Commentary

Since my high school days, I have used some form of artificial sweetener in lieu of sugar. Long believing that sugar avoidance was the key to weight maintenance, I didn’t give much thought to the published ill effects of sugar substitutes—after all, I wasn’t a mouse, and I wasn’t consuming mass doses. Did the artificial sweeteners assist in controlling my weight? Quite honestly, I doubt it—but I was so used to being “sugar free” that I was habituated to using these products.

Several years ago at a luncheon, I was reaching for a packet of artificial sweetener to pour into my iced tea when an NP friend stopped me. She and her husband (a pharmacist) had sworn off these products after noting that he was having issues with his cognition and experiencing increased irritability. With no obvious cause for these symptoms, they investigated his diet. He had, over the previous year, increased his use of aspartame. They found research supporting an association between aspartame and changes in behavior and cognition. When he stopped using the product, they both noticed a return to his former jovial, intellectual self. I acknowledged their research conclusion as an “n = 1” but gave it no further credence.

More recently, friends who had adopted an “all-natural” diet chastised me for drinking sugar-free seltzer. I had switched years ago from diet sodas to this beverage as my primary source of hydration. What could be wrong? It had zero calories, no sodium, and no sugar. Ah, but it contained aspartame! Since switching to a food plan without aspartame, my friends had observed that they were feeling better and more alert. Hmm, sounded familiar … maybe there was something to these claims after all. I did a little research of my own, and was I surprised!

On the exterior, aspartame is a highly studied food additive with decades of research demonstrating its safety for human consumption.¹ But what exactly happens when this sweetener is ingested? First, aspartame breaks down into amino acids and methanol (ie, wood alcohol). The methanol continues to break down into formaldehyde and formic acid, a substance commonly found in bee and ant venom (see Figure). And if that weren’t enough, a potential brain tumor agent (aspartylphenylalanine diketopiperazine) is also a residual byproduct.^2,3 As you might expect, these components and byproducts come with varying adverse effects and potential health risks.

The majority of artificially sweetened beverages (ASBs) contain aspartame. As early as 1984—a mere six months after aspartame was approved for use in soft drinks—the FDA, with the assistance of the CDC, undertook an investigation of consumer complaints related to its use. The research team interviewed 517 complainants; 346 (67%) reported neurologic/behavioral symptoms, including headache, dizziness, and mood alteration.⁴ Despite that statistic, however, the researchers reported no evidence for the existence of serious, widespread, adverse health consequences resulting from aspartame consumption.⁴

Reading these reports reminded me of my friends’ comments and strongly suggested to me that soft drinks containing aspartame may be hard on the brain. Further to this point, a recent study found that ASB consumption is associated with an increased risk for stroke and dementia.⁵

Additional studies—including evaluations of possible associations between aspartame and headaches, seizures, behavior, cognition, and mood, as well as allergic-type reactions and use by potentially sensitive subpopulations—have been conducted. The verdict? Scientists maintain that aspartame is safe and that there are no unresolved questions regarding its safety when used as intended.⁶ Some researchers question the validity of the link between ASB consumption and negative health consequences, suggesting that individuals in worse health consume diet beverages in an effort to slow health deterioration or to lose weight.⁷ Yet, the debate about the effects of aspartame on our organs continues.

The number of epidemiologic studies that document strong associations between frequent ASB consumption and illness suggests that substituting or promoting artificial sweeteners as “healthy alternatives” to sugar may not be advisable.⁸ In fact, the most recent studies indicate that artificial sweeteners—the very compounds marketed to assist with weight control—can lead to weight gain, as they trick our brains into craving high-calorie foods. Moreover, ASB consumption is associated with a 21% increased risk for type 2 diabetes.⁹ Azad and colleagues found that evidence does not clearly support the use of nonnutritive sweeteners for weight management; they recommend using caution with these products until the long-term risks and benefits are fully understood.⁷

Is satisfying your sweet tooth with sugar alternatives worth the potential risk? Most of the studies conducted to support or refute aspartame-related health concerns prove correlation, not causality. A purist might point out that many of the studies have limitations that can lead to faulty conclusions. Be that as it may, it still gives one pause.

Small doses of aspartame each day might not be a tipping point toward the documented health complaints, but the consistent concerns about its effects were enough for me to make the switch to plain water, and sugar for my coffee. I do believe that Mary Poppins was correct—a spoonful of sugar does help—and I, for one, am following her lead.

What do you think? Are these concerns unfounded, or are we sweetening our road to poor health? Share your thoughts with me at [email protected]. 

Since my high school days, I have used some form of artificial sweetener in lieu of sugar. Long believing that sugar avoidance was the key to weight maintenance, I didn’t give much thought to the published ill effects of sugar substitutes—after all, I wasn’t a mouse, and I wasn’t consuming mass doses. Did the artificial sweeteners assist in controlling my weight? Quite honestly, I doubt it—but I was so used to being “sugar free” that I was habituated to using these products.

Several years ago at a luncheon, I was reaching for a packet of artificial sweetener to pour into my iced tea when an NP friend stopped me. She and her husband (a pharmacist) had sworn off these products after noting that he was having issues with his cognition and experiencing increased irritability. With no obvious cause for these symptoms, they investigated his diet. He had, over the previous year, increased his use of aspartame. They found research supporting an association between aspartame and changes in behavior and cognition. When he stopped using the product, they both noticed a return to his former jovial, intellectual self. I acknowledged their research conclusion as an “n = 1” but gave it no further credence.

More recently, friends who had adopted an “all-natural” diet chastised me for drinking sugar-free seltzer. I had switched years ago from diet sodas to this beverage as my primary source of hydration. What could be wrong? It had zero calories, no sodium, and no sugar. Ah, but it contained aspartame! Since switching to a food plan without aspartame, my friends had observed that they were feeling better and more alert. Hmm, sounded familiar … maybe there was something to these claims after all. I did a little research of my own, and was I surprised!

On the exterior, aspartame is a highly studied food additive with decades of research demonstrating its safety for human consumption.¹ But what exactly happens when this sweetener is ingested? First, aspartame breaks down into amino acids and methanol (ie, wood alcohol). The methanol continues to break down into formaldehyde and formic acid, a substance commonly found in bee and ant venom (see Figure). And if that weren’t enough, a potential brain tumor agent (aspartylphenylalanine diketopiperazine) is also a residual byproduct.^2,3 As you might expect, these components and byproducts come with varying adverse effects and potential health risks.

The majority of artificially sweetened beverages (ASBs) contain aspartame. As early as 1984—a mere six months after aspartame was approved for use in soft drinks—the FDA, with the assistance of the CDC, undertook an investigation of consumer complaints related to its use. The research team interviewed 517 complainants; 346 (67%) reported neurologic/behavioral symptoms, including headache, dizziness, and mood alteration.⁴ Despite that statistic, however, the researchers reported no evidence for the existence of serious, widespread, adverse health consequences resulting from aspartame consumption.⁴

Reading these reports reminded me of my friends’ comments and strongly suggested to me that soft drinks containing aspartame may be hard on the brain. Further to this point, a recent study found that ASB consumption is associated with an increased risk for stroke and dementia.⁵

Additional studies—including evaluations of possible associations between aspartame and headaches, seizures, behavior, cognition, and mood, as well as allergic-type reactions and use by potentially sensitive subpopulations—have been conducted. The verdict? Scientists maintain that aspartame is safe and that there are no unresolved questions regarding its safety when used as intended.⁶ Some researchers question the validity of the link between ASB consumption and negative health consequences, suggesting that individuals in worse health consume diet beverages in an effort to slow health deterioration or to lose weight.⁷ Yet, the debate about the effects of aspartame on our organs continues.

The number of epidemiologic studies that document strong associations between frequent ASB consumption and illness suggests that substituting or promoting artificial sweeteners as “healthy alternatives” to sugar may not be advisable.⁸ In fact, the most recent studies indicate that artificial sweeteners—the very compounds marketed to assist with weight control—can lead to weight gain, as they trick our brains into craving high-calorie foods. Moreover, ASB consumption is associated with a 21% increased risk for type 2 diabetes.⁹ Azad and colleagues found that evidence does not clearly support the use of nonnutritive sweeteners for weight management; they recommend using caution with these products until the long-term risks and benefits are fully understood.⁷

Is satisfying your sweet tooth with sugar alternatives worth the potential risk? Most of the studies conducted to support or refute aspartame-related health concerns prove correlation, not causality. A purist might point out that many of the studies have limitations that can lead to faulty conclusions. Be that as it may, it still gives one pause.

Small doses of aspartame each day might not be a tipping point toward the documented health complaints, but the consistent concerns about its effects were enough for me to make the switch to plain water, and sugar for my coffee. I do believe that Mary Poppins was correct—a spoonful of sugar does help—and I, for one, am following her lead.

What do you think? Are these concerns unfounded, or are we sweetening our road to poor health? Share your thoughts with me at [email protected]. 

Since my high school days, I have used some form of artificial sweetener in lieu of sugar. Long believing that sugar avoidance was the key to weight maintenance, I didn’t give much thought to the published ill effects of sugar substitutes—after all, I wasn’t a mouse, and I wasn’t consuming mass doses. Did the artificial sweeteners assist in controlling my weight? Quite honestly, I doubt it—but I was so used to being “sugar free” that I was habituated to using these products.

Several years ago at a luncheon, I was reaching for a packet of artificial sweetener to pour into my iced tea when an NP friend stopped me. She and her husband (a pharmacist) had sworn off these products after noting that he was having issues with his cognition and experiencing increased irritability. With no obvious cause for these symptoms, they investigated his diet. He had, over the previous year, increased his use of aspartame. They found research supporting an association between aspartame and changes in behavior and cognition. When he stopped using the product, they both noticed a return to his former jovial, intellectual self. I acknowledged their research conclusion as an “n = 1” but gave it no further credence.

More recently, friends who had adopted an “all-natural” diet chastised me for drinking sugar-free seltzer. I had switched years ago from diet sodas to this beverage as my primary source of hydration. What could be wrong? It had zero calories, no sodium, and no sugar. Ah, but it contained aspartame! Since switching to a food plan without aspartame, my friends had observed that they were feeling better and more alert. Hmm, sounded familiar … maybe there was something to these claims after all. I did a little research of my own, and was I surprised!

On the exterior, aspartame is a highly studied food additive with decades of research demonstrating its safety for human consumption.¹ But what exactly happens when this sweetener is ingested? First, aspartame breaks down into amino acids and methanol (ie, wood alcohol). The methanol continues to break down into formaldehyde and formic acid, a substance commonly found in bee and ant venom (see Figure). And if that weren’t enough, a potential brain tumor agent (aspartylphenylalanine diketopiperazine) is also a residual byproduct.^2,3 As you might expect, these components and byproducts come with varying adverse effects and potential health risks.

The majority of artificially sweetened beverages (ASBs) contain aspartame. As early as 1984—a mere six months after aspartame was approved for use in soft drinks—the FDA, with the assistance of the CDC, undertook an investigation of consumer complaints related to its use. The research team interviewed 517 complainants; 346 (67%) reported neurologic/behavioral symptoms, including headache, dizziness, and mood alteration.⁴ Despite that statistic, however, the researchers reported no evidence for the existence of serious, widespread, adverse health consequences resulting from aspartame consumption.⁴

Reading these reports reminded me of my friends’ comments and strongly suggested to me that soft drinks containing aspartame may be hard on the brain. Further to this point, a recent study found that ASB consumption is associated with an increased risk for stroke and dementia.⁵

Additional studies—including evaluations of possible associations between aspartame and headaches, seizures, behavior, cognition, and mood, as well as allergic-type reactions and use by potentially sensitive subpopulations—have been conducted. The verdict? Scientists maintain that aspartame is safe and that there are no unresolved questions regarding its safety when used as intended.⁶ Some researchers question the validity of the link between ASB consumption and negative health consequences, suggesting that individuals in worse health consume diet beverages in an effort to slow health deterioration or to lose weight.⁷ Yet, the debate about the effects of aspartame on our organs continues.

The number of epidemiologic studies that document strong associations between frequent ASB consumption and illness suggests that substituting or promoting artificial sweeteners as “healthy alternatives” to sugar may not be advisable.⁸ In fact, the most recent studies indicate that artificial sweeteners—the very compounds marketed to assist with weight control—can lead to weight gain, as they trick our brains into craving high-calorie foods. Moreover, ASB consumption is associated with a 21% increased risk for type 2 diabetes.⁹ Azad and colleagues found that evidence does not clearly support the use of nonnutritive sweeteners for weight management; they recommend using caution with these products until the long-term risks and benefits are fully understood.⁷

Is satisfying your sweet tooth with sugar alternatives worth the potential risk? Most of the studies conducted to support or refute aspartame-related health concerns prove correlation, not causality. A purist might point out that many of the studies have limitations that can lead to faulty conclusions. Be that as it may, it still gives one pause.

Small doses of aspartame each day might not be a tipping point toward the documented health complaints, but the consistent concerns about its effects were enough for me to make the switch to plain water, and sugar for my coffee. I do believe that Mary Poppins was correct—a spoonful of sugar does help—and I, for one, am following her lead.

What do you think? Are these concerns unfounded, or are we sweetening our road to poor health? Share your thoughts with me at [email protected]. 

It is human nature to practice things that we are already good at doing. If you’re a golfer, then you know what I’m talking about. I hit the driver over and over again on the range, but never practice hitting the bad lie in the bunker, or the half-swing wedge from a tight lie. I sink hundreds of 3 footers, but can’t putt into this range from 50 feet. I’ve gotten much better at golf since I started playing, but my scores have hardly gone down.

I think a similar thing happens in our orthopedic practices. I read everything I can on the anterior cruciate ligament, yet I already feel comfortable with my reconstruction technique. I skim, or avoid reading altogether, articles about topics I don’t like to treat, like the hand or spine. Yet, I still see these things every day in my practice and on call. If my depth of knowledge in these areas was as good as it is in sports medicine, I could provide better, more immediate care to my patients, rather than refer them to subspecialists.

A perfect orthopedic example would be the patellofemoral joint. One of the least enjoyable patient encounters for me is the young adult with normal alignment and intractable anterior knee pain that does not respond to nonoperative treatment. I’m concerned any surgical intervention may make them worse and I’m often left without much to offer the patient.

It’s for this reason AJO has partnered with Dr. Jack Farr to produce the patellofemoral issue; to provide a comprehensive guide to the latest thinking in the treatment of patellofemoral disorders (see the March/April 2017 issue). We solicited so much outstanding content, that a single issue could not hold all of the articles. In this issue, our patellofemoral series continues with 3 outstanding articles. Magnussen presents "Patella Alta Sees You, Do You See It?" and Hinckel and colleagues have authored a guide to patellofemoral cartilage restoration. Unal and colleagues follow-up with a review of the lateral retinaculum.

In our "Codes to Know" section, we reexamine diagnostic arthroscopy, a code most of us have billed infrequently. New technologies, however, have made it possible to peer into the joint in the office, and McMillan and colleagues teach us how to make it economically feasible, even for employed physicians.

Finally, we have a number of great articles on difficult problems—the stiff elbow, complex distal radius fractures, and intraoperative acetabular fractures during total hip arthroplasty.

Please enjoy this issue and think about what topics you tend to shy away from. I’m willing to bet you can add the most to your practice by studying up on these topics. As always, please provide your feedback to our editorial team so that we can continue to make improvements to our journal. We envision a change in the way orthopedists utilize a journal in their practice, and are continuously looking for ways to make AJO a more relevant tool for improving your patient care and workflow. We are working hard to give our readers the journal they deserve, but in my spare time, I’ll be brushing up on trochleoplasties and half-swing wedges.

It is human nature to practice things that we are already good at doing. If you’re a golfer, then you know what I’m talking about. I hit the driver over and over again on the range, but never practice hitting the bad lie in the bunker, or the half-swing wedge from a tight lie. I sink hundreds of 3 footers, but can’t putt into this range from 50 feet. I’ve gotten much better at golf since I started playing, but my scores have hardly gone down.

I think a similar thing happens in our orthopedic practices. I read everything I can on the anterior cruciate ligament, yet I already feel comfortable with my reconstruction technique. I skim, or avoid reading altogether, articles about topics I don’t like to treat, like the hand or spine. Yet, I still see these things every day in my practice and on call. If my depth of knowledge in these areas was as good as it is in sports medicine, I could provide better, more immediate care to my patients, rather than refer them to subspecialists.

A perfect orthopedic example would be the patellofemoral joint. One of the least enjoyable patient encounters for me is the young adult with normal alignment and intractable anterior knee pain that does not respond to nonoperative treatment. I’m concerned any surgical intervention may make them worse and I’m often left without much to offer the patient.

It’s for this reason AJO has partnered with Dr. Jack Farr to produce the patellofemoral issue; to provide a comprehensive guide to the latest thinking in the treatment of patellofemoral disorders (see the March/April 2017 issue). We solicited so much outstanding content, that a single issue could not hold all of the articles. In this issue, our patellofemoral series continues with 3 outstanding articles. Magnussen presents "Patella Alta Sees You, Do You See It?" and Hinckel and colleagues have authored a guide to patellofemoral cartilage restoration. Unal and colleagues follow-up with a review of the lateral retinaculum.

In our "Codes to Know" section, we reexamine diagnostic arthroscopy, a code most of us have billed infrequently. New technologies, however, have made it possible to peer into the joint in the office, and McMillan and colleagues teach us how to make it economically feasible, even for employed physicians.

Finally, we have a number of great articles on difficult problems—the stiff elbow, complex distal radius fractures, and intraoperative acetabular fractures during total hip arthroplasty.

Please enjoy this issue and think about what topics you tend to shy away from. I’m willing to bet you can add the most to your practice by studying up on these topics. As always, please provide your feedback to our editorial team so that we can continue to make improvements to our journal. We envision a change in the way orthopedists utilize a journal in their practice, and are continuously looking for ways to make AJO a more relevant tool for improving your patient care and workflow. We are working hard to give our readers the journal they deserve, but in my spare time, I’ll be brushing up on trochleoplasties and half-swing wedges.

It is human nature to practice things that we are already good at doing. If you’re a golfer, then you know what I’m talking about. I hit the driver over and over again on the range, but never practice hitting the bad lie in the bunker, or the half-swing wedge from a tight lie. I sink hundreds of 3 footers, but can’t putt into this range from 50 feet. I’ve gotten much better at golf since I started playing, but my scores have hardly gone down.

I think a similar thing happens in our orthopedic practices. I read everything I can on the anterior cruciate ligament, yet I already feel comfortable with my reconstruction technique. I skim, or avoid reading altogether, articles about topics I don’t like to treat, like the hand or spine. Yet, I still see these things every day in my practice and on call. If my depth of knowledge in these areas was as good as it is in sports medicine, I could provide better, more immediate care to my patients, rather than refer them to subspecialists.

A perfect orthopedic example would be the patellofemoral joint. One of the least enjoyable patient encounters for me is the young adult with normal alignment and intractable anterior knee pain that does not respond to nonoperative treatment. I’m concerned any surgical intervention may make them worse and I’m often left without much to offer the patient.

It’s for this reason AJO has partnered with Dr. Jack Farr to produce the patellofemoral issue; to provide a comprehensive guide to the latest thinking in the treatment of patellofemoral disorders (see the March/April 2017 issue). We solicited so much outstanding content, that a single issue could not hold all of the articles. In this issue, our patellofemoral series continues with 3 outstanding articles. Magnussen presents "Patella Alta Sees You, Do You See It?" and Hinckel and colleagues have authored a guide to patellofemoral cartilage restoration. Unal and colleagues follow-up with a review of the lateral retinaculum.

In our "Codes to Know" section, we reexamine diagnostic arthroscopy, a code most of us have billed infrequently. New technologies, however, have made it possible to peer into the joint in the office, and McMillan and colleagues teach us how to make it economically feasible, even for employed physicians.

Finally, we have a number of great articles on difficult problems—the stiff elbow, complex distal radius fractures, and intraoperative acetabular fractures during total hip arthroplasty.

Please enjoy this issue and think about what topics you tend to shy away from. I’m willing to bet you can add the most to your practice by studying up on these topics. As always, please provide your feedback to our editorial team so that we can continue to make improvements to our journal. We envision a change in the way orthopedists utilize a journal in their practice, and are continuously looking for ways to make AJO a more relevant tool for improving your patient care and workflow. We are working hard to give our readers the journal they deserve, but in my spare time, I’ll be brushing up on trochleoplasties and half-swing wedges.

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.

I would like to note that this pathology was previously reported by our group in 2015.¹ We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.

It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.

Brooks W. Ficke, MD

Brent A. Ponce, MD

Birmingham, AL

Authors' Response

We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.

Charles M. Jobin, MD

Usama Qayyum, MBBS

Diego Villacis, MD

New York, NY

I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.

I would like to note that this pathology was previously reported by our group in 2015.¹ We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.

It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.

Brooks W. Ficke, MD

Brent A. Ponce, MD

Birmingham, AL

Authors' Response

We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.

Charles M. Jobin, MD

Usama Qayyum, MBBS

Diego Villacis, MD

New York, NY

I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.

I would like to note that this pathology was previously reported by our group in 2015.¹ We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.

It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.

Brooks W. Ficke, MD

Brent A. Ponce, MD

Birmingham, AL

Authors' Response

We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.

Charles M. Jobin, MD

Usama Qayyum, MBBS

Diego Villacis, MD

New York, NY

Office based-testing is convenient and often useful.

Often, but not always.

Sadly, a number of practices are increasingly turning to tests of questionable value as a way to make up for decreasing reimbursements. While I have nothing against making money, I have to question where this trend is going. I see many of them even being done by physicians outside of their fields.

Graffoto8/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Office based-testing is convenient and often useful.

Often, but not always.

Sadly, a number of practices are increasingly turning to tests of questionable value as a way to make up for decreasing reimbursements. While I have nothing against making money, I have to question where this trend is going. I see many of them even being done by physicians outside of their fields.

Graffoto8/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Office based-testing is convenient and often useful.

Often, but not always.

Sadly, a number of practices are increasingly turning to tests of questionable value as a way to make up for decreasing reimbursements. While I have nothing against making money, I have to question where this trend is going. I see many of them even being done by physicians outside of their fields.

Graffoto8/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Low malignant potential tumors of the ovary – otherwise known as borderline tumors – include ovarian tumors with atypical cellularity, which lack stromal invasion that differentiates them from low grade and high grade invasive carcinomas. They can coexist with extraovarian disease, however, in the setting of borderline tumors these foci are referred to as “implants” rather than metastases. As discussed below, these implants can exhibit the presence of invasion or not.

Classification

The two most common histologic categories of borderline tumors are serous and mucinous cell types. Rarer histologic types such as endometrioid, clear cell, and Brenner also exist. However, these are so infrequent that they will not be covered in this discussion as there are very limited data to make generalizations about these histologies.

Serous borderline tumors contain cellularity similar to that of fallopian tubal epithelium. Approximately 25% of all serous ovarian tumors exhibit borderline features. Compared with mucinous tumors, they are more commonly bilateral and smaller in size (mean size of 12 cm) at the time of diagnosis and they are more likely to be associated with extraovarian implants (typically peritoneal). In fact, up to 25% of serous borderline tumors have concomitant extraovarian implants. Cancer antigen (CA) 125 is commonly a tumor marker for these tumors (elevated in 45% of early stage disease and 80% of advanced stage disease).¹

Courtesy Dr. Julia Manny

Incidence

The incidence of borderline ovarian tumors is 2.5 per 100,000 woman years in the United States. About 70% are diagnosed at stage I.³ They arise in a younger population compared with invasive ovarian carcinomas. Risk factors for development of borderline tumors are similar to those of invasive ovarian carcinomas (such as nulliparity) but there may be a stronger association between the development of borderline ovarian tumors and infertility, as well as prior use of infertility treatment.⁴

Diagnosis

The diagnosis of borderline tumors of the ovaries occurs almost exclusively at the time of surgical pathology (either frozen section or definitive pathology).

Preoperative assessments with imaging and tumor markers – usually CA 125 and carcinoembryonic antigen (CEA) – are nonspecific for this tumor type. Preoperative imaging will typically reveal complex ovarian cysts with papillations and vascularity. However, in the case of mucinous borderline tumors, unilocular cysts are common.¹ The presence of ascites and peritoneal implants can be observed on preoperative imaging of serous borderline tumors with extraovarian disease. However, it is not possible for this imaging to accurately differentiate borderline tumors with implants from low grade and high grade carcinomas with metastases.

Surgical management

Borderline tumors are commonly diagnosed in women of reproductive age and decisions need to be made regarding fertility sparing surgery, ovarian sparing surgery, and whether staging is performed. The recommended surgery for women who have completed child bearing is complete hysterectomy with bilateral salpingo-oophorectomy. However, cystectomy or unilateral salpingo-oophorectomy can be considered for women who desire fertility preservation. Conservative fertility preserving surgery is associated with an increased risk of recurrence, but with no negative impact on survival.¹

Staging – with at least omentectomy and comprehensive evaluation of the peritoneal cavity, with or without peritoneal biopsies – can be considered, though staging is not associated with improved survival. Lymphadenectomy is also not associated with improved oncologic outcomes and routine lymphadenectomy is not recommended for borderline tumors.¹ However, about a quarter of patients with gross evidence of extraovarian disease have implants within lymph nodes. Bulky lymph nodes should be removed, particularly in this group of patients.

Complete removal of extraovarian implants is the surgical intervention that is most important for survival and recurrence.¹ This requires that surgeons thoroughly evaluate the peritoneal cavity and retroperitoneum, and possess the capability to completely resect all sites of disease.

Historically appendectomy was part of surgical staging of mucinous borderline tumors in order to identify a primary appendiceal lesion, but only 1% of patients with a grossly normal appearing appendix have significant pathology identified. This is no longer recommended.²

Treatment

The primary treatment for borderline tumors of the ovary is surgery. A minimally invasive approach is appropriate when feasible, though it may be associated with an increased risk of cyst rupture, particularly if cystectomy is attempted. Outcomes are best when extraovarian implants are completely resected. Adjuvant chemotherapy is not associated with improved survival and is not routinely recommended, though the guidelines from the National Comprehensive Cancer Network include this as an option for patients with advanced stage disease that is either completely or incompletely resected.⁵

Prognosis

In general, prognosis is excellent for borderline tumors with 5- and 10-year survival of 99% and 97%, 98% and 90%, and 96% and 88% for stages I, II and III tumors, respectively.¹ However, several pathologic, molecular, and anatomic features are important in predicting who is at highest risk for recurrence.

Serous borderline tumors with invasive implants (as opposed to desmoplastic implants) and incompletely resected extraovarian implants are associated with increased recurrence and poor prognosis.Micropapillary features and stromal invasion are histologic features that have historically been associated with worse prognosis, but it is unclear if these are independent risk factors, or instead associated with invasive implants. For mucinous borderline tumors, intraepithelial carcinoma has been inconclusively associated with poor prognosis.^1,6

Surveillance

Recurrences do occur in patients with a history of borderline tumors of the ovary, however these typically occur late. For this reason, surveillance is important and should continue for many years after diagnosis. Most recurrences are within the peritoneal cavity and are treated with surgical excision and patients should be counseled regarding symptoms of recurrence that include gastrointestinal symptoms, bloating, and pain.

In accordance with guidelines from the Society of Gynecologic Oncology, surveillance examinations can take place annually as there is no evidence that more frequent evaluations improve outcomes. These visits should include physical examinations (with pelvic examinations), symptom assessment, and, if elevated preoperatively, assessment of relevant tumor markers (typically CA 125 and/or CEA).⁷ Surveillance should continue for at least 10 years postoperatively.

Routine imaging is not recommended for all patients in surveillance. However, for patients who have had fertility-sparing surgery, imaging with pelvic ultrasound is recommended, particularly for women with a history of cystectomy or serous borderline tumor (who are at increased risk for bilateral tumors).

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.

References

1. Lancet Oncol. 2012 Mar;13(3):e103-15.

2. Arch Gynecol Obstet. 2016 Nov;294(6):1283-9.

3. Cancer. 2002 Dec 1;95(11):2380-9.

4. Am J Epidemiol. 2002 Feb 1;155(3):217-24.

5. J Natl Compr Canc Netw. 2016 Sep;14(9):1134-63.

6. BJOG. 2016 Mar;123(4):498-508.

7. Gynecol Oncol. 2017 Jul;146(1):3-10.

Low malignant potential tumors of the ovary – otherwise known as borderline tumors – include ovarian tumors with atypical cellularity, which lack stromal invasion that differentiates them from low grade and high grade invasive carcinomas. They can coexist with extraovarian disease, however, in the setting of borderline tumors these foci are referred to as “implants” rather than metastases. As discussed below, these implants can exhibit the presence of invasion or not.

Classification

The two most common histologic categories of borderline tumors are serous and mucinous cell types. Rarer histologic types such as endometrioid, clear cell, and Brenner also exist. However, these are so infrequent that they will not be covered in this discussion as there are very limited data to make generalizations about these histologies.

Serous borderline tumors contain cellularity similar to that of fallopian tubal epithelium. Approximately 25% of all serous ovarian tumors exhibit borderline features. Compared with mucinous tumors, they are more commonly bilateral and smaller in size (mean size of 12 cm) at the time of diagnosis and they are more likely to be associated with extraovarian implants (typically peritoneal). In fact, up to 25% of serous borderline tumors have concomitant extraovarian implants. Cancer antigen (CA) 125 is commonly a tumor marker for these tumors (elevated in 45% of early stage disease and 80% of advanced stage disease).¹

Courtesy Dr. Julia Manny

Incidence

The incidence of borderline ovarian tumors is 2.5 per 100,000 woman years in the United States. About 70% are diagnosed at stage I.³ They arise in a younger population compared with invasive ovarian carcinomas. Risk factors for development of borderline tumors are similar to those of invasive ovarian carcinomas (such as nulliparity) but there may be a stronger association between the development of borderline ovarian tumors and infertility, as well as prior use of infertility treatment.⁴

Diagnosis

The diagnosis of borderline tumors of the ovaries occurs almost exclusively at the time of surgical pathology (either frozen section or definitive pathology).

Preoperative assessments with imaging and tumor markers – usually CA 125 and carcinoembryonic antigen (CEA) – are nonspecific for this tumor type. Preoperative imaging will typically reveal complex ovarian cysts with papillations and vascularity. However, in the case of mucinous borderline tumors, unilocular cysts are common.¹ The presence of ascites and peritoneal implants can be observed on preoperative imaging of serous borderline tumors with extraovarian disease. However, it is not possible for this imaging to accurately differentiate borderline tumors with implants from low grade and high grade carcinomas with metastases.

Surgical management

Borderline tumors are commonly diagnosed in women of reproductive age and decisions need to be made regarding fertility sparing surgery, ovarian sparing surgery, and whether staging is performed. The recommended surgery for women who have completed child bearing is complete hysterectomy with bilateral salpingo-oophorectomy. However, cystectomy or unilateral salpingo-oophorectomy can be considered for women who desire fertility preservation. Conservative fertility preserving surgery is associated with an increased risk of recurrence, but with no negative impact on survival.¹

Staging – with at least omentectomy and comprehensive evaluation of the peritoneal cavity, with or without peritoneal biopsies – can be considered, though staging is not associated with improved survival. Lymphadenectomy is also not associated with improved oncologic outcomes and routine lymphadenectomy is not recommended for borderline tumors.¹ However, about a quarter of patients with gross evidence of extraovarian disease have implants within lymph nodes. Bulky lymph nodes should be removed, particularly in this group of patients.

Complete removal of extraovarian implants is the surgical intervention that is most important for survival and recurrence.¹ This requires that surgeons thoroughly evaluate the peritoneal cavity and retroperitoneum, and possess the capability to completely resect all sites of disease.

Historically appendectomy was part of surgical staging of mucinous borderline tumors in order to identify a primary appendiceal lesion, but only 1% of patients with a grossly normal appearing appendix have significant pathology identified. This is no longer recommended.²

Treatment

The primary treatment for borderline tumors of the ovary is surgery. A minimally invasive approach is appropriate when feasible, though it may be associated with an increased risk of cyst rupture, particularly if cystectomy is attempted. Outcomes are best when extraovarian implants are completely resected. Adjuvant chemotherapy is not associated with improved survival and is not routinely recommended, though the guidelines from the National Comprehensive Cancer Network include this as an option for patients with advanced stage disease that is either completely or incompletely resected.⁵

Prognosis

In general, prognosis is excellent for borderline tumors with 5- and 10-year survival of 99% and 97%, 98% and 90%, and 96% and 88% for stages I, II and III tumors, respectively.¹ However, several pathologic, molecular, and anatomic features are important in predicting who is at highest risk for recurrence.

Serous borderline tumors with invasive implants (as opposed to desmoplastic implants) and incompletely resected extraovarian implants are associated with increased recurrence and poor prognosis.Micropapillary features and stromal invasion are histologic features that have historically been associated with worse prognosis, but it is unclear if these are independent risk factors, or instead associated with invasive implants. For mucinous borderline tumors, intraepithelial carcinoma has been inconclusively associated with poor prognosis.^1,6

Surveillance

Recurrences do occur in patients with a history of borderline tumors of the ovary, however these typically occur late. For this reason, surveillance is important and should continue for many years after diagnosis. Most recurrences are within the peritoneal cavity and are treated with surgical excision and patients should be counseled regarding symptoms of recurrence that include gastrointestinal symptoms, bloating, and pain.

In accordance with guidelines from the Society of Gynecologic Oncology, surveillance examinations can take place annually as there is no evidence that more frequent evaluations improve outcomes. These visits should include physical examinations (with pelvic examinations), symptom assessment, and, if elevated preoperatively, assessment of relevant tumor markers (typically CA 125 and/or CEA).⁷ Surveillance should continue for at least 10 years postoperatively.

Routine imaging is not recommended for all patients in surveillance. However, for patients who have had fertility-sparing surgery, imaging with pelvic ultrasound is recommended, particularly for women with a history of cystectomy or serous borderline tumor (who are at increased risk for bilateral tumors).

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.

References

1. Lancet Oncol. 2012 Mar;13(3):e103-15.

2. Arch Gynecol Obstet. 2016 Nov;294(6):1283-9.

3. Cancer. 2002 Dec 1;95(11):2380-9.

4. Am J Epidemiol. 2002 Feb 1;155(3):217-24.

5. J Natl Compr Canc Netw. 2016 Sep;14(9):1134-63.

6. BJOG. 2016 Mar;123(4):498-508.

7. Gynecol Oncol. 2017 Jul;146(1):3-10.

Low malignant potential tumors of the ovary – otherwise known as borderline tumors – include ovarian tumors with atypical cellularity, which lack stromal invasion that differentiates them from low grade and high grade invasive carcinomas. They can coexist with extraovarian disease, however, in the setting of borderline tumors these foci are referred to as “implants” rather than metastases. As discussed below, these implants can exhibit the presence of invasion or not.

Classification

The two most common histologic categories of borderline tumors are serous and mucinous cell types. Rarer histologic types such as endometrioid, clear cell, and Brenner also exist. However, these are so infrequent that they will not be covered in this discussion as there are very limited data to make generalizations about these histologies.

Serous borderline tumors contain cellularity similar to that of fallopian tubal epithelium. Approximately 25% of all serous ovarian tumors exhibit borderline features. Compared with mucinous tumors, they are more commonly bilateral and smaller in size (mean size of 12 cm) at the time of diagnosis and they are more likely to be associated with extraovarian implants (typically peritoneal). In fact, up to 25% of serous borderline tumors have concomitant extraovarian implants. Cancer antigen (CA) 125 is commonly a tumor marker for these tumors (elevated in 45% of early stage disease and 80% of advanced stage disease).¹

Courtesy Dr. Julia Manny

Incidence

The incidence of borderline ovarian tumors is 2.5 per 100,000 woman years in the United States. About 70% are diagnosed at stage I.³ They arise in a younger population compared with invasive ovarian carcinomas. Risk factors for development of borderline tumors are similar to those of invasive ovarian carcinomas (such as nulliparity) but there may be a stronger association between the development of borderline ovarian tumors and infertility, as well as prior use of infertility treatment.⁴

Diagnosis

The diagnosis of borderline tumors of the ovaries occurs almost exclusively at the time of surgical pathology (either frozen section or definitive pathology).

Preoperative assessments with imaging and tumor markers – usually CA 125 and carcinoembryonic antigen (CEA) – are nonspecific for this tumor type. Preoperative imaging will typically reveal complex ovarian cysts with papillations and vascularity. However, in the case of mucinous borderline tumors, unilocular cysts are common.¹ The presence of ascites and peritoneal implants can be observed on preoperative imaging of serous borderline tumors with extraovarian disease. However, it is not possible for this imaging to accurately differentiate borderline tumors with implants from low grade and high grade carcinomas with metastases.

Surgical management

Borderline tumors are commonly diagnosed in women of reproductive age and decisions need to be made regarding fertility sparing surgery, ovarian sparing surgery, and whether staging is performed. The recommended surgery for women who have completed child bearing is complete hysterectomy with bilateral salpingo-oophorectomy. However, cystectomy or unilateral salpingo-oophorectomy can be considered for women who desire fertility preservation. Conservative fertility preserving surgery is associated with an increased risk of recurrence, but with no negative impact on survival.¹

Staging – with at least omentectomy and comprehensive evaluation of the peritoneal cavity, with or without peritoneal biopsies – can be considered, though staging is not associated with improved survival. Lymphadenectomy is also not associated with improved oncologic outcomes and routine lymphadenectomy is not recommended for borderline tumors.¹ However, about a quarter of patients with gross evidence of extraovarian disease have implants within lymph nodes. Bulky lymph nodes should be removed, particularly in this group of patients.

Complete removal of extraovarian implants is the surgical intervention that is most important for survival and recurrence.¹ This requires that surgeons thoroughly evaluate the peritoneal cavity and retroperitoneum, and possess the capability to completely resect all sites of disease.

Historically appendectomy was part of surgical staging of mucinous borderline tumors in order to identify a primary appendiceal lesion, but only 1% of patients with a grossly normal appearing appendix have significant pathology identified. This is no longer recommended.²

Treatment

The primary treatment for borderline tumors of the ovary is surgery. A minimally invasive approach is appropriate when feasible, though it may be associated with an increased risk of cyst rupture, particularly if cystectomy is attempted. Outcomes are best when extraovarian implants are completely resected. Adjuvant chemotherapy is not associated with improved survival and is not routinely recommended, though the guidelines from the National Comprehensive Cancer Network include this as an option for patients with advanced stage disease that is either completely or incompletely resected.⁵

Prognosis

In general, prognosis is excellent for borderline tumors with 5- and 10-year survival of 99% and 97%, 98% and 90%, and 96% and 88% for stages I, II and III tumors, respectively.¹ However, several pathologic, molecular, and anatomic features are important in predicting who is at highest risk for recurrence.

Serous borderline tumors with invasive implants (as opposed to desmoplastic implants) and incompletely resected extraovarian implants are associated with increased recurrence and poor prognosis.Micropapillary features and stromal invasion are histologic features that have historically been associated with worse prognosis, but it is unclear if these are independent risk factors, or instead associated with invasive implants. For mucinous borderline tumors, intraepithelial carcinoma has been inconclusively associated with poor prognosis.^1,6

Surveillance

Recurrences do occur in patients with a history of borderline tumors of the ovary, however these typically occur late. For this reason, surveillance is important and should continue for many years after diagnosis. Most recurrences are within the peritoneal cavity and are treated with surgical excision and patients should be counseled regarding symptoms of recurrence that include gastrointestinal symptoms, bloating, and pain.

In accordance with guidelines from the Society of Gynecologic Oncology, surveillance examinations can take place annually as there is no evidence that more frequent evaluations improve outcomes. These visits should include physical examinations (with pelvic examinations), symptom assessment, and, if elevated preoperatively, assessment of relevant tumor markers (typically CA 125 and/or CEA).⁷ Surveillance should continue for at least 10 years postoperatively.

Routine imaging is not recommended for all patients in surveillance. However, for patients who have had fertility-sparing surgery, imaging with pelvic ultrasound is recommended, particularly for women with a history of cystectomy or serous borderline tumor (who are at increased risk for bilateral tumors).

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.

References

1. Lancet Oncol. 2012 Mar;13(3):e103-15.

2. Arch Gynecol Obstet. 2016 Nov;294(6):1283-9.

3. Cancer. 2002 Dec 1;95(11):2380-9.

4. Am J Epidemiol. 2002 Feb 1;155(3):217-24.

5. J Natl Compr Canc Netw. 2016 Sep;14(9):1134-63.

6. BJOG. 2016 Mar;123(4):498-508.

7. Gynecol Oncol. 2017 Jul;146(1):3-10.