Louis Keith, MD, PhD

   “Good morning,  I’m Marshall Smith the Publisher of OBGYN.net, and we’re honored to have  Professor Keith from Chicago with us.  He’s been working frantically  behind the scenes at this year’s FIGO 2000 meeting.  Primarily, a lot of  his work has been on the International Journal with which you’re all  familiar.  I’m going to let him tell us some of the things that have  gone on behind the scenes as far as the Journal and then we’ll probably  lead into some other things that are common to all journals -  electronically or printed, Professor Keith.”
       
       

  “Thank you  very much.  I’m pleased to give this interview because many times people  don’t understand what goes on behind the scenes at a I have been on  editorial boards for many years, and the International Journal of  Gynecology and Obstetrics is somewhat unique in the sense that all of  the editors meet annually, we discuss the problems from a very detailed  agenda, and I can see over the years the progress.  Now of course as  editors of a journal, we and our publishers, Elsevier, are very much  aware of the fact that the younger generation is turning to the Internet  to get its medical information.  I don’t think we are looking at that  as an either/or situation but rather how can we work together to improve  the access of information.  One of the reasons that I’m intrigued with  OBGYN.net is that I was told that a very large number of your daily hits  are not from physicians or healthcare professionals.  This means that  the general public, any place in the world with access to a computer,  can have access to good information.”
       
       

  “That’s  absolutely true.  One of things that I think is evolving that we’re all  seeing is how these journals integrate electronic dissemination of  information with print, because obviously each have advantages, and some  prefer one over the other.  What do you see in the future as far as the  way journals go and how they’re going to integrate this?”
       
       

   “Let’s talk first about the preference.  I was at a dinner last night  that was given by Elsevier and Roy Pitkin who is the Editor of the Green  Journal, and we were talking about how people review articles.   Professor Sciarra, who’s the Editor of the IJGO, said to the people at  Elsevier - and I think he spoke for many of us in the room - that he  preferred to read sheets of paper on his desk where he could consult the  references or the figures or the tables as opposed to scrolling down.   We recognize that our residents and our younger attendings prefer at  times to scroll down to get their information but when you’re in the  process of looking at a new manuscript that may not be too easy.  That  was the first part of your question now.  What about the second, what  was it again?” 
       
       

  “One comment -  I prefer to read the printed articles because I can mark on them when I  write them up.  I think the second is, and you certainly have a good  overview of this, what do you see in the future?  You had said it would  be an integration of electronic versus printed media, what do you see in  the future?  Do you have any forecasts or predictions?”
       
       

  “Obviously,  my prediction is if I had good predictions I would be a millionaire on  the stock market but my predictions are just predictions.  There’s no  way that we’re going to be able to maintain the system that’s worked for  the last 150 years of everything on paper because the younger people  won’t buy it, at least in our country, but maybe in other countries.  So  the sooner we, the people, who deal with the paper print journals  everyday recognize there has to be an easy access.  Now some of the  journals are already easy access because you get onto a major search  engine and you can get full text but you need to have a computer.  If  you go around to conventions, when the computer savvy people land in an  airport, they want to know where is the Cyber Caf because they’re  absolutely unable to reach the world without the Cyber Caf.  Now some  hotels have plug-ins, others don’t.  I have a briefcase that I’m taking  to Poland this afternoon, when I have my down time in the airport, I  have two articles that I have to review and I will do the same thing  that you do, I will mark them up.  Now it’s true there are programs  where you can cross out and you can add but that doesn’t say to the  author, ‘Hey Joe or Jane - as the case may be - is this really what you  want to say because if this is the point that you’re trying to make,  it’s not coming through to me.’  Have you ever thought of another point  of view or you forgot this reference or you know your discussion begins  with the sixth paragraph.  I once heard a lecture by Morris Fishbein,  who was the legendary Editor of JAMA.  I was a medical student at the  time, and he was telling us how he edited early on and he said he wrote  to the first person, ‘Dear Doctor, your paper begins on page six.’   That’s really something that young writers have to understand, that  isn’t going to change with the Internet because if doctors want  something on the Internet, they want it vetted, they want it edited, and  they want the excess garbage or verbiage taken out.  They don’t want to  read jargon, and they want to be sure that references are absolutely  up-to-date.  That brings us to the problem of, let’s say, OBGYN.net  opened a journal tomorrow - you would be flooded by submissions.   Someone is going to have to read these submissions because I can tell  you as an editor, some of the submissions are not submissions; they’re  three paragraphs with no beginning, no middle, and no end.  If a young  writer wants to learn how to write, then read Shakespeare.  They’re five  acts because the first act is the introduction, the climax is in the  middle, and everything else sort of drags on.  The Verde opera is the  same thing, there’s always a beginning, middle, and an end.  A medical  article needs that.”
       
       

  “Absolutely, hopefully, the Internet can help them learn that along the way also.”
       
       

  “But you  know, the younger doctors often think that the publication of an  abstract is enough.  The publication of an abstract is a slice, a bread  slice, and it may get to a very few people.  Now the Internet may be a  great place to put abstracts because then you can go back and get the  whole article if you want it but I think articles will still be around.”
       
       

  “I totally  agree, especially with the advent of evidence based medicine.  That’s  what’s hopefully driving us and our medical care.”
       
       

  “Professor Keith, thank you very much.  It’s always a honor to have you with us.”

Articles

OBGYN.net Conference CoverageFrom FIGOWashington D.C., USA - September 2000

Behind the Scenes – Editing a Worldwide Journal

 “It’s April  2003, we’re in Berlin at the Controversies in Obstetrics, Gynaecology and  Infertility Conference and next to me are two world-leading experts on multiple  pregnancy. Please could you introduce yourselves?” 
 
 

 “Well, I  would like to introduce my friend, Louis Keith, who is a Professor at  Northwestern University, Chicago. He is running the Centre of Multiple Births in  Chicago with his twin brother, Donald, and currently he is the Co-President of  the ICS International Society of Twin Studies, author of a zillion papers  related to multiple pregnancy and also with me on two books now and a lot of  papers in the past and in the future.” 
 
 

 “My friend Isaac Blickstein is Professor of  Obstetrics and Gynaecology at the Hebrew University in Jerusalem, a  professorship which he just got this last year and, I must say, a professorship  which is long overdue based on his acknowledged leadership in the world of  multiple pregnancies and those publications I’ve worked with him on; this is our  third book and it has been a pleasure, Isaac.” 
 
 

 “Could you  both tell me, you have almost a lifelong history of collaboration, when and  especially how did it start?” 
 
 

 “Well, it began in Helsingborg, Sweden, where  we met for the first time. It continued in Israel at a meeting that he was  chairman of, but it really began in Copenhagen, Denmark, when I looked at Isaac  and I said, 'Isaac, it’s time that you edit a book for your career' and then  what did you say, Isaac?” 
 
 

 “The idea  came forth and the layout of this book, Iatrogenic Multiple Pregnancy, was  written on napkins of SAS. It was conceived on the ground but born in the air.” 
 
 

 “Exactly, because when I suggested it to  Isaac, he said somehow or other in the words that came out, the words iatrogenic  pregnancy came out, and I said, that’s it, that is your book and he looked at me  like I was insane, probably many of the viewers would say, yes, you’re right,  Isaac, he’s nuts, but aside from that, that was a topic that became obvious to  us because there was nothing on it in a monograph form and then came the flight  to Dusseldorf to see a mutual colleague, Hugo Verhoeven, for dinner and by the  time we landed, we put the pile of napkins on the plate and said, Hugo, what do  you think, this is the outline for the new book on iatrogenic pregnancies and it  came to pass.” 
 
 

 “Yeah, and  then we continued with the collaboration on the triplet book which was published  a few months ago and this idea came from Louis actually, because we witnessed  this tremendous increase in triplets in the United States. This kind of multiple  pregnancy, this kind of obstetric challenge, is indeed the most important thing  now in perinatal medicine. 
 
 The most important, in our view at least, and Louis got the collaboration with  the company in the United States that sponsored our research, extensive research  of their database and I think without their help and without knowing the  material at hand, nobody before could analyse samples of more than 60 triplets,  100 triplets, and for the first time we analysed 3,000 sets of triplets and it  is the cornerstone of this triplet book.” 
 
 

 “Yes, and when the company asked us to do the  analysis, I remember saying to them distinctly, well, we could do the analysis,  I know the right person, meaning you, but the question is how do you present it  so that it isn’t just another paper that lies on your desk and the way to do it  was to build a book around this analysis in which we tried to do everything we  could to get the world’s best authorities to write about every aspect of triplet  pregnancies and it’s about 600 pages this book, something like that.” 
 
 

 “And then we  come to revision of your first book and I think it will be the textbook on  multiple pregnancy, forthcoming next year.” 
 
 

 “Next year, 2004, if everybody is willing and  able to contribute their chapter on time. It will have 84 chapters.” 
 
 

 “At least, and it will represent not a  revision but a complete re-write with very few carry-overs from the first book.  Obviously, the chapter on conjoined twins isn’t going to change except we are  going to add to that a chapter by a young man in Poland who was instrumental in  the successful separation of a set of twins and it shows you really what can be  done now by internet and e-mail because the analysis of the children  pre-operatively was directed by a Doctor Scott Adsik at the Children’s Hospital  of Philadelphia in a series of e-mails to a former student of mine in Lublin,  Poland, who got every one of the tests performed in Lublin, digitised all the  results, sent them by e-mail, they were downloaded in Philadelphia, interpreted  in Philadelphia, the most complex types of tele-medicine that you could imagine,  and then the children were brought over courtesy of LOT Airlines, met at the  airport by the Polish counsel, whisked through customs and everything, every  courtesy was given, and they were ultimately successfully separated at the  Children’s Hospital of Philadelphia. 
 
 At the time, they were very skittish about having the newspapers know and there  was no publicity, but now that it’s over and now that the children are running  around like two other children of their age with very minimal scars, this is  going to be added to that chapter. But the rest of the chapters are essentially  new.” 
 
 

 “Yes, I  agree, because everything changed during the last decade, since 1995, when your  first book appeared because I think there are few topics in medicine that got so  much energy in it from all parts involved. I mean reproductive medicine is  nothing similar to what it was ten years ago. Neonatal medicine is nothing  similar to what it was ten years ago and perinatal medicine, ultrasound,  everything, is nothing like what it was before, so we had to change, even if the  outline is approximately similar, every chapter would be totally revised where  we would recognise or developed previously.” 
 
 

 “And I think that the situation with  multiples, of which twins are clearly the most common, is a worldwide epidemic,  there is no other terminology to explain it. Not only are women older when they  want to get pregnant, but many of them need help and, of course, you have all of  these twins. 
 
 When I’ve been studying the literature on twins since the mid-70s, you know, a  dataset of a 1,000 sets of twins in the mid-70s was an astronomical number, but  now there are many community hospitals when they want to review their data  internally, they have a 1,000 sets of twins in the last decade, so you just have  to put all this information together in a compendium.” 
 
 

“I totally  agree with you. I suppose that is what happened in terms of higher-order  multiples. I think that in one year, there were more high-order multiples  delivered in the United States than in the previous decade and 1998 was the  hallmark of the triplets. In 1998 alone there were more triplets born to mothers  over 35 than in the entire decade before and no other adjective like epidemic  can describe it. I mean, it is also contagious because it comes from one country  to another and from one developing country to another developing country and now  all countries have their own rate of infertility and couples want their children  and the risk of high-order multiples or multiples with infertility treatment is  equal, whether it is in the United States or in India, it is the same risk.” 
 
 

“And I think that’s one of the points that  we’re going to bring out very clearly in this revision, that it is absolutely  crucial that when women go to any form of assisted reproductive technology that  they be thoroughly informed of these risks. Not only should they go for some of  the more sophisticated manipulative types of therapy, but when they get the  simple drugs like clomiphene citrate, people don’t realise when they go to the  PDR in the United States and look at clomiphene citrate, it will give you the  dose but unless you read the fine, fine print, you won’t realise that the  references for which this dosing is made are forty years old. 
 
 Now, when you think about that, we certainly know that the results that we’re  getting with clomiphene today are not the results that were originally given to  the FDA forty years ago, but this doesn’t come out. It will certainly come out  in the book.” 
 
 

 “Yes, sure,  but I mean in iatrogenic pregnancies, that’s two kinds of iatrogenic multiples,  those who may be avoidable and those who may not be avoidable. I think that once  you stimulate the ovary, whether with clomiphene citrate or with gonadotrophins,  the ovary is stimulated and unless you abort the cycle, you cannot know exactly  how many multiples will come out or if it will be a singleton at all. 
 
 However, the avoidable cases are those in which you are yourself putting in the  number, you are deciding on the number of embryo transfers during an assisted  reproductive technology cycle. For example, in IVF, you are in charge of how  many embryos will be transferred and now the trend is in Scandinavia, for  example, is to minimise the risk of multiple pregnancy, more cycles with less  embryo transfer as opposed to doing everything necessary in order to achieve a  pregnancy and, in many ways, it is existentialistic position of the IVF centres. 
 
 They must have success. If they are not successful in getting a pregnancy, they  don’t have any role in medicine and, at certain times, it may result in a higher  rate of multiple pregnancies which are a complication of the treatment.” 
 
 

 “But this need to have success, I can  certainly understand from the point of view of the IVF centre. But in the last  two or three years, there has been a very critical review of what is success. We  were both in Australia and heard a paper from the people in Sydney, called IVF  Sydney, where they were so alarmed at their 41% twinning rate with, I think it  was two embryo transfers, they decided to do a trial where they only put in one  embryo and they got almost the same success rate in terms of total pregnancy  rate, but they brought the twinning rate down to 6%. 
 
 Now, in that regard, there have been some papers that are in the process of  being written now in the UK, which looks at all of the data for the entire  country and there they have shown it is absolutely economically feasible to put  an upper limit on the number of embryos transferred and spend the extra money on  giving more cycles because they will save so many days in the NICU units and the  costs that are associated with that, that it would pay the National Health  Service of England to give out more cycles and they would still save money  rather than paying these astronomical NICU bills because in the end, it is  society that pays the NICU bills. 
 
 We think of a couple in Israel or in Chicago or wherever, going to an IVF  centre, public or private, they pay or they don’t pay, and you can cost out this  at X, but that’s a given thing and that’s what people have in their mind. They  don’t think about two additional costs: Y and Z. Y is the neonatal intensive  care costs and Z is the lifetime cost of bringing up children who may be  neurologically impaired and whether we want to, we certainly don’t say that this  is wonderful, but we have to admit the truth of it. Not every higher-order  multiple child survives without neurological impairment and you have done some  studies to that effect.” 
 
 

 “Yes. We  calculated the risk of cerebral palsy, the quadriplegic type, which means the  baby or the child can’t move anything except his head and living in the  wheelchair for his lifetime, and the risk is about sixfold increased when there  is transferred three embryos and this idea was picked up by John Kiley from the  National Centre of Health Statistics and he did a study with me and it seems  that assisted reproductive technology in the United States adds 8% to the  cerebral palsy rate and if we do everything for it, every pregnancy, we do  seeing them daily, we do ultrasound weekly, we screen for every virus, every  bacteria, we do whatever is needed for pregnancy, amniocentesis, whatever we do,  we cannot reduce the cerebral palsy rate by 1%. However, with assisted  reproductive technology, we increase the numbers tremendously, 8% increase,  because the main idea is that we cannot avoid prematurity in these high-order  multiples and prematurity is definitely associated with neurological handicap.” 
 
 

 “And with that, perhaps, we ought to bring  this interview to a close and say to our listeners if you want to know more . .  . 
 
 

 “Well, it isn’t a question of buying our book,  it’s a question of looking forward to the publication. Let’s hope that we both  survive going through these 80 chapters to get it out on time in 2004. Thank  you, Isaac.” 
 
 

OBGYN.net Conference Reportingfrom the 4th World Congress on Controversies in Obstetrics, Gynaecology and Infertility

The Expanding World of Multiple Gestations

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Louis Keith, MD, PhD

Articles

Behind the Scenes – Editing a Worldwide Journal

The Expanding World of Multiple Gestations

The Expanding World of Multiple Gestations Video