ROME – A new risk-stratification formula for atrial fibrillation patients starting oral anticoagulant therapy helps sort out their potential net benefit on edoxaban, compared with warfarin.

This risk score “could help guide selection of treatment” with a vitamin K antagonist such as warfarin or a new oral anticoagulant (NOAC) such as edoxaban, Christina L. Fanola, MD, said at the annual congress of the European Society of Cardiology.

“It’s a great time to think about this type of score, because so many more patients are being diagnosed with atrial fibrillation and there is a lot of clinical equipoise” over which anticoagulant to start patients on, said Dr. Fanola, a cardiologist at Brigham and Women’s Hospital in Boston. She said she and her associates hope to externally validate the score and test it in cohorts that received other NOACs, such as apixaban (Eliquis), dabigatran (Pradaxa), or rivaroxaban (Xarelto), but it is very possible that scoring might differ from one NOAC to the next. “Each NOAC may need its own scoring formula,” Dr. Fanola said in an interview.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

ROME – A new risk-stratification formula for atrial fibrillation patients starting oral anticoagulant therapy helps sort out their potential net benefit on edoxaban, compared with warfarin.

This risk score “could help guide selection of treatment” with a vitamin K antagonist such as warfarin or a new oral anticoagulant (NOAC) such as edoxaban, Christina L. Fanola, MD, said at the annual congress of the European Society of Cardiology.

“It’s a great time to think about this type of score, because so many more patients are being diagnosed with atrial fibrillation and there is a lot of clinical equipoise” over which anticoagulant to start patients on, said Dr. Fanola, a cardiologist at Brigham and Women’s Hospital in Boston. She said she and her associates hope to externally validate the score and test it in cohorts that received other NOACs, such as apixaban (Eliquis), dabigatran (Pradaxa), or rivaroxaban (Xarelto), but it is very possible that scoring might differ from one NOAC to the next. “Each NOAC may need its own scoring formula,” Dr. Fanola said in an interview.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

ROME – A new risk-stratification formula for atrial fibrillation patients starting oral anticoagulant therapy helps sort out their potential net benefit on edoxaban, compared with warfarin.

This risk score “could help guide selection of treatment” with a vitamin K antagonist such as warfarin or a new oral anticoagulant (NOAC) such as edoxaban, Christina L. Fanola, MD, said at the annual congress of the European Society of Cardiology.

“It’s a great time to think about this type of score, because so many more patients are being diagnosed with atrial fibrillation and there is a lot of clinical equipoise” over which anticoagulant to start patients on, said Dr. Fanola, a cardiologist at Brigham and Women’s Hospital in Boston. She said she and her associates hope to externally validate the score and test it in cohorts that received other NOACs, such as apixaban (Eliquis), dabigatran (Pradaxa), or rivaroxaban (Xarelto), but it is very possible that scoring might differ from one NOAC to the next. “Each NOAC may need its own scoring formula,” Dr. Fanola said in an interview.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

Providing Kenyan women attending prenatal or postpartum health care visits with HIV self-testing kits raised the rates of partner and couples testing to more than 90%, according to a report published online in PLOS Medicine.

HIV testing remains underused in many parts of sub-Saharan Africa, particularly among men, for reasons including social stigma, fear of poor prognosis, lack of awareness of HIV risk, fear that their results would be disclosed, inconvenience, and transportation costs. To assess one strategy for improving male testing rates, researchers performed a study at a hospital and two clinics in urban and suburban Kisumu, Kenya, where the HIV prevalence is approximately 20% among adult residents.

©MattZ90/Thinkstock.com

The International Initiative for Impact Evaluation funded the study. Dr. Thirumurthy and his associates reported having no relevant financial disclosures.

Providing Kenyan women attending prenatal or postpartum health care visits with HIV self-testing kits raised the rates of partner and couples testing to more than 90%, according to a report published online in PLOS Medicine.

HIV testing remains underused in many parts of sub-Saharan Africa, particularly among men, for reasons including social stigma, fear of poor prognosis, lack of awareness of HIV risk, fear that their results would be disclosed, inconvenience, and transportation costs. To assess one strategy for improving male testing rates, researchers performed a study at a hospital and two clinics in urban and suburban Kisumu, Kenya, where the HIV prevalence is approximately 20% among adult residents.

©MattZ90/Thinkstock.com

The International Initiative for Impact Evaluation funded the study. Dr. Thirumurthy and his associates reported having no relevant financial disclosures.

Providing Kenyan women attending prenatal or postpartum health care visits with HIV self-testing kits raised the rates of partner and couples testing to more than 90%, according to a report published online in PLOS Medicine.

HIV testing remains underused in many parts of sub-Saharan Africa, particularly among men, for reasons including social stigma, fear of poor prognosis, lack of awareness of HIV risk, fear that their results would be disclosed, inconvenience, and transportation costs. To assess one strategy for improving male testing rates, researchers performed a study at a hospital and two clinics in urban and suburban Kisumu, Kenya, where the HIV prevalence is approximately 20% among adult residents.

©MattZ90/Thinkstock.com

The International Initiative for Impact Evaluation funded the study. Dr. Thirumurthy and his associates reported having no relevant financial disclosures.

On Oct. 25, 2016, the Food and Drug Administration issued a draft guidance document titled “Low Sexual Interest, Desire, and/or Arousal in Women: Developing Drugs for Treatment.” The document outlines FDA’s current thinking about how best to design phase III trials for drugs to treat these problems. The purpose of this guidance is to provide pharmaceutical companies with a road map of what the FDA recommends should be addressed in clinical trials designed for new drug approval.

The FDA makes it clear that this guidance is only a “recommendation,” reflecting the agency’s current thinking on this important issue, and is not a requirement (unless specific regulatory or statutory requirements are cited). That may well be, but this puts me in mind of my graduate school days when my advisor used to tell me that his suggestions for my dissertation were only “recommendations.” I knew, of course, that to ignore these recommendations was folly.

Dr. Kingsberg is chief of the division of behavioral medicine in the department of obstetrics and gynecology at MacDonald Women’s Hospital, part of the University Hospitals Cleveland Medical Center, Ohio. She is also a professor in the departments of reproductive biology and psychiatry at Case Western Reserve University, Cleveland. Dr. Kingsberg reported being a consultant or member of the scientific advisory board for Acerus, AMAG, Bayer, Emotional Brain, Endoceutics, NovoNordisk, Palatin, Pfizer, Shionogi, Sprout, TherapeuticsMD, Sermonix, Strategic Science & Technologies, and Valeant. Valeant is the manufacturer of the HSDD drug flibanserin.

On Oct. 25, 2016, the Food and Drug Administration issued a draft guidance document titled “Low Sexual Interest, Desire, and/or Arousal in Women: Developing Drugs for Treatment.” The document outlines FDA’s current thinking about how best to design phase III trials for drugs to treat these problems. The purpose of this guidance is to provide pharmaceutical companies with a road map of what the FDA recommends should be addressed in clinical trials designed for new drug approval.

The FDA makes it clear that this guidance is only a “recommendation,” reflecting the agency’s current thinking on this important issue, and is not a requirement (unless specific regulatory or statutory requirements are cited). That may well be, but this puts me in mind of my graduate school days when my advisor used to tell me that his suggestions for my dissertation were only “recommendations.” I knew, of course, that to ignore these recommendations was folly.

Dr. Kingsberg is chief of the division of behavioral medicine in the department of obstetrics and gynecology at MacDonald Women’s Hospital, part of the University Hospitals Cleveland Medical Center, Ohio. She is also a professor in the departments of reproductive biology and psychiatry at Case Western Reserve University, Cleveland. Dr. Kingsberg reported being a consultant or member of the scientific advisory board for Acerus, AMAG, Bayer, Emotional Brain, Endoceutics, NovoNordisk, Palatin, Pfizer, Shionogi, Sprout, TherapeuticsMD, Sermonix, Strategic Science & Technologies, and Valeant. Valeant is the manufacturer of the HSDD drug flibanserin.

On Oct. 25, 2016, the Food and Drug Administration issued a draft guidance document titled “Low Sexual Interest, Desire, and/or Arousal in Women: Developing Drugs for Treatment.” The document outlines FDA’s current thinking about how best to design phase III trials for drugs to treat these problems. The purpose of this guidance is to provide pharmaceutical companies with a road map of what the FDA recommends should be addressed in clinical trials designed for new drug approval.

The FDA makes it clear that this guidance is only a “recommendation,” reflecting the agency’s current thinking on this important issue, and is not a requirement (unless specific regulatory or statutory requirements are cited). That may well be, but this puts me in mind of my graduate school days when my advisor used to tell me that his suggestions for my dissertation were only “recommendations.” I knew, of course, that to ignore these recommendations was folly.

Dr. Kingsberg is chief of the division of behavioral medicine in the department of obstetrics and gynecology at MacDonald Women’s Hospital, part of the University Hospitals Cleveland Medical Center, Ohio. She is also a professor in the departments of reproductive biology and psychiatry at Case Western Reserve University, Cleveland. Dr. Kingsberg reported being a consultant or member of the scientific advisory board for Acerus, AMAG, Bayer, Emotional Brain, Endoceutics, NovoNordisk, Palatin, Pfizer, Shionogi, Sprout, TherapeuticsMD, Sermonix, Strategic Science & Technologies, and Valeant. Valeant is the manufacturer of the HSDD drug flibanserin.

SAN FRANCISCO – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.

That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.

alexsokolov/Thinkstock

Taking steps toward integration

If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.

“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.

The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.

Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.

Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.

Establishing effective protocols with integration

The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.

“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.

Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.

It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.

“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”

Planning for reimbursement challenges

Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.

Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.

“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.

“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”

He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.

Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.

Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.

SAN FRANCISCO – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.

That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.

alexsokolov/Thinkstock

Taking steps toward integration

If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.

“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.

The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.

Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.

Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.

Establishing effective protocols with integration

The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.

“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.

Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.

It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.

“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”

Planning for reimbursement challenges

Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.

Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.

“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.

“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”

He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.

Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.

Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.

SAN FRANCISCO – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.

That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.

alexsokolov/Thinkstock

Taking steps toward integration

If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.

“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.

The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.

Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.

Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.

Establishing effective protocols with integration

The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.

“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.

Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.

It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.

“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”

Planning for reimbursement challenges

Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.

Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.

“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.

“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”

He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.

Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.

Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.

SAN DIEGO—Among women with migraine, low-dose combined estrogen–progestin contraceptives do not increase the risk of stroke, and continuous hormonal contraceptive use may reduce menstrual migraine, according to a lecture delivered at the 58th Annual Scientific Meeting of the American Headache Society.

High doses of combined oral contraceptives do increase stroke risk, and migraine with aura confers an independent increased risk of stroke, said Anne H. Calhoun, MD, Professor of Anesthesiology and Psychiatry at the University of North Carolina in Chapel Hill and partner and cofounder of the Carolina Headache Institute in Durham. Evidence does not suggest, however, that low-dose hormonal contraceptive use together with history of migraine confers additive risk, she said.

Over the last several decades, various combined oral contraceptive regimens (eg, triphasic, extended cycle, and continuous) with a range of estrogen doses have been developed. “They are all over the place, and we really need to know what we are dealing with,” Dr. Calhoun said. Risks of combined oral contraceptives, including myocardial infarction and stroke, are almost exclusively seen with smoking and high-dose pills, she said.

Dr. Calhoun prefers to prescribe pills that inhibit ovulation while using 20 μg or less of the synthetic estrogen ethinyl estradiol (EE) for women at increased risk of stroke. The highest dose pill in the United States contains 50 μg of estrogen. The lowest dose pill contains 10 μg.

Placebo Side Effects

In hormonal contraception, headache often develops during the placebo week. A typical contraceptive regimen includes 21 active pills and seven placebo pills. Sulak et al found that 70% of women taking birth control pills had headache during the placebo week, and peak incidence of headache was on the third day of the placebo week. “When you eliminated the placebo week, it improved mood scores, improved headache scores, there was less dysmenorrhea and pelvic pain,” Dr. Calhoun said.

When estrogen concentrations decrease upon taking placebo, 5HT concentration in the CNS declines, serotonin synthesis declines, monoamine oxidase and calcitonin gene-related peptide concentrations increase, and beta endorphins decline. “All pain is perceived as more intense,” she said. Furthermore, flow-mediated vasodilation parallels estrogen levels.

“You would think looking at all this, in a field where most of the patients are women, and the majority of them have menstrual migraine, and all of these things happen when estrogen falls, that headache specialists would be really interested in preventing estrogen from declining every month,” Dr. Calhoun said.

Reducing Migraine

In 2012, Dr. Calhoun and colleagues published a retrospective database review that identified 23 women in a subspecialty menstrual migraine clinic who had migraine with aura, a confirmed diagnosis of menstrual-related migraine, and who received treatment with extended-cycle dosing of a transvaginal ring contraceptive containing 0.120 mg of etonogestrel and 15 μg of EE for at least a month. The women were treated with the transvaginal ring for the purpose of migraine prevention, and not to prevent pregnancy. Participants were observed for an average of eight months. Women used the ultralow-dose ring contraceptive continuously. Instead of using the ring for three weeks followed by one week without the ring, women replaced the ring every three weeks. “With that, you stop ovulation with a level of estrogen that is lower than your own natural menstrual cycle. You do not have the high ovulatory peaks or even the peaks of the luteal phase,” she said.

At baseline, subjects experienced a median of 3.2 auras per month. With treatment, the median number of auras per month decreased to 0.2. Frequency of aura decreased from baseline for each participant, and menstrual migraine was eliminated in 91.3% of patients. Such use of hormonal contraceptives for the prevention of migraine is off label, Dr. Calhoun noted.

Risk of Stroke

How oral contraceptives affect risk of stroke has been studied for decades. In a 1975 study in JAMA, researchers looked at 140 cases of stroke in young women and compared them with hospital controls. There was a 4.6 times increased risk of stroke if a woman was taking high-dose oral contraceptives.

Hannaford et al in 1994 published a nested case–control analysis using data mainly from the 1970s and 1980s. They found that high-dose oral contraceptive use was associated with a sixfold increased risk of first stroke. Low-dose pills—including 30-μg and 35-μg pills, “which I do not think of as particularly low dose these days”—did not significantly increase risk, Dr. Calhoun said. However, the risk with these moderate-dose pills is usually around 1.2 to 2.5 times greater and is significant in some studies, she noted. Today’s “low-dose” pills (≤ 20 μg EE) are the best for decreasing risk.

In 1996, a study by Petitti et al looked at risk of stroke with “low-dose” (at that time meaning simply < 50 μg EE) hormonal contraceptives in the US. They identified 408 strokes in 3.6 million women-years and concluded that stroke is rare in this population. Low-dose pills did not increase the risk. At that time, 99.4% of prescriptions for hormonal contraception in the US contained less than 50 μg of estrogen.

ACOG Guideline

In 2006, however, the American College of Obstetrics and Gynecology (ACOG) recommended against using combination hormonal contraceptives in patients with migraine with aura. This guideline and some of the studies on which the recommendation was based are problematic, Dr. Calhoun said.

The recommendation stemmed in part from a concern that all women with migraine are at increased risk of stroke if they take combined hormonal contraceptives. That concern was based on a 1996 World Health Organization study that had no US sites. In the study, the majority of stroke cases were smokers and the average age was over 35. In the US, 35 tends to be the age at which physicians—in accordance with ACOG recommendations—no longer prescribe combined hormonal contraceptives for smokers, Dr. Calhoun said. In addition, the majority of the stroke cases were using high-dose pills. The authors concluded that migraine of greater than 12 years’ duration, migraine with aura, and frequent migraine with aura increased the risk of stroke. “But the authors concluded themselves, in no case did corrections for oral contraceptive use alter these observations. It was not a factor,” Dr. Calhoun said.

The ACOG guideline also was based on a Danish population-based case–control study by Lidegaard et al that found a threefold increased risk of ischemic stroke among migraineurs using oral contraceptives. In this study, however, they reported that only 6% of the control group had migraine, whereas 16% to 18% of women in Denmark have migraine—a rate similar to what was seen in the cases. That produced the threefold increased risk reported in the study, Dr. Calhoun said. A similar study in France did not find increased risk among migraineurs using oral contraceptives, but in that study, both controls and migraineurs had the normal frequency of migraine in the population.

Finally, the ACOG recommendation was based on a pooled analysis of two large US case–control studies that found a twofold increased risk of ischemic stroke among migraineurs using oral contraceptives. This finding by Schwartz et al was based on only four cases. The prevalence of migraine was virtually identical among ischemic stroke cases and controls who were using oral contraceptives (7.8% and 7.7%, respectively), but became significant after adjustment for other factors. But a key factor that was not taken into account was use of high-dose (≥ 50 μg EE) pills, Dr. Calhoun said. They were used by only 11 of the 1,564 ischemic and hemorrhagic stroke cases and controls, but accounted for four of the strokes.


Low Doses Appear Safe

Recent studies have had similar findings. A 15-year prospective population-based study by Lidegaard et al in 2012 analyzed 3,300 thrombotic strokes and 1,700 myocardial infarctions in more than 1.6 million women. The overall risk was low, and the absolute risk of thrombotic stroke and myocardial infarction was not increased with 20-μg pills. Pills with doses of 30 μg to 40 μg, however, as much as doubled the risk. “It is still better than the 4.5-times increased risk we had with the 50-μg pills, but we do not want to go there,” Dr. Calhoun said.

A 2013 study by Sidney et al compared a 20-μg oral birth control pill with a 30-μg oral birth control pill, a 20-μg patch birth control product, and a 15-μg ring birth control product. As expected, the 30-μg pill increased risk of thrombotic events, relative to the 20-μg pill, whereas the other products did not, Dr. Calhoun said.

“The argument against using combined hormonal contraceptives in migraine with aura is based on concerns that all women are at increased risk of stroke with oral contraceptives. That is false,” she said. “It is high-dose oral contraceptives that increase the risk.”

—Jake Remaly

Suggested Reading

ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453-1472.

Calhoun A, Ford S, Pruitt A. The impact of extended-cycle vaginal ring contraception on migraine aura: a retrospective case series. Headache. 2012;52(8):1246-1253.

Hannaford PC, Croft PR, Kay CR. Oral contraception and stroke. Evidence from the Royal College of General Practitioners’ Oral Contraception study. Stroke. 1994;25(5):935-942.

Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-control study. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. 1996;348(9026):498-505.

Lidegaard Ø, Kreiner S. Contraceptives and cerebral thrombosis: a five-year national case-control study. Contraception. 2002;65(3):197-205.

Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366(24):2257-2266.

MacGregor EA. Contraception and headache. Headache. 2013;53(2):247-276.

Oral contraceptives and stroke in young women. Associated risk factors. JAMA. 1975;231(7):718-722.

Petitti DB, Sidney S, Bernstein A, et al. Stroke in users of low-dose oral contraceptives. N Engl J Med. 1996;335(1):8-15.

Schwartz SM, Petitti DB, Siscovick DS, et al. Stroke and use of low-dose oral contraceptives in young women: a pooled analysis of two US studies. Stroke. 1998;29(11):2277-2284.

Sidney S, Cheetham TC, Connell FA, et al. Recent combined hormonal contraceptives (CHCs) and the risk of thromboembolism and other cardiovascular events in new users. Contraception. 2013;87(1):93-100.

Sulak P, Willis S, Kuehl T, et al. Headaches and oral contraceptives: impact of eliminating the standard 7-day placebo interval. Headache. 2007;47(1):27-37.

Sulak PJ, Scow RD, Preece C, et al. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol. 2000;95(2):261-266.

SAN DIEGO—Among women with migraine, low-dose combined estrogen–progestin contraceptives do not increase the risk of stroke, and continuous hormonal contraceptive use may reduce menstrual migraine, according to a lecture delivered at the 58th Annual Scientific Meeting of the American Headache Society.

High doses of combined oral contraceptives do increase stroke risk, and migraine with aura confers an independent increased risk of stroke, said Anne H. Calhoun, MD, Professor of Anesthesiology and Psychiatry at the University of North Carolina in Chapel Hill and partner and cofounder of the Carolina Headache Institute in Durham. Evidence does not suggest, however, that low-dose hormonal contraceptive use together with history of migraine confers additive risk, she said.

Over the last several decades, various combined oral contraceptive regimens (eg, triphasic, extended cycle, and continuous) with a range of estrogen doses have been developed. “They are all over the place, and we really need to know what we are dealing with,” Dr. Calhoun said. Risks of combined oral contraceptives, including myocardial infarction and stroke, are almost exclusively seen with smoking and high-dose pills, she said.

Dr. Calhoun prefers to prescribe pills that inhibit ovulation while using 20 μg or less of the synthetic estrogen ethinyl estradiol (EE) for women at increased risk of stroke. The highest dose pill in the United States contains 50 μg of estrogen. The lowest dose pill contains 10 μg.

Placebo Side Effects

In hormonal contraception, headache often develops during the placebo week. A typical contraceptive regimen includes 21 active pills and seven placebo pills. Sulak et al found that 70% of women taking birth control pills had headache during the placebo week, and peak incidence of headache was on the third day of the placebo week. “When you eliminated the placebo week, it improved mood scores, improved headache scores, there was less dysmenorrhea and pelvic pain,” Dr. Calhoun said.

When estrogen concentrations decrease upon taking placebo, 5HT concentration in the CNS declines, serotonin synthesis declines, monoamine oxidase and calcitonin gene-related peptide concentrations increase, and beta endorphins decline. “All pain is perceived as more intense,” she said. Furthermore, flow-mediated vasodilation parallels estrogen levels.

“You would think looking at all this, in a field where most of the patients are women, and the majority of them have menstrual migraine, and all of these things happen when estrogen falls, that headache specialists would be really interested in preventing estrogen from declining every month,” Dr. Calhoun said.

Reducing Migraine

In 2012, Dr. Calhoun and colleagues published a retrospective database review that identified 23 women in a subspecialty menstrual migraine clinic who had migraine with aura, a confirmed diagnosis of menstrual-related migraine, and who received treatment with extended-cycle dosing of a transvaginal ring contraceptive containing 0.120 mg of etonogestrel and 15 μg of EE for at least a month. The women were treated with the transvaginal ring for the purpose of migraine prevention, and not to prevent pregnancy. Participants were observed for an average of eight months. Women used the ultralow-dose ring contraceptive continuously. Instead of using the ring for three weeks followed by one week without the ring, women replaced the ring every three weeks. “With that, you stop ovulation with a level of estrogen that is lower than your own natural menstrual cycle. You do not have the high ovulatory peaks or even the peaks of the luteal phase,” she said.

At baseline, subjects experienced a median of 3.2 auras per month. With treatment, the median number of auras per month decreased to 0.2. Frequency of aura decreased from baseline for each participant, and menstrual migraine was eliminated in 91.3% of patients. Such use of hormonal contraceptives for the prevention of migraine is off label, Dr. Calhoun noted.

Risk of Stroke

How oral contraceptives affect risk of stroke has been studied for decades. In a 1975 study in JAMA, researchers looked at 140 cases of stroke in young women and compared them with hospital controls. There was a 4.6 times increased risk of stroke if a woman was taking high-dose oral contraceptives.

Hannaford et al in 1994 published a nested case–control analysis using data mainly from the 1970s and 1980s. They found that high-dose oral contraceptive use was associated with a sixfold increased risk of first stroke. Low-dose pills—including 30-μg and 35-μg pills, “which I do not think of as particularly low dose these days”—did not significantly increase risk, Dr. Calhoun said. However, the risk with these moderate-dose pills is usually around 1.2 to 2.5 times greater and is significant in some studies, she noted. Today’s “low-dose” pills (≤ 20 μg EE) are the best for decreasing risk.

In 1996, a study by Petitti et al looked at risk of stroke with “low-dose” (at that time meaning simply < 50 μg EE) hormonal contraceptives in the US. They identified 408 strokes in 3.6 million women-years and concluded that stroke is rare in this population. Low-dose pills did not increase the risk. At that time, 99.4% of prescriptions for hormonal contraception in the US contained less than 50 μg of estrogen.

ACOG Guideline

In 2006, however, the American College of Obstetrics and Gynecology (ACOG) recommended against using combination hormonal contraceptives in patients with migraine with aura. This guideline and some of the studies on which the recommendation was based are problematic, Dr. Calhoun said.

The recommendation stemmed in part from a concern that all women with migraine are at increased risk of stroke if they take combined hormonal contraceptives. That concern was based on a 1996 World Health Organization study that had no US sites. In the study, the majority of stroke cases were smokers and the average age was over 35. In the US, 35 tends to be the age at which physicians—in accordance with ACOG recommendations—no longer prescribe combined hormonal contraceptives for smokers, Dr. Calhoun said. In addition, the majority of the stroke cases were using high-dose pills. The authors concluded that migraine of greater than 12 years’ duration, migraine with aura, and frequent migraine with aura increased the risk of stroke. “But the authors concluded themselves, in no case did corrections for oral contraceptive use alter these observations. It was not a factor,” Dr. Calhoun said.

The ACOG guideline also was based on a Danish population-based case–control study by Lidegaard et al that found a threefold increased risk of ischemic stroke among migraineurs using oral contraceptives. In this study, however, they reported that only 6% of the control group had migraine, whereas 16% to 18% of women in Denmark have migraine—a rate similar to what was seen in the cases. That produced the threefold increased risk reported in the study, Dr. Calhoun said. A similar study in France did not find increased risk among migraineurs using oral contraceptives, but in that study, both controls and migraineurs had the normal frequency of migraine in the population.

Finally, the ACOG recommendation was based on a pooled analysis of two large US case–control studies that found a twofold increased risk of ischemic stroke among migraineurs using oral contraceptives. This finding by Schwartz et al was based on only four cases. The prevalence of migraine was virtually identical among ischemic stroke cases and controls who were using oral contraceptives (7.8% and 7.7%, respectively), but became significant after adjustment for other factors. But a key factor that was not taken into account was use of high-dose (≥ 50 μg EE) pills, Dr. Calhoun said. They were used by only 11 of the 1,564 ischemic and hemorrhagic stroke cases and controls, but accounted for four of the strokes.


Low Doses Appear Safe

Recent studies have had similar findings. A 15-year prospective population-based study by Lidegaard et al in 2012 analyzed 3,300 thrombotic strokes and 1,700 myocardial infarctions in more than 1.6 million women. The overall risk was low, and the absolute risk of thrombotic stroke and myocardial infarction was not increased with 20-μg pills. Pills with doses of 30 μg to 40 μg, however, as much as doubled the risk. “It is still better than the 4.5-times increased risk we had with the 50-μg pills, but we do not want to go there,” Dr. Calhoun said.

A 2013 study by Sidney et al compared a 20-μg oral birth control pill with a 30-μg oral birth control pill, a 20-μg patch birth control product, and a 15-μg ring birth control product. As expected, the 30-μg pill increased risk of thrombotic events, relative to the 20-μg pill, whereas the other products did not, Dr. Calhoun said.

“The argument against using combined hormonal contraceptives in migraine with aura is based on concerns that all women are at increased risk of stroke with oral contraceptives. That is false,” she said. “It is high-dose oral contraceptives that increase the risk.”

—Jake Remaly

Suggested Reading

ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453-1472.

Calhoun A, Ford S, Pruitt A. The impact of extended-cycle vaginal ring contraception on migraine aura: a retrospective case series. Headache. 2012;52(8):1246-1253.

Hannaford PC, Croft PR, Kay CR. Oral contraception and stroke. Evidence from the Royal College of General Practitioners’ Oral Contraception study. Stroke. 1994;25(5):935-942.

Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-control study. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. 1996;348(9026):498-505.

Lidegaard Ø, Kreiner S. Contraceptives and cerebral thrombosis: a five-year national case-control study. Contraception. 2002;65(3):197-205.

Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366(24):2257-2266.

MacGregor EA. Contraception and headache. Headache. 2013;53(2):247-276.

Oral contraceptives and stroke in young women. Associated risk factors. JAMA. 1975;231(7):718-722.

Petitti DB, Sidney S, Bernstein A, et al. Stroke in users of low-dose oral contraceptives. N Engl J Med. 1996;335(1):8-15.

Schwartz SM, Petitti DB, Siscovick DS, et al. Stroke and use of low-dose oral contraceptives in young women: a pooled analysis of two US studies. Stroke. 1998;29(11):2277-2284.

Sidney S, Cheetham TC, Connell FA, et al. Recent combined hormonal contraceptives (CHCs) and the risk of thromboembolism and other cardiovascular events in new users. Contraception. 2013;87(1):93-100.

Sulak P, Willis S, Kuehl T, et al. Headaches and oral contraceptives: impact of eliminating the standard 7-day placebo interval. Headache. 2007;47(1):27-37.

Sulak PJ, Scow RD, Preece C, et al. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol. 2000;95(2):261-266.

SAN DIEGO—Among women with migraine, low-dose combined estrogen–progestin contraceptives do not increase the risk of stroke, and continuous hormonal contraceptive use may reduce menstrual migraine, according to a lecture delivered at the 58th Annual Scientific Meeting of the American Headache Society.

High doses of combined oral contraceptives do increase stroke risk, and migraine with aura confers an independent increased risk of stroke, said Anne H. Calhoun, MD, Professor of Anesthesiology and Psychiatry at the University of North Carolina in Chapel Hill and partner and cofounder of the Carolina Headache Institute in Durham. Evidence does not suggest, however, that low-dose hormonal contraceptive use together with history of migraine confers additive risk, she said.

Over the last several decades, various combined oral contraceptive regimens (eg, triphasic, extended cycle, and continuous) with a range of estrogen doses have been developed. “They are all over the place, and we really need to know what we are dealing with,” Dr. Calhoun said. Risks of combined oral contraceptives, including myocardial infarction and stroke, are almost exclusively seen with smoking and high-dose pills, she said.

Dr. Calhoun prefers to prescribe pills that inhibit ovulation while using 20 μg or less of the synthetic estrogen ethinyl estradiol (EE) for women at increased risk of stroke. The highest dose pill in the United States contains 50 μg of estrogen. The lowest dose pill contains 10 μg.

Placebo Side Effects

In hormonal contraception, headache often develops during the placebo week. A typical contraceptive regimen includes 21 active pills and seven placebo pills. Sulak et al found that 70% of women taking birth control pills had headache during the placebo week, and peak incidence of headache was on the third day of the placebo week. “When you eliminated the placebo week, it improved mood scores, improved headache scores, there was less dysmenorrhea and pelvic pain,” Dr. Calhoun said.

When estrogen concentrations decrease upon taking placebo, 5HT concentration in the CNS declines, serotonin synthesis declines, monoamine oxidase and calcitonin gene-related peptide concentrations increase, and beta endorphins decline. “All pain is perceived as more intense,” she said. Furthermore, flow-mediated vasodilation parallels estrogen levels.

“You would think looking at all this, in a field where most of the patients are women, and the majority of them have menstrual migraine, and all of these things happen when estrogen falls, that headache specialists would be really interested in preventing estrogen from declining every month,” Dr. Calhoun said.

Reducing Migraine

In 2012, Dr. Calhoun and colleagues published a retrospective database review that identified 23 women in a subspecialty menstrual migraine clinic who had migraine with aura, a confirmed diagnosis of menstrual-related migraine, and who received treatment with extended-cycle dosing of a transvaginal ring contraceptive containing 0.120 mg of etonogestrel and 15 μg of EE for at least a month. The women were treated with the transvaginal ring for the purpose of migraine prevention, and not to prevent pregnancy. Participants were observed for an average of eight months. Women used the ultralow-dose ring contraceptive continuously. Instead of using the ring for three weeks followed by one week without the ring, women replaced the ring every three weeks. “With that, you stop ovulation with a level of estrogen that is lower than your own natural menstrual cycle. You do not have the high ovulatory peaks or even the peaks of the luteal phase,” she said.

At baseline, subjects experienced a median of 3.2 auras per month. With treatment, the median number of auras per month decreased to 0.2. Frequency of aura decreased from baseline for each participant, and menstrual migraine was eliminated in 91.3% of patients. Such use of hormonal contraceptives for the prevention of migraine is off label, Dr. Calhoun noted.

Risk of Stroke

How oral contraceptives affect risk of stroke has been studied for decades. In a 1975 study in JAMA, researchers looked at 140 cases of stroke in young women and compared them with hospital controls. There was a 4.6 times increased risk of stroke if a woman was taking high-dose oral contraceptives.

Hannaford et al in 1994 published a nested case–control analysis using data mainly from the 1970s and 1980s. They found that high-dose oral contraceptive use was associated with a sixfold increased risk of first stroke. Low-dose pills—including 30-μg and 35-μg pills, “which I do not think of as particularly low dose these days”—did not significantly increase risk, Dr. Calhoun said. However, the risk with these moderate-dose pills is usually around 1.2 to 2.5 times greater and is significant in some studies, she noted. Today’s “low-dose” pills (≤ 20 μg EE) are the best for decreasing risk.

In 1996, a study by Petitti et al looked at risk of stroke with “low-dose” (at that time meaning simply < 50 μg EE) hormonal contraceptives in the US. They identified 408 strokes in 3.6 million women-years and concluded that stroke is rare in this population. Low-dose pills did not increase the risk. At that time, 99.4% of prescriptions for hormonal contraception in the US contained less than 50 μg of estrogen.

ACOG Guideline

In 2006, however, the American College of Obstetrics and Gynecology (ACOG) recommended against using combination hormonal contraceptives in patients with migraine with aura. This guideline and some of the studies on which the recommendation was based are problematic, Dr. Calhoun said.

The recommendation stemmed in part from a concern that all women with migraine are at increased risk of stroke if they take combined hormonal contraceptives. That concern was based on a 1996 World Health Organization study that had no US sites. In the study, the majority of stroke cases were smokers and the average age was over 35. In the US, 35 tends to be the age at which physicians—in accordance with ACOG recommendations—no longer prescribe combined hormonal contraceptives for smokers, Dr. Calhoun said. In addition, the majority of the stroke cases were using high-dose pills. The authors concluded that migraine of greater than 12 years’ duration, migraine with aura, and frequent migraine with aura increased the risk of stroke. “But the authors concluded themselves, in no case did corrections for oral contraceptive use alter these observations. It was not a factor,” Dr. Calhoun said.

The ACOG guideline also was based on a Danish population-based case–control study by Lidegaard et al that found a threefold increased risk of ischemic stroke among migraineurs using oral contraceptives. In this study, however, they reported that only 6% of the control group had migraine, whereas 16% to 18% of women in Denmark have migraine—a rate similar to what was seen in the cases. That produced the threefold increased risk reported in the study, Dr. Calhoun said. A similar study in France did not find increased risk among migraineurs using oral contraceptives, but in that study, both controls and migraineurs had the normal frequency of migraine in the population.

Finally, the ACOG recommendation was based on a pooled analysis of two large US case–control studies that found a twofold increased risk of ischemic stroke among migraineurs using oral contraceptives. This finding by Schwartz et al was based on only four cases. The prevalence of migraine was virtually identical among ischemic stroke cases and controls who were using oral contraceptives (7.8% and 7.7%, respectively), but became significant after adjustment for other factors. But a key factor that was not taken into account was use of high-dose (≥ 50 μg EE) pills, Dr. Calhoun said. They were used by only 11 of the 1,564 ischemic and hemorrhagic stroke cases and controls, but accounted for four of the strokes.


Low Doses Appear Safe

Recent studies have had similar findings. A 15-year prospective population-based study by Lidegaard et al in 2012 analyzed 3,300 thrombotic strokes and 1,700 myocardial infarctions in more than 1.6 million women. The overall risk was low, and the absolute risk of thrombotic stroke and myocardial infarction was not increased with 20-μg pills. Pills with doses of 30 μg to 40 μg, however, as much as doubled the risk. “It is still better than the 4.5-times increased risk we had with the 50-μg pills, but we do not want to go there,” Dr. Calhoun said.

A 2013 study by Sidney et al compared a 20-μg oral birth control pill with a 30-μg oral birth control pill, a 20-μg patch birth control product, and a 15-μg ring birth control product. As expected, the 30-μg pill increased risk of thrombotic events, relative to the 20-μg pill, whereas the other products did not, Dr. Calhoun said.

“The argument against using combined hormonal contraceptives in migraine with aura is based on concerns that all women are at increased risk of stroke with oral contraceptives. That is false,” she said. “It is high-dose oral contraceptives that increase the risk.”

—Jake Remaly

Suggested Reading

ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453-1472.

Calhoun A, Ford S, Pruitt A. The impact of extended-cycle vaginal ring contraception on migraine aura: a retrospective case series. Headache. 2012;52(8):1246-1253.

Hannaford PC, Croft PR, Kay CR. Oral contraception and stroke. Evidence from the Royal College of General Practitioners’ Oral Contraception study. Stroke. 1994;25(5):935-942.

Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-control study. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. 1996;348(9026):498-505.

Lidegaard Ø, Kreiner S. Contraceptives and cerebral thrombosis: a five-year national case-control study. Contraception. 2002;65(3):197-205.

Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366(24):2257-2266.

MacGregor EA. Contraception and headache. Headache. 2013;53(2):247-276.

Oral contraceptives and stroke in young women. Associated risk factors. JAMA. 1975;231(7):718-722.

Petitti DB, Sidney S, Bernstein A, et al. Stroke in users of low-dose oral contraceptives. N Engl J Med. 1996;335(1):8-15.

Schwartz SM, Petitti DB, Siscovick DS, et al. Stroke and use of low-dose oral contraceptives in young women: a pooled analysis of two US studies. Stroke. 1998;29(11):2277-2284.

Sidney S, Cheetham TC, Connell FA, et al. Recent combined hormonal contraceptives (CHCs) and the risk of thromboembolism and other cardiovascular events in new users. Contraception. 2013;87(1):93-100.

Sulak P, Willis S, Kuehl T, et al. Headaches and oral contraceptives: impact of eliminating the standard 7-day placebo interval. Headache. 2007;47(1):27-37.

Sulak PJ, Scow RD, Preece C, et al. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol. 2000;95(2):261-266.

COLUMBUS, OHIO – General anesthesia during carotid endarterectomy carries almost twice the risk of complications and unplanned intubation as regional anesthesia, but the latter approach, which is not available in all hospitals, has its own issues, an analysis of procedures from a statewide database in Michigan found.

“This study is timely because of CMS [Center for Medicare & Medicaid Services] initiatives tying reimbursement to specific quality measures,” Ahmad S Hussain, MD, of Wayne State University in Detroit said in reporting the study results at the annual meeting of the Midwestern Vascular Surgery Society.

COLUMBUS, OHIO – General anesthesia during carotid endarterectomy carries almost twice the risk of complications and unplanned intubation as regional anesthesia, but the latter approach, which is not available in all hospitals, has its own issues, an analysis of procedures from a statewide database in Michigan found.

“This study is timely because of CMS [Center for Medicare & Medicaid Services] initiatives tying reimbursement to specific quality measures,” Ahmad S Hussain, MD, of Wayne State University in Detroit said in reporting the study results at the annual meeting of the Midwestern Vascular Surgery Society.

COLUMBUS, OHIO – General anesthesia during carotid endarterectomy carries almost twice the risk of complications and unplanned intubation as regional anesthesia, but the latter approach, which is not available in all hospitals, has its own issues, an analysis of procedures from a statewide database in Michigan found.

“This study is timely because of CMS [Center for Medicare & Medicaid Services] initiatives tying reimbursement to specific quality measures,” Ahmad S Hussain, MD, of Wayne State University in Detroit said in reporting the study results at the annual meeting of the Midwestern Vascular Surgery Society.

Scientists with the U.S. Department of Defense have launched a Phase I clinical trial to test an investigational Zika vaccine that relies on inactivated virus.

The candidate vaccine is known as the Zika Purified Inactivated Virus (ZPIV) vaccine and contains whole but inactivated Zika virus particles to stimulate an immune system response without replicating and causing illness.

[email protected]

Scientists with the U.S. Department of Defense have launched a Phase I clinical trial to test an investigational Zika vaccine that relies on inactivated virus.

The candidate vaccine is known as the Zika Purified Inactivated Virus (ZPIV) vaccine and contains whole but inactivated Zika virus particles to stimulate an immune system response without replicating and causing illness.

[email protected]

Scientists with the U.S. Department of Defense have launched a Phase I clinical trial to test an investigational Zika vaccine that relies on inactivated virus.

The candidate vaccine is known as the Zika Purified Inactivated Virus (ZPIV) vaccine and contains whole but inactivated Zika virus particles to stimulate an immune system response without replicating and causing illness.

[email protected]

More than a quarter of U.S. parents surveyed refused human papillomavirus (HPV) vaccination for their adolescents because of a lack of overall trust in adolescent vaccination programs and higher levels of perceived harm, a study found.

In an online survey of 1,484 U.S. parents, 28% of respondents reported they had refused the HPV vaccine on behalf of their children aged 11-17 years at least once. Another 8% responded they had elected to delay vaccination. The remaining two-thirds of respondents said they had neither refused nor delayed the vaccination, reported Melissa B. Gilkey, PhD, of Harvard Medical School, Boston, and her associates (Hum Vaccin Immunother. 2016. doi: 10.1080/21645515.2016.1247134).

jarun011/Thinkstock

[email protected]

On Twitter @whitneymcknight

More than a quarter of U.S. parents surveyed refused human papillomavirus (HPV) vaccination for their adolescents because of a lack of overall trust in adolescent vaccination programs and higher levels of perceived harm, a study found.

In an online survey of 1,484 U.S. parents, 28% of respondents reported they had refused the HPV vaccine on behalf of their children aged 11-17 years at least once. Another 8% responded they had elected to delay vaccination. The remaining two-thirds of respondents said they had neither refused nor delayed the vaccination, reported Melissa B. Gilkey, PhD, of Harvard Medical School, Boston, and her associates (Hum Vaccin Immunother. 2016. doi: 10.1080/21645515.2016.1247134).

jarun011/Thinkstock

[email protected]

On Twitter @whitneymcknight

More than a quarter of U.S. parents surveyed refused human papillomavirus (HPV) vaccination for their adolescents because of a lack of overall trust in adolescent vaccination programs and higher levels of perceived harm, a study found.

In an online survey of 1,484 U.S. parents, 28% of respondents reported they had refused the HPV vaccine on behalf of their children aged 11-17 years at least once. Another 8% responded they had elected to delay vaccination. The remaining two-thirds of respondents said they had neither refused nor delayed the vaccination, reported Melissa B. Gilkey, PhD, of Harvard Medical School, Boston, and her associates (Hum Vaccin Immunother. 2016. doi: 10.1080/21645515.2016.1247134).

jarun011/Thinkstock

[email protected]

On Twitter @whitneymcknight

Case

A 48-year-old man presented to the ED with a 2-day history of cough and congestion. He described the cough as gradual in onset and, though initially nonproductive, it was now productive of green sputum. He denied fevers or chills, chest pain, nausea, vomiting, or diarrhea, and complained of only mild shortness of breath. His medical history was significant for hypertension, which was well managed with daily lisinopril-hydrochlorothiazide. He admitted to smoking one pack of cigarettes per day for the past 25 years, but denied alcohol or illicit drug use.

On physical examination, the patient’s vital signs were: blood pressure, 112/64 mm Hg; heart rate, 84 beats/min; respiratory rate, 20 breaths/min; and temperature, 98^oF. Oxygen saturation was 97% on room air. The head, eyes, ears, nose, and throat examination was normal. Auscultation of the lungs revealed bilateral breath sounds with scattered, faint expiratory wheezing; the heart had a regular rate and rhythm, without murmurs, rubs, or gallops.

The emergency physician (EP) ordered posteroanterior and lateral chest X-rays (CXR), which he interpreted as normal. He also ordered an albuterol handheld nebulizer treatment for the patient. After the albuterol treatment, the patient felt he was breathing more easily. The frequency of his cough had also decreased following treatment and, on re-examination, he exhibited no wheezing and was given azithromycin 500 mg orally in the ED. The EP diagnosed the patient with acute bronchitis and discharged him home with an albuterol metered dose inhaler with a spacer, and a 4-day course of azithromycin. He also encouraged the patient to quit smoking.

The next day the radiologist’s official reading of the patient’s radiographs included the finding of a very small pulmonary nodule, which was seen only on the lateral X-ray. The radiologist recommended a repeat CXR or a computed tomography (CT) scan of the chest in 6 months.

Unfortunately, the EP never saw this information, and the patient was not contacted regarding the abnormal radiology finding and the need for follow-up. Approximately 20 months later, the patient was diagnosed with lung cancer with metastasis to the thoracic spine and liver. Despite chemotherapy and radiation treatment, he died from the cancer.

The patient’s family brought a malpractice suit against the EP, stating that the cancer could have been successfully treated prior to any metastasis if the patient had been informed of the abnormal radiology findings at his ED visit 20 months prior. The EP argued that he never saw the official radiology report, and therefore had no knowledge of the need for follow-up. At trial, a jury verdict was returned in favor of the defendant.

Discussion

Unfortunately, some version of this scenario occurs on a frequent basis. While imaging studies account for the majority of such cases, the same situation can occur with abnormal laboratory results, body-fluid cultures, or pathology reports in which an abnormality is identified (eg, positive blood culture, missed fracture) but, for a myriad of reasons, the critical information does not get related to the patient.

Because of the episodic nature of the practice of emergency medicine (EM), a process must be in place to ensure any “positive” test results or findings discovered after patient discharge are reviewed and compared to the ED diagnosis, and that any “misses” result in notifying the patient and/or his or her primary care physician and arranging follow-up. In cases such as the one presented here, a system issue existed—one that was not due to any fault or oversight of the EP. Ideally, EM leadership should work closely with leadership from radiology and laboratory services and hospital risk management to develop such a process—one that will be effective every day, including weekends and holidays.

Missed fractures on radiographs are a common cause of malpractice litigation against EPs. In one review by Kachalia et al¹ examining malpractice claims involving EPs, missed fractures on radiographs accounted for 19% (the most common) of the 79 missed diagnoses identified in their study.In a similar study by Karcz et al,² missed fractures ranked second in frequency and dollars lost in malpractice cases against EPs in Massachusetts.

While missed lesions on CXR do not occur with the same frequency as missed fractures, the results are much more devastating when the lesion turns out to be malignant. Three common areas where such lesions are missed on CXR include: the apex of the lung, obscured by overlying clavicle and ribs; the retrocardiac region (as in the patient in this case); and the lung bases obscured by the diaphragm.

Emergency physicians are neither trained nor expected to identify every single abnormality—especially subtle radiographic abnormalities. This is why there are radiology overreads, and a system or process must be in place to ensure patients are informed of any positive findings and to arrange proper follow-up.

Case

A 48-year-old man presented to the ED with a 2-day history of cough and congestion. He described the cough as gradual in onset and, though initially nonproductive, it was now productive of green sputum. He denied fevers or chills, chest pain, nausea, vomiting, or diarrhea, and complained of only mild shortness of breath. His medical history was significant for hypertension, which was well managed with daily lisinopril-hydrochlorothiazide. He admitted to smoking one pack of cigarettes per day for the past 25 years, but denied alcohol or illicit drug use.

On physical examination, the patient’s vital signs were: blood pressure, 112/64 mm Hg; heart rate, 84 beats/min; respiratory rate, 20 breaths/min; and temperature, 98^oF. Oxygen saturation was 97% on room air. The head, eyes, ears, nose, and throat examination was normal. Auscultation of the lungs revealed bilateral breath sounds with scattered, faint expiratory wheezing; the heart had a regular rate and rhythm, without murmurs, rubs, or gallops.

The emergency physician (EP) ordered posteroanterior and lateral chest X-rays (CXR), which he interpreted as normal. He also ordered an albuterol handheld nebulizer treatment for the patient. After the albuterol treatment, the patient felt he was breathing more easily. The frequency of his cough had also decreased following treatment and, on re-examination, he exhibited no wheezing and was given azithromycin 500 mg orally in the ED. The EP diagnosed the patient with acute bronchitis and discharged him home with an albuterol metered dose inhaler with a spacer, and a 4-day course of azithromycin. He also encouraged the patient to quit smoking.

The next day the radiologist’s official reading of the patient’s radiographs included the finding of a very small pulmonary nodule, which was seen only on the lateral X-ray. The radiologist recommended a repeat CXR or a computed tomography (CT) scan of the chest in 6 months.

Unfortunately, the EP never saw this information, and the patient was not contacted regarding the abnormal radiology finding and the need for follow-up. Approximately 20 months later, the patient was diagnosed with lung cancer with metastasis to the thoracic spine and liver. Despite chemotherapy and radiation treatment, he died from the cancer.

The patient’s family brought a malpractice suit against the EP, stating that the cancer could have been successfully treated prior to any metastasis if the patient had been informed of the abnormal radiology findings at his ED visit 20 months prior. The EP argued that he never saw the official radiology report, and therefore had no knowledge of the need for follow-up. At trial, a jury verdict was returned in favor of the defendant.

Discussion

Unfortunately, some version of this scenario occurs on a frequent basis. While imaging studies account for the majority of such cases, the same situation can occur with abnormal laboratory results, body-fluid cultures, or pathology reports in which an abnormality is identified (eg, positive blood culture, missed fracture) but, for a myriad of reasons, the critical information does not get related to the patient.

Because of the episodic nature of the practice of emergency medicine (EM), a process must be in place to ensure any “positive” test results or findings discovered after patient discharge are reviewed and compared to the ED diagnosis, and that any “misses” result in notifying the patient and/or his or her primary care physician and arranging follow-up. In cases such as the one presented here, a system issue existed—one that was not due to any fault or oversight of the EP. Ideally, EM leadership should work closely with leadership from radiology and laboratory services and hospital risk management to develop such a process—one that will be effective every day, including weekends and holidays.

Missed fractures on radiographs are a common cause of malpractice litigation against EPs. In one review by Kachalia et al¹ examining malpractice claims involving EPs, missed fractures on radiographs accounted for 19% (the most common) of the 79 missed diagnoses identified in their study.In a similar study by Karcz et al,² missed fractures ranked second in frequency and dollars lost in malpractice cases against EPs in Massachusetts.

While missed lesions on CXR do not occur with the same frequency as missed fractures, the results are much more devastating when the lesion turns out to be malignant. Three common areas where such lesions are missed on CXR include: the apex of the lung, obscured by overlying clavicle and ribs; the retrocardiac region (as in the patient in this case); and the lung bases obscured by the diaphragm.

Emergency physicians are neither trained nor expected to identify every single abnormality—especially subtle radiographic abnormalities. This is why there are radiology overreads, and a system or process must be in place to ensure patients are informed of any positive findings and to arrange proper follow-up.

Case

A 48-year-old man presented to the ED with a 2-day history of cough and congestion. He described the cough as gradual in onset and, though initially nonproductive, it was now productive of green sputum. He denied fevers or chills, chest pain, nausea, vomiting, or diarrhea, and complained of only mild shortness of breath. His medical history was significant for hypertension, which was well managed with daily lisinopril-hydrochlorothiazide. He admitted to smoking one pack of cigarettes per day for the past 25 years, but denied alcohol or illicit drug use.

On physical examination, the patient’s vital signs were: blood pressure, 112/64 mm Hg; heart rate, 84 beats/min; respiratory rate, 20 breaths/min; and temperature, 98^oF. Oxygen saturation was 97% on room air. The head, eyes, ears, nose, and throat examination was normal. Auscultation of the lungs revealed bilateral breath sounds with scattered, faint expiratory wheezing; the heart had a regular rate and rhythm, without murmurs, rubs, or gallops.

The emergency physician (EP) ordered posteroanterior and lateral chest X-rays (CXR), which he interpreted as normal. He also ordered an albuterol handheld nebulizer treatment for the patient. After the albuterol treatment, the patient felt he was breathing more easily. The frequency of his cough had also decreased following treatment and, on re-examination, he exhibited no wheezing and was given azithromycin 500 mg orally in the ED. The EP diagnosed the patient with acute bronchitis and discharged him home with an albuterol metered dose inhaler with a spacer, and a 4-day course of azithromycin. He also encouraged the patient to quit smoking.

The next day the radiologist’s official reading of the patient’s radiographs included the finding of a very small pulmonary nodule, which was seen only on the lateral X-ray. The radiologist recommended a repeat CXR or a computed tomography (CT) scan of the chest in 6 months.

Unfortunately, the EP never saw this information, and the patient was not contacted regarding the abnormal radiology finding and the need for follow-up. Approximately 20 months later, the patient was diagnosed with lung cancer with metastasis to the thoracic spine and liver. Despite chemotherapy and radiation treatment, he died from the cancer.

The patient’s family brought a malpractice suit against the EP, stating that the cancer could have been successfully treated prior to any metastasis if the patient had been informed of the abnormal radiology findings at his ED visit 20 months prior. The EP argued that he never saw the official radiology report, and therefore had no knowledge of the need for follow-up. At trial, a jury verdict was returned in favor of the defendant.

Discussion

Unfortunately, some version of this scenario occurs on a frequent basis. While imaging studies account for the majority of such cases, the same situation can occur with abnormal laboratory results, body-fluid cultures, or pathology reports in which an abnormality is identified (eg, positive blood culture, missed fracture) but, for a myriad of reasons, the critical information does not get related to the patient.

Because of the episodic nature of the practice of emergency medicine (EM), a process must be in place to ensure any “positive” test results or findings discovered after patient discharge are reviewed and compared to the ED diagnosis, and that any “misses” result in notifying the patient and/or his or her primary care physician and arranging follow-up. In cases such as the one presented here, a system issue existed—one that was not due to any fault or oversight of the EP. Ideally, EM leadership should work closely with leadership from radiology and laboratory services and hospital risk management to develop such a process—one that will be effective every day, including weekends and holidays.

Missed fractures on radiographs are a common cause of malpractice litigation against EPs. In one review by Kachalia et al¹ examining malpractice claims involving EPs, missed fractures on radiographs accounted for 19% (the most common) of the 79 missed diagnoses identified in their study.In a similar study by Karcz et al,² missed fractures ranked second in frequency and dollars lost in malpractice cases against EPs in Massachusetts.

While missed lesions on CXR do not occur with the same frequency as missed fractures, the results are much more devastating when the lesion turns out to be malignant. Three common areas where such lesions are missed on CXR include: the apex of the lung, obscured by overlying clavicle and ribs; the retrocardiac region (as in the patient in this case); and the lung bases obscured by the diaphragm.

Emergency physicians are neither trained nor expected to identify every single abnormality—especially subtle radiographic abnormalities. This is why there are radiology overreads, and a system or process must be in place to ensure patients are informed of any positive findings and to arrange proper follow-up.

Case Scenario

A young man presented to the ED for evaluation of a large laceration to the anterior thigh that resulted from an industrial accident (Figure 1).

Femoral nerve blocks are useful in a variety of clinical scenarios, including fractures of the femur or hip¹ and laceration repairs (Figure 2).

Identifying the Femoral Nerve on Ultrasound

To perform this nerve block, one must recall the anatomy of femoral central-line placement. The femoral nerve lies lateral to the femoral artery and vein. The high-frequency probe should be placed over the femoral crease (Figure 3).

Performing the Block

An ultrasound-guided femoral nerve block can be performed using a 22-gauge blunt tip spinal needle, and an in-plane or out-of-plane technique can be employed. We prefer using an in-plane technique because the entire shaft of the needle can be visualized as it approaches the nerve. Anatomically, the femoral nerve lies in a separate fascial plane from the artery and vein, beneath the fascia iliaca (Figure 4). You can use this anatomic location of the femoral nerve to your advantage when performing the block. The needle can be advanced to a target slightly lateral to the nerve until it pops beneath the fascia iliaca. On the ultrasound, you can monitor the spread of anesthetic as it is injected. If the needle is in the right location, the hypoechoic fluid will spread medially toward the nerve, but will not track around the artery or vein. At least 15 cc to 20 cc of local anesthetic is typically required.^2,3 If you prefer, the anesthetic can be diluted in normal saline, in a 1:1 ratio, to achieve adequate volume.

If you do not see the anesthetic spread during the injection, you should stop and check the needle placement, as it may be intravascular. Using a more lateral approach, targeting the injection at the fascial plane, rather than the nerve, helps to avoid direct intraneural injection or contact with the nerve—and it keeps the needle far away from the femoral vascular bundle.

Safety Considerations

As with any technique, prior to the procedure, aseptic measures should be taken, including the use of a sterile probe cover and sterile gloves. All patients undergoing ultrasound-guided nerve blocks proximal to the wrist or ankle should be placed on a cardiac monitor. In addition, intralipid emulsion should be readily available for administration in the unlikely event there is inadvertent intravascular injection of local anesthetic and cardiovascular collapse occurs.

Summary

With practice, ultrasound guidance can improve the procedural success of femoral nerve blocks and decrease the risk of nerve injury compared to blind nerve blocks

Case Scenario

A young man presented to the ED for evaluation of a large laceration to the anterior thigh that resulted from an industrial accident (Figure 1).

Femoral nerve blocks are useful in a variety of clinical scenarios, including fractures of the femur or hip¹ and laceration repairs (Figure 2).

Identifying the Femoral Nerve on Ultrasound

To perform this nerve block, one must recall the anatomy of femoral central-line placement. The femoral nerve lies lateral to the femoral artery and vein. The high-frequency probe should be placed over the femoral crease (Figure 3).

Performing the Block

An ultrasound-guided femoral nerve block can be performed using a 22-gauge blunt tip spinal needle, and an in-plane or out-of-plane technique can be employed. We prefer using an in-plane technique because the entire shaft of the needle can be visualized as it approaches the nerve. Anatomically, the femoral nerve lies in a separate fascial plane from the artery and vein, beneath the fascia iliaca (Figure 4). You can use this anatomic location of the femoral nerve to your advantage when performing the block. The needle can be advanced to a target slightly lateral to the nerve until it pops beneath the fascia iliaca. On the ultrasound, you can monitor the spread of anesthetic as it is injected. If the needle is in the right location, the hypoechoic fluid will spread medially toward the nerve, but will not track around the artery or vein. At least 15 cc to 20 cc of local anesthetic is typically required.^2,3 If you prefer, the anesthetic can be diluted in normal saline, in a 1:1 ratio, to achieve adequate volume.

If you do not see the anesthetic spread during the injection, you should stop and check the needle placement, as it may be intravascular. Using a more lateral approach, targeting the injection at the fascial plane, rather than the nerve, helps to avoid direct intraneural injection or contact with the nerve—and it keeps the needle far away from the femoral vascular bundle.

Safety Considerations

As with any technique, prior to the procedure, aseptic measures should be taken, including the use of a sterile probe cover and sterile gloves. All patients undergoing ultrasound-guided nerve blocks proximal to the wrist or ankle should be placed on a cardiac monitor. In addition, intralipid emulsion should be readily available for administration in the unlikely event there is inadvertent intravascular injection of local anesthetic and cardiovascular collapse occurs.

Summary

With practice, ultrasound guidance can improve the procedural success of femoral nerve blocks and decrease the risk of nerve injury compared to blind nerve blocks

Case Scenario

A young man presented to the ED for evaluation of a large laceration to the anterior thigh that resulted from an industrial accident (Figure 1).

Femoral nerve blocks are useful in a variety of clinical scenarios, including fractures of the femur or hip¹ and laceration repairs (Figure 2).

Identifying the Femoral Nerve on Ultrasound

To perform this nerve block, one must recall the anatomy of femoral central-line placement. The femoral nerve lies lateral to the femoral artery and vein. The high-frequency probe should be placed over the femoral crease (Figure 3).

Performing the Block

An ultrasound-guided femoral nerve block can be performed using a 22-gauge blunt tip spinal needle, and an in-plane or out-of-plane technique can be employed. We prefer using an in-plane technique because the entire shaft of the needle can be visualized as it approaches the nerve. Anatomically, the femoral nerve lies in a separate fascial plane from the artery and vein, beneath the fascia iliaca (Figure 4). You can use this anatomic location of the femoral nerve to your advantage when performing the block. The needle can be advanced to a target slightly lateral to the nerve until it pops beneath the fascia iliaca. On the ultrasound, you can monitor the spread of anesthetic as it is injected. If the needle is in the right location, the hypoechoic fluid will spread medially toward the nerve, but will not track around the artery or vein. At least 15 cc to 20 cc of local anesthetic is typically required.^2,3 If you prefer, the anesthetic can be diluted in normal saline, in a 1:1 ratio, to achieve adequate volume.

If you do not see the anesthetic spread during the injection, you should stop and check the needle placement, as it may be intravascular. Using a more lateral approach, targeting the injection at the fascial plane, rather than the nerve, helps to avoid direct intraneural injection or contact with the nerve—and it keeps the needle far away from the femoral vascular bundle.

Safety Considerations

As with any technique, prior to the procedure, aseptic measures should be taken, including the use of a sterile probe cover and sterile gloves. All patients undergoing ultrasound-guided nerve blocks proximal to the wrist or ankle should be placed on a cardiac monitor. In addition, intralipid emulsion should be readily available for administration in the unlikely event there is inadvertent intravascular injection of local anesthetic and cardiovascular collapse occurs.

Summary

With practice, ultrasound guidance can improve the procedural success of femoral nerve blocks and decrease the risk of nerve injury compared to blind nerve blocks