Requiring a second opinion by a pathologist before surgery or treatment for cancer or other serious illness can reduce diagnostic errors that, although uncommon, have "an enormous human and financial impact," researchers at Johns Hopkins Medical Institutions reported in a study published in the Dec. 1 issue of the journal Cancer.

Pathologists Joseph Kronz, William Westra and Jonathan I. Epstein reviewed more than 6,171 cases of patients seeking care at Hopkins after a diagnosis by a pathologist at another institution. Hopkins requires that patients undergoing surgery or other significant treatment have their biopsy slides and lab tests reviewed by an in-house pathologist first.

Cases in which an outside pathologist requested a consultation because a diagnosis was uncertain were excluded, as were those involving kidney or liver disease because of the inherent difficulties in diagnosis. Cases in which the stage or grade of a cancer were changed also were excluded.

During a 21-month period beginning in April 1995, the Hopkins team found that in 86 cases, or 1.4 percent of those studied, the opinion of the Hopkins pathologists was significantly different from that of outside physicians. In 90 percent of the 86 cases, the change in diagnosis altered the treatment plan, and 70 percent benefited from an improved prognosis.

In 20 cases, Kronz and colleagues report, the diagnosis changed from an "overtly malignant diagnosis to an overtly benign diagnosis," while in five cases the reverse was true: A benign condition was found to be malignant.

Certain parts of the body--the female reproductive tract and the lungs--were more likely to result in discrepant diagnoses, they noted.

In 60 percent of the disputed cases, Kronz and his co-authors obtained follow-up information. In seven patients, this follow-up appeared to support the original diagnosis rather than the opinion by Hopkins' doctors.

"Our data indicate that at Johns Hopkins Hospital approximately one patient per week would receive inappropriate treatment and/or inaccurate prognostication if we did not have a policy of mandatory second opinion," the authors wrote.

They suggest that other hospitals, particularly large academic medical centers, institute mandatory second opinion programs for pathology.

--Sandra G. Boodman



Could thinking about sexual fantasies increase pain tolerance?

A study of college students suggests it might.

During the study by researchers at Johns Hopkins Medical Institutions, 40 students each plunged a hand into a vat of ice water and kept it there until the pain became unbearable. Researchers timed the length of the plunge and also used several standard psychological tests to measure the participants' mood, worry and pain before and after the submersion.

Later, students were randomly assigned to one of four groups for a second plunge. During this part of the experiment, one group of students was asked to think of a sexual fantasy, such as kissing, flirting or other pleasurable activity with their favorite partner. Participants in another group were told to imagine a neutral fantasy, such as walking to class, while those in a third group were asked to envision a sexual fantasy that was not pleasurable. The fourth group served as a control group and was not given any special instructions.

Students envisioning a pleasurable sexual fantasy were able to tolerate the ice water for three minutes, more than twice as long as those in the other groups, the study found. The team of researchers led by Peter S. Staats, director of the Division of Pain Medicine at Johns Hopkins, also found that envisioning pleasurable sexual fantasies improved mood, reduced worry and tension and enhanced participants' feelings of self-worth during the experiment.

The findings add to a growing body of evidence that shows how pain causes not only physiological problems, but also strong negative emotional responses in people. These studies could help point to simple, inexpensive ways to lessen pain, Staats said, and underscore the powerful role that emotion plays in tempering pain.

Doctors are "so pressed for time that we don't always have a chance to really converse with patients, to listen to their fears and anxieties," said Staats, who presented the findings at the American Pain Society's annual meeting in October. "Whether patients think positive thoughts themselves or whether you say positive things to them, it will have an impact on their response to pain."

--Sally Squires



Teenage girls who go on strict diets, use diet pills or induce vomiting to help them lose weight are more likely to gain weight afterward and to be at risk for obesity than those who do not engage in such practices, according to a study by researchers at the University of Texas at Austin and Stanford University.

The study of 692 girls enrolled in the ninth grade at three high schools in Northern California compared the body mass index of students who engaged in restrictive dietary practices with those who did not. Researchers led by Eric Stice, a psychologist at the University of Texas, asked girls to complete questionnaires annually over a four-year period. The girls' weight and height were also measured annually.

Stice and his co-authors from Stanford found that teenagers who reported strict dieting and radical weight loss efforts were more likely to gain weight than those who did not take special pains to try to lose weight.

One unexpected finding noted by the researchers, whose study appears in the December issue of the Journal of Consulting and Clinical Psychology, is that girls who exercised to try to control their weight were more likely to gain weight during the study. Stice and his colleagues suggest that this may reflect the growth in bone density or muscle mass that exercise produces.

There are two reasons why dieting and other weight-reduction efforts might backfire, Stice and his co-authors say. One may be self-delusion common to many dieters: They think they are dieting and exercising more than they actually are. The second may be that some students may have a familial propensity toward obesity.

"Perhaps," they write, "individuals with a family history of obesity have already initiated weight-control efforts because they are concerned that they will follow in the footsteps of their parents."

--Sandra G. Boodman