Opinion

Compared with the complicated and ever-changing recommended vaccine schedule for infants and children, vaccines for adults have been straightforward. Adults without compromised immunity who received all their childhood vaccinations are eligible for a tetanus and diphtheria (Td) or tetanus, diphtheria, and pertussis (Tdap) booster every 10 years, recombinant herpes zoster vaccine at age 50, and pneumococcal vaccines at age 65, along with annual influenza and (likely) COVID-19 vaccines. Last year, due to rising rates of acute hepatitis B, the Centers for Disease Control and Prevention first recommended universal hepatitis B vaccination for adults aged 19-59 years without a record of previous hepatitis B infection or vaccination.

An additional routine vaccine for adults is now on the horizon. The U.S. Food and Drug Administration recently approved Arexvy, a vaccine against respiratory syncytial virus (RSV) for adults aged 60 years or older. Two more RSV vaccines are in the final stages of development. Why should family physicians prioritize vaccinating older adults against RSV, and how can we incorporate this new vaccine into our practices and overcome patient hesitancy to receive yet another vaccine?

Clinicians tend to think of RSV as a serious disease in young children – which it is – but data suggest that in 2019, RSV infection led to more than 100,000 hospitalizations and 7,700 deaths in older adults in the United States. In a randomized controlled trial of 25,000 adults aged 60 years or older with a median of 6.7 months of follow-up, Arexvy reduced severe RSV disease by 94% and RSV-related acute respiratory infections by 71%, with similar effectiveness in adults with underlying health conditions. That’s considerably better protection than current influenza vaccines and comparable to COVID-19 mRNA vaccines before variants became widespread. Pain and fatigue were the most common side effects and usually resolved within 1-2 days.

Although the seasonal pattern of RSV shifted during the COVID-19 pandemic, RSV season historically begins in October, peaks in December, and ends in April. If the vaccine is recommended by the CDC and is widely available by fall, as the manufacturer, GSK, expects, it could be administered around the same time as influenza and COVID-19 vaccines.

The challenges of incorporating this new vaccine into practice will feel familiar: Many of our patients won’t have heard about it, may feel that they don’t need it, or may decline it because of concerns about side effects, real or imagined. (Of note, the FDA is requiring GSK to perform a postmarketing study to rule out associations with rare cases of Guillain-Barré syndrome and acute disseminated encephalomyelitis, and the company also plans to monitor the incidence of atrial fibrillation, which was slightly more common in the vaccine group than the placebo group.)

While a strong recommendation from a family physician is often enough to convince patients to accept vaccination, rampant misinformation during the pandemic may have worsened vaccine hesitancy for some. It may feel like a fruitless exercise to try to convince adults who have refused COVID-19 and influenza vaccines to accept a newer vaccine against a respiratory virus that causes less serious illness overall. But with other RSV vaccines and monoclonal antibodies for older adults and infants likely to be approved soon, it’s important for us to start laying the groundwork now by educating colleagues, staff, and patients about preventing serious illness caused by RSV.

Dr. Lin is an associate professor in the Department of Family Medicine at Georgetown University and a staff physician atMedStar Health Center, both in Washington. He has received income from UpToDate, Wiley-Blackwell, and the American Academy of Family Physicians.

A version of this article first appeared on Medscape.com.

Compared with the complicated and ever-changing recommended vaccine schedule for infants and children, vaccines for adults have been straightforward. Adults without compromised immunity who received all their childhood vaccinations are eligible for a tetanus and diphtheria (Td) or tetanus, diphtheria, and pertussis (Tdap) booster every 10 years, recombinant herpes zoster vaccine at age 50, and pneumococcal vaccines at age 65, along with annual influenza and (likely) COVID-19 vaccines. Last year, due to rising rates of acute hepatitis B, the Centers for Disease Control and Prevention first recommended universal hepatitis B vaccination for adults aged 19-59 years without a record of previous hepatitis B infection or vaccination.

An additional routine vaccine for adults is now on the horizon. The U.S. Food and Drug Administration recently approved Arexvy, a vaccine against respiratory syncytial virus (RSV) for adults aged 60 years or older. Two more RSV vaccines are in the final stages of development. Why should family physicians prioritize vaccinating older adults against RSV, and how can we incorporate this new vaccine into our practices and overcome patient hesitancy to receive yet another vaccine?

Clinicians tend to think of RSV as a serious disease in young children – which it is – but data suggest that in 2019, RSV infection led to more than 100,000 hospitalizations and 7,700 deaths in older adults in the United States. In a randomized controlled trial of 25,000 adults aged 60 years or older with a median of 6.7 months of follow-up, Arexvy reduced severe RSV disease by 94% and RSV-related acute respiratory infections by 71%, with similar effectiveness in adults with underlying health conditions. That’s considerably better protection than current influenza vaccines and comparable to COVID-19 mRNA vaccines before variants became widespread. Pain and fatigue were the most common side effects and usually resolved within 1-2 days.

Although the seasonal pattern of RSV shifted during the COVID-19 pandemic, RSV season historically begins in October, peaks in December, and ends in April. If the vaccine is recommended by the CDC and is widely available by fall, as the manufacturer, GSK, expects, it could be administered around the same time as influenza and COVID-19 vaccines.

The challenges of incorporating this new vaccine into practice will feel familiar: Many of our patients won’t have heard about it, may feel that they don’t need it, or may decline it because of concerns about side effects, real or imagined. (Of note, the FDA is requiring GSK to perform a postmarketing study to rule out associations with rare cases of Guillain-Barré syndrome and acute disseminated encephalomyelitis, and the company also plans to monitor the incidence of atrial fibrillation, which was slightly more common in the vaccine group than the placebo group.)

While a strong recommendation from a family physician is often enough to convince patients to accept vaccination, rampant misinformation during the pandemic may have worsened vaccine hesitancy for some. It may feel like a fruitless exercise to try to convince adults who have refused COVID-19 and influenza vaccines to accept a newer vaccine against a respiratory virus that causes less serious illness overall. But with other RSV vaccines and monoclonal antibodies for older adults and infants likely to be approved soon, it’s important for us to start laying the groundwork now by educating colleagues, staff, and patients about preventing serious illness caused by RSV.

Dr. Lin is an associate professor in the Department of Family Medicine at Georgetown University and a staff physician atMedStar Health Center, both in Washington. He has received income from UpToDate, Wiley-Blackwell, and the American Academy of Family Physicians.

A version of this article first appeared on Medscape.com.

Compared with the complicated and ever-changing recommended vaccine schedule for infants and children, vaccines for adults have been straightforward. Adults without compromised immunity who received all their childhood vaccinations are eligible for a tetanus and diphtheria (Td) or tetanus, diphtheria, and pertussis (Tdap) booster every 10 years, recombinant herpes zoster vaccine at age 50, and pneumococcal vaccines at age 65, along with annual influenza and (likely) COVID-19 vaccines. Last year, due to rising rates of acute hepatitis B, the Centers for Disease Control and Prevention first recommended universal hepatitis B vaccination for adults aged 19-59 years without a record of previous hepatitis B infection or vaccination.

An additional routine vaccine for adults is now on the horizon. The U.S. Food and Drug Administration recently approved Arexvy, a vaccine against respiratory syncytial virus (RSV) for adults aged 60 years or older. Two more RSV vaccines are in the final stages of development. Why should family physicians prioritize vaccinating older adults against RSV, and how can we incorporate this new vaccine into our practices and overcome patient hesitancy to receive yet another vaccine?

Clinicians tend to think of RSV as a serious disease in young children – which it is – but data suggest that in 2019, RSV infection led to more than 100,000 hospitalizations and 7,700 deaths in older adults in the United States. In a randomized controlled trial of 25,000 adults aged 60 years or older with a median of 6.7 months of follow-up, Arexvy reduced severe RSV disease by 94% and RSV-related acute respiratory infections by 71%, with similar effectiveness in adults with underlying health conditions. That’s considerably better protection than current influenza vaccines and comparable to COVID-19 mRNA vaccines before variants became widespread. Pain and fatigue were the most common side effects and usually resolved within 1-2 days.

Although the seasonal pattern of RSV shifted during the COVID-19 pandemic, RSV season historically begins in October, peaks in December, and ends in April. If the vaccine is recommended by the CDC and is widely available by fall, as the manufacturer, GSK, expects, it could be administered around the same time as influenza and COVID-19 vaccines.

The challenges of incorporating this new vaccine into practice will feel familiar: Many of our patients won’t have heard about it, may feel that they don’t need it, or may decline it because of concerns about side effects, real or imagined. (Of note, the FDA is requiring GSK to perform a postmarketing study to rule out associations with rare cases of Guillain-Barré syndrome and acute disseminated encephalomyelitis, and the company also plans to monitor the incidence of atrial fibrillation, which was slightly more common in the vaccine group than the placebo group.)

While a strong recommendation from a family physician is often enough to convince patients to accept vaccination, rampant misinformation during the pandemic may have worsened vaccine hesitancy for some. It may feel like a fruitless exercise to try to convince adults who have refused COVID-19 and influenza vaccines to accept a newer vaccine against a respiratory virus that causes less serious illness overall. But with other RSV vaccines and monoclonal antibodies for older adults and infants likely to be approved soon, it’s important for us to start laying the groundwork now by educating colleagues, staff, and patients about preventing serious illness caused by RSV.

Dr. Lin is an associate professor in the Department of Family Medicine at Georgetown University and a staff physician atMedStar Health Center, both in Washington. He has received income from UpToDate, Wiley-Blackwell, and the American Academy of Family Physicians.

A version of this article first appeared on Medscape.com.

What role does diagnostic office hysteroscopy play in an infertility evaluation?

Performed properly, office hysteroscopy can transform your practice by accurately, gently, and safely assessing the uterine cavity as well as assessing tubal patency.¹

More specifically, hysteroscopy is the gold standard for assessing the uterine cavity. The sensitivity, specificity, and positive predictive and negative predictive values of hysterosalpingography (HSG) in evaluating uterine cavity abnormalities were 44.83%; 86.67%; 56.52%; and 80.25%, respectively.² Given the poor sensitivity of HSG, a diagnosis of endometrial polyps and/or chronic endometritis is more likely to be missed.

Our crossover trial comparing HSG to office hysteroscopy for tubal patency showed that women were 110 times more likely to have the maximum level of pain with HSG than diagnostic hysteroscopy when using a 2.8-mm flexible hysteroscope.³ Further, infection rates and vasovagal events were far lower with hysteroscopy.¹

Finally, compared with HSG, we showed 98%-100% sensitivity and 84% specificity for tubal occlusion with hysteroscopy by air-infused saline. Conversely, HSG typically is associated with 76%-96% sensitivity and 67%-100% specificity.⁴ Additionally, we can often perform diagnostic hysteroscopies for approximately $35 per procedure for total fixed and disposable equipment costs.
 

How should physicians perform office hysteroscopy to minimize patient discomfort?

The classic paradigm has been to focus on paracervical blocks, anxiolytics, and a supportive environment (such as mood music). However, those are far more important when your hysteroscope is larger than the natural cervical lumen. If you can use small hysteroscopes (< 3 mm for the nulliparous cervix, < 4 mm for the parous cervix), most women will not require cervical dilation, which further enhances the patient experience.

Using a flexible hysteroscope for suspected pathology, making sure not to overdistend the uterus (particularly in high-risk patients such as those with tubal occlusion and cervical stenosis), and vaginoscopy can all minimize patient discomfort. We have published data showing that by using a 2.8-mm flexible diagnostic hysteroscope in a group of mostly nulliparous women, greater than 50% have no discomfort, and more than 90% will have mild to no discomfort.³

What operative hysteroscopy procedures can be performed safely in a physician’s office, and what equipment is required?

Though highly dependent on experience and resources, reproductive endocrinology and infertility specialists (REIs) arguably have the easiest transition to operative office hysteroscopy by utilizing the analgesia and procedure room that is standard for oocyte retrieval and simply adding hysteroscopic procedures. The accompanying table stratifies general hysteroscopic procedures by difficulty.

Dr. Parry and Dr. Trolice

If one can use propofol or a similar level of sedation (which is routinely utilized for oocyte aspiration), there are few hysteroscopies that cannot be accomplished in the office. However, the less sedation and analgesia, the more judicious one must be in patient selection. Moreover, there are trade-offs between visualization, comfort, and instrumentation.

The greater the uterine distention and diameter of the hysteroscope, the more patients experience pain. One-third of patients (especially nulliparous) will discontinue a procedure with a 5-mm hysteroscope because of discomfort.⁵ However, as one drops to 4.5 mm and smaller operative hysteroscopes, instruments often occupy the inflow channel, limiting distention and visualization, which also can affect completion rates and safety.
 

When is operative hysteroscopy best suited for the OR?

In addition to physician experience and clinical resources, the critical factors guiding our choices for selecting the OR rather than the office, include:

• Loss of landmarks. Though Dr. Parry now does most severe intrauterine adhesion cases in the office with ultrasound guidance, when neither ostia can be visualized there is meaningful risk for perforation. Preoperative estrogen, development of planes with the diagnostic hysteroscope prior, and preparing the patient for a possible multistage procedure are all important.
• Use of energy. There are many excellent hysteroscopic surgeons who use the resectoscope well in the office. However, with possible patient movement and potential perforation with energy leading to a bowel injury, there can be greater risk when using energy relative to other methods (such as forceps, scissors, and mechanical morcellation).
• Deeper fibroids. Fibroids displace rather than invade the myometrium, and one can sonographically visualize the myometrium reapproximate over a fibroid as it herniates more into the uterine cavity. Nevertheless, the closer a fibroid comes to the serosa, the more mindful one should be of risks and balances for hysteroscopic removal.

In a patient with a severely stenotic cervix or tortuous endocervical canal, what preprocedure methods do you find helpful, and do you utilize abdominal ultrasound guidance?

If using a 2.8-mm flexible diagnostic hysteroscope, we find 99.8%-99.9% of cervices can be successfully cannulated in the office, with rare exception, that is, following cryotherapy or chlamydia cervicitis. This is the equivalent of your dilator having a camera on the tip and fully articulating to adjust to the cervical path.

Transvaginal sonography prior to hysteroscopy where one maps the cervical lumen helps anticipate problems (along with being familiar with the patient’s history). For the rare dilation under anesthesia, concurrent sonography with a 2.8-mm flexible hysteroscope and intermittent dilator use has been sufficient for our exceptions without the need for lacrimal dilators, vasopressin, misoprostol, and other adjuncts. Of note, we use a 1080p flexible endoscope, as lower resolution would make this more challenging.
 

In patients with recurrent implantation failure following IVF, is hysteroscopy superior to 3D saline infusion sonogram?

At an American Society of Reproductive Medicine 2021 session, Ilan Tur-Kaspa, MD, and Dr. Parry debated the topic of 2D ultrasound combined with hysteroscopy vs. 3D saline infusion sonography. Core areas of agreement were that expert hands for any approach are better than nonexpert, and high-resolution technology is better than lower resolution. There was also agreement that extrauterine and myometrial disease, such as intramural fibroids and adenomyosis, are contributory factors.

So, sonography will always have a role. However, existing and forthcoming data show hysteroscopy to improve live birth rates for patients with recurrent implantation failure after IVF. Dr. Parry finds diagnostic hysteroscopy easier for identifying endometritis, sessile and cornual polyps, retained products of conception (which are often isoechogenic with the endometrium) and lateral adhesions.

The reality is that there is variability among physicians and midlevel providers in both sonographic and diagnostic hysteroscopic skill. If one wants to verify findings with another team member, acknowledging that there can be nuances to identifying these pathologies by sonography, it is easier to share and discuss findings through hysteroscopic video than sonographic records.
 

When is endometrial biopsy indicated during office hysteroscopy?

The patients of an REI are very unlikely to have endometrial cancer (or even hyperplasia) outside of polyps (or arguably hypervascular areas of overgrowth), so the focus is on resecting visualized pathology relative to random biopsy.

However, the threshold for biopsy should be adjusted to the patient population, as well as to individual findings and risk. RVUs are greatly increased (11.1 > 41.57) with biopsy, helping sustainability. Additionally, if one places the hysteroscope on endometrium and applies suction through the inflow channel, one can obtain a sample with small-caliber diagnostic hysteroscopes and without having to use forceps.
 

What is your threshold for fluid deficit in hysteroscopy?

We follow AAGL guidelines, which for operative hysteroscopy are 2,500 mL of isotonic fluids or 1,000 mL of hypotonic fluids in low-risk patients. This should be further reduced to 500 mL of isotonic fluids in the elderly and even 300 mL in those with cardiovascular compromise.⁶

For patients who request sedation for office hysteroscopy, which option do you recommend – paracervical block alone, nitrous oxide, or the combination?

For diagnostic, greater than 95% of our patients do not require even over-the-counter analgesic medications. For operative, we consider all permissible resources that allow for a safe combination that is appropriate to the pathology and clinical setting, such as paracervical blocks, nitrous oxide, NSAIDs such as ketorolac, anxiolytics, and more.

The goal is to optimize the patient experience. However, the top three criteria that influence successful operative office hysteroscopy for a conscious patient are a parous cervix, judicious patient selection, and pre- and intraoperative verbal analgesia. Informed consent and engagement improve the experience of both the patient and physician.

Dr. Parry is the founder of Positive Steps Fertility in Madison, Miss. Dr. Trolice is director of The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.

References

1. Parry JP et al. J Minim Invasive Gynecol. 2017 May-Jun. doi: 10.1016/j.jmig.2017.02.010.

2. Wadhwa L et al. 2017 Apr-Jun. doi: 10.4103/jhrs.JHRS_123_16.

3. Parry JP et al. Fertil Steril. 2017 Oct. doi: 10.1016/j.fertnstert.2017.07.1159.

4. Penzias A et al. Fertil Steril. 2021 Nov. doi: 10.1016/j.fertnstert.2021.08.038.

5. Campo R et al. Hum Reprod. 2005 Jan;20(1):258-63. doi: 10.1093/humrep/deh559.

6. AAGL AAGL practice report: Practice guidelines for the management of hysteroscopic distending media. J Minim Invasive Gynecol. 2013 Mar-Apr. doi: 10.1016/j.jmig.2012.12.002.

What role does diagnostic office hysteroscopy play in an infertility evaluation?

Performed properly, office hysteroscopy can transform your practice by accurately, gently, and safely assessing the uterine cavity as well as assessing tubal patency.¹

More specifically, hysteroscopy is the gold standard for assessing the uterine cavity. The sensitivity, specificity, and positive predictive and negative predictive values of hysterosalpingography (HSG) in evaluating uterine cavity abnormalities were 44.83%; 86.67%; 56.52%; and 80.25%, respectively.² Given the poor sensitivity of HSG, a diagnosis of endometrial polyps and/or chronic endometritis is more likely to be missed.

Our crossover trial comparing HSG to office hysteroscopy for tubal patency showed that women were 110 times more likely to have the maximum level of pain with HSG than diagnostic hysteroscopy when using a 2.8-mm flexible hysteroscope.³ Further, infection rates and vasovagal events were far lower with hysteroscopy.¹

Finally, compared with HSG, we showed 98%-100% sensitivity and 84% specificity for tubal occlusion with hysteroscopy by air-infused saline. Conversely, HSG typically is associated with 76%-96% sensitivity and 67%-100% specificity.⁴ Additionally, we can often perform diagnostic hysteroscopies for approximately $35 per procedure for total fixed and disposable equipment costs.
 

How should physicians perform office hysteroscopy to minimize patient discomfort?

The classic paradigm has been to focus on paracervical blocks, anxiolytics, and a supportive environment (such as mood music). However, those are far more important when your hysteroscope is larger than the natural cervical lumen. If you can use small hysteroscopes (< 3 mm for the nulliparous cervix, < 4 mm for the parous cervix), most women will not require cervical dilation, which further enhances the patient experience.

Using a flexible hysteroscope for suspected pathology, making sure not to overdistend the uterus (particularly in high-risk patients such as those with tubal occlusion and cervical stenosis), and vaginoscopy can all minimize patient discomfort. We have published data showing that by using a 2.8-mm flexible diagnostic hysteroscope in a group of mostly nulliparous women, greater than 50% have no discomfort, and more than 90% will have mild to no discomfort.³

What operative hysteroscopy procedures can be performed safely in a physician’s office, and what equipment is required?

Though highly dependent on experience and resources, reproductive endocrinology and infertility specialists (REIs) arguably have the easiest transition to operative office hysteroscopy by utilizing the analgesia and procedure room that is standard for oocyte retrieval and simply adding hysteroscopic procedures. The accompanying table stratifies general hysteroscopic procedures by difficulty.

Dr. Parry and Dr. Trolice

If one can use propofol or a similar level of sedation (which is routinely utilized for oocyte aspiration), there are few hysteroscopies that cannot be accomplished in the office. However, the less sedation and analgesia, the more judicious one must be in patient selection. Moreover, there are trade-offs between visualization, comfort, and instrumentation.

The greater the uterine distention and diameter of the hysteroscope, the more patients experience pain. One-third of patients (especially nulliparous) will discontinue a procedure with a 5-mm hysteroscope because of discomfort.⁵ However, as one drops to 4.5 mm and smaller operative hysteroscopes, instruments often occupy the inflow channel, limiting distention and visualization, which also can affect completion rates and safety.
 

When is operative hysteroscopy best suited for the OR?

In addition to physician experience and clinical resources, the critical factors guiding our choices for selecting the OR rather than the office, include:

• Loss of landmarks. Though Dr. Parry now does most severe intrauterine adhesion cases in the office with ultrasound guidance, when neither ostia can be visualized there is meaningful risk for perforation. Preoperative estrogen, development of planes with the diagnostic hysteroscope prior, and preparing the patient for a possible multistage procedure are all important.
• Use of energy. There are many excellent hysteroscopic surgeons who use the resectoscope well in the office. However, with possible patient movement and potential perforation with energy leading to a bowel injury, there can be greater risk when using energy relative to other methods (such as forceps, scissors, and mechanical morcellation).
• Deeper fibroids. Fibroids displace rather than invade the myometrium, and one can sonographically visualize the myometrium reapproximate over a fibroid as it herniates more into the uterine cavity. Nevertheless, the closer a fibroid comes to the serosa, the more mindful one should be of risks and balances for hysteroscopic removal.

In a patient with a severely stenotic cervix or tortuous endocervical canal, what preprocedure methods do you find helpful, and do you utilize abdominal ultrasound guidance?

If using a 2.8-mm flexible diagnostic hysteroscope, we find 99.8%-99.9% of cervices can be successfully cannulated in the office, with rare exception, that is, following cryotherapy or chlamydia cervicitis. This is the equivalent of your dilator having a camera on the tip and fully articulating to adjust to the cervical path.

Transvaginal sonography prior to hysteroscopy where one maps the cervical lumen helps anticipate problems (along with being familiar with the patient’s history). For the rare dilation under anesthesia, concurrent sonography with a 2.8-mm flexible hysteroscope and intermittent dilator use has been sufficient for our exceptions without the need for lacrimal dilators, vasopressin, misoprostol, and other adjuncts. Of note, we use a 1080p flexible endoscope, as lower resolution would make this more challenging.
 

In patients with recurrent implantation failure following IVF, is hysteroscopy superior to 3D saline infusion sonogram?

At an American Society of Reproductive Medicine 2021 session, Ilan Tur-Kaspa, MD, and Dr. Parry debated the topic of 2D ultrasound combined with hysteroscopy vs. 3D saline infusion sonography. Core areas of agreement were that expert hands for any approach are better than nonexpert, and high-resolution technology is better than lower resolution. There was also agreement that extrauterine and myometrial disease, such as intramural fibroids and adenomyosis, are contributory factors.

So, sonography will always have a role. However, existing and forthcoming data show hysteroscopy to improve live birth rates for patients with recurrent implantation failure after IVF. Dr. Parry finds diagnostic hysteroscopy easier for identifying endometritis, sessile and cornual polyps, retained products of conception (which are often isoechogenic with the endometrium) and lateral adhesions.

The reality is that there is variability among physicians and midlevel providers in both sonographic and diagnostic hysteroscopic skill. If one wants to verify findings with another team member, acknowledging that there can be nuances to identifying these pathologies by sonography, it is easier to share and discuss findings through hysteroscopic video than sonographic records.
 

When is endometrial biopsy indicated during office hysteroscopy?

The patients of an REI are very unlikely to have endometrial cancer (or even hyperplasia) outside of polyps (or arguably hypervascular areas of overgrowth), so the focus is on resecting visualized pathology relative to random biopsy.

However, the threshold for biopsy should be adjusted to the patient population, as well as to individual findings and risk. RVUs are greatly increased (11.1 > 41.57) with biopsy, helping sustainability. Additionally, if one places the hysteroscope on endometrium and applies suction through the inflow channel, one can obtain a sample with small-caliber diagnostic hysteroscopes and without having to use forceps.
 

What is your threshold for fluid deficit in hysteroscopy?

We follow AAGL guidelines, which for operative hysteroscopy are 2,500 mL of isotonic fluids or 1,000 mL of hypotonic fluids in low-risk patients. This should be further reduced to 500 mL of isotonic fluids in the elderly and even 300 mL in those with cardiovascular compromise.⁶

For patients who request sedation for office hysteroscopy, which option do you recommend – paracervical block alone, nitrous oxide, or the combination?

For diagnostic, greater than 95% of our patients do not require even over-the-counter analgesic medications. For operative, we consider all permissible resources that allow for a safe combination that is appropriate to the pathology and clinical setting, such as paracervical blocks, nitrous oxide, NSAIDs such as ketorolac, anxiolytics, and more.

The goal is to optimize the patient experience. However, the top three criteria that influence successful operative office hysteroscopy for a conscious patient are a parous cervix, judicious patient selection, and pre- and intraoperative verbal analgesia. Informed consent and engagement improve the experience of both the patient and physician.

Dr. Parry is the founder of Positive Steps Fertility in Madison, Miss. Dr. Trolice is director of The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.

References

1. Parry JP et al. J Minim Invasive Gynecol. 2017 May-Jun. doi: 10.1016/j.jmig.2017.02.010.

2. Wadhwa L et al. 2017 Apr-Jun. doi: 10.4103/jhrs.JHRS_123_16.

3. Parry JP et al. Fertil Steril. 2017 Oct. doi: 10.1016/j.fertnstert.2017.07.1159.

4. Penzias A et al. Fertil Steril. 2021 Nov. doi: 10.1016/j.fertnstert.2021.08.038.

5. Campo R et al. Hum Reprod. 2005 Jan;20(1):258-63. doi: 10.1093/humrep/deh559.

6. AAGL AAGL practice report: Practice guidelines for the management of hysteroscopic distending media. J Minim Invasive Gynecol. 2013 Mar-Apr. doi: 10.1016/j.jmig.2012.12.002.

What role does diagnostic office hysteroscopy play in an infertility evaluation?

Performed properly, office hysteroscopy can transform your practice by accurately, gently, and safely assessing the uterine cavity as well as assessing tubal patency.¹

More specifically, hysteroscopy is the gold standard for assessing the uterine cavity. The sensitivity, specificity, and positive predictive and negative predictive values of hysterosalpingography (HSG) in evaluating uterine cavity abnormalities were 44.83%; 86.67%; 56.52%; and 80.25%, respectively.² Given the poor sensitivity of HSG, a diagnosis of endometrial polyps and/or chronic endometritis is more likely to be missed.

Our crossover trial comparing HSG to office hysteroscopy for tubal patency showed that women were 110 times more likely to have the maximum level of pain with HSG than diagnostic hysteroscopy when using a 2.8-mm flexible hysteroscope.³ Further, infection rates and vasovagal events were far lower with hysteroscopy.¹

Finally, compared with HSG, we showed 98%-100% sensitivity and 84% specificity for tubal occlusion with hysteroscopy by air-infused saline. Conversely, HSG typically is associated with 76%-96% sensitivity and 67%-100% specificity.⁴ Additionally, we can often perform diagnostic hysteroscopies for approximately $35 per procedure for total fixed and disposable equipment costs.
 

How should physicians perform office hysteroscopy to minimize patient discomfort?

The classic paradigm has been to focus on paracervical blocks, anxiolytics, and a supportive environment (such as mood music). However, those are far more important when your hysteroscope is larger than the natural cervical lumen. If you can use small hysteroscopes (< 3 mm for the nulliparous cervix, < 4 mm for the parous cervix), most women will not require cervical dilation, which further enhances the patient experience.

Using a flexible hysteroscope for suspected pathology, making sure not to overdistend the uterus (particularly in high-risk patients such as those with tubal occlusion and cervical stenosis), and vaginoscopy can all minimize patient discomfort. We have published data showing that by using a 2.8-mm flexible diagnostic hysteroscope in a group of mostly nulliparous women, greater than 50% have no discomfort, and more than 90% will have mild to no discomfort.³

What operative hysteroscopy procedures can be performed safely in a physician’s office, and what equipment is required?

Though highly dependent on experience and resources, reproductive endocrinology and infertility specialists (REIs) arguably have the easiest transition to operative office hysteroscopy by utilizing the analgesia and procedure room that is standard for oocyte retrieval and simply adding hysteroscopic procedures. The accompanying table stratifies general hysteroscopic procedures by difficulty.

Dr. Parry and Dr. Trolice

If one can use propofol or a similar level of sedation (which is routinely utilized for oocyte aspiration), there are few hysteroscopies that cannot be accomplished in the office. However, the less sedation and analgesia, the more judicious one must be in patient selection. Moreover, there are trade-offs between visualization, comfort, and instrumentation.

The greater the uterine distention and diameter of the hysteroscope, the more patients experience pain. One-third of patients (especially nulliparous) will discontinue a procedure with a 5-mm hysteroscope because of discomfort.⁵ However, as one drops to 4.5 mm and smaller operative hysteroscopes, instruments often occupy the inflow channel, limiting distention and visualization, which also can affect completion rates and safety.
 

When is operative hysteroscopy best suited for the OR?

In addition to physician experience and clinical resources, the critical factors guiding our choices for selecting the OR rather than the office, include:

• Loss of landmarks. Though Dr. Parry now does most severe intrauterine adhesion cases in the office with ultrasound guidance, when neither ostia can be visualized there is meaningful risk for perforation. Preoperative estrogen, development of planes with the diagnostic hysteroscope prior, and preparing the patient for a possible multistage procedure are all important.
• Use of energy. There are many excellent hysteroscopic surgeons who use the resectoscope well in the office. However, with possible patient movement and potential perforation with energy leading to a bowel injury, there can be greater risk when using energy relative to other methods (such as forceps, scissors, and mechanical morcellation).
• Deeper fibroids. Fibroids displace rather than invade the myometrium, and one can sonographically visualize the myometrium reapproximate over a fibroid as it herniates more into the uterine cavity. Nevertheless, the closer a fibroid comes to the serosa, the more mindful one should be of risks and balances for hysteroscopic removal.

In a patient with a severely stenotic cervix or tortuous endocervical canal, what preprocedure methods do you find helpful, and do you utilize abdominal ultrasound guidance?

If using a 2.8-mm flexible diagnostic hysteroscope, we find 99.8%-99.9% of cervices can be successfully cannulated in the office, with rare exception, that is, following cryotherapy or chlamydia cervicitis. This is the equivalent of your dilator having a camera on the tip and fully articulating to adjust to the cervical path.

Transvaginal sonography prior to hysteroscopy where one maps the cervical lumen helps anticipate problems (along with being familiar with the patient’s history). For the rare dilation under anesthesia, concurrent sonography with a 2.8-mm flexible hysteroscope and intermittent dilator use has been sufficient for our exceptions without the need for lacrimal dilators, vasopressin, misoprostol, and other adjuncts. Of note, we use a 1080p flexible endoscope, as lower resolution would make this more challenging.
 

In patients with recurrent implantation failure following IVF, is hysteroscopy superior to 3D saline infusion sonogram?

At an American Society of Reproductive Medicine 2021 session, Ilan Tur-Kaspa, MD, and Dr. Parry debated the topic of 2D ultrasound combined with hysteroscopy vs. 3D saline infusion sonography. Core areas of agreement were that expert hands for any approach are better than nonexpert, and high-resolution technology is better than lower resolution. There was also agreement that extrauterine and myometrial disease, such as intramural fibroids and adenomyosis, are contributory factors.

So, sonography will always have a role. However, existing and forthcoming data show hysteroscopy to improve live birth rates for patients with recurrent implantation failure after IVF. Dr. Parry finds diagnostic hysteroscopy easier for identifying endometritis, sessile and cornual polyps, retained products of conception (which are often isoechogenic with the endometrium) and lateral adhesions.

The reality is that there is variability among physicians and midlevel providers in both sonographic and diagnostic hysteroscopic skill. If one wants to verify findings with another team member, acknowledging that there can be nuances to identifying these pathologies by sonography, it is easier to share and discuss findings through hysteroscopic video than sonographic records.
 

When is endometrial biopsy indicated during office hysteroscopy?

The patients of an REI are very unlikely to have endometrial cancer (or even hyperplasia) outside of polyps (or arguably hypervascular areas of overgrowth), so the focus is on resecting visualized pathology relative to random biopsy.

However, the threshold for biopsy should be adjusted to the patient population, as well as to individual findings and risk. RVUs are greatly increased (11.1 > 41.57) with biopsy, helping sustainability. Additionally, if one places the hysteroscope on endometrium and applies suction through the inflow channel, one can obtain a sample with small-caliber diagnostic hysteroscopes and without having to use forceps.
 

What is your threshold for fluid deficit in hysteroscopy?

We follow AAGL guidelines, which for operative hysteroscopy are 2,500 mL of isotonic fluids or 1,000 mL of hypotonic fluids in low-risk patients. This should be further reduced to 500 mL of isotonic fluids in the elderly and even 300 mL in those with cardiovascular compromise.⁶

For patients who request sedation for office hysteroscopy, which option do you recommend – paracervical block alone, nitrous oxide, or the combination?

For diagnostic, greater than 95% of our patients do not require even over-the-counter analgesic medications. For operative, we consider all permissible resources that allow for a safe combination that is appropriate to the pathology and clinical setting, such as paracervical blocks, nitrous oxide, NSAIDs such as ketorolac, anxiolytics, and more.

The goal is to optimize the patient experience. However, the top three criteria that influence successful operative office hysteroscopy for a conscious patient are a parous cervix, judicious patient selection, and pre- and intraoperative verbal analgesia. Informed consent and engagement improve the experience of both the patient and physician.

Dr. Parry is the founder of Positive Steps Fertility in Madison, Miss. Dr. Trolice is director of The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.

References

1. Parry JP et al. J Minim Invasive Gynecol. 2017 May-Jun. doi: 10.1016/j.jmig.2017.02.010.

2. Wadhwa L et al. 2017 Apr-Jun. doi: 10.4103/jhrs.JHRS_123_16.

3. Parry JP et al. Fertil Steril. 2017 Oct. doi: 10.1016/j.fertnstert.2017.07.1159.

4. Penzias A et al. Fertil Steril. 2021 Nov. doi: 10.1016/j.fertnstert.2021.08.038.

5. Campo R et al. Hum Reprod. 2005 Jan;20(1):258-63. doi: 10.1093/humrep/deh559.

6. AAGL AAGL practice report: Practice guidelines for the management of hysteroscopic distending media. J Minim Invasive Gynecol. 2013 Mar-Apr. doi: 10.1016/j.jmig.2012.12.002.

Answer to ‘What’s your diagnosis?’: Gastric adenocarcinoma and proximal polyposis of the stomach syndrome.

Fundic gland polyps (FGPs) are the most common gastric polyps and when occurring in the sporadic setting are typically benign; however, FGPs that occur in gastrointestinal polyposis syndromes such as familial adenomatosis polyposis can progress to adenocarcinoma and require surveillance. Therefore, it is important to distinguish sporadic versus syndromic fundic gland polyposis. Gastric adenocarcinoma and proximal polyposis of the stomach is a recently described condition that significantly increases the risk of developing invasive gastric adenocarcinoma from FGPs. Diagnostic criteria include (1) gastric polyposis restricted to the body and fundus with no small bowel or colonic involvement, (2) >100 gastric polyps or >30 polyps in a first-degree relative, (3) histology consistent with FGP with areas of dysplasia, (4) a family history consistent with an autosomal-dominant pattern of inheritance, and (5) exclusion of other syndromes and proton pump inhibitor use.¹ Unlike familial adenomatosis polyposis, the polyposis is restricted to the oxyntic mucosa of the gastric body and fundus with sparing of the gastric antrum, small bowel, and colon. The genetic basis of the disease has been attributed to a point mutation in the APC gene promotor IB region leading to a loss of tumor suppressor function.² Typical histology shows large FGPs with areas of low-grade and high-grade dysplasia, as seen in our patient.

There are few data on the natural history of gastric adenocarcinoma and proximal polyposis of the stomach, but effective surveillance is limited by the degree of polyposis. There are multiple reports of hidden adenocarcinoma on surgically resected specimens, as well as rapid progression to metastatic adenocarcinoma despite adequate diagnosis and surveillance.^1,3 Therefore, total gastrectomy should be offered to patients who are surgical candidates. Our patient underwent genetic testing that revealed a point mutation in the APC promotor IB. He declined surgical intervention and opted for surveillance endoscopy every 6 months.
 

References

1. Worthley D.L. et al. Gut. 2012;61:774-9

2. Li J et al. Am J Hum Genet. 2016;98:830-42

3. Rudloff U. Clin Exp Gastroenterol. 2018;11:447-59

Answer to ‘What’s your diagnosis?’: Gastric adenocarcinoma and proximal polyposis of the stomach syndrome.

Fundic gland polyps (FGPs) are the most common gastric polyps and when occurring in the sporadic setting are typically benign; however, FGPs that occur in gastrointestinal polyposis syndromes such as familial adenomatosis polyposis can progress to adenocarcinoma and require surveillance. Therefore, it is important to distinguish sporadic versus syndromic fundic gland polyposis. Gastric adenocarcinoma and proximal polyposis of the stomach is a recently described condition that significantly increases the risk of developing invasive gastric adenocarcinoma from FGPs. Diagnostic criteria include (1) gastric polyposis restricted to the body and fundus with no small bowel or colonic involvement, (2) >100 gastric polyps or >30 polyps in a first-degree relative, (3) histology consistent with FGP with areas of dysplasia, (4) a family history consistent with an autosomal-dominant pattern of inheritance, and (5) exclusion of other syndromes and proton pump inhibitor use.¹ Unlike familial adenomatosis polyposis, the polyposis is restricted to the oxyntic mucosa of the gastric body and fundus with sparing of the gastric antrum, small bowel, and colon. The genetic basis of the disease has been attributed to a point mutation in the APC gene promotor IB region leading to a loss of tumor suppressor function.² Typical histology shows large FGPs with areas of low-grade and high-grade dysplasia, as seen in our patient.

There are few data on the natural history of gastric adenocarcinoma and proximal polyposis of the stomach, but effective surveillance is limited by the degree of polyposis. There are multiple reports of hidden adenocarcinoma on surgically resected specimens, as well as rapid progression to metastatic adenocarcinoma despite adequate diagnosis and surveillance.^1,3 Therefore, total gastrectomy should be offered to patients who are surgical candidates. Our patient underwent genetic testing that revealed a point mutation in the APC promotor IB. He declined surgical intervention and opted for surveillance endoscopy every 6 months.
 

References

1. Worthley D.L. et al. Gut. 2012;61:774-9

2. Li J et al. Am J Hum Genet. 2016;98:830-42

3. Rudloff U. Clin Exp Gastroenterol. 2018;11:447-59

Answer to ‘What’s your diagnosis?’: Gastric adenocarcinoma and proximal polyposis of the stomach syndrome.

Fundic gland polyps (FGPs) are the most common gastric polyps and when occurring in the sporadic setting are typically benign; however, FGPs that occur in gastrointestinal polyposis syndromes such as familial adenomatosis polyposis can progress to adenocarcinoma and require surveillance. Therefore, it is important to distinguish sporadic versus syndromic fundic gland polyposis. Gastric adenocarcinoma and proximal polyposis of the stomach is a recently described condition that significantly increases the risk of developing invasive gastric adenocarcinoma from FGPs. Diagnostic criteria include (1) gastric polyposis restricted to the body and fundus with no small bowel or colonic involvement, (2) >100 gastric polyps or >30 polyps in a first-degree relative, (3) histology consistent with FGP with areas of dysplasia, (4) a family history consistent with an autosomal-dominant pattern of inheritance, and (5) exclusion of other syndromes and proton pump inhibitor use.¹ Unlike familial adenomatosis polyposis, the polyposis is restricted to the oxyntic mucosa of the gastric body and fundus with sparing of the gastric antrum, small bowel, and colon. The genetic basis of the disease has been attributed to a point mutation in the APC gene promotor IB region leading to a loss of tumor suppressor function.² Typical histology shows large FGPs with areas of low-grade and high-grade dysplasia, as seen in our patient.

There are few data on the natural history of gastric adenocarcinoma and proximal polyposis of the stomach, but effective surveillance is limited by the degree of polyposis. There are multiple reports of hidden adenocarcinoma on surgically resected specimens, as well as rapid progression to metastatic adenocarcinoma despite adequate diagnosis and surveillance.^1,3 Therefore, total gastrectomy should be offered to patients who are surgical candidates. Our patient underwent genetic testing that revealed a point mutation in the APC promotor IB. He declined surgical intervention and opted for surveillance endoscopy every 6 months.
 

References

1. Worthley D.L. et al. Gut. 2012;61:774-9

2. Li J et al. Am J Hum Genet. 2016;98:830-42

3. Rudloff U. Clin Exp Gastroenterol. 2018;11:447-59

In my most recent column (AI & U), I suggested that artificial intelligence (AI) in its most recent newsworthy iteration, the chatbot, offers some potentially useful opportunities. For example, in the short term the ability of a machine to search for the diagnostic possibilities and treatment options in a matter of seconds sounds very appealing. The skills needed to ask the chatbot the best questions and then interpret the machine’s responses would still require a medical school education. Good news for those of you worried about job security.

However, let’s look further down the road for how AI and other technological advances might change the look and feel of primary care. It is reasonable to expect that a chatbot could engage the patient in a spoken (or written) dialog in the patient’s preferred language and targeted to his/her educational level. You already deal with this kind of interaction in a primitive form when you call the customer service department of even a small company. That is if you were lucky enough to find the number buried in the company’s website.

The “system” could then perform a targeted exam using a variety of sensors. Electronic stethoscopes and tympanographic sensors already exist. While currently most sonograms are performed by trained technicians, one can envision the technology being dumbed down to a point that the patient could operate most of the sensors himself or herself, provided the patient could reach the body part in question. The camera on a basic cell phone can take an image of a skin lesion that can already be compared with a standard set of normals and abnormals. While currently a questionable lesion triggers the provider to perform a biopsy, it is possible that sensors could become so sensitive and the algorithms so clever that the biopsy would be unnecessary. The pandemic has already shown us that patients can obtain sample swabs and accurately perform simple tests in their home.

Once the “system” has made the diagnosis, it would then converse with the patient about the various treatment options and arrange follow up. One would hope that, if the “system’s” diagnosis included a fatal outcome, it would trigger a face-to-face interaction with a counselor and a team of social workers to break the bad news and provide some kind of emotional support.

Those of you who are doubting Dorothys and Thomases may be asking what about scenarios in which the patient’s chief complaint is difficulty breathing or sudden onset of weakness? Remember, I am talking about the usual 8 a.m–6 p.m. primary care office. Any patient with a possibly life-threatening complaint would be triaged by the chatbot and would be seen at some point by a real human. However, it is likely that individual’s training would not require the breadth of the typical medical school education and instead would be targeted at the most common high-risk scenarios. This higher-acuity specialist would, of course, be assisted by a chatbot.

Patients with complaints primarily associated with mental illness would be seen by humans specializing in that area. Although I suspect there are folks somewhere brainstorming on how chatbots could potentially be effective counselors.

Clearly, the future I am suggesting leaves the patient with fewer interactions with a human, and certainly very rarely with a human who has navigated what we think of today as a traditional medical school education.

Would patients accept a dehumanized type of primary care delivered by AI? Would they do it without complaint? Would they have a choice? Do you like it when you are interrogated by the prerecorded voice on the phone tree of some company’s customer service? Do you have a choice? If that interrogation was refined to the point where it saved you time and resulted in the correct answer 99% of the time would you still complain?

If patients found that most of their primary care complaints could be handled more quickly by an AI system with minimal physician intervention and that system offered a success rate of over 90% when measured by the accuracy of the diagnosis and management plan, would they complain? They may have no other choice than to complain if primary care continues to lose favor among recent medical school graduates.

And what would the patients complain about? They already complain about the current system in which they feel that the face-to-face encounters with their physician are becoming less frequent. I often hear complaints that “the doctor just looked at the computer, and he didn’t really examine me.” By which I think they sometimes mean “touched” me.

I suspect we will discover what most of us already suspect and that is there is something special about the eye-to-eye contact and tactile interaction between the physician and the patient. The osteopathic tradition clearly makes this a priority when it utilizes manipulative medicine. It may be that if primary care medicine follows the AI-paved road I have imagined it won’t be able to match the success rate of the current system. Without that human element, with or without the hands-on aspect or even if the diagnosis is correct and the management is spot on, it just won’t work as well.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In my most recent column (AI & U), I suggested that artificial intelligence (AI) in its most recent newsworthy iteration, the chatbot, offers some potentially useful opportunities. For example, in the short term the ability of a machine to search for the diagnostic possibilities and treatment options in a matter of seconds sounds very appealing. The skills needed to ask the chatbot the best questions and then interpret the machine’s responses would still require a medical school education. Good news for those of you worried about job security.

However, let’s look further down the road for how AI and other technological advances might change the look and feel of primary care. It is reasonable to expect that a chatbot could engage the patient in a spoken (or written) dialog in the patient’s preferred language and targeted to his/her educational level. You already deal with this kind of interaction in a primitive form when you call the customer service department of even a small company. That is if you were lucky enough to find the number buried in the company’s website.

The “system” could then perform a targeted exam using a variety of sensors. Electronic stethoscopes and tympanographic sensors already exist. While currently most sonograms are performed by trained technicians, one can envision the technology being dumbed down to a point that the patient could operate most of the sensors himself or herself, provided the patient could reach the body part in question. The camera on a basic cell phone can take an image of a skin lesion that can already be compared with a standard set of normals and abnormals. While currently a questionable lesion triggers the provider to perform a biopsy, it is possible that sensors could become so sensitive and the algorithms so clever that the biopsy would be unnecessary. The pandemic has already shown us that patients can obtain sample swabs and accurately perform simple tests in their home.

Once the “system” has made the diagnosis, it would then converse with the patient about the various treatment options and arrange follow up. One would hope that, if the “system’s” diagnosis included a fatal outcome, it would trigger a face-to-face interaction with a counselor and a team of social workers to break the bad news and provide some kind of emotional support.

Those of you who are doubting Dorothys and Thomases may be asking what about scenarios in which the patient’s chief complaint is difficulty breathing or sudden onset of weakness? Remember, I am talking about the usual 8 a.m–6 p.m. primary care office. Any patient with a possibly life-threatening complaint would be triaged by the chatbot and would be seen at some point by a real human. However, it is likely that individual’s training would not require the breadth of the typical medical school education and instead would be targeted at the most common high-risk scenarios. This higher-acuity specialist would, of course, be assisted by a chatbot.

Patients with complaints primarily associated with mental illness would be seen by humans specializing in that area. Although I suspect there are folks somewhere brainstorming on how chatbots could potentially be effective counselors.

Clearly, the future I am suggesting leaves the patient with fewer interactions with a human, and certainly very rarely with a human who has navigated what we think of today as a traditional medical school education.

Would patients accept a dehumanized type of primary care delivered by AI? Would they do it without complaint? Would they have a choice? Do you like it when you are interrogated by the prerecorded voice on the phone tree of some company’s customer service? Do you have a choice? If that interrogation was refined to the point where it saved you time and resulted in the correct answer 99% of the time would you still complain?

If patients found that most of their primary care complaints could be handled more quickly by an AI system with minimal physician intervention and that system offered a success rate of over 90% when measured by the accuracy of the diagnosis and management plan, would they complain? They may have no other choice than to complain if primary care continues to lose favor among recent medical school graduates.

And what would the patients complain about? They already complain about the current system in which they feel that the face-to-face encounters with their physician are becoming less frequent. I often hear complaints that “the doctor just looked at the computer, and he didn’t really examine me.” By which I think they sometimes mean “touched” me.

I suspect we will discover what most of us already suspect and that is there is something special about the eye-to-eye contact and tactile interaction between the physician and the patient. The osteopathic tradition clearly makes this a priority when it utilizes manipulative medicine. It may be that if primary care medicine follows the AI-paved road I have imagined it won’t be able to match the success rate of the current system. Without that human element, with or without the hands-on aspect or even if the diagnosis is correct and the management is spot on, it just won’t work as well.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In my most recent column (AI & U), I suggested that artificial intelligence (AI) in its most recent newsworthy iteration, the chatbot, offers some potentially useful opportunities. For example, in the short term the ability of a machine to search for the diagnostic possibilities and treatment options in a matter of seconds sounds very appealing. The skills needed to ask the chatbot the best questions and then interpret the machine’s responses would still require a medical school education. Good news for those of you worried about job security.

However, let’s look further down the road for how AI and other technological advances might change the look and feel of primary care. It is reasonable to expect that a chatbot could engage the patient in a spoken (or written) dialog in the patient’s preferred language and targeted to his/her educational level. You already deal with this kind of interaction in a primitive form when you call the customer service department of even a small company. That is if you were lucky enough to find the number buried in the company’s website.

The “system” could then perform a targeted exam using a variety of sensors. Electronic stethoscopes and tympanographic sensors already exist. While currently most sonograms are performed by trained technicians, one can envision the technology being dumbed down to a point that the patient could operate most of the sensors himself or herself, provided the patient could reach the body part in question. The camera on a basic cell phone can take an image of a skin lesion that can already be compared with a standard set of normals and abnormals. While currently a questionable lesion triggers the provider to perform a biopsy, it is possible that sensors could become so sensitive and the algorithms so clever that the biopsy would be unnecessary. The pandemic has already shown us that patients can obtain sample swabs and accurately perform simple tests in their home.

Once the “system” has made the diagnosis, it would then converse with the patient about the various treatment options and arrange follow up. One would hope that, if the “system’s” diagnosis included a fatal outcome, it would trigger a face-to-face interaction with a counselor and a team of social workers to break the bad news and provide some kind of emotional support.

Those of you who are doubting Dorothys and Thomases may be asking what about scenarios in which the patient’s chief complaint is difficulty breathing or sudden onset of weakness? Remember, I am talking about the usual 8 a.m–6 p.m. primary care office. Any patient with a possibly life-threatening complaint would be triaged by the chatbot and would be seen at some point by a real human. However, it is likely that individual’s training would not require the breadth of the typical medical school education and instead would be targeted at the most common high-risk scenarios. This higher-acuity specialist would, of course, be assisted by a chatbot.

Patients with complaints primarily associated with mental illness would be seen by humans specializing in that area. Although I suspect there are folks somewhere brainstorming on how chatbots could potentially be effective counselors.

Clearly, the future I am suggesting leaves the patient with fewer interactions with a human, and certainly very rarely with a human who has navigated what we think of today as a traditional medical school education.

Would patients accept a dehumanized type of primary care delivered by AI? Would they do it without complaint? Would they have a choice? Do you like it when you are interrogated by the prerecorded voice on the phone tree of some company’s customer service? Do you have a choice? If that interrogation was refined to the point where it saved you time and resulted in the correct answer 99% of the time would you still complain?

If patients found that most of their primary care complaints could be handled more quickly by an AI system with minimal physician intervention and that system offered a success rate of over 90% when measured by the accuracy of the diagnosis and management plan, would they complain? They may have no other choice than to complain if primary care continues to lose favor among recent medical school graduates.

And what would the patients complain about? They already complain about the current system in which they feel that the face-to-face encounters with their physician are becoming less frequent. I often hear complaints that “the doctor just looked at the computer, and he didn’t really examine me.” By which I think they sometimes mean “touched” me.

I suspect we will discover what most of us already suspect and that is there is something special about the eye-to-eye contact and tactile interaction between the physician and the patient. The osteopathic tradition clearly makes this a priority when it utilizes manipulative medicine. It may be that if primary care medicine follows the AI-paved road I have imagined it won’t be able to match the success rate of the current system. Without that human element, with or without the hands-on aspect or even if the diagnosis is correct and the management is spot on, it just won’t work as well.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a 2018 JAMA Viewpoint, Dr. Vineet Chopra, a former colleague of mine at the University of Michigan (now chair of medicine at the University of Colorado) and colleagues wrote about four archetypes of mentorship: mentor, coach, sponsor, and connector. While we are all products of our hard work, passion, and perseverance, none of us would be where we are today without a larger community of individuals who helped us in ways large and small along the way.

For me, DDW serves as an annual reminder of the power of mentorship in building and sustaining careers. Each May, trainees and early career faculty present their projects in oral or poster sessions, cheered on by their research mentors. Senior thought leaders offer career advice and guidance to more junior colleagues through structured sessions or informal conversations and facilitate introductions to new collaborators. Department chairs, division chiefs, and senior practice leaders take time to reconnect with their early mentors who believed in their potential and provided them with opportunities to take their careers to new heights. And, we see the incredible payoff of programs like AGA’s FORWARD and Future Leaders Programs in serving as springboards for career advancement and creating powerful role models and mentors for the future.

This year’s AGA presidential leadership transition served as a particularly poignant example of the power of mentorship as incoming AGA President Dr. Barbara Jung succeeded one of her early mentors, outgoing AGA President Dr. John Carethers, in this prestigious role. I hope you’ll join me in reflecting on the tremendous impact that mentors, coaches, sponsors, and connectors have had on your career, and continue to pay it forward to the next generation.

In this month’s issue, we feature several stories from DDW 2023, including summaries of the AGA presidential address and a study evaluating the impact of state Medicaid expansion on uptake of CRC screening in safety-net practices. From AGA’s flagship journals, we highlight a propensity-matched cohort study assessing the impact of pancreatic cancer surveillance of high-risk patients on important clinical outcomes and a new AGA CPU on management of extraesophageal GERD. In this month’s AGA Policy and Advocacy column, Dr. Amit Patel and Dr. Rotonya Carr review the results of a recent membership survey on policy priorities and outline the many ways you can get involved in advocacy efforts. Finally, our Member Spotlight column celebrates gastroenterologist and humanitarian Kadirawel Iswara, MD, recipient of this year’s AGA Distinguished Clinician Award in Private Practice, who is a cherished mentor to many prominent members of our field.
 

Megan A. Adams, M.D., J.D., MSc

Editor-in-Chief

In a 2018 JAMA Viewpoint, Dr. Vineet Chopra, a former colleague of mine at the University of Michigan (now chair of medicine at the University of Colorado) and colleagues wrote about four archetypes of mentorship: mentor, coach, sponsor, and connector. While we are all products of our hard work, passion, and perseverance, none of us would be where we are today without a larger community of individuals who helped us in ways large and small along the way.

For me, DDW serves as an annual reminder of the power of mentorship in building and sustaining careers. Each May, trainees and early career faculty present their projects in oral or poster sessions, cheered on by their research mentors. Senior thought leaders offer career advice and guidance to more junior colleagues through structured sessions or informal conversations and facilitate introductions to new collaborators. Department chairs, division chiefs, and senior practice leaders take time to reconnect with their early mentors who believed in their potential and provided them with opportunities to take their careers to new heights. And, we see the incredible payoff of programs like AGA’s FORWARD and Future Leaders Programs in serving as springboards for career advancement and creating powerful role models and mentors for the future.

This year’s AGA presidential leadership transition served as a particularly poignant example of the power of mentorship as incoming AGA President Dr. Barbara Jung succeeded one of her early mentors, outgoing AGA President Dr. John Carethers, in this prestigious role. I hope you’ll join me in reflecting on the tremendous impact that mentors, coaches, sponsors, and connectors have had on your career, and continue to pay it forward to the next generation.

In this month’s issue, we feature several stories from DDW 2023, including summaries of the AGA presidential address and a study evaluating the impact of state Medicaid expansion on uptake of CRC screening in safety-net practices. From AGA’s flagship journals, we highlight a propensity-matched cohort study assessing the impact of pancreatic cancer surveillance of high-risk patients on important clinical outcomes and a new AGA CPU on management of extraesophageal GERD. In this month’s AGA Policy and Advocacy column, Dr. Amit Patel and Dr. Rotonya Carr review the results of a recent membership survey on policy priorities and outline the many ways you can get involved in advocacy efforts. Finally, our Member Spotlight column celebrates gastroenterologist and humanitarian Kadirawel Iswara, MD, recipient of this year’s AGA Distinguished Clinician Award in Private Practice, who is a cherished mentor to many prominent members of our field.
 

Megan A. Adams, M.D., J.D., MSc

Editor-in-Chief

In a 2018 JAMA Viewpoint, Dr. Vineet Chopra, a former colleague of mine at the University of Michigan (now chair of medicine at the University of Colorado) and colleagues wrote about four archetypes of mentorship: mentor, coach, sponsor, and connector. While we are all products of our hard work, passion, and perseverance, none of us would be where we are today without a larger community of individuals who helped us in ways large and small along the way.

For me, DDW serves as an annual reminder of the power of mentorship in building and sustaining careers. Each May, trainees and early career faculty present their projects in oral or poster sessions, cheered on by their research mentors. Senior thought leaders offer career advice and guidance to more junior colleagues through structured sessions or informal conversations and facilitate introductions to new collaborators. Department chairs, division chiefs, and senior practice leaders take time to reconnect with their early mentors who believed in their potential and provided them with opportunities to take their careers to new heights. And, we see the incredible payoff of programs like AGA’s FORWARD and Future Leaders Programs in serving as springboards for career advancement and creating powerful role models and mentors for the future.

This year’s AGA presidential leadership transition served as a particularly poignant example of the power of mentorship as incoming AGA President Dr. Barbara Jung succeeded one of her early mentors, outgoing AGA President Dr. John Carethers, in this prestigious role. I hope you’ll join me in reflecting on the tremendous impact that mentors, coaches, sponsors, and connectors have had on your career, and continue to pay it forward to the next generation.

In this month’s issue, we feature several stories from DDW 2023, including summaries of the AGA presidential address and a study evaluating the impact of state Medicaid expansion on uptake of CRC screening in safety-net practices. From AGA’s flagship journals, we highlight a propensity-matched cohort study assessing the impact of pancreatic cancer surveillance of high-risk patients on important clinical outcomes and a new AGA CPU on management of extraesophageal GERD. In this month’s AGA Policy and Advocacy column, Dr. Amit Patel and Dr. Rotonya Carr review the results of a recent membership survey on policy priorities and outline the many ways you can get involved in advocacy efforts. Finally, our Member Spotlight column celebrates gastroenterologist and humanitarian Kadirawel Iswara, MD, recipient of this year’s AGA Distinguished Clinician Award in Private Practice, who is a cherished mentor to many prominent members of our field.
 

Megan A. Adams, M.D., J.D., MSc

Editor-in-Chief

Summer is here. Well, technically not for 3 weeks, but in Phoenix summer as a weather condition generally runs from March to November.

The suprachiasmatic nucleus (yes, the one you learned in neuroanatomy) is pretty tiny, but still remarkable. Nothing brings that into focus like the changing of the seasons.

No matter where you live on Earth, you still have to deal with day and night, even if each is 6 months long. We all have to live with shifting schedules and lengths of night and day and weekdays and weekends.

But what fascinates me is how the internal clock reprograms itself, and then doesn’t change.

Case in point: Except for when I’ve had to catch a flight, I haven’t set an alarm in almost 10 years. Somewhere early in my career (back when I did a lot of hospital work) I began getting up between 4-5 a.m. to start rounds before going to the office.

Today the habit continues. It’s been 14 years since I last did weekday hospital call but I still automatically wake up, ready to go, between 4 a.m. and 5 a.m., Monday through Friday. Without me having to do anything this shuts off on vacations, holidays, and weekends, but is up and running as soon as I have to go back to the office.

It’s fascinating (at least to me) in that the suprachiasmatic nucleus didn’t evolve many millions of years ago so I could get to work without an alarm clock. Early animals needed to respond to changing conditions of night, day, and shifting seasons. Light and dark are universal for almost everything that walks, flies, and swims, so given enough time a way of internally keeping track of them developed. Bears use it to hibernate. Birds to migrate with the seasons.

Of course, it’s not all good. In some people it’s likely behind the bizarre predictability of their cluster headaches.

In the modern era we’ve also found ways to confuse it, with the invention of time zones and air travel. Anyone who’s made the leap across several time zones has had to adjust. It’s certainly not a major issue, but does take some getting used to.

But still, it’s pretty fascinating stuff. A reminder that, for all we do in our every day lives, the brain does things on autopilot that we don’t even think about.

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

Summer is here. Well, technically not for 3 weeks, but in Phoenix summer as a weather condition generally runs from March to November.

The suprachiasmatic nucleus (yes, the one you learned in neuroanatomy) is pretty tiny, but still remarkable. Nothing brings that into focus like the changing of the seasons.

No matter where you live on Earth, you still have to deal with day and night, even if each is 6 months long. We all have to live with shifting schedules and lengths of night and day and weekdays and weekends.

But what fascinates me is how the internal clock reprograms itself, and then doesn’t change.

Case in point: Except for when I’ve had to catch a flight, I haven’t set an alarm in almost 10 years. Somewhere early in my career (back when I did a lot of hospital work) I began getting up between 4-5 a.m. to start rounds before going to the office.

Today the habit continues. It’s been 14 years since I last did weekday hospital call but I still automatically wake up, ready to go, between 4 a.m. and 5 a.m., Monday through Friday. Without me having to do anything this shuts off on vacations, holidays, and weekends, but is up and running as soon as I have to go back to the office.

It’s fascinating (at least to me) in that the suprachiasmatic nucleus didn’t evolve many millions of years ago so I could get to work without an alarm clock. Early animals needed to respond to changing conditions of night, day, and shifting seasons. Light and dark are universal for almost everything that walks, flies, and swims, so given enough time a way of internally keeping track of them developed. Bears use it to hibernate. Birds to migrate with the seasons.

Of course, it’s not all good. In some people it’s likely behind the bizarre predictability of their cluster headaches.

In the modern era we’ve also found ways to confuse it, with the invention of time zones and air travel. Anyone who’s made the leap across several time zones has had to adjust. It’s certainly not a major issue, but does take some getting used to.

But still, it’s pretty fascinating stuff. A reminder that, for all we do in our every day lives, the brain does things on autopilot that we don’t even think about.

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

Summer is here. Well, technically not for 3 weeks, but in Phoenix summer as a weather condition generally runs from March to November.

The suprachiasmatic nucleus (yes, the one you learned in neuroanatomy) is pretty tiny, but still remarkable. Nothing brings that into focus like the changing of the seasons.

No matter where you live on Earth, you still have to deal with day and night, even if each is 6 months long. We all have to live with shifting schedules and lengths of night and day and weekdays and weekends.

But what fascinates me is how the internal clock reprograms itself, and then doesn’t change.

Case in point: Except for when I’ve had to catch a flight, I haven’t set an alarm in almost 10 years. Somewhere early in my career (back when I did a lot of hospital work) I began getting up between 4-5 a.m. to start rounds before going to the office.

Today the habit continues. It’s been 14 years since I last did weekday hospital call but I still automatically wake up, ready to go, between 4 a.m. and 5 a.m., Monday through Friday. Without me having to do anything this shuts off on vacations, holidays, and weekends, but is up and running as soon as I have to go back to the office.

It’s fascinating (at least to me) in that the suprachiasmatic nucleus didn’t evolve many millions of years ago so I could get to work without an alarm clock. Early animals needed to respond to changing conditions of night, day, and shifting seasons. Light and dark are universal for almost everything that walks, flies, and swims, so given enough time a way of internally keeping track of them developed. Bears use it to hibernate. Birds to migrate with the seasons.

Of course, it’s not all good. In some people it’s likely behind the bizarre predictability of their cluster headaches.

In the modern era we’ve also found ways to confuse it, with the invention of time zones and air travel. Anyone who’s made the leap across several time zones has had to adjust. It’s certainly not a major issue, but does take some getting used to.

But still, it’s pretty fascinating stuff. A reminder that, for all we do in our every day lives, the brain does things on autopilot that we don’t even think about.

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

This transcript has been edited for clarity.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study.

I am here today to talk about the effectiveness of COVID vaccine boosters in the midst of 2023. The reason I want to talk about this isn’t necessarily to dig into exactly how effective vaccines are. This is an area that’s been trod upon multiple times. But it does give me an opportunity to talk about a neat study design called the “test-negative case-control” design, which has some unique properties when you’re trying to evaluate the effect of something outside of the context of a randomized trial.

So, just a little bit of background to remind everyone where we are. These are the number of doses of COVID vaccines administered over time throughout the pandemic.

Centers for Disease Control and Prevention

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Centers for Disease Control and Prevention

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. He disclosed no relevant conflicts of interest.
 

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study.

I am here today to talk about the effectiveness of COVID vaccine boosters in the midst of 2023. The reason I want to talk about this isn’t necessarily to dig into exactly how effective vaccines are. This is an area that’s been trod upon multiple times. But it does give me an opportunity to talk about a neat study design called the “test-negative case-control” design, which has some unique properties when you’re trying to evaluate the effect of something outside of the context of a randomized trial.

So, just a little bit of background to remind everyone where we are. These are the number of doses of COVID vaccines administered over time throughout the pandemic.

Centers for Disease Control and Prevention

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Centers for Disease Control and Prevention

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. He disclosed no relevant conflicts of interest.
 

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study.

I am here today to talk about the effectiveness of COVID vaccine boosters in the midst of 2023. The reason I want to talk about this isn’t necessarily to dig into exactly how effective vaccines are. This is an area that’s been trod upon multiple times. But it does give me an opportunity to talk about a neat study design called the “test-negative case-control” design, which has some unique properties when you’re trying to evaluate the effect of something outside of the context of a randomized trial.

So, just a little bit of background to remind everyone where we are. These are the number of doses of COVID vaccines administered over time throughout the pandemic.

Centers for Disease Control and Prevention

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Dr. F. Perry Wilson

Centers for Disease Control and Prevention

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. He disclosed no relevant conflicts of interest.
 

A version of this article first appeared on Medscape.com.

Introduction: Reassurance through pregnancy loss and workups

Pregnancy loss is not an uncommon complication but it can be associated with significant stress among parents and loved ones when it occurs. Especially when recurrent, it also becomes a medical dilemma for physicians and nurses because the cause is not always obvious immediately, and even with exploration, the cause may not always be found.

First and foremost, it is important that physicians provide counseling and reassurance to families experiencing loss, and that they encourage a level of patience while the investigation for loss is done. Investigations tend not to be linear. One must look at a number of diagnostic areas including genetics, anatomy, immunology, and infections.

Even with an extensive workup, what often is found are potential associations rather than precise causes. For instance, one may find that certain antibodies or certain conditions are present, or that certain anatomic structures are abnormal. While such findings are not necessarily causative, there are therapeutic interventions that we can offer to address many of the conditions (e.g., surgical correction of the septate uterus, and low-dose aspirin and heparin for antiphospholipid syndrome).

Less than 1% of couples experience recurrent pregnancy loss (traditionally defined as three or more losses), so parents who experience one loss should be given reassurance that their loss was likely a sporadic miscarriage and that chances of recurrence will be low. Even as workups proceed, reassurance is important.

For this month’s Master Class in Obstetrics we’ve invited Wendy L. Kinzler, MD, and Anthony Vintzileos, MD, both of whom have expertise in the area of recurrent pregnancy loss, to review the potential causes and the management approach. They focus on the first trimester, when genetic causes predominate, and the early second trimester, when undetected uterine factors can be at play. They explain that the gestational age at which recurrent losses occur is an important factor in decoding etiology and management.

Dr. Kinzler is associate dean, graduate medical education, and professor of obstetrics and gynecology at NYU Long Island School of Medicine, Mineola, N.Y., and Dr. Vintzileos is chief patient safety officer for obstetrics, Northwell Health–Western Region, and professor in the department of obstetrics and gynecology in the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. Dr. Kinzler and Dr. Vintzileos reported no relevant disclosures.
 

E. Albert Reece, MD, PhD, MBA, a maternal-fetal medicine specialist, is dean emeritus of the University of Maryland School of Medicine, former university executive vice president; currently the endowed professor and director of the Center for Advanced Research Training and Innovation (CARTI), and senior scientist in the Center for Birth Defects Research. Dr. Reece reported no relevant disclosures. He is the medical editor of this column. Contact him at [email protected].

Investigating the etiology of recurrent pregnancy loss

Pregnancy loss is defined as a loss occurring at < 20 weeks’ gestation. Any pregnancy loss is a devastating experience and couples deserve a thoughtful approach to identifying possible causes and/or predisposing factors.

Consideration of the timing of the pregnancy loss can provide a useful guide to this evaluation, as etiologies vary depending on when in gestation losses occur. In this Master Class, we will address the evaluation of pregnancy loss at < 20 weeks’ gestation, with particular attention to first trimester and early second trimester causes. Literature on the role of the cervix and intra-amniotic infection in midtrimester loss is extensive and will not be covered here.

Although early first trimester miscarriage is common, occurring in approximately 15% of clinically recognized pregnancies, only 2%-3% of couples experience two or more miscarriages and 0.5%-1% experience three or more.

When to begin a diagnostic workup should be part of a shared decision-making process, taking into consideration future family planning, parity, number of previous losses, and notably, the gestational age at which loss(es) occurred. Recurrence rates for first trimester miscarriage are similar after two versus three consecutive losses and either situation usually prompts an evaluation, whereas any second-trimester loss should be evaluated.

Increasingly, we are appreciating the value of a more targeted, gestational age–driven approach to the evaluation of pregnancy loss in an attempt to provide grieving parents with useful information without subjecting them to a wide array of expensive and unnecessary tests.
 

Genetic causes

The earlier the pregnancy loss, the more likely it is the result of abnormal fetal genetics. Genetic factors should be considered as the most likely cause for first trimester pregnancy losses (especially those occurring at < 10 weeks’ gestation), the most frequent being autosomal trisomies or monosomy X. The vast majority of trisomy conceptuses are sporadic in nature and are related to the natural aging process of the ovary (increasing the rate of meiotic nondisjunction).

NYU Long Island School of Medicine

If fetal aneuploidy is identified in a pregnancy loss, couples can be counseled about the definitive cause of the loss and can be counseled about recurrence based on age-related risks and/or tests of ovarian reserve. Recurrent pregnancy loss (RPL) is only rarely associated with a parental translocation (< 5%). Testing parental karyotypes should be reserved for cases in which the fetal karyotypes are unknown or in which an unbalanced translocation was identified in the fetus.

When a first trimester pregnancy loss is diagnosed, chorionic villus sampling (CVS) with microarray testing is the most reliable and comprehensive method for evaluating potential genetic causes. It provides valuable information even when cells are not viable and reduces the risk of maternal cell contamination – two significant limitations to standard karyotype analysis performed on tissue passed spontaneously or at the time of D&C. Studies of products of conception (POC) testing with microarray have documented the detection of abnormalities in an additional 10%-15% of cases compared with traditional karyotype analysis.

Hofstra/Northwell

When CVS is not feasible, testing maternal serum for cell-free DNA is a reasonable alternative. In a prospective cohort study of 50 maternal blood samples taken after fetal demise, 76% of samples yielded cell-free DNA results, meaning fetal fractions were within the detectable range. The higher the gestational age at the time of loss, the higher the chance of obtaining a result: Findings in the study were possible in 88% of samples when the gestational age was 8 weeks or greater, and in 53% of cases involving a lower gestational age. The time from demise to blood draw did not affect the likelihood of obtaining a result (Obstet Gynecol. 2015 Jun;125[6]:1321-29).

When neither CVS nor cell-free DNA analysis is feasible, analysis of either spontaneously passed tissue or tissue obtained at the time of a D&C may still be worthwhile. Maternal cell contamination, of course, is the main downside.

A paper published in 2020 documented the value of refocusing the initial workup. Researchers reported that 57% of 1,400 cases of recurrent pregnancy loss went unexplained using the 2012 ASRM guidelines, which included parental karyotyping but not POC cytogenetic analysis. When parental karyotypes were omitted from the initial workup and POC analysis with 24-chromosome microarray was added, at least one potential explanation for loss could be identified in 92% of cases. Only 8% were left “unexplained” (Curr Opin Obstet Gynecol. 2020 Oct;32[5]:371-9).
 

When genetics are ruled out

Issues that are top of mind when we lack genetic information or when genetic causes are ruled out include maternal metabolic disorders (uncontrolled diabetes, obesity, uncontrolled thyroid disease), environmental exposures (smoking), uterine abnormalities, and antiphospholipid syndrome.

Thorough evaluation of the uterine cavity after recurrent first trimester miscarriage – or after any second trimester loss – is too often a missing element of investigation. It is a vital component of the evaluation, and information about uterine structure is easily obtained.

A saline infusion sonogram (SIS) allows us to look at the external contour of the uterus, assess the myometrium for muscular abnormalities, visualize the uterine lining, and assess uterine orientation. Performed in the nonpregnant state, and ideally coupled with 3D technology, this relatively simple test can identify congenital uterine anomalies, intracavitary abnormalities (such as fibroids, polyps, or synechiae) which can surgically be removed prior to another pregnancy, a retroverted uterus that may be predisposed to incarceration during pregnancy, and other potentially impactful conditions, such as adenomyosis.
 

Structural anomalies

Congenital uterine anomalies are associated with first trimester miscarriage, second trimester pregnancy loss, and preterm birth. A uterine septum is of particular concern for early miscarriage, as the early embryo can implant on the relatively avascular septum.

Other congenital uterine anomalies (bicornuate, didelphys, unicornuate) can be associated with concomitant cervical structural abnormalities leading to cervical insufficiency and/or result in pathologic uterine stretch of a space-limited cavity, leading to midtrimester loss or preterm birth. The diagnosis of these anomalies is an important part of the evaluation of pregnancy loss, as it can guide monitoring in future pregnancies, or can be surgically corrected, as in the case of a uterine septum, significantly improving pregnancy outcomes.

A short cervix can result either congenitally or from injury or trauma and may also be associated with cervical insufficiency and miscarriage. It can be evaluated and monitored by ultrasound and, in some cases, treated by surgical cerclage. Pregnancy losses due to cervical insufficiency usually occur after 16 weeks of gestation and frequently are associated with intra-amniotic infections.
 

Incarcerated uterus and adenomyosis

Other uterine factors that can contribute to pregnancy loss and that are largely underdiagnosed or undiagnosed are an incarcerated retroverted uterus and adenomyosis.

Martin R. Chavez, MD. NYU Long Island School of Medicine

Most of the time, a retroverted uterus naturally assumes an anteverted position by the late first trimester or early second trimester, allowing for continued growth of the uterus and developing fetus. In approximately 10% of cases, however, the retroverted uterus becomes “stuck” or incarcerated in the posterior pelvis. This is more likely if there are large uterine fibroids or in the presence of pelvic adhesions due to endometriosis or previous pelvic surgery.

When this occurs, the fundus is wedged on the sacral promontory (may cause pelvic discomfort and constipation) and the cervix is markedly displaced anteriorly under the pubic symphysis (causing bladder outlet obstruction and urinary retention).

It is critical that ob.gyns. and emergency medicine providers are aware of this condition, which typically presents between 12 and 16 weeks’ gestation. The most frequent complaint is lower abdominal discomfort due to distended bladder and inability to void, which usually leads to bladder catheterization with drainage of large amounts of urine. An incarcerated uterus can predispose to pregnancy loss during this time (few other conditions cause loss during this time window), presumably due to impaired uterine artery blood flow.

Once the diagnosis is made, uterine incarceration may be corrected by elevating the gravid uterus out of the pelvis either manually, or by using a transvaginal ultrasound probe. (The latter minimally invasive approach was described in March at the American Institute of Ultrasound in Medicine’s annual conference by Martin Chavez, MD, and coinvestigators. More invasive approaches are rarely required but include CO₂ intraperitoneal insufflation, as used prior to laparoscopy, or laparotomy.

The later in gestation the condition is allowed to persist, the less likely correction will be possible due to the enlarging fundus. Correction between 14 and 16 weeks, or earlier if symptoms develop, is recommended.

Martin R. Chavez, MD. NYU Long Island School of Medicine

A word about antiphospholipid syndrome

Antiphospholipid syndrome can cause a variety of adverse pregnancy outcomes, including first and second trimester pregnancy loss, fetal demise, fetal growth restriction, preeclampsia, preterm birth, and maternal thromboembolism. The classical presentation of miscarriage due to untreated antiphospholipid antibody syndrome is early severe fetal growth restriction, oligohydramnios, and IUFD in the second trimester.

The diagnosis requires at least one clinical criterion and one laboratory criterion. The mere presence of low level antibodies does not make the diagnosis of antiphospholipid antibody syndrome, and care should be taken to consider both the clinical and laboratory diagnostic criteria to make an accurate diagnosis.

When present, close maternal and fetal surveillance and a combination of low-dose aspirin and heparin are mainstays of treatment. The majority of studies suggest that low-molecular weight heparin (LMWH) and unfractionated heparin have comparable clinical efficacy. However, if a recurrent loss is experienced despite treatment with LMWH, the use of unfractionated heparin in a subsequent pregnancy should be considered.

Introduction: Reassurance through pregnancy loss and workups

Pregnancy loss is not an uncommon complication but it can be associated with significant stress among parents and loved ones when it occurs. Especially when recurrent, it also becomes a medical dilemma for physicians and nurses because the cause is not always obvious immediately, and even with exploration, the cause may not always be found.

First and foremost, it is important that physicians provide counseling and reassurance to families experiencing loss, and that they encourage a level of patience while the investigation for loss is done. Investigations tend not to be linear. One must look at a number of diagnostic areas including genetics, anatomy, immunology, and infections.

Even with an extensive workup, what often is found are potential associations rather than precise causes. For instance, one may find that certain antibodies or certain conditions are present, or that certain anatomic structures are abnormal. While such findings are not necessarily causative, there are therapeutic interventions that we can offer to address many of the conditions (e.g., surgical correction of the septate uterus, and low-dose aspirin and heparin for antiphospholipid syndrome).

Less than 1% of couples experience recurrent pregnancy loss (traditionally defined as three or more losses), so parents who experience one loss should be given reassurance that their loss was likely a sporadic miscarriage and that chances of recurrence will be low. Even as workups proceed, reassurance is important.

For this month’s Master Class in Obstetrics we’ve invited Wendy L. Kinzler, MD, and Anthony Vintzileos, MD, both of whom have expertise in the area of recurrent pregnancy loss, to review the potential causes and the management approach. They focus on the first trimester, when genetic causes predominate, and the early second trimester, when undetected uterine factors can be at play. They explain that the gestational age at which recurrent losses occur is an important factor in decoding etiology and management.

Dr. Kinzler is associate dean, graduate medical education, and professor of obstetrics and gynecology at NYU Long Island School of Medicine, Mineola, N.Y., and Dr. Vintzileos is chief patient safety officer for obstetrics, Northwell Health–Western Region, and professor in the department of obstetrics and gynecology in the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. Dr. Kinzler and Dr. Vintzileos reported no relevant disclosures.
 

E. Albert Reece, MD, PhD, MBA, a maternal-fetal medicine specialist, is dean emeritus of the University of Maryland School of Medicine, former university executive vice president; currently the endowed professor and director of the Center for Advanced Research Training and Innovation (CARTI), and senior scientist in the Center for Birth Defects Research. Dr. Reece reported no relevant disclosures. He is the medical editor of this column. Contact him at [email protected].

Investigating the etiology of recurrent pregnancy loss

Pregnancy loss is defined as a loss occurring at < 20 weeks’ gestation. Any pregnancy loss is a devastating experience and couples deserve a thoughtful approach to identifying possible causes and/or predisposing factors.

Consideration of the timing of the pregnancy loss can provide a useful guide to this evaluation, as etiologies vary depending on when in gestation losses occur. In this Master Class, we will address the evaluation of pregnancy loss at < 20 weeks’ gestation, with particular attention to first trimester and early second trimester causes. Literature on the role of the cervix and intra-amniotic infection in midtrimester loss is extensive and will not be covered here.

Although early first trimester miscarriage is common, occurring in approximately 15% of clinically recognized pregnancies, only 2%-3% of couples experience two or more miscarriages and 0.5%-1% experience three or more.

When to begin a diagnostic workup should be part of a shared decision-making process, taking into consideration future family planning, parity, number of previous losses, and notably, the gestational age at which loss(es) occurred. Recurrence rates for first trimester miscarriage are similar after two versus three consecutive losses and either situation usually prompts an evaluation, whereas any second-trimester loss should be evaluated.

Increasingly, we are appreciating the value of a more targeted, gestational age–driven approach to the evaluation of pregnancy loss in an attempt to provide grieving parents with useful information without subjecting them to a wide array of expensive and unnecessary tests.
 

Genetic causes

The earlier the pregnancy loss, the more likely it is the result of abnormal fetal genetics. Genetic factors should be considered as the most likely cause for first trimester pregnancy losses (especially those occurring at < 10 weeks’ gestation), the most frequent being autosomal trisomies or monosomy X. The vast majority of trisomy conceptuses are sporadic in nature and are related to the natural aging process of the ovary (increasing the rate of meiotic nondisjunction).

NYU Long Island School of Medicine

If fetal aneuploidy is identified in a pregnancy loss, couples can be counseled about the definitive cause of the loss and can be counseled about recurrence based on age-related risks and/or tests of ovarian reserve. Recurrent pregnancy loss (RPL) is only rarely associated with a parental translocation (< 5%). Testing parental karyotypes should be reserved for cases in which the fetal karyotypes are unknown or in which an unbalanced translocation was identified in the fetus.

When a first trimester pregnancy loss is diagnosed, chorionic villus sampling (CVS) with microarray testing is the most reliable and comprehensive method for evaluating potential genetic causes. It provides valuable information even when cells are not viable and reduces the risk of maternal cell contamination – two significant limitations to standard karyotype analysis performed on tissue passed spontaneously or at the time of D&C. Studies of products of conception (POC) testing with microarray have documented the detection of abnormalities in an additional 10%-15% of cases compared with traditional karyotype analysis.

Hofstra/Northwell

When CVS is not feasible, testing maternal serum for cell-free DNA is a reasonable alternative. In a prospective cohort study of 50 maternal blood samples taken after fetal demise, 76% of samples yielded cell-free DNA results, meaning fetal fractions were within the detectable range. The higher the gestational age at the time of loss, the higher the chance of obtaining a result: Findings in the study were possible in 88% of samples when the gestational age was 8 weeks or greater, and in 53% of cases involving a lower gestational age. The time from demise to blood draw did not affect the likelihood of obtaining a result (Obstet Gynecol. 2015 Jun;125[6]:1321-29).

When neither CVS nor cell-free DNA analysis is feasible, analysis of either spontaneously passed tissue or tissue obtained at the time of a D&C may still be worthwhile. Maternal cell contamination, of course, is the main downside.

A paper published in 2020 documented the value of refocusing the initial workup. Researchers reported that 57% of 1,400 cases of recurrent pregnancy loss went unexplained using the 2012 ASRM guidelines, which included parental karyotyping but not POC cytogenetic analysis. When parental karyotypes were omitted from the initial workup and POC analysis with 24-chromosome microarray was added, at least one potential explanation for loss could be identified in 92% of cases. Only 8% were left “unexplained” (Curr Opin Obstet Gynecol. 2020 Oct;32[5]:371-9).
 

When genetics are ruled out

Issues that are top of mind when we lack genetic information or when genetic causes are ruled out include maternal metabolic disorders (uncontrolled diabetes, obesity, uncontrolled thyroid disease), environmental exposures (smoking), uterine abnormalities, and antiphospholipid syndrome.

Thorough evaluation of the uterine cavity after recurrent first trimester miscarriage – or after any second trimester loss – is too often a missing element of investigation. It is a vital component of the evaluation, and information about uterine structure is easily obtained.

A saline infusion sonogram (SIS) allows us to look at the external contour of the uterus, assess the myometrium for muscular abnormalities, visualize the uterine lining, and assess uterine orientation. Performed in the nonpregnant state, and ideally coupled with 3D technology, this relatively simple test can identify congenital uterine anomalies, intracavitary abnormalities (such as fibroids, polyps, or synechiae) which can surgically be removed prior to another pregnancy, a retroverted uterus that may be predisposed to incarceration during pregnancy, and other potentially impactful conditions, such as adenomyosis.
 

Structural anomalies

Congenital uterine anomalies are associated with first trimester miscarriage, second trimester pregnancy loss, and preterm birth. A uterine septum is of particular concern for early miscarriage, as the early embryo can implant on the relatively avascular septum.

Other congenital uterine anomalies (bicornuate, didelphys, unicornuate) can be associated with concomitant cervical structural abnormalities leading to cervical insufficiency and/or result in pathologic uterine stretch of a space-limited cavity, leading to midtrimester loss or preterm birth. The diagnosis of these anomalies is an important part of the evaluation of pregnancy loss, as it can guide monitoring in future pregnancies, or can be surgically corrected, as in the case of a uterine septum, significantly improving pregnancy outcomes.

A short cervix can result either congenitally or from injury or trauma and may also be associated with cervical insufficiency and miscarriage. It can be evaluated and monitored by ultrasound and, in some cases, treated by surgical cerclage. Pregnancy losses due to cervical insufficiency usually occur after 16 weeks of gestation and frequently are associated with intra-amniotic infections.
 

Incarcerated uterus and adenomyosis

Other uterine factors that can contribute to pregnancy loss and that are largely underdiagnosed or undiagnosed are an incarcerated retroverted uterus and adenomyosis.

Martin R. Chavez, MD. NYU Long Island School of Medicine

Most of the time, a retroverted uterus naturally assumes an anteverted position by the late first trimester or early second trimester, allowing for continued growth of the uterus and developing fetus. In approximately 10% of cases, however, the retroverted uterus becomes “stuck” or incarcerated in the posterior pelvis. This is more likely if there are large uterine fibroids or in the presence of pelvic adhesions due to endometriosis or previous pelvic surgery.

When this occurs, the fundus is wedged on the sacral promontory (may cause pelvic discomfort and constipation) and the cervix is markedly displaced anteriorly under the pubic symphysis (causing bladder outlet obstruction and urinary retention).

It is critical that ob.gyns. and emergency medicine providers are aware of this condition, which typically presents between 12 and 16 weeks’ gestation. The most frequent complaint is lower abdominal discomfort due to distended bladder and inability to void, which usually leads to bladder catheterization with drainage of large amounts of urine. An incarcerated uterus can predispose to pregnancy loss during this time (few other conditions cause loss during this time window), presumably due to impaired uterine artery blood flow.

Once the diagnosis is made, uterine incarceration may be corrected by elevating the gravid uterus out of the pelvis either manually, or by using a transvaginal ultrasound probe. (The latter minimally invasive approach was described in March at the American Institute of Ultrasound in Medicine’s annual conference by Martin Chavez, MD, and coinvestigators. More invasive approaches are rarely required but include CO₂ intraperitoneal insufflation, as used prior to laparoscopy, or laparotomy.

The later in gestation the condition is allowed to persist, the less likely correction will be possible due to the enlarging fundus. Correction between 14 and 16 weeks, or earlier if symptoms develop, is recommended.

Martin R. Chavez, MD. NYU Long Island School of Medicine

A word about antiphospholipid syndrome

Antiphospholipid syndrome can cause a variety of adverse pregnancy outcomes, including first and second trimester pregnancy loss, fetal demise, fetal growth restriction, preeclampsia, preterm birth, and maternal thromboembolism. The classical presentation of miscarriage due to untreated antiphospholipid antibody syndrome is early severe fetal growth restriction, oligohydramnios, and IUFD in the second trimester.

The diagnosis requires at least one clinical criterion and one laboratory criterion. The mere presence of low level antibodies does not make the diagnosis of antiphospholipid antibody syndrome, and care should be taken to consider both the clinical and laboratory diagnostic criteria to make an accurate diagnosis.

When present, close maternal and fetal surveillance and a combination of low-dose aspirin and heparin are mainstays of treatment. The majority of studies suggest that low-molecular weight heparin (LMWH) and unfractionated heparin have comparable clinical efficacy. However, if a recurrent loss is experienced despite treatment with LMWH, the use of unfractionated heparin in a subsequent pregnancy should be considered.

Introduction: Reassurance through pregnancy loss and workups

Pregnancy loss is not an uncommon complication but it can be associated with significant stress among parents and loved ones when it occurs. Especially when recurrent, it also becomes a medical dilemma for physicians and nurses because the cause is not always obvious immediately, and even with exploration, the cause may not always be found.

First and foremost, it is important that physicians provide counseling and reassurance to families experiencing loss, and that they encourage a level of patience while the investigation for loss is done. Investigations tend not to be linear. One must look at a number of diagnostic areas including genetics, anatomy, immunology, and infections.

Even with an extensive workup, what often is found are potential associations rather than precise causes. For instance, one may find that certain antibodies or certain conditions are present, or that certain anatomic structures are abnormal. While such findings are not necessarily causative, there are therapeutic interventions that we can offer to address many of the conditions (e.g., surgical correction of the septate uterus, and low-dose aspirin and heparin for antiphospholipid syndrome).

Less than 1% of couples experience recurrent pregnancy loss (traditionally defined as three or more losses), so parents who experience one loss should be given reassurance that their loss was likely a sporadic miscarriage and that chances of recurrence will be low. Even as workups proceed, reassurance is important.

For this month’s Master Class in Obstetrics we’ve invited Wendy L. Kinzler, MD, and Anthony Vintzileos, MD, both of whom have expertise in the area of recurrent pregnancy loss, to review the potential causes and the management approach. They focus on the first trimester, when genetic causes predominate, and the early second trimester, when undetected uterine factors can be at play. They explain that the gestational age at which recurrent losses occur is an important factor in decoding etiology and management.

Dr. Kinzler is associate dean, graduate medical education, and professor of obstetrics and gynecology at NYU Long Island School of Medicine, Mineola, N.Y., and Dr. Vintzileos is chief patient safety officer for obstetrics, Northwell Health–Western Region, and professor in the department of obstetrics and gynecology in the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. Dr. Kinzler and Dr. Vintzileos reported no relevant disclosures.
 

E. Albert Reece, MD, PhD, MBA, a maternal-fetal medicine specialist, is dean emeritus of the University of Maryland School of Medicine, former university executive vice president; currently the endowed professor and director of the Center for Advanced Research Training and Innovation (CARTI), and senior scientist in the Center for Birth Defects Research. Dr. Reece reported no relevant disclosures. He is the medical editor of this column. Contact him at [email protected].

Investigating the etiology of recurrent pregnancy loss

Pregnancy loss is defined as a loss occurring at < 20 weeks’ gestation. Any pregnancy loss is a devastating experience and couples deserve a thoughtful approach to identifying possible causes and/or predisposing factors.

Consideration of the timing of the pregnancy loss can provide a useful guide to this evaluation, as etiologies vary depending on when in gestation losses occur. In this Master Class, we will address the evaluation of pregnancy loss at < 20 weeks’ gestation, with particular attention to first trimester and early second trimester causes. Literature on the role of the cervix and intra-amniotic infection in midtrimester loss is extensive and will not be covered here.

Although early first trimester miscarriage is common, occurring in approximately 15% of clinically recognized pregnancies, only 2%-3% of couples experience two or more miscarriages and 0.5%-1% experience three or more.

When to begin a diagnostic workup should be part of a shared decision-making process, taking into consideration future family planning, parity, number of previous losses, and notably, the gestational age at which loss(es) occurred. Recurrence rates for first trimester miscarriage are similar after two versus three consecutive losses and either situation usually prompts an evaluation, whereas any second-trimester loss should be evaluated.

Increasingly, we are appreciating the value of a more targeted, gestational age–driven approach to the evaluation of pregnancy loss in an attempt to provide grieving parents with useful information without subjecting them to a wide array of expensive and unnecessary tests.
 

Genetic causes

The earlier the pregnancy loss, the more likely it is the result of abnormal fetal genetics. Genetic factors should be considered as the most likely cause for first trimester pregnancy losses (especially those occurring at < 10 weeks’ gestation), the most frequent being autosomal trisomies or monosomy X. The vast majority of trisomy conceptuses are sporadic in nature and are related to the natural aging process of the ovary (increasing the rate of meiotic nondisjunction).

NYU Long Island School of Medicine

If fetal aneuploidy is identified in a pregnancy loss, couples can be counseled about the definitive cause of the loss and can be counseled about recurrence based on age-related risks and/or tests of ovarian reserve. Recurrent pregnancy loss (RPL) is only rarely associated with a parental translocation (< 5%). Testing parental karyotypes should be reserved for cases in which the fetal karyotypes are unknown or in which an unbalanced translocation was identified in the fetus.

When a first trimester pregnancy loss is diagnosed, chorionic villus sampling (CVS) with microarray testing is the most reliable and comprehensive method for evaluating potential genetic causes. It provides valuable information even when cells are not viable and reduces the risk of maternal cell contamination – two significant limitations to standard karyotype analysis performed on tissue passed spontaneously or at the time of D&C. Studies of products of conception (POC) testing with microarray have documented the detection of abnormalities in an additional 10%-15% of cases compared with traditional karyotype analysis.

Hofstra/Northwell

When CVS is not feasible, testing maternal serum for cell-free DNA is a reasonable alternative. In a prospective cohort study of 50 maternal blood samples taken after fetal demise, 76% of samples yielded cell-free DNA results, meaning fetal fractions were within the detectable range. The higher the gestational age at the time of loss, the higher the chance of obtaining a result: Findings in the study were possible in 88% of samples when the gestational age was 8 weeks or greater, and in 53% of cases involving a lower gestational age. The time from demise to blood draw did not affect the likelihood of obtaining a result (Obstet Gynecol. 2015 Jun;125[6]:1321-29).

When neither CVS nor cell-free DNA analysis is feasible, analysis of either spontaneously passed tissue or tissue obtained at the time of a D&C may still be worthwhile. Maternal cell contamination, of course, is the main downside.

A paper published in 2020 documented the value of refocusing the initial workup. Researchers reported that 57% of 1,400 cases of recurrent pregnancy loss went unexplained using the 2012 ASRM guidelines, which included parental karyotyping but not POC cytogenetic analysis. When parental karyotypes were omitted from the initial workup and POC analysis with 24-chromosome microarray was added, at least one potential explanation for loss could be identified in 92% of cases. Only 8% were left “unexplained” (Curr Opin Obstet Gynecol. 2020 Oct;32[5]:371-9).
 

When genetics are ruled out

Issues that are top of mind when we lack genetic information or when genetic causes are ruled out include maternal metabolic disorders (uncontrolled diabetes, obesity, uncontrolled thyroid disease), environmental exposures (smoking), uterine abnormalities, and antiphospholipid syndrome.

Thorough evaluation of the uterine cavity after recurrent first trimester miscarriage – or after any second trimester loss – is too often a missing element of investigation. It is a vital component of the evaluation, and information about uterine structure is easily obtained.

A saline infusion sonogram (SIS) allows us to look at the external contour of the uterus, assess the myometrium for muscular abnormalities, visualize the uterine lining, and assess uterine orientation. Performed in the nonpregnant state, and ideally coupled with 3D technology, this relatively simple test can identify congenital uterine anomalies, intracavitary abnormalities (such as fibroids, polyps, or synechiae) which can surgically be removed prior to another pregnancy, a retroverted uterus that may be predisposed to incarceration during pregnancy, and other potentially impactful conditions, such as adenomyosis.
 

Structural anomalies

Congenital uterine anomalies are associated with first trimester miscarriage, second trimester pregnancy loss, and preterm birth. A uterine septum is of particular concern for early miscarriage, as the early embryo can implant on the relatively avascular septum.

Other congenital uterine anomalies (bicornuate, didelphys, unicornuate) can be associated with concomitant cervical structural abnormalities leading to cervical insufficiency and/or result in pathologic uterine stretch of a space-limited cavity, leading to midtrimester loss or preterm birth. The diagnosis of these anomalies is an important part of the evaluation of pregnancy loss, as it can guide monitoring in future pregnancies, or can be surgically corrected, as in the case of a uterine septum, significantly improving pregnancy outcomes.

A short cervix can result either congenitally or from injury or trauma and may also be associated with cervical insufficiency and miscarriage. It can be evaluated and monitored by ultrasound and, in some cases, treated by surgical cerclage. Pregnancy losses due to cervical insufficiency usually occur after 16 weeks of gestation and frequently are associated with intra-amniotic infections.
 

Incarcerated uterus and adenomyosis

Other uterine factors that can contribute to pregnancy loss and that are largely underdiagnosed or undiagnosed are an incarcerated retroverted uterus and adenomyosis.

Martin R. Chavez, MD. NYU Long Island School of Medicine

Most of the time, a retroverted uterus naturally assumes an anteverted position by the late first trimester or early second trimester, allowing for continued growth of the uterus and developing fetus. In approximately 10% of cases, however, the retroverted uterus becomes “stuck” or incarcerated in the posterior pelvis. This is more likely if there are large uterine fibroids or in the presence of pelvic adhesions due to endometriosis or previous pelvic surgery.

When this occurs, the fundus is wedged on the sacral promontory (may cause pelvic discomfort and constipation) and the cervix is markedly displaced anteriorly under the pubic symphysis (causing bladder outlet obstruction and urinary retention).

It is critical that ob.gyns. and emergency medicine providers are aware of this condition, which typically presents between 12 and 16 weeks’ gestation. The most frequent complaint is lower abdominal discomfort due to distended bladder and inability to void, which usually leads to bladder catheterization with drainage of large amounts of urine. An incarcerated uterus can predispose to pregnancy loss during this time (few other conditions cause loss during this time window), presumably due to impaired uterine artery blood flow.

Once the diagnosis is made, uterine incarceration may be corrected by elevating the gravid uterus out of the pelvis either manually, or by using a transvaginal ultrasound probe. (The latter minimally invasive approach was described in March at the American Institute of Ultrasound in Medicine’s annual conference by Martin Chavez, MD, and coinvestigators. More invasive approaches are rarely required but include CO₂ intraperitoneal insufflation, as used prior to laparoscopy, or laparotomy.

The later in gestation the condition is allowed to persist, the less likely correction will be possible due to the enlarging fundus. Correction between 14 and 16 weeks, or earlier if symptoms develop, is recommended.

Martin R. Chavez, MD. NYU Long Island School of Medicine

A word about antiphospholipid syndrome

Antiphospholipid syndrome can cause a variety of adverse pregnancy outcomes, including first and second trimester pregnancy loss, fetal demise, fetal growth restriction, preeclampsia, preterm birth, and maternal thromboembolism. The classical presentation of miscarriage due to untreated antiphospholipid antibody syndrome is early severe fetal growth restriction, oligohydramnios, and IUFD in the second trimester.

The diagnosis requires at least one clinical criterion and one laboratory criterion. The mere presence of low level antibodies does not make the diagnosis of antiphospholipid antibody syndrome, and care should be taken to consider both the clinical and laboratory diagnostic criteria to make an accurate diagnosis.

When present, close maternal and fetal surveillance and a combination of low-dose aspirin and heparin are mainstays of treatment. The majority of studies suggest that low-molecular weight heparin (LMWH) and unfractionated heparin have comparable clinical efficacy. However, if a recurrent loss is experienced despite treatment with LMWH, the use of unfractionated heparin in a subsequent pregnancy should be considered.

Since the November 2022 release of a much-discussed artificial intelligence (AI)-based chatbot, I have been curious what all the buzz is about. I decided to engage my well-connected software-savvy son-in-law to hear where he thought things were going.

He started by suggesting that I pose a question to the chatbot about something of which I had some current knowledge. I had recently researched the concept of primal beliefs and so we asked the chatbot to write a short essay about when an individual develops his/her primal beliefs.

In a matter of seconds the “machine” spit out a very readable document that included all the information that had taken me several hours to unearth and digest. And ... it included the references that I had determined to be valid and appropriate. It was an impressive performance to say the least.

Obviously, a technological development with this capability is sending tremors through the educational establishment. One can easily think of several human skills that an AI like this might eventually make superfluous. It will also make it increasingly difficult for educators to determine a students’ true abilities – research, synthesis, and writing to name just a few. But, of course, one could question whether we will need to teach and then test for these skills that the chatbot can perform more quickly. I’m going to leave it to the educators to struggle with that question.

In the long term you and I may find that AI is a serious threat to our existence as health care providers. In the meantime I’ve decided to focus on how we in primary care can take advantage of the wonders of the current AI technology.

My first thought is that if I were having trouble arriving at a diagnosis, I might appreciate having a chatbot to ask for help. Of course this would require that I had already taken a history, done a good exam, and ordered some obvious lab and imaging studies. It would also mean that I had decent knowledge and understanding of basic pathophysiology and was capable of thinking broadly enough to ask a question that would give me the greatest chance of getting the correct answer.

Knowing how to ask the right question is a skill that can be taught. For example, my wife is a successful and experienced online shopper but she acknowledges that when we have medical questions, I can often find the answer more quickly than she can. My relative success usually hinges on my choice of the key word(s) to begin the search, clearly the result of my medical training.

Once I have received a list of possible diagnoses from the chatbot, I must then be able to evaluate the validity and applicability of the references it has supplied. That too is a skill that can be taught. And, for the moment the critical importance of having these two skills suggests that graduating from medical school will continue to give us some job security in the face of expanding AI.

The same process I could used to coax the chatbot to arrive at a diagnosis could be applied when faced with a therapeutic question. Is surgery better than a pharmacological approach? If I need help with a dosage regimen, I could find this information online now. But, wouldn’t it be quicker and maybe better if I asked the chatbot to do the research for me and print a short essay on the pros and cons of different management approaches?

Once I’ve made the diagnosis, crafted a management plan, and now want to hand the patient a document in his/her primary language and at his/her reading skill level describing the diagnosis and giving detailed instructions to follow, this would seem to be a piece of cake for a chatbot given the appropriate commands. Hopefully I would remember to include the disclaimer that “This document was created with the help of a chatbot.”

Clearly, there is nothing to prevent our patients from asking the chatbot the same questions I have posed. And, no doubt, this will happen. It is already happening in a more cumbersome fashion when patients research their own symptoms. However, in the short term I believe we will retain the upper hand.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Since the November 2022 release of a much-discussed artificial intelligence (AI)-based chatbot, I have been curious what all the buzz is about. I decided to engage my well-connected software-savvy son-in-law to hear where he thought things were going.

He started by suggesting that I pose a question to the chatbot about something of which I had some current knowledge. I had recently researched the concept of primal beliefs and so we asked the chatbot to write a short essay about when an individual develops his/her primal beliefs.

In a matter of seconds the “machine” spit out a very readable document that included all the information that had taken me several hours to unearth and digest. And ... it included the references that I had determined to be valid and appropriate. It was an impressive performance to say the least.

Obviously, a technological development with this capability is sending tremors through the educational establishment. One can easily think of several human skills that an AI like this might eventually make superfluous. It will also make it increasingly difficult for educators to determine a students’ true abilities – research, synthesis, and writing to name just a few. But, of course, one could question whether we will need to teach and then test for these skills that the chatbot can perform more quickly. I’m going to leave it to the educators to struggle with that question.

In the long term you and I may find that AI is a serious threat to our existence as health care providers. In the meantime I’ve decided to focus on how we in primary care can take advantage of the wonders of the current AI technology.

My first thought is that if I were having trouble arriving at a diagnosis, I might appreciate having a chatbot to ask for help. Of course this would require that I had already taken a history, done a good exam, and ordered some obvious lab and imaging studies. It would also mean that I had decent knowledge and understanding of basic pathophysiology and was capable of thinking broadly enough to ask a question that would give me the greatest chance of getting the correct answer.

Knowing how to ask the right question is a skill that can be taught. For example, my wife is a successful and experienced online shopper but she acknowledges that when we have medical questions, I can often find the answer more quickly than she can. My relative success usually hinges on my choice of the key word(s) to begin the search, clearly the result of my medical training.

Once I have received a list of possible diagnoses from the chatbot, I must then be able to evaluate the validity and applicability of the references it has supplied. That too is a skill that can be taught. And, for the moment the critical importance of having these two skills suggests that graduating from medical school will continue to give us some job security in the face of expanding AI.

The same process I could used to coax the chatbot to arrive at a diagnosis could be applied when faced with a therapeutic question. Is surgery better than a pharmacological approach? If I need help with a dosage regimen, I could find this information online now. But, wouldn’t it be quicker and maybe better if I asked the chatbot to do the research for me and print a short essay on the pros and cons of different management approaches?

Once I’ve made the diagnosis, crafted a management plan, and now want to hand the patient a document in his/her primary language and at his/her reading skill level describing the diagnosis and giving detailed instructions to follow, this would seem to be a piece of cake for a chatbot given the appropriate commands. Hopefully I would remember to include the disclaimer that “This document was created with the help of a chatbot.”

Clearly, there is nothing to prevent our patients from asking the chatbot the same questions I have posed. And, no doubt, this will happen. It is already happening in a more cumbersome fashion when patients research their own symptoms. However, in the short term I believe we will retain the upper hand.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Since the November 2022 release of a much-discussed artificial intelligence (AI)-based chatbot, I have been curious what all the buzz is about. I decided to engage my well-connected software-savvy son-in-law to hear where he thought things were going.

He started by suggesting that I pose a question to the chatbot about something of which I had some current knowledge. I had recently researched the concept of primal beliefs and so we asked the chatbot to write a short essay about when an individual develops his/her primal beliefs.

In a matter of seconds the “machine” spit out a very readable document that included all the information that had taken me several hours to unearth and digest. And ... it included the references that I had determined to be valid and appropriate. It was an impressive performance to say the least.

Obviously, a technological development with this capability is sending tremors through the educational establishment. One can easily think of several human skills that an AI like this might eventually make superfluous. It will also make it increasingly difficult for educators to determine a students’ true abilities – research, synthesis, and writing to name just a few. But, of course, one could question whether we will need to teach and then test for these skills that the chatbot can perform more quickly. I’m going to leave it to the educators to struggle with that question.

In the long term you and I may find that AI is a serious threat to our existence as health care providers. In the meantime I’ve decided to focus on how we in primary care can take advantage of the wonders of the current AI technology.

My first thought is that if I were having trouble arriving at a diagnosis, I might appreciate having a chatbot to ask for help. Of course this would require that I had already taken a history, done a good exam, and ordered some obvious lab and imaging studies. It would also mean that I had decent knowledge and understanding of basic pathophysiology and was capable of thinking broadly enough to ask a question that would give me the greatest chance of getting the correct answer.

Knowing how to ask the right question is a skill that can be taught. For example, my wife is a successful and experienced online shopper but she acknowledges that when we have medical questions, I can often find the answer more quickly than she can. My relative success usually hinges on my choice of the key word(s) to begin the search, clearly the result of my medical training.

Once I have received a list of possible diagnoses from the chatbot, I must then be able to evaluate the validity and applicability of the references it has supplied. That too is a skill that can be taught. And, for the moment the critical importance of having these two skills suggests that graduating from medical school will continue to give us some job security in the face of expanding AI.

The same process I could used to coax the chatbot to arrive at a diagnosis could be applied when faced with a therapeutic question. Is surgery better than a pharmacological approach? If I need help with a dosage regimen, I could find this information online now. But, wouldn’t it be quicker and maybe better if I asked the chatbot to do the research for me and print a short essay on the pros and cons of different management approaches?

Once I’ve made the diagnosis, crafted a management plan, and now want to hand the patient a document in his/her primary language and at his/her reading skill level describing the diagnosis and giving detailed instructions to follow, this would seem to be a piece of cake for a chatbot given the appropriate commands. Hopefully I would remember to include the disclaimer that “This document was created with the help of a chatbot.”

Clearly, there is nothing to prevent our patients from asking the chatbot the same questions I have posed. And, no doubt, this will happen. It is already happening in a more cumbersome fashion when patients research their own symptoms. However, in the short term I believe we will retain the upper hand.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The old man was restrained at the last moment from jumping off the hospital’s fifth floor atrium parapet. He was suffering from terminal cancer and had been racked with chronic, severe pain for months.

The consult recognized symptoms of depression arising from his continuous physical suffering, advising that a male aide be dispatched to sit with the man and that he be put on a regimen of 10 mg of methadone twice a day to alleviate the pain. The following day the man was calm; he no longer wanted to kill himself. He expressed a strong desire to go home, return to gardening, and to play with his grandchildren.

Dr. Behar

Most of the 47,000 suicides that occur in the United States every year are preventable.¹ Our national policy on this front has been nothing short of an abject failure. The government implemented a system with limited effect on completed suicides – a telephone hotline. This hotline is not called by the most common suicide victims: male, old, and quiet.²

The consequences of this national policy disaster have been profound, resulting in the biggest loss of productive years of life for any fatal condition.³ The grief experienced by the families of those who commit suicide is far greater than normal bereavement: The cause of death of their loved ones was not an unfortunate accident or a disease, it was an intentional act, and families take it personally.

One of the greatest achievements of psychiatry during the 20th century was the lowering of suicide rates in prisons by 70% with no treatment, no additional staffing, and no additional expenditures of funds. Today if inmates threaten suicide, they are immediately placed under eyesight supervision by guards. The federal pamphlet that describes this protocol was published in 1995 and is freely available online.⁴

Half of all suicide attempts are made by individuals who are legally drunk.⁵ Watch them for 6 hours and then ask them if they want to kill themselves and the response will almost invariably be “Of course not,” with the risk of further attempts dissipating in step with their blood alcohol level. The best resources to provide this kind of intervention are responsible adult family members, at no cost to the government. Indeed, in many cases family supervision is superior to that provided by a locked psychiatric ward with three staff members chasing after 20 agitated people all night long. The one-on-one attention that a family member can provide is free as well as far more personal and insightful, and more sincerely caring.

Guarantees in the field of medicine are rare. But, one such guarantee is that after their mood has improved, 100% of people will be thankful that they did not hurt themselves.⁶ This means that successful treatment will prevent 100% of all suicides.⁷ Not all treatments are successful, but 95% can be.⁸ At autopsy, few successful suicide victims have psychiatric medications in their system.⁹ The urge to kill oneself might best be characterized as a temporary chemical alteration of the brain causing delusional thoughts, including the ultimate delusion that life is not worth living.¹⁰ This alteration suppresses the strongest, most fundamental urge of all, namely, the survival instinct.

We must overturn the catastrophic decision of the U.S. Supreme Court that requires the showing of a dangerous act and the holding of a trial employing at least three lawyers for involuntary commitment to be authorized. Rather, involuntary treatment is justified by medical necessity as determined by two licensed professionals with no conflicts of interest. It can be outpatient.

The Supreme Court’s decision in O’Connor v. Donaldson in 1975 remedied an illusory wrong, addressing an act of blatant malpractice, not policy inequity.¹¹ The superintendent of the state facility in that case was not even a doctor. He kept O’Connor prisoner for more than a decade, perhaps to keep a bed filled. Over the past half-century, this one decision has resulted in 1 million preventable suicides¹² and half a million senseless murders by paranoid individuals, including many rampage shootings.¹³

More than two-thirds of homeless individuals suffer from an untreated mental condition.¹⁴ The vast majority of them will refuse all offers of treatment because they also have anosognosia, a brain-based disorder causing denial of illness.¹⁵ By referring to these individuals as “homeless,” we are also lowering real estate values for a square block around where they happen to be camped out. That cost has never been calculated, but it is another real consequence of this devastating Supreme Court decision.¹⁶

Detractors and mental health rights activists may argue that individual rights cannot be infringed. In that case, those same detractors and mental health rights activists must take responsibility for the thousands of lives and billions of dollars in economic damage caused by their refusal to allow an effective solution to the suicide epidemic to be implemented. Enforced outpatient treatment by the U.S. Air Force dropped its suicide rate by 60%. As an unintended benefit, the murder rate dropped by 50%.¹⁷

Through the adoption of well-established, indisputably effective approaches, suicide and its horrible and painful costs can be ended. It is high time we did so.

Dr. Behar is a psychiatrist in Lower Merion, Pa. He graduated from Hahnemann Medical College, Philadelphia, in 1975, and has had postgraduate training at SUNY Stony Brook, University of Iowa, the National Institute of Mental Health, and Columbia University. His practice focuses on difficult, treatment-resistant cases.

References

1. U.S. Centers for Disease Control and Prevention. Suicide Prevention. 2020.

2. Luoma JB et al. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 2002 Jun 1. doi: 10.1176/appi.ajp.159.6.909.

3. World Health Organization. Suicide. 2021 Jun 17.

4. National Institute of Corrections. Correctional suicide prevention: Policies and procedures. 1995.

5. Hufford MR. Alcohol and suicidal behavior. Clin Psychol Rev. 2001 Jul;21(5):797-811.

6. Stanley B and Brown GK. Safety planning intervention: A brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012 May;19(2):256-64.

7. Ibid.

8. Brown GK and Jager-Hyman S. Evidence-based psychotherapies for suicide prevention: Future directions. Am J Prev Med. 2014 Sep;47(3 Suppl 2):S186-94.

9. Isometsä ET. Psychological autopsy studies – A review. Eur Psychiatry. 2001 Nov;16(7):379-85.

10. Van Orden KA et al. The interpersonal theory of suicide. Psychol Rev. 2010 Apr; 117(2):575-600.

11. O’Connor v. Donaldson, 422 U.S. 563 (1975).

12. Calculated based on annual suicide statistics from the CDC and the time elapsed since the Supreme Court decision in O’Connor v. Donaldson.

13. Metzl JM and MacLeish KT. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015 Feb;105(2):240-9.

14. Fazel S et al. The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Med. 2008 Dec 2;5(12):e225.

15. Amador XF and David AS. (eds.) Insight and psychosis: Awareness of illness in schizophrenia and related disorders (2nd ed.). Oxford Univ Press. 2004.

16. Calculated based on the potential impact of homelessness on property values and the relationship between untreated mental illness and homelessness.

17. Armed Forces Health Surveillance Branch. Surveillance snapshot: Manner and cause of death, active component, U.S. Armed Forces, 1998-2015. Medical Surveillance Monthly Report. 2016 Apr;23(4):19.

The old man was restrained at the last moment from jumping off the hospital’s fifth floor atrium parapet. He was suffering from terminal cancer and had been racked with chronic, severe pain for months.

The consult recognized symptoms of depression arising from his continuous physical suffering, advising that a male aide be dispatched to sit with the man and that he be put on a regimen of 10 mg of methadone twice a day to alleviate the pain. The following day the man was calm; he no longer wanted to kill himself. He expressed a strong desire to go home, return to gardening, and to play with his grandchildren.

Dr. Behar

Most of the 47,000 suicides that occur in the United States every year are preventable.¹ Our national policy on this front has been nothing short of an abject failure. The government implemented a system with limited effect on completed suicides – a telephone hotline. This hotline is not called by the most common suicide victims: male, old, and quiet.²

The consequences of this national policy disaster have been profound, resulting in the biggest loss of productive years of life for any fatal condition.³ The grief experienced by the families of those who commit suicide is far greater than normal bereavement: The cause of death of their loved ones was not an unfortunate accident or a disease, it was an intentional act, and families take it personally.

One of the greatest achievements of psychiatry during the 20th century was the lowering of suicide rates in prisons by 70% with no treatment, no additional staffing, and no additional expenditures of funds. Today if inmates threaten suicide, they are immediately placed under eyesight supervision by guards. The federal pamphlet that describes this protocol was published in 1995 and is freely available online.⁴

Half of all suicide attempts are made by individuals who are legally drunk.⁵ Watch them for 6 hours and then ask them if they want to kill themselves and the response will almost invariably be “Of course not,” with the risk of further attempts dissipating in step with their blood alcohol level. The best resources to provide this kind of intervention are responsible adult family members, at no cost to the government. Indeed, in many cases family supervision is superior to that provided by a locked psychiatric ward with three staff members chasing after 20 agitated people all night long. The one-on-one attention that a family member can provide is free as well as far more personal and insightful, and more sincerely caring.

Guarantees in the field of medicine are rare. But, one such guarantee is that after their mood has improved, 100% of people will be thankful that they did not hurt themselves.⁶ This means that successful treatment will prevent 100% of all suicides.⁷ Not all treatments are successful, but 95% can be.⁸ At autopsy, few successful suicide victims have psychiatric medications in their system.⁹ The urge to kill oneself might best be characterized as a temporary chemical alteration of the brain causing delusional thoughts, including the ultimate delusion that life is not worth living.¹⁰ This alteration suppresses the strongest, most fundamental urge of all, namely, the survival instinct.

We must overturn the catastrophic decision of the U.S. Supreme Court that requires the showing of a dangerous act and the holding of a trial employing at least three lawyers for involuntary commitment to be authorized. Rather, involuntary treatment is justified by medical necessity as determined by two licensed professionals with no conflicts of interest. It can be outpatient.

The Supreme Court’s decision in O’Connor v. Donaldson in 1975 remedied an illusory wrong, addressing an act of blatant malpractice, not policy inequity.¹¹ The superintendent of the state facility in that case was not even a doctor. He kept O’Connor prisoner for more than a decade, perhaps to keep a bed filled. Over the past half-century, this one decision has resulted in 1 million preventable suicides¹² and half a million senseless murders by paranoid individuals, including many rampage shootings.¹³

More than two-thirds of homeless individuals suffer from an untreated mental condition.¹⁴ The vast majority of them will refuse all offers of treatment because they also have anosognosia, a brain-based disorder causing denial of illness.¹⁵ By referring to these individuals as “homeless,” we are also lowering real estate values for a square block around where they happen to be camped out. That cost has never been calculated, but it is another real consequence of this devastating Supreme Court decision.¹⁶

Detractors and mental health rights activists may argue that individual rights cannot be infringed. In that case, those same detractors and mental health rights activists must take responsibility for the thousands of lives and billions of dollars in economic damage caused by their refusal to allow an effective solution to the suicide epidemic to be implemented. Enforced outpatient treatment by the U.S. Air Force dropped its suicide rate by 60%. As an unintended benefit, the murder rate dropped by 50%.¹⁷

Through the adoption of well-established, indisputably effective approaches, suicide and its horrible and painful costs can be ended. It is high time we did so.

Dr. Behar is a psychiatrist in Lower Merion, Pa. He graduated from Hahnemann Medical College, Philadelphia, in 1975, and has had postgraduate training at SUNY Stony Brook, University of Iowa, the National Institute of Mental Health, and Columbia University. His practice focuses on difficult, treatment-resistant cases.

References

1. U.S. Centers for Disease Control and Prevention. Suicide Prevention. 2020.

2. Luoma JB et al. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 2002 Jun 1. doi: 10.1176/appi.ajp.159.6.909.

3. World Health Organization. Suicide. 2021 Jun 17.

4. National Institute of Corrections. Correctional suicide prevention: Policies and procedures. 1995.

5. Hufford MR. Alcohol and suicidal behavior. Clin Psychol Rev. 2001 Jul;21(5):797-811.

6. Stanley B and Brown GK. Safety planning intervention: A brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012 May;19(2):256-64.

7. Ibid.

8. Brown GK and Jager-Hyman S. Evidence-based psychotherapies for suicide prevention: Future directions. Am J Prev Med. 2014 Sep;47(3 Suppl 2):S186-94.

9. Isometsä ET. Psychological autopsy studies – A review. Eur Psychiatry. 2001 Nov;16(7):379-85.

10. Van Orden KA et al. The interpersonal theory of suicide. Psychol Rev. 2010 Apr; 117(2):575-600.

11. O’Connor v. Donaldson, 422 U.S. 563 (1975).

12. Calculated based on annual suicide statistics from the CDC and the time elapsed since the Supreme Court decision in O’Connor v. Donaldson.

13. Metzl JM and MacLeish KT. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015 Feb;105(2):240-9.

14. Fazel S et al. The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Med. 2008 Dec 2;5(12):e225.

15. Amador XF and David AS. (eds.) Insight and psychosis: Awareness of illness in schizophrenia and related disorders (2nd ed.). Oxford Univ Press. 2004.

16. Calculated based on the potential impact of homelessness on property values and the relationship between untreated mental illness and homelessness.

17. Armed Forces Health Surveillance Branch. Surveillance snapshot: Manner and cause of death, active component, U.S. Armed Forces, 1998-2015. Medical Surveillance Monthly Report. 2016 Apr;23(4):19.

The old man was restrained at the last moment from jumping off the hospital’s fifth floor atrium parapet. He was suffering from terminal cancer and had been racked with chronic, severe pain for months.

The consult recognized symptoms of depression arising from his continuous physical suffering, advising that a male aide be dispatched to sit with the man and that he be put on a regimen of 10 mg of methadone twice a day to alleviate the pain. The following day the man was calm; he no longer wanted to kill himself. He expressed a strong desire to go home, return to gardening, and to play with his grandchildren.

Dr. Behar

Most of the 47,000 suicides that occur in the United States every year are preventable.¹ Our national policy on this front has been nothing short of an abject failure. The government implemented a system with limited effect on completed suicides – a telephone hotline. This hotline is not called by the most common suicide victims: male, old, and quiet.²

The consequences of this national policy disaster have been profound, resulting in the biggest loss of productive years of life for any fatal condition.³ The grief experienced by the families of those who commit suicide is far greater than normal bereavement: The cause of death of their loved ones was not an unfortunate accident or a disease, it was an intentional act, and families take it personally.

One of the greatest achievements of psychiatry during the 20th century was the lowering of suicide rates in prisons by 70% with no treatment, no additional staffing, and no additional expenditures of funds. Today if inmates threaten suicide, they are immediately placed under eyesight supervision by guards. The federal pamphlet that describes this protocol was published in 1995 and is freely available online.⁴

Half of all suicide attempts are made by individuals who are legally drunk.⁵ Watch them for 6 hours and then ask them if they want to kill themselves and the response will almost invariably be “Of course not,” with the risk of further attempts dissipating in step with their blood alcohol level. The best resources to provide this kind of intervention are responsible adult family members, at no cost to the government. Indeed, in many cases family supervision is superior to that provided by a locked psychiatric ward with three staff members chasing after 20 agitated people all night long. The one-on-one attention that a family member can provide is free as well as far more personal and insightful, and more sincerely caring.

Guarantees in the field of medicine are rare. But, one such guarantee is that after their mood has improved, 100% of people will be thankful that they did not hurt themselves.⁶ This means that successful treatment will prevent 100% of all suicides.⁷ Not all treatments are successful, but 95% can be.⁸ At autopsy, few successful suicide victims have psychiatric medications in their system.⁹ The urge to kill oneself might best be characterized as a temporary chemical alteration of the brain causing delusional thoughts, including the ultimate delusion that life is not worth living.¹⁰ This alteration suppresses the strongest, most fundamental urge of all, namely, the survival instinct.

We must overturn the catastrophic decision of the U.S. Supreme Court that requires the showing of a dangerous act and the holding of a trial employing at least three lawyers for involuntary commitment to be authorized. Rather, involuntary treatment is justified by medical necessity as determined by two licensed professionals with no conflicts of interest. It can be outpatient.

The Supreme Court’s decision in O’Connor v. Donaldson in 1975 remedied an illusory wrong, addressing an act of blatant malpractice, not policy inequity.¹¹ The superintendent of the state facility in that case was not even a doctor. He kept O’Connor prisoner for more than a decade, perhaps to keep a bed filled. Over the past half-century, this one decision has resulted in 1 million preventable suicides¹² and half a million senseless murders by paranoid individuals, including many rampage shootings.¹³

More than two-thirds of homeless individuals suffer from an untreated mental condition.¹⁴ The vast majority of them will refuse all offers of treatment because they also have anosognosia, a brain-based disorder causing denial of illness.¹⁵ By referring to these individuals as “homeless,” we are also lowering real estate values for a square block around where they happen to be camped out. That cost has never been calculated, but it is another real consequence of this devastating Supreme Court decision.¹⁶

Detractors and mental health rights activists may argue that individual rights cannot be infringed. In that case, those same detractors and mental health rights activists must take responsibility for the thousands of lives and billions of dollars in economic damage caused by their refusal to allow an effective solution to the suicide epidemic to be implemented. Enforced outpatient treatment by the U.S. Air Force dropped its suicide rate by 60%. As an unintended benefit, the murder rate dropped by 50%.¹⁷

Through the adoption of well-established, indisputably effective approaches, suicide and its horrible and painful costs can be ended. It is high time we did so.

Dr. Behar is a psychiatrist in Lower Merion, Pa. He graduated from Hahnemann Medical College, Philadelphia, in 1975, and has had postgraduate training at SUNY Stony Brook, University of Iowa, the National Institute of Mental Health, and Columbia University. His practice focuses on difficult, treatment-resistant cases.

References

1. U.S. Centers for Disease Control and Prevention. Suicide Prevention. 2020.

2. Luoma JB et al. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 2002 Jun 1. doi: 10.1176/appi.ajp.159.6.909.

3. World Health Organization. Suicide. 2021 Jun 17.

4. National Institute of Corrections. Correctional suicide prevention: Policies and procedures. 1995.

5. Hufford MR. Alcohol and suicidal behavior. Clin Psychol Rev. 2001 Jul;21(5):797-811.

6. Stanley B and Brown GK. Safety planning intervention: A brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012 May;19(2):256-64.

7. Ibid.

8. Brown GK and Jager-Hyman S. Evidence-based psychotherapies for suicide prevention: Future directions. Am J Prev Med. 2014 Sep;47(3 Suppl 2):S186-94.

9. Isometsä ET. Psychological autopsy studies – A review. Eur Psychiatry. 2001 Nov;16(7):379-85.

10. Van Orden KA et al. The interpersonal theory of suicide. Psychol Rev. 2010 Apr; 117(2):575-600.

11. O’Connor v. Donaldson, 422 U.S. 563 (1975).

12. Calculated based on annual suicide statistics from the CDC and the time elapsed since the Supreme Court decision in O’Connor v. Donaldson.

13. Metzl JM and MacLeish KT. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015 Feb;105(2):240-9.

14. Fazel S et al. The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Med. 2008 Dec 2;5(12):e225.

15. Amador XF and David AS. (eds.) Insight and psychosis: Awareness of illness in schizophrenia and related disorders (2nd ed.). Oxford Univ Press. 2004.

16. Calculated based on the potential impact of homelessness on property values and the relationship between untreated mental illness and homelessness.

17. Armed Forces Health Surveillance Branch. Surveillance snapshot: Manner and cause of death, active component, U.S. Armed Forces, 1998-2015. Medical Surveillance Monthly Report. 2016 Apr;23(4):19.