A recording of this presentation can be found HERE
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There is almost nothing that gets me more professionally excited than an in-person gathering of teachers and learners reviewing the medical literature and discussing the evidence for how we should best be practicing family medicine. This week's Grand Rounds was all of that -- a fast-paced review of a few important 2023 studies in Obstetrics and Pediatrics -- studies that either reinforce a practice and/or change our practice.
The two faculty who spoke did a fantastic job! Dr. Douglas Jimenez focused his Ob portion on hypertensive disorders in pregnancy, including: ASA for Pre-E prevention, management of chronic hypertension in pregnancy, and intrapartum BP management. Dr. Deirdre Bernard-Pearl spent her peds time on cannabis intoxication and adolescent depression, with a particular emphasis on exercise and patient-centered counseling.
All of it made me proud to be a family doctor. A link to a recording of their presentations is available above. If you want the take-homes, here they are:
OB (Douglas Jimenez):
1) Aspirin definitely works to reduce Pre-Eclampsia! For maximum effect, ASA should be dosed a minimum of 100 mg daily (in the US, that means 160mg = 2 baby aspirin), ideally started between 12-16 weeks (closer to 12 the better, but ACOG recommends starting as late as 28 weeks), and taken at night. ASA should ideally be stopped 1 week prior to delivery.
2) Good BP control in chronic hypertension in pregnancy is associated with better outcomes-- for the baby and the mom (NNT=14). Contrary to common practice, you should treat elevations in pressures with medication for BPs above 140/90. There is even some evidence that a lower goal (<130/80) is associated with even better outcomes. This BP management does not lead to SGA babies.
3) Intrapartum management of elevated BPs has historically been more based on practice comfort than science. There is evolving evidence that BP management should be considered using a physiological approach. Pre E should probably be considered as two distinct entities: early onset (vasoconstrictive) and late onset (hyperdynamic). As such, hydralazine -- a potent vasodilator -- may be a better BP med choice intrapartum for vasoconstrictive hypertension, and labetalol a Beta blocker may be a better BP med choice for hyperdynamic hypertension. As an aside, oral nifedipine may actually be as good as (or even better) than IV BP meds intrapartum.
4) For volume overloaded patients with Pre-E who are post partum and continue to have elevated BPs, a 5 day course of furosemide may help both problems. Dosing is 20mgx 5 days.
Pediatrics (Deirdre Bernard-Pearl):
1) Edible MJ products have skyrocketed in the last decade, as have documented pediatric marijuana toxicity, which increased 13X (!!) from 2017-2021. Lethargy is the number one effect of accidental edible MJ consumption in children. Safe storage of edibles should be integrated into well-child care preventive care.
2) Adolescent depression rates remain high since COVID -- as 2X the rate prior to the pandemic. Exercise is a potent treatment for adolescent depression. A 2023 Meta-analysis of 13 studies found that exercise had SAME strength of effect as SSRIs for depression treatment. This review concluded that 20-60 minutes of exercise, 3x per week, for at least 12 weeks had the largest and most sustained effect. Group exercise is more effective than individual exercise, and mixed exercise (aerobic and non-aerobic) is superior as well.
3) We can definitely do better assessing and treating our teens with depression and anxiety! See the table below to see how poorly we are doing, and don't forget to use a screening tool, counsel about exercise and sleep, refer for CBT (we know, mental health is hard to access), and see teens with new diagnosis of depression and anxiety WEEKLY until they are stable.
Thanks again to these 2 excellent teachers for their 2023 Game Changers. Stay tuned in coming months for a medicine version of the same (Inpatient and Outpatient).
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