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Archive for the ‘Clinical’ Category

Regional Anesthesia For Abdominal Surgery

Thursday, August 23rd, 2018

By Stephen M. Anderson, M.D.

Regional anesthesia plays an important role in patient recovery. Opioid-sparing techniques show benefits including decreased length of stay (LOS), improved postoperative pulmonary function and decreased overall morbidity and mortality. This article will discuss indications for regional anesthesia for abdominal surgery, the techniques by which they are used, and the risks and benefits of each, as well as thoracic epidural analgesia (TEA), transversus abdominis plane (TAP) blocks and rectus sheath blocks.

Comparison of sensory block achieved by rectus sheath block (large black circle over abdominal midline), bilateral standard TAP block (grey semi-circle over lower abdomen), and unilateral oblique subcostal TAP block (which can vary but approximately covers the area shaded in grey in the upper abdominal quadrant)7

Thoracic Epidural Analgesia (TEA)
Open abdominal surgery is associated with significant pain that typically requires a substantial opioid regimen to control. The benefits of TEA have long been recognized, such as improved pulmonary function with decreased incidence of postoperative respiratory depression and pneumonia, increased coronary perfusion and decreased incidence of postoperative ileus. In addition to organ system-specific benefits, TEA is associated with improved pain scores, decreased opioid requirements, shortened LOS and improved mortality.1

Risks and limitations are also associated with TEA. Organ-specific risks include vasodilation and hypotension, paresthesias with placement, post dural puncture headache (PDPH), subarachnoid placement, limitations associated with anticoagulation regimens and coagulopathy, and epidural abscess and/or hematoma formation. In addition, adequate nurse education, cost of placement and management teams and time constraints must be taken into account.1 When there are significant limitations or for patients for whom TEA would be contraindicated, multimodal analgesia regimens have also been shown to have benefits.2,3

Transversus Abdominis Plane (TAP) blocks
As mentioned earlier, abdominal surgery is often associated with significant pain, and most of this pain originates from the anterior abdominal wall. Traditionally, this pain has been relieved with an opioid regimen or a combination of multimodal analgesia, which may or may not have included neuraxial analgesia. While effective at treating pain, opioids have significant side effects including nausea, sedation, urinary retention and inhibition of gastrointestinal function.4

Even thoracic epidurals, which have long been considered the gold standard of regional analgesia for abdominal surgery, are not without limitations and complications. Coagulopathy, infection at the insertion site, prior spine surgery or trauma, hypovolemia, sepsis, hemodynamic instability and patient refusal are just a few of the contraindications.5 Limitations of epidurals are also significant and include hypotension, splanchnic hypoperfusion, patient immobility and cost.4

A good multimodal analgesia regimen that adequately controls pain and minimizes the side effects of opioids is essential to an ERAS protocol for abdominal surgery. TAP blocks have been shown to decrease pain scores, decrease opioid requirements and shorten hospital length of stay in patients following laparoscopic abdominal surgery.4 However, compared to trocar site infiltration by the surgeon, TAP blocks showed no analgesic or opioid-sparing benefits.5

Limitations of TAP blocks include cost of equipment (specifically ultrasound), training of block nursing staff, accidental peritoneal puncture, accidental intravascular injection causing local anesthetic toxicity and preoperative time limitations.

Target for Local Anesthetic Infiltration during a rectus sheath block (RAM = Rectus Abdominis Muscle)

The introduction of ultrasound has greatly improved the anesthesia provider’s ability to provide regional anesthesia in general and TAP blocks specifically. The direct visualization of vessels, muscles and other structures has not only aided in the placement of local anesthesia in the correct fascial plane, but it has allowed us to minimize the complication rate of intravascular injection and peritoneal puncture.

The ultrasound probe is placed in a transverse fashion between the lower costal margin and iliac crest on the lateral abdominal wall at the midaxillary line. The abdominal muscle layers are then identified from shallow to deepest: external oblique (EO), internal oblique (IO) and transversus abdominis (TA). Deep to those are the peritoneum and bowel contents.

The needle is inserted in plane, and local anesthetic is deposited in the plane between the IO and TA. With this posterior approach, it is reasonable to expect analgesia between T10 and L1.6

If a higher level of analgesia is desired, the posterior TAP may need to be supplemented with a subcostal TAP to achieve a level up to T7. In this approach, the ultrasound probe is placed just beneath the costal margin. The needle is introduced into the fascial layer separating the rectus abdominis and the transversus abdominis.6

Rectus Sheath Block
The aim of this technique is to block the terminal branches of the T7-12 nerves, which run in the plane between the internal oblique and transversus abdominis muscles to penetrate the posterior wall of the rectus abdominis muscle (RAM) and end in an anterior cutaneous branch supplying the skin of the umbilical area. Like TAP blocks, rectus sheath blocks relieve somatic pain of the anterior abdomen and not the visceral structures. This block is more clinically useful for umbilical hernia repairs and more midline surgeries.

Like TAP blocks, care must be taken to avoid accidental peritoneal puncture. In addition, with epigastric arteries running in the midline, ultrasound with or without Doppler is recommended to avoid vascular puncture and intravascular local anesthetic injection. Local anesthetic toxicity is also a concern since this block may be combined with TAP blocks, which are high-volume blocks.

The patient is placed in the supine position, and the transducer placed in the transverse position immediately lateral to the umbilicus. Color Doppler can be used to identify the epigastric arteries. The oval shaped RAM is identified, and the needle is inserted in-plane in a medial to lateral orientation through the anterior rectus sheath. The needle is further advanced through the body of the muscle until the tip rests in the posterior rectus sheath. In an adult patient, 10 mL of local anesthetic (e.g., 0.5 percent ropivacaine) per side is usually sufficient for successful blockade.8 Since this paired muscle is separated in the midline by the linea alba, the block will need to be repeated on the other side to achieve bilateral analgesia.


References
1. Gan, TJ; et al. Enhanced Recovery for Major Abdominal Surgery. First Edition. Professional Communications, Inc. 2016. 165-168.
2. Ahmed, Aliya; Latif, Naveed; Khan, Robyna. Posteroperatiev analgesia for abdominal surgery and it’s effeectiveness in a tertiary care hospital. J Anaesthesiol Clin Pharmacol. 2013 Oct-Dec; 29(4): 472–477.
3. Rigg, John; et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. The Lancet. Volume 359: 9314. 1276–1282. April 2002 4. Ris, F; Findlay, JM; Hompes, R; Warwick; Cunningham, C; Jones, O; Crabtree,N; Lindsey, I. Addition of transversus abdominis plane block to patient controlled analgesia for laparoscopic high anterior resection improves analgesia, reduces opiod requirement and expedites recover of bowel function. Ann R Coll Surg Engl. 2014; 96: 579-585
5. Chawla, J; Schraga, E. Epidural Nerve Block. Medscape; 2015
6. Mukhtar, K. Transversus Abdominis Plane (TAP) Block. The Journal of NYSORA. 2009. 12: 28-33.
7. Webster, Katrina. Ultrasound guided rectus sheath block – analgesia for abdominal surgery. Update in Anesthesia. 2010. 12-16
8. Truncal and Cutaneous Blocks. The New York School of Regional Anesthesia. 2013. http://www.nysora.com/techniques/ultrasound-guided-techniques/3253- truncal-and-cutaneous-blocks.html

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Hernia Repair: Current Diagnosis and Management for Abdominal Wall Hernia Repair

Monday, July 30th, 2018

By Mark B. Wilkiemeyer, M.D., FACS

Abdominal wall hernia, simply defined as a space or gap in the abdominal wall, is one of the most common complaints seen by the practicing general surgeon. Literature tends to focus on management of hernia once it is identified and classified, but this ignores the necessary diagnostic steps to correctly classify the location of the hernia. The history and physical examination provides many of the clues necessary for proper hernia identification and subsequent classification and management.

History: Use the OLD CARTS Mnemonic
Onset can provide context for hernia identification and management. The sudden appearance of a bulge or the gradual “coming and going” of vague pain will help guide the physician towards an accurate diagnosis and help triage the patient. Sudden unrelenting painful bulges would prompt much more rapid assessment and surgical treatment than the slow, gradual onset of discomfort.

Location is an important component for hernia management. The patient’s subjective reporting of location of pain and/or a bulge provides the starting point for hernia identification. Incisional, umbilical and inguinal/groin hernias can be quickly localized by patient complaint.

Duration is less specific for hernia identification. As hernias can have long durations and gradually become more symptomatic, the duration of the hernia rarely is the most important factor in classification or management strategies.

Character of the pain can give clues to the hernia contents (bowel more crampy, preperitoneal fat sharp localized pain, omentum sharp but more generalized in location). As hernias can be painless but still bothersome, the character of the hernia symptoms should be noted but are not essential to initial diagnosis. It may prompt further diagnostic workup or more urgent management.

Aggravating factors and relieving factors will generally be related to abdominal wall musculature utilization and rest. Increases in intra-abdominal pressure through coughing, sneezing or exercise will commonly exacerbate discomfort.

Radiation of pain can provide additional clues as to the contents of the hernia.

Timing or temporal factors will sometimes help with hernia diagnosis and management but are often associated with aggravating factors and won’t often distinguish hernias alone.

Severity of symptoms will prompt urgent or elective management but rarely give additional information about the hernia itself. However, severe unrelenting crampy pain can point to a strangulated hernia containing ischemic or compromised bowel.

Physical Exam: Experience Counts
The comprehensive physical exam remains critical to assessment and management of the patient with a hernia complaint. Experience with examination improves diagnostic accuracy and likely reduces the use of imaging.

Generally, the hernia should be classified as “reducible” or “incarcerated”; this will assist in determining timing of repair if needed. Incarcerated hernias, or hernias thought to contain compromised viscera, will generally be explored and repaired as a surgical emergency. Conversely, the reducible hernia is often managed on an elective basis. Chronically incarcerated but minimally symptomatic umbilical or incisional hernias are exceptions to this rule, where severity of symptoms will help us make recommendations for urgency of surgical treatment.

Examination will include multiple positions (standing and supine) along with multiple degrees of intra-abdominal pressure. A relaxed abdominal wall can allow the physician to palpate the fascial edges of the hernia defect; a Valsalva maneuver provides “proof” of hernia bulge and possibly clues as to the contents.

Thorough inspection of overlying skin incisions and anatomic landmarks help improve accuracy of diagnosis and management; for example, umbilical hernias and incisional hernias at the umbilicus can provide vastly different challenges during surgical management.

Partial thickness abdominal wall hernias can provide diagnostic confusion; if no “hole” is present in the most superficial fascial layer, then a vague bulge may be identified but a focal fascial defect may be absent. We see this with lateral trocar site incisional hernias and lower lateral abdominal wall Spigelian hernias; generally, hernias in or near the midline will not cause this confusion.

One common point of confusion is the presence of rectus diastasis. This is not a true hernia but is the separation of the rectus muscles due to chronic abdominal distention. This separation is commonly secondary to truncal obesity or multiple pregnancies. This presents as a vertical abdominal bulge above the umbilicus which appears when doing a sit up. This does not represent a true hernia and therefore does not require repair unless there are cosmetic concerns.

Imaging When Necessary
Cross-sectional imaging of the abdomen and pelvis can provide assistance when history and physical examination are not sufficient to confirm diagnosis and accurate localization of an abdominal wall hernia. They are not necessary to make a diagnosis or recommendation for surgery, and can sometimes cloud the issue if there is no obvious hernia seen but history and physical are clearly pointing towards surgical management.

Cross-sectional imaging of the abdomen and pelvis can incidentally identify abdominal wall defects. When identified these should be evaluated by an experienced surgeon.

Surgical Management of Abdominal Wall Hernias
In general, symptomatic hernias will be repaired in suitable surgical candidates. Regional anesthesia is available to reduce anesthesia risk, but care should be given to prioritize the ability of the surgeon to produce a durable repair. If regional anesthesia alone is insufficient for reduction and proper repair of the hernia, then the surgical risk outweighs benefit and the procedure should be carefully reconsidered.

The main surgical principals of hernia repair are reduction of the hernia contents, clear identification of the borders of the defect, followed by closure of the defect with as little tension as possible. Mesh is commonly used to reinforce and add durability to the repair. The location of the mesh reinforcement has changed over the years. Current trends in hernia repair place the mesh within the layers of the abdominal wall as opposed to inside the peritoneal cavity or above the fascia.

Minimally invasive surgical techniques for abdominal wall hernias include laparoscopic and robotic approaches. Traditional repairs are done with open incisions. Each of these has benefits and drawbacks; nonetheless, the patient is well served by meeting with surgeons who can offer a wide variety of treatment options.

Mesh is used to reduce the risk of recurrence. In some cases mesh is required to “bridge” a defect that cannot be closed with suture, although this is less than ideal. The use of mesh can increase the risk of complications, but its value in adding durability to the repair generally outweighs these concerns.

Common materials used to manufacture synthetic mesh include polypropylene and polyester. In recent years biologic meshes have become common with porcine- and bovine-derived materials being used in certain complicated and high-risk situations. Generally these biologic materials are thought to carry less risk of chronic infection but are much more expensive than synthetic mesh and are commonly perceived as a less durable over the long term.

The ideal hernia repair continues to be an evolving science. Advances in technique and options for abdominal reinforcement create an exciting and changing landscape for patients and general surgeons.


Mark Wilkiemeyer, M.D., FACS

Dr. Wilkiemeyer grew up in Atlanta and attended Vanderbilt University, then went on to attend Tulane University School of Medicine in New Orleans, where he graduated Alpha Omega Alpha in 1998 as a Doctor of Medicine. He trained in General Surgery at University of Texas Southwestern, subsequently completing a fellowship in laparoscopic surgery at the Duke University Medical Center. He lives in
Atlanta with his wife, Claire Dudley Wilkiemeyer, M.D., and their two children.

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Fertility Treatment for the PCOS Patient

Monday, June 25th, 2018

By Kathryn Calhoun, M.D.

Chronic anovulation is a hallmark of Polycystic Ovary Syndrome (PCOS), so the vast majority of women with PCOS will require fertility treatment to conceive.

In a young PCOS patient with no obvious barriers to conception (other than anovulation), it is reasonable to start ovulation induction medicines before evaluating her uterus/tubes or her partner’s semen analysis. If the woman/ couple has not conceived after three successful ovulations, then a hysterosalpingogram (HSG) and semen analysis should be performed.

In contrast, an older woman (> 35 years) or a couple with risk factors for pelvic disease or sperm problems should have an HSG and a semen analysis before proceeding with ovulation induction therapy. Examples of risk factors for pelvic disease include a prior history of infections, surgery, pain, broids, endometriosis or pregnancy loss. Examples of risk factors for an abnormal semen analysis include changes in strength/libido, erectile dysfunction, obesity, sleep apnea, diabetes or cardiovascular disease.

Until recently, the first-line medication for ovulation induction in women with PCOS was clomiphene citrate (Clomid). Clomid is a selective estrogen receptor modulator (SERM) that blocks estrogen feedback on receptors throughout the body. At the brain (hypothalamic-pituitary) level, this perceived low estrogen state results in altered hormone (FSH/LH) signaling to the ovaries.

In 80 percent of PCOS women, this change in FSH/LH levels will result in ovulation.1 Side effects of Clomid are due to this reduced estrogen signaling and include headaches, hot ashes, mood changes, decreased cervical mucus, vaginal dryness and a temporary thinning of the uterine lining. Rarely, women may experience changes in vision, and this is a reason to discontinue Clomid use. The risk of twins is ~8 percent per cycle, the risk of triplets is < 1 percent. No causal relationship has been established between ovulation induction medicines and birth defects, miscarriage or ovarian cancer.1

A recent study followed women with PCOS for up to five treatment cycles and reported better rates of ovulation (61.7 percent vs 48.3 percent) and live birth (27.5 percent vs 19.1 percent) with Letrozole (Femara) rather than Clomid.2 Thus, Femara is now the first choice for ovulation induction in PCOS patients. Femara is an aromatase inhibitor that blocks the conversion of androgens to estrogens, thereby actually lowering estrogen levels in the body. The effect on the brain is similar to Clomid, though the side effects (hot ashes, headaches, thinning of uterine lining) are often less. Though it was underpowered to detect a significant difference, the risk of twins in this study was lower with Femara (3.9 percent) than Clomid (6.9 percent).2

Both Femara and Clomid are taken daily for 5 days at the start of a menstrual cycle. Progesterone may be used to induce a menstrual period, if necessary. Ovulation most often occurs 5-12 days after the last pill, and the patient should begin ovulation predictor kits (“OPKs”) and regular intercourse (if possible) during this interval.1 An ultrasound is performed to check ovarian response, to evaluate the uterine lining and to help the couple plan further intercourse and/or intrauterine insemination (IUI). If the ovaries are not responding, dosing can be immediately adjusted at this visit.

If Femara is unsuccessful at inducing ovulation, the dose can be increased, the duration may be extended or the patient can then try Clomid. Adjunct medications are sometimes used, such as low-dose Dexamethasone or Metformin, though these may yield minimal additional benefit.

Using Metformin alone has demonstrated lower rates of ovulation, live birth and twin pregnancy than Clomid.3 If the patient demonstrates continued resistance to oral medications, the importance of lifestyle modification (weight loss, if applicable) is reinforced and ovarian drilling (surgery to reduce the androgen-producing stromal portion of the ovary) may be considered. After six months of therapy, the chance of pregnancy drops significantly despite ovulation.1

If oral medications are unsuccessful, the next step may be injectable gonadotropins (FSH/LH.) Women with PCOS have a very high follicular/egg count, so these medicines may be risky if combined with intercourse or IUI. The chance of over-response, ovarian hyperstimulation syndrome (OHSS) or higher-order multiple gestations (triplets+) can lead to canceled cycles, treatment delays and disappointment.

For PCOS patients who do not succeed with lesser therapies, in vitro fertilization (IVF) represents a safe and effective next step. For the youngest PCOS patients, per cycle pregnancy rates can approach 70 percent. In an IVF cycle, a woman administers injectable gonadotropins (FSH/LH) for 9-12 days in order to mature a high percentage of her monthly egg group. The eggs are then retrieved with a short outpatient surgical procedure, then fertilization and early embryo development occur in the laboratory. An embryo is replaced in the uterus to begin the pregnancy.

Women with PCOS require special IVF care due to their robust egg count. The focus of treatment is to safely recruit a moderate-size group of eggs without significant OHSS. OHSS causes fluid shifts and third-spacing that can lead to symptomatic ascites and intravascular depletion. In addition to illness, OHSS can also result in lower-quality eggs/embryos. PCOS IVF protocols should employ lower doses and different combinations of medicines, as well as adjunctive therapies (i.e Metformin), to ensure an optimal and safe response.4 Even with appropriate treatment, at the end of the stimulation, most PCOS patients will have hormone levels that are too high for ideal implantation. To ensure the highest pregnancy rates, and a safe and healthy pregnancy overall, embryos are often frozen and transferred in the next cycle as a frozen embryo transfer (FET).

The good news is that most PCOS patients will conceive and enjoy a low-risk pregnancy. This is especially true for those patients with singleton gestations and no other comorbidities (i.e. obesity, insulin resistance/diabetes, hypertension). It is possible that the observed increased risks of pregnancy loss and late pregnancy complications in PCOS are most common in women with those additional risk factors.


REFERENCES
1. Fritz, Marc A.; Speroff, Leon. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia: Lippincott Williams & Wilkins; c2010.

2. Legro RS, Kunselman AR, Brzyski RG, Casson PR, Diamond MP, Schlaff WD, Christman GM, Coutifaris C, Taylor HS, Eisenberg E, Santoro N, Zhang H; NICHD Reproductive Medicine Network. The Pregnancy in Polycystic Ovary Syndrome II (PP- COS II) trial: rationale and design of a double-blind randomized trial of clomiphene citrate and letrozole for the treatment of infertility in women with polycystic ovary syndrome. Contemp Clin Trials. 2012 May;33(3):470-81. doi: 10.1016/j.cct.2011.12.005. Epub 2012 Jan 13.

3. Legro RS, Barnhart KH, Schlaff WD, etc al. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med. 2007; 356: 551-566.

4. Practice Committee of the American Society for Reproductive Medicine. Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline. Fertil Steril. 2016; 106: 1634-1647.

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Polycystic Ovary Syndrome – A Simplified Approach to Diagnosis

Tuesday, May 29th, 2018

by Jennifer F. Kawwass, MD and Heather S. Hipp, MD

Polycystic Ovary Syndrome, or PCOS, the enigmatic syndrome ascribed to infertile, overweight females with irregular menstrual cycles, may be simpler to understand than it seems. The syndrome can be confusing: no clear linear causal pathway has been elucidated, and many endocrine axes interact to accentuate the classical physical manifestations. In addition, it is a broad diagnosis, and many women with PCOS do not fit the stereotypical PCOS mold.

Despite the heterogeneity of women that can meet criteria for PCOS, understanding the diagnostic basics can make the syndrome much easier to recognize.

Importantly, the diagnosis is independent of body mass index (BMI) or weight. In fact, 10-15 percent of women with PCOS are lean with a normal BMI. According to the 2003 NIH Rotterdam criteria, a diagnosis of PCOS requires two of the following three characteristics:

1. Oligoovulation and/or anovulation (i.e. irregular menstrual cycles)
Can be determined by patient history: menstrual cycles occurring in an unpredictable pattern or greater than 42 days apart are suggestive of anovulation.

2. Elevated androgens (clinical and/or biochemical)
Can be determined by laboratory value of testosterone above the female reference range or by clinical signs of hirsutism/ acne that exceed ethnic norms.

3. Polycystic appearing ovaries on transvaginal ultrasound
Can be determined by ultrasound assessment of the ovaries having a “PCOS” appearance. A formal antral follicle count (12 or more follicles measuring 2-9mm in diameter) on each ovary can also be done.

Although AMH is not part of the diagnostic criteria, an elevated AMH (e.g. over 4 ng/mL) in combination with the other diagnostic criteria is suggestive of PCOS.

Given that the criteria only requires two of the three above characteristics, women may have PCOS without hyperandrogenism or irregular cycles. There is a sub-category of women with PCOS who are lean (aka “lean PCOS”). These women often do not have hyperandrogenism and present with infertility due to anovulation. Due to their BMI, they are sometimes diagnosed with functional hypothalamic amenorrhea (see below), which is treated in a different fashion.

The primary tenet in diagnosing PCOS is appreciation that it is a diagnosis of exclusion. One can only clearly diagnose a woman as having PCOS after ruling out all potential masqueraders. As women with PCOS often present with irregular or absent menstrual cycles, excluding other causes of amenorrhea or oligomenorrhea is usually a good place to start. Common masqueraders include pregnancy, thyroid disease and hyperprolactinemia, which can be assessed with a laboratory evaluation including bHCG, a TSH a prolactin. A more rare cause is delayed onset congenital adrenal hyperplasia (CAH), which is screened for with 17-hydroxyprogesterone.

On a patient-specific basis, one can also screen for other rare causes of oligomenorrhea: Cushing’s syndrome in someone with rapid weight gain and new-onset hypertension, an ovarian or adrenal testosterone-secreting tumor in an individual with rapid-onset severe virilization, or acromegaly in someone with increasing glove, shoe or hat size. Most often, however, ruling out pregnancy, pituitary and thyroid disease, and CAH is a reasonable place to start.

Particularly in a lean woman with absent cycles, functional hypothalamic amenorrhea (FHA) may cause absent periods and may even be present in addition to underlying PCOS. Women with FHA typically present with a low BMI and a history consistent with excessive exercise or calorie restriction. If the FSH, LH, and estradiol are all low or in the low range of normal, referral to a reproductive endocrinologist for help with treatment of FHA would be reasonable.

Lastly, severe diminished ovarian reserve can cause irregular cycles. It can be very helpful to ascertain ovarian reserve and hypothalamic-pituitary-ovarian function. An overweight patient with irregular cycles may actually have diminished ovarian reserve and not PCOS. Obesity and irregular cycles are not synonymous with PCOS. An FSH and estradiol in the early follicular phase or after a progesterone-induced bleed may help clarify ovarian reserve in a patient that is not on oral contraceptives. An FSH over 10 would suggest diminished ovarian reserve and not PCOS. An anti-mullerian hormone (AMH) or transvaginal ultrasound with antral follicle count (AFC) may also help in the differentiation.

Figure 1. Simplified Approach to Diagnosing PCOS

Adolescents are a unique population. Because of young age and resultant robust ovarian reserve, polycystic ovarian morphology may not necessarily represent PCOS. Moreover, oligomenorrhea is normal around the time of menarche. Some researchers argue that to give a diagnosis of PCOS to an adolescent, she must have all three of the Rotterdam criteria.

Lifestyle counseling is warranted in women with a diagnosis of PCOS. For women who are overweight, a 5-10 percent weight loss has been associated with improvement in menstrual regularity and resumption of menses. Counseling regarding heightened risk of insulin resistance compared to women without PCOS may also help guide dietary and exercise choices for patients with the syndrome. Finally, when not trying to conceive, the importance of uterine lining protection with some form of hormonal contraception, including intrauterine devices, is worth discussing.

The next step is to determine fertility intentions. The treatment course diverges based on desire for either fertility or contraception. For those who are not currently interested in conceiving, oral contraceptive pills (OCPs) are often the first line of treatment. OCPs offer endometrial lining protection and can also improve symptoms of hyperandrogenism.

For those who desire pregnancy, the first line agent for ovulation induction is letrozole. Referral to an REI is reasonable before attempt at ovulation induction or after one to three cycles of failed attempts at pregnancy with the use of ovulation induction.

Women who have PCOS are at a higher lifetime risk of diabetes and, when pregnant, gestational diabetes, even if they are lean. Screening for diabetes should be strongly considered in any women with PCOS; this can be done with a hemoglobin A1c or a 2-hour oral glucose tolerance test. If pre-diabetes is diagnosed, Metformin can be offered to aid in insulin resistance and, in some women, weight loss.

It is also possible that someone on the PCOS-spectrum may develop more overt symptoms with weight gain. As such, a female with mild PCOS may benefit from counseling regarding the avoidance of weight gain.

PCOS affects 10-15 percent of reproductive-age women. As a result, it warrants the attention of not only obstetrician gynecologists, but also physicians in other specialties. The associated cardiovascular, endocrine and fertility sequelae can impact all aspects of a PCOS female’s medical care.


References
Carmina, E, Oberfield, SE, Lobo, RA. “The diagnosis of polycystic ovary syndrome in adolescents.” Am J Obstet Gynecol; 2010; 03 (3): 201. E1-5.

Good C, Tulchinsky M, et al. “Bone Mineral density and body composition in lean women with polcystic ovary syndrome.” Fertility and Sterility 1999; 72: 21-25.

Goodman NF, Cobin RH, et al. “American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society Disease State Clinical Review: Guide to the Best practices in the Evaluation and Treatment of Polycystic Ovary Syndrome- Part 2.” Endocr Pract 2015; 21: 1415-1426

Goyal, M, Dawood, AS. “Debates regarding lean patients with polycystic ovary syndrome: A narrative review.” J Hum Reprod Sci. 2017; 10 (3): 154-161.

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An Unforeseen Threat: The Impact of Viral Hepatitis on Reproduction

Friday, April 20th, 2018
Alexis P. Calloway, M.D.

Alexis P. Calloway, M.D.

By Alexis P. Calloway, M.D.

Much focus is given to the long- and short-term impact of commonly tested sexually transmitted infections such as HIV, chlamydia, gonorrhea and HPV on reproductive health. As the medical landscape of diagnosis and therapeutic options for infertility evolve, it is just as important to focus on viral hepatitis as well, with particular emphasis on Hepatitis B and C.

Viral Hepatitis in the United States
According to the Centers for Disease Control and Prevention (CDC), there were an estimated 33,900 new Hepatitis C virus ( HCV) infections in 2015, representing a 2.9-fold increase since 2010 with 75 percent to 85 percent of infections becoming chronic. The estimated number of new Hepatitis B virus (HBV) infections in 2015 was 21,900, however these rates are decreasing.

HCV is generally acquired through IV drug use and blood transfusions until changes in screening regulation for donations in the early 1990s. HCV can rarely also be acquired through sexual transmission. Alternatively, HBV is commonly acquired through sexual transmission, particularly in heterosexuals with multiple partners and unvaccinated men who have sex with men. Other common sources of transmission for HBV include mother-to- child transmission (MTCT), intravenous drug abuse and rarely through paternal transmission. (Iqbal et al., 2015) Chronic viral hepatitis, with HCV accounting for the majority of cases, is one of the most common causes of cirrhosis in the U.S. and carries a significant burden on the healthcare system. Given the multifaceted impact to the body, it is unknown what the specific burden to reproductive health may be.

Viral Hepatitis and Male Fertility
It is already known that many chronic viruses have the ability to infect sperm and adversely impact male fertility. Specifically in the last decade, it has been found that HCV causes a statistically significant decrease in semen volume, sperm count and progressive sperm motility and an increase in abnormal sperm morphology compared with healthy controls. Furthermore, the duration of HCV infection has been negatively correlated with semen volume and sperm motility where the HCV RNA viral load was negatively correlated with sperm count and sperm motility. (Hofny et al., 2011) In a study published in 2011, it was found that couples whose male partner was infected with HBV had a higher risk of low fertility rates after IVF, a risk which was independent from the initial sperm motility. (Oger et al., 2011)

As viral hepatitis may be asymptomatic until the onset of advanced disease, these barriers may not be identified as a potential etiology for infertility in younger populations. Targeted screening in this at-risk group may be of benefit in reproductive counseling, though no clear guidelines have been established. Some literature does attempt to address the issue of disparity of screening asymptomatic men in comparison to their heterosexual partners.

In a study of 1,243 male partners of 2,400 women who attended ultrasound examinations between 2010 and 2011, 430 accepted HIV and STI testing. It was ultimately found this is an acceptable time to feasibly engage the heterosexual male partner for screening. (Dhairyawan, Creighton, Sivyour, & Anderson, 2012) Other opportunities may arise to address screening and should be pursued on an individual basis by the patient’s healthcare provider.

Table 1. Pathology Structure of female reproductive system with HBV - and HCV- infection

Kurmanova, A.M., et al. (2016). “Reproductive dysfunctions in viral hepatitis.” Gynecol Endocrinol 32(sup2): 37-40.

Viral Hepatitis and Female Fertility
Menstrual disorders serve as the predominant cause of reproductive barriers in a patient affected with HBV and HCV due to intra- and extrahepatic pathology (as displayed in Table 1). (Kurmanova, Kurmanova, & Lokshin, 2016) Premenopausal women who are HCV positive or have chronic liver disease are at risk for premature ovarian failure impacting their lifelong fertility.

A study published in 2017 found that most new cases of HCV infection are among people who inject drugs, including reproductive-age females. Reproductive-age women who are HCV positive display markers of ovarian failure. This is associated with infertility and adverse pregnancy outcomes such as stillbirth, miscarriage, fewer live births and gestational diabetes. (Karampatou et al., 2017)

There is not much research surrounding the impact of HBV on reproduction in women specifically. One small study measuring pregnancy rates and implantation rates of HBV-sero- positive women and their partners found a higher rate of tubal blockage, often leading to signficantly higher rates of IVF and embryo transfer cycles if at least one partner was positive when compared to seronegative control couples. (Lam et al., 2010)

No matter the etiology, there are overarching impacts of cirrhosis on the reproductive health of women. Cirrhosis leading to generalized infertility and pregnancy is rare, but when it does occur specialized care is required.

Viral Hepatitis and the Pregnant Patient
Mother-to-child transmission is responsible for more than one third to one half of chronic HBV infections worldwide and can occur during pregnancy, delivery or after birth if not treated. Acute HBV infection during pregnancy is usually mild and not associated with increased mortality or teratogenicity. However, transmission rates significantly increase if acute infection occurs in the perinatal period, with rates as high as 60 percent reported. (Sookoian, 2006)

Chronic hepatitis B serves as a larger medical management consideration with emphasis on decision to treat during pregnancy with anti-retroviral therapy. This decision is generally influenced by ALT elevation greater than two times the upper limit of normal, HBV DNA levels, detection of Hepatitis B Surface Antigen (HBSAg) and anti-Hepatitis B e antibody (anti-HBe), and the presence or absence of cirrhosis.

Women with high viral loads (HBV DNA) in the third trimester should be treated even in the setting of normal ALT to decrease the vertical transmission risk to the infant. Furthermore, neonates of HBSAg-positive mothers should receive monovalent hepatitis B vaccine and HBIG 0.5ml as soon after delivery as possible (preferably within 12-24 hours) regardless of birth weight. (Committee On Infectious, Committee On, & Newborn, 2017) As perinatal transmission of HCV is unlikely, decision to treat can be deferred until after delivery. Subspecialist assistance may serve valuable in determining patient candidacy and timing for treatment.

Though HCV can be detected in maternal colostrum, this is not considered a factor associated with vertical transmission. In a study of 76 samples of breast milk from 73 chronically HCV-infected mothers, none of the samples contained HCV RNA and only one of the breastfed infants had evidence of HCV one month after birth without clear correlation to breastfeeding itself. (Polywka, Schroter, Feucht, Zollner, & Laufs, 1999) It is accepted by multiple organizations that breastfeeding is considered generally safe in asymptomatic HCV-positive mothers.

Reproductive Planning
Though initially targeted for the baby boomer population, emerging and highly effective therapies for HCV may prove beneficial to improving infertility in reproductive-age individuals burdened with this disease as well. Rates of sustained virologic response (SVR) have been found to be in the high 90th percentile for patients with common genotypes of the virus undergoing eight or 12 weeks of treatment. (Terrault et al., 2016)

Additionally, treatment is beneficial as early menopause in patients with chronic HCV was associated with low likelihood of SVR likely due to inflammatory factors and physiologic variations in estrogen that change at menopause. (Villa et al., 2011) Vaccination should also be pursued in household and sexual contacts for those with HBV.

As providers, viral hepatitis should be a part of the reproductive health discussion, with appropriate screening and treatment as indicated in this special and occasionally missed population.


References
Committee On Infectious, D., Committee On, F., & Newborn. (2017). Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 Hours of Birth. Pediatrics, 140(3). doi:10.1542/peds.2017-1870
Dhairyawan, R., Creighton, S., Sivyour, L., & Anderson, J. (2012). Testing the fathers: carrying out HIV and STI tests on partners of pregnant women. Sex Transm Infect, 88(3), 184-186. doi:10.1136/sextrans-2011-050232

Hofny, E. R., Ali, M. E., Taha, E. A., Nafeh, H. M., Sayed, D. S., Abdel-Azeem, H. G., . . . Mostafa, T. (2011). Semen and hormonal parameters in men with chronic hepatitis C infection. Fertil Steril, 95(8), 2557-2559. doi:10.1016/j.fertnstert.2011.05.014

Iqbal, K., Klevens, R. M., Kainer, M. A., Baumgartner, J., Gerard, K., Poissant, T., . . . Teshale, E. (2015). Epidemiology of Acute Hepatitis B in the United States From Population-Based Surveillance, 2006-2011. Clin Infect Dis, 61(4), 584-592. doi:10.1093/ cid/civ332

Karampatou, A., Han, X., Kondili, L. A., Taliani, G., Ciancio, A., Morisco, F., . . . Investigators, P. (2017). Premature ovarian senescence and a high miscarriage rate impair fertility in women with HCV. J Hepatol. doi:10.1016/j.jhep.2017.08.019

Kurmanova, A. M., Kurmanova, G. M., & Lokshin, V. N. (2016). Reproductive dysfunctions in viral hepatitis. Gynecol Endocrinol, 32(sup2), 37-40. doi:10.1080/0951 3590.2016.1232780

Lam, P. M., Suen, S. H., Lao, T. T., Cheung, L. P., Leung, T. Y., & Haines, C. (2010). Hepatitis B infection and outcomes of in vitro fertilization and embryo transfer treatment. Fertil Steril, 93(2), 480-485. doi:10.1016/j.fertnstert.2009.01.137

Oger, P., Yazbeck, C., Gervais, A., Dorphin, B., Gout, C., Jacquesson, L., . . . Rougier, N. (2011). Adverse effects of hepatitis B virus on sperm motility and fertilization ability during IVF. Reprod Biomed Online, 23(2), 207-212. doi:10.1016/j.rbmo.2011.04.008

Polywka, S., Schroter, M., Feucht, H. H., Zollner, B., & Laufs, R. (1999). Low risk of vertical transmission of hepatitis C virus by breast milk. Clin Infect Dis, 29(5), 1327-1329. doi:10.1086/313473

Sookoian, S. (2006). Liver disease during pregnancy: acute viral hepatitis. Ann Hepatol, 5(3), 231-236.

Terrault, N. A., Zeuzem, S., Di Bisceglie, A. M., Lim, J. K., Pockros, P. J., Frazier, L. M., . . . Group, H.-T. S. (2016). Effectiveness of Ledipasvir-Sofosbuvir Combination in Patients With Hepatitis C Virus Infection and Factors Associated With Sustained Virologic Response. Gastroenterology, 151(6), 1131-1140 e1135. doi:10.1053/j.gastro.2016.08.004

Villa, E., Karampatou, A., Camma, C., Di Leo, A., Luongo, M., Ferrari, A., . . . Francavilla, A. (2011). Early menopause is associated with lack of response to antiviral therapy in women with chronic hepatitis C. Gastroenterology, 140(3), 818-829. doi:10.1053/j.gastro.2010.12.027

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Melanoma

Wednesday, March 21st, 2018

By Helen K. Kelley

Melanoma, typically a malignant tumor associated with skin cancer and the cause of the vast majority of skin cancer deaths, can also occur in the eye or any mucous membrane of the body. While the risk of melanoma increases with age, it is one of the most common cancers found in young adults, particularly young women.

Georgia is one of the states with the highest incidence of melanoma in the U.S. To learn more about why this number is rising and how doctors are treating the disease, Atlanta Medicine recently spoke with two physicians who are specialists in melanoma.

B. Scott Davidson, M.D.

Multidisciplinary approach to treatment; physicians should know signs
“I think a multidisciplinary team approach is crucial in the successful treatment of melanoma,” says B. Scott Davidson, M.D., a surgical oncologist with Northside Hospital Cancer Institute’s Melanoma and Sarcoma Program.

“It’s important to have close collaboration between surgical, medical and radiation oncologists who share their ideas about treating individual patients.”

He adds that since there are many variations in patient care, having input from a team of practitioners with different knowledge and skills can create a more effective treatment for each individual.

“There are a lot of components to treating melanoma, all of them important. It’s best to review those options during a multidisciplinary conference,” he says. “During these meetings, we form a game plan. We determine the best treatment options – immunotherapy, radiation and/or surgery – and the sequence of their delivery for the individual patient.”

Davidson adds that all physicians can play a role in the early detection of melanoma in their patients.
“It can be tricky to identify a melanoma just on gross examination. Certainly, any changing mole should be suspicious and the patient referred to a dermatologist for biopsy,” he says. “It’s good for every doctor to know the signs of skin cancer.”

He recommends following the guidelines set forth by The American Academy of Dermatology (AAD), known as the ABCDEs of melanoma:
• Asymmetry: Is one half of a mole unlike the other half?
• Border: Does a mole have an irregular, scalloped or poorly defined border?
• Color: It there more than one color in a mole, such as shades of tan and brown, black, white, red or blue?
• Diameter: Is a mole bigger than 6 mm (the size of a pencil eraser)? Melanomas are usually bigger than 6 mm when diagnosed, but they can be smaller.
• Evolving: Does a mole or another spot on the skin that look different from the rest? Is a mole or another spot changing in size, shape or color?

“The majority of melanoma occurs on sun-exposed areas, although there are certainly exceptions. And it is still a disease of all age groups,” Davidson adds. “The changing of a mole from benign to malignant probably calls into question the genetics that a person may harbor.”

Andrew Page, M.D.

Stimulating the immune system; rising numbers of skin cancer in younger people
According to Andrew Page, M.D., director of pancreas, liver and cancer surgery at Piedmont Hospital, the landscape in melanoma treatment has made phenomenal progress, particularly for patients with metastatic melanoma.

“Up until about seven years ago, the medications available to treat metastatic melanoma were not very good. Patient responses were not durable, and side-effects were not tolerable,” he says. “But starting in 2011, many groups began publishing remarkable outcomes for patients using novel treatments that were previously not available. Specifically, researchers had identified medications that target both the molecular pathogenesis of melanoma and the patient’s own immune system – and the results have revolutionized the treatment landscape for melanoma. Effectively, we now have medications to treat patients better with durable responses, without as severe toxic side effects.”

Newer drugs like Opdivo (nivolumab), used in the past couple of years for patients who have advanced (stage IV) melanoma, are now approved for people with stage III disease.

“In the past, if a person had comorbidities, the treatment itself – Interleukin-2 – could have killed them,” Page says. “But today, we have immunotherapeutic agents like Opdivo that are used, with some success, to treat advanced-stage melanoma. That’s amazing progress.”

Page warns that even though treatment of the disease is improving, the incidence of melanoma continues to rise.

“We have medications that work so much better today, yet melanoma is on the rise, about 90,000 incidences in the U.S. annually. While certainly many factors contribute to melanoma, young people, even children, are still getting too much sun exposure,” he says. “I’m seeing younger patients coming in with melanoma. Almost every single one of my young female patients admits to using tanning beds throughout high school.”

Study finds timing of diagnosis, treatment critical to survival
A new Cleveland Clinic study underscores the importance of early detection and treatment of melanoma, the deadliest form of skin cancer. The research, recently published in the Journal of the American Academy of Dermatology, indicates that the sooner patients were treated, the better their survival, particularly for stage I melanoma.

Using the National Cancer Database, researchers from Cleveland Clinic’s Dermatology & Plastic Surgery Institute studied 153,218 adult patients diagnosed with stage I-III melanoma from 2004 to 2012 and found that overall survival decreased in patients who waited longer than 90 days for surgical treatment, regardless of stage. In addition, the delay of surgery beyond the first 29 days negatively impacted overall survival for stage I melanoma, though not for stage II or III.

Compared to patients who were treated within 30 days, patients with stage I melanoma were 5 percent more likely to die when treated between 30 and 59 days; 16 percent more likely to die when treated between 60 and 89 days; 29 percent more likely to die when treated between 91 and 120 days; and 41 percent more likely to die when treated after 120 days. Patients with a longer time to treatment initiation tended to be older and male, and have more co-morbidities.

According to the authors, it is likely that more advanced cases represent delays in diagnosis, and these delays overwhelm the impact of a speedier treatment. However, in early-stage cases, early diagnosis allows for the opportunity to improve the chances of survival with a prompt surgery. Although many physicians follow a rule-of-thumb to treat melanoma surgically three to four weeks after diagnosis, there is no official recommendation on time to treatment.

The study is a stark reminder of the importance of detecting skin cancer early, when it’s most treatable. Anyone who notices any new, changing or suspicious spots on their skin, or any spots that are changing, itching or bleeding, should see a board-certified dermatologist for diagnosis.

The public can take steps to reduce their melanoma risk by protecting themselves from exposure to harmful ultraviolet radiation from the sun and indoor tanning beds, a risk factor for all types of skin cancer. The AAD recommends that everyone protect their skin from the sun by seeking shade, wearing protective clothing and using a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

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Sexually Transmitted Infections and Fertility

Wednesday, March 21st, 2018

Kalinda D. Woods, M.D.

By Kalinda D. Woods, M.D.

Those of us who study science may remember sitting in an introductory general biology lecture hall at some point in our academic past. An esteemed lecturer after formal introduction and orientation to the course may have opened the semester of study by insisting students internalize a single concept to begin to study biology: life persists. The desire to reproduce a version of ourselves is very human and innate to a sense of being for many people. It is estimated that approximately ten percent of couples will experience infertility, a diagnosis which can be emotionally and socially
devastating for families desiring pregnancy. Preventable causes of infertility include environmental exposures, and certain sexually transmitted
infections play a significant
role. As physicians, it is imperative that we educate about, screen for and address these disease processes to maximize best outcomes for our patients.

The term “sexually transmitted infection” encompasses several disease entities some of which have little or no impact on fertility directly. In fact, the most common STI worldwide is high-risk human papilloma virus, which is the causative agent of cervical dysplasia and cervical carcinoma. Although high-risk HPV infection, which will typically resolve with no consequence, is almost ubiquitous in young sexually active individuals, it appears to have no impact on fertility. The infections which more significantly affect fertility are gonorrhea, chlamydia and HIV. Physicians can impact fertility in many ways with regard to the preceding three infections.

According to the CDC1, if untreated, about ten to fifteen percent of women with chlamydia will develop pelvic inflammatory disease, a condition determined by fever, pelvic pain and ascending infection associated with inflammation of the endometrium, fallopian tubes, and possibly peritonitis/tubo-ovarian abscess formation. Chlamydia can also cause fallopian tube infection without any symptoms. PID and “silent” infection in the upper genital tract can cause permanent tissue damage leading to infertility by way of tubal obstruction. An estimated 2.86 million cases of chlamydia and 820,000 cases of gonorrhea, which infects similarly, occur annually in the United States and most women are asymptomatic.2 For these reasons, the CDC recommends screening of all sexually active women younger than 25 years, as well as older women with risk factors. Risk factors are further determined as new or multiple sex partners, or a partner who has had a recent STI.

We know that infertility is determined as no conception after 12 months of unprotected sex. We also know that with heterosexual couples, the male factor represents a significant percentage of identifiable causes of infertility. In men, chlamydial infection is known to cause urethritis, epididymitis, and prostatitis. There has been recent evidence suggesting that there is molecular damage to chlamydia-exposed sperm, which is irreparable and seems to be associated with poor sperm parameters among infertile individuals.3 Given these data, it is prudent to screen asymptomatic men with the same scrutiny and the same criteria as their female counterparts above.
 Syphilis infection rates have been rising in the US since 2014. While there is no specific relationship between syphilis and fertility or the ability to spontaneously conceive per se, congenital syphilis can be a devastating diagnosis. CDC data tells us that among 458 mothers of infants with CS in 2014, 100 (21.8%) received no prenatal care, and no information about prenatal care was available for 44 mothers (9.6%). (Among the 314 mothers with one or more prenatal visit, 135 (43.0%) received no treatment for syphilis during the course of their pregnancy and 94 (30.0%) received inadequate treatment. The 135 mothers who received no treatment include 21 mothers who were never tested for syphilis during pregnancy and 52 mothers who tested negative for syphilis in early pregnancy and subsequently acquired syphilis before delivery. The remaining 62 mothers tested positive, but were not treated. Benzathine penicillin G is the only known effective treatment for preventing CS. Maternal treatment was considered inadequate if it was initiated too late (<30 days before delivery), if a non-penicillin therapy was administered, or if the dose of penicillin administered was inadequate for the mother’s stage of syphilis.4

Identifying this very treatable spirochete therefore offers physicians yet another opportunity for intervention and prevention. Screening guidelines for syphilis are similar to those for chlamydia and gonorrhea above: sexually active individuals up to age 25 and older individuals with risks factors (IV drug use, men having sex with men, sex industry workers, multiple partners) annually. Pregnant women are also screened at initiation of prenatal care and again in the third trimester. Patients are typically screened via rapid plasma reagin (RPR) serum testing which is widely available, and inexpensive. Positive screening RPR will prompt further treponemal antibody testing which is confirmatory when positive.

HIV infection poses a significant roadblock with regard to fertility when partners are sero-discordant. Typically, barrier forms of contraception will be necessary to prevent viral transmission from one partner to the other, which is in itself a hindrance to fertility. While transmission rates between discordant partners continue to fall largely due to the sophistication of antiviral therapy and low to un- detectable viral loads in compliant individuals; HIV infection is obviously an impediment to achieving pregnancy. Factors which are considered by HIV positive individuals when making pregnancy planning choices are understudied. Contradicting factors, such as higher risk of horizontal transmission with condomless sex, versus sperm washing and IVF for example, which is costly are real life tradeoffs for those affected by HIV.5 As providers, routine screening for early diagnosis and options counseling are most appropriate for these patients.

Fertility is certainly achievable without increasing risk of transmission, but may be costly and must be carefully planned for. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at in- creased risk should also be screened. Screening intervals will vary based on the HIV frequency in the community, presence of high risk behaviors, homelessness. The task force also recommends screening at initiation of prenatal care for women and again in the third trimester of pregnancy.

As with all things in medicine, we will never have the answers to the questions we don’t or won’t ask. Family planning and fertility are essential parts of the human experience and integral to the happiness and feeling of wholeness and wellbeing for many people. Although uncomfortable at times, it is important for physicians to ask the hard questions, obtain a thorough sexual history and inquire about reproductive goals so we are able to offer important testing, counseling and referral when needed, for our patients as part of our goals of comprehensive evidence based and compassionate care.


References
1. Centers for Disease Control. Division of STD prevention, national center for HIV/ AIDS Prevention
2. CDC 2015 STD treatment Guidelines
3. Moazenchi et al. The impact of CT infection on sperm parameters and male fertility: a comprehensive study. International Journal of STD and AIDS 2017. 1-8.
4. CDC Morbidity and Mortality Weekly Report, November 2015
5. Loutfy, et al. Pregnancy planning preferences among people and couples affected by HIV: Piloting a discrete choice experiment. J of Obstetrics and Gynec Can 2012; 34: 575-590
6. Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening. U.S. Preventive Services Task Force. December 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/
RecommendationStatementFinal/human-immunodeficiency-virus-hiv-infection-screening

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Altitude Sickness

Wednesday, February 21st, 2018

By Helen K. Kelley

 Altitude sickness, also called acute mountain sickness, is caused by climbing or walking to a higher and higher altitude too quickly, not giving the enough time to adapt to the lower air pressure and oxygen level in the higher elevation. To understand more about altitude sickness and how to prevent or treat it, we spoke with three Atlanta area physicians who shared their expertise and experience.

Symptoms, prevention and the heart of the matter
At higher altitudes, the barometric pressure decreases, resulting in fewer oxygen molecules available to breathe, ultimately resulting in decreased oxygen delivery to tissues. According to Andrew Smith, M.D., a cardiologist and Medical Director of the Advanced Heart Failure Program at Emory Healthcare, this decreased oxygen availability causes a number of physiological symptoms identified with altitude sickness.

Andrew Smith, M.D.

“With the decreased oxygen availability to the tissues, the result is an increased release of adrenalin, which can cause increase in heart rate and also possibly an increase in pulmonary artery pressures,” he said. “Additionally, what occurs within this is an increase in respiratory rate, and therefore, hyperventilation occurs, at least initially. Resting heart rate increases. Often the humidity tends to be lower at high altitudes, so, along with the increased adrenaline drive, there is a tendency to become dehydrated.”

Along with dehydration, people who are experiencing altitude sickness may have symptoms like mild headaches, nausea, more rapid breathing, fatigue and difficulty sleeping at night. In fact, because the breathing rate tends to be lower when sleeping, the lower level of oxygen delivery to the tissues can put more stress on the body at night.

Smith adds that more serious symptoms can occur at extreme altitudes in both normal people and those with genetic predispositions or health issues.

“For example, high altitude pulmonary edema can happen to anyone. If you develop a bad cough, become short of breath or cough up frothy sputum, that is a sign,” he said. “High altitude cerebral edema, or HACE, can cause a change in mental status, with symptoms like worsening headaches, lethargy, ataxia and confusion. ‘Leaky capillary syndrome,’ in which fluid leaks out of the capillaries in lungs, can also occur in the brain. Symptoms like these indicate you need to get down to a much lower elevation and seek medical attention immediately.”

For those who are traveling to higher elevations, Smith says there are a number of measures they can take to prevent the symptoms.

“Hydrate well and travel slowly to different degrees of elevation, so that some degree of acclimation occurs every few days. If you’re going to be doing something strenuous at a higher elevation, take breaks,” he advised. “Hiking and climbing to higher levels may be fine, but not camping and sleeping there. You can also prepare by getting yourself in better physical condition before you go.”

Most of all, common sense should prevail, especially for people who lead a sedentary lifestyle or who haven’t gotten regular check-ups.

“Travel to a high altitude location can unmask preexisting heart disease. I’d advise anyone planning to do so and who hasn’t been exercising regularly, to see a physician in advance for a cardiac stress test. Chest pain, angina, persistent shortness of breath… those are all warning signs,” Smith said. “Of course, for patients who have known heart disease, travel to high elevations can be extremely risky. It’s important that they recognize that they will be in situations where they don’t have control of their environment; environment will be controlling things like their heart rate response.”

Allen Dollar, M.D.

One physician’s personal experience
Allen Dollar, M.D., Associate Professor at Emory University School of Medicine and Section Chief of Cardiology at Grady Memorial Hospital, has been an avid backpacker since his teens. In recent years, Dollar and two friends have made an annual trip to Colorado to go hiking in the San Juan Mountains. It was there that he experienced altitude sickness for the first time in his life.

“The first year we made the trip I had no problems, but the second year, we ascended more rapidly from the ground level — we went from 6,500 ft. to 13,200 ft. in just two days,” he recalled. “I became sick as a dog. Basically, altitude sickness felt like the worst hangover you could ever have.”

While the treatment is to immediately descend to a safer level, Dollar and his friends were on the far side of a ridge that meant ascending another 500 ft. on a treacherous trail before being able to travel downward. It took an additional 24 hours before Dollar felt well enough to make the ascent and the descent.

He says that he was fortunate not to experience worse symptoms.

“I never developed shortness of breath or high-altitude cerebral edema,” he said. “My friends tested my mental clarity with math problems to be sure I was all right.”

Dollar said that one of his group had been taking Diamox (acetezolomide), a drug that been shown to help in preventing altitude sickness. After seeing his positive results, the others now begin taking Diamox two days prior to starting their climb and the regimen has proved successful.

He adds that there is no way to predict who will experience altitude sickness and who won’t.

“What I can tell you is that altitude sickness doesn’t have anything to do with a person’s fitness level,” he said. “You’re either susceptible or you’re not.”

Abubakr Chaudhry M.D.

Q & A:  Altitude and the lungs
To learn more about how altitude affects the lungs, we asked Abubakr Chaudhry M.D., a pulmonary and critical care physician and specialist in pulmonary vascular diseases with Northside Hospital, to share his insights in a two-part Q & A.

Q. How does altitude affect breathing?
AC: In order to understand how altitude effects breathing, we first have to understand what happens physiologically when we experience rapid changes in barometric pressure, such as during an ascent from sea level (760 mmHg) to the summit of Mount Everest (253 mmHg) per say. It is important to note that there is not a depletion of atmospheric oxygen content at higher altitudes, but rather a change in the driving pressure of the gas in the lungs. The higher you go, the lower the barometric pressure, and thus the lower the driving pressure.

Next, we must understand how gas exchange occurs in the membranes of the lung and how our bodies react to this change in driving pressure. The decreased driving pressure results in tissue hypoxia, decreasing the substrate available for aerobic respiration and stimulating us to hyperventilate. This phenomenon can be quantified by the alveolar-ventilation equation, which demonstrates an inverse relationship between the level of alveolar ventilation and the alveolar PCO2 (if CO2 production is constant). Thus, the more we breathe the less CO2 we retain. Furthermore, at higher altitudes it has been reported that climbers can decrease their PCO2 from a normal value of 40 to a value of 8 ( five-fold!). This change in breathing patterns leads to respiratory alkalosis. Alkalosis has the deleterious effect of increasing hemoglobin’s affinity to oxygen but it also enhances the uptake of oxygen in the pulmonary capillaries, an effect that is highly beneficial in these individuals. With changes in breathing patterns comes the question of need for oxygen.

We used the extreme example of Mount Everest but most normal individuals will not need supplemental oxygen unless they are ascending above 6500 meters.

Q: What are some ways an individual with a lung condition can prepare for travel to a high altitude?
AC: If someone has an underlying lung condition and is preparing for high altitude travel, the best thing to do is see a pulmonologist to assess his or her “hypoxic ventilatory response.” As previously stated, the major physiologic change that occurs with ascent is hyperventilation. If a patient cannot decrease their carbon dioxide levels, it will be unlikely they will have the energy required to oxygenate well, either. Supplemental oxygen can help, but the amount needed will likely change depending on the barometric pressure (the elevation to which the person climbs). If the patient’s hypoxic ventilatory response is poor, I would recommend against high altitude travel.

Preparing for high altitude travel is possible, but not in the way usually advertised. There are a lot of gimmicks out there that promise to “increase your red blood cells” with “hypoxia training.” I do not recommend these even in normal individuals, as the physiologic change is transient. I do recommend safe intensive strength and endurance training with a plan that is doctor supervised. Particularly in patients who have underlying lung disease, not only does training improve mortality, but it also improves the hypoxic ventilatory response by maximizing the body’s utilization of oxygen.

To someone who is planning a climb and has been cleared by their doctor, I recommend remembering the climber’s adage of “climb high and sleep low.” This means you should acclimatize yourself progressively. Once you get above 3000m, try not to climb more than 300m a day and rest every third or fourth day. If you experience symptoms of mountain sickness, you don’t have to run down the mountain, but try to descend at least 500m. In most cases of acute mountain sickness this descent will resolve the symptoms.

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Treating the LGBT Patient Population

Wednesday, February 21st, 2018

Approach matters of cultural and gender diversity with “cultural humility” to give all your patients the best access to healthcare.

By Elizabeth Walton, MD

Elizabeth Walton, MD. Photo by Michael A. Schwarz

When it comes to providing demographic information about relationships, the choices facing a new patient have long been the same: Married, Single, Widowed, Divorced.

I’m a lesbian with a long-term partner. We have two children together. For years, I never knew which box to check because none applied to me.

More recently, practices began including “Partner” as one of the categories. I finally felt included, although the term still didn’t quite feel like it adequately characterized my relationship. As a result, I never felt as if I would be completely safe or even welcome at that practice.

When the federal marriage laws were expanded to include same-sex couples, my partner and I got married. I can now check a box on the form that correctly labels my relationship status, but it still leaves some gaps. More often than not, healthcare providers will assume I am married to a man.

My experience isn’t unique. Those first forms a patient fills out are essential indicators that telegraph what kind of care a patient might receive. For patients who are gay, lesbian, bisexual or transgender, practices that limit the categories to metronormative categories immediately impact the nature of the relationship between patient and doctor. If you don’t even exist on a form, it can be very scary to reveal this information about yourself to your doctor.

To illustrate the point, consider an experience I had as a college sophomore. I was hospitalized for severe abdominal pain. The surgeon asked me if I was sexually active. I said I was. She then asked if I was trying to get pregnant since I wasn’t using contraception. When I told her I wasn’t, the surgeon asked, “Then what are you using? A hope and a prayer?” I had to explain to her that I was not having sex with men. The trust between me and the doctor who was about to operate on me was greatly diminished.

Health equity is the attainment of the highest level of health for all people, and as physicians, we have made a commitment to provide excellent care to the person sitting across from us. When inequities exist, they result in health disparities for individuals, communities and global societies.

The increasing cultural, racial and ethnic diversity of the United States provides challenges and opportunities to physicians in all specialties. As physicians in the United States, we are hardwired to master a theoretically finite body of knowledge and completely “get it right.” This cultural norm among doctors doesn’t serve us well when it comes to issues of diversity and making our care appropriate for people from all walks of life.

It is time to allow us to approach matters of cultural and gender diversity with “cultural humility” as opposed to “cultural competence.” This opens the door for a lifelong commitment to self-evaluation and self-critique that, ultimately, will lead to a more inclusive practice and better healthcare.

Cultural humility does require the constant seeking of more information, especially among issues of gender and sexuality, which are rapidly evolving, especially among younger populations. In the U.S., about 9 million people (3.5 percent) identify as lesbian, gay or bisexual, but about 19 million (8.2 percent) have acknowledged engaging in same-sex behavior. Estimates about the transgender population range from 0.1 percent to 0.5 percent.

Intersectionality and Terminology
LGBTQ individuals are not part of just one community. Many people carry multiple identities, and often they may have to choose one over another at different times, such as being African American or lesbian. Transgender people are very diverse and use many different terms to describe themselves. Language is being created while experiences develop and is changing over time. Some common terms include:

Sex refers to the presence of specific anatomy. It also may be referred to as “sex assigned at birth.”

Gender refers to attitudes, feelings and behaviors that a culture typically associates with masculinity or femininity.

Gender identity is a person’s internal sense of their gender as man, woman, a mix of both or neither. It is often a spectrum. It begins to develop by age 3 and may remain stable over time, change or be fluid. Since gender identity is internal, it may not be visible to others.

Sexual orientation is completely unrelated to gender identity. Sexual orientation is how a person identifies their physical and emotional attraction to others. It encompasses attraction, behavior and identity. It may fluctuate and shift over time. Gender expression is how one externally presents their gender identity through their behavior, mannerisms, speech patterns, dress, hairstyles, etc.

Gender variant/non-conforming refers to people whose gender expression is different from traditional expectations of their gender.

Transgender is an adjective used to describe people whose gender identity differs from their sex assigned at birth and can include male, female, neither or some combination.

Cisgender or cis is a person who is not transgender.

Transsexual may be considered an out-of-date term by some. It historically referred to individuals who had undergone medical/surgical treatment to transition to the opposite gender. This term may be used by some as a self-affirming description of themselves.

Genderqueer, gender fluid refers to someone who rejects distinct categories of male or female. They view gender as a spectrum that fluctuates.

Gender dysphoria is a DSM-5 diagnosis for individuals who have a strong and persistent cross-gender identification and a persistent discomfort with his or her sex, or sense of inappropriateness in the gender role of that sex.

Intersex refers to individuals whose physical bodies are not easily categorized as male or female (previously referred to as hermaphrodite). The number of intersex individuals is estimated between one in 1,000 to 4,500 newborns each year in the U.S. The DSM-V classifies these as Disorders of Sex Development. Since the term ‘disorder’ is used, it is considered pejorative by many and not used in the Intersex community. Intersex people are sometimes grouped with transgender people, but they are not the same. Some intersex individuals see themselves as part of the LGBTQ community; others don’t.

Queer is often used as a self-affirming and inclusive umbrella term for LGBT people, but can be considered an offensive term when used to cause harm.

Best Practices for the Best Healthcare
The LGBTQ community has unique health issues. Although many healthcare providers have developed practices specific to the healthcare needs of gay men, lesbians and bisexuals, fewer have had experience with transgender patients. As transgender people become more visible and are telling their healthcare providers, it’s important for us to develop some rudimentary procedures and best practices to help provide the best possible healthcare.

Trans patients often fear the medical community and delay seeking help for a problem. Many have been met with hostility from healthcare providers, sometimes being called the dehumanizing pronoun “it.” Others may have had physicians refuse to use their preferred name or pronoun.

A friend who is a psychiatrist told me about her experience with her trans son, who was born with female genitalia and raised as a girl until fourteen when he came out to his parents. My friend trained with her son’s pediatrician in residency. This doctor had treated him since birth. At their first appointment as a trans male, mother and son were met with extreme hostility. The doctor asked him inappropriate questions, such as whether he had sex with girls and whether he liked it.

The experience was very traumatic for both people. The mother later called a longtime friend and pediatrician to share this traumatic event. Her friend’s response was “Well, we don’t have those kinds of people in South Carolina.” Not surprisingly, it is not uncommon for patients to have to drive four or five hours to find a therapist or doctor capable and willing to treat trans patients in smaller cities and towns.

Clinicians have differing views on whether gender nonconformity should be regarded as a normal variation of gender expression, a medical condition or a psychiatric disorder. An alternate perspective views gender as a continuum from male to female, permitting a spectrum of gender identities with varying proportions of maleness and femaleness.

Nonconformity and Identity
It is impossible to predict with certainty whether gender nonconformity in an individual child will persist into adolescence or adulthood. Review of the evidence from prospective and retrospective follow-up studies suggests that gender dysphoria in prepubertal children persists into adolescence/ adulthood in a minority of children.

Children with consistent, persistent and insistent nonconforming behaviors and expression are more likely to maintain nonconforming gender identity in the long term. Demonstration of gender-nonconforming behaviors and expression reflects an innate preference of the child. Young children who are gender non-conforming generally are not gender dysphoric because they lack a clear understanding that their internal gender identity does not match their genitals.

The physical changes of puberty usually are exceptionally difficult for gender-nonconforming youth. The development of unwanted secondary sexual characteristics is described by many as a betrayal of one’s body, the final confirmation that they must live in an adult version of a body that is not reflective of their true self. Gender dysphoria that intensifies with the onset of puberty rarely subsides.

Trans people experience very high rates of stigma and discrimination that can lead to health disparities. It is legal in 28 states to fire an employee or deny housing because they are gay or transgender. The U.S. Department of Justice recently argued in front of an appeals court in New York that Title VII (of the Civil Rights Act of 1964 prohibiting discrimination on the basis of sex, race, color, national origin, and religion) did not provide protections to gay, lesbian or transgender workers.

Not surprisingly, LGBT people experience higher rates of substance abuse, HIV/STDs, tobacco use, violence, depression, suicidality and self harm. Forty one percent of trans people have attempted suicide (compared to 5.6-14.3 percent of U.S. adults). Trans women are murdered at a much higher rate than the general population. Trans women of color experience the highest.

Gender identity is not obvious by looking at someone. We should ask the same questions of all patients and not assume that people are heterosexual or cisgender, regardless of how they look.

1) Ask about current gender identity (preferably with a blank, instead of boxes to check)
2) Ask about sex assigned at birth
3) Ask what pronoun they use
4) Ask legal name
5) Ask preferred name

Clinical care should be based on an up-to-date anatomical inventory: Breasts, cervix, ovaries, penis, prostate, testes, uterus, vagina. Trans men still need pap smears if they have not had a hysterectomy. Trans women need prostate exams. The majority of trans individuals have not had surgery.

There is an abundance of erroneous information on the internet about trans people.

Physicians have an opportunity to provide more reliable information. For example, there are numerous reports about high rates of regret in patients who have had gender affirming surgery. More recent studies suggest that less than four percent of people who have gender-reassignment surgery regret it. Researchers have also found that the surgery dramatically reduces suicide rates among trans people.

For trans youth, family non-acceptance is a very strong risk factor for mental health issues. These youth are at a much higher risk of verbal and physical victimization, social isolation and peer rejection, school problems, depression and anxiety, self harm and suicidality, homelessness and sexual exploitation. Conversely, a recent article published in the journal Pediatrics presented a study that showed no difference in depression and only a small increase in anxiety in trans youth who are supported by their family compared to the general youth population.

In addition to conveying the strong evidence that family nonsupport is a very big risk factor for negative health impacts, the physician should address safety and bullying. It is very important to help the family advocate for the the child/ adolescent in the school system. It may be helpful or even necessary for you as the physician to write a letter of support and medical necessity for the child to express his/her gender identity. This can also be helpful to educate staff and students.

Make sure that referrals you make to other physicians are safe for the patient by doing your research. If you know that a physician has ethical or religious issues with LGBT individuals, you should not refer them to these people. Similarly, if you do not feel comfortable taking care of an LGBT individual, you should recognize your bias and refer to someone who is.

If in doubt, you can never go wrong using the ‘Golden Rule.’ Do unto others as you would have them do unto you.

Resources and Reading Materials

Make sure to have adequate resources for treating the LGBT community. Here is a list for yourself, your patients and their families.

LGBT Resources
• Human Rights Campaign: www.hrc.org
• Georgia Equality: www.georgiaequality.org
• Family Acceptance Project: www.familyproject.sfsu.edu
• Gay and Lesbian Medical Association: www.glma.org
• PFLAG (Parent/Friend/LGBT Support): www.pflag.org
• The Health Initiative: www.thehealthinitiative.com
• The Trevor Project: www.thetrevorproject.org

Trans-specific Resources
• Trans Youth Support Network: www.transyouthsupportnetwork.org
• Trans Youth Equality Foundation: www.transyouthequality.org
• I Am: Trans People Speak: www.transpeoplespeak.org
• Trans Student Educational Resources:www.transstudent.org
• National Center for Transgender Equality: www.transequality.org
• Trans Family Support Services: www.transfamilysos.org
• Trans Active: www.transactiveonline.org/index.php
• Queer Med: www.queermed.com

Teacher, Parent and Other Supportive Adult Titles
• 50 Ways of Saying Fabulous, Graeme Aitken, 2015 (20th anniversary edition)
• BALLS: It Takes Some to Get Some, Chris Edwards, 2016.
• Becoming Nicole: The Transformation of an American Family, Amy Ellis Nutt, 2016.
• Circle of Change (ebook), Laney Cairo, 2016.
• Helping Your Transgender Child, Irwin Krieger, 2011.
• Gender Born, Gender Made: Raising Healthy, Gender-Nonconforming Children, Diane Ehrensaft, 2011.
• Gender Dysphoria: An Essential Guide for Understanding and Dealing with Gender Identity Disorder. Eleanor Nye, 2015.
• Gender Outlaws: The Next Generation, Katie Bornstein, 2010.
• My Child is Transgender: 10 Tips for Parents of Adult Trans Children, Matt Kailey, 2012.
• My Daughter He: Transitioning with our Transgender Children, Candace Waldron, 2014.
• Principles of Transgender Medicine and Surgery, Randi Ettner, Stan Monstrey, & Eli Coleman, 2016.
• Rainbow Family Collection: Selecting and Using Children’s Books with Lesbian, Gay, Bisexual, Transgender, and Queer Content, Jamie Campbell Naidoo, 2012.
• Raising Ryland. Hillary Whittington, 2016.
• Safe Spaces: Making Schools and Communities Welcoming to LGBT Youth. Annemarie Vaccaro, Gerri August, & Megan S. Kennedy, 2011.
• Second Son: Transitioning Toward My Destiny, Love, and Life, Ryan K. Sallans, 2012.
• The Gender Creative Child, Diane Ehrensaft 2016.
• The Lives of Transgender People, Genny Beemyn & Susan Rankin, 2011.
• The Transgender Child: A Handbook for Families and Professionals.
• Stephanie Brill & Rachel Pepper, 2008.
• The Transgender Teen, Stephanie A. Brill & Lisa Kenney, 2016.
• Trans/Portraits: Voices from Transgender Communities. Jackson Wright.
• Shultz, 2015.
• Transgender Family Law: A Guide to Effective Advocacy, Jennifer L. Levi (Editor), 2012.
• Transgender Transition: Quick Start Guidebook, Sky Logan, 2016.
• Transitions of the Heart: Stories of Love, Struggle, and Acceptance by Mothers of Transgender and Gender Variant Children, Rachel Pepper, Ed., 2012

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Post-Bariatric Plastic Surgery

Monday, January 15th, 2018

By Marisa Lawrence, MD

According to the Centers for Disease Control and Prevention, 36.5 percent of adults in the United States 2011-2014 are obese – a body mass index (BMI) greater than 30kg/m2. 1 Health effects include diabetes, coronary artery disease, hypertension, osteoarthritis, obstructive sleep apnea and deep venous thrombosis (DVT).

Severe obesity is a BMI above 35 kg/m2; morbid obesity is a BMI above 40 kg/m2.

The American Society of Bariatric and Metabolic Surgery reports 196,000 bariatric procedures in the United States in 2015.2 Many physicians will encounter post-bariatric surgery patients, so understanding their medical and psychological issues enable us to better care for them.

Patients undergoing weight loss surgery experience health benefits, but the skin envelope deflates throughout the body. Skin folds can cause poor hygiene, intertrigo, skin breakdown and functional impairment. Surgical recontouring can relieve these symptoms.

Such surgery improves quality of life, self-esteem and body image. 3 Therefore, post-bariatric plastic surgery has both reconstructive and aesthetic components.

Patient selection is important for satisfactory outcomes and minimal morbidity. The preoperative evaluation considers the bariatric procedure performed, BMI, comorbidities, nutritional deficiencies and psychological issues; all must be optimized prior to surgery.

Among 511 post–bariatric surgery body contouring cases, higher pre-bariatric surgery maximum BMI and higher BMI at presentation were associated with increased complications.4 The best candidates for extensive body contouring surgery after weight loss have a BMI below 30 kg/m2 and may have multiple procedures.5 Patients with a BMI between 30 and 35 kg/m2 are higher risk; surgical planning is individualized . Symptomatic patients with a BMI between 35 and 40 kg/m2 may have one functional operation, e.g.panniculectomy or reduction mammoplasty. Patients with a BMI above 40 kg/m2 need further weight loss unless symptoms are very severe.

Following bariatric surgery, weight typically decreases exponentially over three to six months and stabilizes after 15 to 18 months. Body contouring surgery is done after the weight has plateaued for three months or longer 6 – weight loss after body contouring surgery generally leads to continued skin deflation and patient dissatisfaction.

Nutritional deficiencies are common in this population. Roux-en-Y gastric bypass patients have malabsorption from a bypassed proximal small bowel. Caloric restriction and noncompliance with prescribed diets lead to malnutrition. Protein malnourishment can impact wound healing. Mal-absorbed vitamins include thiamine, vitamin D, calcium, iron, vitamin B12 and folate.7 Anemia may occur, associated with decreased iron and vitamin B12.8 Preoperative laboratory work up includes complete blood count, electrolytes, albumin and pre-albumin. Patients should increase their protein intake before surgery to 70-100 g/day. Supplemental iron, calcium, B12, folate and thiamine may be required.

Smokers should stop smoking one month before and one month after surgery.* Major body contouring surgery creates large tissue flaps; nicotine causes vasoconstriction, risking flap necrosis, infection and poor wound healing.9 Preoperative cessation of smoking is confirmed by urine cotinine tests; positive tests will delay surgery.

Patient also have many risk factors for venous thromboembolism (DVT): obesity, immobility, increasing age and venous varicosities. The overall DVT risk for body contouring surgery is 2.9-8.9 percent.10 A hematologist should see patients with histories of DVT, pulmonary embolism and hypercoagulable states for perioperative management. Intermittent pneumatic compression devices are placed before general anesthesia. Peri-operative unfractionated or low-molecular-weight heparin depends on the Caprini Risk Assessment Model.11

Patient expectations are discussed at the consultation – there will be visible scars and prolonged recovery times. Emotional stability and the patient’s support network are also evaluated. Up to 68.6 percent of bariatric surgery candidates have had a psychiatric disorder during their lifetime.12 Those with issues relating to body image and body dysmorphic disorder are less likely to be satisfied, so realistic expectations are discussed prior to scheduling surgery.

Up to 85 percent of post-bariatric patients desire body contouring, but only 12 percent to 21 percent actually have it.13 Many expect insurance to cover the cost. Insurance may cover panniculectomy, ventral hernia repair and breast reduction; patients can have cosmetic procedures performed at the same time to reduce the cosmetic costs.

Fig. 1

Several variables affect the staging of procedures, including the patient’s personal goals, finances and insurance as well as the surgeon’s experience and operative team. Longer operating times increase complications; shorter operations and staging procedures appropriately mean less anesthetic time, blood loss and infection.14 The patient’s complaints and desires are the most important determinants of the first area of the body to approach.

Fig. 2

The abdomen is of most concern; the hanging skin pannus overlaps the pubis, affecting hygiene. A panniculectomy removes this lower abdominal apron of skin and is often a functional operation, performed on significantly overweight patients who have skin irritation from hanging skin. This surgery reduces skin problems but not the abdominal contour. Traditional abdominoplasty excises redundant abdominal skin, plicates the rectus muscles, elevates the mons and repositions the umbilicus. (See Figure 1.) The belt lipectomy is a circumferential operation that excises hip and lower back rolls and elevates the buttocks. The lower body lift is similar, but incisions are lower and less conspicuous in clothing. (See Figure 2.)

Fig. 3

Some patients have vertical and horizontal laxity, so a fleur-de-lis abdominoplasty is performed with a vertical midline incision in addition to the lower incision. (See Figure 3.) Gluteal augmentation may be combined with these procedures; many weight loss patients experience flatter buttocks with tissue deflation. Options include a de-epithelialized back flap using redundant skin, fat grafting or implants.

Fig. 4

After massive weight loss, the female breast deflates. A breast lift, or mastopexy, rejuvenates the breasts by raising and reshaping them – lifting nipples, removing extra skin and repositioning breast tissue higher on the chest. Scars are around the nipple-areola complex, vertically from the areola to the inframammary fold and along the fold. Skin folds that extend laterally may be removed with an upper body lift, extending the inframammary fold incision to excise excess back skin. (See Figure 4.) Breast implants can be placed with the breast lift, but complication rates of 20 percent are reported.15

Fig. 5

A brachioplasty, or arm lift, contours the excess skin and fat of the upper arm. (See Figure 5.) This involves an incision from the axilla to the elbow. If the deformity extends to the lateral chest wall, the incision may extend into the axilla with a Z-plasty and along the chest wall. Liposuction may be performed concomitantly. Scars are initially conspicuous; scar management with silicone cream and lasers improves their quality.

Fig. 6

Thigh lifts remove excess thigh skin and fat to improve thigh appearance. (See Figure 6.) Patients with excess proximal tissue may need horizontal resection, leaving the scar along the groin and infra gluteal creases. Patients with excess tissue from groin to knee require a vertical scar down to the knee as well as the horizontal scar. Liposuction can help reduce the size of the thigh and can be performed three to six months before the thigh lift to allow skin retraction.

After dramatic weight loss, the face loses volume, soft tissues descend and the neck loosens and sags. A face and neck lift repositions the cheeks, corrects the jowls and removes the loose, sagging skin. Fat grafting restores facial volume. The incisions are inconspicuous around the ears, extending into the hair above and behind the ear. (See Figure 7.)
With the increase in bariatric surgery procedures, physicians will encounter patients with massive weight loss requesting body contouring procedures. With comprehensive evaluation of the patient’s weight loss, timing, medical comorbidities, and nutritional and psychological statuses, these operations can be performed safely, yielding satisfactory, life-altering results.


References

1. Centers for Disease Control and Prevention. Prevalence of obesity among adults and youth: United States 2011-2014. https://www.cdc.gov/obesity/data/adult.html

2. Maciejewski ML, Arterburn DE, Scoyoc BA et al. Bariatric Surgery and Long-term Durability of Weight Loss JAMA Surg. 2016;151 (11):1046-1055.

3. Van der Beek ES Greene R de Heer FA et al. Quality of life long term after body contouring surgery following bariatric surgery:sustained improvement after 7 years. Plast Reconstr Surg 2012:130:1133-1139

4. Coon D, Gusenoff JA, Kannan N, El Khoudary SR, Naghshineh N, Rubin JP. Body mass and surgical complications in the postbariatric reconstructive patient: Analysis of 511 cases. Ann Surg. 2009;249:397–401.

5. Rubin JP, Nguyen V, Schwntker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg. 2004;31:601–610.

6. Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg 2004;52:435–441.

7. Xanthakos SA, Inge TH. Nutritional consequences of bariatric surgery. Curr Opin Clin Nutr Metab Care 2006;9:489–496.

8. Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg 2007;119:1590–1596.

9. Payne CE, Southern SJ. Urinary point-of-care test for smoking in the pre-operative assessment of patients undergoing elective plastic surgery. J Plast Reconstr Aesthet Surg 2006;59:1156–1161.

10. Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119:1590–1596; discussion 1597–1598.

11. Pannucci CJ, Dreszer G, Wachtman CF, et al.. Postoperative enoxaparin prevents symptomatic venous thromboembolism in high-risk plastic surgery patients. Plast Reconstr Surg. 2011;128:1093–1103

12. Mitchell JE, Selzer F, Kalarchian MA, et al. Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study.
Surg Obes Relat Dis. 2012;8(5):533-541.

13. Gusenoff J, Rubin JP, Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthetic Surg J 2008;28:452-455

14. Gussenoff JA, Messing S, O’Malley W et cl Temporal and demographic factors influencing the desire for plastic surgery after gastric bypass surgery, Plast Reconst Surg 2008:121;2120-2126

15. Spear SL, Low M, Ducic I. Revision augmentation mastopexy: indications, operations, and outcomes. Ann Plast Surg. 2003:51:540-546.

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