Letters To The Editor

Cervical screening recommendations do not cover all circumstances

Starting cervical cancer screening at age 21 does not necessarily take into account the fact that we are seeing youngsters initiating sexual activity as young as age 9. We obviously see pregnancies early as well. Waiting to screen until age 21, therefore, may cause us to miss the development of high-grade lesions and cervical cancer. As you know, cases in the literature report instances of invasive cancer with first Pap test at age 21. Also, human papillomavirus (HPV) is spread by sexual activity, with the squamous columnar junction more susceptible to infection at a young age.

Recommendations regarding cervical cancer screening for older women also should take into account new sexual partners. Currently, both men and women are living longer and are remarrying or are sexually active with multiple partners. The fact that older women are desiring hormone replacement for vaginal lubrication and dyspareunia shows that they are sexually active even in their late 70s. I believe that the incidence of HPV infection to cervical, vaginal, and vulvar tissue will be increasing as a result.

In an age in which primary care physicians do not have time to perform Pap tests or vaginal, cervical, and vulvar exams because they are overwhelmed with keeping up with patients’ major medical issues is a misunderstanding regarding current recommendations for Pap test screening.

Elizabeth Reinoehl-McClaskey, DO
Onley, Virginia

Dr. Einstein responds

Sexual behavior can start early, but this does not lead to cancer. When we screen, we are looking for cancer, not HPV infection, which is quite common in women and men younger than age 21. Also, one might question whether current screening techniques pick up early-onset tumors. Regarding older women, sexual activity and the rate of older women getting cervical cancer should be considered in future guidelines.

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.

Cervical screening recommendations do not cover all circumstances

Starting cervical cancer screening at age 21 does not necessarily take into account the fact that we are seeing youngsters initiating sexual activity as young as age 9. We obviously see pregnancies early as well. Waiting to screen until age 21, therefore, may cause us to miss the development of high-grade lesions and cervical cancer. As you know, cases in the literature report instances of invasive cancer with first Pap test at age 21. Also, human papillomavirus (HPV) is spread by sexual activity, with the squamous columnar junction more susceptible to infection at a young age.

Recommendations regarding cervical cancer screening for older women also should take into account new sexual partners. Currently, both men and women are living longer and are remarrying or are sexually active with multiple partners. The fact that older women are desiring hormone replacement for vaginal lubrication and dyspareunia shows that they are sexually active even in their late 70s. I believe that the incidence of HPV infection to cervical, vaginal, and vulvar tissue will be increasing as a result.

In an age in which primary care physicians do not have time to perform Pap tests or vaginal, cervical, and vulvar exams because they are overwhelmed with keeping up with patients’ major medical issues is a misunderstanding regarding current recommendations for Pap test screening.

Elizabeth Reinoehl-McClaskey, DO
Onley, Virginia

Dr. Einstein responds

Sexual behavior can start early, but this does not lead to cancer. When we screen, we are looking for cancer, not HPV infection, which is quite common in women and men younger than age 21. Also, one might question whether current screening techniques pick up early-onset tumors. Regarding older women, sexual activity and the rate of older women getting cervical cancer should be considered in future guidelines.

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.

Cervical screening recommendations do not cover all circumstances

Starting cervical cancer screening at age 21 does not necessarily take into account the fact that we are seeing youngsters initiating sexual activity as young as age 9. We obviously see pregnancies early as well. Waiting to screen until age 21, therefore, may cause us to miss the development of high-grade lesions and cervical cancer. As you know, cases in the literature report instances of invasive cancer with first Pap test at age 21. Also, human papillomavirus (HPV) is spread by sexual activity, with the squamous columnar junction more susceptible to infection at a young age.

Recommendations regarding cervical cancer screening for older women also should take into account new sexual partners. Currently, both men and women are living longer and are remarrying or are sexually active with multiple partners. The fact that older women are desiring hormone replacement for vaginal lubrication and dyspareunia shows that they are sexually active even in their late 70s. I believe that the incidence of HPV infection to cervical, vaginal, and vulvar tissue will be increasing as a result.

In an age in which primary care physicians do not have time to perform Pap tests or vaginal, cervical, and vulvar exams because they are overwhelmed with keeping up with patients’ major medical issues is a misunderstanding regarding current recommendations for Pap test screening.

Elizabeth Reinoehl-McClaskey, DO
Onley, Virginia

Dr. Einstein responds

Sexual behavior can start early, but this does not lead to cancer. When we screen, we are looking for cancer, not HPV infection, which is quite common in women and men younger than age 21. Also, one might question whether current screening techniques pick up early-onset tumors. Regarding older women, sexual activity and the rate of older women getting cervical cancer should be considered in future guidelines.

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.

Royer and colleagues¹ have performed a meta-analysis comparing shorter versus longer courses of antibiotics for treating infections in hospitalized patients. They conclude that shorter courses are safe. However, the authors do not address a flaw in the analysis; they included studies in which treatment with azithromycin was considered a short antibiotic course relative to treatment with another antibiotic. Azithromycin is a macrolide antibiotic that has a relatively long terminal serum half-life, which has been reported to be 35-96 hours.^2-4 Moreover, the half-life of azithromycin in lung tissue can be as long as 132 hours,⁴ which is important because tissue concentrations are thought to be more indicative of the clinical efficacy of macrolides.⁵ In 4 of 19 studies in the meta-analysis,¹ azithromycin was used as a short course for the treatment of pneumonia and compared with longer courses of antibiotics with a much shorter half-life. This implies that in these studies, the duration of the effective antibiotic tissue concentration in the short arms was probably not shorter than in the comparator arms. It could even be longer due to azithromycin’s favorable pharmacokinetics. In our view, these studies have unfairly contributed to the clinical efficacy of short courses, thereby threatening the validity of the overall conclusions. We think that effective antibiotic blood/tissue levels determine the clinical outcome, not just shorter or longer antibiotic courses.

Disclosures

The authors declare that they have no conflicts of interest to report.

Royer and colleagues¹ have performed a meta-analysis comparing shorter versus longer courses of antibiotics for treating infections in hospitalized patients. They conclude that shorter courses are safe. However, the authors do not address a flaw in the analysis; they included studies in which treatment with azithromycin was considered a short antibiotic course relative to treatment with another antibiotic. Azithromycin is a macrolide antibiotic that has a relatively long terminal serum half-life, which has been reported to be 35-96 hours.^2-4 Moreover, the half-life of azithromycin in lung tissue can be as long as 132 hours,⁴ which is important because tissue concentrations are thought to be more indicative of the clinical efficacy of macrolides.⁵ In 4 of 19 studies in the meta-analysis,¹ azithromycin was used as a short course for the treatment of pneumonia and compared with longer courses of antibiotics with a much shorter half-life. This implies that in these studies, the duration of the effective antibiotic tissue concentration in the short arms was probably not shorter than in the comparator arms. It could even be longer due to azithromycin’s favorable pharmacokinetics. In our view, these studies have unfairly contributed to the clinical efficacy of short courses, thereby threatening the validity of the overall conclusions. We think that effective antibiotic blood/tissue levels determine the clinical outcome, not just shorter or longer antibiotic courses.

Disclosures

The authors declare that they have no conflicts of interest to report.

Royer and colleagues¹ have performed a meta-analysis comparing shorter versus longer courses of antibiotics for treating infections in hospitalized patients. They conclude that shorter courses are safe. However, the authors do not address a flaw in the analysis; they included studies in which treatment with azithromycin was considered a short antibiotic course relative to treatment with another antibiotic. Azithromycin is a macrolide antibiotic that has a relatively long terminal serum half-life, which has been reported to be 35-96 hours.^2-4 Moreover, the half-life of azithromycin in lung tissue can be as long as 132 hours,⁴ which is important because tissue concentrations are thought to be more indicative of the clinical efficacy of macrolides.⁵ In 4 of 19 studies in the meta-analysis,¹ azithromycin was used as a short course for the treatment of pneumonia and compared with longer courses of antibiotics with a much shorter half-life. This implies that in these studies, the duration of the effective antibiotic tissue concentration in the short arms was probably not shorter than in the comparator arms. It could even be longer due to azithromycin’s favorable pharmacokinetics. In our view, these studies have unfairly contributed to the clinical efficacy of short courses, thereby threatening the validity of the overall conclusions. We think that effective antibiotic blood/tissue levels determine the clinical outcome, not just shorter or longer antibiotic courses.

Disclosures

The authors declare that they have no conflicts of interest to report.

We appreciate the interest in our review of antibiotic duration in hospitalized patients. Drs. Sikkens and van Agtmael comment that drug pharmacokinetics can alter true treatment duration.^1,2 Specifically, azithromycin has a long half-life in tissues.³ We did not consider pharmacokinetics in our prespecified protocol for study inclusion, nor require that studies compare the same drug between treatment groups. This is consistent with a systematic review of antibiotic duration in community-acquired pneumonia, which included 3 of the 4 studies comparing short-course azithromycin to a longer course of another antibiotic.⁴ Similarly, in a recent pilot study of antibiotic duration in bloodstream infections, only treatment duration was prespecified.⁵ We agree that the differing pharmacokinetics between drugs is a limitation to our findings.

To assess whether the inclusion of studies using short-course azithromycin biased our conclusions, we performed an additional meta-analysis for clinical efficacy excluding the 4 studies that compared azithromycin with another drug. This subgroup included 9 trials comprising 1270 patients. The overall risk difference was 0.3% (95% CI −2.7%, 3.3%), consistent with the primary findings that short-course antibiotic treatment is non-inferior to long-course antibiotic treatment. None of these 4 studies examined mortality; thus, the meta-analyses for short-term and long-term mortality are unaffected.

Disclosures

Dr. Royer holds stock in Pfizer. The authors have no other potential financial conflicts of interest to report.

Funding

This work was supported by K08 GM115859 [HCP]. This manuscript does not necessarily represent the position or policy of the US government or the Department of Veterans Affairs.

We appreciate the interest in our review of antibiotic duration in hospitalized patients. Drs. Sikkens and van Agtmael comment that drug pharmacokinetics can alter true treatment duration.^1,2 Specifically, azithromycin has a long half-life in tissues.³ We did not consider pharmacokinetics in our prespecified protocol for study inclusion, nor require that studies compare the same drug between treatment groups. This is consistent with a systematic review of antibiotic duration in community-acquired pneumonia, which included 3 of the 4 studies comparing short-course azithromycin to a longer course of another antibiotic.⁴ Similarly, in a recent pilot study of antibiotic duration in bloodstream infections, only treatment duration was prespecified.⁵ We agree that the differing pharmacokinetics between drugs is a limitation to our findings.

To assess whether the inclusion of studies using short-course azithromycin biased our conclusions, we performed an additional meta-analysis for clinical efficacy excluding the 4 studies that compared azithromycin with another drug. This subgroup included 9 trials comprising 1270 patients. The overall risk difference was 0.3% (95% CI −2.7%, 3.3%), consistent with the primary findings that short-course antibiotic treatment is non-inferior to long-course antibiotic treatment. None of these 4 studies examined mortality; thus, the meta-analyses for short-term and long-term mortality are unaffected.

Disclosures

Dr. Royer holds stock in Pfizer. The authors have no other potential financial conflicts of interest to report.

Funding

This work was supported by K08 GM115859 [HCP]. This manuscript does not necessarily represent the position or policy of the US government or the Department of Veterans Affairs.

We appreciate the interest in our review of antibiotic duration in hospitalized patients. Drs. Sikkens and van Agtmael comment that drug pharmacokinetics can alter true treatment duration.^1,2 Specifically, azithromycin has a long half-life in tissues.³ We did not consider pharmacokinetics in our prespecified protocol for study inclusion, nor require that studies compare the same drug between treatment groups. This is consistent with a systematic review of antibiotic duration in community-acquired pneumonia, which included 3 of the 4 studies comparing short-course azithromycin to a longer course of another antibiotic.⁴ Similarly, in a recent pilot study of antibiotic duration in bloodstream infections, only treatment duration was prespecified.⁵ We agree that the differing pharmacokinetics between drugs is a limitation to our findings.

To assess whether the inclusion of studies using short-course azithromycin biased our conclusions, we performed an additional meta-analysis for clinical efficacy excluding the 4 studies that compared azithromycin with another drug. This subgroup included 9 trials comprising 1270 patients. The overall risk difference was 0.3% (95% CI −2.7%, 3.3%), consistent with the primary findings that short-course antibiotic treatment is non-inferior to long-course antibiotic treatment. None of these 4 studies examined mortality; thus, the meta-analyses for short-term and long-term mortality are unaffected.

Disclosures

Dr. Royer holds stock in Pfizer. The authors have no other potential financial conflicts of interest to report.

Funding

This work was supported by K08 GM115859 [HCP]. This manuscript does not necessarily represent the position or policy of the US government or the Department of Veterans Affairs.

Midwife-physician alliance benefits women

I want to thank Dr. Barbieri for the introduction to his April editorial in which he states that the “trusted nurse midwife asks you to consult on her patient.” Where I practice (in a large suburb of Kansas with a hospital where more than 5,000 babies are delivered yearly), there is a serious lack of midwives and an even greater lack of physicians to support them. As the co-owner of an independently owned nurse-midwife practice, after losing our collaborating physician, we were unable to secure collaboration from any other group, despite our cesarean delivery rate of 5%, vaginal birth after cesarean success rate of 87%, and chorioamnionitis rate of 0%. Please continue to educate your readers on the benefit to women when all obstetric providers work together.

Julie Gorenc, CNM
Lenexa, Kansas

Dr. Barbieri responds

I thank Ms. Gorenc for her support of OBG Management and share her concern about optimizing obstetric care. Given the pending shortage of clinicians, we will need all experienced clinicians to work together to ensure access to high-quality obstetric care. My observation is that many obstetricians are concerned about liability issues that can be associated with coverage of other clinicians, including nurse midwives. The quality of obstetric care and collaboration would be enhanced if our medical tort system could evolve to a “just culture,” ending the “blame and shame” associated with tort litigation.

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.

Midwife-physician alliance benefits women

I want to thank Dr. Barbieri for the introduction to his April editorial in which he states that the “trusted nurse midwife asks you to consult on her patient.” Where I practice (in a large suburb of Kansas with a hospital where more than 5,000 babies are delivered yearly), there is a serious lack of midwives and an even greater lack of physicians to support them. As the co-owner of an independently owned nurse-midwife practice, after losing our collaborating physician, we were unable to secure collaboration from any other group, despite our cesarean delivery rate of 5%, vaginal birth after cesarean success rate of 87%, and chorioamnionitis rate of 0%. Please continue to educate your readers on the benefit to women when all obstetric providers work together.

Julie Gorenc, CNM
Lenexa, Kansas

Dr. Barbieri responds

I thank Ms. Gorenc for her support of OBG Management and share her concern about optimizing obstetric care. Given the pending shortage of clinicians, we will need all experienced clinicians to work together to ensure access to high-quality obstetric care. My observation is that many obstetricians are concerned about liability issues that can be associated with coverage of other clinicians, including nurse midwives. The quality of obstetric care and collaboration would be enhanced if our medical tort system could evolve to a “just culture,” ending the “blame and shame” associated with tort litigation.

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.

Midwife-physician alliance benefits women

I want to thank Dr. Barbieri for the introduction to his April editorial in which he states that the “trusted nurse midwife asks you to consult on her patient.” Where I practice (in a large suburb of Kansas with a hospital where more than 5,000 babies are delivered yearly), there is a serious lack of midwives and an even greater lack of physicians to support them. As the co-owner of an independently owned nurse-midwife practice, after losing our collaborating physician, we were unable to secure collaboration from any other group, despite our cesarean delivery rate of 5%, vaginal birth after cesarean success rate of 87%, and chorioamnionitis rate of 0%. Please continue to educate your readers on the benefit to women when all obstetric providers work together.

Julie Gorenc, CNM
Lenexa, Kansas

Dr. Barbieri responds

I thank Ms. Gorenc for her support of OBG Management and share her concern about optimizing obstetric care. Given the pending shortage of clinicians, we will need all experienced clinicians to work together to ensure access to high-quality obstetric care. My observation is that many obstetricians are concerned about liability issues that can be associated with coverage of other clinicians, including nurse midwives. The quality of obstetric care and collaboration would be enhanced if our medical tort system could evolve to a “just culture,” ending the “blame and shame” associated with tort litigation.

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.

Diagnostics company asserts medical and pathology groups prefer cotesting for cervical cancer screening

We are concerned about Dr. Wright’s March 2018 gynecologic cancer coverage of US Preventive Services Task Force (USPSTF) screening guidelines for cervical cancer.

The article suggests that draft USPSTF cervical cancer guidelines issued in September 2017 are final when in fact that is not the case. The USPSTF issued draft guidelines in late 2017, butfinal publication is pending USPSTFrevisions in response to submitted public comments. This means that, for now, existing USPSTF guidelines remain in place, and these guidelines clearly recommend cotesting (high-risk HPV and cytology/Pap) in women 30 to 65 years of age every 5 years as an appropriate screening modality, in alignment with the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the American Cancer Society, among others.

It is also notable that the proposed USPSTF guidelines have been met with sharp resistance. ACOG, as well as several organizations, including the American Society of Clinical Pathology, American Society of Cytopathology, the American Society for Cytotechnology, the College of American Pathologists, the International Academy of Cytology, and the Papanicolaou Society of Cytopathology, cite concerns with the proposed USPSTF guidelines and continue to argue in favor of cotesting in women 30 to 65 years of age.^1,2

We also fear that Dr. Wright may have provided data out of context. For instance, he notes that the USPSTF, in its draft guidelines, found that cotesting increased the number of follow-up tests but did not increase detection of CIN3+ in a decision model. Yet, the USPSTF analysis overrelied on research from European populations (not representative of the US cervical cancer experience) and excluded peer-reviewed data of women in the United States, which clearly shows that HPV-Pap together catches more cervical cancers than either Pap or HPV alone.³

D.P. Alagia, MD, and Harvey W. Kaufman, MD, MBA
Quest Diagnostics
Madison, New Jersey

Dr. Wright responds

I thank Drs. Alagia and Kaufman for their interest in the work and their comments regarding the USPSTF cervical cancer guidelines. As stated in the article, the USPSTF recommendations are currently in draft form and subject to revision based on public comment. The guidelines are a synthesis of best available evidence and are meant to weigh the benefits and harms of various cervical cancer screening strategies. The recommendations are based in part on simulation modeling that incorporates available evidence and projects the long-term effects of multiple rounds of screening. While the decision models incorporated a large amount of data and were robust in a variety of sensitivity analyses, as with all decision analyses, they are limited by the underlying assumptions utilized in the model. Over the last 2 decades, screening practices for cervical cancer have dramatically shifted. Highlighting the USPSTF draft guidelines was meant to raise awareness among clinicians and policy makers of the evolving role of high-risk HPV testing, either alone or in combination with cytology, as a screening modality for cervical cancer.

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.

Diagnostics company asserts medical and pathology groups prefer cotesting for cervical cancer screening

We are concerned about Dr. Wright’s March 2018 gynecologic cancer coverage of US Preventive Services Task Force (USPSTF) screening guidelines for cervical cancer.

The article suggests that draft USPSTF cervical cancer guidelines issued in September 2017 are final when in fact that is not the case. The USPSTF issued draft guidelines in late 2017, butfinal publication is pending USPSTFrevisions in response to submitted public comments. This means that, for now, existing USPSTF guidelines remain in place, and these guidelines clearly recommend cotesting (high-risk HPV and cytology/Pap) in women 30 to 65 years of age every 5 years as an appropriate screening modality, in alignment with the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the American Cancer Society, among others.

It is also notable that the proposed USPSTF guidelines have been met with sharp resistance. ACOG, as well as several organizations, including the American Society of Clinical Pathology, American Society of Cytopathology, the American Society for Cytotechnology, the College of American Pathologists, the International Academy of Cytology, and the Papanicolaou Society of Cytopathology, cite concerns with the proposed USPSTF guidelines and continue to argue in favor of cotesting in women 30 to 65 years of age.^1,2

We also fear that Dr. Wright may have provided data out of context. For instance, he notes that the USPSTF, in its draft guidelines, found that cotesting increased the number of follow-up tests but did not increase detection of CIN3+ in a decision model. Yet, the USPSTF analysis overrelied on research from European populations (not representative of the US cervical cancer experience) and excluded peer-reviewed data of women in the United States, which clearly shows that HPV-Pap together catches more cervical cancers than either Pap or HPV alone.³

D.P. Alagia, MD, and Harvey W. Kaufman, MD, MBA
Quest Diagnostics
Madison, New Jersey

Dr. Wright responds

I thank Drs. Alagia and Kaufman for their interest in the work and their comments regarding the USPSTF cervical cancer guidelines. As stated in the article, the USPSTF recommendations are currently in draft form and subject to revision based on public comment. The guidelines are a synthesis of best available evidence and are meant to weigh the benefits and harms of various cervical cancer screening strategies. The recommendations are based in part on simulation modeling that incorporates available evidence and projects the long-term effects of multiple rounds of screening. While the decision models incorporated a large amount of data and were robust in a variety of sensitivity analyses, as with all decision analyses, they are limited by the underlying assumptions utilized in the model. Over the last 2 decades, screening practices for cervical cancer have dramatically shifted. Highlighting the USPSTF draft guidelines was meant to raise awareness among clinicians and policy makers of the evolving role of high-risk HPV testing, either alone or in combination with cytology, as a screening modality for cervical cancer.

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.

Diagnostics company asserts medical and pathology groups prefer cotesting for cervical cancer screening

We are concerned about Dr. Wright’s March 2018 gynecologic cancer coverage of US Preventive Services Task Force (USPSTF) screening guidelines for cervical cancer.

The article suggests that draft USPSTF cervical cancer guidelines issued in September 2017 are final when in fact that is not the case. The USPSTF issued draft guidelines in late 2017, butfinal publication is pending USPSTFrevisions in response to submitted public comments. This means that, for now, existing USPSTF guidelines remain in place, and these guidelines clearly recommend cotesting (high-risk HPV and cytology/Pap) in women 30 to 65 years of age every 5 years as an appropriate screening modality, in alignment with the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the American Cancer Society, among others.

It is also notable that the proposed USPSTF guidelines have been met with sharp resistance. ACOG, as well as several organizations, including the American Society of Clinical Pathology, American Society of Cytopathology, the American Society for Cytotechnology, the College of American Pathologists, the International Academy of Cytology, and the Papanicolaou Society of Cytopathology, cite concerns with the proposed USPSTF guidelines and continue to argue in favor of cotesting in women 30 to 65 years of age.^1,2

We also fear that Dr. Wright may have provided data out of context. For instance, he notes that the USPSTF, in its draft guidelines, found that cotesting increased the number of follow-up tests but did not increase detection of CIN3+ in a decision model. Yet, the USPSTF analysis overrelied on research from European populations (not representative of the US cervical cancer experience) and excluded peer-reviewed data of women in the United States, which clearly shows that HPV-Pap together catches more cervical cancers than either Pap or HPV alone.³

D.P. Alagia, MD, and Harvey W. Kaufman, MD, MBA
Quest Diagnostics
Madison, New Jersey

Dr. Wright responds

I thank Drs. Alagia and Kaufman for their interest in the work and their comments regarding the USPSTF cervical cancer guidelines. As stated in the article, the USPSTF recommendations are currently in draft form and subject to revision based on public comment. The guidelines are a synthesis of best available evidence and are meant to weigh the benefits and harms of various cervical cancer screening strategies. The recommendations are based in part on simulation modeling that incorporates available evidence and projects the long-term effects of multiple rounds of screening. While the decision models incorporated a large amount of data and were robust in a variety of sensitivity analyses, as with all decision analyses, they are limited by the underlying assumptions utilized in the model. Over the last 2 decades, screening practices for cervical cancer have dramatically shifted. Highlighting the USPSTF draft guidelines was meant to raise awareness among clinicians and policy makers of the evolving role of high-risk HPV testing, either alone or in combination with cytology, as a screening modality for cervical cancer.

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.

Hands-on surgical training is incomparable

I am not one to critique new technology or new technique. The article on use of virtual reality to not only teach technique but also to grade it caught my attention. I work in a small hospital without a million-dollar robot. Very complicated cases are sent out to larger hospitals. We have 2 new graduates who, like most new grads, have little experience with many surgical techniques. Dr. Lenihan and I were resident classmates, so I know he understands the rigors of a no-hour limit residency. Even with our residency, when we got out we relied on our partners to assist us until they knew we could do cases with a surgical assistant (SA) or a less experienced helper.

We are asking too much of our new graduates. It is up to us to provide the help and assistance with surgeries that they are not comfortable doing. While virtual reality training is great for teaching robotics and some laparoscopic techniques, it cannot teach things such as anterior and posterior repairs, tension-free vaginal tape procedures, and enterocoele repair. We can all watch YouTube tutorials, but actually doing surgery is very different. We owe it to our new graduates to provide mentoring and encouragement with their surgical cases. At our hospital, mentoring the first 10 cases performed by a new physician (new grad or otherwise) used to be required, but that requirement is gone. Our service is one of the few that still has 2 physicians at every major case. We have an SA available, but we prefer to assist each other. This makes our laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy cases a 30- to 35-minute case. It allows us to teach anterior and posterior repair technique.

The involvement in surgical improvement is hands-on, and virtual reality training will never replace it.

Anthony J. Lemanski, MD
Kingman, Arizona

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.

Hands-on surgical training is incomparable

I am not one to critique new technology or new technique. The article on use of virtual reality to not only teach technique but also to grade it caught my attention. I work in a small hospital without a million-dollar robot. Very complicated cases are sent out to larger hospitals. We have 2 new graduates who, like most new grads, have little experience with many surgical techniques. Dr. Lenihan and I were resident classmates, so I know he understands the rigors of a no-hour limit residency. Even with our residency, when we got out we relied on our partners to assist us until they knew we could do cases with a surgical assistant (SA) or a less experienced helper.

We are asking too much of our new graduates. It is up to us to provide the help and assistance with surgeries that they are not comfortable doing. While virtual reality training is great for teaching robotics and some laparoscopic techniques, it cannot teach things such as anterior and posterior repairs, tension-free vaginal tape procedures, and enterocoele repair. We can all watch YouTube tutorials, but actually doing surgery is very different. We owe it to our new graduates to provide mentoring and encouragement with their surgical cases. At our hospital, mentoring the first 10 cases performed by a new physician (new grad or otherwise) used to be required, but that requirement is gone. Our service is one of the few that still has 2 physicians at every major case. We have an SA available, but we prefer to assist each other. This makes our laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy cases a 30- to 35-minute case. It allows us to teach anterior and posterior repair technique.

The involvement in surgical improvement is hands-on, and virtual reality training will never replace it.

Anthony J. Lemanski, MD
Kingman, Arizona

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.

Hands-on surgical training is incomparable

I am not one to critique new technology or new technique. The article on use of virtual reality to not only teach technique but also to grade it caught my attention. I work in a small hospital without a million-dollar robot. Very complicated cases are sent out to larger hospitals. We have 2 new graduates who, like most new grads, have little experience with many surgical techniques. Dr. Lenihan and I were resident classmates, so I know he understands the rigors of a no-hour limit residency. Even with our residency, when we got out we relied on our partners to assist us until they knew we could do cases with a surgical assistant (SA) or a less experienced helper.

We are asking too much of our new graduates. It is up to us to provide the help and assistance with surgeries that they are not comfortable doing. While virtual reality training is great for teaching robotics and some laparoscopic techniques, it cannot teach things such as anterior and posterior repairs, tension-free vaginal tape procedures, and enterocoele repair. We can all watch YouTube tutorials, but actually doing surgery is very different. We owe it to our new graduates to provide mentoring and encouragement with their surgical cases. At our hospital, mentoring the first 10 cases performed by a new physician (new grad or otherwise) used to be required, but that requirement is gone. Our service is one of the few that still has 2 physicians at every major case. We have an SA available, but we prefer to assist each other. This makes our laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy cases a 30- to 35-minute case. It allows us to teach anterior and posterior repair technique.

The involvement in surgical improvement is hands-on, and virtual reality training will never replace it.

Anthony J. Lemanski, MD
Kingman, Arizona

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.

Hypertensive crisis of pregnancy must be treated with all urgency

The following happened approximately 27 years ago when I worked as an attending at a regional level 2 hospital in Puerto Rico. One afternoon I received a call from the emergency department that they had been managing a patient (G4P3) at 33 weeks of gestation for about 4 hours. The patient was consulted for hypertension when she went into a hypertensive encephalopathic coma. The patient was brought back to the birth center. Apresoline was given but did not bring the blood pressure down. Magnesium sulfate also was started at that time. I called a colleague from internal medicine and started to give nitroprusside.

Every time the patient’s blood pressure dropped from 120 mm Hg diastolic, she would become conscious and speak with us. As soon as her blood pressure went up, she would go into a coma. The patient was then transferred to a tertiary center in as stable a condition as possible. Cesarean delivery was performed, and the baby did not survive. The mother had an intracerebral hemorrhage. She was transferred to the supra-tertiary center in San Juan where she later passed away from complications of the hypertensive crisis. If the emergency physician had called me earlier, more could have been done.

This event is always fresh I my mind when I manage my patients in Ohio. Thank God for the newer medications we have available and the protocols to manage hypertensive crisis in pregnancy. I hope this experience heightens awareness of how deadly this condition can be.

David A. Rosado, MD
Celina, Ohio

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.

Hypertensive crisis of pregnancy must be treated with all urgency

The following happened approximately 27 years ago when I worked as an attending at a regional level 2 hospital in Puerto Rico. One afternoon I received a call from the emergency department that they had been managing a patient (G4P3) at 33 weeks of gestation for about 4 hours. The patient was consulted for hypertension when she went into a hypertensive encephalopathic coma. The patient was brought back to the birth center. Apresoline was given but did not bring the blood pressure down. Magnesium sulfate also was started at that time. I called a colleague from internal medicine and started to give nitroprusside.

Every time the patient’s blood pressure dropped from 120 mm Hg diastolic, she would become conscious and speak with us. As soon as her blood pressure went up, she would go into a coma. The patient was then transferred to a tertiary center in as stable a condition as possible. Cesarean delivery was performed, and the baby did not survive. The mother had an intracerebral hemorrhage. She was transferred to the supra-tertiary center in San Juan where she later passed away from complications of the hypertensive crisis. If the emergency physician had called me earlier, more could have been done.

This event is always fresh I my mind when I manage my patients in Ohio. Thank God for the newer medications we have available and the protocols to manage hypertensive crisis in pregnancy. I hope this experience heightens awareness of how deadly this condition can be.

David A. Rosado, MD
Celina, Ohio

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.

Hypertensive crisis of pregnancy must be treated with all urgency

The following happened approximately 27 years ago when I worked as an attending at a regional level 2 hospital in Puerto Rico. One afternoon I received a call from the emergency department that they had been managing a patient (G4P3) at 33 weeks of gestation for about 4 hours. The patient was consulted for hypertension when she went into a hypertensive encephalopathic coma. The patient was brought back to the birth center. Apresoline was given but did not bring the blood pressure down. Magnesium sulfate also was started at that time. I called a colleague from internal medicine and started to give nitroprusside.

Every time the patient’s blood pressure dropped from 120 mm Hg diastolic, she would become conscious and speak with us. As soon as her blood pressure went up, she would go into a coma. The patient was then transferred to a tertiary center in as stable a condition as possible. Cesarean delivery was performed, and the baby did not survive. The mother had an intracerebral hemorrhage. She was transferred to the supra-tertiary center in San Juan where she later passed away from complications of the hypertensive crisis. If the emergency physician had called me earlier, more could have been done.

This event is always fresh I my mind when I manage my patients in Ohio. Thank God for the newer medications we have available and the protocols to manage hypertensive crisis in pregnancy. I hope this experience heightens awareness of how deadly this condition can be.

David A. Rosado, MD
Celina, Ohio

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.

To the Editor: We read with great interest the excellent article on thrombosis secondary to antiphospholipid antibody syndrome.¹ We wish to comment on the section “Antiphospholipid antibodies are not all the same,” specifically on question 6: “Which of the following antiphospholipid antibodies have not been associated with an increased thrombotic risk?”

 The answer offered was antiphosphatidylserine, and the authors stated, “While lupus anticoagulant, anti-beta-2-glycoprotein I, and anticardiolipin antibodies are associated with thrombosis, antiprothrombin antibodies (including antiprothrombin and antiphosphatidylserine antibodies) are not.”¹ 

Antiphospholipid antibody testing in antiphospholipid antibody syndrome is complicated, but we feel the information provided was inaccurate. It should be noted that 3 antibodies are under discussion: in addition to antiphosphatidylserine (aPS) antibodies, antiprothrombin antibodies are heterogeneous, comprising antibodies to prothrombin alone (aPT-A) and antibodies to the antiphosphatidylserine-prothrombin complex (aPS/PT). While the diagnostic utility of these antibodies is in evolution, there are numerous studies on their association with thrombosis or antiphospholipid antibody syndrome, or both.^2,3 Most recently, a systematic review (N = 7,000) concluded that prothrombin antibodies (aPT, aPS/PT) were strong risk factors for thrombosis (odds ratio 2.3, 95% confidence interval 1.72–3.5).⁴

The revised Sapporo (Sydney) guidelines referenced by the authors addressed these “non-criteria” antiphospholipid antibodies.⁵ At that time (2006), it was thought premature to include these antibodies as independent criteria for definite antiphospholipid antibody syndrome, even though their association with the syndrome was recognized by the committee. The guidelines considered an interesting scenario: What if a case fulfills the clinical criteria of antiphospholipid antibody syndrome, but serology is positive only for these “non-criteria” antibodies? It was suggested that these cases be classified as “probable” antiphospholipid antibody syndrome. Also, aPS/PT was proposed as a confirmatory assay for lupus anticoagulant testing.

In 2010, the International Congress on Antiphospholipid Antibodies concluded that aPS/PT is truly relevant to thrombosis and antiphospholipid antibody syndrome, with the possibility of aPS/PT becoming a criterion for the syndrome in the future.⁶ Studies have already started on this.⁷ Since then, 2 scoring systems to quantify the risk of thrombosis and obstetric events have incorporated aPS/PT—the Antiphospholipid Score (2012) and the Global Anti-Phospholipid Syndrome Score (2013).^8.9

In conclusion, these antibodies are associated with thrombosis, can be considered features of antiphospholipid antibody syndrome in the right clinical context, and have a role in contemporary discussion of this disease.

To the Editor: We read with great interest the excellent article on thrombosis secondary to antiphospholipid antibody syndrome.¹ We wish to comment on the section “Antiphospholipid antibodies are not all the same,” specifically on question 6: “Which of the following antiphospholipid antibodies have not been associated with an increased thrombotic risk?”

 The answer offered was antiphosphatidylserine, and the authors stated, “While lupus anticoagulant, anti-beta-2-glycoprotein I, and anticardiolipin antibodies are associated with thrombosis, antiprothrombin antibodies (including antiprothrombin and antiphosphatidylserine antibodies) are not.”¹ 

Antiphospholipid antibody testing in antiphospholipid antibody syndrome is complicated, but we feel the information provided was inaccurate. It should be noted that 3 antibodies are under discussion: in addition to antiphosphatidylserine (aPS) antibodies, antiprothrombin antibodies are heterogeneous, comprising antibodies to prothrombin alone (aPT-A) and antibodies to the antiphosphatidylserine-prothrombin complex (aPS/PT). While the diagnostic utility of these antibodies is in evolution, there are numerous studies on their association with thrombosis or antiphospholipid antibody syndrome, or both.^2,3 Most recently, a systematic review (N = 7,000) concluded that prothrombin antibodies (aPT, aPS/PT) were strong risk factors for thrombosis (odds ratio 2.3, 95% confidence interval 1.72–3.5).⁴

The revised Sapporo (Sydney) guidelines referenced by the authors addressed these “non-criteria” antiphospholipid antibodies.⁵ At that time (2006), it was thought premature to include these antibodies as independent criteria for definite antiphospholipid antibody syndrome, even though their association with the syndrome was recognized by the committee. The guidelines considered an interesting scenario: What if a case fulfills the clinical criteria of antiphospholipid antibody syndrome, but serology is positive only for these “non-criteria” antibodies? It was suggested that these cases be classified as “probable” antiphospholipid antibody syndrome. Also, aPS/PT was proposed as a confirmatory assay for lupus anticoagulant testing.

In 2010, the International Congress on Antiphospholipid Antibodies concluded that aPS/PT is truly relevant to thrombosis and antiphospholipid antibody syndrome, with the possibility of aPS/PT becoming a criterion for the syndrome in the future.⁶ Studies have already started on this.⁷ Since then, 2 scoring systems to quantify the risk of thrombosis and obstetric events have incorporated aPS/PT—the Antiphospholipid Score (2012) and the Global Anti-Phospholipid Syndrome Score (2013).^8.9

In conclusion, these antibodies are associated with thrombosis, can be considered features of antiphospholipid antibody syndrome in the right clinical context, and have a role in contemporary discussion of this disease.

To the Editor: We read with great interest the excellent article on thrombosis secondary to antiphospholipid antibody syndrome.¹ We wish to comment on the section “Antiphospholipid antibodies are not all the same,” specifically on question 6: “Which of the following antiphospholipid antibodies have not been associated with an increased thrombotic risk?”

 The answer offered was antiphosphatidylserine, and the authors stated, “While lupus anticoagulant, anti-beta-2-glycoprotein I, and anticardiolipin antibodies are associated with thrombosis, antiprothrombin antibodies (including antiprothrombin and antiphosphatidylserine antibodies) are not.”¹ 

Antiphospholipid antibody testing in antiphospholipid antibody syndrome is complicated, but we feel the information provided was inaccurate. It should be noted that 3 antibodies are under discussion: in addition to antiphosphatidylserine (aPS) antibodies, antiprothrombin antibodies are heterogeneous, comprising antibodies to prothrombin alone (aPT-A) and antibodies to the antiphosphatidylserine-prothrombin complex (aPS/PT). While the diagnostic utility of these antibodies is in evolution, there are numerous studies on their association with thrombosis or antiphospholipid antibody syndrome, or both.^2,3 Most recently, a systematic review (N = 7,000) concluded that prothrombin antibodies (aPT, aPS/PT) were strong risk factors for thrombosis (odds ratio 2.3, 95% confidence interval 1.72–3.5).⁴

The revised Sapporo (Sydney) guidelines referenced by the authors addressed these “non-criteria” antiphospholipid antibodies.⁵ At that time (2006), it was thought premature to include these antibodies as independent criteria for definite antiphospholipid antibody syndrome, even though their association with the syndrome was recognized by the committee. The guidelines considered an interesting scenario: What if a case fulfills the clinical criteria of antiphospholipid antibody syndrome, but serology is positive only for these “non-criteria” antibodies? It was suggested that these cases be classified as “probable” antiphospholipid antibody syndrome. Also, aPS/PT was proposed as a confirmatory assay for lupus anticoagulant testing.

In 2010, the International Congress on Antiphospholipid Antibodies concluded that aPS/PT is truly relevant to thrombosis and antiphospholipid antibody syndrome, with the possibility of aPS/PT becoming a criterion for the syndrome in the future.⁶ Studies have already started on this.⁷ Since then, 2 scoring systems to quantify the risk of thrombosis and obstetric events have incorporated aPS/PT—the Antiphospholipid Score (2012) and the Global Anti-Phospholipid Syndrome Score (2013).^8.9

In conclusion, these antibodies are associated with thrombosis, can be considered features of antiphospholipid antibody syndrome in the right clinical context, and have a role in contemporary discussion of this disease.