Commentary

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

The American Congress of Obstetricians and Gynecologists held its State Legislative Roundtable in late October in Arlington, Va., with ob.gyns. and their lobbyists from 46 states. This is the largest number of states ever represented at the roundtable event, and it reflects the increased participation and engagement in policy making by women’s health care providers.

Dr. Bohon is an ob.gyn. in private practice in Washington. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

The American Congress of Obstetricians and Gynecologists held its State Legislative Roundtable in late October in Arlington, Va., with ob.gyns. and their lobbyists from 46 states. This is the largest number of states ever represented at the roundtable event, and it reflects the increased participation and engagement in policy making by women’s health care providers.

Dr. Bohon is an ob.gyn. in private practice in Washington. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

The American Congress of Obstetricians and Gynecologists held its State Legislative Roundtable in late October in Arlington, Va., with ob.gyns. and their lobbyists from 46 states. This is the largest number of states ever represented at the roundtable event, and it reflects the increased participation and engagement in policy making by women’s health care providers.

Dr. Bohon is an ob.gyn. in private practice in Washington. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?

Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. The interaction between a child and his or her mother can provide the child critical emotional support.

BananaStock/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at pdnews@frontlinemedcom.com.

How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?

Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. The interaction between a child and his or her mother can provide the child critical emotional support.

BananaStock/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at pdnews@frontlinemedcom.com.

How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?

Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. The interaction between a child and his or her mother can provide the child critical emotional support.

BananaStock/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at pdnews@frontlinemedcom.com.

The new book by Ravi Chandra, MD, is a concise introduction to Buddhism, and a forceful exposition on the power and danger of social networking – deftly interwoven with a moving account of the author’s personal life and professional growth as well as his arduous quest for identity.

Social networking has exploded into a major global industry within the last decade, rapidly penetrating and dominating all aspects of our personal and social lives. Instead of promoting social interactions and connections, the lure of instant intimacy often proves illusory. For far too many, the virtual world deepens their sense of isolation and loneliness, fosters jealousy and narcissism, engenders a profound sense of insecurity, and leads to anxiety, depression, and much worse.

By juxtaposing the Buddha with social networking in the book title, Dr. Chandra expresses his hope and faith that Buddhism could serve as an effective tool for harnessing the force unleashed by these powerful new technologies, helping us to put the genie of our invention back into the bottle. Over the millenia, Buddhism has guided societies and individuals to overcome (“transcend”) crises and adversities, and could play a crucial role in negotiating these still largely uncharted territories.

Despite the popularity of terms such as Zen, meditation, transcendence, and mindfulness, Buddhism remains mysterious and exotic to most modern readers, and is laden with misconceptions and prejudices. This is regrettable, since Buddhism is the most clinically relevant of all major philosophical traditions, and its tenets are most compatible with modern neuroscience. The term philosophical is used here because, at its core, Buddhism represents an uncompromisingly rational approach to dealing with the “human condition.” Siddhartha Gautama (Buddha), its founder, admonished against speculating on questions that are “unanswerables,” such as eternity, existence after death, and the origin and ending of the universe. Instead, Siddhartha focused on identifying life’s vicissitudes (Dukkha, “bumpy rides in life,” commonly translated as “suffering”), clarifying forces responsible for these problems, delineating the ultimate goal, and specifying methods for achieving the goal (the “Four Noble Truths”). He then provided systematic paths for solving problems (the “Eightfold Noble Path”). His approaches are akin to what we clinicians strive to do on a daily basis, albeit on a grander scale: diagnosis, pathogenesis, treatment goals, and therapeutic approaches. The framework Siddhartha proposed is austere, rational, practical. It is exactly for this reason that Siddhartha has been called a great physician, a doctor, and a healer.

Dr. Lin is professor emeritus of psychiatry, University of California, Los Angeles, and Distinguished Life Fellow, American Psychiatric Association. He was the founding director of the National Institute of Mental Health/Harbor-UCLA Research Center on the Psychobiology of Ethnicity, the Coastal Asian Pacific Mental Health Center, and the Long Beach Asian Pacific Mental Health Center. The honors Dr. Lin has received include the Kun-Po Soo Asian American Award, American Psychiatric Association; William Sargant Lecturer, Royal College of Psychiatrists, Great Britain; and honorary professor, Hunan (China) Medical University. Information about the book can be found at www.facebuddha.co.

The new book by Ravi Chandra, MD, is a concise introduction to Buddhism, and a forceful exposition on the power and danger of social networking – deftly interwoven with a moving account of the author’s personal life and professional growth as well as his arduous quest for identity.

Social networking has exploded into a major global industry within the last decade, rapidly penetrating and dominating all aspects of our personal and social lives. Instead of promoting social interactions and connections, the lure of instant intimacy often proves illusory. For far too many, the virtual world deepens their sense of isolation and loneliness, fosters jealousy and narcissism, engenders a profound sense of insecurity, and leads to anxiety, depression, and much worse.

By juxtaposing the Buddha with social networking in the book title, Dr. Chandra expresses his hope and faith that Buddhism could serve as an effective tool for harnessing the force unleashed by these powerful new technologies, helping us to put the genie of our invention back into the bottle. Over the millenia, Buddhism has guided societies and individuals to overcome (“transcend”) crises and adversities, and could play a crucial role in negotiating these still largely uncharted territories.

Despite the popularity of terms such as Zen, meditation, transcendence, and mindfulness, Buddhism remains mysterious and exotic to most modern readers, and is laden with misconceptions and prejudices. This is regrettable, since Buddhism is the most clinically relevant of all major philosophical traditions, and its tenets are most compatible with modern neuroscience. The term philosophical is used here because, at its core, Buddhism represents an uncompromisingly rational approach to dealing with the “human condition.” Siddhartha Gautama (Buddha), its founder, admonished against speculating on questions that are “unanswerables,” such as eternity, existence after death, and the origin and ending of the universe. Instead, Siddhartha focused on identifying life’s vicissitudes (Dukkha, “bumpy rides in life,” commonly translated as “suffering”), clarifying forces responsible for these problems, delineating the ultimate goal, and specifying methods for achieving the goal (the “Four Noble Truths”). He then provided systematic paths for solving problems (the “Eightfold Noble Path”). His approaches are akin to what we clinicians strive to do on a daily basis, albeit on a grander scale: diagnosis, pathogenesis, treatment goals, and therapeutic approaches. The framework Siddhartha proposed is austere, rational, practical. It is exactly for this reason that Siddhartha has been called a great physician, a doctor, and a healer.

Dr. Lin is professor emeritus of psychiatry, University of California, Los Angeles, and Distinguished Life Fellow, American Psychiatric Association. He was the founding director of the National Institute of Mental Health/Harbor-UCLA Research Center on the Psychobiology of Ethnicity, the Coastal Asian Pacific Mental Health Center, and the Long Beach Asian Pacific Mental Health Center. The honors Dr. Lin has received include the Kun-Po Soo Asian American Award, American Psychiatric Association; William Sargant Lecturer, Royal College of Psychiatrists, Great Britain; and honorary professor, Hunan (China) Medical University. Information about the book can be found at www.facebuddha.co.

The new book by Ravi Chandra, MD, is a concise introduction to Buddhism, and a forceful exposition on the power and danger of social networking – deftly interwoven with a moving account of the author’s personal life and professional growth as well as his arduous quest for identity.

Social networking has exploded into a major global industry within the last decade, rapidly penetrating and dominating all aspects of our personal and social lives. Instead of promoting social interactions and connections, the lure of instant intimacy often proves illusory. For far too many, the virtual world deepens their sense of isolation and loneliness, fosters jealousy and narcissism, engenders a profound sense of insecurity, and leads to anxiety, depression, and much worse.

By juxtaposing the Buddha with social networking in the book title, Dr. Chandra expresses his hope and faith that Buddhism could serve as an effective tool for harnessing the force unleashed by these powerful new technologies, helping us to put the genie of our invention back into the bottle. Over the millenia, Buddhism has guided societies and individuals to overcome (“transcend”) crises and adversities, and could play a crucial role in negotiating these still largely uncharted territories.

Despite the popularity of terms such as Zen, meditation, transcendence, and mindfulness, Buddhism remains mysterious and exotic to most modern readers, and is laden with misconceptions and prejudices. This is regrettable, since Buddhism is the most clinically relevant of all major philosophical traditions, and its tenets are most compatible with modern neuroscience. The term philosophical is used here because, at its core, Buddhism represents an uncompromisingly rational approach to dealing with the “human condition.” Siddhartha Gautama (Buddha), its founder, admonished against speculating on questions that are “unanswerables,” such as eternity, existence after death, and the origin and ending of the universe. Instead, Siddhartha focused on identifying life’s vicissitudes (Dukkha, “bumpy rides in life,” commonly translated as “suffering”), clarifying forces responsible for these problems, delineating the ultimate goal, and specifying methods for achieving the goal (the “Four Noble Truths”). He then provided systematic paths for solving problems (the “Eightfold Noble Path”). His approaches are akin to what we clinicians strive to do on a daily basis, albeit on a grander scale: diagnosis, pathogenesis, treatment goals, and therapeutic approaches. The framework Siddhartha proposed is austere, rational, practical. It is exactly for this reason that Siddhartha has been called a great physician, a doctor, and a healer.

Dr. Lin is professor emeritus of psychiatry, University of California, Los Angeles, and Distinguished Life Fellow, American Psychiatric Association. He was the founding director of the National Institute of Mental Health/Harbor-UCLA Research Center on the Psychobiology of Ethnicity, the Coastal Asian Pacific Mental Health Center, and the Long Beach Asian Pacific Mental Health Center. The honors Dr. Lin has received include the Kun-Po Soo Asian American Award, American Psychiatric Association; William Sargant Lecturer, Royal College of Psychiatrists, Great Britain; and honorary professor, Hunan (China) Medical University. Information about the book can be found at www.facebuddha.co.

I am not going to tell you about the dangers of lead, as it is well known and publicized, but I will tell you my family’s story with lead.

In 2012, 1 year after my younger daughter was born, I took her for her 1-year checkup. As I would do with any of my pediatric patients at this age, I took her for a lead level check. Never during my residency training or my first few years of practice as a pediatrician have I encountered a positive lead level. So when I opened the lab result sheet, I thought I would be shredding it the next moment. Well, that didn’t happen. It turned out that her lead level was 7 mcg/dL! Not too high, but detectable. The only question that kept on coming back over the next month or so was a big WHY? Why my child? Now my older daughter’s lead level was normal at her 1-year visit. We had just moved into a new house before my youngest daughter was born. I thought, it has to do with the house, and since my 1-year-old was putting everything in her mouth at this stage, then she must be getting the lead that way.

Dr. Faddoul is a private practice pediatrician in La Canada Flintridge, Calif.

I am not going to tell you about the dangers of lead, as it is well known and publicized, but I will tell you my family’s story with lead.

In 2012, 1 year after my younger daughter was born, I took her for her 1-year checkup. As I would do with any of my pediatric patients at this age, I took her for a lead level check. Never during my residency training or my first few years of practice as a pediatrician have I encountered a positive lead level. So when I opened the lab result sheet, I thought I would be shredding it the next moment. Well, that didn’t happen. It turned out that her lead level was 7 mcg/dL! Not too high, but detectable. The only question that kept on coming back over the next month or so was a big WHY? Why my child? Now my older daughter’s lead level was normal at her 1-year visit. We had just moved into a new house before my youngest daughter was born. I thought, it has to do with the house, and since my 1-year-old was putting everything in her mouth at this stage, then she must be getting the lead that way.

Dr. Faddoul is a private practice pediatrician in La Canada Flintridge, Calif.

I am not going to tell you about the dangers of lead, as it is well known and publicized, but I will tell you my family’s story with lead.

In 2012, 1 year after my younger daughter was born, I took her for her 1-year checkup. As I would do with any of my pediatric patients at this age, I took her for a lead level check. Never during my residency training or my first few years of practice as a pediatrician have I encountered a positive lead level. So when I opened the lab result sheet, I thought I would be shredding it the next moment. Well, that didn’t happen. It turned out that her lead level was 7 mcg/dL! Not too high, but detectable. The only question that kept on coming back over the next month or so was a big WHY? Why my child? Now my older daughter’s lead level was normal at her 1-year visit. We had just moved into a new house before my youngest daughter was born. I thought, it has to do with the house, and since my 1-year-old was putting everything in her mouth at this stage, then she must be getting the lead that way.

Dr. Faddoul is a private practice pediatrician in La Canada Flintridge, Calif.

On the heels of Hurricane Harvey, which devastated the city of Houston and other communities in Texas and Louisiana, Hurricane Irma ravaged several islands in the Caribbean—and then headed for the states. In the days before she made landfall in the US, the media offered seemingly minute-to-minute updates on her progress. Each new forecast seemed to contradict the previous, demonstrating the unpredictability of natural disasters. But as the hurricane crept closer, one thing was evident: Florida was going to take a hard hit.

Keeping up with the fluctuating weather report was like watching a tennis match: East Coast … nope, not the East Coast … probably the middle of the state. We breathed periodic sighs of relief but remained leery. Then, several of the spaghetti plots (may I never hear that term again!) showed Irma veering west—right over our heads. Hysteria set in. One meteorologist sounded absolutely frantic as she warned people to GET READY!!!!

Now, to be clear: My purpose in writing is not to disparage media coverage or governmental response, nor to minimize anyone else’s struggles. Rather, I want to share how the hurricane affected my neighbors, friends, family, and myself—and continues to do so, weeks afterward.

Once Irma’s course was set, we swept into action. Our emergency plan included hurricane-proofing our home—protective awnings placed over the windows; outside decorations put away; grill stored properly; palm trees trimmed—and laying in sufficient supplies (gallon jugs of water, needed medications, bread and peanut butter). We gathered important documents, filled the car with gas, and made sure to have cash on hand. This flurry of activity got the adrenaline pumping, but there was something satisfying about checking off each item on our list. Before you knew it, we were set.

Then Governor Scott took the proactive step of declaring a state of emergency, before Irma was even in striking distance. This was beneficial for all Floridians, since it positioned us to receive federal assistance if needed and allowed local officials to act quickly, without the burden of bureaucracy or red tape.

However, as this news spread, our phones began to ring, buzz, and ping. Friends around the country wanted to know, “Are you okay?” and to offer us a place to stay if we needed to get out. These well-intentioned messages were appreciated—but each expression of concern reminded us that we were facing something big. We were fine, though. Prepared. And the storm could still bypass us or at least hit in a weakened state.

As Irma moved closer, the nervous energy in our little community began to rise. Some neighbors headed north several days before the predicted arrival, spending hours in traffic. We were glad we’d decided to shelter in place instead! Our decision was met with worried looks and wringing hands, which perplexed us. After all, we live about two miles from the Gulf of Mexico and 40-plus feet above sea level. My parents had moved to the area in 1978, and Dad always told us it was where people evacuated to, not from. No problem!

Except … then the mandatory evacuation notice was given. Uh oh! Time to revisit our “shelter in place” plan. What were the options again?

Plan A: Call a friend who lives three towns away in a non-evacuation zone. But her daughter gets evacuated every storm, so she, her husband, and their three dogs had already claimed the guest room.

Plan B: Call another friend in the next town over. She was happy to accommodate us! We planned to arrive the night before the predicted hit and wait out the storm there. The plan was foolproof ... until she also got a mandatory evacuation notice.

Plan C: Find a hotel in a safe area. No luck—all booked.

Admittedly, with each snag in our plans, our stress and anxiety increased. We began to question our initial decision to stay put. Had we missed our opportunity to get out of town?

Then, thankfully, the phone rang. Our friend’s daughter had miraculously secured us hotel rooms about 30 miles from our home.

The strangest thing about riding out a hurricane is that you have days of anticipation and action—you prepare—and then you just have to wait. In the confines of our “bunker,” we had naught to do but track the storm. For three days, local television stations aired only the weather; there was no respite from the red tracking markers. The endless barrage of information added to our already heightened stress levels. We wondered what we would face once we returned home. The thought of major damage sickened us.

Three days after Irma visited, we were cleared to head home. We were admittedly nervous to see what she had left behind—but incredibly, we found our house exactly as we had left it. We hugged each other, in tears. The surrounding damage ranged from minor to major, but thankfully, no one was injured. Neighbors who had fled town asked us to send pictures of their homes so they could see for themselves. The consensus: What was broken can be fixed; we are all thankful to have survived. In a way, I expected that to be the end of the story. But I was wrong.

In my February 2010 editorial, I addressed the aftermath of the earthquake that had struck Haiti the month before.¹ Seven years later, 2.5 million Haitians are still in need of humanitarian aid, and 55,000 people are in camps and makeshift camps.² You might be thinking, “An earthquake in Haiti is much different from a hurricane in the United States.” That may be true, but some victims of Hurricane Sandy are still trying to repair damage to their homes, five years later.³ So while Hurricanes Irma and Harvey—let alone Hurricane Sandy—are already off the front pages, the despair, emotional impact, and disbelief associated with the disasters endure. As one woman described, “You’re in complete shock. You’re trying to figure out, ‘Is this happening to me? Am I in some sort of dream I can’t wake up from?’”³

We are not people who are easily discouraged or quick to worry about things we can’t control. But this experience was very different: The sensory overload was unnerving, and the anxiety and stress linger. As a result, I have an entirely new perspective on the effect of disaster on mental health. The worst we suffered was four days without power, yet as I write this weeks later, I find myself in tears, reliving the fear and anxiety we felt during Irma’s wrath. We were ready for a hurricane, but not for the emotional turmoil that has followed.

Have you experienced a disaster, natural or otherwise, that left you shaken? Share your experience, and any advice you may have, with me at NPEditor@frontlinemedcom.com.

On the heels of Hurricane Harvey, which devastated the city of Houston and other communities in Texas and Louisiana, Hurricane Irma ravaged several islands in the Caribbean—and then headed for the states. In the days before she made landfall in the US, the media offered seemingly minute-to-minute updates on her progress. Each new forecast seemed to contradict the previous, demonstrating the unpredictability of natural disasters. But as the hurricane crept closer, one thing was evident: Florida was going to take a hard hit.

Keeping up with the fluctuating weather report was like watching a tennis match: East Coast … nope, not the East Coast … probably the middle of the state. We breathed periodic sighs of relief but remained leery. Then, several of the spaghetti plots (may I never hear that term again!) showed Irma veering west—right over our heads. Hysteria set in. One meteorologist sounded absolutely frantic as she warned people to GET READY!!!!

Now, to be clear: My purpose in writing is not to disparage media coverage or governmental response, nor to minimize anyone else’s struggles. Rather, I want to share how the hurricane affected my neighbors, friends, family, and myself—and continues to do so, weeks afterward.

Once Irma’s course was set, we swept into action. Our emergency plan included hurricane-proofing our home—protective awnings placed over the windows; outside decorations put away; grill stored properly; palm trees trimmed—and laying in sufficient supplies (gallon jugs of water, needed medications, bread and peanut butter). We gathered important documents, filled the car with gas, and made sure to have cash on hand. This flurry of activity got the adrenaline pumping, but there was something satisfying about checking off each item on our list. Before you knew it, we were set.

Then Governor Scott took the proactive step of declaring a state of emergency, before Irma was even in striking distance. This was beneficial for all Floridians, since it positioned us to receive federal assistance if needed and allowed local officials to act quickly, without the burden of bureaucracy or red tape.

However, as this news spread, our phones began to ring, buzz, and ping. Friends around the country wanted to know, “Are you okay?” and to offer us a place to stay if we needed to get out. These well-intentioned messages were appreciated—but each expression of concern reminded us that we were facing something big. We were fine, though. Prepared. And the storm could still bypass us or at least hit in a weakened state.

As Irma moved closer, the nervous energy in our little community began to rise. Some neighbors headed north several days before the predicted arrival, spending hours in traffic. We were glad we’d decided to shelter in place instead! Our decision was met with worried looks and wringing hands, which perplexed us. After all, we live about two miles from the Gulf of Mexico and 40-plus feet above sea level. My parents had moved to the area in 1978, and Dad always told us it was where people evacuated to, not from. No problem!

Except … then the mandatory evacuation notice was given. Uh oh! Time to revisit our “shelter in place” plan. What were the options again?

Plan A: Call a friend who lives three towns away in a non-evacuation zone. But her daughter gets evacuated every storm, so she, her husband, and their three dogs had already claimed the guest room.

Plan B: Call another friend in the next town over. She was happy to accommodate us! We planned to arrive the night before the predicted hit and wait out the storm there. The plan was foolproof ... until she also got a mandatory evacuation notice.

Plan C: Find a hotel in a safe area. No luck—all booked.

Admittedly, with each snag in our plans, our stress and anxiety increased. We began to question our initial decision to stay put. Had we missed our opportunity to get out of town?

Then, thankfully, the phone rang. Our friend’s daughter had miraculously secured us hotel rooms about 30 miles from our home.

The strangest thing about riding out a hurricane is that you have days of anticipation and action—you prepare—and then you just have to wait. In the confines of our “bunker,” we had naught to do but track the storm. For three days, local television stations aired only the weather; there was no respite from the red tracking markers. The endless barrage of information added to our already heightened stress levels. We wondered what we would face once we returned home. The thought of major damage sickened us.

Three days after Irma visited, we were cleared to head home. We were admittedly nervous to see what she had left behind—but incredibly, we found our house exactly as we had left it. We hugged each other, in tears. The surrounding damage ranged from minor to major, but thankfully, no one was injured. Neighbors who had fled town asked us to send pictures of their homes so they could see for themselves. The consensus: What was broken can be fixed; we are all thankful to have survived. In a way, I expected that to be the end of the story. But I was wrong.

In my February 2010 editorial, I addressed the aftermath of the earthquake that had struck Haiti the month before.¹ Seven years later, 2.5 million Haitians are still in need of humanitarian aid, and 55,000 people are in camps and makeshift camps.² You might be thinking, “An earthquake in Haiti is much different from a hurricane in the United States.” That may be true, but some victims of Hurricane Sandy are still trying to repair damage to their homes, five years later.³ So while Hurricanes Irma and Harvey—let alone Hurricane Sandy—are already off the front pages, the despair, emotional impact, and disbelief associated with the disasters endure. As one woman described, “You’re in complete shock. You’re trying to figure out, ‘Is this happening to me? Am I in some sort of dream I can’t wake up from?’”³

We are not people who are easily discouraged or quick to worry about things we can’t control. But this experience was very different: The sensory overload was unnerving, and the anxiety and stress linger. As a result, I have an entirely new perspective on the effect of disaster on mental health. The worst we suffered was four days without power, yet as I write this weeks later, I find myself in tears, reliving the fear and anxiety we felt during Irma’s wrath. We were ready for a hurricane, but not for the emotional turmoil that has followed.

Have you experienced a disaster, natural or otherwise, that left you shaken? Share your experience, and any advice you may have, with me at NPEditor@frontlinemedcom.com.

On the heels of Hurricane Harvey, which devastated the city of Houston and other communities in Texas and Louisiana, Hurricane Irma ravaged several islands in the Caribbean—and then headed for the states. In the days before she made landfall in the US, the media offered seemingly minute-to-minute updates on her progress. Each new forecast seemed to contradict the previous, demonstrating the unpredictability of natural disasters. But as the hurricane crept closer, one thing was evident: Florida was going to take a hard hit.

Keeping up with the fluctuating weather report was like watching a tennis match: East Coast … nope, not the East Coast … probably the middle of the state. We breathed periodic sighs of relief but remained leery. Then, several of the spaghetti plots (may I never hear that term again!) showed Irma veering west—right over our heads. Hysteria set in. One meteorologist sounded absolutely frantic as she warned people to GET READY!!!!

Now, to be clear: My purpose in writing is not to disparage media coverage or governmental response, nor to minimize anyone else’s struggles. Rather, I want to share how the hurricane affected my neighbors, friends, family, and myself—and continues to do so, weeks afterward.

Once Irma’s course was set, we swept into action. Our emergency plan included hurricane-proofing our home—protective awnings placed over the windows; outside decorations put away; grill stored properly; palm trees trimmed—and laying in sufficient supplies (gallon jugs of water, needed medications, bread and peanut butter). We gathered important documents, filled the car with gas, and made sure to have cash on hand. This flurry of activity got the adrenaline pumping, but there was something satisfying about checking off each item on our list. Before you knew it, we were set.

Then Governor Scott took the proactive step of declaring a state of emergency, before Irma was even in striking distance. This was beneficial for all Floridians, since it positioned us to receive federal assistance if needed and allowed local officials to act quickly, without the burden of bureaucracy or red tape.

However, as this news spread, our phones began to ring, buzz, and ping. Friends around the country wanted to know, “Are you okay?” and to offer us a place to stay if we needed to get out. These well-intentioned messages were appreciated—but each expression of concern reminded us that we were facing something big. We were fine, though. Prepared. And the storm could still bypass us or at least hit in a weakened state.

As Irma moved closer, the nervous energy in our little community began to rise. Some neighbors headed north several days before the predicted arrival, spending hours in traffic. We were glad we’d decided to shelter in place instead! Our decision was met with worried looks and wringing hands, which perplexed us. After all, we live about two miles from the Gulf of Mexico and 40-plus feet above sea level. My parents had moved to the area in 1978, and Dad always told us it was where people evacuated to, not from. No problem!

Except … then the mandatory evacuation notice was given. Uh oh! Time to revisit our “shelter in place” plan. What were the options again?

Plan A: Call a friend who lives three towns away in a non-evacuation zone. But her daughter gets evacuated every storm, so she, her husband, and their three dogs had already claimed the guest room.

Plan B: Call another friend in the next town over. She was happy to accommodate us! We planned to arrive the night before the predicted hit and wait out the storm there. The plan was foolproof ... until she also got a mandatory evacuation notice.

Plan C: Find a hotel in a safe area. No luck—all booked.

Admittedly, with each snag in our plans, our stress and anxiety increased. We began to question our initial decision to stay put. Had we missed our opportunity to get out of town?

Then, thankfully, the phone rang. Our friend’s daughter had miraculously secured us hotel rooms about 30 miles from our home.

The strangest thing about riding out a hurricane is that you have days of anticipation and action—you prepare—and then you just have to wait. In the confines of our “bunker,” we had naught to do but track the storm. For three days, local television stations aired only the weather; there was no respite from the red tracking markers. The endless barrage of information added to our already heightened stress levels. We wondered what we would face once we returned home. The thought of major damage sickened us.

Three days after Irma visited, we were cleared to head home. We were admittedly nervous to see what she had left behind—but incredibly, we found our house exactly as we had left it. We hugged each other, in tears. The surrounding damage ranged from minor to major, but thankfully, no one was injured. Neighbors who had fled town asked us to send pictures of their homes so they could see for themselves. The consensus: What was broken can be fixed; we are all thankful to have survived. In a way, I expected that to be the end of the story. But I was wrong.

In my February 2010 editorial, I addressed the aftermath of the earthquake that had struck Haiti the month before.¹ Seven years later, 2.5 million Haitians are still in need of humanitarian aid, and 55,000 people are in camps and makeshift camps.² You might be thinking, “An earthquake in Haiti is much different from a hurricane in the United States.” That may be true, but some victims of Hurricane Sandy are still trying to repair damage to their homes, five years later.³ So while Hurricanes Irma and Harvey—let alone Hurricane Sandy—are already off the front pages, the despair, emotional impact, and disbelief associated with the disasters endure. As one woman described, “You’re in complete shock. You’re trying to figure out, ‘Is this happening to me? Am I in some sort of dream I can’t wake up from?’”³

We are not people who are easily discouraged or quick to worry about things we can’t control. But this experience was very different: The sensory overload was unnerving, and the anxiety and stress linger. As a result, I have an entirely new perspective on the effect of disaster on mental health. The worst we suffered was four days without power, yet as I write this weeks later, I find myself in tears, reliving the fear and anxiety we felt during Irma’s wrath. We were ready for a hurricane, but not for the emotional turmoil that has followed.

Have you experienced a disaster, natural or otherwise, that left you shaken? Share your experience, and any advice you may have, with me at NPEditor@frontlinemedcom.com.

Question: A middle-aged woman developed cellulitis after sustaining multiple mosquito bites in her lower left leg. The area of infection did not appear to reach the knee, which housed a prosthesis implanted there 3 years earlier. Over the next few days, she had significant knee pain, which was attributed to the surrounding cellulitis. Her pulse rate reached 105 beats per min, and her temperature was 101° F, but she was continued on oral antibiotics as an outpatient. Later that evening, she collapsed at home.

Which of the following is best?

A. Fever and tachycardia alone are enough to make the diagnosis of systemic inflammatory response syndrome (SIRS) and should have raised sepsis as a cause.

B. In septic patients, even a short delay in antibiotic administration can significantly affect morbidity and mortality.

C. Failure to diagnose is the most common basis for a medical malpractice claim.

D. The doctor may have anchored his diagnosis on the mosquito-bite incident, and should have considered a septic joint and/or sepsis in the differential.

E. All are correct.

Answer: E. “Failure to diagnose” is a legal term, whereas in medical usage we tend to use terms such “missed diagnosis,” “overlooked condition,” or “diagnostic error.” If such failure is shown to be a breach of the standard of care and is proven to be a proximate cause of the patient’s injury, then a case for medical negligence is made out. Even if the situation is atypical or complex, there still is the duty to refer, if customarily required, to an appropriate specialist, and failure to do so may also constitute negligence.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials may have been published in earlier columns in Internal Medicine News, and can be accessed at www.mdedge.com/taxonomy/term/83/path_term/21/latest. For additional information, readers may contact the author at siang@hawaii.edu.
 

References

1. BMJ Qual Saf. 2013 Aug;22(8):672-80.

2. JAMA Intern Med. 2013 Mar 25;173(6):418-25.

3. MIEC, the Exchange, Issue 8, March 2017.

4. Crit Care Med. 2006 Jun;34(6):1589-96.

5. The Sullivan Group. Case: Avoiding cognitive bias in diagnosing sepsis.

6. Acad Med. 2003 Aug;78(8):775-80.

Question: A middle-aged woman developed cellulitis after sustaining multiple mosquito bites in her lower left leg. The area of infection did not appear to reach the knee, which housed a prosthesis implanted there 3 years earlier. Over the next few days, she had significant knee pain, which was attributed to the surrounding cellulitis. Her pulse rate reached 105 beats per min, and her temperature was 101° F, but she was continued on oral antibiotics as an outpatient. Later that evening, she collapsed at home.

Which of the following is best?

A. Fever and tachycardia alone are enough to make the diagnosis of systemic inflammatory response syndrome (SIRS) and should have raised sepsis as a cause.

B. In septic patients, even a short delay in antibiotic administration can significantly affect morbidity and mortality.

C. Failure to diagnose is the most common basis for a medical malpractice claim.

D. The doctor may have anchored his diagnosis on the mosquito-bite incident, and should have considered a septic joint and/or sepsis in the differential.

E. All are correct.

Answer: E. “Failure to diagnose” is a legal term, whereas in medical usage we tend to use terms such “missed diagnosis,” “overlooked condition,” or “diagnostic error.” If such failure is shown to be a breach of the standard of care and is proven to be a proximate cause of the patient’s injury, then a case for medical negligence is made out. Even if the situation is atypical or complex, there still is the duty to refer, if customarily required, to an appropriate specialist, and failure to do so may also constitute negligence.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials may have been published in earlier columns in Internal Medicine News, and can be accessed at www.mdedge.com/taxonomy/term/83/path_term/21/latest. For additional information, readers may contact the author at siang@hawaii.edu.
 

References

1. BMJ Qual Saf. 2013 Aug;22(8):672-80.

2. JAMA Intern Med. 2013 Mar 25;173(6):418-25.

3. MIEC, the Exchange, Issue 8, March 2017.

4. Crit Care Med. 2006 Jun;34(6):1589-96.

5. The Sullivan Group. Case: Avoiding cognitive bias in diagnosing sepsis.

6. Acad Med. 2003 Aug;78(8):775-80.

Question: A middle-aged woman developed cellulitis after sustaining multiple mosquito bites in her lower left leg. The area of infection did not appear to reach the knee, which housed a prosthesis implanted there 3 years earlier. Over the next few days, she had significant knee pain, which was attributed to the surrounding cellulitis. Her pulse rate reached 105 beats per min, and her temperature was 101° F, but she was continued on oral antibiotics as an outpatient. Later that evening, she collapsed at home.

Which of the following is best?

A. Fever and tachycardia alone are enough to make the diagnosis of systemic inflammatory response syndrome (SIRS) and should have raised sepsis as a cause.

B. In septic patients, even a short delay in antibiotic administration can significantly affect morbidity and mortality.

C. Failure to diagnose is the most common basis for a medical malpractice claim.

D. The doctor may have anchored his diagnosis on the mosquito-bite incident, and should have considered a septic joint and/or sepsis in the differential.

E. All are correct.

Answer: E. “Failure to diagnose” is a legal term, whereas in medical usage we tend to use terms such “missed diagnosis,” “overlooked condition,” or “diagnostic error.” If such failure is shown to be a breach of the standard of care and is proven to be a proximate cause of the patient’s injury, then a case for medical negligence is made out. Even if the situation is atypical or complex, there still is the duty to refer, if customarily required, to an appropriate specialist, and failure to do so may also constitute negligence.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials may have been published in earlier columns in Internal Medicine News, and can be accessed at www.mdedge.com/taxonomy/term/83/path_term/21/latest. For additional information, readers may contact the author at siang@hawaii.edu.
 

References

1. BMJ Qual Saf. 2013 Aug;22(8):672-80.

2. JAMA Intern Med. 2013 Mar 25;173(6):418-25.

3. MIEC, the Exchange, Issue 8, March 2017.

4. Crit Care Med. 2006 Jun;34(6):1589-96.

5. The Sullivan Group. Case: Avoiding cognitive bias in diagnosing sepsis.

6. Acad Med. 2003 Aug;78(8):775-80.

Postmenopausal bleeding is a symptom that can announce the presence of a gynecologic malignancy. In this column, we will discuss the important considerations to make in the work-up of this symptom.

Roughly 10% of women will present for evaluation of postmenopausal bleeding.¹ More than a third of these women will have benign pathology, with the incidence of endometrial cancer in this group at only about 5%.² Other gynecologic malignancies should be considered as well, including cervical, vaginal, vulvar, and more rarely, those of the fallopian tubes or ovaries.

Use of ultrasound

Ultrasound is a commonly performed initial approach to work-up because of its noninvasive nature. Transvaginal ultrasound has a high negative predictive value of 99.4%-100% in ruling out malignancy.³ Among women with postmenopausal bleeding, the risk of cancer is 7.3% if their endometrial lining is 5 mm or greater and less than 0.07% risk if their lining is 4 mm or less. Therefore, this cutoff dimension is typically used to triage patients to additional sampling.

If ultrasound is performed on postmenopausal women who are asymptomatic (no bleeding), then an endometrial stripe of greater than 11 mm is considered justification for further work-up and is associated with a 6.7% risk of endometrial cancer.⁴ If the ultrasound reveals intracavitary lesions, a sonohysterogram would be preferred to characterize intrauterine pathology. In fact, sonohysterography is superior to transvaginal ultrasound (with a sensitivity of 80% vs. 49%, respectively) in detecting endometrial polypoid lesions.⁵ Preoperative identification of an intracavitary lesion may assist in selecting the best sampling technique (blind vs. hysteroscopy-guided approach).
 

Endometrial sampling

If an ultrasound reveals a thickened or unevaluable endometrial stripe or if the clinician chooses to proceed directly with diagnostic confirmation, several options for endometrial sampling exist, including office-based or operative procedures, as well as blind or visually guided ones. Endometrial pipelle biopsy, D&C without hysteroscopy, endometrial lavage, and endometrial brush biopsy all constitute “blind” sampling techniques. Targeted biopsy techniques include hysteroscopy D&C and saline infusion sonohysterography–guided biopsy.

Blind D&C

Although D&C may be considered the gold standard of diagnostic sampling techniques, it should be noted that 60% of these procedures sample less than half of the endometrium.⁶ When used in conjunction with hysteroscopy, the sensitivity in detecting cancer is high at 97% with a specificity of 93%-100%.⁷

While some patients are candidates for office-based procedures, D&C often requires regional or general anesthesia and is frequently performed in a hospital-based environment or surgical center. This may be most appropriate for patients who have had failed office attempts at sampling, have multiple medical comorbidities that limit the feasibility of office-based procedures (such as morbid obesity), or have severe cervical stenosis. D&C is associated with an increased risk for uterine perforation, compared with outpatient sampling procedures.

The need to go to the operating room rather than to an ambulatory setting also may increase the costs borne by the patient. The advantages of D&C include the potential for large-volume sampling and the potentially therapeutic nature of the procedure in cases of benign pathology.
 

Office-based procedures

Office-based sampling techniques include those using a pipelle, those employing an endometrial brush, and those guided by saline infusion sonohysterography. If performed in the office, they require minimal or no cervical dilation, are associated with a lower risk of perforation or adverse reaction to anesthesia, and usually have lower costs for patients.

Endometrial pipelle biopsies are a very effective diagnostic tool when there is global, endometrial pathology; they have a sensitivity of 83% in confirming cancer.⁸ It is an inexpensive and technically straightforward technique that can be easily performed in an office setting.

However, when the endometrial lining is atrophied, alternative tools may provide superior results. Endometrial brushes have been shown to be 33% more successful in collecting adequate samples,compared with pipelles, because they sample a larger endometrial surface area.⁹

There is ongoing development of sampling techniques, such as endometrial lavage or the combination of saline infusion sonohysterography and endometrial biopsy.¹⁰ However, future studies regarding accuracy, cost, and patient acceptability are needed before these techniques are translated to the clinical setting.
 

Targeted endometrial sampling

Targeted or visually guided sampling, such as hysteroscopy, has been shown to be very accurate in identifying benign pathology, although the sensitivity of hysteroscopic diagnosis of cancer is significantly lower at approximately 50%.¹¹ Therefore, the benefit of hysteroscopy is in complementing the blind nature of D&C by guiding sampling of intracavitary lesions, should they exist.

Hysteroscopy is safe in endometrial cancer and is not associated with upstaging the cancer from transtubal extirpation of malignant cells.¹²

The addition of hysteroscopy contributes some cost and equipment to the blind D&C procedure; therefore, it might be best applied in cases where there is known intracavitary pathology or inadequate prior sampling. In well-selected patients, hysteroscopy often can be used in an office setting, which improves the practicality of the procedure. Smaller and, in some cases, disposable equipment aids in the feasibility of adding visual guidance to office sampling.
 

Optimizing sampling

Postmenopausal women have a higher risk for sampling failure, compared with younger women. Obesity also is a risk for failed sampling.¹³ Cervical ripening with misoprostol may increase access to the endometrial cavity, and ultrasound guidance may decrease the risk of uterine perforation in a stenotic cervix.

Clinicians should ensure that histology results are concordant with clinical data. Discordant results should be reevaluated. For example, if an ultrasound demonstrates a thickened endometrial stripe, but the sampling reveals “scant atrophic tissue,” then there is unexplained pathology to address. Further work-up, such as more comprehensive sampling with hysteroscopy, should be considered in such cases. Additionally, persistent postmenopausal bleeding, despite a benign endometrial biopsy, should be reevaluated over time to rule out occult disease missed during prior sampling.

Appropriate strategies for the work-up of postmenopausal bleeding should be tailored to each patient and their risk factors. Clinicians are now equipped with multiple ways of obtaining clinical data, and patients have options that may decrease barriers to their care. Hysteroscopy does not improve upon D&C in the diagnosis of endometrial cancer, although it may be helpful in distinguishing and treating nonmalignant lesions.
 

Dr. Cotangco is a resident in the department of obstetrics and gynecology at the University of Illinois, Chicago. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina, Chapel Hill. They reported having no relevant financial disclosures.

References

1. Acta Obstet Gynecol Scand. 2004 Feb;83(2):203-7.

2. Menopause Int. 2010 Mar;16(1):5-8.

3. Obstet Gynecol. 2009 Aug;114(2 Pt 1):409-11.

4. Ultrasound Obstet Gynecol. 2004 Oct;24(5):558-65.

5. Ultrasound Obstet Gynecol. 2001 Aug;18(2):157-62.

6. Am J Obstet Gynecol. 2009 Jul;201(1):5-11.

7. Obstet Gynecol Clin North Am. 2000 Jun;27(2):235-44.

8. J Reprod Med. 1995 Aug;40(8):553-5.

9. BJOG. 2008 Jul;115(8):1028-36.

10. PLoS Med. 2016 Dec. doi: 10.1371/journal.pmed.1002206.

11. Arch Gynecol Obstet. 2012 Mar;285(3):839-43.

12. Am J Obstet Gynecol. 2012 Jul;207(1):71.e1-5.

13. Gynecol Oncol. 2017 Feb;144(2):324-8.

Postmenopausal bleeding is a symptom that can announce the presence of a gynecologic malignancy. In this column, we will discuss the important considerations to make in the work-up of this symptom.

Roughly 10% of women will present for evaluation of postmenopausal bleeding.¹ More than a third of these women will have benign pathology, with the incidence of endometrial cancer in this group at only about 5%.² Other gynecologic malignancies should be considered as well, including cervical, vaginal, vulvar, and more rarely, those of the fallopian tubes or ovaries.

Use of ultrasound

Ultrasound is a commonly performed initial approach to work-up because of its noninvasive nature. Transvaginal ultrasound has a high negative predictive value of 99.4%-100% in ruling out malignancy.³ Among women with postmenopausal bleeding, the risk of cancer is 7.3% if their endometrial lining is 5 mm or greater and less than 0.07% risk if their lining is 4 mm or less. Therefore, this cutoff dimension is typically used to triage patients to additional sampling.

If ultrasound is performed on postmenopausal women who are asymptomatic (no bleeding), then an endometrial stripe of greater than 11 mm is considered justification for further work-up and is associated with a 6.7% risk of endometrial cancer.⁴ If the ultrasound reveals intracavitary lesions, a sonohysterogram would be preferred to characterize intrauterine pathology. In fact, sonohysterography is superior to transvaginal ultrasound (with a sensitivity of 80% vs. 49%, respectively) in detecting endometrial polypoid lesions.⁵ Preoperative identification of an intracavitary lesion may assist in selecting the best sampling technique (blind vs. hysteroscopy-guided approach).
 

Endometrial sampling

If an ultrasound reveals a thickened or unevaluable endometrial stripe or if the clinician chooses to proceed directly with diagnostic confirmation, several options for endometrial sampling exist, including office-based or operative procedures, as well as blind or visually guided ones. Endometrial pipelle biopsy, D&C without hysteroscopy, endometrial lavage, and endometrial brush biopsy all constitute “blind” sampling techniques. Targeted biopsy techniques include hysteroscopy D&C and saline infusion sonohysterography–guided biopsy.

Blind D&C

Although D&C may be considered the gold standard of diagnostic sampling techniques, it should be noted that 60% of these procedures sample less than half of the endometrium.⁶ When used in conjunction with hysteroscopy, the sensitivity in detecting cancer is high at 97% with a specificity of 93%-100%.⁷

While some patients are candidates for office-based procedures, D&C often requires regional or general anesthesia and is frequently performed in a hospital-based environment or surgical center. This may be most appropriate for patients who have had failed office attempts at sampling, have multiple medical comorbidities that limit the feasibility of office-based procedures (such as morbid obesity), or have severe cervical stenosis. D&C is associated with an increased risk for uterine perforation, compared with outpatient sampling procedures.

The need to go to the operating room rather than to an ambulatory setting also may increase the costs borne by the patient. The advantages of D&C include the potential for large-volume sampling and the potentially therapeutic nature of the procedure in cases of benign pathology.
 

Office-based procedures

Office-based sampling techniques include those using a pipelle, those employing an endometrial brush, and those guided by saline infusion sonohysterography. If performed in the office, they require minimal or no cervical dilation, are associated with a lower risk of perforation or adverse reaction to anesthesia, and usually have lower costs for patients.

Endometrial pipelle biopsies are a very effective diagnostic tool when there is global, endometrial pathology; they have a sensitivity of 83% in confirming cancer.⁸ It is an inexpensive and technically straightforward technique that can be easily performed in an office setting.

However, when the endometrial lining is atrophied, alternative tools may provide superior results. Endometrial brushes have been shown to be 33% more successful in collecting adequate samples,compared with pipelles, because they sample a larger endometrial surface area.⁹

There is ongoing development of sampling techniques, such as endometrial lavage or the combination of saline infusion sonohysterography and endometrial biopsy.¹⁰ However, future studies regarding accuracy, cost, and patient acceptability are needed before these techniques are translated to the clinical setting.
 

Targeted endometrial sampling

Targeted or visually guided sampling, such as hysteroscopy, has been shown to be very accurate in identifying benign pathology, although the sensitivity of hysteroscopic diagnosis of cancer is significantly lower at approximately 50%.¹¹ Therefore, the benefit of hysteroscopy is in complementing the blind nature of D&C by guiding sampling of intracavitary lesions, should they exist.

Hysteroscopy is safe in endometrial cancer and is not associated with upstaging the cancer from transtubal extirpation of malignant cells.¹²

The addition of hysteroscopy contributes some cost and equipment to the blind D&C procedure; therefore, it might be best applied in cases where there is known intracavitary pathology or inadequate prior sampling. In well-selected patients, hysteroscopy often can be used in an office setting, which improves the practicality of the procedure. Smaller and, in some cases, disposable equipment aids in the feasibility of adding visual guidance to office sampling.
 

Optimizing sampling

Postmenopausal women have a higher risk for sampling failure, compared with younger women. Obesity also is a risk for failed sampling.¹³ Cervical ripening with misoprostol may increase access to the endometrial cavity, and ultrasound guidance may decrease the risk of uterine perforation in a stenotic cervix.

Clinicians should ensure that histology results are concordant with clinical data. Discordant results should be reevaluated. For example, if an ultrasound demonstrates a thickened endometrial stripe, but the sampling reveals “scant atrophic tissue,” then there is unexplained pathology to address. Further work-up, such as more comprehensive sampling with hysteroscopy, should be considered in such cases. Additionally, persistent postmenopausal bleeding, despite a benign endometrial biopsy, should be reevaluated over time to rule out occult disease missed during prior sampling.

Appropriate strategies for the work-up of postmenopausal bleeding should be tailored to each patient and their risk factors. Clinicians are now equipped with multiple ways of obtaining clinical data, and patients have options that may decrease barriers to their care. Hysteroscopy does not improve upon D&C in the diagnosis of endometrial cancer, although it may be helpful in distinguishing and treating nonmalignant lesions.
 

Dr. Cotangco is a resident in the department of obstetrics and gynecology at the University of Illinois, Chicago. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina, Chapel Hill. They reported having no relevant financial disclosures.

References

1. Acta Obstet Gynecol Scand. 2004 Feb;83(2):203-7.

2. Menopause Int. 2010 Mar;16(1):5-8.

3. Obstet Gynecol. 2009 Aug;114(2 Pt 1):409-11.

4. Ultrasound Obstet Gynecol. 2004 Oct;24(5):558-65.

5. Ultrasound Obstet Gynecol. 2001 Aug;18(2):157-62.

6. Am J Obstet Gynecol. 2009 Jul;201(1):5-11.

7. Obstet Gynecol Clin North Am. 2000 Jun;27(2):235-44.

8. J Reprod Med. 1995 Aug;40(8):553-5.

9. BJOG. 2008 Jul;115(8):1028-36.

10. PLoS Med. 2016 Dec. doi: 10.1371/journal.pmed.1002206.

11. Arch Gynecol Obstet. 2012 Mar;285(3):839-43.

12. Am J Obstet Gynecol. 2012 Jul;207(1):71.e1-5.

13. Gynecol Oncol. 2017 Feb;144(2):324-8.

Postmenopausal bleeding is a symptom that can announce the presence of a gynecologic malignancy. In this column, we will discuss the important considerations to make in the work-up of this symptom.

Roughly 10% of women will present for evaluation of postmenopausal bleeding.¹ More than a third of these women will have benign pathology, with the incidence of endometrial cancer in this group at only about 5%.² Other gynecologic malignancies should be considered as well, including cervical, vaginal, vulvar, and more rarely, those of the fallopian tubes or ovaries.

Use of ultrasound

Ultrasound is a commonly performed initial approach to work-up because of its noninvasive nature. Transvaginal ultrasound has a high negative predictive value of 99.4%-100% in ruling out malignancy.³ Among women with postmenopausal bleeding, the risk of cancer is 7.3% if their endometrial lining is 5 mm or greater and less than 0.07% risk if their lining is 4 mm or less. Therefore, this cutoff dimension is typically used to triage patients to additional sampling.

If ultrasound is performed on postmenopausal women who are asymptomatic (no bleeding), then an endometrial stripe of greater than 11 mm is considered justification for further work-up and is associated with a 6.7% risk of endometrial cancer.⁴ If the ultrasound reveals intracavitary lesions, a sonohysterogram would be preferred to characterize intrauterine pathology. In fact, sonohysterography is superior to transvaginal ultrasound (with a sensitivity of 80% vs. 49%, respectively) in detecting endometrial polypoid lesions.⁵ Preoperative identification of an intracavitary lesion may assist in selecting the best sampling technique (blind vs. hysteroscopy-guided approach).
 

Endometrial sampling

If an ultrasound reveals a thickened or unevaluable endometrial stripe or if the clinician chooses to proceed directly with diagnostic confirmation, several options for endometrial sampling exist, including office-based or operative procedures, as well as blind or visually guided ones. Endometrial pipelle biopsy, D&C without hysteroscopy, endometrial lavage, and endometrial brush biopsy all constitute “blind” sampling techniques. Targeted biopsy techniques include hysteroscopy D&C and saline infusion sonohysterography–guided biopsy.

Blind D&C

Although D&C may be considered the gold standard of diagnostic sampling techniques, it should be noted that 60% of these procedures sample less than half of the endometrium.⁶ When used in conjunction with hysteroscopy, the sensitivity in detecting cancer is high at 97% with a specificity of 93%-100%.⁷

While some patients are candidates for office-based procedures, D&C often requires regional or general anesthesia and is frequently performed in a hospital-based environment or surgical center. This may be most appropriate for patients who have had failed office attempts at sampling, have multiple medical comorbidities that limit the feasibility of office-based procedures (such as morbid obesity), or have severe cervical stenosis. D&C is associated with an increased risk for uterine perforation, compared with outpatient sampling procedures.

The need to go to the operating room rather than to an ambulatory setting also may increase the costs borne by the patient. The advantages of D&C include the potential for large-volume sampling and the potentially therapeutic nature of the procedure in cases of benign pathology.
 

Office-based procedures

Office-based sampling techniques include those using a pipelle, those employing an endometrial brush, and those guided by saline infusion sonohysterography. If performed in the office, they require minimal or no cervical dilation, are associated with a lower risk of perforation or adverse reaction to anesthesia, and usually have lower costs for patients.

Endometrial pipelle biopsies are a very effective diagnostic tool when there is global, endometrial pathology; they have a sensitivity of 83% in confirming cancer.⁸ It is an inexpensive and technically straightforward technique that can be easily performed in an office setting.

However, when the endometrial lining is atrophied, alternative tools may provide superior results. Endometrial brushes have been shown to be 33% more successful in collecting adequate samples,compared with pipelles, because they sample a larger endometrial surface area.⁹

There is ongoing development of sampling techniques, such as endometrial lavage or the combination of saline infusion sonohysterography and endometrial biopsy.¹⁰ However, future studies regarding accuracy, cost, and patient acceptability are needed before these techniques are translated to the clinical setting.
 

Targeted endometrial sampling

Targeted or visually guided sampling, such as hysteroscopy, has been shown to be very accurate in identifying benign pathology, although the sensitivity of hysteroscopic diagnosis of cancer is significantly lower at approximately 50%.¹¹ Therefore, the benefit of hysteroscopy is in complementing the blind nature of D&C by guiding sampling of intracavitary lesions, should they exist.

Hysteroscopy is safe in endometrial cancer and is not associated with upstaging the cancer from transtubal extirpation of malignant cells.¹²

The addition of hysteroscopy contributes some cost and equipment to the blind D&C procedure; therefore, it might be best applied in cases where there is known intracavitary pathology or inadequate prior sampling. In well-selected patients, hysteroscopy often can be used in an office setting, which improves the practicality of the procedure. Smaller and, in some cases, disposable equipment aids in the feasibility of adding visual guidance to office sampling.
 

Optimizing sampling

Postmenopausal women have a higher risk for sampling failure, compared with younger women. Obesity also is a risk for failed sampling.¹³ Cervical ripening with misoprostol may increase access to the endometrial cavity, and ultrasound guidance may decrease the risk of uterine perforation in a stenotic cervix.

Clinicians should ensure that histology results are concordant with clinical data. Discordant results should be reevaluated. For example, if an ultrasound demonstrates a thickened endometrial stripe, but the sampling reveals “scant atrophic tissue,” then there is unexplained pathology to address. Further work-up, such as more comprehensive sampling with hysteroscopy, should be considered in such cases. Additionally, persistent postmenopausal bleeding, despite a benign endometrial biopsy, should be reevaluated over time to rule out occult disease missed during prior sampling.

Appropriate strategies for the work-up of postmenopausal bleeding should be tailored to each patient and their risk factors. Clinicians are now equipped with multiple ways of obtaining clinical data, and patients have options that may decrease barriers to their care. Hysteroscopy does not improve upon D&C in the diagnosis of endometrial cancer, although it may be helpful in distinguishing and treating nonmalignant lesions.
 

Dr. Cotangco is a resident in the department of obstetrics and gynecology at the University of Illinois, Chicago. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina, Chapel Hill. They reported having no relevant financial disclosures.

References

1. Acta Obstet Gynecol Scand. 2004 Feb;83(2):203-7.

2. Menopause Int. 2010 Mar;16(1):5-8.

3. Obstet Gynecol. 2009 Aug;114(2 Pt 1):409-11.

4. Ultrasound Obstet Gynecol. 2004 Oct;24(5):558-65.

5. Ultrasound Obstet Gynecol. 2001 Aug;18(2):157-62.

6. Am J Obstet Gynecol. 2009 Jul;201(1):5-11.

7. Obstet Gynecol Clin North Am. 2000 Jun;27(2):235-44.

8. J Reprod Med. 1995 Aug;40(8):553-5.

9. BJOG. 2008 Jul;115(8):1028-36.

10. PLoS Med. 2016 Dec. doi: 10.1371/journal.pmed.1002206.

11. Arch Gynecol Obstet. 2012 Mar;285(3):839-43.

12. Am J Obstet Gynecol. 2012 Jul;207(1):71.e1-5.

13. Gynecol Oncol. 2017 Feb;144(2):324-8.

On a recent visit to my daughter’s school, I caught sight of a set of encyclopedias on the shelf. It brought me back to the days where I would open my own set to find out the information I needed to write reports for school. But my sense of nostalgia was short lived as I thought about all of the limitations of the format. If it wasn’t in the encyclopedias, I couldn’t write the report and would need to head to the library. The Internet changed all of that. Now, when I want to know something I don’t look it up in a book anymore. I ask Siri or Alexa or head to the Google home page. When one of my kids asks me a question I can’t answer, like how a tornado forms, I take out my phone and search for the answer on the Internet.

When it comes to medical information, I can’t remember the last time I opened up a journal sitting on my shelf and leafed through the contents to identify the article I needed. I simply go online and search PubMed or download the article from the AJO website. My office is no longer filled with volumes of journals, and I need only my phone to research whatever topic I’m interested in.

The way I prefer to prepare for cases has changed as well. In the past I would simply open a book or technique article and read about the best way to perform the case. Now, I prefer to watch a video or download the technique guide. I find it easier and faster than reading a book chapter or article.

When we began to change the format of the journal, we stated that AJO would be filled with practical information that would be directly impactful to your practice. That’s the number one criteria we utilize when evaluating content. We wanted to make AJO the journal you wanted to read, because it would improve your knowledge, your outcomes, and your bottom line. We have made many changes to AJO in the last 2 years of print issues. But to truly provide the experience our readers demand and deserve, we have to take a huge next step. Right now we are limited by page and word counts, printed media, and advertising pages. We receive hundreds of submissions a month, yet can only print a fraction of the great material we receive.

If you’ve been following the journal for the last 24 months, you’ve noticed that we have been testing the limits of printed media. We’ve included QR codes for videos, companion PDFs, patient information sheets, and downloadable reports to incorporate into your practice.

The way we access the journal is also changing. We’ve looked closely at our web statistics since the redesign. Our website visits have gone up by a factor of 6 with nearly half of our website traffic coming from mobile usage. It became clear that the days of the printed journal are slowly coming to an end. Surgeons don’t have time to read the journal cover to cover, and now most of our traffic comes from our eBlasts. Surgeons find an article that catches their eye and click a link to find out more. We’ve dramatically increased our eBlasts, and our website volume has been increasing exponentially.

While these small steps have been met with great success, it’s now time to make a giant leap. But unlike most journals, where the online version is just an electronic copy of the printed book, we wanted to make the new AJO something vastly different. We wanted to change the way surgeons utilized a journal and interacted with it on a daily basis. We wanted to be the electronic companion to your practice; a trusted, media rich, peer-reviewed source where you and your patients can turn to for the practical day-to-day information you can use to improve your practice.

We’ve built it, and now I’m proud to unveil it. Beginning January 1, AJO will be published exclusively online. All articles will still be PubMed cited, but will contain more photos, videos, handouts and all the information you need to replicate the findings or procedures in your practice. For example, new surgical techniques will be published with the presenting surgeon’s preference cards, rehab protocols, surgical video, and a PowerPoint presentation that can be presented to referral sources or prospective patients.

New features on our web portal will include:

An orthopedic product guide: A database organized by pathology which contains all of the relevant orthopedic products that could be used for treatment. Relevant products will be cross-referenced to articles so you can quickly identify and order equipment for new cases.

Smart article selection: You can filter the articles that match your interests and have them delivered directly to your inbox. For example, foot and ankle surgeons will no longer need to sift through hundreds of pages to find articles relevant to their practice.

A coding and billing section: Discuss and share tips and tricks with your peers and ask questions of the experts. Regular articles will present relevant codes and how to use them appropriately to get the reimbursement you deserve for your services.

Practice management and business strategies: Get advice from, and interact with, the experts in all areas of your practice.

Ask the experts: Present your cases to our editorial board and enjoy a written, peer-reviewed response. Discuss cases and mutual challenges in communities organized by subspecialty and sport. Cover a high school football team? Imagine a place where you can present your football-related injury to the world’s best football doctors and have them review and comment on the case.

These are just some of the changes you will see in the coming months. We will continuously work to improve and welcome your future suggestions as to how we can provide a truly valuable, customized journal.

Looking to the future, it is my opinion that patient-reported outcome scores will be a large part of what we do. By presenting our successful outcomes, we will ultimately justify the procedures which we perform and justify the reimbursement to third party payers. In this issue, we examine the concept of patient-reported outcome measures (PROMs), and how and why to apply them to your practice.

On a recent visit to my daughter’s school, I caught sight of a set of encyclopedias on the shelf. It brought me back to the days where I would open my own set to find out the information I needed to write reports for school. But my sense of nostalgia was short lived as I thought about all of the limitations of the format. If it wasn’t in the encyclopedias, I couldn’t write the report and would need to head to the library. The Internet changed all of that. Now, when I want to know something I don’t look it up in a book anymore. I ask Siri or Alexa or head to the Google home page. When one of my kids asks me a question I can’t answer, like how a tornado forms, I take out my phone and search for the answer on the Internet.

When it comes to medical information, I can’t remember the last time I opened up a journal sitting on my shelf and leafed through the contents to identify the article I needed. I simply go online and search PubMed or download the article from the AJO website. My office is no longer filled with volumes of journals, and I need only my phone to research whatever topic I’m interested in.

The way I prefer to prepare for cases has changed as well. In the past I would simply open a book or technique article and read about the best way to perform the case. Now, I prefer to watch a video or download the technique guide. I find it easier and faster than reading a book chapter or article.

When we began to change the format of the journal, we stated that AJO would be filled with practical information that would be directly impactful to your practice. That’s the number one criteria we utilize when evaluating content. We wanted to make AJO the journal you wanted to read, because it would improve your knowledge, your outcomes, and your bottom line. We have made many changes to AJO in the last 2 years of print issues. But to truly provide the experience our readers demand and deserve, we have to take a huge next step. Right now we are limited by page and word counts, printed media, and advertising pages. We receive hundreds of submissions a month, yet can only print a fraction of the great material we receive.

If you’ve been following the journal for the last 24 months, you’ve noticed that we have been testing the limits of printed media. We’ve included QR codes for videos, companion PDFs, patient information sheets, and downloadable reports to incorporate into your practice.

The way we access the journal is also changing. We’ve looked closely at our web statistics since the redesign. Our website visits have gone up by a factor of 6 with nearly half of our website traffic coming from mobile usage. It became clear that the days of the printed journal are slowly coming to an end. Surgeons don’t have time to read the journal cover to cover, and now most of our traffic comes from our eBlasts. Surgeons find an article that catches their eye and click a link to find out more. We’ve dramatically increased our eBlasts, and our website volume has been increasing exponentially.

While these small steps have been met with great success, it’s now time to make a giant leap. But unlike most journals, where the online version is just an electronic copy of the printed book, we wanted to make the new AJO something vastly different. We wanted to change the way surgeons utilized a journal and interacted with it on a daily basis. We wanted to be the electronic companion to your practice; a trusted, media rich, peer-reviewed source where you and your patients can turn to for the practical day-to-day information you can use to improve your practice.

We’ve built it, and now I’m proud to unveil it. Beginning January 1, AJO will be published exclusively online. All articles will still be PubMed cited, but will contain more photos, videos, handouts and all the information you need to replicate the findings or procedures in your practice. For example, new surgical techniques will be published with the presenting surgeon’s preference cards, rehab protocols, surgical video, and a PowerPoint presentation that can be presented to referral sources or prospective patients.

New features on our web portal will include:

An orthopedic product guide: A database organized by pathology which contains all of the relevant orthopedic products that could be used for treatment. Relevant products will be cross-referenced to articles so you can quickly identify and order equipment for new cases.

Smart article selection: You can filter the articles that match your interests and have them delivered directly to your inbox. For example, foot and ankle surgeons will no longer need to sift through hundreds of pages to find articles relevant to their practice.

A coding and billing section: Discuss and share tips and tricks with your peers and ask questions of the experts. Regular articles will present relevant codes and how to use them appropriately to get the reimbursement you deserve for your services.

Practice management and business strategies: Get advice from, and interact with, the experts in all areas of your practice.

Ask the experts: Present your cases to our editorial board and enjoy a written, peer-reviewed response. Discuss cases and mutual challenges in communities organized by subspecialty and sport. Cover a high school football team? Imagine a place where you can present your football-related injury to the world’s best football doctors and have them review and comment on the case.

These are just some of the changes you will see in the coming months. We will continuously work to improve and welcome your future suggestions as to how we can provide a truly valuable, customized journal.

Looking to the future, it is my opinion that patient-reported outcome scores will be a large part of what we do. By presenting our successful outcomes, we will ultimately justify the procedures which we perform and justify the reimbursement to third party payers. In this issue, we examine the concept of patient-reported outcome measures (PROMs), and how and why to apply them to your practice.

On a recent visit to my daughter’s school, I caught sight of a set of encyclopedias on the shelf. It brought me back to the days where I would open my own set to find out the information I needed to write reports for school. But my sense of nostalgia was short lived as I thought about all of the limitations of the format. If it wasn’t in the encyclopedias, I couldn’t write the report and would need to head to the library. The Internet changed all of that. Now, when I want to know something I don’t look it up in a book anymore. I ask Siri or Alexa or head to the Google home page. When one of my kids asks me a question I can’t answer, like how a tornado forms, I take out my phone and search for the answer on the Internet.

When it comes to medical information, I can’t remember the last time I opened up a journal sitting on my shelf and leafed through the contents to identify the article I needed. I simply go online and search PubMed or download the article from the AJO website. My office is no longer filled with volumes of journals, and I need only my phone to research whatever topic I’m interested in.

The way I prefer to prepare for cases has changed as well. In the past I would simply open a book or technique article and read about the best way to perform the case. Now, I prefer to watch a video or download the technique guide. I find it easier and faster than reading a book chapter or article.

When we began to change the format of the journal, we stated that AJO would be filled with practical information that would be directly impactful to your practice. That’s the number one criteria we utilize when evaluating content. We wanted to make AJO the journal you wanted to read, because it would improve your knowledge, your outcomes, and your bottom line. We have made many changes to AJO in the last 2 years of print issues. But to truly provide the experience our readers demand and deserve, we have to take a huge next step. Right now we are limited by page and word counts, printed media, and advertising pages. We receive hundreds of submissions a month, yet can only print a fraction of the great material we receive.

If you’ve been following the journal for the last 24 months, you’ve noticed that we have been testing the limits of printed media. We’ve included QR codes for videos, companion PDFs, patient information sheets, and downloadable reports to incorporate into your practice.

The way we access the journal is also changing. We’ve looked closely at our web statistics since the redesign. Our website visits have gone up by a factor of 6 with nearly half of our website traffic coming from mobile usage. It became clear that the days of the printed journal are slowly coming to an end. Surgeons don’t have time to read the journal cover to cover, and now most of our traffic comes from our eBlasts. Surgeons find an article that catches their eye and click a link to find out more. We’ve dramatically increased our eBlasts, and our website volume has been increasing exponentially.

While these small steps have been met with great success, it’s now time to make a giant leap. But unlike most journals, where the online version is just an electronic copy of the printed book, we wanted to make the new AJO something vastly different. We wanted to change the way surgeons utilized a journal and interacted with it on a daily basis. We wanted to be the electronic companion to your practice; a trusted, media rich, peer-reviewed source where you and your patients can turn to for the practical day-to-day information you can use to improve your practice.

We’ve built it, and now I’m proud to unveil it. Beginning January 1, AJO will be published exclusively online. All articles will still be PubMed cited, but will contain more photos, videos, handouts and all the information you need to replicate the findings or procedures in your practice. For example, new surgical techniques will be published with the presenting surgeon’s preference cards, rehab protocols, surgical video, and a PowerPoint presentation that can be presented to referral sources or prospective patients.

New features on our web portal will include:

An orthopedic product guide: A database organized by pathology which contains all of the relevant orthopedic products that could be used for treatment. Relevant products will be cross-referenced to articles so you can quickly identify and order equipment for new cases.

Smart article selection: You can filter the articles that match your interests and have them delivered directly to your inbox. For example, foot and ankle surgeons will no longer need to sift through hundreds of pages to find articles relevant to their practice.

A coding and billing section: Discuss and share tips and tricks with your peers and ask questions of the experts. Regular articles will present relevant codes and how to use them appropriately to get the reimbursement you deserve for your services.

Practice management and business strategies: Get advice from, and interact with, the experts in all areas of your practice.

Ask the experts: Present your cases to our editorial board and enjoy a written, peer-reviewed response. Discuss cases and mutual challenges in communities organized by subspecialty and sport. Cover a high school football team? Imagine a place where you can present your football-related injury to the world’s best football doctors and have them review and comment on the case.

These are just some of the changes you will see in the coming months. We will continuously work to improve and welcome your future suggestions as to how we can provide a truly valuable, customized journal.

Looking to the future, it is my opinion that patient-reported outcome scores will be a large part of what we do. By presenting our successful outcomes, we will ultimately justify the procedures which we perform and justify the reimbursement to third party payers. In this issue, we examine the concept of patient-reported outcome measures (PROMs), and how and why to apply them to your practice.

Throughout my 40 years in private psychiatric practice, I have found some treatments for premenstrual syndrome (PMS) that were not mentioned in “Etiology of premenstrual dysphoric disorder: 5 interwoven pieces” (Evidence-Based Reviews, Current Psychiatry. September 2017, p. 20-28).

This started in 1972 when I was serving in the Army in Oklahoma. A 28-year-old woman with severe PMS had been treated by internal medicine, an OB/GYN, and endocrinology, all to no avail. Three days before her menses began, she would start driving north. When menses commenced, she would find herself in Nebraska and have to call her husband so he could wire her money to come back.

Through my evaluation, I found that she would gain 10 lb before her menses. I prescribed a diuretic and instructed her to start taking it when she began swelling and to stop taking it after her menses began. This alleviated all of her symptoms. If a woman gains more than 3 to 5 lb, her brain also will swell, along with everything else. Because the brain is encapsulated in the skull, the swelling puts pressure on the brain, which might have been the cause of these brief psychotic episodes.

If a woman who develops PMS does not experience significant weight gain, the first thing I try is vitamin B6, 100 mg/d, prior to menses. Vitamin B6 is a cofactor in the production of numerous neurotransmitters. I found that prescribing vitamin B6 would alleviate about 20% of PMS symptoms. If the patient has a personal or family history of affective disorder, I often try antidepressants prior to menses, which alleviate approximately another 20% of her symptoms. If none of the previous 3 factors are present, I often add a low dose of progesterone, which appears to help. If all else fails, I will try a low dose of lithium, 300 mg/d, before menses. This also seems to have some positive effect.

I have not written an article about these approaches to PMS, although I have discussed them with OB/GYNs, who never seem to follow these recommendations. Because I am not university-based, I have not been able to put these treatments to scientific scrutiny. It would be helpful to conduct clinical trials to attempt to substantiate my clinical findings.

Throughout my 40 years in private psychiatric practice, I have found some treatments for premenstrual syndrome (PMS) that were not mentioned in “Etiology of premenstrual dysphoric disorder: 5 interwoven pieces” (Evidence-Based Reviews, Current Psychiatry. September 2017, p. 20-28).

This started in 1972 when I was serving in the Army in Oklahoma. A 28-year-old woman with severe PMS had been treated by internal medicine, an OB/GYN, and endocrinology, all to no avail. Three days before her menses began, she would start driving north. When menses commenced, she would find herself in Nebraska and have to call her husband so he could wire her money to come back.

Through my evaluation, I found that she would gain 10 lb before her menses. I prescribed a diuretic and instructed her to start taking it when she began swelling and to stop taking it after her menses began. This alleviated all of her symptoms. If a woman gains more than 3 to 5 lb, her brain also will swell, along with everything else. Because the brain is encapsulated in the skull, the swelling puts pressure on the brain, which might have been the cause of these brief psychotic episodes.

If a woman who develops PMS does not experience significant weight gain, the first thing I try is vitamin B6, 100 mg/d, prior to menses. Vitamin B6 is a cofactor in the production of numerous neurotransmitters. I found that prescribing vitamin B6 would alleviate about 20% of PMS symptoms. If the patient has a personal or family history of affective disorder, I often try antidepressants prior to menses, which alleviate approximately another 20% of her symptoms. If none of the previous 3 factors are present, I often add a low dose of progesterone, which appears to help. If all else fails, I will try a low dose of lithium, 300 mg/d, before menses. This also seems to have some positive effect.

I have not written an article about these approaches to PMS, although I have discussed them with OB/GYNs, who never seem to follow these recommendations. Because I am not university-based, I have not been able to put these treatments to scientific scrutiny. It would be helpful to conduct clinical trials to attempt to substantiate my clinical findings.

Throughout my 40 years in private psychiatric practice, I have found some treatments for premenstrual syndrome (PMS) that were not mentioned in “Etiology of premenstrual dysphoric disorder: 5 interwoven pieces” (Evidence-Based Reviews, Current Psychiatry. September 2017, p. 20-28).

This started in 1972 when I was serving in the Army in Oklahoma. A 28-year-old woman with severe PMS had been treated by internal medicine, an OB/GYN, and endocrinology, all to no avail. Three days before her menses began, she would start driving north. When menses commenced, she would find herself in Nebraska and have to call her husband so he could wire her money to come back.

Through my evaluation, I found that she would gain 10 lb before her menses. I prescribed a diuretic and instructed her to start taking it when she began swelling and to stop taking it after her menses began. This alleviated all of her symptoms. If a woman gains more than 3 to 5 lb, her brain also will swell, along with everything else. Because the brain is encapsulated in the skull, the swelling puts pressure on the brain, which might have been the cause of these brief psychotic episodes.

If a woman who develops PMS does not experience significant weight gain, the first thing I try is vitamin B6, 100 mg/d, prior to menses. Vitamin B6 is a cofactor in the production of numerous neurotransmitters. I found that prescribing vitamin B6 would alleviate about 20% of PMS symptoms. If the patient has a personal or family history of affective disorder, I often try antidepressants prior to menses, which alleviate approximately another 20% of her symptoms. If none of the previous 3 factors are present, I often add a low dose of progesterone, which appears to help. If all else fails, I will try a low dose of lithium, 300 mg/d, before menses. This also seems to have some positive effect.

I have not written an article about these approaches to PMS, although I have discussed them with OB/GYNs, who never seem to follow these recommendations. Because I am not university-based, I have not been able to put these treatments to scientific scrutiny. It would be helpful to conduct clinical trials to attempt to substantiate my clinical findings.