From the Editor

CASE: Febrile laboring mother transferred to hospital
You are in the hospital managing the induction of labor for one of your nulliparous patients who is postterm. You are hoping for a quiet and uneventful shift.

At midnight the nursing administrator pages you and asks if you would please provide care to a pregnant woman attempting a home birth who is in labor and is being transferred to your hospital.

The woman is a 41-year-old G2P1 with one prior cesarean delivery who has attempted a trial of labor at home. According to the nursing administrator the patient has a temperature of 100.4°F and the most recent cervical examination shows her to be fully dilated at +3/5 station in an occiput posterior position. She has been fully dilated for 5 hours. The fetal heart rate, assessed by Doppler monitor, is reported to be reassuring.

What is your clinical plan?

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that pregnant women should deliver at certified birth centers or hospital-based obstetric units to optimize clinical outcomes for newborns and mothers.^1,2 Both organizations also recognize a woman’s right to exercise her autonomy and choose a planned home birth.

In 2012, approximately 0.8% of pregnant women in the United States planned a home birth (31,500 home births and 3,999,386 total births).³ In 2009, three states had home birth rates above 1.9%, including Montana (2.6%), Oregon (1.96%), and Vermont (1.91%). Five states had home birth rates above 1.5%, including Idaho, Pennsylvania, Utah, Washington, and Wisconsin.⁴ Because planned home births may require transport to the hospital to complete the birth, all obstetric units should develop written plans for dealing with these high-risk patients.

Hospital transfer is common for women attempting a home birth
Many home birth experts regard the Netherlands as the country with the best organized and most successful home birth system that is fully integrated with hospital-based obstetric care. Approximately 23% of births in Holland occur at home supervised by a midwife. A key feature of the highly regulated Dutch system is that all pregnant women with a high-risk condition are required to give birth in a hospital and cannot have a home delivery. Consequently, only women with a low-risk pregnancy are permitted to attempt a home birth.

By contrast, in the United States, with a less well-regulated home birth system, women with high-risk conditions, such as one or more prior cesarean deliveries, may try to birth at home. In a Dutch study of 168,618 low-risk women attempting a home birth, 32% (N=53,809) were transferred to the hospital. Most of the transfers occurred during labor.⁵

In England about 2.8% of births occur at home. In a study of 16,840 planned home births in England, 21% (N=3,530) of the women were transferred to the hospital.⁶ Of the 3,530 transfers to the hospital, 70% were transferred before delivery and 30% after birth. In this study among 4,568 nulliparous women attempting home birth, 45% were transferred to the hospital. Among 12,272 multiparous women attempting home birth, 12% were transferred to the hospital.

Among the nulliparous women, but not among the multiparous women, there was a significantly increased risk of adverse newborn outcomes. Adverse newborn outcome was a composite measure that included perinatal death, stillbirth after the onset of labor, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, or fractured humerus or clavicle. The risk of an adverse newborn outcome among nulliparous women was 0.9% for those delivering at home and 0.5% for those delivering at the hospital.⁶

Your patient asks you, “Are home births safe for the baby?”
No large-scale randomized trials have compared home birth versus hospital birth.¹ Consequently, the best evidence evaluating the risks and benefits of home birth is based on observational studies of large cohorts. Recent studies from the United States have reported that neonatal complications, including the risk of a low Apgar score and neonatal seizures, is significantly increased with planned home birth compared with birth at a hospital.^2,3 In one study, the risk of a 5-minute Apgar score of zero was 1 in 615 home births and 1 in 6,493 hospital births.³ Studies from the Netherlands also have reported that planned home birth is associated with increased perinatal mortality and morbidity.^4,5
Because planned home birth is associated with an increased risk of neonatal morbidity and mortality, some experts conclude that obstetricians have an ethical obligation to recommend against home birth and to respond to refusal of that recommendation with respectful persuasion.⁶

References
1. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012; (9):CD000352.
2. Grunebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209(4):323.e1–e6.
3. Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209(4).325.e1–e8.
4. Evers AC, Brouwers HA, Hukkelhoven CW, et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: Prospective cohort study. BMJ. 2010;341:c5639.
5. Arabin B, Visser GHA. Comparison of obstetric care in Germany and in the Netherlands. J Health Med Informat. 2013;S11:014.
6. Chervenak FA, McCullough LB, Arabin B. Obstetric ethics: An essential dimension of planned home birth. Obstet Gynecol. 2011;117(5):1183–1187.

Interprofessional team care
For the woman planning a home birth, transfer from home to the hospital is a jarring experience. The woman may feel that she has not achieved a highly desired and important life goal. In a survey of women birthing in the Netherlands, transfer from home to the hospital was associated with a high rate of patient dissatisfaction with their birthing experience. Compared with women who were satisfied with their birth experience, women who were dissatisfied more often reported that the care providers at the hospital were rushed, insensitive, rude, inconsiderate, condescending, and unhelpful.⁷

Creating a positive birthing experience
Given that transfer to the hospital is associated with an increased rate of being dissatisfied with the birth experience, and that dissatisfied women may perceive their care providers negatively, it is important for the interprofessional hospital team to devote adequate time to listen the patient’s concerns, demonstrate a high degree of sensitivity, and be especially polite and helpful. It is probably best to avoid referring to the transfer as a “failed home birth.” Trust may be enhanced by asking open-ended questions about the patient’s expectations and expressing empathy for her situation. The hospital professional team might prioritize acknowledging the right of the woman to make informed choices and provide an overview of the standard procedures used at the hospital. The clinicians should explicitly state that the health of the mother and newborn are their top priority. The hospital team should also express confidence in the benefit of the standard practices they use to ensure a safe birth experience.

Successful negotiation: An art best achieved as a small group
When a laboring woman is transferred from home to the hospital, a negotiation begins with the hospital professionals about the best clinical path to a successful birth. The patient often arrives with a support team that includes her partner, a support person, and a midwife or trained birth attendant. These individuals often demonstrate strong group cohesion and may be skeptical of the benefits of hospital birthing practices including intravenous access, oxytocin administration, epidural anesthesia, and operative delivery. The goal for the patient and her support team and the hospital professionals is to achieve a safe birth for the baby and mother. Because the goal is aligned among all parties, the negotiation is focused on the clinical path that will best achieve the goal with minimal risks.

To enhance the likelihood of a successful negotiation, it is best if the team of hospital professionals, including an obstetrician, a senior nurse, and an obstetric anesthesiologist, jointly discuss hospital birthing practices with the patient and her support team. An obstetrician, negotiating independently, is in the difficult position of one professional trying to redirect the choices of a cohesive team of four individuals. Most experienced negotiators would not voluntarily enter a situation in which acting alone they needed to simultaneously negotiate with four people. A joint discussion between the interprofessional team and the patient reduces the opportunity for the patient and her team to generate disagreements among the hospital professionals.

An important issue is that the home midwife or trained birth attendant is not permitted to participate in the practice of medicine at the hospital. Only credentialed and licensed nurses, obstetricians, anesthesiologists, and pediatricians are permitted to participate in the practice of medicine at the hospital. It may be prudent to provide the home midwife a written statement from the hospital indicating that home midwives are not permitted to practice medicine at the institution.

Related article: Lay midwives and the ObGyn: Is collaboration risky? Lucia DiVenere, MA (Practice Management; May 2012)

Occasionally, negotiations between the hospital professional team and the patient and her support team are unsuccessful and the patient refuses the best advice of the hospital team. In these situations there should be a written plan of how the patient–clinician conflict will be communicated to other members of the hospital staff and hospital leadership. For example, another senior clinician may be asked to join in the planning process.

A high-risk patient population
In some cases of planned home birth, the patient and midwife have made management decisions that are inconsistent with standard obstetric protocols. Commonly encountered situations include 1) conservative home management of spontaneous rupture of the membranes at term, 2) prolonged conservative management of the arrest of the active phase of the first stage of labor, 3) prolonged second stage of labor, up to 24 hours in length, and 4) attempted home birth after multiple previous cesarean deliveries. I am also aware of multiple reports of attempted home birth of a fetus in the breech presentation.

On arrival to the hospital these patients and their newborns are at exceptionally high risk for adverse birth outcomes. If an adverse outcome were to occur, it would be unjust to assign sole or primary responsibility to the obstetrician for the adverse outcome. Hence, the hospital should have a written plan for helping to minimize the risk that the obstetrician, playing the role of Good Samaritan, will bear primary responsibility for an adverse outcome.

Related article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations. Robert L. Barbieri, MD (Editorial; August 2013)

CASE: Resolved
In the case presented above, the obstetrician, nurse, and obstetric anesthesiologist successfully negotiated with the patient. Intravenous access and an epidural anesthetic were established. Antibiotics were administered. Using ultrasound, the obstetrician confirmed that the fetus was in the occiput posterior position. The mother was exhausted from many hours of pushing and agreed to an operative delivery. Forceps were used to deliver a healthy baby and a perineal laceration was repaired.

CASE: Febrile laboring mother transferred to hospital
You are in the hospital managing the induction of labor for one of your nulliparous patients who is postterm. You are hoping for a quiet and uneventful shift.

At midnight the nursing administrator pages you and asks if you would please provide care to a pregnant woman attempting a home birth who is in labor and is being transferred to your hospital.

The woman is a 41-year-old G2P1 with one prior cesarean delivery who has attempted a trial of labor at home. According to the nursing administrator the patient has a temperature of 100.4°F and the most recent cervical examination shows her to be fully dilated at +3/5 station in an occiput posterior position. She has been fully dilated for 5 hours. The fetal heart rate, assessed by Doppler monitor, is reported to be reassuring.

What is your clinical plan?

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that pregnant women should deliver at certified birth centers or hospital-based obstetric units to optimize clinical outcomes for newborns and mothers.^1,2 Both organizations also recognize a woman’s right to exercise her autonomy and choose a planned home birth.

In 2012, approximately 0.8% of pregnant women in the United States planned a home birth (31,500 home births and 3,999,386 total births).³ In 2009, three states had home birth rates above 1.9%, including Montana (2.6%), Oregon (1.96%), and Vermont (1.91%). Five states had home birth rates above 1.5%, including Idaho, Pennsylvania, Utah, Washington, and Wisconsin.⁴ Because planned home births may require transport to the hospital to complete the birth, all obstetric units should develop written plans for dealing with these high-risk patients.

Hospital transfer is common for women attempting a home birth
Many home birth experts regard the Netherlands as the country with the best organized and most successful home birth system that is fully integrated with hospital-based obstetric care. Approximately 23% of births in Holland occur at home supervised by a midwife. A key feature of the highly regulated Dutch system is that all pregnant women with a high-risk condition are required to give birth in a hospital and cannot have a home delivery. Consequently, only women with a low-risk pregnancy are permitted to attempt a home birth.

By contrast, in the United States, with a less well-regulated home birth system, women with high-risk conditions, such as one or more prior cesarean deliveries, may try to birth at home. In a Dutch study of 168,618 low-risk women attempting a home birth, 32% (N=53,809) were transferred to the hospital. Most of the transfers occurred during labor.⁵

In England about 2.8% of births occur at home. In a study of 16,840 planned home births in England, 21% (N=3,530) of the women were transferred to the hospital.⁶ Of the 3,530 transfers to the hospital, 70% were transferred before delivery and 30% after birth. In this study among 4,568 nulliparous women attempting home birth, 45% were transferred to the hospital. Among 12,272 multiparous women attempting home birth, 12% were transferred to the hospital.

Among the nulliparous women, but not among the multiparous women, there was a significantly increased risk of adverse newborn outcomes. Adverse newborn outcome was a composite measure that included perinatal death, stillbirth after the onset of labor, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, or fractured humerus or clavicle. The risk of an adverse newborn outcome among nulliparous women was 0.9% for those delivering at home and 0.5% for those delivering at the hospital.⁶

Your patient asks you, “Are home births safe for the baby?”
No large-scale randomized trials have compared home birth versus hospital birth.¹ Consequently, the best evidence evaluating the risks and benefits of home birth is based on observational studies of large cohorts. Recent studies from the United States have reported that neonatal complications, including the risk of a low Apgar score and neonatal seizures, is significantly increased with planned home birth compared with birth at a hospital.^2,3 In one study, the risk of a 5-minute Apgar score of zero was 1 in 615 home births and 1 in 6,493 hospital births.³ Studies from the Netherlands also have reported that planned home birth is associated with increased perinatal mortality and morbidity.^4,5
Because planned home birth is associated with an increased risk of neonatal morbidity and mortality, some experts conclude that obstetricians have an ethical obligation to recommend against home birth and to respond to refusal of that recommendation with respectful persuasion.⁶

References
1. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012; (9):CD000352.
2. Grunebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209(4):323.e1–e6.
3. Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209(4).325.e1–e8.
4. Evers AC, Brouwers HA, Hukkelhoven CW, et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: Prospective cohort study. BMJ. 2010;341:c5639.
5. Arabin B, Visser GHA. Comparison of obstetric care in Germany and in the Netherlands. J Health Med Informat. 2013;S11:014.
6. Chervenak FA, McCullough LB, Arabin B. Obstetric ethics: An essential dimension of planned home birth. Obstet Gynecol. 2011;117(5):1183–1187.

Interprofessional team care
For the woman planning a home birth, transfer from home to the hospital is a jarring experience. The woman may feel that she has not achieved a highly desired and important life goal. In a survey of women birthing in the Netherlands, transfer from home to the hospital was associated with a high rate of patient dissatisfaction with their birthing experience. Compared with women who were satisfied with their birth experience, women who were dissatisfied more often reported that the care providers at the hospital were rushed, insensitive, rude, inconsiderate, condescending, and unhelpful.⁷

Creating a positive birthing experience
Given that transfer to the hospital is associated with an increased rate of being dissatisfied with the birth experience, and that dissatisfied women may perceive their care providers negatively, it is important for the interprofessional hospital team to devote adequate time to listen the patient’s concerns, demonstrate a high degree of sensitivity, and be especially polite and helpful. It is probably best to avoid referring to the transfer as a “failed home birth.” Trust may be enhanced by asking open-ended questions about the patient’s expectations and expressing empathy for her situation. The hospital professional team might prioritize acknowledging the right of the woman to make informed choices and provide an overview of the standard procedures used at the hospital. The clinicians should explicitly state that the health of the mother and newborn are their top priority. The hospital team should also express confidence in the benefit of the standard practices they use to ensure a safe birth experience.

Successful negotiation: An art best achieved as a small group
When a laboring woman is transferred from home to the hospital, a negotiation begins with the hospital professionals about the best clinical path to a successful birth. The patient often arrives with a support team that includes her partner, a support person, and a midwife or trained birth attendant. These individuals often demonstrate strong group cohesion and may be skeptical of the benefits of hospital birthing practices including intravenous access, oxytocin administration, epidural anesthesia, and operative delivery. The goal for the patient and her support team and the hospital professionals is to achieve a safe birth for the baby and mother. Because the goal is aligned among all parties, the negotiation is focused on the clinical path that will best achieve the goal with minimal risks.

To enhance the likelihood of a successful negotiation, it is best if the team of hospital professionals, including an obstetrician, a senior nurse, and an obstetric anesthesiologist, jointly discuss hospital birthing practices with the patient and her support team. An obstetrician, negotiating independently, is in the difficult position of one professional trying to redirect the choices of a cohesive team of four individuals. Most experienced negotiators would not voluntarily enter a situation in which acting alone they needed to simultaneously negotiate with four people. A joint discussion between the interprofessional team and the patient reduces the opportunity for the patient and her team to generate disagreements among the hospital professionals.

An important issue is that the home midwife or trained birth attendant is not permitted to participate in the practice of medicine at the hospital. Only credentialed and licensed nurses, obstetricians, anesthesiologists, and pediatricians are permitted to participate in the practice of medicine at the hospital. It may be prudent to provide the home midwife a written statement from the hospital indicating that home midwives are not permitted to practice medicine at the institution.

Related article: Lay midwives and the ObGyn: Is collaboration risky? Lucia DiVenere, MA (Practice Management; May 2012)

Occasionally, negotiations between the hospital professional team and the patient and her support team are unsuccessful and the patient refuses the best advice of the hospital team. In these situations there should be a written plan of how the patient–clinician conflict will be communicated to other members of the hospital staff and hospital leadership. For example, another senior clinician may be asked to join in the planning process.

A high-risk patient population
In some cases of planned home birth, the patient and midwife have made management decisions that are inconsistent with standard obstetric protocols. Commonly encountered situations include 1) conservative home management of spontaneous rupture of the membranes at term, 2) prolonged conservative management of the arrest of the active phase of the first stage of labor, 3) prolonged second stage of labor, up to 24 hours in length, and 4) attempted home birth after multiple previous cesarean deliveries. I am also aware of multiple reports of attempted home birth of a fetus in the breech presentation.

On arrival to the hospital these patients and their newborns are at exceptionally high risk for adverse birth outcomes. If an adverse outcome were to occur, it would be unjust to assign sole or primary responsibility to the obstetrician for the adverse outcome. Hence, the hospital should have a written plan for helping to minimize the risk that the obstetrician, playing the role of Good Samaritan, will bear primary responsibility for an adverse outcome.

Related article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations. Robert L. Barbieri, MD (Editorial; August 2013)

CASE: Resolved
In the case presented above, the obstetrician, nurse, and obstetric anesthesiologist successfully negotiated with the patient. Intravenous access and an epidural anesthetic were established. Antibiotics were administered. Using ultrasound, the obstetrician confirmed that the fetus was in the occiput posterior position. The mother was exhausted from many hours of pushing and agreed to an operative delivery. Forceps were used to deliver a healthy baby and a perineal laceration was repaired.

CASE: Febrile laboring mother transferred to hospital
You are in the hospital managing the induction of labor for one of your nulliparous patients who is postterm. You are hoping for a quiet and uneventful shift.

At midnight the nursing administrator pages you and asks if you would please provide care to a pregnant woman attempting a home birth who is in labor and is being transferred to your hospital.

The woman is a 41-year-old G2P1 with one prior cesarean delivery who has attempted a trial of labor at home. According to the nursing administrator the patient has a temperature of 100.4°F and the most recent cervical examination shows her to be fully dilated at +3/5 station in an occiput posterior position. She has been fully dilated for 5 hours. The fetal heart rate, assessed by Doppler monitor, is reported to be reassuring.

What is your clinical plan?

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that pregnant women should deliver at certified birth centers or hospital-based obstetric units to optimize clinical outcomes for newborns and mothers.^1,2 Both organizations also recognize a woman’s right to exercise her autonomy and choose a planned home birth.

In 2012, approximately 0.8% of pregnant women in the United States planned a home birth (31,500 home births and 3,999,386 total births).³ In 2009, three states had home birth rates above 1.9%, including Montana (2.6%), Oregon (1.96%), and Vermont (1.91%). Five states had home birth rates above 1.5%, including Idaho, Pennsylvania, Utah, Washington, and Wisconsin.⁴ Because planned home births may require transport to the hospital to complete the birth, all obstetric units should develop written plans for dealing with these high-risk patients.

Hospital transfer is common for women attempting a home birth
Many home birth experts regard the Netherlands as the country with the best organized and most successful home birth system that is fully integrated with hospital-based obstetric care. Approximately 23% of births in Holland occur at home supervised by a midwife. A key feature of the highly regulated Dutch system is that all pregnant women with a high-risk condition are required to give birth in a hospital and cannot have a home delivery. Consequently, only women with a low-risk pregnancy are permitted to attempt a home birth.

By contrast, in the United States, with a less well-regulated home birth system, women with high-risk conditions, such as one or more prior cesarean deliveries, may try to birth at home. In a Dutch study of 168,618 low-risk women attempting a home birth, 32% (N=53,809) were transferred to the hospital. Most of the transfers occurred during labor.⁵

In England about 2.8% of births occur at home. In a study of 16,840 planned home births in England, 21% (N=3,530) of the women were transferred to the hospital.⁶ Of the 3,530 transfers to the hospital, 70% were transferred before delivery and 30% after birth. In this study among 4,568 nulliparous women attempting home birth, 45% were transferred to the hospital. Among 12,272 multiparous women attempting home birth, 12% were transferred to the hospital.

Among the nulliparous women, but not among the multiparous women, there was a significantly increased risk of adverse newborn outcomes. Adverse newborn outcome was a composite measure that included perinatal death, stillbirth after the onset of labor, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, or fractured humerus or clavicle. The risk of an adverse newborn outcome among nulliparous women was 0.9% for those delivering at home and 0.5% for those delivering at the hospital.⁶

Your patient asks you, “Are home births safe for the baby?”
No large-scale randomized trials have compared home birth versus hospital birth.¹ Consequently, the best evidence evaluating the risks and benefits of home birth is based on observational studies of large cohorts. Recent studies from the United States have reported that neonatal complications, including the risk of a low Apgar score and neonatal seizures, is significantly increased with planned home birth compared with birth at a hospital.^2,3 In one study, the risk of a 5-minute Apgar score of zero was 1 in 615 home births and 1 in 6,493 hospital births.³ Studies from the Netherlands also have reported that planned home birth is associated with increased perinatal mortality and morbidity.^4,5
Because planned home birth is associated with an increased risk of neonatal morbidity and mortality, some experts conclude that obstetricians have an ethical obligation to recommend against home birth and to respond to refusal of that recommendation with respectful persuasion.⁶

References
1. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012; (9):CD000352.
2. Grunebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209(4):323.e1–e6.
3. Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209(4).325.e1–e8.
4. Evers AC, Brouwers HA, Hukkelhoven CW, et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: Prospective cohort study. BMJ. 2010;341:c5639.
5. Arabin B, Visser GHA. Comparison of obstetric care in Germany and in the Netherlands. J Health Med Informat. 2013;S11:014.
6. Chervenak FA, McCullough LB, Arabin B. Obstetric ethics: An essential dimension of planned home birth. Obstet Gynecol. 2011;117(5):1183–1187.

Interprofessional team care
For the woman planning a home birth, transfer from home to the hospital is a jarring experience. The woman may feel that she has not achieved a highly desired and important life goal. In a survey of women birthing in the Netherlands, transfer from home to the hospital was associated with a high rate of patient dissatisfaction with their birthing experience. Compared with women who were satisfied with their birth experience, women who were dissatisfied more often reported that the care providers at the hospital were rushed, insensitive, rude, inconsiderate, condescending, and unhelpful.⁷

Creating a positive birthing experience
Given that transfer to the hospital is associated with an increased rate of being dissatisfied with the birth experience, and that dissatisfied women may perceive their care providers negatively, it is important for the interprofessional hospital team to devote adequate time to listen the patient’s concerns, demonstrate a high degree of sensitivity, and be especially polite and helpful. It is probably best to avoid referring to the transfer as a “failed home birth.” Trust may be enhanced by asking open-ended questions about the patient’s expectations and expressing empathy for her situation. The hospital professional team might prioritize acknowledging the right of the woman to make informed choices and provide an overview of the standard procedures used at the hospital. The clinicians should explicitly state that the health of the mother and newborn are their top priority. The hospital team should also express confidence in the benefit of the standard practices they use to ensure a safe birth experience.

Successful negotiation: An art best achieved as a small group
When a laboring woman is transferred from home to the hospital, a negotiation begins with the hospital professionals about the best clinical path to a successful birth. The patient often arrives with a support team that includes her partner, a support person, and a midwife or trained birth attendant. These individuals often demonstrate strong group cohesion and may be skeptical of the benefits of hospital birthing practices including intravenous access, oxytocin administration, epidural anesthesia, and operative delivery. The goal for the patient and her support team and the hospital professionals is to achieve a safe birth for the baby and mother. Because the goal is aligned among all parties, the negotiation is focused on the clinical path that will best achieve the goal with minimal risks.

To enhance the likelihood of a successful negotiation, it is best if the team of hospital professionals, including an obstetrician, a senior nurse, and an obstetric anesthesiologist, jointly discuss hospital birthing practices with the patient and her support team. An obstetrician, negotiating independently, is in the difficult position of one professional trying to redirect the choices of a cohesive team of four individuals. Most experienced negotiators would not voluntarily enter a situation in which acting alone they needed to simultaneously negotiate with four people. A joint discussion between the interprofessional team and the patient reduces the opportunity for the patient and her team to generate disagreements among the hospital professionals.

An important issue is that the home midwife or trained birth attendant is not permitted to participate in the practice of medicine at the hospital. Only credentialed and licensed nurses, obstetricians, anesthesiologists, and pediatricians are permitted to participate in the practice of medicine at the hospital. It may be prudent to provide the home midwife a written statement from the hospital indicating that home midwives are not permitted to practice medicine at the institution.

Related article: Lay midwives and the ObGyn: Is collaboration risky? Lucia DiVenere, MA (Practice Management; May 2012)

Occasionally, negotiations between the hospital professional team and the patient and her support team are unsuccessful and the patient refuses the best advice of the hospital team. In these situations there should be a written plan of how the patient–clinician conflict will be communicated to other members of the hospital staff and hospital leadership. For example, another senior clinician may be asked to join in the planning process.

A high-risk patient population
In some cases of planned home birth, the patient and midwife have made management decisions that are inconsistent with standard obstetric protocols. Commonly encountered situations include 1) conservative home management of spontaneous rupture of the membranes at term, 2) prolonged conservative management of the arrest of the active phase of the first stage of labor, 3) prolonged second stage of labor, up to 24 hours in length, and 4) attempted home birth after multiple previous cesarean deliveries. I am also aware of multiple reports of attempted home birth of a fetus in the breech presentation.

On arrival to the hospital these patients and their newborns are at exceptionally high risk for adverse birth outcomes. If an adverse outcome were to occur, it would be unjust to assign sole or primary responsibility to the obstetrician for the adverse outcome. Hence, the hospital should have a written plan for helping to minimize the risk that the obstetrician, playing the role of Good Samaritan, will bear primary responsibility for an adverse outcome.

Related article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations. Robert L. Barbieri, MD (Editorial; August 2013)

CASE: Resolved
In the case presented above, the obstetrician, nurse, and obstetric anesthesiologist successfully negotiated with the patient. Intravenous access and an epidural anesthetic were established. Antibiotics were administered. Using ultrasound, the obstetrician confirmed that the fetus was in the occiput posterior position. The mother was exhausted from many hours of pushing and agreed to an operative delivery. Forceps were used to deliver a healthy baby and a perineal laceration was repaired.

We are mindful of our role in providing our readers with quality research- and literature-based articles about emerging therapies and diagnostic and palliative approaches that will have a positive impact on how they practice. So far this year, we have brought you articles on current therapies for metastatic melanoma and hairy cell leukemia as well as updates on managing chronic myelogenous leukemia, the late effects of cancer therapies, and most recently, small renal tumors...

Click on the PDF icon at the top of this introduction to read the full article.

We are mindful of our role in providing our readers with quality research- and literature-based articles about emerging therapies and diagnostic and palliative approaches that will have a positive impact on how they practice. So far this year, we have brought you articles on current therapies for metastatic melanoma and hairy cell leukemia as well as updates on managing chronic myelogenous leukemia, the late effects of cancer therapies, and most recently, small renal tumors...

Click on the PDF icon at the top of this introduction to read the full article.

We are mindful of our role in providing our readers with quality research- and literature-based articles about emerging therapies and diagnostic and palliative approaches that will have a positive impact on how they practice. So far this year, we have brought you articles on current therapies for metastatic melanoma and hairy cell leukemia as well as updates on managing chronic myelogenous leukemia, the late effects of cancer therapies, and most recently, small renal tumors...

Click on the PDF icon at the top of this introduction to read the full article.

I explained to them that schizophrenia is a neurodevelopmental syndrome that comprises hundreds of different disorders of genetic or non-genetic etiology, all of which share a similar psychotic phenotype. Although the various genetic causes of schizophre­nia are difficult to prevent—but may be prevented in the future with epi­genetic techniques—the many non-genetic (environmental) pathways to schizophrenia can be avoided to significantly reduce the incidence of schizophrenia by 40% to 50%, accord­ing to some estimates.

I will share what I told this couple, because even couples without any family history of psychosis may have a child who develops schizophrenia because of a variety of environmental risk factors.

Genetic risk factors
One-half of the 20,000 genes in the 23 chromosomes of the human genome participate in constructing and sculpt­ing the extremely intricate and com­plex human brain. There are many ways that genetic factors can increase the risk of schizophrenia,¹ and only some are transmitted by parents:

Risk genes. More than 30 risk genes have been identified as heritable in schizophrenia. They are spread over many chromosomes and more are likely to be discovered. Most of those risk genes regulate glutamate— not dopamine—pathways, and each increases the risk by 2% to 4%.

Copy number variations (CNVs) are pro­duced via meiosis mishaps, where 1 or 3 alleles of certain genes are formed instead of the usual 2. A high frequency of CNVs have been found in schizophrenia com­pared with the general population—but also are found in autism and bipolar disorders—and are believed to disrupt brain development in various ways.

De novo mutations. Recent studies on large samples of people with schizo­phrenia (50,000 to 100,000) uncovered a much higher rate of mutations (some code for proteins while others are non­sense mutations that code for noth­ing). Obviously, these mutations led to anomalous neurodevelopment.

There are hundreds, maybe thou­sands, of genetic subtypes within the schizophrenia syndrome. Advances in epigenetics, which allow silencing of culprit genes or overexpression of protective genes, one day may enable psychiatric geneticists to prevent schizo­phrenia in fetuses at risk.

Non-genetic risk factors
Just as with the genetic patho-genic heterogeneity, the schizo­phrenia syndrome can be caused by numerous environmental adverse events,² many of which can be avoided, including:

Older paternal age (>45) at time of conception doubles or triples the risk of schizophrenia³ as well as autism and bipolar disorder. Aging sperm are associated with a higher rate of DNA fragmentation and genetic mutations.

Prenatal complications, especially during the second trimester when CNS development takes place. These adverse prenatal events skew fetal brain development to produce psy­chosis in adulthood and can be mini­mized with optimal prenatal care, which sadly is lacking among the poor. These include:
   • Vaginal infections before preg­nancy,⁴ such as herpes simplex virus, can cause fetal brain inflammation and increased risk of schizophrenia.
   • Infections during pregnancy— whether bacterial, viral, or proto­zoan (Toxoplasma gondii)—have been shown to significantly increase the risk of schizophrenia in offspring.⁵ An increase in serum C-reactive protein during pregnancy also is a biomarker of increased risk.
   • Poor diet, especially starva­tion, can double or triple the risk of schizophrenia.
   • Vitamin deficiency, especially folate and vitamin D, are critical for normal brain development.⁶ Vitamin D is vital to mitigate neuroinflammation.
   • Smoking before and during pregnancy.⁴
   • Medical illness during preg­nancy, especially gestational diabetes, increases the risk of schizophrenia in the fetus by 800%.⁷
   • Severe stress during pregnancy, such as the death of the spouse, dou­bles the risk of schizophrenia.²
   • Schizophrenia risk is 400% to 500% higher among those born and raised in an urban area, compared with a rural area.⁸
   • Babies born in northern latitudes, such as in Sweden, Norway, or Canada, have a 10-fold risk of schizophrenia in adulthood compared with babies born near the equator.⁶ This has been attrib­uted to lack of sunshine and the risk of severe vitamin D deficiency in north­ern latitudes.
   • High maternal body mass index during the first trimester⁷ increases the child’s risk of schizophrenia.
   • Low number of prenatal vis­its is associated with higher risk of schizophrenia.
   • Obstetric complications that cause hypoxia and a low Apgar score after birth increase the risk of schizophrenia. This includes long labor, cord around the neck, meco­nium spillage into the amniotic fluid, and mechanical injury with forceps delivery.
   • Infection in the newborn shortly after birth.

Severe physical or sexual abuse before age 5 is associated with increased risk of schizophrenia in adulthood.² This may be because of stress-induced epigenetic mechanisms (silencing or overexpressing certain genes).

Migration has been shown to increase the risk of schizophrenia by 3 to 5 fold. The exact reason is unclear, but it could be a combination of social stress, exposure to new types of germs, less sunshine, and even a different diet.

My advice to the couple? Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids); take ade­quate doses of folate and vitamin D, per­haps even choline⁹; avoid smoking before and during pregnancy; adopt a healthy, balanced diet; avoid excessive weight gain and/or gestational diabetes; avoid contact with people with infections; avoid expo­sure to cat feces (toxoplasmosis); sched­ule frequent prenatal visits; and hope for a smooth and uneventful delivery and a newborn with an Apgar score of 9 or 10. All this will greatly reduce the non-genetic risks of schizophrenia, but is unlikely to modify the genetic risks. However, it has been shown that a combination of both genetic and non-genetic risk factors is associated with a more severe form of schizophrenia.¹⁰

Optimal prenatal and postnatal care can be helpful for couples with a family history of schizophrenia (without mov­ing to deliver their baby in a rural village near the equator). However, if their child starts using marijuana during adolescence, all bets are off. The risk of schizophrenia and serious cortical tissue loss increases dramatically when a carrier of risk genes use Cannabis. But that’s another editorial, to be read by clinicians in states where marijuana has been (foolishly, I believe) legalized.

I explained to them that schizophrenia is a neurodevelopmental syndrome that comprises hundreds of different disorders of genetic or non-genetic etiology, all of which share a similar psychotic phenotype. Although the various genetic causes of schizophre­nia are difficult to prevent—but may be prevented in the future with epi­genetic techniques—the many non-genetic (environmental) pathways to schizophrenia can be avoided to significantly reduce the incidence of schizophrenia by 40% to 50%, accord­ing to some estimates.

I will share what I told this couple, because even couples without any family history of psychosis may have a child who develops schizophrenia because of a variety of environmental risk factors.

Genetic risk factors
One-half of the 20,000 genes in the 23 chromosomes of the human genome participate in constructing and sculpt­ing the extremely intricate and com­plex human brain. There are many ways that genetic factors can increase the risk of schizophrenia,¹ and only some are transmitted by parents:

Risk genes. More than 30 risk genes have been identified as heritable in schizophrenia. They are spread over many chromosomes and more are likely to be discovered. Most of those risk genes regulate glutamate— not dopamine—pathways, and each increases the risk by 2% to 4%.

Copy number variations (CNVs) are pro­duced via meiosis mishaps, where 1 or 3 alleles of certain genes are formed instead of the usual 2. A high frequency of CNVs have been found in schizophrenia com­pared with the general population—but also are found in autism and bipolar disorders—and are believed to disrupt brain development in various ways.

De novo mutations. Recent studies on large samples of people with schizo­phrenia (50,000 to 100,000) uncovered a much higher rate of mutations (some code for proteins while others are non­sense mutations that code for noth­ing). Obviously, these mutations led to anomalous neurodevelopment.

There are hundreds, maybe thou­sands, of genetic subtypes within the schizophrenia syndrome. Advances in epigenetics, which allow silencing of culprit genes or overexpression of protective genes, one day may enable psychiatric geneticists to prevent schizo­phrenia in fetuses at risk.

Non-genetic risk factors
Just as with the genetic patho-genic heterogeneity, the schizo­phrenia syndrome can be caused by numerous environmental adverse events,² many of which can be avoided, including:

Older paternal age (>45) at time of conception doubles or triples the risk of schizophrenia³ as well as autism and bipolar disorder. Aging sperm are associated with a higher rate of DNA fragmentation and genetic mutations.

Prenatal complications, especially during the second trimester when CNS development takes place. These adverse prenatal events skew fetal brain development to produce psy­chosis in adulthood and can be mini­mized with optimal prenatal care, which sadly is lacking among the poor. These include:
   • Vaginal infections before preg­nancy,⁴ such as herpes simplex virus, can cause fetal brain inflammation and increased risk of schizophrenia.
   • Infections during pregnancy— whether bacterial, viral, or proto­zoan (Toxoplasma gondii)—have been shown to significantly increase the risk of schizophrenia in offspring.⁵ An increase in serum C-reactive protein during pregnancy also is a biomarker of increased risk.
   • Poor diet, especially starva­tion, can double or triple the risk of schizophrenia.
   • Vitamin deficiency, especially folate and vitamin D, are critical for normal brain development.⁶ Vitamin D is vital to mitigate neuroinflammation.
   • Smoking before and during pregnancy.⁴
   • Medical illness during preg­nancy, especially gestational diabetes, increases the risk of schizophrenia in the fetus by 800%.⁷
   • Severe stress during pregnancy, such as the death of the spouse, dou­bles the risk of schizophrenia.²
   • Schizophrenia risk is 400% to 500% higher among those born and raised in an urban area, compared with a rural area.⁸
   • Babies born in northern latitudes, such as in Sweden, Norway, or Canada, have a 10-fold risk of schizophrenia in adulthood compared with babies born near the equator.⁶ This has been attrib­uted to lack of sunshine and the risk of severe vitamin D deficiency in north­ern latitudes.
   • High maternal body mass index during the first trimester⁷ increases the child’s risk of schizophrenia.
   • Low number of prenatal vis­its is associated with higher risk of schizophrenia.
   • Obstetric complications that cause hypoxia and a low Apgar score after birth increase the risk of schizophrenia. This includes long labor, cord around the neck, meco­nium spillage into the amniotic fluid, and mechanical injury with forceps delivery.
   • Infection in the newborn shortly after birth.

Severe physical or sexual abuse before age 5 is associated with increased risk of schizophrenia in adulthood.² This may be because of stress-induced epigenetic mechanisms (silencing or overexpressing certain genes).

Migration has been shown to increase the risk of schizophrenia by 3 to 5 fold. The exact reason is unclear, but it could be a combination of social stress, exposure to new types of germs, less sunshine, and even a different diet.

My advice to the couple? Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids); take ade­quate doses of folate and vitamin D, per­haps even choline⁹; avoid smoking before and during pregnancy; adopt a healthy, balanced diet; avoid excessive weight gain and/or gestational diabetes; avoid contact with people with infections; avoid expo­sure to cat feces (toxoplasmosis); sched­ule frequent prenatal visits; and hope for a smooth and uneventful delivery and a newborn with an Apgar score of 9 or 10. All this will greatly reduce the non-genetic risks of schizophrenia, but is unlikely to modify the genetic risks. However, it has been shown that a combination of both genetic and non-genetic risk factors is associated with a more severe form of schizophrenia.¹⁰

Optimal prenatal and postnatal care can be helpful for couples with a family history of schizophrenia (without mov­ing to deliver their baby in a rural village near the equator). However, if their child starts using marijuana during adolescence, all bets are off. The risk of schizophrenia and serious cortical tissue loss increases dramatically when a carrier of risk genes use Cannabis. But that’s another editorial, to be read by clinicians in states where marijuana has been (foolishly, I believe) legalized.

I explained to them that schizophrenia is a neurodevelopmental syndrome that comprises hundreds of different disorders of genetic or non-genetic etiology, all of which share a similar psychotic phenotype. Although the various genetic causes of schizophre­nia are difficult to prevent—but may be prevented in the future with epi­genetic techniques—the many non-genetic (environmental) pathways to schizophrenia can be avoided to significantly reduce the incidence of schizophrenia by 40% to 50%, accord­ing to some estimates.

I will share what I told this couple, because even couples without any family history of psychosis may have a child who develops schizophrenia because of a variety of environmental risk factors.

Genetic risk factors
One-half of the 20,000 genes in the 23 chromosomes of the human genome participate in constructing and sculpt­ing the extremely intricate and com­plex human brain. There are many ways that genetic factors can increase the risk of schizophrenia,¹ and only some are transmitted by parents:

Risk genes. More than 30 risk genes have been identified as heritable in schizophrenia. They are spread over many chromosomes and more are likely to be discovered. Most of those risk genes regulate glutamate— not dopamine—pathways, and each increases the risk by 2% to 4%.

Copy number variations (CNVs) are pro­duced via meiosis mishaps, where 1 or 3 alleles of certain genes are formed instead of the usual 2. A high frequency of CNVs have been found in schizophrenia com­pared with the general population—but also are found in autism and bipolar disorders—and are believed to disrupt brain development in various ways.

De novo mutations. Recent studies on large samples of people with schizo­phrenia (50,000 to 100,000) uncovered a much higher rate of mutations (some code for proteins while others are non­sense mutations that code for noth­ing). Obviously, these mutations led to anomalous neurodevelopment.

There are hundreds, maybe thou­sands, of genetic subtypes within the schizophrenia syndrome. Advances in epigenetics, which allow silencing of culprit genes or overexpression of protective genes, one day may enable psychiatric geneticists to prevent schizo­phrenia in fetuses at risk.

Non-genetic risk factors
Just as with the genetic patho-genic heterogeneity, the schizo­phrenia syndrome can be caused by numerous environmental adverse events,² many of which can be avoided, including:

Older paternal age (>45) at time of conception doubles or triples the risk of schizophrenia³ as well as autism and bipolar disorder. Aging sperm are associated with a higher rate of DNA fragmentation and genetic mutations.

Prenatal complications, especially during the second trimester when CNS development takes place. These adverse prenatal events skew fetal brain development to produce psy­chosis in adulthood and can be mini­mized with optimal prenatal care, which sadly is lacking among the poor. These include:
   • Vaginal infections before preg­nancy,⁴ such as herpes simplex virus, can cause fetal brain inflammation and increased risk of schizophrenia.
   • Infections during pregnancy— whether bacterial, viral, or proto­zoan (Toxoplasma gondii)—have been shown to significantly increase the risk of schizophrenia in offspring.⁵ An increase in serum C-reactive protein during pregnancy also is a biomarker of increased risk.
   • Poor diet, especially starva­tion, can double or triple the risk of schizophrenia.
   • Vitamin deficiency, especially folate and vitamin D, are critical for normal brain development.⁶ Vitamin D is vital to mitigate neuroinflammation.
   • Smoking before and during pregnancy.⁴
   • Medical illness during preg­nancy, especially gestational diabetes, increases the risk of schizophrenia in the fetus by 800%.⁷
   • Severe stress during pregnancy, such as the death of the spouse, dou­bles the risk of schizophrenia.²
   • Schizophrenia risk is 400% to 500% higher among those born and raised in an urban area, compared with a rural area.⁸
   • Babies born in northern latitudes, such as in Sweden, Norway, or Canada, have a 10-fold risk of schizophrenia in adulthood compared with babies born near the equator.⁶ This has been attrib­uted to lack of sunshine and the risk of severe vitamin D deficiency in north­ern latitudes.
   • High maternal body mass index during the first trimester⁷ increases the child’s risk of schizophrenia.
   • Low number of prenatal vis­its is associated with higher risk of schizophrenia.
   • Obstetric complications that cause hypoxia and a low Apgar score after birth increase the risk of schizophrenia. This includes long labor, cord around the neck, meco­nium spillage into the amniotic fluid, and mechanical injury with forceps delivery.
   • Infection in the newborn shortly after birth.

Severe physical or sexual abuse before age 5 is associated with increased risk of schizophrenia in adulthood.² This may be because of stress-induced epigenetic mechanisms (silencing or overexpressing certain genes).

Migration has been shown to increase the risk of schizophrenia by 3 to 5 fold. The exact reason is unclear, but it could be a combination of social stress, exposure to new types of germs, less sunshine, and even a different diet.

My advice to the couple? Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids); take ade­quate doses of folate and vitamin D, per­haps even choline⁹; avoid smoking before and during pregnancy; adopt a healthy, balanced diet; avoid excessive weight gain and/or gestational diabetes; avoid contact with people with infections; avoid expo­sure to cat feces (toxoplasmosis); sched­ule frequent prenatal visits; and hope for a smooth and uneventful delivery and a newborn with an Apgar score of 9 or 10. All this will greatly reduce the non-genetic risks of schizophrenia, but is unlikely to modify the genetic risks. However, it has been shown that a combination of both genetic and non-genetic risk factors is associated with a more severe form of schizophrenia.¹⁰

Optimal prenatal and postnatal care can be helpful for couples with a family history of schizophrenia (without mov­ing to deliver their baby in a rural village near the equator). However, if their child starts using marijuana during adolescence, all bets are off. The risk of schizophrenia and serious cortical tissue loss increases dramatically when a carrier of risk genes use Cannabis. But that’s another editorial, to be read by clinicians in states where marijuana has been (foolishly, I believe) legalized.

Estrogen therapy is highly effective in the treatment of hot flashes among postmenopausal women. For postmenopausal women with a uterus, estrogen treatment for hot flashes is almost always combined with a progestin to reduce the risk of endometrial polyps, hyperplasia, and cancer. For instance, in the Postmenopausal Estrogen/Progestin Interventions Trial, 62% of the women with a uterus treated with conjugated equine estrogen (CEE) 0.625 mg daily without a progestin developed endometrial hyperplasia.¹

In the United States, the most commonly prescribed progestin for hormone therapy has been medroxyprogesterone acetate (MPA; Provera). However, data from the Women’s Health Initiative (WHI) trials indicate that MPA, when combined with CEE, may have adverse health effects among postmenopausal women.

Let’s examine the WHI data
Among women 50 to 59 years of age with a uterus, the combination of CEE plus MPA was associated with a trend toward an increased risk of breast cancer, coronary heart disease, and myocardial infarction.² In contrast, among women 50 to 59 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of invasive breast cancer, coronary heart disease, and myocardial infarction (TABLE 1).

Among women 50 to 79 years of age with a uterus, the combination of CEE plus MPA was associated with a significantly increased risk of breast cancer (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.01–1.53; P = .04).² In contrast, among women 50 to 79 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of breast cancer (HR, 0.79; 95% CI, 0.61–1.02, P = .07).²

Related article: In the latest report from the WHI, the data contradict the conclusions. Holly Thacker, MD (Commentary; March 2014)

When the analysis was limited to women consistently adherent to their CEE monotherapy, the estrogen treatment significantly decreased the risk of invasive breast cancer (HR, 0.67; 95% CI, 0.47–0.97; P = .03).³

The addition of MPA to CEE appears to reverse some of the health benefits of CEE monotherapy, although the biological mechanisms are unclear. This observation should prompt us to explore alternative and novel treatments of vasomotor symptoms that do not utilize MPA. Some options for MPA-free hormone therapy include:

• transdermal estradiol plus micronized progesterone
• CEE plus a levonorgestrel-releasing intrauterine system
• bazedoxifene plus CEE.

In addition, nonhormonal treatment of hot flashes is an option, with selective serotonin reuptake inhibitors (SSRIs).

Related article: Is one oral estrogen formulation safer than another for menopausal women? Andrew M. Kaunitz, MD (Examining the Evidence; January 2014)

MPA-free hormone therapy for hot flashes
Estrogen plus micronized progesterone
When using an estrogen plus progestin regimen to treat hot flashes, many experts favor a combination of low-dose transdermal estradiol and oral micronized progesterone (Prometrium). This combination is believed by some experts to result in a lower risk of venous thromboembolism, stroke, cardiovascular disease, and breast cancer than an estrogen-MPA combination.^4–7

When prescribing transdermal estradiol plus oral micronized progesterone for a woman within 1 to 2 years of her last menses, a cyclic regimen can help reduce episodes of irregular, unscheduled uterine bleeding. I often use this cyclic regimen: transdermal estradiol 0.0375 mg plus cyclic oral micronized progesterone 200 mg prior to bedtime for calendar days 1 to 12.

When using transdermal estradiol plus oral micronized progesterone in a woman more than 2 years from her last menses, a continuous regimen is often prescribed. I often use this continuous regimen: transdermal estradiol 0.0375 mg plus continuous oral micronized progesterone 100 mg daily prior to bedtime.

Related article: When should a menopausal woman discontinue hormone therapy? Andrew M. Kaunitz, MD (Cases in Menopause; February 2014)

Estrogen plus a levonorgestrel-releasing intrauterine systemThe levonorgestrel intrauterine system (LNG-IUS; 20 µg daily; Mirena) is frequently used in Europe to protect the endometrium against the adverse effects of estrogen therapy in postmenopausal women. In a meta-analysis of five clinical trials involving postmenopausal women, the LNG-IUS provided excellent protection against endometrial hyperplasia, compared with MPA.8

One caution about using the LNG-IUS system with estrogen in postmenopausal women is that an observational study of all women with breast cancer in Finland from 1995 through 2007 reported a significantly increased risk of breast cancer among postmenopausal women using an LNG-IUS compared with women who did not use hormones or used only estrogen because they had a hysterectomy (TABLE 2).⁹ This study was not a randomized clinical trial and patients at higher baseline risk for breast cancer, including women with a high body mass index, may have been preferentially treated with an LNG-IUS. More information is needed to better understand the relationship between the LNG-IUS and breast cancer in postmenopausal women.

Paroxetine can block the metabolism of tamoxifen to its highly potent metabolite, endoxifen. Consequently, paroxetine may reduce the effectiveness of tamoxifen treatment for breast cancer and should be used with caution in postmenopausal women with breast cancer being treated with tamoxifen.

Related article: Paroxetine mesylate 7.5 mg found to be a safe alternative to hormone therapy for menopausal women with hot flashes. (News for your Practice; June 2014)

Escitalopram
Gynecologists are familiar with the use of venlafaxine, desvenlafaxine, clonidine, citalopram, sertraline, and fluoxetine for the treatment of postmenopausal hot flashes. Recently, escitalopram (Lexapro) at doses of 10 to 20 mg daily has been shown to be more effective than placebo in the treatment of hot flashes and sleep disturbances in postmenopausal women.^23,24 In one trial of escitalopram 10 to 20 mg daily versus placebo in 205 postmenopausal women averaging 9.8 hot flashes daily at baseline, escitalopram and placebo reduced mean daily hot flashes by 4.6 and 3.2, respectively (P<.001), after 8 weeks of treatment.

In a meta-analysis of SSRIs for the treatment of hot flashes, data from a mixed-treatment comparison analysis indicated that the rank order from most to least effective therapy for hot flashes was: escitalopram > paroxetine > sertraline > citalopram > fluoxetine.²⁵ Venlafaxine and desvenlafaxine, two serotonin and  norepinephrine reuptake inhibitors that are effective in the treatment of hot flashes, were not included in the mixed-treatment comparison.

Use of alternatives to MPA could mean fewer health risks for women on a wide scale
Substantial data indicate that MPA is not an optimal progestin to combine with estrogen for hormone therapy. Currently, many health insurance plans and Medicare use pharmacy management formularies that prioritize dispensing MPA for postmenopausal hormone therapy. Dispensing an alternative to MPA, such as micronized progesterone, often requires the patient to make a significant copayment.

Hopefully, health insurance companies, Medicare, and their affiliated pharmacy management administrators will soon stop their current policy of using financial incentives to favor dispensing MPA when hormone therapy is prescribed because alternatives to MPA appear to be associated with fewer health risks for postmenopausal women.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: rbarbieri@frontlinemedcom.com 

Estrogen therapy is highly effective in the treatment of hot flashes among postmenopausal women. For postmenopausal women with a uterus, estrogen treatment for hot flashes is almost always combined with a progestin to reduce the risk of endometrial polyps, hyperplasia, and cancer. For instance, in the Postmenopausal Estrogen/Progestin Interventions Trial, 62% of the women with a uterus treated with conjugated equine estrogen (CEE) 0.625 mg daily without a progestin developed endometrial hyperplasia.¹

In the United States, the most commonly prescribed progestin for hormone therapy has been medroxyprogesterone acetate (MPA; Provera). However, data from the Women’s Health Initiative (WHI) trials indicate that MPA, when combined with CEE, may have adverse health effects among postmenopausal women.

Let’s examine the WHI data
Among women 50 to 59 years of age with a uterus, the combination of CEE plus MPA was associated with a trend toward an increased risk of breast cancer, coronary heart disease, and myocardial infarction.² In contrast, among women 50 to 59 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of invasive breast cancer, coronary heart disease, and myocardial infarction (TABLE 1).

Among women 50 to 79 years of age with a uterus, the combination of CEE plus MPA was associated with a significantly increased risk of breast cancer (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.01–1.53; P = .04).² In contrast, among women 50 to 79 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of breast cancer (HR, 0.79; 95% CI, 0.61–1.02, P = .07).²

Related article: In the latest report from the WHI, the data contradict the conclusions. Holly Thacker, MD (Commentary; March 2014)

When the analysis was limited to women consistently adherent to their CEE monotherapy, the estrogen treatment significantly decreased the risk of invasive breast cancer (HR, 0.67; 95% CI, 0.47–0.97; P = .03).³

The addition of MPA to CEE appears to reverse some of the health benefits of CEE monotherapy, although the biological mechanisms are unclear. This observation should prompt us to explore alternative and novel treatments of vasomotor symptoms that do not utilize MPA. Some options for MPA-free hormone therapy include:

• transdermal estradiol plus micronized progesterone
• CEE plus a levonorgestrel-releasing intrauterine system
• bazedoxifene plus CEE.

In addition, nonhormonal treatment of hot flashes is an option, with selective serotonin reuptake inhibitors (SSRIs).

Related article: Is one oral estrogen formulation safer than another for menopausal women? Andrew M. Kaunitz, MD (Examining the Evidence; January 2014)

MPA-free hormone therapy for hot flashes
Estrogen plus micronized progesterone
When using an estrogen plus progestin regimen to treat hot flashes, many experts favor a combination of low-dose transdermal estradiol and oral micronized progesterone (Prometrium). This combination is believed by some experts to result in a lower risk of venous thromboembolism, stroke, cardiovascular disease, and breast cancer than an estrogen-MPA combination.^4–7

When prescribing transdermal estradiol plus oral micronized progesterone for a woman within 1 to 2 years of her last menses, a cyclic regimen can help reduce episodes of irregular, unscheduled uterine bleeding. I often use this cyclic regimen: transdermal estradiol 0.0375 mg plus cyclic oral micronized progesterone 200 mg prior to bedtime for calendar days 1 to 12.

When using transdermal estradiol plus oral micronized progesterone in a woman more than 2 years from her last menses, a continuous regimen is often prescribed. I often use this continuous regimen: transdermal estradiol 0.0375 mg plus continuous oral micronized progesterone 100 mg daily prior to bedtime.

Related article: When should a menopausal woman discontinue hormone therapy? Andrew M. Kaunitz, MD (Cases in Menopause; February 2014)

Estrogen plus a levonorgestrel-releasing intrauterine systemThe levonorgestrel intrauterine system (LNG-IUS; 20 µg daily; Mirena) is frequently used in Europe to protect the endometrium against the adverse effects of estrogen therapy in postmenopausal women. In a meta-analysis of five clinical trials involving postmenopausal women, the LNG-IUS provided excellent protection against endometrial hyperplasia, compared with MPA.8

One caution about using the LNG-IUS system with estrogen in postmenopausal women is that an observational study of all women with breast cancer in Finland from 1995 through 2007 reported a significantly increased risk of breast cancer among postmenopausal women using an LNG-IUS compared with women who did not use hormones or used only estrogen because they had a hysterectomy (TABLE 2).⁹ This study was not a randomized clinical trial and patients at higher baseline risk for breast cancer, including women with a high body mass index, may have been preferentially treated with an LNG-IUS. More information is needed to better understand the relationship between the LNG-IUS and breast cancer in postmenopausal women.

Paroxetine can block the metabolism of tamoxifen to its highly potent metabolite, endoxifen. Consequently, paroxetine may reduce the effectiveness of tamoxifen treatment for breast cancer and should be used with caution in postmenopausal women with breast cancer being treated with tamoxifen.

Related article: Paroxetine mesylate 7.5 mg found to be a safe alternative to hormone therapy for menopausal women with hot flashes. (News for your Practice; June 2014)

Escitalopram
Gynecologists are familiar with the use of venlafaxine, desvenlafaxine, clonidine, citalopram, sertraline, and fluoxetine for the treatment of postmenopausal hot flashes. Recently, escitalopram (Lexapro) at doses of 10 to 20 mg daily has been shown to be more effective than placebo in the treatment of hot flashes and sleep disturbances in postmenopausal women.^23,24 In one trial of escitalopram 10 to 20 mg daily versus placebo in 205 postmenopausal women averaging 9.8 hot flashes daily at baseline, escitalopram and placebo reduced mean daily hot flashes by 4.6 and 3.2, respectively (P<.001), after 8 weeks of treatment.

In a meta-analysis of SSRIs for the treatment of hot flashes, data from a mixed-treatment comparison analysis indicated that the rank order from most to least effective therapy for hot flashes was: escitalopram > paroxetine > sertraline > citalopram > fluoxetine.²⁵ Venlafaxine and desvenlafaxine, two serotonin and  norepinephrine reuptake inhibitors that are effective in the treatment of hot flashes, were not included in the mixed-treatment comparison.

Use of alternatives to MPA could mean fewer health risks for women on a wide scale
Substantial data indicate that MPA is not an optimal progestin to combine with estrogen for hormone therapy. Currently, many health insurance plans and Medicare use pharmacy management formularies that prioritize dispensing MPA for postmenopausal hormone therapy. Dispensing an alternative to MPA, such as micronized progesterone, often requires the patient to make a significant copayment.

Hopefully, health insurance companies, Medicare, and their affiliated pharmacy management administrators will soon stop their current policy of using financial incentives to favor dispensing MPA when hormone therapy is prescribed because alternatives to MPA appear to be associated with fewer health risks for postmenopausal women.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: rbarbieri@frontlinemedcom.com 

Estrogen therapy is highly effective in the treatment of hot flashes among postmenopausal women. For postmenopausal women with a uterus, estrogen treatment for hot flashes is almost always combined with a progestin to reduce the risk of endometrial polyps, hyperplasia, and cancer. For instance, in the Postmenopausal Estrogen/Progestin Interventions Trial, 62% of the women with a uterus treated with conjugated equine estrogen (CEE) 0.625 mg daily without a progestin developed endometrial hyperplasia.¹

In the United States, the most commonly prescribed progestin for hormone therapy has been medroxyprogesterone acetate (MPA; Provera). However, data from the Women’s Health Initiative (WHI) trials indicate that MPA, when combined with CEE, may have adverse health effects among postmenopausal women.

Let’s examine the WHI data
Among women 50 to 59 years of age with a uterus, the combination of CEE plus MPA was associated with a trend toward an increased risk of breast cancer, coronary heart disease, and myocardial infarction.² In contrast, among women 50 to 59 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of invasive breast cancer, coronary heart disease, and myocardial infarction (TABLE 1).

Among women 50 to 79 years of age with a uterus, the combination of CEE plus MPA was associated with a significantly increased risk of breast cancer (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.01–1.53; P = .04).² In contrast, among women 50 to 79 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of breast cancer (HR, 0.79; 95% CI, 0.61–1.02, P = .07).²

Related article: In the latest report from the WHI, the data contradict the conclusions. Holly Thacker, MD (Commentary; March 2014)

When the analysis was limited to women consistently adherent to their CEE monotherapy, the estrogen treatment significantly decreased the risk of invasive breast cancer (HR, 0.67; 95% CI, 0.47–0.97; P = .03).³

The addition of MPA to CEE appears to reverse some of the health benefits of CEE monotherapy, although the biological mechanisms are unclear. This observation should prompt us to explore alternative and novel treatments of vasomotor symptoms that do not utilize MPA. Some options for MPA-free hormone therapy include:

• transdermal estradiol plus micronized progesterone
• CEE plus a levonorgestrel-releasing intrauterine system
• bazedoxifene plus CEE.

In addition, nonhormonal treatment of hot flashes is an option, with selective serotonin reuptake inhibitors (SSRIs).

Related article: Is one oral estrogen formulation safer than another for menopausal women? Andrew M. Kaunitz, MD (Examining the Evidence; January 2014)

MPA-free hormone therapy for hot flashes
Estrogen plus micronized progesterone
When using an estrogen plus progestin regimen to treat hot flashes, many experts favor a combination of low-dose transdermal estradiol and oral micronized progesterone (Prometrium). This combination is believed by some experts to result in a lower risk of venous thromboembolism, stroke, cardiovascular disease, and breast cancer than an estrogen-MPA combination.^4–7

When prescribing transdermal estradiol plus oral micronized progesterone for a woman within 1 to 2 years of her last menses, a cyclic regimen can help reduce episodes of irregular, unscheduled uterine bleeding. I often use this cyclic regimen: transdermal estradiol 0.0375 mg plus cyclic oral micronized progesterone 200 mg prior to bedtime for calendar days 1 to 12.

When using transdermal estradiol plus oral micronized progesterone in a woman more than 2 years from her last menses, a continuous regimen is often prescribed. I often use this continuous regimen: transdermal estradiol 0.0375 mg plus continuous oral micronized progesterone 100 mg daily prior to bedtime.

Related article: When should a menopausal woman discontinue hormone therapy? Andrew M. Kaunitz, MD (Cases in Menopause; February 2014)

Estrogen plus a levonorgestrel-releasing intrauterine systemThe levonorgestrel intrauterine system (LNG-IUS; 20 µg daily; Mirena) is frequently used in Europe to protect the endometrium against the adverse effects of estrogen therapy in postmenopausal women. In a meta-analysis of five clinical trials involving postmenopausal women, the LNG-IUS provided excellent protection against endometrial hyperplasia, compared with MPA.8

One caution about using the LNG-IUS system with estrogen in postmenopausal women is that an observational study of all women with breast cancer in Finland from 1995 through 2007 reported a significantly increased risk of breast cancer among postmenopausal women using an LNG-IUS compared with women who did not use hormones or used only estrogen because they had a hysterectomy (TABLE 2).⁹ This study was not a randomized clinical trial and patients at higher baseline risk for breast cancer, including women with a high body mass index, may have been preferentially treated with an LNG-IUS. More information is needed to better understand the relationship between the LNG-IUS and breast cancer in postmenopausal women.

Paroxetine can block the metabolism of tamoxifen to its highly potent metabolite, endoxifen. Consequently, paroxetine may reduce the effectiveness of tamoxifen treatment for breast cancer and should be used with caution in postmenopausal women with breast cancer being treated with tamoxifen.

Related article: Paroxetine mesylate 7.5 mg found to be a safe alternative to hormone therapy for menopausal women with hot flashes. (News for your Practice; June 2014)

Escitalopram
Gynecologists are familiar with the use of venlafaxine, desvenlafaxine, clonidine, citalopram, sertraline, and fluoxetine for the treatment of postmenopausal hot flashes. Recently, escitalopram (Lexapro) at doses of 10 to 20 mg daily has been shown to be more effective than placebo in the treatment of hot flashes and sleep disturbances in postmenopausal women.^23,24 In one trial of escitalopram 10 to 20 mg daily versus placebo in 205 postmenopausal women averaging 9.8 hot flashes daily at baseline, escitalopram and placebo reduced mean daily hot flashes by 4.6 and 3.2, respectively (P<.001), after 8 weeks of treatment.

In a meta-analysis of SSRIs for the treatment of hot flashes, data from a mixed-treatment comparison analysis indicated that the rank order from most to least effective therapy for hot flashes was: escitalopram > paroxetine > sertraline > citalopram > fluoxetine.²⁵ Venlafaxine and desvenlafaxine, two serotonin and  norepinephrine reuptake inhibitors that are effective in the treatment of hot flashes, were not included in the mixed-treatment comparison.

Use of alternatives to MPA could mean fewer health risks for women on a wide scale
Substantial data indicate that MPA is not an optimal progestin to combine with estrogen for hormone therapy. Currently, many health insurance plans and Medicare use pharmacy management formularies that prioritize dispensing MPA for postmenopausal hormone therapy. Dispensing an alternative to MPA, such as micronized progesterone, often requires the patient to make a significant copayment.

Hopefully, health insurance companies, Medicare, and their affiliated pharmacy management administrators will soon stop their current policy of using financial incentives to favor dispensing MPA when hormone therapy is prescribed because alternatives to MPA appear to be associated with fewer health risks for postmenopausal women.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: rbarbieri@frontlinemedcom.com 

It’s likely that you have just returned from ASCO 2014 in Chicago with 33,000 of your closest oncology friends, or that you have at least heard all about the meeting and some of the exciting presentations. Either way, you must be wondering how best to sift through the mountain of data and information that came out of the meeting so that you can organize it, absorb it, and here’s the real challenge, apply it in the real-clinic setting going forward.
 

Click on the PDF icon at the top of this introduction to read the full article.

It’s likely that you have just returned from ASCO 2014 in Chicago with 33,000 of your closest oncology friends, or that you have at least heard all about the meeting and some of the exciting presentations. Either way, you must be wondering how best to sift through the mountain of data and information that came out of the meeting so that you can organize it, absorb it, and here’s the real challenge, apply it in the real-clinic setting going forward.
 

Click on the PDF icon at the top of this introduction to read the full article.

It’s likely that you have just returned from ASCO 2014 in Chicago with 33,000 of your closest oncology friends, or that you have at least heard all about the meeting and some of the exciting presentations. Either way, you must be wondering how best to sift through the mountain of data and information that came out of the meeting so that you can organize it, absorb it, and here’s the real challenge, apply it in the real-clinic setting going forward.
 

Click on the PDF icon at the top of this introduction to read the full article.

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

I might have a jaundiced view of prog­ress but, across most medical special­ties, diseases are still managed, not cured. Chronicity is almost ubiquitous among medical ailments, and no specialty can boast that it restores function com­pletely and fully restores patients’ qual­ity of life.

Psychiatry has had its share of missteps
Prefrontal lobotomy is perhaps the most infamous of many discredited treatments that were introduced as a great solution to severe brain disor­ders such as schizophrenia.¹ Prefrontal lobotomy (leucotomy) was initially heralded as a major medical advance in 1935; its originator, neurosurgeon António Egas Moniz, shared the Nobel Prize in Medicine or Physiology in 1949 for what is now regarded as may­hem. Prefrontal lobotomy was widely used for many conditions—not just for psychosis—but it fell from favor rapidly after the discovery of anti-psychotic drugs.

A similar fate befell other treatments that were introduced to psychiatry:
   • malaria therapy (1917) for gen­eral paresis of the insane (the condi­tion was later recognized as tertiary syphilis)
   • deep sleep therapy (1920) for schizophrenia
   • insulin shock therapy (1933), also for schizophrenia.

Those discredited therapies were lauded as significant advances, only to be shunned later as harmful, even barbaric.

Treating addiction is another saga of false steps. Fifty-nine different treat­ments for addiction have been intro­duced over the past few decades, many later discredited as “psychoquackery.”² In the breathless rush to cure desperate conditions, there often is the risk that pseudoscience will masquerade as sci­ence. Many patients suffer needlessly before the medical community exam­ines the accumulated evidence and dis­credits useless or harmful treatments.

Psychiatry isn’t alone in lacking cures
A fitting slogan of many non-psychiatric medical specialties is “to treat, perchance to cure.” Consider some examples:
   • In cardiology, congestive heart fail­ure, a chronic illness, is managed but rarely cured, and leads to early mortality.
   • Nephrologists struggle to maintain a semblance of kidney function in renal failure patients, before placing them on the long waiting list for a kidney transplant.
   • Gastroenterologists can only hope to maintain liver function in severe hep­atitis, or to alleviate the misery of ulcer­ative colitis.
   • Rheumatologists do what they can to relieve the debilitating symptoms of rheumatoid arthritis, systemic lupus erythematosus, and Sjögren’s syndrome.
   • Pulmonologists know they can never restore normal lung function for their patients with chronic obstructive pulmonary disease; they can only help them hang on with partial function.
   • Oncologists valiantly fight aggres­sive cancers with the hope of prolonging life for a few months or years.
   • Neurologists valiantly try to manage multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, epilepsy, stroke, myasthenia gravis, and amyotrophic lat­eral sclerosis—often with limited, if any, success at achieving remission.

Internal medicine has had its share of discredited therapies, too—ones that were withdrawn because they caused harm or were of dubious or inconclu­sive efficacy.³ Thanks to careful analy­sis of the efficacy and safety of medical procedures introduced during the past decade, we know that 40% of 146 pro­cedures examined were eventually dis­credited and withdrawn. (That kind of analysis should be undertaken in psychotherapy, where evidence-based therapies can be counted on one hand but dozens more are promoted as legiti­mate.⁴ Psychotherapy can be harmful.⁵)

As with patients in psychiatry, patients of all these specialties are at risk of suffering disruptive iatrogenic side effects that, at times, approach torture—just to have progression of disease halted but not necessarily to deliver full remission. The quality of life for patients who have a chronic disease ranges from barely tolerable to poor, but is rarely good or optimal—and that is the case across all of medicine, includ­ing psychiatry.

Desperation often drives dubious innovation
There are numerous “desperate” dis­eases across all medical specialties, including psychiatry. Radical and harm­ful measures are sometimes proposed and marketed to treat many of those conditions; more often, useless, ineffec­tive, futile “treatments” are introduced, and it might take years before they are discredited and withdrawn.^6,7 Useless treatments can be harmful, too, because they delay the use of potentially effective procedures.

Move forward with caution!
What does this brief look at the missteps of medicine tell us? First, medical prog­ress is like the mambo: We take steps forward but then step backward again; and, as Karl Popper noted, science learns more from its failures than from its suc­cesses.⁸ Second, all physicians must be judicious and guided by evidence when they select treatments.

For your patients’ sake, choose wisely!⁹

I might have a jaundiced view of prog­ress but, across most medical special­ties, diseases are still managed, not cured. Chronicity is almost ubiquitous among medical ailments, and no specialty can boast that it restores function com­pletely and fully restores patients’ qual­ity of life.

Psychiatry has had its share of missteps
Prefrontal lobotomy is perhaps the most infamous of many discredited treatments that were introduced as a great solution to severe brain disor­ders such as schizophrenia.¹ Prefrontal lobotomy (leucotomy) was initially heralded as a major medical advance in 1935; its originator, neurosurgeon António Egas Moniz, shared the Nobel Prize in Medicine or Physiology in 1949 for what is now regarded as may­hem. Prefrontal lobotomy was widely used for many conditions—not just for psychosis—but it fell from favor rapidly after the discovery of anti-psychotic drugs.

A similar fate befell other treatments that were introduced to psychiatry:
   • malaria therapy (1917) for gen­eral paresis of the insane (the condi­tion was later recognized as tertiary syphilis)
   • deep sleep therapy (1920) for schizophrenia
   • insulin shock therapy (1933), also for schizophrenia.

Those discredited therapies were lauded as significant advances, only to be shunned later as harmful, even barbaric.

Treating addiction is another saga of false steps. Fifty-nine different treat­ments for addiction have been intro­duced over the past few decades, many later discredited as “psychoquackery.”² In the breathless rush to cure desperate conditions, there often is the risk that pseudoscience will masquerade as sci­ence. Many patients suffer needlessly before the medical community exam­ines the accumulated evidence and dis­credits useless or harmful treatments.

Psychiatry isn’t alone in lacking cures
A fitting slogan of many non-psychiatric medical specialties is “to treat, perchance to cure.” Consider some examples:
   • In cardiology, congestive heart fail­ure, a chronic illness, is managed but rarely cured, and leads to early mortality.
   • Nephrologists struggle to maintain a semblance of kidney function in renal failure patients, before placing them on the long waiting list for a kidney transplant.
   • Gastroenterologists can only hope to maintain liver function in severe hep­atitis, or to alleviate the misery of ulcer­ative colitis.
   • Rheumatologists do what they can to relieve the debilitating symptoms of rheumatoid arthritis, systemic lupus erythematosus, and Sjögren’s syndrome.
   • Pulmonologists know they can never restore normal lung function for their patients with chronic obstructive pulmonary disease; they can only help them hang on with partial function.
   • Oncologists valiantly fight aggres­sive cancers with the hope of prolonging life for a few months or years.
   • Neurologists valiantly try to manage multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, epilepsy, stroke, myasthenia gravis, and amyotrophic lat­eral sclerosis—often with limited, if any, success at achieving remission.

Internal medicine has had its share of discredited therapies, too—ones that were withdrawn because they caused harm or were of dubious or inconclu­sive efficacy.³ Thanks to careful analy­sis of the efficacy and safety of medical procedures introduced during the past decade, we know that 40% of 146 pro­cedures examined were eventually dis­credited and withdrawn. (That kind of analysis should be undertaken in psychotherapy, where evidence-based therapies can be counted on one hand but dozens more are promoted as legiti­mate.⁴ Psychotherapy can be harmful.⁵)

As with patients in psychiatry, patients of all these specialties are at risk of suffering disruptive iatrogenic side effects that, at times, approach torture—just to have progression of disease halted but not necessarily to deliver full remission. The quality of life for patients who have a chronic disease ranges from barely tolerable to poor, but is rarely good or optimal—and that is the case across all of medicine, includ­ing psychiatry.

Desperation often drives dubious innovation
There are numerous “desperate” dis­eases across all medical specialties, including psychiatry. Radical and harm­ful measures are sometimes proposed and marketed to treat many of those conditions; more often, useless, ineffec­tive, futile “treatments” are introduced, and it might take years before they are discredited and withdrawn.^6,7 Useless treatments can be harmful, too, because they delay the use of potentially effective procedures.

Move forward with caution!
What does this brief look at the missteps of medicine tell us? First, medical prog­ress is like the mambo: We take steps forward but then step backward again; and, as Karl Popper noted, science learns more from its failures than from its suc­cesses.⁸ Second, all physicians must be judicious and guided by evidence when they select treatments.

For your patients’ sake, choose wisely!⁹

I might have a jaundiced view of prog­ress but, across most medical special­ties, diseases are still managed, not cured. Chronicity is almost ubiquitous among medical ailments, and no specialty can boast that it restores function com­pletely and fully restores patients’ qual­ity of life.

Psychiatry has had its share of missteps
Prefrontal lobotomy is perhaps the most infamous of many discredited treatments that were introduced as a great solution to severe brain disor­ders such as schizophrenia.¹ Prefrontal lobotomy (leucotomy) was initially heralded as a major medical advance in 1935; its originator, neurosurgeon António Egas Moniz, shared the Nobel Prize in Medicine or Physiology in 1949 for what is now regarded as may­hem. Prefrontal lobotomy was widely used for many conditions—not just for psychosis—but it fell from favor rapidly after the discovery of anti-psychotic drugs.

A similar fate befell other treatments that were introduced to psychiatry:
   • malaria therapy (1917) for gen­eral paresis of the insane (the condi­tion was later recognized as tertiary syphilis)
   • deep sleep therapy (1920) for schizophrenia
   • insulin shock therapy (1933), also for schizophrenia.

Those discredited therapies were lauded as significant advances, only to be shunned later as harmful, even barbaric.

Treating addiction is another saga of false steps. Fifty-nine different treat­ments for addiction have been intro­duced over the past few decades, many later discredited as “psychoquackery.”² In the breathless rush to cure desperate conditions, there often is the risk that pseudoscience will masquerade as sci­ence. Many patients suffer needlessly before the medical community exam­ines the accumulated evidence and dis­credits useless or harmful treatments.

Psychiatry isn’t alone in lacking cures
A fitting slogan of many non-psychiatric medical specialties is “to treat, perchance to cure.” Consider some examples:
   • In cardiology, congestive heart fail­ure, a chronic illness, is managed but rarely cured, and leads to early mortality.
   • Nephrologists struggle to maintain a semblance of kidney function in renal failure patients, before placing them on the long waiting list for a kidney transplant.
   • Gastroenterologists can only hope to maintain liver function in severe hep­atitis, or to alleviate the misery of ulcer­ative colitis.
   • Rheumatologists do what they can to relieve the debilitating symptoms of rheumatoid arthritis, systemic lupus erythematosus, and Sjögren’s syndrome.
   • Pulmonologists know they can never restore normal lung function for their patients with chronic obstructive pulmonary disease; they can only help them hang on with partial function.
   • Oncologists valiantly fight aggres­sive cancers with the hope of prolonging life for a few months or years.
   • Neurologists valiantly try to manage multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, epilepsy, stroke, myasthenia gravis, and amyotrophic lat­eral sclerosis—often with limited, if any, success at achieving remission.

Internal medicine has had its share of discredited therapies, too—ones that were withdrawn because they caused harm or were of dubious or inconclu­sive efficacy.³ Thanks to careful analy­sis of the efficacy and safety of medical procedures introduced during the past decade, we know that 40% of 146 pro­cedures examined were eventually dis­credited and withdrawn. (That kind of analysis should be undertaken in psychotherapy, where evidence-based therapies can be counted on one hand but dozens more are promoted as legiti­mate.⁴ Psychotherapy can be harmful.⁵)

As with patients in psychiatry, patients of all these specialties are at risk of suffering disruptive iatrogenic side effects that, at times, approach torture—just to have progression of disease halted but not necessarily to deliver full remission. The quality of life for patients who have a chronic disease ranges from barely tolerable to poor, but is rarely good or optimal—and that is the case across all of medicine, includ­ing psychiatry.

Desperation often drives dubious innovation
There are numerous “desperate” dis­eases across all medical specialties, including psychiatry. Radical and harm­ful measures are sometimes proposed and marketed to treat many of those conditions; more often, useless, ineffec­tive, futile “treatments” are introduced, and it might take years before they are discredited and withdrawn.^6,7 Useless treatments can be harmful, too, because they delay the use of potentially effective procedures.

Move forward with caution!
What does this brief look at the missteps of medicine tell us? First, medical prog­ress is like the mambo: We take steps forward but then step backward again; and, as Karl Popper noted, science learns more from its failures than from its suc­cesses.⁸ Second, all physicians must be judicious and guided by evidence when they select treatments.

For your patients’ sake, choose wisely!⁹