Commentary

Story

M.S. was an 89-year-old woman whose medical history was consistent with chronic mesenteric ischemia (weight loss, postprandial abdominal pain, diarrhea), and a 6-cm infrarenal aortic aneurysm for which she had previously declined surgery. She was admitted to the hospital with increased abdominal pain (constant, and unrelated to meals), bloody stools, nausea with emesis, a profound leukocytosis (WBC, 56,000 cells/mcL) and renal insufficiency (creatinine ratio, 1.63 mg/dL). One week prior to this admission, she had been discharged from the same hospital following treatment for urosepsis. She had just finished 10 days of antibiotics (ceftriaxone and cephalexin) the day before this admission.

CDC / Jennifer Hulsey

M.S. was admitted to a regular nursing floor by Dr. Hospitalist 1 and started on intravenous fluids (2L, then hep-lock) plus oral metronidazole (for suspected Clostridium difficile infection [CDI]) and oral ciprofloxacin (for possible infectious colitis/diverticulitis). No abdominal imaging was performed by the emergency room or Dr. Hospitalist 1.

For the next 2 days, M.S. was seen daily by Dr. Hospitalist 2 in conjunction with a GI consultant. The GI consultant discontinued the ciprofloxacin and both were awaiting the results of the C. difficile toxin assay. M.S. continued to have leukocytosis (WBC 36,000 cells/mcL) with a heart rate consistently greater than 90 beats/min. However, M.S. was able to achieve adequate abdominal pain control with oral acetaminophen, and she was taking a liquid diet. Dr. Hospitalist 2 commented in his progress notes that M.S. was improving clinically.

At 11 p.m. of hospital day 2, M.S. suffered a fall from her bedside commode and hit her head, causing a laceration. Nurses noted she was lethargic and hypotensive (BP 80/50 mm Hg) with labored breathing. Dr. Hospitalist 3 was contacted, but deferred a physical assessment in favor of restarting intravenous fluids (the IV fluids ordered on admission had been discontinued earlier that afternoon) and obtaining an arterial blood gas. One hour later, M.S. had a BP 102/65 mm Hg with saline running at 150 cc/hr. The arterial blood gas demonstrated a mixed respiratory and metabolic acidosis (pH, 7.06; PaCO₂ 21 mm Hg). Dr. Hospitalist 3 continued to defer a physical assessment and ordered a repeat arterial blood gas that showed a worsening respiratory and metabolic acidosis (pH, 7.00; PaCO₂ 37 mm Hg).

At 3 a.m., the nurses called a rapid response team for lethargy and tachypnea, and M.S. quickly lost her pulse. M.S. was a "Do not resuscitate/Do not intubate" patient, and she was therefore pronounced dead. No autopsy was performed.

Complaint

Although M.S. was 89 years old, the family was surprised at her passing. Prior to her last two admissions (urosepsis and this index event), M.S. was independent, lived in her own home, hosted a weekly bridge club, and routinely interacted with family and friends.

The family was particularly troubled by the laceration on her forehead, which at the time of her death, was a deep enough wound to have required stitches for closure (which had not been performed antemortem). The laceration led to discovery of the fall, which the led to the realization that no physician went to see M.S. prior to her death. The family was suspicious and contacted an attorney who had the case reviewed and subsequently filed suit.

The complaint alleged that all of the hospitalists failed to appreciate, appropriately monitor, and appropriately treat severe CDI with severe sepsis. The complaint further alleged that Dr. Hospitalist 3 breached the standard of care by failing to attend to M.S. after her fall and initiating therapies for her acidosis.

Scientific principles

C. difficile infection is one of the most common hospital-acquired (nosocomial) infections and is an increasingly frequent cause of morbidity and mortality among elderly hospitalized patients. Patients with acute CDI may develop signs of systemic toxicity with or without profuse diarrhea warranting admission to an ICU or for emergency surgery.

Guideline parameters for severe CDI include WBC count of more than 15,000 cells/mcL or a serum creatinine level equal to 1.5 times the premorbid level. Patients with severe disease should be treated with oral vancomycin (125 mg to 500 mg q.i.d.). In the setting of ileus, addition of IV metronidazole (500 mg every 8 hours) is appropriate. Intracolonic vancomycin may be considered in patients with profound ileus. Some severely ill patients with CDI require surgical intervention as a result of toxic megacolon, perforation, or impending perforation, necrotizing colitis or rapidly progressive and/or refractory disease with systemic inflammatory response syndrome leading to multiorgan system failure

Complaint rebuttal and discussion

Without an autopsy (or abdominal imaging of any kind), defense experts first argued that M.S. died from a progression of her mesenteric ischemia (gangrene, with or without perforation), not CDI. The defense further argued that if M.S. did have severe CDI, then she ultimately would have needed surgery (regardless of appropriate fluid resuscitation, ICU care, and appropriate antibiotics), and she was not an operative candidate. If M.S. had gone for surgery, she would have in all probability died intraoperatively.

In sum, the defense focused on causation, not the failures of the hospitalists to treat severe CDI. The plaintiff maintained that severe CDI was far more likely than acute mesenteric thrombosis (given her clinical presentation and pain control with acetaminophen), and that had appropriate and timely treatment been given, M.S.’s severe CDI was a reversible condition without surgery.

Conclusion

This case further highlights the importance of family perception in the circumstances surrounding death. If M.S. had not fallen and suffered a visible injury, or if Dr. Hospitalist 3 had responded immediately to the fall with care and treatment, it is very likely that this case would not have been filed.

Nonetheless, the hospitalist care appeared deficient in several important aspects – particularly the approach to sepsis and the possibility of severe CDI. Also, it is not easy to defend a hospitalist who failed to respond to an 89-year-old inpatient who is status post a fall with a deep forehead laceration and a pH of less than 7.1. That being said, this case went to trial, and the hospitalists received a full defense verdict from the jury.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.

Story

M.S. was an 89-year-old woman whose medical history was consistent with chronic mesenteric ischemia (weight loss, postprandial abdominal pain, diarrhea), and a 6-cm infrarenal aortic aneurysm for which she had previously declined surgery. She was admitted to the hospital with increased abdominal pain (constant, and unrelated to meals), bloody stools, nausea with emesis, a profound leukocytosis (WBC, 56,000 cells/mcL) and renal insufficiency (creatinine ratio, 1.63 mg/dL). One week prior to this admission, she had been discharged from the same hospital following treatment for urosepsis. She had just finished 10 days of antibiotics (ceftriaxone and cephalexin) the day before this admission.

CDC / Jennifer Hulsey

M.S. was admitted to a regular nursing floor by Dr. Hospitalist 1 and started on intravenous fluids (2L, then hep-lock) plus oral metronidazole (for suspected Clostridium difficile infection [CDI]) and oral ciprofloxacin (for possible infectious colitis/diverticulitis). No abdominal imaging was performed by the emergency room or Dr. Hospitalist 1.

For the next 2 days, M.S. was seen daily by Dr. Hospitalist 2 in conjunction with a GI consultant. The GI consultant discontinued the ciprofloxacin and both were awaiting the results of the C. difficile toxin assay. M.S. continued to have leukocytosis (WBC 36,000 cells/mcL) with a heart rate consistently greater than 90 beats/min. However, M.S. was able to achieve adequate abdominal pain control with oral acetaminophen, and she was taking a liquid diet. Dr. Hospitalist 2 commented in his progress notes that M.S. was improving clinically.

At 11 p.m. of hospital day 2, M.S. suffered a fall from her bedside commode and hit her head, causing a laceration. Nurses noted she was lethargic and hypotensive (BP 80/50 mm Hg) with labored breathing. Dr. Hospitalist 3 was contacted, but deferred a physical assessment in favor of restarting intravenous fluids (the IV fluids ordered on admission had been discontinued earlier that afternoon) and obtaining an arterial blood gas. One hour later, M.S. had a BP 102/65 mm Hg with saline running at 150 cc/hr. The arterial blood gas demonstrated a mixed respiratory and metabolic acidosis (pH, 7.06; PaCO₂ 21 mm Hg). Dr. Hospitalist 3 continued to defer a physical assessment and ordered a repeat arterial blood gas that showed a worsening respiratory and metabolic acidosis (pH, 7.00; PaCO₂ 37 mm Hg).

At 3 a.m., the nurses called a rapid response team for lethargy and tachypnea, and M.S. quickly lost her pulse. M.S. was a "Do not resuscitate/Do not intubate" patient, and she was therefore pronounced dead. No autopsy was performed.

Complaint

Although M.S. was 89 years old, the family was surprised at her passing. Prior to her last two admissions (urosepsis and this index event), M.S. was independent, lived in her own home, hosted a weekly bridge club, and routinely interacted with family and friends.

The family was particularly troubled by the laceration on her forehead, which at the time of her death, was a deep enough wound to have required stitches for closure (which had not been performed antemortem). The laceration led to discovery of the fall, which the led to the realization that no physician went to see M.S. prior to her death. The family was suspicious and contacted an attorney who had the case reviewed and subsequently filed suit.

The complaint alleged that all of the hospitalists failed to appreciate, appropriately monitor, and appropriately treat severe CDI with severe sepsis. The complaint further alleged that Dr. Hospitalist 3 breached the standard of care by failing to attend to M.S. after her fall and initiating therapies for her acidosis.

Scientific principles

C. difficile infection is one of the most common hospital-acquired (nosocomial) infections and is an increasingly frequent cause of morbidity and mortality among elderly hospitalized patients. Patients with acute CDI may develop signs of systemic toxicity with or without profuse diarrhea warranting admission to an ICU or for emergency surgery.

Guideline parameters for severe CDI include WBC count of more than 15,000 cells/mcL or a serum creatinine level equal to 1.5 times the premorbid level. Patients with severe disease should be treated with oral vancomycin (125 mg to 500 mg q.i.d.). In the setting of ileus, addition of IV metronidazole (500 mg every 8 hours) is appropriate. Intracolonic vancomycin may be considered in patients with profound ileus. Some severely ill patients with CDI require surgical intervention as a result of toxic megacolon, perforation, or impending perforation, necrotizing colitis or rapidly progressive and/or refractory disease with systemic inflammatory response syndrome leading to multiorgan system failure

Complaint rebuttal and discussion

Without an autopsy (or abdominal imaging of any kind), defense experts first argued that M.S. died from a progression of her mesenteric ischemia (gangrene, with or without perforation), not CDI. The defense further argued that if M.S. did have severe CDI, then she ultimately would have needed surgery (regardless of appropriate fluid resuscitation, ICU care, and appropriate antibiotics), and she was not an operative candidate. If M.S. had gone for surgery, she would have in all probability died intraoperatively.

In sum, the defense focused on causation, not the failures of the hospitalists to treat severe CDI. The plaintiff maintained that severe CDI was far more likely than acute mesenteric thrombosis (given her clinical presentation and pain control with acetaminophen), and that had appropriate and timely treatment been given, M.S.’s severe CDI was a reversible condition without surgery.

Conclusion

This case further highlights the importance of family perception in the circumstances surrounding death. If M.S. had not fallen and suffered a visible injury, or if Dr. Hospitalist 3 had responded immediately to the fall with care and treatment, it is very likely that this case would not have been filed.

Nonetheless, the hospitalist care appeared deficient in several important aspects – particularly the approach to sepsis and the possibility of severe CDI. Also, it is not easy to defend a hospitalist who failed to respond to an 89-year-old inpatient who is status post a fall with a deep forehead laceration and a pH of less than 7.1. That being said, this case went to trial, and the hospitalists received a full defense verdict from the jury.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.

Story

M.S. was an 89-year-old woman whose medical history was consistent with chronic mesenteric ischemia (weight loss, postprandial abdominal pain, diarrhea), and a 6-cm infrarenal aortic aneurysm for which she had previously declined surgery. She was admitted to the hospital with increased abdominal pain (constant, and unrelated to meals), bloody stools, nausea with emesis, a profound leukocytosis (WBC, 56,000 cells/mcL) and renal insufficiency (creatinine ratio, 1.63 mg/dL). One week prior to this admission, she had been discharged from the same hospital following treatment for urosepsis. She had just finished 10 days of antibiotics (ceftriaxone and cephalexin) the day before this admission.

CDC / Jennifer Hulsey

M.S. was admitted to a regular nursing floor by Dr. Hospitalist 1 and started on intravenous fluids (2L, then hep-lock) plus oral metronidazole (for suspected Clostridium difficile infection [CDI]) and oral ciprofloxacin (for possible infectious colitis/diverticulitis). No abdominal imaging was performed by the emergency room or Dr. Hospitalist 1.

For the next 2 days, M.S. was seen daily by Dr. Hospitalist 2 in conjunction with a GI consultant. The GI consultant discontinued the ciprofloxacin and both were awaiting the results of the C. difficile toxin assay. M.S. continued to have leukocytosis (WBC 36,000 cells/mcL) with a heart rate consistently greater than 90 beats/min. However, M.S. was able to achieve adequate abdominal pain control with oral acetaminophen, and she was taking a liquid diet. Dr. Hospitalist 2 commented in his progress notes that M.S. was improving clinically.

At 11 p.m. of hospital day 2, M.S. suffered a fall from her bedside commode and hit her head, causing a laceration. Nurses noted she was lethargic and hypotensive (BP 80/50 mm Hg) with labored breathing. Dr. Hospitalist 3 was contacted, but deferred a physical assessment in favor of restarting intravenous fluids (the IV fluids ordered on admission had been discontinued earlier that afternoon) and obtaining an arterial blood gas. One hour later, M.S. had a BP 102/65 mm Hg with saline running at 150 cc/hr. The arterial blood gas demonstrated a mixed respiratory and metabolic acidosis (pH, 7.06; PaCO₂ 21 mm Hg). Dr. Hospitalist 3 continued to defer a physical assessment and ordered a repeat arterial blood gas that showed a worsening respiratory and metabolic acidosis (pH, 7.00; PaCO₂ 37 mm Hg).

At 3 a.m., the nurses called a rapid response team for lethargy and tachypnea, and M.S. quickly lost her pulse. M.S. was a "Do not resuscitate/Do not intubate" patient, and she was therefore pronounced dead. No autopsy was performed.

Complaint

Although M.S. was 89 years old, the family was surprised at her passing. Prior to her last two admissions (urosepsis and this index event), M.S. was independent, lived in her own home, hosted a weekly bridge club, and routinely interacted with family and friends.

The family was particularly troubled by the laceration on her forehead, which at the time of her death, was a deep enough wound to have required stitches for closure (which had not been performed antemortem). The laceration led to discovery of the fall, which the led to the realization that no physician went to see M.S. prior to her death. The family was suspicious and contacted an attorney who had the case reviewed and subsequently filed suit.

The complaint alleged that all of the hospitalists failed to appreciate, appropriately monitor, and appropriately treat severe CDI with severe sepsis. The complaint further alleged that Dr. Hospitalist 3 breached the standard of care by failing to attend to M.S. after her fall and initiating therapies for her acidosis.

Scientific principles

C. difficile infection is one of the most common hospital-acquired (nosocomial) infections and is an increasingly frequent cause of morbidity and mortality among elderly hospitalized patients. Patients with acute CDI may develop signs of systemic toxicity with or without profuse diarrhea warranting admission to an ICU or for emergency surgery.

Guideline parameters for severe CDI include WBC count of more than 15,000 cells/mcL or a serum creatinine level equal to 1.5 times the premorbid level. Patients with severe disease should be treated with oral vancomycin (125 mg to 500 mg q.i.d.). In the setting of ileus, addition of IV metronidazole (500 mg every 8 hours) is appropriate. Intracolonic vancomycin may be considered in patients with profound ileus. Some severely ill patients with CDI require surgical intervention as a result of toxic megacolon, perforation, or impending perforation, necrotizing colitis or rapidly progressive and/or refractory disease with systemic inflammatory response syndrome leading to multiorgan system failure

Complaint rebuttal and discussion

Without an autopsy (or abdominal imaging of any kind), defense experts first argued that M.S. died from a progression of her mesenteric ischemia (gangrene, with or without perforation), not CDI. The defense further argued that if M.S. did have severe CDI, then she ultimately would have needed surgery (regardless of appropriate fluid resuscitation, ICU care, and appropriate antibiotics), and she was not an operative candidate. If M.S. had gone for surgery, she would have in all probability died intraoperatively.

In sum, the defense focused on causation, not the failures of the hospitalists to treat severe CDI. The plaintiff maintained that severe CDI was far more likely than acute mesenteric thrombosis (given her clinical presentation and pain control with acetaminophen), and that had appropriate and timely treatment been given, M.S.’s severe CDI was a reversible condition without surgery.

Conclusion

This case further highlights the importance of family perception in the circumstances surrounding death. If M.S. had not fallen and suffered a visible injury, or if Dr. Hospitalist 3 had responded immediately to the fall with care and treatment, it is very likely that this case would not have been filed.

Nonetheless, the hospitalist care appeared deficient in several important aspects – particularly the approach to sepsis and the possibility of severe CDI. Also, it is not easy to defend a hospitalist who failed to respond to an 89-year-old inpatient who is status post a fall with a deep forehead laceration and a pH of less than 7.1. That being said, this case went to trial, and the hospitalists received a full defense verdict from the jury.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.

Intra-abdominal (intracorporeal) morcellation, especially electronically powered morcellation, has recently come under scrutiny. Generally performed at the time of conventional laparoscopic or robotic supracervical hysterectomy, total hysterectomy for the large uterus, or myomectomy, both power and cold-knife morcellation may splatter tissue fragments in the pelvis and abdomen, leading to potential parasitizing of the tissue and ectopic growth. Recent evidence indicates inadvertent morcellation of a leiomyosarcoma may negatively affect the patient’s subsequent disease-free survival and overall survival.

Concerns about morcellation heightened after Dr. Amy J. Reed, an anesthesiologist at Beth Israel Deaconess Medical Center, Boston, and a mother of 6, underwent presumed fibroid surgery and was diagnosed, post morcellation, with leiomyosarcoma. Dr. Reed’s husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital, Boston, where his wife’s surgery was performed, is calling for a moratorium on intra-abdominal morcellation, whether it involves the use of a power morcellator, or for that matter, the cold knife.

Images courtesy Dr. Charles E. Miller

It is imperative and incumbent upon our specialty to have a detailed evaluation of the risks and benefits of morcellation. While morcellation of the rare leiomyosarcoma is a risk, banning intraabdominal/intrapelvic morcellation will certainly have a profound negative impact on patients who are able to undergo a minimally invasive gynecologic procedure. Banning morcellation would increase intraoperative risk and subsequent concern of postoperative pelvic adhesions and thus, potential impact on fertility (post myomectomy), dyspareunia, and pelvic pain. Further, a ban would incur higher costs and more loss of patient productivity (Hum. Reprod. 1998 13:2102-6). These concerns were the basis for the AAGL position statement touting a minimally invasive approach to hysterectomy (J. Minim. Invasive Gynecol. 2011;18:1-3).

Since their introduction in the mid-1990s, electronically powered morcellators have been used to remove the uterus, fibroid(s), spleen, or kidney. Varying in size from 12-20 mm, electronic morcellators generally consist of a rotating circular blade at the end of a hollow tube. A tenaculum or multitoothed grasper is placed through the tube and blade to grasp the tissue to the revolving blade. The specimen is then removed in strips. Tissue splatter is inevitable, at least until the technique evolves to allow morcellation to be performed within the confines of a bag.

Benign uterine fibroids are the most common pelvic tumor in women. Literature reviews indicate the lifetime risk is 70% for white women and 80% in women of African ancestry. Uterine sarcomas occur in 3-7 women per 100,000 (Am. J. Obstet. Gynecol. 2011;205:492.e1-5). Further, Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and Dr. Ceana H. Dr. Nezhat of Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, conducted a meta-analysis of 5,666 uterine procedures, and found 13 unsuspected uterine sarcomas, for a prevalence of 0.23% (JAMA 2014 [doi:10.1001/jama.2014.1093]).

Images courtesy Dr. Charles E. Miller

This finding is consistent with that of a previous study by Dr. W.H. Parker who also noted a 0.23% risk, based on data from 1,332 women undergoing surgery secondary to uterine fibroids. Interestingly, in Dr. Parker’s study, the risk was 0.27% among women with rapidly growing leiomyoma, often thought to be a risk factor for sarcoma development (Obstet. Gynecol. 1994;83:414-8).

Because of the difficulty of making a preoperative diagnosis of leiomyosarcoma, it is doubtful that this risk will be decreased in the near future. Risk factors have not been well established, although a twofold higher incidence of leiomyosarcomas has been observed in black women (Gynecol. Oncol. 2004;93:204-8). Increasing age would appear to increase uterine sarcoma risk, as the majority of cases are diagnosed in postmenopausal women. Tamoxifen, when used for 5 or more years, appears to be associated with higher sarcoma rates (J. Clin. Oncol. 2002;20:2758-60) as is a history of pelvic irradiation or childhood retinoblastoma.

Unless metastatic disease is present, symptoms are similar for leiomyomas and leiomyosarcomas. A rapidly growing mass, a finding associated with an increased risk of uterine sarcoma, was not seen in Parker’s study of 1,332 women undergoing hysterectomy or myomectomy for uterine leiomyoma. Similarly, size does not count; a large uterine mass or increased uterine size did not appear to be associated with a greater risk of sarcoma (Gynecol. Oncol. 2003;89:460-9).

Some contend that failed response with such therapies as gonadotropin-releasing hormone agonists and uterine artery embolization are associated with increased incidence of leiomyosarcoma, but the data are not convincing (Eur. J. Obstet. Gynecol. Reprod. Biol. 1998;76:237-40).

Physical examination and imaging may be helpful in finding enlarged lymph nodes, but imaging methods have not been reliably shown to enable a preoperative diagnosis of uterine leiomyosarcoma (Lancet Oncol. 2009;10:1188-98; AJR Am. J. Roentgenol. 2003;181:1369-74). Further, while some physicians point out that an ill-defined margin may increase leiomyosarcoma risk, this finding is certainly noted as well with benign adenomyomas.

Finally, data are scant in support of preoperative endometrial sampling to establish a diagnosis of leiomyosarcoma. In two studies comparing a total of 14 patients, 7 were correctly diagnosed with leiomyosarcoma prior to surgery (Am. J. Obstet. Gynecol. 1990;162:968-74; Gynecol. Oncol. 2008;110:43-8).

With little differentiation in clinical presentation and the inability to distinguish leiomyoma from leiomyosarcoma based on imaging or sampling, it is not surprising that patients undergoing morcellation for an expected benign condition would subsequently be diagnosed with uterine leiomyosarcoma. With this in mind, it is important to review the current body of literature to further evaluate the risks and benefits of morcellation, and what place minimally invasive gynecologic surgery will have for the treatment of uterine masses.

Tumor morcellation of unrecognized leiomyosarcomas was significantly associated with poorer disease free survival (odds ratio, 2.59, P = 1.43), higher stage (I vs. II; [OR, 19.12, P = .037]) and poorer overall survival (OR, 3.07, P =.040) in a 2011 study. Park et al. assessed 56 consecutive patients, 25 with morcellation and 31 without tumor morcellation, who had stage I and stage II uterine leiomyosarcomas and were treated between 1989 and 2010. The percentage of patients with dissemination also was noted to be greater in patients with tumor morcellation (44% vs. 12.9%, P =.032). Interestingly, ovarian tissue was more frequently preserved in the morcellation group (38.7% vs. 72%, P =.013) (Gynecol. Oncol. 2011;122:255-9)

In response to a subsequent Letter to the Editor about these risks, the study’s author put the findings in perspective. "The frequency of incidental uterine leiomyosarcoma in patients who undergo surgery for presumed uterine leiomyoma is extremely rare. At our medical center, only 49 of 22,825 patients (0.21%) who underwent surgery for presumed uterine leiomyoma had incidental uterine leiomyosarcoma. Therefore, we believe that surgeons need not avoid non-laparotomic* surgical routes because of the rare possibility of an incidental diagnosis of leiomyosarcoma, even when tumor morcellation is required" (Gynecol. Oncol. 2012;124:172-3).

Additionally, a retrospective study from Brigham & Women’s Hospital found that disease was often already disseminated before morcellation procedures. In 21 patients with a median age of 46 years and no documented evidence of extrauterine disease, 15 had uterine leiomyosarcomas and 6 had smooth muscle tumors of uncertain malignant potential that were inadvertently morcellated; data was incorporated from January 2005 to January 2012. While most patients underwent power morcellation with laparoscopy, two underwent laparoscopically assisted vaginal hysterectomy with hand morcellation, and one patient had a vaginal hysterectomy with hand morcellation.

Immediate surgical reexploration was performed for staging in 12 patients. Significant findings of disseminated intraperitoneal disease were detected in two of seven patients with presumed stage I uterine leiomyosarcoma and in one of four patients with presumed stage I smooth muscle tumors of uncertain malignant potential. Moreover, of the eight patients who did not have disseminated disease at the time of the staging procedure, one subsequently had a recurrence. The remaining patients had no recurrences and remain disease free.

One patient was already FIGO stage IV at the original surgery, two more patients were upstaged at the original surgery and underwent re-exploration at 18 and 20 months respectively (certainly, a long period prior to second look). Moreover, the authors note various reasons why a significant number of patients were upstaged; including incorrect staging after initial surgery, progression of disease during the time interval, or secondary to direct seeding of morcellated tumor fragments. Five of the 15 leiomyosarcoma patients were deceased at the time of the publication. The authors also point out that their study is limited by the fact that it is retrospective, and access to information regarding care received from non-affiliated institutions is limited (Gynecol. Oncol. 2014;132:360-5).

In summary, morcellation of an unsuspected uterine sarcoma, whether using an electrically powered morcellator at the time of laparoscopy or cold knife at time of vaginal surgery, appears to have a negative impact; however, the studies to date are merely retrospective case studies. By no means do they provide the evidence required to place a moratorium on morcellation.

Further, if such a ban is imposed, would it then not be equally justifiable to pose similar regulations on use of oral contraceptives for symptom relief, endometrial ablation when fibroids are involved, or for that matter, uterine artery embolization? All these potential treatment regimens delay diagnosis and treatment and leave the potential uterine sarcoma in situ.

In the end, while the disease-free survival as well as overall survival appears to be hindered by dissemination of leiomyosarcoma at time of both electronic and cold-knife morcellation, the diagnosis is fortunately rare. A moratorium on the technique, however, would increase the number of concomitant laparotomies that would be required, and along with it, the increased inherent risk as well as prolonged recovery. At the present time, without better diagnostic tools or safer morcellation techniques, it is imperative to have an open dialogue of the risks and benefits of morcellation and minimally invasive surgery with patients presenting with anticipated fibroids. Additionally, our industry partners must be empowered to create safer morcellation techniques. This would appear to be morcellation within a bag.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. Dr. Miller said he is a consultant for Ethicon, which manufactures a morcellator.

*Correction, 3/19/2014: An earlier version of this story misstated the type of surgical route.

Intra-abdominal (intracorporeal) morcellation, especially electronically powered morcellation, has recently come under scrutiny. Generally performed at the time of conventional laparoscopic or robotic supracervical hysterectomy, total hysterectomy for the large uterus, or myomectomy, both power and cold-knife morcellation may splatter tissue fragments in the pelvis and abdomen, leading to potential parasitizing of the tissue and ectopic growth. Recent evidence indicates inadvertent morcellation of a leiomyosarcoma may negatively affect the patient’s subsequent disease-free survival and overall survival.

Concerns about morcellation heightened after Dr. Amy J. Reed, an anesthesiologist at Beth Israel Deaconess Medical Center, Boston, and a mother of 6, underwent presumed fibroid surgery and was diagnosed, post morcellation, with leiomyosarcoma. Dr. Reed’s husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital, Boston, where his wife’s surgery was performed, is calling for a moratorium on intra-abdominal morcellation, whether it involves the use of a power morcellator, or for that matter, the cold knife.

Images courtesy Dr. Charles E. Miller

It is imperative and incumbent upon our specialty to have a detailed evaluation of the risks and benefits of morcellation. While morcellation of the rare leiomyosarcoma is a risk, banning intraabdominal/intrapelvic morcellation will certainly have a profound negative impact on patients who are able to undergo a minimally invasive gynecologic procedure. Banning morcellation would increase intraoperative risk and subsequent concern of postoperative pelvic adhesions and thus, potential impact on fertility (post myomectomy), dyspareunia, and pelvic pain. Further, a ban would incur higher costs and more loss of patient productivity (Hum. Reprod. 1998 13:2102-6). These concerns were the basis for the AAGL position statement touting a minimally invasive approach to hysterectomy (J. Minim. Invasive Gynecol. 2011;18:1-3).

Since their introduction in the mid-1990s, electronically powered morcellators have been used to remove the uterus, fibroid(s), spleen, or kidney. Varying in size from 12-20 mm, electronic morcellators generally consist of a rotating circular blade at the end of a hollow tube. A tenaculum or multitoothed grasper is placed through the tube and blade to grasp the tissue to the revolving blade. The specimen is then removed in strips. Tissue splatter is inevitable, at least until the technique evolves to allow morcellation to be performed within the confines of a bag.

Benign uterine fibroids are the most common pelvic tumor in women. Literature reviews indicate the lifetime risk is 70% for white women and 80% in women of African ancestry. Uterine sarcomas occur in 3-7 women per 100,000 (Am. J. Obstet. Gynecol. 2011;205:492.e1-5). Further, Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and Dr. Ceana H. Dr. Nezhat of Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, conducted a meta-analysis of 5,666 uterine procedures, and found 13 unsuspected uterine sarcomas, for a prevalence of 0.23% (JAMA 2014 [doi:10.1001/jama.2014.1093]).

Images courtesy Dr. Charles E. Miller

This finding is consistent with that of a previous study by Dr. W.H. Parker who also noted a 0.23% risk, based on data from 1,332 women undergoing surgery secondary to uterine fibroids. Interestingly, in Dr. Parker’s study, the risk was 0.27% among women with rapidly growing leiomyoma, often thought to be a risk factor for sarcoma development (Obstet. Gynecol. 1994;83:414-8).

Because of the difficulty of making a preoperative diagnosis of leiomyosarcoma, it is doubtful that this risk will be decreased in the near future. Risk factors have not been well established, although a twofold higher incidence of leiomyosarcomas has been observed in black women (Gynecol. Oncol. 2004;93:204-8). Increasing age would appear to increase uterine sarcoma risk, as the majority of cases are diagnosed in postmenopausal women. Tamoxifen, when used for 5 or more years, appears to be associated with higher sarcoma rates (J. Clin. Oncol. 2002;20:2758-60) as is a history of pelvic irradiation or childhood retinoblastoma.

Unless metastatic disease is present, symptoms are similar for leiomyomas and leiomyosarcomas. A rapidly growing mass, a finding associated with an increased risk of uterine sarcoma, was not seen in Parker’s study of 1,332 women undergoing hysterectomy or myomectomy for uterine leiomyoma. Similarly, size does not count; a large uterine mass or increased uterine size did not appear to be associated with a greater risk of sarcoma (Gynecol. Oncol. 2003;89:460-9).

Some contend that failed response with such therapies as gonadotropin-releasing hormone agonists and uterine artery embolization are associated with increased incidence of leiomyosarcoma, but the data are not convincing (Eur. J. Obstet. Gynecol. Reprod. Biol. 1998;76:237-40).

Physical examination and imaging may be helpful in finding enlarged lymph nodes, but imaging methods have not been reliably shown to enable a preoperative diagnosis of uterine leiomyosarcoma (Lancet Oncol. 2009;10:1188-98; AJR Am. J. Roentgenol. 2003;181:1369-74). Further, while some physicians point out that an ill-defined margin may increase leiomyosarcoma risk, this finding is certainly noted as well with benign adenomyomas.

Finally, data are scant in support of preoperative endometrial sampling to establish a diagnosis of leiomyosarcoma. In two studies comparing a total of 14 patients, 7 were correctly diagnosed with leiomyosarcoma prior to surgery (Am. J. Obstet. Gynecol. 1990;162:968-74; Gynecol. Oncol. 2008;110:43-8).

With little differentiation in clinical presentation and the inability to distinguish leiomyoma from leiomyosarcoma based on imaging or sampling, it is not surprising that patients undergoing morcellation for an expected benign condition would subsequently be diagnosed with uterine leiomyosarcoma. With this in mind, it is important to review the current body of literature to further evaluate the risks and benefits of morcellation, and what place minimally invasive gynecologic surgery will have for the treatment of uterine masses.

Tumor morcellation of unrecognized leiomyosarcomas was significantly associated with poorer disease free survival (odds ratio, 2.59, P = 1.43), higher stage (I vs. II; [OR, 19.12, P = .037]) and poorer overall survival (OR, 3.07, P =.040) in a 2011 study. Park et al. assessed 56 consecutive patients, 25 with morcellation and 31 without tumor morcellation, who had stage I and stage II uterine leiomyosarcomas and were treated between 1989 and 2010. The percentage of patients with dissemination also was noted to be greater in patients with tumor morcellation (44% vs. 12.9%, P =.032). Interestingly, ovarian tissue was more frequently preserved in the morcellation group (38.7% vs. 72%, P =.013) (Gynecol. Oncol. 2011;122:255-9)

In response to a subsequent Letter to the Editor about these risks, the study’s author put the findings in perspective. "The frequency of incidental uterine leiomyosarcoma in patients who undergo surgery for presumed uterine leiomyoma is extremely rare. At our medical center, only 49 of 22,825 patients (0.21%) who underwent surgery for presumed uterine leiomyoma had incidental uterine leiomyosarcoma. Therefore, we believe that surgeons need not avoid non-laparotomic* surgical routes because of the rare possibility of an incidental diagnosis of leiomyosarcoma, even when tumor morcellation is required" (Gynecol. Oncol. 2012;124:172-3).

Additionally, a retrospective study from Brigham & Women’s Hospital found that disease was often already disseminated before morcellation procedures. In 21 patients with a median age of 46 years and no documented evidence of extrauterine disease, 15 had uterine leiomyosarcomas and 6 had smooth muscle tumors of uncertain malignant potential that were inadvertently morcellated; data was incorporated from January 2005 to January 2012. While most patients underwent power morcellation with laparoscopy, two underwent laparoscopically assisted vaginal hysterectomy with hand morcellation, and one patient had a vaginal hysterectomy with hand morcellation.

Immediate surgical reexploration was performed for staging in 12 patients. Significant findings of disseminated intraperitoneal disease were detected in two of seven patients with presumed stage I uterine leiomyosarcoma and in one of four patients with presumed stage I smooth muscle tumors of uncertain malignant potential. Moreover, of the eight patients who did not have disseminated disease at the time of the staging procedure, one subsequently had a recurrence. The remaining patients had no recurrences and remain disease free.

One patient was already FIGO stage IV at the original surgery, two more patients were upstaged at the original surgery and underwent re-exploration at 18 and 20 months respectively (certainly, a long period prior to second look). Moreover, the authors note various reasons why a significant number of patients were upstaged; including incorrect staging after initial surgery, progression of disease during the time interval, or secondary to direct seeding of morcellated tumor fragments. Five of the 15 leiomyosarcoma patients were deceased at the time of the publication. The authors also point out that their study is limited by the fact that it is retrospective, and access to information regarding care received from non-affiliated institutions is limited (Gynecol. Oncol. 2014;132:360-5).

In summary, morcellation of an unsuspected uterine sarcoma, whether using an electrically powered morcellator at the time of laparoscopy or cold knife at time of vaginal surgery, appears to have a negative impact; however, the studies to date are merely retrospective case studies. By no means do they provide the evidence required to place a moratorium on morcellation.

Further, if such a ban is imposed, would it then not be equally justifiable to pose similar regulations on use of oral contraceptives for symptom relief, endometrial ablation when fibroids are involved, or for that matter, uterine artery embolization? All these potential treatment regimens delay diagnosis and treatment and leave the potential uterine sarcoma in situ.

In the end, while the disease-free survival as well as overall survival appears to be hindered by dissemination of leiomyosarcoma at time of both electronic and cold-knife morcellation, the diagnosis is fortunately rare. A moratorium on the technique, however, would increase the number of concomitant laparotomies that would be required, and along with it, the increased inherent risk as well as prolonged recovery. At the present time, without better diagnostic tools or safer morcellation techniques, it is imperative to have an open dialogue of the risks and benefits of morcellation and minimally invasive surgery with patients presenting with anticipated fibroids. Additionally, our industry partners must be empowered to create safer morcellation techniques. This would appear to be morcellation within a bag.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. Dr. Miller said he is a consultant for Ethicon, which manufactures a morcellator.

*Correction, 3/19/2014: An earlier version of this story misstated the type of surgical route.

Intra-abdominal (intracorporeal) morcellation, especially electronically powered morcellation, has recently come under scrutiny. Generally performed at the time of conventional laparoscopic or robotic supracervical hysterectomy, total hysterectomy for the large uterus, or myomectomy, both power and cold-knife morcellation may splatter tissue fragments in the pelvis and abdomen, leading to potential parasitizing of the tissue and ectopic growth. Recent evidence indicates inadvertent morcellation of a leiomyosarcoma may negatively affect the patient’s subsequent disease-free survival and overall survival.

Concerns about morcellation heightened after Dr. Amy J. Reed, an anesthesiologist at Beth Israel Deaconess Medical Center, Boston, and a mother of 6, underwent presumed fibroid surgery and was diagnosed, post morcellation, with leiomyosarcoma. Dr. Reed’s husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital, Boston, where his wife’s surgery was performed, is calling for a moratorium on intra-abdominal morcellation, whether it involves the use of a power morcellator, or for that matter, the cold knife.

Images courtesy Dr. Charles E. Miller

It is imperative and incumbent upon our specialty to have a detailed evaluation of the risks and benefits of morcellation. While morcellation of the rare leiomyosarcoma is a risk, banning intraabdominal/intrapelvic morcellation will certainly have a profound negative impact on patients who are able to undergo a minimally invasive gynecologic procedure. Banning morcellation would increase intraoperative risk and subsequent concern of postoperative pelvic adhesions and thus, potential impact on fertility (post myomectomy), dyspareunia, and pelvic pain. Further, a ban would incur higher costs and more loss of patient productivity (Hum. Reprod. 1998 13:2102-6). These concerns were the basis for the AAGL position statement touting a minimally invasive approach to hysterectomy (J. Minim. Invasive Gynecol. 2011;18:1-3).

Since their introduction in the mid-1990s, electronically powered morcellators have been used to remove the uterus, fibroid(s), spleen, or kidney. Varying in size from 12-20 mm, electronic morcellators generally consist of a rotating circular blade at the end of a hollow tube. A tenaculum or multitoothed grasper is placed through the tube and blade to grasp the tissue to the revolving blade. The specimen is then removed in strips. Tissue splatter is inevitable, at least until the technique evolves to allow morcellation to be performed within the confines of a bag.

Benign uterine fibroids are the most common pelvic tumor in women. Literature reviews indicate the lifetime risk is 70% for white women and 80% in women of African ancestry. Uterine sarcomas occur in 3-7 women per 100,000 (Am. J. Obstet. Gynecol. 2011;205:492.e1-5). Further, Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and Dr. Ceana H. Dr. Nezhat of Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, conducted a meta-analysis of 5,666 uterine procedures, and found 13 unsuspected uterine sarcomas, for a prevalence of 0.23% (JAMA 2014 [doi:10.1001/jama.2014.1093]).

Images courtesy Dr. Charles E. Miller

This finding is consistent with that of a previous study by Dr. W.H. Parker who also noted a 0.23% risk, based on data from 1,332 women undergoing surgery secondary to uterine fibroids. Interestingly, in Dr. Parker’s study, the risk was 0.27% among women with rapidly growing leiomyoma, often thought to be a risk factor for sarcoma development (Obstet. Gynecol. 1994;83:414-8).

Because of the difficulty of making a preoperative diagnosis of leiomyosarcoma, it is doubtful that this risk will be decreased in the near future. Risk factors have not been well established, although a twofold higher incidence of leiomyosarcomas has been observed in black women (Gynecol. Oncol. 2004;93:204-8). Increasing age would appear to increase uterine sarcoma risk, as the majority of cases are diagnosed in postmenopausal women. Tamoxifen, when used for 5 or more years, appears to be associated with higher sarcoma rates (J. Clin. Oncol. 2002;20:2758-60) as is a history of pelvic irradiation or childhood retinoblastoma.

Unless metastatic disease is present, symptoms are similar for leiomyomas and leiomyosarcomas. A rapidly growing mass, a finding associated with an increased risk of uterine sarcoma, was not seen in Parker’s study of 1,332 women undergoing hysterectomy or myomectomy for uterine leiomyoma. Similarly, size does not count; a large uterine mass or increased uterine size did not appear to be associated with a greater risk of sarcoma (Gynecol. Oncol. 2003;89:460-9).

Some contend that failed response with such therapies as gonadotropin-releasing hormone agonists and uterine artery embolization are associated with increased incidence of leiomyosarcoma, but the data are not convincing (Eur. J. Obstet. Gynecol. Reprod. Biol. 1998;76:237-40).

Physical examination and imaging may be helpful in finding enlarged lymph nodes, but imaging methods have not been reliably shown to enable a preoperative diagnosis of uterine leiomyosarcoma (Lancet Oncol. 2009;10:1188-98; AJR Am. J. Roentgenol. 2003;181:1369-74). Further, while some physicians point out that an ill-defined margin may increase leiomyosarcoma risk, this finding is certainly noted as well with benign adenomyomas.

Finally, data are scant in support of preoperative endometrial sampling to establish a diagnosis of leiomyosarcoma. In two studies comparing a total of 14 patients, 7 were correctly diagnosed with leiomyosarcoma prior to surgery (Am. J. Obstet. Gynecol. 1990;162:968-74; Gynecol. Oncol. 2008;110:43-8).

With little differentiation in clinical presentation and the inability to distinguish leiomyoma from leiomyosarcoma based on imaging or sampling, it is not surprising that patients undergoing morcellation for an expected benign condition would subsequently be diagnosed with uterine leiomyosarcoma. With this in mind, it is important to review the current body of literature to further evaluate the risks and benefits of morcellation, and what place minimally invasive gynecologic surgery will have for the treatment of uterine masses.

Tumor morcellation of unrecognized leiomyosarcomas was significantly associated with poorer disease free survival (odds ratio, 2.59, P = 1.43), higher stage (I vs. II; [OR, 19.12, P = .037]) and poorer overall survival (OR, 3.07, P =.040) in a 2011 study. Park et al. assessed 56 consecutive patients, 25 with morcellation and 31 without tumor morcellation, who had stage I and stage II uterine leiomyosarcomas and were treated between 1989 and 2010. The percentage of patients with dissemination also was noted to be greater in patients with tumor morcellation (44% vs. 12.9%, P =.032). Interestingly, ovarian tissue was more frequently preserved in the morcellation group (38.7% vs. 72%, P =.013) (Gynecol. Oncol. 2011;122:255-9)

In response to a subsequent Letter to the Editor about these risks, the study’s author put the findings in perspective. "The frequency of incidental uterine leiomyosarcoma in patients who undergo surgery for presumed uterine leiomyoma is extremely rare. At our medical center, only 49 of 22,825 patients (0.21%) who underwent surgery for presumed uterine leiomyoma had incidental uterine leiomyosarcoma. Therefore, we believe that surgeons need not avoid non-laparotomic* surgical routes because of the rare possibility of an incidental diagnosis of leiomyosarcoma, even when tumor morcellation is required" (Gynecol. Oncol. 2012;124:172-3).

Additionally, a retrospective study from Brigham & Women’s Hospital found that disease was often already disseminated before morcellation procedures. In 21 patients with a median age of 46 years and no documented evidence of extrauterine disease, 15 had uterine leiomyosarcomas and 6 had smooth muscle tumors of uncertain malignant potential that were inadvertently morcellated; data was incorporated from January 2005 to January 2012. While most patients underwent power morcellation with laparoscopy, two underwent laparoscopically assisted vaginal hysterectomy with hand morcellation, and one patient had a vaginal hysterectomy with hand morcellation.

Immediate surgical reexploration was performed for staging in 12 patients. Significant findings of disseminated intraperitoneal disease were detected in two of seven patients with presumed stage I uterine leiomyosarcoma and in one of four patients with presumed stage I smooth muscle tumors of uncertain malignant potential. Moreover, of the eight patients who did not have disseminated disease at the time of the staging procedure, one subsequently had a recurrence. The remaining patients had no recurrences and remain disease free.

One patient was already FIGO stage IV at the original surgery, two more patients were upstaged at the original surgery and underwent re-exploration at 18 and 20 months respectively (certainly, a long period prior to second look). Moreover, the authors note various reasons why a significant number of patients were upstaged; including incorrect staging after initial surgery, progression of disease during the time interval, or secondary to direct seeding of morcellated tumor fragments. Five of the 15 leiomyosarcoma patients were deceased at the time of the publication. The authors also point out that their study is limited by the fact that it is retrospective, and access to information regarding care received from non-affiliated institutions is limited (Gynecol. Oncol. 2014;132:360-5).

In summary, morcellation of an unsuspected uterine sarcoma, whether using an electrically powered morcellator at the time of laparoscopy or cold knife at time of vaginal surgery, appears to have a negative impact; however, the studies to date are merely retrospective case studies. By no means do they provide the evidence required to place a moratorium on morcellation.

Further, if such a ban is imposed, would it then not be equally justifiable to pose similar regulations on use of oral contraceptives for symptom relief, endometrial ablation when fibroids are involved, or for that matter, uterine artery embolization? All these potential treatment regimens delay diagnosis and treatment and leave the potential uterine sarcoma in situ.

In the end, while the disease-free survival as well as overall survival appears to be hindered by dissemination of leiomyosarcoma at time of both electronic and cold-knife morcellation, the diagnosis is fortunately rare. A moratorium on the technique, however, would increase the number of concomitant laparotomies that would be required, and along with it, the increased inherent risk as well as prolonged recovery. At the present time, without better diagnostic tools or safer morcellation techniques, it is imperative to have an open dialogue of the risks and benefits of morcellation and minimally invasive surgery with patients presenting with anticipated fibroids. Additionally, our industry partners must be empowered to create safer morcellation techniques. This would appear to be morcellation within a bag.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. Dr. Miller said he is a consultant for Ethicon, which manufactures a morcellator.

*Correction, 3/19/2014: An earlier version of this story misstated the type of surgical route.

At the recent International Congress on Peer Review and Biomedical Publication, researchers at Yale University, New Haven, Conn., presented data on 18,411 original papers published in 2006 from 144 journals in the cardiovascular discipline.

They found that the median number of citations was six; 15.0% of papers were never cited; and 33.3% had only one to five citations in the following 5 years. It was no surprise that the impact factor of the journal predicted subsequent citations: That’s probably one of the reasons why those journals have high impact factors. So what do the authors conclude? They state that their data suggest "substantial waste in some combination of the funding, pursuit, publication or dissemination of cardiovascular science."

An interesting thought but flawed. Sure, the number of publications has expanded, but so what? The cardiovascular medicine community is now very large. No one presupposes that all published papers are high quality, useful, or impactful. Sometimes a paper is redundant and poorly constructed, and may not have been subjected to rigorous peer review. But "diamonds in the rough" do exist, and that is why I sometimes read journals with rather paltry impact factors. New ideas or kernels of new ideas can often be found there. The same goes for abstracts at meetings.

Rather than express concern, we should argue that our field is filled with ideas, that the way forward is often incremental and that limiting publications would potentially damage progress. If any "solution" is needed, it will come from quality peer review and economics. After all, a journal with a minuscule impact factor is not likely to sustain itself on subscriptions and advertising dollars.

So, are we really publishing too much in cardiovascular medicine? Dr. Mort Kern, chief of cardiology at the University of California, Irvine, used to say that "every paper can find a home," but the publication process can be time consuming and difficult. Let’s continue to publish and keep the conversation going.

Dr. Paul Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He serves as an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

At the recent International Congress on Peer Review and Biomedical Publication, researchers at Yale University, New Haven, Conn., presented data on 18,411 original papers published in 2006 from 144 journals in the cardiovascular discipline.

They found that the median number of citations was six; 15.0% of papers were never cited; and 33.3% had only one to five citations in the following 5 years. It was no surprise that the impact factor of the journal predicted subsequent citations: That’s probably one of the reasons why those journals have high impact factors. So what do the authors conclude? They state that their data suggest "substantial waste in some combination of the funding, pursuit, publication or dissemination of cardiovascular science."

An interesting thought but flawed. Sure, the number of publications has expanded, but so what? The cardiovascular medicine community is now very large. No one presupposes that all published papers are high quality, useful, or impactful. Sometimes a paper is redundant and poorly constructed, and may not have been subjected to rigorous peer review. But "diamonds in the rough" do exist, and that is why I sometimes read journals with rather paltry impact factors. New ideas or kernels of new ideas can often be found there. The same goes for abstracts at meetings.

Rather than express concern, we should argue that our field is filled with ideas, that the way forward is often incremental and that limiting publications would potentially damage progress. If any "solution" is needed, it will come from quality peer review and economics. After all, a journal with a minuscule impact factor is not likely to sustain itself on subscriptions and advertising dollars.

So, are we really publishing too much in cardiovascular medicine? Dr. Mort Kern, chief of cardiology at the University of California, Irvine, used to say that "every paper can find a home," but the publication process can be time consuming and difficult. Let’s continue to publish and keep the conversation going.

Dr. Paul Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He serves as an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

At the recent International Congress on Peer Review and Biomedical Publication, researchers at Yale University, New Haven, Conn., presented data on 18,411 original papers published in 2006 from 144 journals in the cardiovascular discipline.

They found that the median number of citations was six; 15.0% of papers were never cited; and 33.3% had only one to five citations in the following 5 years. It was no surprise that the impact factor of the journal predicted subsequent citations: That’s probably one of the reasons why those journals have high impact factors. So what do the authors conclude? They state that their data suggest "substantial waste in some combination of the funding, pursuit, publication or dissemination of cardiovascular science."

An interesting thought but flawed. Sure, the number of publications has expanded, but so what? The cardiovascular medicine community is now very large. No one presupposes that all published papers are high quality, useful, or impactful. Sometimes a paper is redundant and poorly constructed, and may not have been subjected to rigorous peer review. But "diamonds in the rough" do exist, and that is why I sometimes read journals with rather paltry impact factors. New ideas or kernels of new ideas can often be found there. The same goes for abstracts at meetings.

Rather than express concern, we should argue that our field is filled with ideas, that the way forward is often incremental and that limiting publications would potentially damage progress. If any "solution" is needed, it will come from quality peer review and economics. After all, a journal with a minuscule impact factor is not likely to sustain itself on subscriptions and advertising dollars.

So, are we really publishing too much in cardiovascular medicine? Dr. Mort Kern, chief of cardiology at the University of California, Irvine, used to say that "every paper can find a home," but the publication process can be time consuming and difficult. Let’s continue to publish and keep the conversation going.

Dr. Paul Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He serves as an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

My office hours are possibly the most laid back in medicine. In a field like medicine, I try not to worry about such things.

I’ve intentionally never put regular hours on my office door or phone message, because in my small office they’re subject to change. If my secretary is tied up in traffic, the phone may not get rolled on time. But, as a general rule, we open between 8:45 and 9:00.

Once the starting gun goes off, I work straight through. No lunch break (sorry, drug reps). I’ve never been a lunch person, and would rather use the time for seeing people who need me. I see patients nonstop, squeezing in phone calls, refills, and test results in the cracks, and I try very hard to stay on time.

The day ends as quickly as it starts. As soon as the last patient is done, we’re done. Whether it’s at 4:00 (the usual time), 3:15, or (rarely) 2:00, we close. The phones are rolled, the lights out, and my secretary and I walk down to our cars.

I’m sure some feel we should be answering our phones until a specific time, but I don’t. I want to go pick up my kids. My secretary has a long drive home, and the sooner she hits the freeway, the better. If there are emergencies, patients will still be able to reach me. If they’re not having emergencies, they can call back when we reopen the next day. I’ll finish up the dictations when I come in early the next morning.

A medical practice is pretty stressful. There’s nothing wrong with calling it a day as soon as you can. And I do.

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

My office hours are possibly the most laid back in medicine. In a field like medicine, I try not to worry about such things.

I’ve intentionally never put regular hours on my office door or phone message, because in my small office they’re subject to change. If my secretary is tied up in traffic, the phone may not get rolled on time. But, as a general rule, we open between 8:45 and 9:00.

Once the starting gun goes off, I work straight through. No lunch break (sorry, drug reps). I’ve never been a lunch person, and would rather use the time for seeing people who need me. I see patients nonstop, squeezing in phone calls, refills, and test results in the cracks, and I try very hard to stay on time.

The day ends as quickly as it starts. As soon as the last patient is done, we’re done. Whether it’s at 4:00 (the usual time), 3:15, or (rarely) 2:00, we close. The phones are rolled, the lights out, and my secretary and I walk down to our cars.

I’m sure some feel we should be answering our phones until a specific time, but I don’t. I want to go pick up my kids. My secretary has a long drive home, and the sooner she hits the freeway, the better. If there are emergencies, patients will still be able to reach me. If they’re not having emergencies, they can call back when we reopen the next day. I’ll finish up the dictations when I come in early the next morning.

A medical practice is pretty stressful. There’s nothing wrong with calling it a day as soon as you can. And I do.

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

My office hours are possibly the most laid back in medicine. In a field like medicine, I try not to worry about such things.

I’ve intentionally never put regular hours on my office door or phone message, because in my small office they’re subject to change. If my secretary is tied up in traffic, the phone may not get rolled on time. But, as a general rule, we open between 8:45 and 9:00.

Once the starting gun goes off, I work straight through. No lunch break (sorry, drug reps). I’ve never been a lunch person, and would rather use the time for seeing people who need me. I see patients nonstop, squeezing in phone calls, refills, and test results in the cracks, and I try very hard to stay on time.

The day ends as quickly as it starts. As soon as the last patient is done, we’re done. Whether it’s at 4:00 (the usual time), 3:15, or (rarely) 2:00, we close. The phones are rolled, the lights out, and my secretary and I walk down to our cars.

I’m sure some feel we should be answering our phones until a specific time, but I don’t. I want to go pick up my kids. My secretary has a long drive home, and the sooner she hits the freeway, the better. If there are emergencies, patients will still be able to reach me. If they’re not having emergencies, they can call back when we reopen the next day. I’ll finish up the dictations when I come in early the next morning.

A medical practice is pretty stressful. There’s nothing wrong with calling it a day as soon as you can. And I do.

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

America’s use of natural supplements continues to rise, especially in those patients experiencing chronic mental illness. In fact, about 70% of children diagnosed with autism or attention-deficit/hyperactivity disorder use natural supplements or other complementary and alternative medicine (CAM) to augment their care. This is rarely the result of physician advice, though. Many parents simply seek out supplements on their own, rarely discussing them with their child’s psychiatrist. And the psychiatrists seldom think to ask. When it comes to talking about CAM, Dr. David M. Eisenberg and others have documented a "don’t ask, don’t tell" policy between medical professionals and patients (JAMA 1998;280:1569-75).

Outside of mental health, about 38% of Americans use natural supplements on a regular basis. They are typically female, over 30, well educated, and affluent. Children whose parents use CAM treatments are much more likely to use them, both now and in the future. Why do these individuals select CAM options? And why has this utilization continued to grow among families, especially those with chronic illness?

In 1998, John A. Astin, Ph.D., published a landmark article in JAMA asking this very question (1998;279:1548-53). He found that patients were drawn to CAM not by dissatisfaction with conventional medicine or a desire for more control, but rather because CAM better fit their value system. This is perhaps the best explanation for why research continues to document the hesitation of most Americans to take psychiatric drugs. "Americans believe that psychiatric medications are effective at relieving symptoms associated with mental disorders," wrote Dr. Ramin Mojtabai, "yet they are relatively unwilling to use them in most situations" (Psychiatr. Serv. 2009;60:1015-23) As you might expect, that unwillingness is high among parents of psychiatrically ill children, the same group that’s flocking to natural supplements.

It’s values, not empiricism or a physician’s advice, that inform many patients’ and parents’ treatment choices. And that phenomenon sees more and more people turning away from conventional medicine and toward the use of natural supplements. As a practitioner, think of it in terms of cross-cultural psychiatry. By virtue of their choice, CAM users reflect a different worldview, one that shares many of the underlying premises of holistic medicine.

Holistic medicine believes the body has innate healing power and that treatment works best when done with this force. Rather than impose hasty treatments or introduce new, untested agents, the CAM culture prefers to adjust the environmental milieu and lifestyle of the patient in order to gently foster a more positive, innate healing effect. Because of this, and in light of the fact that correctly prescribed medications cause more than 100,000 American deaths a year, safety is often more important than efficacy in the view of these patients.

Both critics and supporters are often quick to assume this safety vs. efficacy dichotomy separates conventional medicine from CAM in the United States. But the characterization is not totally accurate. CAM is not an alternative to conventional care, but a complement to it. This is has long been clear to patients, even if practitioners are slow on the uptick. More than 90% of patients diagnosed with a malignancy, for example, embrace the tools of CAM with their ongoing conventional treatments. Patients and parents appreciate our expertise with diagnosis, experience with significant mental illness, and extensive training. But they often want more.

Sadly, at-home CAM research can often be misguided or lead patients astray through hype and illegitimate claims. Research has consistently demonstrated that patients and parents do not ask their practitioners for advice or information about CAM out of a fear of condemnation, as well as a sense of practitioner bias and ignorance. In the era of Internet self-diagnosis, it’s up to practitioners to understand the mind-set of values-driven patients and create an environment where they feel comfortable bringing all options to the table. If we take the time to do this, we can more effectively reach them and build a strong therapeutic alliance based on common goals, open communication, and shared values.

A few questions can assist the practitioner in better understanding their patient’s worldview. Do you prefer to use natural supplements? What else do you do to support your health (or your child’s health)? Do you believe that the body has the ability to heal itself? Do you believe in holistic or natural medicine? Only after you have a basic grasp of the patient’s perspective can you start a real dialogue about healing. A few dismissive words or a roll of your eyes will shut communication down for good.

Remember, CAM is not only a treatment option but also represents a wide-ranging belief system. And like those who ascribe to any belief system, CAM users range from skeptical to unwavering. The challenge here, just as in cross-cultural psychiatry, is feeling out the individual features of that belief system, and then navigating it with respect and candor.

Most practitioners build trust and rapport with patients through a tried-and-true display of trust and understanding. Discussing natural supplements can provide just that, with a range of options for clinical conditions that are both evidence based and safe. Most of our patients are already using CAM modalities on their own without guidance. If the practitioner is able to incorporate these options into his or her treatment plan for the patient with a holistic or natural perspective, it increases the likelihood of positive rapport, good compliance, and open communication.

Dr. Shannon is an associate clinical professor in the department of psychiatry at the University of Colorado at Denver. He also is author of the textbook titled, Mental Health for the Whole Child (New York: Norton, 2013). He is past president of the American Board of Integrative Holistic Medicine.

America’s use of natural supplements continues to rise, especially in those patients experiencing chronic mental illness. In fact, about 70% of children diagnosed with autism or attention-deficit/hyperactivity disorder use natural supplements or other complementary and alternative medicine (CAM) to augment their care. This is rarely the result of physician advice, though. Many parents simply seek out supplements on their own, rarely discussing them with their child’s psychiatrist. And the psychiatrists seldom think to ask. When it comes to talking about CAM, Dr. David M. Eisenberg and others have documented a "don’t ask, don’t tell" policy between medical professionals and patients (JAMA 1998;280:1569-75).

Outside of mental health, about 38% of Americans use natural supplements on a regular basis. They are typically female, over 30, well educated, and affluent. Children whose parents use CAM treatments are much more likely to use them, both now and in the future. Why do these individuals select CAM options? And why has this utilization continued to grow among families, especially those with chronic illness?

In 1998, John A. Astin, Ph.D., published a landmark article in JAMA asking this very question (1998;279:1548-53). He found that patients were drawn to CAM not by dissatisfaction with conventional medicine or a desire for more control, but rather because CAM better fit their value system. This is perhaps the best explanation for why research continues to document the hesitation of most Americans to take psychiatric drugs. "Americans believe that psychiatric medications are effective at relieving symptoms associated with mental disorders," wrote Dr. Ramin Mojtabai, "yet they are relatively unwilling to use them in most situations" (Psychiatr. Serv. 2009;60:1015-23) As you might expect, that unwillingness is high among parents of psychiatrically ill children, the same group that’s flocking to natural supplements.

It’s values, not empiricism or a physician’s advice, that inform many patients’ and parents’ treatment choices. And that phenomenon sees more and more people turning away from conventional medicine and toward the use of natural supplements. As a practitioner, think of it in terms of cross-cultural psychiatry. By virtue of their choice, CAM users reflect a different worldview, one that shares many of the underlying premises of holistic medicine.

Holistic medicine believes the body has innate healing power and that treatment works best when done with this force. Rather than impose hasty treatments or introduce new, untested agents, the CAM culture prefers to adjust the environmental milieu and lifestyle of the patient in order to gently foster a more positive, innate healing effect. Because of this, and in light of the fact that correctly prescribed medications cause more than 100,000 American deaths a year, safety is often more important than efficacy in the view of these patients.

Both critics and supporters are often quick to assume this safety vs. efficacy dichotomy separates conventional medicine from CAM in the United States. But the characterization is not totally accurate. CAM is not an alternative to conventional care, but a complement to it. This is has long been clear to patients, even if practitioners are slow on the uptick. More than 90% of patients diagnosed with a malignancy, for example, embrace the tools of CAM with their ongoing conventional treatments. Patients and parents appreciate our expertise with diagnosis, experience with significant mental illness, and extensive training. But they often want more.

Sadly, at-home CAM research can often be misguided or lead patients astray through hype and illegitimate claims. Research has consistently demonstrated that patients and parents do not ask their practitioners for advice or information about CAM out of a fear of condemnation, as well as a sense of practitioner bias and ignorance. In the era of Internet self-diagnosis, it’s up to practitioners to understand the mind-set of values-driven patients and create an environment where they feel comfortable bringing all options to the table. If we take the time to do this, we can more effectively reach them and build a strong therapeutic alliance based on common goals, open communication, and shared values.

A few questions can assist the practitioner in better understanding their patient’s worldview. Do you prefer to use natural supplements? What else do you do to support your health (or your child’s health)? Do you believe that the body has the ability to heal itself? Do you believe in holistic or natural medicine? Only after you have a basic grasp of the patient’s perspective can you start a real dialogue about healing. A few dismissive words or a roll of your eyes will shut communication down for good.

Remember, CAM is not only a treatment option but also represents a wide-ranging belief system. And like those who ascribe to any belief system, CAM users range from skeptical to unwavering. The challenge here, just as in cross-cultural psychiatry, is feeling out the individual features of that belief system, and then navigating it with respect and candor.

Most practitioners build trust and rapport with patients through a tried-and-true display of trust and understanding. Discussing natural supplements can provide just that, with a range of options for clinical conditions that are both evidence based and safe. Most of our patients are already using CAM modalities on their own without guidance. If the practitioner is able to incorporate these options into his or her treatment plan for the patient with a holistic or natural perspective, it increases the likelihood of positive rapport, good compliance, and open communication.

Dr. Shannon is an associate clinical professor in the department of psychiatry at the University of Colorado at Denver. He also is author of the textbook titled, Mental Health for the Whole Child (New York: Norton, 2013). He is past president of the American Board of Integrative Holistic Medicine.

America’s use of natural supplements continues to rise, especially in those patients experiencing chronic mental illness. In fact, about 70% of children diagnosed with autism or attention-deficit/hyperactivity disorder use natural supplements or other complementary and alternative medicine (CAM) to augment their care. This is rarely the result of physician advice, though. Many parents simply seek out supplements on their own, rarely discussing them with their child’s psychiatrist. And the psychiatrists seldom think to ask. When it comes to talking about CAM, Dr. David M. Eisenberg and others have documented a "don’t ask, don’t tell" policy between medical professionals and patients (JAMA 1998;280:1569-75).

Outside of mental health, about 38% of Americans use natural supplements on a regular basis. They are typically female, over 30, well educated, and affluent. Children whose parents use CAM treatments are much more likely to use them, both now and in the future. Why do these individuals select CAM options? And why has this utilization continued to grow among families, especially those with chronic illness?

In 1998, John A. Astin, Ph.D., published a landmark article in JAMA asking this very question (1998;279:1548-53). He found that patients were drawn to CAM not by dissatisfaction with conventional medicine or a desire for more control, but rather because CAM better fit their value system. This is perhaps the best explanation for why research continues to document the hesitation of most Americans to take psychiatric drugs. "Americans believe that psychiatric medications are effective at relieving symptoms associated with mental disorders," wrote Dr. Ramin Mojtabai, "yet they are relatively unwilling to use them in most situations" (Psychiatr. Serv. 2009;60:1015-23) As you might expect, that unwillingness is high among parents of psychiatrically ill children, the same group that’s flocking to natural supplements.

It’s values, not empiricism or a physician’s advice, that inform many patients’ and parents’ treatment choices. And that phenomenon sees more and more people turning away from conventional medicine and toward the use of natural supplements. As a practitioner, think of it in terms of cross-cultural psychiatry. By virtue of their choice, CAM users reflect a different worldview, one that shares many of the underlying premises of holistic medicine.

Holistic medicine believes the body has innate healing power and that treatment works best when done with this force. Rather than impose hasty treatments or introduce new, untested agents, the CAM culture prefers to adjust the environmental milieu and lifestyle of the patient in order to gently foster a more positive, innate healing effect. Because of this, and in light of the fact that correctly prescribed medications cause more than 100,000 American deaths a year, safety is often more important than efficacy in the view of these patients.

Both critics and supporters are often quick to assume this safety vs. efficacy dichotomy separates conventional medicine from CAM in the United States. But the characterization is not totally accurate. CAM is not an alternative to conventional care, but a complement to it. This is has long been clear to patients, even if practitioners are slow on the uptick. More than 90% of patients diagnosed with a malignancy, for example, embrace the tools of CAM with their ongoing conventional treatments. Patients and parents appreciate our expertise with diagnosis, experience with significant mental illness, and extensive training. But they often want more.

Sadly, at-home CAM research can often be misguided or lead patients astray through hype and illegitimate claims. Research has consistently demonstrated that patients and parents do not ask their practitioners for advice or information about CAM out of a fear of condemnation, as well as a sense of practitioner bias and ignorance. In the era of Internet self-diagnosis, it’s up to practitioners to understand the mind-set of values-driven patients and create an environment where they feel comfortable bringing all options to the table. If we take the time to do this, we can more effectively reach them and build a strong therapeutic alliance based on common goals, open communication, and shared values.

A few questions can assist the practitioner in better understanding their patient’s worldview. Do you prefer to use natural supplements? What else do you do to support your health (or your child’s health)? Do you believe that the body has the ability to heal itself? Do you believe in holistic or natural medicine? Only after you have a basic grasp of the patient’s perspective can you start a real dialogue about healing. A few dismissive words or a roll of your eyes will shut communication down for good.

Remember, CAM is not only a treatment option but also represents a wide-ranging belief system. And like those who ascribe to any belief system, CAM users range from skeptical to unwavering. The challenge here, just as in cross-cultural psychiatry, is feeling out the individual features of that belief system, and then navigating it with respect and candor.

Most practitioners build trust and rapport with patients through a tried-and-true display of trust and understanding. Discussing natural supplements can provide just that, with a range of options for clinical conditions that are both evidence based and safe. Most of our patients are already using CAM modalities on their own without guidance. If the practitioner is able to incorporate these options into his or her treatment plan for the patient with a holistic or natural perspective, it increases the likelihood of positive rapport, good compliance, and open communication.

Dr. Shannon is an associate clinical professor in the department of psychiatry at the University of Colorado at Denver. He also is author of the textbook titled, Mental Health for the Whole Child (New York: Norton, 2013). He is past president of the American Board of Integrative Holistic Medicine.