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Late Tx of Stroke; ‘Low Normal’ Apgar; It’s PodMed Double T!

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include progesterone in threatened miscarriage, Apgar scores, Mohs surgery use, and late treatment of stroke.

Program notes:

0:35 Mohs surgery use

1:35 Compare one surgeon to another

2:35 How to deal with outlying physicians?

3:33 More money per excision

3:43 Thrombolysis up to 9 hours post stroke

4:45 Did a scan to assess living tissue

5:45 Increased risk for bleeding

6:10 Apgar scores in normal window

7:10 A score of 7, 8 or 9

8:10 Do carry prognostic information

9:00 Progesterone and bleeding in early pregnancy

10:00 Followed to end of pregnancy

10:53 End


Elizabeth Tracey: Can we change how often Mohs surgery is employed?

Rick Lange, MD: Can late treatment of stroke be beneficial?

Elizabeth: What do Apgar scores of newborn babies tell us about the future?

Rick: And for women who are threatening to have a miscarriage, can progesterone help?

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on May 10th, 2019.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso and also the Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I think I’d like to start first with this issue of Mohs surgery, something that I served up as, “Can we change how often it’s used?” I thought this was really interesting because, of course, we’re moving into the summer here, in at least our part of the world, and people are going to get a lot more sun exposure. We know that skin cancer is the #1, actually, malignancy that’s diagnosed domestically and I bet you even worldwide.

Mohs surgery, of course, is this treatment that uses a staged approach where they take a look at the margins and they say, “Hey, are we clear now? Can we close up and be done with removing this particular lesion?” Is it always appropriate?

There’s been some question about that. So in this case, what they did was they said, “Well, if we provide surgeons who perform this particular procedure with data relative one to another — How often are you doing it? How many excisions do you perform when you undertake a Mohs procedure? Will that help to reduce the number of times that people actually use it?” They had 2,300+ surgeons who were a part of this. They had an intervention and a control group. And they identified outliers, people who actually had more stages per case, more times that they did an excision in comparison.

They found that among the intervention group, when that data was provided, there was a reduction in mean stages per case compared with the outliers in the control group. And this reduction would have resulted in a reduction in Medicare spending for this procedure of over $11 million. The other beauty of this particular intervention was it wasn’t like they were getting beaten over the head visibly one to another. They were able to really self-police and say, “Hmm, how am I comparing?”

Rick: Elizabeth, you hit the nail on the head. There are some outlying physicians. When I say outlying, they took many more sections than the others. How to deal with that? This was unique in that it was taken on by the national organization. So this is a well-respected peer-physician leadership group. They worked together to set the metrics, so it was a clear, achievable benchmark and a consensus of what was considered to be normal.

Then they just informed all the physicians about where they sat. Then based upon that, the physicians self-corrected their behavior. As you said, you didn’t have to beat them over the head. You had to present them with data that said, “Hey, listen, you’re not matching up to your peers,” and as a result of that, they decreased the number of excisions. This is a great story, but it doesn’t take a regulation. It just takes information.

Elizabeth: And patients, of course, benefit also because it’s not that Mohs is so terribly challenging for most people, but often people have copays that they have to pay for when they have this kind of thing, and also the more you have excision, the more stitches and all the rest of it. So I think it’s a great outcome.

Rick: Unfortunately, the physicians get more money the more excisions they do. You’d say, “Even presented with this confidential information, they wouldn’t correct their behavior?” But actually they did, so that’s good news.

Elizabeth: Let’s turn from here to the New England Journal of Medicine, one of yours, thrombolysis up to 9 hours after onset of stroke and expanding window.

Rick: When people have a stroke, we talk about time being brain, and that is, you want to restore blood flow to the brain as quickly as possible to minimize the results of the stroke. The data suggests that if you do that within 4 1/2 hours, either by mechanically disrupting the thrombus, the clot, or giving an agent that dissolves it, does the patient have a much better outcome? But we know that up to 50% of people that have a large-vessel stroke don’t develop it all at once. It’s a slowly progressing stroke because they have collaterals, blood vessels from other regions of the brain that can actually supply blood flow there for a period of time.

So recent evidence suggests that with thrombectomy, if you can identify people that have tissue that’s at risk, but hasn’t yet died, that thrombectomy can be helpful. What this study addressed is can we get the same results if we give an IV agent, the thrombolysis or clot-dissolving agent?

They planned to do 310 patients, but only stopped the study after 225 because there was another result from a previous trial that was positive. What they determined was, if they did a scan and it looked like all the tissue had not yet infarcted or died and they give a thrombolytic agent between 4 1/2 to 9 hours after the onset of stroke, there was a 44% increased opportunity for the patient to have zero or very minimal neurologic deficits at 90 days. This is a therapy not based upon the time of the stroke, but actually the results of the CT or MRI scan to show there’s still viable tissue.

Elizabeth: And I would ask you does this suggest that it would be a good idea to employ these imaging technologies to assess that almost irrespective of when someone comes in with the presentation of a stroke?

Rick: Elizabeth, I wouldn’t waste time for those that present early on, that is within 4 1/2 hours because I think the studies clearly show that those receive a benefit. For those that present later, I think the imaging studies can be very beneficial. The downside of this is that there was an increased risk of intracerebral bleeding or hemorrhage. It was about 1% in those that received placebo and about 6% in those that received the IV thrombolytic agent, so there is a bit of a downside. But 90 days later, a 44% increased opportunity for individuals to have no significant residual neurologic deficits.

Elizabeth: And yet one more reason when anybody feels like they may be having a stroke or you notice that in loved one, to get them help right away. Let’s turn now to the British Medical Journal, a huge study, 1.5+ million infants and taking a look at Apgar scores. Apgar scores, of course, are a really brief and non-invasive kind of assessment that’s done after a child is born. They’re usually done at 1, 5, and 10 minutes after birth.

They take a look at really pretty simple metrics: skin, how you’re breathing, how you’re looking, how you respond to stimuli. And in this case, they took a look at all of that data. They gathered Apgar scores at 1, 5, and 10 minutes after birth, and they assessed those who are given what’s so-called a “normal” score that could range from 7 to 10 and then their subsequent outcomes.

This is interestingly the first time, according to them, that anyone has actually done this. How does that so-called normal score impact on other kinds of outcomes, specifically neonatal mortality and morbidity? And they found that there is a relationship between lower so-called normal — so if you’ve got a 7 or an 8 or a 9 versus a 10 — and subsequent development of other symptoms.

They point out in here that a lot of times the 10-minute score is not even done, and so they make an argument based on this data that they do see this linear relationship and that it is predictive, that those 10-minute scores really need to be recorded in medical charts, and this would actually help providers to have a higher index of suspicion when it comes to the management of the newborn.

Rick: Currently, we consider scores less than 7 as having a low Apgar score, and between 7 and 10 as being “in the normal range.” By the way, very few kids have an Apgar score of 10 in the first minute. Only about 10% or 11% have an Apgar score that’s normal 10 at 1 minute. But as you highlighted, if your Apgar score is less than 10 at 5 minutes or 10 minutes, it means it’s associated with an increased risk of neonatal infection, respiratory distress, and also neonatal hypoglycemia or low sugar. Even these “normal” scores do carry some prognostic information. Now, whether that translates later to delayed neurocognitive function is unknown.

Elizabeth: Right. But I think, as I said, it really raises the index of suspicion. If a child, if a neonate, has a 7, an 8, or a 9, then it says, “Maybe we ought to be paying closer attention.”

Rick: We know that there are several factors associated with this Apgar score of even 7, 8, or 9, that the mother has diabetes or preeclampsia or an infection that’s called chorioamnionitis, or she’s had induced labor or there’s been meconium aspiration from the baby. All those are associated with lower Apgar scores, even within the “normal” range.

Elizabeth: Yep, so we need to pay attention. Let’s turn to your final one, back to the New England Journal of Medicine. This is a study taking a look, since we were talking about neonates, let’s take a look at pregnancy. Does progesterone help women who have bleeding in early pregnancy avoid miscarriage?

Rick: This is what’s known as a threatened miscarriage or, in the medical term, threatened spontaneous abortion. And it occurs in up to 25% of women and usually presents as bleeding in the first trimester. It’s estimated that of those women that experience that, the 25%, that about 10% to 20% or more will actually go on to miscarry. There’s been an off-label use of progesterone to treat these mothers.

Why is that? We know that progesterone is important for preparing the lining of the uterus, and when the embryo has implanted, progesterone goes up. So there was some thought that in mothers that had bleeding and threatened miscarriage if you gave progesterone it could prevent that.

To address that, this is a very large study of over 4,100 women at 48 hospitals in the United Kingdom. These were women that had bleeding and they were randomized to either receive vaginal progesterone twice daily or placebo during the first trimester. Then they followed them to the end of pregnancy to see how many of them had live births at 34 weeks of gestation or longer.And what they discovered was that that number was not different whether the mothers received placebo or progesterone, and it was about 75% of mothers that had bleeding, that is threatened abortion or threatened miscarriage.

Elizabeth: This, of course, is good information even though it’s a negative study.

Rick: It is because these authors did a previous study of mothers that had recurrent miscarriages to see whether progesterone would be helpful in advance, and it wasn’t. This is the follow-up study, and so if we can avoid unnecessary treatments or direct our attention perhaps to some other things that might be beneficial, that’s useful information.

Elizabeth: On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.