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.

Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.

agallegos@frontlinemedcom.com

On Twitter @legal_med

Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.

Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.

agallegos@frontlinemedcom.com

On Twitter @legal_med

Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.

Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.

agallegos@frontlinemedcom.com

On Twitter @legal_med

Q2: Answer: E 

This patient has elevated transaminases with normal alkaline phosphatase and total bilirubin levels. His AST is greater than his ALT. He does not meet criteria for having nonalcolholic steatohepatitis because of his history of drinking at least five drinks per day. Additionally, his AST:ALT ratio would be atypical for classic NASH presentation. This patient does not have chronic hepatitis B as his serologies reveal that he is hepatitis B immune. This patient’s labs are not suggestive of iron overload with a normal serum ferritin and normal iron saturation. Although this patient has emphysema diagnosed at a young age and an undetectable alpha-1-antitrypsin level, this patient’s liver enzyme elevations are not due to alpha-1-antitrypsin deficiency. Alpha-1-antitrypsin is a glycoprotein that functions as a serine protease inhibitor and is produced predominantly in hepatocytes and then secreted from the cell.

In alpha-1-antitrypsin mutations that affect the liver (most commonly the ZZ phenotype), there is an amino acid substitution that results in the production of an abnormal alpha-1-antitrypsin molecule that polymerizes within the hepatocyte preventing secretion from the cell and resulting in abnormal accumulation of the alpha-1-antitrypsin in hepatocytes with resulting hepatic damage over time. This patient, however, has the alpha-1-antitrypsin phenotype null/null, which results in the absence of alpha-1-antitrypsin production. As such, null/null individuals are at very high risk for emphysema due to the complete absence of the alpha-1-antitrypsin enzyme. However, since null/null individuals produce no alpha-1-antitrypsin at all, there is no abnormally polymerized alpha-1-antitrypsin protein build-up. Based upon the clinical history and laboratory data, this patient’s liver enzyme elevations are most likely due to alcohol abuse.  

References

1. Fairbanks K.D., Tavill A.S. Liver disease in alpha-1-antitrypsin deficiency: A review. Am J Gastro. 2008;103:2136-41.

2. Silverman E.A., Sandhaus R.A. Alpha-1 antitrypsin deficiency. N Engl J Med. 2009;360;2749-5.

Q2: Answer: E 

This patient has elevated transaminases with normal alkaline phosphatase and total bilirubin levels. His AST is greater than his ALT. He does not meet criteria for having nonalcolholic steatohepatitis because of his history of drinking at least five drinks per day. Additionally, his AST:ALT ratio would be atypical for classic NASH presentation. This patient does not have chronic hepatitis B as his serologies reveal that he is hepatitis B immune. This patient’s labs are not suggestive of iron overload with a normal serum ferritin and normal iron saturation. Although this patient has emphysema diagnosed at a young age and an undetectable alpha-1-antitrypsin level, this patient’s liver enzyme elevations are not due to alpha-1-antitrypsin deficiency. Alpha-1-antitrypsin is a glycoprotein that functions as a serine protease inhibitor and is produced predominantly in hepatocytes and then secreted from the cell.

In alpha-1-antitrypsin mutations that affect the liver (most commonly the ZZ phenotype), there is an amino acid substitution that results in the production of an abnormal alpha-1-antitrypsin molecule that polymerizes within the hepatocyte preventing secretion from the cell and resulting in abnormal accumulation of the alpha-1-antitrypsin in hepatocytes with resulting hepatic damage over time. This patient, however, has the alpha-1-antitrypsin phenotype null/null, which results in the absence of alpha-1-antitrypsin production. As such, null/null individuals are at very high risk for emphysema due to the complete absence of the alpha-1-antitrypsin enzyme. However, since null/null individuals produce no alpha-1-antitrypsin at all, there is no abnormally polymerized alpha-1-antitrypsin protein build-up. Based upon the clinical history and laboratory data, this patient’s liver enzyme elevations are most likely due to alcohol abuse.  

References

1. Fairbanks K.D., Tavill A.S. Liver disease in alpha-1-antitrypsin deficiency: A review. Am J Gastro. 2008;103:2136-41.

2. Silverman E.A., Sandhaus R.A. Alpha-1 antitrypsin deficiency. N Engl J Med. 2009;360;2749-5.

Q2: Answer: E 

This patient has elevated transaminases with normal alkaline phosphatase and total bilirubin levels. His AST is greater than his ALT. He does not meet criteria for having nonalcolholic steatohepatitis because of his history of drinking at least five drinks per day. Additionally, his AST:ALT ratio would be atypical for classic NASH presentation. This patient does not have chronic hepatitis B as his serologies reveal that he is hepatitis B immune. This patient’s labs are not suggestive of iron overload with a normal serum ferritin and normal iron saturation. Although this patient has emphysema diagnosed at a young age and an undetectable alpha-1-antitrypsin level, this patient’s liver enzyme elevations are not due to alpha-1-antitrypsin deficiency. Alpha-1-antitrypsin is a glycoprotein that functions as a serine protease inhibitor and is produced predominantly in hepatocytes and then secreted from the cell.

In alpha-1-antitrypsin mutations that affect the liver (most commonly the ZZ phenotype), there is an amino acid substitution that results in the production of an abnormal alpha-1-antitrypsin molecule that polymerizes within the hepatocyte preventing secretion from the cell and resulting in abnormal accumulation of the alpha-1-antitrypsin in hepatocytes with resulting hepatic damage over time. This patient, however, has the alpha-1-antitrypsin phenotype null/null, which results in the absence of alpha-1-antitrypsin production. As such, null/null individuals are at very high risk for emphysema due to the complete absence of the alpha-1-antitrypsin enzyme. However, since null/null individuals produce no alpha-1-antitrypsin at all, there is no abnormally polymerized alpha-1-antitrypsin protein build-up. Based upon the clinical history and laboratory data, this patient’s liver enzyme elevations are most likely due to alcohol abuse.  

References

1. Fairbanks K.D., Tavill A.S. Liver disease in alpha-1-antitrypsin deficiency: A review. Am J Gastro. 2008;103:2136-41.

2. Silverman E.A., Sandhaus R.A. Alpha-1 antitrypsin deficiency. N Engl J Med. 2009;360;2749-5.

Minimally invasive gynecologic surgeons can combat the opioid epidemic by devising creative, multimodal approaches to analgesia, according to the authors of an extensive narrative review.

Acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration all significantly reduce postoperative pain, as does reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case, reported Marron Wong, MD, of Newton (Mass.)-Wellesley Hospital and her associates.

“In the midst of the opioid crisis currently affecting the United States, we believe that it is imperative for [minimally invasive gynecologic surgeons] to use these available tools,” Dr. Wong and her associates wrote in the Journal of Minimally Invasive Gynecology.

The experts reviewed studies identified through PubMed, EMBASE, and the Cochrane Database. They focused on randomized controlled trials and highlighted the role of multimodal approaches. “Reasonable evidence” supports the preemptive and postoperative use of NSAIDs and acetaminophen, as well as the preemptive use of gabapentin, pregabalin and dexamethasone, they concluded (J Minim Invasive Gynecol. 2017 Sep 27. doi: 10.1016/j.jmig.2017.09.016).

Preemptive liposomal bupivacaine also is promising, the reviewers said. In a randomized controlled trial, transverse abdominis plane (TAP) infiltration with liposomal bupivacaine was associated with significant and clinically meaningful reductions in pain, morphine use, and postoperative nausea and vomiting, compared with transverse abdominis plane infiltration with regular bupivacaine (Gynecol Oncol. 2015 Sep;138[3]:609-13).

“Local infiltration [also] has been shown to decrease pain as well as opioid intake,” the reviewers wrote. “Pre-closure infiltration has been shown to have more effect than pre-incisional dosing.” Bupivicaine has a longer duration of action (120-240 minutes) than lidocaine (30-60 minutes), which can be extended further by adding epinephrine, they noted.

The adverse effects of alpha-2 agonists (bradycardia and hypotension) and N-methyl-d-aspartate receptor antagonists (vivid dreams, hallucination, emergence confusion) limit their use, the reviewers found.

Another recent systematic review drew similar conclusions, recommending NSAIDs, acetaminophen, anti-epileptics, and dexamethasone for nonopioid pain management in benign minimally invasive hysterectomy (Am J Obstet Gynecol. 2017 Jun;216[6]:557-67). That review found no positive results for local anesthesia, suggesting that the benefits of local anesthesia are limited to minor procedures, Dr. Wong and her associates noted.

The authors reported having no financial disclosures.

Minimally invasive gynecologic surgeons can combat the opioid epidemic by devising creative, multimodal approaches to analgesia, according to the authors of an extensive narrative review.

Acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration all significantly reduce postoperative pain, as does reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case, reported Marron Wong, MD, of Newton (Mass.)-Wellesley Hospital and her associates.

“In the midst of the opioid crisis currently affecting the United States, we believe that it is imperative for [minimally invasive gynecologic surgeons] to use these available tools,” Dr. Wong and her associates wrote in the Journal of Minimally Invasive Gynecology.

The experts reviewed studies identified through PubMed, EMBASE, and the Cochrane Database. They focused on randomized controlled trials and highlighted the role of multimodal approaches. “Reasonable evidence” supports the preemptive and postoperative use of NSAIDs and acetaminophen, as well as the preemptive use of gabapentin, pregabalin and dexamethasone, they concluded (J Minim Invasive Gynecol. 2017 Sep 27. doi: 10.1016/j.jmig.2017.09.016).

Preemptive liposomal bupivacaine also is promising, the reviewers said. In a randomized controlled trial, transverse abdominis plane (TAP) infiltration with liposomal bupivacaine was associated with significant and clinically meaningful reductions in pain, morphine use, and postoperative nausea and vomiting, compared with transverse abdominis plane infiltration with regular bupivacaine (Gynecol Oncol. 2015 Sep;138[3]:609-13).

“Local infiltration [also] has been shown to decrease pain as well as opioid intake,” the reviewers wrote. “Pre-closure infiltration has been shown to have more effect than pre-incisional dosing.” Bupivicaine has a longer duration of action (120-240 minutes) than lidocaine (30-60 minutes), which can be extended further by adding epinephrine, they noted.

The adverse effects of alpha-2 agonists (bradycardia and hypotension) and N-methyl-d-aspartate receptor antagonists (vivid dreams, hallucination, emergence confusion) limit their use, the reviewers found.

Another recent systematic review drew similar conclusions, recommending NSAIDs, acetaminophen, anti-epileptics, and dexamethasone for nonopioid pain management in benign minimally invasive hysterectomy (Am J Obstet Gynecol. 2017 Jun;216[6]:557-67). That review found no positive results for local anesthesia, suggesting that the benefits of local anesthesia are limited to minor procedures, Dr. Wong and her associates noted.

The authors reported having no financial disclosures.

Minimally invasive gynecologic surgeons can combat the opioid epidemic by devising creative, multimodal approaches to analgesia, according to the authors of an extensive narrative review.

Acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration all significantly reduce postoperative pain, as does reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case, reported Marron Wong, MD, of Newton (Mass.)-Wellesley Hospital and her associates.

“In the midst of the opioid crisis currently affecting the United States, we believe that it is imperative for [minimally invasive gynecologic surgeons] to use these available tools,” Dr. Wong and her associates wrote in the Journal of Minimally Invasive Gynecology.

The experts reviewed studies identified through PubMed, EMBASE, and the Cochrane Database. They focused on randomized controlled trials and highlighted the role of multimodal approaches. “Reasonable evidence” supports the preemptive and postoperative use of NSAIDs and acetaminophen, as well as the preemptive use of gabapentin, pregabalin and dexamethasone, they concluded (J Minim Invasive Gynecol. 2017 Sep 27. doi: 10.1016/j.jmig.2017.09.016).

Preemptive liposomal bupivacaine also is promising, the reviewers said. In a randomized controlled trial, transverse abdominis plane (TAP) infiltration with liposomal bupivacaine was associated with significant and clinically meaningful reductions in pain, morphine use, and postoperative nausea and vomiting, compared with transverse abdominis plane infiltration with regular bupivacaine (Gynecol Oncol. 2015 Sep;138[3]:609-13).

“Local infiltration [also] has been shown to decrease pain as well as opioid intake,” the reviewers wrote. “Pre-closure infiltration has been shown to have more effect than pre-incisional dosing.” Bupivicaine has a longer duration of action (120-240 minutes) than lidocaine (30-60 minutes), which can be extended further by adding epinephrine, they noted.

The adverse effects of alpha-2 agonists (bradycardia and hypotension) and N-methyl-d-aspartate receptor antagonists (vivid dreams, hallucination, emergence confusion) limit their use, the reviewers found.

Another recent systematic review drew similar conclusions, recommending NSAIDs, acetaminophen, anti-epileptics, and dexamethasone for nonopioid pain management in benign minimally invasive hysterectomy (Am J Obstet Gynecol. 2017 Jun;216[6]:557-67). That review found no positive results for local anesthesia, suggesting that the benefits of local anesthesia are limited to minor procedures, Dr. Wong and her associates noted.

The authors reported having no financial disclosures.

The goal of comparative effectiveness research should be to find the best products to meet a clinical situation instead of a tool to be used by payers to make cost-based coverage decisions, the American College of Rheumatology recently said.

The ACR’s Committee on Rheumatologic Care recently updated its position statement on CER, noting that high-quality comparative effectiveness research and cost-effectiveness analysis “can and should inform individual provider and patient decisions about the relative value of diagnostic and therapeutic options.”

gtwachtman@frontlinemedcom.com

The goal of comparative effectiveness research should be to find the best products to meet a clinical situation instead of a tool to be used by payers to make cost-based coverage decisions, the American College of Rheumatology recently said.

The ACR’s Committee on Rheumatologic Care recently updated its position statement on CER, noting that high-quality comparative effectiveness research and cost-effectiveness analysis “can and should inform individual provider and patient decisions about the relative value of diagnostic and therapeutic options.”

gtwachtman@frontlinemedcom.com

The goal of comparative effectiveness research should be to find the best products to meet a clinical situation instead of a tool to be used by payers to make cost-based coverage decisions, the American College of Rheumatology recently said.

The ACR’s Committee on Rheumatologic Care recently updated its position statement on CER, noting that high-quality comparative effectiveness research and cost-effectiveness analysis “can and should inform individual provider and patient decisions about the relative value of diagnostic and therapeutic options.”

gtwachtman@frontlinemedcom.com

NEW ORLEANS – Ketamine infusions are becoming more and more routine for refractory depression, but the literature is just not clear about the optimal treatment regimen.

Studies have run the gamut from daily, to weekly, to monthly infusions, with scant information on how to predict who will respond and how to maintain response.

aotto@frontlinemedcom.com

NEW ORLEANS – Ketamine infusions are becoming more and more routine for refractory depression, but the literature is just not clear about the optimal treatment regimen.

Studies have run the gamut from daily, to weekly, to monthly infusions, with scant information on how to predict who will respond and how to maintain response.

aotto@frontlinemedcom.com

NEW ORLEANS – Ketamine infusions are becoming more and more routine for refractory depression, but the literature is just not clear about the optimal treatment regimen.

Studies have run the gamut from daily, to weekly, to monthly infusions, with scant information on how to predict who will respond and how to maintain response.

aotto@frontlinemedcom.com