Commentary

Mobile phones became commonplace in just a few years and are now used everywhere, included remote areas of the world. These communication tools are used for personal and professional purposes, frequently by health care workers (HCWs) during care.

We and others believe that mobile phones improve the quality, rapidity, and efficiency of communication in health care settings and, therefore, improve the management of patients. In fact, professional mobile phones allow communication between HCWs anywhere in the hospital. In addition, personal mobile phones, frequently smartphones, allow the use of medical apps for evidence-based management of patients.

Mobile phones, both professional and personal, are used in close proximity to patients, as reported in behavioral studies. In a recent study we performed in a hospital setting (Clin Microbiol Infect. 2016 May;22[5]:456.e1-e6. doi: 10.1016/j.cmi.2015.12.008), more than 60% of HCWs who participated declared using phones during care, and also declared that they had halted care to patients while answering a call.

Several studies have shown that mobile phones used at hospitals are contaminated by bacteria, including highly pathogenic ones, such as methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter species, vancomycin-resistant enterococci, Pseudomonas species, and coliforms. Research suggests that these devices may serve as a reservoir of bacteria known to cause nosocomial infections and may play a role in transmission of them to patients through the hands of HCWs.

For the first time, we demonstrated the presence of RNA of epidemic viruses such as rotavirus, influenza virus, syncytial respiratory virus, and metapneumovirus on mobile phones (professional and personal) held by HCWs. In our study, 38.5% of sampled mobile phones were contaminated with RNA from viruses. RNA of rotavirus was the most frequently-detected virus, mainly on phones sampled in the pediatric emergency ward. Interestingly, we found that HCWs in pediatric wards admitted disinfecting their mobile phones less frequently than did other HCWs we interviewed.

Epidemic viruses have already been discovered on other electronic device surfaces, such as keyboards, computers, and telephone handsets. However, in contrast to these other devices, mobile phones are mobile and could be shared and transported anywhere, including in close proximity to patients. Rotaviruses are frequently found on hospital surfaces several months after an epidemic period, after surfaces were cleaned. The high prevalence of rotavirus in pediatric ward patients during our study, and its capacity to persist in the environment, are probably the main factors that explain the high frequency of rotavirus RNA detection on mobile phones in our study.

This finding highlights the possible role of mobile phones in cross-transmission of epidemic viruses, with the transfer from nonporous fomites to fingers, and from fingers to fomites – including mobile phones. Due to the difficulty and fastidiousness of viral culture, the viruses were detected only by molecular biology; the viability of the viruses could not be demonstrated. However, we believe that cross-transmission of viruses may occur, notably in health care settings. The recently reported case of a 40-year-old Ugandan man who stole a phone from a patient with Ebola and contracted the disease, also supports this hypothesis.

We also demonstrated in our study that hand hygiene after the use of mobile phones does not seem to be systematic, even for HCWs continuing care that was in process before picking up their phones. Around 30% of HCWs declared that they never perform hand hygiene before or after handling mobile phones. In addition, more than 30% of HCWs admitted that they never disinfect their phones, even their professional ones; this lack of hygiene could contribute to the persistence of RNA of epidemic viruses.

Our study does not support banning the use of mobile phones in hospitals. We just want to make HCWs aware that mobile phones, which are part of our daily practice, can be contaminated by pathogens, notably viruses. The use of disinfection wipes to clean phones, together with adherence to hand hygiene, is crucial to prevent cross-transmission.

Frequent disinfection of personal and professional mobile phones needs to be promoted to reduce contamination of phones by viruses, especially during epidemics.

In practice, each clinician needs to remember that hand hygiene should be the last thing done before patient contact, as recommended by the World Health Organization. Touching a mobile phone could transfer bacteria or viruses onto hands, and we hypothesize that it could be a factor in cross-transmission of pathogens.

Elisabeth Botelho-Nevers, MD, PhD, is an infectious diseases specialist at the University Hospital of Saint-Étienne (France) and Sylvie Pillet, PharmD, PhD, is a virologist in the Laboratory of Infectious Agents and Hygiene, University Hospital of Saint-Étienne.

Mobile phones became commonplace in just a few years and are now used everywhere, included remote areas of the world. These communication tools are used for personal and professional purposes, frequently by health care workers (HCWs) during care.

We and others believe that mobile phones improve the quality, rapidity, and efficiency of communication in health care settings and, therefore, improve the management of patients. In fact, professional mobile phones allow communication between HCWs anywhere in the hospital. In addition, personal mobile phones, frequently smartphones, allow the use of medical apps for evidence-based management of patients.

Mobile phones, both professional and personal, are used in close proximity to patients, as reported in behavioral studies. In a recent study we performed in a hospital setting (Clin Microbiol Infect. 2016 May;22[5]:456.e1-e6. doi: 10.1016/j.cmi.2015.12.008), more than 60% of HCWs who participated declared using phones during care, and also declared that they had halted care to patients while answering a call.

Several studies have shown that mobile phones used at hospitals are contaminated by bacteria, including highly pathogenic ones, such as methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter species, vancomycin-resistant enterococci, Pseudomonas species, and coliforms. Research suggests that these devices may serve as a reservoir of bacteria known to cause nosocomial infections and may play a role in transmission of them to patients through the hands of HCWs.

For the first time, we demonstrated the presence of RNA of epidemic viruses such as rotavirus, influenza virus, syncytial respiratory virus, and metapneumovirus on mobile phones (professional and personal) held by HCWs. In our study, 38.5% of sampled mobile phones were contaminated with RNA from viruses. RNA of rotavirus was the most frequently-detected virus, mainly on phones sampled in the pediatric emergency ward. Interestingly, we found that HCWs in pediatric wards admitted disinfecting their mobile phones less frequently than did other HCWs we interviewed.

Epidemic viruses have already been discovered on other electronic device surfaces, such as keyboards, computers, and telephone handsets. However, in contrast to these other devices, mobile phones are mobile and could be shared and transported anywhere, including in close proximity to patients. Rotaviruses are frequently found on hospital surfaces several months after an epidemic period, after surfaces were cleaned. The high prevalence of rotavirus in pediatric ward patients during our study, and its capacity to persist in the environment, are probably the main factors that explain the high frequency of rotavirus RNA detection on mobile phones in our study.

This finding highlights the possible role of mobile phones in cross-transmission of epidemic viruses, with the transfer from nonporous fomites to fingers, and from fingers to fomites – including mobile phones. Due to the difficulty and fastidiousness of viral culture, the viruses were detected only by molecular biology; the viability of the viruses could not be demonstrated. However, we believe that cross-transmission of viruses may occur, notably in health care settings. The recently reported case of a 40-year-old Ugandan man who stole a phone from a patient with Ebola and contracted the disease, also supports this hypothesis.

We also demonstrated in our study that hand hygiene after the use of mobile phones does not seem to be systematic, even for HCWs continuing care that was in process before picking up their phones. Around 30% of HCWs declared that they never perform hand hygiene before or after handling mobile phones. In addition, more than 30% of HCWs admitted that they never disinfect their phones, even their professional ones; this lack of hygiene could contribute to the persistence of RNA of epidemic viruses.

Our study does not support banning the use of mobile phones in hospitals. We just want to make HCWs aware that mobile phones, which are part of our daily practice, can be contaminated by pathogens, notably viruses. The use of disinfection wipes to clean phones, together with adherence to hand hygiene, is crucial to prevent cross-transmission.

Frequent disinfection of personal and professional mobile phones needs to be promoted to reduce contamination of phones by viruses, especially during epidemics.

In practice, each clinician needs to remember that hand hygiene should be the last thing done before patient contact, as recommended by the World Health Organization. Touching a mobile phone could transfer bacteria or viruses onto hands, and we hypothesize that it could be a factor in cross-transmission of pathogens.

Elisabeth Botelho-Nevers, MD, PhD, is an infectious diseases specialist at the University Hospital of Saint-Étienne (France) and Sylvie Pillet, PharmD, PhD, is a virologist in the Laboratory of Infectious Agents and Hygiene, University Hospital of Saint-Étienne.

Mobile phones became commonplace in just a few years and are now used everywhere, included remote areas of the world. These communication tools are used for personal and professional purposes, frequently by health care workers (HCWs) during care.

We and others believe that mobile phones improve the quality, rapidity, and efficiency of communication in health care settings and, therefore, improve the management of patients. In fact, professional mobile phones allow communication between HCWs anywhere in the hospital. In addition, personal mobile phones, frequently smartphones, allow the use of medical apps for evidence-based management of patients.

Mobile phones, both professional and personal, are used in close proximity to patients, as reported in behavioral studies. In a recent study we performed in a hospital setting (Clin Microbiol Infect. 2016 May;22[5]:456.e1-e6. doi: 10.1016/j.cmi.2015.12.008), more than 60% of HCWs who participated declared using phones during care, and also declared that they had halted care to patients while answering a call.

Several studies have shown that mobile phones used at hospitals are contaminated by bacteria, including highly pathogenic ones, such as methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter species, vancomycin-resistant enterococci, Pseudomonas species, and coliforms. Research suggests that these devices may serve as a reservoir of bacteria known to cause nosocomial infections and may play a role in transmission of them to patients through the hands of HCWs.

For the first time, we demonstrated the presence of RNA of epidemic viruses such as rotavirus, influenza virus, syncytial respiratory virus, and metapneumovirus on mobile phones (professional and personal) held by HCWs. In our study, 38.5% of sampled mobile phones were contaminated with RNA from viruses. RNA of rotavirus was the most frequently-detected virus, mainly on phones sampled in the pediatric emergency ward. Interestingly, we found that HCWs in pediatric wards admitted disinfecting their mobile phones less frequently than did other HCWs we interviewed.

Epidemic viruses have already been discovered on other electronic device surfaces, such as keyboards, computers, and telephone handsets. However, in contrast to these other devices, mobile phones are mobile and could be shared and transported anywhere, including in close proximity to patients. Rotaviruses are frequently found on hospital surfaces several months after an epidemic period, after surfaces were cleaned. The high prevalence of rotavirus in pediatric ward patients during our study, and its capacity to persist in the environment, are probably the main factors that explain the high frequency of rotavirus RNA detection on mobile phones in our study.

This finding highlights the possible role of mobile phones in cross-transmission of epidemic viruses, with the transfer from nonporous fomites to fingers, and from fingers to fomites – including mobile phones. Due to the difficulty and fastidiousness of viral culture, the viruses were detected only by molecular biology; the viability of the viruses could not be demonstrated. However, we believe that cross-transmission of viruses may occur, notably in health care settings. The recently reported case of a 40-year-old Ugandan man who stole a phone from a patient with Ebola and contracted the disease, also supports this hypothesis.

We also demonstrated in our study that hand hygiene after the use of mobile phones does not seem to be systematic, even for HCWs continuing care that was in process before picking up their phones. Around 30% of HCWs declared that they never perform hand hygiene before or after handling mobile phones. In addition, more than 30% of HCWs admitted that they never disinfect their phones, even their professional ones; this lack of hygiene could contribute to the persistence of RNA of epidemic viruses.

Our study does not support banning the use of mobile phones in hospitals. We just want to make HCWs aware that mobile phones, which are part of our daily practice, can be contaminated by pathogens, notably viruses. The use of disinfection wipes to clean phones, together with adherence to hand hygiene, is crucial to prevent cross-transmission.

Frequent disinfection of personal and professional mobile phones needs to be promoted to reduce contamination of phones by viruses, especially during epidemics.

In practice, each clinician needs to remember that hand hygiene should be the last thing done before patient contact, as recommended by the World Health Organization. Touching a mobile phone could transfer bacteria or viruses onto hands, and we hypothesize that it could be a factor in cross-transmission of pathogens.

Elisabeth Botelho-Nevers, MD, PhD, is an infectious diseases specialist at the University Hospital of Saint-Étienne (France) and Sylvie Pillet, PharmD, PhD, is a virologist in the Laboratory of Infectious Agents and Hygiene, University Hospital of Saint-Étienne.

What does your patient need to know at the first visit?

In my practice, we try our best to start the education process before the patient even comes in for the first visit. If a patient is going to have a filler injection, we mail out an information packet that contains information on what to expect, how to minimize bruising, what side effects (eg, bruising, swelling) may occur, and what to avoid posttreatment. By providing them with this information prior to their visit, they can better plan their treatment around social and work obligations.

We ask patients to avoid or minimize blood-thinning agents such as aspirin, ibuprofen, fish oil, or vitamin E starting 2 weeks prior to and 1 week after the procedure. We recommend that patients take a pineapple extract such as bromelain 500 mg twice daily on an empty stomach starting 1 week prior to the treatment and for up to 1 week posttreatment. We ask that patients avoid exercise for 24 hours to reduce late-onset bruising and to avoid dental work for 2 weeks posttreatment to reduce the risk for the filler becoming infected.

What are your go-to treatments?

I use a variety of fillers depending on the area I am treating (thin vs thick skin) or the amount of lift I need (ie, G')(Restylane [Galderma Laboratories, LP] has a high G', thus it gives a lot of lift) versus the amount of water absorption I am seeking to further plump an area after the filler integrates (Juvéderm [Allergan] can absorb up to 300% its weight in water) versus the filler’s cohesiveness (Belotero [Merz Aesthetics] is highly cohesive). If I am treating a thin-faced individual, I may start with a global volumizer such as poly-L-lactic acid to get a good foundation set in the temples, cheeks, and jawline, and then after a few months, I will add a hyaluronic acid filler to focal areas that still need to be lifted (eg, nasolabial folds, tear troughs).

What are the side effects?

Side effects are divided into common and rare. Common would be bruising and swelling, which are temporary and will go away in all patients. Rare but serious side effects are infection and embolization. Both can cause notable tissue loss and risk to the patient. Every practitioner needs to know how to recognize and treat these complications should they arise.

How do you keep patients compliant?

Patients who get good results will always return, which means being up front about how much filler a patient needs and how frequently he/she will need it, and also doing everything we can to reduce bruising and swelling.


Suggested Readings

• Dayan SH, Arkins JP, Brindise R. Soft tissue fillers and biofilms. Facial Plast Surg. 2011;27:23-28.
• Orsini RA; Plastic Surgery Educational Technology Assessment Committee. Bromelain. Plast Reconstr Surg. 2006;118:1640-1644.

What does your patient need to know at the first visit?

In my practice, we try our best to start the education process before the patient even comes in for the first visit. If a patient is going to have a filler injection, we mail out an information packet that contains information on what to expect, how to minimize bruising, what side effects (eg, bruising, swelling) may occur, and what to avoid posttreatment. By providing them with this information prior to their visit, they can better plan their treatment around social and work obligations.

We ask patients to avoid or minimize blood-thinning agents such as aspirin, ibuprofen, fish oil, or vitamin E starting 2 weeks prior to and 1 week after the procedure. We recommend that patients take a pineapple extract such as bromelain 500 mg twice daily on an empty stomach starting 1 week prior to the treatment and for up to 1 week posttreatment. We ask that patients avoid exercise for 24 hours to reduce late-onset bruising and to avoid dental work for 2 weeks posttreatment to reduce the risk for the filler becoming infected.

What are your go-to treatments?

I use a variety of fillers depending on the area I am treating (thin vs thick skin) or the amount of lift I need (ie, G')(Restylane [Galderma Laboratories, LP] has a high G', thus it gives a lot of lift) versus the amount of water absorption I am seeking to further plump an area after the filler integrates (Juvéderm [Allergan] can absorb up to 300% its weight in water) versus the filler’s cohesiveness (Belotero [Merz Aesthetics] is highly cohesive). If I am treating a thin-faced individual, I may start with a global volumizer such as poly-L-lactic acid to get a good foundation set in the temples, cheeks, and jawline, and then after a few months, I will add a hyaluronic acid filler to focal areas that still need to be lifted (eg, nasolabial folds, tear troughs).

What are the side effects?

Side effects are divided into common and rare. Common would be bruising and swelling, which are temporary and will go away in all patients. Rare but serious side effects are infection and embolization. Both can cause notable tissue loss and risk to the patient. Every practitioner needs to know how to recognize and treat these complications should they arise.

How do you keep patients compliant?

Patients who get good results will always return, which means being up front about how much filler a patient needs and how frequently he/she will need it, and also doing everything we can to reduce bruising and swelling.


Suggested Readings

• Dayan SH, Arkins JP, Brindise R. Soft tissue fillers and biofilms. Facial Plast Surg. 2011;27:23-28.
• Orsini RA; Plastic Surgery Educational Technology Assessment Committee. Bromelain. Plast Reconstr Surg. 2006;118:1640-1644.

What does your patient need to know at the first visit?

In my practice, we try our best to start the education process before the patient even comes in for the first visit. If a patient is going to have a filler injection, we mail out an information packet that contains information on what to expect, how to minimize bruising, what side effects (eg, bruising, swelling) may occur, and what to avoid posttreatment. By providing them with this information prior to their visit, they can better plan their treatment around social and work obligations.

We ask patients to avoid or minimize blood-thinning agents such as aspirin, ibuprofen, fish oil, or vitamin E starting 2 weeks prior to and 1 week after the procedure. We recommend that patients take a pineapple extract such as bromelain 500 mg twice daily on an empty stomach starting 1 week prior to the treatment and for up to 1 week posttreatment. We ask that patients avoid exercise for 24 hours to reduce late-onset bruising and to avoid dental work for 2 weeks posttreatment to reduce the risk for the filler becoming infected.

What are your go-to treatments?

I use a variety of fillers depending on the area I am treating (thin vs thick skin) or the amount of lift I need (ie, G')(Restylane [Galderma Laboratories, LP] has a high G', thus it gives a lot of lift) versus the amount of water absorption I am seeking to further plump an area after the filler integrates (Juvéderm [Allergan] can absorb up to 300% its weight in water) versus the filler’s cohesiveness (Belotero [Merz Aesthetics] is highly cohesive). If I am treating a thin-faced individual, I may start with a global volumizer such as poly-L-lactic acid to get a good foundation set in the temples, cheeks, and jawline, and then after a few months, I will add a hyaluronic acid filler to focal areas that still need to be lifted (eg, nasolabial folds, tear troughs).

What are the side effects?

Side effects are divided into common and rare. Common would be bruising and swelling, which are temporary and will go away in all patients. Rare but serious side effects are infection and embolization. Both can cause notable tissue loss and risk to the patient. Every practitioner needs to know how to recognize and treat these complications should they arise.

How do you keep patients compliant?

Patients who get good results will always return, which means being up front about how much filler a patient needs and how frequently he/she will need it, and also doing everything we can to reduce bruising and swelling.


Suggested Readings

• Dayan SH, Arkins JP, Brindise R. Soft tissue fillers and biofilms. Facial Plast Surg. 2011;27:23-28.
• Orsini RA; Plastic Surgery Educational Technology Assessment Committee. Bromelain. Plast Reconstr Surg. 2006;118:1640-1644.

In 1961 before Congress, and in 1962 at Rice University, Houston, President John F. Kennedy called on America to land a man on the moon and bring him back safely, and to look beyond the moon as well, and pursue an ambitious space exploration program. He challenged the country to think and act boldly, telling Americans in his speech at Rice that “we choose to go the moon in this decade and do the other things, not because they are easy, but because they are hard.”

When Neil Armstrong and Buzz Aldrin set foot on the moon in 1969 – even before President Kennedy’s 10-year deadline had arrived – the country’s primary moonshot was realized. The President had inspired the nation, teams of engineers and others had collectively met daunting technological challenges, and space consequently was more open to us than ever before.

In looking at the field of obstetrics and how far it has come in the past 50 years, since the 1960s, it is similarly astonishing and inspiring to reflect on what extraordinary advances we have made. Who would have thought that the fetus would become such a visible and intimate patient – one who, like the mother, can be interrogated, monitored, and sometimes treated before birth? Who would have thought we would be utilizing genomic studies in a now well-established field of prenatal diagnosis, or that fetal therapy would become a field in and of itself?

Our specialty has advanced through a series of moonshots that have been inspired and driven by technological advancement and by our continually bold goals and vision for the health and well-being of women and their offspring. We have taken on ambitious challenges, achieved many goals, and embraced advancements in practice only to then set new targets that previously were unimaginable.

Yet just as our country’s space exploration program has faced disappointments, so has our field. It is sobering, for instance, that we have made only incremental improvements in prematurity and infant mortality, and that the age-old maternal problem of preeclampsia is still with us. We also face new challenges, such as the rising rate of maternal obesity and diabetes, which threaten both maternal and fetal health.

President Kennedy spoke of having “examined where we are strong, and where we are not.” Such self-reflection and assessment is a critical underpinning of advancement in fields across all of science, medicine, and health care, and in our specialty, it is a process that has driven ambitious new research efforts to improve fetal and maternal health.

A step back to more in-depth fundamental research on the biomolecular mechanisms of premature labor and diabetes-associated birth defects, for instance, as well as new efforts to approach fetal surgery less invasively, are positioning us to both conquer our disappointments and achieve ambitious new moonshots.

The fetus as our patient

Fifty years ago, in 1966, a seminal paper in the Lancet reported that amniotic fluid cells could be cultured and were suitable for karyotyping (1[7434]:383-5). The tapping and examination of amniotic fluid had been reported on sporadically for many decades, for various clinical purposes, but by and large the fetal compartment was not invaded or directly examined. The fetus was instead the hopeful beneficiary of pregnancy care that focused on the mother. Fetal outcome was clouded in mystery, known only at birth.

With the Lancet report, prenatal detection of chromosomal disorders began to feel achievable, and the 1960s marked the beginning of a journey first through invasive methods of prenatal diagnosis and then through increasingly non-invasive approaches.

In 1970, just several years after the report on chromosome analysis of amniotic-fluid cells, another landmark paper in the New England Journal of Medicine described 162 amniocenteses performed between the 13th and 18th weeks of gestation and the detection of 10 cases of Down syndrome, as well as a few other cases of metabolic and other disorders (282[11]:596-9). This report provided an impetus for broader use of the procedure to detect neural tube defects, Down syndrome, and other abnormalities.

The adoption of amniocentesis for prenatal diagnosis still took some time, however. The procedure was used primarily early on to determine fetal lung maturity, and to predict the ability of the fetus to survive after delivery.

At the time, it was widely praised as an advanced method for evaluating the fetus. Yet, looking back, the early years of the procedure seem primitive. The procedure was done late in pregnancy and it was performed blindly, with the puncture site located either with external palpation of the uterus or with the assistance of static ultrasound. Patients who had scans would usually visit the radiologist, who would mark on the patient’s abdomen a suggested location for needle insertion. Upon the patient’s return, the obstetrician would then insert a needle into that spot, blindly and likely after the fetus had moved.

The development and adoption of real-time ultrasound was a revolutionary achievement. Ultrasound-guided amniocentesis was first described in 1972, 14 years after Ian Donald’s seminal paper introducing obstetric ultrasound was published in the Lancet (1958 Jun 7;1[7032]:1188-95).

As real-time ultrasound made its way into practice, it marked the true realization of a moonshot for obstetrics.

Not only could we simultaneously visualize the needle tip and place the needle safety, but we could see the real-time movement of the fetus, its activity, and the surrounding pockets of fluid. It was like looking up into the sky and seeing the stars for the first time. We could see fetal arrhythmia – not only hear it. With this window into the fetal compartment, we could visualize the fetal bowel migrating into the chest cavity due to a hole (hernia) in the diaphragm. We could visualize other malformations as well.

Chorionic villus sampling (CVS) was technically more difficult and took longer to evolve. For years, through the early 1980s, it was performed only at select centers throughout the country. Patients traveled for the procedure and faced relatively significant risks of complications.

By the end of the 1980s, however, with successive improvements in equipment and technique (including development of a transabdominal approach in addition to transvaginal) the procedure was deemed safe, effective, and acceptable for routine use. Fetoscopy, pioneered by John Hobbins, MD, and his colleagues at Yale University, New Haven, Conn., had also advanced and was being used to diagnose sickle cell anemia, Tay-Sachs disease, congenital fetal skin diseases, and other disorders.

With these advances and with our newfound ability to obtain and analyze a tissue sample earlier in pregnancy – even before a woman shared the news of her pregnancy, in some cases – it seemed that we had achieved our goals and may have even reached past the moon.

Yet there were other moonshots being pursued, including initiatives to make prenatal diagnosis less invasive. The discovery in 1997 of cell-free fetal DNA in maternal plasma and serum, for instance, was a pivotal development that opened the door for noninvasive prenatal testing.

This, and other advances in areas from biochemistry to ultrasound to genomic analysis, led to an array of prenatal diagnostic tools that today enable women and their physicians to assess the genetic, chromosomal, and biophysical aspects of their fetus considerably before the time of viability, and from both the maternal side and directly in the fetal compartment.

First-trimester screening is a current option, and we now have the ability to more selectively perform amniocentesis and CVS based on probability testing, and not solely on maternal age. Ultrasound technology now encompasses color Doppler, 3D and 4D imaging, and other techniques that can be used to assess the placenta, various structures inside the brain, and the heart, as well as blood flow through the ductus venosus.

Parents have called for and welcomed having the option of assessing the fetus in greater detail, and of having either assurance when anomalies are excluded or the opportunity to plan and make decisions when anomalies are detected.

Fetal surgery has been a natural extension of our unprecedented access to the fetus. Our ability to visualize malformations and their evolution led to animal studies that advanced our interest in arresting, correcting, or reversing fetal anomalies through in-utero interventions. In 1981, surgeons performed the first human open fetal surgery to correct congenital hydronephrosis.

Today, we can employ endoscopic laser ablation or laser coagulation to treat severe twin-to-twin syndrome, for instance, as well as other surgical techniques to repair defects such as congenital diaphragmatic hernia, lower urinary tract obstruction, and myelomeningocele. Such advances were unimaginable decades ago.

Old foes and new threats

Despite these advances in diagnosis and care, obstetrics faces unrealized moonshots – lingering challenges that, 50 years ago, we would have predicted would have been solved. Who would have thought that we would still have as high an infant mortality rate as we do, and that we would not be further along in solving the problem of prematurity? Our progress has been only incremental.

Fifty years ago, we lacked an understanding of the basic biology of preterm labor. Prematurity was viewed simply as term labor occurring too early, and many efforts were made over the years to halt the premature labor process through the use of various drugs and other therapeutics, with variable and minimally impactful levels of success.

In the last 25 years, and especially in the last decade, we have made greater efforts to better understand the biology of premature labor – to elucidate how and why it occurs – and we have come to understand that premature labor is very different physiologically from term labor.

Thanks to the work at the Perinatology Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), led by Roberto Romero, MD, attention has consequently shifted toward prediction, identification of women at highest risk, and prevention of the onset of premature labor among those deemed to be at highest risk.

Cervical length in the mid-trimester is now a well-verified predictor of preterm birth, and vaginal progesterone has been shown to benefit women without other known risk factors who are diagnosed with a shortened cervical length.

We have consequently seen the preterm birth rate decline a bit. In 2013, the last year for which we have complete data, the preterm birth rate dropped to 11.4%, down from a high of 12.8% in 2006, according to the Centers for Disease Control and Prevention.

Infant mortality similarly remains unacceptably high, due largely to the high preterm birth rate and to our failure to significantly alter the prevalence of birth defects. In 2010, according to the CDC, the infant mortality rate in the U.S. was 6.1 deaths per 1,000 live births (compared with 6.87 in 2005), and the United States ranked 26th in infant mortality among countries belonging to the Organisation for Economic Co-operation and Development, despite the fact that we spend a significant portion of our gross domestic product (17.5% in 2014) on health care.

Birth defects have taken over as a leading cause of infant mortality after early newborn life, and while we’ve made some advancements in understanding and diagnosing them, the majority of causes of birth defects are still unknown.

On the maternal side of obstetrical care, our progress has similarly been more modest than we have hoped for. Preeclampsia remains a problem, for instance. Despite decades of research into its pathogenesis, our advancements have been only incremental, and the condition – particularly its severe form – continues to be a vexing and high-risk problem.

Added to such age-old foes, moreover, are the growing threats of maternal obesity and diabetes, two closely related and often chronic conditions that affect not only the health of the mother but the in-utero environment and the health of the fetus. Today, more than one-third of all adults in the U.S., and 34% of women aged 20-39 years, are obese, and almost 10% of the U.S. population has diabetes.

Both conditions are on the rise, and obstetrics is confronting an epidemic of “diabesity” that would not necessarily have been predicted 50 years ago. It is particularly alarming given our growing knowledge of how obesity can be programmed in-utero and essentially passed on from generation to generation, of how diabetes can negatively affect perinatal outcomes, and of how the two conditions can have an additive effect on fetal complications.

Achieving new moonshots

Concerted efforts in the past several decades to step back and try to understand the basic biology and physiology of term labor and of premature labor have better positioned our specialty to achieve the moonshot of significantly reducing the incidence of preterm birth.

Establishment in the mid-1980s of the NICHD’s Perinatology Research Branch was a major development in this regard, helping to build and direct research efforts, including basic laboratory science, toward questions about what triggers and propagates labor. There has been notable progress in the past decade, in particular, and our specialty is now on the right path toward development of therapeutic interventions for preventing prematurity.

Additionally, the NICHD’s recently launched Human Placenta Project is building upon the branch-sponsored animal and cell culture model systems of the placenta to allow researchers, for the first time, to monitor human placental health in real time. By more fully understanding the role of the placenta in health and disease, we will be able to better evaluate pregnancy risks and improve pregnancy outcomes.

We also are learning through research in the University of Maryland Birth Defects Research Laboratory, which I am privileged to direct, and at other facilities, that maternal hyperglycemia is a teratogen, creating insults that can trigger a series of developmental fetal defects. By studying the biomolecular mechanisms of hyperglycemia-induced birth defects and developing “molecular maps,” we expect to be able to develop strategies for preventing or mitigating the development of such anomalies. I hope and expect that these future advancements, combined with reductions in prematurity, will significantly impact the infant mortality rate.

Fetal therapy and surgery will also continue to advance, with a much more minimally invasive approach taken in the next 50 years to addressing the fetal condition without putting the mother at increased risk. Just as surgery in other fields has moved from open laparotomy to minimally invasive techniques, I believe we will develop endoscopic or laparoscopic means of correcting the various problems in-utero, such as the repair of neural tube defects and diaphragmatic hernias. It already appears likely that a fetoscopic approach to treating myelomeningocele can reduce maternal morbidity while achieving infant neurological outcomes that are at least as good as outcomes achieved with open fetal surgery.

We’re in a much different position than we were 50 years ago in that we have two patients – the mother and the fetus – with whom we can closely work. We also have a relatively new and urgent obligation to place our attention not only on women’s reproductive health, but on the general gynecologic state. Ob.gyns. often are the only primary care physicians whom women see for routine care, and the quality of our attention to their weight and their diabetes risk factors will have far-reaching consequences, both for them and for their offspring.

As we have since the 1960s, we will continue to set new moonshots and meet new challenges, working with each other and with our patients to evaluate where we are strong and where we must improve. We will persistently harness the power of technology, choosing to do the things that “are hard,” while stepping back as needed to ask and address fundamental questions.

As a result, I can envision the next 50 years as a revolutionary time period for obstetrics – a time in which current problems and disorders are abated or eliminated through a combination of genomics, microbiomics, and other technological advances. Someday in the future, we will look back on some of our many achievements and marvel at how we have transformed the unimaginable to reality.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Select advances through the years

1960s

1965: Siemens Corp. introduces first real-time ultrasound scanner.

1966: Lancet paper reports that amniotic fluid cells can be cultured and karyotyped.

1970s

1970: New England Journal of Medicine paper describes mid-trimester amniocenteses and detection of Down syndrome cases.

1972: Ultrasound-guided amniocentesis first described.

1973: Fetoscopy introduced.

1980s

1981: First human open fetal surgery to correct congenital hydronephrosis.

Early 1980s: Chorionic villus sampling introduced at select centers.

1985: Color Doppler incorporated into ultrasound.

1990s

1990: Embryoscopy first described.

Mid-1990s: 3D/4D ultrasound begins to assume major role in ob.gyn. imaging.1997: Discovery of cell-free fetal DNA in maternal plasma.

2000s

2003: MOMS (Management of Myelomeningocele Study) was launched.

2010s

2012: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine support cell-free DNA screening for women at increased risk of fetal aneuploidy.

2013: Preterm birth rate drops to 11.4%

2014: Diabetes incidence marks a 4-fold increase since 1980.

In 1961 before Congress, and in 1962 at Rice University, Houston, President John F. Kennedy called on America to land a man on the moon and bring him back safely, and to look beyond the moon as well, and pursue an ambitious space exploration program. He challenged the country to think and act boldly, telling Americans in his speech at Rice that “we choose to go the moon in this decade and do the other things, not because they are easy, but because they are hard.”

When Neil Armstrong and Buzz Aldrin set foot on the moon in 1969 – even before President Kennedy’s 10-year deadline had arrived – the country’s primary moonshot was realized. The President had inspired the nation, teams of engineers and others had collectively met daunting technological challenges, and space consequently was more open to us than ever before.

In looking at the field of obstetrics and how far it has come in the past 50 years, since the 1960s, it is similarly astonishing and inspiring to reflect on what extraordinary advances we have made. Who would have thought that the fetus would become such a visible and intimate patient – one who, like the mother, can be interrogated, monitored, and sometimes treated before birth? Who would have thought we would be utilizing genomic studies in a now well-established field of prenatal diagnosis, or that fetal therapy would become a field in and of itself?

Our specialty has advanced through a series of moonshots that have been inspired and driven by technological advancement and by our continually bold goals and vision for the health and well-being of women and their offspring. We have taken on ambitious challenges, achieved many goals, and embraced advancements in practice only to then set new targets that previously were unimaginable.

Yet just as our country’s space exploration program has faced disappointments, so has our field. It is sobering, for instance, that we have made only incremental improvements in prematurity and infant mortality, and that the age-old maternal problem of preeclampsia is still with us. We also face new challenges, such as the rising rate of maternal obesity and diabetes, which threaten both maternal and fetal health.

President Kennedy spoke of having “examined where we are strong, and where we are not.” Such self-reflection and assessment is a critical underpinning of advancement in fields across all of science, medicine, and health care, and in our specialty, it is a process that has driven ambitious new research efforts to improve fetal and maternal health.

A step back to more in-depth fundamental research on the biomolecular mechanisms of premature labor and diabetes-associated birth defects, for instance, as well as new efforts to approach fetal surgery less invasively, are positioning us to both conquer our disappointments and achieve ambitious new moonshots.

The fetus as our patient

Fifty years ago, in 1966, a seminal paper in the Lancet reported that amniotic fluid cells could be cultured and were suitable for karyotyping (1[7434]:383-5). The tapping and examination of amniotic fluid had been reported on sporadically for many decades, for various clinical purposes, but by and large the fetal compartment was not invaded or directly examined. The fetus was instead the hopeful beneficiary of pregnancy care that focused on the mother. Fetal outcome was clouded in mystery, known only at birth.

With the Lancet report, prenatal detection of chromosomal disorders began to feel achievable, and the 1960s marked the beginning of a journey first through invasive methods of prenatal diagnosis and then through increasingly non-invasive approaches.

In 1970, just several years after the report on chromosome analysis of amniotic-fluid cells, another landmark paper in the New England Journal of Medicine described 162 amniocenteses performed between the 13th and 18th weeks of gestation and the detection of 10 cases of Down syndrome, as well as a few other cases of metabolic and other disorders (282[11]:596-9). This report provided an impetus for broader use of the procedure to detect neural tube defects, Down syndrome, and other abnormalities.

The adoption of amniocentesis for prenatal diagnosis still took some time, however. The procedure was used primarily early on to determine fetal lung maturity, and to predict the ability of the fetus to survive after delivery.

At the time, it was widely praised as an advanced method for evaluating the fetus. Yet, looking back, the early years of the procedure seem primitive. The procedure was done late in pregnancy and it was performed blindly, with the puncture site located either with external palpation of the uterus or with the assistance of static ultrasound. Patients who had scans would usually visit the radiologist, who would mark on the patient’s abdomen a suggested location for needle insertion. Upon the patient’s return, the obstetrician would then insert a needle into that spot, blindly and likely after the fetus had moved.

The development and adoption of real-time ultrasound was a revolutionary achievement. Ultrasound-guided amniocentesis was first described in 1972, 14 years after Ian Donald’s seminal paper introducing obstetric ultrasound was published in the Lancet (1958 Jun 7;1[7032]:1188-95).

As real-time ultrasound made its way into practice, it marked the true realization of a moonshot for obstetrics.

Not only could we simultaneously visualize the needle tip and place the needle safety, but we could see the real-time movement of the fetus, its activity, and the surrounding pockets of fluid. It was like looking up into the sky and seeing the stars for the first time. We could see fetal arrhythmia – not only hear it. With this window into the fetal compartment, we could visualize the fetal bowel migrating into the chest cavity due to a hole (hernia) in the diaphragm. We could visualize other malformations as well.

Chorionic villus sampling (CVS) was technically more difficult and took longer to evolve. For years, through the early 1980s, it was performed only at select centers throughout the country. Patients traveled for the procedure and faced relatively significant risks of complications.

By the end of the 1980s, however, with successive improvements in equipment and technique (including development of a transabdominal approach in addition to transvaginal) the procedure was deemed safe, effective, and acceptable for routine use. Fetoscopy, pioneered by John Hobbins, MD, and his colleagues at Yale University, New Haven, Conn., had also advanced and was being used to diagnose sickle cell anemia, Tay-Sachs disease, congenital fetal skin diseases, and other disorders.

With these advances and with our newfound ability to obtain and analyze a tissue sample earlier in pregnancy – even before a woman shared the news of her pregnancy, in some cases – it seemed that we had achieved our goals and may have even reached past the moon.

Yet there were other moonshots being pursued, including initiatives to make prenatal diagnosis less invasive. The discovery in 1997 of cell-free fetal DNA in maternal plasma and serum, for instance, was a pivotal development that opened the door for noninvasive prenatal testing.

This, and other advances in areas from biochemistry to ultrasound to genomic analysis, led to an array of prenatal diagnostic tools that today enable women and their physicians to assess the genetic, chromosomal, and biophysical aspects of their fetus considerably before the time of viability, and from both the maternal side and directly in the fetal compartment.

First-trimester screening is a current option, and we now have the ability to more selectively perform amniocentesis and CVS based on probability testing, and not solely on maternal age. Ultrasound technology now encompasses color Doppler, 3D and 4D imaging, and other techniques that can be used to assess the placenta, various structures inside the brain, and the heart, as well as blood flow through the ductus venosus.

Parents have called for and welcomed having the option of assessing the fetus in greater detail, and of having either assurance when anomalies are excluded or the opportunity to plan and make decisions when anomalies are detected.

Fetal surgery has been a natural extension of our unprecedented access to the fetus. Our ability to visualize malformations and their evolution led to animal studies that advanced our interest in arresting, correcting, or reversing fetal anomalies through in-utero interventions. In 1981, surgeons performed the first human open fetal surgery to correct congenital hydronephrosis.

Today, we can employ endoscopic laser ablation or laser coagulation to treat severe twin-to-twin syndrome, for instance, as well as other surgical techniques to repair defects such as congenital diaphragmatic hernia, lower urinary tract obstruction, and myelomeningocele. Such advances were unimaginable decades ago.

Old foes and new threats

Despite these advances in diagnosis and care, obstetrics faces unrealized moonshots – lingering challenges that, 50 years ago, we would have predicted would have been solved. Who would have thought that we would still have as high an infant mortality rate as we do, and that we would not be further along in solving the problem of prematurity? Our progress has been only incremental.

Fifty years ago, we lacked an understanding of the basic biology of preterm labor. Prematurity was viewed simply as term labor occurring too early, and many efforts were made over the years to halt the premature labor process through the use of various drugs and other therapeutics, with variable and minimally impactful levels of success.

In the last 25 years, and especially in the last decade, we have made greater efforts to better understand the biology of premature labor – to elucidate how and why it occurs – and we have come to understand that premature labor is very different physiologically from term labor.

Thanks to the work at the Perinatology Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), led by Roberto Romero, MD, attention has consequently shifted toward prediction, identification of women at highest risk, and prevention of the onset of premature labor among those deemed to be at highest risk.

Cervical length in the mid-trimester is now a well-verified predictor of preterm birth, and vaginal progesterone has been shown to benefit women without other known risk factors who are diagnosed with a shortened cervical length.

We have consequently seen the preterm birth rate decline a bit. In 2013, the last year for which we have complete data, the preterm birth rate dropped to 11.4%, down from a high of 12.8% in 2006, according to the Centers for Disease Control and Prevention.

Infant mortality similarly remains unacceptably high, due largely to the high preterm birth rate and to our failure to significantly alter the prevalence of birth defects. In 2010, according to the CDC, the infant mortality rate in the U.S. was 6.1 deaths per 1,000 live births (compared with 6.87 in 2005), and the United States ranked 26th in infant mortality among countries belonging to the Organisation for Economic Co-operation and Development, despite the fact that we spend a significant portion of our gross domestic product (17.5% in 2014) on health care.

Birth defects have taken over as a leading cause of infant mortality after early newborn life, and while we’ve made some advancements in understanding and diagnosing them, the majority of causes of birth defects are still unknown.

On the maternal side of obstetrical care, our progress has similarly been more modest than we have hoped for. Preeclampsia remains a problem, for instance. Despite decades of research into its pathogenesis, our advancements have been only incremental, and the condition – particularly its severe form – continues to be a vexing and high-risk problem.

Added to such age-old foes, moreover, are the growing threats of maternal obesity and diabetes, two closely related and often chronic conditions that affect not only the health of the mother but the in-utero environment and the health of the fetus. Today, more than one-third of all adults in the U.S., and 34% of women aged 20-39 years, are obese, and almost 10% of the U.S. population has diabetes.

Both conditions are on the rise, and obstetrics is confronting an epidemic of “diabesity” that would not necessarily have been predicted 50 years ago. It is particularly alarming given our growing knowledge of how obesity can be programmed in-utero and essentially passed on from generation to generation, of how diabetes can negatively affect perinatal outcomes, and of how the two conditions can have an additive effect on fetal complications.

Achieving new moonshots

Concerted efforts in the past several decades to step back and try to understand the basic biology and physiology of term labor and of premature labor have better positioned our specialty to achieve the moonshot of significantly reducing the incidence of preterm birth.

Establishment in the mid-1980s of the NICHD’s Perinatology Research Branch was a major development in this regard, helping to build and direct research efforts, including basic laboratory science, toward questions about what triggers and propagates labor. There has been notable progress in the past decade, in particular, and our specialty is now on the right path toward development of therapeutic interventions for preventing prematurity.

Additionally, the NICHD’s recently launched Human Placenta Project is building upon the branch-sponsored animal and cell culture model systems of the placenta to allow researchers, for the first time, to monitor human placental health in real time. By more fully understanding the role of the placenta in health and disease, we will be able to better evaluate pregnancy risks and improve pregnancy outcomes.

We also are learning through research in the University of Maryland Birth Defects Research Laboratory, which I am privileged to direct, and at other facilities, that maternal hyperglycemia is a teratogen, creating insults that can trigger a series of developmental fetal defects. By studying the biomolecular mechanisms of hyperglycemia-induced birth defects and developing “molecular maps,” we expect to be able to develop strategies for preventing or mitigating the development of such anomalies. I hope and expect that these future advancements, combined with reductions in prematurity, will significantly impact the infant mortality rate.

Fetal therapy and surgery will also continue to advance, with a much more minimally invasive approach taken in the next 50 years to addressing the fetal condition without putting the mother at increased risk. Just as surgery in other fields has moved from open laparotomy to minimally invasive techniques, I believe we will develop endoscopic or laparoscopic means of correcting the various problems in-utero, such as the repair of neural tube defects and diaphragmatic hernias. It already appears likely that a fetoscopic approach to treating myelomeningocele can reduce maternal morbidity while achieving infant neurological outcomes that are at least as good as outcomes achieved with open fetal surgery.

We’re in a much different position than we were 50 years ago in that we have two patients – the mother and the fetus – with whom we can closely work. We also have a relatively new and urgent obligation to place our attention not only on women’s reproductive health, but on the general gynecologic state. Ob.gyns. often are the only primary care physicians whom women see for routine care, and the quality of our attention to their weight and their diabetes risk factors will have far-reaching consequences, both for them and for their offspring.

As we have since the 1960s, we will continue to set new moonshots and meet new challenges, working with each other and with our patients to evaluate where we are strong and where we must improve. We will persistently harness the power of technology, choosing to do the things that “are hard,” while stepping back as needed to ask and address fundamental questions.

As a result, I can envision the next 50 years as a revolutionary time period for obstetrics – a time in which current problems and disorders are abated or eliminated through a combination of genomics, microbiomics, and other technological advances. Someday in the future, we will look back on some of our many achievements and marvel at how we have transformed the unimaginable to reality.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Select advances through the years

1960s

1965: Siemens Corp. introduces first real-time ultrasound scanner.

1966: Lancet paper reports that amniotic fluid cells can be cultured and karyotyped.

1970s

1970: New England Journal of Medicine paper describes mid-trimester amniocenteses and detection of Down syndrome cases.

1972: Ultrasound-guided amniocentesis first described.

1973: Fetoscopy introduced.

1980s

1981: First human open fetal surgery to correct congenital hydronephrosis.

Early 1980s: Chorionic villus sampling introduced at select centers.

1985: Color Doppler incorporated into ultrasound.

1990s

1990: Embryoscopy first described.

Mid-1990s: 3D/4D ultrasound begins to assume major role in ob.gyn. imaging.1997: Discovery of cell-free fetal DNA in maternal plasma.

2000s

2003: MOMS (Management of Myelomeningocele Study) was launched.

2010s

2012: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine support cell-free DNA screening for women at increased risk of fetal aneuploidy.

2013: Preterm birth rate drops to 11.4%

2014: Diabetes incidence marks a 4-fold increase since 1980.

In 1961 before Congress, and in 1962 at Rice University, Houston, President John F. Kennedy called on America to land a man on the moon and bring him back safely, and to look beyond the moon as well, and pursue an ambitious space exploration program. He challenged the country to think and act boldly, telling Americans in his speech at Rice that “we choose to go the moon in this decade and do the other things, not because they are easy, but because they are hard.”

When Neil Armstrong and Buzz Aldrin set foot on the moon in 1969 – even before President Kennedy’s 10-year deadline had arrived – the country’s primary moonshot was realized. The President had inspired the nation, teams of engineers and others had collectively met daunting technological challenges, and space consequently was more open to us than ever before.

In looking at the field of obstetrics and how far it has come in the past 50 years, since the 1960s, it is similarly astonishing and inspiring to reflect on what extraordinary advances we have made. Who would have thought that the fetus would become such a visible and intimate patient – one who, like the mother, can be interrogated, monitored, and sometimes treated before birth? Who would have thought we would be utilizing genomic studies in a now well-established field of prenatal diagnosis, or that fetal therapy would become a field in and of itself?

Our specialty has advanced through a series of moonshots that have been inspired and driven by technological advancement and by our continually bold goals and vision for the health and well-being of women and their offspring. We have taken on ambitious challenges, achieved many goals, and embraced advancements in practice only to then set new targets that previously were unimaginable.

Yet just as our country’s space exploration program has faced disappointments, so has our field. It is sobering, for instance, that we have made only incremental improvements in prematurity and infant mortality, and that the age-old maternal problem of preeclampsia is still with us. We also face new challenges, such as the rising rate of maternal obesity and diabetes, which threaten both maternal and fetal health.

President Kennedy spoke of having “examined where we are strong, and where we are not.” Such self-reflection and assessment is a critical underpinning of advancement in fields across all of science, medicine, and health care, and in our specialty, it is a process that has driven ambitious new research efforts to improve fetal and maternal health.

A step back to more in-depth fundamental research on the biomolecular mechanisms of premature labor and diabetes-associated birth defects, for instance, as well as new efforts to approach fetal surgery less invasively, are positioning us to both conquer our disappointments and achieve ambitious new moonshots.

The fetus as our patient

Fifty years ago, in 1966, a seminal paper in the Lancet reported that amniotic fluid cells could be cultured and were suitable for karyotyping (1[7434]:383-5). The tapping and examination of amniotic fluid had been reported on sporadically for many decades, for various clinical purposes, but by and large the fetal compartment was not invaded or directly examined. The fetus was instead the hopeful beneficiary of pregnancy care that focused on the mother. Fetal outcome was clouded in mystery, known only at birth.

With the Lancet report, prenatal detection of chromosomal disorders began to feel achievable, and the 1960s marked the beginning of a journey first through invasive methods of prenatal diagnosis and then through increasingly non-invasive approaches.

In 1970, just several years after the report on chromosome analysis of amniotic-fluid cells, another landmark paper in the New England Journal of Medicine described 162 amniocenteses performed between the 13th and 18th weeks of gestation and the detection of 10 cases of Down syndrome, as well as a few other cases of metabolic and other disorders (282[11]:596-9). This report provided an impetus for broader use of the procedure to detect neural tube defects, Down syndrome, and other abnormalities.

The adoption of amniocentesis for prenatal diagnosis still took some time, however. The procedure was used primarily early on to determine fetal lung maturity, and to predict the ability of the fetus to survive after delivery.

At the time, it was widely praised as an advanced method for evaluating the fetus. Yet, looking back, the early years of the procedure seem primitive. The procedure was done late in pregnancy and it was performed blindly, with the puncture site located either with external palpation of the uterus or with the assistance of static ultrasound. Patients who had scans would usually visit the radiologist, who would mark on the patient’s abdomen a suggested location for needle insertion. Upon the patient’s return, the obstetrician would then insert a needle into that spot, blindly and likely after the fetus had moved.

The development and adoption of real-time ultrasound was a revolutionary achievement. Ultrasound-guided amniocentesis was first described in 1972, 14 years after Ian Donald’s seminal paper introducing obstetric ultrasound was published in the Lancet (1958 Jun 7;1[7032]:1188-95).

As real-time ultrasound made its way into practice, it marked the true realization of a moonshot for obstetrics.

Not only could we simultaneously visualize the needle tip and place the needle safety, but we could see the real-time movement of the fetus, its activity, and the surrounding pockets of fluid. It was like looking up into the sky and seeing the stars for the first time. We could see fetal arrhythmia – not only hear it. With this window into the fetal compartment, we could visualize the fetal bowel migrating into the chest cavity due to a hole (hernia) in the diaphragm. We could visualize other malformations as well.

Chorionic villus sampling (CVS) was technically more difficult and took longer to evolve. For years, through the early 1980s, it was performed only at select centers throughout the country. Patients traveled for the procedure and faced relatively significant risks of complications.

By the end of the 1980s, however, with successive improvements in equipment and technique (including development of a transabdominal approach in addition to transvaginal) the procedure was deemed safe, effective, and acceptable for routine use. Fetoscopy, pioneered by John Hobbins, MD, and his colleagues at Yale University, New Haven, Conn., had also advanced and was being used to diagnose sickle cell anemia, Tay-Sachs disease, congenital fetal skin diseases, and other disorders.

With these advances and with our newfound ability to obtain and analyze a tissue sample earlier in pregnancy – even before a woman shared the news of her pregnancy, in some cases – it seemed that we had achieved our goals and may have even reached past the moon.

Yet there were other moonshots being pursued, including initiatives to make prenatal diagnosis less invasive. The discovery in 1997 of cell-free fetal DNA in maternal plasma and serum, for instance, was a pivotal development that opened the door for noninvasive prenatal testing.

This, and other advances in areas from biochemistry to ultrasound to genomic analysis, led to an array of prenatal diagnostic tools that today enable women and their physicians to assess the genetic, chromosomal, and biophysical aspects of their fetus considerably before the time of viability, and from both the maternal side and directly in the fetal compartment.

First-trimester screening is a current option, and we now have the ability to more selectively perform amniocentesis and CVS based on probability testing, and not solely on maternal age. Ultrasound technology now encompasses color Doppler, 3D and 4D imaging, and other techniques that can be used to assess the placenta, various structures inside the brain, and the heart, as well as blood flow through the ductus venosus.

Parents have called for and welcomed having the option of assessing the fetus in greater detail, and of having either assurance when anomalies are excluded or the opportunity to plan and make decisions when anomalies are detected.

Fetal surgery has been a natural extension of our unprecedented access to the fetus. Our ability to visualize malformations and their evolution led to animal studies that advanced our interest in arresting, correcting, or reversing fetal anomalies through in-utero interventions. In 1981, surgeons performed the first human open fetal surgery to correct congenital hydronephrosis.

Today, we can employ endoscopic laser ablation or laser coagulation to treat severe twin-to-twin syndrome, for instance, as well as other surgical techniques to repair defects such as congenital diaphragmatic hernia, lower urinary tract obstruction, and myelomeningocele. Such advances were unimaginable decades ago.

Old foes and new threats

Despite these advances in diagnosis and care, obstetrics faces unrealized moonshots – lingering challenges that, 50 years ago, we would have predicted would have been solved. Who would have thought that we would still have as high an infant mortality rate as we do, and that we would not be further along in solving the problem of prematurity? Our progress has been only incremental.

Fifty years ago, we lacked an understanding of the basic biology of preterm labor. Prematurity was viewed simply as term labor occurring too early, and many efforts were made over the years to halt the premature labor process through the use of various drugs and other therapeutics, with variable and minimally impactful levels of success.

In the last 25 years, and especially in the last decade, we have made greater efforts to better understand the biology of premature labor – to elucidate how and why it occurs – and we have come to understand that premature labor is very different physiologically from term labor.

Thanks to the work at the Perinatology Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), led by Roberto Romero, MD, attention has consequently shifted toward prediction, identification of women at highest risk, and prevention of the onset of premature labor among those deemed to be at highest risk.

Cervical length in the mid-trimester is now a well-verified predictor of preterm birth, and vaginal progesterone has been shown to benefit women without other known risk factors who are diagnosed with a shortened cervical length.

We have consequently seen the preterm birth rate decline a bit. In 2013, the last year for which we have complete data, the preterm birth rate dropped to 11.4%, down from a high of 12.8% in 2006, according to the Centers for Disease Control and Prevention.

Infant mortality similarly remains unacceptably high, due largely to the high preterm birth rate and to our failure to significantly alter the prevalence of birth defects. In 2010, according to the CDC, the infant mortality rate in the U.S. was 6.1 deaths per 1,000 live births (compared with 6.87 in 2005), and the United States ranked 26th in infant mortality among countries belonging to the Organisation for Economic Co-operation and Development, despite the fact that we spend a significant portion of our gross domestic product (17.5% in 2014) on health care.

Birth defects have taken over as a leading cause of infant mortality after early newborn life, and while we’ve made some advancements in understanding and diagnosing them, the majority of causes of birth defects are still unknown.

On the maternal side of obstetrical care, our progress has similarly been more modest than we have hoped for. Preeclampsia remains a problem, for instance. Despite decades of research into its pathogenesis, our advancements have been only incremental, and the condition – particularly its severe form – continues to be a vexing and high-risk problem.

Added to such age-old foes, moreover, are the growing threats of maternal obesity and diabetes, two closely related and often chronic conditions that affect not only the health of the mother but the in-utero environment and the health of the fetus. Today, more than one-third of all adults in the U.S., and 34% of women aged 20-39 years, are obese, and almost 10% of the U.S. population has diabetes.

Both conditions are on the rise, and obstetrics is confronting an epidemic of “diabesity” that would not necessarily have been predicted 50 years ago. It is particularly alarming given our growing knowledge of how obesity can be programmed in-utero and essentially passed on from generation to generation, of how diabetes can negatively affect perinatal outcomes, and of how the two conditions can have an additive effect on fetal complications.

Achieving new moonshots

Concerted efforts in the past several decades to step back and try to understand the basic biology and physiology of term labor and of premature labor have better positioned our specialty to achieve the moonshot of significantly reducing the incidence of preterm birth.

Establishment in the mid-1980s of the NICHD’s Perinatology Research Branch was a major development in this regard, helping to build and direct research efforts, including basic laboratory science, toward questions about what triggers and propagates labor. There has been notable progress in the past decade, in particular, and our specialty is now on the right path toward development of therapeutic interventions for preventing prematurity.

Additionally, the NICHD’s recently launched Human Placenta Project is building upon the branch-sponsored animal and cell culture model systems of the placenta to allow researchers, for the first time, to monitor human placental health in real time. By more fully understanding the role of the placenta in health and disease, we will be able to better evaluate pregnancy risks and improve pregnancy outcomes.

We also are learning through research in the University of Maryland Birth Defects Research Laboratory, which I am privileged to direct, and at other facilities, that maternal hyperglycemia is a teratogen, creating insults that can trigger a series of developmental fetal defects. By studying the biomolecular mechanisms of hyperglycemia-induced birth defects and developing “molecular maps,” we expect to be able to develop strategies for preventing or mitigating the development of such anomalies. I hope and expect that these future advancements, combined with reductions in prematurity, will significantly impact the infant mortality rate.

Fetal therapy and surgery will also continue to advance, with a much more minimally invasive approach taken in the next 50 years to addressing the fetal condition without putting the mother at increased risk. Just as surgery in other fields has moved from open laparotomy to minimally invasive techniques, I believe we will develop endoscopic or laparoscopic means of correcting the various problems in-utero, such as the repair of neural tube defects and diaphragmatic hernias. It already appears likely that a fetoscopic approach to treating myelomeningocele can reduce maternal morbidity while achieving infant neurological outcomes that are at least as good as outcomes achieved with open fetal surgery.

We’re in a much different position than we were 50 years ago in that we have two patients – the mother and the fetus – with whom we can closely work. We also have a relatively new and urgent obligation to place our attention not only on women’s reproductive health, but on the general gynecologic state. Ob.gyns. often are the only primary care physicians whom women see for routine care, and the quality of our attention to their weight and their diabetes risk factors will have far-reaching consequences, both for them and for their offspring.

As we have since the 1960s, we will continue to set new moonshots and meet new challenges, working with each other and with our patients to evaluate where we are strong and where we must improve. We will persistently harness the power of technology, choosing to do the things that “are hard,” while stepping back as needed to ask and address fundamental questions.

As a result, I can envision the next 50 years as a revolutionary time period for obstetrics – a time in which current problems and disorders are abated or eliminated through a combination of genomics, microbiomics, and other technological advances. Someday in the future, we will look back on some of our many achievements and marvel at how we have transformed the unimaginable to reality.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Select advances through the years

1960s

1965: Siemens Corp. introduces first real-time ultrasound scanner.

1966: Lancet paper reports that amniotic fluid cells can be cultured and karyotyped.

1970s

1970: New England Journal of Medicine paper describes mid-trimester amniocenteses and detection of Down syndrome cases.

1972: Ultrasound-guided amniocentesis first described.

1973: Fetoscopy introduced.

1980s

1981: First human open fetal surgery to correct congenital hydronephrosis.

Early 1980s: Chorionic villus sampling introduced at select centers.

1985: Color Doppler incorporated into ultrasound.

1990s

1990: Embryoscopy first described.

Mid-1990s: 3D/4D ultrasound begins to assume major role in ob.gyn. imaging.1997: Discovery of cell-free fetal DNA in maternal plasma.

2000s

2003: MOMS (Management of Myelomeningocele Study) was launched.

2010s

2012: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine support cell-free DNA screening for women at increased risk of fetal aneuploidy.

2013: Preterm birth rate drops to 11.4%

2014: Diabetes incidence marks a 4-fold increase since 1980.

One of the most frustrating problems we encounter is helping patients with skin issues that we cannot immediately fix or cure. Teaching them the art of concealing skin blemishes gives patients a sense of relief. Color correction is an art and requires an understanding of basic color theory and Fitzpatrick skin type.

On the color wheel, each color sits directly across from another color, making them complementary colors.

Thoth_Adan (thinkstockimages)

If we look at red, the color opposing it is green. When red and green are combined, they neutralize each other. One of the greatest dermatologists of all time and my mentor, Timothy Berger, MD, taught me that in dermatology color “hue” is a clue to understanding morphology. Everything that is red cannot just be called “erythematous.” There is orange/red (pityriasis rosea, tinea versicolor, seborrheic dermatitis), deep red (cellulitis, Sweet’s syndrome, acne scars, rosacea, psoriasis), purple/red (vasculitis, lichen planus (LP), veins, under-eye circles), brown/red (pigmented purpura, pigmented acne scars, sarcoid).

The combination of the underlying pathology, morphology, and Fitzpatrick type is both a clue to diagnosis and a pallet for skin concealers. We can use the following techniques to help patients color correct skin imperfections:

Red: rosacea, acne scars, acne

Green-based concealers and primers are the best option to significantly reduce the redness. While green primers and correctors tend to be great for Fitzpatrick skin types I-III, a yellow-based concealer/corrector can help to cover redness on those with skin types IV-VI.

Blue: periorbital veins

If you are dealing with blue-toned skin lesions, such as periorbital veins, the ideal corrector is one with a peach or orange undertones. For skin types I-III, a peach/salmon corrector works best, whereas skin types IV-VI requires an orange-toned corrector.

Purple: under-eye circles, LP, postprocedure bruising

If under-eye circles tend to have a more purple hue to them, a yellow-based corrector works best for skin types I-III. For skin types IV-VI skin types, you will need a corrector with a red undertone.

Yellow: bruising

Purple/lavender correctors are best suited for eliminating yellow tones from the face. Purple also combats sallow undertones of the skin.

Brown: lentigines, melasma, seborrheic keratosis, post-inflammatory hyperpigmentation, nevi, café au lait spots

Brown is actually the hardest of all colors to correct. The deeper the pigment (ashy dermatitis, melasma) the more gray the areas appear with skin concealers. The more superficial the pigment (ephelides, lentigines), the easier it is to correct. Generally speaking, peach toned concealers work best, not beige or brown. The corrector, however, should be lighter than the skin tone or the lesion itself will appear darker.

Helping patients conceal imperfections with these simple guidelines is a great way to help relieve some anxiety and help our patients fell more confident in their skin.

Dr. Talakoub and Dr. Wesley are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

One of the most frustrating problems we encounter is helping patients with skin issues that we cannot immediately fix or cure. Teaching them the art of concealing skin blemishes gives patients a sense of relief. Color correction is an art and requires an understanding of basic color theory and Fitzpatrick skin type.

On the color wheel, each color sits directly across from another color, making them complementary colors.

Thoth_Adan (thinkstockimages)

If we look at red, the color opposing it is green. When red and green are combined, they neutralize each other. One of the greatest dermatologists of all time and my mentor, Timothy Berger, MD, taught me that in dermatology color “hue” is a clue to understanding morphology. Everything that is red cannot just be called “erythematous.” There is orange/red (pityriasis rosea, tinea versicolor, seborrheic dermatitis), deep red (cellulitis, Sweet’s syndrome, acne scars, rosacea, psoriasis), purple/red (vasculitis, lichen planus (LP), veins, under-eye circles), brown/red (pigmented purpura, pigmented acne scars, sarcoid).

The combination of the underlying pathology, morphology, and Fitzpatrick type is both a clue to diagnosis and a pallet for skin concealers. We can use the following techniques to help patients color correct skin imperfections:

Red: rosacea, acne scars, acne

Green-based concealers and primers are the best option to significantly reduce the redness. While green primers and correctors tend to be great for Fitzpatrick skin types I-III, a yellow-based concealer/corrector can help to cover redness on those with skin types IV-VI.

Blue: periorbital veins

If you are dealing with blue-toned skin lesions, such as periorbital veins, the ideal corrector is one with a peach or orange undertones. For skin types I-III, a peach/salmon corrector works best, whereas skin types IV-VI requires an orange-toned corrector.

Purple: under-eye circles, LP, postprocedure bruising

If under-eye circles tend to have a more purple hue to them, a yellow-based corrector works best for skin types I-III. For skin types IV-VI skin types, you will need a corrector with a red undertone.

Yellow: bruising

Purple/lavender correctors are best suited for eliminating yellow tones from the face. Purple also combats sallow undertones of the skin.

Brown: lentigines, melasma, seborrheic keratosis, post-inflammatory hyperpigmentation, nevi, café au lait spots

Brown is actually the hardest of all colors to correct. The deeper the pigment (ashy dermatitis, melasma) the more gray the areas appear with skin concealers. The more superficial the pigment (ephelides, lentigines), the easier it is to correct. Generally speaking, peach toned concealers work best, not beige or brown. The corrector, however, should be lighter than the skin tone or the lesion itself will appear darker.

Helping patients conceal imperfections with these simple guidelines is a great way to help relieve some anxiety and help our patients fell more confident in their skin.

Dr. Talakoub and Dr. Wesley are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

One of the most frustrating problems we encounter is helping patients with skin issues that we cannot immediately fix or cure. Teaching them the art of concealing skin blemishes gives patients a sense of relief. Color correction is an art and requires an understanding of basic color theory and Fitzpatrick skin type.

On the color wheel, each color sits directly across from another color, making them complementary colors.

Thoth_Adan (thinkstockimages)

If we look at red, the color opposing it is green. When red and green are combined, they neutralize each other. One of the greatest dermatologists of all time and my mentor, Timothy Berger, MD, taught me that in dermatology color “hue” is a clue to understanding morphology. Everything that is red cannot just be called “erythematous.” There is orange/red (pityriasis rosea, tinea versicolor, seborrheic dermatitis), deep red (cellulitis, Sweet’s syndrome, acne scars, rosacea, psoriasis), purple/red (vasculitis, lichen planus (LP), veins, under-eye circles), brown/red (pigmented purpura, pigmented acne scars, sarcoid).

The combination of the underlying pathology, morphology, and Fitzpatrick type is both a clue to diagnosis and a pallet for skin concealers. We can use the following techniques to help patients color correct skin imperfections:

Red: rosacea, acne scars, acne

Green-based concealers and primers are the best option to significantly reduce the redness. While green primers and correctors tend to be great for Fitzpatrick skin types I-III, a yellow-based concealer/corrector can help to cover redness on those with skin types IV-VI.

Blue: periorbital veins

If you are dealing with blue-toned skin lesions, such as periorbital veins, the ideal corrector is one with a peach or orange undertones. For skin types I-III, a peach/salmon corrector works best, whereas skin types IV-VI requires an orange-toned corrector.

Purple: under-eye circles, LP, postprocedure bruising

If under-eye circles tend to have a more purple hue to them, a yellow-based corrector works best for skin types I-III. For skin types IV-VI skin types, you will need a corrector with a red undertone.

Yellow: bruising

Purple/lavender correctors are best suited for eliminating yellow tones from the face. Purple also combats sallow undertones of the skin.

Brown: lentigines, melasma, seborrheic keratosis, post-inflammatory hyperpigmentation, nevi, café au lait spots

Brown is actually the hardest of all colors to correct. The deeper the pigment (ashy dermatitis, melasma) the more gray the areas appear with skin concealers. The more superficial the pigment (ephelides, lentigines), the easier it is to correct. Generally speaking, peach toned concealers work best, not beige or brown. The corrector, however, should be lighter than the skin tone or the lesion itself will appear darker.

Helping patients conceal imperfections with these simple guidelines is a great way to help relieve some anxiety and help our patients fell more confident in their skin.

Dr. Talakoub and Dr. Wesley are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

Buy our EHR. Come to a dinner and see our EHR. Our EHR is the best.

I hear that a lot, but am not rushing out to get one. Yes, I have an EHR, but it’s one I designed myself. It works very well for my dinky little practice, and I’m happy with it.

I get notes from practices that use commercial EHRs all the time. They’re usually a pile of gobbledygook, mixing labs, vital signs, medication lists, and ICD-10 codes that tell you absolutely nothing about the patient or the physician’s thought process.

Recently, while reviewing malpractice cases, I saw some where I thought that the EHR was contributing to the problem. Medication lists that showed everything a patient had ever taken, without showing when some were discontinued. Prescribing lists that allowed you to enter only certain doses or schedules, therefore blocking the physician from tailoring them to a specific person’s needs. Physical exam forms that allowed only positive or negative answers, with nowhere to comment on unusual findings.

Of course, I’m just one person, so I thought “maybe it’s just me.” After all, a lot of practices out there use EHRs.

But apparently I’m not the only one. A recent report by one of the nation’s largest doctor-owned malpractice companies found that EHRs may increase the risks of liability and medical errors. In 2013, The Doctor’s Company found 28 closed claims where the EHR contributed, and 26 in just the first half of 2014.

These include both technological problems with the systems and human error in their use. Troubles included erroneous medication dose and schedules, diagnosis-related errors, and the sadly common pitfall of cutting and pasting previous notes without modification.

Medicine has always been, and will always be, a thinking profession, and trying to have computers take part of this job off of us is never good. EHRs, while they have advantages in convenience and space savings, are as imperfect as those who write them.

Patients are not one-size-fits-all, and individual treatments have to be customized in ways that current systems often don’t recognize, sometimes with sad consequences for all involved.

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

Buy our EHR. Come to a dinner and see our EHR. Our EHR is the best.

I hear that a lot, but am not rushing out to get one. Yes, I have an EHR, but it’s one I designed myself. It works very well for my dinky little practice, and I’m happy with it.

I get notes from practices that use commercial EHRs all the time. They’re usually a pile of gobbledygook, mixing labs, vital signs, medication lists, and ICD-10 codes that tell you absolutely nothing about the patient or the physician’s thought process.

Recently, while reviewing malpractice cases, I saw some where I thought that the EHR was contributing to the problem. Medication lists that showed everything a patient had ever taken, without showing when some were discontinued. Prescribing lists that allowed you to enter only certain doses or schedules, therefore blocking the physician from tailoring them to a specific person’s needs. Physical exam forms that allowed only positive or negative answers, with nowhere to comment on unusual findings.

Of course, I’m just one person, so I thought “maybe it’s just me.” After all, a lot of practices out there use EHRs.

But apparently I’m not the only one. A recent report by one of the nation’s largest doctor-owned malpractice companies found that EHRs may increase the risks of liability and medical errors. In 2013, The Doctor’s Company found 28 closed claims where the EHR contributed, and 26 in just the first half of 2014.

These include both technological problems with the systems and human error in their use. Troubles included erroneous medication dose and schedules, diagnosis-related errors, and the sadly common pitfall of cutting and pasting previous notes without modification.

Medicine has always been, and will always be, a thinking profession, and trying to have computers take part of this job off of us is never good. EHRs, while they have advantages in convenience and space savings, are as imperfect as those who write them.

Patients are not one-size-fits-all, and individual treatments have to be customized in ways that current systems often don’t recognize, sometimes with sad consequences for all involved.

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

Buy our EHR. Come to a dinner and see our EHR. Our EHR is the best.

I hear that a lot, but am not rushing out to get one. Yes, I have an EHR, but it’s one I designed myself. It works very well for my dinky little practice, and I’m happy with it.

I get notes from practices that use commercial EHRs all the time. They’re usually a pile of gobbledygook, mixing labs, vital signs, medication lists, and ICD-10 codes that tell you absolutely nothing about the patient or the physician’s thought process.

Recently, while reviewing malpractice cases, I saw some where I thought that the EHR was contributing to the problem. Medication lists that showed everything a patient had ever taken, without showing when some were discontinued. Prescribing lists that allowed you to enter only certain doses or schedules, therefore blocking the physician from tailoring them to a specific person’s needs. Physical exam forms that allowed only positive or negative answers, with nowhere to comment on unusual findings.

Of course, I’m just one person, so I thought “maybe it’s just me.” After all, a lot of practices out there use EHRs.

But apparently I’m not the only one. A recent report by one of the nation’s largest doctor-owned malpractice companies found that EHRs may increase the risks of liability and medical errors. In 2013, The Doctor’s Company found 28 closed claims where the EHR contributed, and 26 in just the first half of 2014.

These include both technological problems with the systems and human error in their use. Troubles included erroneous medication dose and schedules, diagnosis-related errors, and the sadly common pitfall of cutting and pasting previous notes without modification.

Medicine has always been, and will always be, a thinking profession, and trying to have computers take part of this job off of us is never good. EHRs, while they have advantages in convenience and space savings, are as imperfect as those who write them.

Patients are not one-size-fits-all, and individual treatments have to be customized in ways that current systems often don’t recognize, sometimes with sad consequences for all involved.

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

While most Americans were still reacting in horror and disbelief to news of a mass shooting at the Pulse nightclub in Orlando, Florida in the early morning hours of June 12, 2016, the thoughts of most emergency physicians (EPs) were probably focused on the ongoing efforts to save as many victims as possible: What was the closest Level 1 trauma center, and how deep was the ED staffing there that night? Was there a need for additional resources, and perhaps even, could they get there in time to help? In this issue of Emergency Medicine (EM), Residency Program Director Salvatore Silvestri, MD, and his emergency medicine colleagues masterfully recount events from that night as they unfolded, both at the scene and two blocks away at the Orlando Regional Medical Center (ORMC) ED, in the minutes and hours following the first reported shootings.

Being prepared for a mass-casualty incident (MCI) is an extraordinarily expensive requirement of a hospital: It must acquire and maintain adequate resources and communication capabilities; periodically perform unannounced drills that disrupt other hospital activities; and ensure that all EPs and staff are not only able to perform their own day-to-day roles as attending physicians, residents, nurses, etc, but are also capable of taking on even greater responsibilities during an MCI—depending on the day and time it occurs. As you will read in the pages that follow, in the early morning hours of June 12, many of the practiced exercises and rehearsed procedures proved useful, even life-saving, while others had to be discarded or ignored in favor of improvised solutions to rapidly transport and treat the large number of victims with unanticipated needs, under unique conditions. 

In any MCI, saving the largest number of victims invariably depends on rapidly instituting some deviations from standard operating procedures (SOPs) and standards of care (SOCs). As described by the ORMC EP authors, “...law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload….minimal interventions were performed and unlike standard procedure, EMS could offer no prearrival report to the hospital.”

Deviations from SOPs and SOCs during an MCI are not confined to prehospital care, but often extend into the ED and beyond. Most difficult for an EP participating in an MCI is the moment of realization that the sheer number of seriously injured and dying patients arriving en masse mandates a change from “ED triage” to “battlefield triage.” As Dr Ponder recalled, “One of the first few patients I saw was pulse­less, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’”

In EDs, dying patients are attended to first with extensive staff and resources, while, as a result, less seriously ill patients must sometimes wait longer for care. The opposite is true on the battlefield, where near-death victims of lethal injuries are provided only with comfort care, at most, in order to save those who have a chance of surviving their extensive or serious injuries. 

For hospitals and staff, the costs incurred by disaster preparedness are great and invariably exceed government funding provided for these efforts, but how much greater would be the human toll from an MCI without such efforts? All EPs should be proud of what our colleagues at ORMC accomplished on June 12. Though most EPs may never have to deal directly with an MCI, the Orlando nightclub shooting incident was only one of the latest MCIs, certainly not one of the last.

Previous editorials on MCIs may be found in EM September 2006 (9/11), June 2011 (first responders), September 2011 (9/11), November 2011 (surge capacity), and September 2012 (surge capacity/Hurricane Sandy).

While most Americans were still reacting in horror and disbelief to news of a mass shooting at the Pulse nightclub in Orlando, Florida in the early morning hours of June 12, 2016, the thoughts of most emergency physicians (EPs) were probably focused on the ongoing efforts to save as many victims as possible: What was the closest Level 1 trauma center, and how deep was the ED staffing there that night? Was there a need for additional resources, and perhaps even, could they get there in time to help? In this issue of Emergency Medicine (EM), Residency Program Director Salvatore Silvestri, MD, and his emergency medicine colleagues masterfully recount events from that night as they unfolded, both at the scene and two blocks away at the Orlando Regional Medical Center (ORMC) ED, in the minutes and hours following the first reported shootings.

Being prepared for a mass-casualty incident (MCI) is an extraordinarily expensive requirement of a hospital: It must acquire and maintain adequate resources and communication capabilities; periodically perform unannounced drills that disrupt other hospital activities; and ensure that all EPs and staff are not only able to perform their own day-to-day roles as attending physicians, residents, nurses, etc, but are also capable of taking on even greater responsibilities during an MCI—depending on the day and time it occurs. As you will read in the pages that follow, in the early morning hours of June 12, many of the practiced exercises and rehearsed procedures proved useful, even life-saving, while others had to be discarded or ignored in favor of improvised solutions to rapidly transport and treat the large number of victims with unanticipated needs, under unique conditions. 

In any MCI, saving the largest number of victims invariably depends on rapidly instituting some deviations from standard operating procedures (SOPs) and standards of care (SOCs). As described by the ORMC EP authors, “...law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload….minimal interventions were performed and unlike standard procedure, EMS could offer no prearrival report to the hospital.”

Deviations from SOPs and SOCs during an MCI are not confined to prehospital care, but often extend into the ED and beyond. Most difficult for an EP participating in an MCI is the moment of realization that the sheer number of seriously injured and dying patients arriving en masse mandates a change from “ED triage” to “battlefield triage.” As Dr Ponder recalled, “One of the first few patients I saw was pulse­less, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’”

In EDs, dying patients are attended to first with extensive staff and resources, while, as a result, less seriously ill patients must sometimes wait longer for care. The opposite is true on the battlefield, where near-death victims of lethal injuries are provided only with comfort care, at most, in order to save those who have a chance of surviving their extensive or serious injuries. 

For hospitals and staff, the costs incurred by disaster preparedness are great and invariably exceed government funding provided for these efforts, but how much greater would be the human toll from an MCI without such efforts? All EPs should be proud of what our colleagues at ORMC accomplished on June 12. Though most EPs may never have to deal directly with an MCI, the Orlando nightclub shooting incident was only one of the latest MCIs, certainly not one of the last.

Previous editorials on MCIs may be found in EM September 2006 (9/11), June 2011 (first responders), September 2011 (9/11), November 2011 (surge capacity), and September 2012 (surge capacity/Hurricane Sandy).

While most Americans were still reacting in horror and disbelief to news of a mass shooting at the Pulse nightclub in Orlando, Florida in the early morning hours of June 12, 2016, the thoughts of most emergency physicians (EPs) were probably focused on the ongoing efforts to save as many victims as possible: What was the closest Level 1 trauma center, and how deep was the ED staffing there that night? Was there a need for additional resources, and perhaps even, could they get there in time to help? In this issue of Emergency Medicine (EM), Residency Program Director Salvatore Silvestri, MD, and his emergency medicine colleagues masterfully recount events from that night as they unfolded, both at the scene and two blocks away at the Orlando Regional Medical Center (ORMC) ED, in the minutes and hours following the first reported shootings.

Being prepared for a mass-casualty incident (MCI) is an extraordinarily expensive requirement of a hospital: It must acquire and maintain adequate resources and communication capabilities; periodically perform unannounced drills that disrupt other hospital activities; and ensure that all EPs and staff are not only able to perform their own day-to-day roles as attending physicians, residents, nurses, etc, but are also capable of taking on even greater responsibilities during an MCI—depending on the day and time it occurs. As you will read in the pages that follow, in the early morning hours of June 12, many of the practiced exercises and rehearsed procedures proved useful, even life-saving, while others had to be discarded or ignored in favor of improvised solutions to rapidly transport and treat the large number of victims with unanticipated needs, under unique conditions. 

In any MCI, saving the largest number of victims invariably depends on rapidly instituting some deviations from standard operating procedures (SOPs) and standards of care (SOCs). As described by the ORMC EP authors, “...law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload….minimal interventions were performed and unlike standard procedure, EMS could offer no prearrival report to the hospital.”

Deviations from SOPs and SOCs during an MCI are not confined to prehospital care, but often extend into the ED and beyond. Most difficult for an EP participating in an MCI is the moment of realization that the sheer number of seriously injured and dying patients arriving en masse mandates a change from “ED triage” to “battlefield triage.” As Dr Ponder recalled, “One of the first few patients I saw was pulse­less, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’”

In EDs, dying patients are attended to first with extensive staff and resources, while, as a result, less seriously ill patients must sometimes wait longer for care. The opposite is true on the battlefield, where near-death victims of lethal injuries are provided only with comfort care, at most, in order to save those who have a chance of surviving their extensive or serious injuries. 

For hospitals and staff, the costs incurred by disaster preparedness are great and invariably exceed government funding provided for these efforts, but how much greater would be the human toll from an MCI without such efforts? All EPs should be proud of what our colleagues at ORMC accomplished on June 12. Though most EPs may never have to deal directly with an MCI, the Orlando nightclub shooting incident was only one of the latest MCIs, certainly not one of the last.

Previous editorials on MCIs may be found in EM September 2006 (9/11), June 2011 (first responders), September 2011 (9/11), November 2011 (surge capacity), and September 2012 (surge capacity/Hurricane Sandy).

“What Insect repellents are safe during pregnancy?”

ANUSHKA CHELLIAH, MD, AND PATRICK DUFF, MD (JUNE 2016)

Alternatives to DEET

Picaridin is not mentioned in this brief report from Drs. Chelliah and Duff. I suggest reviewing the July 2015 Consumer Reports article on repellents; picaridin is a likely safer alternative to DEET, with the highest efficacy of all those tested, at least in Sawyer Fisherman’s Formula Picaridin Insect Repellent and Natrapel 8 Hour Insect Repellent. Products that have little or no efficacy also were not mentioned, including Avon Skin So Soft, Coleman Naturals Insect Repellent Snap Band, and SuperBand Wristband. In addition, the concentration of products is very important, as is the precise formulation within brands. For example, Off! Deep Woods VIII (with DEET 25%) is very effective versus Off! FamilyCare II Clean Feel (with picaridin 5%), which has very little benefit.

David H. Janowitz, MD
Houston, Texas

Drs. Chelliah and Duff respond

In our short discussion of mosquito repellents, we based our recommendations on publications from the Centers for Disease Control and Prevention (CDC) and the Florida Department of Health. Those publications presented DEET (N,N-diethyl-m-toluamide) at the top of the list for preferred repellents. A recent publication from the Organization of Teratology Information Specialists (MotherToBaby, September 2013) indicated that, in a concentration of 20% to 30%, DEET was safe in pregnancy and was effective in protecting against 90% of all mosquito bites and tick attachments. Increasing the concentration of DEET above 30% does not enhance the product’s effectiveness or prolong its duration of action.

However, Dr. Janowitz is correct in stating that other agents are also highly effective and safe in pregnancy. These agents include picaridin (20%) and oil of lemon/eucalyptus (30%). We thank Dr. Janowitz for directing us to the most recent testing program conducted by Consumer Reports.¹ That testing program demonstrated that Sawyer Fisherman’s Formula Picaridin and Natrapel 8 Hour, which each contain 20% picaridin, and Off! Deep Woods VIII, which contains 25% DEET, kept Aedes mosquitoes from biting for approximately 8 hours. The Sawyer product was also effective in preventing bites from the Culex mosquitoes, which carry West Nile virus, and deer ticks, which can transmit Lyme disease. Repel Lemon Eucalyptus (30%) stopped Aedes mosquito bites for 7 hours.

In the Consumer Reports testing program, IR3535 products, which we recommended in our article, did not perform well, nor did repellents that contained only 7% DEET or less than 20% picaridin. Moreover, products made from natural plant oils—such as citronella, lemongrass oil, cedar oil, geraniol, rosemary oil, and cinnamon oil—were not particularly effective. Some did not last for more than 1 hour; some failed immediately.

When applying any of these products, individuals should observe the following guidelines:

• apply insect repellents only to exposed skin or clothing
• do not apply repellents on cuts, wounds, or abraded skin or immediately after shaving
• avoid the eyes and mouth when applying repellent to the face
• after exposure is over, wash the skin with soap and water
• clothing that has been treated with one of these agents or with permethrin should be washed separately before it is worn again.

Reference

“Tissue extraction: Can the pendulum change direction?”

ARNOLD P. ADVINCULA, MD (JUNE 2016)

We have met the enemy and he is us

While I share the optimism Dr. Advincula expressed in his recent guest editorial regarding a change in the direction of the pendulum that swung away from use of the power morcellator, I feel compelled to express the opinion that this entire fiasco has been nothing other than an outrageous regulatory overreach.

Shortly after the US Food and Drug Administration (FDA) issued its proclamation in April 2014, the Society of Gynecologic Oncology repudiated the bogus statistics that were being used to describe the incidence of leiomyosarcoma and, further, stated that it would not matter how someone’s uterus containing this rare tumor was removed because the outcome would be poor. Similarly, the American Journal of Obstetrics and Gynecology published an article enumerating the expected significant increase in complications and the resulting misery that could be expected for patients whose management was diverted from minimally invasive to open hysterectomy.¹ The AAGL also expressed opinions that this was an unnecessary, and counterproductive, policy—all to no avail.

My optimism, however, is tempered by a number of questions: 1) Why did it take more than a year for 36 nationally recognized gynecologic surgeons to write a letter to the FDA denouncing the warning, yet again, and reiterating the errors in analysis used to establish the policy? 2) Why are gynecologic surgeons only now being asked to serve in the FDA’s Network of Experts? Should not that have been the case before the warning was issued? 3) If the perioperative outcomes are similar using a containment bag compared with open morcellation, what is the benefit of using the containment system? I, for one, think that prolonging a procedure another half hour is significant.

The FDA’s egregious policy clearly has had a net negative impact on the welfare of our patients. The gynecologic surgeon community should have pushed back more forcefully and effectively. I hope the next time something like this happens (and it will) we can be better advocates for our patients. 

Mark S. Finkelston, DO
Shawnee Mission, Kansas

Reference

Dr. Advincula responds

I thank Dr. Finkelston for his thoughts regarding my editorial. There is no doubt that the issues surrounding tissue extraction have been heated. Although I do not have definitive answers that explain all of the various reactions, whether immediate or delayed, to the cascade of events surrounding morcellation, I do believe that much of it was a response to N-of-1 policy-making, as very nicely discussed in a New England Journal of Medicine article by Lisa Rosenbaum.¹ We must continue to foster constructive dialogues with our regulatory bodies and cultivate the spirit of innovation that has brought so many advances to the field of surgery. Ultimately, going forward, it will be important for clinicians and other health care providers to speak up and not remain silent for fear of being vilified.

Reference

Vaginal hysterectomy solves the tissue morcellation dilemma

Dr. Advincula starts his guest editorial with the statement, “With practical, evidence-based, sound clinical judgement, I believe that it can.”

In fact, what “practical, evidence-based, sound clinical judgement” supports is a return to vaginal hysterectomy with transvaginal extracorporeal morcellation techniques. As Dr. Carl Zimmerman said in a recent debate at the Society of Gynecologic Surgeons (SGS annual meeting), “There is no recorded case of a vaginal hysterectomy with morcellation upgrading a patient with leiomyosarcoma.” In addition, the majority of cases in which Dr. Advincula and others are performing robot-assisted laparoscopic hysterectomy or total laparoscopic hysterectomy have this clinical and demographic profile: average age, 42; average parity, G2; average body mass index, 30; most common diagnosis, abnormal uterine bleeding, fibroids; most common pathology, fibroids; average uterine weight, 165 g. The majority of these can be performed much more safely, quickly, and cost effectively by transvaginal hysterectomy/morcellation. Please see an excellent commentary by Dr. Andrew Walter, immediate past president of SGS, on “Why we should strive for a vaginal hysterectomy rate of 40%.”¹

But the main reason Dr. Advincula should not be given a voice on this issue is because he has significant financial conflict of interest with the medical device industry. Should he even be on the OBG <scaps>Management</scaps> board of editors? I do not believe the rest of your editors have anywhere near his level of conflict of interest. Should he not be asked to recuse himself in this debate or abandon his financial connections with the medical device industry? Is this not the whole purpose of the Sunshine Act? Please, should you not be supporting what is in the best interest of our patients and payers?

R. Bruce Councell, MD
Asheville, North Carolina

Reference

Dr. Barbieri responds

At OBG Management, we wholeheartedly agree with Dr. Councell that vaginal hysterectomy is an excellent approach to removing the uterus in most women with noncancer indications for surgery. Our recently featured articles focused on vaginal hysterectomy include: “Transforming vaginal hysterectomy: 7 solutions to the most daunting challenges,” “Is energy-based vessel sealing safer than suturing for vaginal hysterectomy?,” Is same-day discharge feasible and safe for women undergoing vaginal hysterectomy?,” and “Can we reduce the use of abdominal hysterectomy and increase the use of vaginal and laparoscopic approaches?” We plan to publish more content on advances in both vaginal and laparoscopic surgery.

We are proud to have Dr. Advincula, an internationally recognized leader in gynecologic surgery, serve on the OBG Management Editorial Board. His expertise and perspective is of great value to our readers. It is true that many leading surgeons, including Dr. Advincula, serve as consultants with manufacturers of surgical devices. Working together, clinical experts and device manufacturers help to advance medical care. In his editorial, Dr. Advincula did disclose these relationships. As a check on the quality and balance in our editorial material, I personally review all content and I have no financial relationships with any pharmaceutical or device manufacturer.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“What Insect repellents are safe during pregnancy?”

ANUSHKA CHELLIAH, MD, AND PATRICK DUFF, MD (JUNE 2016)

Alternatives to DEET

Picaridin is not mentioned in this brief report from Drs. Chelliah and Duff. I suggest reviewing the July 2015 Consumer Reports article on repellents; picaridin is a likely safer alternative to DEET, with the highest efficacy of all those tested, at least in Sawyer Fisherman’s Formula Picaridin Insect Repellent and Natrapel 8 Hour Insect Repellent. Products that have little or no efficacy also were not mentioned, including Avon Skin So Soft, Coleman Naturals Insect Repellent Snap Band, and SuperBand Wristband. In addition, the concentration of products is very important, as is the precise formulation within brands. For example, Off! Deep Woods VIII (with DEET 25%) is very effective versus Off! FamilyCare II Clean Feel (with picaridin 5%), which has very little benefit.

David H. Janowitz, MD
Houston, Texas

Drs. Chelliah and Duff respond

In our short discussion of mosquito repellents, we based our recommendations on publications from the Centers for Disease Control and Prevention (CDC) and the Florida Department of Health. Those publications presented DEET (N,N-diethyl-m-toluamide) at the top of the list for preferred repellents. A recent publication from the Organization of Teratology Information Specialists (MotherToBaby, September 2013) indicated that, in a concentration of 20% to 30%, DEET was safe in pregnancy and was effective in protecting against 90% of all mosquito bites and tick attachments. Increasing the concentration of DEET above 30% does not enhance the product’s effectiveness or prolong its duration of action.

However, Dr. Janowitz is correct in stating that other agents are also highly effective and safe in pregnancy. These agents include picaridin (20%) and oil of lemon/eucalyptus (30%). We thank Dr. Janowitz for directing us to the most recent testing program conducted by Consumer Reports.¹ That testing program demonstrated that Sawyer Fisherman’s Formula Picaridin and Natrapel 8 Hour, which each contain 20% picaridin, and Off! Deep Woods VIII, which contains 25% DEET, kept Aedes mosquitoes from biting for approximately 8 hours. The Sawyer product was also effective in preventing bites from the Culex mosquitoes, which carry West Nile virus, and deer ticks, which can transmit Lyme disease. Repel Lemon Eucalyptus (30%) stopped Aedes mosquito bites for 7 hours.

In the Consumer Reports testing program, IR3535 products, which we recommended in our article, did not perform well, nor did repellents that contained only 7% DEET or less than 20% picaridin. Moreover, products made from natural plant oils—such as citronella, lemongrass oil, cedar oil, geraniol, rosemary oil, and cinnamon oil—were not particularly effective. Some did not last for more than 1 hour; some failed immediately.

When applying any of these products, individuals should observe the following guidelines:

• apply insect repellents only to exposed skin or clothing
• do not apply repellents on cuts, wounds, or abraded skin or immediately after shaving
• avoid the eyes and mouth when applying repellent to the face
• after exposure is over, wash the skin with soap and water
• clothing that has been treated with one of these agents or with permethrin should be washed separately before it is worn again.

Reference

“Tissue extraction: Can the pendulum change direction?”

ARNOLD P. ADVINCULA, MD (JUNE 2016)

We have met the enemy and he is us

While I share the optimism Dr. Advincula expressed in his recent guest editorial regarding a change in the direction of the pendulum that swung away from use of the power morcellator, I feel compelled to express the opinion that this entire fiasco has been nothing other than an outrageous regulatory overreach.

Shortly after the US Food and Drug Administration (FDA) issued its proclamation in April 2014, the Society of Gynecologic Oncology repudiated the bogus statistics that were being used to describe the incidence of leiomyosarcoma and, further, stated that it would not matter how someone’s uterus containing this rare tumor was removed because the outcome would be poor. Similarly, the American Journal of Obstetrics and Gynecology published an article enumerating the expected significant increase in complications and the resulting misery that could be expected for patients whose management was diverted from minimally invasive to open hysterectomy.¹ The AAGL also expressed opinions that this was an unnecessary, and counterproductive, policy—all to no avail.

My optimism, however, is tempered by a number of questions: 1) Why did it take more than a year for 36 nationally recognized gynecologic surgeons to write a letter to the FDA denouncing the warning, yet again, and reiterating the errors in analysis used to establish the policy? 2) Why are gynecologic surgeons only now being asked to serve in the FDA’s Network of Experts? Should not that have been the case before the warning was issued? 3) If the perioperative outcomes are similar using a containment bag compared with open morcellation, what is the benefit of using the containment system? I, for one, think that prolonging a procedure another half hour is significant.

The FDA’s egregious policy clearly has had a net negative impact on the welfare of our patients. The gynecologic surgeon community should have pushed back more forcefully and effectively. I hope the next time something like this happens (and it will) we can be better advocates for our patients. 

Mark S. Finkelston, DO
Shawnee Mission, Kansas

Reference

Dr. Advincula responds

I thank Dr. Finkelston for his thoughts regarding my editorial. There is no doubt that the issues surrounding tissue extraction have been heated. Although I do not have definitive answers that explain all of the various reactions, whether immediate or delayed, to the cascade of events surrounding morcellation, I do believe that much of it was a response to N-of-1 policy-making, as very nicely discussed in a New England Journal of Medicine article by Lisa Rosenbaum.¹ We must continue to foster constructive dialogues with our regulatory bodies and cultivate the spirit of innovation that has brought so many advances to the field of surgery. Ultimately, going forward, it will be important for clinicians and other health care providers to speak up and not remain silent for fear of being vilified.

Reference

Vaginal hysterectomy solves the tissue morcellation dilemma

Dr. Advincula starts his guest editorial with the statement, “With practical, evidence-based, sound clinical judgement, I believe that it can.”

In fact, what “practical, evidence-based, sound clinical judgement” supports is a return to vaginal hysterectomy with transvaginal extracorporeal morcellation techniques. As Dr. Carl Zimmerman said in a recent debate at the Society of Gynecologic Surgeons (SGS annual meeting), “There is no recorded case of a vaginal hysterectomy with morcellation upgrading a patient with leiomyosarcoma.” In addition, the majority of cases in which Dr. Advincula and others are performing robot-assisted laparoscopic hysterectomy or total laparoscopic hysterectomy have this clinical and demographic profile: average age, 42; average parity, G2; average body mass index, 30; most common diagnosis, abnormal uterine bleeding, fibroids; most common pathology, fibroids; average uterine weight, 165 g. The majority of these can be performed much more safely, quickly, and cost effectively by transvaginal hysterectomy/morcellation. Please see an excellent commentary by Dr. Andrew Walter, immediate past president of SGS, on “Why we should strive for a vaginal hysterectomy rate of 40%.”¹

But the main reason Dr. Advincula should not be given a voice on this issue is because he has significant financial conflict of interest with the medical device industry. Should he even be on the OBG <scaps>Management</scaps> board of editors? I do not believe the rest of your editors have anywhere near his level of conflict of interest. Should he not be asked to recuse himself in this debate or abandon his financial connections with the medical device industry? Is this not the whole purpose of the Sunshine Act? Please, should you not be supporting what is in the best interest of our patients and payers?

R. Bruce Councell, MD
Asheville, North Carolina

Reference

Dr. Barbieri responds

At OBG Management, we wholeheartedly agree with Dr. Councell that vaginal hysterectomy is an excellent approach to removing the uterus in most women with noncancer indications for surgery. Our recently featured articles focused on vaginal hysterectomy include: “Transforming vaginal hysterectomy: 7 solutions to the most daunting challenges,” “Is energy-based vessel sealing safer than suturing for vaginal hysterectomy?,” Is same-day discharge feasible and safe for women undergoing vaginal hysterectomy?,” and “Can we reduce the use of abdominal hysterectomy and increase the use of vaginal and laparoscopic approaches?” We plan to publish more content on advances in both vaginal and laparoscopic surgery.

We are proud to have Dr. Advincula, an internationally recognized leader in gynecologic surgery, serve on the OBG Management Editorial Board. His expertise and perspective is of great value to our readers. It is true that many leading surgeons, including Dr. Advincula, serve as consultants with manufacturers of surgical devices. Working together, clinical experts and device manufacturers help to advance medical care. In his editorial, Dr. Advincula did disclose these relationships. As a check on the quality and balance in our editorial material, I personally review all content and I have no financial relationships with any pharmaceutical or device manufacturer.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“What Insect repellents are safe during pregnancy?”

ANUSHKA CHELLIAH, MD, AND PATRICK DUFF, MD (JUNE 2016)

Alternatives to DEET

Picaridin is not mentioned in this brief report from Drs. Chelliah and Duff. I suggest reviewing the July 2015 Consumer Reports article on repellents; picaridin is a likely safer alternative to DEET, with the highest efficacy of all those tested, at least in Sawyer Fisherman’s Formula Picaridin Insect Repellent and Natrapel 8 Hour Insect Repellent. Products that have little or no efficacy also were not mentioned, including Avon Skin So Soft, Coleman Naturals Insect Repellent Snap Band, and SuperBand Wristband. In addition, the concentration of products is very important, as is the precise formulation within brands. For example, Off! Deep Woods VIII (with DEET 25%) is very effective versus Off! FamilyCare II Clean Feel (with picaridin 5%), which has very little benefit.

David H. Janowitz, MD
Houston, Texas

Drs. Chelliah and Duff respond

In our short discussion of mosquito repellents, we based our recommendations on publications from the Centers for Disease Control and Prevention (CDC) and the Florida Department of Health. Those publications presented DEET (N,N-diethyl-m-toluamide) at the top of the list for preferred repellents. A recent publication from the Organization of Teratology Information Specialists (MotherToBaby, September 2013) indicated that, in a concentration of 20% to 30%, DEET was safe in pregnancy and was effective in protecting against 90% of all mosquito bites and tick attachments. Increasing the concentration of DEET above 30% does not enhance the product’s effectiveness or prolong its duration of action.

However, Dr. Janowitz is correct in stating that other agents are also highly effective and safe in pregnancy. These agents include picaridin (20%) and oil of lemon/eucalyptus (30%). We thank Dr. Janowitz for directing us to the most recent testing program conducted by Consumer Reports.¹ That testing program demonstrated that Sawyer Fisherman’s Formula Picaridin and Natrapel 8 Hour, which each contain 20% picaridin, and Off! Deep Woods VIII, which contains 25% DEET, kept Aedes mosquitoes from biting for approximately 8 hours. The Sawyer product was also effective in preventing bites from the Culex mosquitoes, which carry West Nile virus, and deer ticks, which can transmit Lyme disease. Repel Lemon Eucalyptus (30%) stopped Aedes mosquito bites for 7 hours.

In the Consumer Reports testing program, IR3535 products, which we recommended in our article, did not perform well, nor did repellents that contained only 7% DEET or less than 20% picaridin. Moreover, products made from natural plant oils—such as citronella, lemongrass oil, cedar oil, geraniol, rosemary oil, and cinnamon oil—were not particularly effective. Some did not last for more than 1 hour; some failed immediately.

When applying any of these products, individuals should observe the following guidelines:

• apply insect repellents only to exposed skin or clothing
• do not apply repellents on cuts, wounds, or abraded skin or immediately after shaving
• avoid the eyes and mouth when applying repellent to the face
• after exposure is over, wash the skin with soap and water
• clothing that has been treated with one of these agents or with permethrin should be washed separately before it is worn again.

Reference

“Tissue extraction: Can the pendulum change direction?”

ARNOLD P. ADVINCULA, MD (JUNE 2016)

We have met the enemy and he is us

While I share the optimism Dr. Advincula expressed in his recent guest editorial regarding a change in the direction of the pendulum that swung away from use of the power morcellator, I feel compelled to express the opinion that this entire fiasco has been nothing other than an outrageous regulatory overreach.

Shortly after the US Food and Drug Administration (FDA) issued its proclamation in April 2014, the Society of Gynecologic Oncology repudiated the bogus statistics that were being used to describe the incidence of leiomyosarcoma and, further, stated that it would not matter how someone’s uterus containing this rare tumor was removed because the outcome would be poor. Similarly, the American Journal of Obstetrics and Gynecology published an article enumerating the expected significant increase in complications and the resulting misery that could be expected for patients whose management was diverted from minimally invasive to open hysterectomy.¹ The AAGL also expressed opinions that this was an unnecessary, and counterproductive, policy—all to no avail.

My optimism, however, is tempered by a number of questions: 1) Why did it take more than a year for 36 nationally recognized gynecologic surgeons to write a letter to the FDA denouncing the warning, yet again, and reiterating the errors in analysis used to establish the policy? 2) Why are gynecologic surgeons only now being asked to serve in the FDA’s Network of Experts? Should not that have been the case before the warning was issued? 3) If the perioperative outcomes are similar using a containment bag compared with open morcellation, what is the benefit of using the containment system? I, for one, think that prolonging a procedure another half hour is significant.

The FDA’s egregious policy clearly has had a net negative impact on the welfare of our patients. The gynecologic surgeon community should have pushed back more forcefully and effectively. I hope the next time something like this happens (and it will) we can be better advocates for our patients. 

Mark S. Finkelston, DO
Shawnee Mission, Kansas

Reference

Dr. Advincula responds

I thank Dr. Finkelston for his thoughts regarding my editorial. There is no doubt that the issues surrounding tissue extraction have been heated. Although I do not have definitive answers that explain all of the various reactions, whether immediate or delayed, to the cascade of events surrounding morcellation, I do believe that much of it was a response to N-of-1 policy-making, as very nicely discussed in a New England Journal of Medicine article by Lisa Rosenbaum.¹ We must continue to foster constructive dialogues with our regulatory bodies and cultivate the spirit of innovation that has brought so many advances to the field of surgery. Ultimately, going forward, it will be important for clinicians and other health care providers to speak up and not remain silent for fear of being vilified.

Reference

Vaginal hysterectomy solves the tissue morcellation dilemma

Dr. Advincula starts his guest editorial with the statement, “With practical, evidence-based, sound clinical judgement, I believe that it can.”

In fact, what “practical, evidence-based, sound clinical judgement” supports is a return to vaginal hysterectomy with transvaginal extracorporeal morcellation techniques. As Dr. Carl Zimmerman said in a recent debate at the Society of Gynecologic Surgeons (SGS annual meeting), “There is no recorded case of a vaginal hysterectomy with morcellation upgrading a patient with leiomyosarcoma.” In addition, the majority of cases in which Dr. Advincula and others are performing robot-assisted laparoscopic hysterectomy or total laparoscopic hysterectomy have this clinical and demographic profile: average age, 42; average parity, G2; average body mass index, 30; most common diagnosis, abnormal uterine bleeding, fibroids; most common pathology, fibroids; average uterine weight, 165 g. The majority of these can be performed much more safely, quickly, and cost effectively by transvaginal hysterectomy/morcellation. Please see an excellent commentary by Dr. Andrew Walter, immediate past president of SGS, on “Why we should strive for a vaginal hysterectomy rate of 40%.”¹

But the main reason Dr. Advincula should not be given a voice on this issue is because he has significant financial conflict of interest with the medical device industry. Should he even be on the OBG <scaps>Management</scaps> board of editors? I do not believe the rest of your editors have anywhere near his level of conflict of interest. Should he not be asked to recuse himself in this debate or abandon his financial connections with the medical device industry? Is this not the whole purpose of the Sunshine Act? Please, should you not be supporting what is in the best interest of our patients and payers?

R. Bruce Councell, MD
Asheville, North Carolina

Reference

Dr. Barbieri responds

At OBG Management, we wholeheartedly agree with Dr. Councell that vaginal hysterectomy is an excellent approach to removing the uterus in most women with noncancer indications for surgery. Our recently featured articles focused on vaginal hysterectomy include: “Transforming vaginal hysterectomy: 7 solutions to the most daunting challenges,” “Is energy-based vessel sealing safer than suturing for vaginal hysterectomy?,” Is same-day discharge feasible and safe for women undergoing vaginal hysterectomy?,” and “Can we reduce the use of abdominal hysterectomy and increase the use of vaginal and laparoscopic approaches?” We plan to publish more content on advances in both vaginal and laparoscopic surgery.

We are proud to have Dr. Advincula, an internationally recognized leader in gynecologic surgery, serve on the OBG Management Editorial Board. His expertise and perspective is of great value to our readers. It is true that many leading surgeons, including Dr. Advincula, serve as consultants with manufacturers of surgical devices. Working together, clinical experts and device manufacturers help to advance medical care. In his editorial, Dr. Advincula did disclose these relationships. As a check on the quality and balance in our editorial material, I personally review all content and I have no financial relationships with any pharmaceutical or device manufacturer.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The issues of racial tensions have surfaced in plain sight in America. These are very trying times for our nation, and I fear some of my European American colleagues may not “get it.”

I recall a decade ago when I was involved with the Committee of Black Psychiatrists in crafting the American Psychiatric Association’s position statement, “Resolution Against Racism and Racial Discrimination and Their Adverse Impacts on Mental Health.” There was great concern that some of our European American colleagues would not get it, so in the preamble to the position statement, we explained that African Americans and European Americans had similar and different experiences in America, and that those differences made dialogue between both groups difficult.

Specifically, both groups believed that in America, people should be judged by the content of their character and not the color of their skin; after all, that is a basic value of the United States – it is one of our ideals. So, when a European American is accused of racism, the person often replies: “No, I am not; I believe in the American ideal of not being prejudiced.”

Unfortunately, the experiences of African Americans too often indicate that they are being judged by the color of our skin and not by our character. Most of the gross societal outcome indicators illustrate those disparities. So, African Americans, although occasionally experience the ideal that makes America great, all too often experience the reality of racial discrimination – including, but not limited to, phenomena the founder of the Black Psychiatrists of America, Chester M. Pierce, MD, coined “microinsults” and “microaggressions.” Women, too, experience these subtle and not-so-subtle put-downs by men all the time.

Accordingly, when we come together to dialogue about racial issues in our nation, many European Americans are focused on the ideal, and African Americans are focused on our reality, leaving the two groups on different pages. Having put everyone on the same page with this preface, I am told by members of the APA’s assembly that the position statement passed easily as a result of this understanding.

The problem is that being European American often prevents absorbing the perspective from the other side. So I thought it would be a good idea to share some personal experiences to help illuminate why so many African Americans feel the way they do about law enforcement.

I clearly recall being around 9 years old and being instructed that when running from the police, we should run zigzag, so it would be more difficult for them to shoot and kill us. We were instructed that running around corners worked better, because bullets fly straight and do not turn corners.

Of course, there also was the occasional experience (about two or three times each year) of sitting on a fence with a few of my friends of the same age, talking about what we were going to do when we grew up. A police car would drive up to the curb, and a police officer would call one of us over to talk. I recall clearly once when I got called over – of course, I took my sweet time, as I was not doing anything wrong, other than being 9 years old and black. The police officer got angry that I had tried to preserve my dignity by cruising over to the car. I remember his threat: Since I thought I was smart, he would drive me down to the police station, and he would not be surprised if my hand accidentally got broken in the car door during my transportation. I was 9 years old! Obviously, that abuse of power might have ruined my future career as a physician, but he let me go.

Years later as a teenager, I learned from my brother, a Chicago police officer, that the police are taught to take control of situations and assert their authority to prevent any potential conflicts. My brother also told me that the police were unofficially taught to carry “drop guns” in case they shot an unarmed suspect.

The idea was that they could drop the gun on the person, in other words, plant it and say the person had a gun after they had killed him. (It was always better in these accidents to leave the person dead, so he could not tell his side of the story.)

I often wonder where my brother would stand on this issue in 2016, but unfortunately as a police officer, while in plain clothes, he tried to help some fellow white officers intervene in a robbery. After identifying himself as a Chicago police officer, he and the other two white officers gave chase, but he outran them and trapped the suspect in a vestibule of a Southside Chicago apartment building. While my brother and the suspect were exchanging gunfire, two newer white Chicago police officers came upon a black man (my brother) with a gun, and he was promptly shot and killed. Of course, exactly what happened is murky, but I have my suspicions. Of course, the suspect also was killed during this shootout, so neither of the two black men involved was left alive to tell his side of the story.

Then there was the time I was in college being advised by my white guidance counselor that I should seek a career in something like auto mechanics. Little did he know that my African American grandfather obtained his PhD from Yale in 1924, and my father, like his father, had a couple of PhDs. What caused him to think I could accomplish only blue-collar goals? Charles Pinderhughes, MD, (another wise black psychiatrist) did an excellent dissertation in the American Journal of Psychiatry on “stereotyping,” that explained much of the reason (1979 Jan;136[1]33-7).

Because I was from Chicago and a psychiatrist, I was called in to evaluate several of the more than 100 innocent black men whom Jon Burge (a former Chicago police commander) allegedly tortured to get them to confess to murders they did not commit. Officer Burge was never found guilty of this crime, but he was sent to federal prison for three counts of obstruction of justice and perjury for lying about police torture.

Accordingly, in Chicago we have a saying, “The police hunt black men.” Of course, this statement rang true when a white Chicago police officer was caught on film shooting a 17-year-old child who may have had a developmental disability – Laquan McDonald – 16 times in October 2014.

Until the perceptions of race are viewed from both sides of the equation, there will continue to be racial strife, and America will not be as strong as it could be. I have tried to present some of the perspectives many black people experience as their reality. Of course, there is another side we as Americans believe in – justice and equality for all.

This election places America at a pivotal crossroads – which path will we take? Will we seek a more perfect union – or a country divided?

Dr. Bell is staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

The issues of racial tensions have surfaced in plain sight in America. These are very trying times for our nation, and I fear some of my European American colleagues may not “get it.”

I recall a decade ago when I was involved with the Committee of Black Psychiatrists in crafting the American Psychiatric Association’s position statement, “Resolution Against Racism and Racial Discrimination and Their Adverse Impacts on Mental Health.” There was great concern that some of our European American colleagues would not get it, so in the preamble to the position statement, we explained that African Americans and European Americans had similar and different experiences in America, and that those differences made dialogue between both groups difficult.

Specifically, both groups believed that in America, people should be judged by the content of their character and not the color of their skin; after all, that is a basic value of the United States – it is one of our ideals. So, when a European American is accused of racism, the person often replies: “No, I am not; I believe in the American ideal of not being prejudiced.”

Unfortunately, the experiences of African Americans too often indicate that they are being judged by the color of our skin and not by our character. Most of the gross societal outcome indicators illustrate those disparities. So, African Americans, although occasionally experience the ideal that makes America great, all too often experience the reality of racial discrimination – including, but not limited to, phenomena the founder of the Black Psychiatrists of America, Chester M. Pierce, MD, coined “microinsults” and “microaggressions.” Women, too, experience these subtle and not-so-subtle put-downs by men all the time.

Accordingly, when we come together to dialogue about racial issues in our nation, many European Americans are focused on the ideal, and African Americans are focused on our reality, leaving the two groups on different pages. Having put everyone on the same page with this preface, I am told by members of the APA’s assembly that the position statement passed easily as a result of this understanding.

The problem is that being European American often prevents absorbing the perspective from the other side. So I thought it would be a good idea to share some personal experiences to help illuminate why so many African Americans feel the way they do about law enforcement.

I clearly recall being around 9 years old and being instructed that when running from the police, we should run zigzag, so it would be more difficult for them to shoot and kill us. We were instructed that running around corners worked better, because bullets fly straight and do not turn corners.

Of course, there also was the occasional experience (about two or three times each year) of sitting on a fence with a few of my friends of the same age, talking about what we were going to do when we grew up. A police car would drive up to the curb, and a police officer would call one of us over to talk. I recall clearly once when I got called over – of course, I took my sweet time, as I was not doing anything wrong, other than being 9 years old and black. The police officer got angry that I had tried to preserve my dignity by cruising over to the car. I remember his threat: Since I thought I was smart, he would drive me down to the police station, and he would not be surprised if my hand accidentally got broken in the car door during my transportation. I was 9 years old! Obviously, that abuse of power might have ruined my future career as a physician, but he let me go.

Years later as a teenager, I learned from my brother, a Chicago police officer, that the police are taught to take control of situations and assert their authority to prevent any potential conflicts. My brother also told me that the police were unofficially taught to carry “drop guns” in case they shot an unarmed suspect.

The idea was that they could drop the gun on the person, in other words, plant it and say the person had a gun after they had killed him. (It was always better in these accidents to leave the person dead, so he could not tell his side of the story.)

I often wonder where my brother would stand on this issue in 2016, but unfortunately as a police officer, while in plain clothes, he tried to help some fellow white officers intervene in a robbery. After identifying himself as a Chicago police officer, he and the other two white officers gave chase, but he outran them and trapped the suspect in a vestibule of a Southside Chicago apartment building. While my brother and the suspect were exchanging gunfire, two newer white Chicago police officers came upon a black man (my brother) with a gun, and he was promptly shot and killed. Of course, exactly what happened is murky, but I have my suspicions. Of course, the suspect also was killed during this shootout, so neither of the two black men involved was left alive to tell his side of the story.

Then there was the time I was in college being advised by my white guidance counselor that I should seek a career in something like auto mechanics. Little did he know that my African American grandfather obtained his PhD from Yale in 1924, and my father, like his father, had a couple of PhDs. What caused him to think I could accomplish only blue-collar goals? Charles Pinderhughes, MD, (another wise black psychiatrist) did an excellent dissertation in the American Journal of Psychiatry on “stereotyping,” that explained much of the reason (1979 Jan;136[1]33-7).

Because I was from Chicago and a psychiatrist, I was called in to evaluate several of the more than 100 innocent black men whom Jon Burge (a former Chicago police commander) allegedly tortured to get them to confess to murders they did not commit. Officer Burge was never found guilty of this crime, but he was sent to federal prison for three counts of obstruction of justice and perjury for lying about police torture.

Accordingly, in Chicago we have a saying, “The police hunt black men.” Of course, this statement rang true when a white Chicago police officer was caught on film shooting a 17-year-old child who may have had a developmental disability – Laquan McDonald – 16 times in October 2014.

Until the perceptions of race are viewed from both sides of the equation, there will continue to be racial strife, and America will not be as strong as it could be. I have tried to present some of the perspectives many black people experience as their reality. Of course, there is another side we as Americans believe in – justice and equality for all.

This election places America at a pivotal crossroads – which path will we take? Will we seek a more perfect union – or a country divided?

Dr. Bell is staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

The issues of racial tensions have surfaced in plain sight in America. These are very trying times for our nation, and I fear some of my European American colleagues may not “get it.”

I recall a decade ago when I was involved with the Committee of Black Psychiatrists in crafting the American Psychiatric Association’s position statement, “Resolution Against Racism and Racial Discrimination and Their Adverse Impacts on Mental Health.” There was great concern that some of our European American colleagues would not get it, so in the preamble to the position statement, we explained that African Americans and European Americans had similar and different experiences in America, and that those differences made dialogue between both groups difficult.

Specifically, both groups believed that in America, people should be judged by the content of their character and not the color of their skin; after all, that is a basic value of the United States – it is one of our ideals. So, when a European American is accused of racism, the person often replies: “No, I am not; I believe in the American ideal of not being prejudiced.”

Unfortunately, the experiences of African Americans too often indicate that they are being judged by the color of our skin and not by our character. Most of the gross societal outcome indicators illustrate those disparities. So, African Americans, although occasionally experience the ideal that makes America great, all too often experience the reality of racial discrimination – including, but not limited to, phenomena the founder of the Black Psychiatrists of America, Chester M. Pierce, MD, coined “microinsults” and “microaggressions.” Women, too, experience these subtle and not-so-subtle put-downs by men all the time.

Accordingly, when we come together to dialogue about racial issues in our nation, many European Americans are focused on the ideal, and African Americans are focused on our reality, leaving the two groups on different pages. Having put everyone on the same page with this preface, I am told by members of the APA’s assembly that the position statement passed easily as a result of this understanding.

The problem is that being European American often prevents absorbing the perspective from the other side. So I thought it would be a good idea to share some personal experiences to help illuminate why so many African Americans feel the way they do about law enforcement.

I clearly recall being around 9 years old and being instructed that when running from the police, we should run zigzag, so it would be more difficult for them to shoot and kill us. We were instructed that running around corners worked better, because bullets fly straight and do not turn corners.

Of course, there also was the occasional experience (about two or three times each year) of sitting on a fence with a few of my friends of the same age, talking about what we were going to do when we grew up. A police car would drive up to the curb, and a police officer would call one of us over to talk. I recall clearly once when I got called over – of course, I took my sweet time, as I was not doing anything wrong, other than being 9 years old and black. The police officer got angry that I had tried to preserve my dignity by cruising over to the car. I remember his threat: Since I thought I was smart, he would drive me down to the police station, and he would not be surprised if my hand accidentally got broken in the car door during my transportation. I was 9 years old! Obviously, that abuse of power might have ruined my future career as a physician, but he let me go.

Years later as a teenager, I learned from my brother, a Chicago police officer, that the police are taught to take control of situations and assert their authority to prevent any potential conflicts. My brother also told me that the police were unofficially taught to carry “drop guns” in case they shot an unarmed suspect.

The idea was that they could drop the gun on the person, in other words, plant it and say the person had a gun after they had killed him. (It was always better in these accidents to leave the person dead, so he could not tell his side of the story.)

I often wonder where my brother would stand on this issue in 2016, but unfortunately as a police officer, while in plain clothes, he tried to help some fellow white officers intervene in a robbery. After identifying himself as a Chicago police officer, he and the other two white officers gave chase, but he outran them and trapped the suspect in a vestibule of a Southside Chicago apartment building. While my brother and the suspect were exchanging gunfire, two newer white Chicago police officers came upon a black man (my brother) with a gun, and he was promptly shot and killed. Of course, exactly what happened is murky, but I have my suspicions. Of course, the suspect also was killed during this shootout, so neither of the two black men involved was left alive to tell his side of the story.

Then there was the time I was in college being advised by my white guidance counselor that I should seek a career in something like auto mechanics. Little did he know that my African American grandfather obtained his PhD from Yale in 1924, and my father, like his father, had a couple of PhDs. What caused him to think I could accomplish only blue-collar goals? Charles Pinderhughes, MD, (another wise black psychiatrist) did an excellent dissertation in the American Journal of Psychiatry on “stereotyping,” that explained much of the reason (1979 Jan;136[1]33-7).

Because I was from Chicago and a psychiatrist, I was called in to evaluate several of the more than 100 innocent black men whom Jon Burge (a former Chicago police commander) allegedly tortured to get them to confess to murders they did not commit. Officer Burge was never found guilty of this crime, but he was sent to federal prison for three counts of obstruction of justice and perjury for lying about police torture.

Accordingly, in Chicago we have a saying, “The police hunt black men.” Of course, this statement rang true when a white Chicago police officer was caught on film shooting a 17-year-old child who may have had a developmental disability – Laquan McDonald – 16 times in October 2014.

Until the perceptions of race are viewed from both sides of the equation, there will continue to be racial strife, and America will not be as strong as it could be. I have tried to present some of the perspectives many black people experience as their reality. Of course, there is another side we as Americans believe in – justice and equality for all.

This election places America at a pivotal crossroads – which path will we take? Will we seek a more perfect union – or a country divided?

Dr. Bell is staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Imagine the following scenario: a hospitalist on the previous shift accepted a patient from another hospital and received a verbal sign-out at the time of acceptance. Now, 14 hours later, a bed at your hospital is finally available. You were advised that the patient was hemodynamically stable, but that was 8 hours ago. The patient arrives in respiratory distress with a blood pressure of 75/40, and phenylephrine running through a 20g IV in the forearm.

A 400-page printout of the patient’s electronic chart arrives – but no discharge summary is found. You are now responsible for stabilizing the patient and getting to the bottom of why your patient decompensated.

The above vignette is the “worst-case” scenario, yet it highlights how treacherous interhospital transfer can be. A recent study, published in the Journal of Hospital Medicine (doi: 10.1002/jhm.2515), found increased in-hospital mortality (adjusted odds ratio 1.36 [1.29-1.43]) for medical interhospital transfer patients as compared with those admitted from the ED. When care is transferred between hospitals, additional hurdles such as lack of face-to-face sign-out, delays in transport and bed availability, and lack of electronic medical record (EMR) interoperability all contribute to miscommunication and may lead to errors in diagnosis and delay of definitive care.

Diametrically opposed to our many victories in providing technologically advanced medical care, our inability to coordinate even the most basic care across hospitals is an unfortunate reality of our fragmented health care system, and must be promptly addressed.

There currently exists no widely accepted standard of care for communication between hospitals regarding transferred patients. Commonalities include a mandatory three-way recorded physician verbal handoff and a transmission of an insurance face sheet. However, real-time concurrent EMR connectivity and clinical status updates as frequently as every 2 hours in critically ill patients are uncommon, as our own study found (doi: 10.1002/jhm.2577).

The lack of a standard of care for interhospital handoffs is, in part, why every transfer is potentially problematic. Many tertiary referral centers receive patients from more than 100 different hospitals and networks, amplifying the need for universal expectations. With differences in expectations among sending and receiving hospitals, there is ample room for variable outcomes, ranging from smooth transfers to the worst-case scenario described above. Enhanced shared decision making between providers at both hospitals, facilitated via communication tools and transfer centers, could lead to more fluid care of the transferred patient.

In order to establish standardized interhospital handoffs, a multicenter study is needed to examine outcomes of various transfer practices. A standard of communication and transfer handoff practices, based on those that lead to better outcomes, could potentially be established. Until this is studied, it is imperative that hospital systems and the government work to adopt broader EMR interoperability and radiology networks; comprehensive health information exchanges can minimize redundancy and provide real-time clinical data to make transfers safer.

Ideally, interhospital transfer should provide no more risk to a patient than a routine shift change of care providers.

Dr. Dana Herrigel is associate program director, internal medicine residency at Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Madeline Carroll is PGY-3 internal medicine at Robert Wood Johnson Medical School.

Imagine the following scenario: a hospitalist on the previous shift accepted a patient from another hospital and received a verbal sign-out at the time of acceptance. Now, 14 hours later, a bed at your hospital is finally available. You were advised that the patient was hemodynamically stable, but that was 8 hours ago. The patient arrives in respiratory distress with a blood pressure of 75/40, and phenylephrine running through a 20g IV in the forearm.

A 400-page printout of the patient’s electronic chart arrives – but no discharge summary is found. You are now responsible for stabilizing the patient and getting to the bottom of why your patient decompensated.

The above vignette is the “worst-case” scenario, yet it highlights how treacherous interhospital transfer can be. A recent study, published in the Journal of Hospital Medicine (doi: 10.1002/jhm.2515), found increased in-hospital mortality (adjusted odds ratio 1.36 [1.29-1.43]) for medical interhospital transfer patients as compared with those admitted from the ED. When care is transferred between hospitals, additional hurdles such as lack of face-to-face sign-out, delays in transport and bed availability, and lack of electronic medical record (EMR) interoperability all contribute to miscommunication and may lead to errors in diagnosis and delay of definitive care.

Diametrically opposed to our many victories in providing technologically advanced medical care, our inability to coordinate even the most basic care across hospitals is an unfortunate reality of our fragmented health care system, and must be promptly addressed.

There currently exists no widely accepted standard of care for communication between hospitals regarding transferred patients. Commonalities include a mandatory three-way recorded physician verbal handoff and a transmission of an insurance face sheet. However, real-time concurrent EMR connectivity and clinical status updates as frequently as every 2 hours in critically ill patients are uncommon, as our own study found (doi: 10.1002/jhm.2577).

The lack of a standard of care for interhospital handoffs is, in part, why every transfer is potentially problematic. Many tertiary referral centers receive patients from more than 100 different hospitals and networks, amplifying the need for universal expectations. With differences in expectations among sending and receiving hospitals, there is ample room for variable outcomes, ranging from smooth transfers to the worst-case scenario described above. Enhanced shared decision making between providers at both hospitals, facilitated via communication tools and transfer centers, could lead to more fluid care of the transferred patient.

In order to establish standardized interhospital handoffs, a multicenter study is needed to examine outcomes of various transfer practices. A standard of communication and transfer handoff practices, based on those that lead to better outcomes, could potentially be established. Until this is studied, it is imperative that hospital systems and the government work to adopt broader EMR interoperability and radiology networks; comprehensive health information exchanges can minimize redundancy and provide real-time clinical data to make transfers safer.

Ideally, interhospital transfer should provide no more risk to a patient than a routine shift change of care providers.

Dr. Dana Herrigel is associate program director, internal medicine residency at Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Madeline Carroll is PGY-3 internal medicine at Robert Wood Johnson Medical School.

Imagine the following scenario: a hospitalist on the previous shift accepted a patient from another hospital and received a verbal sign-out at the time of acceptance. Now, 14 hours later, a bed at your hospital is finally available. You were advised that the patient was hemodynamically stable, but that was 8 hours ago. The patient arrives in respiratory distress with a blood pressure of 75/40, and phenylephrine running through a 20g IV in the forearm.

A 400-page printout of the patient’s electronic chart arrives – but no discharge summary is found. You are now responsible for stabilizing the patient and getting to the bottom of why your patient decompensated.

The above vignette is the “worst-case” scenario, yet it highlights how treacherous interhospital transfer can be. A recent study, published in the Journal of Hospital Medicine (doi: 10.1002/jhm.2515), found increased in-hospital mortality (adjusted odds ratio 1.36 [1.29-1.43]) for medical interhospital transfer patients as compared with those admitted from the ED. When care is transferred between hospitals, additional hurdles such as lack of face-to-face sign-out, delays in transport and bed availability, and lack of electronic medical record (EMR) interoperability all contribute to miscommunication and may lead to errors in diagnosis and delay of definitive care.

Diametrically opposed to our many victories in providing technologically advanced medical care, our inability to coordinate even the most basic care across hospitals is an unfortunate reality of our fragmented health care system, and must be promptly addressed.

There currently exists no widely accepted standard of care for communication between hospitals regarding transferred patients. Commonalities include a mandatory three-way recorded physician verbal handoff and a transmission of an insurance face sheet. However, real-time concurrent EMR connectivity and clinical status updates as frequently as every 2 hours in critically ill patients are uncommon, as our own study found (doi: 10.1002/jhm.2577).

The lack of a standard of care for interhospital handoffs is, in part, why every transfer is potentially problematic. Many tertiary referral centers receive patients from more than 100 different hospitals and networks, amplifying the need for universal expectations. With differences in expectations among sending and receiving hospitals, there is ample room for variable outcomes, ranging from smooth transfers to the worst-case scenario described above. Enhanced shared decision making between providers at both hospitals, facilitated via communication tools and transfer centers, could lead to more fluid care of the transferred patient.

In order to establish standardized interhospital handoffs, a multicenter study is needed to examine outcomes of various transfer practices. A standard of communication and transfer handoff practices, based on those that lead to better outcomes, could potentially be established. Until this is studied, it is imperative that hospital systems and the government work to adopt broader EMR interoperability and radiology networks; comprehensive health information exchanges can minimize redundancy and provide real-time clinical data to make transfers safer.

Ideally, interhospital transfer should provide no more risk to a patient than a routine shift change of care providers.

Dr. Dana Herrigel is associate program director, internal medicine residency at Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Madeline Carroll is PGY-3 internal medicine at Robert Wood Johnson Medical School.

When our second daughter was born, she came home from the hospital in a box. All the babies born at Duke University Medical Center in 1973 were sent home in a cardboard box that had served as their bassinets during their stay in the newborn nursery. As I recall, the boxes were decorated with storks and musical notes; had spaces for the babies’ names, measurements, and birth dates; and had open slots that functioned as carrying handles.

Of course, 1973 predated crash-tested car seats, and so we put little Emily and her box in what we referred to as the “wayback” of our Ford Pinto wagon, a car that subsequently earned a reputation for turning into a fireball when involved in a rear-end collision. However, I believe I did take the extra precaution of “securing” the box in place with a bungee cord.

But Emily survived, and I filed away the memory of her cardboard bassinet until a few weeks ago when I read a story in the New York Times, “Why Finland’s Newborns Sleep in Cardboard Cribs” (Eli Rosenberg, July 6, 2016). It turns out the Finnish government gives out 40,000 cardboard boxes to pregnant women who agree to have a medical exam during the first trimester of their pregnancy. The gift boxes come along with 50 items of baby ware appropriate for Finland’s frigid climate, including a warm coat and a balaclava.

The baby box program began in the late 1930s as a way to encourage mothers to visit physicians. The current Finnish infant mortality is one of the lowest in the world and less than half of ours in the United States. There are some who have been tempted to attribute this dramatic decline to the baby box program. But it is hard to tease out one factor in a country that offers a 10-month paid parental leave and guarantees that a stay-at-home parent may return to his or her job at any time before the child’s third birthday.

Even without a broad social service support system, the cardboard box crib can save lives. For families who can’t afford a crib, the box offers a safer alternative to a couch with soft cushions and face-trapping gaps between its cushions, or to a bed shared with a sleep-deprived or inebriated parent, or to an antique crib with neck-pinching slats and layers of lead-laced paint.

Given this high costs of raising a child, the option of a no-cost cardboard box crib should appeal to most young families. But you know as well as I do that parents to be (and grandparents to be) are primed to buy and are focused on creating nurseries that match the images they see in the glossy magazines targeted at their vulnerable demographic.

It will require a major public relations campaign to counteract the image that bedding one’s precious newborn in a cardboard box conjures up. But maybe there is a role for us. If pediatricians began promoting the advantages of cardboard cribs, they might just catch on. On second thought, maybe we should focus our energies on promoting more child-friendly parental leave policies.

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.”

When our second daughter was born, she came home from the hospital in a box. All the babies born at Duke University Medical Center in 1973 were sent home in a cardboard box that had served as their bassinets during their stay in the newborn nursery. As I recall, the boxes were decorated with storks and musical notes; had spaces for the babies’ names, measurements, and birth dates; and had open slots that functioned as carrying handles.

Of course, 1973 predated crash-tested car seats, and so we put little Emily and her box in what we referred to as the “wayback” of our Ford Pinto wagon, a car that subsequently earned a reputation for turning into a fireball when involved in a rear-end collision. However, I believe I did take the extra precaution of “securing” the box in place with a bungee cord.

But Emily survived, and I filed away the memory of her cardboard bassinet until a few weeks ago when I read a story in the New York Times, “Why Finland’s Newborns Sleep in Cardboard Cribs” (Eli Rosenberg, July 6, 2016). It turns out the Finnish government gives out 40,000 cardboard boxes to pregnant women who agree to have a medical exam during the first trimester of their pregnancy. The gift boxes come along with 50 items of baby ware appropriate for Finland’s frigid climate, including a warm coat and a balaclava.

The baby box program began in the late 1930s as a way to encourage mothers to visit physicians. The current Finnish infant mortality is one of the lowest in the world and less than half of ours in the United States. There are some who have been tempted to attribute this dramatic decline to the baby box program. But it is hard to tease out one factor in a country that offers a 10-month paid parental leave and guarantees that a stay-at-home parent may return to his or her job at any time before the child’s third birthday.

Even without a broad social service support system, the cardboard box crib can save lives. For families who can’t afford a crib, the box offers a safer alternative to a couch with soft cushions and face-trapping gaps between its cushions, or to a bed shared with a sleep-deprived or inebriated parent, or to an antique crib with neck-pinching slats and layers of lead-laced paint.

Given this high costs of raising a child, the option of a no-cost cardboard box crib should appeal to most young families. But you know as well as I do that parents to be (and grandparents to be) are primed to buy and are focused on creating nurseries that match the images they see in the glossy magazines targeted at their vulnerable demographic.

It will require a major public relations campaign to counteract the image that bedding one’s precious newborn in a cardboard box conjures up. But maybe there is a role for us. If pediatricians began promoting the advantages of cardboard cribs, they might just catch on. On second thought, maybe we should focus our energies on promoting more child-friendly parental leave policies.

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.”

When our second daughter was born, she came home from the hospital in a box. All the babies born at Duke University Medical Center in 1973 were sent home in a cardboard box that had served as their bassinets during their stay in the newborn nursery. As I recall, the boxes were decorated with storks and musical notes; had spaces for the babies’ names, measurements, and birth dates; and had open slots that functioned as carrying handles.

Of course, 1973 predated crash-tested car seats, and so we put little Emily and her box in what we referred to as the “wayback” of our Ford Pinto wagon, a car that subsequently earned a reputation for turning into a fireball when involved in a rear-end collision. However, I believe I did take the extra precaution of “securing” the box in place with a bungee cord.

But Emily survived, and I filed away the memory of her cardboard bassinet until a few weeks ago when I read a story in the New York Times, “Why Finland’s Newborns Sleep in Cardboard Cribs” (Eli Rosenberg, July 6, 2016). It turns out the Finnish government gives out 40,000 cardboard boxes to pregnant women who agree to have a medical exam during the first trimester of their pregnancy. The gift boxes come along with 50 items of baby ware appropriate for Finland’s frigid climate, including a warm coat and a balaclava.

The baby box program began in the late 1930s as a way to encourage mothers to visit physicians. The current Finnish infant mortality is one of the lowest in the world and less than half of ours in the United States. There are some who have been tempted to attribute this dramatic decline to the baby box program. But it is hard to tease out one factor in a country that offers a 10-month paid parental leave and guarantees that a stay-at-home parent may return to his or her job at any time before the child’s third birthday.

Even without a broad social service support system, the cardboard box crib can save lives. For families who can’t afford a crib, the box offers a safer alternative to a couch with soft cushions and face-trapping gaps between its cushions, or to a bed shared with a sleep-deprived or inebriated parent, or to an antique crib with neck-pinching slats and layers of lead-laced paint.

Given this high costs of raising a child, the option of a no-cost cardboard box crib should appeal to most young families. But you know as well as I do that parents to be (and grandparents to be) are primed to buy and are focused on creating nurseries that match the images they see in the glossy magazines targeted at their vulnerable demographic.

It will require a major public relations campaign to counteract the image that bedding one’s precious newborn in a cardboard box conjures up. But maybe there is a role for us. If pediatricians began promoting the advantages of cardboard cribs, they might just catch on. On second thought, maybe we should focus our energies on promoting more child-friendly parental leave policies.

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.”