Kate Johnson

MONTREAL — A dramatic increase in the incidence of postpneumonic empyema requiring decortication is an “alarming” phenomenon that may possibly signal a new crisis in the management of community-acquired pneumonia, according to Shona E. Smith, M.D., a third-year general surgery resident at the University of Western Ontario's London Health Sciences Centre.

In a review of all adult cases of postpneumonic empyema [defined as a pus-containing pleural effusion] requiring decortication at her center between April 1997 and December 2004, Dr. Smith discovered the annual numbers of cases of empyema were 44, 35, 36, 42, 75, 68, 72, and 55 in the final 9 months of the study period. The numbers of decortications required in each of those years were 0, 0, 6, 9, 20, 22, 30, and 24 in the final 9 months, she said.

When the first 4 years of the study period were compared with the last 3 years and 9 months, there was a 74% increase in the incidence of empyema and a 540% increase in empyema requiring decortication, she reported at the annual meeting of the Canadian Association of Thoracic Surgeons.

The etiology of this increase is not known, but it could be a reflection of changes in the treatment of community-acquired pneumonia, she suggested. “Empyema can be an indicator of delay in diagnosis and treatment of pneumonia, and this may be the case with more patients being treated at home.”

The mean age of the patients was 56 years, and 77% were male. There was a median of 2 days from the time of diagnosis until admission to hospital and a median of 14 days spent in the hospital. A total of 12 deaths were recorded.

At the time of admission, 22% of patients had been treated with antibiotics alone, and the type of antibiotic was known in 32% of these cases (51% macrolides, 32% quinolones, 30% combination, and 17% other). Another 20% of patients had received thoracentesis in addition to antibiotics, and 45% had received both treatments as well as a chest tube.

Pleural cultures (obtained in 98% of patients) were negative in 36%, gram negative in 26%, and gram positive in 38% (streptococcal species in 29%, staphylococcal species in 7%), Dr. Smith said. Among those patients requiring decortication, 77% of patients had this performed by thoracotomy, 9% had video-assisted thorascopic surgery, and 14% had an initial VATS procedure that was then converted to thoracotomy.

MONTREAL — A dramatic increase in the incidence of postpneumonic empyema requiring decortication is an “alarming” phenomenon that may possibly signal a new crisis in the management of community-acquired pneumonia, according to Shona E. Smith, M.D., a third-year general surgery resident at the University of Western Ontario's London Health Sciences Centre.

In a review of all adult cases of postpneumonic empyema [defined as a pus-containing pleural effusion] requiring decortication at her center between April 1997 and December 2004, Dr. Smith discovered the annual numbers of cases of empyema were 44, 35, 36, 42, 75, 68, 72, and 55 in the final 9 months of the study period. The numbers of decortications required in each of those years were 0, 0, 6, 9, 20, 22, 30, and 24 in the final 9 months, she said.

When the first 4 years of the study period were compared with the last 3 years and 9 months, there was a 74% increase in the incidence of empyema and a 540% increase in empyema requiring decortication, she reported at the annual meeting of the Canadian Association of Thoracic Surgeons.

The etiology of this increase is not known, but it could be a reflection of changes in the treatment of community-acquired pneumonia, she suggested. “Empyema can be an indicator of delay in diagnosis and treatment of pneumonia, and this may be the case with more patients being treated at home.”

The mean age of the patients was 56 years, and 77% were male. There was a median of 2 days from the time of diagnosis until admission to hospital and a median of 14 days spent in the hospital. A total of 12 deaths were recorded.

At the time of admission, 22% of patients had been treated with antibiotics alone, and the type of antibiotic was known in 32% of these cases (51% macrolides, 32% quinolones, 30% combination, and 17% other). Another 20% of patients had received thoracentesis in addition to antibiotics, and 45% had received both treatments as well as a chest tube.

Pleural cultures (obtained in 98% of patients) were negative in 36%, gram negative in 26%, and gram positive in 38% (streptococcal species in 29%, staphylococcal species in 7%), Dr. Smith said. Among those patients requiring decortication, 77% of patients had this performed by thoracotomy, 9% had video-assisted thorascopic surgery, and 14% had an initial VATS procedure that was then converted to thoracotomy.

MONTREAL — A dramatic increase in the incidence of postpneumonic empyema requiring decortication is an “alarming” phenomenon that may possibly signal a new crisis in the management of community-acquired pneumonia, according to Shona E. Smith, M.D., a third-year general surgery resident at the University of Western Ontario's London Health Sciences Centre.

In a review of all adult cases of postpneumonic empyema [defined as a pus-containing pleural effusion] requiring decortication at her center between April 1997 and December 2004, Dr. Smith discovered the annual numbers of cases of empyema were 44, 35, 36, 42, 75, 68, 72, and 55 in the final 9 months of the study period. The numbers of decortications required in each of those years were 0, 0, 6, 9, 20, 22, 30, and 24 in the final 9 months, she said.

When the first 4 years of the study period were compared with the last 3 years and 9 months, there was a 74% increase in the incidence of empyema and a 540% increase in empyema requiring decortication, she reported at the annual meeting of the Canadian Association of Thoracic Surgeons.

The etiology of this increase is not known, but it could be a reflection of changes in the treatment of community-acquired pneumonia, she suggested. “Empyema can be an indicator of delay in diagnosis and treatment of pneumonia, and this may be the case with more patients being treated at home.”

The mean age of the patients was 56 years, and 77% were male. There was a median of 2 days from the time of diagnosis until admission to hospital and a median of 14 days spent in the hospital. A total of 12 deaths were recorded.

At the time of admission, 22% of patients had been treated with antibiotics alone, and the type of antibiotic was known in 32% of these cases (51% macrolides, 32% quinolones, 30% combination, and 17% other). Another 20% of patients had received thoracentesis in addition to antibiotics, and 45% had received both treatments as well as a chest tube.

Pleural cultures (obtained in 98% of patients) were negative in 36%, gram negative in 26%, and gram positive in 38% (streptococcal species in 29%, staphylococcal species in 7%), Dr. Smith said. Among those patients requiring decortication, 77% of patients had this performed by thoracotomy, 9% had video-assisted thorascopic surgery, and 14% had an initial VATS procedure that was then converted to thoracotomy.

MONTREAL — In patients with postpneumonic empyema, early intervention with video-assisted thorascopic surgery can result in immediate and complete resolution, according to Donna E. Maziak, M.D., a thoracic surgeon at Ottawa Hospital.

And if VATS does not solve the problem, thoracotomy should be the logical next step, she added.

“Rather than trying to choose between doing VATS or thoracotomy, we should probably consider them both as a combination approach,” she said at the annual meeting of the Canadian Association of Thoracic Surgeons.

The advantages of early VATS are that it is minimally invasive, requires a short-acting anesthetic, and can often completely resolve the parapneumonic effusion.

With this approach, loculations can also be broken down immediately with no wait-and-see period for assessing success, said Dr. Maziak, also of the department of medicine at the University of Ottawa.

A study comparing VATS to thoracotomy in the treatment of postpneumonic empyema favored VATS for a lower relapse rate (0% versus 12%) and a nonsignificant trend toward shorter hospital stay (7 versus 11 days), with identical morbidity and mortality rates (Ann. Thorac. Surg. 1996;61:1626–30), she said.

Expanded figures from the same group showed much lower morbidity and mortality rates for VATS (6% and 2%, respectively), compared with thoracotomy (15% and 3%).

The authors concluded that “VATS debridement for loculated fibrinopurulent postpneumonic empyema offers better results than thoracotomy in terms of resolution of the disease and length of stay in hospital. It also seems to be more advantageous, resulting in fewer surgical sequelae, lower cost, less labor impediment, and better cosmesis” (World J. Surg. 1999;23:1110–3).

Although early intervention with a minimally invasive technique such as VATS has obvious advantages, clinicians should not hesitate to move immediately on to thoracotomy if necessary, Dr. Maziak advised.

“Don't be afraid to operate. Think thoracotomy earlier rather than later,” she said.

In fact, pooled data in the American College of Chest Physicians consensus statement on the treatment of parapneumonic effusions suggest that mortality is actually higher with VATS (4.8%) than with thoracotomy (1.9%), she said (Chest 2000;118:1158–71).

Balancing this, however, the statement also shows evidence that no VATS patients need a second intervention to resolve the effusion, while 10.7% of thoracotomy patients do, she said.

The ACCP statement says that existing evidence is equally supportive of VATS, surgery, or fibrinolytics as acceptable approaches for managing complicated empyema.

A randomized trial comparing VATS with chest-tube pleural drainage and streptokinase therapy favored VATS for higher efficacy and shorter hospital stay (Chest 1997;111:1548–51). However, the numbers in this study, as well as in the VATS versus thoracotomy studies, are too small to draw firm conclusions, according to the ACCP statement.

MONTREAL — In patients with postpneumonic empyema, early intervention with video-assisted thorascopic surgery can result in immediate and complete resolution, according to Donna E. Maziak, M.D., a thoracic surgeon at Ottawa Hospital.

And if VATS does not solve the problem, thoracotomy should be the logical next step, she added.

“Rather than trying to choose between doing VATS or thoracotomy, we should probably consider them both as a combination approach,” she said at the annual meeting of the Canadian Association of Thoracic Surgeons.

The advantages of early VATS are that it is minimally invasive, requires a short-acting anesthetic, and can often completely resolve the parapneumonic effusion.

With this approach, loculations can also be broken down immediately with no wait-and-see period for assessing success, said Dr. Maziak, also of the department of medicine at the University of Ottawa.

A study comparing VATS to thoracotomy in the treatment of postpneumonic empyema favored VATS for a lower relapse rate (0% versus 12%) and a nonsignificant trend toward shorter hospital stay (7 versus 11 days), with identical morbidity and mortality rates (Ann. Thorac. Surg. 1996;61:1626–30), she said.

Expanded figures from the same group showed much lower morbidity and mortality rates for VATS (6% and 2%, respectively), compared with thoracotomy (15% and 3%).

The authors concluded that “VATS debridement for loculated fibrinopurulent postpneumonic empyema offers better results than thoracotomy in terms of resolution of the disease and length of stay in hospital. It also seems to be more advantageous, resulting in fewer surgical sequelae, lower cost, less labor impediment, and better cosmesis” (World J. Surg. 1999;23:1110–3).

Although early intervention with a minimally invasive technique such as VATS has obvious advantages, clinicians should not hesitate to move immediately on to thoracotomy if necessary, Dr. Maziak advised.

“Don't be afraid to operate. Think thoracotomy earlier rather than later,” she said.

In fact, pooled data in the American College of Chest Physicians consensus statement on the treatment of parapneumonic effusions suggest that mortality is actually higher with VATS (4.8%) than with thoracotomy (1.9%), she said (Chest 2000;118:1158–71).

Balancing this, however, the statement also shows evidence that no VATS patients need a second intervention to resolve the effusion, while 10.7% of thoracotomy patients do, she said.

The ACCP statement says that existing evidence is equally supportive of VATS, surgery, or fibrinolytics as acceptable approaches for managing complicated empyema.

A randomized trial comparing VATS with chest-tube pleural drainage and streptokinase therapy favored VATS for higher efficacy and shorter hospital stay (Chest 1997;111:1548–51). However, the numbers in this study, as well as in the VATS versus thoracotomy studies, are too small to draw firm conclusions, according to the ACCP statement.

MONTREAL — In patients with postpneumonic empyema, early intervention with video-assisted thorascopic surgery can result in immediate and complete resolution, according to Donna E. Maziak, M.D., a thoracic surgeon at Ottawa Hospital.

And if VATS does not solve the problem, thoracotomy should be the logical next step, she added.

“Rather than trying to choose between doing VATS or thoracotomy, we should probably consider them both as a combination approach,” she said at the annual meeting of the Canadian Association of Thoracic Surgeons.

The advantages of early VATS are that it is minimally invasive, requires a short-acting anesthetic, and can often completely resolve the parapneumonic effusion.

With this approach, loculations can also be broken down immediately with no wait-and-see period for assessing success, said Dr. Maziak, also of the department of medicine at the University of Ottawa.

A study comparing VATS to thoracotomy in the treatment of postpneumonic empyema favored VATS for a lower relapse rate (0% versus 12%) and a nonsignificant trend toward shorter hospital stay (7 versus 11 days), with identical morbidity and mortality rates (Ann. Thorac. Surg. 1996;61:1626–30), she said.

Expanded figures from the same group showed much lower morbidity and mortality rates for VATS (6% and 2%, respectively), compared with thoracotomy (15% and 3%).

The authors concluded that “VATS debridement for loculated fibrinopurulent postpneumonic empyema offers better results than thoracotomy in terms of resolution of the disease and length of stay in hospital. It also seems to be more advantageous, resulting in fewer surgical sequelae, lower cost, less labor impediment, and better cosmesis” (World J. Surg. 1999;23:1110–3).

Although early intervention with a minimally invasive technique such as VATS has obvious advantages, clinicians should not hesitate to move immediately on to thoracotomy if necessary, Dr. Maziak advised.

“Don't be afraid to operate. Think thoracotomy earlier rather than later,” she said.

In fact, pooled data in the American College of Chest Physicians consensus statement on the treatment of parapneumonic effusions suggest that mortality is actually higher with VATS (4.8%) than with thoracotomy (1.9%), she said (Chest 2000;118:1158–71).

Balancing this, however, the statement also shows evidence that no VATS patients need a second intervention to resolve the effusion, while 10.7% of thoracotomy patients do, she said.

The ACCP statement says that existing evidence is equally supportive of VATS, surgery, or fibrinolytics as acceptable approaches for managing complicated empyema.

A randomized trial comparing VATS with chest-tube pleural drainage and streptokinase therapy favored VATS for higher efficacy and shorter hospital stay (Chest 1997;111:1548–51). However, the numbers in this study, as well as in the VATS versus thoracotomy studies, are too small to draw firm conclusions, according to the ACCP statement.

MONTREAL — Female urinary and fecal incontinence is associated with lifestyle, according to a recent longitudinal study.

“Body mass index, smoking, and hormone replacement therapy remain bad news for the pelvic floor,” said Kaven Baessler, M.D., who conducted the study at Royal Women's Hospital in Brisbane, Australia.

Speaking at the annual meeting of the International Continence Society, Dr. Baessler, who has since moved to Charité University Hospital in Berlin, said neither age nor mode of delivery was associated with incontinence in her study population of 443 women aged 40–80 years.

“In some studies, age definitely plays a role, but the women in this study were already aged 40 and up—age had taken its toll already when we assessed them,” she said in an interview. “Results would be different when more premenopausal and younger women are considered. That vaginal delivery and parity itself plays a role in women aged 30–50 is not a question.”

The data were analyzed based on three delivery modes: women who'd had no births, women with a cesarean delivery, and women who'd had either a spontaneous or instrumental delivery. This analysis showed no association between any of these three categories and incontinence.

The study grouped together women who'd had either a spontaneous or instrumental vaginal delivery. U.S. studies that have looked exclusively at women who've undergone instrumental delivery or episiotomy have shown an association between these procedures and pelvic floor damage, Luis Sanz, M.D., head of the urogynecology and pelvic surgery program at Virginia Hospital Center, Arlington, noted in an interview.

At the meeting Dr. Baessler said, “Many people want to blame something, and vaginal delivery is so easy to blame. Many studies with large numbers have shown that cesarean section increases the risk of incontinence just slightly less than vaginal delivery, so it is pregnancy itself that is the risk factor.”

The study randomly sampled women from the list of registered voters and assessed them with an interview, a clinical exam, and a validated pelvic floor function questionnaire. These assessments were repeated a year later.

Urinary and fecal incontinence increased significantly between the two assessments. At baseline, 47% of the population reported stress urinary incontinence (SUI), 30% reported urge urinary incontinence (UUI), and about 11% reported fecal incontinence. An additional 16% of previously asymptomatic women reported SUI, 16% reported UUI, and roughly 7% reported fecal incontinence at the second assessment.

SUI was associated with high body mass index (odds ratio 1.56 for BMI between 25 and 30, and OR 1.8 for BMI over 30) and waist circumference of more than 88 cm (OR 1.6), but not with hormone therapy (HT), smoking, age, or mode of delivery.

Urge incontinence was associated with HT use (OR 2.17), but not with BMI, waist circumference, age, smoking, or mode of delivery.

Fecal incontinence for loose stool was associated with BMI over 30 (OR 2.9) and waist circumference of more than 88 cm (OR 3.64), but not with age, smoking, mode of delivery, or HT use.

Fecal incontinence for formed stool was associated with current smoking (OR 3.57), but not with age, HT, BMI, waist circumference, or mode of delivery.

“Health care providers have to inform and educate their patients about these factors,” Dr. Baessler said. “And women should also take greater responsibility for their lifestyle.”

MONTREAL — Female urinary and fecal incontinence is associated with lifestyle, according to a recent longitudinal study.

“Body mass index, smoking, and hormone replacement therapy remain bad news for the pelvic floor,” said Kaven Baessler, M.D., who conducted the study at Royal Women's Hospital in Brisbane, Australia.

Speaking at the annual meeting of the International Continence Society, Dr. Baessler, who has since moved to Charité University Hospital in Berlin, said neither age nor mode of delivery was associated with incontinence in her study population of 443 women aged 40–80 years.

“In some studies, age definitely plays a role, but the women in this study were already aged 40 and up—age had taken its toll already when we assessed them,” she said in an interview. “Results would be different when more premenopausal and younger women are considered. That vaginal delivery and parity itself plays a role in women aged 30–50 is not a question.”

The data were analyzed based on three delivery modes: women who'd had no births, women with a cesarean delivery, and women who'd had either a spontaneous or instrumental delivery. This analysis showed no association between any of these three categories and incontinence.

The study grouped together women who'd had either a spontaneous or instrumental vaginal delivery. U.S. studies that have looked exclusively at women who've undergone instrumental delivery or episiotomy have shown an association between these procedures and pelvic floor damage, Luis Sanz, M.D., head of the urogynecology and pelvic surgery program at Virginia Hospital Center, Arlington, noted in an interview.

At the meeting Dr. Baessler said, “Many people want to blame something, and vaginal delivery is so easy to blame. Many studies with large numbers have shown that cesarean section increases the risk of incontinence just slightly less than vaginal delivery, so it is pregnancy itself that is the risk factor.”

The study randomly sampled women from the list of registered voters and assessed them with an interview, a clinical exam, and a validated pelvic floor function questionnaire. These assessments were repeated a year later.

Urinary and fecal incontinence increased significantly between the two assessments. At baseline, 47% of the population reported stress urinary incontinence (SUI), 30% reported urge urinary incontinence (UUI), and about 11% reported fecal incontinence. An additional 16% of previously asymptomatic women reported SUI, 16% reported UUI, and roughly 7% reported fecal incontinence at the second assessment.

SUI was associated with high body mass index (odds ratio 1.56 for BMI between 25 and 30, and OR 1.8 for BMI over 30) and waist circumference of more than 88 cm (OR 1.6), but not with hormone therapy (HT), smoking, age, or mode of delivery.

Urge incontinence was associated with HT use (OR 2.17), but not with BMI, waist circumference, age, smoking, or mode of delivery.

Fecal incontinence for loose stool was associated with BMI over 30 (OR 2.9) and waist circumference of more than 88 cm (OR 3.64), but not with age, smoking, mode of delivery, or HT use.

Fecal incontinence for formed stool was associated with current smoking (OR 3.57), but not with age, HT, BMI, waist circumference, or mode of delivery.

“Health care providers have to inform and educate their patients about these factors,” Dr. Baessler said. “And women should also take greater responsibility for their lifestyle.”

MONTREAL — Female urinary and fecal incontinence is associated with lifestyle, according to a recent longitudinal study.

“Body mass index, smoking, and hormone replacement therapy remain bad news for the pelvic floor,” said Kaven Baessler, M.D., who conducted the study at Royal Women's Hospital in Brisbane, Australia.

Speaking at the annual meeting of the International Continence Society, Dr. Baessler, who has since moved to Charité University Hospital in Berlin, said neither age nor mode of delivery was associated with incontinence in her study population of 443 women aged 40–80 years.

“In some studies, age definitely plays a role, but the women in this study were already aged 40 and up—age had taken its toll already when we assessed them,” she said in an interview. “Results would be different when more premenopausal and younger women are considered. That vaginal delivery and parity itself plays a role in women aged 30–50 is not a question.”

The data were analyzed based on three delivery modes: women who'd had no births, women with a cesarean delivery, and women who'd had either a spontaneous or instrumental delivery. This analysis showed no association between any of these three categories and incontinence.

The study grouped together women who'd had either a spontaneous or instrumental vaginal delivery. U.S. studies that have looked exclusively at women who've undergone instrumental delivery or episiotomy have shown an association between these procedures and pelvic floor damage, Luis Sanz, M.D., head of the urogynecology and pelvic surgery program at Virginia Hospital Center, Arlington, noted in an interview.

At the meeting Dr. Baessler said, “Many people want to blame something, and vaginal delivery is so easy to blame. Many studies with large numbers have shown that cesarean section increases the risk of incontinence just slightly less than vaginal delivery, so it is pregnancy itself that is the risk factor.”

The study randomly sampled women from the list of registered voters and assessed them with an interview, a clinical exam, and a validated pelvic floor function questionnaire. These assessments were repeated a year later.

Urinary and fecal incontinence increased significantly between the two assessments. At baseline, 47% of the population reported stress urinary incontinence (SUI), 30% reported urge urinary incontinence (UUI), and about 11% reported fecal incontinence. An additional 16% of previously asymptomatic women reported SUI, 16% reported UUI, and roughly 7% reported fecal incontinence at the second assessment.

SUI was associated with high body mass index (odds ratio 1.56 for BMI between 25 and 30, and OR 1.8 for BMI over 30) and waist circumference of more than 88 cm (OR 1.6), but not with hormone therapy (HT), smoking, age, or mode of delivery.

Urge incontinence was associated with HT use (OR 2.17), but not with BMI, waist circumference, age, smoking, or mode of delivery.

Fecal incontinence for loose stool was associated with BMI over 30 (OR 2.9) and waist circumference of more than 88 cm (OR 3.64), but not with age, smoking, mode of delivery, or HT use.

Fecal incontinence for formed stool was associated with current smoking (OR 3.57), but not with age, HT, BMI, waist circumference, or mode of delivery.

“Health care providers have to inform and educate their patients about these factors,” Dr. Baessler said. “And women should also take greater responsibility for their lifestyle.”

MONTREAL — Gastroesophageal reflux symptoms are poorly controlled across North America and Europe, and people with nocturnal symptoms represent the largest treatment gap, according to two different industry-sponsored studies that were presented in a series of posters at the 13th World Congress of Gastroenterology.

“There's a huge unmet prescribing need,” said Farah Husein-Bhabha, from Janssen-Ortho Inc. in Toronto, which sponsored one of the studies. “We found that the use of over-the-counter drugs is much higher than prescription drug use, and yet these patients continue to experience symptoms,” she told this publication.

The Canadian study randomly polled 2,001 individuals by telephone to assess the prevalence and impact of gastroesophageal reflux disease (GERD) in the general population.

Just over 40% of the respondents (820) reported at least one upper gastrointestinal symptom in the last month, with the most common complaint being GERD (367). Among GERD sufferers, 54% had sought medical help for their problem, while 46% had not.

The U.S./European study (sponsored by AstraZeneca) which randomly polled a much larger sample of about 212,000 households, identified 1,908 respondents who were either formally diagnosed (52%) or undiagnosed but with symptoms suggestive of GERD (48%). Both studies identified a high percentage (64% and 50%, respectively) of patients who reported nocturnal GERD symptoms either alone or together with daytime symptoms.

In the Canadian study, 47% of those with nocturnal symptoms reported disturbed sleep, and 43% of these people reported a negative impact on their daytime functioning and productivity as a result.

The U.S./European study found that, when woken up with GERD symptoms, people stayed awake an average of 70 minutes and missed an average of 30 minutes of work per week as a result. This compared with only 6 minutes of lost work time per week in GERD patients without disturbed sleep. GERD-related sleep disturbance was estimated to be responsible for a 15% reduction in work productivity and a 14% reduction in leisure time, compared with an 8% and 10% reduction in GERD patients without disturbed sleep.

Nocturnal GERD symptoms are of particular concern, not only for quality of life reasons but also because of their long-term implications, said Ms. Husein-Bhabha. “If a patient has nocturnal symptoms, it generally means a more severe type of GERD, and there may also be an association with more erosive disease. There is a certain percentage of the population that may progress to esophageal cancer if they are untreated. But for many patients who do not have erosive disease, that risk is small and probably less than we had originally thought.” Both studies found that GERD symptoms are undertreated.

In the Canadian population, 57% of GERD patients were taking over-the-counter (OTC) medications, while 25% used prescription medications.

In the U.S./European study, 74% of the diagnosed group were taking prescription medications (55% of which were proton pump inhibitors), while 85% of the undiagnosed group were taking OTC medications.

Despite some improvement resulting from these treatments, the majority of patients in the U.S./European study reported unresolved symptoms (81% of the self-treated group and 68% of those taking prescription medications).

In the Canadian study, only 54% of patients using proton pump inhibitors (PPIs) for nocturnal relief felt satisfied with the treatment.

“[U]se of medication for management of GERD can be improved,” concluded the authors. “Symptoms were more likely to improve when GERD was formally diagnosed by a physician and PPIs prescribed. … Individuals with persistent GERD symptoms should consult a physician.”

MONTREAL — Gastroesophageal reflux symptoms are poorly controlled across North America and Europe, and people with nocturnal symptoms represent the largest treatment gap, according to two different industry-sponsored studies that were presented in a series of posters at the 13th World Congress of Gastroenterology.

“There's a huge unmet prescribing need,” said Farah Husein-Bhabha, from Janssen-Ortho Inc. in Toronto, which sponsored one of the studies. “We found that the use of over-the-counter drugs is much higher than prescription drug use, and yet these patients continue to experience symptoms,” she told this publication.

The Canadian study randomly polled 2,001 individuals by telephone to assess the prevalence and impact of gastroesophageal reflux disease (GERD) in the general population.

Just over 40% of the respondents (820) reported at least one upper gastrointestinal symptom in the last month, with the most common complaint being GERD (367). Among GERD sufferers, 54% had sought medical help for their problem, while 46% had not.

The U.S./European study (sponsored by AstraZeneca) which randomly polled a much larger sample of about 212,000 households, identified 1,908 respondents who were either formally diagnosed (52%) or undiagnosed but with symptoms suggestive of GERD (48%). Both studies identified a high percentage (64% and 50%, respectively) of patients who reported nocturnal GERD symptoms either alone or together with daytime symptoms.

In the Canadian study, 47% of those with nocturnal symptoms reported disturbed sleep, and 43% of these people reported a negative impact on their daytime functioning and productivity as a result.

The U.S./European study found that, when woken up with GERD symptoms, people stayed awake an average of 70 minutes and missed an average of 30 minutes of work per week as a result. This compared with only 6 minutes of lost work time per week in GERD patients without disturbed sleep. GERD-related sleep disturbance was estimated to be responsible for a 15% reduction in work productivity and a 14% reduction in leisure time, compared with an 8% and 10% reduction in GERD patients without disturbed sleep.

Nocturnal GERD symptoms are of particular concern, not only for quality of life reasons but also because of their long-term implications, said Ms. Husein-Bhabha. “If a patient has nocturnal symptoms, it generally means a more severe type of GERD, and there may also be an association with more erosive disease. There is a certain percentage of the population that may progress to esophageal cancer if they are untreated. But for many patients who do not have erosive disease, that risk is small and probably less than we had originally thought.” Both studies found that GERD symptoms are undertreated.

In the Canadian population, 57% of GERD patients were taking over-the-counter (OTC) medications, while 25% used prescription medications.

In the U.S./European study, 74% of the diagnosed group were taking prescription medications (55% of which were proton pump inhibitors), while 85% of the undiagnosed group were taking OTC medications.

Despite some improvement resulting from these treatments, the majority of patients in the U.S./European study reported unresolved symptoms (81% of the self-treated group and 68% of those taking prescription medications).

In the Canadian study, only 54% of patients using proton pump inhibitors (PPIs) for nocturnal relief felt satisfied with the treatment.

“[U]se of medication for management of GERD can be improved,” concluded the authors. “Symptoms were more likely to improve when GERD was formally diagnosed by a physician and PPIs prescribed. … Individuals with persistent GERD symptoms should consult a physician.”

MONTREAL — Gastroesophageal reflux symptoms are poorly controlled across North America and Europe, and people with nocturnal symptoms represent the largest treatment gap, according to two different industry-sponsored studies that were presented in a series of posters at the 13th World Congress of Gastroenterology.

“There's a huge unmet prescribing need,” said Farah Husein-Bhabha, from Janssen-Ortho Inc. in Toronto, which sponsored one of the studies. “We found that the use of over-the-counter drugs is much higher than prescription drug use, and yet these patients continue to experience symptoms,” she told this publication.

The Canadian study randomly polled 2,001 individuals by telephone to assess the prevalence and impact of gastroesophageal reflux disease (GERD) in the general population.

Just over 40% of the respondents (820) reported at least one upper gastrointestinal symptom in the last month, with the most common complaint being GERD (367). Among GERD sufferers, 54% had sought medical help for their problem, while 46% had not.

The U.S./European study (sponsored by AstraZeneca) which randomly polled a much larger sample of about 212,000 households, identified 1,908 respondents who were either formally diagnosed (52%) or undiagnosed but with symptoms suggestive of GERD (48%). Both studies identified a high percentage (64% and 50%, respectively) of patients who reported nocturnal GERD symptoms either alone or together with daytime symptoms.

In the Canadian study, 47% of those with nocturnal symptoms reported disturbed sleep, and 43% of these people reported a negative impact on their daytime functioning and productivity as a result.

The U.S./European study found that, when woken up with GERD symptoms, people stayed awake an average of 70 minutes and missed an average of 30 minutes of work per week as a result. This compared with only 6 minutes of lost work time per week in GERD patients without disturbed sleep. GERD-related sleep disturbance was estimated to be responsible for a 15% reduction in work productivity and a 14% reduction in leisure time, compared with an 8% and 10% reduction in GERD patients without disturbed sleep.

Nocturnal GERD symptoms are of particular concern, not only for quality of life reasons but also because of their long-term implications, said Ms. Husein-Bhabha. “If a patient has nocturnal symptoms, it generally means a more severe type of GERD, and there may also be an association with more erosive disease. There is a certain percentage of the population that may progress to esophageal cancer if they are untreated. But for many patients who do not have erosive disease, that risk is small and probably less than we had originally thought.” Both studies found that GERD symptoms are undertreated.

In the Canadian population, 57% of GERD patients were taking over-the-counter (OTC) medications, while 25% used prescription medications.

In the U.S./European study, 74% of the diagnosed group were taking prescription medications (55% of which were proton pump inhibitors), while 85% of the undiagnosed group were taking OTC medications.

Despite some improvement resulting from these treatments, the majority of patients in the U.S./European study reported unresolved symptoms (81% of the self-treated group and 68% of those taking prescription medications).

In the Canadian study, only 54% of patients using proton pump inhibitors (PPIs) for nocturnal relief felt satisfied with the treatment.

“[U]se of medication for management of GERD can be improved,” concluded the authors. “Symptoms were more likely to improve when GERD was formally diagnosed by a physician and PPIs prescribed. … Individuals with persistent GERD symptoms should consult a physician.”

MONTREAL — Clinicians looking for a less invasive treatment for stress urinary incontinence can choose transobturator tape instead of tension-free vaginal tape, according to Italian researchers.

“The results [efficacy] are equal and the complications are very similar,” said Ervin Kocjancic, M.D., a urology specialist at the University of Piemonte Orientale in Novara, Italy.

“This is a very important study because, until now, we had very little research comparing these methods,” he said in an interview.

Dr. Kocjancic was one of the investigators in a multicenter trial that randomized 96 women with stress or mixed urinary incontinence to treatment with either tension-free vaginal tape (TVT) or transobturator tape (TOT).

All women had stress or mixed urinary incontinence with urethral hypermobility and a positive Bonney test, coinvestigator Elisabetta Costantini, M.D., reported at the annual meeting of the International Continence Society.

Follow-up included clinical check-ups at 3, 6, 9, and 12 months; symptom questionnaires (the Urogenital Distress Inventory, or UDI-6, and the Incontinence Impact Questionnaire, or IIQ-7); and free flowmetry with postmicturitional residue evaluation.

Intraoperative and postoperative complications (early and late) were recorded, as were treatment efficacy (subjective and objective) and any new-onset urinary disturbances, said Dr. Costantini, of the University of Perugia (Italy).

There were no significant differences between groups in complications or outcome. However, there was a trend toward slightly worse outcome in TVT patients with mixed incontinence in that they experienced more new cases of urgency disturbances after surgery, compared with the TOT patients, said Dr. Kocjancic.

“Mixed incontinence patients are the most complicated group of patients, and they did better with TOT,” he said.

Roughly 2% of the TOT group reported new-onset storage symptoms following surgery, compared with roughly 10% of the TVT group, but this difference was not significant.

Among those with mixed incontinence, however, storage symptoms were significantly improved in the TOT group—with 85% reporting an improvement in urgency, compared with 19% in the TVT group.

Roughly 2% of the TOT group reported new-onset storage symptoms following surgery, compared with roughly 10% of the TVT group.

The study is ongoing, and the results require confirmation with more patients and longer follow-up, Dr. Costantini concluded.

MONTREAL — Clinicians looking for a less invasive treatment for stress urinary incontinence can choose transobturator tape instead of tension-free vaginal tape, according to Italian researchers.

“The results [efficacy] are equal and the complications are very similar,” said Ervin Kocjancic, M.D., a urology specialist at the University of Piemonte Orientale in Novara, Italy.

“This is a very important study because, until now, we had very little research comparing these methods,” he said in an interview.

Dr. Kocjancic was one of the investigators in a multicenter trial that randomized 96 women with stress or mixed urinary incontinence to treatment with either tension-free vaginal tape (TVT) or transobturator tape (TOT).

All women had stress or mixed urinary incontinence with urethral hypermobility and a positive Bonney test, coinvestigator Elisabetta Costantini, M.D., reported at the annual meeting of the International Continence Society.

Follow-up included clinical check-ups at 3, 6, 9, and 12 months; symptom questionnaires (the Urogenital Distress Inventory, or UDI-6, and the Incontinence Impact Questionnaire, or IIQ-7); and free flowmetry with postmicturitional residue evaluation.

Intraoperative and postoperative complications (early and late) were recorded, as were treatment efficacy (subjective and objective) and any new-onset urinary disturbances, said Dr. Costantini, of the University of Perugia (Italy).

There were no significant differences between groups in complications or outcome. However, there was a trend toward slightly worse outcome in TVT patients with mixed incontinence in that they experienced more new cases of urgency disturbances after surgery, compared with the TOT patients, said Dr. Kocjancic.

“Mixed incontinence patients are the most complicated group of patients, and they did better with TOT,” he said.

Roughly 2% of the TOT group reported new-onset storage symptoms following surgery, compared with roughly 10% of the TVT group, but this difference was not significant.

Among those with mixed incontinence, however, storage symptoms were significantly improved in the TOT group—with 85% reporting an improvement in urgency, compared with 19% in the TVT group.

Roughly 2% of the TOT group reported new-onset storage symptoms following surgery, compared with roughly 10% of the TVT group.

The study is ongoing, and the results require confirmation with more patients and longer follow-up, Dr. Costantini concluded.

MONTREAL — Clinicians looking for a less invasive treatment for stress urinary incontinence can choose transobturator tape instead of tension-free vaginal tape, according to Italian researchers.

“The results [efficacy] are equal and the complications are very similar,” said Ervin Kocjancic, M.D., a urology specialist at the University of Piemonte Orientale in Novara, Italy.

“This is a very important study because, until now, we had very little research comparing these methods,” he said in an interview.

Dr. Kocjancic was one of the investigators in a multicenter trial that randomized 96 women with stress or mixed urinary incontinence to treatment with either tension-free vaginal tape (TVT) or transobturator tape (TOT).

All women had stress or mixed urinary incontinence with urethral hypermobility and a positive Bonney test, coinvestigator Elisabetta Costantini, M.D., reported at the annual meeting of the International Continence Society.

Follow-up included clinical check-ups at 3, 6, 9, and 12 months; symptom questionnaires (the Urogenital Distress Inventory, or UDI-6, and the Incontinence Impact Questionnaire, or IIQ-7); and free flowmetry with postmicturitional residue evaluation.

Intraoperative and postoperative complications (early and late) were recorded, as were treatment efficacy (subjective and objective) and any new-onset urinary disturbances, said Dr. Costantini, of the University of Perugia (Italy).

There were no significant differences between groups in complications or outcome. However, there was a trend toward slightly worse outcome in TVT patients with mixed incontinence in that they experienced more new cases of urgency disturbances after surgery, compared with the TOT patients, said Dr. Kocjancic.

“Mixed incontinence patients are the most complicated group of patients, and they did better with TOT,” he said.

Roughly 2% of the TOT group reported new-onset storage symptoms following surgery, compared with roughly 10% of the TVT group, but this difference was not significant.

Among those with mixed incontinence, however, storage symptoms were significantly improved in the TOT group—with 85% reporting an improvement in urgency, compared with 19% in the TVT group.

Roughly 2% of the TOT group reported new-onset storage symptoms following surgery, compared with roughly 10% of the TVT group.

The study is ongoing, and the results require confirmation with more patients and longer follow-up, Dr. Costantini concluded.

MONTREAL — A cough is worth a thousand contractions of the pelvic floor muscles, since it can often reveal the otherwise hidden beginnings of pelvic organ prolapse, according to Marÿke Slieker-ten Hove of Erasmus Medical Center in Rotterdam, The Netherlands.

Symptoms of pelvic organ prolapse (POP) are present in more than 90% of parous women, but in the remaining asymptomatic group, early and sometimes advanced POP can be detected simply by asking patients to cough, she discovered during her research.

“It's often at a very early stage; there's no leakage and they are not aware of it—but you can feel that they lose control of their muscles when they cough,” she said in an interview.

“Physicians will tell women who have a firm contraction that they don't have a pelvic floor muscle problem. But they don't ask them to cough. Although many women have a very strong muscle, they don't have control when they cough,” she said.

In her study, which she presented during the annual meeting of the International Continence Society, Ms. Slieker-ten Hove, who is head of pelvic physiotherapy education at the medical center, randomly selected 653 women from one small town who had agreed to answer questionnaires on urinary and fecal incontinence and quality of life. The women also underwent a physical examination to assess their pelvic floor muscles.

All women who were nulliparous and all those who answered positively on any questions concerning pelvic floor dysfunction were excluded.

This left 51 asymptomatic parous women (about 8% of the original population) for analysis.

The research team then assessed the women for signs of POP, including conscious and unconscious contractions and relaxations of the pelvic floor muscles, as well as counter action of the muscles during coughing.

Despite being completely asymptomatic, 18 women (35%) had signs of POP that were stage 2 or higher, 23 had signs of stage 1 POP, and only 9 women had no signs of POP.

By detecting these early, asymptomatic signs of POP, physicians might have more success at preventing the development of incontinence, rather than treating it once it becomes evident.

“We only do something about incontinence at the end when patients already have complaints. We should be preventive [by] giving them information about protecting their pelvic floor,” Ms. Slieker-ten Hove said.

MONTREAL — A cough is worth a thousand contractions of the pelvic floor muscles, since it can often reveal the otherwise hidden beginnings of pelvic organ prolapse, according to Marÿke Slieker-ten Hove of Erasmus Medical Center in Rotterdam, The Netherlands.

Symptoms of pelvic organ prolapse (POP) are present in more than 90% of parous women, but in the remaining asymptomatic group, early and sometimes advanced POP can be detected simply by asking patients to cough, she discovered during her research.

“It's often at a very early stage; there's no leakage and they are not aware of it—but you can feel that they lose control of their muscles when they cough,” she said in an interview.

“Physicians will tell women who have a firm contraction that they don't have a pelvic floor muscle problem. But they don't ask them to cough. Although many women have a very strong muscle, they don't have control when they cough,” she said.

In her study, which she presented during the annual meeting of the International Continence Society, Ms. Slieker-ten Hove, who is head of pelvic physiotherapy education at the medical center, randomly selected 653 women from one small town who had agreed to answer questionnaires on urinary and fecal incontinence and quality of life. The women also underwent a physical examination to assess their pelvic floor muscles.

All women who were nulliparous and all those who answered positively on any questions concerning pelvic floor dysfunction were excluded.

This left 51 asymptomatic parous women (about 8% of the original population) for analysis.

The research team then assessed the women for signs of POP, including conscious and unconscious contractions and relaxations of the pelvic floor muscles, as well as counter action of the muscles during coughing.

Despite being completely asymptomatic, 18 women (35%) had signs of POP that were stage 2 or higher, 23 had signs of stage 1 POP, and only 9 women had no signs of POP.

By detecting these early, asymptomatic signs of POP, physicians might have more success at preventing the development of incontinence, rather than treating it once it becomes evident.

“We only do something about incontinence at the end when patients already have complaints. We should be preventive [by] giving them information about protecting their pelvic floor,” Ms. Slieker-ten Hove said.

MONTREAL — A cough is worth a thousand contractions of the pelvic floor muscles, since it can often reveal the otherwise hidden beginnings of pelvic organ prolapse, according to Marÿke Slieker-ten Hove of Erasmus Medical Center in Rotterdam, The Netherlands.

Symptoms of pelvic organ prolapse (POP) are present in more than 90% of parous women, but in the remaining asymptomatic group, early and sometimes advanced POP can be detected simply by asking patients to cough, she discovered during her research.

“It's often at a very early stage; there's no leakage and they are not aware of it—but you can feel that they lose control of their muscles when they cough,” she said in an interview.

“Physicians will tell women who have a firm contraction that they don't have a pelvic floor muscle problem. But they don't ask them to cough. Although many women have a very strong muscle, they don't have control when they cough,” she said.

In her study, which she presented during the annual meeting of the International Continence Society, Ms. Slieker-ten Hove, who is head of pelvic physiotherapy education at the medical center, randomly selected 653 women from one small town who had agreed to answer questionnaires on urinary and fecal incontinence and quality of life. The women also underwent a physical examination to assess their pelvic floor muscles.

All women who were nulliparous and all those who answered positively on any questions concerning pelvic floor dysfunction were excluded.

This left 51 asymptomatic parous women (about 8% of the original population) for analysis.

The research team then assessed the women for signs of POP, including conscious and unconscious contractions and relaxations of the pelvic floor muscles, as well as counter action of the muscles during coughing.

Despite being completely asymptomatic, 18 women (35%) had signs of POP that were stage 2 or higher, 23 had signs of stage 1 POP, and only 9 women had no signs of POP.

By detecting these early, asymptomatic signs of POP, physicians might have more success at preventing the development of incontinence, rather than treating it once it becomes evident.

“We only do something about incontinence at the end when patients already have complaints. We should be preventive [by] giving them information about protecting their pelvic floor,” Ms. Slieker-ten Hove said.

SAN FRANCISCO — Elderly women should not be denied major gynecologic surgery solely on the basis of their presumed age-based operative risk, according to Lindsay M. Mains, M.D.

In a study she presented at the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Mains showed that morbidity and mortality among elderly women undergoing major gynecologic surgery is relatively high, compared with rates in younger women undergoing this surgery. But attention to the specific perioperative needs of the elderly might further reduce this risk, said Dr. Mains of the Ochsner Clinic Foundation in New Orleans.

Dr. Mains' study reviewed data from 110 major gynecologic surgeries on women aged 80 to 90 years old. All patients received preoperative medical clearance, except one who required emergent surgery.

Although half of the patients were overweight or obese, 61% had no serious medical history otherwise, and 96% had an American Society of Anesthesiologists' (ASA) score of 3 or less.

Most procedures (77%) were performed to remove cancer or a benign mass; the rest were undertaken to treat pelvic organ prolapse and/or urinary incontinence. Almost all patients (95.5%) received general endotracheal anesthesia.

An abdominal procedure was performed in 65% of patients, while 32.5% underwent laparoscopy. A total of 4.5% had a vaginal procedure.

Dr. Mains reported an intraoperative complication rate of 4% and a post-operative complication rate of 45%. Eight percent of the total study group had major life-threatening complications, including death in 3.6% of patients.

The most common postoperative complications were ileus, which occurred in 14% of patients, infection in 14% (urinary tract infection in 6%, wound infection in 5%, and death due to sepsis in 3%), cardiopulmonary events in 13%, and fever of unknown origin in 11%.

There were four fatalities—one due to myocardial infarction and three due to sepsis and intravascular coagulation.

“Our mortality rate was lower than other studies on elderly patients, which include men and women and have shown mortality rates up to 13%. This is an interesting finding and warrants further study,” she said.

One of the mortalities occurred on postoperative day 10 in the only patient who had undergone emergent surgery because of intraabdominal hemorrhage, she noted.

Dr. Mains suggested that some of the complications in the study subjects might be specific to the elderly population, and attention to these issues could help in reducing risk. For example, half of the 14% of patients who experienced postoperative ileus were readmitted for this problem.

“We could attribute the slow return of bowel function in our subjects to their general decreased mobility and increased sensitivity to narcotics. Emphasis on early ambulation and physical therapy as well as reduction in narcotic use in these patients may help reduce these complications,” she said.

Similarly, a high rate of infection in this population might indicate an increased need for perioperative prophylactic antibiotics. And she speculated that because of an increased rate of pulmonary problems in these patients, greater use of incentive spirometers and bronchodilators perioperatively would likely be beneficial.

Finally, almost one-quarter of the patients received blood transfusions although only 16% had blood loss in excess of 500 cc. This may be an indication of an inability of elderly patients to compensate for perioperative blood loss, she said.

“Aggressive correction of preoperative anemia and dehydration in these patients could benefit their surgical outcome.”

Dr. Mains suggested that elderly women should be advised there is a 5%–10% risk of serious morbidity associated with major gynecologic surgery in their age group. However, with attention to the specific perioperative needs of the elderly, this risk might be further reduced.

She suggested that physicians consider that many elderly patients are willing to accept greater risks for smaller benefits. “The decision about a patient's operability should weigh her risks and benefits. Therefore, as physicians, we must have a clear understanding of these risks and their incidence when counseling patients,” she said.

SAN FRANCISCO — Elderly women should not be denied major gynecologic surgery solely on the basis of their presumed age-based operative risk, according to Lindsay M. Mains, M.D.

In a study she presented at the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Mains showed that morbidity and mortality among elderly women undergoing major gynecologic surgery is relatively high, compared with rates in younger women undergoing this surgery. But attention to the specific perioperative needs of the elderly might further reduce this risk, said Dr. Mains of the Ochsner Clinic Foundation in New Orleans.

Dr. Mains' study reviewed data from 110 major gynecologic surgeries on women aged 80 to 90 years old. All patients received preoperative medical clearance, except one who required emergent surgery.

Although half of the patients were overweight or obese, 61% had no serious medical history otherwise, and 96% had an American Society of Anesthesiologists' (ASA) score of 3 or less.

Most procedures (77%) were performed to remove cancer or a benign mass; the rest were undertaken to treat pelvic organ prolapse and/or urinary incontinence. Almost all patients (95.5%) received general endotracheal anesthesia.

An abdominal procedure was performed in 65% of patients, while 32.5% underwent laparoscopy. A total of 4.5% had a vaginal procedure.

Dr. Mains reported an intraoperative complication rate of 4% and a post-operative complication rate of 45%. Eight percent of the total study group had major life-threatening complications, including death in 3.6% of patients.

The most common postoperative complications were ileus, which occurred in 14% of patients, infection in 14% (urinary tract infection in 6%, wound infection in 5%, and death due to sepsis in 3%), cardiopulmonary events in 13%, and fever of unknown origin in 11%.

There were four fatalities—one due to myocardial infarction and three due to sepsis and intravascular coagulation.

“Our mortality rate was lower than other studies on elderly patients, which include men and women and have shown mortality rates up to 13%. This is an interesting finding and warrants further study,” she said.

One of the mortalities occurred on postoperative day 10 in the only patient who had undergone emergent surgery because of intraabdominal hemorrhage, she noted.

Dr. Mains suggested that some of the complications in the study subjects might be specific to the elderly population, and attention to these issues could help in reducing risk. For example, half of the 14% of patients who experienced postoperative ileus were readmitted for this problem.

“We could attribute the slow return of bowel function in our subjects to their general decreased mobility and increased sensitivity to narcotics. Emphasis on early ambulation and physical therapy as well as reduction in narcotic use in these patients may help reduce these complications,” she said.

Similarly, a high rate of infection in this population might indicate an increased need for perioperative prophylactic antibiotics. And she speculated that because of an increased rate of pulmonary problems in these patients, greater use of incentive spirometers and bronchodilators perioperatively would likely be beneficial.

Finally, almost one-quarter of the patients received blood transfusions although only 16% had blood loss in excess of 500 cc. This may be an indication of an inability of elderly patients to compensate for perioperative blood loss, she said.

“Aggressive correction of preoperative anemia and dehydration in these patients could benefit their surgical outcome.”

Dr. Mains suggested that elderly women should be advised there is a 5%–10% risk of serious morbidity associated with major gynecologic surgery in their age group. However, with attention to the specific perioperative needs of the elderly, this risk might be further reduced.

She suggested that physicians consider that many elderly patients are willing to accept greater risks for smaller benefits. “The decision about a patient's operability should weigh her risks and benefits. Therefore, as physicians, we must have a clear understanding of these risks and their incidence when counseling patients,” she said.

SAN FRANCISCO — Elderly women should not be denied major gynecologic surgery solely on the basis of their presumed age-based operative risk, according to Lindsay M. Mains, M.D.

In a study she presented at the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Mains showed that morbidity and mortality among elderly women undergoing major gynecologic surgery is relatively high, compared with rates in younger women undergoing this surgery. But attention to the specific perioperative needs of the elderly might further reduce this risk, said Dr. Mains of the Ochsner Clinic Foundation in New Orleans.

Dr. Mains' study reviewed data from 110 major gynecologic surgeries on women aged 80 to 90 years old. All patients received preoperative medical clearance, except one who required emergent surgery.

Although half of the patients were overweight or obese, 61% had no serious medical history otherwise, and 96% had an American Society of Anesthesiologists' (ASA) score of 3 or less.

Most procedures (77%) were performed to remove cancer or a benign mass; the rest were undertaken to treat pelvic organ prolapse and/or urinary incontinence. Almost all patients (95.5%) received general endotracheal anesthesia.

An abdominal procedure was performed in 65% of patients, while 32.5% underwent laparoscopy. A total of 4.5% had a vaginal procedure.

Dr. Mains reported an intraoperative complication rate of 4% and a post-operative complication rate of 45%. Eight percent of the total study group had major life-threatening complications, including death in 3.6% of patients.

The most common postoperative complications were ileus, which occurred in 14% of patients, infection in 14% (urinary tract infection in 6%, wound infection in 5%, and death due to sepsis in 3%), cardiopulmonary events in 13%, and fever of unknown origin in 11%.

There were four fatalities—one due to myocardial infarction and three due to sepsis and intravascular coagulation.

“Our mortality rate was lower than other studies on elderly patients, which include men and women and have shown mortality rates up to 13%. This is an interesting finding and warrants further study,” she said.

One of the mortalities occurred on postoperative day 10 in the only patient who had undergone emergent surgery because of intraabdominal hemorrhage, she noted.

Dr. Mains suggested that some of the complications in the study subjects might be specific to the elderly population, and attention to these issues could help in reducing risk. For example, half of the 14% of patients who experienced postoperative ileus were readmitted for this problem.

“We could attribute the slow return of bowel function in our subjects to their general decreased mobility and increased sensitivity to narcotics. Emphasis on early ambulation and physical therapy as well as reduction in narcotic use in these patients may help reduce these complications,” she said.

Similarly, a high rate of infection in this population might indicate an increased need for perioperative prophylactic antibiotics. And she speculated that because of an increased rate of pulmonary problems in these patients, greater use of incentive spirometers and bronchodilators perioperatively would likely be beneficial.

Finally, almost one-quarter of the patients received blood transfusions although only 16% had blood loss in excess of 500 cc. This may be an indication of an inability of elderly patients to compensate for perioperative blood loss, she said.

“Aggressive correction of preoperative anemia and dehydration in these patients could benefit their surgical outcome.”

Dr. Mains suggested that elderly women should be advised there is a 5%–10% risk of serious morbidity associated with major gynecologic surgery in their age group. However, with attention to the specific perioperative needs of the elderly, this risk might be further reduced.

She suggested that physicians consider that many elderly patients are willing to accept greater risks for smaller benefits. “The decision about a patient's operability should weigh her risks and benefits. Therefore, as physicians, we must have a clear understanding of these risks and their incidence when counseling patients,” she said.

MONTREAL — Asthma patients who have comorbid gastroesophageal reflux disease are able to improve their lung function by treating their acid reflux, Stephen K. Field, M.D., reported in a poster presentation at the 13th World Congress of Gastroenterology.

Patients with more severe asthma combined with nocturnal respiratory symptoms are the most likely to benefit, according to the study sponsored by AstraZeneca Pharmaceuticals.

“Clinicians should ask their asthma patients whether they have symptomatic reflux, and if they do, they should treat them like anyone who has symptomatic reflux,” said Dr. Field of the University of Calgary (Alta.).

Studies have shown that the prevalence of gastroesophageal reflux disease (GERD) is high in adults with asthma, and it has been speculated that reflux, particularly at night, may be an asthma trigger, Dr. Field said in an interview.

However, the reverse has also been suggested, namely that asthma might trigger GERD.

In this study, 770 patients with persistent, moderate to severe asthma and daily use of inhaled corticosteroids and/or leukotriene modifiers were randomized to receive esomeprazole (Nexium) 40 mg twice daily or placebo for 16 weeks.

The primary objective of the study was to assess the change in morning peak expiratory flow (PEF) from baseline to the end of treatment.

The participants were divided into three categories based on symptoms. One group had nocturnal respiratory symptoms but no GERD (201), one group had GERD but no nocturnal respiratory symptoms (219), and one group had both GERD and nocturnal respiratory symptoms (350).

Among the entire study population, morning PEF increased significantly more from baseline in patients treated with esomeprazole (22 L/min), compared with those who were treated with placebo (16 L/min).

This effect was most pronounced among the patients with both GERD and nocturnal respiratory symptoms.

However, no statistically significant differences were observed between the treatment groups or the symptom groups in terms of patient-reported forced expiratory volume in 1 second, asthma symptoms, or use of rescue medications.

The strongest treatment effect for esomeprazole was found in a subgroup of 307 patients who were taking both inhaled corticosteroids and long-acting β-agonists (suggesting more severe asthma).

In this group, the mean increase in both morning and evening PEF from baseline was significantly higher than it was among patients treated with placebo (26.1 L/min vs. 13.9 L/min for morning PEF, and 20.2 L/min vs. 9.1 L/min for evening PEF).

Again, within this subgroup of more severe asthma, the 119 patients reporting both GERD and nocturnal respiratory symptoms showed the most improvement in lung function with esomeprazole, with a change in morning PEF from baseline of 14.8 L/min, and evening PEF from baseline of 19 L/min. But once again, within this group of more severe asthma, esomeprazole resulted in no significant improvements in other asthma parameters.

The main weakness of the study is that those patients most likely to show an improvement with esomeprazole could not be included, said Dr. Field.

“You have to do what's ethically appropriate, so we had to exclude those with the worst reflux symptoms and those with erosive esophagitis because it would have been unethical to randomize them to possibly receive placebo.”

He said the study highlights the fact that GERD and asthma should be investigated simultaneously.

“Lots of patients with asthma have symptomatic GERD, but it's not something all clinicians ask their asthma patients about.”

MONTREAL — Asthma patients who have comorbid gastroesophageal reflux disease are able to improve their lung function by treating their acid reflux, Stephen K. Field, M.D., reported in a poster presentation at the 13th World Congress of Gastroenterology.

Patients with more severe asthma combined with nocturnal respiratory symptoms are the most likely to benefit, according to the study sponsored by AstraZeneca Pharmaceuticals.

“Clinicians should ask their asthma patients whether they have symptomatic reflux, and if they do, they should treat them like anyone who has symptomatic reflux,” said Dr. Field of the University of Calgary (Alta.).

Studies have shown that the prevalence of gastroesophageal reflux disease (GERD) is high in adults with asthma, and it has been speculated that reflux, particularly at night, may be an asthma trigger, Dr. Field said in an interview.

However, the reverse has also been suggested, namely that asthma might trigger GERD.

In this study, 770 patients with persistent, moderate to severe asthma and daily use of inhaled corticosteroids and/or leukotriene modifiers were randomized to receive esomeprazole (Nexium) 40 mg twice daily or placebo for 16 weeks.

The primary objective of the study was to assess the change in morning peak expiratory flow (PEF) from baseline to the end of treatment.

The participants were divided into three categories based on symptoms. One group had nocturnal respiratory symptoms but no GERD (201), one group had GERD but no nocturnal respiratory symptoms (219), and one group had both GERD and nocturnal respiratory symptoms (350).

Among the entire study population, morning PEF increased significantly more from baseline in patients treated with esomeprazole (22 L/min), compared with those who were treated with placebo (16 L/min).

This effect was most pronounced among the patients with both GERD and nocturnal respiratory symptoms.

However, no statistically significant differences were observed between the treatment groups or the symptom groups in terms of patient-reported forced expiratory volume in 1 second, asthma symptoms, or use of rescue medications.

The strongest treatment effect for esomeprazole was found in a subgroup of 307 patients who were taking both inhaled corticosteroids and long-acting β-agonists (suggesting more severe asthma).

In this group, the mean increase in both morning and evening PEF from baseline was significantly higher than it was among patients treated with placebo (26.1 L/min vs. 13.9 L/min for morning PEF, and 20.2 L/min vs. 9.1 L/min for evening PEF).

Again, within this subgroup of more severe asthma, the 119 patients reporting both GERD and nocturnal respiratory symptoms showed the most improvement in lung function with esomeprazole, with a change in morning PEF from baseline of 14.8 L/min, and evening PEF from baseline of 19 L/min. But once again, within this group of more severe asthma, esomeprazole resulted in no significant improvements in other asthma parameters.

The main weakness of the study is that those patients most likely to show an improvement with esomeprazole could not be included, said Dr. Field.

“You have to do what's ethically appropriate, so we had to exclude those with the worst reflux symptoms and those with erosive esophagitis because it would have been unethical to randomize them to possibly receive placebo.”

He said the study highlights the fact that GERD and asthma should be investigated simultaneously.

“Lots of patients with asthma have symptomatic GERD, but it's not something all clinicians ask their asthma patients about.”

MONTREAL — Asthma patients who have comorbid gastroesophageal reflux disease are able to improve their lung function by treating their acid reflux, Stephen K. Field, M.D., reported in a poster presentation at the 13th World Congress of Gastroenterology.

Patients with more severe asthma combined with nocturnal respiratory symptoms are the most likely to benefit, according to the study sponsored by AstraZeneca Pharmaceuticals.

“Clinicians should ask their asthma patients whether they have symptomatic reflux, and if they do, they should treat them like anyone who has symptomatic reflux,” said Dr. Field of the University of Calgary (Alta.).

Studies have shown that the prevalence of gastroesophageal reflux disease (GERD) is high in adults with asthma, and it has been speculated that reflux, particularly at night, may be an asthma trigger, Dr. Field said in an interview.

However, the reverse has also been suggested, namely that asthma might trigger GERD.

In this study, 770 patients with persistent, moderate to severe asthma and daily use of inhaled corticosteroids and/or leukotriene modifiers were randomized to receive esomeprazole (Nexium) 40 mg twice daily or placebo for 16 weeks.

The primary objective of the study was to assess the change in morning peak expiratory flow (PEF) from baseline to the end of treatment.

The participants were divided into three categories based on symptoms. One group had nocturnal respiratory symptoms but no GERD (201), one group had GERD but no nocturnal respiratory symptoms (219), and one group had both GERD and nocturnal respiratory symptoms (350).

Among the entire study population, morning PEF increased significantly more from baseline in patients treated with esomeprazole (22 L/min), compared with those who were treated with placebo (16 L/min).

This effect was most pronounced among the patients with both GERD and nocturnal respiratory symptoms.

However, no statistically significant differences were observed between the treatment groups or the symptom groups in terms of patient-reported forced expiratory volume in 1 second, asthma symptoms, or use of rescue medications.

The strongest treatment effect for esomeprazole was found in a subgroup of 307 patients who were taking both inhaled corticosteroids and long-acting β-agonists (suggesting more severe asthma).

In this group, the mean increase in both morning and evening PEF from baseline was significantly higher than it was among patients treated with placebo (26.1 L/min vs. 13.9 L/min for morning PEF, and 20.2 L/min vs. 9.1 L/min for evening PEF).

Again, within this subgroup of more severe asthma, the 119 patients reporting both GERD and nocturnal respiratory symptoms showed the most improvement in lung function with esomeprazole, with a change in morning PEF from baseline of 14.8 L/min, and evening PEF from baseline of 19 L/min. But once again, within this group of more severe asthma, esomeprazole resulted in no significant improvements in other asthma parameters.

The main weakness of the study is that those patients most likely to show an improvement with esomeprazole could not be included, said Dr. Field.

“You have to do what's ethically appropriate, so we had to exclude those with the worst reflux symptoms and those with erosive esophagitis because it would have been unethical to randomize them to possibly receive placebo.”

He said the study highlights the fact that GERD and asthma should be investigated simultaneously.

“Lots of patients with asthma have symptomatic GERD, but it's not something all clinicians ask their asthma patients about.”

MONTREAL — Gastroesophageal reflux symptoms are poorly controlled across North America and Europe, and people with nocturnal symptoms represent the largest treatment gap, according to two different industry-sponsored studies presented in a series of posters at the 12th World Congress of Gastroenterology.

“There's a huge unmet prescribing need,” said Farah Husein-Bhabha, from Janssen-Ortho Inc. in Toronto, which sponsored one of the studies. “We found that the use of over-the-counter drugs is much higher than prescription drug use, and yet these patients continue to experience symptoms,” she told FAMILY PRACTICE NEWS.

The Canadian study randomly polled 2,001 individuals by telephone to assess the prevalence and impact of gastroesophageal reflux disease (GERD) in the general population.

Just over 40% of the respondents (820) reported at least one upper gastrointestinal symptom in the last month, with the most common complaint being GERD (367). Among GERD sufferers, 54% had sought medical help for their problem, while 46% had not.

The U.S./European study (sponsored by AstraZeneca) which randomly polled a much larger sample of about 212,000 households, identified 1,908 respondents who were either formally diagnosed (52%) or undiagnosed but with symptoms suggestive of GERD (48%).

Both studies identified a high percentage (64% and 50%, respectively) of patients who reported nocturnal GERD symptoms either alone, or together with daytime symptoms.

In the Canadian study, 47% of those with nocturnal symptoms reported disturbed sleep, and 43% of these people reported a negative impact on their daytime functioning and productivity as a result.

The U.S./European study found that, when woken up with GERD symptoms, people stayed awake an average of 70 minutes and missed an average of 30 minutes of work per week as a result. This compared with only 6 minutes of lost work time per week in GERD patients without disturbed sleep. GERD-related sleep disturbance was estimated to be responsible for a 15% reduction in work productivity and a 14% reduction in leisure time, compared with an 8% and 10% reduction in GERD patients without disturbed sleep.

Nocturnal GERD symptoms are of particular concern not only for quality of life reasons, but also because of their long-term implications, said Ms. Husein-Bhabha.

“If a patient has nocturnal symptoms, it generally means a more severe type of GERD, and there may also be an association with more erosive disease. There is a certain percentage of the population that may progress to esophageal cancer if they are untreated. But for many patients who do not have erosive disease that risk is small and probably less than we had originally thought.”

Both studies found that GERD symptoms are undertreated.

In the Canadian population, 57% of GERD sufferers were taking over-the-counter (OTC) medications, while 25% used prescription medications. In the U.S./European study, 74% of the diagnosed group were taking prescription medications (55% of which were proton pump inhibitors), while 85% of the undiagnosed group were taking OTC medications.

Despite some improvement resulting from these treatments, the majority of patients in the U.S./European study reported unresolved symptoms (81% of the self-treated group and 68% of those taking prescription medications).

In the Canadian study, only 54% of patients using proton pump inhibitors (PPI) for nocturnal relief felt satisfied with the treatment.

“Our findings imply the use of medication for management of GERD can be improved,” concluded the authors of the U.S./European study. “Symptoms were more likely to improve when GERD was formally diagnosed by a physician and PPIs prescribed… Individuals with persistent GERD symptoms should consult a physician.”

The Canadian study found that the strongest predictor of a person seeking GERD treatment from a physician was nocturnal GERD that disrupted sleep. Other predictors were older age, more severe symptoms, and longer duration of symptoms.

MONTREAL — Gastroesophageal reflux symptoms are poorly controlled across North America and Europe, and people with nocturnal symptoms represent the largest treatment gap, according to two different industry-sponsored studies presented in a series of posters at the 12th World Congress of Gastroenterology.

“There's a huge unmet prescribing need,” said Farah Husein-Bhabha, from Janssen-Ortho Inc. in Toronto, which sponsored one of the studies. “We found that the use of over-the-counter drugs is much higher than prescription drug use, and yet these patients continue to experience symptoms,” she told FAMILY PRACTICE NEWS.

The Canadian study randomly polled 2,001 individuals by telephone to assess the prevalence and impact of gastroesophageal reflux disease (GERD) in the general population.

Just over 40% of the respondents (820) reported at least one upper gastrointestinal symptom in the last month, with the most common complaint being GERD (367). Among GERD sufferers, 54% had sought medical help for their problem, while 46% had not.

The U.S./European study (sponsored by AstraZeneca) which randomly polled a much larger sample of about 212,000 households, identified 1,908 respondents who were either formally diagnosed (52%) or undiagnosed but with symptoms suggestive of GERD (48%).

Both studies identified a high percentage (64% and 50%, respectively) of patients who reported nocturnal GERD symptoms either alone, or together with daytime symptoms.

In the Canadian study, 47% of those with nocturnal symptoms reported disturbed sleep, and 43% of these people reported a negative impact on their daytime functioning and productivity as a result.

The U.S./European study found that, when woken up with GERD symptoms, people stayed awake an average of 70 minutes and missed an average of 30 minutes of work per week as a result. This compared with only 6 minutes of lost work time per week in GERD patients without disturbed sleep. GERD-related sleep disturbance was estimated to be responsible for a 15% reduction in work productivity and a 14% reduction in leisure time, compared with an 8% and 10% reduction in GERD patients without disturbed sleep.

Nocturnal GERD symptoms are of particular concern not only for quality of life reasons, but also because of their long-term implications, said Ms. Husein-Bhabha.

“If a patient has nocturnal symptoms, it generally means a more severe type of GERD, and there may also be an association with more erosive disease. There is a certain percentage of the population that may progress to esophageal cancer if they are untreated. But for many patients who do not have erosive disease that risk is small and probably less than we had originally thought.”

Both studies found that GERD symptoms are undertreated.

In the Canadian population, 57% of GERD sufferers were taking over-the-counter (OTC) medications, while 25% used prescription medications. In the U.S./European study, 74% of the diagnosed group were taking prescription medications (55% of which were proton pump inhibitors), while 85% of the undiagnosed group were taking OTC medications.

Despite some improvement resulting from these treatments, the majority of patients in the U.S./European study reported unresolved symptoms (81% of the self-treated group and 68% of those taking prescription medications).

In the Canadian study, only 54% of patients using proton pump inhibitors (PPI) for nocturnal relief felt satisfied with the treatment.

“Our findings imply the use of medication for management of GERD can be improved,” concluded the authors of the U.S./European study. “Symptoms were more likely to improve when GERD was formally diagnosed by a physician and PPIs prescribed… Individuals with persistent GERD symptoms should consult a physician.”

The Canadian study found that the strongest predictor of a person seeking GERD treatment from a physician was nocturnal GERD that disrupted sleep. Other predictors were older age, more severe symptoms, and longer duration of symptoms.

MONTREAL — Gastroesophageal reflux symptoms are poorly controlled across North America and Europe, and people with nocturnal symptoms represent the largest treatment gap, according to two different industry-sponsored studies presented in a series of posters at the 12th World Congress of Gastroenterology.

“There's a huge unmet prescribing need,” said Farah Husein-Bhabha, from Janssen-Ortho Inc. in Toronto, which sponsored one of the studies. “We found that the use of over-the-counter drugs is much higher than prescription drug use, and yet these patients continue to experience symptoms,” she told FAMILY PRACTICE NEWS.

The Canadian study randomly polled 2,001 individuals by telephone to assess the prevalence and impact of gastroesophageal reflux disease (GERD) in the general population.

Just over 40% of the respondents (820) reported at least one upper gastrointestinal symptom in the last month, with the most common complaint being GERD (367). Among GERD sufferers, 54% had sought medical help for their problem, while 46% had not.

The U.S./European study (sponsored by AstraZeneca) which randomly polled a much larger sample of about 212,000 households, identified 1,908 respondents who were either formally diagnosed (52%) or undiagnosed but with symptoms suggestive of GERD (48%).

Both studies identified a high percentage (64% and 50%, respectively) of patients who reported nocturnal GERD symptoms either alone, or together with daytime symptoms.

In the Canadian study, 47% of those with nocturnal symptoms reported disturbed sleep, and 43% of these people reported a negative impact on their daytime functioning and productivity as a result.

The U.S./European study found that, when woken up with GERD symptoms, people stayed awake an average of 70 minutes and missed an average of 30 minutes of work per week as a result. This compared with only 6 minutes of lost work time per week in GERD patients without disturbed sleep. GERD-related sleep disturbance was estimated to be responsible for a 15% reduction in work productivity and a 14% reduction in leisure time, compared with an 8% and 10% reduction in GERD patients without disturbed sleep.

Nocturnal GERD symptoms are of particular concern not only for quality of life reasons, but also because of their long-term implications, said Ms. Husein-Bhabha.

“If a patient has nocturnal symptoms, it generally means a more severe type of GERD, and there may also be an association with more erosive disease. There is a certain percentage of the population that may progress to esophageal cancer if they are untreated. But for many patients who do not have erosive disease that risk is small and probably less than we had originally thought.”

Both studies found that GERD symptoms are undertreated.

In the Canadian population, 57% of GERD sufferers were taking over-the-counter (OTC) medications, while 25% used prescription medications. In the U.S./European study, 74% of the diagnosed group were taking prescription medications (55% of which were proton pump inhibitors), while 85% of the undiagnosed group were taking OTC medications.

Despite some improvement resulting from these treatments, the majority of patients in the U.S./European study reported unresolved symptoms (81% of the self-treated group and 68% of those taking prescription medications).

In the Canadian study, only 54% of patients using proton pump inhibitors (PPI) for nocturnal relief felt satisfied with the treatment.

“Our findings imply the use of medication for management of GERD can be improved,” concluded the authors of the U.S./European study. “Symptoms were more likely to improve when GERD was formally diagnosed by a physician and PPIs prescribed… Individuals with persistent GERD symptoms should consult a physician.”

The Canadian study found that the strongest predictor of a person seeking GERD treatment from a physician was nocturnal GERD that disrupted sleep. Other predictors were older age, more severe symptoms, and longer duration of symptoms.

Although exercise is promoted to the general population for its well-recognized benefits, it is still not adequately accepted or recommended during pregnancy, according to Raul Artal, M.D., professor and chair of obstetrics, gynecology, and women's health at St. Louis University.

The hesitance of physicians to recommend exercise to pregnant women is rooted in old-fashioned notions of pregnancy as a time of confinement, he said.

With evidence to show that regular, moderate exercise in women with healthy pregnancies results in no adverse maternal or fetal effects, it could be argued that, in the spirit of “primum non nocere,” physicians should make exercise recommendations a priority, said Dr. Artal, a noted expert in exercise physiology in pregnancy.

Because it is recognized that habits adopted during pregnancy can result in persistent lifestyle improvements, the promotion of exercise during pregnancy is an important public health issue that could significantly reduce the lifetime risks of obesity, chronic hypertension, and diabetes—not only for pregnant women, but also but for their families, he said.

Dr. Artal's pregnancy exercise recommendations include:

Healthy Pregnancy? Few Restrictions

Women with healthy pregnancies and no contraindications can exercise just as their nonpregnant counterparts do. (See box.)

A clinical evaluation of each patient is recommended before prescribing exercise, including an assessment of the type and intensity of exercise, as well as the duration and frequency of exercise sessions.

Contact sports and exercises with a high risk of falling or abdominal trauma should be avoided. Scuba diving should be avoided because this activity puts the fetus at increased risk for decompression sickness secondary to the inability of the fetal pulmonary circulation to filter bubbles.

Exercise Intensity

Moderate exercise is defined as a level of intensity that still allows normal conversation—equivalent, for example, to brisk walking at 3–4 miles per hour. For women who have been sedentary and are taking up exercise for the first time, a gradual progression is recommended.

Those who are fit should be advised that pregnancy is not a time for greatly improving physical fitness.

Pregnant women should use caution in increasing the intensity of their workouts, especially when they are extending exercise sessions beyond 45 minutes, because body core temperatures can rise above safe limits after that time. Strenuous exercise has not been proved to increase overall benefit and could actually be harmful.

Fetal Effects

Maternal cardiovascular, respiratory, and thermoregulatory adaptation occurs as a result of pregnancy and is further challenged by the addition of exercise.

Some physicians are hesitant to prescribe exercise for pregnant women because of the hypothetical fetal risks of impaired transplacental blood flow of oxygen, carbon dioxide, and nutrients during exercise, as well as the potentially teratogenic effects of raising fetal temperature.

Most studies show a minimal to moderate increase in fetal heart rate during exercise, and there is also evidence of heart rate decelerations and bradycardia; however, no lasting fetal effects have been reported.

Loss of fluid through sweat may compromise heat dissipation, so maintenance of hydration—and thus blood volume—is essential to controlling core temperature.

Extra Nutritional Requirements

Although published data on a link between low birth weight and maternal exercise are conflicting, it appears that adequate energy intake can offset any exercise-induced decrease in birth weight.

By the second trimester of pregnancy, an extra 300 calories are needed daily to meet general metabolic needs in pregnancy; exercise increases this requirement.

Pregnant women use carbohydrates at a greater rate than do nonpregnant women and there is preferential use of this form of energy during non-weight-bearing exercise, making adequate carbohydrate intake of particular importance.

Elite Athletes

Most elite athletes choose to continue training during pregnancy, but they must be told that they probably will not achieve the same level of performance as they did before pregnancy, and the physiologic changes they experience will also make them more prone to injury.

Although routine prenatal care is sufficient for most women who exercise, elite athletes require closer observation.

Women engaging in endurance sports can be prone to anemia that results from increased blood volume during pregnancy. High-intensity, prolonged, and frequent exercise can put women at greater risk of thermoregulatory complications as well, and will usually result in less maternal and fetal weight gain.

Gestational Diabetes

The American Diabetes Association has endorsed exercise as a helpful adjunctive therapy for gestational diabetes mellitus (GDM) when glycemic control cannot be achieved through diet alone.

Approximately 39% of patients with GDM require insulin therapy, but in my experience, exercise is a safe and effective alternative for most of these women.

The key to achieving euglycemia through exercise is ensuring the adequate duration and intensity of the activity. At least half an hour of brisk walking per day is sufficient to upregulate insulin sensitivity, obviating the need for insulin therapy.

Weight Control

Although exercise should never be used for weight control during pregnancy, excessive weight gain should be avoided.

The current Institute of Medicine (IOM) guidelines on weight gain—which recommend a gain of 25–35 pounds for normal-weight women with a singleton pregnancy—are too high and are based on historical concerns about the effects of famine on fetal growth retardation.

The effect of gestational weight gain on pregnancy outcomes in obese women is not well studied. “It is my opinion that the IOM guidelines are outdated, and that weight gain recommendations should be individualized,” he noted.

Postpartum Exercise

Because failure to lose weight gained in pregnancy is a significant contributor to the obesity epidemic, the promotion of good exercise habits during pregnancy can also sow the seeds for postpartum exercise and weight loss.

In a study by Dr. Artal and colleagues, a weekly structured exercise program plus diet in postpartum overweight women were found to be much more effective in achieving weight loss after 12 weeks, compared with a single 1-hour education session about diet and exercise (J. Women's Health [Larchmt] 2003;12:991–8).

Staying hydrated is key, as sweating may compromise heat dissipation. Lynda Banzi

Contraindications To Exercising During Pregnancy

Absolute Contraindications

Hemodynamically significant heart disease

Restrictive lung disease

Incompetent cervix/cerclage

Multiple gestation at risk forpremature labor

Persistent second- or third-trimester bleeding

Placenta previa after 26 weeks'gestation

Premature labor during the current pregnancy

Ruptured membranes

Preeclampsia/pregnancy-induced hypertension

Relative Contraindications

Severe anemia

Unevaluated maternal cardiac arrhythmia

Chronic bronchitis

Poorly controlled type 1 diabetes

Extreme morbid obesity

Extreme underweight (body massindex [kg/m

History of extremely sedentary lifestyle

Intrauterine growth restriction in current pregnancy

Poorly controlled hypertension

Orthopedic limitations

Poorly controlled seizure disorder

Poorly controlled hyperthyroidism

Heavy smoker

Source: Obstet. Gynecol. 2002;99:171–3

Although exercise is promoted to the general population for its well-recognized benefits, it is still not adequately accepted or recommended during pregnancy, according to Raul Artal, M.D., professor and chair of obstetrics, gynecology, and women's health at St. Louis University.

The hesitance of physicians to recommend exercise to pregnant women is rooted in old-fashioned notions of pregnancy as a time of confinement, he said.

With evidence to show that regular, moderate exercise in women with healthy pregnancies results in no adverse maternal or fetal effects, it could be argued that, in the spirit of “primum non nocere,” physicians should make exercise recommendations a priority, said Dr. Artal, a noted expert in exercise physiology in pregnancy.

Because it is recognized that habits adopted during pregnancy can result in persistent lifestyle improvements, the promotion of exercise during pregnancy is an important public health issue that could significantly reduce the lifetime risks of obesity, chronic hypertension, and diabetes—not only for pregnant women, but also but for their families, he said.

Dr. Artal's pregnancy exercise recommendations include:

Healthy Pregnancy? Few Restrictions

Women with healthy pregnancies and no contraindications can exercise just as their nonpregnant counterparts do. (See box.)

A clinical evaluation of each patient is recommended before prescribing exercise, including an assessment of the type and intensity of exercise, as well as the duration and frequency of exercise sessions.

Contact sports and exercises with a high risk of falling or abdominal trauma should be avoided. Scuba diving should be avoided because this activity puts the fetus at increased risk for decompression sickness secondary to the inability of the fetal pulmonary circulation to filter bubbles.

Exercise Intensity

Moderate exercise is defined as a level of intensity that still allows normal conversation—equivalent, for example, to brisk walking at 3–4 miles per hour. For women who have been sedentary and are taking up exercise for the first time, a gradual progression is recommended.

Those who are fit should be advised that pregnancy is not a time for greatly improving physical fitness.

Pregnant women should use caution in increasing the intensity of their workouts, especially when they are extending exercise sessions beyond 45 minutes, because body core temperatures can rise above safe limits after that time. Strenuous exercise has not been proved to increase overall benefit and could actually be harmful.

Fetal Effects

Maternal cardiovascular, respiratory, and thermoregulatory adaptation occurs as a result of pregnancy and is further challenged by the addition of exercise.

Some physicians are hesitant to prescribe exercise for pregnant women because of the hypothetical fetal risks of impaired transplacental blood flow of oxygen, carbon dioxide, and nutrients during exercise, as well as the potentially teratogenic effects of raising fetal temperature.

Most studies show a minimal to moderate increase in fetal heart rate during exercise, and there is also evidence of heart rate decelerations and bradycardia; however, no lasting fetal effects have been reported.

Loss of fluid through sweat may compromise heat dissipation, so maintenance of hydration—and thus blood volume—is essential to controlling core temperature.

Extra Nutritional Requirements

Although published data on a link between low birth weight and maternal exercise are conflicting, it appears that adequate energy intake can offset any exercise-induced decrease in birth weight.

By the second trimester of pregnancy, an extra 300 calories are needed daily to meet general metabolic needs in pregnancy; exercise increases this requirement.

Pregnant women use carbohydrates at a greater rate than do nonpregnant women and there is preferential use of this form of energy during non-weight-bearing exercise, making adequate carbohydrate intake of particular importance.

Elite Athletes

Most elite athletes choose to continue training during pregnancy, but they must be told that they probably will not achieve the same level of performance as they did before pregnancy, and the physiologic changes they experience will also make them more prone to injury.

Although routine prenatal care is sufficient for most women who exercise, elite athletes require closer observation.

Women engaging in endurance sports can be prone to anemia that results from increased blood volume during pregnancy. High-intensity, prolonged, and frequent exercise can put women at greater risk of thermoregulatory complications as well, and will usually result in less maternal and fetal weight gain.

Gestational Diabetes

The American Diabetes Association has endorsed exercise as a helpful adjunctive therapy for gestational diabetes mellitus (GDM) when glycemic control cannot be achieved through diet alone.

Approximately 39% of patients with GDM require insulin therapy, but in my experience, exercise is a safe and effective alternative for most of these women.

The key to achieving euglycemia through exercise is ensuring the adequate duration and intensity of the activity. At least half an hour of brisk walking per day is sufficient to upregulate insulin sensitivity, obviating the need for insulin therapy.

Weight Control

Although exercise should never be used for weight control during pregnancy, excessive weight gain should be avoided.

The current Institute of Medicine (IOM) guidelines on weight gain—which recommend a gain of 25–35 pounds for normal-weight women with a singleton pregnancy—are too high and are based on historical concerns about the effects of famine on fetal growth retardation.

The effect of gestational weight gain on pregnancy outcomes in obese women is not well studied. “It is my opinion that the IOM guidelines are outdated, and that weight gain recommendations should be individualized,” he noted.

Postpartum Exercise

Because failure to lose weight gained in pregnancy is a significant contributor to the obesity epidemic, the promotion of good exercise habits during pregnancy can also sow the seeds for postpartum exercise and weight loss.

In a study by Dr. Artal and colleagues, a weekly structured exercise program plus diet in postpartum overweight women were found to be much more effective in achieving weight loss after 12 weeks, compared with a single 1-hour education session about diet and exercise (J. Women's Health [Larchmt] 2003;12:991–8).

Staying hydrated is key, as sweating may compromise heat dissipation. Lynda Banzi

Contraindications To Exercising During Pregnancy

Absolute Contraindications

Hemodynamically significant heart disease

Restrictive lung disease

Incompetent cervix/cerclage

Multiple gestation at risk forpremature labor

Persistent second- or third-trimester bleeding

Placenta previa after 26 weeks'gestation

Premature labor during the current pregnancy

Ruptured membranes

Preeclampsia/pregnancy-induced hypertension

Relative Contraindications

Severe anemia

Unevaluated maternal cardiac arrhythmia

Chronic bronchitis

Poorly controlled type 1 diabetes

Extreme morbid obesity

Extreme underweight (body massindex [kg/m

History of extremely sedentary lifestyle

Intrauterine growth restriction in current pregnancy

Poorly controlled hypertension

Orthopedic limitations

Poorly controlled seizure disorder

Poorly controlled hyperthyroidism

Heavy smoker

Source: Obstet. Gynecol. 2002;99:171–3

Although exercise is promoted to the general population for its well-recognized benefits, it is still not adequately accepted or recommended during pregnancy, according to Raul Artal, M.D., professor and chair of obstetrics, gynecology, and women's health at St. Louis University.

The hesitance of physicians to recommend exercise to pregnant women is rooted in old-fashioned notions of pregnancy as a time of confinement, he said.

With evidence to show that regular, moderate exercise in women with healthy pregnancies results in no adverse maternal or fetal effects, it could be argued that, in the spirit of “primum non nocere,” physicians should make exercise recommendations a priority, said Dr. Artal, a noted expert in exercise physiology in pregnancy.

Because it is recognized that habits adopted during pregnancy can result in persistent lifestyle improvements, the promotion of exercise during pregnancy is an important public health issue that could significantly reduce the lifetime risks of obesity, chronic hypertension, and diabetes—not only for pregnant women, but also but for their families, he said.

Dr. Artal's pregnancy exercise recommendations include:

Healthy Pregnancy? Few Restrictions

Women with healthy pregnancies and no contraindications can exercise just as their nonpregnant counterparts do. (See box.)

A clinical evaluation of each patient is recommended before prescribing exercise, including an assessment of the type and intensity of exercise, as well as the duration and frequency of exercise sessions.

Contact sports and exercises with a high risk of falling or abdominal trauma should be avoided. Scuba diving should be avoided because this activity puts the fetus at increased risk for decompression sickness secondary to the inability of the fetal pulmonary circulation to filter bubbles.

Exercise Intensity

Moderate exercise is defined as a level of intensity that still allows normal conversation—equivalent, for example, to brisk walking at 3–4 miles per hour. For women who have been sedentary and are taking up exercise for the first time, a gradual progression is recommended.

Those who are fit should be advised that pregnancy is not a time for greatly improving physical fitness.

Pregnant women should use caution in increasing the intensity of their workouts, especially when they are extending exercise sessions beyond 45 minutes, because body core temperatures can rise above safe limits after that time. Strenuous exercise has not been proved to increase overall benefit and could actually be harmful.

Fetal Effects

Maternal cardiovascular, respiratory, and thermoregulatory adaptation occurs as a result of pregnancy and is further challenged by the addition of exercise.

Some physicians are hesitant to prescribe exercise for pregnant women because of the hypothetical fetal risks of impaired transplacental blood flow of oxygen, carbon dioxide, and nutrients during exercise, as well as the potentially teratogenic effects of raising fetal temperature.

Most studies show a minimal to moderate increase in fetal heart rate during exercise, and there is also evidence of heart rate decelerations and bradycardia; however, no lasting fetal effects have been reported.

Loss of fluid through sweat may compromise heat dissipation, so maintenance of hydration—and thus blood volume—is essential to controlling core temperature.

Extra Nutritional Requirements

Although published data on a link between low birth weight and maternal exercise are conflicting, it appears that adequate energy intake can offset any exercise-induced decrease in birth weight.

By the second trimester of pregnancy, an extra 300 calories are needed daily to meet general metabolic needs in pregnancy; exercise increases this requirement.

Pregnant women use carbohydrates at a greater rate than do nonpregnant women and there is preferential use of this form of energy during non-weight-bearing exercise, making adequate carbohydrate intake of particular importance.

Elite Athletes

Most elite athletes choose to continue training during pregnancy, but they must be told that they probably will not achieve the same level of performance as they did before pregnancy, and the physiologic changes they experience will also make them more prone to injury.

Although routine prenatal care is sufficient for most women who exercise, elite athletes require closer observation.

Women engaging in endurance sports can be prone to anemia that results from increased blood volume during pregnancy. High-intensity, prolonged, and frequent exercise can put women at greater risk of thermoregulatory complications as well, and will usually result in less maternal and fetal weight gain.

Gestational Diabetes

The American Diabetes Association has endorsed exercise as a helpful adjunctive therapy for gestational diabetes mellitus (GDM) when glycemic control cannot be achieved through diet alone.

Approximately 39% of patients with GDM require insulin therapy, but in my experience, exercise is a safe and effective alternative for most of these women.

The key to achieving euglycemia through exercise is ensuring the adequate duration and intensity of the activity. At least half an hour of brisk walking per day is sufficient to upregulate insulin sensitivity, obviating the need for insulin therapy.

Weight Control

Although exercise should never be used for weight control during pregnancy, excessive weight gain should be avoided.

The current Institute of Medicine (IOM) guidelines on weight gain—which recommend a gain of 25–35 pounds for normal-weight women with a singleton pregnancy—are too high and are based on historical concerns about the effects of famine on fetal growth retardation.

The effect of gestational weight gain on pregnancy outcomes in obese women is not well studied. “It is my opinion that the IOM guidelines are outdated, and that weight gain recommendations should be individualized,” he noted.

Postpartum Exercise

Because failure to lose weight gained in pregnancy is a significant contributor to the obesity epidemic, the promotion of good exercise habits during pregnancy can also sow the seeds for postpartum exercise and weight loss.

In a study by Dr. Artal and colleagues, a weekly structured exercise program plus diet in postpartum overweight women were found to be much more effective in achieving weight loss after 12 weeks, compared with a single 1-hour education session about diet and exercise (J. Women's Health [Larchmt] 2003;12:991–8).

Staying hydrated is key, as sweating may compromise heat dissipation. Lynda Banzi

Contraindications To Exercising During Pregnancy

Absolute Contraindications

Hemodynamically significant heart disease

Restrictive lung disease

Incompetent cervix/cerclage

Multiple gestation at risk forpremature labor

Persistent second- or third-trimester bleeding

Placenta previa after 26 weeks'gestation

Premature labor during the current pregnancy

Ruptured membranes

Preeclampsia/pregnancy-induced hypertension

Relative Contraindications

Severe anemia

Unevaluated maternal cardiac arrhythmia

Chronic bronchitis

Poorly controlled type 1 diabetes

Extreme morbid obesity

Extreme underweight (body massindex [kg/m

History of extremely sedentary lifestyle

Intrauterine growth restriction in current pregnancy

Poorly controlled hypertension

Orthopedic limitations

Poorly controlled seizure disorder

Poorly controlled hyperthyroidism

Heavy smoker

Source: Obstet. Gynecol. 2002;99:171–3