Archive for September, 2009

Academic OB/GYN Podcast Episode 8 – Grey Journal September 2009

September 26, 2009 3 comments

Host Nicholas Fogelson discusses three articles from the Grey Journal from September 2009.

Academic OB/GYN Episode 8 – Grey Journal September 2009

This episode is sponsored by Hooah! Software and their iPhone program Due Dater, a gestational wheel and calculator for obstetric professionals.

Surgical Video – Ovarian Torsion with Mass

September 26, 2009 2 comments

This patient presented with severe right lower quadarant pain and an ovarian mass was seen on ultrasound.  This video shows the huge necrotic torsed ovary that was found at laparoscopy.

Ovarian Torsion with Mass

Categories: Surgical Videos

Grey Journal Sept 2009 – No association between BMI and OCP effectiveness… or is there?

September 21, 2009 Leave a comment

This month’s Grey Journal brings us a bunch of great articles, but here’s one that caught my eye:

Oral Contraceptive effectiveness according to body mass index, weight, age, and other factors by Dinger et al.

I thought been pretty well established that oral birth control pills have somewhat lower effectiveness in patients with higher BMIs (30+), and then this study comes around and throws a wrench in the works:  In 112,659 women years of exposure and 545 unplanned pregnancies, there was no statistical association between patient BMI and contraception failure.

An unexpected result, for certain.  So here’s how they studied the questionThis study is a  secondary analysis of the EURAS-OC study, a large European prospective cohort study intended to investigate the potential association between the new progestin drosperinone and cardiovascular events, created by Bayer at the demands of European drug authorities.  This study created a huge dataset of women on oral contraceptives, including demographic data and long term clinical outcomes.  In order to investigate the effects of BMI on contraceptive failures, our compared rates of unintended pregnancy in different groups of women within the EURAS-OC study.  Given the large dataset, the authors were able to stratify risk of unintended pregnancy not only by BMI, but also by progestin.

After data analysis, overall failure rates were strikingly low – Year 1 failure rate was 0.75%, year 2 1.33%, year 3 1.53%, and year 4 1.67%.  Furthermore, for all progestins except for chlormadinone (which is not available in the US), there was no association between BMI and failure rate.    With chlormadinone there was a 3x risk of failure rate at BMI > 30, which is thought to be due to the highly lipophilic nature of that particular progestin, and thus a higher relative volume of distribution compared to other progestins.

So why is that all worth talking about?  – Its because this data is just so different that what we have seen before –

Holt et al Green Journal 2005 – case control of unintended pregnancies on OCPs, odds ratio of failure 1.58 – 2.22 for BMIs > 27, depending on level of obesity and consistency of OCP use.

Brunner  et al Ann Epidemiol 2006 – case control of unintended pregnancies on OCPs in South Carolina, odds ratio of failure  2.54 – 2.82 for obese women.

Brunner et al Matern Child Health 2005 – retrospective cohort of 18,445 women, adjusted OR for unintended pregnancy in obese women 1.73 – 1.75.

Furthermore, the overall failure rate of around 1% is much different than the 9% first  year failure rate reported in the last iteration of the US National Survey of Family Growth.

When we see such different results of studies that seem to ask the same question, one of the following must be true: 1) One of the studies is biased, or both are 2) The studies are looking at different populations or 3) The studies may be defining their outcomes differently.   In this case, I think all three are happening.

The biggest difference that I see between this study and the American studies is the way patients were recruited, and think this difference could have a strong effect on the outcomes.   This study was a prospective cohort with data gathered over many years.  Each patient studied was approached after they had decided to use OCPs.  If they decided to enter the study, they were closely monitored for years for a large number of outcomes, and had medication compliance frequently measured.   The American studies were either case control studies looking at contraceptive failures compared to matched controls, or in the case of the second Brunner study, a retrospectively constructed cohort.  So why does this matter?  It goes back to an old engineering saying: Anything you measure you will improve.  The patients in the European study knew they were in a study, and that they would be asked to report their OCP compliance, making them more likely to be compliant with medications than someone who does not know their outcomes would be analyzed.   2 American case control studies suggested that the effects of obesity on pill efficacy is pronounced in women who are not consistent with their pills.   As such, it is possible that this huge study misses the real life effect of obesity by producing a preposterous population of peristently perfect pill popping patients!

Another difference between the European study and the previous American data is the type of obesity seen in the study populations.   Unfortunately for America, we have a lot more obesity than Europe.  This study had a mean BMI of around 22, and sadly the current mean BMI in the United States is 26.4. This translates to a larger number of superobese ( > 35 ) in American study populations, which are not as well addressed in this large data set composed of less obese people.

Finally, overall failure rate is calculated much differently in the European study that in the large American population studies.  In the American studies women-years are counted in month by month increments, but only when women are sexually active.  The European study counts a woman-month irrespective of whether or not the woman has had sex in that month.  It is arguable which of these methods is more appropriate, but inarguable that it has a profound effect on the absolute value of the failure rate.  As we (the Americans) are counting months only when there is intercourse during the month, there will assuredly be a higher failure rates than if we excluded the non-exposed months, which increase the denominator(exposure) without possibly increasing the numerator(failures.)  As such, the overall failure rate of around 1% is difficult in this study is hard to compare to the American failure rate of 9%, as it could represent decreased sexual activity in Europe relative to America as much as it could represent different contraceptive efficacy.

So what do we take from all this?    I think this new study shows us that if people are highly compliant with OCPs, failure rates are very low and are not strongly affected by BMI – but given the potential biases created by study design and interpretation, I’m not ready to say that OCPs work just as well in obese and superobese women as they do in lower BMI women.

So what do you think?


Dinger JC, Cronin M, Möhner S, Schellschmidt I, Minh TD, Westhoff C. Oral contraceptive effectiveness according to body mass index, weight, age, and other factors.  Am J Obstet Gynecol. 2009 Sep;201(3):263.e1-9. Epub 2009 May 30.

Categories: Grey Journal

Surgical Video – Bartholin’s Cyst Marsupialization

September 17, 2009 Leave a comment

Here is a montage video of a recent bartholin’s cyst marsupialization I did.   The blog video embedding seems broken so just click the link to get out to the video.

Bartholin Marsupialization #1

Categories: Surgical Videos

Current CDC Recommendations for Novel H1N1 Vaccination

September 14, 2009 1 comment

It is expected that providers and practices that have signed up to become distributors for Novel H1N1 Vaccine will start getting vaccine soon.   It is the hope that vaccination is widespread and can be given to all people who desire it.  However, there may be shortage of vaccine in the early weeks, requiring triage of who is most in need of vaccination.  As of right now, the CDC recommends that the following people have priority for vaccination:

  • Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
  • Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by “cocooning” them from the virus;
  • Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
  • All people from 6 months through 24 years of age
    • Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
    • Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
  • Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

If initial supplies are inadequate to immunize all the patients in the above group, the following groups should have first access to vaccine:

  • pregnant women,
  • people who live with or care for children younger than 6 months of age,
  • health care and emergency medical services personnel with direct patient contact,
  • children 6 months through 4 years of age, and
  • children 5 through 18 years of age who have chronic medical conditions.

Once the highest risk people are immunized, recommendations will likely grow to include all people 25 to 64, and finally to people 65+.   Unlike seasonal flu, Novel H1N1 (pandemic flu / swine flu) is actually less likely to strike older patients due to their likelihood to having been exposed earlier in their life (last outbreak of a related strain was 1974!)

It should also be noted that while many strains of seasonal flu are resistant to oseltamavir (Tamiflu), Novel H1N1 (Swine Flu) is typically  oseltamavir sensitive.   Patients or providers exposed to H1N1 patients may benefit from post exposure prophylaxis with Tamiflu.  Articles are being published weekly on new resistance in both Novel H1N1 and Seasonal Influenza A H1N1 and H3N2.   Check the CDC website for the most up to date information!


CDC  2009 H1N1 Vaccination Recommendations, updated July 29, 2009

Categories: Infectious Disease

New Data Published on Novel H1N1 Vaccine Immune Response

September 14, 2009 1 comment

New data is being published in the upcoming issue of the New England Journal of Medicine on the immune response associated with the new Novel H1N1 Flu Vaccine, and in the interest of public health it has already been distributed on the web.

Three articles will be published, two on the ability of various dosages of the vaccine to create an immune response, and a third on the presence of immune antibodies in people exposed to previous seasonal flu vaccines, and to past outbreaks of natural H1N1 “swine” flu.

The bottom line:

1) A single 15 microgram dose of the novel H1N1 vaccine creates an adequate immune response in near 100% of people within 14 days of administration.  There will be no need to have a second shot.   CDC guidelines will likely be changed to reflect this.

2) People who were immunized to the seasonal flu last year in the Northern Hemisphere have no or low chance of having immunity to Novel H1N1 (swine) flu.   People who were immunized with the southern hemisphere vaccine last year have some chance of immunity, but still should get the new vaccine this year.

3) People who were exposed to previous pandemic flu strains often have resistance to this pandemic flu.   Today’s novel H1N1 pandemic flu strain is likely related to the flu strains that caused outbreaks in 1918 and 1976.  Older patients are more likely to have been exposed to one of these outbreaks and be immune today.   Still, there are enough people in that age group that are not immune (higher than 50% in many cases) that all people should be immunized if possible.


Response after One Dose of a Monovalent Influenza A (H1N1) 2009 Vaccine — Preliminary Report.  Greenberg ME, Lai MH, Hartel GF, Wichems CH, Gittleson C, Bennet J, Dawson G, Hu W, Leggio C, Washington D, Basser RL.N Engl J Med.  2009 Sep 10.

Trial of Influenza A (H1N1) 2009 Monovalent MF59-Adjuvanted Vaccine — Preliminary Report.  Clark TW, Pareek M, Hoschler K, Dillon H, Nicholson KG, Groth N, Stephenson I.  N Engl J Med. 2009 Sep 10.

Cross-Reactive Antibody Responses to the 2009 Pandemic H1N1 Influenza Virus.  Hancock K, Veguilla V, Lu X, Zhong W, Butler EN, Sun H, Liu F, Dong L, Devos JR, Gargiullo PM, Brammer TL, Cox NJ, Tumpey TM, Katz JM. N Engl J Med. 2009 Sep 10.

Categories: Infectious Disease

Academic OB/GYN Podcast Episode 7 – Green Journal September 2009

Host Nicholas Fogelson reviews the best and worst of the Green Journal from September 2009.  Topics include: LEEP and Preterm Labor, Magnesium for Neuroprotection, Atypical Complex Hyperplasia and EMB reliability, and what makes a bad study title.

This episode is sponsored by Hooah! Software and their iPhone program Due Dater, a gestational wheel and calculator for obstetric professionals.

Academic OB/GYN Episode 7 – Green Journal September 2009

Green Journal Sept 2009 – LEEP increases risk of preterm birth. Scandinavian LEEP throw down!

September 6, 2009 3 comments

scandinavia-map.gifThis month’s Green brings us not one but two articles on the effect of LEEP on subsequent risk of preterm birth.   The first article, published by Fins and Swedes Jakobsson and Gissler et al, looks at a wide population of patients, while the Danes Noehr and Jensen et al fire back with a look at the effect of LEEP on preterm birth rates in twins.

It’s a Scandinavian throw down!  Who did it better?

Bottom line:  LEEP increases the risk of subsequent preterm birth, and the Danes do a better job at showing it.
Read more…

Follow Academic OB/GYN on Twitter

September 4, 2009 2 comments

Follow us at @academicobgyn for little thoughts about articles, issues in academics, research thoughts, and whatever else comes to mind.

Categories: Uncategorized
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