Thursday, November 13, 2014

Do Not Go Gentle Into That Good Night

Ezekiel Emanuel, MD, PhD penned a controversial opinion piece for The Atlantic on why he would hope to die at 75. This piece created a firestorm of pushback, including a resolution at the recent interim AMA meeting by MSSNY's own Greg Pinto, MD to rebuke Dr. Emanuel. While the resolution was ultimately defeated, Dr. Pinto's principled stance was not the only voice heard in opposition to Dr. Emanuel. One piece in particular by Brant Mittler MD JD was posted on MedpageToday.

My reaction to Zeke's article is one of disgust and outrage. Even if he is the smartest guy in the room, he's dumb when it comes to understanding what the average person wants. How dare he claim to know that someone over age 75 who walks slowly, has some memory lapses, and has some medical disabilities and limited resources doesn't deserve to enjoy music, sunsets, or the company of children and grandchildren?

And why will Zeke stop at age 75? When will he and his political cronies -- of both major political parties -- decide that a disabled paraplegic wounded warrior is consuming more than he is contributing?

While Emanuel claims he's only musing about his own personal decision to forgo colonoscopy after age 65 and flu shots, antibiotics, cancer care, and doctor visits after age 75, his writings are dangerous because they influence major media and national leaders.

The subtitle of this irresponsible article proves he wants to influence you to follow his lead, while he admits at the end of the article he reserves the right to change his mind. Sure, you jump off the cliff first. Zeke will follow you. Not.

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Dylan Thomas

Wednesday, October 22, 2014

Ebola: Don't Believe The Hype

There's a lot of news about Ebola lately. It's tough to separate concern from hyperbole. The Medical Society of the State of New York has provided this presentation by Dr. William Valenti, an Infectious Disease specialist, on Ebola. This was originally a webinar geared toward physicians so please forgive me if it seems overly technical. However, if you're a physician, this is definitely must see.

I do hope you find this helpful.

Monday, September 8, 2014

3D Trumps 2D For Localizing IUD's

In the August issue of OBG Management, NYU's Dr.Steven R. Goldstein penned an article suggesting that we stop relying on the standard 2D ultrasound for localizing an IUD. The reason: that 3D or volume ultrasound allows visualization of planes, specifically a coronal plane, not often seen on the standard sonogram. Why is this important? Read on.

Dr. Goldstein's article demonstrates several images from studies in which the IUD's location doesn't look unusual on the 2D image. However, in the coronal plane of 3D imaging, a problem is demonstrated. Benacerraf et al found that 75% of patients with abnormally situated IUD's presented with either pain or bleeding - more than twice the rate of women whose IUD's were found normally situated. We recently saw a young woman who had been in the Emergency Department complaining of pelvic pain for whom the diagnosis of her problem was far from clear. Visualization of the IUD in the coronal plane of her 3D sonogram clearly showed that not only was the device malpositioned in the lower uterus but one of the lateral arms penetrated the wall as well.

So now that you know a 3D study is superior, where should it be done? My answer would be more shameless self-promotion. For more information or to schedule a 3D ultrasound, please call (718) 925-6277.

Monday, August 25, 2014

Shameless Self-Promotion

Many patients, colleagues, friends and family have all asked me: "Who's the most qualified to perform Ob-Gyn ultrasounds?" So here is my unvarnished and completely biased opinion.

An ultrasound study can be performed by either a sonographer or a sonologist (a doctor who performs or supervises ultrasounds.) However, a doctor will have a more extensive background in both health and disease processes than someone who is not a physician as a general rule. A physician will have spent far more time on the clinical side of the equation so will be more able to formulate a better differential diagnosis.

Now while a radiologist and gynecologist can both perform a decent pelvic ultrasound study, a gynecologist is generally far more familiar with female pelvic physiology and pathophysiology than a general radiologist. When it comes to a vaginal ultrasound, this shouldn't even be a question. An old friend once remarked that if radiologists performed vaginal sonography, the transducer handle would be long enough to reach into the reading room. Instead, most if not all radiologists read the studies performed by sonographers. A gynecologist performs a vaginal sonogram in much the same way an old-fashioned pelvic exam is performed, even down to occasionally using the abdominal hand.

Also, when a sonographer performs a sonogram in the standard radiology practice, the patient usually has to leave without knowing the result. When a gynecologist performs the exam, the result, at least preliminarily, is available right away. This eliminates a great deal of anziety.

OK, so now we've agreed your pelvic sonogram is best performed by an Ob-Gyn, why should it be performed by THIS "Recovering Obstetrician?" The short answer is Experience. I have been performing Ob-Gyn sonography since the late 1970's and exclusively since 1986. Since that time, when I decided to limit my practice to consultative ultrasound, I have had a chance to learn what works, what doesn't work, and have climbed to the summit of a rather steep learning curve. I've also learned a great deal about how to deal with both anxious patients and concerned referring clinicians. Do keep all this in mind if and when you need an ultrasound.

Thanks for reading. This concludes my infomercial.

For more information or to schedule an ultrasound, please call 718-925-6277.

Friday, August 22, 2014

Vitamin D: Shedding Some Light on Infertility

I've posted on the present epidemic of low vitamin D previously. Now we find yet another association of low levels of Vitamin D - Infetility.

Publishing in the European Journal of Endocrinology, researchers Elizabeth Lerchbaum and Barbara Obermayer-Pietsch performed a systematic review of studies published until October of 2011. A short summary of their results from PubMed:

The vitamin D receptor (VDR) and vitamin D metabolizing enzymes are found in reproductive tissues of women and men. Vdr knockout mice have significant gonadal insufficiency, decreased sperm count and motility, and histological abnormalities of testis, ovary and uterus. Moreover, we present evidence that vitamin D is involved in female reproduction including IVF outcome (clinical pregnancy rates) and polycystic ovary syndrome (PCOS). In PCOS women, low 25-hydroxyvitamin D (25(OH)D) levels are associated with obesity, metabolic, and endocrine disturbances and vitamin D supplementation might improve menstrual frequency and metabolic disturbances in those women. Moreover, vitamin D might influence steroidogenesis of sex hormones (estradiol and progesterone) in healthy women and high 25(OH)D levels might be associated with endometriosis. In men, vitamin D is positively associated with semen quality and androgen status. Moreover, vitamin D treatment might increase testosterone levels. Testiculopathic men show low CYP21R expression, low 25(OH)D levels, and osteoporosis despite normal testosterone levels.

While more work needs to be done, the impact of Vitamin D on both the male and female reproductive systems is far-reaching and still poorly understood. Stay tuned.

For more information or to schedule a sonogram, please call 718-925-6722.

Thursday, August 7, 2014

Screening Guidelines And Ageism

Most of the controversy surrounding mammography involves when to start screening - 35? 40? 50? However, the US Preventative Services Task Force has also suggested that the evidence for continued screening after age 75 is lacking. Now there may be some evidence for older women.

Malmgren et al from the Swedish Cancer Institute in Seattle reported on findings to suggest the benefit of continued breast cancer screening in older women.

The researchers recently looked at the impact of mammography detection on older women by studying data from an institutional registry that includes more than 14,000 breast cancer cases with 1,600 patients aged older than 75 years.

The majority of mammography-detected cases were early stage, while physician- and patient-detected cancers were more likely to be advanced stage disease. Patients with mammography-detected invasive breast cancer were more often treated with lumpectomy and radiation and had fewer mastectomies and less chemotherapy than patient- or physician-detected cases.

Mammography detection was associated with a 97% five-year disease-specific invasive cancer survival rate, compared with 87% for patient- or physician-detected invasive cancers.

“Mammography enables detection when breast cancer is at an early stage and is easier to treat with more tolerable options,” said Dr. Malmgren. “In this study, older women with mammography-detected invasive cancer had a 10% reduction in breast cancer disease-specific mortality after 5 years.”

This all has little to do with ultrasound but everything to do with the doctor patient relationship. Ultimately, the decision to screen or not to screen should properly rest with the patient and her doctor, based on medical evidence, not cost. Older folks are people too.

If you've any questions or need to schedule an ultrasound, please call (718) 925-6277.

Monday, July 28, 2014

Vitamin D Is More Than Just Bones

Since someone close to me was recently diagnosed with Systemic Lupus Erythematosus aka Lupus aka SLE, I started thinking about the effect that being told to avoid the sun might have on both vitamin D levels and the impact on lupus.

Since the root cause of many diseases such as SLE remains elusive, I was intrigued to find that specialists in the field were asking similar questions. Abou-Raya and colleagues conducted a placebo-controlled trial of vitamin D supplementation in patients with lupus.

Their findings were interesting. First, the lupus patients tended to have lower baseline vitamin D levels when compared with the control group. Second, and more importantly, vitamin D supplementation for 12 months led to significant improvements in both markers of disease activity and in clinical disease activity as well.

From the discussion: ... The overall effect of vitamin D is enhancement of protective innate immune response, while maintaining self-tolerance by dampening overactive adaptive immune responses30. Amelioration of proinflammatory cytokines by vitamin D supplementation may be attributed to the antiinflammatory and immunomodulation effect of vitamin D.

Finally, they conclude: Vitamin D, a safe, inexpensive, and widely available agent, may be effective as a disease-suppressing intervention for patients with SLE. In addition to the potential benefit of vitamin D replacement on improvement of SLE activity, vitamin D seems to have an immune-inflammatory-modulatory role that may benefit musculoskeletal and cardiovascular manifestations of SLE. This role could also help maintain immune health, thus avoiding the excess morbidity and mortality associated with vitamin D deficiency. We recommend routine assessment of vitamin D levels and adequate supplementation of the vitamin in patients with SLE.

When it comes to knowledge about vitamin D, let the sunshine in.

I know this has little to do with ultrasound but a lot to do with our health and that of our loved ones. If you do need an appointment for an ultrasound, feel free to call (718) 925-6277.

Monday, July 14, 2014

Pelvic Exam for the 21st Century

The American College of Physicians (ACP) certainly stirred up a hornets' nest with their pronouncement on the value of pelvic exams.

...“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost,” said Dr. Linda Humphrey, a co-author of the guideline and a member of ACP’s Clinical Practice Guidelines Committee.

As I have posted previously, perhaps it's time to think about replacing the pelvic exam with ultrasound.

...So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

When it comes to the issue of screening for ovarian cancer, the pelvic exam has failed miserably. Dr. Nick Summerton writes in the Spectator :

In seeking to pick up ovarian cancer at an early stage — with an improved chance of cure — much better alternatives to the vaginal examination are trans-vaginal ultrasound and CA125 testing. CA125 is a chemical given off by cancer cells that circulates in the bloodstream and women with ovarian cancer tend to have higher levels.

In 2015, the UKCTOCS screening trial for ovarian cancer will publish its results. Preliminary findings look very promising but, of course, "it ain't over 'til it's over."

Stay tuned.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Tuesday, July 8, 2014

Where's Waldo?

We've all seen Waldo, the guy with the striped shirt and matching cap.

Seems pretty easy to spot, right?

But what if Waldo is in a large, busy crowd - is he still easy to spot?

Sometimes, an early pregnancy is harder to spot than Waldo. Because pregnancy tests are so sensitive, women are getting that first ultrasound quite early on in gestation. There is a window of about 2 - 3 weeks after conception when an early intrauterine pregnancy might not be visualized. This creates a quandary - is she really pregnant, is there a problem with the pregnancy or a problem with the dates, and, worst case scenario, is the pregnancy ectopic. Doctors refer to this clinical situation as "Pregnancy of Uncertain Location" or PUL. The usual management consists of serial measurements of the blood pregnancy hormone or Beta HCG and repeating the ultrasound until the situation is resolved. The protocol had been that failure to see a normally-situated pregnancy on ultrasound at a critical level of Beta HCG was highly suspicious for an ectopic pregnancy or a failed intrauterine pregnancy. Unfortunately, as we all are aware, life is not always so neat.

Doubilet et al, writing in the New England Journal of Medicine reviewed the diagnostic criteria of pregnancy of uncertain location and failed pregnancy and found that previously utilized criteria were a set up for diagnostic error, resulting in administration of a powerful teratogenic drug, Methotrexate, in cases subsequently found to be normal pregnancy. Nurmohamed et al found 8 cases of intrauterine pregnancy in which methotrexate was administered for suspected ectopic. None of these cases had a happy outcome.

Doubilet's review offered new consensus guidelines for the diagnosis of both early pregnancy failure and pregnancy of uncertain location, nicely summarized Here.

So if you find yourself in this situation, please review this post again and perhaps ask your doctor to review it as well.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Monday, June 30, 2014

The Short Life of the Pregnant Fetus

The news of Mary Lambert's pregnant fetus spread like wildfire across the intertubes, the flames fanned by social media.

A pregnant woman in Portland, Oregon was hospitalized this week with extreme stomach pains, and doctors were extremely shocked at what they discovered.

Mary Lambert, who is 8 months pregnant, went to Silverstein Memorial Hospital in Portland when she thought she might be going into labor. Doctors examined her, and initially could not figure out what was causing Lambert’s pain. After an ultrasound to check on her baby, they were taken aback to find that her unborn daughter was also pregnant.

“I have never in my life seen anything like this.” Said Dr. Joseph Goldsmith, a pediatric surgeon at Silverstein. “I don’t think anyone has. This is the first time that an unborn baby has become impregnated. It’s so far beyond rare that we didn’t know it was possible.”

There was an obvious reason that this complication is so rare - it's a Hoax.

... But, of course, the report is fanciful nonsense. No unborn baby is pregnant, in Oregon, or anywhere else. The fictional report originates from the fake-news website, Empire News.

In fact, nothing published on Empire News is true. A disclaimer on the site notes: Empire News is a satirical and entertainment website. We only use invented names in all our stories, except in cases when public figures are being satirized. Any other use of real names is accidental and coincidental.

The internet is replete with tall tales and rumor-mongering. It pays to check out the sources before passing on incredible stories. Be careful out there.

One final note - there is a condition called Fetus In Fetu which can occur as a complication of embryogenesis during a twin pregnancy. In this condition, a nonviable twin fetus becomes enclosed within a normally developing twin fetus. This condition became the inspiration for Stephen King's The Dark Half. This, however, is far from the short-lived saga of the pregnant fetus.

For more information or to schedule a sonogram, please call (718) 925-6277.

Monday, June 23, 2014

It Ain't Over 'Til It's Over

This morning, I found this disturbing story from India.

A man upon finding his first born baby deformed created a ruckus in government women's hospital on Wednesday alleging that the administration had changed his baby after delivery. Dozens of villagers gathered in his support in the hospital and shouted slogans against the doctors. The man stated that he had twice got the sonography of his unborn baby done from a privated doctor who claimed that the baby was perfectly normal.

According to sources, Farhan of nearby Gagwana village, was very excited about his first child and he took his wife for sonography in her third and seventh months. "The doctor told me that the baby was perfectly alright and we were happy with it," said Farhan.

On Sunday, Farhan's wife delivered the baby in a government hospital and afterwards the baby was brought to the couple. "The child was deformed and we were shocked to see that. When I enquired the doctors, they said that the baby was born deformed," added Farhan.

Farhan again went to the same private doctor who had conducted the sonography of his wife, "The doctor claimed that it is not possible after looking at the sonography report that the baby would be born deformed," Farhan said.

Farhan on Wednesday came back to the hospital and returned the baby to the hospital administration demanding to return his real child, "They changed my baby with another and I demanded DNA test before taking the baby," said Farhan.

Dozens of villagers from Gagwana also gathered in the hospital and created ruckus. They shouted slogans against the hospital administration. Police was also called on the spot to control the situation.

Having a child with a birth defect is obviously difficult but when it's unexpected, it literally gut-wrenching for all concerned. At issue is the question: what are the reasonable expectations after an apparently normal 20 week scan?

In the Netherlands, Baardman et al reported on the introduction of a routine 20 week scan increased the detection rate for serious congenital heart defects. However, at best, 15% of the defects went undetected before birth.

Magriples and Copel analyzed a series of 901 patients who underwent ultrasound screening with referral for a targeted exam if an abnormality were suspected. The babies were then examined at birth. There were 28 abnormalities in total. Of these, 5 or 17.8% were missed. In general, the more severe were detected while some of those missed were more subtle.

So what's the take home message? Trying to perform a physical exam on someone who is inside someone else is often exceedingly difficult. Moreover, prenatally, the sonographer is not looking at the finished product.

As Yogi Berra once said in 1973, "It ain't over 'til it's over." To contact me or to schedule an ultrasound, call (718) 925-6277.

Thursday, June 19, 2014

Vitamin D: Let The Sunshine In

As a follow-up to my previous post on sunscreens, I need to point out that there is a downside. We are in the midst of a global epidemic of vitamin D deficiency.

Vitamin D ... regulates the functions of over 200 genes and is essential for growth and development. There are two forms of vitamin D. Vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D status depends on the production of vitamin D 3 in the skin under the influence of ultraviolet radiation from sun and vitamin D intake through diet or vitamin D supplements. Usually 50 to 90% of vitamin D is produced by sunshine exposure of skin and the remainder comes from the diet. Natural diet, most human consume, contain little vitamin D. Traditionally the human vitamin D system begins in the skin, not in the mouth. However, important sources of vitamin D are egg yolk, fatty fish, fortified dairy products and beef liver.

Vitamin D3 deficiency can result in obesity, diabetes, hypertension, depression, fibromyalgia, chronic fatigue syndrome, osteoporosis and neuro-degenerative diseases including Alzheimer’s disease. Vitamin D may even contribute to the development of cancers, especially breast, prostate, and colon cancers.

Why is sun avoidance important?

...Exposure to sunshine each day helps human body to manufacture the required amount of vitamin D. However, due to fear of developing skin cancer most people avoid the sun exposure. To prevent vitamin D deficiency, one should spend 15 to 20 minutes daily in the sunshine with 40% of the skin surface exposed. High concentration of melanin in the skin slows the production of vitamin D; similarly aging greatly reduces skin production of vitamin D. Use of sunblock, common window glass in homes or cars and clothing, all effectively block UVB radiation – even in the summer. People who work indoors, wear extensive clothing, regularly use sunblock, are dark skinned, obese, aged or consciously avoid the sun, are at risk of vitamin D deficiency.

Balance, Daniel san - Balance.

For more information, or to schedule an ultrasound, call: (718) 925-6277.

Monday, June 16, 2014

Sunshine On Sunscreens

Once again, summer beach and pool days are upon us and we need to remind ourselves to deal prudently with exposure to the sun's rays. Sunscreens are the most widely promoted means of protection but there are more than a few caveats.

No Spray Ons - Too easy to miss a spot.

No super high SPFs - EWG advises avoiding products higher than SPF 50.

No oxybenzone - There can be significant absorption into the bloodstream, with an estrogen-like effect.

No retinyl palmitate - EWG recommends avoiding as research shows synergistic effect with sun exposure for tumor development.

No combined sunscreen/bug repellent - combining screens with repellent may increase repellent absorption.

No sunscreen towlettes or powders - FDA sunscreen rules bar these.

No tanning oils - products with SPF lower than 15 are worthless.

For more info, check out more useful info at

Let's be careful out there. H/T Also, for more info or to schedule an ultrasound, call 718 - 925 - 6277.

Monday, June 2, 2014

New Fertility Hope For Chemo Patients

From this weekend's New York Times:

A commonly used drug can help young women with breast cancer retain the ability to have babies, apparently protecting their ovariesfrom the damage caused by chemotherapy, researchers reported here on Friday.

The treatment could provide a new option for dealing with one of the painful dilemmas faced by young cancer patients — that doing the utmost to save their lives might impair or even ruin their fertility. Researchers said the drug, goserelin, which temporarily shuts down the ovaries, appears to protect women from the more permanent premature menopause that can be induced by chemotherapy. In a clinical trial, women who were given goserelin injections along with chemotherapy had less ovarian failure and gave birth to more babies than women receiving only the chemotherapy.

“Premenopausal women beginning chemotherapy for early breast cancer should consider this new option to prevent premature ovarian death,” the study’s lead author, Dr. Halle Moore of the Cleveland Clinic, said at a news conference here at the annual meeting of the American Society of Clinical Oncology.

This is wonderful news indeed for many young women awaiting chemotherapy. There is one catch, however. On the GoodRx website, Zoladex (Goserelin) is listed as:

This drug is considered a specialty medication, which means:

It is very expensive. A typical fill can cost $1,326 or more for 1 kit of Zoladex 10.8mg.

Patients in need of this drug will usually find most of the cost paid by an insurance company, government or non profit organization. If you are uninsured or need help with your co-pay, the manufacturer may also offer assistance.

Most retail pharmacies will not stock this medication. The manufacturer may offer more information on how to fill this prescription.

Physicians and patients considering this therapy as always should do some homework first.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Tuesday, May 27, 2014

Polycystic Ovarian Syndrome: A Silent Misery

From The Daily Star:

A young girl, 15 years old, struggles with acne ever since her periods started. And not too long ago, she noticed dark thick facial hair around her chin and over her cheeks, something that can be socially crippling in school. No amount of waxing, threading and bleaching helps and this 15-year-old is miserable.

A couple has been trying to conceive for nine months with no positive result. In a country with an over-population problem and a serious lack of understanding of infertility and sexual health, there are usually misunderstandings on the varied number of reasons as to why a couple may not be able to conceive. There are grumbling in-laws, a lot of finger-pointing and blaming, usually the women, which does little to help the situation.

A 27-year-old woman has very irregular periods. She has gained a lot of weight over a year or two. She feels bloated and uncomfortable with friends and family being rather insensitive to her recent weight gains. Not having periods regularly also makes her scared about her future, especially when she thinks about marriage and children.

A 22-year-old woman feels extreme pain in her lower abdomen. When she is rushed to hospital, the doctors suspect appendicitis but ultrasounds show that her appendix is fine. However, because she has a sexually active relationship with her boyfriend and does not want her family or even her doctor to find out, she provides limited information on her symptoms which leads to inconclusive diagnosis.

What do these women have in common? They have Polycystic Ovarian Syndrome.

For reasons that are not well understood, in PCOS the hormones get out of balance. One hormone change triggers another, which changes another. For example:

The sex hormones get out of balance. Normally, the ovaries make a tiny amount of male sex hormones (androgens). In PCOS, they start making slightly more androgens. This may cause you to stop ovulating, get acne, and grow extra facial and body hair.

The body may have a problem using insulin, called insulin resistance. When the body doesn't use insulin well, blood sugar levels go up. Over time, this increases your chance of getting diabetes.

The cause of PCOS is not fully understood, but genetics may be a factor. PCOS seems to run in families, so your chance of having it is higher if other women in your family have it or have irregular periods or diabetes. PCOS can be passed down from either your mother's or father's side.

For more information or to schedule an ultrasound, please call: (718)925-6277.

Monday, May 19, 2014

The New Pregnancy Test

When I began my career in medicine, pregnancy tests were relatively insensitive. You had to wait until about 4-6 weeks after the last menstrual period before the results could be regarded as reliable. Real time ultrasounds was a gleam in a few researchers' eyes. Most women with a tubal pregnancy had the diagnosis made when they arrived in the emergency room with serious intra-abdominal bleeding. The confirmative diagnostic test of choice was a culdocentesis - the insertion of a long needle into the abdominal cavity through the vagina. Aspiration of non-clotting blood was considered diagnostic of internal bleeding. An unruptured ectopic pregnancy was considered a reportable case. The treatment was removal of the affected tube at laparotomy.

All that has changed. Today, thanks to Dr. Yalow's development of radioimmunoassay, pregnancy can be diagnosed sometimes before a period is missed. Transvaginal ultrasaound can diagnose an ectopic pregnancy often prior to the onset of significant symptoms. Surgery is done, not via large incisions, but via small laparoscopes - the so-called "bandaid surgery." And often, tubal pregnancy is treated medically or even followed expectantly. These have been truly remarkable developments.

In fact, the new pregnancy test may well be the vaginal sonogram. The new protocol for a woman who is seeing her gynecologist for suspected early pregnancy to empty her bladder and save that specimen of urine for the lab. But today, the office doesn't run the urine test yet. Today, her gyn performs a vaginal sonogram. If pregnancy is seen, that's it - she's pregnant. Done! If a small embroy/fetus is seen, a measurement yields an estimated delivery date which is more accurate than that predicted by last period. Early diagnosis of twins can also be made. If a fetus is seen, so can the heartbeat be seen. Everyone is ahead of the game.

The flip side is if no evidence of pregnancy is found on the sonogram. Now, that urine test is crucial and should be run. Urine tests are far more reliable than they were in the 1960's and early 1970's. If the test is negative, pregnancy is doubtful. Conversely, if the test is positive, then blood should be taken right then and there to look for the level of pregnancy hormone - the Beta HCG. Further management would then depend on that level which could be available often in less than a day. An investigative work up which often took weeks can sometimes be compressed into a few days or less.

Of course, I am oversimplifying but the change in the investigation and treatment of suspected tubal pregnancy has been truly remarkable stuff.

For more information, or to schedule an ultrasound, call: (718) 925 - 6277.

Thursday, May 15, 2014

Lupus In Pregnancy - What Should I Know?

Continuing the lupus thread duing Lupus Awareness Month, let's look at lupus during pregnancy. First, you should know that having lupus does not preclude a successful pregnancy outcome. There are risks involved, however, for both mom and baby. The March of Dimes ists the following:

What problems can lupus cause during your pregnancy?

Lupus may increase the risk of these problems during pregnancy:

Lupus flares. You may experience flares during pregnancy or in the first few months after giving birth. If your lupus is in remission or under good control, you’re less likely to have flares.

Preeclampsia. This is a certain kind of high blood pressure that only pregnant women can get.

Premature birth. This is birth that happens too early, before 37 weeks of pregnancy.

Miscarriage. This is when a baby dies in the womb before 20 weeks of pregnancy.

Stillbirth. This is when a baby dies in the womb after 20 weeks of pregnancy.

If you’ve been in remission or had your condition under good control for at least 6 months before pregnancy, you’re less likely to have complications. Talk with your health care provider before getting pregnant about the safest time for pregnancy.

What problems can lupus cause in your baby?

Most babies of mothers with lupus are healthy. However, some babies may face health risks, like:

Premature birth. About 3 in 10 babies (30 percent) of mothers with lupus are born prematurely. Premature babies may need to stay in the hospital longer or have more health problems than babies born full term (39 to 41 weeks of pregnancy).

Neonatal lupus. About 3 in 100 babies (3 percent) are born with this temporary form of lupus. This condition causes a rash and blood problems but usually clear up by 6 months of age. However, up to half of these babies have a heart problem called heart block. This is a condition that causes a slow heartbeat. Heart block is often permanent. Some babies need a pacemaker to help make their heart beat regularly.

As you would expect, pregnancy for a lupus patient is hardly a walk in the park. However, there is ample evidence that remission in disease activity optimizes a woman's chances for a successful outcome.

During pregnancy, expect to see two consultants on a regular basis - the Maternal Fetal Subspecialist and your Rheumatologist. Expect to have many tests and frequent visits. Do keep your appointments to give yourself and your baby the best possible odds. And above all else, hang in there. You can emerge with a healthy, happy baby.

For more information or to schedule an appointment for an ultrasound, call: (718-925-6277)

Monday, May 12, 2014

Cervical Cancer Rates Rising in Seniors

Recent changes in pap smear frequency suggest that pap smears may no longer be necessary for women 65 years of age or older. There are a few big IF's:

Those with three consecutive negative Pap tests in the last 10 years, or two consecutive negative Pap tests combined with negative HPV tests in the last 10 years, with the most recent test performed within the past 5 years.

Now comes this news.

Previous studies determined that the rate of cervical cancer was approximately 12 cases per 100,000 women in the U.S. The incidence of the disease peaks in women between 40 to 44 years, then tapers off. However, such estimates did not take into account women who had hysterectomies, and are therefore no longer at risk for developing cervical cancer. Once these women were factored out, the incidence of this type of cancer increased to 18.6 cases per 100,000 women. The rate steadily increased as women age, particularly in women between 65 and 69 years of age.

African-American women had a higher incidence of cervical cancer at nearly all ages compared to caucasian women, with the discrepancy becoming more pronounced at older ages.

The study’s lead author Anne F. Rositch, Ph.D., M.S.P.H., an assistant professor of epidemiology and public health at the University of Maryland School of Medicine and a researcher at the University of Maryland Marlene and Stewart Greenebaum Cancer Center, believes these findings are important when reevaluating the screening guidelines for cervical cancer in older women in the U.S. Appropriate interventions need to be initiated to lower the burden of cervical cancer in these women.

Will the abandonment of the annual pap snatch defeat from the jaws of victory in the fight against the cancer that killed Evita Peron? While we do not want to spend precious healthcare dollars on needless testing, we do not want to put women's lives at risk in the process. I would urge any woman to have these conversations with her doctor before choosing either to continue or to forgo pap smears. Choose wisely indeed.

For more information or to schedule an appointment for an ultrasound exam, call: (718)-925-6277.

Friday, May 9, 2014

Miscarriage - Can It Be Lupus?

May is Lupus Awareness Month. Lupus is an autoimmune disease in which the immune system attacks the body's own tissues, causing inflammation, swelling, pain, and damage. Lupus symptoms include fatigue, joint pain, fever, and a lupus rash. But sometimes, adverse pregnancy outcomes such as repeated miscarriage are the first sign of this disease.

Although an uncommon cause, risk of miscarriage is higher in patients with an autoimmune disease such as lupus.

If you've had two or more miscarriages and are unsure, you should ask about a diagnostic investigation. Your health as well as a successful pregnancy outcome may depend on it.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Wednesday, May 7, 2014

Handle With Care

I'm sure everyone's seen the headlines trumpeting Powerball-sized verdicts in medical liability cases involving children born with severe neurological impairment. I mean it's common knowledge that these injuries are always caused by lack of oxygen during the birth process, right?

It turns out that in most cases, common knowledge is wrong.

From this week's New York Times:

... The truth is far more complex, according to an important new report by a committee of experts in obstetrics, pediatrics, neurology and fetal-maternal medicine. Many conditions that occur during or even before pregnancy can lead to neurological damage to full-term babies.

The document, called Neonatal Encephalopathy and Neurologic Outcome, updates a version published in 2003 that focused on oxygen deprivation, or asphyxia, around the time of birth. The new report, which highlights significant advances in diagnosis and treatment in the decade since, was published by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. Brain injuries affect about three in 1,000 babies born full-term in the United States, but only half of these cases are linked to oxygen deprivation during labor and delivery, according to the new report. And even in those instances, a problem that occurred long before birth might have exaggerated the effects of a reduced oxygen supply that would have not otherwise caused a lasting brain injury.

According to the 2003 report, fewer than 10 percent of children with cerebral palsy, the most severe such brain injury, showed signs of asphyxia at birth. Unless certain clear-cut symptoms are present then, brain abnormalities are probably not the result of a complication during labor or delivery, the new report states.

The other side of the coin is that because of the way these cases are handled and the monumental cost involved, not only monetary by the way, many folks feel they have little choice but to find a lawyer. Additionally, obstetricians' response has been predictable with C-Section rates amounting to about one in three births in an effort to avoid the courtroom.

Surely, there has to be a better way.

Tuesday, May 6, 2014

Autism and Labor Induction: ACOG Weighs In

In October, a study by Gregory et al using North Carolina birth records reported a possible association between labor induction or augmentation with an increased risk for autism. Because of the increased incidence of autism and the frequency of oxytocin use in labor, this study resulted in quite a bit of both media buzz and alarm. Many, including both the authors and one recovering obstetrician, commented on the problems with this study and urged caution in interpreting the study's findings.

In the May issue of the journal Obstetrics and Gynecology, the American Congress of Obstetricians and Gynecologists (ACOG) weigh in with a Committee Opinion also endorsed by the Society for Maternal-Fetal Medicine (SMFM.)

...Although the Gregory study suggested an association between ASD and labor induction or augmentation, the study design could not determine if such findings were truly a result of cause and effect. This was recognized by the authors, who noted that interpretation of their findings was limited by missing data regarding important potential confounders, the use of education as a proxy for socioeconomic status, and a lack of data regarding induction indications and methods. They concluded that the “results are not sufficient to suggest altering the standard of care regarding induction or augmentation…though additional research is warranted” (20).

Subsequent to its publication, the Gregory study has been criticized because of limitations in defining the exposure and the outcome of interest (21). Critics note that investigators did not know the specific individual or combination of agents that were used for labor induction or augmentation. The critics also note that the American Psychiatric Association reported an editorial error in the criteria listed for the diagnosis of pervasive developmental disorder not otherwise specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); an error potentially leading to overdiagnosis during much of the time covered by the Gregory study (21).

The ACOG publication concludes:

Current evidence does not identify a causal relationship between labor induction or augmentation in general, or oxytocin labor induction specifically, and autism or ASD. Recognizing the limitations of available study design, conflicting data, and the potential consequences of limiting labor induction and augmentation, the Committee on Obstetric Practice recommends against a change in current guidance regarding counseling and indications for and methods of labor induction and augmentation.

Stay tuned.

Monday, May 5, 2014

Five Prenatal Tests Women Over 35 Should Consider

The other day, this piece on prenatal diagnosis appeared in my inbox.

While the CDC reports almost 15 percent of all U.S. babies -- or 1 in 7 -- were born in 2010 to women 35 and over, much tongue-clucking persists about women waiting to have a baby at "advanced maternal age." The reason may stem from data that shows certain risks (such as having a baby with Down syndrome) can increase with age. However, many women are happily embracing motherhood later on.

That said, certain tests and procedures are often recommended for women over 35. Here, 5 prenatal protocols these expectant moms may want to consider and what "older" moms who've been through them say about their experience.

The article goes on to list the 5 tests -

1. amniocentesis
2. nuchal translucency screening
3. Noninvasive Prenatal Testing (NIPT)
4. chorionic villus sampling (CVS)
5. midtrimester ultrasound

While this is a useful article as it provides background prep for moms to be for conversatons with their OB's and midwives, it lumps screening tests together with diagnostic tests, losing some perspective.

So let's look at this issue in another way. Put simply, a screening test is one which is relatively noninvasive, provides odds and stratifies risk, but does not tell you yes or no. A diagnostic test is often more invasive with real risks and answers specific questions. For example, a screening test for Down's Syndrome would yield a risk in the form of odds. A diagnostic test for Down's would yield a definitive result.

Amniocentesis and CVS are diagnostic tests. While they usually provide definitive results (with a few, thankfully rare exceptions,) nuchal translucency, NIPT and midtrimester ultrasound are more screening tests.

Also, some of these are performed in the first trimester, others in the second. NIPT, nuchal scan, and CVS are first trimester tests. The advantage here is that the earlier this hurdle is jumped, the less stressful the longer remainder of the pregnancy is.

Finally, a few words about ultrasound. IMHO, both first and second trimester ultrasound will remain standard in prenatal care, similar to early newborn physicals and the more comprehensive baby visit a month or so after birth. Many abnormalities and syndromes do not have a basis in chromosome complement, thus a test designed to screen for a chromosome issue such as Down's would not find cases of spina bifida, for example.

Prenatal ultrasound is also more than just looking at structure. It keeps pregnancy real in a tangible way for not only mom but also for dad.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Thursday, May 1, 2014

Nature Or Nurture

We all have heard the saying, "You are what you eat." Now there may be evidence that statement may apply to developing fetuses too. Research shows that a mother's diet around the time of conception can permanently influence her baby's DNA.

... Scientists followed 84 pregnant women who conceived at the peak of the rainy season, and about the same number who conceived at the peak of the dry season.

Nutrient levels were measured in blood samples taken from the women; while the DNA of their babies was analysed two to eight months after birth.

Lead scientist Dr Branwen Hennig, from the London School of Hygiene & Tropical Medicine, said it was the first demonstration in humans that a mother's nutrition at the time of conception can change how her child's genes will be interpreted for life.

She told BBC News: "Our results have shown that maternal nutrition pre-conception and in early pregnancy is important and may have implications for health outcomes of the next generation.

"Women should have a well-balanced food diet prior to conception and during pregnancy."

What's going on here? Epigenetics, functionally relevant changes to the genome that do not involve a change in the nucleotide sequence.

...One such modification involves attaching chemicals called methyl groups to DNA.

Infants from rainy season conceptions had consistently higher rates of methylation in all six genes studied, the researchers found.

These were linked to various levels of nutrients in the mother's blood.

But it is not yet known what the genes do, and what effect the process might have.

The study, published in Nature Communications, demonstrates that a mother's diet can have epigenetic effects.

So which is it - Nature or Nurture? The answer may truly be both.

For more information, or to schedule an ultrasound, please call: (718) 925-6277

Tuesday, April 29, 2014

Can Ovarian Cancer Be Found Early?

Ovarian cancer is the deadliest of all pelvic cancers for a woman. Overall, about one in seventy-two women will develop this disease. Of these, over half will have died within five years of diagnosis. If ever a disease cried out for a screening test, this would be it. Unlike the breasts, for example, the ovaries lie deep within the body and are therefore less accessible to physical exam. The bimanual pelvic exam is also uncomfortable and the discomfort causes women to tighten the abdominal muscles, making detection that much more difficult. If you add factors such as obesity and scars from Cesareans, you find the examiner's ability to feel the ovaries decreases exponentially.

Ultrasound has been suggested as a screening technique since the 1980's. In the US, the leading proponent of transvaginal ultrasound for ovarian cancer screening has been Dr. Van Nagell's group at the University of Kentucky.

Some have tried utilizing blood markers such as CA-125. Most recently, the group at MD Anderson found that evaluating changes in the level of CA-125 over time and combining that with transvaginal ultrasound yielded promising results in finding more early ovarian cancers.

Others, however, have not met with similar success. The US Preventive Services Task Force, in fact, recommends not screening for ovarian cancer.

Later this year, The UKCTOCS,the largest randomized trial of screening will publish its results, hopefully shedding more light on this issue.

In the meantime, there are some women at significantly higher risk for ovarian cancer, those whose strong family history or genetic tests place in a high risk group. For this group of women, screening, with all its foibles, should be considered. For more information or to schedule an ultrasound, please call: (718) 925-6277.

Monday, April 28, 2014

Dad's Magic Moment

Everyone knows that the prenatal ultrasound provides the opportunity for mom to bond with her baby to be. Even before she first feels movement, seeing that tiny heart's beating, watching those movements, makes it all real. There is ample literature to describe the maternal bonding experience. But what about dad? Few have studied his reactions to the process - that is until now. Dr. Tova Walsh and colleagues at the University of Michigan interviewed 22 expectant fathers after they viewed a midtrimester ultrasound.

They found that the ultrasound experience was an important moment for men, establishing the reality of the coming child, and reassuring them that all was going well with the pregnancy.

It also caused the men to reflect on their roles in the life of mother and child, making it an important practical and psychological preparation for parenthood. The study noted that the men’s “plans and dreams alike extended beyond the immediate future of infancy and across the child’s lifespan.”

One man told the researchers, “Now that we know that it’s a girl, you know, now I’m thinking about ... walking her down the aisle someday, you know, (I’m) thinking that far ahead ... which is crazy, but I mean, it’s like my brain went from bringing her into the world and taking care of her and making sure she is taken care of (as) to her future and everything ...”

Another had more immediate worries: “I need to make sure I have a steady job because my child eating depends on me. If I don’t work, he don’t eat. And I’d rather my child eat before I do.”

Dads have magic moments too.

Walsh is a Robert Wood Johnson Foundation Health & Society Scholar at the UW School of Medicine and Public Health. Her study, “Moving up the Magic Moment: Fathers’ Experience of Prenatal Ultrasound,” is being published in the winter 2014 edition of the journal "Fathering".

For more information, or to schedule an appointment for an ultrasound, call: (718) 925 - 6277.

Friday, April 25, 2014

Abnormal Bleeding - My Doctor Scheduled An Ultrasound

Abnormal bleeding is one of the most common reasons for a woman to seek medical attention. About ten to thirty percent of reproductive age women will experience some form of menstrual disturbance. There is a whole laundry list of causes, including stress, underlying hormone imbalance, tumors, clotting disorders and even cigarette smoking. While a disturbance in the normal hormone fluctuation may be the most common reason, it is not the only cause. For this reason, an ultrasound is often performed, usually with transvaginal views. The transvaginal approach obviates the need for that overly filled bladder and can often more easily see pathology such as submucus fibroids or endometrial polyps. The thickness of the uterine lining can also be measured as well.

Sometimes, a 3D sonogram is done to note the architecture of the uterine cavity and to further delineate suspected intracavitary pathology. Finally, if either there is the suspicion of focal pathology or to amplify the findings from the sonogram, a saline sonohysterogram can be performed.

Depending on the results of these tests, further evaluation and treatment can be discussed. For more information or to schedule an ultrasound, call: (718) 925 - 6277.

Thursday, April 24, 2014

My Placenta Is Low-Lying. Now What?

Now that most pregnant women have a midpregnancy ultrasound, they are often alerted to findings of uncertain significance. One of the most common of these involves the placenta. A placenta is low-lying when the lower edge extends to within 2 centimeters of the internal cervical opening or os. This is different from a placenta previa which actually covers the internal os. A group of investigators at the Brigham and Women's Hospital in Boston reported on their experience with the eventual outcome of pregnancies complicated by these low placentas.

Here's the short answer: Most of these situations resolve by the end of the pregnancy.

In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks.

A small minority were not so lucky.

Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries.

So, about 98/100 times all turns out well. In about 2/100 cases, the situation persists. Moreover, a very few unfortunate women were found to have vasa previa, a condition in which fetal blood vessels actually cross that internal os in front of the baby. Think about that for a moment. If the baby descends toward the birth canal and puts pressure on these blood vessels, those vessels can tear, resulting in a fetal hemorrhage, often severe.

So what should be the plan if they do find a low-lying placenta during your ultrasound? The authors suggest a repeat sonogram after 28-30 weeks to confirm resolution, repeating again at 34-36 weeks if the situation remains the same. During those studies, a search for vasa previa can also be conducted.

So if you're told you have a low-lying placenta, you should be optimistic but should follow up. The late Ronald Reagan said it best: "Trust but verify."

For more information or to schedule an ultrasound, please call: (718) 925-6277.

Wednesday, April 23, 2014

New UK Project To Improve Prenatal Detection of Birth Defects

Presently, most if not all pregnant women undergo at least two sonograms during pregnancy for the purpose of screening for serious birth defects - the first at 11.5 - 14 weeks and the second at about 20 weeks. While some abnormalities are virtually always detected, many still are missed for a variety of reasons. For one thing, mom's with increased weight gain pose a technical imaging problem as the ultrasound frequency necessary for sufficient penetration may not yield the optimal resolution. Another factor is the fetal position - "if the baby has his back to the camera, you don't get a good picture." For these reasons and more, a groups of investigators at Kings College London are trying to see if technology can solve these issues.

Professor Reza Razavi and colleagues at King's College London, as part of King's Health Partners Academic Health Sciences Centre, have been awarded funding under the joint Wellcome Trust and EPSRC Innovative Engineering for Health scheme to develop a fully automated and computer-guided ultrasound system, which will allow midwives to acquire three-dimensional images of a whole baby in a much higher resolution than is currently possible. The team are also aiming to develop computer software that will be able to automatically analyse the images acquired. These techniques should substantially improve detection rates of congenital abnormalities.

Professor Razavi, who is Head of Imaging Sciences at King's College London and Director of Research at King's Health Partners, said: "Identifying birth defects at an early stage is essential both for medical professionals and for the parents themselves. Current ultrasound scans are relatively crude and many serious abnormalities are not detected, leading to these babies becoming very ill soon after birth, and substantial delay before a diagnosis is made and they can be transferred to a specialist centre for appropriate treatment.

"We are developing a radically new approach to fetal screening, largely removing the need for experts to acquire and interpret the images. It will allow the initial screening scans to be done in a few minutes, and provide a consistently higher detection rate for major abnormalities."

I wish them well.

For more information or to schedule an appointment for an ultrasound, call: (718) 925-6277.

Tuesday, April 22, 2014

Irregular Cycles May Be More Than An Annoyance

It's been a theory that infrequent ovulation may have some beneficial effect at lessening the risk for ovarian cancer. Women who take oral contraceptives, for example, have a lower incidence. This protective effect of irregular cycles may not always hold true. At the recent American Association for Cancer Research (AACR) meeting, Barbara Cohn, Director of Child Health and Development Studies at the Public Health Institute in Berkeley, CA presented some evidence that irregular cycles may actually be a risk factor for later development of ovarian cancer.

Background. Early detection of ovarian cancer has proved elusive, resulting in poor survival. This is the first prospective study to link a common reproductive condition to risk. Polycystic ovarian syndrome (PCOS) is an endocrine disorder, characterized by irregular menstrual cycles with long-term health consequences. Although some women with PCOS are infertile, the majority achieve pregnancy. It has been suggested that women with less frequent ovulation are protected, however, previous reports are inconsistent. Here we examine whether irregular cycling is associated with subsequent ovarian cancer death in a large prospective pregnancy cohort, The Child Health and Development Studies.

Methods. Subjects were 14,403 pregnant women recruited from the Kaiser Permanente Health Plan in 1959-1967 and followed for over 50 years. Menstrual irregularity, cycles >35 days or anovulation, was a proxy for PCOS, identified from medical record and self-report, at a median age of 26 years in 13% of women. Linkage to California Vital Statistics and National Death Index records identified 64 ovarian cancer deaths diagnosed at a median age of 69 years.

Results. Contrary to expectations, women with irregular cycles had a two-fold greater risk of ovarian cancer (Hazard Ratio=2.4; 95% Confidence Interval=1.3,4.5), independent of age, race, parity, and weight. This association was specific to cancer of the ovary - no association was observed for breast or uterine cancer - and it increased over the follow-up period (p=0.08 for time-dependence).

Conclusions. This is the first large prospective study of irregular cycles as an early marker of ovarian cancer. If confirmed, women with irregular cycles could be targeted for screening. This finding offers a strategy to search for antecedent ovarian cancer biomarkers, creating the opportunity for new early detection strategies.

It's not clear what exactly is going on here. Could later cancer be a side effect of abnormal hormone fluctuations? Could this be a receptor issue in the ovary iteslf? Or could the underlying cause of the hormone pathophysiology be the culprit? It's far too soon to know the answer but further research is clearly needed.

At this point, the best advice is to discuss your concerns with your gynecologist. For more information or to schedule an appointment for a pelvic ultrasound, please call: (718) 925-6277.

Monday, April 21, 2014

Maternal Weight And Stillbirth

This past week in the Journal of the American Medical Association, a statistical analysis of 38 studies of moms' weight either prior to pregnancy or in early pregnancy showed a relationship between maternal BMI and risk of stillbirth. The loss of a wanted pregnancy at any gestational age is tragic but the worst has to be a fetal death in the few weeks prior to birth. The nursery has been set up. The birth announcements prepared. Often, the room is packed with gifts from the baby shower. All this adds to the immense suffering of the loss of a child.

So how is maternal weight linked to stillbirth? The authors suggest the possibility that the increased amount of adipose tissue may exert metabolic effects which affect placental function. We already know the effect of weight, fat, and type 2 diabetes, for example. A similar altered biology may be at work here as well. Another possibility is that heavier women become less sensitive to fetal movement and are thus less apt to pick up on the signals of decreasing fetal movement. The lack of this alarm mechanism may miss that narrow window for life-saving intervention.

So what should a woman considering having a baby do in light of this information? The best, obviously, is to get as close to ideal body weight as possible prior to conception. When this is not possible, early prenatal care would be essential, with a special emphasis to nutritional counseling. As pregnancy enters the "home stretch," certain tests of fetal well-being can be considered - monitoring or non-stress tests, serial ultrasounds for fetal growth, and biophysical profiles. Additionally, fetal kick counts can be done at home which require no sophisticated equipment.

Moms to be should voice any concerns with their Obstetricians. For more information, or to schedule an appointment for an ultrasound, you can call my office at: (718) 925 - 6277.

Friday, April 18, 2014

JWoww's Pregnancy Scare

Jenni Farley aka JWoww of "Jersey Shore" fame (or infamy) described the impact of learning about a minor abnormality in her prenatal ultrasound.

Jenni reported on her blog recently that a routine ultrasound turned into a moment of pure terror when her doctor informed her that he identified what may be a cyst on the fetus' brain. "At this point I honestly can't tell you what he's saying because I go numb and tears are just flowing," Jenni wrote of the incident. A scary diagnosis, to be sure, but using her trademark tenacity, Jenni secured an appointment with a specialist who delivered some good news: Jenni writes that the new doc informed her: "It's called choroid plexus cyst and over time the cyst should go away." She added, "Honestly I was happy but still my heart felt heavy. And even though I know I did nothing to cause it, I felt guilty and so helpless." Well, apparently Jenni has developed a skill for suspenseful storytelling during her months of sobriety because she ends the blog post by revealing that this all happened several weeks ago: "Fast forward to this check-up which brings me to 25 weeks aka 6 months," JWoww writes. "My daughter's cyst went away!"

There are a variety of findings whose significance seems relatively minor to obstetricians and sonographers yet strike fear in the hearts of moms to be. Choroid plexus cyst is one of these findings. Choroid plexus cyst or CPC is a small fluid-filled structure found in the choroid tissue in the ventricle of the developing fetal brain. CPC's are found in about 1 - 2% of all fetuses so these are quite common. While earlier descriptions found an association between CPC and Trisomy 18 (an extra copy of chromosome 18,) this association has not panned out in further investigations. CPC's do not cause swelling on the brain or hydrocephaly. They are not in and of themselves a major abnormality and have no effect on mental development. In the absence of other risk factors for chromosome problems, eg. age, family history, previously affected children, or other malformations, these should not warrant either worry or further investigation. In fact, most, as in Ms. Farley's case, resolve spontaneously.

For more information, or to schedule an appointment, please call my office: (718)-925-6277.

Thursday, April 17, 2014

Bloody Cycles

The transition to menopause is thought to consist of increasingly prolonged intervals between menstrual flow. The recently published SWAN study, however, suggests that early in that transition, the frequency of heavier and longer cycles may be far more common.

... We found that the large majority of women in SWAN, over 50% of whom were not white, reported menses duration of 10+ days, spotting of 6+ days and/or 3+ days of heavy bleeding during the MT. The likelihood of experiencing these menstrual bleeding events varied by race/ethnicity, BMI and reported uterine fibroids. These data confirm that two types of bleeding, longer menses with more days of spotting and heavier menses, occur in most women during the MT. These data provide clinicians and women with important normative data regarding the expected frequency of these bleeding changes during the menopausal transition, data that may facilitate decision-making in clinical practice. Such information, particularly when coupled with the emerging information about duration of the stages of the menopausal transition, will be of great value to women in this life-stage who wish to be active participants in their own health care. Such normative data can greatly alleviate concerns about midlife changes in ones bleeding patterns and facilitate coping with what, in most cases, will probably be a time-limited experience. Further research on the correlation between such bleeding and documented pathology is warranted to better support recommendations for watchful waiting versus clinical intervention.

Changes may be marked by differences in estrogen and progesterone production, signifying either greater or fewer ovulatory episodes. These changes may also signify underlying pathology such as uterine fibroids, adenomyosis, polyps or even hyperplasia. The last is especially troubling as prolonged estrogen stimulation without the periodic interjection of progesterone may lead not only to unscheduled bleeding but in a few cases, cancer.

A transvaginal sonogram is a simple test to gauge the thickness of the endometrial lining and should be considered as an integral part of the workup for abnormal bleeding. For more information, or to schedule an appointment, you can call my office at North Shore LIJ: (718) 925-6277.

Tuesday, April 15, 2014


It's really something when you receive props from your peers. Over the weekend, the Medical Society of the State of New York had its annual House of Delegates. At that meeting, officers were elected. One of the new officers is yours truly.

Tarrytown, NY (4/14/14)--Arthur C. Fougner, MD, was elected Assistant Secretary of the Medical Society of the State of New York (MSSNY) at its 208th annual House of Delegates (HOD) meeting in Tarrytown, NY, on April 12. Board certified in Obstetrics and Gynecology, Dr. Fougner is Chief of Gynecologic Ultrasound at North Shore LIJ.

A graduate of the University of Notre Dame, Dr. Fougner earned his MD degree from Tulane University School of Medicine. He completed his postdoctoral training in OB-GYN at St. Clare's Hospital, NYU Medical Center, Bellevue Hospital and Booth Memorial Medical Center.

An attending OB-GYN at North Shore University Hospital, Long Island Jewish Medical Center and Forest Hills Hospital, Dr. Fougner is an assistant professor of OB-GYN at the Hofstra North Shore- LIJ School of Medicine at Hofstra University and formerly an assistant clinical professor at SUNY Stony Brook and Albert Einstein College of Medicine.

Dr. Fougner is a member of the International Society for Ultrasound in Obstetrics and Gynecology and of the American Institute of Ultrasound in Medicine.

Active in organized medicine since 1979, Dr. Fougner served as MSSNY's Commissioner of Communications from 2012-2013. He previously served as MSSNY's Assistant Commissioner of Public Health from 2009-2010 and Commissioner of Governmental Affairs from 2010-2012. He serves as both a trustee and a Councilor for the Medical Society of Queens.

Founded in 1807, the Medical Society of the State of New York is the state's principal non-profit professional organization for physicians, residents and medical students of all specialties. Its mission is to represent the interests of patients and physicians to assure quality healthcare services for all.

I guess every organization needs a Marv Throneberry.

I am truly humbled.

Monday, April 7, 2014

Hepatitis C: To Screen Or Not To Screen, That Is The Question

Recently, NY State passed a law requiring screening for Hepatitis C be offered to all patients born between 1945 - 1965. Hepatitis C is a potentially fatal disease which can attack the liver silently over time. It is thought that as many as 1 in 30 "Baby Boomers" could be infected with the virus. For these reasons, screening this group makes sense. But of course, as always, there is a catch. It seems the cost of treatment for those infected is prohibitive for all but those on research protocols, better than platinum insurance plans, or those with incomes in the Warren Buffett range. Sovaldi, a new drug for Hep C treatment, costs about $84,0000 for a 12 week treatment.

What can be done about the cost? Right now, not much save to check with your insurer about treatment coverage and copay, etc. Still think screening asymptomatic folks is a good idea? For each individual, the answer may be different. Before asking a question, it's always best to know what you'll do with the answer.

Tuesday, April 1, 2014

You Now Have Health Insurance - Now What?

Now that Open Enrollment in Individual Health Plans is over (for most folks,) what do you do now?

For starters, go to either the webpage or the healthplan's book and check out what it is you actually purchased. You need to know three numbers - your premium, of course, your co-pay, and your deductible. When you selected your plan, you should have noted each of these numbers but many haven't. Please note them now for the true cost of your plan is not merely the monthly premium.

Now look at the "Provider Book" or the list of so-called Healthcare Providers on the plan website. Being a physician, let me point out that I didn't go to "Provider School." But that's a matter for another day. If you have an ongoing relationship with a doctor, make sure that your doctor is on the network list. If you can't find this information, call the plan's info number and find out. Again, you should have checked this out before choosing a plan, but that's water under the bridge now. Most if not all of the new individual plans set up under the "Affordable Care Act" are In-Network only plans and these networks are usually quite narrow with fewer choices. If after calling the plan and/or your doctor's office, emailing the plan, or sending out an APB, you still can't find out if your doctor participates in this plan, alert your state's insurance department. In NY State, that would be under the Department of Financial Services. Unfortunately for many, you may have to choose a new Primary Care Physician and you should do so asap. If you have a chronic illness for which you are undergoing treatment, you also have to find out if your specialist doctors are "in network" as well. If not, sadly, you will have to choose whether to pay a rather large bill for care or switch to a whole new set of treating physicians and start from square one.

Here's the problem - these new plans are for the most part "In Network" only. That means that whatever benefits your plan involve services provided only by In Network Providers. There are NO Out of Network Benefits for most Individual Plans save for a few scattered exceptions. If you need to go "Out of Network," the insurance version of "Off the Res," NONE of those services will be covered unless you get a special dispensation from the plan's hierarchy, usually the Medical Director. For example, if you have advanced colon cancer and wish to be treated at a Cancer Center like NY's Sloan Kettering which you find is not in your network, expect that you will be responsible for the entire bill. Moreover, and here's the kicker, none of the money you shell out will count toward your plan deductible - zip, zero, nada.

If you do not think this is fair, you are not alone. Unfortunately, the law isn't about fairness and it is what it is. My suggestion is that while you're still upset, you contact the State Insurance Dept (Again, in NY State, the Dept of Financial Services) and register a complaint. You should also call your state legislator and your local news consumer affairs reporter. The more light you shine on this issue, the sooner this will be dealt with. Everyone in NY State I've spoken with has acknowledged this problem with the individual plans.

Now, you may luck out. You may be healthy, not need care, and, if you do, find In Network doctors who are competent, caring and professional to handle your medical issues. But it shouldn't be left to luck, chance or God, should it?

Realize also that many doctors are in the same boat. It seems the plans were not so forthcoming at giving doctors the choice of either joining an insurer's new plan networks or informing them that they were either in or out of the new narrow network. This is a recipe for chaos. Also, if the plan lists a doctor as In Network but the doctor really is not, you will assuredly get a bill. And as I pointed out above, that bill will not count toward your deductible.

In reality, most of these plans are the worst of all worlds - an amalgam of an old HMO with a High Deductible Plan. There's little anyone can do about this situation right now, unfortunately. If you do run into a problem, please don't take it out on the doctor. Most of the doctors I know have been pleading with the states to do something as the end of enrollment approached. During the Second World War, the motto in Britain was "Keep Calm And Carry On." Both doctors and patients will need to do that. However, that doesn't mean you shouldn't complain. You should. For sure, it really is the squeaky wheel that gets the grease.

One last suggestion - other resources you should consider are your County and State Medical Societies. They have dedicate staff who are well-acquainted with the situation and are well-positioned to get you advice and also, to pursue your issues as they meld with their doctors' issues.

"Fasten your seatbelts, it's going to be a bumpy night." Bette Davis

Monday, March 24, 2014


There are many disruptions in the flow of care these days, especially in the Emergency Department. However, Disruptive has taken on a whole meaning lately, what with the proliferation of mobile and even wearable tech. Today, I cam across this post by Dr. Teresa Wu..

...As you are supervising two of your residents putting in bilateral chest tubes, your eager medical student runs up to the trauma bay with a pair of Google Glass. You are researching ways to incorporate wearable technology like Google Glass into your clinical practice and medical education so you and your medical student have a few pairs of Glass with you at work. You put on Glass and ask your medical student, “What can I help you with?” He informs you that your senior resident wants you to take a look at an ocular ultrasound of a patient he staffed with you a little while ago. He knows you are going to be tied up in the trauma bays for quite some time and wants to know if he can discharge the patient with ophthalmology follow up.

...You turn on Google Glass and link to your senior resident who is also wearing Google Glass while performing the bedside ocular ultrasound (Image 1). Through Glass you can see the ultrasound screen as he views it. What does the B-mode ocular ultrasound demonstrate? What’s the patient’s diagnosis?

Bedside Ultrasound meets Google Glass. Read the whole thing.

Just Wow!

Wednesday, March 12, 2014

EMR: Promises Unfulfilled

Welcome to my nightmare.

My practice is limited to consultative ultrasound in Obstetrics and Gynecology. It's been that way since the mid 1980's. My routine used to be simple. A medical assistant or sonographer would escort a patient into the exam room and take a history, inserting pertinent information on a report form. Patient identifiers would then be entered into the name and data fields on the ultrasound screen. After seeing that the patient was properly set up and doing some preliminary scanning, I would be called in. After asking the patient a few questions and a little small talk, I would then perform the ultrasound exam. I would give the patient a synopsis of my findings sans medicalese and then leave to write a preliminary report. The chart would then go to for transcription and from there to billing. Life was good.

Then I joined a large health system which had incorporated all the 21st century technology, including both an EMR and Ultrasound Reporting software as well, neither of which talk to each other. My routine is considerably different.

Now I am either handed a stack of demographic info or obtain my own demographic info off a computer screen. I then enter this data into another computer screen. This is invariably incomplete as it's usually unclear who referred the patient and to whom the report will be sent. A medical assistant fetches the patient and escorts her into the exam room, but usually I am the one to enter the info into the data field in the ultrasound machine. I am most often the one now who takes patient's history. I also figure what needs to be done and in what order. I then leave the room so the patient can change. After an appropriate interlude, I return and perform the ultrasound examination. I again give the patient a synopsis of my findings and then leave to write my report.

I return to the computer and then finish entering the demographics and some historical data. Because the images are usually not incorporated with a patient's demographics (remember, I couldn't enter that until I spoke with the patient,) I have to "attach the images" to a patient. Then I am ready to write my report. I pull up an image and input data from it into the appropriate field in the report page. I find some fields arranged in a nonintuitive fashion. I entered descriptive information by keyboard now rather than pen as I am now the transcriptionist.

Periodically, I have to launch an additional program to find the appropriate diagnosis codes so the examination I performed can be justified. The present diagnosis code system of about 14,000 codes is set to switch to a whole new system featuring 70,000 codes, which will not make my life any easier. After completing the report and seeing that the exams are entered, the indications are entered and they all are coded, I electronically sign the report and then send it to a network fax driver. Unfortunately, because many of these reports find themselves mysteriously transferred to Altair 4, I also print the report and then walk over to a fax machine to do that myself. In some cases, when the patient's physician is in the same group of offices, I will leave the report with the office staff to be scanned into the EMR. (Remember, I told you the EMR and the reporting software don't talk to each other.

Looking at the two practice systems, I ask myself which system enhances productivity? I used to be a doctor. Now I not only see patients, but I'm a transcriptionist, a biller and a coder as well. And this in a health system with an army of billers and coders. I am not the only practioner with these issues. I can tell you that the increased time subsequent patients wait for their exam because I am dealing with tech issues is not boosting my patient satisfaction scores. But that's a topic for another day.

Sunday, March 9, 2014

Quo Vadis

NJ Medical Society Past President Ralph Kristeller MD gives Fee For Service some historical perspective.

Fee For Service does not operate in a vacuum. It operates in an environment.

My apology in advance for this long email; however, the subject “Fee For Service” urgently requires an airing.

In January 1963, after 8 years of active duty in the US Air Force – the largest HMO in the world at the time, I completed my obligation under the “doctor draft” law. I returned home to Millburn NJ where I rented space in a building almost fully occupied by physicians in solo or 2 or 3 partner practices and opened my office for the solo practice of Internal Medicine. Having entered Military Service the day I graduated from Medical School, I had no experience as a physician in civilian life. An older seasoned Internist gratuitously told me “Ralph it will take you a year to establish your “fee schedule.” How correct he was. Nevertheless I began by charging $5.00 for an office visit, $10.00 for a house call $15.00 for an EKG and $20.00 for a PA and Lateral Chest X-ray.

My cost for doing business included my rent, salary for a part time secretary, interest on my loan, premium payments for disability insurance and premiums for a medical negligence policy. The premium for the negligence policy was less than $100.00 a year.

I applied for membership in my County Medical Society. In order to qualify for full membership I was required to accept call by roster for 2 years. This entailed taking call for the Society’s answering service.

Patients who had an “emergency” and did not have a physician called the County Medical Society and I was required to respond with a house call. There were, as yet, no Emergency Rooms. Other than Blue Cross/Blue Shield, a.k.a the Surgeons Plan because it only covered hospitalization, there were no third party payers. It was a cash and carry system IF the patient had the cash. Otherwise it was Pro Bono.

In addition I applied for membership on the Staffs of two local hospitals. Again there was a requirement for participating in the hospital’s “clinic” which met, as I recall, every 2 weeks. This of course was also Pro Bono.

Since “time is money” Pro Bono must be considered a cost of doing business and therefore factored into my fee schedule. Accordingly, my challenge was: If I set my fees too low I would be in financial difficulty, if I set my fees too high, I lost the patient, the patient’s family and any potential patient referrals. Furthermore, if I failed, in the patient’s opinion, to provide value for my fee, the patient walked across the hall and made an appointment with an older more established physician. Parenthetically, I garnered some patients who walked across the hall to me from my competitor because of patient dissatisfaction. In my view this real world experience is “fee for service” in its pure form.

In 1966 Title XVIII, Medicare, became the law of the land. It promised non interference by government in the practice of medicine and non interference in the fees charged by physicians.

Well, everyone knows what happened and is happening to that promise.

Most importantly failure to keep a promise to the public by government was a little noted C change in the culture of our country and our country continues to pay a very dear price for that change.

To continue - In the 1970’s the Plaintiffs Bar found the deep pockets in negligence litigation.

The cost of doing business for physicians escalated tremendously due to the steep rise in the cost of negligence policy premiums. Paradoxically physicians were conveniently blamed for charging too much for their services. In addition physicians were accused of ordering unnecessary tests in order to increase their incomes. However, what was never brought forth was the astute observation by Mr. Chuck Hardwick when he ran unsuccessfully for Governor of NJ. He stated: “The power to sue is the power to terrorize.” Extra testing as a defense against terror by rational physicians was mischaracterized as “unnecessary testing” by politicians for their own self interest. It has been estimated that the added cost to our current health care system, due to “mal practice” expenses, is 50 Billion dollars a year. For politicians the medical tort system is the third rail and they refuse to touch the issue. However, unassailable studies by Professor Localio et al have shown that our medical tort system does almost nothing to compensate truly injured patients. Meanwhile for the country it creates an economic disaster.

By manipulating the words, and thereby poisoning minds, politicians captured public attention and focused the debate on the need to control cost, implying that physician fees are the main culprit.

However, the facts are that Physicians have been under price control ever since the promise of non interference by Medicare was broken. More importantly there has been no attempt to control practice costs which are the main ingredient in physician fees. Rather it has been politically profitable to blame physicians rather than deal with the core issues that contribute to the real cost of our healthcare system.

In short the “Victims (physicians) Are Blamed For the Crime.”, quality of medical care, as defined in AMA policy, continues to deteriorate, the lobbyists and the politicians continue their lucrative careers and the country is, according to the polls, going in the wrong direction.

Finally: Two thoughts come to mind:

"No one can make you feel inferior without your consent." Eleanor Roosevelt

More to the point:

Ann Landers adage: "If you act like a doormat, don’t be surprised when people wipe their feet on you."

Ralph Kristeller

Well said, Dr. Kristeller.

Tuesday, March 4, 2014

Finding The Cancer In A Haystack

March is UK Ovarian Cancer Awareness Month. (It's September in the US.) This year, approximately 14,000 women will be killed by this dread disease. While screening tests have reduced the death rates from other cancer, the same cannot be said for ovarian ca ncer. The search for the appropriate screening regimen for most women remains elusive.

Newer technologies may yet impact on the detection rate. Recently, investigators from MD Anderson Cancer Center reported on a new wrinkle in a commonly utilized blood test, the CA125. What they found was that rather than a specific trigger value, the rate of change over time is a better predictor of risk.

While ovarian cancer is thought to be a "silent killer," this may be a misconception. Another development is a report that Symptom Triggered Screening may reveal many women with early stages of the disease whi le reduce unnecessary surgeries. Anderson et al found that frequent pelvic or abdominal pain, bloating, or feeling of fullness while/after eating of relatively recent onset warrants further investigation and may be life-saving. CA125 blood test and a vaginal ultrasound (a regular bimanual pelvic exam is less able to find abnormalities) would be reasonable diagnostic investigations. Again, often it is the rate of change of CA125 that is most diagnostic.

Some women with BRCA1 gene mutations are at extremely high risk and should consider Risk Reductive Surgery.

There are also reports that an aspirin a day can keep the oncologist away. Daily low dose aspirin may reduce ovarian cancer risk by up to 20&.

Hopefully one day soon, we will make real progress in reducing the toll of ovarian cancer.

For more info, feel free to leave a message in the comments section. To schedule an appointment for an ultrasound in the NYC are, call (718) 925-6277. We are all in this together.

Thursday, February 27, 2014

A Better Blood Test For Down's Syndrome?

Presently, moms-to-be are offered prenatal screening for a third chromosome number 21 by either blood tests, ultrasound, or a combination of the two. Recently, a newer blood test was cleared for use in women at higher risk - eg. older women or those with abnormal ultrasound findings. The use of this test, involving examining the cell-free dna in mom's circulation, for women at lower risk is still considered investigational. As such, the test, called Noninvasive Prenatal Testing or NIPT, in low risk women is not recommended by specialty societies and not covered by insurance plans.

Yesterday's publication by Drs. Diana Bianchi, Rajeevi Madankumar and many other investigators in the New England Journal of Medicine brings this test one step closer to more widespread usage.

In conclusion. our head-to-head comparison showed that noninvasive prenatal cfDNA testing performed better than standard screening methods, with an improvement by a factor of 10 in the positive predictive value for trisomy 21 in our predominantly low-risk patient population. The major advantage of using cfDNA testing was the reduction in rates of false positive results. A consideration of cost-effective ways to incorporate cfDNA testing into general obstetrical practice26 is beyond the scope of this study. Our findings, however, suggest that cfDNA testing merits serious consideration as a primary screening method for fetal autosomal aneuploidy.

It is still far to early to recommend widespread introduction of this test. The study was not meant to be a head to head comparison of present screening practice vs NIPT. The test was less predictive in one major chromosome syndrome other than Down's. Nevertheless, NIPT's lower false positive rate would mean fewer anxious moments, fewer invasive procedures, and fewer losses of normal wanted babies.

Faster, please.

Monday, February 17, 2014

Should Ultrasound Replace The Bimanual Pelvic Exam?

For complete disclosure, let me point out that my practice is limited to consultative ultrasound, having ceased the practice of clinical gynecology in 1986. When I trained at Bellevue in the late 1970's, even asking such a question would have outted you as a heretic punishable by intense re-education. But medicine swings like a pendulum do and today, this is a fair question. What's changed? The dual developments of portable real-time ultrasound followed by the vaginal transducer have swung that pendulum toward the imaging side. While sonograms have been thought of as the stethoscope for the obstetrician, the vaginal probe has greatly facilitated the pelvic exam. Further, there is now accumulated evidence to highlight the superiority of sonography to evaluate the female pelvis. One eye-opening study was by Padilla et al in 2000, assessing the predictive value of pelvic exam under anesthesia. Conclusion?

Bimanual pelvic examination has marked limitations for evaluating adnexa, even with ideal circumstances. Experience during postgraduate training in gynecology did not seem to improve examination accuracy. Patient characteristics such as obesity, uterine size, and abdominal scars limit the accurate palpation of the adnexa.

Now one reason why the pelvic exam is decidedly unpopular with patients is that, setting aside its invasiveness, it's uncomfortable. The more discomfort felt results in more patient's tensing the abdomen, causing the examiner to press harder and causing more discomfort. In this particular study, anesthesia removed the pain - pressure cycle from the equation and still found the bimanual examination lacking.

So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

Similarly, sonography has been shown to be superior to bimanual exam in assessing gestational age in the first trimester and facilitating the management of inflammatory disease. In the assessment of uterine fibroids, an experienced examiner fared as well as sonography except in obese patients. As more and more Americans are dealing with obesity, the pendulum here again favors sonography.

My colleague from NYU Dr. Steven R. Goldstein suggested incorporating endovaginal sonography into routine gynecologic examinations. That time is long overdue.

To contact me or to schedule an appointment, please call my office:(718) 925-6277