Damian McNamara

MIAMI BEACH – A scoring system based on three factors identified in a study could aid your decision whether to proceed with surgery for girls with suspected adnexal torsion, results of a small study suggest.

Adnexal torsion is often part of the differential diagnosis of girls who present to an emergency department with abdominal or pelvic pain. An accurate diagnosis of torsion and swift surgical intervention can be important to preclude serious reproductive consequences including loss of an ovary or adnexa.

Dr. Samantha E. Montgomery and her colleagues prospectively studied 32 girls who underwent surgery for suspected adnexal torsion. They compared 16 cases with confirmed torsion (13 ovarian, 2 tubal, and 1 paratubal) with 16 controls with other adnexal findings.

They looked for significant predictors based on patient presentation. "No single factor was significant alone, so we developed a composite score," Dr. Montgomery said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A score of 0 to 6 is possible based on premenarchal status (yes = 2, no = 0); presence of nausea and/or vomiting (nausea = 1, vomiting = 2, none = 0); and adnexal volume (20 mL or less = 0, 21 mL to 70 mL = 1, greater than 70 mL = 2).

There were six girls who scored a 0 or 1 and none were diagnosed with torsion, for 100% specificity. A score of 4 or more correctly identified 12 out of 14 girls with torsion, for 75% sensitivity and 86% specificity. A score of 2 or 3 was less definitive; this group included four girls with torsion and eight girls without this condition. Patients who score 2 or 3 should be considered for surgery, said Dr. Montgomery, a pediatric and adolescent gynecology fellow at the University of Cincinnati and Cincinnati Children’s Hospital.

Doppler flow, duration of pain, affected volume in mL, and adnexal ratio were not significantly associated with torsion in the study.

The cross-sectional study included patients 6-21 years of age with abdominal or pelvic pain. They each presented to the emergency department at Cincinnati Children’s Hospital Medical Center between August 2007 and August 2009.

Strengths of the study include its prospective design and inclusion of prepubertal patients, Dr. Montgomery said. Limitations include a small sample size and an inability to distinguish ovarian from isolated tubal torsion so all cases were termed "adnexal torsion."

The composite score has not yet been validated, Dr. Montgomery said in response to a meeting attendee question.

Radiologic assessment was standardized in a sequential protocol that started with right lower quadrant ultrasound followed by pelvic ultrasound. If the appendix could not be visualized at this point, an abdominal/pelvic CT scan could be ordered as well.

A future aim is to assess a larger sample of premenarchal girls, Dr. Montgomery said.

Dr. Montgomery said she had no relevant financial disclosures.

MIAMI BEACH – A scoring system based on three factors identified in a study could aid your decision whether to proceed with surgery for girls with suspected adnexal torsion, results of a small study suggest.

Adnexal torsion is often part of the differential diagnosis of girls who present to an emergency department with abdominal or pelvic pain. An accurate diagnosis of torsion and swift surgical intervention can be important to preclude serious reproductive consequences including loss of an ovary or adnexa.

Dr. Samantha E. Montgomery and her colleagues prospectively studied 32 girls who underwent surgery for suspected adnexal torsion. They compared 16 cases with confirmed torsion (13 ovarian, 2 tubal, and 1 paratubal) with 16 controls with other adnexal findings.

They looked for significant predictors based on patient presentation. "No single factor was significant alone, so we developed a composite score," Dr. Montgomery said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A score of 0 to 6 is possible based on premenarchal status (yes = 2, no = 0); presence of nausea and/or vomiting (nausea = 1, vomiting = 2, none = 0); and adnexal volume (20 mL or less = 0, 21 mL to 70 mL = 1, greater than 70 mL = 2).

There were six girls who scored a 0 or 1 and none were diagnosed with torsion, for 100% specificity. A score of 4 or more correctly identified 12 out of 14 girls with torsion, for 75% sensitivity and 86% specificity. A score of 2 or 3 was less definitive; this group included four girls with torsion and eight girls without this condition. Patients who score 2 or 3 should be considered for surgery, said Dr. Montgomery, a pediatric and adolescent gynecology fellow at the University of Cincinnati and Cincinnati Children’s Hospital.

Doppler flow, duration of pain, affected volume in mL, and adnexal ratio were not significantly associated with torsion in the study.

The cross-sectional study included patients 6-21 years of age with abdominal or pelvic pain. They each presented to the emergency department at Cincinnati Children’s Hospital Medical Center between August 2007 and August 2009.

Strengths of the study include its prospective design and inclusion of prepubertal patients, Dr. Montgomery said. Limitations include a small sample size and an inability to distinguish ovarian from isolated tubal torsion so all cases were termed "adnexal torsion."

The composite score has not yet been validated, Dr. Montgomery said in response to a meeting attendee question.

Radiologic assessment was standardized in a sequential protocol that started with right lower quadrant ultrasound followed by pelvic ultrasound. If the appendix could not be visualized at this point, an abdominal/pelvic CT scan could be ordered as well.

A future aim is to assess a larger sample of premenarchal girls, Dr. Montgomery said.

Dr. Montgomery said she had no relevant financial disclosures.

MIAMI BEACH – A scoring system based on three factors identified in a study could aid your decision whether to proceed with surgery for girls with suspected adnexal torsion, results of a small study suggest.

Adnexal torsion is often part of the differential diagnosis of girls who present to an emergency department with abdominal or pelvic pain. An accurate diagnosis of torsion and swift surgical intervention can be important to preclude serious reproductive consequences including loss of an ovary or adnexa.

Dr. Samantha E. Montgomery and her colleagues prospectively studied 32 girls who underwent surgery for suspected adnexal torsion. They compared 16 cases with confirmed torsion (13 ovarian, 2 tubal, and 1 paratubal) with 16 controls with other adnexal findings.

They looked for significant predictors based on patient presentation. "No single factor was significant alone, so we developed a composite score," Dr. Montgomery said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A score of 0 to 6 is possible based on premenarchal status (yes = 2, no = 0); presence of nausea and/or vomiting (nausea = 1, vomiting = 2, none = 0); and adnexal volume (20 mL or less = 0, 21 mL to 70 mL = 1, greater than 70 mL = 2).

There were six girls who scored a 0 or 1 and none were diagnosed with torsion, for 100% specificity. A score of 4 or more correctly identified 12 out of 14 girls with torsion, for 75% sensitivity and 86% specificity. A score of 2 or 3 was less definitive; this group included four girls with torsion and eight girls without this condition. Patients who score 2 or 3 should be considered for surgery, said Dr. Montgomery, a pediatric and adolescent gynecology fellow at the University of Cincinnati and Cincinnati Children’s Hospital.

Doppler flow, duration of pain, affected volume in mL, and adnexal ratio were not significantly associated with torsion in the study.

The cross-sectional study included patients 6-21 years of age with abdominal or pelvic pain. They each presented to the emergency department at Cincinnati Children’s Hospital Medical Center between August 2007 and August 2009.

Strengths of the study include its prospective design and inclusion of prepubertal patients, Dr. Montgomery said. Limitations include a small sample size and an inability to distinguish ovarian from isolated tubal torsion so all cases were termed "adnexal torsion."

The composite score has not yet been validated, Dr. Montgomery said in response to a meeting attendee question.

Radiologic assessment was standardized in a sequential protocol that started with right lower quadrant ultrasound followed by pelvic ultrasound. If the appendix could not be visualized at this point, an abdominal/pelvic CT scan could be ordered as well.

A future aim is to assess a larger sample of premenarchal girls, Dr. Montgomery said.

Dr. Montgomery said she had no relevant financial disclosures.

MIAMI BEACH – Physician champions can spur the adoption of long-acting reversible contraception post partum among teenaged mothers, a study has shown.

Researchers at the Medical University of South Carolina in Charleston assessed the records of 720 adolescents aged 13-19 years who received prenatal care at their institution and were delivered of a viable baby between December 2005 and May 2010.

Dr. Ashlyn H. Savage and her associates found that if an adolescent mother had a documented postpartum contraception plan in her prenatal record, she was more likely to receive long-acting reversible contraception (LARC) at her 6-week postpartum visit (odds ratio, 3.7), compared with those without such a plan.

An estimated 15%-30% of adolescent mothers become pregnant again within 1 year of delivery, and LARC is one of the best strategies to reduce this risk, Dr. Savage said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Early on [in the study] almost no teenagers had a documented plan prenatally for postpartum pregnancy prevention," she said.

Dr. Savage suggested that physician champions are responsible, at least in part, for a significant increase in prenatal documentation for any form of postpartum contraception. Such written plans in the prenatal records increased 13.5-fold between 2006 and 2009.

"At our institution, in the last few years we’ve had an influx of new faculty members, including a family planning specialist. The three of us are physician champions of long-acting reversible contraception in adolescents," said Dr. Savage of the department of obstetrics and gynecology at the university.

LARC use increased 3 years after the physician champions joined the staff, with an odds ratio of 5.2 for 2009 vs. 2006.

She and her colleagues plan to continue emphasizing the importance of prenatal plans for postpartum contraception based on these findings, Dr. Savage said. In addition, because 293 (41%) of 720 adolescent mothers did not return for a postpartum visit, "we are now studying implantation [of LARC] in the hospital before they leave."

Of the 427 teenaged mothers who did return at 6 weeks post partum, 66 (15%) obtained LARC at this visit. LARC was either an intrauterine device or an etonogestrel hormonal implant (Implanon, Organon). Another 218 patients (51%) were using medroxyprogesterone (Depo-Provera) as contraception; 101 (24%) selected a combination hormonal contraceptive; and 21 (5%) chose a barrier method. A total of 21 adolescent mothers (5%) chose no form of contraception.

Race was associated with the likelihood of receiving LARC at 6 weeks. "African American and Hispanic girls had the highest risks of repeat teen pregnancy. Unfortunately, they were also the least likely to use LARC," Dr. Savage said. Compared with white adolescents, for example, the odds ratio for postpartum LARC use at 6 weeks was 0.48 for African American teenagers and 0.15 for Hispanic teens. She and her colleagues plan to focus more effort on encouraging LARC use among African American and Hispanic adolescent mothers.

Age, parity, marital status, and funding for contraception did not predict LARC use in the study.

Dr. Savage said she had no relevant financial disclosures.

MIAMI BEACH – Physician champions can spur the adoption of long-acting reversible contraception post partum among teenaged mothers, a study has shown.

Researchers at the Medical University of South Carolina in Charleston assessed the records of 720 adolescents aged 13-19 years who received prenatal care at their institution and were delivered of a viable baby between December 2005 and May 2010.

Dr. Ashlyn H. Savage and her associates found that if an adolescent mother had a documented postpartum contraception plan in her prenatal record, she was more likely to receive long-acting reversible contraception (LARC) at her 6-week postpartum visit (odds ratio, 3.7), compared with those without such a plan.

An estimated 15%-30% of adolescent mothers become pregnant again within 1 year of delivery, and LARC is one of the best strategies to reduce this risk, Dr. Savage said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Early on [in the study] almost no teenagers had a documented plan prenatally for postpartum pregnancy prevention," she said.

Dr. Savage suggested that physician champions are responsible, at least in part, for a significant increase in prenatal documentation for any form of postpartum contraception. Such written plans in the prenatal records increased 13.5-fold between 2006 and 2009.

"At our institution, in the last few years we’ve had an influx of new faculty members, including a family planning specialist. The three of us are physician champions of long-acting reversible contraception in adolescents," said Dr. Savage of the department of obstetrics and gynecology at the university.

LARC use increased 3 years after the physician champions joined the staff, with an odds ratio of 5.2 for 2009 vs. 2006.

She and her colleagues plan to continue emphasizing the importance of prenatal plans for postpartum contraception based on these findings, Dr. Savage said. In addition, because 293 (41%) of 720 adolescent mothers did not return for a postpartum visit, "we are now studying implantation [of LARC] in the hospital before they leave."

Of the 427 teenaged mothers who did return at 6 weeks post partum, 66 (15%) obtained LARC at this visit. LARC was either an intrauterine device or an etonogestrel hormonal implant (Implanon, Organon). Another 218 patients (51%) were using medroxyprogesterone (Depo-Provera) as contraception; 101 (24%) selected a combination hormonal contraceptive; and 21 (5%) chose a barrier method. A total of 21 adolescent mothers (5%) chose no form of contraception.

Race was associated with the likelihood of receiving LARC at 6 weeks. "African American and Hispanic girls had the highest risks of repeat teen pregnancy. Unfortunately, they were also the least likely to use LARC," Dr. Savage said. Compared with white adolescents, for example, the odds ratio for postpartum LARC use at 6 weeks was 0.48 for African American teenagers and 0.15 for Hispanic teens. She and her colleagues plan to focus more effort on encouraging LARC use among African American and Hispanic adolescent mothers.

Age, parity, marital status, and funding for contraception did not predict LARC use in the study.

Dr. Savage said she had no relevant financial disclosures.

MIAMI BEACH – Physician champions can spur the adoption of long-acting reversible contraception post partum among teenaged mothers, a study has shown.

Researchers at the Medical University of South Carolina in Charleston assessed the records of 720 adolescents aged 13-19 years who received prenatal care at their institution and were delivered of a viable baby between December 2005 and May 2010.

Dr. Ashlyn H. Savage and her associates found that if an adolescent mother had a documented postpartum contraception plan in her prenatal record, she was more likely to receive long-acting reversible contraception (LARC) at her 6-week postpartum visit (odds ratio, 3.7), compared with those without such a plan.

An estimated 15%-30% of adolescent mothers become pregnant again within 1 year of delivery, and LARC is one of the best strategies to reduce this risk, Dr. Savage said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Early on [in the study] almost no teenagers had a documented plan prenatally for postpartum pregnancy prevention," she said.

Dr. Savage suggested that physician champions are responsible, at least in part, for a significant increase in prenatal documentation for any form of postpartum contraception. Such written plans in the prenatal records increased 13.5-fold between 2006 and 2009.

"At our institution, in the last few years we’ve had an influx of new faculty members, including a family planning specialist. The three of us are physician champions of long-acting reversible contraception in adolescents," said Dr. Savage of the department of obstetrics and gynecology at the university.

LARC use increased 3 years after the physician champions joined the staff, with an odds ratio of 5.2 for 2009 vs. 2006.

She and her colleagues plan to continue emphasizing the importance of prenatal plans for postpartum contraception based on these findings, Dr. Savage said. In addition, because 293 (41%) of 720 adolescent mothers did not return for a postpartum visit, "we are now studying implantation [of LARC] in the hospital before they leave."

Of the 427 teenaged mothers who did return at 6 weeks post partum, 66 (15%) obtained LARC at this visit. LARC was either an intrauterine device or an etonogestrel hormonal implant (Implanon, Organon). Another 218 patients (51%) were using medroxyprogesterone (Depo-Provera) as contraception; 101 (24%) selected a combination hormonal contraceptive; and 21 (5%) chose a barrier method. A total of 21 adolescent mothers (5%) chose no form of contraception.

Race was associated with the likelihood of receiving LARC at 6 weeks. "African American and Hispanic girls had the highest risks of repeat teen pregnancy. Unfortunately, they were also the least likely to use LARC," Dr. Savage said. Compared with white adolescents, for example, the odds ratio for postpartum LARC use at 6 weeks was 0.48 for African American teenagers and 0.15 for Hispanic teens. She and her colleagues plan to focus more effort on encouraging LARC use among African American and Hispanic adolescent mothers.

Age, parity, marital status, and funding for contraception did not predict LARC use in the study.

Dr. Savage said she had no relevant financial disclosures.

SAN FRANCISCO – Additional research continues to show good outcomes with a new process that allows successful transplant of lungs that might otherwise be deemed unacceptable.

Researchers at the Organ Regeneration Laboratory at the University of Toronto evaluated and repaired 58 donor lungs over 4-6 hours in a process called normothermic ex vivo lung perfusion (EVLP). In all, 50 of these lungs were successfully transplanted into patients, for a final utilization rate of 86%, Dr. Marcelo Cypel reported at the annual meeting of the American Association for Thoracic Surgery.

The current study builds on a previous report on initial experience with EVLP from the same research team (N. Engl. J. Med. 2011;364:1431-40).

"As we all know, one of the major problems in doing lung transplantation is the organ shortage and the low utilization rates. Only 17% of the lungs from brain death donors and 2% of the lungs from cardiac death donors are used currently," Dr. Cypel said. EVLP lungs accounted for 20% of the transplantations at Toronto General Hospital in 2011.

The EVLP lungs came from 32 brain death donors and 26 cardiac death donors. Dr. Cypel and his colleagues compared the outcomes of these EVLP procedures to another 253 conventional lung transplantations performed at their institution from September 2008 to December 2011.

EVLP patients received a significantly higher percentage of lungs from cardiac death donors, which are generally considered less desirable than lungs from brain death donors. They also received a higher percentage of high-risk lungs from brain death donors (PaO₂/FIO₂ below 300 mm Hg) and more lungs with chest x-ray abnormalities, such as signs of pulmonary edema, compared with the conventional group.

"Donor lungs in the EVLP group were significantly more injured at baseline, however, the outcomes were comparable," said Dr. Cypel, a member of the surgical faculty in the Division of Thoracic Surgery at Toronto General Hospital University Health Network.

For example, posttransplant survival at 1 year was 86% for the EVLP group and 87% for the traditional transplant group in this retrospective study; at 3 years these rates dropped to 70% and 72%. There were no significant differences in survival for patients who received lungs from brain death or cardiac death donors.

Other findings included no significant difference in the rate of primary graft grade 3 dysfunction at 72 hours between groups according to International Society for Heart and Lung Transplantation criteria. The EVLP patients had a trend toward a decreased length of hospital stay, compared with conventional transplant recipients, Dr. Cypel said.

"Again, you and your colleagues have demonstrated the safety and efficacy of using EVLP in the transplantation of lungs that previously would not have been used by your group," said study discussant Dr. R. Duane Davis, director of transplant services at Duke University Health System in Durham, N.C. "Using this technology, we may be able to start applying lung transplant more practically for societal needs."

Dr. Davis asked Dr. Cypel how surgeons at Toronto General Hospital achieved an 86% EVLP utilization rate compared with the 54% rate observed in the U.S. trial and comparable rates in the United Kingdom and elsewhere.

"Our experience with the procedure and extensive laboratory research prior to starting the clinical trial" explain the difference, Dr. Cypel replied. Donor selection criteria also could play a role.

"The important thing is it is taking some of the adventure out of lung transplantation," study coauthor Dr. Shaf Keshavjee said during a separate presentation at the meeting. "Ex vivo lung perfusion is clinically feasible. We can we do a long-term perfusion of lungs outside the body without injuring them. It is possible to keep lung 12 hours outside the body and normothermic."

"We are developing ways to figure out which lungs need a fix and to target treatment to lungs that need treatment," said Dr. Keshavjee, director of the Toronto Lung Transplant program and chair of the Division of Thoracic Surgery at the University of Toronto. Examples include resolution of pulmonary edema and infections through EVLP. Treating infected lungs with lavage and high-dose antibiotics may one day make these organs acceptable for transplantation, even in cases of pneumonia.

The goal is to double or triple the overall number of lung transplants using the EVLP technique in the United States, said Dr. Davis. EVLP comprises 20% of transplants in Toronto, but the overall transplant volume has not increased.

EVLP has allowed the overall number of 100 transplants or so per year in Toronto to remain steady at the same time that organ donation rates have decreased, Dr. Cypel responded.

"The major contribution of EVLP will not be for the large transplant centers like Duke or Toronto, which already use 40% of the organs and for whom a marginal increase is not that large," Dr. Cypel said. "Look at the majority of lung transplant centers that use 10% or less of the offered lungs; that is where we can have a major impact by increasing the number of organs available."

Vitrolife supported the clinical trial. Dr. Cypel and Dr. Keshavjee reported no other relevant disclosures. Dr. Davis said he received research support from Vitrolife for a U.S. study.

SAN FRANCISCO – Additional research continues to show good outcomes with a new process that allows successful transplant of lungs that might otherwise be deemed unacceptable.

Researchers at the Organ Regeneration Laboratory at the University of Toronto evaluated and repaired 58 donor lungs over 4-6 hours in a process called normothermic ex vivo lung perfusion (EVLP). In all, 50 of these lungs were successfully transplanted into patients, for a final utilization rate of 86%, Dr. Marcelo Cypel reported at the annual meeting of the American Association for Thoracic Surgery.

The current study builds on a previous report on initial experience with EVLP from the same research team (N. Engl. J. Med. 2011;364:1431-40).

"As we all know, one of the major problems in doing lung transplantation is the organ shortage and the low utilization rates. Only 17% of the lungs from brain death donors and 2% of the lungs from cardiac death donors are used currently," Dr. Cypel said. EVLP lungs accounted for 20% of the transplantations at Toronto General Hospital in 2011.

The EVLP lungs came from 32 brain death donors and 26 cardiac death donors. Dr. Cypel and his colleagues compared the outcomes of these EVLP procedures to another 253 conventional lung transplantations performed at their institution from September 2008 to December 2011.

EVLP patients received a significantly higher percentage of lungs from cardiac death donors, which are generally considered less desirable than lungs from brain death donors. They also received a higher percentage of high-risk lungs from brain death donors (PaO₂/FIO₂ below 300 mm Hg) and more lungs with chest x-ray abnormalities, such as signs of pulmonary edema, compared with the conventional group.

"Donor lungs in the EVLP group were significantly more injured at baseline, however, the outcomes were comparable," said Dr. Cypel, a member of the surgical faculty in the Division of Thoracic Surgery at Toronto General Hospital University Health Network.

For example, posttransplant survival at 1 year was 86% for the EVLP group and 87% for the traditional transplant group in this retrospective study; at 3 years these rates dropped to 70% and 72%. There were no significant differences in survival for patients who received lungs from brain death or cardiac death donors.

Other findings included no significant difference in the rate of primary graft grade 3 dysfunction at 72 hours between groups according to International Society for Heart and Lung Transplantation criteria. The EVLP patients had a trend toward a decreased length of hospital stay, compared with conventional transplant recipients, Dr. Cypel said.

"Again, you and your colleagues have demonstrated the safety and efficacy of using EVLP in the transplantation of lungs that previously would not have been used by your group," said study discussant Dr. R. Duane Davis, director of transplant services at Duke University Health System in Durham, N.C. "Using this technology, we may be able to start applying lung transplant more practically for societal needs."

Dr. Davis asked Dr. Cypel how surgeons at Toronto General Hospital achieved an 86% EVLP utilization rate compared with the 54% rate observed in the U.S. trial and comparable rates in the United Kingdom and elsewhere.

"Our experience with the procedure and extensive laboratory research prior to starting the clinical trial" explain the difference, Dr. Cypel replied. Donor selection criteria also could play a role.

"The important thing is it is taking some of the adventure out of lung transplantation," study coauthor Dr. Shaf Keshavjee said during a separate presentation at the meeting. "Ex vivo lung perfusion is clinically feasible. We can we do a long-term perfusion of lungs outside the body without injuring them. It is possible to keep lung 12 hours outside the body and normothermic."

"We are developing ways to figure out which lungs need a fix and to target treatment to lungs that need treatment," said Dr. Keshavjee, director of the Toronto Lung Transplant program and chair of the Division of Thoracic Surgery at the University of Toronto. Examples include resolution of pulmonary edema and infections through EVLP. Treating infected lungs with lavage and high-dose antibiotics may one day make these organs acceptable for transplantation, even in cases of pneumonia.

The goal is to double or triple the overall number of lung transplants using the EVLP technique in the United States, said Dr. Davis. EVLP comprises 20% of transplants in Toronto, but the overall transplant volume has not increased.

EVLP has allowed the overall number of 100 transplants or so per year in Toronto to remain steady at the same time that organ donation rates have decreased, Dr. Cypel responded.

"The major contribution of EVLP will not be for the large transplant centers like Duke or Toronto, which already use 40% of the organs and for whom a marginal increase is not that large," Dr. Cypel said. "Look at the majority of lung transplant centers that use 10% or less of the offered lungs; that is where we can have a major impact by increasing the number of organs available."

Vitrolife supported the clinical trial. Dr. Cypel and Dr. Keshavjee reported no other relevant disclosures. Dr. Davis said he received research support from Vitrolife for a U.S. study.

SAN FRANCISCO – Additional research continues to show good outcomes with a new process that allows successful transplant of lungs that might otherwise be deemed unacceptable.

Researchers at the Organ Regeneration Laboratory at the University of Toronto evaluated and repaired 58 donor lungs over 4-6 hours in a process called normothermic ex vivo lung perfusion (EVLP). In all, 50 of these lungs were successfully transplanted into patients, for a final utilization rate of 86%, Dr. Marcelo Cypel reported at the annual meeting of the American Association for Thoracic Surgery.

The current study builds on a previous report on initial experience with EVLP from the same research team (N. Engl. J. Med. 2011;364:1431-40).

"As we all know, one of the major problems in doing lung transplantation is the organ shortage and the low utilization rates. Only 17% of the lungs from brain death donors and 2% of the lungs from cardiac death donors are used currently," Dr. Cypel said. EVLP lungs accounted for 20% of the transplantations at Toronto General Hospital in 2011.

The EVLP lungs came from 32 brain death donors and 26 cardiac death donors. Dr. Cypel and his colleagues compared the outcomes of these EVLP procedures to another 253 conventional lung transplantations performed at their institution from September 2008 to December 2011.

EVLP patients received a significantly higher percentage of lungs from cardiac death donors, which are generally considered less desirable than lungs from brain death donors. They also received a higher percentage of high-risk lungs from brain death donors (PaO₂/FIO₂ below 300 mm Hg) and more lungs with chest x-ray abnormalities, such as signs of pulmonary edema, compared with the conventional group.

"Donor lungs in the EVLP group were significantly more injured at baseline, however, the outcomes were comparable," said Dr. Cypel, a member of the surgical faculty in the Division of Thoracic Surgery at Toronto General Hospital University Health Network.

For example, posttransplant survival at 1 year was 86% for the EVLP group and 87% for the traditional transplant group in this retrospective study; at 3 years these rates dropped to 70% and 72%. There were no significant differences in survival for patients who received lungs from brain death or cardiac death donors.

Other findings included no significant difference in the rate of primary graft grade 3 dysfunction at 72 hours between groups according to International Society for Heart and Lung Transplantation criteria. The EVLP patients had a trend toward a decreased length of hospital stay, compared with conventional transplant recipients, Dr. Cypel said.

"Again, you and your colleagues have demonstrated the safety and efficacy of using EVLP in the transplantation of lungs that previously would not have been used by your group," said study discussant Dr. R. Duane Davis, director of transplant services at Duke University Health System in Durham, N.C. "Using this technology, we may be able to start applying lung transplant more practically for societal needs."

Dr. Davis asked Dr. Cypel how surgeons at Toronto General Hospital achieved an 86% EVLP utilization rate compared with the 54% rate observed in the U.S. trial and comparable rates in the United Kingdom and elsewhere.

"Our experience with the procedure and extensive laboratory research prior to starting the clinical trial" explain the difference, Dr. Cypel replied. Donor selection criteria also could play a role.

"The important thing is it is taking some of the adventure out of lung transplantation," study coauthor Dr. Shaf Keshavjee said during a separate presentation at the meeting. "Ex vivo lung perfusion is clinically feasible. We can we do a long-term perfusion of lungs outside the body without injuring them. It is possible to keep lung 12 hours outside the body and normothermic."

"We are developing ways to figure out which lungs need a fix and to target treatment to lungs that need treatment," said Dr. Keshavjee, director of the Toronto Lung Transplant program and chair of the Division of Thoracic Surgery at the University of Toronto. Examples include resolution of pulmonary edema and infections through EVLP. Treating infected lungs with lavage and high-dose antibiotics may one day make these organs acceptable for transplantation, even in cases of pneumonia.

The goal is to double or triple the overall number of lung transplants using the EVLP technique in the United States, said Dr. Davis. EVLP comprises 20% of transplants in Toronto, but the overall transplant volume has not increased.

EVLP has allowed the overall number of 100 transplants or so per year in Toronto to remain steady at the same time that organ donation rates have decreased, Dr. Cypel responded.

"The major contribution of EVLP will not be for the large transplant centers like Duke or Toronto, which already use 40% of the organs and for whom a marginal increase is not that large," Dr. Cypel said. "Look at the majority of lung transplant centers that use 10% or less of the offered lungs; that is where we can have a major impact by increasing the number of organs available."

Vitrolife supported the clinical trial. Dr. Cypel and Dr. Keshavjee reported no other relevant disclosures. Dr. Davis said he received research support from Vitrolife for a U.S. study.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH -- Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well- studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, said Dr. Douketis, director of the vascular medicine program at St. Joseph?s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can?t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical device?can be worn out of bed and out of the hospital, Dr. Colwell said.

Dr. Colwell conducted a multicenter, prospective study with his associates that compared effectiveness of the portable device low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery, but it?s a second-line strategy," said Dr. Douketis. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended-duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic VTE, compared with placebo after hip or knee replacement (Lancet 2001;358:9-15). There is less confidence about prevention of proximal DVTs with mechanical devices. The risks should be weighed against this efficacy, Dr. Douketis said.

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. Dr. Colwell disclosed he is a consultant and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH -- Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well- studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, said Dr. Douketis, director of the vascular medicine program at St. Joseph?s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can?t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical device?can be worn out of bed and out of the hospital, Dr. Colwell said.

Dr. Colwell conducted a multicenter, prospective study with his associates that compared effectiveness of the portable device low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery, but it?s a second-line strategy," said Dr. Douketis. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended-duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic VTE, compared with placebo after hip or knee replacement (Lancet 2001;358:9-15). There is less confidence about prevention of proximal DVTs with mechanical devices. The risks should be weighed against this efficacy, Dr. Douketis said.

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. Dr. Colwell disclosed he is a consultant and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH -- Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well- studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, said Dr. Douketis, director of the vascular medicine program at St. Joseph?s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can?t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical device?can be worn out of bed and out of the hospital, Dr. Colwell said.

Dr. Colwell conducted a multicenter, prospective study with his associates that compared effectiveness of the portable device low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery, but it?s a second-line strategy," said Dr. Douketis. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended-duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic VTE, compared with placebo after hip or knee replacement (Lancet 2001;358:9-15). There is less confidence about prevention of proximal DVTs with mechanical devices. The risks should be weighed against this efficacy, Dr. Douketis said.

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. Dr. Colwell disclosed he is a consultant and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – Compliance with postpartum visits and long-acting reversible contraception significantly reduced repeat pregnancies among 210 first-time adolescent mothers, according to a retrospective chart review.

These are "the most important tools for preventing subsequent adolescent pregnancy," Dr. Lauren F. Damle said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We are currently at an all-time low in teenage pregnancies. However, despite this, rates are still higher in our country than in most other industrialized countries," Dr. Damle said.

"Rapid repeat pregnancy is a major problem, with up to 50% of adolescent mothers becoming pregnant again within 2 years of their first delivery. Adolescent mothers in general are also more likely to be living in poverty, and those who have a second child during their adolescence are less likely to ever achieve economic self-sufficiency," said Dr. Damle, a gynecology fellow at MedStar Washington Hospital Center in Washington.

Dr. Damle and her associates conducted a study to answer two questions: Does early initiation of contraception post partum prevent rapid repeat pregnancy? Do adolescent mothers who use long-acting reversible contraception (LARC) have a lower chance of a repeat pregnancy?

Of the 4,721 deliveries at MedStar Washington Hospital Center in 2008, 757 involved adolescents 18 years and younger. This group included 210 first time mothers who had a live birth, and this group was studied further.

A minority of the 210 first-time mothers, 19%, received a medroxyprogesterone (Depo-Provera, Pharmacia & Upjohn Company) injection before going home. The remaining 81% received no contraception prior to discharge.

At their 6-week postpartum follow-up visit, 23% had received a medroxyprogesterone shot, 11% had an IUD placed, and 4% received an etonogestrel 68 mg implant (Implanon). "Interestingly, only 10% were using oral contraceptives, a very, very common form of birth control," Dr. Damle said.

In terms of LARC usage, 16% had an implant or IUD placed within the first 8 weeks. Another 5% had documented their intention to start LARC.

The rapid repeat pregnancy rate was high in this cohort, Dr. Damle said. A total of 74 adolescent mothers had another pregnancy within 2 years, comprising 35% of the entire cohort and 49% of those within the 2 year follow-up. "This is in line with what is reported in the literature, but it is still very concerning."

Mean time between delivery and conception was 424 days.

In all, 74 of 152 (49%) first time adolescent mothers had a repeat pregnancy within 2 years.

Follow-up within 8 weeks post partum was associated with lower chance of repeat pregnancy (odds ratio, 0.246). Initiation of LARC also was associated with decreased chance of rapid repeat pregnancy (OR, 0.135).

An interesting finding was no significant difference in the repeat pregnancy rate between adolescent mothers who received medroxyprogesterone and those who did not, Dr. Damle said. She added that this was the only form of contraception administered at the hospital in 2008.

All participated in prenatal care at the institution, including 103 teenagers who participated in Teen Alliance for Prepared Parenting (TAPP), a program specifically aimed at preventing repeat teenage pregnancies. The TAPP cohort, however, did not have a significantly lower rapid repeat pregnancy rate, compared with the non-TAPP group.

The mean age at first delivery was 17.5 years. The majority of first time adolescent mothers, 197 of the 210 (94%), were black. A total 91% had Medicaid or other form of public insurance.

A meeting attendee asked if the lower repeat pregnancy rate for the group who returned for postpartum care within 8 weeks could be due to patient self-selection. "I don’t think my study answers that question," Dr. Damle said. "Those who come in may be more responsible adolescents in starting contraception." The next study is to do an intervention before people leave the hospital, she said, although that is difficult to do without research funding because patients are typically not reimbursed by their insurance for LARC in the hospital setting. "Implementing immediate postpartum LARC may further prevent unwanted pregnancy."

The retrospective cohort design of the study is a potential limitation, Dr. Damle said. In addition, she and her colleagues assumed all the adolescent pregnancies were undesired and unplanned, but admitted that may not have been the case in all instances. Also, 58 first-time mothers were lost to follow-up and were not included in the 2-year follow-up analysis.

Dr. Damle said she had no relevant financial disclosures.

MIAMI BEACH – Compliance with postpartum visits and long-acting reversible contraception significantly reduced repeat pregnancies among 210 first-time adolescent mothers, according to a retrospective chart review.

These are "the most important tools for preventing subsequent adolescent pregnancy," Dr. Lauren F. Damle said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We are currently at an all-time low in teenage pregnancies. However, despite this, rates are still higher in our country than in most other industrialized countries," Dr. Damle said.

"Rapid repeat pregnancy is a major problem, with up to 50% of adolescent mothers becoming pregnant again within 2 years of their first delivery. Adolescent mothers in general are also more likely to be living in poverty, and those who have a second child during their adolescence are less likely to ever achieve economic self-sufficiency," said Dr. Damle, a gynecology fellow at MedStar Washington Hospital Center in Washington.

Dr. Damle and her associates conducted a study to answer two questions: Does early initiation of contraception post partum prevent rapid repeat pregnancy? Do adolescent mothers who use long-acting reversible contraception (LARC) have a lower chance of a repeat pregnancy?

Of the 4,721 deliveries at MedStar Washington Hospital Center in 2008, 757 involved adolescents 18 years and younger. This group included 210 first time mothers who had a live birth, and this group was studied further.

A minority of the 210 first-time mothers, 19%, received a medroxyprogesterone (Depo-Provera, Pharmacia & Upjohn Company) injection before going home. The remaining 81% received no contraception prior to discharge.

At their 6-week postpartum follow-up visit, 23% had received a medroxyprogesterone shot, 11% had an IUD placed, and 4% received an etonogestrel 68 mg implant (Implanon). "Interestingly, only 10% were using oral contraceptives, a very, very common form of birth control," Dr. Damle said.

In terms of LARC usage, 16% had an implant or IUD placed within the first 8 weeks. Another 5% had documented their intention to start LARC.

The rapid repeat pregnancy rate was high in this cohort, Dr. Damle said. A total of 74 adolescent mothers had another pregnancy within 2 years, comprising 35% of the entire cohort and 49% of those within the 2 year follow-up. "This is in line with what is reported in the literature, but it is still very concerning."

Mean time between delivery and conception was 424 days.

In all, 74 of 152 (49%) first time adolescent mothers had a repeat pregnancy within 2 years.

Follow-up within 8 weeks post partum was associated with lower chance of repeat pregnancy (odds ratio, 0.246). Initiation of LARC also was associated with decreased chance of rapid repeat pregnancy (OR, 0.135).

An interesting finding was no significant difference in the repeat pregnancy rate between adolescent mothers who received medroxyprogesterone and those who did not, Dr. Damle said. She added that this was the only form of contraception administered at the hospital in 2008.

All participated in prenatal care at the institution, including 103 teenagers who participated in Teen Alliance for Prepared Parenting (TAPP), a program specifically aimed at preventing repeat teenage pregnancies. The TAPP cohort, however, did not have a significantly lower rapid repeat pregnancy rate, compared with the non-TAPP group.

The mean age at first delivery was 17.5 years. The majority of first time adolescent mothers, 197 of the 210 (94%), were black. A total 91% had Medicaid or other form of public insurance.

A meeting attendee asked if the lower repeat pregnancy rate for the group who returned for postpartum care within 8 weeks could be due to patient self-selection. "I don’t think my study answers that question," Dr. Damle said. "Those who come in may be more responsible adolescents in starting contraception." The next study is to do an intervention before people leave the hospital, she said, although that is difficult to do without research funding because patients are typically not reimbursed by their insurance for LARC in the hospital setting. "Implementing immediate postpartum LARC may further prevent unwanted pregnancy."

The retrospective cohort design of the study is a potential limitation, Dr. Damle said. In addition, she and her colleagues assumed all the adolescent pregnancies were undesired and unplanned, but admitted that may not have been the case in all instances. Also, 58 first-time mothers were lost to follow-up and were not included in the 2-year follow-up analysis.

Dr. Damle said she had no relevant financial disclosures.

MIAMI BEACH – Compliance with postpartum visits and long-acting reversible contraception significantly reduced repeat pregnancies among 210 first-time adolescent mothers, according to a retrospective chart review.

These are "the most important tools for preventing subsequent adolescent pregnancy," Dr. Lauren F. Damle said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We are currently at an all-time low in teenage pregnancies. However, despite this, rates are still higher in our country than in most other industrialized countries," Dr. Damle said.

"Rapid repeat pregnancy is a major problem, with up to 50% of adolescent mothers becoming pregnant again within 2 years of their first delivery. Adolescent mothers in general are also more likely to be living in poverty, and those who have a second child during their adolescence are less likely to ever achieve economic self-sufficiency," said Dr. Damle, a gynecology fellow at MedStar Washington Hospital Center in Washington.

Dr. Damle and her associates conducted a study to answer two questions: Does early initiation of contraception post partum prevent rapid repeat pregnancy? Do adolescent mothers who use long-acting reversible contraception (LARC) have a lower chance of a repeat pregnancy?

Of the 4,721 deliveries at MedStar Washington Hospital Center in 2008, 757 involved adolescents 18 years and younger. This group included 210 first time mothers who had a live birth, and this group was studied further.

A minority of the 210 first-time mothers, 19%, received a medroxyprogesterone (Depo-Provera, Pharmacia & Upjohn Company) injection before going home. The remaining 81% received no contraception prior to discharge.

At their 6-week postpartum follow-up visit, 23% had received a medroxyprogesterone shot, 11% had an IUD placed, and 4% received an etonogestrel 68 mg implant (Implanon). "Interestingly, only 10% were using oral contraceptives, a very, very common form of birth control," Dr. Damle said.

In terms of LARC usage, 16% had an implant or IUD placed within the first 8 weeks. Another 5% had documented their intention to start LARC.

The rapid repeat pregnancy rate was high in this cohort, Dr. Damle said. A total of 74 adolescent mothers had another pregnancy within 2 years, comprising 35% of the entire cohort and 49% of those within the 2 year follow-up. "This is in line with what is reported in the literature, but it is still very concerning."

Mean time between delivery and conception was 424 days.

In all, 74 of 152 (49%) first time adolescent mothers had a repeat pregnancy within 2 years.

Follow-up within 8 weeks post partum was associated with lower chance of repeat pregnancy (odds ratio, 0.246). Initiation of LARC also was associated with decreased chance of rapid repeat pregnancy (OR, 0.135).

An interesting finding was no significant difference in the repeat pregnancy rate between adolescent mothers who received medroxyprogesterone and those who did not, Dr. Damle said. She added that this was the only form of contraception administered at the hospital in 2008.

All participated in prenatal care at the institution, including 103 teenagers who participated in Teen Alliance for Prepared Parenting (TAPP), a program specifically aimed at preventing repeat teenage pregnancies. The TAPP cohort, however, did not have a significantly lower rapid repeat pregnancy rate, compared with the non-TAPP group.

The mean age at first delivery was 17.5 years. The majority of first time adolescent mothers, 197 of the 210 (94%), were black. A total 91% had Medicaid or other form of public insurance.

A meeting attendee asked if the lower repeat pregnancy rate for the group who returned for postpartum care within 8 weeks could be due to patient self-selection. "I don’t think my study answers that question," Dr. Damle said. "Those who come in may be more responsible adolescents in starting contraception." The next study is to do an intervention before people leave the hospital, she said, although that is difficult to do without research funding because patients are typically not reimbursed by their insurance for LARC in the hospital setting. "Implementing immediate postpartum LARC may further prevent unwanted pregnancy."

The retrospective cohort design of the study is a potential limitation, Dr. Damle said. In addition, she and her colleagues assumed all the adolescent pregnancies were undesired and unplanned, but admitted that may not have been the case in all instances. Also, 58 first-time mothers were lost to follow-up and were not included in the 2-year follow-up analysis.

Dr. Damle said she had no relevant financial disclosures.

MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.

Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).

Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.

"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."

Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.

Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.

A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."

Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."

The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.

All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.

Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."

Dr. Opoku-Anane said that she had no relevant financial disclosures.

MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.

Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).

Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.

"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."

Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.

Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.

A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."

Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."

The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.

All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.

Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."

Dr. Opoku-Anane said that she had no relevant financial disclosures.

MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.

Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).

Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.

"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."

Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.

Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.

A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."

Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."

The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.

All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.

Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."

Dr. Opoku-Anane said that she had no relevant financial disclosures.

MIAMI BEACH – Recommendations to stop taking aspirin therapy 7-10 days before surgery aren’t optimal for everyone, according to several experts who sought to tease out the best approach for multiple clinical scenarios given the lack of data on the issue.

Yet many clinicians have reservations about continuing aspirin perioperatively because, unlike other antiplatelet agents, it irreversibly inhibits platelet cyclooxygenase. In other words, once a platelet is inhibited by aspirin, the effect lasts for the 7-10 days it takes the body to replace circulating platelets.

As a result, most low-risk patients who are taking aspirin therapy for primary prevention of cardiovascular disease currently are advised to stop taking it 7 to 10 days before surgery," said Dr. Amir Jaffer, chief of the Division of Hospital Medicine and member of the medicine faculty at the University of Miami. New guidelines from the American College of Chest Physicians shore up that practice by advising an interruption of an aspirin regimen 7-10 days prior to major or minor surgery if the patient is at lower risk (Chest 2012;141:e326S-50S).

But such a blanket recommendation isn’t necessarily the best approach for every patient taking therapy for primary prevention, according to Dr. Jaffer and others at the meeting. Instead, aspirin should in many cases probably be continued perioperatively at least for some of the time.

Changing practice is a systems issue, he added. "We need to get all the stakeholders together and create an algorithm or guideline so you can keep patients on their aspirin at the time of surgery."

It should be noted that the ACCP guidelines recommend continuing aspirin prior to major or minor surgery if the patient is at higher risk for cardiovascular events and taking the agent as a means of secondary prevention.

In a separate presentation, Dr. Steven L. Cohn said that "3-5 days before surgery may be the most ideal for stopping aspirin if you are going to stop it at all." He added, "Try to continue aspirin as much as possible."

It comes down to balancing the potential for perioperative bleeding with the risk for potential rebound clotting effects after aspirin withdrawal, said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

And given the paucity of great evidence on the issue, it makes sense to consider expert consensus, Dr. Cohn said. For example, continue aspirin for minor surgery, according to an international consensus paper (Thromb. Haemost. 2011;105:743-9).

In the setting of primary prevention, stop aspirin 5 days before surgery. Continue aspirin for secondary prevention except if surgery is to take place in a closed space or a major bleeding complication is anticipated (in those cases, stop 5 days before surgery and restart in a stable patient 24 hours postoperatively), he said.

Experts at the meeting also agreed that elective surgery should be delayed for patients on a dual agent regimen. If the surgery is semi-elective or urgent, "you may need to prematurely stop one of the agents," Dr. Cohn said. In the case of emergency surgery, "you won’t have a choice." Have platelets available for transfusion during emergency procedures, these experts recommend.

Dr. Kurt J. Pfeifer also outlined the benefits and risks of perioperative aspirin continuation and offered advice on optimal dosing.

There is stronger evidence of aspirin’s benefits outside the perioperative setting, Dr. Pfeiffer said. However, data to support continuation of aspirin perioperatively include a decrease in incidence of intra- and postoperative stroke (grade 1A evidence, ACCP guidelines); peripheral arterial disease (Br. J. Surg. 2001;88:777-800); and myocardial infarction and other major cardiovascular events (Br. J. Anaesth. 2010;104:305-12).

Stent thrombosis risk is clearly increased when you withdraw aspirin therapy in patients, said Dr. Pfeifer, an attending in Perioperative and Consultative Medicine at Froedtert Hospital and member of the medicine faculty at the Medical College of Wisconsin, Milwaukee.

© Darren Hester/Fotolia.com

The risk is further elevated if patients have renal insufficiency, diabetes mellitus, or multiple stents. In contrast, the risk is lower for patients on dual clopidogrel-aspirin therapy who discontinue clopidogrel only preoperatively, he added.

The incidence of thrombosis ranges up to 15% within 90 days of stent placement to about 1% of drug-eluting stents up to 1 year (J. Am. Coll. Cardiol. 2007;49:734-9).

"Even though it’s 1%, up to 45% die, so it’s a big deal," Dr. Pfeifer said.

The risks related to in-stent thrombosis obviously also differ based on location of the stent, Dr. Pfeifer said. Risks for myocardial infarction and death are elevated with cardiac stents, for example. Occlusion at other sites can be serious as well, he added, "but you have more time to do something."

"It appears that operating on aspirin appears to be safe," Dr. Pfeifer said. Exceptions include intracranial procedures and surgery on the medullary canal of the spine; posterior eye chamber; and non-laser transurethral resection of the prostate.

In terms of perioperative dose, the best available evidence suggests no benefit to increasing aspirin dose above 100 mg for most patients, Dr. Pfeifer said (JAMA 2007;297:2018-24).

And dose increases mean increased risk of bleeding as well, he added.

"It seems reasonable to use 81 mg as your perioperative dose, and then to give them a higher dose after that," Dr. Pfeifer said. "The old saying of an aspirin a day keeps the doctor away does not apply to the surgeon."

More definitive answers could come from POISE-2 (PeriOperative ISchemic Evaluation Trial), which is currently enrolling participants with a goal of including 10,000 patients, Dr. Cohn said. Researchers aim to compare patients taking clonidine, aspirin, both, or neither. The results are scheduled for release in 2014.

Dr. Jaffer is a medical advisor to Hospitalist News. Dr. Jaffer, Dr. Cohn, and Dr. Pfeifer had no relevant disclosures.

MIAMI BEACH – Recommendations to stop taking aspirin therapy 7-10 days before surgery aren’t optimal for everyone, according to several experts who sought to tease out the best approach for multiple clinical scenarios given the lack of data on the issue.

Yet many clinicians have reservations about continuing aspirin perioperatively because, unlike other antiplatelet agents, it irreversibly inhibits platelet cyclooxygenase. In other words, once a platelet is inhibited by aspirin, the effect lasts for the 7-10 days it takes the body to replace circulating platelets.

As a result, most low-risk patients who are taking aspirin therapy for primary prevention of cardiovascular disease currently are advised to stop taking it 7 to 10 days before surgery," said Dr. Amir Jaffer, chief of the Division of Hospital Medicine and member of the medicine faculty at the University of Miami. New guidelines from the American College of Chest Physicians shore up that practice by advising an interruption of an aspirin regimen 7-10 days prior to major or minor surgery if the patient is at lower risk (Chest 2012;141:e326S-50S).

But such a blanket recommendation isn’t necessarily the best approach for every patient taking therapy for primary prevention, according to Dr. Jaffer and others at the meeting. Instead, aspirin should in many cases probably be continued perioperatively at least for some of the time.

Changing practice is a systems issue, he added. "We need to get all the stakeholders together and create an algorithm or guideline so you can keep patients on their aspirin at the time of surgery."

It should be noted that the ACCP guidelines recommend continuing aspirin prior to major or minor surgery if the patient is at higher risk for cardiovascular events and taking the agent as a means of secondary prevention.

In a separate presentation, Dr. Steven L. Cohn said that "3-5 days before surgery may be the most ideal for stopping aspirin if you are going to stop it at all." He added, "Try to continue aspirin as much as possible."

It comes down to balancing the potential for perioperative bleeding with the risk for potential rebound clotting effects after aspirin withdrawal, said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

And given the paucity of great evidence on the issue, it makes sense to consider expert consensus, Dr. Cohn said. For example, continue aspirin for minor surgery, according to an international consensus paper (Thromb. Haemost. 2011;105:743-9).

In the setting of primary prevention, stop aspirin 5 days before surgery. Continue aspirin for secondary prevention except if surgery is to take place in a closed space or a major bleeding complication is anticipated (in those cases, stop 5 days before surgery and restart in a stable patient 24 hours postoperatively), he said.

Experts at the meeting also agreed that elective surgery should be delayed for patients on a dual agent regimen. If the surgery is semi-elective or urgent, "you may need to prematurely stop one of the agents," Dr. Cohn said. In the case of emergency surgery, "you won’t have a choice." Have platelets available for transfusion during emergency procedures, these experts recommend.

Dr. Kurt J. Pfeifer also outlined the benefits and risks of perioperative aspirin continuation and offered advice on optimal dosing.

There is stronger evidence of aspirin’s benefits outside the perioperative setting, Dr. Pfeiffer said. However, data to support continuation of aspirin perioperatively include a decrease in incidence of intra- and postoperative stroke (grade 1A evidence, ACCP guidelines); peripheral arterial disease (Br. J. Surg. 2001;88:777-800); and myocardial infarction and other major cardiovascular events (Br. J. Anaesth. 2010;104:305-12).

Stent thrombosis risk is clearly increased when you withdraw aspirin therapy in patients, said Dr. Pfeifer, an attending in Perioperative and Consultative Medicine at Froedtert Hospital and member of the medicine faculty at the Medical College of Wisconsin, Milwaukee.

© Darren Hester/Fotolia.com

The risk is further elevated if patients have renal insufficiency, diabetes mellitus, or multiple stents. In contrast, the risk is lower for patients on dual clopidogrel-aspirin therapy who discontinue clopidogrel only preoperatively, he added.

The incidence of thrombosis ranges up to 15% within 90 days of stent placement to about 1% of drug-eluting stents up to 1 year (J. Am. Coll. Cardiol. 2007;49:734-9).

"Even though it’s 1%, up to 45% die, so it’s a big deal," Dr. Pfeifer said.

The risks related to in-stent thrombosis obviously also differ based on location of the stent, Dr. Pfeifer said. Risks for myocardial infarction and death are elevated with cardiac stents, for example. Occlusion at other sites can be serious as well, he added, "but you have more time to do something."

"It appears that operating on aspirin appears to be safe," Dr. Pfeifer said. Exceptions include intracranial procedures and surgery on the medullary canal of the spine; posterior eye chamber; and non-laser transurethral resection of the prostate.

In terms of perioperative dose, the best available evidence suggests no benefit to increasing aspirin dose above 100 mg for most patients, Dr. Pfeifer said (JAMA 2007;297:2018-24).

And dose increases mean increased risk of bleeding as well, he added.

"It seems reasonable to use 81 mg as your perioperative dose, and then to give them a higher dose after that," Dr. Pfeifer said. "The old saying of an aspirin a day keeps the doctor away does not apply to the surgeon."

More definitive answers could come from POISE-2 (PeriOperative ISchemic Evaluation Trial), which is currently enrolling participants with a goal of including 10,000 patients, Dr. Cohn said. Researchers aim to compare patients taking clonidine, aspirin, both, or neither. The results are scheduled for release in 2014.

Dr. Jaffer is a medical advisor to Hospitalist News. Dr. Jaffer, Dr. Cohn, and Dr. Pfeifer had no relevant disclosures.

MIAMI BEACH – Recommendations to stop taking aspirin therapy 7-10 days before surgery aren’t optimal for everyone, according to several experts who sought to tease out the best approach for multiple clinical scenarios given the lack of data on the issue.

Yet many clinicians have reservations about continuing aspirin perioperatively because, unlike other antiplatelet agents, it irreversibly inhibits platelet cyclooxygenase. In other words, once a platelet is inhibited by aspirin, the effect lasts for the 7-10 days it takes the body to replace circulating platelets.

As a result, most low-risk patients who are taking aspirin therapy for primary prevention of cardiovascular disease currently are advised to stop taking it 7 to 10 days before surgery," said Dr. Amir Jaffer, chief of the Division of Hospital Medicine and member of the medicine faculty at the University of Miami. New guidelines from the American College of Chest Physicians shore up that practice by advising an interruption of an aspirin regimen 7-10 days prior to major or minor surgery if the patient is at lower risk (Chest 2012;141:e326S-50S).

But such a blanket recommendation isn’t necessarily the best approach for every patient taking therapy for primary prevention, according to Dr. Jaffer and others at the meeting. Instead, aspirin should in many cases probably be continued perioperatively at least for some of the time.

Changing practice is a systems issue, he added. "We need to get all the stakeholders together and create an algorithm or guideline so you can keep patients on their aspirin at the time of surgery."

It should be noted that the ACCP guidelines recommend continuing aspirin prior to major or minor surgery if the patient is at higher risk for cardiovascular events and taking the agent as a means of secondary prevention.

In a separate presentation, Dr. Steven L. Cohn said that "3-5 days before surgery may be the most ideal for stopping aspirin if you are going to stop it at all." He added, "Try to continue aspirin as much as possible."

It comes down to balancing the potential for perioperative bleeding with the risk for potential rebound clotting effects after aspirin withdrawal, said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

And given the paucity of great evidence on the issue, it makes sense to consider expert consensus, Dr. Cohn said. For example, continue aspirin for minor surgery, according to an international consensus paper (Thromb. Haemost. 2011;105:743-9).

In the setting of primary prevention, stop aspirin 5 days before surgery. Continue aspirin for secondary prevention except if surgery is to take place in a closed space or a major bleeding complication is anticipated (in those cases, stop 5 days before surgery and restart in a stable patient 24 hours postoperatively), he said.

Experts at the meeting also agreed that elective surgery should be delayed for patients on a dual agent regimen. If the surgery is semi-elective or urgent, "you may need to prematurely stop one of the agents," Dr. Cohn said. In the case of emergency surgery, "you won’t have a choice." Have platelets available for transfusion during emergency procedures, these experts recommend.

Dr. Kurt J. Pfeifer also outlined the benefits and risks of perioperative aspirin continuation and offered advice on optimal dosing.

There is stronger evidence of aspirin’s benefits outside the perioperative setting, Dr. Pfeiffer said. However, data to support continuation of aspirin perioperatively include a decrease in incidence of intra- and postoperative stroke (grade 1A evidence, ACCP guidelines); peripheral arterial disease (Br. J. Surg. 2001;88:777-800); and myocardial infarction and other major cardiovascular events (Br. J. Anaesth. 2010;104:305-12).

Stent thrombosis risk is clearly increased when you withdraw aspirin therapy in patients, said Dr. Pfeifer, an attending in Perioperative and Consultative Medicine at Froedtert Hospital and member of the medicine faculty at the Medical College of Wisconsin, Milwaukee.

© Darren Hester/Fotolia.com

The risk is further elevated if patients have renal insufficiency, diabetes mellitus, or multiple stents. In contrast, the risk is lower for patients on dual clopidogrel-aspirin therapy who discontinue clopidogrel only preoperatively, he added.

The incidence of thrombosis ranges up to 15% within 90 days of stent placement to about 1% of drug-eluting stents up to 1 year (J. Am. Coll. Cardiol. 2007;49:734-9).

"Even though it’s 1%, up to 45% die, so it’s a big deal," Dr. Pfeifer said.

The risks related to in-stent thrombosis obviously also differ based on location of the stent, Dr. Pfeifer said. Risks for myocardial infarction and death are elevated with cardiac stents, for example. Occlusion at other sites can be serious as well, he added, "but you have more time to do something."

"It appears that operating on aspirin appears to be safe," Dr. Pfeifer said. Exceptions include intracranial procedures and surgery on the medullary canal of the spine; posterior eye chamber; and non-laser transurethral resection of the prostate.

In terms of perioperative dose, the best available evidence suggests no benefit to increasing aspirin dose above 100 mg for most patients, Dr. Pfeifer said (JAMA 2007;297:2018-24).

And dose increases mean increased risk of bleeding as well, he added.

"It seems reasonable to use 81 mg as your perioperative dose, and then to give them a higher dose after that," Dr. Pfeifer said. "The old saying of an aspirin a day keeps the doctor away does not apply to the surgeon."

More definitive answers could come from POISE-2 (PeriOperative ISchemic Evaluation Trial), which is currently enrolling participants with a goal of including 10,000 patients, Dr. Cohn said. Researchers aim to compare patients taking clonidine, aspirin, both, or neither. The results are scheduled for release in 2014.

Dr. Jaffer is a medical advisor to Hospitalist News. Dr. Jaffer, Dr. Cohn, and Dr. Pfeifer had no relevant disclosures.

MIAMI BEACH – What do the timing of smoking cessation prior to surgery, reliable prediction of postoperative respiratory failure, and biomarkers that point to elevated postoperative myocardial infarction risk have in common? They emerged as some of the most prominent findings published in the past year, according to three experts in hospital medicine.

Dr. Gerald W. Smetana, Dr. Steven L. Cohn, and Dr. Paul J. Grant each selected studies of particular relevance to hospitalists and explained why during a panel presentation at a meeting on perioperative medicine sponsored by the University of Miami:

© milosluz/istockphoto.com

• Preoperative Smoking Cessation. When a patient stops smoking up to 8 weeks before noncardiac surgery, it does not significantly change the total or pulmonary complication rates, according to a systematic literature review (Arch. Intern. Med. 2011;171:983-9).

"Many patients who quit smoking report they feel worse before they feel better," said Dr. Smetana, an attending in the general medicine division at Beth Israel Deaconess Medical Center, Boston.

Increased cough and sputum production are common right after quitting, he said. "This could be a plausible mechanism to explain why recent quitters might be at increased risk for postoperative pulmonary complications."

However, there was no statistically significant difference in total complications (relative risk of 0.78 for recent quitters, compared with a reference value of 1.0 for current smokers) in the nine eligible studies with 889 participants. Five of the trials assessed pulmonary complications, and found that recent quitters had a nonsignificant increased risk (RR, 1.18) compared with patients who continued to smoke.

Until there is consensus based on large randomized trials, stopping smoking before surgery can be considered safe, said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School. In addition, longer periods of cessation are likely better than shorter ones. He added that despite the lack of a significant finding, it is still worthwhile to counsel patients because any time before surgery is a still a teachable moment for smoking cessation.

• Predicting Postoperative Pulmonary Failure. Type of procedure, emergency surgery, poor dependent functional status, sepsis, and higher American Society of Anesthesiologists classification were the five independent preoperative factors that significantly predicted postoperative respiratory failure in a multicenter database study (Chest 2011;140:1207-15).

The study included 211,410 participants undergoing all types of surgery. Mortality was 26% among those with postoperative respiratory failure, compared with 1% for unaffected patients. "This shows how important pulmonary complications can be," Dr. Smetana said.

The researchers incorporated these five predictors into a surgical risk calculator that is downloadable for free.

Dr. Smetana said, "It is a nice tool that ... helps to stratify patients. It makes a difference in identifying which patients for which you will pull out all the stops."

• Preoperative Peptide Gauges Risk. Although multiple researchers have looked at preoperative B-type natriuretic peptide (BNP) as a predictor of postoperative cardiac events or death, there remain "a lot of unknowns for BNP at this point," said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

A recent meta-analysis may shed some light on the predictive value of BNP (J. Am. Coll. Cardiol. 2011;58:522-9). Investigators assessed five BNP studies with 632 patients to determine cutoff values for screening (high sensitivity) and diagnosis (high specificity), and an optimal value that combines both.

The researchers found that patients with BNP above the optimal cutoff point of 116 pg/mL had a significantly elevated risk for the composite outcome of nonfatal myocardial infarction or cardiovascular death (unadjusted odds ratio, 7.36). Compared with use of the Revised Cardiac Risk Index, the optimal BNP cutoff classification improved risk prediction by 58%. This means some patients moved to a more accurate ranking among the low-, intermediate- and high-risk categories, Dr. Cohn said.

• Troponin and Postoperative MI Risk. Myocardial infarction is the most common major, perioperative vascular complication, so investigators continue to search for an accurate way to identify high-risk patients. Some propose elevated serum levels of the protein troponin as a predictor, Dr. Cohn said, but the question remains: Would it change patient management and improve outcomes?

Researchers found that increased troponin after noncardiac surgery did in fact independently predict postoperative MI mortality in a meta-analysis (Anesthesiology 2011;114:796-806).

Elevated levels significantly predicted increased risk in the 14 studies with 3,318 patients overall (OR, 3.4). However, prediction within the first year was higher (OR, 6.7) compared with studies that measured troponin more than 12 months out (OR, 1.8).

These findings could have implications for practice, because the majority of perioperative MIs are asymptomatic, Dr. Cohn said. "Maybe we should, as the authors suggest, recommend routine troponins after high-risk surgery."

More frequent vital-sign monitoring; transfer to a unit with additional monitoring; and/or screening for hypoxia and anemia could be implemented in patients identified as high risk, Dr. Cohn said. Optimization of intravascular volume and initiation of cardiac medications are additional strategies. Also, closely monitored patients who experience an MI potentially could be transferred for cardiac catheterization or revascularization more quickly.

"It is thought provoking that we can change the management," Dr. Cohn said.

• HF, AF, and Cardiovascular Risk. Heart failure and atrial fibrillation should factor more prominently into cardiovascular risk stratification prior to noncardiac surgery, according to a population-based cohort study of more than 38,000 consecutive patients (Circulation 2011:124:289-96).

"There are many cardiovascular risk stratification tools available with quite a bit of variation. Coronary artery disease [CAD] is typically weighted heavily on most models," said Dr. Grant, director of perioperative and consultative medicine and member of the medicine faculty at the University of Michigan in Ann Arbor.

However, researchers found that ischemic and nonischemic heart failure and atrial fibrillation were more commonly associated with 30-day mortality and readmission rates than CAD in this large cohort, Dr. Grant said. The authors concluded that these risk factors are likely underestimated in current prediction models.

• Liberal vs. Conservative Blood Transfusion. "The hemoglobin level at which we decide to transfuse patients after surgery is controversial," Dr. Grant said, "and has not been adequately studied to date. Great variations in practice exist."

A randomized controlled trial of 2,016 hip fracture surgery patients found no significant difference between liberal and conservative postoperative blood transfusion policies in terms of mortality or ability to walk independently at 60 days for patients at high cardiovascular risk (N. Engl. J. Med. 2011;365:2453-62).

The liberal policy allowed transfusions to maintain hemoglobin at 10 g/dL. In contrast, patients randomized to a conservative approach could only be transfused if they had symptoms of anemia or at the physician’s discretion once hemoglobin was below 8 g/dL.

"Implications for practice, from my point of view, include some more evidence that maybe using more of a restrictive transfusion practice may be reasonable, including for higher-risk populations," Dr. Grant said. However, "red-cell transfusion practices still need to be individualized for your perioperative patient."

Dr. Smetana, Dr. Cohn, and Dr. Grant had no relevant financial disclosures.

MIAMI BEACH – What do the timing of smoking cessation prior to surgery, reliable prediction of postoperative respiratory failure, and biomarkers that point to elevated postoperative myocardial infarction risk have in common? They emerged as some of the most prominent findings published in the past year, according to three experts in hospital medicine.

Dr. Gerald W. Smetana, Dr. Steven L. Cohn, and Dr. Paul J. Grant each selected studies of particular relevance to hospitalists and explained why during a panel presentation at a meeting on perioperative medicine sponsored by the University of Miami:

© milosluz/istockphoto.com

• Preoperative Smoking Cessation. When a patient stops smoking up to 8 weeks before noncardiac surgery, it does not significantly change the total or pulmonary complication rates, according to a systematic literature review (Arch. Intern. Med. 2011;171:983-9).

"Many patients who quit smoking report they feel worse before they feel better," said Dr. Smetana, an attending in the general medicine division at Beth Israel Deaconess Medical Center, Boston.

Increased cough and sputum production are common right after quitting, he said. "This could be a plausible mechanism to explain why recent quitters might be at increased risk for postoperative pulmonary complications."

However, there was no statistically significant difference in total complications (relative risk of 0.78 for recent quitters, compared with a reference value of 1.0 for current smokers) in the nine eligible studies with 889 participants. Five of the trials assessed pulmonary complications, and found that recent quitters had a nonsignificant increased risk (RR, 1.18) compared with patients who continued to smoke.

Until there is consensus based on large randomized trials, stopping smoking before surgery can be considered safe, said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School. In addition, longer periods of cessation are likely better than shorter ones. He added that despite the lack of a significant finding, it is still worthwhile to counsel patients because any time before surgery is a still a teachable moment for smoking cessation.

• Predicting Postoperative Pulmonary Failure. Type of procedure, emergency surgery, poor dependent functional status, sepsis, and higher American Society of Anesthesiologists classification were the five independent preoperative factors that significantly predicted postoperative respiratory failure in a multicenter database study (Chest 2011;140:1207-15).

The study included 211,410 participants undergoing all types of surgery. Mortality was 26% among those with postoperative respiratory failure, compared with 1% for unaffected patients. "This shows how important pulmonary complications can be," Dr. Smetana said.

The researchers incorporated these five predictors into a surgical risk calculator that is downloadable for free.

Dr. Smetana said, "It is a nice tool that ... helps to stratify patients. It makes a difference in identifying which patients for which you will pull out all the stops."

• Preoperative Peptide Gauges Risk. Although multiple researchers have looked at preoperative B-type natriuretic peptide (BNP) as a predictor of postoperative cardiac events or death, there remain "a lot of unknowns for BNP at this point," said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

A recent meta-analysis may shed some light on the predictive value of BNP (J. Am. Coll. Cardiol. 2011;58:522-9). Investigators assessed five BNP studies with 632 patients to determine cutoff values for screening (high sensitivity) and diagnosis (high specificity), and an optimal value that combines both.

The researchers found that patients with BNP above the optimal cutoff point of 116 pg/mL had a significantly elevated risk for the composite outcome of nonfatal myocardial infarction or cardiovascular death (unadjusted odds ratio, 7.36). Compared with use of the Revised Cardiac Risk Index, the optimal BNP cutoff classification improved risk prediction by 58%. This means some patients moved to a more accurate ranking among the low-, intermediate- and high-risk categories, Dr. Cohn said.

• Troponin and Postoperative MI Risk. Myocardial infarction is the most common major, perioperative vascular complication, so investigators continue to search for an accurate way to identify high-risk patients. Some propose elevated serum levels of the protein troponin as a predictor, Dr. Cohn said, but the question remains: Would it change patient management and improve outcomes?

Researchers found that increased troponin after noncardiac surgery did in fact independently predict postoperative MI mortality in a meta-analysis (Anesthesiology 2011;114:796-806).

Elevated levels significantly predicted increased risk in the 14 studies with 3,318 patients overall (OR, 3.4). However, prediction within the first year was higher (OR, 6.7) compared with studies that measured troponin more than 12 months out (OR, 1.8).

These findings could have implications for practice, because the majority of perioperative MIs are asymptomatic, Dr. Cohn said. "Maybe we should, as the authors suggest, recommend routine troponins after high-risk surgery."

More frequent vital-sign monitoring; transfer to a unit with additional monitoring; and/or screening for hypoxia and anemia could be implemented in patients identified as high risk, Dr. Cohn said. Optimization of intravascular volume and initiation of cardiac medications are additional strategies. Also, closely monitored patients who experience an MI potentially could be transferred for cardiac catheterization or revascularization more quickly.

"It is thought provoking that we can change the management," Dr. Cohn said.

• HF, AF, and Cardiovascular Risk. Heart failure and atrial fibrillation should factor more prominently into cardiovascular risk stratification prior to noncardiac surgery, according to a population-based cohort study of more than 38,000 consecutive patients (Circulation 2011:124:289-96).

"There are many cardiovascular risk stratification tools available with quite a bit of variation. Coronary artery disease [CAD] is typically weighted heavily on most models," said Dr. Grant, director of perioperative and consultative medicine and member of the medicine faculty at the University of Michigan in Ann Arbor.

However, researchers found that ischemic and nonischemic heart failure and atrial fibrillation were more commonly associated with 30-day mortality and readmission rates than CAD in this large cohort, Dr. Grant said. The authors concluded that these risk factors are likely underestimated in current prediction models.

• Liberal vs. Conservative Blood Transfusion. "The hemoglobin level at which we decide to transfuse patients after surgery is controversial," Dr. Grant said, "and has not been adequately studied to date. Great variations in practice exist."

A randomized controlled trial of 2,016 hip fracture surgery patients found no significant difference between liberal and conservative postoperative blood transfusion policies in terms of mortality or ability to walk independently at 60 days for patients at high cardiovascular risk (N. Engl. J. Med. 2011;365:2453-62).

The liberal policy allowed transfusions to maintain hemoglobin at 10 g/dL. In contrast, patients randomized to a conservative approach could only be transfused if they had symptoms of anemia or at the physician’s discretion once hemoglobin was below 8 g/dL.

"Implications for practice, from my point of view, include some more evidence that maybe using more of a restrictive transfusion practice may be reasonable, including for higher-risk populations," Dr. Grant said. However, "red-cell transfusion practices still need to be individualized for your perioperative patient."

Dr. Smetana, Dr. Cohn, and Dr. Grant had no relevant financial disclosures.

MIAMI BEACH – What do the timing of smoking cessation prior to surgery, reliable prediction of postoperative respiratory failure, and biomarkers that point to elevated postoperative myocardial infarction risk have in common? They emerged as some of the most prominent findings published in the past year, according to three experts in hospital medicine.

Dr. Gerald W. Smetana, Dr. Steven L. Cohn, and Dr. Paul J. Grant each selected studies of particular relevance to hospitalists and explained why during a panel presentation at a meeting on perioperative medicine sponsored by the University of Miami:

© milosluz/istockphoto.com

• Preoperative Smoking Cessation. When a patient stops smoking up to 8 weeks before noncardiac surgery, it does not significantly change the total or pulmonary complication rates, according to a systematic literature review (Arch. Intern. Med. 2011;171:983-9).

"Many patients who quit smoking report they feel worse before they feel better," said Dr. Smetana, an attending in the general medicine division at Beth Israel Deaconess Medical Center, Boston.

Increased cough and sputum production are common right after quitting, he said. "This could be a plausible mechanism to explain why recent quitters might be at increased risk for postoperative pulmonary complications."

However, there was no statistically significant difference in total complications (relative risk of 0.78 for recent quitters, compared with a reference value of 1.0 for current smokers) in the nine eligible studies with 889 participants. Five of the trials assessed pulmonary complications, and found that recent quitters had a nonsignificant increased risk (RR, 1.18) compared with patients who continued to smoke.

Until there is consensus based on large randomized trials, stopping smoking before surgery can be considered safe, said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School. In addition, longer periods of cessation are likely better than shorter ones. He added that despite the lack of a significant finding, it is still worthwhile to counsel patients because any time before surgery is a still a teachable moment for smoking cessation.

• Predicting Postoperative Pulmonary Failure. Type of procedure, emergency surgery, poor dependent functional status, sepsis, and higher American Society of Anesthesiologists classification were the five independent preoperative factors that significantly predicted postoperative respiratory failure in a multicenter database study (Chest 2011;140:1207-15).

The study included 211,410 participants undergoing all types of surgery. Mortality was 26% among those with postoperative respiratory failure, compared with 1% for unaffected patients. "This shows how important pulmonary complications can be," Dr. Smetana said.

The researchers incorporated these five predictors into a surgical risk calculator that is downloadable for free.

Dr. Smetana said, "It is a nice tool that ... helps to stratify patients. It makes a difference in identifying which patients for which you will pull out all the stops."

• Preoperative Peptide Gauges Risk. Although multiple researchers have looked at preoperative B-type natriuretic peptide (BNP) as a predictor of postoperative cardiac events or death, there remain "a lot of unknowns for BNP at this point," said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

A recent meta-analysis may shed some light on the predictive value of BNP (J. Am. Coll. Cardiol. 2011;58:522-9). Investigators assessed five BNP studies with 632 patients to determine cutoff values for screening (high sensitivity) and diagnosis (high specificity), and an optimal value that combines both.

The researchers found that patients with BNP above the optimal cutoff point of 116 pg/mL had a significantly elevated risk for the composite outcome of nonfatal myocardial infarction or cardiovascular death (unadjusted odds ratio, 7.36). Compared with use of the Revised Cardiac Risk Index, the optimal BNP cutoff classification improved risk prediction by 58%. This means some patients moved to a more accurate ranking among the low-, intermediate- and high-risk categories, Dr. Cohn said.

• Troponin and Postoperative MI Risk. Myocardial infarction is the most common major, perioperative vascular complication, so investigators continue to search for an accurate way to identify high-risk patients. Some propose elevated serum levels of the protein troponin as a predictor, Dr. Cohn said, but the question remains: Would it change patient management and improve outcomes?

Researchers found that increased troponin after noncardiac surgery did in fact independently predict postoperative MI mortality in a meta-analysis (Anesthesiology 2011;114:796-806).

Elevated levels significantly predicted increased risk in the 14 studies with 3,318 patients overall (OR, 3.4). However, prediction within the first year was higher (OR, 6.7) compared with studies that measured troponin more than 12 months out (OR, 1.8).

These findings could have implications for practice, because the majority of perioperative MIs are asymptomatic, Dr. Cohn said. "Maybe we should, as the authors suggest, recommend routine troponins after high-risk surgery."

More frequent vital-sign monitoring; transfer to a unit with additional monitoring; and/or screening for hypoxia and anemia could be implemented in patients identified as high risk, Dr. Cohn said. Optimization of intravascular volume and initiation of cardiac medications are additional strategies. Also, closely monitored patients who experience an MI potentially could be transferred for cardiac catheterization or revascularization more quickly.

"It is thought provoking that we can change the management," Dr. Cohn said.

• HF, AF, and Cardiovascular Risk. Heart failure and atrial fibrillation should factor more prominently into cardiovascular risk stratification prior to noncardiac surgery, according to a population-based cohort study of more than 38,000 consecutive patients (Circulation 2011:124:289-96).

"There are many cardiovascular risk stratification tools available with quite a bit of variation. Coronary artery disease [CAD] is typically weighted heavily on most models," said Dr. Grant, director of perioperative and consultative medicine and member of the medicine faculty at the University of Michigan in Ann Arbor.

However, researchers found that ischemic and nonischemic heart failure and atrial fibrillation were more commonly associated with 30-day mortality and readmission rates than CAD in this large cohort, Dr. Grant said. The authors concluded that these risk factors are likely underestimated in current prediction models.

• Liberal vs. Conservative Blood Transfusion. "The hemoglobin level at which we decide to transfuse patients after surgery is controversial," Dr. Grant said, "and has not been adequately studied to date. Great variations in practice exist."

A randomized controlled trial of 2,016 hip fracture surgery patients found no significant difference between liberal and conservative postoperative blood transfusion policies in terms of mortality or ability to walk independently at 60 days for patients at high cardiovascular risk (N. Engl. J. Med. 2011;365:2453-62).

The liberal policy allowed transfusions to maintain hemoglobin at 10 g/dL. In contrast, patients randomized to a conservative approach could only be transfused if they had symptoms of anemia or at the physician’s discretion once hemoglobin was below 8 g/dL.

"Implications for practice, from my point of view, include some more evidence that maybe using more of a restrictive transfusion practice may be reasonable, including for higher-risk populations," Dr. Grant said. However, "red-cell transfusion practices still need to be individualized for your perioperative patient."

Dr. Smetana, Dr. Cohn, and Dr. Grant had no relevant financial disclosures.

MIAMI – Recent discoveries in epigenetics could soon make a clinical difference for children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and other conditions, according to an expert.

The implications go beyond targeting treatment for an individual child in your practice based on a specific genetic mutation, Dr. Hakon Hakonarson, director of the center for applied genomics at the Children’s Hospital of Philadelphia, said at a pediatric update sponsored by Miami Children’s Hospital. Recent advances point to gene alterations that modify shared pathways, so the potential for wider application beyond ADHD and ASD -- such as unexpected discoveries related to pediatric neuroblastoma -- is a real possibility.

Dr. Hakonarson said that he had no relevant financial disclosures.

MIAMI – Recent discoveries in epigenetics could soon make a clinical difference for children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and other conditions, according to an expert.

The implications go beyond targeting treatment for an individual child in your practice based on a specific genetic mutation, Dr. Hakon Hakonarson, director of the center for applied genomics at the Children’s Hospital of Philadelphia, said at a pediatric update sponsored by Miami Children’s Hospital. Recent advances point to gene alterations that modify shared pathways, so the potential for wider application beyond ADHD and ASD -- such as unexpected discoveries related to pediatric neuroblastoma -- is a real possibility.

Dr. Hakonarson said that he had no relevant financial disclosures.

MIAMI – Recent discoveries in epigenetics could soon make a clinical difference for children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and other conditions, according to an expert.

The implications go beyond targeting treatment for an individual child in your practice based on a specific genetic mutation, Dr. Hakon Hakonarson, director of the center for applied genomics at the Children’s Hospital of Philadelphia, said at a pediatric update sponsored by Miami Children’s Hospital. Recent advances point to gene alterations that modify shared pathways, so the potential for wider application beyond ADHD and ASD -- such as unexpected discoveries related to pediatric neuroblastoma -- is a real possibility.

Dr. Hakonarson said that he had no relevant financial disclosures.