NEWSLINE: Clinical Insights/Professional Updates





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Choose article section... Do breast implants influence the detection/prognosis of breast cancer? Do the ovaries generate new oocytes after birth? OCs don't help or hinder premenstrual mood Two serum proteins could serve as crystal ball for preeclampsia Yet another reason for judicious use of antibiotics Predicting the onset of menopause Can iron improve BMD and reduce LBW births? PROFESSIONAL UPDATE Just how dedicated are younger physicians? Should physicians be forced to testify as expert witnesses? State legislators tackle tort reform Senate votes down tort reform bill for ob/gyns

Do breast implants influence the detection/prognosis of breast cancer?

While the sensitivity of screening mammography is about 20% lower among asymptomatic women with breast implants than among those without, such women actually have fewer false-positive screening results and may have a slightly better prognosis when breast cancer is found. The findings come from a prospective cohort study of over 800 women with and without breast augmentation.

Traditionally, most experts believed that breast augmentation interfered with interpretation of mammography and led to poorer breast cancer prognoses, but the inclusion of displacement views in mammography screening for women with augmentation, which are performed while the breast tissue is pulled forward and the breast implant is pushed back, has largely leveled the playing field.

Among asymptomatic women with breast augmentation, researchers calculated a sensitivity and specificity for screening mammography of 45% and 97.7%, respectively. Among asymptomatic women without breast implants, sensitivity and specificity were 66.8% and 96.7%, respectively.

While both sensitivity and specificity were lower in symptomatic women with augmentation than among those without, tumors tended to be of similar stage, size, estrogen-receptor status, and nodal status in both groups. In fact, the women with augmented breasts tended to have lower grade tumors than those without.

Theories for this finding include that masses are located earlier in women with implants because these women have lower native breast volume, that implants provide a firmer platform on which to palpate, and that women with augmentation are more breast aware and/or body conscious and notice changes and/or seek medical attention sooner than unaugmented counterparts.

Miglioretti DL, Rutter CM, Geller BM, et al. Effect of breast augmentation on the accuracy of mammography and cancer characteristics. JAMA. 2004;291:442-450.

Do the ovaries generate new oocytes after birth?

Conventional wisdom says a woman is born with a set number of eggs, which are gradually exhausted over time. But a new animal study threatens to turn that dogma on its ear. Harvard researchers have discovered that mouse ovaries apparently create new oocytes throughout the animal's reproductive years. Of course, these findings have to be confirmed and similar research has to prove it applies to humans. But, according to the American Society for Reproductive Medicine: "If we could tap the follicle reserve as a means to postpone ovarian failure, that could be the most significant advance in reproductive medicine since the advent of in vitro fertilization more than 25 years ago."

Johnson J, Canning J, Kaneko T et al. Germline stem cells and follicular renewal in the postnatal mammalian ovary. Nature, 2004; 428: 145-150.

OCs don't help or hinder premenstrual mood

Oral contraceptive pills do not seem to positively or negatively affect premenstrual mood in most women, according to a nested case­control study from Boston.

Researchers studied a cohort of 658 premenopausal women between the ages of 36 and 45 using OCs. While 16.3% reported their premenstrual mood to worsen with OCs, 12.3% reported improvement. The vast majority reported no effect.

A few predisposing conditions seemed to increase the likelihood of mood swings. Women with previous depression were twice as likely as others to report mood deterioration with pill use, while women with early-onset premenstrual mood disturbance and dysmenorrhea were three times and more than twice as likely, respectively, as others to report pill-associated premenstrual mood improvement.

Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: predictors of improvement and deterioration. Am J Obstet Gynecol. 2003;189:1523-1530.

Two serum proteins could serve as crystal ball for preeclampsia

In normotensive women, increased serum concentrations of the angiogenic factor soluble fms-like tyrosine kinase 1 (sFlt-1) and decreased levels of free placental growth factor (PlGF) predict the development of preeclampsia in the last 2 months of pregnancy, according to a nested case­control study within the Calcium for Preeclampsia Prevention Trial.

Researchers measured the serum concentrations of the total sFlt-1, free PlGF, and free vascular endothelial growth factor (VEGF) throughout the pregnancies of 120 pairs of women. Within each pair, one had preeclampsia and one did not.

The study found that while the level of sFlt-1 increased and the level of PlGF decreased during the last 2 months of pregnancy in all the normotensive women, these changes occurred earlier and were more pronounced in the women who later developed preeclampsia. SFlt-1 levels began increasing steeply approximately 5 weeks before the onset of the condition, reaching a mean serum level of 4,382 pg per mL in the women with preeclampsia versus 1,643 pg per mL in the normotensive women.

Similarly, PlGF levels were significantly lower in the women who later developed preeclampsia than in the controls. Decreases began at 13 to 16 weeks' gestation, with the greatest decreases occurring during the same 5 weeks prior to the development of the condition as the increase in sFlt-1.

Changes in the levels of both factors were greater in women with preterm preeclampsia and in women with preeclampsia and a small-for-gestational-age infant.

The hypothesis, according to an editorial in the same issue of the New England Journal of Medicine, is that increased levels of sFlt-1 herald placental vascular insufficiency and other manifestations of preeclampsia "by antagonizing the angiogenic and vasodilatory effects of vascular endothelial growth factor and PlGF." While large, longitudinal studies are needed to determine clinically useful and predictive levels of both factors, the study brings us one step closer to a practical intervention for a condition that affects 3% to 5% of pregnancies in the US.

Levine RJ, Maynard SE, Qian C, et al. Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med. 2004;350:672-683.

Solomon CG, Seely EW. Preeclampsia--searching for the cause. N Engl J Med. 2004;350:641-642.

Yet another reason for judicious use of antibiotics

As if increasing rates of antimicrobial resistance were not enough to discourage excessive use of antimicrobial agents, now it seems that antibiotic use is associated with an increased risk of breast cancer.

Researchers conducted a case–control study of 2,266 women older than 19 years with primary invasive breast cancer. They found that the risk of incident and fatal breast cancer increased as did the total number of days of antibiotic use, from an odds ratio for incidence of 1.45 for 1 to 50 days of use to an odds ratio of 2.07 for greater than 1,000 days of use (P<0.001). Increased risk was associated with all antibiotic classes, but not with tetracycline or macrolides used strictly for acne or rosacea.

Researchers are uncertain whether the antibiotics themselves increase the risk of breast carcinoma or whether a weakened immune system predisposes certain women to both an increased number of infections requiring antibiotic treatment and to breast cancer.

Velicer CM, Heckbert SR, Lampe JW, et al. Antibiotic use in relation to the risk of breast cancer. JAMA. 2004;291:827-835.

Predicting the onset of menopause

Ninety days without a menstrual period virtually guarantees the arrival of menopause within 2 to 4 years, according to a recent analysis of 326 menstruating, middle-aged women.

The study found that 87.6% of women who had not had a period for at least 90 days reached menopause in 2 years and 100% did so within 4 years. Other factors that predict the onset of menopause in 2 and 4 years include:

  • variable cycle lengths (69.6%; 90.5%, respectively);

  • more than 60 days without a period in the previous year (56.4%; 98.4%);

  • cycle lengths varying by 19 or more days (35.2%; 70.6%);

  • changes in cycle regularity (29%; 63.4%).

Taylor SM, Kinney AM, Kline JK. Menopausal transition: predicting time to menopause for women 44 years or older from simple questions on menstrual variability. Menopause. 2004;11:40-48.

Can iron improve BMD and reduce LBW births?

Dietary iron may be almost as important as calcium in preserving bone mineral density (BMD), and it may help reduce the risk of low birthweight (LBW) deliveries. At least that's the suggestion gleaned from two recent studies.

Researchers used dual energy x-ray absorptiometry (DEXA) to assess BMD at five sites (lumbar spine, trochanter, femur neck, Ward's triangle, and total body) in 242 healthy nonsmoking postmenopausal women participating in the Bone, Estrogen, and Strength Training (BEST) Study.

They found that increases in dietary iron intake were significantly associated with increases in BMD at every site (P< 0.01), even after adjusting for protein and/or calcium. BMD among women with the highest iron intake was as much as 14% higher than was observed among those with the lowest intake. The investigators also found a synergistic effect at several bone sites between iron (>20 mg) and calcium (800­1,200 mg/d), although no such association was evident in women taking more or less calcium.

In a separate investigation, researchers randomized 275 low-income pregnant women in Cleveland with a hemoglobin concentration > 110 g/L and a ferritin concentration > 20 µg/L (i.e., iron-replete and not anemic) to take either 30 mg of iron as ferrous sulfate or placebo daily until 28 weeks' gestation. At 28 and 38 weeks' gestation, women with a ferritin concentration of 12 to <20 µg/L or <12 µg/L received 30 and 60 mg Fe/d, respectively.

While the iron capsules didn't significantly affect the overall prevalence of maternal anemia in the third trimester or the incidence of preterm births, infants born to woman taking iron were on average 206 g heavier at birth (206 ± 565 g; P=0.01). Similarly the incidence of LBW at term was 4%, compared with 17% in the placebo group (P=0.003), and there was a significantly lower incidence of preterm LBW (3% vs. 10%; P=0.017).

Harris MM, Houtkooper LB, Stanford VA, et al. Dietary iron is associated with bone mineral density in healthy postmenopausal women. J Nutr. 2003;133:3598-3602.

Cogswell ME, Parvanta I, Ickes L, et al. Iron supplementation during pregnancy, anemia, and birth weight: a randomized controlled trial. Am J Clin Nutr. 2003;78:773-781.


Just how dedicated are younger physicians?

Most older physicians who put in long hours and late nights believe they are dedicated professionals, but they question the dedication of their younger colleagues according to a survey of 436 physicians.

The Merritt, Hawkins, & Associates survey found that not one respondent believed that physicians entering the profession are "more dedicated and hardworking" than those who joined the ranks 20 or 30 years ago. Indeed, nearly two thirds of physicians between 50 and 65 years perceive today's physicians as "less dedicated and hardworking."

That perception, however, is challenged by younger physicians who say lifestyle considerations are helping to shape their practices and create a healthier profession. "Just because younger doctors are getting better at setting boundaries between their professional and personal lives doesn't mean they are less committed. Without those boundaries, physicians risk burnout and being committed—to a rehab unit," family physician Douglas Farrago, MD, 38, told American Medical News (2/2/04).

Part of this change in attitude in practicing medicine can be explained by the increasing number of women entering medical school. As more and more female physicians join the profession, an emphasis on lifestyle issues, such as raising a family, will be mixed in with career choices.

Should physicians be forced to testify as expert witnesses?

That's the question before the Wisconsin Supreme Court. At issue is whether an appellate court is wrong to compel a gynecologist to testify as an expert witness in a medical malpractice case against a patient's former obstetrician-gynecologist.

The appellate court ruled that gynecologist Charles Koh, MD, was required to testify in the case because the plaintiff, Sinora Glenn, had missed a deadline for naming an expert witness and without Koh's testimony, the case could be dismissed.

Those supporting the appellate decision argue that Koh should be forced to testify because he has unique insight into the case as the physician who treated Glenn after the defendant Michael Plante, MD, performed a right oophorectomy and a hysterectomy. Court records indicate that Koh, who is reluctant to testify, believes that aspects of Plante's treatment were inappropriate, reported American Medical News (2/2/04).

Looking at the specifics of the case, those opposing the appellate decision note that courts should not allow missed deadlines to force physicians into a position of having to testify against their will. Looking at the case more broadly, some say that upholding the appellate decision could put the freedom of choice for Wisconsin physicians in jeopardy.

"Compelling testimony against an expert's wishes, in essence, deprives that expert of control over his or her professional pursuits," the American Medical Association and the Wisconsin Medical Society wrote in a friend-of-the-court brief. "In no other part of professional life are professionals generally required to forgo their freedom of choice."

The state Supreme Court is expected to rule on the case this year.

State legislators tackle tort reform

In an effort to curb concerns regarding high medical malpractice insurance rates, state legislators are taking matters into their own hands. Here's a look at some of the legislative developments among states, as reported by the electronic newsletter American Health Line (2/20/04) ( ):

• In Connecticut, a committee of the state legislature held a public hearing on a package of bills designed to reduce malpractice premiums in the state. One of the bills would establish an emergency fund to help physicians who cannot afford to pay malpractice insurance premiums.

• Kentucky legislators are considering a bill that would establish an independent, not-for-profit medical malpractice insurer and require private insurers to file rates with the state Department of Insurance. The bill would also require malpractice cases to be mediated before going to court, and would create screening panels to review malpractice claims and offer opinions to be admissible in court. This bill joins another under consideration—one that would create a constitutional amendment to cap noneconomic damages at $250,000.

• In Minnesota, a House committee approved a bill to cap noneconomic damages at $250,000 and punitive damages at $250,000 or two times the amount of economic damages, whichever is greater, in medical malpractice cases. The bill would also direct punitive damage awards away from injured patients and into a state-financed agency that provides health insurance to those who cannot obtain regular coverage.

• New Hampshire legislators held a public hearing on a bill that would establish three-member panels to review malpractice lawsuits and determine which cases should go to trial. The panels would consist of a retired or current judge, an attorney, and a physician. Unanimous decisions by the panels could be used as evidence in a trial.

• Although state representatives in South Carolina have already passed two tort reform bills, physicians there aren't satisfied. One of the house bills places a $300,000 cap on damages for pain and suffering in medical malpractice cases, and the other places a $2 million cap on noneconomic damages in civil litigation cases. The physicians want state senators to strengthen the bills and to cut the $2 million cap in half.

• Responding to a law passed last year that allow health-care providers to refuse providing treatment to patients who do not sign arbitration agreements, members of the Utah Senate Business and Labor Standing Committee approved a bill that would allow patients to choose how they want to settle malpractice claims—whether it's through arbitration, mediation, or a lawsuit.

• The Washington State House passed more than a dozen tort reform bills. The bills would, among other things, limit damages for pain and suffering to the percentage of fault; reduce the statute of limitations to 6 years; require mediation and arbitration in malpractice lawsuits; forbid insurance companies to cancel or not renew malpractice coverage based on unproven malpractice claims; and protect retired medical professionals who want to their volunteer services from malpractice claims.

Senate votes down tort reform bill for ob/gyns

Just 14 days after S. 2061 was introduced, the US Senate held a cloture vote on the ACOG-supported medical liability reform legislation. The 48-45 vote effectively closed debate on the Healthy Mothers and Healthy Babies Access to Care Act in the Senate, according to the electronic newsletter American Health Line (2/20/04).

Among the now-defunct bill's provisions was a cap of $250,000 on noneconomic damages in medical malpractice lawsuits against ob/gyns. The bill also would have capped punitive damages against ob/gyns at $250,000 or twice the amount of economic damages, whichever is higher.

While ACOG and other supporters of the bill had promoted it as a women's health measure that would help stem the tide of skyrocketing insurance premiums, opponents attributed the problem of skyrocketing premiums to insurers wanting to compensate for investment losses—not to high damage awards in malpractice cases.


NEWSLINE: Clinical Insights/Professional Updates. Contemporary Ob/Gyn Apr. 1, 2004;49:13-18.

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