Expert Commentary

After previous attempts in Turkey and Saudi Arabia, the first successful uterine transplantation occurred in 2013. The team of successful surgeons was located in Gothenburg, Sweden, led by Mats Brännström, MD. The team performed 9 transplants in all, and the first birth of a healthy baby boy in October 2014 marked a medical breakthrough.¹ The woman who received the transplanted uterus was born without one, a condition known as Mayer-Rokitanksy-Küster-Hauser syndrome, a cause of uterine factor infertility (UFI).

The previous options for having a child for women with UFI (which is the absence of a functional uterus, either congenital or acquired) were adoption or a gestational carrier/surrogacy.² Surrogacy is not an option for many women, however, as in many countries, including Sweden, the use of gestational carriers and its associated contracts is illegal. All Muslim countries prohibit gestational carriers. Surrogacy also is prohibited in 3 US states, including New York, Michigan, and Arizona. Laws in other US states vary widely.³

Tommaso Falcone, MD, professor and chair, Department of Obstetrics and Gynecology, at the Cleveland Clinic in Cleveland, Ohio, is now co–Principal Investigator on a clinical trial assessing uterine transplantation at his institution, the first such surgeries to be performed in the United States. There will be 7 phases involved in the study: primary and secondary screening, medical evaluation, in vitro fertilization (IVF) with cryopreservation of sufficient number of embryos, transplantation and use of antirejection drugs, embryo transfer, pregnancy/delivery, and ultimately removal of the transplanted uterus. The study team is approved to enroll 10 women.⁴

OBG Management recently caught up with Dr. Falcone on his groundbreaking, and controversial, endeavor.
 

OBG Management: When did the thought of performing uterus transplantation enter your mind?
Tommaso Falcone, MD: The idea for uterus transplants was brought to my attention for the first time in Boston in 2007, at an annual meeting of the International Society for Fertility Preservation (ISFP). It was the inaugural meeting for ISFP, a society focused on helping women with cancer to protect their fertility. In 2007, we talked about the standard topics regarding fertility preservation: IVF and ovarian tissue cryopreservation. Then, right at the end of the meeting, was a presentation on uterus transplantation. Upon hearing the presenter, my thought was, “This will never happen in America, for many reasons.”

As time went on, I concentrated my energy more on ovarian tissue transplants for fertility preservation. Then a couple of years ago Andreas G. Tzakis, MD, a transplant surgeon from the University of Miami joined the Cleveland Clinic Florida. Dr. Tzakis was involved with the Swedish Group, including Mats Brännström’s transplant work in humans.

Of course, Dr. Tzakis had had a completely different journey to lead him to uterus transplantation. But as the director of solid organ transplant surgery at the Cleveland Clinic hospital in Florida, he said to me, “I think we should do this. There are many women who have asked for this procedure.” I was not sure at first, but I was interested in going to Sweden to see Dr. Brännström perform his last of 9 uterus transplants.

In Sweden, I asked Dr. Brännström if I could meet the women he already had performed the transplants on. I had certain preconceived notions on which types of women would accept this kind of major surgery to treat their infertility due to absence of a uterus. I expected perhaps that these women could have been coerced into accepting this surgery as a plausible option since surrogacy was not possible for them. I found out, as people usually do, that my preconceived notions were wrong. The women that I met said, “No, we’ve done this because we wanted to.” The women had independently come to a decision that experiencing pregnancy was important in their lives. There was no coercion. They understood the risks. However, I did not meet the uterus donors.

When I got on the plane to return home, I said to myself, we have to offer this service because it is part of the choices that women have to treat their reproductive infertility.

OBG Management: What are the hurdles you have had to overcome to bring this groundbreaking surgery to the Cleveland Clinic?
Dr. Falcone, MD: As soon as I returned from Sweden, we began the internal review board (IRB) approval process, which was extremely long. The first decision was: Do we use a live donor, as they do in Sweden, in America?

We analyzed the data from the Swedes and found that the surgery is very long for the donor and it put some of the donors, especially those who were older and placed on hormones, at risk for venous thromboembolism. (No blood clots had occurred in the Swedish trial.) In addition, there were some complications for patients. Although not major complications, we felt that these could be limited.

To remove the variable of risks for the donor, we decided that we would go in another direction and use the typical approach to donor transplants that is taken in this country, which is to use cadaveric, or brain dead, donors. The use of deceased donors allows us to isolate larger vascular pedicles for transplantation. Although we do not have IRB approval for live donors we are working in animal models to come up with an alternative technique to obtain vessels appropriate for anastomosis.

To address complications for the recipient, including the necessity to continually take antirejection, or immunosuppressive, medications, our recommendation to patients who undergo uterus transplantation surgery is to remove the uterus after delivery of 2 babies. Our plan at that time will be to perform a cesarean delivery and remove the uterus.

Right now in the process we are going through the screening phase and beginning IVF. We are approved for 10 women, and all potential recipients went through the necessary criteria, including psychological counseling. During IVF, each woman needs to have between 6 and 10 embryos (blastocysts).

OBG Management: Do you think that organ transplant pioneers foresaw successful transplantation of a uterus?
Dr. Falcone, MD: I do not think Dr. Tzakis, who is a transplant pioneer and has been doing this his entire career of 25 years or so, even foresaw this. This is something that has evolved over time. The first transplants (of kidney, heart, and liver) were to save lives. Subsequently, quality-of- life transplants have occurred, such as the face transplant and the larynx transplant. Uterus transplants are not to save lives, but they do improve quality of life, and I think that is what is important.

There is a lot of controversy surrounding this procedure—just like many aspects of reproductive medicine. A lot of what we do is full of controversy: IVF, gestational carriers, and genetic screening in utero. But we are in the quality-of-life era with transplantation medicine. If women have a strong desire to carry their own child, and surrogacy is not an option, then this may be one.

Tommasso Falcone, MD, was co-director of the Pelvic Anatomy and Gynecologic Surgery (PAGS) Symposium held in Las Vegas, Nevada, December 10–12, 2015. He offered workshops and seminars during the Scientific Program on diverse topics, including: hysteroscopy; ultrasonography; pelvic and abdominal anatomy; myometomy; hysterectomy; endometriosis; avoiding laparoscopic complications; medicolegal considerations; and surgical tips and techniques.

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.

After previous attempts in Turkey and Saudi Arabia, the first successful uterine transplantation occurred in 2013. The team of successful surgeons was located in Gothenburg, Sweden, led by Mats Brännström, MD. The team performed 9 transplants in all, and the first birth of a healthy baby boy in October 2014 marked a medical breakthrough.¹ The woman who received the transplanted uterus was born without one, a condition known as Mayer-Rokitanksy-Küster-Hauser syndrome, a cause of uterine factor infertility (UFI).

The previous options for having a child for women with UFI (which is the absence of a functional uterus, either congenital or acquired) were adoption or a gestational carrier/surrogacy.² Surrogacy is not an option for many women, however, as in many countries, including Sweden, the use of gestational carriers and its associated contracts is illegal. All Muslim countries prohibit gestational carriers. Surrogacy also is prohibited in 3 US states, including New York, Michigan, and Arizona. Laws in other US states vary widely.³

Tommaso Falcone, MD, professor and chair, Department of Obstetrics and Gynecology, at the Cleveland Clinic in Cleveland, Ohio, is now co–Principal Investigator on a clinical trial assessing uterine transplantation at his institution, the first such surgeries to be performed in the United States. There will be 7 phases involved in the study: primary and secondary screening, medical evaluation, in vitro fertilization (IVF) with cryopreservation of sufficient number of embryos, transplantation and use of antirejection drugs, embryo transfer, pregnancy/delivery, and ultimately removal of the transplanted uterus. The study team is approved to enroll 10 women.⁴

OBG Management recently caught up with Dr. Falcone on his groundbreaking, and controversial, endeavor.
 

OBG Management: When did the thought of performing uterus transplantation enter your mind?
Tommaso Falcone, MD: The idea for uterus transplants was brought to my attention for the first time in Boston in 2007, at an annual meeting of the International Society for Fertility Preservation (ISFP). It was the inaugural meeting for ISFP, a society focused on helping women with cancer to protect their fertility. In 2007, we talked about the standard topics regarding fertility preservation: IVF and ovarian tissue cryopreservation. Then, right at the end of the meeting, was a presentation on uterus transplantation. Upon hearing the presenter, my thought was, “This will never happen in America, for many reasons.”

As time went on, I concentrated my energy more on ovarian tissue transplants for fertility preservation. Then a couple of years ago Andreas G. Tzakis, MD, a transplant surgeon from the University of Miami joined the Cleveland Clinic Florida. Dr. Tzakis was involved with the Swedish Group, including Mats Brännström’s transplant work in humans.

Of course, Dr. Tzakis had had a completely different journey to lead him to uterus transplantation. But as the director of solid organ transplant surgery at the Cleveland Clinic hospital in Florida, he said to me, “I think we should do this. There are many women who have asked for this procedure.” I was not sure at first, but I was interested in going to Sweden to see Dr. Brännström perform his last of 9 uterus transplants.

In Sweden, I asked Dr. Brännström if I could meet the women he already had performed the transplants on. I had certain preconceived notions on which types of women would accept this kind of major surgery to treat their infertility due to absence of a uterus. I expected perhaps that these women could have been coerced into accepting this surgery as a plausible option since surrogacy was not possible for them. I found out, as people usually do, that my preconceived notions were wrong. The women that I met said, “No, we’ve done this because we wanted to.” The women had independently come to a decision that experiencing pregnancy was important in their lives. There was no coercion. They understood the risks. However, I did not meet the uterus donors.

When I got on the plane to return home, I said to myself, we have to offer this service because it is part of the choices that women have to treat their reproductive infertility.

OBG Management: What are the hurdles you have had to overcome to bring this groundbreaking surgery to the Cleveland Clinic?
Dr. Falcone, MD: As soon as I returned from Sweden, we began the internal review board (IRB) approval process, which was extremely long. The first decision was: Do we use a live donor, as they do in Sweden, in America?

We analyzed the data from the Swedes and found that the surgery is very long for the donor and it put some of the donors, especially those who were older and placed on hormones, at risk for venous thromboembolism. (No blood clots had occurred in the Swedish trial.) In addition, there were some complications for patients. Although not major complications, we felt that these could be limited.

To remove the variable of risks for the donor, we decided that we would go in another direction and use the typical approach to donor transplants that is taken in this country, which is to use cadaveric, or brain dead, donors. The use of deceased donors allows us to isolate larger vascular pedicles for transplantation. Although we do not have IRB approval for live donors we are working in animal models to come up with an alternative technique to obtain vessels appropriate for anastomosis.

To address complications for the recipient, including the necessity to continually take antirejection, or immunosuppressive, medications, our recommendation to patients who undergo uterus transplantation surgery is to remove the uterus after delivery of 2 babies. Our plan at that time will be to perform a cesarean delivery and remove the uterus.

Right now in the process we are going through the screening phase and beginning IVF. We are approved for 10 women, and all potential recipients went through the necessary criteria, including psychological counseling. During IVF, each woman needs to have between 6 and 10 embryos (blastocysts).

OBG Management: Do you think that organ transplant pioneers foresaw successful transplantation of a uterus?
Dr. Falcone, MD: I do not think Dr. Tzakis, who is a transplant pioneer and has been doing this his entire career of 25 years or so, even foresaw this. This is something that has evolved over time. The first transplants (of kidney, heart, and liver) were to save lives. Subsequently, quality-of- life transplants have occurred, such as the face transplant and the larynx transplant. Uterus transplants are not to save lives, but they do improve quality of life, and I think that is what is important.

There is a lot of controversy surrounding this procedure—just like many aspects of reproductive medicine. A lot of what we do is full of controversy: IVF, gestational carriers, and genetic screening in utero. But we are in the quality-of-life era with transplantation medicine. If women have a strong desire to carry their own child, and surrogacy is not an option, then this may be one.

Tommasso Falcone, MD, was co-director of the Pelvic Anatomy and Gynecologic Surgery (PAGS) Symposium held in Las Vegas, Nevada, December 10–12, 2015. He offered workshops and seminars during the Scientific Program on diverse topics, including: hysteroscopy; ultrasonography; pelvic and abdominal anatomy; myometomy; hysterectomy; endometriosis; avoiding laparoscopic complications; medicolegal considerations; and surgical tips and techniques.

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.

After previous attempts in Turkey and Saudi Arabia, the first successful uterine transplantation occurred in 2013. The team of successful surgeons was located in Gothenburg, Sweden, led by Mats Brännström, MD. The team performed 9 transplants in all, and the first birth of a healthy baby boy in October 2014 marked a medical breakthrough.¹ The woman who received the transplanted uterus was born without one, a condition known as Mayer-Rokitanksy-Küster-Hauser syndrome, a cause of uterine factor infertility (UFI).

The previous options for having a child for women with UFI (which is the absence of a functional uterus, either congenital or acquired) were adoption or a gestational carrier/surrogacy.² Surrogacy is not an option for many women, however, as in many countries, including Sweden, the use of gestational carriers and its associated contracts is illegal. All Muslim countries prohibit gestational carriers. Surrogacy also is prohibited in 3 US states, including New York, Michigan, and Arizona. Laws in other US states vary widely.³

Tommaso Falcone, MD, professor and chair, Department of Obstetrics and Gynecology, at the Cleveland Clinic in Cleveland, Ohio, is now co–Principal Investigator on a clinical trial assessing uterine transplantation at his institution, the first such surgeries to be performed in the United States. There will be 7 phases involved in the study: primary and secondary screening, medical evaluation, in vitro fertilization (IVF) with cryopreservation of sufficient number of embryos, transplantation and use of antirejection drugs, embryo transfer, pregnancy/delivery, and ultimately removal of the transplanted uterus. The study team is approved to enroll 10 women.⁴

OBG Management recently caught up with Dr. Falcone on his groundbreaking, and controversial, endeavor.
 

OBG Management: When did the thought of performing uterus transplantation enter your mind?
Tommaso Falcone, MD: The idea for uterus transplants was brought to my attention for the first time in Boston in 2007, at an annual meeting of the International Society for Fertility Preservation (ISFP). It was the inaugural meeting for ISFP, a society focused on helping women with cancer to protect their fertility. In 2007, we talked about the standard topics regarding fertility preservation: IVF and ovarian tissue cryopreservation. Then, right at the end of the meeting, was a presentation on uterus transplantation. Upon hearing the presenter, my thought was, “This will never happen in America, for many reasons.”

As time went on, I concentrated my energy more on ovarian tissue transplants for fertility preservation. Then a couple of years ago Andreas G. Tzakis, MD, a transplant surgeon from the University of Miami joined the Cleveland Clinic Florida. Dr. Tzakis was involved with the Swedish Group, including Mats Brännström’s transplant work in humans.

Of course, Dr. Tzakis had had a completely different journey to lead him to uterus transplantation. But as the director of solid organ transplant surgery at the Cleveland Clinic hospital in Florida, he said to me, “I think we should do this. There are many women who have asked for this procedure.” I was not sure at first, but I was interested in going to Sweden to see Dr. Brännström perform his last of 9 uterus transplants.

In Sweden, I asked Dr. Brännström if I could meet the women he already had performed the transplants on. I had certain preconceived notions on which types of women would accept this kind of major surgery to treat their infertility due to absence of a uterus. I expected perhaps that these women could have been coerced into accepting this surgery as a plausible option since surrogacy was not possible for them. I found out, as people usually do, that my preconceived notions were wrong. The women that I met said, “No, we’ve done this because we wanted to.” The women had independently come to a decision that experiencing pregnancy was important in their lives. There was no coercion. They understood the risks. However, I did not meet the uterus donors.

When I got on the plane to return home, I said to myself, we have to offer this service because it is part of the choices that women have to treat their reproductive infertility.

OBG Management: What are the hurdles you have had to overcome to bring this groundbreaking surgery to the Cleveland Clinic?
Dr. Falcone, MD: As soon as I returned from Sweden, we began the internal review board (IRB) approval process, which was extremely long. The first decision was: Do we use a live donor, as they do in Sweden, in America?

We analyzed the data from the Swedes and found that the surgery is very long for the donor and it put some of the donors, especially those who were older and placed on hormones, at risk for venous thromboembolism. (No blood clots had occurred in the Swedish trial.) In addition, there were some complications for patients. Although not major complications, we felt that these could be limited.

To remove the variable of risks for the donor, we decided that we would go in another direction and use the typical approach to donor transplants that is taken in this country, which is to use cadaveric, or brain dead, donors. The use of deceased donors allows us to isolate larger vascular pedicles for transplantation. Although we do not have IRB approval for live donors we are working in animal models to come up with an alternative technique to obtain vessels appropriate for anastomosis.

To address complications for the recipient, including the necessity to continually take antirejection, or immunosuppressive, medications, our recommendation to patients who undergo uterus transplantation surgery is to remove the uterus after delivery of 2 babies. Our plan at that time will be to perform a cesarean delivery and remove the uterus.

Right now in the process we are going through the screening phase and beginning IVF. We are approved for 10 women, and all potential recipients went through the necessary criteria, including psychological counseling. During IVF, each woman needs to have between 6 and 10 embryos (blastocysts).

OBG Management: Do you think that organ transplant pioneers foresaw successful transplantation of a uterus?
Dr. Falcone, MD: I do not think Dr. Tzakis, who is a transplant pioneer and has been doing this his entire career of 25 years or so, even foresaw this. This is something that has evolved over time. The first transplants (of kidney, heart, and liver) were to save lives. Subsequently, quality-of- life transplants have occurred, such as the face transplant and the larynx transplant. Uterus transplants are not to save lives, but they do improve quality of life, and I think that is what is important.

There is a lot of controversy surrounding this procedure—just like many aspects of reproductive medicine. A lot of what we do is full of controversy: IVF, gestational carriers, and genetic screening in utero. But we are in the quality-of-life era with transplantation medicine. If women have a strong desire to carry their own child, and surrogacy is not an option, then this may be one.

Tommasso Falcone, MD, was co-director of the Pelvic Anatomy and Gynecologic Surgery (PAGS) Symposium held in Las Vegas, Nevada, December 10–12, 2015. He offered workshops and seminars during the Scientific Program on diverse topics, including: hysteroscopy; ultrasonography; pelvic and abdominal anatomy; myometomy; hysterectomy; endometriosis; avoiding laparoscopic complications; medicolegal considerations; and surgical tips and techniques.

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.

Cesarean delivery (CD), the most common surgery performed worldwide, is associated with increased morbidity and mortality compared with vaginal delivery. More than 230 randomized controlled trials (RCTs) have been published on varying technical aspects of CD, yet uncertainty remains regarding the optimal approach(es) to minimize perinatal morbidity.

Previous trials of one such technique, uterine closure, have not demonstrated short-term outcome differences among those randomized to single- versus double-layer closure. Results of long-term outcomes such as uterine rupture remain unclear. Emerging evidence also has associated cesarean scar defects with gynecologic problems like dysmenorrhea, pelvic pain, and postmenstrual spotting, further highlighting the importance of identifying surgical techniques that optimize uterine scar healing after CD.

Details of the study
In their recent RCT, Roberge and colleagues randomly assigned 81 women with singleton pregnancies undergoing elective primary CD (at ≥38 0/7 weeks) and compared the following uterine closure types on residual myometrial thickness during postpartum transvaginal ultrasound at 6 months:

In addition to addressing the single- versus double-layer debate, this study highlights another important aspect of closure technique: locked versus unlocked first-layer suture closure. The residual myometrial thickness, a surrogate measure of uterine scar healing, was significantly greater in those women randomly assigned to double-layer (locked or unlocked) closure compared with controls. Additionally, total myometrial thickness significantly increased in the double- layer unlocked closure group. There were no differences in the short-term outcomes of operative time or estimated blood loss among any of the groups.

Based on these findings, the authors advocate for double-layer unlocked uterine closure during CD to maximize uterine scar healing.

Bottom line
Double-layer uterine closure with unlocked first-layer at CD appears to maximize postpartum uterine scar thickness compared with other techniques; it remains unclear, however, if this improves short- or long-term outcomes. What this evidence means for practice
While residual and total myometrial thickness presents a feasible, albeit indirect, assessment of uterine scar healing, it remains unclear if double-layer unlocked first-layer closure decreases long-term adverse outcomes, such as subsequent uterine rupture, cesarean scar defects, or gynecologic morbidity compared with other techniques. Nevertheless, this study highlights the importance of future research specifying both single- or double-layer and locked or unlocked uterine closure techniques.
— Joshua D. Dahlke, MD

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.

Cesarean delivery (CD), the most common surgery performed worldwide, is associated with increased morbidity and mortality compared with vaginal delivery. More than 230 randomized controlled trials (RCTs) have been published on varying technical aspects of CD, yet uncertainty remains regarding the optimal approach(es) to minimize perinatal morbidity.

Previous trials of one such technique, uterine closure, have not demonstrated short-term outcome differences among those randomized to single- versus double-layer closure. Results of long-term outcomes such as uterine rupture remain unclear. Emerging evidence also has associated cesarean scar defects with gynecologic problems like dysmenorrhea, pelvic pain, and postmenstrual spotting, further highlighting the importance of identifying surgical techniques that optimize uterine scar healing after CD.

Details of the study
In their recent RCT, Roberge and colleagues randomly assigned 81 women with singleton pregnancies undergoing elective primary CD (at ≥38 0/7 weeks) and compared the following uterine closure types on residual myometrial thickness during postpartum transvaginal ultrasound at 6 months:

In addition to addressing the single- versus double-layer debate, this study highlights another important aspect of closure technique: locked versus unlocked first-layer suture closure. The residual myometrial thickness, a surrogate measure of uterine scar healing, was significantly greater in those women randomly assigned to double-layer (locked or unlocked) closure compared with controls. Additionally, total myometrial thickness significantly increased in the double- layer unlocked closure group. There were no differences in the short-term outcomes of operative time or estimated blood loss among any of the groups.

Based on these findings, the authors advocate for double-layer unlocked uterine closure during CD to maximize uterine scar healing.

Bottom line
Double-layer uterine closure with unlocked first-layer at CD appears to maximize postpartum uterine scar thickness compared with other techniques; it remains unclear, however, if this improves short- or long-term outcomes. What this evidence means for practice
While residual and total myometrial thickness presents a feasible, albeit indirect, assessment of uterine scar healing, it remains unclear if double-layer unlocked first-layer closure decreases long-term adverse outcomes, such as subsequent uterine rupture, cesarean scar defects, or gynecologic morbidity compared with other techniques. Nevertheless, this study highlights the importance of future research specifying both single- or double-layer and locked or unlocked uterine closure techniques.
— Joshua D. Dahlke, MD

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.

Cesarean delivery (CD), the most common surgery performed worldwide, is associated with increased morbidity and mortality compared with vaginal delivery. More than 230 randomized controlled trials (RCTs) have been published on varying technical aspects of CD, yet uncertainty remains regarding the optimal approach(es) to minimize perinatal morbidity.

Previous trials of one such technique, uterine closure, have not demonstrated short-term outcome differences among those randomized to single- versus double-layer closure. Results of long-term outcomes such as uterine rupture remain unclear. Emerging evidence also has associated cesarean scar defects with gynecologic problems like dysmenorrhea, pelvic pain, and postmenstrual spotting, further highlighting the importance of identifying surgical techniques that optimize uterine scar healing after CD.

Details of the study
In their recent RCT, Roberge and colleagues randomly assigned 81 women with singleton pregnancies undergoing elective primary CD (at ≥38 0/7 weeks) and compared the following uterine closure types on residual myometrial thickness during postpartum transvaginal ultrasound at 6 months:

In addition to addressing the single- versus double-layer debate, this study highlights another important aspect of closure technique: locked versus unlocked first-layer suture closure. The residual myometrial thickness, a surrogate measure of uterine scar healing, was significantly greater in those women randomly assigned to double-layer (locked or unlocked) closure compared with controls. Additionally, total myometrial thickness significantly increased in the double- layer unlocked closure group. There were no differences in the short-term outcomes of operative time or estimated blood loss among any of the groups.

Based on these findings, the authors advocate for double-layer unlocked uterine closure during CD to maximize uterine scar healing.

Bottom line
Double-layer uterine closure with unlocked first-layer at CD appears to maximize postpartum uterine scar thickness compared with other techniques; it remains unclear, however, if this improves short- or long-term outcomes. What this evidence means for practice
While residual and total myometrial thickness presents a feasible, albeit indirect, assessment of uterine scar healing, it remains unclear if double-layer unlocked first-layer closure decreases long-term adverse outcomes, such as subsequent uterine rupture, cesarean scar defects, or gynecologic morbidity compared with other techniques. Nevertheless, this study highlights the importance of future research specifying both single- or double-layer and locked or unlocked uterine closure techniques.
— Joshua D. Dahlke, MD

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.

In 2009, the US Preventive Services Task Force (USPSTF) recommended that biennial mammography screening in average-risk women begin at age 50.¹ New guidelines, that take into account reviews and modeling studies, clarify the earlier USPSTF recommendations, paying particular attention to individualized screening for women aged 40 to 49, use of tomosynthesis, and supplemental evaluation for women with radiologically dense breasts.

The new guidance only applies to women at average risk for breast cancer (not to those at substantially higher-than-average risk), including those with prior breast cancer or biopsy-confirmed high-risk lesions (eg, atypical hyperplasia), certain genetic conditions (such as BRCA1 or BRCA2 mutation), or histories of chest irradiation (eg, Hodgkin lymphoma).

Major statements:

The Task Force generated controversy with its 2009 recommendation that screening begin at age 50 in average-risk women. The current guidance clarifies that repetitive screening of women through 10 years reduces breast cancer deaths by 4 (aged 40–49), 8 (aged 50–59), and 21 (aged 60–69) per 10,000 women, respectively.²

The term “overdiagnosis” refers to detection and treatment of invasive and noninvasive (usually ductal carcinoma in situ) lesions that would have gone undetected without screening and would not have caused health problems. The USPSTF acknowledges that, while overdiagnosis represents the principal harm from screening, estimating overdiagnosis rates is challenging (best estimates range from 1 in 5 to 1 in 8 breast cancers diagnosed in screened women).^2–4 False-positive results, which lead to unnecessary additional imaging and biopsies,^3,4 can represent an additional harm of screening mammography.

The rationale for recommending that average-risk women begin screening at age 50 is based on the relatively smaller benefits and greater harms incurred when younger women are screened;^3,4 however, in noting that most of the screening benefits for women in their 40s are realized starting at age 45, the USPSTF guidance opens the door to average-risk women to begin screening at that age (congruent with the November 2015 American Cancer Society recommendations⁵). Also, women with a first-degree relative with breast cancer may want to initiate screening at age 40.

Regarding screening frequency, annual screening generates minimal if any benefit while increasing the potential for harm^3,4; thus, for most women at average risk for breast cancer, biennial screening provides the best benefit–harm balance.

What about use of tomosynthesis and women with dense breasts?
Tomosynthesis, which can be performed along with conventional digital screening mammography, seems to diminish the need for follow-up imaging while also increasing cancer detection rates.⁶ However, whether these additional cancers represent overdiagnosis remains unknown. Furthermore, tomosynthesis can expose women to about twice the radiation as conventional digital screening.⁷

Twenty-four states currently mandate that patients with dense breasts identified at screening be notified. Although increased breast density is a common independent risk factor for breast cancer, the degree of radiographic density can vary substantially from one screen to the next in the same woman. Evidence for or against adjunctive imaging is very limited in women found to have dense breasts in an otherwise negative mammogram, and suggests that ultrasonography and MRI (as well as tomosynthesis) can detect additional breast cancers while also generating more false-positive results.⁸ Thus, the USPSTF does not recommend specific screening strategies for women with dense breasts.

How I counsel my patients
I plan to continue recommending screening based on USPSTF guidance. However, I also will continue to support the preferences of many of my patients to:

You and your patients alike may find the USPSTF’s Summary for Patients⁹ (http://annals.org/article.aspx?articleid=2480981&resultClick=3) to be helpful when navigating this territory.

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.

In 2009, the US Preventive Services Task Force (USPSTF) recommended that biennial mammography screening in average-risk women begin at age 50.¹ New guidelines, that take into account reviews and modeling studies, clarify the earlier USPSTF recommendations, paying particular attention to individualized screening for women aged 40 to 49, use of tomosynthesis, and supplemental evaluation for women with radiologically dense breasts.

The new guidance only applies to women at average risk for breast cancer (not to those at substantially higher-than-average risk), including those with prior breast cancer or biopsy-confirmed high-risk lesions (eg, atypical hyperplasia), certain genetic conditions (such as BRCA1 or BRCA2 mutation), or histories of chest irradiation (eg, Hodgkin lymphoma).

Major statements:

The Task Force generated controversy with its 2009 recommendation that screening begin at age 50 in average-risk women. The current guidance clarifies that repetitive screening of women through 10 years reduces breast cancer deaths by 4 (aged 40–49), 8 (aged 50–59), and 21 (aged 60–69) per 10,000 women, respectively.²

The term “overdiagnosis” refers to detection and treatment of invasive and noninvasive (usually ductal carcinoma in situ) lesions that would have gone undetected without screening and would not have caused health problems. The USPSTF acknowledges that, while overdiagnosis represents the principal harm from screening, estimating overdiagnosis rates is challenging (best estimates range from 1 in 5 to 1 in 8 breast cancers diagnosed in screened women).^2–4 False-positive results, which lead to unnecessary additional imaging and biopsies,^3,4 can represent an additional harm of screening mammography.

The rationale for recommending that average-risk women begin screening at age 50 is based on the relatively smaller benefits and greater harms incurred when younger women are screened;^3,4 however, in noting that most of the screening benefits for women in their 40s are realized starting at age 45, the USPSTF guidance opens the door to average-risk women to begin screening at that age (congruent with the November 2015 American Cancer Society recommendations⁵). Also, women with a first-degree relative with breast cancer may want to initiate screening at age 40.

Regarding screening frequency, annual screening generates minimal if any benefit while increasing the potential for harm^3,4; thus, for most women at average risk for breast cancer, biennial screening provides the best benefit–harm balance.

What about use of tomosynthesis and women with dense breasts?
Tomosynthesis, which can be performed along with conventional digital screening mammography, seems to diminish the need for follow-up imaging while also increasing cancer detection rates.⁶ However, whether these additional cancers represent overdiagnosis remains unknown. Furthermore, tomosynthesis can expose women to about twice the radiation as conventional digital screening.⁷

Twenty-four states currently mandate that patients with dense breasts identified at screening be notified. Although increased breast density is a common independent risk factor for breast cancer, the degree of radiographic density can vary substantially from one screen to the next in the same woman. Evidence for or against adjunctive imaging is very limited in women found to have dense breasts in an otherwise negative mammogram, and suggests that ultrasonography and MRI (as well as tomosynthesis) can detect additional breast cancers while also generating more false-positive results.⁸ Thus, the USPSTF does not recommend specific screening strategies for women with dense breasts.

How I counsel my patients
I plan to continue recommending screening based on USPSTF guidance. However, I also will continue to support the preferences of many of my patients to:

You and your patients alike may find the USPSTF’s Summary for Patients⁹ (http://annals.org/article.aspx?articleid=2480981&resultClick=3) to be helpful when navigating this territory.

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.

In 2009, the US Preventive Services Task Force (USPSTF) recommended that biennial mammography screening in average-risk women begin at age 50.¹ New guidelines, that take into account reviews and modeling studies, clarify the earlier USPSTF recommendations, paying particular attention to individualized screening for women aged 40 to 49, use of tomosynthesis, and supplemental evaluation for women with radiologically dense breasts.

The new guidance only applies to women at average risk for breast cancer (not to those at substantially higher-than-average risk), including those with prior breast cancer or biopsy-confirmed high-risk lesions (eg, atypical hyperplasia), certain genetic conditions (such as BRCA1 or BRCA2 mutation), or histories of chest irradiation (eg, Hodgkin lymphoma).

Major statements:

The Task Force generated controversy with its 2009 recommendation that screening begin at age 50 in average-risk women. The current guidance clarifies that repetitive screening of women through 10 years reduces breast cancer deaths by 4 (aged 40–49), 8 (aged 50–59), and 21 (aged 60–69) per 10,000 women, respectively.²

The term “overdiagnosis” refers to detection and treatment of invasive and noninvasive (usually ductal carcinoma in situ) lesions that would have gone undetected without screening and would not have caused health problems. The USPSTF acknowledges that, while overdiagnosis represents the principal harm from screening, estimating overdiagnosis rates is challenging (best estimates range from 1 in 5 to 1 in 8 breast cancers diagnosed in screened women).^2–4 False-positive results, which lead to unnecessary additional imaging and biopsies,^3,4 can represent an additional harm of screening mammography.

The rationale for recommending that average-risk women begin screening at age 50 is based on the relatively smaller benefits and greater harms incurred when younger women are screened;^3,4 however, in noting that most of the screening benefits for women in their 40s are realized starting at age 45, the USPSTF guidance opens the door to average-risk women to begin screening at that age (congruent with the November 2015 American Cancer Society recommendations⁵). Also, women with a first-degree relative with breast cancer may want to initiate screening at age 40.

Regarding screening frequency, annual screening generates minimal if any benefit while increasing the potential for harm^3,4; thus, for most women at average risk for breast cancer, biennial screening provides the best benefit–harm balance.

What about use of tomosynthesis and women with dense breasts?
Tomosynthesis, which can be performed along with conventional digital screening mammography, seems to diminish the need for follow-up imaging while also increasing cancer detection rates.⁶ However, whether these additional cancers represent overdiagnosis remains unknown. Furthermore, tomosynthesis can expose women to about twice the radiation as conventional digital screening.⁷

Twenty-four states currently mandate that patients with dense breasts identified at screening be notified. Although increased breast density is a common independent risk factor for breast cancer, the degree of radiographic density can vary substantially from one screen to the next in the same woman. Evidence for or against adjunctive imaging is very limited in women found to have dense breasts in an otherwise negative mammogram, and suggests that ultrasonography and MRI (as well as tomosynthesis) can detect additional breast cancers while also generating more false-positive results.⁸ Thus, the USPSTF does not recommend specific screening strategies for women with dense breasts.

How I counsel my patients
I plan to continue recommending screening based on USPSTF guidance. However, I also will continue to support the preferences of many of my patients to:

You and your patients alike may find the USPSTF’s Summary for Patients⁹ (http://annals.org/article.aspx?articleid=2480981&resultClick=3) to be helpful when navigating this territory.

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.

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

Preterm birth (PTB) remains a major cause of perinatal morbidity and mortality, and so its prediction and prevention are 2 of the most important issues in obstetrics. Cervical length (CL) measured by ultrasound has been shown to be the best predictor; several interventions (vaginal progesterone and cerclage) have been shown to be effective at reducing PTB if a short CL is identified. In fact, both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommend CL being measured every 2 weeks from 16 to 23 weeks in singletons with prior spontaneous PTB (sPTB), with cerclage placed for CL less than 25 mm. Moreover, both ACOG and SMFM recommend that “universal CL screening” (CL measured in singletons without a prior sPTB) be considered as a single measurement at about 18 to 23 weeks.

Details of the study
Rhoades and colleagues present data on CL screening done by transabdominal ultrasound (TAU), as an alternative to transvaginal ultrasound (TVU). This study confirms early data:

There are several other reasons why TVU is considered the gold standard for CL screening, and instead TAU CL should be avoided as possible. All randomized controlled trials that showed benefit from interventions (vaginal progesterone, cerclage, pessary) aimed at decreasing PTB in women with short CL used TVU CL screening and never TAU CL screening. In addition, TAU CL is less accurate than TVU CL screening. On TAU, fetal parts can obscure the cervix, obesity makes it hard to visualize CL, the distance between probe and cervix is longer, manual pressure can mask CL shortening, and bladder filling can elongate CL.⁷ Cost-effectiveness studies show that TVU CL screening is more effective, and less costly, compared with TAU CL screening, even in singletons without a prior sPTB.⁸

Societies such as ACOG and SMFM all have recommended TVU CL for prediction and prevention of PTB, over TAU CL.^9,10 Importantly, a TVU CL should be done by sonographers educated and trained formally, through such programs as those made available by SMFM.¹¹

What this evidence means for practice
If CL assessment is done, TVU should be preferred, as it is the gold standard, and not TAU.
>>Vincenzo Berghella, MD

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

Preterm birth (PTB) remains a major cause of perinatal morbidity and mortality, and so its prediction and prevention are 2 of the most important issues in obstetrics. Cervical length (CL) measured by ultrasound has been shown to be the best predictor; several interventions (vaginal progesterone and cerclage) have been shown to be effective at reducing PTB if a short CL is identified. In fact, both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommend CL being measured every 2 weeks from 16 to 23 weeks in singletons with prior spontaneous PTB (sPTB), with cerclage placed for CL less than 25 mm. Moreover, both ACOG and SMFM recommend that “universal CL screening” (CL measured in singletons without a prior sPTB) be considered as a single measurement at about 18 to 23 weeks.

Details of the study
Rhoades and colleagues present data on CL screening done by transabdominal ultrasound (TAU), as an alternative to transvaginal ultrasound (TVU). This study confirms early data:

There are several other reasons why TVU is considered the gold standard for CL screening, and instead TAU CL should be avoided as possible. All randomized controlled trials that showed benefit from interventions (vaginal progesterone, cerclage, pessary) aimed at decreasing PTB in women with short CL used TVU CL screening and never TAU CL screening. In addition, TAU CL is less accurate than TVU CL screening. On TAU, fetal parts can obscure the cervix, obesity makes it hard to visualize CL, the distance between probe and cervix is longer, manual pressure can mask CL shortening, and bladder filling can elongate CL.⁷ Cost-effectiveness studies show that TVU CL screening is more effective, and less costly, compared with TAU CL screening, even in singletons without a prior sPTB.⁸

Societies such as ACOG and SMFM all have recommended TVU CL for prediction and prevention of PTB, over TAU CL.^9,10 Importantly, a TVU CL should be done by sonographers educated and trained formally, through such programs as those made available by SMFM.¹¹

What this evidence means for practice
If CL assessment is done, TVU should be preferred, as it is the gold standard, and not TAU.
>>Vincenzo Berghella, MD

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

Preterm birth (PTB) remains a major cause of perinatal morbidity and mortality, and so its prediction and prevention are 2 of the most important issues in obstetrics. Cervical length (CL) measured by ultrasound has been shown to be the best predictor; several interventions (vaginal progesterone and cerclage) have been shown to be effective at reducing PTB if a short CL is identified. In fact, both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommend CL being measured every 2 weeks from 16 to 23 weeks in singletons with prior spontaneous PTB (sPTB), with cerclage placed for CL less than 25 mm. Moreover, both ACOG and SMFM recommend that “universal CL screening” (CL measured in singletons without a prior sPTB) be considered as a single measurement at about 18 to 23 weeks.

Details of the study
Rhoades and colleagues present data on CL screening done by transabdominal ultrasound (TAU), as an alternative to transvaginal ultrasound (TVU). This study confirms early data:

There are several other reasons why TVU is considered the gold standard for CL screening, and instead TAU CL should be avoided as possible. All randomized controlled trials that showed benefit from interventions (vaginal progesterone, cerclage, pessary) aimed at decreasing PTB in women with short CL used TVU CL screening and never TAU CL screening. In addition, TAU CL is less accurate than TVU CL screening. On TAU, fetal parts can obscure the cervix, obesity makes it hard to visualize CL, the distance between probe and cervix is longer, manual pressure can mask CL shortening, and bladder filling can elongate CL.⁷ Cost-effectiveness studies show that TVU CL screening is more effective, and less costly, compared with TAU CL screening, even in singletons without a prior sPTB.⁸

Societies such as ACOG and SMFM all have recommended TVU CL for prediction and prevention of PTB, over TAU CL.^9,10 Importantly, a TVU CL should be done by sonographers educated and trained formally, through such programs as those made available by SMFM.¹¹

What this evidence means for practice
If CL assessment is done, TVU should be preferred, as it is the gold standard, and not TAU.
>>Vincenzo Berghella, MD

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

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

SAN DIEGO – The prevalence of kidney stone disease appears to be rising in the United States.

According to an analysis of responses from the 2007-2012 National Health and Nutrition Examination Survey (NHANES), 8.8% of people in the United States have kidney stone disease (Eur Urol. 2012 Jul;62[1]:160-5), up from a prevalence of 5.2% observed in the 1988-1994 NHANES.

“There’s also been a marked increase in emergency room visits for kidney stones: 91% between 1994 and 2006,” Dr. Anna L. Zisman said at the meeting sponsored by the American Society of Nephrology.

“Unfortunately, it doesn’t only affect adults. There has been an increased incidence in ER visits for kids as well.” Though good national data on the incidence of kidney stone disease in children are lacking, one study conducted in South Carolina found that the incidence of ER visits in children rose from 8 per 100,000 in 1996 to more than 18 per 100,000 in 2007 (J Pediatr. 2010 Jul;157[1]:132-7).

What’s driving these increases? Dr. Zisman, a nephrologist at the University of Chicago, discussed a “recipe” for how to create a kidney stone, with heredity as the first step.

“Pick your parents well,” she said. “The familial clustering index is higher for nephrolithiasis than for diabetes and hypertension. A family history of stone disease is present in 16%-37% of stone formers, compared with 4%-12% of healthy controls. And the heritability estimates – how much of a given disease or trait can be attributable to genetic predisposition – is somewhere between 46% and 63%.”

According to Mayo Clinic researchers, heritable traits for kidney stone disease based on 24-hour urine measurements, adjusted for diet, include calcium, magnesium, pH, and citrate (Clin J Am Soc Nephrol. 2014 May;9[5]:943-50).

“Hypercalciuria is the most well-established risk factor for stone disease,” Dr. Zisman said. “Up to 50% of subjects with stones have a history of hypercalciuria, and 43% of first-degree relatives of hypercalciuric patients have hypercalciuria.”

Race and gender are two factors people can’t control in their risk for kidney stone disease. NHANES data suggest that non-Hispanic whites are at highest risk for stone formation, compared with Hispanics and non-Hispanic blacks. However, among whites and all of the racial categories, males have a higher risk than females.

Step two in the recipe for stone formation is timing: Age matters.

According to an analysis of 49,976 men who participated in the Health Professionals Follow-Up Study, the highest risk of stone formation was in male patients in their 40s (J Am Soc Nephrol. 2004 Dec;15[12]:3225-32). By the time white males reach their 70s, the prevalence is almost 19%, while the prevalence for white women in their 70s is 9.4% (Eur Urol. 2012 Jul;62[1]:160-5).

Step three in the recipe is location. According to Dr. Zisman, the prevalence of kidney stone disease across the world is quite varied. “That likely has to do with both genetic predispositions as well as environmental factors,” she noted. “For example, Iran, which has a pretty warm climate, has a prevalence of 5.7%, Greece 15.2%, whereas Argentina only 4%. In the United States, data suggest that the highest incidence of stone disease is in the south. It is suspected that this is due to more men working outside in manual labor in the heat, but that’s just a hypothesis.”

Step four in the recipe involves the role of certain nutrients. For example, a higher daily calcium intake is associated with a lower risk of kidney stone formation. “The theory is that with higher dietary calcium, your urine oxalate tends to drop,” she said. Increased intake of magnesium, protein, potassium, and fluid are also associated with decreased stone formation.

On the other hand, a higher daily vitamin C intake is associated with an increased risk of stone formation. Specifically, a daily intake of more than 1,000 mg confers a 41% increased risk, compared with a lower intake. “The theory there is that vitamin C intake, once absorbed, results in a higher urine oxalate,” Dr. Zisman said.

Current epidemiology literature draws no clear association between a high-sodium diet and the development of kidney stones. From a clinical standpoint, however, “I think everyone would recommend a low-sodium diet because of the physiologic mechanisms leading to higher urine calcium,” she said.

Higher body mass index and increased waist circumference also impact the risk of developing kidney stones, especially among women. “The higher [they are], the greater the risk,” Dr. Zisman said. “We know that as weight goes up, urinary pH drops. Another potential reason is that as body weight goes up, urinary oxalate goes up as well.”

Step five in the recipe for stone formation is occupation. A study from Israel found that lifeguards in that country faced about a 20-fold increased risk of kidney stones, compared with that of the general population (Adv Exp Med Biol. 1980;128:467-72). Meanwhile, a study of glass factory workers in Italy found that the prevalence of kidney stones was 8.5% among those exposed to blast furnace sites, compared with 2.4% among those who worked in ambient temperatures (P = .03) (J Urol 1993 Dec;150[6]:1757-60). A similar finding was observed in a more recent study of steel factory workers in Brazil (Urology 2005;65[5]:858-61).

Variations to the “recipe” for kidney stones include certain genetic diseases such as primary hyperoxaluria and Dent disease; anatomic variations such as horseshoe kidney and ileal conduits; coexisting disease such as inflammatory bowel disease and primary hyperparathyroidism; and effects from medication such as acetazolamide/topiramate and prednisone.

“Mix up genetic predisposition, environmental factors, and dietary/lifestyle factors and add the magic ingredient,” Dr. Zisman concluded. “There is something that is affecting some people and not others. We don’t know what that is, and we clearly need more research.”

Dr. Zisman reported having no financial disclosures.

[email protected]

SAN DIEGO – The prevalence of kidney stone disease appears to be rising in the United States.

According to an analysis of responses from the 2007-2012 National Health and Nutrition Examination Survey (NHANES), 8.8% of people in the United States have kidney stone disease (Eur Urol. 2012 Jul;62[1]:160-5), up from a prevalence of 5.2% observed in the 1988-1994 NHANES.

“There’s also been a marked increase in emergency room visits for kidney stones: 91% between 1994 and 2006,” Dr. Anna L. Zisman said at the meeting sponsored by the American Society of Nephrology.

“Unfortunately, it doesn’t only affect adults. There has been an increased incidence in ER visits for kids as well.” Though good national data on the incidence of kidney stone disease in children are lacking, one study conducted in South Carolina found that the incidence of ER visits in children rose from 8 per 100,000 in 1996 to more than 18 per 100,000 in 2007 (J Pediatr. 2010 Jul;157[1]:132-7).

What’s driving these increases? Dr. Zisman, a nephrologist at the University of Chicago, discussed a “recipe” for how to create a kidney stone, with heredity as the first step.

“Pick your parents well,” she said. “The familial clustering index is higher for nephrolithiasis than for diabetes and hypertension. A family history of stone disease is present in 16%-37% of stone formers, compared with 4%-12% of healthy controls. And the heritability estimates – how much of a given disease or trait can be attributable to genetic predisposition – is somewhere between 46% and 63%.”

According to Mayo Clinic researchers, heritable traits for kidney stone disease based on 24-hour urine measurements, adjusted for diet, include calcium, magnesium, pH, and citrate (Clin J Am Soc Nephrol. 2014 May;9[5]:943-50).

“Hypercalciuria is the most well-established risk factor for stone disease,” Dr. Zisman said. “Up to 50% of subjects with stones have a history of hypercalciuria, and 43% of first-degree relatives of hypercalciuric patients have hypercalciuria.”

Race and gender are two factors people can’t control in their risk for kidney stone disease. NHANES data suggest that non-Hispanic whites are at highest risk for stone formation, compared with Hispanics and non-Hispanic blacks. However, among whites and all of the racial categories, males have a higher risk than females.

Step two in the recipe for stone formation is timing: Age matters.

According to an analysis of 49,976 men who participated in the Health Professionals Follow-Up Study, the highest risk of stone formation was in male patients in their 40s (J Am Soc Nephrol. 2004 Dec;15[12]:3225-32). By the time white males reach their 70s, the prevalence is almost 19%, while the prevalence for white women in their 70s is 9.4% (Eur Urol. 2012 Jul;62[1]:160-5).

Step three in the recipe is location. According to Dr. Zisman, the prevalence of kidney stone disease across the world is quite varied. “That likely has to do with both genetic predispositions as well as environmental factors,” she noted. “For example, Iran, which has a pretty warm climate, has a prevalence of 5.7%, Greece 15.2%, whereas Argentina only 4%. In the United States, data suggest that the highest incidence of stone disease is in the south. It is suspected that this is due to more men working outside in manual labor in the heat, but that’s just a hypothesis.”

Step four in the recipe involves the role of certain nutrients. For example, a higher daily calcium intake is associated with a lower risk of kidney stone formation. “The theory is that with higher dietary calcium, your urine oxalate tends to drop,” she said. Increased intake of magnesium, protein, potassium, and fluid are also associated with decreased stone formation.

On the other hand, a higher daily vitamin C intake is associated with an increased risk of stone formation. Specifically, a daily intake of more than 1,000 mg confers a 41% increased risk, compared with a lower intake. “The theory there is that vitamin C intake, once absorbed, results in a higher urine oxalate,” Dr. Zisman said.

Current epidemiology literature draws no clear association between a high-sodium diet and the development of kidney stones. From a clinical standpoint, however, “I think everyone would recommend a low-sodium diet because of the physiologic mechanisms leading to higher urine calcium,” she said.

Higher body mass index and increased waist circumference also impact the risk of developing kidney stones, especially among women. “The higher [they are], the greater the risk,” Dr. Zisman said. “We know that as weight goes up, urinary pH drops. Another potential reason is that as body weight goes up, urinary oxalate goes up as well.”

Step five in the recipe for stone formation is occupation. A study from Israel found that lifeguards in that country faced about a 20-fold increased risk of kidney stones, compared with that of the general population (Adv Exp Med Biol. 1980;128:467-72). Meanwhile, a study of glass factory workers in Italy found that the prevalence of kidney stones was 8.5% among those exposed to blast furnace sites, compared with 2.4% among those who worked in ambient temperatures (P = .03) (J Urol 1993 Dec;150[6]:1757-60). A similar finding was observed in a more recent study of steel factory workers in Brazil (Urology 2005;65[5]:858-61).

Variations to the “recipe” for kidney stones include certain genetic diseases such as primary hyperoxaluria and Dent disease; anatomic variations such as horseshoe kidney and ileal conduits; coexisting disease such as inflammatory bowel disease and primary hyperparathyroidism; and effects from medication such as acetazolamide/topiramate and prednisone.

“Mix up genetic predisposition, environmental factors, and dietary/lifestyle factors and add the magic ingredient,” Dr. Zisman concluded. “There is something that is affecting some people and not others. We don’t know what that is, and we clearly need more research.”

Dr. Zisman reported having no financial disclosures.

[email protected]

SAN DIEGO – The prevalence of kidney stone disease appears to be rising in the United States.

According to an analysis of responses from the 2007-2012 National Health and Nutrition Examination Survey (NHANES), 8.8% of people in the United States have kidney stone disease (Eur Urol. 2012 Jul;62[1]:160-5), up from a prevalence of 5.2% observed in the 1988-1994 NHANES.

“There’s also been a marked increase in emergency room visits for kidney stones: 91% between 1994 and 2006,” Dr. Anna L. Zisman said at the meeting sponsored by the American Society of Nephrology.

“Unfortunately, it doesn’t only affect adults. There has been an increased incidence in ER visits for kids as well.” Though good national data on the incidence of kidney stone disease in children are lacking, one study conducted in South Carolina found that the incidence of ER visits in children rose from 8 per 100,000 in 1996 to more than 18 per 100,000 in 2007 (J Pediatr. 2010 Jul;157[1]:132-7).

What’s driving these increases? Dr. Zisman, a nephrologist at the University of Chicago, discussed a “recipe” for how to create a kidney stone, with heredity as the first step.

“Pick your parents well,” she said. “The familial clustering index is higher for nephrolithiasis than for diabetes and hypertension. A family history of stone disease is present in 16%-37% of stone formers, compared with 4%-12% of healthy controls. And the heritability estimates – how much of a given disease or trait can be attributable to genetic predisposition – is somewhere between 46% and 63%.”

According to Mayo Clinic researchers, heritable traits for kidney stone disease based on 24-hour urine measurements, adjusted for diet, include calcium, magnesium, pH, and citrate (Clin J Am Soc Nephrol. 2014 May;9[5]:943-50).

“Hypercalciuria is the most well-established risk factor for stone disease,” Dr. Zisman said. “Up to 50% of subjects with stones have a history of hypercalciuria, and 43% of first-degree relatives of hypercalciuric patients have hypercalciuria.”

Race and gender are two factors people can’t control in their risk for kidney stone disease. NHANES data suggest that non-Hispanic whites are at highest risk for stone formation, compared with Hispanics and non-Hispanic blacks. However, among whites and all of the racial categories, males have a higher risk than females.

Step two in the recipe for stone formation is timing: Age matters.

According to an analysis of 49,976 men who participated in the Health Professionals Follow-Up Study, the highest risk of stone formation was in male patients in their 40s (J Am Soc Nephrol. 2004 Dec;15[12]:3225-32). By the time white males reach their 70s, the prevalence is almost 19%, while the prevalence for white women in their 70s is 9.4% (Eur Urol. 2012 Jul;62[1]:160-5).

Step three in the recipe is location. According to Dr. Zisman, the prevalence of kidney stone disease across the world is quite varied. “That likely has to do with both genetic predispositions as well as environmental factors,” she noted. “For example, Iran, which has a pretty warm climate, has a prevalence of 5.7%, Greece 15.2%, whereas Argentina only 4%. In the United States, data suggest that the highest incidence of stone disease is in the south. It is suspected that this is due to more men working outside in manual labor in the heat, but that’s just a hypothesis.”

Step four in the recipe involves the role of certain nutrients. For example, a higher daily calcium intake is associated with a lower risk of kidney stone formation. “The theory is that with higher dietary calcium, your urine oxalate tends to drop,” she said. Increased intake of magnesium, protein, potassium, and fluid are also associated with decreased stone formation.

On the other hand, a higher daily vitamin C intake is associated with an increased risk of stone formation. Specifically, a daily intake of more than 1,000 mg confers a 41% increased risk, compared with a lower intake. “The theory there is that vitamin C intake, once absorbed, results in a higher urine oxalate,” Dr. Zisman said.

Current epidemiology literature draws no clear association between a high-sodium diet and the development of kidney stones. From a clinical standpoint, however, “I think everyone would recommend a low-sodium diet because of the physiologic mechanisms leading to higher urine calcium,” she said.

Higher body mass index and increased waist circumference also impact the risk of developing kidney stones, especially among women. “The higher [they are], the greater the risk,” Dr. Zisman said. “We know that as weight goes up, urinary pH drops. Another potential reason is that as body weight goes up, urinary oxalate goes up as well.”

Step five in the recipe for stone formation is occupation. A study from Israel found that lifeguards in that country faced about a 20-fold increased risk of kidney stones, compared with that of the general population (Adv Exp Med Biol. 1980;128:467-72). Meanwhile, a study of glass factory workers in Italy found that the prevalence of kidney stones was 8.5% among those exposed to blast furnace sites, compared with 2.4% among those who worked in ambient temperatures (P = .03) (J Urol 1993 Dec;150[6]:1757-60). A similar finding was observed in a more recent study of steel factory workers in Brazil (Urology 2005;65[5]:858-61).

Variations to the “recipe” for kidney stones include certain genetic diseases such as primary hyperoxaluria and Dent disease; anatomic variations such as horseshoe kidney and ileal conduits; coexisting disease such as inflammatory bowel disease and primary hyperparathyroidism; and effects from medication such as acetazolamide/topiramate and prednisone.

“Mix up genetic predisposition, environmental factors, and dietary/lifestyle factors and add the magic ingredient,” Dr. Zisman concluded. “There is something that is affecting some people and not others. We don’t know what that is, and we clearly need more research.”

Dr. Zisman reported having no financial disclosures.

[email protected]

The Mediterranean diet, characterized by an emphasis on plant foods, fish, and olive oil, is known to have cardiovascular benefits. This study by Toledo and colleagues is a secondary analysis of a large randomized trial that assessed the impact of the Mediterranean diet versus a recommended low-fat diet in patients at elevated risk for cardiovascular disease (CVD). The larger trial was stopped after 4.8 years of follow-up, when findings of early cardiovascular benefit became evident.

The 4,282 women in the trial, all of whom were white, were randomly allocated to one of the following groups:

• Mediterranean diet supplemented by EVOO. Participants were given 1 L of EVOO a week for the study duration. At baseline and quarterly thereafter, dieticians ran individual and group sessions. In individual sessions, participants completed a 14-item dietary screening questionnaire to assess adherence to the diet.
• Mediterranean diet supplemented by mixed nuts. Participants were given 30 g of mixed nuts per day (15 g walnuts, 7.5 g hazelnuts, and 7.5 g almonds). They also took part in individual and group sessions at baseline and quarterly thereafter, and completed the same screening questionnaire as the first group.
• A control group. Participants were advised to reduce dietary fat. They also underwent dietary training at the baseline visit and completed the 14-item screener. Thereafter, during the first 3 years of the trial, they received annual mailing of a leaflet explaining the low-fat diet. In 2006, however, the protocol was amended to include personalized advice and quarterly group sessions, with use of a separate 9-item dietary screener. The control group also received gifts of nonfood items as incentives.

Physical activity was not promoted in any group.

Findings of the trialAfter a median follow-up of 4.8 years, 35 confirmed cases of invasive breast cancer occurred among participants in the trial, who ranged in age from 60 to 80 years. The observed rate (per 1,000 person-years) of breast cancer was 1.1 for women following the Mediterranean diet supplemented with EVOO, 1.8 for women on the diet supplemented by mixed nuts, and 2.9 for the control group.

Women allocated to the Mediterranean diet with EVOO had a 62% reduced risk of invasive breast cancer (95% confidence interval [CI], 0.16–0.87). Women allocated to the same diet with mixed nuts had a 38% reduced risk of breast cancer, but this finding was not statistically significant.

Note that women in the control group failed to reduce their total fat intake substantially, even though they were advised to do so, although saturated fat intake remained below 10%.

Strengths and limitations of the trialAlthough the incidence of breast cancer is lower in Mediterranean countries, this is the first randomized trial to assess the impact of the Mediterranean diet on risk of this disease.

Because breast cancer was not the primary outcome, investigators were unable to verify if or when participants underwent mammography screening. However, randomization resulted in large groups of participants between whom mammographic status likely was comparable.

The lack of ethnic diversity represents another limitation.

Toledo and colleagues describe differences between olive oils in general and EVOO, including biologic mechanisms that might result in breast cancer prophylaxis.

WHAT THIS EVIDENCE MEANS FOR PRACTICEGiven the known cardiovascular benefits, it is reasonable to suggest to our menopausal patients that a Mediterranean diet with EVOO may reduce their risk of breast cancer.
—Andrew M. Kaunitz, MD

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

The Mediterranean diet, characterized by an emphasis on plant foods, fish, and olive oil, is known to have cardiovascular benefits. This study by Toledo and colleagues is a secondary analysis of a large randomized trial that assessed the impact of the Mediterranean diet versus a recommended low-fat diet in patients at elevated risk for cardiovascular disease (CVD). The larger trial was stopped after 4.8 years of follow-up, when findings of early cardiovascular benefit became evident.

The 4,282 women in the trial, all of whom were white, were randomly allocated to one of the following groups:

• Mediterranean diet supplemented by EVOO. Participants were given 1 L of EVOO a week for the study duration. At baseline and quarterly thereafter, dieticians ran individual and group sessions. In individual sessions, participants completed a 14-item dietary screening questionnaire to assess adherence to the diet.
• Mediterranean diet supplemented by mixed nuts. Participants were given 30 g of mixed nuts per day (15 g walnuts, 7.5 g hazelnuts, and 7.5 g almonds). They also took part in individual and group sessions at baseline and quarterly thereafter, and completed the same screening questionnaire as the first group.
• A control group. Participants were advised to reduce dietary fat. They also underwent dietary training at the baseline visit and completed the 14-item screener. Thereafter, during the first 3 years of the trial, they received annual mailing of a leaflet explaining the low-fat diet. In 2006, however, the protocol was amended to include personalized advice and quarterly group sessions, with use of a separate 9-item dietary screener. The control group also received gifts of nonfood items as incentives.

Physical activity was not promoted in any group.

Findings of the trialAfter a median follow-up of 4.8 years, 35 confirmed cases of invasive breast cancer occurred among participants in the trial, who ranged in age from 60 to 80 years. The observed rate (per 1,000 person-years) of breast cancer was 1.1 for women following the Mediterranean diet supplemented with EVOO, 1.8 for women on the diet supplemented by mixed nuts, and 2.9 for the control group.

Women allocated to the Mediterranean diet with EVOO had a 62% reduced risk of invasive breast cancer (95% confidence interval [CI], 0.16–0.87). Women allocated to the same diet with mixed nuts had a 38% reduced risk of breast cancer, but this finding was not statistically significant.

Note that women in the control group failed to reduce their total fat intake substantially, even though they were advised to do so, although saturated fat intake remained below 10%.

Strengths and limitations of the trialAlthough the incidence of breast cancer is lower in Mediterranean countries, this is the first randomized trial to assess the impact of the Mediterranean diet on risk of this disease.

Because breast cancer was not the primary outcome, investigators were unable to verify if or when participants underwent mammography screening. However, randomization resulted in large groups of participants between whom mammographic status likely was comparable.

The lack of ethnic diversity represents another limitation.

Toledo and colleagues describe differences between olive oils in general and EVOO, including biologic mechanisms that might result in breast cancer prophylaxis.

WHAT THIS EVIDENCE MEANS FOR PRACTICEGiven the known cardiovascular benefits, it is reasonable to suggest to our menopausal patients that a Mediterranean diet with EVOO may reduce their risk of breast cancer.
—Andrew M. Kaunitz, MD

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

The Mediterranean diet, characterized by an emphasis on plant foods, fish, and olive oil, is known to have cardiovascular benefits. This study by Toledo and colleagues is a secondary analysis of a large randomized trial that assessed the impact of the Mediterranean diet versus a recommended low-fat diet in patients at elevated risk for cardiovascular disease (CVD). The larger trial was stopped after 4.8 years of follow-up, when findings of early cardiovascular benefit became evident.

The 4,282 women in the trial, all of whom were white, were randomly allocated to one of the following groups:

• Mediterranean diet supplemented by EVOO. Participants were given 1 L of EVOO a week for the study duration. At baseline and quarterly thereafter, dieticians ran individual and group sessions. In individual sessions, participants completed a 14-item dietary screening questionnaire to assess adherence to the diet.
• Mediterranean diet supplemented by mixed nuts. Participants were given 30 g of mixed nuts per day (15 g walnuts, 7.5 g hazelnuts, and 7.5 g almonds). They also took part in individual and group sessions at baseline and quarterly thereafter, and completed the same screening questionnaire as the first group.
• A control group. Participants were advised to reduce dietary fat. They also underwent dietary training at the baseline visit and completed the 14-item screener. Thereafter, during the first 3 years of the trial, they received annual mailing of a leaflet explaining the low-fat diet. In 2006, however, the protocol was amended to include personalized advice and quarterly group sessions, with use of a separate 9-item dietary screener. The control group also received gifts of nonfood items as incentives.

Physical activity was not promoted in any group.

Findings of the trialAfter a median follow-up of 4.8 years, 35 confirmed cases of invasive breast cancer occurred among participants in the trial, who ranged in age from 60 to 80 years. The observed rate (per 1,000 person-years) of breast cancer was 1.1 for women following the Mediterranean diet supplemented with EVOO, 1.8 for women on the diet supplemented by mixed nuts, and 2.9 for the control group.

Women allocated to the Mediterranean diet with EVOO had a 62% reduced risk of invasive breast cancer (95% confidence interval [CI], 0.16–0.87). Women allocated to the same diet with mixed nuts had a 38% reduced risk of breast cancer, but this finding was not statistically significant.

Note that women in the control group failed to reduce their total fat intake substantially, even though they were advised to do so, although saturated fat intake remained below 10%.

Strengths and limitations of the trialAlthough the incidence of breast cancer is lower in Mediterranean countries, this is the first randomized trial to assess the impact of the Mediterranean diet on risk of this disease.

Because breast cancer was not the primary outcome, investigators were unable to verify if or when participants underwent mammography screening. However, randomization resulted in large groups of participants between whom mammographic status likely was comparable.

The lack of ethnic diversity represents another limitation.

Toledo and colleagues describe differences between olive oils in general and EVOO, including biologic mechanisms that might result in breast cancer prophylaxis.

WHAT THIS EVIDENCE MEANS FOR PRACTICEGiven the known cardiovascular benefits, it is reasonable to suggest to our menopausal patients that a Mediterranean diet with EVOO may reduce their risk of breast cancer.
—Andrew M. Kaunitz, MD

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As gynecologists are well aware, in November 2014, the FDA issued a safety communication, warning “against the use of laparoscopic power morcellators in the majority of women undergoing myomectomy or hysterectomy for treatment of fibroids.” Now, a group of 46 experts in gynecologic surgery, including Dr. Eva Chalas, question the FDA’s decision and provide their own clinical recommendations for FDA consideration.

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As gynecologists are well aware, in November 2014, the FDA issued a safety communication, warning “against the use of laparoscopic power morcellators in the majority of women undergoing myomectomy or hysterectomy for treatment of fibroids.” Now, a group of 46 experts in gynecologic surgery, including Dr. Eva Chalas, question the FDA’s decision and provide their own clinical recommendations for FDA consideration.

 Click here to read the open letter to the FDA.

As gynecologists are well aware, in November 2014, the FDA issued a safety communication, warning “against the use of laparoscopic power morcellators in the majority of women undergoing myomectomy or hysterectomy for treatment of fibroids.” Now, a group of 46 experts in gynecologic surgery, including Dr. Eva Chalas, question the FDA’s decision and provide their own clinical recommendations for FDA consideration.

 Click here to read the open letter to the FDA.