The Death of Queen Jane


One of the saddest songs from the Coen Brothers wonderful new movie “Inside Llewyn Davis” is “The Death of Queen Jane”.

It is a traditional folk song that Davis (Oscar Isaac), on the down and out from the NYC folk scene, chooses to sing in an impromptu audition  for Chicago music producer Bud Grossman (F. Murray Abraham). Given that Davis is still mourning the death of his musical partner and reeling from the knowledge that he has fathered a child, the song choice is not surprising. But like almost every choice Davis makes in this movie, it is a poor one.

The song is the legend of King Henry’s second wife Jane Seymour, who died in 1537 after giving birth to Prince Edward I. After laboring for nine days, her attendants so tired that they can no longer attend her, the Queen begs King Henry for a Cesarean section, which he at first refuses for fear of losing both mother and child – “If I lose the flower of England I shall lose the branch too”. But eventually, the Queen swoons, a C- section is done, and later, she dies.

Grossman listens intently as Davis sings (watching Abraham is itself worth the entire film) and when the song is done, utters a single sentence –

“I don’t see a lot of money here.”

He’s right, of course. Maternal death doesn’t sell records. It’s just too depressing.

What is even more depressing than Llewyn Davis’s song choice is the fact that today, almost 500 years since the death of Queen Jane, some 350,000 women worldwide still die each year as a result of giving birth, almost all from preventable causes.

That rate is half what it was a decade ago, but we still have a long long way to go before childbirth is for every woman the joyous event it should be.

Lest you think maternal deaths are Africa’s problem, know that maternal mortality here in the US has actually doubled in the past 25 years. Despite all our advanced and expensive healthcare, the US ranks 50th in the world in maternal mortality, with the highest rate of all the developed countries. The major causes of maternal death in the US are preeclampsia, hemorrhage, embolisms and cardiovascular disease, with death rates 3-4 times higher in African American women.  Reasons for the rise are complex, but include increased C section rates, multiple births and higher rates of underlying maternal diabetes and cardiovascular disease.

Approaches to reducing maternal morality here in the US include reduction in C section rates, protocols for rapid response for transfusion for maternal hemorrhage, and team training to respond to obstetric emergencies. Here in New York State, ACOG has instituted the Safe Motherhood Initiative, developing and implementing standardized protocols for tackling maternal hemorrhage, hypertension and venous thromboembolism in hospitals across the state.  Using lessons learned from the airline industry, states are beginning to take a  centralized approach to data collection and response to adverse events.  It’s a multi-pronged approach to a complex problem that has the potential for a real and lasting impact.

Inside Llewyn Davis is a fabulous movie that will be getting lots and lots of press in the upcoming month as Oscars approach. Here’s hoping that some of that limelight will get cast on the problem of maternal mortality, and lead to conversations about more than just folk music.

The Death of Queen Jane

Queen Jane lay in labor full nine days or more
‘Til her women grew so tired, they could no longer there
They could no longer there

“Good women, good women, good women that you may be
Will you open my right side and find my baby?
And find my baby

“Oh no,” cried the women, “That’s a thing that can never be
We will send for King Henry and hear what he may say
And hear what he may say”

King Henry was sent for, King Henry did come
Saying, “What does ail you my lady? Your eyes, they look so dim
Your eyes, they look so dim”

“King Henry, King Henry, will you do one thing for me?
That’s to open my right side and find my baby
And find my baby”

“Oh no, cried King Henry, “That’s a thing I’ll never do
If I lose the flower of England, I shall lose the branch too
I shall lose the branch too”

There was fiddling, aye, and dancing on the day the babe was born
But poor Queen Jane beloved lay cold as the stone
Lay cold as the stone

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More Reading

Penne with Vodka Sauce

A guest post by OBS Housekeeper, pasta cook extraordinaire and sister of TBTAM.

penne vodka 5The kids are all together for the first time in months and we have just 5 days until Christmas so it’s time to decorate the tree. In need of something simple and delicious for dinner I hit the freezer for some Vodka Sauce that I had made a few weeks ago.

penne vodka 1

Pair it with penne,

Penne vodka 2

a Caesar saladpenne vodka 3 and crusty Italian bread and dinner is served.

It must have been tasty because there were no leftovers! And the tree couldn’t be more beautiful! Happy holidays!

PENNE with VODKA SAUCE
Vodka sauce traditionally does not include garlic, but OBS housekeeper says “What’s a pasta sauce without garlic?”

Ingredients
1 stick Butter
1 Onion, finely diced
3 cloves garlic, finely chopped
1 Cup Vodka
2 – 28 ounce cans Crushed Tomatoes
1 pint heavy cream

Directions
1. In a skillet over medium heat, saute onion in butter until slightly brown and soft, add the garlic in the last munite or so.
2. Pour in vodka and let cook for 10 minutes.
3. Mix in crushed tomatoes and cook for 30 minutes.
4. Pour in heavy cream and cook for another 30 minutes.
5. Toss sauce with penne.
6. Add plenty of freshly grated parmesan cheese.
7. Enjoy!

The Forty Part Motet & Thoughts on Choral Singing

40 Motets Cloisters NYC

Thanks to my friend Rachel, I visited the Cloisters on the final day of Jane Cardiff’s stunning installation “The Forty Part Motet“. I’m sure I had a very different experience than what Cardiff imagined when she set up 40 speakers around an empty room, each one playing the voice of one of the singers of the Salisbury Chorus performing Thomas Tallis’s Spem in Allum.


Cardiff meant for listeners to move freely about the space, sampling the piece from the vantage point of the different singers in the choir, then stepping into the center to feel them all hit you at once.

“While listening to a concert you are normally seated in front of the choir, in traditional audience position. With this piece I want the audience to be able to experience a piece of music from the viewpoint of the singers. Every performer hears a unique mix of the piece of music. Enabling the audience to move throughout the space allows them to be intimately connected with the voices. It also reveals the piece of music as a changing construct. As well I am interested in how sound may physically construct a space in a sculptural way and how a viewer may choose a path through this physical yet virtual space.

I placed the speakers around the room in an oval so that the listener would be able to really feel the sculptural construction of the piece by Tallis. You can hear the sound move from one choir to another, jumping back and forth, echoing each other and then experience the overwhelming feeling as the sound waves hit you when all of the singers are singing.”

But on this last day of the exhibit, the crowds were too large to allow for free movement without disturbing others. Thus, I stood in one place for the entire piece, and then to listened to it 7 more times from 7 different vantage points in that glorious space. Only once did I make it to the center of the room, but found my favorite spot was in the back in front of a baritone, where I could feel the music starting far away then moving towards me, till finally I was in the music.

But no matter where I stood, I experienced an incredible feeling of community with the others around me, as we all were transfixed by the hauntingly beautiful voices and themes of Tallis’s music. Even small children were stunned into glorious silence, their wriggling stopped, their heads upon their parent’s shoulder as they stared dreamily upward.  As I looked around the room, the swell of the music combined with that feeling of shared emotion literally drove me to tears. I have rarely felt so connected to a roomful of strangers as I did in the midst of that music.

As a choral singer, I should be able to say that I experience this feeling of collective joy frequently, but the truth is that I don’t. When I’m singing, I’m usually too focused on getting the notes and the entrances right, counting along with my finger on the score, reading the notes I’ve written along the staff that remind me to slow down, or speed up, or watch my pitch, or the little eyeglasses that tell me to look at the conductor for an ending or change in tempo. It is rare that I experience the swell of emotion that comes from the experience of being in the midst of a collective voice.

But then it happened – on the very same evening as my visit to the Closters – when, as chance would have it, I was performing the Durufle Requiem with my chorus in our annual winter concert.

I had been standing at the back of my section for the rehearsals, a piece of cotton in one ear so that I could hear my own voice in the crazy acoustics of the space, afraid that I would be off pitch, knowing that it only takes one slightly off note from anywhere to throw me off, trusting only the organ to keep me from going sharp or flat.  But just before the performance, my fellow Soprani begged me to squeeze in between them so they could hear me – since I had only recently sung the same piece with the Cornell Music & Medicine Chorus, I knew it relatively well and had the entrances right, and they were counting on me for that.  So in the performance, I did as they asked. And whether it was because they got the entrances from me, or I got the pitch from them, or we all finally had had enough rehearsal to know the piece well, it was the best performance we’ve ever given.

And there were moments – not enough, but a few – where I felt confident enough in my singing to let myself listen for it, and there it was – that swell of emotion that comes from shared vocalization. That point in the Kyrie when we echo one another , then join in together. The soaring highs of the Libera mi. And those moments in the In Paradisum when we sopranos totally nailed our group solo.

Those moments of joy in choral singing really only come when you are confident enough in the music to let go and feel. And I got there because, between the two choruses and two performances, I had finally had enough rehearsal to get to that place.

I’m going to remember this next season, and dedicate myself to really learning the music early on. Woodshedding, we call it. The rehearsing you do on your own with the score and a piano or rehearsal CD to really learn the music. It’s  a lot of hard work, hours really, outside of the hours already spend in group rehearsal.

But the payoff ? It’s glorious.

Nuvaring – Weighing the Risks & Benefits

NuvaRing_compressedNOTE – THIS POST HAS BEEN UPDATED TO INCLUDE TWO NEW RESEARCH STUDIES THAT DO NOT FIND AN INCREASED CLOT RISK AMONG NEW RING USERS

You’re probably here because you read the recent article in Vanity Fair that highlights the stories of young women who suffered blood clots while using Nuvaring, and asks why this method is still on the market.

You may be wondering whether or not you should stop using the ring, and worried about what risks you’d be taking if you kept on using it.

I’m not going to get into the Vanity Fair article itself, except to say that highlighting individual stories, while making compelling reading, does little to really educate women about their own risks. Making Pharma into the bad guy is also compelling, and given how they behave in general, pretty easy to do.  But compelling reading does not necessarily make for good medical advice. Which is what women really need.

So let’s see if I can help out a bit with that.

As I see it, this issue at hand, is this – are the risk of blood clots, which are inherent in any estrogen-containing birth control method, higher in Nuvaring than in other birth control methods you might choose to use? If so, is that difference big enough for you to consider using something other than the Ring?  Or are the benefits you may get from using the Ring (convenience, compliance, and for some women, steadier hormone levels) enough to outweigh the increased risks?

 LET’S START WITH THE BASICS

You need to know a few things before we start.

1. If you have sex, unless you use birth control, you will most likely get pregnant.  The odds are about 80% in a year. So unless you plan on being pregnant, you’ll need to use something for birth control. That something is most effective if it is either hormonal or an IUD.

2. On average, your annual chance of getting a blood clot is about 3 in 10,000 if  you don’t use birth control.  This background risk varies with age, increasing from a low of 0.7 per  10,000 at age 17 to about 6 per 10,0000 at age 45. Other factors can increase your risk even further – genetics, obesity, and varicose veins can double the background risk at any given age.

3. Having a baby is always riskier that using birth control.  The risk of blood clots in pregnancy is the highest risk any woman can take, ranging from 4-28 times the background risk.

4. All estrogen containing birth control methods increase the risk of blood clots. Quantifying that risk is difficult, but it ranges from 3-6 times the background risk, depending on which study you quote and which method you are comparing. The risk is related to both the dose of estrogen (the higher the dose, the higher the risk) and the type of progestin used.

5. First and second generation pills have the lowest clot risk – These pills contain levonorgestrel, norethindrone and norgestimate, and their clot risk is about 3 times higher than the background risk. Newer pills using gestodene, desogestrel and drosperinone  have risks about twice that of levonorgestrel pills, as do the Nuvaring and Patch.  That risk is about 6 times the background risk.

6.  Overall, your chance from dying from estrogen-containing birth control methods is about 1 in a million.  

7. Birth control has benefits as well as risks. Birth control pills, the Ring and the Patch lower the risk of ovarian and uterine cancer. Birth control pills also lowers the risk of colon cancer and do not increase the lifetime risk of breast cancer. Birth control pills, the Nuvaring and the Patch are effective treatments for heavy menstrual periods, endometriosis, PMDD, acne, menstrual cramps and fibrocystic breast disease.

8. If you don’t want to be pregnant, and don’t want the risk of estrogen containing birth control, there are other methods you can use. These include condoms, progesterone only pills, spermacides diaphragm, and IUD. These methods each carries their own set of benefits and risks, but do not cause blood clots.

NOW, WHAT ABOUT NUVARING? 

A large Danish study suggested that the risk for a blood clot among users of the Nuvaring is about twice that of older levonorgestrel-containing pills, and is about the same as that from using the Patch, Yaz or pills containing desogestrel.  Initial data from the FDA in 2011 suggested the same thing.

However, when only new hormonal contraceptive users are studied, that increased risks is not seen. Two newer studies – one funded by the FDA, the other by the ring manufacturer, have shown equivalent risks between the ring and older pills. This data makes mores sense clinically than the Danish study because prior research has shown equivalent estrogen levels in the ring compared to pills.  It is important in studies of clot risk to compare new users to new users, since clot risks are generally highest in the first 6-12 months of hormonal contraceptive use.

At this point (As of update 2/16/14), the FDA has not changed the RING labeling other than to include the data from these last two trials. The manufacturer, however has settled lawsuits pending against it. (See this post for more)

BOTTOM LINE

Only you (hopefully with your doctor) can decide if the benefits you are getting from using Nuvaring warrant the risk of clots inherent in all estrogen containing contraceptives. For now, that risk seems that it may not to be larger than that in older pills, at least in two of three studies published to date.

For those who cannot remember to take a pill, or who have gotten pregnant due to missed pills in the past, the convenience of the Nuvaring may far outweigh their concerns about the potential for added risk. I have patients who have been through most of the major pills brands, and only found satisfaction on the Nuvaring. For such women, the relative difference in risk seems small in comparison to the benefit they are getting.

But if you’re considering starting hormonal birth control for the first time, and especially if your are over age 35, most experts would say to start with a low dose levonorgestrel, norethindrone or norgestimate containing pill first. If these pills work for you, why take an additional risk by starting with the Ring (or the patch, or Yaz or a desogestrel pill), even if  that risk is a small one?

__________________________________________________

Additional Reading

Additional Reading on Clots & Contraception from TBTAM

A Dignified Plea for Death with Dignity

Just 8 days prior to his death from a brain tumor, physician and researcher Donald Low filmed a profoundly moving and important interview,in which he makes a most cogent plea for the legalization of physician assisted suicide in his home country of Canada.

I’m going to die. What worries me is how I’m going to die.

There is no place in Canada where you can have support to have dying with dignity, as there is in several countries and several states in the United States…. A lot of clinicians have opposition to dying with dignity. I wish they could live in my body for 24 hours, and I think they would change that opinion.

Low was a world renowned microbiologist who came to public prominence during the SARS crisis in Canada.

“During the SARS crisis Low became known as the expert who was the most easy to understand and the most understanding of the public’s fear, while showing no fear himself. ”

“What many of us in Toronto don’t recognize is the loss he leaves behind to microbiology and infectious diseases in Canada, and to all of his research work in emerging diseases around the world.”

Unfortunately, Low did not have the death he had hoped for. Although not in pain, he became completely paralyzed and was dependent on his family for everything in the last days of his life.

Low’s wife, Maureen Taylor, a physician assistant who speaks quite candidly about Low’s last days, has vowed to continue to fight for death with dignity in Canada.

Taylor said her husband was in favour of laws that allow patients to be prescribed a lethal dose of barbiturates after they’ve had a psychiatric evaluation and had their terminal illness confirmed by two doctors.

In this scenario, the medication sits at the patient’s bedside, giving them the option of a pain-free death they initiate themselves. She said that in many cases, the medication is never used.

“I won’t stop this fight. If I can do anything to bring this forward in the political sphere, then I will do that,” she said.

I urge you to watch Don’s and Maureen’s  videos, and to share their message so that the discussion doesn’t end here.

Valley Green

Valley Green

I love this place.

Hands down, best place on earth to run, bike, walk or horseback ride. Even at its busiest, its never as crowded as Central Park.  I caught this empty stretch last Sunday morning during a long walk with Jane after breakfast at Bruno’s and a little post high school reunion debrief.

If we ever move back to Philly, Valley Green will be one reason why.

Trash Picked – Large Lamp

Lamp
Yet another in a post series of great things we found in the trash.

What: Large Wood Carved Lamp

Where and When : 63rd between 1st and York, sometime in July 2013

Why We Picked it  – We needed something for the big round table in the cottage

Why We Kept It –  The big primitive carvings echo the large pineapple print on the sofas.  (See?) I’m looking for a larger white shade for it, and may need to replace the switch, as it seems to be a bit fussy in action.

Lamp and Sofa

Big Apple Apples (and a recipe for Apple-Pear Sauce)

BIg Apple Apples

We’ve got a real bumper crop of apples ripening on the tree on our roof right now.

I’m not sure who or what to credit, since laisse faire has been our unintentional gardening principle this year.  I think maybe I fed the trees twice and you can tell by the color of the leaves that I never sprayed them.

Container Garden Apples

Maybe it was the rain. Or the sun. Or someone has bees nearby. 

APPLES IN THE SUN

Regardless, these little macintoshes are white and unblemished inside and while not as crisp as say, a ginger gold or granny smith, they have a nice flavor,

APPLES

and make a very good applesauce, especially when you add in a couple of small overipe pears you found sitting on the counter.

APPLESAUCE JAR

Apple-Pear Sauce

1 cup orange juice (plus a little water if needed for larger apples)
6 small macintosh apples
2 small soft pears
1 cinnamon stick

Rinse the apples and pears in water and dry. Do not peel. Cut into quarters, removing the occasional brown spot, and core. Add the fruit to a heavy saucepan. Pour in the orange juice and toss in a cinnamon stick. Cover the pot and cook over low heat till the fruit is soft (20-30 mins), stirring occasionally to be sure all the fruit spends some time immersed in the juice.

Remove cinnamon stick. Using a large slotted spoon, remove the fruit from the juice and run it through a food mill (or press through a fine mesh strainer). Add back some of the juice if you need it to thin the sauce. The juice you don’t use, pour into a glass and drink slowly – hmmmm…..

If possible, serve the apple-pear sauce warm.

Trash Picked – Small Fan

Fan
Another post in an ongoing series of things we found in the trash, either on the streets or in our building.

What: Allaire desk fan

Where & When :  In the trash room by the service elevator last week.

Why We Picked It:  It’s pretty!

Why We Kept It:  It works! Extremely quiet, and most importantly, keeps me cool enough while working at the desk that I don’t need the AC.

Early Mammograms – New Study Misses the Mark

mammogram2A recent study has concluded that women with breast cancer who failed to get annual mammograms are more likely to die from their disease than those who had annual mammograms, and argues that more frequent mammograms are warranted in women under age 50. Unfortunately, despite all the media attention this study is getting, I don’t think the researcher’s conclusions are supported by the study results.

The researchers did a retrospective medical record review on deaths that occurred among breast cancer patients receiving care at Mass General or Brigham & Women’s Hospitals in Boston between 1990-1999 and followed until 2007. They call this a Failure Analysis.

Invasive breast cancer failure analysis defined 7301 patients between 1990 and 1999, with 1705 documented deaths from breast cancer (n = 609) or other causes (n = 905). Among 609 confirmed breast cancer deaths, 29% were among women who had been screened (19% screen-detected and 10% interval cancers), whereas 71% were among unscreened women, including > 2 years since last mammogram (6%), or never screened (65%). Overall, 29% of cancer deaths were screened, whereas 71% were unscreened. Median age at diagnosis of fatal cancers was 49 years; in deaths not from breast cancer, median age at diagnosis was 72 years

The authors concluded that because most deaths from breast cancer occur in un-screened women under age 50, initiation of regular mammograms before age 50 years should be encouraged.

Where this Failure Analysis Fails

Despite its strongly worded conclusions, the study raises more questions than it answers, and has a number of severe limitations.

  • The study fails to tell us what percent of women who did not die got annual vs not annual mammograms. This is akin to reporting that 80% of auto accident deaths occur among those who started their trip at home vs a public parking garage, without telling you what percentage of all car trips originate from home.
  • The study did not compare breast cancer treatments between women who died and those who did not die. The researchers just assumed that all women got standard of care at their medical center for their cancer. That’s a huge assumption to make without any proof.  It would have been actually quite easy to review a statistical sampling of charts to determine if this assumption was correct, but the researchers did not do this.
  • Women who don’t get regular mammograms may differ from those who do in other ways that increase the risk for death from breast cancer death, including low socioeconomic status, lack of health insurance, and distrust of medical treatments.
  • The researchers try to make the point that among those who died of their cancer, those who had not had mammograms prior to diagnosis had later stage cancers. Given that this analysis was confined to patients died of their cancer, I’m not sure stage at diagnosis mattered.
  • The entire analysis is conducted among women who died, either from breast cancer or from other causes. Since death from non-cancer causes is rare in women under age 50, breast cancer deaths will be over-represented in younger women in the sample. Older women not getting mammograms may be not getting screening because they are ill from other causes and are also more likely to die from these other causes during the follow up period, making breast cancer deaths less common in this group.  Who knows which way the data ultimately skewed as a result of these biases, but regardless, it is skewing every which way as far as I’m concerned. All of which muddies the conclusions.
  • The study was conducted at a Mass General and Brigham and Women’s Hospital using records from their breast cancer registry. Both these hospitals are referral centers likely to attract younger women with more aggressive cancers for treatment, who may not be representative of the general population of women presenting for mammogram screening or who are diagnosed with breast cancer. Indeed, the study population was over 90% white and of high socioeconomic status, pretty standard for a referral population if I ever saw one.

One thing that is evident is that breast cancers in younger women tend to be more aggressive than those in older women, an idea that would support more aggressive screening in younger women since each life saved carries more years of life saved. However, this is countermanded by the argument that breast cancer, despite being more aggressive, occurs much less frequently in younger than older women. Add in that mammograms are much better at detecting slower growing, less fatal breast cancers than the more aggressive cancers, and that screening is less effective in the denser breasts of younger women, and you have a sense of the screening conundrum we face for this cancer that claims so many women’s lives each year.

Unfortunately, this retrospective analysis is not going to solve the issue.

_______________________________________________________

Webb, M. L., Cady, B., Michaelson, J. S., Bush, D. M., Calvillo, K. Z., Kopans, D. B. and Smith, B. L. (2013), A failure analysis of invasive breast cancer. Cancer. doi: 10.1002/cncr.28199

More on mammograms –

Trash Picked – Painting

Trash picked painting
First in a new series – Trash Picked, or great things we found in the trash, either in our building or on the streets.

What: Still Life Painting

Where: East 63rd between 1st and 2nd, one fall evening a few years ago while walking home from the theater.

Why We Picked It: I liked the colors and the primitive style. Probably someone’s art class assignment…

Why We Kept It:  It looks great on the wall going up the stairs at the cottage, and goes perfectly with the carpet on the stairs. (See?)

PIC AND STAIRS

Seared Scallops with Mushroom Cream Sauce

Seared Scallops in Mushroom Cream Sauce

An elegant and actually quite easy preparation from Emeril Legasse. The sauce has cream, but lemon used in the scallops lightens the flavor considerably.  (Half and Half would probably work just as well as the cream if you want to lighten it calorie wise as well.)

Mr TBTAM prepared this last week – it was so good,we used the leftover sauce, seared a few more scallops the following night and had it again.  The sauce can be made a bit ahead, making it an easy dish to serve company.

We had it with Farro and brussels sprouts. Made for a real pretty plate.  Recipe here.

Shallots, Farro and Brussels Sprouts

New 2-Stage Ovarian Cancer Screening Strategy Looking Interesting

Normal ovaryOne study does not a recommendation make, and results of a larger clinical trial are pending, but a new 2 stage approach to ovarian cancer screening is starting to look like something reasonable for ovarian cancer screening.

In a multi-center study led by researchers at MD Anderson Cancer Center, over 4,000 women were followed with annual Ca125 levels for 11 years, using an established algorithm (ROCA or Risk for Ovarian Cancer) that stratifies women into low, intermediate or high risk for ovarian cancer based on changes in ca125 levels over time, even when Ca125 levels are in the normal range.  Based on the ROCA, which was re-calculated after each periodic screening, low risk women continued with annual Ca125 levels, intermediate risk women had repeat Ca125 levels done in 3 months, and high risk women went to immediate sonogram.

By confining sonogram use to only those women with concerning increases in Ca125 (0.9% annual rate of sonogram referral), the researchers were able to avoid the high rates of unnecessary surgery for false positives that has kept sonogram from being an effective screening tool for ovarian cancer. Their results are impressive for the small number of surgeries done – only 10 over 11 years – and the relatively high rate of pathology found at those surgeries –

The average annual rate of referral to a CA125 test in 3 months was 5.8%, and the average annual referral rate to TVS and review by a gynecologic oncologist was 0.9%. Ten women underwent surgery on the basis of TVS, with 4 invasive ovarian cancers (1 with stage IA disease, 2 with stage IC disease, and 1 with stage IIB disease), 2 ovarian tumors of low malignant potential (both stage IA), 1 endometrial cancer (stage I), and 3 benign ovarian tumors, providing a positive predictive value of 40% (95% confidence interval = 12.2%, 73.8%) for detecting invasive ovarian cancer. The specificity was 99.9% (95% confidence interval = 99.7%, 100%). All 4 women with invasive ovarian cancer were enrolled in the study for at least 3 years with low-risk annual CA125 test values prior to rising CA125 levels.

If the cost of Ca125 screens is low, this strategy could begin to make sense as a screening strategy for ovarian cancer. This all depends  of course, on whether it actually reduces mortality. The answer to that question will await the results of the much larger UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), which will randomize over 200,000 women to either Ca125-ROCA (as in the Texas study), annual sono or routine care.  Enrollment in that study has closed, and initial results are expected in 2015.  It’s also important to note that other ovarian cancer markers are currently under investigation, both alone and in combination with one another and Ca125, and may prove superior to Ca125 alone.

Bottom line

Interesting, but not yet practice changing. Stay tuned.

Caring for Pregnant Disaster Victims – Lessons Learned in Haiti and Japan

Israel_Defense_Forces_-_First_Baby_Delivered_at_IDF_Field_Hospital_in_Haiti

Israeli Defense Forces deliver a baby at field hospital in Haiti

In a landmark article in this months Green Journal, Israeli and Canadian Ob-Gyns who deployed with international relief efforts to Japan and Haiti earthquake areas have summarized the lessons they learned in the field there.

The objectives of this report are to emphasize the often overlooked need to include obstetrics and gynecology personnel among essential medical aid rescue teams and to provide recommendations and guidelines for obstetrician–gynecologists who may find themselves working under comparable extraordinary natural disasters.

The article includes a list of recommended supplies (and amounts) to bring, and a layout for an Ob-Gyn field hospital. While I urge you to read the entire article, here are excerpts from their 10 essential lessons learned –

1. An obstetrics and gynecology team is invaluable however scarce its resources, because the provision of even the most basic prenatal care plummets after a natural disaster. ..as many as 10% of the victims seeking medical assistance may need an obstetrician–gynecologist.

2. The mix of cases that the obstetrics and gynecology team will confront requires that they are highly trained specialists prepared for and trained in dealing with emergencies in a suboptimal environment.  Miscarriages, premature deliveries, intrauterine growth restriction, low-birth-weight neonates, gender-based violence, and undesired pregnancies increase after natural disasters….Approximately 50% of the cases the Israel Defense Forces hospital team encountered in Haiti were complicated deliveries.

3. Preparations for treating extreme prematurity should be made before departure to the disaster zone. … increased seismic activity could increase delivery rates and preterm births up to 48 hours after an earthquake and a significantly higher rate of premature births was reported over a 7-month period in the wake of the earthquake in Japan.

4. Foreign aid relief teams operating in a disaster area will inevitably encounter unique and difficult ethical dilemmas, often arising from insufficient medical resources. … not every victim in need would be able to receive the necessary treatment. … the dilemma of whether to impose a minimum weight threshold for preterm neonates to receive treatment is an ethical issue, which obstetrics and gynecology teams operating in natural disaster conditions should be prepared to deal with.

 5. Obstetrics and gynecology teams treating pregnant women under natural disaster conditions should be especially sensitive to the catastrophic environment’s effect on maternal mental health.

6. Indications for cesarean delivery in a field hospital … will differ from the typical paradigm. … For example, fetuses in breech presentation with estimated birth weight less than 3,500 g were to be delivered vaginally. …with only one available fetal heart rate monitor, monitoring had to be carried out intermittently, possibly meaning some abnormality might have been missed. Potential contingencies such as these must be addressed and discussed before the team is deployed.

7. The delivery “suite” should be prepared for emergent cesarean deliveries in the event that a designated operating room may not be immediately available.

8. The likelihood of quickly obtaining additional equipment and medications is remote once the team has arrived to the disaster zone; …a list of recommended essential equipment and medications for obstetrics and gynecology relief teams is provided.

9. An outreach obstetrics and gynecology team with a portable mobile ultrasound machine including vaginal and abdominal probes not only detects problematic pregnancies, but also provides enormous psychological comfort to pregnant disaster victims.

10. The team must be briefed by someone knowledgeable about local cultural sensitivities and taboos, including local volunteers who serve as translators.

Kudos to the authors for providing an essential global resource for disaster planning.
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