Hutzel Hospital Research Articles

Laparoscopic Supracervical Hysterectomy versus Laparoscopic-Assisted Vaginal Hysterectomy

Study Objective To compare laparoscopic supracervical hysterectomy (LSH) with laparoscopic-assisted vaginal hysterectomy (LAVH) in terms of indications, pathology, length and weight of removed uteri, operative time, intraoperative blood loss, intra and postoperative complications, and later sexual function. Design Cohort retrospective analysis of consecutive cases (Canadian Task Force classification II-3). Setting Hutzel Hospital, Detroit Medical Center, Wayne State University, Detroit, Michigan; Vert-Pre Nouvelle Clinique, Geneva, Switzerland; and Benha University Hospitals, Egypt. Patients Two hundred and fifty-nine women. Interventions LSH and LAVH. Measurements and Main Results Patients in both groups were matched regarding age, indications, and pathology of the removed uteri. Blood loss with the LSH procedure was significantly lower than it was with the LAVH procedure (mean 125 ± 5 vs 149 ± 7 mL, p = .001). Patients that underwent LSH had significantly shorter operating times (mean 120 ± 3 vs 150 ± 5 minutes, p = .007). The length of the removed uteri was 14.2 ± 0.5 cm (range 5.2–18) in the LSH group versus 11.8 ± 0.4 cm (range, 5.6–14) in the LAVH group. Weight of the removed uteri was 280 ± 6 g (range, 65–750) in the LSH group compared with 235 ± 8 g (range, 59–560) in the LAVH group. There was no difference between the groups in hospital length of stay. The number of complications was less in the LSH group (3/123, 2.4%) compared with 5/136 (3.7%) in the LAVH group. Sexual function after surgery was better in the LSH group. Conclusion After exclusion of preoperative cervical disease, LSH can be considered as a safer alternative to LAVH in patients that are candidates for laparoscopic hysterectomy.

Multifetal pregnancy reduction: Perinatal and fiscal outcomes

Objective: This study was undertaken to compare the birth outcomes of a multifetal pregnancy reduction population with those of other patients delivered at Hutzel Hospital, Detroit, and to determine the fiscal impact of the multifetal pregnancy reduction program. Study Design: In a retrospective review patients who were delivered after multifetal pregnancy reduction were compared with a general obstetric population who were delivered at Hutzel Hospital from January 1, 1986, through June 30, 1998. Outcome data were determined through a comprehensive perinatal database. The χ2 analysis was used to examine the relationship between gestational age and delivery group. Financial data were estimated from published reports of neonatal intensive care unit admissions, cost estimates for neonatal intensive care unit care, and charges for multifetal pregnancy reduction. Results: Pregnancies reduced to triplets, twins, and singletons had outcomes at least comparable to unreduced pregnancies starting at these numbers and substantially better than unreduced pregnancies with the same starting number. Financial estimates of hospitalization costs averted in the multifetal pregnancy reduction population exceeded $28 million. Conclusion: Use of multifetal pregnancy reduction improved obstetric outcomes for pregnancies with multiple gestations and also was associated with significant fiscal savings. (Am J Obstet Gynecol 2000;182:1575-80.)

The legendary superior strength of the Pfannenstiel incision: A myth?

Objective: This study was undertaken to determine whether there is a difference in the frequency of fascial dehiscence between midline vertical lower abdominal and Pfannenstiel incisions among women undergoing obstetric and gynecologic operations. Study Design: A case-control study of 48 cases of fascial dehiscence complicating 17,995 major operations (8950 cesarean deliveries and 9405 gynecologic procedures) during a 6-year period at Wayne State University Hutzel Hospital, Detroit, was performed. Univariate analysis identified significant independent variables related to fascial dehiscence. Stepwise logistic regression analysis then identified those risk factors that were independently associated with fascial dehiscence. Results: Among the 48 patients who underwent repair of fascial dehiscence after a major obstetric or gynecologic operation, 27 were from the obstetric service and 21 were from the benign and cancer gynecologic services. Wound dehiscence occurred in 10 vertical incisions and 17 Pfannenstiel incisions among the obstetric patients and in 12 vertical and 9 Pfannenstiel incisions among the gynecologic patients. The risk for dehiscence with vertical lower abdominal incisions was not increased with respect to that associated with Pfannenstiel incisions (P =.39, 2-tailed). This finding was true for all patients (odds ratio, 1.3; 95% confidence interval, 0.7-2.6), obstetric patients (odds ratio, 1.3; 95% confidence interval, 0.5-3.4), and gynecologic patients (odds ratio, 1.5; 95% confidence interval, 0.5-4.0). Forty-seven of the 48 case patients had documented wound infections, compared with 1 of the 144 control subjects (P <.0001, odds ratio, 37.8; 95% confidence interval, 14.8-96.8). Conclusion: Wound infection was the most important risk factor for fascial dehiscence among women who underwent major obstetric and gynecologic operations. Our results do not support the long-held belief that Pfannenstiel incisions are stronger than lower abdominal vertical incisions and reduce the risk for fascial dehiscence. (Am J Obstet Gynecol 2000;182:1446-51.)

Fiscal impact of a potential legislative ban on second trimester elective terminations for prenatally diagnosed abnormalities

This study was designed to determine the fiscal impact of a theoretical legislative ban on elective terminations for prenatally diagnosed abnormalities at Hutzel Hospital/Wayne State University. A fiscal comparison was completed for patients who had second trimester elective terminations for prenatally diagnosed abnormalities versus not allowing the procedure. An eight-year database of genetics cases and hospital and physician cost estimates for performing elective terminations for prenatally diagnosed abnormalities, and published reports of the average lifetime costs per selected birth defects, were used to calculate the net cost. The estimated lifetime cost for an average cohort year of a legislative ban on elective terminations for prenatally diagnosed abnormalities was found to be at least $8.5 million for patients treated at Hutzel Hospital. Extrapolated, a similar ban on second trimester elective terminations would have a net cost of $74 million in Michigan and $2 billion annually in the United States.

Fetal therapy for obstructive uropathy: past, present.future?

Antenatal treatment of obstructive uropathy, although widely performed, remains controversial. An overview of prenatal therapy for obstructive uropathy, the limitations of the early published experience, advances of recent years, and future directions for treatment are reviewed. The clinical approach and outcomes of the Fetal Treatment Program of Hutzel Hospital and Wayne State University are presented. Patient selection for antenatal treatment is based on the existence of a significant threat of neonatal death due to pulmonary hypoplasia, pending exclusion criteria such as anatomical structural anomalies and chromosomal defects. Ultrasonography, karyotyping, and sequential urinary electrolyte analysis are essential. Current treatment involves the placement under ultrasonic guidance of a Rodeck vesicoamniotic shunt. Recent technical advances include the use of amnioinfusion for fetal visualization, temporary fetal paralysis, routine antibiotics, and more-precise catheter placement. The establishment of standardized short- and long-term outcome measures and the documentation of fetal and maternal complications are in progress. Procedural refinement, development of fetoscopic techniques and equipment, identification of urinary markers to aid patient selection, and the collection of multicenter outcome data will assist the future management of prenatally detected obstructive uropathy.

Staging of Twin-Twin Transfusion Syndrome

The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS). Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of > or = 8 cm) and oligohydramnios (maximum vertical pocket of < or = 2 cm). Nonvisualization of the bladder in the donor twin (-BDT) and absence of presence of hydrops was also noted. The middle cerebral artery, umbilical artery, ductus venosus, and umbilical vein in both fetuses were assessed with pulsed Doppler. Critically abnormal Doppler studies (CADs) were defined as absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in the ductus venosus, or pulsatile flow in the umbilical vein. TTTS was staged as follows: stage I, BDT still visible; stage II, BDT no longer visible, no CADs; stage III, CADs; stage IV, hydrops; stage V, demise of one or both twins. Laser photocoagulation of communicating vessels (LPCV) or umbilical cord ligation was performed depending on the severity of the condition. The study was approved by the Institutional Review Board of St. Joseph's Hospital in Tampa and by the Fetal Therapy Board at Hutzel Hospital, Detroit, and all patients gave informed consent. A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (chi-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome. Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.

Synthetic graft placement in the treatment of fascial dehiscence with necrosis and infection

Objective: The objective of this study was to describe the use of synthetic grafts in repairing fascial dehiscence complicated by fascial necrosis and infection after obstetric and gynecologic operations. Study Design: A retrospective review of the operating room records at Hutzel Hospital (Detroit, Mich) was performed to find all cases of fascial dehiscence repaired during a 6-year period between January 1, 1991, and December 31, 1996. Patients with partial or complete disruption of the fascia with evidence of fascial necrosis and infection were included in this study. Demographic information; the initial surgical procedure, including type of incision; suture material; use of synthetic graft and closure technique for repair of dehiscence; postoperative complications, microbiologic results; antibiotic therapy; subsequent operations; length of hospital stay; and late complications were recorded. Results: During the study period 52 patients underwent repair of fascial dehiscence; 36 of these had concurrent fascial necrosis and infection, including 4 women with necrotizing fasciitis. Eighteen patients were from the obstetric service and 18 were from the benign or cancer gynecology service. Ninety-one bacterial isolates were recovered from the infected wounds. Extensive fascial resection precluded closure without tension in 18 cases and necessitated synthetic graft placement to prevent evisceration. Graft materials included polypropylene (11 cases) and polyglactin (7 cases). Late complications of graft placement included extrusion of the graft in 3 patients and incisional hernia in 1. Conclusions: Extensive fascial débridement with resection prevents primary closure of wound dehiscence. Synthetic grafts permit primary closure of large fascial defects and can be used with extensive débridement in the presence of infection. (Am J Obstet Gynecol 1998;179:1430-5.)

The cost-effectiveness of routine type and screen admission testing for expected vaginal delivery

Objective: To evaluate the cost effectiveness of routine admission type and screen testing for expected vaginal delivery. Methods: A retrospective review was conducted in patients transfused with blood during an admission that anticipated a vaginal delivery over a 3-year period, at Hutzel Hospital, in Detroit, Michigan. Results: Of 16,291 patients admitted for an expectant vaginal delivery, 76 (.47%) (95% confidence interval [CI] .37%, .58%) required blood transfusion during the time of their admission. Medical records of these 76 patients were evaluated as to urgency and risk factors. Most of the blood transfusions were related to previously identified risk factors, including previous postpartum hemorrhage, multiple pregnancies, previous cesarean delivery, abruptio placentae, and admission anemia. Four patients received an urgent blood transfusion without a previously identifiable risk factor. We found an overall urgent blood transfusion rate without admission risk factors to be 2.5 per 10,000 vaginal deliveries (95% CI .9 per 10,000, 6.3 per 10,000) Conclusion: Routine admission type and screen testing for an expected normal vaginal delivery does not seem to enhance patient care and should be eliminated for patients without substantial risk factors. In the rare event that a patient without a previously identified risk factor required an urgent blood transfusion, O negative blood could be given in the interim pending formal type and cross match.

Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess

Objective: Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess. Study Design: A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed. Results: Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess ( p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients. Conclusions: Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess. (Am J Obstet Gynecol 1998;178:1272-8.)

Special stains, the old and the new: the impact of immunocytochemistry in effusion cytology.

Diagnostic CytopathologyVolume 18, Issue 2 p. 141-149 Advances in Technology Special stains, the old and the new: The impact of immunocytochemistry in effusion cytology† Carlos W. M. Bedrossian M.D., FIAC, Corresponding Author Carlos W. M. Bedrossian M.D., FIAC Department of Pathology, Hutzel Hospital, Detroit, MichiganDepartment of Pathology, Northwestern Memorial Hospital, 303 E. Superior, Pass. Pav. 314A, Chicago, IL 60611Search for more papers by this author Carlos W. M. Bedrossian M.D., FIAC, Corresponding Author Carlos W. M. Bedrossian M.D., FIAC Department of Pathology, Hutzel Hospital, Detroit, MichiganDepartment of Pathology, Northwestern Memorial Hospital, 303 E. Superior, Pass. Pav. 314A, Chicago, IL 60611Search for more papers by this author First published: 07 December 1998 https://doi.org/10.1002/(SICI)1097-0339(199802)18:2<141::AID-DC11>3.0.CO;2-LCitations: 37 † Presented at the IAP Symposium, Budapest, Hungary, October 1996. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume18, Issue2February 1998Pages 141-149 RelatedInformation

Pediatric and Adolescent Gynecology Experience in Two Michigan OB/GYN Residency Programs

Background Pediatric and Adolescent Gynecology (PAG) is an important but long neglected field. While interest has grown tremendously over the past few years, training is still limited, with only two fellowship programs in the United States in 1997–98. The purpose of this study is to assess training and experience in PAG at the OB/GYN resident level. Methods Two programs were studied: in Detroit, MI, Hutzel Hospital (HH), one of the largest academic inner city programs in the country, and William Beaumont Hospital (WB), a community based program in Royal Oak, MI. 71 questionnaires were distributed to OB/GYN residents. Descriptive analysis of answers to demographic, training, attitude, and knowledge based questions in PAG was perlbrmed. Results 57 questionnaires were returned. The majority of respondents reported no experience in PAG with no rotations or clinics and only limited teaching with 0–2 lectures. 97% of HH and 92.3% of WB residents requested more PAG training. Comfort levels regarding sexual history, sex, sexual abuse, physical abuse, substance abuse, and birth control in PAG patients were assessed on a 5 paint scale (1=low, 5=high); HH scored 3.21/5 in pediatric and 4.22/5 in adolescent issues, and WB scored 4.22/5 in pediatric and 4.55/5 in adolescent issues. The most commonly recognized differences in the care of PAG patients were attention to stage of mental development (38.6% in pediatrics/36.4% in adolescents at HH; 38.5%/46.2% at WB), cooperation strategies (38.6%/36.4% at HH; 0%/0% at WB), and parental involvement(15.9%/0.% at HH; 30.8%/7.7% at WB). Residents failed to note the important physical and anatomical differences in the PAG patient(0%/0% at HH; 0%/0% at WB). HH residents responded with familiarity 60.5% and WB residents 59.7% of the time to knowledge based questions (see table). % residents showing familiarity HH WB HH WB Treating imperforate hymen 89 77 Indications for 1st speculum exam 81 83 Treating labial adhesions 89 77 Normallabnonnal hymens 11/41 7/15 Etiology of vulvovaginitis 20 0 Initiation of OCPs 64 31 Etiology of vaginal discharge 63 85 Exam positions 86 69 Conclusions Residents of both academic and community programs report litt1e experience and scant training in PAG. The same residents expressed interest in formal PAG training. Moderate to high levels of confidence in discussing PAG issues reported by both WB and HH residents were not supported by complete answers to knowledge based questions. Many residents demonstrated some familiarity with PAG issues, but Done demonstrated proficiency. It is concerning that residents in OB/GYN lack the basic knowledge that is required in routine daily care of the PAG population. More emphasis to be placed on these issues in residency training programs.

Glandular Lesions of the Uterine Cervix

Department of Pathology, Hutzel Hospital and the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Wayne State University School of Medicine, Detroit, Michigan. Int J Gynecol Pathol 1997;16:103-110.

The construction of the new Kresge Eye Institute.

The present Kresge Eye Institute building, the site of the Department of Ophthalmology of the Wayne State University School of Medicine, opened in 1989. The new building was the culmination of a decade of planning, persuasion, perseverance, and compromise. The previous facility was physically connected to the Harper Hospital in the Detroit Medical Center and began operation in 1974. A campaign to expand the Kresge Eye Institute started in 1979 when the dean of the medical school and the majority of the administrators and trustees agreed that expansion was justified, but there were many political and economic obstacles. After ten years of negotiation, when the situation seemed hopeless, fiscal problems threatened to close the Hutzel Hospital, a component of the Detroit Medical Center. The Medical Center Board agreed with the Hutzel Hospital trustees to sustain the Hutzel Hospital by transforming the hospital into a specialty hospital containing only three services: ophthalmology, orthopedics, and obstetrics. A new Kresge Eye Institute was approved on the condition that it be moved from the Harper Hospital to the Hutzel Hospital. By 1989, a four-story building connected to the Hutzel Hospital was completed. Although economic and political factors were more important than medical needs in obtaining the new building, the result was an institution of the appropriate size and scope to serve the ophthalmic needs of metropolitan Detroit and the Wayne State University School of Medicine.

Vascular disruption birth defects and history of prenatal cocaine exposure: a case control study.

To test the hypothesis that prenatal cocaine exposure is associated with a 3-fold increased risk for vascular disruption among malformations. A retrospective case-control study was based upon >68,000 delivery records at Hutzel Hospital for a 9-year period. Ascertainment was based upon ICD-9 codes for limb defects, abdominal wall defects, and facial clefts. Transverse limb defects and gastroschisis were defined as cases, and nondisruption anomalies served as controls. Statistical analysis for history of maternal cocaine use reported during pregnancy was performed by chi(2) analysis and the odds ratio determined. A total of 190 cases of limb anomalies, abdominal wall defects, and cleft lips were identified after exclusion criteria. Statistical analysis was performed on the 119 cases informative for maternal cocaine use during pregnancy. Seven of 34 vascular disruption cases had cocaine exposure reported versus 12 of 85 other malformations controls. The odds ratio for cocaine exposure and vascular disruption is 1.58 (95% confidence interval = 0.55-4.47). The putative association of prenatal cocaine exposure and vascular disruption birth defects remains unresolved, but the attributable risk is very likely less than the 3-fold odds ratio previously reported.

A cost-effectiveness evaluation of preoperative type-and-screen testing for vaginal hysterectomy

OBJECTIVE: Our purpose was to evaluate the usefulness and cost-effectiveness of routine preoperative type-and-screen testing before vaginal hysterectomy. STUDY DESIGN: A retrospective review of all vaginal hysterectomies performed at Hutzel Hospital between 1988 and 1994 with an emphasis on those that required blood transfusion was done. All vaginal hysterectomies completed at Hutzel Hospital were included in this 6-year time period for all noncancerous indications, including fibroid uterus, endometriosis, menorrhagia, uterine prolapse, pelvic pain, cervical dysplasia, and adenomyosis. RESULTS: Among 1063 patients who underwent vaginal hysterectomy, 26 needed a blood transfusion at the time of hospitalization. Medical records of the patients who needed blood transfusions were reviewed to determine the urgency and indication. Ten of the transfusions were given preoperatively because of anemia, 7 were given intraoperatively, and 9 were given postoperatively. The seven intraoperative transfusions were given because of the physician's perception of excessive blood loss; however, none of the patients received an emergency transfusion with extreme urgency. That is, the need for the intraoperative transfusion was not immediate. All patients who received a transfusion could have waited for 20 to 30 minutes for proper type and crossmatching and subsequent transfusion. CONCLUSION: In the absence of preoperative indications, routine preoperative type-and-screen testing of blood before vaginal hysterectomy is not cost-effective, does not enhance patient care, and should be eliminated. (Am J Obstet Gynecol 1996;175:1201-3.)

EFFECT OF PERINATAL FACTORS ON BLOOD PRESSURE IN PRETERM NEONATES.1352

Blood pressure regulation is a commonly encountered problem among preterm neonates. This study was conducted: 1) to determine if perinatal factors influence blood pressure and 2) to determine if antenatal steroid (ANS) use influences neonatal blood pressure of very low birthweight (VLBW) neonates. A review of medical records of infants admitted to the NICU of Hutzel Hospital between 7/93 to 6/94 was conducted. A total of 238 neonates were born with birthweights =1000 g(n=112). Likewise there was a significant difference in MAP (35 ± 9 vs. 41 ± 9 mm Hg, p=0.001) between infants =30 wks (n=43). Of the perinatal factors tested (prenatal care, PIH, alcohol, tobacco, marijuana, cocaine or opiate use, preterm labor, PPROM, chorioamnionitis, placenta previa, placental abruption, fetal distress, MgSO4, maternal GBS, gonorrhea, syphilis, monilia, HIV or HSV infection) only PIH was associated with an increase in MAP (36 ± 9 vs. 41 ± 11 mm Hg, p=0.007) whereas GBS colonization significantly decreased MAP (36 ± 10 vs. 41 ± 8 mm Hg, p=0.02). Of the 177 infants, 113 (64%) did not receive ANS, 17 (10%) received 1 dose and 47 (27%) received two doses. There was a tendency for a higher MAP in infants who were ≥ 1000 g who had been given ANS. In infants <1000 g there was a tendency for a lower MAP among those who had received ANS. We conclude that of the perinatal factors, only PIH and GBS significantly affect blood pressure on VLBW infants.

Cost-effectiveness of routine blood type and screen testing before elective laparoscopy

To evaluate the usefulness and cost-effectiveness of the routine preoperative evaluation of blood type and screen testing before laparoscopy. A retrospective review was conducted in patients transfused with blood during or after laparoscopy over a 3-year period at Hutzel Hospital, Detroit, Michigan; Grace Hospital, Southfield, Michigan; and Bixby Medical Center, Adrian, Michigan. Of 7529 women receiving laparoscopic procedures, 57 required blood transfusion at laparoscopy. Medical records of the 57 patients requiring blood transfusion were evaluated as to urgency and indication. All 57 subsequent blood transfusions were found to be the result of previously identifiable problems, including ectopic pregnancy and preoperative anemia. No patient required transfusion for a vascular injury. In the absence of preoperative indications, routine preoperative type and screen testing for elective and emergency laparoscopic procedures does not enhance patient care and should be eliminated.

The osteomed M3-X fixation system: A new bone screw with applications in foot surgery

The purpose of this article is to familiarize the reader with the Osteomed M3-X Fixation System. The authors present a description of the instrumentation and design characteristics of this system, as well as some comparisons to other similar fixation devices. The indications for the screw's use and the correct techniques of insertion are also discussed. In addition, a review of over 200 forefoot procedures utilizing this system, and performed by the podiatric surgeons at Hutzel Hospital, is presented.

Extensive personal experience: the clinical evaluation and management of osteoporosis.

T HIS REVIEW reflects my own clinical experience over a number of years, and it seems appropriate to describe this practice setting, at least briefly. Until recently, as a member of the Bone and Mineral Division of the Henry Ford Health System in Detroit, Michigan, I worked with a group of specialists, all but one of whom was an endocrinologist, but our clinical practice was restricted to disorders of bone and mineral metabolism: no diabetes, no thyroid, just bones. Consequently, many of our referrals were from fellow endocrinologists seeking consultation for what they regarded as out of the ordinary in our field or patients who were potential participants in clinical research trials. It was uncommon, unfortunately, for us to see patients with established osteoporosis, for example, who were “virginal” with respect to evaluation or therapy. The other source of referral to my personal practice within this group was from gynecologists whose perimenopausal patients wanted further discussion about hormone replacement therapy. More specifically, these women requested an analysis of their risk of developing osteoporosis to complete the hormone replacement “risk/benefit” equation. My admittedly extremist views on hormone replacement, that the benefits far outweigh the risks for most women, are well known in my community, and this was reflected in the referral pattern. Recently, I was fortunate to have joined the Division of Endocrinology and Metabolism at Wayne State University, still in Detroit. My metabolic bone disease clinic is conducted in the rheumatology section of the university’s major women’s hospital (Hutzel Hospital), with a significant impact on the source and type of referral. The nation’s largest obstetrics and gynecology residency program, with a long-standing active menopause program, is in the same facility. Referrals for skeletal management of perimenopausal women focuses more directly on that segment for whom hormone replacement is absolutely or relatively contraindicated. Working with rheumatologists (who as a specialty are making an increasingly aggressive attempt to move into the osteoporosis area), a major new source of referral is patients whom these rheumatologists are treating with corticosteroids. Fortunately, the outstanding group with whom I am associated recognizes this major clinical problem, and together we are moving toward a program of addressing the skeletal complications of steroids at the initiation of therapy rather than after the third or fourth osteoporotic fracture. It is worth noting that in neither facility were orthopedists or primary care providers a major source of new patient referral to a specialty bone program. From my personal experience, general endocrinologists are more likely to receive referrals from these sources, even in a major metropolitan area with acknowledged clinical expertise in bone and mineral disorders. Thus, osteoporosis has already outstripped thyroid disease and is overtaking diabetes as “bread and butter” endocrinology. This first person, biased contribution to the Journal offers some perspectives on patient evaluation and management. The current accepted definition of osteoporosis is low bone mass and microarchitectural deterioration of the skeleton, leading to an increased risk of fracture after minimal trauma (1). In practice, however, patients are seen by a clinician because of one of the following distinct clinical situations: 1) the patient concerned about her or his individual risk of developing osteoporosis; 2) the patient with diagnosed osteoporosis who has not yet sustained a fracture or in whom there is concern that a vertebral deformity seen on x-ray may have resulted from an osteoporotic fracture; and 3) the patient with established osteoporosis complicated by fractures after minimal trauma. In this review I will focus on each of these situations separately, recognizing that there will be substantial overlap in the approaches.

Percutaneous fetal cystoscopy in the evaluation and management of the fetus with lower obstructive uropathy: [formula omitted] Roberto Romero, Luis Gonçalves x, Mark P. Johnson, Craig Smith x, Alan W. Flake x, David B. Cotton, and Mark I. Evans. From the Departments of Obstetrics and Gynecology, Pediatric Surgery and Pediatric Urology, Hutzel Hospital, Wayne State University, Detroit, MI; and the

percutaneous fetal cystoscopy in the evaluation and management of the fetus with lower obstructive uropathy: [formula omitted] Roberto Romero, Luis Gonçalves x, Mark P. Johnson, Craig Smith x, Alan W. Flake x, David B. Cotton, and Mark I. Evans. From the Departments of Obstetrics and Gynecology, Pediatric Surgery and Pediatric Urology, Hutzel Hospital, Wayne State University, Detroit, MI; and the